2009

Lamri-Senhadji MY, El Kebir B, Belleville J, Bouchenak M
Correspondence: Prof M Bouchenak, mbouchenak@netcourrier.com

ABSTRACT
Introduction During the month of Ramadan, fasting is obligatory for all healthy adult Muslims, with the only exempted adults being those who have to travel or are sick. The aim of this study was to see whether changes in food intake and meal patterns during Ramadan fasting could modify serum lipid and lipoprotein parameters in healthy Algerian young men and women volunteers. The time-course prospective study was done in order to investigate at what time eventual changes to these parameters occur during Ramadan and their disappearance after Ramadan.
Methods Subjects were interviewed by trained interviewers using the method of the “seven day recall and record”, before, during and after Ramadan. The serum lipid and lipoprotein contents were analysed at different times.
Results The total energy intake was higher during Ramadan (13 and 11 MJ/day) than before and after Ramadan (11 and 9 MJ/day) in men and women, respectively. In the second week of Ramadan, carbohydrate intake was elevated by 22 percent and 24 percent in men and women, respectively, compared to before and after Ramadan. At the end of Ramadan, the low density lipoproteins (LDL) percentages decreased by 20 percent in women and 55 percent in men compared to the values obtained before Ramadan. In both groups, the amount of serum high density lipoproteins (HDL) was 1.4-fold higher, in particular on day 28 of Ramadan, in comparison with the period before and after Ramadan. Indeed, a progressive decrease in LDL-C was noted in women and was particularly drastic in men. In contrast, HDL-C had increased by 30 percent on day 15 of Ramadan, compared to before Ramadan.
Conclusion This study shows that striking changes in nutritional habits during Ramadan may be useful in reducing LDL levels and in increasing HDL levels. The young Muslim’s diet during Ramadan may contribute to favourable modifications of the serum lipoprotein profile related to cardiovascular protection.

Keywords: cholesterol, dietary consumption, lipids, lipoproteins, Ramadan
Singapore Med J 2009; 50(3): 288-294

Tan VKM, Tan SG
Correspondence: Dr Veronique KM Tan, vquetan@gmail.com

ABSTRACT
Introduction The aim of this study was to describe an original technique of using ultrasound-guided foam sclerotherapy in the long saphenous veins (LSV) for the treatment of varicose veins, and report the early results.
Methods Only patients with lower limb varicose veins and demonstrable incompetent saphenofemoral junction with reflux down the LSVs underwent ultrasound-guided injection of foam sclerosant into the LSV. Foam sclerosant was made by the Tessari’s method using three percent sodium tetradecyl sulphate to air in a 1:3 ratio. The LSV was accessed below the knee with a micropuncture set. A Headhunter angiographic catheter was cut to length and advanced over a guide wire to the saphenofemoral junction (SFJ). With the patient in the Trendelenburg position and the leg raised, the SFJ was manually compressed and foam was injected into the Headhunter catheter while the tip was withdrawn. Direct ultrasound visualisation ensured accurate catheter placement.
Results 66 lower limbs in 62 patients were treated in the manner described above. The diameter of the treated LSV ranged from 4 to 13.4 mm. Ultrasound duplex assessment one day post-treatment showed complete occlusion in 62 veins (94 percent). Early complications included superficial thrombophlebitis, skin pigmentation, cellulitis and thrombosis of the superficial femoral vein.
Conclusion Immediate results using our method of ultrasound-guided foam sclerotherapy showed a high obliteration rate of the LSV.

Keywords: foam sclerotherapy, long saphenous vein, ultrasound-guided sclerotherapy, varicose veins
Singapore Med J 2009; 50(3): 284-287

Yeo YYC, Lee SK, Lim CY, Quek LS, Ooi SBS
Correspondence: Dr Cindy Yeo Ying Ying, cindy.yeo@nathealthgroup.com

ABSTRACT
Introduction The elderly population in Singapore is steadily increasing, thus increasing the stress on healthcare provision and financing. Elderly injuries result in significant mortality and morbidity. This study aimed to identify the injury patterns, specific risk factors involved and needs of the elderly so that the current emergency model of care for the injured elderly can be improved and injury prevention strategies devised.
Methods We conducted a retrospective study of all elderly aged 65 years and older seen for trauma in an emergency department over six months. Data captured in the real-time computer system was studied with regard to patient profile, mechanism of injury and patient disposition.
Results 720 patients aged 65 years and older were seen for trauma in the first six months of 2005, accounting for 10.4 percent of the total attendance for that age group. Home injuries (67.9 percent) were the most common, followed by road-related injuries (21.2 percent). 85.3 percent of the injuries were due to falls. 49.9 percent of the patients were admitted to hospital. We also examined the underlying causes of the injuries and the common injuries sustained.
Conclusion Injuries in the elderly is a significant problem. Most of the injuries occur at home and falling is the commonest cause. Many of the injuries are potentially preventable. Several possible injury prevention strategies and improvements to the current emergency model of care of the injured elderly are discussed. The establishment of a national elderly injury surveillance database is advocated.

Keywords: elderly injuries, emergency department, falls, geriatric injuries, trauma
Singapore Med J 2009; 50(3): 278-283

Ling ZJ, Lian WB, Ho SKY, Yeo CL
Correspondence: Dr Lian Wee Bin, lian.wee.bin@sgh.com.sg

ABSTRACT
Introduction Current medical advances have increased the survival rate of the premature infant with its complications. Risk factors for prematurity include maternal diabetes mellitus, hypertension, smoking and alcohol intake.
Methods A true/false questionnaire survey focusing on risk factors, outcomes/follow-up and costs was administered to adults attending a parenting-related public forum. One point was awarded per correct answer. Entire prematurity knowledge and section T-scores were calculated, (a pass mark was defined as at least 50 percent for each T-score). Missing answers and affected T-scores were considered invalid.
Results There were 81 respondents: predominantly within 21–40 years of age, Chinese, female, public-housing dwellers, first-time parents-to-be and with graduate or higher-level qualifications. A pass in entire and prematurity knowledge T-scores was achieved in 69 percent (median 13 [range 3–21]) and 62 percent (median 12 [range 0–19]) respectively. A pass in section T-scores on risk factors, outcomes and costs was achieved in 62, 53 and 75 percent, respectively. Awareness of risks and outcomes did not correlate with awareness of costs. Logistic regression did not reveal any factors contributing to a pass or higher T-scores.
Conclusion Although the majority achieved a pass in all T-scores, general knowledge among this childbearing group was deemed inadequate by the median scores. As survival improves, awareness of prematurity and its risks has to be improved, with a target to reduce the incidence of prematurity and to support those infants who require resource-intensive follow-up.

Keywords: antenatal care, infants, neonatal risk factors, parental knowledge, preterm labour
Singapore Med J 2009; 50(3): 270-277

Suzana S, Cham BG, Ahmad Rohi G, Mohd Rizal R, Fairulnizal MN, Normah H, Fatimah A
Correspondence: Dr Suzana Shahar, suzanas@medic.ukm.my

ABSTRACT
Introduction The purpose of this study was to assess the relationship between selenium status and intake among breast cancer patients from the Klang Valley.
Methods 64 cases and 127 controls were matched for age (range 30–65 years) and ethnicity, with an 80 percent study power. Subjects were interviewed to obtain information on their habitual dietary intakes, demographic data and medical history. Selenium status was determined from toenail and hair analysis using an inductively coupled plasma mass spectrometer.
Results The nutrient analysis showed that total energy and protein intake was significantly higher among controls (1,403 +/- 367 kcal/day, 75.6 +/- 33.2 g/day) as compared to cases (1,273 +/- 295 kcal/day, 60.9 +/- 19.1 g/day) (p-value is less than 0.05). The selenium intake among cases (78.47 +/- 25.34 µg/day) was significantly lower than the controls (89.34 +/- 36.85 µg/day) (p-value is less than 0.05). Breast cancer risk decreased with the increasing quartiles of selenium intake, with odds ratios (95 percent confidence interval) of 2.95 (1.22–7.12), 2.17 (1.13–4.19) and 1.71 (0.84–3.52), respectively. However, the association diminished after adjustment for confounding factors. Selenium in hair did not differ among cases and controls, but selenium status in the nails of controls was significantly higher as compared to cases (p-value is less than 0.05). Breast cancer risk decreased with the increasing quartiles of toenail selenium status as measured in the toenail and hair.
Conclusion Selenium intake and status was associated with breast cancer risk. Thus, it is essential for Malaysian women to achieve a good selenium status by consuming good food sources of selenium as a chemopreventive agent.

Keywords: selenium, breast cancer, cancer risk factors, case-control studies, chemopreventive agent, selenium intake
Singapore Med J 2009; 50(3): 265-269

Tang IP, Shashinder S, Gopala Krishnan G, Narayanan P
Correspondence: Dr Ing Ping Tang, ingptang@yahoo.com

ABSTRACT
Introduction This is a retrospective study that aimed to examine the outcomes of patients presenting with juvenile nasopharyngeal angiofibroma (JNA) at a tertiary centre in Malaysia.
Methods The demographical data, clinical presentation, investigations as well as treatment of 13 JNA patients were reviewed and collected from the medical record office at our centre from 1995 to 2005.
Results All JNA patients were male and the average age at diagnosis was 17 (range 14–28) years. They presented with recurrent painless spontaneous epistaxis, nasal obstruction, nasal discharge, a reduced sense of smell, snoring, headache and facial swelling. One patient was at stage I, eight were at stage II, three at stage III and one patient was at stage IV, based on the Fisch classification. Angiography showed that nine tumours were supplied by both internal maxillary arteries of the external carotid system, and only four tumours received blood supply from the ipsilateral internal maxillary artery. All 13 patients underwent primary surgical resection. The overall recurrence rate was 38.5 percent for the first procedure and 60 percent for the second procedure. No major complications occurred in this group of patients as a consequence of treatment, neither for the primary tumours nor for the recurrences.
Conclusion JNA is a rare vascular benign tumour with highly exclusive persistence and recurrence, and typically affects adolescent boys. The management of JNA presents a challenge to ENT surgeons. Preoperative angiography and embolisation minimise intraoperative blood loss and the current shift in the treatment to endoscopic excision in selected lesions reduces perioperative morbidity.

Keywords: angiofibroma, juvenile nasopharyngeal angiofibroma, nasopharyngeal tumour
Singapore Med J 2009; 50(3): 261-264

Tan HH, Lee GH, Thia KTJ, Ng HS, Chow WC, Lui HF
Correspondence: Dr Hui-Hui Tan, tan.hui.hui@sgh.com.sg

ABSTRACT
Introduction Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients.
Methods The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile).
Results Baseline characteristics were: age 52.9 +/- 11.0 years; Child’s A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child’s scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE.
Conclusion It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.

Keywords: cirrhosis, hepatic encephalopathy, minimal hepatic encephalopathy
Singapore Med J 2009; 50(3): 255-260

Chong E, Poh KK, Shen L, Chai P, Tan HC
Correspondence: Dr Eric Chong, ericchong80@hotmail.com

ABSTRACT
Introduction We hypothesised that diabetic patients with normal baseline renal impairment who do not receive prophylaxis before percutaneous coronary intervention (PCI) are at an increased risk of developing contrast-induced nephropathy (CIN).
Methods We conducted a cohort study involving 839 patients who underwent PCI between 2004 and 2006, and divided them into three groups: Group A (304 diabetics with normal baseline serum creatinine [Cr] of less than 1.5 mg/dL); Group B (465 non-diabetics with normal Cr); Group C (70 patients with impaired baseline renal function with Cr more than or equal to 1.5 mg/dL). CIN prophylaxis, including oral N-acetylcysteine and saline hydration, were administered only to Group C patients.
Results The median age for Groups A, B and C was 58, 56 and 64 years, respectively. The prevalence of hypertension in Groups A, B and C was 76.3, 56 and 85.7 percent, respectively. Baseline demographics were comparable among the three groups with regard to gender, left ventricular systolic function and contrast volume use. Incidences of CIN in Groups A, B and C were 8.9 percent, 4.3 percent and 4.5 percent, respectively (p-value is 0.042). The incidence of CIN in diabetic patients with a normal baseline Cr who did not receive prophylaxis (Group A) was significantly higher than in the other two groups (p-value is less than 0.001).
Conclusion Our findings suggest that diabetic patients, despite having a normal baseline Cr, are at an increased risk of developing CIN post-PCI. Routine prophylaxis in this cohort may be beneficial.

Keywords: contrast-induced nephropathy, diabetes mellitus, percutaneous coronary intervention, renal function
Singapore Med J 2009; 50(3): 250-254

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

ABSTRACT
Illustrations (also known as figures) are visual representations of the results obtained from a scientific study. Graphs are a common type of illustration that are often used in scientific papers to present information clearly and effectively, as well as to demonstrate relationships between variables in the data. Graphs also serve to reveal trends or patterns in the data. This article provides some basic guidelines to assist authors in preparing effective graphs for their papers.

Keywords: figures, graphs, illustrations, medical writing, scientific paper
Singapore Med J 2009; 50(3): 245-249

Durai R
Correspondence: Mr Rajaraman Durai, dr_durai@yahoo.com

ABSTRACT
Colonic pseudo-obstruction is often confused with mechanical intestinal obstruction. It occurs when there is an autonomic imbalance resulting in sympathetic over-activity affecting some part of the colon. The patient is often elderly with numerous comorbidities. Once mechanical obstruction is excluded by contrast enema, the patient should be treated conservatively with nasogastric and flatus tubes for at least 48 hours, and precipitating factors should be treated. When pseudo-obstruction does not settle with waitful watching, prokinetic agents and/or colonoscopic decompression can be tried. When there is a risk of impending perforation of the caecum from massive colonic dilatation and colonic ischaemia, it should be dealt with by caecostomy or hemicolectomy. In spite of available medical and surgical interventions, the outcome remains poor.

Keywords: caecostomy, colonic pseudo-obstruction, intestinal pseudo-obstruction, neostigmine, Ogilvie’s syndrom
Singapore Med J 2009; 50(3): 237-244