2009

Awd Allah RS, Dkhil MA, Farhoud E
Correspondence: Dr Mohamed Abdel-Monem Dkhil, mohameddkhil@yahoo.com

ABSTRACT
Introduction An investigation was carried out to determine the morphological characteristics of fibroblasts in two portions of the vocal fold (VF) mucosa, the macula flava (MF) and Reinke’s space (RS), of three different age groups: newborns, adults and geriatrics.
Methods Normal human VF obtained from autopsy cases were included in this study: four from mature newborns; four from middle-aged adults; and four from geriatric cases. Fibroblasts in RS and MF were investigated by transmission electron microscopy.
Results The fibroblasts of the MF in both adults and newborns tended to be stellate in shape, with a small nucleus/cytoplasm (N/C) ratio and a well-developed rough endoplasmic reticulum (rER) and Golgi apparatus (GA). Most of the fibroblasts present in RS were oval in newborns and spindle-shaped in adults, with a large N/C ratio and less developed rER and GA. The majority of fibroblasts of the geriatric MF were stellate in shape; while in geriatric RS, the majority of fibroblasts were spindle-shaped with an N/C ratio of 0.5 to 2.0 as in the case of adults. However, the development of rER and GA was less marked in geriatrics than in adults.
Conclusion Histological changes of fibroblasts in the VF mucosa are one of the important causes of the change in voice quality with ageing. Furthermore, geriatric changes in the vocal ligament can be attributed to the activities and the presence of ageing processes in fibroblasts of geriatric VF mucosa.

Keywords: fibroblasts, human vocal fold mucosa, macula flava, Reinke’s space
Singapore Med J 2009; 50(2): 201-207

Gupta PP, Yadav R, Verma M, Gupta KB, Agarwal D
Correspondence: Dr Prem Parkash Gupta, gparkas@yahoo.co.in

ABSTRACT
Introduction In recent years, there has been increasing interest in diagnosing various components of chronic obstructive pulmonary disease (COPD) using high-resolution computed tomography (HRCT). The present study was undertaken to evaluate HRCT features in patients with COPD.
Methods 40 male patients with COPD (age 40 years or older) and with a significant smoking history (20 pack-years or more) were included in the study. They were evaluated for HRCT features including vascular attenuation and distortion, mosaic attenuation pattern, directly visible small airways, low attenuation areas of emphysema and measures of hyperinflation of the lungs: tracheal index, sterno-aortic distance, thoracic cage ratio and thoracic cross-sectional area.
Results The tracheal index ranged from 0.46 to 0.94; Saber-sheath trachea was found in 14 patients. The mean thoracic cage ratio at two levels, carina and 5 cm below carina, were 0.69 (range 0.61–0.78) and 0.73 (range 0.62–0.83), respectively. Sterno-aortic distance at carinal level ranged from 1.43 to 4.55 cm, with a mean of 3.00 cm. Directly visible small airways was the commonest finding (36 patients), followed by vascular attenuation (25 patients), mosaic attenuation pattern (16 patients) and vascular distortion (8 patients). Among various subtypes of emphysema, centriacinar emphysema was commonest (16 patients), followed by paraseptal (13) and panacinar emphysema (11).
Conclusion There are certain specific HRCT features of emphysema and it is possible on HRCT to identify the subtypes of emphysema, such as centriacinar, panacinar and paraseptal emphysema. Various features of hyperinflation can also be well identified and quantified on HRCT.

Keywords: chronic bronchitis, chronic obstructive pulmonary disease, emphysema, high-resolution computed tomography
Singapore Med J 2009; 50(2): 193-200

Noshad H, Sadreddini S, Nezami N, Salekzamani Y, Ardalan MR
Correspondence: Dr Hamid Noshad, hamidnoshad1@yahoo.com

ABSTRACT
Introduction Ever since peritoneal dialysis (PD) was introduced as a form of renal replacement therapy, its efficacy and complications have been compared with that of haemodialysis (HD). The aim of this study was to determine the efficacy and outcome of PD in comparison to HD in our region.
Methods We compared 60 patients on PD with 60 matched patients on HD in Tabriz’s Sina Hospital during the period 2004–2006. The technique, patients’ survival and quality of life were compared by means of a health-related quality-of-life questionnaire (GHQ-28).
Results There was no significant difference in the mean age and duration of dialysis between patients on PD and HD. Survival of diabetic patients was better with HD than PD, but in non-diabetic patients, there was no difference in the survival rates between the two groups. Among patients on PD, diabetics had a 25 percent higher mortality rate and non-diabetic patients had a three percent higher mortality rate than their corresponding counterparts on HD. In all four axes of the questionnaire, i.e. psychophysical dysfunction, stress and sleep disorders, social dysfunction and major depression, PD patients had lower scores than HD patients (p-values are less than 0.001, less than 0.001, equal to 0.002 and less than 0.001, respectively), indicating that patients on PD had a better quality of life compared to those on HD.
Conclusion In this study, technique, patients’ survival and their quality of life were better on PD than on HD. However, survival and mortality of diabetic patients on HD were better than those on PD.

Keywords: haemodialysis, peritoneal dialysis, quality of life
Singapore Med J 2009; 50(2): 185-192

Roudbari M, Roudbari S, Fazaeli A
Correspondence: Dr Masoud Roudbari, mroudbari@yahoo.co.uk

ABSTRACT
Introduction The practice of breastfeeding, an important need for infants, can be affected by several factors that need to be investigated. This study was designed to survey the patterns and period of breastfeeding and its associated factors in women.
Methods The study was performed in Zahedan, southeast Iran, in 2004–2005, with a sample of 450 mothers via a questionnaire to collect information about the period of breastfeeding and some important factors concerning both mothers and children.
Results The exclusive breastfeeding ratio obtained from this study was 98 percent. The proportion of breastfeeding in months 1, 3, 6, 12 and 24 after birth were 92 percent, 85 percent, 69 percent, 56 percent and 8 percent, respectively. The median breastfeeding period was 15 months, with a standard error of 1.17. The period of breastfeeding showed a significant relationship with the age of the children and mothers, the mothers’ education level, night breastfeeding, breastfeeding to an ill child, breastfeeding during a mother’s illness and the frequency of breastfeeding per 24 hours. The Cox regression also confirmed a significant relationship between the period of breastfeeding and the above-mentioned variables, except for mother’s education level and breastfeeding to an ill child.
Conclusion Young pregnant women need to be aware of the importance of breastfeeding and of avoiding the reduction or interruption of the breastfeeding period. It is recommended that the health authorities incorporate training and education programmes as well as healthcare measures to their family health programmes in order to overcome the problems of insufficient breastfeeding.

Keywords: breastfeeding patterns, breastfeeding period, health programme, pregnancy
Singapore Med J 2009; 50(2): 181-184

Jahanfar S, Lye MS, Rampal L
Correspondence: Dr Shayesteh Jahanfar, jahanfar2000@yahoo.com

ABSTRACT
Introduction The aim of this study was to investigate the knowledge, attitudes and behaviour of university students regarding acquired immunodeficiency syndrome (AIDS) and the human immunodeficiency virus (HIV).
Methods A randomised controlled trial of 530 university students was done using peer-adult facilitators. Participants completed a questionnaire before and after the intervention, which was a four-hour group session. A prevention programme was developed by local experts, health educators and peer facilitators. The peer-adult-led programme was designed to provide a conceptual model of HIV risk reduction through information, motivational and behavioural skills, a harm reduction module and health promotion theme.
Results The main outcome measured was the level of knowledge, attitudes and behaviour scores. The results suggest that relative to the control group, participants in the intervention group had higher levels of knowledge (30.37 vs. 25.40; p-value is 0.001) and a better attitude (12.27 vs. 10.84; p-value is 0.001). However, there was no difference in the behavioural score (9.47 vs. 9.41; p-value is 0.530). The correlation between the level of knowledge and age and the level of education was found in the intervention group, but not in the control group (p-value is 0.01). Attitude and gender were found to be correlated in the intervention group only (p-value is 0.01).
Conclusion Our programme was successful in increasing knowledge and improving attitudes towards AIDS and HIV. However, it did not improve risk-taking behaviour. Peer-adult-led educational programmes for youth using various interactional activities, such as small group discussions, poster activity and empathy exercises, can be successful in changing the prevailing youth perceptions of AIDS and HIV.

Keywords: acquired immunodeficiency syndrome, health education, human immunodeficiency virus, sexually-transmitted disease
Singapore Med J 2009; 50(2): 173-180

Tian HH, Ong WS, Tan CL
Correspondence: Dr Tian Ho Heng, roger_tian@cgh.com.sg

ABSTRACT
Introduction Nutritional supplements used by athletes can be classified as sports food, dietary supplements and ergogenic aids. The aim of this study was to examine the use of such supplements among university athletes in Singapore.
Methods 82 athletes from 16 sport disciplines completed a questionnaire which sought information on demographical parameters, type of supplements, frequency of use, motivations, knowledge, expenditure and side effects.
Results The prevalence of supplement use was 76.8 percent and 20 different products were used. Each individual consumed a mean and standard deviation of 3.18 ± 1.7 products over a 12-month period. The mean number of products consumed daily was 2.1 ± 1.2. Popular products included sports drinks, vitamin C, multivitamins and traditional/herbal preparations such as essence of chicken, bird’s nest and ginseng. Before using a product, 65.9 percent sought information, usually from the media, the Internet, coaches and fellow athletes. However, many did not know where to obtain reliable information and 86.4 percent were also unaware that supplementation can have adverse effects.
Conclusion Although there is a high prevalence of supplement use in our study population, many do not have accurate information about these products. Hence, there is an urgent need to provide athletes with education and access to scientific and unbiased information.

Keywords: dietary supplements, ergogenic aids, nutritional supplements, sports food
Singapore Med J 2009; 50(2): 165-172

Tan NC, Tay IH, Ngoh A, Tan M
Correspondence: Dr Tan Ngiap Chuan, tan.ngiap.chuan@singhealth.com.sg

ABSTRACT
Introduction The Written Asthma Action Plan (WAAP) educates patients on the early recognition and treatment of deteriorating asthma. It has been adopted in Singapore polyclinics and restructured hospitals in the past few years as recommended by the Singapore National Asthma Programme. Local asthma patients can choose to be treated by family physicians at public polyclinics or by private general practitioners (GPs). In a previous study, half of the physicians in primary care self-reported that they formulated an asthma action plan for their patients, but little is known about their actual practices. This qualitative study explored family physicians’ views of WAAP and its implementation in primary care in Singapore.
Methods Qualitative data was obtained for 29 participants from polyclinics, GP clinics or locum doctors at five separate focus group discussions. The data was coded using NVivo-7 software, audited and analysed to identify emergent themes.
Results The participants generally perceived the usefulness of WAAP. While WAAP was widely used in polyclinics, GPs rarely used it. Even in polyclinics, usage varied and was associated with participants’ training and practice of WAAP and task substitution to nurses. They perceived that WAAP would benefit only selected motivated patients who could understand and use it. They were hampered by language barriers in educating their multiracial patients and the perceived lack of time related to patient loads in polyclinics. The GPs lacked training and practice, role models and relied on verbal instructions as a personalised form of care delivery.
Conclusion Family physicians generally perceived WAAP as useful, but implementation was hampered by lack of training and practice, language barriers and perceived benefits for patients.

Keywords: asthma, family physician training, Written Asthma Action Plan
Singapore Med J 2009; 50(2): 160-164

Boo NY
Correspondence: Prof Nem-Yun Boo, nemyun_boo@imu.edu.my

ABSTRACT
Introduction The neonatal resuscitation programme (NRP) published by the American Academy of Paediatrics and American Heart Association was launched in Malaysia in 1996. This study aimed to review the outcome of NRP in Malaysia during the first eight years.
Methods Information on basic demographical data and training activities of NRP providers were collected prospectively from NRP instructors from all over Malaysia during the eight years following the inception of the NRP. The national perinatal and neonatal mortality data during the five-year period before and eight years following implementation of the NRP were compared.
Results During the eight years following the launch, 14,575 personnel were trained. 40 percent of NRP-certified personnel worked in areas where delivery services were provided, viz. labour room, operation theatre, obstetric ward, emergency department and maternal and child health clinic. There were very few NRP-certified providers working in emergency departments and most of them were medical assistants. Most of the providers working in neonatal intensive care units (NICUs) and labour rooms were nurses while those in paediatric wards were doctors. All NRP-certified doctors working in NICUs and labour rooms obtained full certificates. Only 80 percent of NRP-certified nurses in these two areas obtained full certificates. There was further serial decrease in perinatal mortality and neonatal mortality rates in Malaysia during the years following the launch of the NRP programme.
Conclusion The launch of the Malaysian NRP was associated with further improvement in perinatal and neonatal mortality rates.

Keywords: neonatal mortality rates, neonatal resuscitation programme
Singapore Med J 2009; 50(2): 152-159

Sumathi B, Ramalingam S, Navaneethan U, Jayanthi V
Correspondence: Dr Udayakumar Navaneethan, navaneur@ucmail.uc.edu

ABSTRACT
Introduction Stomach cancer is the third most common cancer in South India. A higher incidence has been reported from certain states in northern India, where potential risk factors have been identified. Similar data is available only to a limited extent from southern India. The aim of this case-control study was to evaluate the effects of lifestyle habits and dietary factors on the risk of gastric cancer in South Indians.
Methods A hospital-based case-control study of matched pairs was conducted in Chennai, India, from 2002 to 2006 in a large tertiary care referral centre in South India. We studied 89 gastric cancer patients and 89 age- and gender-matched healthy controls of the same socioeconomic status. All subjects were interviewed face-to-face by a trained interviewer using a structured questionnaire to collect data about lifestyle habits, such as cigarette smoking, alcohol consumption, tobacco chewing and dietary factors, with special attention to known factors like salted fish, smoked and pickled foods as well as intake of vegetables and fruits.
Results The response rate was 100 percent. There were 64 male and 25 female patients. The male to female ratio was 2.6:1. The demographic characteristics were similar in the case and control populations. Less than ten percent of patients were below the age of 30 years. Approximately 50 percent were between 30 and 60 years of age, and the rest were over 60 years of age. Multivariate logistic regression models indicated that alcohol consumption (odds ratio [OR] 2.3, 95 percent confidence interval [CI] 1.1–4.9, p-value is 0.04) and consumption of pickled food (OR 1.8, 95 percent CI 1.2–3.9, p-value is 0.05) are independent risk factors for the development of gastric cancer. A protective effect of the consumption of pulses (OR 0.4, 95 percent CI 0.2–0.9, p-value is 0.05), showing a 55 percent reduction in risk, was also identified; this could be of use for possible control and prevention of this cancer. Tobacco chewing and cigarette smoking did not emerge as high risk factors for stomach cancer.
Conclusion The study showed alcohol and pickled food consumption as independent risk factors for the development of gastric cancer, while consumption of pulses were protective. Cigarette smoking did not predict an increased risk of contracting the disease.

Keywords: cancer risk factors, dietary factors, gastric cancer, stomach factors
Singapore Med J 2009; 50(2): 147-151

Manoharan S, Balakrishnan S, Menon VP, Alias LM, Reena AR
Correspondence: Dr Shanmugam Manoharan, sakshiman@rediffmail.com

ABSTRACT
Introduction Oral carcinoma accounts for 40–50 percent of all cancers in India. Tobacco chewing, smoking and alcohol consumption are the major risk factors associated with the high incidence of oral cancer in India. Our aim was to investigate the chemopreventive potential of curcumin and piperine during 7,12-dimethylbenz[a]anthra-cene (DMBA)-induced hamster buccal pouch carcinogenesis.
Methods Oral squamous cell carcinoma was developed in the buccal pouch of Syrian golden hamsters, by painting them with 0.5 percent DMBA in liquid paraffin, three times a week for 14 weeks. The tumour incidence, tumour volume and burden were determined in the buccal pouches. The status of phase II detoxification agents, lipid peroxidation and antioxidants were estimated by specific colorimetric methods.
Results We observed 100 percent tumour formation in DMBA-alone painted hamsters. Disturbances in the status of lipid peroxidation, antioxidants and phase II detoxification agents were noticed in DMBA-alone painted hamsters. Oral administration of curcumin (80 mg/kg body weight) and piperine (50 mg/kg body weight) to DMBA-painted hamsters on alternate days to DMBA painting for 14 weeks completely prevented the formation of oral carcinoma. Also, curcumin and piperine restored the status of lipid peroxidation, antioxidants and detoxifying agents in DMBA-painted hamsters.
Conclusion The chemopreventive efficacy of curcumin and piperine is probably due to their antilipidperoxidative and antioxidant potential as well as their modulating effect on the carcinogen detoxification process.

Keywords: 7,12-dimethylbenz[a]anthracene, antioxidants, buccal pouch carcinogenesis, curcumin, lipid peroxidation, oral carcinoma, piperine
Singapore Med J 2009; 50(2): 139-146