Original Article

SVS Deo, NK Shukla, S Asthana, B Niranjan, G Srinivas
Correspondence: Dr N K Shukla, nkshukla2@yahoo.com

ABSTRACT
Aim The harmonic scalpel is recently emerging as an alternative surgical tool for dissection and haemostasis and has been extensively used in the field of minimally invasive surgery. We studied the utility and advantages of this instrument over electrocautery for performing modified radical mastectomy.
Methods The operative and morbidity details of twenty-three breast cancer patients who underwent modified radical mastectomy using the harmonic scalpel were compared with 23 matched controls operated with electrocautery by the same surgical team.
Results There was no significant difference in the operating time between the harmonic scalpel and electrocautery group (104 and 100 mins, p > 0.05). The blood loss (60 +/- 35 ml and 294 +/- 155, p < 0.001) and drainage volume (590 +/- 430 ml and 1,085 +/- 690 ml, p < 0.001) were significantly lower in the harmonic scalpel group. There was a significant reduction of drain days in harmonic scalpel group (mean five and nine days, p < 0.05). There was no significant difference in the seroma rate between two groups (16% and 22%).
Conclusion Modified radical mastectomy using harmonic scalpel is feasible and learning curve is short. Harmonic scalpel significantly reduces the blood loss and duration of drainage as compared to electrocautery.

Keywords: Modified radical mastectomy (MRM), harmonic scalpel
Singapore Med J 2002; 43(5): 226-228

SJW Lew, JKH Lim
Correspondence: Lew Jin Wen Sennen, slew_man@yahoo.com

ABSTRACT
Background The prevalence of atrial fibrillation increases with age. Atrial fibrillation has been shown to be a significant risk factor for stroke in the elderly. Anticoagulation is effective in preventing stroke in geriatric patients with atrial fibrillation, yet many elderly patients with atrial fibrillation are not anticoagulated.
Objectives This study aims to determine the prevalence of atrial fibrillation in an inpatient population of a geriatric unit and explores the usage of anticoagulants in those patients diagnosed with atrial fibrillation.
Methods Consecutive admissions to a geriatric unit were screened with an electrocardiogram to establish a diagnosis of atrial fibrillation. Those with atrial fibrillation were evaluated for risk factors for stroke and for contraindications for anticoagulation. Documentation of reasons for withholding anticoagulation was also examined.
Results Five hundred and six consecutive inpatient admissions were screened. Fifty-six patients had atrial fibrillation (11.1%). Forty of these were known cases of atrial fibrillation whereas sixteen were newly diagnosed. There were 22 (39.3%) males and 34 (60.7%) females. The mean age was 83.3 years (S.D. 6.8). The four most common risk concomitant factors for stroke were age above 75 years (54, 96.4%), hypertension (41, 73.2%), congestive cardiac failure (28, 50%), and a history of strokes (20, 35.7%). Fifty-five (98.2%) patients had at least two other concomitant risk factors for stroke. On discharge, only nine (16.1%) out of 56 patients were anticoagulated. Anticoagulation was withheld because of contraindications in 44 (78.6%) patients and because of patients' objection to anticoagulation in 3 (5.3%) patients. The two most common reasons for withholding anticoagulation were the risk of recurrent falls (18, 38.3%) and peptic ulcer disease (15, 31.9%).
Conclusion The prevalence rate of atrial fibrillation in elderly inpatients was found to be 11.1%. Most of the elderly with atrial fibrillation had multiple concomitant risk factors for stroke and would benefit from anticoagulant therapy. However, in the majority, anticoagulation was withheld because of contraindications (78.6%) and patients' objection to anticoagulation (5.3%).

Keywords: Atrial fibrillation, elderly, arrhythmia, anticoagulation, stroke
Singapore Med J 2002; 43(4): 198-201

P Balraj, ASB Khoo, L Volpi, JAMA Tan, S Nair, H Abdullah
Correspondence: Dr Alan Soo Beng Khoo, alankhoo@imr.gov.my

ABSTRACT
Thirty patients with early onset breast cancer or familial breast cancer from Malaysia were analysed for germline mutation in the early onset breast cancer I gene (BRCA1). Direct sequencing of the entire coding region of BRCA1 identified a frameshift mutation, c.5447-5448insC (insC5447) (codon 1776 of exon 21) in a patient aged 32 of the Malay ethnic origin, who had no family history of breast and/or ovarian cancer. Eight polymorphisms (2201C > T, 2430T > C, P871L, E1038G, K1183R, 4427T > C, S1613G and IVS8-57delT) were identified in the samples tested.

Keywords: BRCA1, Breast cancer, Ethnic, Mutation, Malaysian
Singapore Med J 2002; 43(4): 194-197

JK Tan, DJC Png, LCH Liew, MK Li, ML Wong
Correspondence: Dr James K Tan, james_tan_kn@ttsh.com.sg

ABSTRACT
Objective To study the prevalence of prostatitis-like symptoms in a generally healthy population.
Subjects and Methods A population-based cross-sectional survey was conducted in Singapore to evaluate "prostatitis-like symptoms" (PS), lower urinary tract symptoms (LUTS),erectile dysfunction (ED), and quality of life (QoL). Respondents with pain or discomfort in the perineum, testicles, tip of penis or bladder/suprapubic region were identified as having prostatitis-like symptoms.
Results Altogether, 1087 males aged 21 to 70 were evaluated. While at least 20% of them had some degree of LUTS, only 2.67% (29 out of 1087) had pain or discomfort suggestive of prostatitis. Six men had pain in the bladder or suprapubic region, two in the perineum, six at the tip of penis and 26 had pain during micturition (11 subjects had more than one location of pain). Only two men had severe pain while seven had moderate and the rest had mild pain. The mean age of subjects with PS was 43.14. In terms of racial distribution, 2.23% (18) of Chinese, 3.15% (4) of Malay, 4.49% (4) of Indians and 12.12% (3) of other ethnic origin had PS. Those who had PS had worse erectile function (International Index of Erectile Function (IIEF) 11.92 vs. 17.16, p < 0.003) and a worse QoL score (2.96 vs. 1.38, p < 0.001) than those without PS. Those with PS were more bothered and worried about their symptoms.
Conclusion The prevalence of prostatitis-like symptoms in a largely Chinese population is 2.67%. Prostatitis-like symptoms have a negative impact on the quality of life and erectile function.

Keywords: prostatitis, prevalence, population-based study
Singapore Med J 2002; 43(4): 189-193

LC Wong, TL Yang, F Gao, AM Tan, VK Sethi, EJ Chua
Correspondence: Dr Wong Lea Choung, trdwlc@nccs.com.sg

ABSTRACT
Background Intracranial germ cell tumours (IGCT) are rare. We present our experience in Therapeutic Radiology Department, National Cancer Centre, Singapore.
Methods A retrospective study was conducted through case notes review on 25 patients with IGCT referred between January 1988 and January 1999.
Results The median age at diagnosis was 13 years (range 6-22). The tumours were mainly pineal germinoma (72%). Median follow-up for living patients was 2.57 years (range 0.12-10.8). Median radiotherapy (RT) dose to whole brain, primary site and spine was 35.3,54 and 30 Gys respectively. Four to six cycles of BEP or JEB chemotherapy (CM) were given in 10 patients. As for the whole study group, the seven-year overall survival (OS) and recurrence-free survival (RFS) were 86% (95% CI 72-100) and 78% (95% CI 60-100) respectively. The 10-year OS and RFS were 65% (95% CI 36-100) and 78% (95% CI 60-100) respectively. The germinoma group had 75% 10-year OS and 86% 10-year RFS. Mixed germinoma and non-germinoma germ cell tumours (NGGCT) group had 50% one-year RFS and 44% two-year OS. Acute side-effects of RT and CM were minimal. There was no statistically significant difference in side-effects when treatment modalities were compared.
Conclusion In the treatment of intracranial germinoma, we recommend biopsy and CSRT. Primary chemotherapy (+/- low-dose cranial RT) should be used in the protocol or clinical trial settings. Chemo-radiotherapy is recommended for mixed germinoma and NGGCT. A multicentre trial is needed to address various controversial issues.

Keywords: Chemotherapy, Craniospinal radio-therapy, Germinoma, Intracranial germ cell tumour, Singaporean
Singapore Med J 2002; 43(4): 182-188

FH Loh, N Hameed, SC Ng
Correspondence: Dr F H Loh, fh_loh@pacific.net.sg

ABSTRACT
Objective To assess the impact of minimal access surgery in replacing traditional open approach of surgery for benign gynaecological pathology.
Setting Gynaecological unit in a university hospital.
Methodology All surgical procedures for the treatment of ectopic pregnancy, benign ovarian cyst, myomectomy, and hysterectomy for benign gynaecological pathology over a 10-year period (1991 to 2000) were studied. The percentages of procedures performed with the minimal access approach were compared with the traditional open approach over the study period.
Findings The percentage of ectopic pregnancies treated laparoscopically has increased from a low of 27% in the initial two-year period of 1991-92 to stabilise at approximately 70% at the end of the decade. Laparoscopic approach for the treatment of benign ovarian cysts constituted just 31% of cases in the initial period (1991-92) and rose steadily to stabilise at approximately 50% of cases during the last four years of the decade. The proportion of advanced minimal access procedures such as myomectomy and hysterectomy increased at a more gradual pace during the decade. By 1999-2000, laparoscopic and hysteroscopic myomectomy constituted about 30% of all myomectomies but laparoscopic hysterectomy accounted for just about 5% of all hysterectomies performed.
Conclusion Minimal access surgery has largely replaced the open approach for the treatment of ectopic pregnancy and benign ovarian cysts. Advanced minimal access procedures such as myomectomy and hysterectomy showed a rising trend through the decade, but still accounted for a minority of procedures at the end of the decade.

Keywords: Gynaecological Surgery, Laparoscopy, Hysteroscopy
Singapore Med J 2002; 43(4): 177-181

Y Ismail
Correspondence: Dr Ismail Yaacob, ppu@pc.jaring.my

ABSTRACT
We reviewed the 52 new cases of pulmonary tuberculosis diagnosed at Pusat Pakar Utara, Kedah in 1998. It was found that the majority of the patients had symptoms for many years. They had seen many doctors but were not diagnosed. In 40% of the patients, no investigations for tuberculosis were done and in the others tuberculosis was excluded because of negative sputum smear examination. Many had typical history and X-ray changes suggestive of tuberculosis but more sensitive investigations such as sputum culture for Mycobacterium or bronchoscopy were not performed. Cases are presented to illustrate the problems in the diagnosis.

Keywords: Tuberculosis, Diagnosis, smear-negative, Bronchoscopy
Singapore Med J 2002; 43(4): 172-176

K Devendra, SK Tay
Correspondence: Dr Devendra Kanagalingam, dharkan@singnet.com.sg

ABSTRACT
Aim To study the outcomes of 42 consecutive patients who were scheduled for a laparoscopically-assisted vaginal hysterectomy (LAVH) between I January 1994 to 31 December 1999.
Method Retrospective study
Results Two patients required conversion to an abdominal hysterectomy. The range of uteri removed was from six to 16 weeks' size. Menorrhagia was the commonest presenting complaint and uterine fibroids was the commonest diagnosis. The mean duration of surgery (+/- SD) was 131.0 +/- 31.7 minutes. Mean blood loss (+/- SD) was estimated at 417 +/- 169 mls. Six percent of patients required a perioperative blood transfusion. Fifty-five percent of patients did not require any injectable analgesics and 45% were able to ambulate on the day of surgery. The mean duration of hospital stay (+/- SD) was 4.2 +/- 2.3 days;The commonest complication was post-operative fever.
Conclusion LAVH patients have a quick postoperative recovery with less pain at the expense of a long duration of surgery. LAVH is a feasible option in a selected group of patients who would otherwise require an abdominal hysterectomy.

Keywords: hysterectomy complications, minimally-invasive surgery, laparoscopy
Singapore Med J 2002; 43(3): 138-142

CK Low, WYC Chew
Correspondence: Dr C K Low, chee_kwang_low@notes.ttsh.gov.sg

ABSTRACT
Introduction Sauve-Kapandji procedure is used to treat distal radioulnar joint disorder.
Materials and Method Sixteen patients with distal radioulnar joint (DRUJ) disease treated with Sauve-Kapandji procedure between 1996 and 1998 were available for review at an average follow up period of 32.8 months,ranging from 24 to 48 months. The patients were young and the average age at the time of procedure was 33.6 years. There were eight cases of post-traumatic DRUJ arthritis, two cases of dislocation of DRUJ with malunion of radial fractures and six cases of rheumatoid patients with destruction of DRUJ. The distal end of ulnar shaft was stabilised with a sling created using radial 1/2 slip of extensor carpi ulnaris (ECU) tendon. Functional results were evaluated with Mayo wrist score.
Results Fusion of DRUJ was achieved in all cases by two months. Excellent results were achieved in eight cases, good in six, fair in one and poor in one. All except one case gained increase range of forearm rotation. Complications included one case of closure of pseudoarthrosis and required excision of the ulna head to restore forearm rotation.
Conclusion Sauve-Kapandji procedure is recommended in young patients with distal radioulnar joint disorder.

Keywords: DRUJ disease, DRUJ Fusion, Pseudoarthrosis, ECU sling, Mayo Wrist Score
Singapore Med J 2002; 43(3): 135-137

HL Wee, HK Ho, SC Li
Correspondence: Dr S C Li, phalisc@nus.edu.sg

ABSTRACT
Introduction Much effort has been devoted to educating the public about diabetes. However, the impact of such efforts has yet to be formally evaluated.
Objectives To identify areas of knowledge that might require additional educational efforts.
Methodology A cross-sectional survey was conducted to evaluate the general public's knowledge of diabetes. The respondents were required to answer 45 questions from a pre-tested questionnaire divided into five main sections, namely, general knowledge, risk factors, symptoms and complications, treatment and management, monitoring and other miscellaneous questions. A point was awarded for each correct response and zero for wrong or unsure responses. The maximum total score was 41. The miscellaneous questions were not scored.
Results A total of 1337 subjects were interviewed. The mean score obtained by the respondents was 66.1% of the maximum possible total score (i.e. 27.1 points out of 41). The "correct answer" percentages for the individual questions from each section ranges from 22 to 83% (General knowledge), 31 to 91% (Risk factors), 48 to 81% (Symptoms and complications), 35 to 87% (Treatment and management), and 58 to 93% (Monitoring of condition).With respect to the source of medical information, health care professionals did not feature prominently (20.7%).
Conclusion The public as represented by the samples in this survey is generally well informed about diabetes except for a few areas. Analysis of these areas would have a significant implication for future public education programme. Health care professionals should be more proactive in disseminating health information about diabetes to the public.

Keywords: diabetes mellitus, knowledge, public sector, health promotion, survey
Singapore Med J 2002; 43(3): 128-134