Original Article

Darlong V, Shende D, Singh M, Garg R, Pandey R, Punj J
Correspondence: A/Prof Vanlal Darlong, drrgarg@hotmail.com

ABSTRACT
Introduction Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication.
Methods This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKl received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted.
Results A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. at 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in group MKl and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation scores, mean response to induction and mask acceptance. The time to reach aldrete score of 10 was shorter in Group MKl (22 +/- 5 min) and Group M (36 +/- 1 min) compared to Group MKH (52 +/- 2 min). Group MKH had a higher incidence of excessive salivation compared to the other groups.
Conclusion A combination of low-dose midazolam and ketamine is as effective as high-dose midazolam and ketamine for achieving optimum anxiolysis and a faster recovery, with a lower incidence of excessive salivation in children undergoing ophthalmic surgery.

Keywords: children, combination, high-dose ketamine, low dose, midazolam, premedication
Singapore Med J 2011; 52(7): 512-516

Ahmad WAW, Ramesh SV, Zambahari R
Correspondence: Prof Wan Azman Wan Ahmad, wanazman@ummc.edu.my

ABSTRACT
Introduction The ACute CORonary syndromes Descriptive study (ACCORD ) is a prospective observational study that evaluates the management of acute coronary syndrome (ACS) in clinical practice and the use of antiplatelet agents in acute settings and after discharge. The secondary objective of this study was to obtain information on risk factors in a large cohort of patients with ACS.
Methods The study population included subjects aged at least 21 years who had unstable angina or non-ST elevation myocardial infarction. The patients had four follow-up visits over a one-year period.
Results A total of 525 patients from Malaysia were enrolled into the study. The mean age of the patients was 58.14 +/− 11.3 years, and the mean body mass index was 25.4 +/− 4.3 kg/m2. 96.8 percent of subjects had at least one cardiovascular risk factor. Following hospitalisation, 83.6 percent of patients were managed medically. During the follow-up visits, 62.7–77.6 percent of patients received aspirin only, 5.0–6.8 percent received clopidogrel only and 15.6–32.3 percent received dual antiplatelet medications. Compliance with aspirin was 93.5–96.5 percent. Clopidogrel compliance was above 80 percent of the prescribed tablets for more than 88 percent of patients.
Conclusion Patients in the Malaysia-ACCORD registry were much younger compared to those in the Global Registry of Acute Coronary Events. The majority of patients had cardiovascular risk factors at presentation and were treated medically, and those on dual antiplatelet therapy had a relatively high level of compliance.

Keywords: acute coronary syndrome, antiplatelets, compliance, guidelines
Singapore Med J 2011; 52(7): 508-511

Rath G, Soni S, Prasad CP, Salhan S, Jain AK, Saxena S
Correspondence: Dr Gayatri Rath, gayatrirathvmmc@gmail.com

ABSTRACT
Introduction Hydatidiform moles have a high incidence rate in asian countries like india. The molecular pathway leading to the pathogenesis and progression of hydatidiform moles is not yet understood. This study aimed to investigate the biological significance of Bcl-2 and p53 in complete hydatidiform moles (cHMs) as well as their influence on disease progression in the indian population.
Methods Archival tissues from 35 patients with cHMs and 35 age-matched controls were examined for Bcl-2 and p53 expressions by immunohistochemistry.
Results Bcl-2 was found to be immunolocalised in the cytoplasm of the syncytiotrophoblast, whereas p53 was observed in both the nucleus and cytoplasm of the syncytiotrophoblast and cytotrophoblasts. In cHMs, Bcl-2 was detected in 23 percent of patients and p53 nuclear expression, in 66 percent. A significant decrease in Bcl-2 expression was observed in cHMs (p-value is 0.015), and the down-regulation of Bcl-2 significantly correlated with higher nuclear expression of p53 (p-value is 0.002), indicating an inverse association between the two proteins (p-value is 0.0001). However, no correlation was found between the clinical progress of patients with cHMs and p53 and those with Bcl-2 protein expression.
Conclusion The current study demonstrated the significance of Bcl-2 and p53 in the pathogenesis of cHMs but did not reveal any association with disease progression.

Keywords: Bcl-2, complete hydatidiform moles, placenta, p53
Singapore Med J 2011; 52(7): 502-507

Ong CWG, Chio TWM, Sen P, Tan HH, Hu Y, Chan R
Correspondence: Dr Gavin Ong Chun Wei, gavinong@nsc.gov.sg

ABSTRACT
Introduction The department of Sexually Transmitted infections (STI) control (DSC) clinic is the only public STI clinic in Singapore. This study aimed to determine patients’ perception of the clinic as well as the factors that may influence their choice of DSC Clinic over other medical facilities. The concerns of certain risk groups were also assessed.
Methods Self-administered anonymous questionnaires were offered to Singaporeans and permanent residents over 18 years of age who were seeking treatment at the DSC Clinic. 1,000 responses were collected over a period of four weeks in May 2009.
Results More than two-thirds of the patients had a positive experience at the DSC Clinic and would recommend the clinic to their family and friends. Positive attributes included competence of staff and the convenience of a one-stop treatment facility. The patients’ visits to the DSC Clinic also prompted them to engage in safer sexual practices. Stigma was surprisingly not an issue among more than three-quarters of the patients. Confidentiality of medical records was a major concern, with more than half of the patients unwilling to share their records with other healthcare providers, employers or insurance companies. The majority of patients would like to see the provision of clinics catering to special groups such as young people, women as well as men-who-have-sex-with-men.
Conclusion The majority of patients were satisfied with the health services provided at the DSC Clinic. Confidentiality in consultation was of prime importance to patients.

Keywords: confidentiality, healthcare surveys, public health, sexually transmitted diseases
Singapore Med J 2011; 52(7): 496-501

Zare A, Hajhashemi M, Hassan ZM, Zarrin S, Pourpak Z, Moin M, Salarilak S, Masudi S, Shahabi S
Correspondence: Dr Shahram Shahabi, s_shahabi@umsu.ac.ir

ABSTRACT
Introduction Ramadan, the holy month for the Islamic world, is a period every year when food and fluid intake is restricted to the pre-sunrise and post-sunset hours. The aim of this study was to evaluate the effect of Ramadan fasting on the serum concentration of heat shock protein 70 (HSp70) and serum lipid profile in healthy men.
Methods A total of 32 male volunteers with a mean age of 28.5 (range 23–37) years were selected for the study. Blood samples were obtained one day prior to Ramadan and on the 3rd and 25th days of fasting. Serum HSp70, triglyceride (Tg), cholesterol (chol), low-density lipoprotein (ldl) and high-density lipoprotein (Hdl), ldl/Hdl and chol/Hdl ratios were investigated.
Results It was observed that the mean concentrations of serum HSp70 and Hdl on the 25th day of Ramadan were significantly higher than those recorded one day before Ramadan and on the 3rd day of Ramadan, and the levels on the 3rd day of Ramadan was significantly higher than those recorded one day before Ramadan. Mean concentrations of serum Tg, chol, ldl, and ldl/Hdl and chol/Hdl ratios on the 25th day of Ramadan were significantly lower than those recorded one day before Ramadan and on the 3rd day of Ramadan, and the levels found on the 3rd day of Ramadan were also significantly lower than those recorded one day before Ramadan.
Conclusion Ramadan fasting increases serum HSp70 and improves serum lipid profile.

Keywords: heat shock protein, lipid profile, ramadan fasting, stress tolerance
Singapore Med J 2011; 52(7): 491-495

Hsu LY, Jin J, Ang BS, Kurup A, Tambyah PA
Correspondence: Dr Hsu Li Yang, mdchly@nus.edu.sg

ABSTRACT
Introduction Infection control and hand hygiene are taught at different points in the undergraduate medical curriculum. We conducted a survey on fifth year medical (M5) students pre- and periinfluenza a (H1N1-2009) pandemic, attempting to ascertain whether the pandemic had affected their knowledge, perception and practice of hand hygiene and other aspects of infection control.
Methods A self-administered anonymous survey of M5 students was performed between August 2008 and February 2010, corresponding to two successive classes: M5-2008 (class of 2004/09) and M5-2009 (class of 2005/10). completed survey forms were collated and analysed centrally.
Results There were 191 and 123 respondents for M5-2008 and M5-2009, respectively, corresponding to 74.9% and 47.3% of the respective classes. More M5-2009 respondents recognised alcohol hand rub as the preferred mode of hand hygiene practice and felt that there were insufficient isolation facilities in hospitals. Otherwise, survey responses were consistent. The majority felt that few doctors practiced hand hygiene appropriately, with the major obstructing factor being lack of time during ward rounds. The most important factor for improving hand hygiene compliance among junior doctors and students was for senior clinicians to lead by example. A significant minority believed that it was necessary to isolate patients with chikungunya, malaria or HiV.
Conclusion The 2009 H1N1 pandemic made little impact on medical students’ knowledge and practice of infection control. Nonetheless, their responses have suggested avenues for improving infection control practice, including persuading senior clinicians to lead by example in hand hygiene practice and addressing gaps in knowledge on patient isolation policies.

Keywords: hand hygiene, infection control, influenza pandemic, medical education, survey
Singapore Med J 2011; 52(7): 486-490

Wijaya L, Chua YY, Cui L, Chan K, Tan BH
Correspondence: Dr Limin Wijaya, limin.wijaya@sgh.com.sg

ABSTRACT
Introduction The 2009 (H1N1) influenza A pandemic started in april 2009 and has since spread globally. We have noticed that critically ill patients with confirmed pandemic 2009 (H1N1) influenza A require mechanical ventilation. This paper describes the use of intravenous zanamivir in this group of patients.
Methods Patients who had severe pneumonia with 2009 (H1N1) influenza A and required intravenous zanamivir were referred to the Infectious Diseases Department of our institution. Clinical data was collected from these patients. Clinical samples were sent to the National Public Health Laboratory for sequencing.
Results A total of five patients used intravenous zanamivir from April 8 to May 8, 2010. Only one death was reported. There were no side effects attributable to the use of intravenous zanamivir. H275 mutation, which confers resistance to oseltamivir, was seen in a subpopulation of the virus in one case.
Conclusion Physicians can consider using intravenous zanamivir for the treatment of critically ill patients with 2009 (H1N1) influenza A infection.

Keywords: H1N1 virus, influenza, intensive care unit, pneumonia, zanamivir
Singapore Med J 2011; 52(7): 481-485

Siau C, Tee A, Au V, Raghuram J, Oh HML, Fock KM, Teo EK
Correspondence: Dr Siau Chuin, chuin_siau@cgh.com.sg

ABSTRACT
Introduction The worldwide spread of influenza A H1N1 (2009) has proceeded at an unprecedented rate, with the World Health Organization rapidly raising its influenza pandemic alert to phase six. We describe the disease spectrum of H1N1 (2009) to aid the triaging and identification of patients at risk.
Methods This is a retrospective chart review of all confirmed H1N1 (2009) cases admitted to our institution between June and September 2009.
Results The disease severity of the 153 patients studied was classified as mild (n is 75), moderate (n is 55) and severe (n is 23). 81 patients were female. The median age was 26 years. While comorbidities were more prevalent among patients with moderate–severe illness, 47.4 percent reported no pre-existing illness. presenting complaints of breathlessness, tachycardia, low-pulse oximetry, higher leukocyte counts and c-reactive protein with low albumin levels were more commonly noted in moderate–severe illness (p-value less than 0.001). All patients received oseltamivir at a median of four days from illness onset. 18 required intensive care unit admission, with the majority (94.4 percent) within the first 24 hours of hospitalisation. The overall mortality rate was 4.6 percent. Median lengths of hospitalisation were four and nine days for moderate and severe cases, respectively.
Conclusion While the majority of H1N1 (2009) patients have mild illness, a subgroup can become critically ill. Prior good health is not necessarily a good discriminator against severe illness. The presence of dyspnoea, tachycardia and desaturation at triage should heighten the index of suspicion for H1N1 (2009)-related complications.

Keywords: H1N1 (2009), influenza pandemic, influenza-like illness, oseltamivir
Singapore Med J 2011; 52(7): 475-480

Herlina M, Nataprawira HMD, Garna H
Correspondence: Dr Murfariza Herlina, murfariza_h@yahoo.co.id

ABSTRACT
Introduction Wasting is a systemic manifestation of tuberculosis (TB) and is often thought to affect the severity and outcome of the disease. Leptin and several cytokines/proteins are thought to play a role in the relationship between TB, nutritional status and host immune response. The aim of this study was to determine the association of C-reactive protein (CRP), an inflammatory response protein and serum leptin levels with wasting in childhood TB.
Methods A cross-sectional observational analytic study was conducted at two hospitals in West Java from January to March 2010. The subjects were 13 children aged 2–120 months who were infected with TB and 26 healthy children of the same age and gender as the comparison group. History-taking and anthropometric, physical, serum CRP and leptin examinations were conducted for each subject. The association of CRP and serum leptin levels with wasting in childhood TB was studied.
Results Serum leptin levels were lower (95 percent confidence interval [CI] 314.0–1,228.9 pg/mL, p-value less than 0.001) and serum CRP levels were higher (95 percent CI 16.5–81.1 mg/L) in the subjects than in the comparison group. There were positive correlations between leptin and body mass index (p-value less than 0.001) and between CRP and wasting (p-value less than 0.001), but a negative correlation between leptin and wasting (p-value less than 0.001).
Conclusion Elevated serum CRP levels and a decrease in serum leptin levels are associated with an increase in wasting in childhood TB.

Keywords: childhood tuberculosis, C-reactive protein, leptin, wasting
Singapore Med J 2011; 52(6): 446-450

Papakonstantinou O, Athanassopoulou A, Passomenos D, Kalogeropoulos I, Balanika A, Baltas C, Gouliamos A, Guglielmi G
Correspondence: Prof Giuseppe Guglielmi, g.guglielmi@unifg.it

ABSTRACT
Introduction This study aimed to describe a spectrum of magnetic resonance (MR) imaging findings in a case series of four patients with recurrent vertebral hydatid disease (HD).
Methods Four patients with recurrent spinal HD, who were studied with MR imaging at 1.5T or 0.5T MR units, were encountered during a ten-year period. All patients had a history of repeated spinal surgery for hydatid resection.
Results HD involving the lumbar spine was found in two patients, the thoracolumbar spine in one patient and the lumbosacral in one patient. Skip lesions were seen in one patient. All patients had extensive involvement of the extradural space, soft tissues of the back and posterior vertebral elements. HD involving the vertebral body, intervertebral disk and iliopsoas muscles were noted in three, two and three patients, respectively. Bone and extradural hydatids were typically small, and appeared hypointense on T1-weighted images, with a mildly enhancing rim on post-contrast T1-weighted images. Sacral hydatid was an expansile multicystic process. Muscle hydatids were large, surrounded by a gadolinium-enhancing rim and assumed a variety of patterns – either multilocular or a nonspecific inhomogenous cystic or dumbbell configuration.
Conclusion MR imaging is a valuable diagnostic tool for follow-up of patients with vertebral HD. Recurrent HD is characterised by extensive involvement of soft tissues of the back and extradural space. Extension into the intervertebral disk and iliopsoas muscles and skip lesions in the extradural space are not uncommon.

Keywords: hydatid cysts, magnetic resonance imaging, spine
Singapore Med J 2011; 52(6): 440-445