Original Article

CL Foo, E Seow
Correspondence: Dr Chik-Loon Foo, chik_loon_foo@ttsh.com.sg

ABSTRACT
Introduction To investigate whether the profile of female victims of domestic violence in Singapore has changed over the past ten years.
Methods 163 female victims of domestic violence presenting to an emergency department in Singapore were surveyed. The survey included information on the victims' demographics, assault characteristics and knowledge of help services. The results were compared against a similar survey done locally ten years ago, which involved 233 victims.
Results There were no significant differences in the racial composition, marital status, weapon use and admission rates of victims ten years on. However, a significantly higher proportion of female victims in 2002 knew where to seek help, compared to a decade ago (50.9 percent versus 20.6 percent, p-value is less than 0.0001).
Conclusion The proportion of victims with an awareness of community and legal help services has more than doubled over the past ten years.

Keywords: assault, battered women, domestic violence
Singapore Med J 2005; 46(2): 69-73

TLW Lim, KH Tan, CS Tee, GSH Yeo
Correspondence: Dr Tan Kok Hian, khtan@kkh.com.sg

ABSTRACT
Introduction A stillbirth remains a distressing enigma to parents and clinicians alike as the cause often remains elusive. Few papers describe a protocol for the investigation of stillbirths. We evaluate the first obstetric events-based protocol designed for local use with an aim to adequately investigate stillbirths in a cost-effective manner.
Methods A prospective cohort study was performed on 61 stillbirths at KK Women's and Children's Hospital. There were a total of 16,980 births in the year 2000.
Results 37.7 percent of cases remained unexplained. There was protocol compliance in 51 cases (83.6 percent) with deviation in 10 cases (16.4 percent). The protocol helped to minimise costs in 18 cases (29.5 percent) as selected investigations were performed in view of obvious causes. The overall postmortem rate was 27.9 percent with the lowest rates in the Malay population.
Conclusion An obstetric events-based protocol allows clinicians to tailor their investigations easily and appropriately. It helps to provide optimal investigations and minimise unnecessary costs. It could be further fine-tuned by initiating detailed serum investigations only after delivery so as to exclude an obvious cause, like cord accidents, where full investigations are unnecessary.

Keywords: autopsy, obstetric protocol, placental biopsy, stillbirth
Singapore Med J 2005; 46(2): 63-68

A Mukhopadhyay, TK Lim
Correspondence: Dr Lim Tow Keang, mdclimtk@nus.edu.sg

ABSTRACT
Introduction This prospective audit examines the diagnostic and clinical outcomes of consecutive adult inpatients who were admitted to a university hospital for other reasons and referred for breathlessness to respiratory physicians.
Methods We enrolled all adult inpatients referred for breathlessness from May 2000 to October 2001. We evaluated the clinical features and utility of routine investigations, such as blood tests and radiology. Subsequent investigations were undertaken at the discretion of the physician.
Results Of the 105 patients, 49 were men and 56 were women. Their mean age was 66 plus or minus 18 years. Surgical departments and cardiology were the main referring departments. Respiratory infection (31 percent) was the most common diagnosis. Acute pulmonary embolism (PE) was diagnosed in four patients postoperatively. Chest radiographs were helpful in making a diagnosis in 66 percent of patients. Computed tomography pulmonary angiogram of the thorax was performed in 31 of the 34 patients who were investigated for acute PE. More postoperative than non-postoperative patients were tested for PE (p-value less than 0.0001).
Conclusion In hospitalised patients referred for breathlessness, respiratory infections were the most common diagnosis and the chest radiograph was the most useful initial investigation. Computed tomography pulmonary angiogram was the preferred investigation for acute PE and clinicians were more inclined to investigate for PE in postoperative patients.

Keywords: chest radiograph, computed tomography pulmonary angiogram, dyspnoea, pulmonary embolism
Singapore Med J 2005; 46(1): 21-24

V Ashok, A Nishkantha, KH Leong, HD Luo, RM El-Oakley, CTT Tan, CN Lee, EK Sim
Correspondence: Dr Eugene Sim, sursimkw@nus.edu.sg

ABSTRACT
Introduction Off-pump coronary artery bypass grafting (OPCABG) is gaining widespread acceptance as the preferred choice for myocardial revascularisation. However, no definite data exist as to whether it is better than conventional CABG. We aimed to study the efficacy of the procedure in our patients, which constituted of a predominantly Asian population.
Methods Between January 2000 and December 2002, 1062 patients underwent isolated coronary artery bypass in our institution. 184 patients (17.3 percent) underwent OPCABG. Patients were preoperatively prospectively risk stratified under the EuroSCORE risk assessment model under high, medium and low risk classes thereby making them comparable. Post-operative complications, intensive care unit stay, hospital stay, types of grafts done were then analysed in these different risk classes.
Results The incidence of off-pump procedures showed a gradual increase over the last three years in this institution. A reduction in the number of post-operative complications, hospital stay, intensive care unit stay and mortality in the off-pump group was observed. Certain differences were found to be statistically significant.
Conclusion Off-pump CABG is a safe and viable alternative to conventional CABG as a treatment modality for surgical coronary revascularisation.

Keywords: cardiac disease, coronary artery bypass grafting, myocardial revascularisation, off-pump coronary artery bypass, grafting
Singapore Med J 2005; 46(1): 15-20

MZC Lam, TJ Lee, PY Boey, WF Ng, HW Hey, KY Ho, PY Cheong
Correspondence: Dr Cheong Pak Yean, cpy@cfps.org.sg

ABSTRACT
Introduction We assessed the accuracy of physician trainees in identifying different cardiac sounds and examined the factors influencing their cardiac auscultation proficiency.
Methods A total of 106 physicians in the Family Medicine Training Programme were asked to identify 10 cardiac sounds played sequentially on the Littmann electronic stethoscope, which functioned as a surrogate patient. Their auscultation accuracy was scored numerically out of a maximum of 10. Demographical data of the physicians was collected prospectively.
Results The mean (+/-SD) auscultation proficiency score of the study population was 4.0 +/- 1.7. Physicians who graduated in 1994 or earlier fared significantly poorer than those who obtained their Bachelor of Medicine and Bachelor of Surgery degrees between 1995 and 2000 (p-value equals 0.02). Auscultation proficiency was not related to current practice, previous years of primary care, cardiology, internal medicine or paediatric medicine postings, or cumulative years of postings. Normal heart sounds were most accurately identified. Prosthetic cardiac sounds were better identified than other extra-cardiac sounds while systolic murmurs were more accurately identified than diastolic murmurs. Tachycardia had the lowest identification rate.
Conclusion Our data suggest that cardiac auscultation skill declined with time, being significantly impaired eight years after graduation. We suggest that there is a need for retraining in the form of continuing medical education to address not only new knowledge and skills, but also basic skill competency.

Keywords: basic skill competency, cardiac auscultation, continuing medical education, physician training
Singapore Med J 2005; 46(1): 11-14

NC Tan, SL Cheah, EK Teo
Correspondence: Dr Ngiap-Chuan Tan, Tan.Ngiap.Chuan@singhealth.com.sg

ABSTRACT
Introduction Asymptomatic Hepatitis virus (HBV) carriers are often followed up at primary and secondary care centres in Singapore. Compliance to disease monitoring is perceived to be a barrier in their management. The study used qualitative methods to determine the health-seeking behavior of HBV carriers. Understanding such behavior will enable the attending physicians to optimise their care and promote regular disease surveillance.
Methods Data were collected from 39 HBV carriers from primary and secondary healthcare centres, with different demographic profiles in eight respective focus group discussions (FGD). A nurse conducted the FGDs using a semi-structured guideline. The qualitative data were analysed using standard content analysis technique.
Results There was evidence of doctor hopping among the HBV carriers in seeking the follow-up of their disease. Cost of review and investigations and preference for specialists' care appeared to be determinants of the sites of disease monitoring. Compliance to follow-up seemed to be sub-optimal, arising from apathy, denial, perceived inconvenience and cost of review. A significant proportion of the carriers had tried alternate therapy, took liver supplements but most found them to be ineffective. Most carriers had adopted healthier lifestyle after their diagnosis with regular exercise, smoking cessation and alcohol abstinence.
Conclusion Many HBV carriers' inadequate understanding of the disease resulted in indifferent or inappropriate health-seeking behavior towards their disease management. There is room for health education for these carriers to enhance their awareness of the disease and improve compliance to disease monitoring.

Keywords: chronic Hepatitis B infection, focus group discussion, disease monitoring, health education, health-seeking behavior
Singapore Med J 2005; 46(1): 6-10

Khealani BA, Baig SM
Correspondence: Dr Bhojo Asumal Khealani, bhojo.khealani@aku.edu

ABSTRACT
Introduction Parkinson's disease is an idiopathic disorder of the extrapyramidal system. It has a worldwide prevalence but data from developing countries is scanty. We describe the clinical spectrum of the disease from Pakistan, a developing country.
Methods Patients with Parkinson's disease, over a period of 11 years, were identified by ICD-9 coding system of the hospital medical records. Demographical characteristics, clinical features, laboratory investigations and radiological investigations were recorded and analysed.
Results A total of 80 patients were identified. 50 (63 percent) were males and 30 (37 percent) were females. Mean age of onset of the disease was 54 years. 47 (59 percent) patients had onset of illness during the sixth or seventh decade of life. Mean duration of illness at the time of presentation was five years. Rigidity, bradykinesia, tremors, hypomimia, primitive reflexes, difficulty in performing fine work and walking difficulty were the most common clinical features. 52 (65 percent) patients had stage I or II (Hoehn-Yahr staging) disease at the time of presentation. 56 (70 percent) patients had predominantly unilateral symptoms. 15 (19 percent) patients had cognitive impairment. Cognitive decline was more common in the elderly and in patients with disease duration of longer than ten years.
Conclusion Parkinson's disease is more common in males. Tremor, rigidity, walking difficulty, bradykinesia and difficulty in performing fine work are the commonest clinical features. Disease severity increases with duration of the disease. Cognitive impairment is not uncommon in these patients and is associated with disease duration and age of onset of the illness.

Keywords: hypokinesia, muscle rigidity, Parkinson’s disease, Parkinsonian disorders, tremor
Singapore Med J 2006; 47(12): 1075-1079

Kagu MB, Nggada HA, Garandawa HI, Askira BH, Durosinmi MA
Correspondence: Dr Modu Baba Kagu, bmk449@yahoo.com; bmk449@gmail.com

ABSTRACT
Introduction Kaposi's sarcoma is an acquired immunodeficiency syndrome (AIDS)-defining illness, and with the size of the human immunodeficiency virus (HIV)/AIDS pandemic in sub-Saharan Africa, AIDS-related Kaposi's sarcoma (KS) are now being diagnosed more frequently, although the true incidence of HIV-associated KS is not known. The clinical presentations of AIDS-related KS varied markedly across the African continent. This article reports a series of unusual clinical presentations of the tumour in Northeastern Nigeria.
Methods This is a prospective study carried out from September 2003 to August 2005, at the University of Maiduguri Teaching Hospital, Borno State, Northeastern Nigeria.
Results 20 cases of histologically-confirmed KS were prospectively studied. There were 17 (85 percent) men and three (15 percent) women, giving a male to female ratio of 5.7:1. Their ages ranged from 21-45 (median 37) years. 18 (90 percent) of the patients were anaemic. Mean haematocrit value, CD4+ cell count and duration of symptoms for all the patients were 29.5 +/- 7.5 percent, 119.0 +/- 91.4 cells per microlitre and 3.5 +/-1.7 months, respectively. Multiple lesions were a common presentation affecting sites such as lower limbs, trunk, conjunctiva, upper limbs and rectum as well as penis, lymph node, scrotum and oropharynx.
Conclusion Contrary to other reports that KS is not associated with HIV infection, our study has demonstrated otherwise. This study also showed that both sexes are affected but with a male preponderance. KS is also a late presentation of the HIV/AIDS disease spectrum in our environment and has varied clinical manifestations. There is an urgent need to develop health education programmes to enhance the understanding of this disease and how it spreads, particularly among the young generation.

Keywords: acquired immunodeficiency syndrome, human immunodeficiency virus, Kaposi’s sarcoma
Singapore Med J 2006; 47(12): 1069-1074

Chong VH, Jalihal A
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk

ABSTRACT
Introduction Solitary rectal ulcer syndrome (SRUS) is a rare disorder of defaecation and persistence of symptoms is common, particularly bleeding per rectum (BPR). This study assessed the clinical, endoscopical characteristics and predictive profiles for persistent BPR.
Methods 28 patients (14 males) with biopsy-proven SRUS were identified from 1989 to 2003, and the clinical and endoscopical findings were retrospectively reviewed.
Results At presentation, the mean age was 29.5 +/- 16.1 (range ten to 81) years. Common symptoms reported included BPR (86 percent), abdominal pain (36 percent), mucus per rectum (25 percent), straining at defaecation (25 percent), diarrhoea (14 percent) and constipation (14 percent). Digital manual evacuation was reported by 11 percent. 68 percent were anaemic and 57 percent required blood transfusion. Lesions were located anteriorly (38.5 percent), posteriorly (30.7 percent) and circumferentially (31.8 percent). The lesions were multiple (34 percent), ulcerative (64.3 percent) and polypoidal/nodular (32.1 percent). At a mean follow-up of 43.5 +/- 36 months, 64 percent (n=18) had multiple admissions (mean 3.1, range one to 12), mainly for transfusion (mean 7.4 units, range two to 27). There was no difference in clinical responses between patients with polypoidal/nodular or ulcerative lesions (p-value is 0.653). Follow-up endoscopies showed improvement (58 percent), progression (21 percent) and no change (21 percent) in the lesions. Four patients had surgery for concerns of neoplasms (n=2) and persistent BPR (n=2). BPR was persistent in 39 percent. Presence of abdominal pain (p-value is 0.008) and passage of abnormal stool (p-value is 0.002) were predictive of persistent BPR.
Conclusion SRUS occurs predominantly in young patients and despite being a benign condition, morbidity remains a problem. Patients' profiles are predictive of persistent BPR.

Keywords: haematochezia, rectal prolapse, rectal ulcer, solitary rectal ulcer syndrome
Singapore Med J 2006; 47(12): 1063-1068

Lai NM, Ramesh JC
Correspondence: Dr Lai Nai Ming, lainm@imu.edu.my

ABSTRACT
Introduction Outcome-based curriculum is adopted at the International Medical University (IMU), Malaysia, where specific learning objectives are laid out progressively under eight major outcomes. We present an outcome-guided, self-reported competency profile of our undergraduate students near the end of their training, focusing on elements that are considered most immediately relevant for their internship.
Methods Anonymous surveys were conducted on two cohorts of medical students in their final semester at IMU. The surveys covered a range of competencies, including practical skills, ward routines, generic attributes and evidence-based medicine, grouped under the exit outcomes as defined by the university.
Results A total of 92 students were assessed. In general, the students were confident of their ability on common practical skills and ward routines. They were comfortable with the level of professionalism and personal attributes required for internship, with the prospect of handling unexpected additional tasks and working away from home perceived as the main difficulties. Most students referred to at least three sources of clinical information to answer their clinical queries. However, they referred more to single journals than databases or collections. The majority could critically appraise journal articles to a variable extent, but nearly half took 30 minutes or longer to trace an abstract of interest.
Conclusion This report demonstrates the strength of outcome-based curriculum in its ability to produce competent students that are well prepared for their internship. Assessing students using this educational approach provides a clear picture of their strengths and weaknesses, and identifies stages in their training where additional inputs are required.

Keywords: clinical competence, internship, medical education, outcome-based curriculum
Singapore Med J 2006; 47(12): 1053-1062