Original Article

Razalee S, Poh BK, Ismail MN
Correspondence: Dr Razalee Sedek, razalee@ukm.my

ABSTRACT
Introduction The basal metabolic rate (BMR) is essential in deriving estimates of energy requirements for a population. The aim of this study was to measure the BMR in order to derive a predictive equation for the Malaysian Armed Forces (MAF) naval trainees.
Methods A total of 79 naval trainees aged 18 to 25 years from a training centre (Group A) and on board a ship (Group B) participated in the study. Anthropometric measurements included height and weight. Body fat and free fat mass were measured using the bioelectrical impedance analysis method. BMR was measured by indirect calorimetry with a canopy system.
Results The mean height, weight and body fat for Group A was 1.67 +/- 0.04 m, 61.0 +/- 3.9 kg and 12.7 percent +/- 2.5 percent, respectively, and 1.67 +/- 0.05 m, 62.3 +/- 6.2 kg and 14.0 percent +/- 3.5 percent, respectively, for Group B. The mean BMR for Group A (6.28 +/- 0.40 MJ/day) did not differ significantly (p is more than 0.05) from that of Group B (6.16 +/- 0.67 MJ/day). The Food and Agriculture Organization/World Health Organization/United Nations University and the Henry and Rees equations overestimated the measured BMR by 9 percent (p is less than 0.001) and 0.5 percent (p is more than 0.05), respectively, while the Ismail et al equation underestimated the measured BMR by 5.6 percent (p is less than 0.001). A predictive equation, BMR = 3.316 + 0.047 (weight in kg) expressed in MJ/day with weight as the only independent variable, was derived using regression analysis.
Conclusion We recommend that this predictive equation be used to estimate the energy requirements of MAF naval trainees.

Keywords: armed forces, basal metabolic rate, energy requirement, indirect calorimetry, predictive equation
Singapore Med J 2010; 51(8): 635-640

Goh PP, Omar MA, Yusoff AF
Correspondence: Dr Pik Pin Goh, gohpp@crc.gov.my

ABSTRACT
Introduction Diabetic retinopathy (DR) is the commonest complication of diabetes mellitus (DM), and is the leading cause of blindness among working adults. Modification of the associated risk factors as well as early detection and treatment of sight-threatening DR can prevent blindness. Clinical practice guidelines recommend annual eye screening for patients with DM. The proportion of patients in Malaysia who adhere to this recommendation was initially unknown.
Methods The Malaysian National Health and Morbidity Survey is a population-based survey conducted once every decade on the various aspects of health, behaviour and diseases. The DM questionnaire on eye screening was administered as face-to-face interviews with 2,373 patients with known DM who were aged 18 years and older.
Results In all, 55 percent of patients with known DM had never undergone an eye examination. Among patients who had undergone eye examinations, 32.8 percent had the last examination within the last one year, 49.8 percent within the last one to two years, and 17.4 percent more than two years ago. A significantly lower proportion of younger patients and patients who received treatment for DM from non-government facilities had previously undergone eye examinations.
Conclusion The prevalence of DM observed among Malaysians aged 30 and above is 14.9 percent; thus, there is a significant number of people with potential blinding DR. Adherence to eye screening guidelines and the prompt referral of sight-threatening DR are essential in order to reduce the incidence of blindness among patients with DM.

Keywords: diabetic eye screening, diabetic retinopathy
Singapore Med J 2010; 51(8): 631-634

Tan EK, Lim LH, Teoh YL, Ong G, Bock HL
Correspondence: Dr Kevin Tan Eng Kiat, dr@ktclinic.com

ABSTRACT
Introduction Seasonal influenza vaccination is recommended for diabetics; however, the vaccination uptake rate among diabetics remains low. This study explored the knowledge, attitudes and practices among diabetics in Singapore with regard to influenza and influenza vaccination.
Methods A survey was conducted among type 1 and 2 diabetes mellitus patients who attended three management centres of the Diabetic Society of Singapore in January 2007. The pilot-tested questionnaire covered influenza and influenza vaccination in terms of the patient demographics, medical history and knowledge, attitudes and practices.
Results A total of 307 diabetics participated in the study. Of these, 139 (45.3 percent) claimed to know the difference between influenza and the common cold, while 98 (31.9 percent) and 18 (5.9 percent) participants thought that influenza vaccines protected against all influenza strains and provided lifelong immunity, respectively. 247 (80.4 percent) participants were aware that they were at a moderate or higher risk for influenza-related complications, while 181 (58.9 percent) considered vaccination to be effective in preventing influenza and its complications. Only 94 (30.6 percent) participants were previously vaccinated. Among those unvaccinated, 117 (54.9 percent) did not think vaccination was necessary, while 104 (48.8 percent) had never considered it. As observed from the multivariate analysis, income was a key predictor of influenza vaccination. While 241 (78.5 percent) participants cited healthcare professional advice as the main guiding factor for getting vaccinated, 199 (64.8 percent) had never been advised on influenza vaccination. Of the 108 (35.1 percent) participants who had received previous advice on influenza vaccination, the majority had received it from their healthcare professionals.
Conclusion Uptake of influenza vaccination among diabetics in Singapore is low, and the key predictor is income. Perception and knowledge are the main barriers, and hence, healthcare professionals should educate and encourage vaccination among diabetics.

Keywords: attitudes, diabetes mellitus, influenza, knowledge, vaccination
Singapore Med J 2010; 51(8): 623-630

Imran N, Jawaid M, Haider II, Masood Z
Correspondence: Dr Nazish Imran, nazishimran@hotmail.com

ABSTRACT
Introduction The aim of this study was to determine the prevalence of workplace bullying among junior doctors in Pakistan, identify the types and sources of bullying behaviours and investigate the perceived barriers to making complaints against bullying.
Methods We conducted a cross-sectional survey of junior doctors using convenience sampling in three tertiary care hospitals in two provinces of Pakistan. Demographic details and information about the different types of bullying behaviours experienced by junior doctors in the 12 months preceding the study were collected using a previously validated list of 20 such behaviours. Respondents were also asked to indicate the sources of bullying, any complaints made and if not, the reasons behind it. The data was analysed using the Statistical Package for the Social Sciences.
Results A total of 654 doctors participated in the study. 417 (63.8 percent) of them reported experiencing one or more type of bullying in the past 12 months. 436 (66.7 percent) doctors had witnessed the bullying of others. The most common source of bullying was consultants (51.6 percent). 306 (73.4 percent) respondents did not make a complaint against the bullying.
Conclusion Bullying is faced by a fairly large proportion of junior doctors in Pakistan. The most frequent perpetrators of this bullying are consultants. Major changes are required at the national, organisational and individual levels in Pakistan to tackle the bullying problem and prevent its adverse consequences in an already vulnerable healthcare delivery system.

Keywords: cross-sectional studies, doctors, Pakistan, social behaviour, workplace bullying
Singapore Med J 2010; 51(7): 592-595

Lugah V, Ganesh B, Darus A, Retneswari M, Rosnawati MR, Sujatha D
Correspondence: Dr Azlan Darus, azdarus@ummc.edu.my

ABSTRACT
Introduction Awareness of occupational safety and health (OSH) plays an important role in the prevention of occupational injuries and diseases. Following the enactment of the Occupational Safety and Health Act (OSHA) in 1994, various programmes have been implemented by different agencies to increase awareness and knowledge of OSH in the workplace, including among healthcare workers. The objective of this study was to determine the level of OSH awareness and knowledge among healthcare professionals in Malaysia.
Methods A cross-sectional study was conducted using a 21-item self-administered questionnaire addressing information on demographics, general OSH issues, OSH legislations, occupational hazards in the healthcare setting and personal protective equipment (PPE).
Results The response rate was 93.1 percent (284 healthcare professionals). The overall level of knowledge on OSH was moderate, with a mean score of 62.0 percent. A larger proportion of doctors showed good OSH knowledge compared to other categories of healthcare workers, with administrative staff scoring the poorest marks. Participants were most knowledgeable about PPE, with a mean score of 72.0 percent (95 percent confidence interval [CI] 68.3, 75.6), compared to other sections such as general OSH, legislations and occupational hazards, with mean scores of 58.0 percent (95 percent CI 56.1, 60.1), 57.0 percent (95 percent CI 54.1, 60.8) and 64.0 percent (95 percent CI 61.7, 66.2), respectively.
Conclusion Although the OSHA 1994 has existed in Malaysia for more than ten years, awareness of OSH remains relatively poor. This warrants a greater effort to promote OSH knowledge and principles among the professionals.

Keywords: healthcare workers, healthcare professionals, Occupational Safety and Health Act (OSHA) 1994, occupational safety and health knowledge
Singapore Med J 2010; 51(7): 586-591

Nakhjavani M, Esteghamati A, Nowroozi S, Asgarani F, Rashidi A, Khalilzadeh O
Correspondence: Dr Nakhjavani Manouchehr, nakhjavanim@tums.ac.ir

ABSTRACT
Introduction Patients with type 2 diabetes mellitus (DM) are subject to chronic oxidative stress. Lipid peroxidation of cellular structures is an important process in atherosclerosis and late complications of DM. Malondialdehyde (MDA) plays a major role in low-density lipoprotein modification. This study aimed to evaluate whether DM duration is an independent predictor of serum MDA levels.
Methods A total of 120 patients with type 2 DM (60 with DM duration of 120 months or less and 60, with more than 120 months) and 45 gender-and body mass index (BMI)-matched healthy adults were studied. Fasting blood samples were obtained and the fasting plasma glucose (FPG), cholesterol, high- and low-density lipoprotein cholesterol, triglycerides, creatinine, haemoglobin A1c (HbA1c), extracellular superoxide dismutase (EC-SOD) and MDA levels were measured.
Results The MDA level was significantly higher in DM patients than in controls (p is less than 0.001), and in those with DM duration more than 120 months than those with DM duration of 120 months or less (p is less than 0.001). The level of MDA was significantly correlated with DM duration (correlation coefficient 0.254, p is less than 0.01) and the EC-SOD level (correlation coefficient 0.299, p is less than 0.001). In multivariate regression analysis, the association between MDA and DM duration remained significant after adjustments were made for age, gender, BMI, FPG, HbA1c, EC-SOD, plasma creatinine and anti-diabetic medications (p is less than 0.05).
Conclusion The results of this study suggest that in type 2 DM patients, DM duration is independently associated with increased levels of lipid peroxidation. Longitudinal studies are required to confirm these results.

Keywords: diabetes mellitus, lipid peroxidation, low-density lipoproteins, malondialdehyde, superoxide dismutase
Singapore Med J 2010; 51(7): 582-585

Pulla Reddy B, Srikanth Babu BMV, Venkata Karunakar K, Yasovanthi J, Munshi A, Sampath Kumar P, Sharath A, Jyothy A
Correspondence: Prof A Jyothy, jyothycell@rediffmail.com

ABSTRACT
Introduction Recently, there has been increasing evidence that genetic variation in the angiotensin-converting enzyme (ACE) plays an important role in myocardial infarction. Therefore, the present study was carried out with the aim of investigating the association of the ACE gene insertion/deletion (I/D) polymorphism and its levels in myocardial infarction patients and their first-degree relatives (FDRs).
Methods 206 patients with myocardial infarction, 168 FDRs and 210 control subjects were enrolled in the study. ACE I/D polymorphism was determined using the polymerase chain reaction method. Serum ACE levels were measured using the photometric method.
Results The DD genotype and ACE activity were significantly higher in patients (p-value is 0.00006 and 0.0001, respectively) and FDRs (p-value is 0.003 and 0.04, respectively) compared with the controls.
Conclusion ACE DD genotype and ACE levels are important risk factors for myocardial infarction. This study indicates that the higher frequency of the DD genotype and ACE levels observed in FDRs may increase susceptibility to developing myocardial infarction.

Keywords: ACE activity, angiotensin-converting enzyme, first-degree relatives, I/D gene polymorphism, myocardial infarction, South Indian population
Singapore Med J 2010; 51(7): 576-581

Kang GS, Soh YF, Kofidis T, Lee CN
Correspondence: Dr Kang Giap Swee, kangzilun@yahoo.com

ABSTRACT
Introduction Surgical procedures performed for congenital heart disease are usually complex and variable. The aims of this paper were to analyse patient demographics in a centre that caters to congenital cardiac surgery, compare departmental standards to international centres, and investigate the relationship between patient volume and clinical outcome.
Methods A total of 163 patients who presented to the Cardiac, Thoracic and Vascular Surgery Department of the National University Hospital, Singapore between 2002 and 2006 were identified and studied retrospectively. Patient demographics were analysed. The mortality rates and patient volume were compared with those observed at international centres.
Results The mean annual patient volume was 32.6 cases. The mean age of the patients was 15.7 years, with the oldest patient being 73 years old. 57.1 percent of the patients were Chinese, 23.3 percent were Malay and 19.6 percent were Indian and other races. Foreigners made up nearly half of the patient cohort (45.4 percent). Atrial septal defect was found to be the most common diagnosis (n is 64), with the secundum being most commonly involved (76.9 percent). The commonest postoperative morbidities encountered were arrhythmias and pleural effusions. Patient volume was not found to be a significant factor affecting clinical outcomes.
Conclusion With a growing population of adults with congenital heart disease and a significant number of foreign patients, improvements to our resources and infrastructure need to be considered in order to cope with the increasing demands. Despite having a low patient volume, the centre is still able to provide congenital heart surgery with good clinical outcomes that are comparable to those of international centres with similar or higher patient volumes.

Keywords: clinical outcomes, congenital cardiac surgery, congenital heart disease, patient volume
Singapore Med J 2010; 51(7): 570-575

Tan BY, Ho KL, Ching CK, Teo WS
Correspondence: Dr Tan Boon Yew, drboonyewtan@msn.com

ABSTRACT
Introduction Arrhythmias are often intermittent, and a normal electrocardiogram (ECG) may not be diagnostic. The purpose of this study was to evaluate the usefulness of HeartWave500 (HW), a novel web-based ambulatory ECG monitoring device.
Methods A total of 120 patients from the National Heart Centre, Singapore were prospectively randomised in a three to one ratio to either HW or a standard transtelephonic (TT) event recorder. HW records five leads and transmits to an internet server, while TT transmits audio data to a central station. Monitoring was conducted for two weeks. The diagnostic yield was calculated in two ways: the percentage of patients successfully diagnosed as a function of time, and the absolute number of new diagnoses per patient per week.
Results 33 patients (14 male, 19 female; mean age 49.6 +/- 11.1 years) were randomised to TT. 87 patients (32 male, 55 female; mean age 43.7 +/- 12.2 years) were randomised to HW. At the end of two weeks, the percentage of patients diagnosed with any arrhythmia was similar for both groups (66.7 percent for TT versus 67.8 percent for HW). There was a trend toward significance for the number of diagnoses per patient per week for Week 2 between TT and HW (0.58 +/- 0.75 versus 0.34 +/- 0.55, p is 0.06). Transmitted ECGs were read earlier for HW (18 minutes vs. 1107 minutes, Mann-Whitney non-parametric test, p is less than 0.05). Transmitted recordings that were unreadable were also significantly lower for HW (8.0 percent vs. 17.6 percent, chi-square test, p is less than 0.05).
Conclusion HW and TT have similar diagnostic yields. There is a trend toward a shorter monitoring time for HW. The ability of HW to record and transmit via the web, the earlier review of data and low unreadable data make HW an attractive alternative to TT.

Keywords: arrhythmia detection, HeartWave500, transtelephonic event recorder, web-based monitoring
Singapore Med J 2010; 51(7): 565-569

Bhattacharya R, Pani A, Dutta D, Basak S, Gangopadhyay S, Das Baksi S, Sarkar RN
Correspondence: Dr Rabindra Bhattacharya, docrabin@gmail.com

ABSTRACT
Introduction Glycoprotein IIb/IIIa inhibitors such as tirofiban inhibit platelet aggregation. We evaluated the immediate and early outcomes in patients with high-risk non-ST elevation acute coronary syndrome (NSTE ACS) who received tirofiban with conventional therapy compared to patients who received only conventional therapy (a combination of aspirin, clopidogrel, low-molecular-weight heparin with or without beta-blockers and angiotensin-converting enzyme inhibitors).
Methods A total of 165 patients received conventional therapy with a placebo, and 136 patients received conventional therapy with tirofiban after randomisation. The outcomes were measured on Day 7, Day 14, one month and three months after the administration of therapy.
Results A significant reduction was noted in the occurrence of primary endpoints in patients receiving tirofiban, compared to those who received a placebo at seven days (14 versus 32; p-value is 0.036), 14 days (14 versus 28; p-value is 0.043), one month (19 versus 34; p-value is 0.01) and three months (30 versus 44; p-value is less than 0.001) after administration. There was a significant reduction in the occurrence of fatal myocardial infarction (MI) (1 versus 8; p-value is 0.044) and non-fatal MI at Day 7 (1 versus 8; p-value is 0.044), and refractory ischaemia at the end of one month (14 versus 24; p-value is 0.04) and three months (25 versus 36; p-value is less than 0.01) in patients receiving tirofiban as compared to those receiving a placebo.
Conclusion It may be concluded that tirofiban has a definite role in improving the outcome of patients with high-risk NSTE ACS.

Keywords: acute coronary syndrome, non-ST elevation myocardial infarction, TIMI score, tirofiban
Singapore Med J 2010; 51(7): 558-564