2009

Ong LC, Kanaheswari Y, Chandran V, Rohana J, Yong SC, Boo NY
Correspondence: Prof Ong Lai Choo, onglc@ppukm.ukm.my

ABSTRACT
Introduction The early identification of asphyxiated infants at high risk of adverse outcomes and the early selection of those who might benefit from neuroprotective therapies are required. A prospective observational study was conducted to determine if there were any early clinical, neuroimaging or neurophysiological parameters that might predict the outcome in term newborns with asphyxia.
Methods 44 term newborns with acute asphyxia had a cranial ultrasonography (US), electroencephalography (EEG) and clinical examination performed between three and eight hours of life to determine the parameters that might predict outcome. US findings were classified as normal or abnormal (ventricular dilatation or compression and/or focal/diffuse echogenicities). EEG background activity was classified into two categories:normal/mildly abnormal/intermediate, or severely abnormal (low voltage activity or “suppression-burst”). An intrapartum score (based on graded abnormalities of foetal heart monitoring, umbilical arterial base deficit and five-minute Apgar score) and a hypoxic ischaemic encephalopathy (HIE) score (based on graded abnormalities of the neurological and respiratory status at 3–8 hours of life) was also obtained.
Results At one year of life, eight infants had died, six had defaulted follow-up, five had major impairment, two minor impairment and 23 were normal. On univariate analysis, poor outcome (death or major impairment) was associated with abnormal cranial US, severely abnormal EEG and a high HIE score (greater than or equal to 15). The positive predictive value was 54.5, 100 and 100 percent, respectively, while the negative predictive value was 93.8, 80.6 and 80.6 percent, respectively. Combining these factors did not improve the predictive values.
Conclusion There was no added advantage in combining EEG or US parameters over a clinical neurological scoring system alone in predicting the outcome of asphyxiated term newborns.

Keywords: asphyxia, cranial ultrasonography, electroencephalography, neonatal asphyxia, newborn
Singapore Med J 2009; 50(7): 705-709

Chuckpaiwong B, Harnroongroj T
Correspondence: Dr Bavornrit Chuckpaiwong, chuck003@gmail.com

ABSTRACT
Introduction Doing repetitive push-ups is among the most common exercise for the upper body and shoulder stabiliser muscle strength training. However, adverse effects such as neck pain, back pain, palmar pain and wrist pain have been reported. To date, to our knowledge, palmar pressure when performing push-ups has not been previously reported. We hypothesised that various hand positions during push-ups may provide different palmar pressures.
Methods Bilateral palmar pressures were recorded in ten individual volunteers. All the subjects were set up for doing push-ups in five positions of the hand. Peak palmar pressure was recorded by Emed pressure platform system (Novel GmBH, Munich, Germany). The palm was divided into the following five anatomic regions, viz. thenar, lunate, hypothenar, metacarpals and fingers. Statistical comparison between the five positions of the hand was analysed using the analysis of variance test.
Results A distribution of the mean peak pressure of the lunate and hypothenar areas were relatively higher than the other areas in both standby and full-elbow flexion positions. At the palmar position 30 cm wider than the shoulder width, the palmar pressure revealed significantly higher peak pressure in the lunate area in the standby and fully-flexed elbow positions (p-value is less than 0.05). At the palmar position 10 cm narrower than the shoulder width, palmar pressure showed significantly higher peak pressure in the hypothenar area only in the fully-flexed elbow position.
Conclusion The information regarding palmar pressures while performing push-ups in different hand positions may be used as a guideline for exercise modification, especially in injured athletes.

Keywords: exercise complication, palmar pain, palmar pressure, push-up exercise, sports injury, wrist pain
Singapore Med J 2009; 50(7): 702-704

Lojanapiwat B, Weerusawin T, Kuanprasert S
Correspondence: Dr Lojanapiwat Bannakij, blojanap@mail.med.cmu.ac.th

ABSTRACT
Introduction Vascular disease is the major underlying cause of erectile dysfunction (ED). Endothelial dysfunction acts as a marker of “peripheral vascular disease” that occurs prior to clinical vascular disease. ED is the first clinical manifestation of endothelial disease due to the small size of the penile artery. Brachial flow-mediated vasodilation (FMD) is one of the accurate tests for evaluating endothelial function. We compared the endothelial function by FMD between ED patients without clinical signs of vascular disease and non-ED patients.
Methods 41 ED patients and 30 age-matched normal control subjects were assessed for cardiovascular risks and endothelial function. We measured the FMD in order to evaluate the endothelial function, by comparing the percentage change of the brachial arterial diameter after the brachial arterial occlusion.
Results There were no significant differences in baseline characteristics, cardiovascular risks and lipid values between both groups, except that the high-density lipoprotein cholesterol was higher in the control group. The percentage change of the FMD was 8.7 +/- 1.0 percent and 5.1 +/- 0.6 percent in ED patients and control subjects, respectively (p-value is 0.007).
Conclusion ED is the first clinical presentation of sub-clinical endothelial dysfunction disease prior to the appearance of clinical cardiovascular disease or cardiovascular risk factors. ED can be the sentinel marker of early cardiovascular and other systemic vascular diseases and it should thus be employed in preventive strategies.

Keywords: brachial flow-mediated vasodilation, cardiovascular disease, endothelial dysfunction disease, erectile dysfunction, sentinel marker
Singapore Med J 2009; 50(7): 698-701

Koh E, Devendra K, Tan LK
Correspondence: Dr Elisa Koh, elisakoh@gmail.com

ABSTRACT
Introduction Over 125,000 women die of postpartum haemorrhage (PPH) each year, with the commonest cause being uterine atony (75–90 percent). Failing conservative management, hysterectomy is usually the final resort. In 1997, Christopher B-Lynch devised an innovative technique to treat uterine atony, and it has been widely used around the world since its original report. However, there are hardly any reports of this technique being utilised in East Asian countries, including Singapore. Our study reviews the cases in which the B-Lynch suture was used to treat uterine atony, and the clinical outcomes of these cases.
Methods A retrospective study of data of all women who delivered between May 2004 and June 2007 was collected from the department’s database, to identify patients who had undergone the B-Lynch procedure. Primary PPH is defined as a blood loss of more than 500 ml at or within 24 hours of delivery.
Results There were a total of 5,470 deliveries during this period, with primary PPH occurring in 100 cases. The B-Lynch procedure was performed in seven women, avoiding the need for a hysterectomy in five cases.
Conclusion Our series of cases treated with the B-Lynch procedure showed that it is an effective method of containing PPH. It has the advantage of being applied easily and rapidly, and should be taught to all trainees and registrars in obstetrics. It should be attempted when conservative management of PPH fails and before any radical surgery is considered.

Keywords: B-Lynch suture, hysterectomy, postpartum haemorrhage, uterine atony
Singapore Med J 2009; 50(7): 693-697

Agarwal S, Zaman T, Handa R
Correspondence: Dr Rohini Handa, rohinihanda@hotmail.com

ABSTRACT
Introduction Disease-modifying anti-rheumatic drugs (DMARDs) currently form the mainstay of treatment of rheumatoid arthritis (RA). We aimed to evaluate the retention rates of “therapeutic segments” of DMARDs in patients with RA.
Methods This was a cross-sectional study of RA patients with at least one year of follow-up. A therapeutic segment is said to begin when one DMARD combination is instituted and it ends with a subsequent change. The disability index for each patient was calculated using a modified health assessment questionnaire. Retention rates were calculated using the Kaplan Meier survival analysis.
Results 375 DMARD courses in 102 patients were analysed. 99 courses were being continued at the time of the study and hence were censored for the purposes of analysis. The respective median (interquartile range [IQR]) retention period for segments containing methotrexate (MTX), sulfasalazine, hydroxychloroquine and leflunomide was 28 (15–45), 12 (3–20), 18 (9–24), 15 (4–32) months. The log-rank statistical test indicated that MTX was retained longer singly (median [IQR] 43 [32–70] months) than in combination (median [IQR] 19 [10–24] months) (p-value is 0.001). The commonest reason for the discontinuation of the DMARD segment was the disease “slipping out” of control (51.1 percent) followed by adverse effects (24.3 percent). Treatment termination on account of disease control was encountered in 16.3 percent of courses only. As many as 63 percent of single DMARD segments were changed because of disease “slip out” as compared to 41 percent of combination DMARD segments. Adverse effects were a more frequent cause of termination of the combination segments (32 vs. 15 percent).
Conclusion MTX, used singly, had the highest retention rates among all the DMARDs used in RA patients. Disease “slip out” and adverse effects frequently required a change of the therapeutic segment.

Keywords: disease-modifying anti-rheumatic drugs, methotrexate, retention rate, rheumatoid arthritis, therapeutic segment
Singapore Med J 2009; 50(7): 686-692

Ramakrishna CD, Khadar SA, George R, Jayaprakash VL, Sudhayakumar N, Jayaprakash K, Pappachan JM
Correspondence: Dr Joseph M Pappachan, drpappachan@yahoo.co.in

ABSTRACT
Introduction This cross-sectional study on the age-specific clinical and anatomical characteristics of mitral stenosis was conducted at the Department of Cardiology at Kottayam Medical College, South India.
Methods The clinical profile, laboratory details and transthoracic echocardiographical features of 203 consecutive patients with mitral stenosis were studied. Wilkins score was used to assess the valve morphology and the feasibility of balloon mitral valvotomy (BMV)/closed mitral valvotomy (CMV). Patients were grouped according to age, into Group I (younger than 40 years; 68 cases), Group II (40–65 years; 78 cases) and Group III (older than 65 years; 57 cases) for analysis.
Results The mean age of the patients was 53 years. History of rheumatic fever was less common in Group III (37 percent in Group I vs. 20 percent in Group III, p-value is equal to 0.05). Acute pulmonary oedema occurred commonly in Group III (six percent in Group I vs. 36 percent in Group III, p-value is less than 0.001). Incidence of ischaemic strokes increased with increasing age (three percent in Group I vs. 12 percent in Group II, p-value is equal to 0.05; 12 percent in Group II vs. 25 percent in Group III, p-value is equal to 0.05; and three percent in Group I vs. 25 percent in Group III, p-value is less than 0.001). Prevalence of atrial fibrillation (AF) increased progressively with increasing age (nine percent in Group I vs. 30 percent in Group II, p-value is less than 0.001; 30 percent in Group II vs. 64 percent in Group III, p-value equal to 0.003). Clinical features of pulmonary hypertension was highest among Group I (66 percent in Group I vs. 42 percent and 43 percent in Groups II and III, respectively, p-value is equal to 0.01). The mean duration of exertional dyspnoea, history of paroxysmal nocturnal dyspnoea, mean NYHA class, mean left atrial sizes, mean mitral valve areas and mean mitral valve gradients did not vary significantly among the three groups. Mitral valve scores were prohibitive for BMV/CMV in significant numbers of older patients (seven percent in Group I vs. 38 percent in Group II vs. 80 percent in Group III; p-value is less than 0.001).
Conclusion When compared to the trends in developed countries, the mean age at presentation of mitral stenosis is similar, but the degree of valve deformity is higher. Incidence of pulmonary oedema, AF and stroke increases with advancing age in mitral stenosis.

Keywords: atrial fibrillation, mitral stenosis, mitral valvotomy, pulmonary oedema, rheumatic heart disease, stroke
Singapore Med J 2009; 50(7): 680-685

Chang G, Luo HD, Emmert MY, Lee CN, Kofidis T
Correspondence: Dr Theo Kofidis, surtk@nus.edu.sg

ABSTRACT
Introduction Stroke is a debilitating complication of cardiac surgery. Many intraoperative and postoperative factors predict the likelihood of post-cardiac surgery stroke. We evaluated preoperative parameters, seeking correlations with adverse neurological outcome following cardiac surgery. We investigated the possibility of preoperative carotid ultrasonography to select patients for carotid endarterectomy pre-or intraoperatively.
Methods We conducted a retrospective analysis of 61 patients who suffered stroke post-cardiac surgery from 2003 to 2006. Data was collected for patient and disease characteristics, preoperative status, intraoperative events and postoperative course. Postoperative neurological complications were sub divided into three groups: mild/temporary events, moderate events such as seizures, and severe events such as stroke. A mild/temporary event was defined as a focal neurological deficit of less than 24 hours in duration.
Results A total of 2,226 cardiac cases were retrospectively evaluated. The frequency of stroke was 61 patients (2.7 percent). The mean age of these patients was 63.7 +/- 7.4 years, and 40 (65.6 percent) were males. Logistic EuroSCORE, left ventricular ejection fraction (as determined by two-dimensional echocardiogram) and aortic cross-clamp time were significantly correlated with postoperative neurological complications, with a p-value of less than 0.05 for all subgroups. There was a significant correlation between the presence of preoperative carotid disease (as proven by pre-and postoperative carotid ultrasonography) and postoperative neurological events (p-value equals 0.033). However, atrial fibrillation did not correlate with postoperative stroke.
Conclusion The stage of cardiac disease (risk factor level, ejection fraction and presence of carotid stenosis) correlates with stroke and may predict an adverse neurological outcome.

Keywords: cardiac disease, cardiac surgery, carotid endarterectomy, carotid stenosis, postoperative neurological complications, stroke
Singapore Med J 2009; 50(7): 674-679

Chan CEZ, Chan AHY, Hanson BJ, Ooi EE
Correspondence: Mr Conrad En Zuo Chan, cenzuo@dso.org.sg

ABSTRACT
There is a long history of the use of antibodies in the treatment and prophylaxis of infectious diseases, because these molecules play a critical role in directing the effector mechanisms of the immune system against the pathogens they recognise. However, the widespread application of this therapy has been hampered by allergic reactions, production costs and the availability of alternative drugs such as antibiotics. Some of these obstacles can now be overcome with advances in biotechnology, which has enabled the development of antibody-based drugs for use first in treating cancer, and recently, for treating infectious diseases. The efficacy of such antibodies has been demonstrated in various in vitro studies, animal models and clinical trials for a variety of both viral and bacterial pathogens. Antibodies appear to hold great promise as a new class of drugs against infectious diseases.

Keywords: immunotherapy, monoclonal antibody, passive immunity, therapeutic antibodies
Singapore Med J 2009; 50(7): 663-673

Peh WCG, Ng KH
Correspondence: Prof Wilfred CG Peh, smj.editor@sma.org.sg

ABSTRACT
In a scientific paper, the references serve to provide background information and allow the researcher to compare and contrast the work of others in relation to his own study. Authors are responsible for the accuracy of all references cited. The references quoted should be easily accessible and retrievable by anyone wishing to obtain further information. There is a strong preference for citing journal articles listed in PubMed. The two major reference format systems are the Vancouver and Harvard systems, with increasing preference for the Vancouver system. Authors should adhere exactly to the instructions to authors of the target journal.

Keywords: citations, medical writing, references, scientific paper
Singapore Med J 2009; 50(7): 659-662