Original Article

Lim JJBH, Lu PKS, Koh DSQ, Eng SP
Correspondence: Ms Lim Bee Hong Joyce Jeanne, joyce_lim@cgh.com.sg

ABSTRACT
Introduction The effects of tinnitus on quality of life (QOL) have never been extensively studied in Singapore. We describe the characteristics of tinnitus and its impact on QOL as measured by the Tinnitus Handicap Inventory (THI) in a series of ear, nose and throat clinic patients.
Methods A total of 327 patients who attended a tinnitus counselling clinic completed the THI questionnaire, a self-report measure with 25 items grouped into functional, emotional and catastrophic subscales.
Results The mean age of the 134 female and 193 male patients was 48.9 years. 36.7 percent of these patients had bilateral tinnitus and 64.6 percent had symptoms for less than one year. 270 patients had hearing loss, 74 percent of whom presented with bilateral high frequency hearing loss. Most patients (84.1 percent) perceived only one type of sound. The total THI score distribution was: 107 (33 percent) patients had THI less than 16, 100 (31 percent) had THI 18 to 36, 59 (18 percent) had THI 38 to 56, and 61 (19 percent) had THI more than 58. There were no differences in the overall THI and subscale scores between the patients’ gender, those with or without hearing loss, and those with unilateral or bilateral tinnitus. However, significantly higher total THI and all subscale scores were found among patients who were hearing more than one type of tinnitus sound. The areas of concern that were commonly reported by the patients in this series were a lack of control over tinnitus, frustration and stress.
Conclusion Tinnitus patients who hear multiple sounds tend to have a higher THI and subscale scores. The management of tinnitus should address common areas of concern, and may include counselling. The THI is a potential screening tool to determine if patients require counselling. A series of THI assessments can be used to chart the progress of treatment.

Keywords: quality of life, tinnitus, Tinnitus Handicap Inventory
Singapore Med J 2010; 51(7): 551-557

Ho CCK, Hafidzul J, Praveen S, Goh EH, Bong JJ, Lee BC, Zulkifli MZ
Correspondence: Dr Christopher Ho Chee Kong, chrisckho2002@yahoo.com

ABSTRACT
Introduction Extracorporeal shock wave lithotripsy (ESWL) is accepted as the gold standard treatment for renal stones that are smaller than 2 cm. Recently, retrograde intrarenal surgery (RIRS) has been introduced as another form of treatment. We report our experience in dealing with renal stones smaller than 2 cm using RIRS as the primary treatment and following failed ESWL.
Methods A retrospective analysis was conducted over a five-year period on patients with stone(s) measuring less than 2 cm each and who had undergone RIRS. The patients were divided into two groups: RIRS as the primary procedure and RIRS post-ESWL.
Results A total of 46 patients underwent RIRS in our institute. The total stone clearance rate was 61 percent. The clearance rate was better for RIRS as the primary procedure when compared to RIRS as an adjunct procedure (70 percent versus 52 percent; p-value is 0.23). Patients with mid-pole stones achieved an 80 percent stone clearance rate as compared to 60 percent for those with lower pole stones. The clearance rate for upper pole stones was only 29 percent. When RIRS was the primary procedure for lower pole stones, the success rate was 75 percent, compared to 56 percent when it was used as an adjunct procedure post-ESWL.
Conclusion For renal stones measuring less than 2 cm, the stone clearance rate for RIRS was as good as that for EWSL as a primary procedure and achieved a good clearance rate following the failure of ESWL.

Keywords: extracorporeal shock wave lithotripsy, kidney calculi, lithotripsy, retrograde intrarenal surgery, therapy
Singapore Med J 2010; 51(6): 512-515

Eze JN, Ibekwe PC
Correspondence: Dr Justus Ndulue Eze, justndueze@gmail.com

ABSTRACT
Introduction Uterine rupture is an obstetric catastrophe that is associated with high maternal and perinatal mortality rates. Its incidence is high in developing countries. In Nigeria, the incidence of uterine rupture continues to increase due to poverty, illiteracy, ignorance, the lack of quality obstetric care and bad governance.
Methods A retrospective review was conducted of all cases of ruptured uterus seen at the Mater Misericordiae Hospital in Afikpo, Nigeria between January 2001 and December 2007.
Results There were a total of 51 ruptured uteri out of 4,361 deliveries, yielding a ratio of one in 86. A total of 19 (37.3 percent) patients had a scarred uterus, while 32 (62.7 percent) had an intact uterus, yielding a scarred to unscarred uterus ratio of one in 1.7. The mean maternal age was 32.0 years, and the mean parity was 3.4. Patients with a scarred uterus had a lower mean age and parity. 29 (56.9 percent) cases were unbooked, out of which seven (24.1 percent) had a scarred uterus. Obstructed labour (88.2 percent), grandmultiparity (27.5 percent) and abnormal lie (9.8 percent) were the main causes of rupture. 39 (76.5 percent) patients had their labour managed at home or by traditional birth attendants before presentation. 45 (88.2 percent) patients underwent uterine repair alone, five (9.8 percent) had uterine repair with bilateral tubal ligation and one (two percent) had a hysterectomy. Three maternal deaths occurred, yielding a case fatality rate of 5.9 percent. The perinatal mortality rate was 84.6 percent.
Conclusion Health education, the provision of quality obstetric care, improved governance and monitoring of the activities of traditional birth attendants may help to reduce the menace of uterine rupture.

Keywords: grandmultiparity, Nigeria, obstructed labour, scarred uteri, secondary hospital, uterine rupture
Singapore Med J 2010; 51(6): 506-511

Atalay C, Dogan N, Aykan S, Gundogdu C, Keles MS
Correspondence: Dr Canan Atalay, cananatalay@hotmail.com

ABSTRACT
Introduction This study aimed to test the feasibility of spironolactone treatment in comparison with a surfactant in the early stage of acute respiratory distress syndrome (ARDS) in rats, as assessed by the acute lung injury (ALI) score, blood gas, brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP).
Methods A total of 40 rats were randomly allocated into one of five groups (n is eight). The baseline group (Group B) was subjected to neither tracheotomy nor ARDS induction, while the sham group (Group N) was subjected to tracheotomy upon ARDS induction by acid aspiration. The other three groups were administered either a single dose of spironolactone (100 mg/kg, Group Sp) or surfactant (100 mg/kg, Group S), or were untreated (Group A). Blood samples were collected from the femoral artery for blood gases, BNP and NT-proBNP measurements.
Results ARDS induction decreased the blood PO2 /FiO2 ratio and increased the BNP and NT-proBNP levels (p is less than 0.001). Compared with the ARDS-untreated group, spironolactone treatment was more effective at reducing the elevated BNP (72 percent versus 37 percent) and NT-proBNP (53 percent versus 23 percent) levels and ALI score (28 percent versus 7 percent) than surfactant treatment. Moreover, the blood PO2/FiO2 ratio was negatively correlated with the BNP (r is -0.79), NT-proBNP (r is -0.85) and ALI scores (r is -0.85).
Conclusion Spironolactone is an effective form of treatment for ARDS at an early stage, as reflected by an increased blood O2/FiO2 ratio, decreased BNP and NT-proBNP levels, and ALI score.

Keywords: acute lung injury, acute respiratory distress syndrome, blood gas, brain natriuretic peptide, spironolactone, surfactant
Singapore Med J 2010; 51(6): 501-505

Sabzghabaee AM, Eizadi-Mood N, Montazeri K, Yaraghi A, Golabi M
Correspondence: Dr Nastaran Eizadi-Mood, izadi@med.mui.ac.ir

ABSTRACT
Introduction Acute paraquat (PQ) poisoning continues to be a major public health concern in many developing countries. This study was designed to evaluate the data on cases of acute PQ poisoning and compare the different variables between survivors and non-survivors.
Methods All patients of PQ poisoning who were admitted to the poisoning emergency department during the past five years were retrospectively evaluated. The different variables that were compared between survivors and non-survivors included age and gender, the time from ingestion of PQ to hospital admission, the amount of PQ ingested, occurrence of vomiting after ingestion, the time from hospital admission to initiation of haemodialysis, the length of hospital stay and the outcomes.
Results A total of 29 patients were evaluated. The in-hospital fatality rate was 55.2 percent. No significant differences were observed between survivors and non-survivors with regard to the patient characteristics. Most of the patients who died had ingested more than 40 mg/kg of 20 percent PQ (62.5 percent). There was a correlation between the outcome of patients and vomiting (p-value is 0.05; correlation coefficient is 0.45) and age (p-value is 0.013; correlation coefficient is 0.56).
Conclusion A large amount of ingested PQ, vomiting and age may be important variables to consider in association with the high fatality rate of PQ poisoning.

Keywords: fatal, outcome, paraquat, poisoning
Singapore Med J 2010; 51(6): 496-500

Siau C, Law J, Tee A, Poulose V, Raghuram J
Correspondence: Dr Siau Chuin, chuin_siau@cgh.com.sg

ABSTRACT
Introduction The management of Influenza A (H1N1) patients with acute respiratory distress syndrome (ARDS) is an emerging challenge, especially during the 2009 pandemic. These patients frequently require advanced mechanical ventilation (MV) and on occasion, rescue therapy. We describe the demographics, presentation, course and outcomes of the first 12 H1N1 patients with ARDS who were admitted to our institution.
Methods This was a retrospective chart review of H1N1 patients with ARDS who were admitted to our intensive care unit (ICU) between July and September 2009.
Results Seven of the 12 patients were female. The median age was 46 (range 27–66) years. 25 percent of the patients had good health prior to the infection. The presenting symptoms were mainly cough (100 percent), fever (92 percent) and dyspnoea (64 percent). The median times from symptom onset to both hospitalisation and ICU admission were five (range 2–9) days. Ten (83 percent) patients required invasive MV within 24 hours of presentation. The mean PaO2/FiO2 ratio was 87.9 +/- 37.3 mmHg, with a mean positive end expiratory pressure at 16.1 +/- 7.3 cm H2O. Three patients required either unconventional MV and/or prone positioning, inhaled nitric oxide or nebulised prostacyclin. The mean Acute Physiology and Chronic Health Evaluation II score was 12.7 +/- 9.1. Among survivors, the median number of ventilator days was 7.5 (range 5–11), with a median length of ICU stay of ten (range 6–14) days. The median length of hospitalisation was 13.5 (range 9–31) days. The mortality rate in our case series was 50 percent.
Conclusion Unlike patients of seasonal influenza, our severe H1N1 patients were of a younger age. A significant proportion had no underlying risk factors. Despite high ventilatory requirements, unconventional MV and adjunct therapy, the mortality rate remained high.

Keywords: H1N1, acute respiratory distress syndrome, influenza pandemic, primary viral pneumonitis
Singapore Med J 2010; 51(6): 490-495

Subasinghe D, Wijekoon NS, Nawarathne NMM, Samarasekera DN
Correspondence: Prof DN Samarasekera, samarasekera58@yahoo.co.uk

ABSTRACT
Introduction Disease-related knowledge plays a critical role in facilitating patients’ acceptance of their diagnosis and compliance with active participation in the treatment of inflammatory bowel disease (IBD). The aim of this study was to analyse the deficits in knowledge for future health education programmes.
Methods A validated questionnaire was used to assess and analyse disease-related knowledge among patients with ulcerative colitis (UC) and Crohn’s disease who attended outpatient gastroenterology clinics of a tertiary care hospital in Sri Lanka.
Results There were 184 patients (83 males) with a mean age of 44.5 (range 20–78) years. 83.2 percent of the patients had UC. The mean duration of IBD was 8.17 (range 1–28) years, and 33.7 percent of the patients had IBD for over ten years. The mean Crohn’s and Colitis Knowledge questionnaire score was 6.86. The majority (68.5 percent) of the patients were aware that sulfasalazine can be used to reduce exacerbations. There was no statistical difference in disease-related knowledge between genders, but the level of education showed a significant difference. Only 14.1 percent of patients were aware that prolonged IBD is a risk factor for colorectal cancer and that screening for colorectal cancer is important. 9.2 percent of the study population was aware of restorative proctocolectomy.
Conclusion There is a lack of knowledge regarding colorectal cancer risk and surgical interventions. There was no significant difference in the knowledge scores between genders but there was a significant association with the educational level.

Keywords: Crohn’s disease, disease-related knowledge, inflammatory bowel disease, ulcerative colitis
Singapore Med J 2010; 51(6): 484-489

Skalova S, Rejtar P
Correspondence: Dr Sylva Skalova, skalovasylva@seznam.cz

ABSTRACT
Introduction Renal biopsy (RB) is a decisive diagnostic procedure for patients with renal disease. Our aim was to assess the safety of RB and the prevalence of associated clinical complications.
Methods A total of 166 RBs were performed in 164 children (88 boys, 76 girls) in East Bohemia in 1997–2007. The mean age of the children was 12.9 +/- 4.1 years. All RBs were performed by a single consultant nephrologist. 27 biopsies were performed in 27 patients (16.3 percent) in 1997 under radiography control, while the remaining 139 biopsies (83.7 percent) were performed under ultrasonographic guidance. Renal ultrasonography (USG) following RB was not a general rule in patients who were biopsied under radiography control before 1998; therefore, only the USG results in patients after USG-guided RB (n = 139) were evaluated.
Results No major complications were encountered, and only minor complications occurred in 39 (23.5 percent) patients, which did not require medical intervention. The most common complication was asymptomatic perirenal haematoma, which was detected by USG one to three days after a USG-guided RB (30 out of 139 biopsies; 21.6 percent). Perirenal haematoma accompanied by abdominal pain occurred in two (1.4 percent) patients. Macroscopic haematuria was present in seven (4.2 percent) patients on Days 1–3 post biopsy. The complications were neither age-dependent nor were they related to the serum creatinine levels.
Conclusion The results obtained are consistent with those in other reports of paediatric patients. The absence of major complications is a favourable outcome. Thus, the present practice of USG-guided percutaneous RB in children is safe and clinically beneficial.

Keywords: haematuria, perirenal haematoma, post-biopsy complications, renal biopsy
Singapore Med J 2010; 51(6): 481-483

Hennedige T, Teo L, Ang B, Cheong WK, Venkatesh SK
Correspondence: Dr Sudhakar Kundapur Venkatesh, dnrskv@nus.edu.sg

ABSTRACT
Introduction This study aimed to determine the accuracy of computed tomography (CT) in the evaluation of local tumour invasion and regional lymphadenopathy in colorectal carcinomas.
Methods A total of 99 consecutive patients who had undergone a contrast-enhanced CT within two weeks prior to surgery with histopathological confirmation of colorectal carcinoma were selected. Intravenous contrast-enhanced CT was performed with a 5–7 mm collimation. Axial images were retrospectively and independently reviewed by two radiologists (R1 and R2) who were blinded to the surgical findings and histopathology. The readers assessed the primary tumour according to modified CT staging criteria. The radiological assessment was then compared with the surgical findings and histopathology for accuracy and inter-observer agreement.
Results At histopathology, the T-stage of the tumours was T2 in five, T3 in 62 and T4 in 32 patients, and the N-stage was N0 in 36, N1 in 28 and N2 in 35 patients. The accuracy of CT for T-stage and N-stage for the two readers was 45.5 percent and 60.6 percent (k is 0.30) and 33.3 percent and 45.4 percent (k is 0.23), respectively. The understaging and overstaging by R1 and R2 was 40.4 percent, 21.2 percent and 14.1 percent, 17.2 percent for T-stage and 22.2 percent, 37.4 percent and 32.3 percent, 28.3 percent for N-stage. The accuracy of serosal invasion for R1 and R2 (tumour perforates the visceral peritoneum or directly involves the adjacent organs) was 63.6 percent and 66.7 percent (k is 0.51), respectively. The understaging and overstaging by R1 and R2 for serosal invasion was 24.1 percent, 12.1 percent and 20.1 percent, 12.1 percent, respectively.
Conclusion Our study results show that the accuracy for CT staging of colorectal carcinomas for T-stage and in particular, serosal invasion, is moderate, but it is relatively low for N-stage.

Keywords: colorectal cancer, computed tomography, local staging, regional lymphadenopathy, serosal invasion
Singapore Med J 2010; 51(6): 475-480

Shakiba M, Sadr S, Nefei Z, Mozaffari-Khosravi H, Lotfi MH, Bemanian MH
Correspondence: Dr Mehrdad Shakiba, shakiba@ssu.ac.ir

ABSTRACT
Introduction The present study was designed to compare two methods of vitamin D supplementation in infants: every two months as a routine vaccination versus a daily dose.
Methods A randomised clinical trial was performed on 120 healthy breastfed infants between January and September 2007 in Yazd, Iran. The infants were randomly divided into three groups with different doses of vitamin D3 supplementation: 200 IU daily, 400 IU daily and a bolus of 50,000 IU every two months. A blood sample was taken and evaluated for 25-hydroxy vitamin D and calcium levels when the infants were six months old. The data was reported as the mean and standard deviation.
Results No significant differences were observed between the serum level of 25-hydroxy vitamin D in the groups administered with 200 IU and 400 IU vitamin D daily. However, the serum level of 25-hydroxy vitamin D reached significance in the third group (p is less than 0.001). All the blood calcium measured was below 11 mg/dl in the bolus group. A few complications such as diarrhoea and agitation, all of which were self-limited, were seen in the bolus group. No other significant side effects were reported in the other groups.
Conclusion This study demonstrates that a bolus of 50,000 IU of vitamin D every two months with a routine child vaccination program provides the ideal serum level of vitamin D. This method produces no serious side effects and offers a highly convenient way to supply vitamin D, especially among non-compliant parents.

Keywords: 25-hydroxy vitamin D, bolus dose, dietary supplements, infant
Singapore Med J 2010; 51(5): 440-445