2009

Chogtu B, Singh NP, Chawla S, Gupta U
Correspondence: Dr Bharti Chogtu, bhartimagazine@gmail.com

ABSTRACT
Introduction Diabetes mellitus is a common disorder associated with a number of metabolic abnormalities such as insulin resistance, dyslipidaemia and high blood pressure. These abnormalities are recognised risk factors for cardiovascular diseases. Insulin-sensitising drugs exert an effect on these cardiovascular risk factors. The present study was done with the objective of elucidating the differences in glycaemic control, plasma lipid levels and blood pressure in diabetic patients who were prescribed glitazones in combination with sulphonylureas.
Methods Patients were randomly assigned to receive either pioglitazone or rosiglitazone in addition to glimepiride in an open-labelled study. Fasting and postprandial blood glucose levels, glycosylated haemoglobin, fasting lipid profile and blood pressure were recorded at baseline and at various intervals until the end of the study period at 12 weeks.
Results A total of 56 patients (28 in the pioglitazone group and 28 in the rosiglitazone group) completed the study. There was no significant difference in the baseline values of various parameters between the two treatment groups. The efficacy of the two treatment groups was similar in terms of the maintenance of blood glucose levels (fasting blood glucose, p-value is 0.10; postprandial blood glucose, p-value is 0.95; glycosylated haemoglobin, p-value is 0.30) and the effect on blood pressure (systolic blood pressure, p-value is 0.45; diastolic blood pressure, p-value is 0.95), while the pioglitazone group showed significantly better efficacy in improving the lipid profile compared to the rosiglitazone group (total cholesterol, p-value is 0.002; triglycerides, p-value is 0.002; low density lipoprotein, p-value is 0.005; and high density lipoprotein, p-value is 0.43).
Conclusion The two drugs showed a similar effect on blood glucose levels and blood pressure. However, the pioglitazone group was superior to the rosiglitazone group in improving the lipid profile.

Keywords: blood pressure, diabetes mellitus, glimepiride, lipid profile, pioglitazone, rosiglitazone
Singapore Med J 2009; 50(4): 395-399

Termizy HM, Mafauzy M
Correspondence: Prof Mafauzy Mohamed, mafauzy@kb.usm.my

ABSTRACT
Introduction The increased prevalence of metabolic syndrome worldwide is closely related to the rising obesity epidemic. The objectives of the study were to determine the prevalence and identify the associated and prognostic factors that influence the risk of metabolic syndrome among obese patients attending the Obesity Clinic at Hospital Universiti Sains Malaysia.
Methods A study was conducted involving 102 obese persons who attended the Obesity Clinic from January 1 to December 31, 2005. Metabolic syndrome was defined according to the International Diabetes Federation criteria.
Results The overall prevalence of metabolic syndrome among obese patients was 40.2 percent. The prevalence was higher in females (43.7 percent) than in males (32.3 percent). The prevalence of metabolic syndrome was noted to increase with increasing body mass index class, from class 1 to class 2. However, the prevalence was lower in obesity class 3. The prevalence of metabolic comorbidities of raised blood pressure, reduced high density lipoprotein, high triglyceride and raised fasting blood glucose was 42, 40, 36 and 17 percent, respectively. A quarter of obese patients in this study had no other comorbidity. Based on logistic regression multivariable analysis, age was the only significant associated factor that influenced the risk of having metabolic syndrome.
Conclusion The prevalence of metabolic syndrome was high and the highest comorbidity was high blood pressure. Age was the only significant risk factor of having this syndrome.

Keywords: blood glucose, high density lipoprotein, metabolic syndrome, obesity, triglycerides
Singapore Med J 2009; 50(4): 390-394

Ng TH, How SH, Amran AR, Razali MR, Kuan YC
Correspondence: Dr Ng Teck Han, ngteckhan@hotmail.com

ABSTRACT
Melioidosis is caused by Burkholderia pseudomallei, a Gram-negative bacillus. Melioidosis can affect many organs, including the prostate. However, prostatic abscess due to melioidosis is uncommon. We describe five cases of melioidosis with prostatic abscess. Four of five patients had diabetes mellitus and had more than one organ involvement. The diagnosis of prostatic abscess in our patients was only made with computed tomography of the abdomen and pelvis. None of our patients underwent surgical drainage and all remained well after treatment with antibiotics, except for one mortality secondary to severe septicaemia.

Keywords: Burkholderia pseudomallei, melioidosis, melioidotic prostatic abscess, prostatic abscess
Singapore Med J 2009; 50(4): 385-389

Boonsarngsuk V, Tansirichaiya K, Kiatboonsri S
Correspondence: Dr Viboon Boonsarngsuk, bss-vb@hotmail.com

ABSTRACT
Introduction This study aimed to determine the prevalence and risk factors of drug-resistant tuberculosis (TB), and to develop a diagnostic algorithm for newly-diagnosed TB patients.
Methods This is a retrospective medical chart review of 290 patients who were diagnosed with bacteriological-proven pulmonary TB between 2000 and 2006 in Ramathibodi Hospital, Thailand. Patient characteristics, radiological and microbiological findings, as well as a history of previous TB disease and treatment, were included in the analysis of predictive factors of drug resistance. Predictive scores were derived from statistically significant factors at the cut-off point of the receiver-operating curve that yielded the best area under the curve.
Results The resistance rate to each of these drugs among 290 patients was: isoniazid, 6.9 percent; rifampicin, 4.5 percent; either isoniazid or rifampicin, 9.0 percent; and multidrug resistance, 2.4 percent. Far advanced TB was an independent risk factor for isoniazid resistance. Rifampicin resistance was associated with recurrent TB within six months after the completion of treatment and prior incomplete TB treatment. A drug-resistant TB predictive score of either isoniazid or rifampicin resistance was developed based on the aforementioned factors. The cut-off score of greater than or equal to 3 yielded the least error of classification in differentiating patients with the resistant strain from those with the susceptible strain at a sensitivity of 57.7 percent, a specificity of 67.8 percent, a positive predictive value of 15 percent and a negative predictive value of 94.2 percent.
Conclusion Our study suggested a drug-resistant TB predictive score for the exclusion of either isoniazid or rifampicin resistance, and provides a decisional guide for the clinician on whether to send a patient’s respiratory specimen for sputum culture and drug susceptibility testing.

Keywords: drug-resistant tuberculosis, drug susceptibility testing, tuberculosis
Singapore Med J 2009; 50(4): 378-384

Hsien YC, Abdullah MS, Telesinghe PU, Ramasamy R
Correspondence: Prof Ranjan Ramasamy, ramasamy@im.ubd.edu.bn

ABSTRACT
Introduction Little or no information is available on the prevalence of nasopharyngeal carcinoma (NPC) among different ethnic groups in Brunei, or how useful plasma IgA antibodies are against viral capsid antigen (VCA) and early antigen (EA) in the diagnosis of NPC, even though they are routinely measured in patients suspected to have NPC.
Methods The National Cancer Registry at Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital was used to identify NPC patients diagnosed between 2000 and 2006. Clinical data and antibody test results for 38 NPC patients and for nine patients suspected of NPC but later diagnosed as negative for NPC by biopsy (control group) were obtained from the Oncology and Histopathology Departments at RIPAS Hospital.
Results The annual incidence rates for NPC among the major ethnic groups in Brunei were determined and compared to data from Singapore and Peninsular Malaysia. The most significant finding was that the average annual incidence of NPC among Bruneian Chinese males (4.1 per 100,000 persons) was significantly lower than that for Chinese males from Singapore (15.9) and Peninsular Malaysia (19.6). IgA anti-VCA and IgA anti-EA were sensitive and specific to NPC in Brunei in accordance with studies elsewhere. The measurement of IgA antibodies against VCA by ELISA was the better serological test for NPC. However, many stage IV NPC cases did not possess IgA anti-VCA and IgA anti-EA.
Conclusion Determining the factors that are responsible for a lower incidence of NPC among Chinese males in Brunei Darussalam may be useful for formulating measures to reduce NPC incidence elsewhere. The possible tendency for the loss of IgA antibodies against VCA and EA in advanced stages of NPC needs to be established with a larger number of patients, and the causes elucidated, in order to better understand the disease process in NPC.

Keywords: cancer biomarkers, cancer epidemiology, Epstein-Barr virus antigens, IgA antibodies, nasopharyngeal carcinoma
Singapore Med J 2009; 50(4): 371-377

Chan A, Lim LLC, Tao M
Correspondence: Dr Alexandre Chan, phaac@nus.edu.sg

ABSTRACT
Introduction Recombinant erythropoietin-stimulating agents have been used to ameliorate the symptoms of anaemia in cancer patients. However, there have been concerns about an increased risk of thromboembolic events and mortality. This study reviews the usage of epoetin alfa in treating chemotherapy-induced anaemia at the National Cancer Centre Singapore (NCCS), as well as the prescribing and monitoring practices employed.
Methods Cancer patients who have received at least one dose of epoetin alfa at the NCCS between January 1, 2005 and October 15, 2007 were included in this study.
Results A total of 121 patients were identified and 91 patients were eligible for data collection. The majority of patients manifested breast cancer (30.8 percent) and ovarian cancer (15.4 percent). Over 90 percent of the patients were receiving either chemotherapy or radiotherapy when epoetin alfa was initiated. Epoetin alfa was initiated at a median haemoglobin level of 8.7 (range 7–14.3) g/dL. Approximately 41.8 percent of the patients had a positive response after the initiation of epoetin alfa. Baseline iron studies were performed in 12.1 percent of the patients. Blood pressure was uncontrolled, according to the Singapore Ministry of Health Hypertension guideline, in a substantial number of patients (32.6 percent) prior to the initiation epoetin alfa. There were no documented thromboembolic events.
Conclusion This study identified a broad range of practices in the utilisation of epoetin alfa at NCCS, which may explain the variable patient response to epoetin alfa. The results of this study will be used to improve the management of chemotherapy-induced anaemia at the institution.

Keywords: anaemia, cancer, epoetin alfa, erythropoietin-stimulating agent, recombinant erythropoietin-stimulating agent
Singapore Med J 2009; 50(4): 365-370

Kumar P, Kaman L, Singh G, Singh R
Correspondence: Dr Lileswar Kaman, kamanlil@yahoo.com

ABSTRACT
Introduction Nonoperative measures using an oral water soluble contrast agent is a significant development in the management of patients with postoperative small bowel obstruction.
Methods In this prospective randomised trial, patients were randomised into two groups: Group A patients were given an oral water soluble contrast agent and Group B patients were managed conventionally. Surgery was performed as and when indicated. The end-points of the study were to evaluate the time interval between admission and relief of obstruction, the length of hospital stay and the need for surgery.
Results Of a total of 41 patients, 21 were in Group A and 20 were in Group B. The mean age of Group A patients was 40.48 +/- 14.96 years and it was 43.40 +/- 16.33 years for Group B patients (p-value is 0.553). There were 17 males and four females in Group A, and 14 males and six females in Group B (p-value is 0.441). In Group A, 14 patients had relief of obstruction after administration of the contrast material, and the mean time for relief of obstruction was 7.47 hours. In Group B, 18 patients had relief of obstruction and the time interval was 35.20 hours (p-value is less than 0.001). The mean length of hospital stay was 3.43 +/- 1.08 days for Group A and 5.33 +/- 2.95 days for Group B (p-value is 0.029). Seven patients in Group A and two in Group B were operated on (p-value is 0.071).
Conclusion Administration of an oral water soluble contrast agent in postoperative small bowel obstruction helps in the earlier resolution of the obstruction and decreases the length of hospital stay.

Keywords: intestinal obstruction, nonoperative management of bowel obstruction, postoperative small bowel obstruction, small bowel obstruction
Singapore Med J 2009; 50(4): 360-364

Wang E, Kow AWC, Chan CY, Liau KH, Ho CK
Correspondence: Mr Ho Choon Kiat, choon_kiat_ho@ttsh.com.sg

ABSTRACT
Introduction Laparoscopic hepatectomy has been performed in many overseas centres. By avoiding long incisions associated with open hepatectomies, patients suffer less pain, recover faster and enjoy a shorter hospital stay. In Singapore, many centres have recently embarked on this approach. We believe that careful patient selection can facilitate scaling the learning curve. The aim of this study was to review our centre’s initial outcome with laparoscopic anatomical liver resection when stringent selection criteria were applied.
Methods For our initial experience, we based our patient selection on criteria recommended by centres more experienced with laparoscopic hepatectomy. We selected only patients with small lesions confined to Couinaud’s liver segments of II, III, IVB, V and VI. The surgical technique was similar in all cases, including intraoperative ultrasonography for localisation, ultrasonic shears and surgical staplers for parenchymal transection, and delivery of the specimen via a Pfannenstiel incision. No hand ports were used. Patients’ records were retrospectively reviewed.
Results Between July 2006 and August 2007, we had five consecutive patients. Their median age was 50 (range 36–66) years. Four of these patients had hepatocellular carcinomas and one had a liver abscess. The median operation time was 275 (range 250–290) minutes, and median intraoperative blood loss was 400 (range 200–700) ml. The median hospital stay was four days.
Conclusion At the initial stages of a laparoscopic hepatectomy programme, we propose that a stringent patient selection criteria coupled with the proper surgical expertise can ensure favourable outcomes, comparable to more established centres.

Keywords: hepatectomy, laparoscopic hepatectomy, laparoscopy, liver surgery, liver tumour
Singapore Med J 2009; 50(4): 354-359

Chew MH, Suzanah N, Ho KS, Lim JF, Ooi BS, Tang CL, Eu KW
Correspondence: Prof Kong Weng Eu, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction Colorectal cancer (CRC) is a leading cause of morbidity and mortality with human and financial costs. Screening by faecal occult blood test (FOBT) has proven to be effective in decreasing mortality from CRC in both randomised trials and case-control studies. We report on the results of a CRC screening event using quantitative FOBT (QFOBT) held in Singapore.
Methods The mass screening event was held over two days, and participants 40 years or older without prior screening performed in the preceding year were eligible. Those with significant symptoms or medical comorbidities were excluded. Stool sampling was done with two issued immunochemical QFOBT kits, and participants with positive stool samples with equal or greater than 100 ng haemoglobin/ml sample solution in any two samples were advised to have a colonoscopy screening conducted.
Results A total of 1,048 participants took part in the screening event. 222 (21 percent) of the participants claimed to have some abdominal symptoms prior to screening. 49 participants (26 males, 23 females) tested positive for QFOBT and 47 were evaluated. 10 (21 percent) had polyps and one case of colorectal cancer was detected. Seven of these cases had significant neoplasia (lesions 1 cm or larger) and were treated. Two patients required surgery.
Conclusion Our study demonstrates wide variation in the attitudes of participants who turned up for screening. In addition, the number of significant colorectal neoplasia patients (14 percent) in those with positive QFOBT provides further evidence of the importance of screening with a potential reduction in CRC mortality. Continuous education of the public in events such as this, is essential to improving attitudes towards screening.

Keywords: cancer screening, colorectal cancer, faecal occult blood test, quantitative faecal occult blood test
Singapore Med J 2009; 50(4): 348-353

Poongothai J, Gopenath TS, Manonayaki S
Correspondence: Dr Poongothai Sakthivel, poongothai_jp@yahoo.co.in

ABSTRACT
Infertility is defined as a failure to conceive in a couple trying to reproduce for a period of two years without conception. Approximately 15 percent of couples are infertile, and among these couples, male factor infertility accounts for approximately 50 percent of causes. Male infertility is a multifactorial syndrome encompassing a wide variety of disorders. In more than half of infertile men, the cause of their infertility is unknown (idiopathic) and could be congenital or acquired. Infertility in men can be diagnosed initially by semen analysis. Seminograms of infertile men may reveal many abnormal conditions, which include azoospermia, oligozoospermia, teratozoospermia, asthenozoospermia, necrospermia and pyospermia. The current estimate is that about 30 percent of men seeking help at the infertility clinic are found to have oligozoospermia or azoospermia of unknown aetiology. Therefore, there is a need to find the cause of infertility. The causes are known in less than half of these cases, out of which genetic or inherited disease and specific abnormalities in the Y chromosome are major factors. About 10–20 percent of males presenting without sperm in the ejaculate carry a deletion of the Y chromosome. This deleted region includes the Azoospermia Factor (AZF) locus, located in the Yq11, which is divided into four recurrently deleted non-overlapping subregions designated as AZFa, AZFb, AZFc and AZFd. Each of these regions may be associated with a particular testicular histology, and several candidate genes have been found within these regions. The Deleted in Azoospermia (DAZ) gene family is reported to be the most frequently deleted AZF candidate gene and is located in the AZFc region. Recently, a partial, novel Y chromosome 1.6-Mb deletion, designated “gr/gr” deletion, has been described specifically in infertile men with varying degrees of spermatogenic failure. The DAZ gene has an autosomal homologue, DAZL (DAZ-Like), on the short arm of the chromosome 3 (3p24) and it is possible that a defective autosomal DAZL may be responsible for the spermatogenic defect. The genetic complexity of the AZF locus on the long arm of the Y chromosome could be revealed only with the development of sequence tagged sites. Random attacks on the naked mitochondrial DNA (mtDNA) of sperm by reactive oxygen species or free radicals will inevitably cause oxidative damage or mutation to the mitochondrial genome with pathological consequences and lead to infertility in males. The key nuclear enzyme involved in the elongation and repair of mtDNA strands is DNA polymerase gamma, mapped to the long arm of chromosome 15 (15q25), and includes a CAG repeat region. Its mutation affects the adenosine triphosphate production.The introduction of molecular techniques has provided great insight into the genetics of infertility. Yet, our understanding of the genetic causes of male infertility remains limited.

Keywords: genetic counselling, infertility, oligozoospermia, semen analysis, Y chromosome
Singapore Med J 2009; 50(4): 336-347