Original Article

Al-Awadhi AM, Olusi S, Hasan EA, Abdullah A
Correspondence:Dr Adel M Al-Awadhi, aalawadhi@hsc.edu.kw

ABSTRACT
Introduction Some reports in the literature suggest that cardiac troponin-I (cTnI) is falsely elevated in patients with seropositive rheumatoid arthritis (RA) because of the presence of rheumatoid factor (RF). But, there are no reports in the literature on cTnI concentrations in other autoimmune diseases. We therefore decided to measure the serum concentrations of cTnI in patients with seropositive and seronegative RA, systemic lupus erythematosus (SLE), primary Sjogren's syndrome (pSS) and Graves' disease (GD), in order to find out if this cardiac marker is falsely elevated or not.
Methods Serum samples were drawn from 50 patients with seropositive RA, 50 patients with seronegative RA, 50 patients with SLE, 20 patients with pSS and 15 patients with GD. We measured cTnI levels using the Beckman Access Immunoassay System in these serum samples.
Results Of the 50 patients with seropositive RA, five had cTnI levels higher than 0.1 ng per ml (the diagnostic value for myocardial infarction in our hospital laboratory), while none of the patients with seronegative RA, SLE, pSS, or GD had levels above this value. Furthermore, univariate regression analysis showed a positive association (r equals 0.35, p-value equals 0.02) between cTnI and RF in patients with seropositive RA.
Conclusion Using the Beckman Access Immunoassay System for cTnI quantification, it was found that some patients with seropositive RA had falsely-elevated cTnI, while none of the patients with seronegative RA, SLE, pSS, or GD had falsely-elevated cTnl.

Keywords: cardiac troponin-I, Grave’s disease, primary Sjogren’s disease, rheumatoid arthritis, serum rheumatoid factor, systemic lupus erythematosus
Singapore Med J 2007; 48(9): 847–849

Farvid MS, Djalali M, Siassi F, Farvid SS
Correspondence: Dr Maryam Sadat Farvid, farvidm@yahoo.ca

ABSTRACT
Introduction This study was conducted to investigate the relationship of glomerular and tubular dysfunctions with glycaemic control, lipid, lipoprotein, apolipoproteins and antioxidant status in 72 patients with type 2 diabetes mellitus.
Methods Urine albumin concentration was measured by immunoturbidimetric and urine N-acetyl-beta-D-glucosaminidase (NAG) and alanine aminopeptidase (AAP) activities with colorimetric methods. Glycated haemoglobin was measured using affinity chromatography. Erythrocyte glutathione reductase and glutathione peroxidase activities and serum levels of malondialdehyde, lipids, lipoproteins and apolipoproteins were determined in patients with type 2 diabetes mellitus.
Results In univariate regression, urinary albumin excretion, and activities of NAG and AAP were associated with glycaemic control. These glycaemic factors included serum glucose concentrations and glycated haemoglobin. Urinary albumin excretion was also inversely correlated with erythrocyte glutathione peroxidase activity, and positively correlated with erythrocyte glutathione reductase activity. No significant associations were found with serum levels of insulin, lipids, lipoproteins, apolipoproteins, malondialdehyde or blood pressure. In multivariate regression, glycated haemoglobin was the most significant predictor of urinary albumin concentration and with erythrocyte glutathione reductase, whereas only glycated haemoglobin was the independent predictor of tubular dysfunctions. Erythrocyte glutathione peroxidase was not an independent predictor of urinary albumin excretion, after adjusting for glycated haemoglobin, glutathione reductase, systolic blood pressure, diastolic blood pressure and apolipoprotein B.
Conclusion In type 2 diabetes mellitus, both glomerular and tubular dysfunctions are dependent on glycaemic control. Glomerular, but not tubular, dysfunction is also significantly associated with increased glutathione reductase activity.

Keywords: antioxidants, diabetes mellitus, diabetic nephropathy, glomerular dysfunction, tubular dysfunction
Singapore Med J 2007; 48(9): 840–846

Loo CY, Tan HJ, Teh HS, Raymond AA
Correspondence: Dr Loo Chee Yean, cyloo7@gmail.com

ABSTRACT
Introduction Migraine is a common disabling condition that results in considerable socioeconomic loss. The role of non-steroidal anti-inflammatory drugs (NSAIDs) in acute migraine has been well-established. We compared the efficacy of the cyclooxygenase-2 inhibitor celecoxib with the NSAID, naproxen sodium, in the treatment of acute migraine.
Methods This was a randomised, open label, controlled trial. We selected patients with a diagnosis of migraine, based on the International Headache Society revised criteria. 60 patients were randomised to either celecoxib 400 mg (30 patients) or naproxen sodium 550 mg (30 patients). Patients took the study medicine for the first acute migraine episode that occurred during the study period and reported the headache reduction based on a visual analogue score (VAS). Patients were reviewed after a month to check on VAS at one and two hours, compared to the baseline. Any side effects of the medication were also recorded.
Results Of the 52 patients who completed the study, eight did not experience any headaches. The mean VAS in the celecoxib group improved significantly from baseline (6.48 +/- 1.53) to one hour (4.28 +/- 2.11) and two hours (2.24 +/- 2.57) (p-value is less than 0.0005). The mean VAS in the naproxen sodium group also improved significantly from baseline (7.30 +/- 1.66) to one hour (4.81 +/- 2.50) and two hours (2.63 +/- 2.65) (p-value is less than 0.0005). However, there was no significant difference between the magnitudes of improvement between the treatment groups. The incidence of gastric pain was significantly higher in the naproxen sodium group (p-value is equal to 0.029).
Conclusion In comparison with naproxen sodium, celecoxib was equally effective in relieving pain in acute migraine and caused significantly less gastric pain.

Keywords: acute migraine, celecoxib, drug side-effects, gastric pain, migraine, naproxen sodium, visual analogue score
Singapore Med J 2007; 48(9): 834–839

Chowdhury FR, Nazmul Ahasan HAM, Mamunur Rashid AKM, Al Mamun A, Khaliduzzaman SM
Correspondence: Dr Fazle Rabbi Chowdhury, shakilrabbi@yahoo.com

ABSTRACT
Introduction Puffer fish (tetrodotoxin) poisoning is now a common form of poisoning throughout coastal countries, but its diagnosis and management are still unclear. In this paper, we aim to share our experience and to find out the toxic manifestations, lag period between ingestion of fish and development of symptoms, the short-term clinical outcome, and value of neostigmine in its management.
Methods The study was carried out in the Department of Medicine and Paediatrics, Khulna Medical College Hospital, Khulna, Bangladesh, from May 1, 2001 to May 1, 2006. A total of 53 patients were admitted with the history of puffer fish ingestion. All the cases were clinically analysed from admission to discharge, for the following variables: Onset of symptoms in minutes after the ingestion of fish, toxic manifestations that developed after ingestion, relation of clinical outcome with approximate amount of fish ingested, and the role of neostigmine.
Results All patients developed toxic manifestation. Important symptoms were perioral paraesthesia (38), weakness of all limbs (33), paraesthesia all over the body (34), headache (25), and difficulty in respiration. Eight patients died, probably due to respiratory muscle paralysis, of which five patients died immediately after admission. We used neostigmine in those patients who developed respiratory failure. 13 patients improved significantly (p-value is less than 0.5), while only three patients died.
Conclusion Because of the availability and affordability of puffer fish, the occurrence of tetrodotoxin poisoning throughout coastal countries is very likely. Therefore, health personnel should have enough knowledge regarding its toxic manifestations and management.

Keywords: neostigmine, perioral paraesthesia, poisoning, puffer fish, tetrodotoxin
Singapore Med J 2007; 48(9): 830–833

Low S, Chan FLF, Cutter J, Ma S, Goh KT, Chew SK
Correspondence: Dr Serena Low, lowkiatmun@yahoo.com

ABSTRACT
Introduction Infections with Streptococcus pneumoniae cause significant morbidity and mortality. In this study, we describe the epidemiology of pneumococcal disease based on hospitalisation rates for all age groups in Singapore. This is important for evaluating prevention and control strategies of pneumococcal disease.
Methods We conducted a retrospective study of hospitalisation cases admitted to all public and private hospitals from 1995 to 2004. 4,275 hospitalisation records were extracted, based on the International Classification of Diseases, Ninth Revision (ICD-9) codes for pneumococcal disease. We analysed the demographics, type of pneumococcal disease, length of stay and case fatality of these cases.
Results Our study showed that the mean annual hospitalisation rate for pneumococcal disease was 10.9 per 100,000 population from 1995 to 2004. The mean annual hospitalisation rate was highest in the young and the elderly.
Conclusion Baseline information on the epidemiology of pneumococcal disease is important for the formulation and evaluation of a national prevention and control programme.

Keywords: International Classification of Diseases, pneumonia, pneumococcal disease, Streptococcus pneumoniae
Singapore Med J 2007; 48(9): 824–829

Hassan Y, Alfadly SO, Azmin MN, Peh KK, Tan TFY, Noorizan AA, Ismail O
Correspondence: Dr Yahaya Hassan, yahaya@usm.my

ABSTRACT
Introduction A bioequivalence study of two oral formulations of 500 mg tablets of ciprofloxacin (RAZA Pharmaniaga, Malaysia) as test and Ciprobay (Bayer AG, Germany) as reference, was carried out in 24 healthy human volunteers. Each volunteer received a single dose of ciprofloxacin.
Methods The study method used was a double-blind, two-period, two-treatment, two-sequence, and crossover randomised design. Blood samples were taken before, and within 24 hours after drug administration. Plasma concentrations of ciprofloxacin were determined by a high-performance liquid chromatographic method with ultraviolet detection. The pharmacokinetic parameters, C(max) and T(max), were obtained directly from plasma data, k(e) was estimated by log-linear regression, and the area under the curve (AUC) was calculated by the linear trapezoidal rule. The parameters, AUC(0-infinity) and C(max), were tested for bioequivalence after log-transformation of data, while the differences of T(max) were evaluated nonparametrically.
Results When AUC(0-infinity) and C(max) were analysed using analysis of variance, no statistically significant difference was observed between the two different formulations. The 90 percent confidence intervals of the mean values for the test/reference ratios were 0.95-1.07 for AUC(0-infinity) and 0.90-1.07 for C(max), respectively. Both of these values were within the bioequivalence acceptance range of 0.80-1.25.
Conclusion We found that both formulations are bioequivalent and, therefore, interchangeable.

Keywords: bioequivalence, ciprofloxacin, healthy volunteers, high-performance liquid chromatographic analysis, pharmacokinetics
Singapore Med J 2007; 48(9): 819–823

Loh LC, Chin HK, Chong YY, Jeyaratnam A, Raman S, Vijayasingham P, Thayaparan T, Kumar S
Correspondence: Dr Li-Cher Loh, richard.loh@imu.edu.my

ABSTRACT
Introduction Klebsiella pneumoniae ranks high as a cause of community-acquired pneumonia in hospitalised patients in Malaysia.
Methods A retrospective study of 5,990 clinical respiratory specimens in patients, with a mean age of 54 (standard deviation 18.5) years, admitted to an urban-based general hospital between 2000 and 2004, was conducted.
Results The percentages of K. pneumoniae isolates during these years were 11, 19.1, 41.4, 27.8 and 16.6 percent, respectively. During this time, the percentage of isolates resistant to ampicillin were consistently in excess of 80 percent, those resistant to cephalosporins were relatively stable between eight and 23 percent, while those resistant to beta-lactam/beta-lactamase inhibitors [amoxicillin clavulanic acid/ ampicillin-sulbactam] and aminoglycosides steadily increased between six and 58 percent. Compared with hospital consumption of these corresponding antibiotic classes, only beta-lactam/beta-lactamase inhibitors and aminoglycosides showed a clear trend of eight- and four-fold increases, respectively. Co-resistance rates in isolates resistant to ampicillin and amoxicillin-clavulanic acid/ampicillin-sulbactam were generally low to second to third generation cephalosporins (less than 20 percent).
Conclusion Our local findings highlighted the changing trend in respiratory K. pneumoniae over a five-year period, and its escalating resistance to beta-lactam/beta-lactamase inhibitors and aminoglycosides that is possibly attributable to the widespread use of these antibiotics in our hospital.

Keywords: antibiotic resistence, community-acquired pneumonia, Klebsiella pneumoniae, respiratory infection, respiratory isolates
Singapore Med J 2007; 48(9): 813–818

Loi K, Khoo CK, Tan KH, Yeo GSH, Kwek K
Correspondence: Dr Kenneth Kwek, kwekeroo@kkh.com.sg

ABSTRACT
Introduction This study aims to assess the epidemiology of severe preeclampsia in Singapore, the disease characteristics, maternal and perinatal outcome, and to identify risk factors for complications.
Methods Data of 93 consecutive women with severe preeclampsia in KK Women's and Children's Hospital in Singapore was collected prospectively and analysed using the unpaired t-test for normally-distributed continuous variables and Fisher's exact chi-square test for discrete variables. Multivariate logistic regression analysis was performed for prediction of complicated cases.
Results The incidence of severe pre-eclampsia was 29.3 per 10,000 deliveries, with an increased risk in women who were aged more than 35 years and who were nulliparous. The risk was also increased in women of the Malay race and they also had the tendency to book later, compared with the other races. 43 percent of women had maternal complications, including eclampsia, haemolysis/elevated liver enzymes/low platelets syndrome, oliguria, pulmonary oedema and placental abruption. Significantly raised levels of uric acid (439.5 +/- 114.1 micromol/L versus 395.4 +/- 96.7 micromol/L, p-value equals 0.047) and aspartate transaminase (80.1 +/- 107.4 IU/L versus 38.8 +/- 16.1 IU/L, p-value equals 0.021) were found in those with complications, compared to those without complications. The average gestation at time of diagnosis was 33 weeks and the average gestation at delivery was 34 weeks. 89.3 percent of women required caesarean section and 59.1 percent of women were admitted to intensive care.
Conclusion Age, parity and race are risk factors for severe preeclampsia with increased levels of uric acid and aspartate transaminase found in the complicated cases. The morbidity and cost of treatment of severe preeclampsia are high with a large percentage requiring caesarean section and intensive care admission.

Keywords: maternal morbidity, perinatal outcome, preeclampsia, pregnancy complications, severe preeclampsia
Singapore Med J 2007; 48(9): 808–812

Ranganathan S, Faridah Y, Ng KH
Correspondence: Prof Ng Kwan Hoong, ngkh@um.edu.my

ABSTRACT
Introduction Breast cancer is the commonest cancer in women and represents a significant problem from the clinical and public health perspectives. The aim of this paper is to report our experience of transitioning from screen-film mammography (SFM) to computed radiography mammography (CRM), and finally to full-field digital mammography (FFDM), and to evaluate the performance of these three different types of mammographic systems.
Methods A total of 2,734 mammograms using the three different systems were carried out at the University of Malaya Medical Centre. These examinations were evaluated based on time from start of examination to reporting, image quality, archiving, reject and repeat rates and overall diagnostic accuracy for SFM, CRM and FFDM.
Results The time taken from the start of the examination to the radiologist interpretation and reporting were faster in both FFDM and CRM, compared to SFM. Image contrast with better contrast detail was almost equivocal for both CRM and FFDM, but lower for SFM. Easier image storage and archiving were available for CRM and FFDM in the form of magnetic optical discs, rather than hard copy storage as in SFM. The reject rate for FFDM was zero percent, compared to CRM and SFM which were two percent and two percent, respectively. The repeat rate for FFDM, CRM and SSFM was zero percent, 0.1 percent and 1.5 percent, respectively. Overall diagnostic accuracy of FFDM, CRM and SFM were comparable as no cancers were missed on all three systems as double blinded reporting was done.
Conclusion FFDM does improve quality of mammography service by providing better workflow time and archiving system, with good diagnostic accuracy.

Keywords: computed radiography, full-field digital mammography, mammography, screen-film mammography
Singapore Med J 2007; 48(9): 804–807

Yan YW, Yan J, Zhang GP, Gao ZL, Jian HX
Correspondence: Dr Yan Youwang, yyw19560727@sina.com

ABSTRACT
Introduction Abuse of the injection services, namely unnecessary injections and unsafe injections, exists extensively in developing countries. Unsafe injection practices contribute to the transmission of blood-borne pathogens. The aims of this study were to survey the prevalence of injections and knowledge of injection safety among the rural residents in Jingzhou district, Hubei, China and to provide scientific data for developing a health educational programme.
Methods A retrospective cross-sectional study was conducted in 12 villages, which were selected from the Jingzhou district by the random sampling method. 50 rural residents were interviewed per village using a questionnaire.
Results Among the 595 residents studied, 192 had received at least one injection in the past three months, with an injection prevalence of 32.3 percent and an average of 0.93 injections. 90.3 percent of the rural residents knew that unsafe injections could transmit the following blood-borne pathogens: human immunodeficiency virus (74.4 percent), hepatitis B virus (55.8 percent) and hepatitis C virus (22.9 percent). Logistic regression analysis showed that the residents' age, educational level and residential area were important factors in influencing their knowledge about injection safety.
Conclusion The results indicated that the injection prevalence was high among rural residents in the study area, and their knowledge regarding injection safety should be further improved.

Keywords: blood-borne pathogens, injections, patients’ knowledge, patient safety, safe injections
Singapore Med J 2007; 48(8): 769–774