Original Article

Shum CF, Lau KO, Sy JL, Cheng WS
Correspondence: Dr Shum Cheuk Fan, lshum@singnet.com.sg

ABSTRACT
Introduction Renal transplantation has gained much wider acceptance as a treatment option for local patients with end-stage renal failure in the last three decades. However, there are no local reports regarding the associated urological complications and their management. This paper aims to explore these complications in the local setting.
Methods This is a retrospective review of 440 consecutive renal transplantations performed in Singapore General Hospital over a ten-year period. From the retrieved clinical records of transplant recipients, the occurrence of various urological complications and their management were studied.
Results The overall incidence of urological complications among transplant recipients was 7.7 percent. Urological complications included urinary leakage, ureteric strictures, symptomatic lymphocoeles, malignancies, urolithiasis, double-J stent fragmentation as well as haemorrhagic cystitis, and their incidences were 1.4 percent, 2.0 percent, 1.8 percent, 2.3 percent, 0.2 percent, 0.2 percent and 0.2 percent, respectively. Among the malignancies, 70 percent were renal cell carcinomas in the native kidneys.
Conclusion The incidence of urological complications in our series was comparable to those in the various major centres. However, there was a significantly higher incidence of native renal cell carcinoma in our series, which was likely to be secondary to the prolonged period of dialysis prior to renal transplantation.

Keywords: kidney transplantation, postoperative complications, renal cell carcinoma, urological complications
Singapore Med J 2006; 47(5): 388-391

Chong VH, Vu C
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk

ABSTRACT
Introduction The benefits of percutaneous endoscopic gastrostomy (PEG) remain controversial. Patient selection is important to identify those who will benefit from PEG. This study aims to identify patient factors that may help in patient selection for PEG.
Methods Patients who underwent PEG at the Gastroenterology Unit of Tan Tock Seng Hospital, Singapore, from January 1998 to December 1999, were identified. Multiple logistic regression was used to predict patient's outcomes.
Results There were 106 (61 male) patients with a mean follow-up period of 465 days (range 3-1,410 days). The mean patient age was 64.5 years (range 17-94 years). The 30-day, six-month, one-year and two-year mortality rates were 7.5 percent, 26.4 percent, 35.8 percent and 46.2 percent, respectively. Older age (p-value is 0.023), presence of bedsores (p-value is 0.042) and abnormal nutritional status based on body mass index less than 20 kg/square metres (p-value is 0.001) were predictive of mortality. 26 percent of patients were able to wean off PEG in an average period of 185 days (range 3-870 days). Patients were generally younger (p-value is 0.003) and had better renal function (p-value is 0.047).
Conclusion Older age, poor nutritional status and presence of bedsores were predictors of poor outcome. Younger age and preserved renal function were significant predictors of weaning off PEG feeding.

Keywords: endoscopy, enteral feeding, gastrostomy, percutaneous endoscopic gastrostomy
Singapore Med J 2006; 47(5): 383-387

Snodgrass AM, Ang A, Members of the Childhood Injuries Surveillance Project
Correspondence: Dr Alison Marion Snodgrass, amsnodgrass@yahoo.co.uk

ABSTRACT
Introduction To describe the risk factors, causes and outcome of infant injuries so as to guide the formulation of injury prevention strategies specific for Singapore babies less than one year old.
Methods Demographical, socio-economic data, and data on the circumstances of injury, nature, severity of injury and clinical outcome of all infants less than one year old and who sought medical attention for or died from unintentional childhood injuries or poisoning, at the Emergency Departments of three SingHealth hospitals, two SingHealth primary care polyclinics and the Forensic Medicine Department, Health Sciences Authority during a six-month period, were extracted from a larger Childhood Injuries Surveillance database and analysed.
Results 405 cases of accidental injury and poisoning in infants aged less than one year were seen from February to July 2002. 40.5 percent of injuries occurred when infants were left alone. Most infants were aged between nine months to one year (37 percent), male (57.3 percent), first-born (57.3 percent) and Chinese (69 percent), with no past medical history (96.1 percent). 91 percent of the injuries occurred at home, of which 60.5 percent occurred in the bedroom. Falls were the major mechanism of injury (77 percent). A total of 431 injuries were sustained. 63 percent were head injuries - mainly stable head injuries, which made up 93.1 percent of all the head injuries. 67.5 percent of the cases were discharged without follow-up, while 17.9 percent required hospital admission, mostly to the general ward (98.6 percent of total admissions), and to the neurosurgery department (84.9 percent of total admissions). There were two fatalities in this study population. The mechanisms and patterns of injury changed with increasing motor ability of the infants.
Conclusion Parents and caregivers of infants should be taught and reminded about the age specific measures in injury prevention as their wards go through the various developmental stages in the first year of life. Emphasis should be placed on close caregiver supervision, identifying potential injury hazards in the home, fall prevention, adopting safe infant care practices and the safe use of infant care products.

Keywords: accidental falls, accident prevention, head injuries, home accidents, infant
Singapore Med J 2006; 47(5): 376-382

Oh D, Arjandas M, Lim KBL, Lee EH
Correspondence: Dr Derrick Oh, derrickoh@ttsh.com.sg

ABSTRACT
Introduction Heelys, a type of shoes with stealth wheels, are extremely popular among children in Singapore. The widespread availability of cheap imitations has led to a proliferation of young users. Coupled with a total lack of safety equipment and instructions, these shoes can lead to significant injuries. The purpose of this study was to examine the incidence and type of injuries sustained by children using Heelys.
Methods During a seven-month period from February to August 2004, all children treated at the Paediatric Orthopaedic Department of the KK Women's and Children's Hospital, were asked if the injury was sustained while "heeling". All the patients were reviewed by the authors. A total of 37 patients with significant injuries sustained while "heeling" were identified. Their radiographs and clinical charts were reviewed. The patients and/or their parents were also interviewed to obtain additional information.
Results Upper limb injuries were by far the most common. Distal radius fractures and elbow injuries predominated. None of the children used safety gear.
Conclusion "Heeling" can lead to serious injuries despite the relatively low velocity involved. Children and their parents need to be educated on the use of safety gear.

Keywords: children, heeling, Heelys, limb injuries, sports injuries
Singapore Med J 2006; 47(5): 373-375

Heng KWJ, Lee AHP, Zhu S, Tham KY, Seow E
Correspondence: Dr Kenneth W J Heng, kenneth_heng@ttsh.com.sg

ABSTRACT
Introduction To describe the relationship between bicycle helmet use and injury pattern sustained by patients presenting to an emergency department (ED) in Singapore for bicycle-related trauma.
Methods Data was collected from all individuals treated for bicycle-related trauma between September 1, 2004 and May 31, 2005 using a closed-ended questionnaire.
Results 160 bicyclists with mean age of 34.4 years (range 10 to 89 years) were surveyed. Among them, 80 percent were male and 30.6 percent were non-residents. Helmets were worn by 10.6 percent of the patients. Alcohol was clinically detected in 11.3 percent of bicyclists. There was no difference in bicycle helmet use between Singaporeans and non-residents (p-value is 0.275). However, compared to younger bicyclists, bicyclists aged 30 years or older (p-value is less than 0.05), and compared to recreational or sport bicyclists, those who commute by bicycle, tended not to wear helmets (p-value is less than 0.01). Compared to Singaporeans (p-value is less than 0.05), non-residents and bicyclists aged 30 years or older (p-value is 0.011) believed that helmets did not protect against head injury. Comparing the helmeted group with the non-helmeted group, injury patterns by body region were: head injury 5.9 percent versus 40.0 percent (p-value is less than 0.01); facial injury 5.9 percent versus 37.1 percent (p-value is less than 0.05). Not wearing a helmet, being hit by a motor vehicle and age were significantly associated with higher injury severity scores, after adjusting for several potential confounding factors.
Conclusion Bicycle helmet use was low in our sample of injured patients. When worn, protection against injury was demonstrated. A campaign to promote use of bicycle helmets should be targeted at non-residents and older bicyclists. Authorities should consider compulsory helmet laws for bicyclists and expanding anti-drunk driving campaigns to target alcohol-intoxicated bicyclists.

Keywords: bicycling, head injury, helmets, multiple injuries
Singapore Med J 2006; 47(5): 367-372

Wu AYT, Tan CB, Eng PHK, Tan KT, Lim SC, Tan EK
Correspondence: Dr Akira Y T Wu, akirawu@pacific.net.sg

ABSTRACT
Introduction Microalbuminuria is a marker of increased cardiovascular morbidity and mortality. It represents the earliest clinical evidence of diabetic nephropathy. Its early detection allows for implementation of individually-tailored cardiovascular risk reduction management programmes. Despite this, information on the prevalence of microalbuminuria in hypertensive patients with type 2 diabetes mellitus in Singapore is limited.
Methods The Microalbuminuria Prevalence Study (MAPS) assessed the prevalence of macroalbuminuria and microalbuminuria in consecutively-screened hypertensive adult patients with type 2 diabetes mellitus in ten Asian countries. This paper presents the results of a sub-analysis of data from patients in Singapore.
Results Singapore contributed seven percent of the overall enrolment into MAPS; a total of 499 patients were enrolled and 388 constituted the per-protocol population (patients with bacteriuria and haematuria were excluded). Overall, the prevalence of diabetic kidney disease was high. In our study population, 23.5 percent of patients had macroalbuminuria (95 percent confidence interval [CI] 21.3-25.6), and 48.5 percent of patients had microalbuminuria (95 percent CI 45.9-51.0). Only 28.1 percent (95 percent CI 25.8-30.4) of patients were normoalbuminuric. Associated factors were poor glycaemic control and poor blood pressure control.
Conclusion The high prevalence (72 percent) of microalbuminuria and macroalbuminuria found in hypertensive patients with type 2 diabetes mellitus in Singapore is a cause for concern. These findings highlight the need to screen for microalbuminuria and better manage hypertensive patients with type 2 diabetes mellitus, if we are to avoid a major increase in end-stage renal disease.

Keywords: diabetic nephropathy, diabetes mellitus, hypertension, macroalbuminuria, microalbuminuria
Singapore Med J 2006; 47(4): 315-320

Rajesh H, Yap HAC, Wu YJ
Correspondence: Dr Hemashree Rajesh, hemashreerajesh@yahoo.com

ABSTRACT
Introduction The purpose of this study was to compare the obstetrical course of in-vitro fertilisation pregnancies with and without intracytoplasmic sperm injection, and to ascertain any difference in the outcome. Both singleton and multiple pregnancies were assessed individually in areas where they could confound results.
Methods This was a retrospective analysis of all successful in-vitro fertilisation pregnancies at the Singapore General Hospital during the period 1998-2003. A total of 271 pregnancies with and without intracytoplasmic sperm injection were evaluated. The details of the pregnancies were obtained from the Assisted Reproductive Technology Registry and Birth Defects Registry.
Results The obstetrical outcome was comparable between the two groups, in terms of the number of deliveries, biochemical and ectopic pregnancies. There was no significant difference in the miscarriage rate. The preterm rates for an intracytoplasmic injection pregnancy were two times higher than that reported in literature for both singletons and multiple pregnancies. The singleton intracytoplasmic sperm injection pregnancies were more likely to deliver preterm (17.5 percent, p-value is 0.041) compared to the ones without intracytoplasmic injection (5.7 percent). The average singleton birth weight was lower for the former (2.94 [+/-0.53] kg) than for the latter (3.19 [+/-0.48] kg, p-value is 0.0173). No definite conclusion could be reached regarding the differences in congenital abnormalities between the two groups.
Conclusion The obstetrical course of an in-vitro fertilisation pregnancy with intracytoplasmic sperm injection pregnancy appears to be similar to one without intracytoplasmic sperm injection except for a slight increase in the preterm deliveries and a lower birth weight at delivery among the singletons.

Keywords: birth weight, intracytoplasmic sperm injection, in-vitro fertilisation, pregnancy outcome, preterm delivery
Singapore Med J 2006; 47(4): 309-314

Bhalla A, Sachdev A, Lehl SS, Singh R, D'Cruz S
Correspondence: Dr Ashish Bhalla, ashish_ritibhalla@yahoo.com

ABSTRACT
Introduction Circadian variation in cardiovascular events is well recognised in vascular events. This study aims to observe any significant difference in circadian variability in geriatric patients when compared to their younger counterparts.
Methods This prospective study was conducted at medical emergency at the Government Medical College and Hospital, Chandigarh, India. All the patients attending medical emergency with symptoms suggestive of coronary artery disease were included. The time of occurrence of first symptom and subsequent symptoms was noted. Electrocardiography, cardiac enzymes and echocardiography were performed to establish the diagnosis of acute coronary syndrome. The 24-hour day was divided into 12 equal parts of two hours each. For the final analysis, the two-hour periods were grouped into six equal periods of four hours each and four quarters of six hours each.
Results We studied 559 patients, out of whom 459 were 65 years old or younger, and 100 patients were older than 65 years old. 459 patients had 498 episodes in all. 100 patients above the age of 65 years had 104 episodes. Both the groups had peaking of acute myocardial infarction in the early morning hours with patients older than 65 years of age having a slightly early peak. However, there was considerable variability for peaking of unstable angina and non-Q myocardial infarction. In patients older than 65 years, early morning peaking of events was noted whereas in 65 years or younger, the peaking of events was noted in the evening hours.
Conclusion Circadian variability exists in occurrence of acute coronary events and is variable in geriatric patients when compared to their younger counterparts.

Keywords: acute myocardial infarction, ageing, cardiovascular events, circadian variation, geriatric patients, unstable angina
Singapore Med J 2006; 47(4): 305-308

Koh KGWW, Gwee KP, Chan YH
Correspondence: Dr Kenneth G W W Koh, kenneth_koh@imh.com.sg

ABSTRACT
Introduction The association between mental illness and violent offenders is an important issue not just for psychiatrists but for the public as well. Several studies have linked an increased prevalence of psychiatric illness among offenders of violent crimes. This study seeks to update the psychiatric community in Singapore on individuals charged with murder from 1997 to 2001, all of whom received a psychiatric assessment.
Methods 110 individuals were charged with murder from 1997 to 2001. Socio-demographical data, psychiatric diagnoses, offence and victim profiles and court outcomes were obtained from prison records and psychiatric files.
Results There were 110 individuals charged with murder between January 1, 1997 to December 31, 2001, with a total of 113 victims. In 70 of the cases, one offender killed one victim. Offenders were mostly unmarried males in the 20-39 year age group who received a secondary school level of education or less. 57 of the remandees were found not to suffer from any mental illness. Alcohol abuse and dependence disorders accounted for the largest diagnostic group. Depressive disorders accounted for 9.1 percent of the accused persons and schizophrenia, 6.4 percent. Victim profiles and court outcomes are also described. A comparison is drawn between this study and the last large report on homicides in Singapore, published in 1985. No difference is detected when the rates of schizophrenia and depression are compared between the two eras.
Conclusion Perpetrators of murder have been shown to have an increased incidence of psychiatric disorders. Reduction of the rate of homicide in the country may be achievable via the reduction of controllable factors found to be linked to the aetiology of murder. Alcohol and other illicit substance use are frequently found to be associated with homicide. The authorities are encouraged to enhance campaigns to dissuade alcohol abuse.

Keywords: alcoholism, forensic psychiatry, homicide, jurisprudence, mental disorders
Singapore Med J 2006; 47(4): 297-304

Ahmed KS, Khan AA, Ahmed I, Tiwari SK, Habeeb MA, Ali SM, Ahi JD, Abid Z, Alvi A, Hussain MA, Ahmed N, Habibullah CM
Correspondence: Prof C M Habibullah, cmhabib@rediffmail.com

ABSTRACT
Introduction Since the discovery of Helicobacter pylori (H. pylori), much progress has been made worldwide in the field of its epidemiology. In spite of these advancements, many aspects of epidemiology still remain unclear, particularly among populations with low socio-economic status. The present study was designed to elucidate the different routes of transmission of H. pylori in the Hyderabad (South India) population and to investigate the impact of certain factors, such as age, gender, and lifestyle.
Methods Samples used for the study included saliva and biopsy samples of 400 symptomatic subjects from Hyderabad, India. The patients were retrospectively grouped, based on histopathology of the biopsy and 16S rRNA amplification of both saliva and biopsy as H. pylori positive and negative.
Results This study showed that the prevalence of H. pylori in both saliva and biopsy samples increased with age. In addition, the H. pylori infection was found more commonly in the saliva and biopsy samples among males (64 percent and 60 percent, respectively) than females (53.3 percent and 64 percent, respectively). Similarly, 71.6 percent and 73.5 percent of those who consumed municipal water acquired H. pylori (which were respectively found in their saliva and biopsy samples) compared to a lesser proportion (12.6 percent and 12.6 percent, respectively) of those who consumed boiled or filtered water. The study also found that subjects who preferred home-cooked food (57.1 percent and 57.7 percent) showed a lower prevalence of H. pylori in saliva and biopsy samples, respectively, compared to those (80 percent and 88 percent) who frequently ate out.
Conclusion The results of the present study suggest that besides the oral-oral route, the transmission of H. pylori also takes place through the consumption of food prepared under unhygienic conditions. Consumption of municipal tap water also has a high impact in the transmission of H. pylori.

Keywords: gastrointestinal disease, Helicobacter pylori, 16S rRNA, saliva, water disease transmission
Singapore Med J 2006; 47(4): 291-296