Original Article

Santra G, Sarkar RN, Phaujdar S, Banerjee S, Siddhanta S
Correspondence: Dr Gouranga Santra, g.santra@yahoo.com

ABSTRACT
Introduction Bisphosphonates have anti-inflammatory properties in arthritic conditions. This study was conducted to assess the therapeutic potential of intravenous pamidronate in nonsteroidal anti-inflammatory drug (NSAID) refractory or intolerant cases of ankylosing spondylitis (AS).
Methods A total of 35 NSAID refractory/intolerant AS patients with Bath AS Disease Activity Index (BASDAI) score 4 or above were recruited for the study. Monthly pamidronate infusions (60 mg) were administered to the patients for six months. Treatment outcomes were assessed by comparing baseline values with the values after six infusions using BASDAI, Bath AS Functional Index (BASFI), Metrology Index (BASMI) and Global Score (BAS-G), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). An improvement was defined according to the Assessments in Ankylosing Spondylitis (ASAS)-20 and BASDAI-50.
Results 26 patients received all the six infusions. Of these, 22 (85 percent) achieved ASAS-20 and 20 (77 percent) achieved BASDAI-50 responses. Decrements were noted in the mean BASDAI (56.4 percent), BASFI (52.66 percent), BASMI (55.72 percent), BAS-G (66.71 percent), ESR (52.12 percent) and CRP (72.84 percent) after six months. The tender and swollen joint counts of 14 (54 percent) patients with peripheral arthritis were respectively reduced to a mean value of 0.85 and nil, from the baseline of 2.57 and 1.2. Early feel good response was noted in 16 (62 percent) patients within 48 hours of the first infusion. Fever, arthralgia and myalgia were observed in six cases after the first infusion, and in one case, after the second infusion. These symptoms resolved spontaneously within 24 hours.
Conclusion Intravenous pamidronate has good efficacy for the treatment of AS.

Keywords: ankylosing spondylitis, pamidronate, tumour necrosis factor-alpha
Singapore Med J 2010; 51(11): 883-887

Rianon NJ, Britt RB, Faisel AJ, Shahidullah SM, LeBlanc AD
Correspondence: Dr Nahid J Rianon, nahid.j.rianon@uth.tmc.edu

ABSTRACT
Introduction Research in the developed countries has documented bone loss in adolescents who use depomedroxyprogesterone acetate (DMPA) as a contraceptive for less than two years. DMPA use often begins during adolescence in Bangladesh, a South Asian developing country, where more than 50% of women are undernourished. Poor nutrition is also associated with low bone mineral density (BMD) in South Asian women. We investigated the effects of long-term (two or more years) DMPA use on BMD in Bangladeshi women who started its use in their adolescence.
Methods Lumbar spine and femur neck BMD were acquired using dual energy X-ray absorptiometry for 100 adolescents (50 DMPA users and 50 non-users) in a cross-sectional study in Dhaka, Bangladesh. Multivariate analysis was used to determine the associations between BMD and DMPA use. Stratified analysis of DMPA use investigated the determinants of BMD in both groups.
Results The participants (mean age 18 +/- 2 years) were generally below their ideal body weight. No significant differences in BMD were found between the two groups. Weight (odds ratio [OR] 0.96, 95 percent confidence interval [CI], 0.92–1.00) and height (OR 0.68, 95 percent CI 0.49–0.94) were independent determinants (p-value is less than 0.05) of lumbar and femur neck BMD, respectively.
Conclusion Poor nutritional status, indicated by a less-than-ideal body weight, may be masking the effects of DMPA on bone loss among adolescent users. Our findings suggest that nutritional supplementation may be required with DMPA prescription to promote bone health in adolescent users who are approaching peak bone mass.

Keywords: adolescent women, Bangladesh, bone mineral density, depomedroxyprogesterone acetate, nutrition
Singapore Med J 2010; 51(11): 876-882

Kaushal J, Gupta MC, Kaushal V, Bhutani G, Dhankar R, Atri R, Verma S
Correspondence: Dr Jyoti Kaushal, kaushaljyoti@yahoo.co.in

ABSTRACT
Introduction Palonosetron and ondansetron are two selective 5-hydroxytryptamine (5-HT3) receptor antagonists that have shown remarkable efficacy in controlling nausea and vomiting following administration of moderately emetic anticancer chemotherapy. Their efficacy is enhanced by the concurrent administration of dexamethasone. In the present study, we aimed to compare the antiemetic efficacy of a palonosetron plus dexamethasone (PD) schedule versus an ondansetron plus dexamethasone (OD) schedule.
Methods A randomised, crossover trial was conducted in 30 patients with head and neck cancer who were receiving moderately emetogenic chemotherapy. The patients were divided into two groups. In the first cycle, one group was given a PD schedule and the other, an OD schedule. For the subsequent cycle, crossover of the antiemetic schedules was done. The antiemetic effects were evaluated by recording the intensity of nausea and the frequency of vomiting in the acute and delayed phases.
Results Complete response in the acute phase was observed in 83.3 percent of the patients on the PD schedule and in 80 percent of those on the OD schedule. In the delayed phase, complete response was observed in 76.7 percent and 66.7 percent of the patients on the PD schedule and OD schedule, respectively. The overall rate of complete response was 66.7 percent in the PD group and 46.7 percent in the OD group. In the PD group, there were 73.3 percent of nausea-free patients as opposed to 66.7 percent in the OD group.
Conclusion The results suggest that the PD schedule was superior to the OD schedule in controlling emesis in cancer chemotherapy, although this difference was not statistically significant.

Keywords: acute emesis, delayed emesis, dexamethasone, ondansetron, palonosetron
Singapore Med J 2010; 51(11): 871-875

Bicer A, Ankarali H
Correspondence: Dr Ali Bicer, alibicer@mersin.edu.tr

ABSTRACT
Introduction The Shoulder Pain and Disability Index (SPADI) is a valid and reliable questionnaire used in shoulder disorders. The purpose of this study was to test the convergent validity and the reliability of the SPADI.
Methods A total of 101 female patients with shoulder pain were enrolled in the study. The SPADI and the Health Assessment Questionnaire (HAQ) were completed by all the participants. Pain was measured using the Visual Analogue Scale (VAS) during the active range of motion. Reliability was measured by internal consistency and test-retest reliability. Internal consistency was determined by calculating Cronbach’s alpha value. Convergent validity was examined by correlating the SPADI questionnaire with the VAS and HAQ scales.
Results Cronbach’s alpha value for the SPADI was found to be 0.94. Test-retest reliability of the SPADI was found to be high (0.92). The correlation coefficient for convergent validity of the SPADI was 0.65 and 0.67 for the VAS and HAQ overall scores, respectively.
Conclusion The results of the present study suggest that the SPADI is a valid and reliable instrument to assess shoulder pain in Turkish female patients.

Keywords: disability, functional status, reliability, shoulder pain, validity
Singapore Med J 2010; 51(11): 865-870

Montoya JE, Domingo F Jr, Luna CA, Berroya RM, Catli CA, Ginete JK, Sanchez OS, Juat NJ, Tiangco BJ, Jamias JD
Correspondence: Dr Jose Enrique Montoya, joeygreen10@yahoo.com

ABSTRACT
Introduction Malnutrition is common among cancer patients. This study aimed to determine the overall prevalence of malnutrition among patients undergoing chemotherapy and to determine the predictors of malnutrition among cancer patients.
Methods A cross-sectional study was conducted on 88 cancer patients admitted for chemotherapy at the National Kidney and Transplant Institute, Philippines, from October to November 2009. Subjective Global Assessment (SGA), anthropometric data and demographic variables were obtained. Descriptive statistics, ANOVA and logistic regression analysis were performed between the outcome and variables.
Results A total of 88 cancer patients were included in the study. The mean age of the patients was 55.7 +/- 14.8 years. The mean duration of illnesswas 9.7 +/- 8.7 months and the mean body mass index (BMI) was 22.9 kg/m2. The mean Karnofsky performance status was 79.3. 29.55 percent of the patients had breast cancer as the aetiology of their illness. 38 patients (43.2 percent) had SGA B and four (4.5 percent) had SGA C, giving a total malnutrition prevalence of 47.7 percent. The patients were statistically different with regard to their cancer stage (p is less than 0.001), weight (p is 0.01), BMI (p is 0.004), haemoglobin level (p is 0.001) and performance status by Karnofsky score (p is less than 0.001), as evaluated by ANOVA. Logistic regression analysis showed that cancer stage and Karnofsky performance score were predictors of malnutrition.
Conclusion About 47.7 percent of cancer patients suffer from malnutrition, as classified by SGA. Only cancer stage and Karnofsky performance status scoring were predictive of malnutrition in this select group of patients.

Keywords: cancer, chemotherapy, nutritional status
Singapore Med J 2010; 51(11): 860-864

Htwe TT, Karim N, Wong J, Jahanfar S, Mansur MA
Correspondence: Dr Than Than Htwe, ththan@rcmp.unikl.edu.my

ABSTRACT
Introduction Galectin-3 is a member of the beta-galactoside-binding protein family that plays an important role in cell-to-cell adhesion and in cell-to-matrix interaction. Cellular expression of galectin-3 is correlated with cancer aggressiveness and metastasis.
Methods We examined the differential expression of galectin-3 in a collection of 142 cases of thyroid lesions, including 108 cases of papillary thyroid carcinoma (PTC) and 34 cases of follicular carcinoma (FCA). An immunohistochemical method was applied and semiquantitative scoring was performed on the staining intensity of the positive tissue. Scoring was done on cells at the central portion of the tumour foci and on cells at the periphery that were adjacent to the neighbouring normal thyroid tissue matrix.
Results A significantly higher expression (p is 0.001) of galectin-3 was observed in the advancing peripheral thyroid cancer cells compared to the centrally located cells that were not in close contact with the neighbouring stromal tissue in cases with PTC compared to those with FCA.
Conclusion This finding supported the role of galectin-3 in its cell-to-cell adhesion and cell-to-matrix interaction. Galectin-3 is a potential tumour marker for indicating local and distance metastasis, especially in cases with PTC.

Keywords: galectin-3, metastasis, thyroid cancer
Singapore Med J 2010; 51(11): 856-859

Kayiran SM, Gürakan B
Correspondence: Dr Sinan Mahir Kayiran, sinanmahir@gmail.com

ABSTRACT
Introduction This study aimed to screen the blood glucose levels in healthy term and near-term neonates, and to assess the influence of mode of delivery, birth weight and gestational age on blood glucose levels.
Methods The blood glucose concentrations of 1,540 healthy term and near-term neonates in the first hour of life were retrospectively evaluated from the clinical charts. Glucose levels were estimated from heel prick capillary samples. The glucose concentration was correlated with the mode of delivery, birth weight and gestational age.
Results Vaginally delivered neonates had higher glucose levels. The glucose concentrations were not significantly different between infants in the different birth weight groups. However, glucose concentration was significantly correlated with gestational age, and the levels were observed to rise with increasing gestational age.
Conclusion Screening asymptomatic, healthy term and near-term neonates for hypoglycaemia in the first hour following birth is unnecessary. Glucose strips and glucose meters are useful only as screening devices for neonatal hypoglycaemia, and a screening cut-off value must be established.

Keywords: birth weight, gestational age, glucose, neonate, screening
Singapore Med J 2010; 51(11): 853-855

Choo KKM, Tan HKK, Balakrishnan A
Correspondence: A/Prof Henry Tan Kun Kiaang, henry.tan.kk@kkh.com.sg

ABSTRACT
Introduction This study aimed to examine the epidemiology and outcome of subglottic stenosis in infants and children, and to evaluate the current techniques used in its diagnosis and management at the KK Women’s and Children’s Hospital, Singapore.
Methods A retrospective review and long-term follow-up was conducted in all infants and children diagnosed with subglottic stenosis between January 1997 and December 2008.
Results A total of 18 patients (nine male and nine female) with a median age of 7.5 months were identified. Two patients were diagnosed with definite congenital stenosis and 16 patients with acquired stenosis. The majority had Grade I stenosis (55.6 percent), followed by Grade II (27.8 percent) and Grade III (16.7 percent). None had Grade IV stenosis. 17 patients were intubated, and seven underwent tracheostomy. The most common surgical intervention performed was microlaryngoscopy and bronchoscopy with bougie dilation. The other surgical interventions included cricoid split, laryngotracheal reconstruction and cricotracheal resection. As of December 2008, the median duration of treatment was four years, with an overall recovery rate of 66.7 percent. The successful decannulation rate was 57.1 percent. Two mortalities were reported due to reasons unrelated to subglottic stenosis. Two patients were still undergoing treatment at the time of the study, and two were lost to follow-up.
Conclusion Conservative management alone may be required in the majority of Grade I stenosis cases. We observed that the mean number of reconstructive procedures performed per patient increased with the increase in the severity of stenosis. Each laryngeal framework procedure has to be customised to suit the individual.

Keywords: laryngotracheal stenosis, larynx, paediatric, retrospective, subglottic stenosis
Singapore Med J 2010; 51(11): 848-852

Sutipornpalangkul W, Janechetsadatham Y, Siritanaratkul N, Harnroongroj T
Correspondence: Dr Werasak Sutipornpalangkul, tewsv@mahidol.ac.th

ABSTRACT
Introduction The association of fractures with thalassaemia syndromes is well established. The aim of this study was to determine the prevalence and risk factors for fracture in Thai people with thalassaemia syndromes.
Methods A retrospective study and a patient interview were conducted in 201 Thai thalassaemia patients who attended the Division of Haematology, Department of Medicine Siriraj Hospital, Thailand. The patient interview questionnaire included sections on demographics, medical, orthopaedic and surgical history, usage of tobacco and alcohol, as well as questions that pertained to fracture. The risk factors for fracture were determined by odds ratio.
Results The prevalence of fracture in Thai people with thalassaemia syndromes was 35.3 percent. Fracture occurred more often in beta thalassaemia patients (44.1 percent) than in alpha thalassaemia patients (16.9 percent). Upper extremity was the most common site of fracture, while falls and motor vehicle accidents were the most common causes of fracture, and cast/splint was the most common choice of treatment. 28 percent of the patients sustained multiple fractures. Among alpha thalassaemia patients, adults sustained fractures more frequently than children and adolescents. In contrast, beta thalassaemia children had a greater rate of fracture than the adults and adolescents. The risk factors for fracture in thalassaemia patients included male gender, beta thalassaemia, splenectomy, transfusion and a low body mass index.
Conclusion A high prevalence of fracture is observed among Thais with thalassaemia. The aetiology was found to be multifactorial.

Keywords: fracture, prevalence, retrospective, thalassaemia, trauma
Singapore Med J 2010; 51(10): 817-821

Han SL, Chen XX, Zheng XF, Yan JY, Shen X, Zhu GB
Correspondence: Dr Shao-liang Han, slhan88@yahoo.com

ABSTRACT
Introduction Castleman’s disease, a rare atypical lymphoproliferative disorder of the lymphoid tissue with unknown cause, remains a diagnostic challenge. This study was conducted to analyse the clinicopathological behaviour and reasonable surgical treatment for patients with abdominal Castleman’s disease.
Methods The medical records of seven patients with abdominal Castleman’s disease were reviewed.
Results The patients comprised two men and five women, and their median age was 42.3 (range 29–53) years. The main clinical manifestation was an abdominal mass or an enlargement of the retroperitoneal lymph node. Other clinical manifestations included anaemia, loss of body weight and hypoalbuminaemia. The mean size of the tumour was 5.5 (range 4.0–8.0) cm. Postoperatively, all the patients were diagnosed with a hyaline vascular type of the disease, and had localised manifestations of the disease. All seven patients underwent complete surgical resection, two of whom also received adjuvant irregular chemotherapy (CHOP) and steroids postoperatively. All the patients survived, with no evidence of recurrence. One patient had survived for more than two years, four patients for more than three years, and two patients for more than five years.
Conclusion Abdominal Castleman’s disease is difficult to diagnose preoperatively, and surgical excision remains the treatment of choice, especially for localised disease.

Keywords: angiofollicular lymphoid hyperplasia, Castleman’s disease, clinicopathological behaviour, surgical procedures
Singapore Med J 2010; 51(10): 813-816