Original Article

Omar AR, Suppiah N, Chai P, Chan YH, Seow YH, Quek LL, Tan HC
Correspondence: Dr Omar Abdul Razakjr, abdul_razakjr_bin_omar@nuh.com.sg

ABSTRACT
Introduction A multidisciplinary disease management (DM) programme in chronic heart failure (CHF) improves clinical outcome. The efficacy of such a programme in a heterogeneous Asian community is not well established. Therefore, we undertook the evaluation of the efficacy of the multidisciplinary community-based DM CHF programme.
Methods This was a prospective study involving 154 patients (54 percent male) with a primary diagnosis of CHF, New York Heart Association functional class III/IV CHF, with left ventricular ejection fraction (LVEF) less than 40 percent. The mean age was 65 +/- 12 years and mean LVEF was 27 +/- 9 percent. We evaluated CHF hospitalisation, quality of life, activity status and quality of care (percentage of patients who received ACE inhibitors/angiotensin receptor blockers (ARB) and beta blockers after a period of six months.
Results At six months, there was improvement in the quality of life and activity status (p < 0.001). ACE inhibitors/ARB were maintained in 97 percent of the patients and there was an increased usage of beta blockers (p-value equals 0.001). The rate of CHF hospitalisation was reduced by 68 percent (p-value is less than 0.001) and there was no mortality.
Conclusion The multidisciplinary DM of CHF in a heterogeneous Asian community showed significant improvement in quality of life, quality of care and reduction in CHF hospitalisation.

Keywords: chronic heart failure, disease management, heart failure, quality of care, quality of life
Singapore Med J 2007; 48(6): 528–531

Tan SS, Tan NC, Ibrahim S, Tay KH
Correspondence: Dr Siong San Tan, siongsan@singnet.com.sg

ABSTRACT
Introduction Choledochal cyst is a rare benign biliary disease mostly presenting during childhood. Adult presentation is rare and associated diseases and complications are common. This paper aims to review the management of adult patients who presented to our institution with choledochal cyst, focusing on their presentation, preoperative investigations, surgical treatment given and postoperative course.
Methods A retrospective review of all our choledochal cyst patients from January 2000 to August 2004 was performed. Data collected included demographics and clinical information.
Results There were ten patients, eight female (80 percent) and two male (20 percent). The average age at presentation was 38.6 (range 16-81) years. The commonest presenting complaints were obstructive biliary disease (nine out of ten, 90 percent). There were seven Type I (70 percent), one type IVA (10 percent), one type IVB (10 percent) and one (10 percent) with Caroli's disease. Two patients had concomitant cholangiocarcinoma (20 percent). Three patients had associated cystolithiasis and one patient had pancreatitis. One patient had early cirrhosis due to her disease. Six patients underwent total cyst excision with a Roux-en-Y hepaticojejunostomy. One patient who previously had a biliary bypass underwent further resection of her cyst and Whipple's operation because of development of cholangiocarcinoma in the distal remnant cyst. They are currently well with no surgical complications. The average length of follow-up was 16 months (range six months to three years).
Conclusion Adult patients with choledochal cyst have associated biliary problems such as the presence of cholangiocarcinoma, cystolithiasis, cholecystitis and liver cirrhosis with portal hypertension. They tend to present similar to obstructive biliary disease. The best surgical option for these patients is a total cyst excision together with a Roux-en-Y hepaticojejunostomy.

Keywords: adult choledochal cyst, biliary disease, biliary dilatation, obstructive biliary disease
Singapore Med J 2007; 48(6): 524–527

Mansoor S, Islam N, Siddiqui I, Jabbar A
Correspondence: Dr Shireen Mansoor, shireen.mansoor@aku.edu

ABSTRACT
Introduction Previous studies have indicated that most individuals reach peak cortisol levels in 60 minutes during the short Synacthen test (SST) done to exclude adrenal insufficiency. Therefore, measuring serum cortisol at only 60 minutes may suffice. This study was carried out to evaluate the significance of the 60-minute serum cortisol level in SST as a reliable and cost-effective screening test in comparison to the conventional SST.
Methods A cross-sectional study was conducted from January 2000 to September 2004, in which data was collected by reviewing medical records of all patients who underwent SST at the Aga Khan University Hospital, Karachi. A total of 236 patients suspected of having adrenal insufficiency were included. Values of serum cortisol at baseline, 30 and 60 minutes post-250 ug-injection Synacthen were recorded. The cortisol level was measured through fluorescence polarisation immunoassay. The cut-off value of 20 ug/dL was used to differentiate normal individuals from hypoadrenal individuals.
Results Out of 236 study participants, 93 (39 percent) were males and 143 (61 percent) were females. The mean age and standard deviation was 44.4 +/- 21 years. Cortisol concentration increased significantly from baseline to 30 minutes and 60 minutes after injecting Synacthen (p-value is less than 0.001 for each). The majority of the patients reached the cortisol peak of greater than 20 ug/dL (555 nmol/L) at 60 minutes. Normal responses were found in 148 patients (63.1 percent) at both 30 and 60 minutes, while 27 participants (12 percent) reached a peak greater than 20 ug/dL (555 nmol/L) at 60 minutes but were less than 20 ug/dL (555 nmol/L) at 30 minutes. In the deficient cases, SST showed abnormal responses in 60 cases (25 percent) at both 30 and 60 minutes. However, there was only one patient who reached a peak value of 21 ug/dL (589 nmol/L) at 30 minutes, which reduced to 17 ug/dL (485 nmol/L) at 60 minutes.
Conclusion This study showed that a 60-minute cortisol value during SST was reliable enough in identifying normal subjects for excluding adrenal insufficiency, and was equally effective in identifying abnormal cases, as compared to values at both 30 and 60 minutes. It is therefore suggested that a single 60-minute post-Synacthen serum cortisol level may suffice, as compared to the conventional SST. This is also significant as a cost-effective measure, especially in third world countries where cost is a major issue for diagnosing and treating patients.

Keywords: adrenal insufficiency, cortisol, short Synacthen test, Synacthen
Singapore Med J 2007; 48(6): 519–523

Rajesh H, Yong YY, Zhu M, Chia D, Yu SL
Correspondence: Dr Hemashree Rajesh, hemashreerajesh@yahoo.com

ABSTRACT
Introduction This study aims to evaluate the differences in oocyte stimulation, endometrial thickness, fertilisation rate and embryo quality at in-vitro fertilisation (IVF) in patients with documented growth hormone (GH) deficiency, after GH supplementation.
Methods This was a retrospective analysis of 20 cases of patients who were pregnant and had GH supplementation during IVF at the Singapore General Hospital between 1993 and 2003. All these patients had previously failed IVF due to poor stimulation, poor egg quality, poor fertilisation at intracytoplasmic sperm injection (ICSI) or failed implantation, and they had documented GH deficiency. These initial cycles were compared with their subsequent IVF cycles with GH supplementation. A non-parametric test was used for statistical analysis.
Results Embryo quality, determined by scoring the embryos on Day two using morphology, improved significantly after supplementation of GH (p-value is less than 0.001, median embryo score increased from 10.7 to 16). There was also a statistically significant increase in the fertilisation rate for those patients who had ICSI. There was no statistical difference in the number of oocytes retrieved or in the mean endometrial thickness with GH.
Conclusion This study implies that GH supplementation may improve embryo quality in selected patients with GH deficiency. Its role in improving fertilisation rate at ICSI merits further research and evaluation.

Keywords: embryo quality, growth hormone deficiency, growth hormone supplementation, in-vitro fertilisation
Singapore Med J 2007; 48(6): 514–518

Khuwaja AK, Ali NS, Zafar AM
Correspondence: Dr Ali Khan Khuwaja, ali.khuwaja@aku.edu

ABSTRACT
Introduction This study was conducted to determine the proportion of usage of psychoactive drugs, and to identify factors associated with its use among patients visiting outpatient clinics of a tertiary care hospital in Karachi, Pakistan.
Methods A cross-sectional study was conducted involving 461 adult (age 18 years and above) patients, who were surveyed by using interviewer-administered questionnaires. All interviews were conducted by a medical students. Out of the total number of participants, 242 (52.5 percent) were males and 219 (47.5 percent) were females.
Results In all, 118 (25.6 percent) of the respondents were using some sort of psychoactive drugs, however, only 20 (4.3 percent) study subjects were diagnosed with any psychiatric illness. Factors found to be significantly associated with usage of psychoactive drugs included belonging to the female gender (p-value equals 0.019), older (more than 50 years) age (p-value is less than 0.001), being married (p-value equals 0.004), having formal schooling of up to 12 years (p-value equals 0.001) and physical inactivity (p-value equals 0.004). In addition, those whose family members were using psychoactive drug(s) or who suffered from non-communicable diseases were more likely to use psychoactive drugs in comparison to others (p-value is less than 0.001).
Conclusion The use of psychoactive drugs is quite common in our patients regardless of having any psychiatric disease. Efforts are required to control and prevent the abuse of these drugs. Education and awareness programmes for doctors and patients may help to prevent the inappropriate use of psychoactive drugs. Regulatory intervention to control use of these drugs is also recommended.

Keywords: drug use, irrational drug use, psychoactive drugs, psychiatric illness
Singapore Med J 2007; 48(6): 509–513

Winslow M, Subramaniam M, Ng WL, Lee A, Song G, Chan YH
Correspondence: Dr Mythily Subramaniam, mythily@imh.com.sg

ABSTRACT
Introduction All over the world, Hepatitis C virus (HCV) accounts for an estimated 130 million chronic infections. Injection drug use has become one of the most important risk factors for HCV, and within the injection drug user population, the prevalence of HCV antibody ranges from 70 to 95 percent depending on an individual's length of use and the prevalence of infection in the community. This study was undertaken to determine the prevalence of and the risk factors for Hepatitis C antibodies in injecting drug users presenting to the Community Addictions Management Programme (CAMP) in Singapore.
Methods Eligibility criteria for inclusion in this study were all intravenous buprenorphine users presenting to CAMP. 106 subjects, who consented to the study, completed an interviewer-administered questionnaire, and underwent a urine and blood analysis.
Results The prevalence rate for HCV was 42.5 percent among the subjects included in our study. The odds of seroprevalence in those sharing needles were 5.6 times that of those who were not, and the odds of seroprevalence among those using with others (peers or partners) were 6.3 times, as compared to among those who were individual users. Racial differences were also seen, but these could be accounted for by the sharing of needles.
Conclusion This study provides important local data at the onset of an early buprenorphine-injecting epidemic in Singapore. This data is useful for disease prevention and healthcare planning.

Keywords: drug abuse, hepatitis C virus, intravenous buprenorphine users, intravenous drug use, needle sharing
Singapore Med J 2007; 48(6): 504–508

Moorchung N, Srivastava AN, Gupta NK, Ghoshal UC, Achyut BR, Mittal B
Correspondence: Dr Balraj Mittal, bml_pgi@yahoo.com

ABSTRACT
Introduction Helicobacter pylori (H. pylori) infection is associated with divergent clinical outcomes and these outcomes are largely influenced by the levels of cytokines in the gastric mucosa. The levels of these cytokines are dependant on cytokine gene polymorphisms. Pro-inflammatory cytokine polymorphisms are strongly associated with severe histological changes in the gastric mucosa in Caucasian populations.
Methods In this study, we evaluated the role of cytokine gene polymorphisms in influencing the pathological severity of gastritis. 120 patients were evaluated. Cytokine gene polymorphisms of interleukin-1 (IL-1) beta, tumour necrosis factor alpha and the IL-1 receptor antagonist genes were done using polymerase chain reaction (PCR) restriction fragment length polymorphism and PCR variable number of tandem repeats markers typed on the deoxyribonucleic acid obtained from the peripheral blood. Histological analysis was done by using the revised Sydney system.
Results There was no association between pro-inflammatory cytokine gene polymorphisms and severity of gastritis.
Conclusion This data suggests that high cytokine levels are not seen in the gastric mucosa in Indians in spite of H. pylori colonisation. IL-1 beta is a potent proinflammatory cytokine which causes a partial clearance of the organism as well as hypochlorhydria. Corporal hypochlorhydria causes a persistent colonisation by H. pylori followed by the development of gastric atrophy and later carcinoma. This lack of association with a pro-inflammatory polymorphism suggests that only low levels of IL-1 beta are present in the gastric mucosa. This causes a low clearance of the organism and a high incidence of duodenal ulceration because of hyperchlorhydria. However, it is protective against the development of gastric carcinoma. This would explain the "Indian Paradox" of the apparent discrepancy of a high degree of colonisation by H. pylori and a low incidence of gastric carcinoma in the Indian population.

Keywords: cytokines, gastritis, gene polymorphisms, Helicobacter pylori
Singapore Med J 2007; 48(5): 447–454

Shabalin VN, Shatokhina SN
Correspondence: Prof Vladimir N Shabalin, du00321@postman.ru

ABSTRACT
Introduction To date, morphology research in laboratory diagnostics has referred only to cell tissues and excluded biological fluids. Our new technology is based on the study of structures of biological fluids formed during transition from liquid to solid state by dehydration under special conditions. These structures are formed due to the special "mosaic" configuration of molecules and microaggregates of the substance (protein and others) dissolved in the studied fluids. It should be considered as well that the specific structure of protein molecules is a fundamental basis of anatomical and physiological peculiarities of an organism. All pathological processes are initiated by the changes in the spatial configuration of protein molecules.
Methods We have developed a special method named "cuneiform dehydration of biological liquids" to obtain thin films which possess specific structures. During the transition of a biological liquid into a solid, organic molecules build specific macrostructures in conformity with their configuration.
Results Studies of the solid phase structures of different biological liquids allow us to find specific markers of various pathological processes in the human organism. In blood serum, we discovered markers of inflammation, sclerosis, chronic intoxication; in tear--markers of different stages of glaucoma; and in synovial fluid--markers of different stages of osteoarthrosis. In our investigation of 143 healthy people and 1,419 patients, a high rate of compliance of the discovered markers with the results of routine clinical and laboratory methods were observed. As the suggested technology has a higher sensitivity, the results obtained by this technology and routine methods do not always coincide.
Conclusion The developed technology gives new information about the state of the human organism and may be used in practice for diagnostics of various pathological processes and at pre-clinical studies of their development, as well as for the evaluation of the efficacy of medical treatment.

Keywords: biological fluid, cuneiform dehydration, dehydration, diagnostic markers of diseases
Singapore Med J 2007; 48(5): 440–446

Kahn FY
Correspondence: Dr Fahmi Yousef Khan, fakhanqal@yahoo.co.uk

ABSTRACT
Introduction Ascites is common and represents an important feature of liver disease and other diseases. The aim of this study is to determine the causes of ascites in Qatar, and to evaluate the value of ascitic fluid analysis in different types of ascites.
Methods This is a descriptive, prospective study of all patients admitted to the medical department at Hamad General Hospital with ascites between January 2004 and January 2005.
Results Of the 104 patients enrolled in the study, 70 (67.3 percent) were males and 34 (32.7 percent) were females, with a mean age of 52.9 (+/-14.8) years. Liver cirrhosis was the most frequent cause of ascites in 62 patients (59.6 percent), while chronic alcoholism was the main cause of liver cirrhosis. Other frequent causes of ascites were malignant ascites in 12 patients (11.5 percent), malignancy-related ascites in ten patients (9.6 percent), and tuberculous peritonitis in eight patients (7.7 percent). Based on the serum-ascites albumin gradient (SAAG), different causes of ascites were divided into two main groups. The first group was characterised by a mean SAAG of 1.1 or higher, and the second group was characterised by a mean SAAG of less than 1.1. The most common cause of high gradient ascites was liver cirrhosis, while the most common causes of low gradient ascites were carcinomatous peritonitis and tuberculous peritonitis. The mean ascitic lactate dehydrogenase (LDH) level was higher in cancer patients than in tuberculous patients (p-value is less than 0.05), while the mean ascitic glucose concentration was significantly lower in peritoneal tuberculosis than in carcinomatous peritonitis (p-value is less than 0.05).
Conclusion Liver cirrhosis is the main cause of ascites in Qatar. SAAG is a better distinguishing marker for separating ascites related to portal hypertension from other causes of ascites without portal hypertension. In patients with low gradient ascites, ascitic fluid glucose and LDH level are useful indicators for separating tuberculous from malignant ascites.

Keywords: ascites, carcinomatous peritonitis, paracentesis, serum-ascites albumin gradient, tuberculosis
Singapore Med J 2007; 48(5): 434–439

Deng J, Zhao Z, Gao G
Correspondence: Dr Guodong Gao, driftsands2002@yahoo.com.cn

ABSTRACT
Introduction Matrix is a type of bioactive coil expected to produce healing of cerebral aneurysms. We reviewed periprocedural complications associated with endovascular embolisation of ruptured intracranial aneurysms with matrix coils and evaluated the effects of matrix coils.
Methods From October 2003 to September 2005, a total of 102 patients with 102 ruptured aneurysms and ten unruptured aneurysms underwent embolisations with matrix coils. We reviewed the medical records, radiographical studies and endovascular procedures to evaluate the morbidity and mortality related to ruptured aneurysm coiling.
Results 16 complications (15.7 percent) occurred, of which 14 were in the anterior circulation and two in the posterior circulation. Complications included nine intraprocedural ruptures (8.8 percent), three thromboembolism (2.9 percent), one coil migration (1.0 percent) and three parent vessel occlusions (2.9 percent). Six complications had no neurological consequences, three were with transient deficits, six resulted in persistent neurological deficits, and one caused the patient to die. No complication was associated with balloon remodelling technique, and coil migration occurred during one of the neuroform-assisted embolisations. Procedural-related neurological morbidity and mortality for all 102 embolisations of ruptured aneurysms were 5.9 percent and 1.0 percent, respectively.
Conclusion Endovascular treatment of ruptured intracranial aneurysms with matrix coils is as safe as with bare platinum coils. Matrix coil does not increase the risk of thromboembolism. However, we must be cautious when we embolise small aneurysms with matrix coils, especially when the aneurysms are less than 5 mm in diameter.

Keywords: cerebral aneurysm, endovascular embolisation, intracranial aneurysm, matrix coil, ruptured aneurysm
Singapore Med J 2007; 48(5): 429–433