Original Article

A Theerapol, BYJ So, SS Ngoi
Correspondence: S S Ngoi, ssngoi@pacific.net.sg

ABSTRACT
Aim Anal fistula is usually treated by either fistulotomy or fistulectomy. We described the routine use of setons to treat anal fistula without any surgery.
Method Forty-seven consecutive patients with diagnosed anal fistulae were treated using setons alone.
Results The median age of the patients was 41 (range: 18-70). Of the 47 patients, 15 had surgery previously for fistula and perianal abscess. At least two setons were inserted through each fistula. One was tied tightly to function as a cutting seton and this was sequentially tightened by the patient and another was tied loosely for drainage. Of the 47 patients, 33 (70%) had the placement of setons in the clinic without any anaesthesia. The remaining 14 patients had the setons inserted in the operating room, with one patient having a complex anal fistula and 13 patients having perianal abscess requiring drainage at the same time. There were no post procedure complications in the series. Forty-one patients had completed follow up at clinic within a median duration of 15 weeks (range: two to 67 weeks). The fistula was completely healed by this method in 37 patients (78%). The median healing time was nine weeks (range: four to 62 weeks). One patient developed recurrent fistula and was healed after another seton placement. No patient developed any faecal incontinence and all patients were satisfied with this treatment.
Conclusion The routine seton method is safe, cheap and effective in the treatment of anal fistula regardless of type. It does not leave an open wound and most patients are satisfied with the treatment.

Keywords: fistula, transphincteric, intersphincteric, seton, treatment
Singapore Med J 2002; 43(6): 305-307

KC Ng, SY Ang
Correspondence: K C Ng, keech@kkh.com.sg

ABSTRACT
Ketamine has been used to "consciously" sedate patients for a variety of paediatric procedures in our department since 1998. This is a retrospective review of the first 500 paediatric patients given ketamine for conscious sedation. Ketamine was given, either intramuscularly (3-4 mg/kg) or intravenously (1-2 mg/kg) together with atropine (0.02 mg/kg), with or without intravenous midazolam (0.05 mg/kg). The main indications for giving ketamine were for laceration repair, especially those of the lip, tongue and buccal mucosa (54.4%); manipulation and reduction of upper limb fractures (25.8%); incision and drainage of abscesses (12%), removal of foreign bodies (6.4%) and a potpourri of other conditions. Seventy-five point six percent of our patients were less than six years old and the male to female ratio was 1.9:1. Ninety-six percent of our patients were discharged home well and only one child (0.2%) was admitted for observation possibly as a consequence of ketamine. We find ketamine to be a relatively effective drug for use for conscious sedation in children.

Keywords: Ketamine, Conscious Sedation, Paediatric Procedures
Singapore Med J 2002; 43(6): 300-304

AHC Loy, AL Tan, PKS Lu
Correspondence: Dr Andrew Loy, a_loy@hotmail.com

ABSTRACT
The objective of the study was to study the microflora and the antibiograms of patients with chronic suppurative otitis media (CSOM) in Singapore. Ninety patients with CSOM were prospectively studied. They had chronic ear discharge and had not received antibiotics for the previous five days. Swabs were taken, and cultured for bacteria. Antibiotic testing was done using modified Kirby Bauer disk diffusion method. In addition to the usual antibiotics, the three most common topically available antibiotics (chloramphenicol, gentamicin and neomycin) were tested. There were 135 positive cultures for organisms from the 90 patients. The most common causal organisms isolated were Pseudomonas aeruginosa (33.3%) and Staphylococcus aureus (33.3%) followed by coagulase negative Staphylococcus (21.1%). Fungi accounted for 8.8% of isolates while 6.6% were anaerobes. Of the three antibiotics commonly available as topical eardrops, gentamicin has the highest susceptibility rate (82.6%), followed by neomycin (67.8%) and chloramphenicol (62.8%).

Keywords: microbiology, chronic otitis media, antibiotics, topical drops
Singapore Med J 2002; 43(6): 296-299

Nuruddin B. Mohammed, Rozina NoorAli, Chinnaiya AnandaKumar
Correspondence: Dr Nuruddin Badruddin Mohammed, medp1156@nus.edu.sg

ABSTRACT
Objective To compare clinical presentation and morbidity of abdominal myomectomy and hysterectomy.
Methods We reviewed medical records of 441 patients with symptomatic fibroid, treated by myomectomy (135) or hysterectomy (306) at The Aga Khan University Hospital, Karachi, from January 1991 to December 1995. Z-test and risk estimates with 95% confidence intervals were calculated.
Results Pregnancy loss [Risk Ratio = 2.79, 95% Confidence Interval = 1.90-4.10], pelvic mass [Risk Ratio = 2.22, 95% Confidence Interval = 1.68-2.92] and infertility [Risk Ratio = 1.44, 95% Confidence Interval = 1.05-1.96] were more likely to be managed by myomectomy than in the absence of these complaints. Abnormal uterine bleeding was less likely to be treated by myomectomy than in its absence [Risk Ratio = 0.54, 95% Confidence Interval = 0.41-0.71]. With myomectomy, both the estimated mean intra-operative blood loss and the risk of febrile morbidity were significantly less than with hysterectomy [Mean (S.D.): 386 milliliters (48) versus 567 milliliters (62), p-value 0.000 and Risk Ratio = 0.37, 95% Confidence Interval = 0.16-0.87, respectively]. The risk of visceral injury [Risk Ratio = 2.24, 95% Confidence Interval = 0.74-6.82], blood transfusion [Risk Ratio = 0.69, 95% Confidence Interval = 0.44-1.07], mean duration of operating time [Mean (S.D.) 127 minutes (35) versus 131 minutes (47), p-value 0.93] and mean duration of hospital stay [Mean (S.D.): 5.44 days (1.28) versus 5.42 days (1.09), p-value 0.92] did not differ significantly between the groups.
Conclusion Myomectomy can be considered as a safe alternative to hysterectomy for the surgical management of uterine fibroids, with an added advantage of preservation of women's sexual and reproductive functions.

Keywords: Uterine fibroid, abdominal myomectomy, total abdominal hysterectomy, intra-operative blood loss, febrile morbidity
Singapore Med J 2002; 43(6): 289-295

P Kandasami, Hanafiah Harunarashid, Harjit Kaur
Correspondence: Dr P Kandasami, kanda@imu.edu.my

ABSTRACT
There is very little information in literature describing ethnic variations in etiologic and clinical outcome of acute pancreatitis in the Asian population. This study describes the demographic, etiologic and clinical course of acute pancreatitis among the three main races in Malaysia namely, the Malays, Chinese and Indians. One hundred and thirty-three consecutive patients were admitted for acute pancreatitis for the period January 1994 to July 1999 and they consisted of 77 males and 56 females with a mean age of 43.5 years (SD+/- 14.7). The racial breakdown of acute pancreatitis was: Malays 38 (28.6%), Chinese 19 (14.3%), Indians 75 (56.4%) and 1 (0.8%) patient was an orang asli. The incidence of alcohol association with acute pancreatitis was significantly increased in the males, while gallstone pancreatitis was principally a disease of the female. Alcohol was identified as the predominant factor associated with acute pancreatitis among the Indians (73.3%) and in contrast, gallstone was the commonest associated etiologic factor for the Malays and Chinese. No etiologic factor could be identified in a substantial proportion of the Malay patients (60.5%) when compared to the Chinese (36.8%) and Indians (35%). Severe disease developed in 25% of the cases reviewed but there was no difference in of the rate of severe pancreatitis in terms of ethnic groupings or etiologic factors. The overall mortality rate was 7.5% and the commonest cause of death was multi-organ failure. The study recognises that there are differences in the characteristics of acute pancreatitis among the three major races in the country and this divergence is primarily due to sociocultural habits.

Keywords: Acute pancreatitis, racial differences, Malaysia
Singapore Med J 2002; 43(6): 284-288

NY Koh, WH Koo
Correspondence: N Y Koh, kohnienyue@yahoo.com.sg

ABSTRACT
Introduction Minimising polypharmacy is important. A study was done to see if this was achievable in patients under palliative care and compares the types of drugs used before and after referral.
Method Medication charts of 345 patients seen in June to August 2000 in hospital-based palliative consultation service, home care and hospice, were reviewed. The drugs used were recorded on two occasions--before referral and two weeks after or just before discharge from hospital or hospice, provided that death was not imminent.
Result The median number of drugs used was five, before and after referral. Analgesics and laxatives were frequently used in palliative care (60.3% and 60% respectively). The commonest analgesic was opiates (41.2% before and 47.8% after referral). Only the difference in laxative usage (50.4% prior to referral and 60% after) was statistically significant at p<0.01. 40.3% of the patients had an increase in the number of drugs after referral and 45.3% of them had addition of laxatives, compared to less than 30% for other drugs. A significantly higher proportion of patients (24.6% versus 18%) were on two or more drugs for constipation after referral.
Conclusion Reducing polypharmacy in palliative care is often difficult. There was higher awareness of bowel habits and treatment of constipation amongst those involved in palliative care. In addition to reviewing the use of some drugs, other measures such as patient education may be useful in minimising polypharmacy.

Keywords: Polypharmacy, palliative care, drugs, laxatives, analgesics
Singapore Med J 2002; 43(6): 279-283

R Kam, J Cutter, SK Chew, A Tan, S Emmanuel, KH Mak, CNS Chan, TH Koh, YL Lim
Correspondence: Dr Ruth Kam, Ruth_KAM@nhc.com.sg

ABSTRACT
Objectives To characterise gender and age-related differences in presentation and outcome after an acute myocardial infarction (AMI).
Design Data were derived retrospectively from the Singapore Myocardial Infarction Registry from 1988 through 1997. This database comprised all AMI cases for ages between 20 and 64 years (group A). For approximately three months a year, data were also collected for all AMI cases above the age of 64 years (group B). There were 13,048 and 4,425 cases in groups A and B respectively.
Results In age - standardised AMI rates, males outnumbered females by a factor of 4.0 and 1.7 for groups A and B respectively.The median age of presentation was higher in females for both age groups being 58 years versus 54 years for group A and 75 years versus 72 years for group B. Younger females had worse survival at 28 days and were more likely to have prior ischaemic heart disease and require resuscitation. They were also more likely to have atypical symptoms. Previous myocardial infarction was not different between the sexes in both groups. Among the older age group, there was no gender difference in prior ischaemic heart disease, 28-day survival and requirement for resuscitation.
Conclusion Women who have AMI tend to be older than men. Gender differences are age-specific. Women who are 64 years and below have more atypical symptoms, prior ischaemic heart disease and worse prognosis than men after AMI. These differences are not seen in those over the age of 64.

Keywords: myocardial infarction, females, survival, symptoms, age
Singapore Med J 2002; 43(5): 243-248

GM Tan, LK Ti, S Suresh, BS Ho, TL Lee
Correspondence: Dr Ti Lian Kah, anatilk@nus.edu.sg

ABSTRACT
Background Although the Human Patient Simulator (HPS) is an effective teaching tool in many medical fields, literature supporting its use in the teaching of physiology to medical students is lacking. This study investigated the effectiveness of HPS-based teaching of cardiovascular physiology to first-year medical students.
Methods Two hundred and ten first-year medical students were scheduled to our HPS laboratory with the purpose of demonstrating "physiology in action". Students were divided into groups of 19-25 each, and attended a lecture followed by a HPS session. Using a theatre-type simulator complete with mannequin, anaesthesia machine and monitors (METI, Sarasota FL), the scenarios of hypovolaemia, sepsis, and cardiac failure were run to demonstrate the physiological changes that occur with changes in preload, afterload, and cardiac contractility. Each student was given a true/false test before, and again after the HPS session, followed by a survey of their learning experience.
Results There was marked improvement in test scores after the HPS session (82.1% vs. 64.6%, P < 0.001). Most of the students felt that HPS was a better teaching tool (94.5%) and raised more questions (76.5%) than lectures. They wanted more topics to be taught this way (96%), as they could apply and re-enforce textbook knowledge, and visualise real-time changes. However, they felt that their experience could have been enhanced with more time and smaller groups.
Discussion HPS is an excellent teaching tool as it stimulates student curiosity and makes knowledge acquisition and understanding easier. It is highly desirable to be incorporated into the teaching of physiology.

Keywords: Simulation, Physiology, Education, Medical Students
Singapore Med J 2002; 43(5): 238-242

Nurgul Arinci Incel, Esma Ceceli, Pinar Bakici Durukan, H Rana Erdem, Z Rezan Yorgancioglu
Correspondence: Dr Nurgul Arinci Incel Mucize Sokak, nincel@hotmail.com

ABSTRACT
Aim of the Study Reliable and valid evaluation of hand strength is important for determining the effectivity of treatment strategies and it is accepted that grip and pinch strength provide an objective index for the functional integrity of upper extremity. This study was designed to evaluate the grip and pinch strength differences between sides for the right and left handed population.
Methods The study included 128 right and 21 left hand dominant volunteers. Grip strength of the participants were measured by using a Jamar dynamometer. Pulp pinch strength measurements were performed by manual pinchmeter.
Results When the study group was totally evaluated, a statistically significant difference was found between the grip and pinch strengths of dominant and nondominant hands in favour of the dominant hand. For further information we grouped 149 participants as right and left handed and investigated the number of subjects with stronger nondominant hand for each group. The percentage of stronger nondominant hand grip was 10.93% and 33.33% for right and left handed groups respectively. The results were less significant for pinch strength with 28.12% and 28.57% for right and left handed subjects respectively.
Conclusion We concluded that the dominant hand is significantly stronger in right handed subjects but no such significant difference between sides could be documented for left handed people.

Keywords: grip strength, pinch, hand dominance, Jamar
Singapore Med J 2002; 43(5): 234-237

M Muttarak, S Pojchamarnwiputh, W Padungchaichote, B Chaiwun
Correspondence: Professor Malai Muttarak, mmuttara@med.cmu.ac.th

ABSTRACT
Objective To assess the value of mammography in the detection of cancer in the contralateral breast in women with ipsilateral breast carcinoma.
Materials and Methods From February 1994 through May 2001, a total of 500 patients with unilateral mastectomy from breast carcinoma had mammograms performed for the first time following mastectomy. We retrospectively reviewed the clinical findings and mammograms of these patients. Four hundred and sixty-four patients were asymptomatic and 36 patients presented with palpable breast or axillary masses. Specific mammographic features of a mass, microcalcifications, architectural distortion and asymmetric density were evaluated. Diagnosis was confirmed by fine needle aspiration biopsy or surgical excision in all patients.
Results Four hundred and sixty-four patients had screening mammograms and 36 patients had diagnostic mammograms. All 36 symptomatic patients had abnormal mammograms. Of these, 12 (33.33%) patients were found to have second primary breast carcinoma, 12 (33.33%) had metastases to the contralateral breast or axillary lymph nodes, six (16.66%) had fibroadenomas, two (5.55%) had abscesses, three (8.33%) had fibrocystic change, and one (2.77%) had axillary node reactive hyperplasia. Of the 464 asymptomatic patients, five (1.07%) had second primary breast carcinoma, five (1.07%) had fibrocystic change, and two (0.43%) had fibroadenomas. The mean age at the time of diagnosis of the first primary carcinoma in the symptomatic patients was 41.9 years (range 35-60 years), and was 43.4 years (range 36-56 years) in the screening group. The mean time interval between the two carcinomas was four years (range one to 13 years) in symptomatic group and 3.4 years (range one to four years) in screening group. The tumour stage in the screened group was in situ (n = 2), stage I (n = 3) and in the symptomatic group was stage I (n = 2), stage II (n = 5), stage III (n = 5).
Conclusion Patients who have ipsilateral breast carcinoma have a strong risk to develop a second primary carcinoma in the contralateral breast. Close follow-up of the second breast with careful clinical examination and mammography are necessary for the early detection of cancer.

Keywords: Bilateral breast carcinoma, mammography, breast diseases
Singapore Med J 2002; 43(5): 229-233