Original Article

Koosha A, Rafizadeh B
Correspondence: Dr Ali Koosha, koosha@doctor.com

ABSTRACT
Introduction Neonatal hyperbilirubinaemia, defined as a total serum bilirubin level above 5 mg/dL, is a frequent problem. This condition accounts for up to 75 percent of hospital readmissions in the first week of life. The purpose of this study was to evaluate the aetiology of indirect hyperbilirubinaemia and the prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency in newborns who were admitted to Vali-e-Asr Hospital in Zanjan City during the period 2001-2003.
Methods Medical records of 376 newborns who had been admitted for management of indirect hyperbilirubinaemia were reviewed. All necessary information, including the results of G6PD activity test (expressed as unit per gramme haemoglobin), were recorded on standardised questionnaires.
Results The subject group included 159 (42.3 percent) boys and 217 (57.7 percent) girls. The prevalence of sepsis, ABO incompatibility, Rhesus incompatibility, and cephalhaematoma, G6PD deficiency was 15.7 percent (59 neonates), 3.7 percent (14 neonates), 2.1 percent (eight neonates), 0.5 percent (two neonates), and 2.1 percent (eight neonates), respectively. The median (interquartile range) of the highest total bilirubin level was 18 (15.8-20) mg/dL and 18.4 (16.3-19.5) mg/dL in normal G6PD and G6PD-deficient newborns, respectively (p-value equals 0.7).
Conclusion We recommend performing G6PD testing in all Iranian and Mediterranean newborns with indirect hyperbilirubinaemia, unless other investigators ascertain and document that this is unnecessary as a routine test.

Keywords: glucose-6-phosphate dehydrogenase, indirect hyperbilirubinaemia, neonatal hyperbilirubinaemia, neonatal jaundice
Singapore Med J 2007; 48(5): 424–428

Badiee Z
Correspondence: Dr Zohreh Badiee, badiei@med.mui.ac.ir

ABSTRACT
Introduction This study aims to determine the aetiology and complications of exchange transfusion (ET) performed for neonatal hyperbilirubinaemia in Isfahan, Iran.
Methods A retrospective chart review of 68 term and near-term newborns who underwent ET at two perinatal centres in Isfahan, Iran between January 2001 and January 2004, was performed.
Results Of the 68 patients who underwent ET, nine (13.2 percent) required more than one ET. The most common causes of ET overall were ABO incompatibility (22.1 percent) and glucose-6-phosphate dehydrogenase deficiency (19.1 percent). The maximum total serum bilirubin concentration was 25.9 +/- 7.5 mg/dL. ET complications occurred in 14 neonates (20.9 percent), the most common being thrombocytopenia (6 percent). One (1.5 percent) of the 68 patients died of complications, probably attributable to ET.
Conclusion ET causes high morbidity, even in term and near-term newborns. Therefore, it should be initiated only when the benefit of preventing kernicterus outweighs the complications associated with the procedure.

Keywords: blood transfusion, exchange transfusion, hyperbilirubinaemia, neonate hyperbilirubinaemia, thrombocytopenia
Singapore Med J 2007; 48(5): 421–423

Bose KSC, Agrawal BK
Correspondence: Dr K Subhash Chandra Bose, subhashbose1@yahoo.co.in

ABSTRACT
Introduction This present study aims to evaluate the beneficial effect of tomatoes, a rich source of lycopene, which is a relatively new carotenoid known to play an important role in human health and disease.
Methods We investigated the lipid peroxidation rate by estimating malondialdehyde (MDA), levels of serum enzymes involved in antioxidant activities such as superoxide dismutase, glutathione peroxidase, glutathione reductase, reduced glutathione and lipid profile, which includes total cholesterol, triglycerides, high density lipoprotein, low density lipoprotein and very low density lipoprotein in a coronary heart disease (CHD) group and an age-matched control group.
Results We observed significantly lower levels of serum antioxidant enzymes and very high lipid peroxidation rate in the CHD group, when compared to the controls (p-value is less than 0.001). At the same time, we observed significantly higher levels of lipids in the CHD group, when compared to the controls (p-value is less than 0.001). 60 days of tomato supplementation in the CHD group showed a significant improvement in the levels of serum enzymes involved in antioxidant activities and decreased lipid peroxidation rate (p-value is less than 0.001), but there were no significant changes in lipid profile (p-value is greater than 0.10).
Conclusion These findings suggest that tomato lycopene may have considerable therapeutic potential as an antioxidant but may not be used as a hypolipidaemic agent in CHD.

Keywords: antioxidant enzymes, coronary heart disease, free radicals, lipid peroxidation, lycopene, oxidative stress, tomato lycopene
Singapore Med J 2007; 48(5): 415–420

Leong GKT, Goh PP, Chang BC, Lingamanaicker J
Correspondence: Dr Kui Toh Gerard Leong, gerard_leong@cgh.com.sg

ABSTRACT
Introduction There are limited data on heart failure (HF) cohorts with objective clinical definition of HF. Many observational HF studies were based on discharge diagnosis codes, making them subjective. Many did not have contemporaneous left ventricular function assessment. This study was done to evaluate the characteristics and one-year prognosis of a single centre multi-ethnic Asian inpatient HF cohort, with these limitations addressed, with the aim of yielding a more accurate picture of true HF.
Methods This was an observational prospective study. Patients who fulfilled the modified Framingham criteria for clinical HF and study inclusion criteria of serum creatinine level less than 267 micromol/L, serum albumin level greater than 28 g/L, and a contemporaneous trans-thoracic echocardiography (TTE) study were enrolled. TTE studies ordered were attempted within 72 hours.
Results 173 patients were enrolled into the study. TTE was done within 72 hours of admission for 86.1 percent (n = 149) of the participants. Diastolic HF constituted 22.0 percent of the cohort. The mean age of the participants was 68.7 (standard deviation, 12.0) years. The prevalence of elderly patients, diabetes mellitus, hypertension and ischaemic cardiomyopathy were high. The one-year mortality rate was 20.8 percent (n = 36). The one-year death or readmission for any cause rate was 69.4 percent (n = 120). The mean time in hospital for any cause within the one year was 11.8 +/- 17.9 days. Ethnicity had prognostic implications. Being elderly, having elevated random blood glucose or serum creatinine levels were associated with a worse prognosis.
Conclusion With strict methodology, HF is truly a disease of the elderly, with significant one-year mortality and morbidity consequences. Prognostic characteristics are reviewed.

Keywords: Framingham criteria for heart failure, heart failure, hypertension, ischaemic cardiomyopathy, trans-thoracic echocardiography
Singapore Med J 2007; 48(5): 408–414

Saxena SK, Koh GCH, Ng TP, Fong NP, Yong D
Correspondence: Dr GCH Koh, cofkohch@nus.edu.sg

ABSTRACT
Introduction Length of stay (LOS) in hospitals is the largest contributor of direct stroke care cost. Rehabilitation accounts for 16 percent of healthcare cost in the six-month post-stroke period. It is important to determine factors extending LOS in rehabilitation hospitals to identify focus areas of cost-control strategies. The aim of the study was to ascertain the predictors of LOS of post-stroke patients admitted into two community hospitals offering rehabilitation.
Methods An observational cohort study was conducted on 200 stroke patients admitted from acute hospitals into two community hospitals. Data collected included baseline sociodemographical variables, and the National Institute of Health Stroke Scale, Abbreviated Mental Test, Geriatric Depression Scale and Barthel Index were used to assess neurological impairment, cognitive impairment, depressive symptoms and functional disability, respectively. Medical complications (defined as new or exacerbated medical problems that generated additional physician evaluation, a change in medication or additional medical intervention), after patients were admitted to the community hospitals until discharged, were recorded. The outcome variables measured were length and cost of stay.
Results The mean LOS in our study was 34.4 (standard deviation [SD] 18.4) days, and the mean cost of hospital stay was S$2,410.83 (SD S$2,167.26). Length and cost of hospital stay were significantly correlated (r equals 0.52; p-value is less than 0.01). On multiple linear regression analysis, the significant variables positively associated with LOS were medical complications and functional dependence on admission. Significant variables negatively associated with LOS were unplanned discharge and recurrent strokes.
Conclusion Medical complication is a key reversible determinant of increased LOS of post-stroke patients receiving rehabilitation in community hospitals. Strategies for prevention, early detection and treatment of medical complications during stroke rehabilitation are discussed.

Keywords: cerebrovascular accident, community hospital, length of stay, post-stroke rehabilitation, rehabilitation, stroke, stroke complications
Singapore Med J 2007; 48(5): 400–407

Thein SS, Hamidon BB, Teh HS, Raymond AA
Correspondence: Dr Teh Hiok Seng, hiokseng2005@gmail.com

ABSTRACT
Introduction Leukoaraiosis (LA) is a term that defines an abnormal appearance of the subcortical white matter of the brain on neuroimaging. This study was done to evaluate the predictive value of LA in terms of mortality, disability and cognitive decline at three months post-stroke and also to identify the risk factors that are independently associated with LA in a stroke population.
Methods This was a prospective observational study of all patients with acute ischaemic stroke who were admitted to Hospital Universiti Kebangsaan Malaysia from June to November 2004. A single observer using the pre-defined diagnostic criteria recorded the information on demography, Barthel Index and mini-mental state examination. LA was diagnosed on brain computed tomography alone.
Results 60 patients were recruited into the study. Three patients (five percent) died and LA was present in 29 patients (48 percent). There was no significant association between LA and mortality (p-value equals 0.89). The independent risk factors that were associated with LA were age (odds-ratio [OR] 4.43; 95 percent confidence interval [CI] 1.28-15.27) and hypertension (OR 14.3; 95 percent CI 1.40-147.42). There was a significant association between LA with early dementia (OR 3.53; 95 percent CI 1.19-10.49). However, LA did not significantly predict any functional disability (Barthel Index is less than 60) in the study population (p-value equals 0.45).
Conclusion Development of LA correlates significantly with ageing and hypertension. The presence of LA can also predict early cognitive dysfunction but is not associated with functional disability at three months post-stroke.

Keywords: brain imaging, computed tomography, hypertension, ischaemic stroke, leukoariosis, stroke risk factors
Singapore Med J 2007; 48(5): 396–399

Panahi Y, Davoodi SM, Khalili H, Dashti-Khavidaki S, Bigdeli M
Correspondence: Dr Hossein Khalili, khalilih@tums.ac.ir

ABSTRACT
Introduction Chronic skin lesions are common late complications of sulphur mustard exposure in veterans injured in chemical warfare. Pruritus is the most common complaint in the chronic phase, with significant effects on the patient's quality of life. The current study evaluated the efficacy of a combination of one percent phenol and one percent menthol in the control of pruritus in these affected patients.
Methods This randomised, double-blinded clinical trial was performed in chemical warfare-injured veterans with mustard gas-induced pruritus. 80 subjects were selected randomly and divided into two equal groups. One group was treated with a combination of one percent phenol and one percent menthol twice a day, while the other group received a placebo. The therapeutic effects and side effects were evaluated during a six-week treatment course. Pruritus score with a range of 1-48 points was used to calculate the severity of pruritus before and after treatment in both groups.
Results The final pruritus score in the drug group was significantly different, compared with the placebo group (p-value equals 0.03). There was also a statistically-significant difference between the pre-treatment (19 points) and post-treatment (15.5 points) pruritus scores in the drug group (p-value equals 0.001), but there was no significant difference in the response in the placebo group (p-value equals 0.66). Only a few patients had complaints about the drug, and these were generally minor. The most common complaints were of the greasy nature of the drug and its intolerable odour.
Conclusion A phenol one percent and menthol one percent combination has significant therapeutic effects for mustard gas-induced pruritus in chemical warfare-injured veterans, in comparison with the placebo.

Keywords: menthol, mustard gas, phenol, pruritus, skin lesions, sulphur mustard
Singapore Med J 2007; 48(5): 392–395

Yang GL, Tan YF, Loh SC, Lim CCT
Correspondence: Dr Tchoyoson CC Lim, tchoyoson_lim@nni.com.sg

ABSTRACT
Introduction Disease registries and databases form an important component of research in clinical medicine, and can be useful to support retrospective studies and prospective clinical trials. However, analysis of radiological imaging databases has not been explored: imaging and clinical data often exist as separate silos of information, even in modern digital-enabled hospitals in Singapore. We describe a computerised method for creating a radiological research database using data from the picture archive and communication system (PACS) and hospital information system (HIS).
Methods Using a relational database and Java programming language, we created the neuroradiology imaging database (NRID). A web-interface for keyword searches were tested with the clinical data from PACS of a tertiary referral hospital for neurological diseases. Keyword and wildcard searches were conducted for various brain neoplasms and compared to HIS discharge diagnosis.
Results The NRID was deployed successfully and keyword search could be completed in real time. Lists of patients with meningioma, oligodendroglial tumour, neurocytomas, cerebral abscess, and neurocysticercosis could be exported and compared with the HIS discharge diagnosis. Patients with neurological diseases could be obtained by manually combining lists.
Conclusion An imaging database can be created using clinical PACS data, which can enable keyword search functions to support brain tumour research. Radiological databases can help support clinical research, but further work needs to be done in order to take full advantage of the potential of digital health information.

Keywords: biomedical research, database management systems, picture archive and communication system, radiology information systems, neuroradiology
Singapore Med J 2007; 48(4): 342–346

Tan JH
Correspondence: Dr Joo-Hui Tan, june_tan@nuh.com.sg

ABSTRACT
Introduction Parkinson's disease (PD) accounts for 75 percent of cases with parkinsonism. 25 percent of parkinsonian patients have alternative and possibly treatable conditions. Early intervention of these conditions lies in the physician's awareness and recognition of atypical features in patients presenting with parkinsonism. This survey studies Singapore general practitioners' (GPs) ability to identify atypical features and alternative diagnoses in patients suspected of having early PD.
Methods 41 out of 57 GPs attending a local symposium participated in a written questionnaire which had the following outcome measures: the ability to identify neurological features that are atypical in early-stage PD; and the awareness of alternative parkinsonian conditions, other than PD.
Results The mean age of the GPs was 56.0 years (standard deviation [SD] 10.4 years), with 36 males and five females. A mean of 1.6 PD patients were under the care of each GP. Only 33 percent (SD 16 percent) of GPs were aware of atypical features in early PD. If the early atypical feature was one that may occur in late-stage PD, the GPs' awareness was even lower at 19 percent (SD 14 percent). 32 percent of GPs were unable to provide any alternative diagnosis to parkinsonism.
Conclusion This survey suggests a poor level of awareness among Singapore GPs on the identification and presence of alternative parkinsonian conditions. Continuing medical education programmes on PD should emphasise on the diagnostic approach to patients with parkinsonism and the impact of missing the diagnosis of treatable parkinsonian conditions.

Keywords: atypical parkinsonism, continuing medical education, general practitioners, Parkinson’s disease, parkinsonism
Singapore Med J 2007; 48(4): 338–341

Ariffin H, Daud SS, Mohamed Z, Ibrahim K, Lee TF, Chong LA
Correspondence: Dr Hany Ariffin, hany@um.edu.my

ABSTRACT
Introduction The follow-up of chimerism status after allogeneic haematopoietic stem cell transplantation (HSCT) is essential to predict successful engraftment to assess the development of graft-versus-host disease, graft rejection and disease relapse. Analysis of short tandem repeats (STR) via polymerase chain reaction is frequently used for chimerism determination. However, most commercially-available kits have been designed for forensic purposes and may not be optimal for chimerism analysis. The present study aims to identify suitable STR markers for patient-donor pairs of predominantly Malay and Chinese ethnicity using two commercially-available forensic kits.
Methods We analysed six STR loci, namely, CSF1PO, TPOX, TH01 (using the CTT multiplex system) and F13A01, FESFPS and vWA (using the FFv multiplex system) in 33 human leukocyte antigen-matched Malaysian patient-donor pairs to determine the suitability of these two multiplex systems for chimerism analysis in our local population.
Results Informativity (different alleles in donor and recipient) of each individual locus was TH01 73 percent, vWA 73 percent, F13A01 52 percent, CSF1PO 61 percent, FESFPS 39 percent and TPOX 45 percent. When combined, the six STR loci were able to give chimerism results in 31 out of 33 (94 percent) cases.
Conclusion We found that TH01 and vWA are informative STR targets for post-HSCT chimerism analysis in predominantly Malay and Chinese patient-donor pairs. The commercially-available kits will also permit laboratories without extensive molecular biology capabilities to perform DNA typing in HSCT recipients.

Keywords: chimerism, microsatellites, polymerase chain reaction, short tandem repeats, stem cell transplantation
Singapore Med J 2007; 48(4): 333–337