2009

Su JW, Chua YL, Ong BH, Lim CH
Correspondence: Dr Jang Wen Su, bottle1001@yahoo.com

ABSTRACT
Malignant peripheral nerve sheath tumour (MPNST) is a rare occurrence in the mediastinum. It is biologically aggressive and is generally resistant to chemoradiation therapy. The mainstay of treatment is complete surgical resection. We report a large MPNST which invaded into the adjacent aortic wall in a 50-year-old man. Extensive resection, which included aortic reconstruction under cardiopulmonary bypass and deep hypothermic arrest, was necessary for a good long-term outcome.

Keywords: aortic reconstruction, cardiopulmonary bypass, malignant mediastinal peripheral nerve sheath tumour, mediastinal nerve sheath tumour, phrenic nerve tumour
Singapore Med J 2009; 50(6): e199-e200

Chong VH, Lim KS
Correspondence: Dr Vui Heng Chong, chongvuih@yahoo.co.uk

ABSTRACT
Tuberculosis (TB) infection is still common and remains an important cause of morbidity and mortality, particularly in underdeveloped and developing nations. The gastrointestinal (GI) tract is the sixth commonest extrapulmonary site to be affected after lymphatic, genitourinary, bones and joints, miliary and meningeal involvement. Manifestations can be non-specific and mimic many conditions, including malignancies. Findings from endoscopy and radiological imaging are myriad, and depend on the stage of the disease and the time at which investigations are carried out. Hence, diagnosis can be difficult. Endoscopy is now the investigation of choice as it allows for visualisation and the sampling of tissue for histology and culture. This is complemented by radiological imaging. This pictorial essay reviews some of the endoscopic and radiological findings of non-human immunodeficiency virus associated proven GI TB infections that we have encountered in a tertiary referral centre.

Keywords: colonic tuberculosis, gastrointestinal tuberculosis, intestinal infection, oesophageal tuberculosis, tuberculosis
Singapore Med J 2009; 50(6): 638-646

Behera B, Mathur P, Das A, Kapil A
Correspondence: Dr Purva Mathur, purvamathur@yahoo.co.in

ABSTRACT
Introduction Infections caused by multidrug-resistant organisms such as extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae have come to assume widespread proportions. Carbapenems (imipenem and meropenem) are the drugs of choice for the treatment of infections caused by ESBL-producing organisms. There is limited clinical data regarding the efficacy of the latest carbapenem, called ertapenem, against these organisms in the Indian subcontinent. In this study, ertapenem susceptibility in ESBL-producing clinical isolates was evaluated. The in vitro activities of the three carbapenems were compared in ertapenem-resistant isolates.
Methods A total of 205 ESBL-producing Enterobacteriaceae collected from inpatients and outpatients at the All India Institute of Medical Sciences, were identified and tested for antimicrobial susceptibility by the disc diffusion method and Vitek 2 advanced expert system. Ertapenem susceptibility was performed by disc diffusion and Vitek 2 in all the isolates and by E-test in 100 isolates.
Results 191 (93 percent) of the ESBL-producing isolates tested were susceptible to ertapenem. All ertapenem-susceptible isolates were also susceptible to imipenem and meropenem. Isolates with low-level ertapenem resistance retained their susceptibility to imipenem and meropenem, whereas those with high-level ertapenem resistance were resistant to both imipenem and meropenem.
Conclusion Our results suggest that ertapenem may be a viable alternative to other carbapenems for the treatment of infections caused by ESBL-producing clinical isolates. Clinical outcome studies are required to determine if ertapenem is effective for the treatment of infections caused by these organisms.

Keywords: Enterobacteriaceae, ertapenem, extended spectrum ß-lactamase, multidrug-resistant organisms
Singapore Med J 2009; 50(6): 628-632

Jain A, Agrawal BK, Varma M, Jadhav AA
Correspondence: Mrs Anuradha Jain, anushokjain@yahoo.co.in

ABSTRACT
Introduction The present study was conducted to assess the association between smoking, dietary intake of antioxidants and plasma indices of oxidative stress and antioxidant defences in male smokers (cigarette and bidi smokers).
Methods The study sample consisted of 100 healthy men, including 50 non-smokers and 50 smokers, who were subclassified into 25 cigarette smokers and 25 bidi smokers, aged 18–55 years. Erythrocyte superoxide dismutase and plasma ascorbic acid were measured as antioxidants and erythrocyte malondialdehyde as an oxidative stress index, by colorimetric methods.
Results Smokers ate less fruits and vegetables than non-smokers, leading to them having a lower antioxidant level. Erythrocyte superoxide dismutase was significantly lower in cigarette smokers (0.193 U/mgP, p-value is less than 0.05) and bidi smokers (0.169 U/mgP, p-value is less than 0.001) as compared to non-smokers (0.231 U/mgP). Plasma ascorbic acid was also significantly lower in cigarette smokers (1.45 mg/100ml, p-value is less than 0.05) as well as in bidi smokers (1.38 mg/100ml, p-value is less than 0.001) as compared to non-smokers (1.73 mg/100ml). There was a significant increase in erythrocyte malondialdehyde concentration levels in cigarette smokers (171.47 µmol/gHb, p-value is less than 0.05) as well as in bidi smokers (231.04 µmol/gHb, p-value is less than 0.001) as compared to non-smokers (127.30 µmol/gHb).
Conclusion These results provide enough evidence of increased oxidative stress and a compromised antioxidant defence system in smokers, and they are more profound in bidi smokers than in those smoking cigarettes. This study also revealed that the diet and nutrient intake of smokers are different from that of non-smokers.

Keywords: antioxidants, ascorbic acid, bidi smokers, cigarette smokers, erythrocyte malondialdehyde, oxidative stress, superoxide dismutase
Singapore Med J 2009; 50(6): 624-627

Chong VH
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk

ABSTRACT
Introduction Fasting during the month of Ramadan is one of the five holy pillars in the Islamic faith and is an obligation for all its followers. Prolonged fasting may precipitate or exacerbate gastrointestinal (GI) complaints. This study assessed the impact of Ramadan on referrals for upper GI endoscopy in a tertiary referral centre.
Methods 1,661 patients referred to the centre a month before, during and a month after the month of Ramadan over a four-year period (2004–07) were retrospectively studied. Significant endoscopic findings were taken as any bleeding lesions, severe or complicated oesophagitis, peptic ulcer disease, portal hypertension related pathologies and malignancies.
Results Overall, there was significantly less workload generated during the fasting month (397 patients, 5.7 +/- 2.7 cases per list) compared to before (603 patients, 6.9 +/- 3.0 cases per list, p-value is equal to 0.036) and after (661 patients, 7.8 +/- 3.4 cases per list, p-value is less than 0.001) the fasting month. There was no significant difference between the period before and after the fasting month (p-value equal to 0.124). There were no significant differences in the mean age and gender of the patients. During the fasting month, there were differences in the ethnicity (fewer Malays and more Chinese, p-value is equal to 0.002) and referral sources (more wards and fewer clinics, p-value is less than 0.001). There were no differences in the referral indications, oesophageal and gastric findings, but there was a significant difference in the duodenal findings (p-value is equal to 0.001), especially ulcer disease, during the fasting month.
Conclusion This study showed that significantly less workload was generated during the fasting month of Ramadan compared to the non-fasting months. There were also some differences in the referral sources, ethnicity and the endoscopic findings.

Keywords: endoscopy referrals, fasting, gastrointestinal bleeding, Ramadan
Singapore Med J 2009; 50(6): 619-623

Emam AA, Gad AM, Ahmed MM, Assal HS, Mousa SG
Correspondence: Dr Ahmed Alsayed Emam, ahmedemam6@hotmail.com

ABSTRACT
Introduction Patients with diabetic neuropathy have an imbalance, which comes with a higher risk of falls. The aim of this study was to assess posture stability using computerised dynamic posturography in type 2 diabetics mellitus patients with neuropathy as well as its relation to glycaemic control.
Methods 54 type 2 diabetics mellitus patients with peripheral neuropathy were recruited, together with 18 type 2 diabetics mellitus patients without peripheral neuropathy acting as the control group. The first group was divided into two subgroups according to glycaemic control assessed by HbA1c (A1c), the first subgroup comprising 24 patients had good glycaemic control with A1c less than or equal to seven percent and the second subgroup with 30 patients had poor glycaemic control with A1c more than 7 percent. The postural stability was evaluated using dynamic posturography.
Results The composite equilibrium score, sensory organisation test 1, 2 and 3 conditions were significantly lower in the neuropathic group as compared to the non-neuropathic group (p-value is less than 0.001). A1c was significantly correlated with the composite equilibrium score in the neuropathic group with poor glycaemic control (r-value equal to -0.395) but not correlated in the neuropathic group with good glycaemic control ( r-value equal to 0.151).
Conclusion Posture instability in type 2 diabetic patients with peripheral neuropathy reflects an impairment of the somatosensory system; also, poor glycaemic control resulted in more posture instability. The early detection of imbalance using dynamic posturography and achieving good glycaemic control may be of great help in the prevention of falls in such patients.

Keywords: glycaemic control, computerised dynamic posturography, diabetes mellitus, glycaemic control, peripheral neuropathy, type 2 diabetes mellitus
Singapore Med J 2009; 50(6): 614-618