2009

Wong EW, Mohd Yusof MY, Bt Mansor M, Anbazhagan D, Ong SY, Sekaran SD
Correspondence: Dr Shamala Devi Sekaran, shamalamy@yahoo.com

ABSTRACT
Introduction The AdeABC pump of Acinetobacter spp. confers resistance to various antibiotic classes. This pump is composed of the AdeA, AdeB, and AdeC proteins where AdeB is a member of the resistance-nodulation-division efflux pump superfamily. The adeA, adeB, and adeC genes are contiguous and adjacent to adeS and adeR, which are transcribed in the opposite direction and which specify proteins homologous to sensors and regulators of two-component systems, respectively. In this study, an attempt is made to elucidate the role of the AdeABC efflux pump in carbapenem resistance in Acinetobacter spp.
Methods 39 carbapenem-resistant clinical isolates of Acinetobacter spp. were used. Minimum inhibitory concentrations were evaluated using the agar dilution method according to Clinical and Laboratory Standards Institute standards. The presence of carbapenem hydrolysing oxacillinases and AdeABC efflux pump genes were determined by PCR amplification. Subsequently, each gene was inactivated by plasmid insertion in order to study the contribution of these genes in developing antibiotic resistance and the resulting mutants were tested for their antimicrobial susceptibilities.
Results Among the multidrug-resistant strains, 36 strains had all the three (A, B, C) genes detected, while the remaining three strains had one or two of the genes detected. Inactivation of these individual genes showed decreased antimicrobial susceptibility indicating its contribution towards the development of antimicrobial resistance.
Conclusion The presence of AdeABC multidrug efflux pump plays a major role in the development of antimicrobial resistance in Acinetobacter spp. The presence of either one or an interplay between these genes may have an effect on antimicrobial resistance in Acinetobacter spp.

Keywords: Acinetobacter spp., AdeABC efflux pump, antimicrobial resistance, carbapenam resistance, multidrug resistance
Singapore Med J 2009; 50(8): 822-826

Ting TH, Wu LL
Correspondence: Dr Ting Tzer Hwu, thting@media.upm.edu.my

ABSTRACT
Introduction Micropenis may be an important sign of underlying hypogonadism or pituitary hypofunction in the neonatal period. Penile lengths of normal newborns have been reported in many Western populations. However, the data may not be applicable in the Asian or the multiracial Malaysian population. Our study aimed to establish the normal penile length and testicular volume in term newborn infants in the major ethnic groups in Malaysia.
Methods The stretched penile length and testicular volume were measured in 340 normal term newborn infants (195 Malays, 129 Chinese and 16 Indians).
Results The mean penile length in Malay term newborn infants was 35 +/- 4 mm, which was similar to Chinese infants. The mean testicular volume was 2.5 +/- 0.6 ml in Malay and 2.4 +/- 0.5 ml in Chinese infants. There was no significant difference between the groups. The sample size for the Indian group during the study period was inadequate.
Conclusion Using -2.5 standard deviations as the cut-off for micropenis, a Malay or Chinese newborn infant in Malaysia with a penile length of less than 25 mm is considered to have a micropenis and further evaluation is warranted.

Keywords: micropenis, penile length, term newborn, race, testes volume
Singapore Med J 2009; 50(8): 817-821

Akhavan Karbasi S, Modares Mosadegh M, Fallah R
Correspondence: Dr Sedighah Akhavan Karbasi, sakarbasi@yahoo.com

ABSTRACT
Introduction Seizure is the most common paediatric neurological disease which occurs in ten percent of children. In approaching a convulsive patient, finding the causes of seizure is essential, and the patient’s history as well as the physical examination are important. The role of routine laboratory tests for children’s seizures (except neonates) is undetermined, but checking for serum sodium, glucose, calcium and urea routinely has been advised. The purpose of this study was to determine the diagnostic efficacy of these serum chemistry tests in the seizures of children older than one month of age.
Methods In this descriptive, retrospective study, medical records of 302 hospitalised children with seizure were reviewed. Results of laboratory tests, like sodium, calcium, blood glucose and urea levels, pertinent history and physical examination, and the change in patient management based on serum chemistry test results, were analysed. All the children in the study were classified as having seizure with or without fever.
Results In 302 hospitalised children with seizure, about ten percent of 938 tests were abnormal. 27.7 percent of these abnormal results were seen in 1–12-month-old infants. Only 11 percent of abnormal tests (1.3 percent of total tests) might have caused a seizure. Also, 0.2 percent of the results could not be predicted from the history or physical examination, which was conducted in patients younger than one year of age.
Conclusion Routine determination of serum chemistry values in seizures of children does not contribute to therapy, and are costly and time-consuming. It may not be helpful and informative unless the patient is less than one year of age.

Keywords: febrile seizure, seizure, serum chemistry
Singapore Med J 2009; 50(8): 814-816

Khan MMH, Kraemer A
Correspondence: Dr MMH Khan, mobarak.khan@uni-bielefeld.de

ABSTRACT
Introduction Extremes of body mass index (BMI), viz.underweight,overweight and obese categories, are associated with a variety of adverse health outcomes such as diabetes mellitus, cardiovascular diseases, low birth weight, poor quality of life and higher mortality. In Bangladesh, the prevalence of underweightness is very high with an increasing trend of overweightness and obesity. This is a serious public health concern as it indicates a dual burden of disease. The present study assessed the associations of being underweight, overweight and obese with socioeconomic, demographical and migration variables among ever-married non-pregnant urban Bangladeshi women aged 13–49 years.
Methods The data was extracted from the Bangladesh Demographic and Health Survey 2004. Bivariable, factor and multinomial logistic regression analyses were performed in this study.
Results The prevalence of being underweight, overweight and obese among ever-married non-pregnant urban women in Bangladesh was 25.2 percent, 15.7 percent and 3.9 percent, respectively. Age, education, region of residence, marital status, current use of contraception and type of occupation were significantly associated with BMI categories. Adjusted multinomial logistic regression analysis indicated that women with a high socioeconomic status were significantly negatively associated with being underweight (odds ratio [OR] 0.55, 95 percent confidence interval [CI] 0.48–0.63) but positively associated with being overweight (OR 1.70, 95 percent CI 1.48–1.96) and obese (OR 2.48, 95 percent CI 1.89–3.26), as compared to the women with normal BMI. In contrast, women who migrated from rural to urban areas showed a significantly positive association with being underweight (OR 1.15, 95 percent CI 1.04–1.27) but negative associations with being overweight (OR 0.80, 95 percent CI 0.71–0.89) and obese (OR 0.75, 95 percent CI 0.62–0.92), when compared with women who did not migrate.
Conclusion Suitable interventions based on further studies are needed to reduce the prevalence of being underweight and overweight among ever-married non-pregnant urban women in Bangladesh. Factors, viz. socioeconomic status, rural-urban migration and education, should be considered while developing interventional strategies to reduce the prevalence of extreme BMIs among women living in urban areas of Bangladesh.

Keywords: obesity, overweight, rural-urban migration, socioeconomic status, underweight
Singapore Med J 2009; 50(8): 804-813

Mathew AJ, Antony J, Eremenco S, Paul BV, Jayakumar B, Philip J
Correspondence: Dr Ashish Jacob Mathew, ashishjacobmathew@gmail.com

ABSTRACT
Introduction Assessment of health-related quality of life (HRQL) has been gaining much importance in the care of rheumatoid arthritis (RA). This study was aimed at assessing the HRQL of patients with RA in South India.
Methods HRQL of consenting RA patients, on disease-modifying anti-rheumatoid drugs (DMARDs) and attending a rheumatology clinic, was assessed using a self-filled Malayalam version of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) version 4 questionnaire.
Results 50 patients were assessed out of 58 responses. The mean duration of the disease was 7.29 years. 46 patients (79.3 percent) had tried complementary and alternative medicines (CAM). The HRQL score in patients who were put on DMARDs within six months of symptoms was significantly higher (p-value is equal to 0.008).
Conclusion HRQL in patients treated early by DMARDs is significantly higher in this region, where a good proportion of patients seek the CAM for treatment of RA.

Keywords: complementary medicine, disease-modifying anti-rheumatic drugs, quality of life, rheumatoid arthritis
Singapore Med J 2009; 50(8): 800-803

Dahlui M, Hishamshah MI, Rahman AJA, Aljunid SM
Correspondence: Dr Maznah Dahlui, maznahd@ummc@edu.my

ABSTRACT
Introduction The quality of life of transfusion-dependent thalassaemia patients is affected by the disease itself and iron overload complications from repeated blood transfusion. Desferrioxamine has been used to remove the excess iron, resulting in decreased mortality and morbidity. In Malaysia, a significant proportion of the transfusion-dependent thalassaemia patients are not prescribed desferrioxamine, due to its high cost, especially as it is not subsidised by the government. The aim of this study was to measure the quality of life of thalassaemia patients on desferrioxamine treatment.
Methods A cross-sectional study was performed on all transfusion-dependent thalassaemia patients on follow-up at two tertiary hospitals in Kuala Lumpur, Malaysia, in 2005. Quality-of-life scores were measured by using the translated MOS SF-36 questionnaires, while diseases related to iron overload complications were obtained from the medical records. Use of desferrioxamine was elicited through interviews and validated by drug records. Quality-adjusted life-years (QALYs) presented were formulated from residual life-years and quality-of-life scores.
Results A total of 112 transfusion-dependent thalassaemia patients were recruited, with 54 (48 percent) and 58 (52 percent) patients on sub-optimum and optimum desferrioxamine treatments, respectively. QALYs were higher in patients on optimum desferrioxamine (9.04, standard deviation [SD] 2.46) than patients on sub-optimum desferrioxamine (5.12, SD 2.51). QALYs were associated with the level of serum ferritin, iron overload complications and total family income.
Conclusion Optimum desferrioxamine usage reduces iron overload complications and provides a better quality of life.

Keywords: desferrioxamine treatment, iron overload complications, quality of life, quality-adjusted life-years, transfusion-dependent thalassaemia
Singapore Med J 2009; 50(8): 794-799

Mamishi S, Mashoori N, Mahboobi N, Pour Akbari B
Correspondence: Ms Negar Mashoori, negar_1400@yahoo.com

ABSTRACT
Introduction The Shigella spp. is an organism with an ongoing changing resistance pattern to different antibiotics, thus making its appropriate treatment difficult. Nalidixic acid has been one of the most common agents used for the treatment of shigellosis. Recently, some studies have reported an emerging resistance to this agent.
Methods In this study, we compared the resistance of Shigella isolates during the period 2001–2003 with the period 2004–2006.
Results Shigella spp. resistance was increased totally and in each subgroup, except for Shigella sonnei.
Conclusion Our results showed an increasing resistance of the Shigella spp., thus identifying an emergent need for an alternative agent for the treatment of shigellosis in future.

Keywords: antimicrobial resistance, dysentery, nalidixic acid, Shigella spp., shigellosis
Singapore Med J 2009; 50(8): 791-793

Ng KW, Chow A, Win MK, Dimatatac F, Neo HY, Lye DC, Leo YS
Correspondence: Dr Angela Li Ping Chow, angela_chow@ttsh.com.sg

ABSTRACT
Chikungunya is a re-emerging mosquito-borne viral infection that has spread from East Africa to Indian Ocean islands and re-emerged in India since 2004. In Malaysia, chikungunya re-emerged after a hiatus of seven years, causing a localised outbreak in a north-western coastal town in 2006 and subsequently widespread outbreaks in 2008. Since the first local outbreak of chikungunya in Singapore in January 2008, chikungunya infections have been increasingly reported in Singapore. In this case series, five patients aged 37–62 years, with chikungunya infection confirmed in August 2008, were reported. Three of the five were male, and only one had medical comorbidities. Two had a travel history to Johor, Malaysia, where local outbreaks of chikungunya had been reported. Fever, arthralgia and rash were the most common symptoms. Fever lasted four to five days while viraemia lasted four to 11 days, persisting two to three days after defervescence in three patients. A biphasic pattern of fever was observed in two patients. Leucopenia was noted in all patients, while mild thrombocytopenia and transaminitis occurred in three of five patients. Two patients had persistent polyarthralgia at two to three weeks after the onset of symptoms. Fever, arthralgia and rash should prompt consideration of acute chikungunya in Singapore. While taking the travel history, doctors should be mindful that indigenous chikungunya cases can occur.

Keywords: arbovirus, arthralgia, chikungunya, infection outbreaks, mosquito-borne viral infection
Singapore Med J 2009; 50(8): 785-790

Agarwal AK, Gupta S, Bhattacharya N, Guha G, Agarwal A
Correspondence: Dr Akhilesh Kr Agarwal, akhil2u@rediffmail.com, akhil_g_2002@yahoo.com

ABSTRACT
Introduction Block dissection of inguinal lymph nodes is done in cases of malignant inguinal lymphadenopathy, which requires the removal of skin where it is involved, or elevation of the flaps which have precarious blood supply leading to necrosis. Thus, wound closure presents a big challenge. It can be done either by primary closure which is frequently complicated by necrosis, or by split thickness skin graft which is complicated by rejection on radiotherapy. Another option is to cover the wound by a vascularised pedicled graft. This prospective study was conducted after obtaining clearance from the ethical committee. The results were compared with the accepted complication rates of the operation.
Methods  We presented our experience of coverage of wounds after block dissection of inguinal lymph nodes for malignant deposits in 15 patients (with median age of 46 years) by pedicled tensor fascia lata thigh flap.
Results The results following the surgery were good. Healing was satisfactory in all 15 cases. There were two cases of marginal flap necrosis, and three cases developed lymphoedema which was managed by stockings. There were two cases of infection which were settled by antibiotics. There were three cases of loss of a small area of skin graft at the donor site. There was no reported case of recurrence in the inguinal region.
Conclusion This technique of coverage of the defect after inguinal block dissection is easy with predictable good results.

Keywords: groin malignancy, inguinal block, dissection, tensor fascia lata flap, vascularised pedicled graft
Singapore Med J 2009; 50(8): 781-784