Original Article

Sen S, Jaiswal AK, Yanpallewar S, Acharya SB
Correspondence: Dr SB Acharya, sbacharya@rediffmail.com

ABSTRACT
Introduction The possible anxiogenic effects of fluoroquinolones, namely ciprofloxacin and norfloxacin, were investigated in adult Charles Foster albino rats of either sex, weighing 150-200 g.
Methods The drugs were given orally, in doses of 50 mg/kg for five consecutive days and the experiments were performed on the fifth day. The tests included open-field exploratory behaviour, elevated plus maze and elevated zero maze, social interaction and novelty-suppressed feeding latency behaviour.
Results The results indicate that ciprofloxacin- and norfloxacin-treated rats showed anxious behaviour in comparison to control rats in all the parameters studied. However, ciprofloxacin- and norfloxacin-treated rats did not differ significantly from each other in various behavioural parameters.
Conclusion The present experimental findings substantiate the clinically observed anxiogenic potential of ciprofloxacin and norfloxacin.

Keywords: anxiogenic effects, ciprofloxacin, fluoroquinolone, norfloxacin, rat
Singapore Med J 2007; 48(11): 1028–1032

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

ABSTRACT
Introduction We evaluated the progress in the self-perceived competence of medical students in a range of common clinical, practical and personal skills, in their final six months of training.
Methods The study was conducted on 65 final-year medical students undertaking their senior clerkship training at International Medical University, Malaysia. Questionnaire surveys were conducted at the beginning and the end of the six-month period, with 44 items covering clinical, practical, personal skills and readiness to work. Correlations were performed for experience and self-perceived competence, with the respective skills.
Results 64 students returned the first survey and 63 returned the second survey. When the two survey results were compared, significant increases were found in self-perceived competence for the majority of the skills examined. The items with no significant improvement were divided into those which the students were already proficient in before senior clerkship, and those in which experience and confidence remained poor at the end of training. There were significant, but moderate, correlations between the experience and confidence of all common practical skills (correlation coefficients: 0.348-0.522, p-value is less than 0.001 for all items). At the end of training, students were, in general, more prepared to work as house officers (mean rating in the first survey: 3.05, second survey: 3.97, p-value is less than 0.001).
Conclusion Significant progresses in clinical experience and confidence can be observed in the final stages of medical training. The findings of inadequate improvements in some skills call for dedicated training sessions and strengthening of on-site supervision.

Keywords: clinical competence, clinical skills, medical education, undergraduate education
Singapore Med J 2007; 48(11): 1018–1027

Thilagaratnam S
Correspondence: Dr S Thilagaratnam, shyamala_thilagaratnam@hpb.gov.sg

ABSTRACT
Introduction School-based scoliosis screening was implemented in Singapore in 1981. The rationale for the programme was so that conservative treatment (bracing) can be initiated early to prevent progression of curves, avoid the complications of severe scoliosis and reduce the need for surgery. The evidence for, or against, scoliosis screening and regular follow-up remains controversial. To date, there has been no formal cost analysis of Singapore's screening programme. The aim of this paper was to examine if there are economic justifications to continue with school-based scoliosis screening.
Methods This cost-effectiveness analysis was done by comparing Singapore's existing school-based scoliosis screening and follow-up programme with the alternative of not having a programme. As the aim of the existing programme was to detect curves early, allowing bracing to be initiated and reducing the need for surgery, this analysis assumed that without the programme, students who otherwise would have received bracing and not needed surgery, would have required surgery instead. This retrospective analysis was based on School Health Service data obtained from screening 45,485 students in 1999 and 44,051 of this same cohort in 2001. Nett programme costs and health effects were computed, and a decision rule applied.
Results The nett cost of the current mass screening programme was negative, while the nett health effects, albeit mostly intangible, positive; which made the programme an economically valuable one.
Conclusion Singapore's school-based scoliosis screening programme, which is implemented as part of a larger school screening and immunisation programme, is cost-effective. Cost-effectiveness may be further improved by targeting screening at high-risk groups, such as prepubertal females. More research is needed to quantify the positive health effects of scoliosis screening.

Keywords: costs analysis, healthcare costs, mass screening, scoliosis, School Health Services, targeted health screening
Singapore Med J 2007; 48(11): 1012–1017

Poon WB, Ho WLC, Yeo CL
Correspondence: Dr Poon Woei Bing, woeibingpoon@yahoo.com

ABSTRACT
Introduction Cultural, religious and personal factors impact greatly on parenting. This survey aims to identify gaps in knowledge and perception about common parenting issues, with respect to mandarin-speaking Chinese in Singapore. There is an emphasis on first-time parents, who the authors feel may be the group which will require additional education and support on these issues.
Methods A 37-item written survey was conducted before a public mandarin-language forum. Our response rate was 67 percent.
Results Only 44 percent felt that paediatricians allocated sufficient time to discuss parenting issues. 99 percent of parents believed that breast milk was better than formula milk and that 93 percent intended to breastfeed. However, the vast majority of respondents thought that breastfeeding should be stopped if jaundice developed, and that sunning was effective in preventing jaundice. Moreover, the majority did not recognise the seriousness of jaundice, prolonged or otherwise. Widespread misconceptions existed about milk formulas, with half of the respondents thinking that it was necessary to change to lactose-free formula once a child developed diarrhoea. The majority also thought that certain milk formulas could help improve IQ.
Conclusion We hope that more comprehensive and accessible parental education will be available to aid in raising awareness of parental practices, and to dispel misconceptions regarding neonatal care.

Keywords: breastfeeding, neonatal jaundice, parent education, parenting
Singapore Med J 2007; 48(11): 1006–1011

Agarwal R, Srinivas R, Aggarwal AN, Gupta D
Correspondence: Dr Ritesh Agarwal, riteshpgi@gmail.com

ABSTRACT
Introduction Immunosuppressive therapy has been shown to improve outcomes in patients with paraquat poisoning. The objective of this study was to evaluate the efficacy of immunosuppressive therapy in the management of lung injury due to paraquat poisoning.
Methods We searched the MEDLINE, OVID, and CINAHL databases for relevant studies published from 1980 to 2006. We included studies if (a) the study design was a randomised controlled trial, observational study with historical controls or observational study; (b) the study population included patients with paraquat poisoning, and received immunosuppressive therapy; and (c) the study provided data on mortality. We calculated the survival rate with 95 percent confidence intervals (CI) for observational studies, and relative risk and 95 percent CI for dichotomous outcomes.
Results 12 studies--four non-randomised, six non-randomised comparing historical controls, and two randomised controlled trials--had employed immunosuppressive therapy in the management of paraquat poisoning. The survival rate in the four non-randomised studies (39 patients) was 74.4 percent (95 percent CI 58.9-85.4). The relative risk of immunosuppressive therapy in decreasing mortality with paraquat poisoning was 0.55 (95 percent CI 0.39-0.77) and 0.6 (95 percent CI 0.27-1.34) for the non-randomised studies (comparing historical controls) and randomised controlled studies, respectively. There was significant heterogeneity and evidence of publication bias.
Conclusion One out of four patients (95 percent CI 3-5) were successfully treated with immunosuppressive therapy for paraquat poisoning. However, due to significant heterogeneity and publication bias, a large randomised controlled trial will be required to affirm the role of immunosuppression in paraquat poisoning.

Keywords: cyclophosphamide, gluco-corticoids, immunosuppressive therapy, lung injury, paraquat poisoning
Singapore Med J 2007; 48(11): 1000–1005

Lee AYJ, Chua BSY, Howe TS
Correspondence: Ms Janise Lee Ai Ye, jaslin_lurve@yahoo.com

ABSTRACT
Introduction A prospective and consecutive documentation of hip fracture care was performed. Outcomes, including quality of life, mortality, complication rates, were documented; and mobility, ambulatory status, freedom from pain and activities of daily living one year before and after treatment, were compared.
Methods We prospectively reviewed the medical records of 70 consecutive patients admitted to the Singapore General Hospital, following either a cervical or intertrochanteric femoral fracture from February 2004 to May 2004. Patients' progress was reviewed at one year post-treatment, and the EuroQOL was used to quantify the patients' quality of life. Description of any problems encountered was also recorded.
Results The follow-up rate at one year for the 70 patients described in this report was 98.6 percent. Mortality rate was 27.1 percent. Early complication rate was 5.7 percent. Outcome was satisfactory in all but two patients. Mortality for surgically-operated patients was 25.4 percent. About a quarter of the patients had excellent ambulatory status and 40.0 percent were able to walk independently. Eight percent suffered from falls after discharge, but no recurrence of hip fracture was recorded. None was re-admitted under suspicion of hip fracture. The average self-scoring system (EuroQOL) yielded an average of 66.6 out of 100.
Conclusion Hip fractures can be treated surgically with good results and low early complication rates, without drastically affecting patients' quality of life.

Keywords: fracture outcome, hip fracture, post-treatment outcome, quality of life
Singapore Med J 2007; 48(11): 996–999

Wong LL, Ooi SBS, Goh LG
Correspondence: Dr Lilian Wong, lilian_wong@alexhosp.com.sg

ABSTRACT
Introduction This study analysed the complaint rates, profile and trend, and complainant profile of patients' complaints received by the National University Hospital Emergency Medicine Department. An earlier ten-year study (1986-1995) was done on the complaint profile.
Methods Records of all patients' complaints, solicited and unsolicited, from January 2002 to December 2003, were retrieved from the Medical Affairs and Quality Improvement Unit files. Complaint profile analysed was reason, validity, and outcome of complaint and staff category involved. Complainant profile analysed was relationship of complainant to patient, ethnic group, gender and residence type of the complainant; and age group and triage category of the patient.
Results Complaint case rate was 1.17 per 1,000 visits, with 1.27 complaints per complaint case. The complaints were organisation/logistics (49.0 percent), communication (26.0 percent), standard of care (22.9 percent) and other issues (1.3 percent). Most standard of care (76.0 percent) and half of organisation/logistics complaints (46.8 percent) were not valid. Most communication complaints were valid (73.7 percent) and involved all staff categories equally. Most complaints (82.8 percent) were resolved with an explanation/apology. Age group specific and triage-specific complaint rates were highest among adult patients and among priority 3 patients, respectively; ethnic group and gender-specific complaint rates were highest among Chinese patients and among female patients, respectively.
Conclusion Staff-patient communication and organisation/logistics must be continually improved to reduce complaints, while upholding a good standard of care. These would translate into cost savings for all parties. There must also be appropriate checks and balances particularly where complaints are not valid, so that doctors can practice cost-effective medicine.

Keywords: complaint rate, emergency service, hospital complaints, patient complaints, patient satisfaction, staff-patient communication
Singapore Med J 2007; 48(11): 990–995

Charles RA, Bee YM, Eng PHK, Goh SY
Correspondence: Dr Rabind A Charles, rabindcharles@yahoo.com.sg

ABSTRACT
Introduction We piloted the use of a blood beta-hydroxybutyrate meter as a point-of-care testing in an emergency department (ED) to establish its role in distinguishing ketosis/ketoacidosis from simple hyperglycaemia, and develop guidelines for its use in the ED.
Methods 111 consecutive patients presenting with capillary glucose levels exceeding 14 mmol/L had a simultaneous blood ketone measurement at triage. This was correlated with clinical diagnosis, venous bicarbonate levels and urine ketone testing.
Results The median beta-hydroxybutyrate levels was 5.7 (range 4.3-6.0) mmol/L for patients with diabetic ketoacidosis (DKA) and 0.1 (0.0-3.2) mmol/L for the remaining patients. Only 47.7 percent could provide urine samples in the ED. A blood ketone result of 3.5 mmol/L yielded 100 percent specificity and sensitivity for the diagnosis of DKA.
Conclusion This is a useful tool that allows clinicians to immediately distinguish between simple hyperglycaemia and potentially life-threatening ketotic states. We formulated simple guidelines for its utilisation in an ED setting.

Keywords: beta-hydroxybutyrate, blood ketone testing, diabetes emergencies, diabetes mellitus, diabetic ketoacidosis
Singapore Med J 2007; 48(11): 986–989

Lim MN, Lau NS, Chang KM, Leong CF, Zakaria Z
Correspondence: Ms Lim Moon Nian, limmn@imr.gov.my

ABSTRACT
Introduction The multidrug resistance gene, MDR1, is one of the genes responsible for resistance to chemotherapy in the treatment of leukaemia and other cancers. The discovery of RNA interference in mammalian cells has provided a powerful tool to inhibit the expression of this gene. However, very little is known about the transfection of leukaemia cells with short interfering RNA (siRNA) targeted at MDR1. This study aims to evaluate the effectiveness of two chemically-synthesised siRNA in modulating MDR1 gene and inhibiting P-glycoprotein expression in leukaemic cells. We also evaluated two siRNA delivery methods in this study.
Methods K562/Adr was transfected with two MDR1-targeted siRNA or negative control siRNA, by using cationic lipid-based transfection reagents or electroporator. Gene expression of MDR1 was quantified by real-time polymerase chain reaction and calculated as a percentage relative to the negative control siRNA. P-glycoprotein expression was evaluated via flow cytometry and drug sensitivity after treatment was assessed by cytotoxicity assays.
Results The percentage of MDR1 gene knockdown from cells transfected with an electroporator was significantly higher (84.4 percent, p-value is 0.094) compared to cells transfected with cationic lipid-based transfection reagents (52.8 percent). Both siRNA significantly reduced the expression of MDR1 by 84.9 percent (p-value is 0.001) and 86.0 percent (p-value is 0.011), respectively. P-glycoprotein expression was down-regulated and drug sensitivity was increased after treatment with the siRNA.
Conclusion This study shows that the two siRNA sequences are capable of modulating MDR1 and P-glycoprotein expressions and increased drug sensitivity. Transfection with an electroporator was superior to chemical transfection for leukaemia cells.

Keywords: leukaemia cells, multidrug resistance gene, P-glycoprotein, short interfering RNA transfection
Singapore Med J 2007; 48(10): 932–938

Rai R, Ranade AV, Prabhu LV, Pai MM, Prakash
Correspondence: Mrs Rajalakshmi Rai, rajalakshmirai@yahoo.co.in

ABSTRACT
Introduction The biceps brachii is one of the muscles of the anterior compartment of the upper arm. It is characteristically described as a two-headed muscle that originates proximally by a long head and a short head. The present study was carried out to find the occurrence of a third head of biceps brachii among a sample Indian population from the southern coastal part.
Methods The arms of 42 cadavers were dissected and observed for variations in the origin and insertion of biceps brachii muscle bilaterally. The cadavers were embalmed and preserved in ten percent formalin.
Results Among 42 arms studied, three had biceps brachii with three heads on the right side. The third head was of humeral origin, which inserted into the radial tuberosity by a common tendon with the long and short heads. The results of the present study compared with that of previous studies from medical literature shows that the occurrence of a third head of the biceps brachii muscle is relatively rare in Indians.
Conclusion Knowledge of the existence of the third head of biceps brachii may become significant in preoperative diagnosis and during surgery of the upper limb.

Keywords: accessory head of biceps brachii, anatomical variants, biceps brachii variations, supernumerary head of biceps brachii, third head of biceps brachii
Singapore Med J 2007; 48(10): 929–931