Original Article

Ooi YP, Raja M, Sung SC, Fung DS, Koh JB
Correspondence: Dr Yoon Phaik Ooi, Yoon_Phaik_Ooi@imh.com.sg 

ABSTRACT
Introduction Selective mutism (SM) is characterised by limited or a lack of speech in selected social settings. Recent reviews suggest that cognitive-behavioural therapy (CBT) is an effective and promising treatment approach for SM. However, there is still a lack of studies documenting the applicability of CBT for SM in diverse populations. The goal of the present study was to examine the use of a web-based CBT programme (‘Meeky Mouse’) among Singaporean children diagnosed with SM.
Methods Five children with SM (one boy and four girls aged 6–11 years) participated in the 14-week ‘Meeky Mouse’ programme, in addition to being prescribed with an unchanged dosage of fluoxetine 10–20 mg daily. The progress made by the children throughout the course of the programme was documented by the therapist.
Results Post treatment, four out of the five children demonstrated improvements in the frequency of speech during therapy sessions at home, in school and at other social situations.
Conclusion Findings from the present study provide support for the use of a web-based CBT programme in improving speech and decreasing the severity of SM among affected children.

Keywords: anxiety, cognitive-behavioural therapy, selective mutism, web-based
Singapore Med J 2012; 53(7):446–450

Lian WB, Ho S, Choo S, Shah VA, Chan D, Yeo CL, Ho LY
Correspondence: Dr Lian Wee Bin, wblian@specialkidsclinic.com.sg
 

ABSTRACT
Introduction Childhood developmental and behavioural disorders (CDABD) have been increasingly recognised in recent years. This study evaluated the profiles and outcomes of children referred for developmental and behavioural concerns to a tertiary child developmental centre in Singapore. This is the first such regional database.
Methods Baseline information, obtained through a questionnaire, together with history at first consultation, provided information for referral, demographic and presentation profiles. Clinical formulations were then made. Definitive developmental and medical diagnoses, as well as outcomes based on clinical assessment and standardised testing, were recorded at one year post first consultation.
Results Out of 1,304 referrals between January 1, 2003 and December 1, 2004, 45% were 2–4 years old and 74% were boys. The waiting time from referral to first consultation exceeded four months in 52% of children. Following clinical evaluation, 7% were found to be developmentally appropriate. The single most common presenting concern was speech and language (S&L) delay (29%). The most common clinical developmental diagnosis was autism spectrum disorder (ASD) (30%), followed by isolated S&L disorder, global developmental delay (GDD) and cognitive impairment (CI). Recommendations included S&L therapy (57%), occupational therapy (50%) and psychological/behavioural services (40%). At one year, ASD remained the most common definitive developmental diagnosis (31%), followed by S&L disorder, CI and GDD. Most were children with high-prevalence, low-moderate severity disorders who could potentially achieve fair-good prognosis with early intervention.
Conclusion Better appreciation of the profile and outcome of children with CDABD in Singapore could enable better resource planning for diagnosis and intervention.

Keywords: attention deficit hyperactivity disorder, autism, childhood developmental and behavioural disorders, early intervention, speech and language
Singapore Med J 2012; 53(7):439–445

Sarkar A, Dutta S, Bal K, Biswas J
Correspondence: Dr Aniruddha Sarkar, drani77@gmail.com

ABSTRACT
Introduction The superficial and deep palmar arterial arches are the main sources of blood supply to all structures in the human hand, and variations in these arterial arches are quite common. Although several studies have reported diameters and variations of these arches, to the authors’ knowledge, no study has correlated such changes to handedness in adults. It is likely that dominance may play a role in arterial variations, such as those seen in the diameter or number of arteries formed in the palmar arches, much like in other areas of the human body. This cadaver study was conducted to determine any such association.
Methods 42 formalin-fixed hands were dissected to expose the superficial and deep palmar arches. These arches were then thoroughly examined for any variations between the dominant and non-dominant hands. All cadavers were noted to be right-handed as per hospital records.
Results 19 complete superficial arterial arches (right hand 14; left hand 5) were found in the 42 hands dissected.
Conclusion Most complete superficial palmar arches were found in the dominant hand of the cadavers studied, and therefore, handedness may have a role to play in determining palmar arterial arch variations in humans. Due to dominance or handedness, some arteries may likely persist into adulthood while others may become obliterated, thus leading to variations. Dissection of foetal hands may help to shed more light on the persistence or obliteration of various arteries after birth. Knowledge of such variations may prove helpful for surgeons during hand surgeries.

Keywords: handedness, palmar arches, variations
Singapore Med J 2012; 53(6): 409–412

Goonasegaran AR, Nabila FM, Shuhada NA
Correspondence: Dr Arvin Raj Goonasegaran, koli1987@gmail.com

ABSTRACT
Introduction Body mass index (BMI) has limited diagnostic performance due to its inability to discriminate between fat and lean mass. This study was conducted to compare the effectiveness of body fat percentage (BFP) against BMI in defining body composition.
Methods A cross-sectional study was conducted on students aged 17–30 years in Melaka, Malaysia. Basic anthropometric measurements were acquired using a manual weighing scale, measuring tape and a fixed stadiometer. BFP was calculated using the United States Navy formula. Data was tabulated and analysed using Epi Info and Statistical Package for the Social Sciences software. Pearson’s correlation coefficient and Kappa values were used. A p-value < 0.05 was considered statistically significant.
Results Out of the 490 subjects recruited, 43% of males and 24.6% of females were found to be overweight, while 14.3% of males and 7.8% of females were obese, when calculated using BMI. However, 8.9% of males and 22.8% of females were considered obese based on the BFP.
Conclusion BFP plays a more important role in distinguishing between healthy and obese individuals, as it has a greater ability to differentiate between lean mass and fat mass compared to BMI.

Keywords: body fat percentage, body mass index, obese, overweight
Singapore Med J 2012; 53(6): 403–408

Biswas SK, Sarai M, Toyama H, Yamada A, Harigaya H, Naruse H, Hishida H, Ozaki Y
Correspondence: Dr Shankar Kumar Biswas, biswas_70@yahoo.com

ABSTRACT
Introduction Myocardial scintigraphy with ¹²³I-15-(p-iodophenyl)-3-methyl pentadecanoic acid (¹²³I-BMIPP) is used to evaluate impaired fatty acid metabolism. B-type natriuretic peptide (BNP), which is secreted by the ventricular myocardium on stretching and/or pressure overload, is a useful cardiac biomarker. This study aimed to evaluate the usefulness of ¹²³I-BMIPP imaging and serum BNP levels in patients with heart failure (HF).
Methods 113 patients with HF were enrolled. There were 68 patients with ischaemic heart disease (IHD) and 22 with overt HF. Cardiac scintigraphy was performed 7 ± 3 days after admission, and heart-to-mediastinum (H/M) count ratios on early and delayed images and washout rates (WR) of ¹²³I-BMIPP were recorded. Serum BNP levels were recorded on the day of ¹²³I-BMIPP imaging. The ejection fraction (EF) was calculated just before cardiac scintigraphy using conventional echocardiography.
Results The mean BNP level and EF were 282 pg/mL and 47%, respectively, with significant correlation between them. The mean H/M count ratios on early and delayed images were 2.29 and 1.93, respectively, showing significant positive correlations with EF (r = 0.31, p = 0.0006). The WR was significantly correlated with EF (r = -0.36, p < 0.0001) and BNP levels (r = 0.33, p = 0.003), and mean WR was significantly higher in patients with overt HF compared to those without (p < 0.001). Patients with IHD had significantly higher EFs than those with non-IHD (p = 0.03).
Conclusion The evaluation of impaired myocardial metabolism using ¹²³I-BMIPP scintigraphy and serum BNP levels appears to be useful for the evaluation of severity of HF.

Keywords: B-type natriuretic peptide, cardiac scintigraphy, heart failure, myocardial fatty acid metabolism
Singapore Med J 2012; 53(6): 398–402

Meybodi FA, Eslick GD, Sasani S, Abdolhoseyni M, Sazegar S, Ebrahimi F
Correspondence: Dr Guy D Eslick, eslickg@med.usyd.edu.au

ABSTRACT
Introduction The number of cases of lead poisoning (LP), a widely known disease with various aetiologies, being reported globally has decreased over the years due to both limited domestic applications of lead and enforcement of stringent safety measures. However, a new presentation of lead poisoning, lead-contaminated opium (LCO), is gradually emerging in our region. This study aimed to determine the prevalence and clinical effects of lead toxicity associated with opium use.
Methods Between November 2006 and December 2007, all patients diagnosed with LP at a central laboratory in Tehran, Iran, were assessed for potential causes of poisoning. Patients with a history of LCO abuse were evaluated and recruited for the study.
Results Overall, there were 240 patients with LP, and poisoning from LCO was diagnosed in 25 patients. The duration of addiction was between three months and 40 years, and the duration of symptoms was 28.1 ± 17.7 days. Mean blood lead levels of the patients were 145 ± 61 (range 61–323) µg/dL. The average creatinine and haemoglobin levels were 77.4 ± 8.1 µmol/L and 105 ± 25 g/L, respectively. The association between the duration of addiction and levels of lead in blood was not statistically significant (r = -0.142, p = 0.54). The most common symptoms were gastrointestinal complaints, followed by musculoskeletal complaints with muscle weakness (92%). Anorexia was also a leading complaint.
Conclusion The results of our study suggest that the possibility of LP should be considered with high suspicion among opium users presenting with acute abdominal symptoms.

Keywords: acute abdominal symptoms, lead poisoning, opium ingestion
Singapore Med J 2012; 53(6): 395–397

Siow WY, Amin Z, Ponnamperuma G, Robless PA
Correspondence: Dr Zubair Amin, paeza@nus.edu.sg

ABSTRACT
Introduction Planning a high-stake clinical examination requires the evaluation of several psychometric and logistical variables. The authors conducted generalisability and decision studies to answer the following research questions in the context of the surgical long case: (1) Does the addition of a third examiner have any added benefit, vis-à-vis reliability, to the examination? (2) Is global marking more reliable than an itemised marking template? (3) What would be the impact on reliability if there was a reduction in the number of examinees that each panel of examiners is required to assess?
Methods A third examiner and global marking were introduced. Separate generalisability and decision studies were carried out for both the two- and three-examiner models as well as for itemised and global scores.
Results The introduction of a third examiner resulted in a modest gain of reliability by 0.05–0.07. Gain in reliability was higher when each candidate was allowed to undertake a higher number of clinical cases. Both the global and itemised scores provided equivalent reliability (generalisability coefficient 0.74–0.89).
Conclusion Our results showed that only a modest improvement in reliability of the surgical long case is achieved through the introduction of an additional examiner. Although the reliability of global scoring and the itemised marking template was comparable, the latter may provide opportunities for individualised feedback to examinees.

Keywords: clinical competency, educational measurements, reproducibility of results
Singapore Med J 2012; 53(6): 390–394

Chua W, Murphy DP, Siow W, Kagda FH, Thambiah J
Correspondence: Dr Chua Weiliang, wei_liang_chua@nuhs.edu.sg

ABSTRACT
Introduction Open fractures of the tibia pose a challenge to orthopaedic and plastic surgeons. A retrospective observational review was conducted to evaluate the epidemiological factors and fracture outcomes in the Singapore context.
Methods A nine-year period of open tibial shaft fractures presenting to our institution was reviewed. Demographic and management data were recorded. Statistical analysis was performed on the outcomes of length of hospital stay, number of operations, time to union and infection rates.
Results 323 fractures met our inclusion criteria (Gustilo [G] 1 = 53, G2 = 100, G3 = 170). Mean age of patients was 36.5 years, 91.3% were male and 40.9% were non-Singaporeans. 69.3% of fractures occurred from road traffic accidents and 21.7% from industrial accidents. Mean length of hospital stay was 28.7 days and number of operations was 4.29. Time to union was 10.7 months and overall infection rate was 20.7%. Infection rates were significantly higher in G3b/G3c compared to G3a (45.7% vs. 21.1%) patients. There was no significant reduction in infection rates when open tibial fractures were operated on within six hours of admission. Multiple injured patients required a longer time to union and hospital stay. There was an exponential cost increase with greater severity of fracture.
Conclusion High Gustilo and AO classification injuries positively correlate with high non-union and infection rates, requiring multiple operations and long hospital stay. There is no benefit in performing surgery on open tibial fractures within six hours of presentation. A significant proportion of these patients would be polytraumatised, indirectly affecting fracture union.

Keywords: amputation, economics, epidemiology, open tibia fractures, salvage
Singapore Med J 2012; 53(6): 385–389

Koh D, Lim JF, Quah HM, Tang CL
Correspondence: A/Prof Tang Choong-Leong, tang.choong.leong@sgh.com.sg

ABSTRACT
Introduction Constipation is a common affliction affecting the general population, with dyssynergic defaecation accounting for a large proportion of tertiary referrals. We sought to review the results of our patients with dyssynergic defaecation treated with biofeedback therapy in order to determine its efficacy.
Methods All patients who were referred to the anorectal physiology laboratory of our tertiary unit for biofeedback therapy for dyssynergic defaecation were reviewed. Patients diagnosed with secondary constipation and slow-transit constipation were excluded. A defaecating proctogram was used to exclude anatomical abnormalities causing outlet obstruction. Patients underwent a four-session, structured biofeedback exercise programme under the supervision of trained nurses. The effectiveness of biofeedback treatment was assessed using the validated Eypasch’s Gastrointestinal Quality of Life Index (GIQLI).
Results 226 patients (85 male, 141 female; median age 48 years) underwent biofeedback treatment. Post treatment, improvement was observed in the overall total score of the GIQLI, with gastrointestinal symptom (68.6%), emotion (61.0%) and physical function (57.9%) components showing the most improvement. These improvements were also reflected in the mean scores of each component and the mean total score. All components, except for social function and medication, and the overall total score showed significant improvement post treatment. At the one-year follow-up, 160 (71%) patients reported that improvements were maintained.
Conclusion Biofeedback is an effective treatment for patients with dyssynergic defaecation. Patients with chronic constipation not improved by fibre and laxatives should be referred to a tertiary centre with facilities for further anorectal physiological assessment.

Keywords: biofeedback, constipation, manometry, puborectalis paradoxus
Singapore Med J 2012; 53(6): 381–384

Chang S, Tan S, Kok YO
Correspondence: Dr Stephen Chang Kin Yong, cfscky@nus.edu.sg

ABSTRACT
Introduction Laparoscopic cholecystectomy is currently the gold standard for removal of symptomatic gallbladders. The push in recent years toward reducing the number of ports required to perform this surgery has led to the development of single-incision laparoscopic cholecystectomy (SILC). We report our early experience with SILC and assess its feasibility and safety.
Methods A prospective study was conducted of the first 100 patients who presented with complaints of biliary colic and underwent laparoscopic cholecystectomy via the single-port technique at our institution. SILC was performed via a single-port device such as a flexible umbilical port that could accommodate up to three surgical instruments. The port was inserted into a transumbilical incision around 15–20 mm long. Data on operative details and postoperative outcomes were collected and evaluated.
Results The mean operation time was 67.8 minutes. Six patients needed conversion, requiring extra 5-mm ports to complete the surgery. No serious intraoperative complications, such as bile duct injury or bile leakage, were encountered. Cosmesis from the scar hidden within the umbilical fold was excellent.
Conclusion Our initial results of single-port laparoscopic cholecystectomy are promising, with no complications being seen in this early series. However, the drawbacks include the higher cost of equipment and a steeper learning curve. Further evaluation is required to assess the risks and benefits of this approach when compared with conventional laparoscopic cholecystectomy

Keywords: laparoscopic cholecystectomy, minimally invasive, SILC, single-incision surgery, single-port laparoscopy
Singapore Med J 2012; 53(6): 377–380