2009

Siddiqi A, Khan DA, Khan FA, Razzaq A
Correspondence: Dr Dilshad Ahmed Khan, saadbinqamar@hotmail.com

ABSTRACT
Introduction Amikacin is a commonly-prescribed drug used for the empirical treatment of bacterial infections in neonates. A marked change in the pharmacokinetics of amikacin has been reported during neonatal life. Amikacin has a very narrow therapeutic range and can cause very serious side effects such as nephrotoxicity and ototoxicity. The current therapeutic dose of amikacin, i.e. 15 mg/kg of body weight, may increase the risk of toxicity in preterm infants with immature renal functions. We aimed to determine the frequency of amikacin toxicity in preterm as compared to term infants by measuring its serum trough levels following the administration of the current therapeutic dose.
Methods A comparative study was conducted at the neonatal intensive care unit of the Military Hospital, Rawalpindi, Pakistan. A total of 104 infants (52 term and 52 preterm) receiving amikacin at a dose of 15 mg/kg of their body weight, once daily for bacterial infection, were included. After clinical evaluation, serum creatinine levels were measured at admission and on the third day. Amikacin trough levels were taken after 72 hours of therapy and measured on the TDx Abbot Drug Analyser.
Results The gestational age range was 37–40 weeks in term and 29–36 weeks in preterm infants. The term and preterm infants had a median weight of 2.8 kg and 2.1 kg, respectively. The preterm infants had significantly higher median (range) 11.33 (1.50–42.60) ug/ml levels of serum amikacin as compared to 8.5 (2.8–33.0) ug/ml in term infants (p-value is less than 0.01). The preterm infants had a high frequency of toxic 32 (62 percent) and subtherapeutic 12 (23 percent) levels, as compared to 11 (21 percent) and 5 (10 percent) in term infants, respectively. Serum amikacin levels revealed a positive correlation with post-dose serum creatinine (r equals 0.48; p-value is less than 0.05).
Conclusion This study demonstrated that the current practice of amikacin treatment for bacterial infection needs to be adjusted due to unique pharmacokinetic variability in preterm infants. There is a need for regular therapeutic drug monitoring and renal function assessment in all infants receiving amikacin therapy in order to avoid nephrotoxicity.

Keywords: amikacin, bacterial infection, neonatal sepsis, nephrotoxicity, serum trough levels, therapeutic drug monitoring
Singapore Med J 2009; 50(5): 486-489

Torkaman M, Afsharpaiman S, Hoseini MJ, Moradi M, Mazraati A, Amirsalari S, Kavehmanesh Z
Correspondence: Dr Shahla Afsharpaiman, safshar@razi.tums.ac.ir

ABSTRACT
Introduction Sepsis is a common complication in the neonatal intensive care unit. It is most common in the smallest and most premature infants in whom the clinical presentation can be subtle and nonspecific. The objectives of the present study were to identify the most common organisms causing sepsis and their associations with thrombocytopenia.
Methods This is a retrospective case analysis of blood culture positive patients between March 2003 and July 2007 in a single centre. We enrolled 53 eligible neonates whose blood culture yielded positively for any organism. Blood for the culture was obtained from a peripheral vessel. The data was analysed for differences in platelet and neutrophil count in terms of the microorganisms causing sepsis using chi-square and Fisher’s exact tests, analysis of variance and Kruskal-Wallis, as appropriate.
Results The most common organism in the blood culture was Enterobacter spp. with 21 cases (39.6 percent) and the least common was coagulase-positive Staphylococcus spp. The most common organisms in infants with normal weight and early onset sepsis were coagulase-positive Staphylococcus spp. (50 percent and 36.7 percent, respectively), while in other neonates with low birth weight, very low birth weight and late onset sepsis, the most common organism was Enterobacter spp. (40.9 percent, 71.4 percent and 47.8 percent, respectively). The patients with Enterobacter spp. sepsis had a higher incidence of thrombocytopenia. The mortality rate was 15.1 percent (8/53 cases), which was significantly higher among those with the Enterobacter spp. sepsis (five cases, p-value is 0.033).
Conclusion Our study shows the changes in the pattern of late onset neonatal infections in the neonatal intensive care unit. Enterobacter spp. is the most common organism causing neonatal sepsis accompanying thrombocytopenia.

Keywords: Enterobacter spp., neonatal infection, neonatal sepsis, thrombocytopenia
Singapore Med J 2009; 50(5): 482-485

Low SY, Eng P
Correspondence: Dr Su-Ying Low, low.su.ying@sgh.com.sg

ABSTRACT
Introduction Infection with human immunodeficiency virus (HIV) is the most well-known risk factor for the development of tuberculosis (TB). The joint statement by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America recommends that all patients with TB undergo testing for HIV infection after counselling. We looked at physician compliance with this recommendation in Singapore.
Methods A retrospective review of the case records of all patients diagnosed with microbiologically-proven TB between September 2005 and December 2006 (inclusive) at the Singapore General Hospital was conducted.
Results Between September 2005 and December 2006, 493 patients were diagnosed with tuberculosis at our institution. HIV testing was performed in 184 patients (37.3 percent), of whom 15 (8.2 percent) was seropositive. Univariate analysis showed that an age equal to or younger than 60 years, male gender, non-pulmonary tuberculosis, inpatient location at diagnosis, and having an infectious diseases physician as the attending doctor were all significantly associated with HIV testing (p-value is less than 0.05).
Conclusion Compliance with HIV testing in all newly-diagnosed tuberculosis patients is poor, with less than 40 percent of patients being tested at our institution. We need to address the factors associated with failure to test, and reinforce to our physicians the importance of HIV testing in these patients.

Keywords: acquired immunodeficiency syndrome, human immunodeficiency virus, pulmonary tuberculosis, tuberculosis
Singapore Med J 2009; 50(5): 479-481

Phua HP, Chua AVL, Ma S, Heng D, Chew SK
Correspondence: Dr Stefan Ma, stefan_ma@moh.gov.sg

ABSTRACT
Introduction The Singapore Burden of Disease (SBoD) Study 2004 provides a comprehensive and detailed assessment of the size and distribution of health problems in Singapore. It is the first local study to use disability-adjusted life years (DALYs) to quantify the total disease burden.
Methods The SBoD study applied the methods developed for the original Global Burden of Disease study to data specific to Singapore to compute the DALYs. DALY is a summary measure of population health that combines time lost due to premature mortality (years of life lost [YLL]) with time spent in ill-health (broadly-termed disability) arising from incident cases of disease or injury (years of life lost due to disability [YLD]). DALYs, stratified by gender and age group, were calculated for more than 130 specific health conditions for the Singapore resident population for the year 2004.
Results In 2004, diabetes mellitus, ischaemic heart disease and stroke were the top three leading causes of premature death and ill-health in Singapore, and together accounted for more than one-quarter (28 percent) of the total disease burden (in DALYs). Morbidity burden (YLD) was responsible for 52 percent of the total DALYs, with diabetes mellitus, anxiety and depression, and Alzheimer’s disease and other dementias being the main sources of the total YLDs. Ischaemic heart disease, stroke and lung cancer were the major contributors to the premature mortality burden (YLL).
Conclusion This study provides an objective and systematic assessment of the fatal and nonfatal health conditions in Singapore to support priority setting in public health policies and research.

Keywords: burden of disease, morbidity, population health problems, premature mortality, public health
Singapore Med J 2009; 50(5): 468-478

Ng CL, Tambyah PA, Wong CY
Correspondence: Mr Ng Chew Lip, ngchewlip@gmail.com

ABSTRACT
Introduction Medical tuition fees have been rising in many countries, including in Singapore. No formal study has been conducted to evaluate the financial situation of medical students in relation to the cost of medical education in Singapore. This study was conducted to determine the financial profile of Singaporean medical students and the financial expenses they incur over the five-year duration of their undergraduate medical course.
Methods A questionnaire study was conducted among Year one to Year five medical students in the Yong Loo Lin School of Medicine, National University of Singapore. The following quantifiable parameters were analysed: monthly household income, financial assistance, monthly allowances and expenses.
Results 64.3 percent (735) of the 1,143 undergraduates completed the survey. 21.9 percent came from families with a monthly income of less than S$3,000, with another 26.2 percent from families with monthly incomes of S$3,000–S$5,000. The total tuition fees for a five-year medical course amounted to S$87,450. The average annual expenditure of medical students amounted to S$4,470. 31.1 percent of respondents were on loans. 14.6 percent received scholarships or bursaries.
Conclusion A five-year medical course can cost more than S$100,000 and pose a significant financial burden for students. The proportion of students who came from lower-income families was lower in medical school than at the national level, while the proportion from high-income families was significantly higher than at the national level. A significant proportion of students took loans to pay for tuition, and a smaller percentage was under scholarships and bursaries. More substantial financial assistance is required, particularly for students from lower-income families.

Keywords: education costs, medical education, medical student
Singapore Med J 2009; 50(5): 462-467

Ng KH, Peh WCG
Correspondence: Prof Ng Kwan Hoong, dwlng@tm.net.my

ABSTRACT
The discussion section comprises the last component in the IMRAD system. The purpose of this section is to provide the interpretation of the results obtained, explain the implications of the findings, state study limitations and make suggestions for future research. This is a critical part of the scientific paper, as it places the particular study within the broader context of how the research contributes to improving diagnosis, treatment or patient care.

Keywords: conclusion, discussion, medical writing, scientific paper
Singapore Med J 2009; 50(5): 458-461

Campbell AV
Correspondence: Prof Alastair V Campbell, medavc@nus.edu.sg

ABSTRACT
The last fifty years have seen an upsurge in both the number of ethical dilemmas confronting the medical profession and an interest in ethics in both lay and professional circles. The first editor of this journal saw the subject as critical for medical practice, though he did not suppose that the perfect day of medical ethics would ever dawn. Taking the human body as a focus, this editorial surveys three currently controversial areas of medical ethics in Singapore: organ donation, cosmetic medicine and the separation of conjoined twins. As always in ethics, there are no simple answers, but we can get a clearer view of the values involved by recognising that we are embodied persons and so a due respect for the human body has to be a central feature of all medical care. The perfect day of medical ethics still has not dawned, but we have perhaps made some progress over the last half century.

Keywords: conjoined twins, cosmetic surgery, embodiment, ethics, medical ethics, organ transplantation
Singapore Med J 2009; 50(5): 451-455

Shiva Prasad BN, Balasubramanian R
Correspondence: Dr Shiva Prasad BN, drshivaravi@yahoo.co.in

ABSTRACT
Upper airway disease, especially nasal and paranasal sinus involvement, is the most common manifestation of Wegener’s granulomatosis. Chronic otitis media and facial palsy are rare but well known presenting features of Wegener’s granulomatosis. We report a 40-year-old woman who presented with complaints of ear discharge, deep-seated ear pain and loss of hearing in her right ear. Early diagnosis demands heightened suspicion in a patient with otological symptoms and facial paralysis.

Keywords: chronic otitis media, facial nerve palsy, hearing loss, Wegener’s granulomatosis
Singapore Med J 2009; 50(4): e155-e157

Tew CW, Han FC, Jureen R, Tey BH
Correspondence: Dr Tew Chee Wee, tewcheewee@hotmail.com

ABSTRACT
We present the first reported case of Aspergillus vertebral osteomyelitis and epidural abscess in Singapore in a 50-year-old man with post-tuberculous bronchiectasis. The patient presented with acute urinary retention and flaccid paraplegia. Despite surgical debridement and treatment with voriconazole, the patient developed multiorgan failure and died two weeks after presentation. Early diagnosis and prompt initiation of treatment are emphasised in the hope of improving the outcome of this aggressive condition.

Keywords: Aspergillus spp., epidural abscess, osteomyelitis, vertebral osteomyelitis
Singapore Med J 2009; 50(4): e151-e154