Original Article

FM Lai, CCM Ng, GSH Yeo
Correspondence: Dr Lai Fon-Min, fonmin@pacific.net.sg

ABSTRACT
Introduction To assess anxiety levels in mothers with low-risk pregnancies before and after offering routine serum screening.
Methods A prospective study was carried out at the Kandang Kerbau Women's and Children's Hospital in Singapore from February 2000 to August 2000. We used standard statistical analysis and Spielberger's state-trait anxiety inventory (STAI) which consists of 40 items to assess anxiety. Anxiety levels were assessed at several stages: before serum screening counselling, after counselling but before serum screening, before the routine 20-week obstetrical screening ultrasound scan, and after ultrasound scan results were acknowledged four to six weeks later. As the STAI questionnaire has only been validated for an English-speaking population, only English-speaking women were recruited for the study. The subjects included 111 women between 15 to 20 weeks gestation that were randomly selected (without any risk factors) for serum screening counselling.
Results Anxiety levels did not decline significantly after counselling by a trained nurse-counsellor. They were highest prior to counselling and were significantly higher compared to all other times in which anxiety was assessed. Anxiety levels were lowest after the serum screening and routine 20-week screening ultrasound scan results were acknowledged. They were also significantly lower compared to all other times in which anxiety was assessed.
Conclusion Anxiety before serum screening was not abnormally high and routine serum screening offered by trained nurse counsellors did not significantly increase maternal anxiety in mothers with low risk pregnancies.

Keywords: anxiety, Down syndrome, maternal serum screening, state-trait anxiety inventory
Singapore Med J 2004; 45(8): 375-378

CCM Ng, FM Lai, GSH Yeo
Correspondence: Dr Christopher Ng Chee Mun, drchrisng@hotmail.com

ABSTRACT
Introduction To assess anxiety levels in mothers before and after undergoing amniocentesis. The secondary aim was to see how counselling by nurse-counsellors affected maternal anxiety levels.
Methods A prospective study was carried out from February 2000 to August 2000 at the Kandang Kerbau Women's and Children's Hospital in Singapore. We used standard statistical analysis and Spielberger's state-trait anxiety inventory (STAI), that consisted of 40 items, to assess anxiety levels. Anxiety levels were assessed at different stages: before and after counselling; before amniocentesis and after amniocentesis; when results were disclosed; and after the routine 20-week screening ultrasound scan was acknowledged four to six weeks later. English-speaking women were recruited for the study as the STAI questionnaire has only been validated for an English-speaking population. 195 at-risk mothers (advanced maternal age, abnormal nuchal translucency on ultrasound scan, previous abnormal baby and high-risk maternal serum screening results) and patients requesting for amniocentesis between 15 to 20 weeks gestation were recruited.
Results 156 mothers agreed to amniocentesis. 38 mothers declined amniocentesis. S-anxiety levels declined significantly after counselling by trained nurse-counsellors in all mothers counselled. S-anxiety levels were highest and significantly higher compared to all other times just prior to amniocentesis despite counselling. Anxiety levels were the lowest and significantly lower compared to all other times at the last assessment stage.
Conclusion High level of anxiety prior to amniocentesis despite counselling is understandable due to the invasive nature of the procedure. There is no long-lasting post-procedural anxiety to the mother.

Keywords: amniocentesis, anxiety, Down syndrome, state-trait anxiety inventory
Singapore Med J 2004; 45(8): 370-374

RMK Tan
Correspondence: Mr Richard Tan Ming Kirk, mingkirk@yahoo.com

ABSTRACT
Introduction The aim of this study was to derive a profile of drowning victims in Singapore in the 10-year period 1992-2001 and determine if there are any patterns, trends or factors which may affect the risk profile of victims. Another objective was to recommend measures for reducing deaths from drowning through a review of some of the current literature and studies on drowning prevention.
Methods Data for epidemiological analysis were studied and analysed. Data was primarily obtained from the annual drowning statistics reported in the annual reports of the Singapore Life Saving Society, which were in turn obtained from the Registry of Births and Deaths, and the Coroner's Court. The review of current literature and studies on drowning was concentrated on the publications of leading drowning experts and agencies and on the papers presented at two important international conferences, the International Drowning Symposium in May 1996 and the first World Congress on Drowning in June 2002. The review was done with a view to identify successful drowning prevention measures that may be adopted or enhanced in Singapore.
Results The study revealed a few important findings. Firstly, Singapore had a drowning rate per 100,000 population that varied from a low of 0.88 in one year to a high of 1.72 in another in the period 1992-2001. Secondly, the male drowning mortality rate in Singapore was much higher than the female drowning mortality rate. Thirdly, persons in the age group of 20-29 years were at the highest risk. Fourthly, the sea, rivers and swimming pools were the locations with the highest number of drowning victims. The study also showed that the main measures of drowning prevention may be broadly divided into supervision, environmental design changes, legislation, swimming lessons and aquatic safety education.
Conclusion The situation in Singapore is generally comparable to that in high income or developed countries although there are some differences. Further studies and research need to be done to provide a better understanding of the epidemiology and prevention of drowning in Singapore. In the meantime, the main measures of drowning prevention should, as far as possible, be followed or enhanced.

Keywords: drowning, epidemiology, risk profile, water safety
Singapore Med J 2004; 45(7): 324-329

J Kok, KH Tan, S Koh, PS Cheng, WY Lim, ML Yew, GSH Yeo
Correspondence: Dr Kelvin Tan Kok Hian, khtan@kkh.com.sg

ABSTRACT
Introduction To study the use, safety and effectiveness of a novel antenatal vaginal birth training device (EPI-NO) in primiparous women.
Methods Antenatal use of the EPI-NO vaginal birth trainer was prospectively studied in 31 primiparous booked patients who were delivered by obstetricians from July to December 2002 at the KK Women's and Children's Hospital. This was studied in relation to episiotomy rate, perineal trauma and analgesic requirements during the postpartum period. A patient questionnaire form was used to assess their perception of pain and how well they coped with its use. For comparison, perineal trauma was also studied retrospectively in 60 consecutive obstetrician-booked primiparous term patients who had normal vaginal delivery (NVD) and who did not use EPI-NO during the same study period.
Results The mean length of usage was for 2.1 weeks (standard deviation [sd] 1.2 weeks). The mean frequency of use was 5.3 episodes per week (sd 2.1, range 1 to 7). There was no laceration and vaginal infection arising from its usage. There was a case of minimal bleeding post-usage. There were 20 (64.5 percent) NVDs, four (12.9 percent) forceps deliveries, five vacuum deliveries (16.1 percent) and two (6.5 percent) Caesarean sections. Of the 29 vaginal delivery cases, 19 (65.5 percent) had episiotomy, eight (27.6 percent) had lacerations, and two (6.9 percent) did not sustain laceration. The reasons for episiotomy in the 19 cases were nine cases of pending tearing of vagina/perineum, nine cases of instrumental vaginal deliveries, and one to shorten second stage. There was no third degree tear. 21 (67.7 percent) out of 30 required a painkiller. The majority of patients (17; 54.8 percent) appeared to be comfortable with the use of EPI-NO. All coped well with vaginal examination after using EPI-NO perineal training. Comparing among term primiparous NVD cases with (n value equals 20) and without (n value equals 60) EPI-NO, the perineal trauma rate (90.0 percent vs 96.6 percent, p value equals 0.24) was slightly but not significantly lower in the EPI-NO group. The episiotomy rate was significantly lower (50.0 percent vs 93.3 percent, p value is less than 0.0001) and the extent of perineal trauma in the patient appeared to be less severe in cases using EPI-NO.
Conclusion EPI-NO appeared to be safe and acceptable to the majority of users. Although birth training with EPI-NO significantly decreases the rate of episiotomies in term primiparous patients, and the degree of perineal tissue injury appeared to be less in the EPI-NO group especially among those with lacerations, the overall perineal trauma rate was slightly but not significantly lower, in view of the higher spontaneous laceration rate in the EPI-NO group.

Keywords: EPI-NO vaginal birth trainer, episiotomy, perineal tissue injury, perineal trauma, vaginal delivery
Singapore Med J 2004; 45(7): 318-323

I Irwani, CM Seet, PG Manning
Correspondence: Dr Irwani Ibrahim, irwani@nuh.com.sg

ABSTRACT
Introduction To compare the door-to-needle time between thrombolysis administration for patients with ST elevation myocardial infarction (STEMI) in the emergency department (EMD) by emergency physicians and those administered in the coronary care unit (CCU) by cardiologists.
Methods The data was collected prospectively for all patients with STEMI who received thrombolysis in the emergency department over a one-year period from January 2001 to December 2001. We recorded the time of arrival in the EMD as well as the time thrombolytic therapy was commenced. This data was compared to those from the previous year, obtained retrospectively, where the patients received thrombolysis in the CCU.
Results 118 patients were thrombolysed in the CCU and 78 patients were thrombolysed in the EMD. The median door-to-needle time was significantly shorter in patients who are thrombolysed in the emergency department by emergency physicians than in the coronary care unit by cardiologists (29 minutes versus 60 minutes, p value is less than 0.001). There was no incident of inappropriate thrombolysis nor was there intracranial or gastrointestinal bleed in the patients who were thrombolysed in the EMD. There was one case of medication dose error but it was of no consequence to the patient.
Conclusion Emergency physicians can administer thrombolytic treatment appropriately, quickly and safely in patients with STEMI.

Keywords: acute myocardial infarction, door-to-needle time, ST elevation, ST elevation myocardial infarction (STEMI), thrombolysis
Singapore Med J 2004; 45(7): 313-317

Y Imran, T Vishvanathan
Correspondence: Dr Imran Yusof, drimran93@yahoo.com

ABSTRACT
Introduction Open fracture of the tibia is very common among motorcyclists. The morbidity associated with this injury is well-documented as treatment of severe open fractures is very difficult. There is currently no study done in the literature to see the relationship between fracture severity and the side of the injury.
Methods We reviewed 239 patients with open fractures of the tibia admitted to our institution from 1998 to 2002.
Results From 241 tibias studied, 150 (62.2 percent) involved the right side and 91 (37.8 percent) involved the left side. Statistical analysis showed that there was a significant difference in the severity of open fracture between the sides of fracture. Less severe injury (grades 1 and 2 fractures) was associated with injury of the left tibia and severe injury (grades 3A, B and C fractures combined) was associated with right tibia fracture.
Conclusion Since the right leg was more exposed to the injury, it is imperative to protect the limb. This may reduce the overall incidence and severity of tibia fractures.

Keywords: fracture, open fracture, road accidents, tibia, tibial fracture
Singapore Med J 2004; 45(6): 280-282

DSY Chia, EY Yap
Correspondence: Dr Dawn Chia, dawnchia@singnet.com.sg

ABSTRACT
Introduction This study determines the accuracy of reading a Polaroid retinal photograph in the diabetic retinal photography programme as compared to a clinical fundal examination in the diagnosis of diabetic retinopathy.
Methods A prospective study recording the additional findings obtained from clinical examination of the eye using indirect ophthalmoscopy and slit lamp biomicroscopy in a restructured tertiary hospital serving an urban community was performed.
Results Seventy-eight eyes in 39 diabetic patients were reviewed by an ophthalmologist for diabetic changes seen on fundus photography. The sensitivity of diabetic retinal photography in diagnosing diabetic eye conditions was 91.6 percent, with a specificity of 99.8 percent and a positive predictive value of 95.6 percent. The degree of agreement kappa was 0.94.
Conclusion The use of diabetic retinal photographs to screen for diabetic eye disease achieved a high sensitivity by capturing diabetic retinal lesions. It was comparable to an examination performed by the ophthalmologist. With appropriate training, the person reading the diabetic retinal photographs can accurately diagnose diabetic eye conditions.

Keywords: diabetes mellitus, diabetic retinal photography, eye diseases, ophthalmologic diagnostic technique, vision tests
Singapore Med J 2004; 45(6): 276-279

K Kannan, C Ng, T Ravintharan
Correspondence: Dr Ravintharan Tharmalingam, ravit@starhub.net.sg; drkannansg@yahoo.com.sg

ABSTRACT
Introduction Laparoscopic ventral hernia repair (LVHR) is a recent development that has been shown to be an effective way of treating ventral hernias. We present the first local series of LVHR with a review of the literature on laparoscopic ventral herniorrhaphy.
Methods We retrospectively reviewed all our patients who underwent laparoscopic surgery for ventral hernias from December 1998 to May 2002. Results of LVHR such as operative time, length of hospital stay, complications and recurrence rates were evaluated.
Results Twenty patients underwent LVHR. There were 16 female and four male patients. The average age was 54 years. The mean fascial defect was 46 square cm. An ePTFE Mesh was used in all the patients except for one patient who had a prolene mesh. The mean operative time was 117 minutes and the hospital stay was two days. There were two minor complications and no major complications. With a mean follow-up period of 14.9 months, the recurrence rate was 5.0 percent with a single recurrence at four months.
Conclusion Our initial experience with this modality shows that LVHR a feasible option with great potential in both treatment success and reduction of surgical morbidity.

Keywords: herniorrhaphy, laparoscopic surgery, laparoscopic ventral hernia repair, ventral hernia
Singapore Med J 2004; 45(6): 271-275

WK Cheah, JB So, D Lomanto
Correspondence: Dr Cheah Wei Keat, cheahwk@nuh.com.sg

ABSTRACT
Introduction The local experience of endoscopic totally-extraperitoneal hernia repair in a major teaching hospital is reviewed.
Methods Between 1997 and 2003, 141 consecutive patients underwent 182 totally-extraperitoneal hernia repairs for inguinal hernia. 100 patients had unilateral hernia and 41 patients had bilateral hernias. The mean age was 51 years (range 20 to 83 years).
Results The mean operation duration was 70 minutes. Bilateral repairs took 24 percent longer than for unilateral repairs (82 versus 66 minutes). However, the mean operative duration for the last 55 (30 percent) cases decreased to 55 minutes. Four patients (2.8 percent) had conversion to open surgery and ten patients had minor complications, mostly groin seroma that resolved. Overall, there were seven hernia recurrences (3.8 percent) in the series. However, no hernia recurrence was present in the last 63 patients (45 percent). Recurrences were higher when the mesh was not anchored than when the mesh was fixed with a tacking device (p value is less than 0.01). The mean inpatient hospital stay was 1.4 days. Of the last 30 patients (21 percent), 70 percent were performed as outpatients.
Conclusion Endoscopic extraperitoneal hernia repair offers the appropriate patient a viable alternative to open hernia surgery. To achieve good results, adequate cases should be performed to overcome the learning curve, and the mesh should be anchored to the inguinal floor to prevent recurrences.

Keywords: endoscopic herniorrhaphy, extraperitoneal inguinal hernia repair, inguinal hernia, laparoscopic surgery
Singapore Med J 2004; 45(6): 267-270

LSU Lee, NI Paton
Correspondence: Dr Lawrence Lee Soon U, llee3@jhsph.edu

ABSTRACT
Singapore remains vulnerable to the introduction of infectious diseases from other countries due to the high traffic of migrant labour and other visitors. We describe seven cases of migrant workers from West Africa who entered Singapore carrying loaisis, a helminthic infection. The clinical presentation, treatment using single dose ivermectin, potential for transmission, and the need for screening of this infection in Singapore are discussed.

Keywords: Chrysops, disease transmission, helminths, loa loa, parasitic infection
Singapore Med J 2004; 45(5): 227-228