Original Article

Santra G, Das BK
Correspondence: Dr Gouranga Santra, g.santra@yahoo.com

ABSTRACT
Introduction Pancytopenia is a common haematological problem. It is suspected when a patient presents with anaemia, prolonged fever and a bleeding tendency. Pancytopenia has multiple causes, but the frequency of these causes has been reported in a limited number of studies. The present study was conducted to assess the aetiological pattern, clinical profile and bone marrow morphology of pancytopenia patients.
Methods A total of 111 adult pancytopenia patients aged 13 to 65 years were studied during a one-year period to determine their clinical features, peripheral blood pictures and bone marrow morphologies. The aetiological pattern was assessed through the relevant investigations in the respective patients.
Results 45.95 percent of the pancytopenic patients had a hypocellular marrow, while 54.05 percent had normocellular or hypercellular marrow. Idiopathic aplastic anaemia (20.72 percent) was the commonest cause of pancytopenia, followed by hypersplenism due to chronic liver disease (11.71 percent). Other important causes were kala-azar (nine percent), megaloblastic anaemia, systemic lupus erythematosus (SLE), infections and drug inducement. Infections such as kala-azar, falciparum malaria and enteric fever, megaloblastic anaemia as well as SLE were found to be treatable and reversible causes of pancytopenia.
Conclusion As a large number of pancytopenic patients have a reversible aetiology, early and proper diagnosis may be life-saving.

Keywords: aplastic anaemia, bone marrow, hypersplenism, kala-azar, pancytopenia
Singapore Med J 2010; 51(10): 806-812

Shamsuddin K, Marmuji LZ
Correspondence: Dr Khadijah Shamsuddin, khadijah@ppukm.ukm.my

ABSTRACT
Introduction Several strategies have been developed to reduce hepatitis B infections. These include antenatal screening, universal immunisation of newborns andimmunoglobulintherapy for babies who are at risk. Antenatal screening for hepatitis B is not routinely performed, but all newborns in Malaysia are immunised against hepatitis B. We assessed the prevalence of hepatitis B and the factors associated with it among antenatal mothers in Ipoh. This information is useful in decision-making for future hepatitis B screening programmes for antenatal mothers, allowing for immunoglobulin therapies for newborns if their mother’s hepatitis B virus (HBV) status is known.
Methods A cross-sectional study of 1,105 antenatal mothers who attended government health clinics in Ipoh was conducted between July 2008 and October 2008. The participants were asked to complete a self-administered questionnaire, and their hepatitis B surface antigen status was ascertained.
Results A total of 7,172 registered births and 97 HBV carriers were included in the weighted analysis. It revealed that none of the high-risk behaviours explored was significantly associated with HBV infection. Multivariate analysis showed age 35 years and above, multigravida (having two or more pregnancies), a positive history of blood transfusion and a family history of HBV to be significant factors associated with HBV infections.
Conclusion The weighted prevalence of HBV infection among antenatal mothers in Ipoh was 1.35 percent. A risk-based screening programme related to past medical and family history may be useful since these two factors are associated with HBV infection.

Keywords: antenatal screening, hepatitis B, prevalence, risk factors, weighted analysis
Singapore Med J 2010; 51(10): 800-805

Thong JF, Mok P, Loke D
Correspondence: Dr Jiun Fong Thong, jiunfong@yahoo.com

ABSTRACT
Introduction Communication between medical specialists and primary care providers in the community plays a pertinent role in patient care and doctor education. Referral and reply letters are the most common means by which doctors exchange information. Much of clinician time is spent writing letters, but the information or the format in which the letter is written may not meet the needs of the recipient. This study aimed to determine the type of reply letter preferred by general practitioners (GPs) and as such, attempts to improve communication between doctors as part of a quality assurance survey.
Methods Questionnaires were mailed out to 1,700 GPs in Singapore. Each questionnaire was accompanied by two sample reply letters from the Department of Otorhinolaryngology - Head and Neck Surgery. The sample letters were written in different formats. Letter 1 was written in a non-structured, free text format and Letter 2 included a structured summary at the beginning. Both letters contained the same amount of information and the same number of words.
Results A total of 535 replies (response rate 32 percent) were received. Letter 2 was preferred in 97 percent of the responses. 96 percent of the doctors found Letter 2 to be easier to read, while 86 percent felt it contained more information and 64 percent felt that Letter 1 took a longer time to read.
Conclusion Our study shows that there is a preference for diagnosis and treatment plan to be presented in a summary style report rather than as free text. A structured format for reply letters, including the use of headings, allows readers to easily identify the information desired and thus improves the quality of correspondence between specialists and GPs.

Keywords: correspondence, education, family physicians, healthcare, quality assurance specialisation
Singapore Med J 2010; 51(10): 796-799

Wong LP
Correspondence: Dr Wong Li Ping, wonglp@ummc.edu.my

ABSTRACT
Introduction This study assessed the information needs, preferred educational messages and channels of delivery, as well as opinions on strategies to promote organ donation. It aimed to provide insight into a culturally sensitive public education campaign to encourage organ donation in diverse ethnic communities in Asia, namely the Malays, Chinese and Indians.
Methods A total of 17 focus group discussions with 105 participants were conducted between September and December 2008. The participants were members of the general public aged 18 to 60 years, who were recruited through convenient sampling in the Klang Valley area of Malaysia.
Results Across ethnic groups, there was a general concern about the mistreatment of the deceased’s body in the organ procurement process. The Chinese and Indian participants wanted assurance that the body would be treated with respect and care. The Muslims wanted assurance that the handling of a Muslim’s body would follow the rules and regulations of the Islamic faith. The most important information requested by the Muslim participants was whether cadaveric donation is permissible in Islam. A lack of national public education and promotion of organ donation was noted. All the three ethnic groups, especially the Malays, required community and religious leaders for support, encouragement and involvement, as sociocultural influences play a significant role in the willingness to donate organs.
Conclusion The pronounced ethnic differences in information needs suggest that culturally sensitive public educational messages are required. Organ donation and transplantation organisations should work closely with community and religious organisations to address the sociocultural barriers identified.

Keywords: channel delivery, educational messages, information needs, multicultural, organ donation
Singapore Med J 2010; 51(10): 790-795

Hamed GM, Bahgat NM, El-Agaty SM, Soliman GZA, Emara MM
Correspondence: Dr Ghada Zaghloul Abbass Soliman, amr_soliman2005@yahoo.com

ABSTRACT
Introduction Cardiovascular disease is the leading cause of death among menopausal women in developed countries, mostly due to the loss of endogenous oestrogen protection. Soybean protein (SP) is rich in isoflavone phytoestrogens. This study aimed to determine the effect of SP on ovariectomised rats subjected to myocardial infarction and its possible cardio-protection.
Methods The study was conducted on 30 adult female albino rats, which were divided into three groups: Group I comprised the sham-operated rats; Group II, the ovariectomised (OVX) rats fed a standard diet; and Group III, OVX rats fed a standard diet supplemented with SP (OVX plus SP). The rats were anaesthetised, and electrocardiograms were conducted. The rats were then sacrificed, after which their hearts and livers were removed, weighed and subjected to histopathological examination. Blood was collected to determine the lipid profile, and the levels of total triiodothyronine, tetraiodothyronine (T4), thyroid-stimulating hormone (TSH), creatinine phosphokinase (CPK), lactate dehydrogenase, superoxide dismutase (SOD) and malonedialdehyde (MDA).
Results The biochemical studies showed a significant increase in plasma CPK (Group II), MDA and triacylglycerol (Groups II and III) levels compared to Group I. The plasma SOD showed a significant decrease in Group II compared to Group I. Total cholesterol, low and very low density lipoprotein cholesterol levels showed a significant increase in Group II, and a significant decrease compared to Group I. Significant increases in T4 and TSH were found in Group III compared to Group II.
Conclusion SP intake can be valuable in protecting the heart against an attack of acute myocardial infarction.

Keywords: isoflavone phytoestrogens, lipid profile, myocardial infarction, ovariectomy, soybean protein
Singapore Med J 2010; 51(10): 781-789

Fazliogullari Z, Karabulut AK, Unver Dogan N, Uysal II
Correspondence: Dr Nadire Unver Dogan, nunver2003@yahoo.com

ABSTRACT
Introduction This study examined the routes and variations of the left coronary artery (LCA), the right coronary artery (RCA), and their branches, as well as the frequency of a median artery in cadaver hearts.
Methods The hearts of 50 adult Turkish cadavers from various centres were dissected.
Results The LCAs branched out of the aortic sinus and had an average diameter of 4.44 +/- 1.79 mm. They gave rise to two branches (bifurcation) in 46 percent, three branches (trifurcation) in 44 percent and four branches (quadrifurcation) in ten percent of the hearts. The median artery was identified in 27 hearts, with a mean diameter of 2.00 mm (standard deviation 0.67). The RCAs branched out from the right aortic sinus and had an average diameter of 3.32 +/- 0.79 mm. The conus branch, classically known as a branch of the RCA, branched out from the RCA in 32 percent of the hearts and from the right aortic sinus in 68 percent. Right dominance was observed in 42 percent, left dominance in 14 percent, and equal dominance in 44 percent of the hearts. Myocardial bridges were found on the LCA branches in 22 of the 27 hearts in which the median artery existed.
Conclusion There is a close relationship between the existence of the median artery and myocardial bridges. This suggests that the median artery might be important in myocardial bridges, which exist in embryos but do not result in any clinical symptoms for many years in a large number of people.

Keywords: left coronary artery, median artery, myocardial bridge, right coronary artery
Singapore Med J 2010; 51(10): 775-780

Lee HY, Tay LK, Thirumoorthy T, Pang SM
Correspondence: Dr Lee Haur Yueh, hauryueh@starhub.net.sg

ABSTRACT
Introduction Serious adverse drug reactions are common in hospitalised patients. There have been few studies examining the clinical presentation, implicated drugs and outcomes in Singapore.
Methods The clinical and laboratory data of all inpatient dermatology consultations with a diagnosis of cutaneous adverse drug reaction were retrospectively analysed over a one-year period.
Results A total of 97 patients were diagnosed with cutaneous adverse drug reactions. Eight different clinical reaction patterns were noted, namely drug exanthems (46.4 percent), drug rash with eosinophilia and systemic symptoms (18.6 percent), Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum (14.4 percent), urticaria/angioedema (11.3 percent), acute generalised exanthematous pustulosis (3.1 percent), fixed drug eruptions (3.1 percent), generalised exfoliative dermatitis (2.1 percent) and drug-induced vasculitis (1.0 percent). The putative medications included antibiotics (50.5 percent), anticonvulsants (11.3 percent), allopurinol (8.2 percent), chemotherapeutic agents (7.2 percent), nonsteroidal anti-inflammatory agents (7.2 percent), intravenous contrasts (3.2 percent), complementary medications (2.1 percent) and various other medications (10.3 percent). 30 patients were admitted primarily for their adverse drug reaction, with an average length of hospital stay of nine days, while the remaining 67 patients developed these reactions as a complication of their inpatient stay. A total of five deaths were recorded.
Conclusion The presentation of cutaneous adverse drug reactions in hospitalised patients is diverse, ranging from self-limiting and benign reaction patterns to those that are life-threatening. Early recognition, accurate diagnosis, withdrawal of putative medications and specific treatments when indicated may improve outcome.

Keywords: cutaneous adverse drug reactions, drug allergy, drug hypersensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis
Singapore Med J 2010; 51(10): 767-774

Arulselvi S, Rangarajan K, Sunita S, Misra MC
Correspondence: Dr Arulselvi Subramanian, drarulselvi@yahoo.co.in

ABSTRACT
Introduction Knowledge of blood usage patterns helps to address major issues such as the management of massive transfusion events, minimisation of transfusion risks, as well as in dealing with blood shortages. The aim of our study was to audit blood component usage at a Level I trauma centre blood bank.
Methods A retrospective analysis of the transfusion data of 4,320 patients who were admitted to the General Surgery, Neurosurgery, Orthopaedics and Emergency Medicine departments during a one-year period was conducted.
Results A total of 4,054 patients underwent transfusion. 88 percent, 94 percent, 80 percent and 100 percent of patients admitted to the General Surgery, Orthopaedics, Neurosurgery and Emergency Medicine departments, respectively, received transfusions. Packed cells were the most commonly utilised component, followed by fresh frozen plasma (FFP) and platelets in the ratio 3:2:1. The highest number of FFPs (2,052 units) and platelet concentrates (950 units) were used in the General Surgery and Neurosurgery departments, respectively. The calculated cross-match to transfusion (C:T) ratio did not exceed 2.5 in any of the departments. Among those transfused, the massive blood transfusion rate was low (1.77 percent). The rates of transfusion reactions and non-group-specific transfusions were also low (0.42 percent and 0.07 percent, respectively).
Conclusion The rate of transfusion of trauma patients was high (94 percent). Using the C:T ratio as a marker, optimal blood utilisation was noted in all departments. The methods of reporting transfusion reactions need to be revised. Future studies on the appropriateness of blood use and blood ordering schedules are required.

Keywords: audit, blood components, blood transfusion, Level I trauma centre
Singapore Med J 2010; 51(9): 736-740

Boopathi S, Chakravarthy Marx S, Dhalapathy S, Anupa S
Correspondence: Dr Chakravarthy Marx S, marxmanipal@gmail.com

ABSTRACT
Introduction The aim of this study was to document the morphological and topographical anatomy of the infraorbital foramen (IOF) in relation to the infraorbital rim (IOR), which is necessary in clinical situations that require regional nerve blocks.
Methods A total of 80 dry South Indian adult human skulls of unknown age and gender were studied. In each skull, the IOF on both sides was measured using a metal casing digital vernier caliper, with the IOR as the reference point. The IOF’s location and its transverse and vertical diameters were measured. The shape, size, orientation and accessory foramens of the IOF were also documented.
Results The majority of IOF among the skulls were oval-shaped on both the right (55 percent) and left (51.25 percent) sides. The majority were directed inferomedially on both the right (55 percent) and left (52.50 percent) sides. The overall combined distance between the IOR and IOF was 4.1 to 11.5 (6.57 +/- 1.28) mm. The overall combined vertical diameter was 1.2 to 4.7 (2.82 +/- 0.79) mm. The overall combined transverse diameter was 1 to 5.1 (2.87 +/- 0.78) mm. Accessory foramens of IOF were found in 13 (16.25 percent) skulls.
Conclusion Knowledge of the anatomical characteristics of IOF locations, diameters, shapes, directions and its accessory foramens may have important implications on blocking the infraorbital nerve for surgical and local anaesthetic planning. Information on the shape of the foramens obtained from this study may provide additional guidance to surgeons when introducing needles in anaesthetic procedures.

Keywords: accessory foramen, directions, infraorbital foramen, locations, shapes
Singapore Med J 2010; 51(9): 730-735

Lai NM, Tan ML, Quah SY, Tan EL, Foong KW
Correspondence: Dr Lai Nai Ming, lainm123@yahoo.co.uk

ABSTRACT
Introduction We conducted a retrospective audit on the inpatient assessment and care of children admitted with febrile convulsion to Hospital Batu Pahat, a district hospital in Malaysia, using the Malaysian national clinical practice guidelines and the American Academy of Paediatrics practice parameters on febrile convulsion as the reference standards.
Methods The case notes of 100 consecutive children admitted in 2004 were analysed. The documentation of major clinical features, selection of investigations, the timeliness of antipyresis and frequency of parental education were evaluated.
Results In general, the major clinical features that were relevant to the presenting problem were adequately documented, although fever was not mentioned as a presenting complaint in one quarter of the cases. On an average, about five investigations were ordered for every patient on admission. There was no major difference in the number of investigations conducted between children who were more severely ill and the rest of the patients. The majority of the investigations did not yield any useful diagnostic information. Only 38 percent of the children received antipyretics and 53 percent were tepid-sponged during fever, with 23 percent having received tepid-sponging without concurrently receiving antipyretics. No parental education on febrile convulsion was recorded in half of the cases.
Conclusion Excessive unjustified investigations, deficient antipyresis when required and inadequate communication with the family of children with febrile convulsion were observed. Awareness of such deficiencies from this audit should lead to regular staff education, monitoring and future audits in order to improve the quality of our clinical care.

Keywords: clinical audit, febrile seizures, fever
Singapore Med J 2010; 51(9): 724-729