Original Article

Ng YH, Chong KW, Tan GM, Rao M
Correspondence: Dr Yeong Huei Ng, nyong95@yahoo.com.sg

ABSTRACT
Introduction The purpose of this study was to evaluate the outcome of our early experience with the distally pedicled peroneus brevis flap in the management of soft tissue defects of the lower leg, ankle and foot.
Methods This was a non-randomised, retrospective study involving five patients who were treated with the peroneus brevis muscle flap for soft tissue defects over the lower leg.
Results In all five patients, the flaps were viable and successful in providing satisfactory soft tissue coverage for the defects. In one diabetic patient, distal flap necrosis was observed, which was treated successfully with a local rotational skin flap.
Conclusion The distally pedicled peroneus brevis muscle flap is an economical, reliable and relatively easy procedure for treating defects of the distal third of the leg, ankle and foot.

Keywords: flap, lower limb reconstruction, peroneus brevis
Singapore Med J 2010; 51(4): 339-342

Nalliah S, Chan SLJ, Ong CLS, Suthan TH, Tan KC, She VNJ, Gupta E
Correspondence: Prof Sivalingam Nalliah, nelsonsivamani@gmail.com

ABSTRACT
Introduction Internet search has been the main source for information and data mining in medical research. Its use by medical students has immensely contributed to learning activities. The main aim of the study was to determine the effectiveness of internet use by medical students during their initial years of clinical instruction in order to establish a diagnosis after being provided with the history and physical findings of a clinical problem.
Methods A total of 47 cases derived from the New England Journal of Medicine (NEJM) were utilised. The Google search engine was utilised to establish a reasonable diagnosis.
Results A congruency rate of 44.7% was obtained. This was considered commendable in view of the complexities of the cases published in the NEJM and the fact that the medical students were only in the third year of their Bachelor of Medicine and Bachelor of Surgery program.
Conclusion The study illustrates that common search engines could complement the traditionally used medical education methods.

Keywords: congruency, Google search, medical diagnosis
Singapore Med J 2010; 51(4): 332-338

Shyamal S, Latha PG, Suja SR, Shine VJ, Anuja GI, Sini S, Pradeep S, Shikha P, Rajasekharan S
Correspondence: Dr Latha Gopalakrishnan, lathagopalakrishnan@yahoo.com

ABSTRACT
Introduction Roots of Ixora coccinea (Rubiaceae), and Rhinacanthus nasuta (Acanthaceae) and whole plants of Spilanthes ciliata (Asteraceae) are extensively used by tribal communities in South India to treat liver diseases. However, the veracity of these tribal claims has not been investigated scientifically using the liver toxin, aflatoxin. This study reports on the protective effects of these three herbal ethanolic extracts on the aflatoxin B1 (AFB1) -intoxicated livers of albino male Wistar rats.
Methods Biochemical parameters, including serum hepatic enzymes (glutamate oxaloacetate transaminase, glutamate pyruvate transaminase and alkaline phosphatase), were studied. Hepatic tissues were processed for assay of reduced glutathione (GSH) and histological alterations.
Results Pre-treatment of the rats with oral administration of the plant ethanolic extracts, Ixora coccinea (IC), Rhinacanthus nasuta (RN), Spilanthes ciliata (SC), prior to AFB1 was found to provide significant protection against toxin-induced liver damage, determined 72 hours after the AFB1 challenge (1.5 mg/kg, intraperitoneally) as evidenced by a significant lowering of the activity of the serum enzymes and enhanced hepatic reduced GSH status. Pathological examination of the liver tissues supported the biochemical findings. The three plant extracts, IC, RN and SC, showed significant antilipid peroxidant effects in vitro.
Conclusion It was concluded that the hepatoprotective effects of the three plant extracts observed in this study might result from their potent antioxidative properties.

Keywords: aflatoxin-induced liver damage, hepatoprotective, Ixora coccinea, Rhinacanthus nasuta, Spilanthes ciliata
Singapore Med J 2010; 51(4): 326-331

Choy DKS, Wu PH, Tan D, Yeo TT, Chou N
Correspondence: Dr David Choy Kim Seng, cfschoyd@nus.edu.sg

ABSTRACT
Introduction The treatment of primary spontaneous supratentorial intracerebral haemorrhage (ICH) by evacuation is not supported by randomised controlled trials. We investigate the effectiveness of the completeness of surgical evacuation of spontaneous supratentorial ICH with respect to the functional neurological outcome and mortality.
Methods A retrospective review of patients who underwent supratentorial ICH evacuations in the Neurosurgical Unit of the National University Hospital, Singapore, between January 2002 and December 2005 was conducted. Preoperative and postoperative computed tomography images were compared, and the patients or their family members completed follow-up questionnaires two years post surgery, in order to assess the neurological outcome.
Results The patients were subdivided into two groups based on the Glasgow Outcome Scale and haematoma volume. Patients with small pre-evacuation haematoma had a median percentage change in volume and a midline shift of 97.63 percent and 63 percent, respectively. Patients with a large haematoma volume had a median percentage change in volume and midline shift of 99.54 percent and 100 percent, respectively (the p-values for percentage change in volume and midline shift are 0.764 and 0.742, respectively). The median percentage change in volume for the poor outcome subgroup was 97.63 percent, compared to 100 percent for the good outcome subgroup (p-value is 0.288). The median change in midline shift in the poor and good outcome subgroups was 63 percent and 100 percent, respectively (p-value is 0.576).
Conclusion Although not statistically significant with regard to the completeness of haematoma evacuation, a trend toward better outcome with more complete evacuation is observed with ICH.

Keywords: Glasgow Outcome Scale, spontaneous intracerebral haemorrhage, surgical evacuation
Singapore Med J 2010; 51(4): 320-325

Wong MTC, Lim JF, Ho KS, Ooi BS, Tang CL, Eu KW
Correspondence: Prof Eu Kong Weng, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction Pelvic radiotherapy is an essential component of potentially curative therapy for many pelvic malignancies; however, the rectum consequently often sustains collateral injury.
Methods The researchers retrieved patient data that was prospectively gathered over a ten-year period between January 1995 and December 2004. The relevant details, including gender, age, pelvic pathology for which radiotherapy was administered, the presenting symptoms, the interval between radiotherapy and the onset of symptoms, the mode of diagnosis, treatments received, length of hospital stay and duration of follow-up, were analysed.
Results During the period under review, 77 patients were admitted for the treatment of radiation proctitis, with a median follow-up period of 14 (range 1–61) months. There were 23 male and 54 female patients, with a median age of 63.9 (range 37–89) years. The most common underlying cancers were gynaecological (63.6 percent), prostate (18.2 percent) and colorectal (15.6 percent) cancer. The most common presenting symptom was bleeding per rectum (89.6 percent), with a change in bowel habits a distant second (10.4 percent). The median latent period between the completion of radiotherapy and the onset of symptoms was 24 (range 3–68) months. The majority of the patients (72.5 percent) received non-surgical treatment, most commonly using topical 4 percent formalin solution to arrest the bleeding, with more than half the patients requiring repeat treatments. 14 (18.2 percent) patients required colorectal resections for intractable bleeding, intestinal obstruction or intra-abdominal sepsis.
Conclusion Radiation proctitis can be a therapeutic challenge, even in the most experienced hands. The majority of patients who present with per rectal bleeding can be treated using topical modalities, while surgery may offer the only chance of relief from life-threatening symptoms.

Keywords: formalin, per-rectal bleeding, proctitis, radiation
Singapore Med J 2010; 51(4): 315-319

Chow TL, Choi CY, Lam SH
Correspondence: Dr Tam-Lin Chow, tamlinc@yahoo.com

ABSTRACT
Introduction Most differentiated thyroid carcinomas (DTC) are treated by total thyroidectomy in Hong Kong. This study investigates the outcome of tumour control in selected patients treated by hemithyroidectomy, which is beneficial in terms of having a lower operative morbidity.
Methods This is a retrospective study of prospectively collected data from our cancer registry. Patients with pathologically proven differentiated thyroid carcinoma were stratified into risk groups according to the patients’ age, tumour size, extrathyroid spread and distant metastasis. Low-risk patients were managed with hemithyroidectomy without postoperative radioactive iodine. Central compartment lymph node dissection was also carried out if the diagnosis was confirmed preoperatively. The oncological outcome and surgical morbidity were evaluated.
Results A total of 236 patients with the diagnosis of DTC underwent a thyroidectomy at our institution during a 24-year period. 93 patients were initially treated by hemithyroidectomy. Subsequent evaluation was focused on this subgroup. The mean follow-up period was 63.3 +/- 55.1 months. The mean tumour diameter was 22.1 +/- 20.8 mm. The histopathologic diagnoses were papillary carcinoma (69 cases; 74.2 percent), follicular carcinoma (20 cases; 21.5 percent) and Hurthle cell carcinoma (four cases; 4.3 percent). 23 (24.7 percent) patients underwent hemithyroidectomy coupled with central compartment dissection. Pathologically proven lymph node metastasis was diagnosed in 12 (12.9 percent) patients. Transient vocal cord palsy occurred in six (6.5 percent) patients, while permanent vocal cord palsy occurred in two (2.2 percent). Local tumour recurrence arose in only one (1.1 percent) patient. No patient succumbed to the thyroid cancer.
Conclusion Hemithyroidectomy coupled with central compartment dissection in selected cases of DTC can achieve excellent tumour control with minimal surgical morbidity.

Keywords: central compartment, differentiated thyroid carcinoma, hemithyroidectomy
Singapore Med J 2010; 51(4): 311-314

Ng CH, Lee KT, Taib NA, Yip CH
Correspondence: Dr Char Hong Ng, charhong@gmail.com

ABSTRACT
Introduction With an increasing number of women undergoing breast screening, an effective method of removing non-palpable lumps detected by mammography or sonography is by hookwire localisation excision biopsy (HWLB). The aim of this paper was to audit the practice of HWLB at the University Malaya Medical Centre.
Methods Patients with benign or suspicious preoperative diagnoses of a non-palpable lump and who underwent HWLB were included in this study. Pathological examination of the surgical specimens was conducted and a correlation with preoperative assessment modalities was reported.
Results A total of 59 HWLBs were carried out in 57 female patients. The mean age of the patients was 51.5 years. The overall malignancy rate was 32.3 percent (19 out of 59 cases) with a benign to malignant ratio of 3.1 to 1. Ten of these cases were ductal carcinoma-in-situ. Out of 25 patients who were suspicious on preoperative assessment, 16 malignancies were found, while in the 33 patients thought to be benign on preoperative assessment, there were three malignancies, giving a sensitivity of 84.2 percent and a specificity of 76.9 percent (p is less than 0.05). The mean tissue volume excised in 53 available records was 50.0 cm3, with pathological tissue comprising only 15.4 percent of the total excised volume. Clear margins were obtained in 42.1 percent of the patients. The overall operative complication rate was 10.2 percent.
Conclusion Malignancy was reported in one third of women undergoing HWLB, of which 16 had suspicious features on radiological assessment and/or fine needle aspiration cytology/core needle biopsy preoperatively. Non-palpable lumps should be excised by HWLB for a definitive diagnosis in case of any suspicion on preoperative assessment, as the prognosis is excellent.

Keywords: breast cancer, excision biopsy, hook-wire localisation, non-palpable breast lesion
Singapore Med J 2010; 51(4): 306-310

Mahmood K, Naqvi IH, Talib A, Salkeen S, Abbasi B, Akhter T, Iftikhar N, Ali A
Correspondence: Dr Iftikhar Haider Naqvi, driftikharhaider@hotmail.com

ABSTRACT
Introduction Snake envenomation is a frequently reported medical emergency at the Civil Hospital Karachi, Pakistan, thus obviating the need to assess the patterns of the clinical course and outcome of snake envenomation cases.
Methods The demographic characteristics, clinical signs and symptoms, laboratory findings, treatment and outcome of 80 victims of snake bite were recorded. These patients were admitted to the Civil Hospital Karachi between January 2006 and September 2007. The data of all the cases was analysed statistically using the Statistical Package for the Social Sciences version 11.0.
Results The majority of the 80 victims of snake bite were male (80 percent) and 20 percent were female. The mean age of the patients was 33.3 years. The main type of envenomation was vasculotoxic (92.5 percent), and none were neurotoxic or myotoxic. Both local and systemic clinical features of envenomation were present. Bleeding was reported in 43.8 percent of the patients. 71.3 percent of the patients showed coagulopathy of defibrination and the anti-coagulant type. All patients received anti-snake venom. Five (6.3 percent) patients in the study died.
Conclusion The most common type of snake envenomation in this part of the province of Sindh is vasculotoxic due to the high inhabitancy of Viperidae. High morbidity and mortality rates can be reduced significantly through patient education on the precautions that need to be taken by farmers and field workers against snake bite. Early referral to a well-equipped health facility is necessary, as the mortality rate was high among those patients who arrived late.

Keywords: activated partial thromboplastin time, anti-snake venom, envenomation, prothrombin time
Singapore Med J 2010; 51(4): 300-305

Hasan SS, Allen YKS, Wayne WGW, Ahmadi K, Anwar M, Goh GK
Correspondence: Mr Syed Shahzad Hasan, shahzad_hasan@imu.edu.my

ABSTRACT
Introduction People with epilepsy are socially discriminated against on the grounds of widespread negative public attitudes, misunderstandings and defensive behaviour. The primary purpose of this study was to evaluate the public understanding of and attitudes toward epilepsy among the Chinese population in Malaysia.
Methods A validated, self-administered questionnaire comprising 23 questions was utilised to evaluate the understanding of and attitudes toward epilepsy among randomly approached respondents from the Chinese population living in the urban areas of Penang, Klang Valley, Kuala Lumpur and Sibu in Malaysia.
Results Out of 1,000 people approached, 697 (69.7 percent) respondents agreed to participate in the study. When asked whether people with epilepsy are slow learners and have intellectual functioning below normal, 448 (64.3 percent) respondents answered ‘no’. This positive answer was mainly provided by female (35.6 percent) as compared to male (28.6 percent) respondents. Moreover, more than half responded positively to the following statements: people with epilepsy should not be isolated from the normal population; epileptics can perform daily activities; epileptics can receive academic education; and epileptics can become useful members of society. In addition, significant associations were discovered between the education level of the respondents and several statements, including whether epileptics are as intelligent as everyone else (p-value is 0.009), whether epilepsy can be treated with drugs (p-value is 0.037) and whether epileptics can be as successful as other people in their chosen career (p-value is 0.009). Positive responses were mainly acquired from those with secondary education and above. A large number of the respondents felt that people with epilepsy should not be employed as lorry drivers, firefighters, doctors and army personnel.
Conclusion The general Chinese population in the urban areas of Malaysia had, at the time of the investigation, a relatively high level of understanding and positive attitudes toward certain aspects of epilepsy, although a minority of the study population demonstrated prejudice and discriminatory behaviours toward people with epilepsy.

Keywords: attitudes, Chinese, epilepsy, understanding, urban areas
Singapore Med J 2010; 51(4): 290-299

Ong LC, Chandran V, Lim YY, Chen AH, Poh BK
Correspondence: Professor Dr Ong Lai Choo, onglc@ppukm.ukm.my

ABSTRACT
Introduction The aim of this study was to identify factors associated with poor academic achievement during the early school years.
Methods This was a cross-sectional study of urban Primary Two children. Sociodemographic and medical data were obtained from questionnaires and interviews. Achievement was based on marks obtained in the core subjects of the Primary One examination. All students underwent the Raven’s Standard Progressive Matrices test as a general measure of cognitive ability, audiometry and visual tests, and standardised measurements of weight and height.
Results Out of 1,470 eligible children, 206 (14 percent) had poor academic achievement. Of the 919 children who participated in the study, 111 (12.1 percent) had poor achievement compared with 95 (17.2 percent) of the 551 non-participants. Using logistic regression analysis, the factors that were found to be independently associated with poor academic achievement were lower mean Raven scores (p-value is less than 0.001), lower mean socioeconomic status scores (p-value is less than 0.001), larger sibship size (p-value is 0.031), male gender (odds ratio [OR] 1.7; 95 percent confidence interval [CI] 1.1–2.65) and a history of prematurity (OR 14; 95 percent CI 2–97.8).
Conclusion Cognitive ability, gender, prematurity and social factors contribute to poor academic achievement during the early school years. The higher proportion of poor achievers among non-participants warrants further attention.

Keywords: academic achievement, cognitive ability, gender, prematurity, socioeconomic status
Singapore Med J 2010; 51(3): 247-252