Original Article

TGHC Ferdinandis, AS Dissanayake, HJ De Silva
Correspondence: Dr T G H C, himanif@hotmail.com

ABSTRACT
Background There is at present no agreement on the type of test meal to be used when performing EGG. To our knowledge the response of the stomach to high carbohydrate isocaloric meals of different consistencies has not been formally assessed.
Aim To study 1) the effects of high carbohydrate meals of varying consistency on EGG activity; and 2) the effects of increasing the calorie content of a meal without changing its consistency and composition on the postprandial EGG.
Subjects Eighteen healthy volunteers, six males (age: 21-35 year, weight: 45-60 kg) and 12 females in the follicular phase of the menstrual cycle (age: 24-30 years, weight: 45-55 kg).
Methods Following an overnight fast subjects were given three high carbohydrate, low fat, isocaloric meals (165-170 kcal) of different consistencies (solid, semisolid, liquid), on three separate days in a random order. The liquid and semisolid meals were equal in volume (200 ml) while the volume of the solid meal was smaller. One hour EGG recordings were done in the fasting and fed states in each subject. As a second step, ten of the above volunteers (taken randomly) were given the solid test meal on a separate day after increasing the calorie content of the meal to 350 kcal.
Results The power of the EGG at the dominant frequency significantly increased after solid (175 kcal meal: fasting 49 +/- 12 dB vs. fed 57 +/- 13 dB; p < 0.05, 375 kcal meal: fasting 48.5 +/- 12.9 dB vs fed 58.1 +/- 11.7 dB) and semisolid (fasting 50 +/- 12 dB vs. fed 55 +/- 13; P < 0.05). The increase in power was not significantly different when fed with solids and semisolids. There was no statistically significant change in EGG power during the first 15 or 60 minutes after the liquid meal. Feeding showed no significant effect on the dominant frequency and the percentage of 2-4 cpm waves of the EGG with any of the three types of test meals.
Conclusion Solid and semisolid meals high in carbohydrate and low in fat are capable of inducing a significant increase in the EGG power in normal subjects. Isocaloric solid and semisolid meals have similar effects on gastric slow wave activity. EGG appears unaffected by the liquid meal. Therefore only an increase in the power of the EGG can be regarded as normal if a high carbohydrate solid or a semisolid meal is given as the test meal when performing an EGG.

Keywords: Electrogastrography, test meal consistency, gastric myoelectrical activity
Singapore Med J 2002; 43(11): 579-582

Gunsah Sahin, Candan Ozturk, Selda Bagis, Ozlem Bolgen Cimen, Canan Erdogan
Correspondence: Dr Gunsah Sahin, gunsahsahin@hotmail.com

ABSTRACT
Cytokine has been postulated to play a role in the pathogenesis of post-menopausal osteoporosis. To test this hypothesis we measured circulating levels of IL-1, IL-6,IL-8 and TNF-alpha in 98 post-menopausal women (30 age matched normal and 68 osteoporotic) with no vertebral fractures. Although the cytokine levels of patients were found in normal cut off values, the difference in cytokine levels between patients and controls was statistically significant for IL-1 and IL-8 (p < 0.01). In osteoporotic patients, none of the cytokines correlated with lumbar, femoral (neck) and total hip bone mineral densities and also with body mass index (p > 0.01). In conclusion, we were unable to demonstrate abnormalities of cytokines affecting bone resorption in peripheral serum of women with post-menopausal osteoporosis. However increased production of these cytokines may occur in the local environment of bone.

Keywords: Osteoporosis, cytokine
Singapore Med J 2002; 43(11): 576-578

KB Tan, TP Thamboo, SC Wang, Barbro Nilsson, A Rajwanshi, M Salto-Tellez
Correspondence: Dr Tan Kong Bing, pattankb@nus.edu.sg

ABSTRACT
Introduction Transthoracic fine-needle aspiration cytology (FNAC) is a useful tool for evaluating neoplastic and inflammatory lung nodules. In view of the relative paucity of published audit studies regionally, such a study was undertaken to assess the use of the technique in our centre.
Methods One hundred and fourteen FNACs were performed during 1997-1999. Immediate assessment for specimen adequacy was done. Diagnoses were correlated with clinical-pathological information and selective blind review performed.
Results Cytologically, 65.8% of cases were malignant, 1.8% were atypical, 25.4% were inflammatory/non-malignant and 7% were inadequate. Cytological-histological tumour diagnostic concordance was 94.4%. Diagnostic sensitivity for malignancy: 93.4%, specificity: 95.8%, accuracy: 94%. Eight inadequate/ benign cases (7%) proved to be malignant with clinical-pathological follow-up. Tuberculosis was confirmed (acid-fast bacilli detected) in six cases (5.3%) and suggested in a further 10 cases (8.8%). The cytological review showed 96% concordance with the original benign/malignant diagnoses. Pneumothorax rate was 18%.
Conclusion FNAC is an accurate and safe method for the evaluation of lung nodules and it enables subclassification of bronchogenic carcinomas in the vast majority of cases. It is also useful for the diagnosis of tuberculous pulmonary nodules. Immediate assessment optimises specimen adequacy; inadequate/non-malignant smears in particular, need clinical correlation, close follow-up and re-biopsy, if necessary.

Keywords: transthoracic FNAC, follow-up, cytology
Singapore Med J 2002; 43(11): 570-575

Fatimah Lateef
Correspondence: Dr Fatimah Lateef, gaefal@sgh.com.sg

ABSTRACT
The morbidity and mortality among motorcyclists involved in road traffic accidents (RTA) in Singapore is high. Due to their relatively small size, they represent a vulnerable group of road-users. Many reports from studies performed overseas have shown that both lower limb and head injuries appear to be common among motorcyclists.
Objectives To study the characteristics of lower limb injuries among motorcyclists involved in RTA, who present to the Department of Emergency Medicine of an urban, tertiary, teaching hospital for treatment.
Methods The study was conducted prospectively from 1 July 2000 to 30 June 2001. Demographic data was collected together with details of the type of injuries, mechanism involved, management and disposition. SPSS (Chicago, Inc.) was utilised for data management and statistical analysis.
Results Of the 1,809 motorcyclists studied, 1,056 (58.3%) sustained lower limb injuries, 328 (18.1%) had head injuries and 256 (14.2%), sustained facial injuries. The mean age was 26.4 +/- 7.2 years and males made up the majority of the patients (1,733, 95.8%). Helmet usage was 100%. The commonest type of lower limb injury was fractures (531, 50.3%). The most common type of fracture was that of the shaft of the tibia and fibula (231, 43.5%), followed by fractures around the ankle (186, 35.0%). For those with more than one body region injured, head injury was noted to be not commonly associated with lower limb injuries. The commonest mechanism of injury was collision with another vehicle, while approaching a turn (769, 42.5%). There were 96 motorcyclists (5.3%) who had clinical evidence of alcohol consumption on their breath at presentation. There were 533 (29.5%) patients who were admitted for in-patient management and the mean duration of stay was 4.8 +/- 4.5 days. Amongst those with lower limb injuries, the admission rate was 30.5% (322 of 1,056) and the mean duration of hospitalisation was 5.3 +/- 3.9 days.
Conclusion Lower limb injuries represent the commonest form of injury among motorcyclists involved in RTA. Improved training via motorcycle rider education, better design of future motorcycles and protective footwear may help to reduce this problem.

Keywords: motorcyclist, lower limb injury, collision, fractures, head injury
Singapore Med J 2002; 43(11): 566-569

R Poopalalingam, MH Goh, YW Chan
Correspondence: R Poopalalingam, rumini@singnet.com.sg

ABSTRACT
Objective The aim of the study was to measure the humidity and temperature of the inspired gas in a circle absorber system at fresh gas flows of 11/min and 31/min and assess the need of a heat and moisture exchanger (HME).
Methods This prospective randomised controlled study received the Hospital Ethics Committee approval and informed consent. Forty adult ASA 1 and 11 patients were randomised into four groups to receive with or without HME fresh gas flow of 1L/min or 3L/min. Temperature and the relative humidity readings were taken at the start and every 10 minutes for the first hour of anaesthesia.
Results There was a significantly higher relative humidity, absolute humidity and temperatures of the inspired gases at fresh gas flow of 1L/min and 3L/min with a HME compared to 3L/min without HME. Patients receiving fresh gas flows of lL/min had higher relative and absolute humidity than patients with fresh gas flows of 3L/min. However, the addition of the HME improved the absolute and relative humidity of the inspired gas in patients receiving fresh gas flow of 3l/min to a comparable level. However, the addition of a HME to a fresh gas flow of 1L/min did not significantly improve the humidity of the inspired gas.
Conclusion This suggests that the inherent humidifying property of the circle system at low fresh gas flow of 1L/min was sufficient in short surgeries lasting less than one hour and that the addition of a HME may not be necessary.

Keywords: Humidity, low flow anaesthesia, heat and moisture exchanger, circle anaesthetic system
Singapore Med J 2002; 43(11): 563-565

MH Tay, SL Tien, TSJ Chua, LL Sim, TH Koh
Correspondence: Dr M H Tay, dr_taymh@yahoo.com

ABSTRACT
Introduction Rapid point-of-care measurement of anticoagulation has become feasible with the advent of new portable devices and offers the potential for home monitoring. This study evaluates the accuracy and feasibility of such a point-of-care device, the ProTime analyser as compared with standard laboratory method (IL MCL2) for monitoring the International Normalised Ratio (INR) level in cardiac patients on oral anticoagulation therapy.
Materials and Methods Fifty patients were studied. The majority were male (86% versus 14%). Chinese accounted for 37(74%) whereas Malay and Indian, constituted 9(18%) and 4(8%) respectively. The mean age was 55 +/- 12 years. Prosthetic heart valve replacement (46%) and atrial fibrillation (38%) were among the main indications for anticoagulation. The mean dosage of warfarin was 3.0 +/- 1.5 mg (range 1.0 to 6.5 mg) and the INR results ranged from 0.83 to 4.69 (based on the hospital laboratory method). Fingerstick and venous blood samples were collected from every patient and subjected to analysis by ProTime and IL MCL2 analysers.
Results There was a good correlation of INRs between ProTime venous and IL MCL2 venous, ProTime fingerstick and IL MCL2 venous and ProTime venous and ProTime fingerstick samplings, with correlation coefficients (r) of 0.9248, 0.9403 and 0.9557, respectively. The Bland-Altman plot also showed a good correlation between the methods used without any systematic bias (limits of agreement ranged from -0.422 to +0.606 INR units on average).
Conclusion This rapid point-of-care device appears to have an acceptable level of accuracy for measuring INR values in the recommended target ranges in adult cardiac patients on oral anticoagulation therapy.

Keywords: Point-of-care INR test, ProTime Microcoagulation System
Singapore Med J 2002; 43(11): 557-562

DK-K Ng, K-L Kwok, G Poon, K-W Chau
Correspondence: Dr D K-K Ng, dkkng@ha.org.hk

ABSTRACT
Objective To determine the prevalence of habitual snoring and sleep bruxism in children attending the out-patient clinics of a paediatric department.
Methodology A cross-sectional survey of parents was conducted with questionnaire administered by paediatric nurses. Parents were recruited when they brought their children to the out-patient clinics. Sex and age were recorded. Presence and absence of habitual snoring and sleep bruxism were noted. Types of diseases that brought the children to the out-patient clinics were also noted.
Results Twenty-nine of the 200 recruited children were noted to have habitual snoring (14.5%, 95% C.I. 10%-20%). The mean age of these habitual snorers was 6.2 +/- 3.1 years. For habitual snorers, male to female ratio was 1.4 to 1. Sixteen of these 28 children accepted a sleep polysomnographic examination. Eleven children were found to have snoring during the night of study. Two were found to have obstructive sleep apnoea syndrome. Sleep bruxism was found in 17 children (8.5%, 95% C.I.5%-13%). Sleep bruxism was closely related to habitual snoring as 16 out of the 17 children with sleep bruxism were also habitual snorers (p < 0.0001).
Conclusion Habitual snoring and sleep bruxism were commonly found in children attending paediatric clinics. Paediatricians should be aware of these problems and be prepared to deal with them. Habitual snoring and sleep bruxism were closely related. Further studies into this relationship is needed.

Keywords: Snoring, bruxism, sleep, children
Singapore Med J 2002; 43(11): 554-556

C Tham, KF Koh
Correspondence: Dr C Tham, constham@yahoo.com

ABSTRACT
Day surgery is becoming more common due to its cost effectiveness as well as patient acceptance. With increasing caseloads, there is a need to maintain quality of care. The purpose of this study is to identify the reasons for unanticipated admissions in our day surgical population, with the aim of improving efficiency of day surgical services, yet maintaining a high standard of patient care. A retrospective review of records of patients who were admitted over the two-year study period was conducted. Unanticipated admission was defined as unplanned admission after a day surgical procedure. Data relating to physical status, perioperative complications and reasons for hospital admission were recorded. A total of 10,801 procedures were done, and 163 patients were admitted. The unanticipated admission rate was 1.5%. Most of the admissions were surgically related (62.8%), followed by anaesthesia (12.2%), social (9.5%) and medical reasons (8.1%). Seventy-five percent of these admissions were potentially preventable. The majority were due to common problems like postoperative pain, admission for surgical observation and for social reasons. Non preventable causes (25%) were mainly due to unrelated medical problems.

Keywords: day surgery, admissions, perioperative, complications
Singapore Med J 2002; 43(10): 522-526

TZ Ong, AA Raymond
Correspondence: Dr T Z Ong, OngTZ@nuh.com.sg

ABSTRACT
Background Stroke is the third most common cause of death in Malaysia.The prevalence of risk factors and predictors of mortality of stroke in Malaysia are poorly understood.
Aim To identify the prevalence of major risk factors for stroke and to determine predictors of one-month mortality.
Method Prospective study of all stroke patients admitted to Penang Hospital between December 1998 and November 1999. All patients were subjected to brain CT. Predictors of one-month mortality: systolic and diastolic hypertension, hyperglycaemia, type of stroke, age > or = 70, poor Glasgow coma score (GCS) on admission and deterioration of score were assessed.
Results A total of 246 (139 male and 107 female) patients were included. Median age was 65 years. Hypertension was the commonest risk factor (71.5%) followed by diabetes mellitus (40.2%) and hyperlipidaemia (37%). 74.8% of the cases were ischaemic in origin and 25.2% haemorrhagic. Mortality at one month was 20.3%. Using multivariate analysis and logistic regression, deterioration of GCS (OR = 46.04), poor GCS on admission (OR = 12.35) and haemorrhagic stroke (OR = 3.45) were independent predictors of one-month mortality.
Conclusion Hypertension and diabetes mellitus are the commonest risk factors of stroke among patients admitted to a tertiary hospital in Malaysia. Significant predictors of one-month mortality include the admission GCS, deterioration of GCS and haemorrhagic stroke.

Keywords: Ischaemic stroke, haemorrhagic stroke, Glasgow coma scale
Singapore Med J 2002; 43(10): 517-521

PN Chong, M Krishnan, CY Hong, TS Swah
Correspondence: Dr Chong Phui-Nah, Phui_Nah_CHONG@nhgp.com.sg

ABSTRACT
Aim of Study The study aimed to examine the knowledge and practice of breast cancer screening amongst Public Health nurses who are patient educators.
Method A self-administered questionnaire was sent to all 447 nurses in the Public Health Service to assess their knowledge and practice of breast cancer screening. Response rate was 96.4%. Knowledge scores ranged from 0-17 with one point given to a correct knowledge question, zero for wrong answer.
Results Median knowledge score was nine and 58.3% of nurses scored > or = 9. Statistically significant factors influencing knowledge scores were related to the nursing profession, namely nursing qualifications, current nursing post and current workplace. 76.2% of Nursing Officers/Higher Nursing Officers and 74.5% of midwives had knowledge scores > or = 9 compared with 57.3% of staff nurses and 40.8% of assistant nurses (p < 0.01). 60.1% of nurses who were taught breast-self examination scored > or = 9 (p < 0.05). As for practice, 93.7% of nurses did breast-self-examination, 54.1% had clinical breast examination in the past one year and 50.2% had mammogram done. On multivariate analysis, significant factors affecting practice of clinical breast examination were marital status (Prevalence Rate Ratio 1.94, 95% Confidence Interval 1.20-3.15), doctor's gender (PRR 1.35, CI 1.04-1.75) and those affecting mammogram were age group (PRR 1.78, CI 1.27-2.48), marital status (PRR 1.63, CI 1.03-2.59), history of breast disease (PRR 1.51, CI 1.06-2.16).
Conclusion The majority of nurses had certain misconceptions in the knowledge of breast cancer and breast cancer screening. A higher proportion of nurses in the Family Health Service had higher knowledge scores than other nurses in the Public Health Service. Most of the nurses did breast-self-examination. Having ever married and the availability of a female doctor influenced the nurses attending clinical breast examination. Nurses who were > or = 50 years old, ever married and those with a positive history of breast disease were more likely to have mammography done.

Keywords: breast-self-examination, clinical breast examination, mammogram, public health, nurses
Singapore Med J 2002; 43(10): 509-516