Original Article

Aekplakorn W, Kongsakon R
Correspondence: Dr Wichai Aekplakorn, rawap@mahidol.ac.th

ABSTRACT
Introduction This study aims to describe the prevalence of intimate partner violence and associated factors among married women in slum communities in Bangkok.
Methods A cross-sectional survey was carried out. A total of 580 married women aged 15 years or older were randomly sampled from seven slum communities in Bangkok. Information on age, education, occupation, income, family size, alcohol use, and experience of partner violence were interviewed. Logistic regression was used to identify risk factors associated with the violence.
Results The prevalence of intimate partner violence was 27.2 percent. Most of the violent episodes were triggered either by factors related to the couple's personal character, such as having a bad temper (89.9 percent) and being grumpy (83.5 percent), or circumstantial factors, such as financial problems (74.7 percent) and suspicions of adultery (28.5 percent). 12 percent of the abuse were moderate violence and 34.2 percent were severe violence. The factors associated with partner violence included a young age group (younger than 35 years) with adjusted odds-ratio (OR) of 3.13 (95 percent confidence interval [CI] 1.33-7.34) compared to those aged 55 years or older; inadequate income for family expenses (OR 1.97, 95 percent CI 1.20-3.22); and regular alcohol use (OR 3.72, 95 percent CI 2.02-6.89).
Conclusion Intimate partner violence was commonly found in slum communities and is strongly related to the socioeconomic status, personality characteristics and alcohol consumption of the couples.

Keywords: abused women, alcohol consumption, domestic violence, partner violence, slum communities, women’s health
Singapore Med J 2007; 48(8): 763–768

Afifi M
Correspondence: Dr Mustafa Afifi, afifidr@yahoo.co.uk

ABSTRACT
Introduction This study aims to assess the potential for the lactational amenorrhoea method (LAM) and passive LAM among women with children below six months of age, and to examine its association with women empowerment in household decisions.
Methods Data from the Egypt Demographic Health Survey 2000 was downloaded from the Demographic and Health Surveys website. A sub-sample of women fulfilling all four criteria were selected: (1) women whose last birth of children was less than three years ago; (2) currently married; (3) not sterilised; and (4) currently breastfeeding their children. Accordingly, only 3,447 women entered into the statistical analysis, of whom 1,141 had children below six months of age.
Results Passive LAM users constituted 82 percent of the women who met LAM criteria, 57.1 percent of exclusive breastfeeding mothers, and 32.9 percent of all nursing mothers of children below six months of age. 11.8 percent of women who met the LAM criteria were under double coverage of family planning methods. In the logistic regression model where all variables were adjusted, women empowerment in household decisions, significantly and independently, inversely predicted passive LAM along with increase in child age (Odds-ratio [OR] of 0.86 and 0.43, respectively). Women with higher birth order children were more likely to use passive LAM (OR 1.11).
Conclusion Women of low empowerment index in household decisions were more likely to use passive LAM. Passive LAM users could be subjected to discontinuation or double coverage of contraceptives.

Keywords: contraceptives, family planning, lactational amenorrhoea method, passive lactational amenorrhoea method, women empowerment
Singapore Med J 2007; 48(8): 758–762

Chow WC, Tai ES, Lian SC, Tan CK, Sng I, Ng HS
Correspondence: Dr Chow Wan Cheng, gm2cwc@sgh.com.sg

ABSTRACT
Introduction To characterise the anthropometrical and metabolic parameters of a group of non-diabetic and non-obese patients who had histologically-proven nonalcoholic steatohepatitis (NASH).
Methods During September 1997 to November 1999, consent for liver biopsies were sought from a consecutive series of patients, whose body mass index (BMI) were equal to or less than 30 kg per square metres, and who had persistently elevated serum alanine transaminase (more than 2.5 times upper limit of normal for more than six months), with no associated viral hepatitis, alcohol or drug-induced liver disease, hereditary liver disease and diabetes mellitus. Patients who were found to have steatohepatitis histologically were further studied. Their body weight, height, waist and hip circumferences were taken, and fasting serum lipid and glucose measured. Serum insulin was measured in six patients and insulin resistance (IR) was calculated by homeostasis model assessment. Oral glucose tolerance tests were done if fasting glucose levels were greater than 6 mmol/L. All liver biopsies were reviewed by a single histopathologist. Three age- and sex-matched controls were randomly selected for each patient.
Results 11 of 12 patients who underwent liver biopsies were found to have NASH. All 11 were Chinese: eight males and three females. 73 percent of them had hepatic fibrosis. Overall, compared to controls, they had significantly higher body weight, BMI, IR and triglyceridaemia. The female patients also had a higher waist-hip ratio than controls. None had diabetes mellitus, and one had impaired glucose tolerance/fasting glycaemia. Nine out of 11 had BMI between 25 and 30 kg per square metres.
Conclusion Significant histological changes of NASH with hepatic fibrosis were found in Singaporean Chinese non-diabetic patients with BMI of less than 30 kg per square metres.

Keywords: fatty liver disease, hepatic fibrosis, insulin resistance, non-alcoholic steatohepatitis, obesity, transaminases
Singapore Med J 2007; 48(8): 752–757

Montazeri K, Kashefi P, Honarmand A
Correspondence: Dr Azim Honarmand, honarmand@med.mui.ac.ir

ABSTRACT
Introduction Gabapentin has demonstrated analgesic effects in clinical trials as a preemptive analgesic and in acute postoperative pain management. This study was conducted to evaluate whether the pre-emptive use of gabapentin could reduce postoperative pain and morphine consumption in patients after lower extremity orthopaedic surgery.
Methods 70 ASA I and II patients were randomly assigned to receive 300 mg gabapentin or placebo in a double-blind manner two hours before surgery under general anaesthesia. Postoperatively, the pain was assessed on a visual analogue scale (VAS) at 2, 4, 12, and 24 hours at rest. Morphine 0.05 mg/kg intravenously was used to treat postoperative pain on patients' demand. Total morphine consumption in the first 24 hours after surgery was also recorded.
Results Patients in the gabapentin group had significantly lower VAS scores at all time intervals of 2, 4, 12, and 24 hours, than those in the placebo group (respectively, 55.50 [mean] +/- 15.80 [standard deviation], 57.30 +/- 19.30, 45.74 +/- 16.00, 44.60 +/- 17.64, versus 72.30 +/- 14.00, 70.50 +/- 18.13, 62.00 +/- 23.32, 66.50 +/- 25.70; p-value is less than 0.05). The total morphine consumed after surgery in the first 24 hours in the gabapentin group (15.43 +/- 2.54) was significantly less than in the placebo group (17.94 +/- 3.00; p-value is less than 0.05).
Conclusion Pre-emptive use of gabapentin 300 mg orally significantly decreases postoperative pain and rescue analgesic requirements in patients who undergo lower extremity orthopaedic surgery.

Keywords: analgesic requirement, gabapentin, morphine demand, orthopaedic procedures, pain management, postoperative pain
Singapore Med J 2007; 48(8): 748–751

Tavangar SM, Monajemzadeh M, Larijani B, Haghpanah V
Correspondence: Dr Maryam Monajemzadeh, m_monajem@yahoo.com

ABSTRACT
Introduction It is well recognised that the pathogenesis of thyroid diseases is complex and different factors such as genetic factors, iodine deficiency, sex, age, radiation therapy in childhood, growth stimulating antibodies, and other epithelial growth factors can influence them. Epidemiological features of thyroid tumours and experimental evidence suggest that female sex hormones may exert effects on the thyroid gland and its neoplasms. This possibility was addressed by investigating the expression of oestrogen receptor protein in 351 thyroid lesions.
Methods The tissues from 351 human thyroid glands comprising 130 nodular goitres and 221 neoplastic lesions were used for the present immunohistochemical assessment of oestrogen receptor expression.
Results Incidence of oestrogen receptor positive cases were 24 percent (31/130) for nodular goitres, 22 percent (8/37) for follicular adenomas, 11 percent (2/18) for follicular carcinomas, 31 percent (37/119) for papillary carcinomas, zero percent (0/35) for medullary carcinomas and zero percent (0/12) for undifferentiated carcinomas. The incidence of oestrogen receptor positivity, which is compatible with other studies, is higher in well-differentiated thyroid lesions. The incidence of oestrogen receptor reactivity does not significantly differ between females and males of different age groups and it does not correlate with lymph node status, and vascular and capsular invasions.
Conclusion The relatively high proportion of oestrogen receptor positivity in goitres, follicular adenomas and papillary carcinomas, compared with its reactivity in other thyroid neoplasms, and contrasted against normal thyroid tissue, suggests that the incidence of oestrogen receptor reactivity tends to increase with better differentiation of thyroid lesions. This finding may have clinical relevance.

Keywords: follicular adenoma, goitre, immunohistochemistry, oestrogen receptor, papillary carcinoma, thyroid cancer
Singapore Med J 2007; 48(8): 744–747

Khosravi AD, Mehdinejad M, Heidari M
Correspondence: Dr Azar Khosravi, khosraviaz@yahoo.com

ABSTRACT
Introduction Isolation of common pathogens involved in ocular infection, and their in-vitro susceptibility to commonly-used ocular antibiotics, as well as the trends in antibiotic resistance developed by these pathogens, were investigated.
Methods Corneal scrapings were obtained from 318 hospitalised patients and inoculated directly onto enriched and differential culture media. Subcultures were performed on selective media. The necessary biochemical tests were conducted and the organisms identified using standard procedures. Susceptibility of isolated pathogens to commonly-used ocular antibiotics was examined using standard susceptibility testing.
Results 70 different organisms were isolated. Gram-positive cocci accounted for 47 (67.2 percent) and gram-negative bacilli for 23 (32.8 percent) bacterial isolates. Coagulase-negative Staphylococci (33 percent) and Pseudomonas species (24 percent) were the most commonly-isolated organisms. In susceptibility testing, Gentamycin had coverage against 35 (74.5 percent) of 47 gram-positive cocci and 19 (82.6 percent) of 23 gram-negative bacilli tested. The coverage of Tetracycline, Cephalotin and Ceftriaxon against gram-positive cocci were 61.7, 55 and 53 percent, respectively. All the tested gram-positive cocci showed resistance to Cefotaxime and Penicillin. Ceftriaxon and Tobramycin had coverage against 17 (73.9 percent) and 14 (60.8 percent) of 23 gram-negative bacilli isolates, respectively. The coverage of Vancomycin against coagulase-negative Staphylococci was 100%, but all the isolates of Staphylococcus aureus were resistant to Vancomycin.
Conclusion Susceptibility analysis revealed that antibiotic with the greatest coverage was Gentamycin (77.1 percent of 54 isolates). Gentamycin also had good coverage against gram-positive cocci, which constituted the majority (67.1 percent) of ocular isolates.

Keywords: antibiotic susceptibility, bacteria, ocular infection, susceptibility patterns
Singapore Med J 2007; 48(8): 741–743

Palanivelu C, Rangarajan M, John SJ, Senthilkumar R, Madhankumar MV
Correspondence: Prof M Rangarajan, rangy68@hotmail.com

ABSTRACT
Introduction Appendicitis in unusual locations or situations always poses a diagnostic dilemma and surgery is never straightforward. We aim to highlight the advantages of laparoscopy, including our own modifications, in some unusual presentations of appendicitis.
Methods We treated a total of 7,210 patients with appendicitis over 14 years from 1992 to 2006. In this study, we included patients with subhepatic appendicitis (0.08 percent), appendectomy in midgut malrotation (0.09 percent), appendicitis in situs inversus totalis (0.01 percent) and appendicitis in the lateral pouch position (0.01 percent). All patients underwent laparoscopic appendectomy.
Results Patients with subhepatic appendicitis, appendicitis in situs inversus and appendicitis in the lateral pouch position had an uneventful postoperative course. For the patients who underwent appendectomy as part of the treatment for malrotation and the patient with the perforated subhepatic appendix, hospital stay was slightly prolonged.
Conclusion Most patients in our study did not have a confirmed preoperative diagnosis. Diagnostic laparoscopy through the umbilical port helped confirm the diagnosis. Port positions were then planned according to the exact position of the appendix and the technique was modified to suit each individual patient. In the surgical scenarios described here, laparoscopy is invaluable in both diagnosis and treatment.

Keywords: appendectomy, laparoscopic appendectomy, laparoscopic surgery, port sites
Singapore Med J 2007; 48(8): 737–740

Nassaji-Zavareh M, Ghorbani R
Correspondence: Dr Mohammad Nassaji-Zavareh, hnassaji@yahoo.com

ABSTRACT
Introduction Peripheral intravenous catheter-related phlebitis is a common and significant problem in clinical practice. This study aims to investigate the incidence of phlebitis and to evaluate some important related factors.
Methods 300 patients admitted to medical and surgical wards of hospitals in Semnan, Iran from April 2003 to February 2004 were prospectively studied. Variables evaluated were age, gender, site and size of catheter, type of insertion and underlying conditions (diabetes mellitus, trauma, infectious disease and burns). Phlebitis was defined when at least four criteria were fulfilled (erythema, pain, tenderness, warmth, induration, palpable cord and swelling). Any patient who was discharged or their catheter removed before three days were excluded.
Results Phlebitis occurred in 26 percent (95 percent confidence interval [CI] 21- 31 percent) of patients. There was no significant relationship between age, catheter bore size, trauma and phlebitis. Related risk factors were gender (odds-ratio [OR] 1.50, 95 percent CI 1.01-2.22), site (OR 3.25, 95 percent CI 2.26-4.67) and type of insertion (OR 2.04, 95 percent CI 1.36-3.05) of catheter, diabetes mellitus (OR 7.78, 95 percent CI 4.59-13.21), infectious disease (OR 6.21, 95 percent CI 4.27-9.03) and burns (OR 3.96, 95 percent CI 3.26-4.82).
Conclusion Phlebitis is still an important and ongoing problem in medical practice. In patients with diabetes mellitus and infectious diseases, more attention is needed.

Keywords: burns, catheter-related complications, diabetes mellitus, peripheral intravenous catheter, phlebitis
Singapore Med J 2007; 48(8): 733–736

Yusof MI, Sulaiman AR, Muslim DAJ
Correspondence: Dr Mohd Imran Yusof, drimran@kb.usm.my; drimran93@yahoo.com

ABSTRACT
Introduction Many conditions, including benign and malignant tumours, peripheral vascular diseases and open fracture grade 3C, have been successfully treated with limb sparing procedures. However, the same could not be said for treatment of limb infection, especially late stage diabetic foot complications.
Methods This is a retrospective review of patients who underwent operations at our hospital from July 2003 to June 2005. All patients who underwent various types of limbs amputations were included. The cohort was divided according to the diagnosis leading to the amputation and the level of amputation. The number and levels of amputation were then compared with the various causes leading to the amputation.
Results There were 203 patients who underwent amputation during the period of study. 135 (66.5 percent) of the patients were diabetic and amputations performed were related to diabetic foot conditions. 68 (33.5 percent) patients were not known to have diabetes mellitus. Among nondiabetic patients, 54 (26.6 percent) amputations were due to trauma, 11 (5.4 percent) were related to musculoskeletal tumours and 3 (1.5 percent) were due to peripheral vascular disease. Among diabetic patients, 23 (17 percent) patients underwent above knee amputation, 44 (33 percent) patients underwent below knee amputation, and 68 (50 percent) patients underwent local foot amputation. 80 of 135 (59.3 percent) patients, who underwent amputation due to diabetic complications, were less than 60 years old.
Conclusion Good diabetic control and detection of early diabetic foot complications will reduce the number of patients undergoing limb amputation as well as the number of amputees. Since the incidence of lower limb amputation is due mainly to poor diabetic control, it is important to protect this group of patients from a probable avoidable amputation.

Keywords: diabetes mellitus, diabetic foot, limb amputation
Singapore Med J 2007; 48(8): 729–732

Shahbaz Sarwar CM, Fatimi S
Correspondence: Dr CM Shahbaz Sarwar, csarwar1@jhmi.edu; shahbaz.sarwar@gmail.com

ABSTRACT
Introduction There are various aetiologies for recurrent pericardial effusions. Malignancy is the commonest cause in the West, but in Asia and sub-Saharan Africa, tuberculosis is common and contributes towards a high prevalence of tuberculous recurrent pericardial effusions.
Methods In our hospital-based descriptive study of 32 patients, we looked into various characteristics of recurrent pericardial effusions using the hospital data.
Results We found tuberculosis to be the commonest cause of recurrent effusions, occurring in 50 percent (n = 16) of our patients, followed by malignancy (n = 9). The clinical features at presentation in patients who eventually developed recurrent pericardial effusions were more severe, compared to uncomplicated pericardial effusions.
Conclusion Knowledge of the presenting features of patients with recurrent pericardial effusions is crucial, so that they can be placed under increased surveillance and considered for early institution of pericardial fluid drainage procedures.

Keywords: pericardial effusions, recurrent pericardial effusions, tuberculosis
Singapore Med J 2007; 48(8): 725–728