Original Article

Boo NY, Mohd-Amin I, Bilkis AA, Yong-Junina F
Correspondence: Professor Nem-Yun Boo, nemyun_boo@imu.edu.my

ABSTRACT
Introduction The aim of this study was to determine predictors of failed closure of patent ductus arteriosus (PDA) following a single course of indomethacin in symptomatic preterm infants.
Methods This prospective observational study was carried out on 60 preterm infants weighing less than 1,750 g with symptomatic PDA confirmed by echocardiography. At a median age of 7.0 days (interquartile range 4.0), they were given indomethacin of 0.1 mg/kg/day intravenously daily for six days. Closure of PDA was reassessed by echocardiography upon completion of therapy.
Results The PDA of 40 percent (n=24) of these infants remained patent. Forward logistic regression analysis showed that the only significant predictors of failed PDA closure in these infants were: PDA size (adjusted odds-ratio [OR] is 7.0; 95 percent confidence interval CI] of OR is 2.0, 24.8; p-value is 0.002), birth weight (adjusted OR is 0.996; 95 percent CI of OR is 0.993, 1.000; p-value is 0.03) and platelet count (adjusted OR is 0.987; 95 percent CI is 0.975, 1.000; p-value is 0.045). Gestational age, maternal age and left atrium/aorta ratios were not significant predictors.
Conclusion Larger PDA, lower birth weight and lower platelet count were significant predictors of high failure in indomethacin therapy given late at one week of life.

Keywords: indomethacin therapy, patent ductus arteriosus, preterm infants
Singapore Med J 2006; 47(9): 763-768

Boo NY, Chew EL
Correspondence: Professor Nem-Yun Boo, nemyun_boo@imu.edu.my

ABSTRACT
Introduction This study aimed to compare the core, abdominal wall, and plantar temperatures of well jaundiced term infants undergoing phototherapy with or without clingfilm covering the lower two-thirds of the upper end of their bassinets.
Methods This was a randomised controlled trial carried out in a tertiary university hospital on normal healthy term infants undergoing phototherapy. 106 eligible infants were randomised to receive phototherapy with (n=52) or without (n=54) the use of clingfilm during a two-hour period. Subsequently, after nappy change and feeding, they were crossed over to receive phototherapy without or with the clingfilm in place, respectively. Their body temperatures were measured at zero and two hours after phototherapy.
Results There was no significant difference in their core, abdominal wall and plantar temperatures at baseline and after two hours of phototherapy (p-value is greater than 0.05) between infants with and without the use of clingfilm. Irrespective of the use of clingfilm, there was significant (p-value is less than 0.001) increase in core body temperatures after two hours of continuous phototherapy, with resultant hyperthermia (greater than 37.5 degree Celsius) in 42 percent of infants when under clingfilm and 35.8 percent when without clingfilm. A few (2.8 percent) infants, though statistically not significant, became mildly hypothermic after two hours of phototherapy when clingfilm was not used (p-value is greater than 0.05).
Conclusion Hyperthermia was common during phototherapy, irrespective of the use of clingfilm. Hypothermia was rare and the preventive role of clingfilm is not certain.

Keywords: clingfilm, hypothermia, neonatal hypothermia, phototherapy
Singapore Med J 2006; 47(9): 757-762

Okumus M, Gokoglu F, Kocaoglu S, Ceceli E, Yorgancioglu ZR
Correspondence: Dr Muyesser Okumus S. Veli Kara Sok., drmuyesser@hotmail.com

ABSTRACT
Introduction Fibromyalgia (FMS) is a syndrome expressed by chronic widespread body pain which leads to reduced physical function and frequent use of healthcare services. This study was performed to examine the muscle performance comprising abdominal and lumbar muscle strength, and measurement of chest expansion in osteoporotic patients with FMS; to evaluate the relation between muscle performance, pain severity, clinical findings and physical activity; and to compare the results with the osteoporotic control group.
Methods 44 osteoporotic women with FMS and 46 osteoporotic women who were physically inactive underwent measurements of three parameters: abdominal and lumbar muscle strength, and chest expansion. Student's t-test was used for statistical analysis.
Results The strength of lumbar muscles and measurement of chest expansion were significantly decreased in the FMS patients as compared to the controls (p-value is less than 0.001). However, lumbar and abdominal muscles strength was low in both patients and controls.
Conclusion Our results indicate that osteoporotic patients with FMS have impairment in strength of lumbar and abdominal muscles and in measurement of chest expansion. Further studies are needed to investigate the mechanism of reduced muscle performance and the effects of aerobic exercise in this patient group.

Keywords: chest expansion, fibromyalgia, muscle performance, osteoporosis
Singapore Med J 2006; 47(9): 752-756

Ang D, Hsu AAL, Tan BH
Correspondence: Dr Tan Ban Hock, gimtbh@sgh.com.sg

ABSTRACT
Introduction Fluoroquinolones (FQs), frequently used for many common infections such as community-acquired pneumonia and urinary tract infection, are also effective against Mycobacterium tuberculosis. This study describes a series of patients in whom the empirical use of FQs for what appeared to be common community-acquired infections led to a delay in the diagnosis of tuberculosis (TB).
Methods We reviewed the records of five patients with TB in whom the early use of FQs led to partial symptom resolution and a prolonged relapsing and remitting course.
Results Of the five patients described, four presented with community-acquired pneumonia and one with urinary tract infection. All were given FQs and improved, though not completely. Their illnesses took a relapsing and remitting course. TB was eventually diagnosed, in four of them by culture and in one by characteristic histopathology (this patient required surgical resection of a lung abscess).
Conclusion FQs may lead to partial symptom resolution in TB. We highlight the problem of a delayed diagnosis, and voice our concern about inadvertent monotherapy of TB in such cases.

Keywords: fluoroquinolones, Mycobacterium tuberculosis, tuberculosis
Singapore Med J 2006; 47(9): 747-751

Tiong HY, Poh J, Sunderaraj K, Wu YJ, Consigliere DT
Correspondence: Dr H Y Tiong, ho_yee_tiong@nuh.com.sg

ABSTRACT
Introduction The objective of this study was to audit the early and late complications of open Tenckhoff catheter insertion under local anaesthesia in a single institution.
Methods A review was carried out on 164 insertions in 139 patients over a three-year period. All patient records were retrospectively analysed until the time of transfer to haemodialysis, death, or to current time if alive and receiving continuous ambulatory peritoneal dialysis (CAPD). Patient characteristics, operative factors, early and late complications were recorded.
Results Early complications were reported in 31 percent of catheter insertions, predominantly wound infections and catheter malfunctions. The factors that were significantly associated with early complications were diabetes mellitus, glomerulonephritis, ongoing sepsis, previous abdominal surgery and prolonged surgical time. Late complications were seen in 26 percent of catheter insertions, mainly CAPD peritonitis. Poor nutritional status had a significant negative impact on late complications. The overall median catheter survival time was 41.9 months (95 percent confidence interval, 25.8-58.0 months). In addition, no significant difference in catheter survival time was detected between those patients with and those without diabetes mellitus.
Conclusion Tenckhoff catheter insertion for CAPD is a procedure associated with significant surgical morbidity. Patients with diabetes mellitus, glomerulonephritis and ongoing sepsis are at greater risk of early complications, and hence, must have their conditions stabilised or treated before surgery. In addition, prolonged surgical time and patients with previous abdominal surgery are at increased risk. The rate of complications may be improved by early consideration of patients with poor tolerance of local anaesthetic surgery or with previous abdominal surgery for laparoscopic insertion under general anaesthesia. To prevent late complications dominated by CAPD peritonitis, patients' nutritional status and care of the catheter should both be optimised.

Keywords: continuous ambulatory peritoneal dialysis, end-stage renal failure, peritoneal dialysis, peritonitis, postoperative complications, Tenckhoff catheter
Singapore Med J 2006; 47(8): 707-711

Eskandarian R, Malek M, Mousavi SH, Babaei M
Correspondence: Dr Rahimeh Eskandarian, malekmoj@yahoo.com

ABSTRACT
Introduction Cardiac syndrome X (CSX) includes chest pain, positive exercise stress test and/or radionuclide test for ischaemia and normal coronary angiography. There is no obvious aetiology for this syndrome. Some mechanisms such as endothelial dysfunction and oestrogen deficiency have been invoked. In this study, we surveyed the association of Helicobacter pylori (HP) infection with cardiac syndrome X.
Methods HP infection was detected by urea breath test (UBT) in patients with cardiac syndrome X, and compared with a sex- and age-matched control group. Patients with dyspepsia and coronary spasm were excluded. Statistical analysis was carried out using chi-square test.
Results 40 patients (29 females and 11 males) with cardiac syndrome X aged between 30 and 65 years (mean 45.51 +/- 5.03 years) were compared with a control group (28 females and 12 males) aged between 31 and 64 years old (mean 44.93 +/- 5.16 years). 95 percent of patients were HP infected, while only 47.5 percent of members of the control group were infected (p-value is less than 0.001).
Conclusion Considering the high prevalence of HP infection in patients with CSX in our sample and probable causative effect of chronic infection in vascular diseases, we believe that there is a probable role for HP infection in the pathogenesis of CSX.

Keywords: cardiac syndrome X, chest pain, coronary artery, Helicobacter pylori, vascular diseases
Singapore Med J 2006; 47(8): 704-706

Puthucheary SD, Nathan SA
Correspondence: Prof Savithri D Puthucheary, puthu@ummc.edu.my

ABSTRACT
Introduction Burkholderia pseudomallei (B. pseudomallei) has been shown to persist intracellularly in patients with melioidosis, until reactivated by decreasing immunocompetence. We have previously demonstrated by transmission electron microscopy, the internalisation of B. pseudomallei by human macrophages and the occurrence of phagosome-lysosome fusion.
Methods Phagocytosis and electron microscopy were used to compare the rate of phagosome-lysosome fusion and the intracellular survival of B. pseudomallei using monocytes obtained from five patients with melioidosis and five normal healthy adults.
Results Ingested bacilli were seen in various stages of degradation, with a few remaining viable within phagolysosomes, and the proliferation of these viable bacteria was observed. Phagocytosis of B. pseudomallei by normal macrophages was two-fold higher than uptake by the melioidosis macrophages (p-value is less than 0.001). Three times more phagolysosomes were present in the normal macrophages, indicating that fusion occurred slowly and inefficiently in the melioidosis macrophages (p-value is less than 0.001), resulting in higher number of organisms within the melioidosis macrophages (p-value is less than 0.001). Both variables were inversely related to each other.
Conclusion Our observations suggest that phagolysosome fusion occurred slowly and inefficiently in monocytes of patients with melioidosis, leading to an increased number of intracellular organisms compared to monocytes obtained from healthy donors.

Keywords: Burkholderia pseudomallei, lysosome, macrophages, melioidosis, phagosome
Singapore Med J 2006; 47(8): 697-703

Atiq M, Bana M, Ahmed US, Bano S, Yousuf M, Fadoo Z, Khurshid M
Correspondence: Dr Mehnaz Atiq, mehnaz.atiq@aku.edu

ABSTRACT
Introduction The aim of this study was to evaluate the spectrum of cardiac involvement and its outcome in beta-thalassaemia major.
Methods There were 75 patients with a mean age of 13.8 (+/- 5.5) years, of whom 33 were male and 42 were female. Clinical history, examination and laboratory investigations were assessed. Electrocardiograms, chest radiographs and echocardiograms were reviewed.
Results 44 patients had cardiac involvement in the form of left ventricular systolic dysfunction in 17, diastolic dysfunction in 22, pericardial effusion in 12 and pulmonary hypertension in 12 patients. With intense chelation therapy and cardiac medications, the condition of 13 of 17 patients with systolic dysfunction, and four of 22 with diastolic dysfunction, improved.
Conclusion Cardiac disease is a common complication of siderotic disease in thalassaemia major and it can be prevented with regular chelation. This study has shown improved systolic function after regular chelation therapy.

Keywords: cardiomyopathy, chelation, haemosiderosis, left ventricular dysfunction, thalassaemia major
Singapore Med J 2006; 47(8): 693-696

Voralu K, Norsa'adah B, Naing NN, Biswal BM
Correspondence: Dr Kirtanaa Voralu, kirtanaa@aimst.edu.my

ABSTRACT
Introduction The aim of this study was to identify the prognostic factors that influence the survival of differentiated thyroid cancer patients treated at Hospital Universiti Sains Malaysia (HUSM).
Methods A total of 178 patients diagnosed with and treated for differentiated thyroid cancer in HUSM between January 1974 and July 2003 were included in this retrospective cohort study. The additional follow-up period was one year after the end of the recruitment phase. The data was collected from the medical records of the patients.
Results The overall five- and ten-year relative survivals of differentiated thyroid cancer patients in HUSM were 90.6 percent (95 percent confidence interval [CI] 84.4-94.4) and 85.3 percent (95 percent CI 76.0-91.2), respectively. The significant prognostic factors for differentiated thyroid cancer were age (hazard ratio [HR] 6.9; 95 percent CI 1.7-28.6), loss of appetite (HR 10.9; 95 percent CI 2.7-43.7), tumour size (HR 3.7; 95 percent CI 1.1-13.8), regional recurrences (HR 3.2; 95 percent CI 1.1-9.8), high-risk stage (HR 19.9; 95 percent CI 4.4-90.4), and treatment (HR 0.2; 95 percent CI: 0.1-0.5).
Conclusion The survival rates obtained in this study were slightly lower than other studies but the pattern of survival rates between groups were similar. Prognostic factors identified in this study were similar to those of other studies, suggesting that the experience of HUSM was almost similar with that of other institutions.

Keywords: cancer prognosis, cancer survival rates, differentiated thyroid cancer, thyroid cancer
Singapore Med J 2006; 47(8): 688-692

Sulaiman AR, Joehaimy J, Iskandar MA, Anwar Hau M, Ezane AM, Faisham WI
Correspondence: Dr A Razak Sulaiman, abdrazak@kb.usm.my

ABSTRACT
Introduction The purpose of this study is to determine the overgrowth phenomenon of the affected femur following plate fixation of femoral fractures in children.
Methods 15 patients (aged between eight and 14 years old), who underwent open reduction and plate fixation for fractures of the femur, were assessed at two years postoperation for limb length discrepancy. Measurements were made using a computed tomography (CT) scanogram. Its association with age, limb dominancy and site of fracture were analysed.
Results There were 12 boys and three girls. All children had femoral overgrowth of the injured femur, ranging from 0.1 cm to 2.0 cm with a mean of 1.15 cm. There was a significant correlation between age and bone overgrowth. Limb dominancy and site of fracture had no significant influence on femoral overgrowth.
Conclusion The amount of femoral overgrowth following fracture stabilisation with plate in children was minimal. It could still occur even without fracture overlapping during the healing process. The overgrowth was less in older subjects.

Keywords: computed tomography, femoral fracture, limb overgrowth, plate stabilisation
Singapore Med J 2006; 47(8): 684-687