Original Article

Owlia MB, Salimzadeh A, Alishiri Gh, Haghighi A
Correspondence: Dr Mohammad  Bagher Owlia, mbowlia2@yahoo.com

ABSTRACT
Introduction Low back pain and lumbar radicular pain are the leading causes of job loss worldwide. Therapeutic approaches to lumbar radicular pain, including sciatica and spinal canal stenosis, are diverse. Many clinicians use 80 mg long-acting glucocorticoids in epidural steroid injections (ESI). The aim of this study is to compare the clinical response of 80 mg versus 40 mg methylprednisolone in ESI.
Methods 84 patients with newly exacerbated lumbar radicular pain were randomly al located into two groups. 43 patients underwent ESI with 80 mg Depo-Medrol and 41 age- and sex-matched cases received 40 mg Depo-Medrol as the comparison group. The pain in the second week, and every month thereafter was assessed using a visual analogue scale (VAS).
Results Remarkable improvement in one month VAS occurred in 64 cases (75 percent) from both groups. VAS values between 80 mg and 40 mg groups were comparable in the two-week (p-value is 0.827) and three-month (p-value is greater than 0.746) post-injection periods. Slightly better results were shown in patients in the 40 mg group after one month.
Conclusion In the case of lumbar radicular pain, ESI with low dose (40 mg) methylprednisolone is as effective as high dose (80 mg) with comparable results and less adverse profile.

Keywords: epidural injection, glucocorticoid, herniated disc, radicular pain, steroid injection
Singapore Med J 2007; 48(3): 241–245

Thong BYH, Cheng YK, Leong KP, Tang CY, Chng HH
Correspondence: Dr Bernard Thong Yu Hor, bernard_thong@ttsh.com.sg

ABSTRACT
Introduction The patient characteristics, clinical features and causative foods in 74 consecutive adult patients with immediate food hypersensitivity were studied.
Methods A retrospective review of 74 consecutive adults who presented during the study period from July 1, 1994 to April 30, 2002 was performed.
Results There were 35 male and 39 female patients, with a mean age of 36.3 +/- 10.9 (range, 19-66) years. The most common causative foods were seafood crustaceans, molluscs and bird's nest. Prawn and crab were the most commonly implicated crustacean, and limpet the commonest culprit mollusc. The main symptoms were periorbital angioedema (64.9 percent), dyspnoea/wheezing (44.6 percent) and urticaria (44.6 percent). 66 percent of the patients developed anaphylaxis. 34 (45.9 percent) had concomitant allergic rhinoconjunctivitis, asthma, eczema or combinations of these atopic diseases. Only six (8.1 percent) patients had a family history of food allergy. Skin prick tests (SPT) to commercially-prepared food allergens were positive in 22 of 36 patients (61.1 percent) tested. SPT to the fresh, cooked or canned food products were positive in 11 of 20 (55 percent) cases where the food allergen was not commercially available. Open food challenges were required for diagnosis in two patients who had negative SPT.
Conclusion The most common food allergens in our patients were seafood crustaceans, molluscs and bird's nest. More than half of the patients had concomitant allergic rhinitis, asthma and/or eczema. The pattern of food allergy in Singapore differs from Caucasian populations, likely to be because of different regional dietary patterns and methods of food preparation.

Keywords: food allergens, food hypersensitivity, radioallergosorbent test, skin tests
Singapore Med J 2007; 48(3): 236–240

Ghosh JR, Bandyopadhyay AR
Correspondence: Mr Jyoti Ratan Ghosh, jrghosh@rediffmail.com

ABSTRACT
Introduction The purpose of the present study was to compare the relationship of all obesity measures with blood pressures and to find out the best obesity measure, associated with greater risk of hypertension.
Methods A total of 180 adult Bengalee Hindu men from Hridoypur of 24 Pgs (N), West Bengal, India were evaluated in the present cross-sectional study. Biosocial data (such as age, education, occupation), anthropometry and blood pressure measurements were obtained. Body mass index (BMI), waist hip ratio (WHR), conicity index (CI) and waist stature ratio (WSR) were subsequently derived. Statistical analysis includes linear and logistic regression.
Results The mean age of the studied individuals was 35.7 years (standard deviation, 9.35 years) and the frequency of hypertensive individuals was 11.7 percent. WSR explained 14.3 percent variance of systolic blood pressure (SBP), followed by waist circumference (WC) (13.0 percent) and BMI (13.1 percent). BMI (8.8 percent), WC (8.6 percent) and WSR (8.4 percent) explained closely the same amount of variance of diastolic blood pressure (DBP). All obesity measures were significantly and positively correlated with blood pressures. The odds-ratio (OR) associated with a 1 kilogramme per square metre increase in BMI was 1.17. Comparing values for a 0.1 increase in WSR was 1.22, followed by WHR (OR 1.09). A 1.0 cm increase in WC was associated with OR 1.07 followed by OR 1.06 for a 1.0 increase in CI. In multivariate analysis, significant predictors of hypertension were age and BMI.
Conclusion Among all obesity measures, WSR and BMI explained comparatively larger amount of variance of SBP and DBP, respectively. However, the greater risk of developing hypertension was associated with increasing BMI.

Keywords: hypertension, obesity, waist stature ratio
Singapore Med J 2007; 48(3): 232–235

Ganesh R, Rao AD, Baladas HG, Leese T
Correspondence: Dr Trevor Leese, tbleese54@hotmail.com

ABSTRACT
Introduction The Bioenteric Intragastric Balloon (BIB, Inamed Health, Santa Barbara, CA, USA) is an endoscopic method for achieving restriction of gastric intake in obese patients. It is less invasive and cheaper than bariatric surgery, but can only be left in the stomach for six months. We report our experience with the BIB in Singapore.
Methods Since its introduction to our hospital in 2004, a prospective database has been kept of all patients undergoing BIB insertion. This database was used to retrieve the information for this study.
Results 20 patients have undergone BIB insertion. Mean patient age was 40 (range, 28-52) years and 85 percent were female. Mean body weight was 79.6 (range, 67.6- 103.7) kg. Mean body mass index (BMI) was 31.5 (range, 27.8-38.8) kilogramme per square metre. Mean excess weight was 21.2 (range, 11.9-37.6) kg. The BIBs were inserted under conscious sedation. BIB intolerance was a major problem and four patients (20 percent) required early BIB removal due to refractive nausea and epigastric discomfort. All remaining BIBs were removed after six months under conscious sedation. The mean maximum weight loss during the six months was 5.9 (range, 1.4-13.4) kg. The mean maximum percentage of excess weight lost was 32.4 (range, 6.7-87). Weight loss was reasonably preserved at the end of the sixmonth period, but by one year, when all the patients had been without BIBs for at least six months, the mean weight loss for the group compared to pre-BIB weight was only 1.5 kg (range, weight gain 5.3 kg to weight loss 9 kg). The mean percentage excess weight loss at one year was 10.9 (range, 15.1 percent weight gain to 31.3 percent weight loss). Only four patients (20 percent) regarded their experience with the BIB as a success.
Conclusion The BIB is poorly tolerated by Asian patients, even when lower volumes are inserted into the balloon to compensate for the smaller Asian stature. Although temporary weight loss can be achieved, mandatory removal of the BIB at six months results in regain of the lost weight in the majority of patients. Eligible patients (BMI 32.5 and above) should be encouraged to undergo bariatric surgery rather than BIB to achieve long-term reliable weight loss. Patients who are ineligible for bariatric surgery may benefit from BIB, especially if they have severe comorbidities and have failed to lose weight by any other means in a validated weight management programme, but the chance of long-term success is poor.

Keywords: Bioenteric intragastric balloon, intragastric balloon, obesity, weight loss
Singapore Med J 2007; 48(3): 227–231

Lim SL, Sinaram S, Ung EK, Kua EH
Correspondence: Ms Lim Su Lin, limsl@nuh.com.sg

ABSTRACT
Introduction Anorexia nervosa (AN) is a growing problem among young female Singaporeans. We studied the demographics and follow-up data of AN patients referred to dietitians for nutritional intervention.
Methods A retrospective nutritional notes review was done on 94 patients seen from 1992 to 2004. All patients were given nutritional intervention, which included individualised counselling for weight gain, personalised diet plan, correction of poor dietary intake and correction of perception towards healthy eating. We collected data on body mass index (BMI), patient demographics and outcome.
Results 96 percent of the patients were female and 86.2 percent were Chinese. The median BMI at initial consultation was 14.7 kilogramme per square metre (range, 8.6-18.8 kilogramme per square metre). 76 percent were between 13 and 20 years old. 83 percent of the patients came back for follow-up appointments with the dietitians in addition to consultation with the psychiatrist. Overall, there was significant improvement in weight and BMI from an average 37 kg to 41 kg and 14.7 kilogramme per square metre to 16.4 kilogramme per square metre, respectively, between the first and final consultations (p-value is less than 0.001). The average duration of followup was about eight months. Among the patients on follow-up, 68 percent showed improvement with an average weight gain of 6 kg. Patients that improved had more outpatient follow-up sessions with the dietitians (4.2 consultations versus 1.6 consultations; p-value is less than 0.05), lower BMI at presentation (14.2 kilogramme per square metre versus 15.7 kilogramme per square metre; p-value is less than 0.01) and shorter duration of disease at presentation (one year versus three years; p-value is less than 0.05) compared with those who did not improve. Seven patients with the disease for more than two years did not show improvement with follow-up.
Conclusion We gained valuable understanding of the AN patients referred to our tertiary hospital for treatment, two-thirds of whom improved with adequate follow-up treatment. Patients that had suffered AN longer before seeking help appeared more resistant to improvement.

Keywords: anorexia nervosa, eating disorders, body mass index, weight gain
Singapore Med J 2007; 48(3): 222–226

Siow A, Nikam YA, Ng C, Su BMC
Correspondence: Dr Anthony Siow, anthony.siow.ym@kkh.com.sg

ABSTRACT
Introduction This review assessed the incidence, predisposing conditions, and key surgical steps, where urological injuries occurred during laparoscopic hysterectomies at the Minimally Invasive Surgery Unit, KK Women's and Children's Hospital over a four-year period.
Methods A retrospective review of 495 cases of laparoscopic assisted vaginal hysterectomies (LAVH) and total laparoscopic hysterectomy (TLH) from January 2001 to December 2004 was conducted.
Results A total of eight urological injuries occurred, all within the initial two years of review. There were seven unintentional bladder injuries occurring at LAVH during dissection of the bladder off the uterovaginal attachment. The associated factors included previous caesarean section and fibroids. All bladder injuries were diagnosed and repaired intraoperatively with no long-term complications. A single case of ureteric injury occurred with TLH. The patient presented on the ninth postoperative day with fever and continuous vaginal discharge. The most likely aetiology was thermal damage from electrocautery used to secure haemostasis of the uterine artery pedicle. Ureteric re-implantation was eventually required in the patient.
Conclusion Urological injuries occurred in 1.6 percent of laparoscopic hysterectomies in our hospital. The predisposing factors include previous caesarean surgery, multiple fibroids and severe endometriosis. A definite learning curve exists with laparoscopic hysterectomy with a thorough knowledge of pelvic anatomy being an essential prerequisite for advanced pelvic surgery. Similarly, good exposure of the surgical field, vigilant dissection and judicious use of electro-surgery are important practices to adopt to prevent injuries.

Keywords: bladder injuries, laparoscopic hysterectomy, ureteric injuries, urological complications
Singapore Med J 2007; 48(3): 217–221

Lingaraj K, Ruben M, Chan YH, Das De S
Correspondence: Dr Krishna Lingaraj, lingaraj_krishna@yahoo.com.sg

ABSTRACT
Introduction Urinary retention is associated with an increased rate of urinary tract infections and deep sepsis following total joint arthroplasty. This study was carried out to investigate the incidence of urinary retention following total knee arthroplasty in a Singapore hospital, and to identify risk factors associated with the development of this complication in our patient population.
Methods The charts of 125 consecutive patients who underwent primary total knee arthroplasty between January and December 2004 were reviewed. The incidence of postoperative urinary retention was correlated with the following factors: age, gender, choice of anaesthesia, duration of surgery, and analgesic technique. Statistical analysis was performed with univariate and multivariate logistic regression models. There were 109 female and 16 male patients. The mean age of the patients was 67.5 years (range, 50-86 years).
Results Ten patients developed urinary retention, giving an overall rate of 8.0 percent (95 percent confidence interval [CI], 3.9-4.2). Male gender (odds-ratio [OR] is 5.9; 95 percent CI, 1.2-29.5; p-value is 0.03) and epidural analgesia (OR is 7.6; 95 percent CI, 1.7-35.0; p-value is 0.009) were found to be the only factors significantly associated with postoperative urinary retention. Patient age, duration of surgery and choice of anaesthesia were not found to be significantly associated with urinary retention.
Conclusion In our patient population, male patients and patients receiving epidural postoperative analgesia are at increased risk of developing urinary retention following total knee arthroplasty.

Keywords: epidural analgesia, knee replacement, total knee arthroplasty, urinary retention
Singapore Med J 2007; 48(3): 213–216

Masud F
Correspondence: Dr Faisal Masud, dr.faisalmasud@gmail.com

ABSTRACT
Introduction Vitamin D deficiency was assessed previously on the basis of rickets and osteomalacia, which represent an extreme end of the spectrum. As a result of this, many clinically-asymptomatic patients go undetected. As vitamin D deficiency results in secondary hyperparathyroidism, we propose to use the normalisation of intact parathyroid hormone (iPTH) as a surrogate marker for assessing the adequacy of vitamin D nutrition.
Methods A descriptive study was undertaken on 195 premenopausal Pakistani women. 25-hydroxy-cholecalciferol and iPTH levels were measured by standard laboratory techniques.
Results The minimum level of vitamin D required to keep iPTH below 53 pg/dL was found to be 16 ng/ml with a 95 percent confidence interval of 13.8 and 18.2. Existing normal range is 9-36 ng/ml.
Conclusion Normalisation of iPTH if taken as a criterion for judging vitamin D deficiency can lead to detection of clinically asymptomatic patients. The simplicity, low cost of correction, and the potential beneficial skeletal and non-skeletal consequences of doing so makes it essential that this criterion be used to redefine the optimal vitamin D levels. This should be internationally standardised and made available to clinicians.

Keywords: 25-hydroxy-cholecalciferol, osteomalacia, rickets, secondary hyper-parathyroidism, vitamin D levels
Singapore Med J 2007; 48(3): 207–212

Ima-Nirwana S, Ahmad Nazrun S, Yee LJ, Loh HC, Yew SF, Norazlina M, Abdul Gapor MT, Kamsiah J
Correspondence: Prof Ima Nirwana Soelaiman, imasoel@medic.ukm.my

ABSTRACT
Introduction The short-term and long- term effects of heated soy oil on bone metabolism in ovariectomised Sprague-Dawley rats were studied.
Methods Three-month-old female rats, were divided into five groups: normal control (NC); ovariectomised control (OVXC); ovariectomised and fed rat chow with added fresh soybean oil (SOF) or once-heated soy oil (SO1) or five-times-heated soy oil (SO5). Short-term parameters measured after one month were serum interleukin-6 (IL-6) and osteocalcin. Long-term parameters measured after six months were the structural bone histomorphometrical parameters. Vitamin E content in the soy oil subjected to the different heating treatments were also measured.
Results Rats in the SO5 group had higher levels of IL-6 after one month compared to the other four groups. Osteocalcin levels in the SO1 and SO5 groups remained high after treatment, while those in the NC and SOF groups declined. After six months, bone mass declined in the SO5 group. Vitamin E assay in the oils showed that levels of alpha-tocopherol decreased after heating the oil once and five times, while levels of gamma- and delta-tocopherols only declined after heating five times.
Conclusion Repeated heating of soy oil destroyed the tocopherols causing raised serum IL-6 and osteocalcin levels, leading to increased bone resorption and osteoporosis in the long term.

Keywords: bone metabolism, heated soy oil, oestrogen deficiency, soy oil, vitamin E
Singapore Med J 2007; 48(3): 200–206

Norazline M, Kee PL, Lukman HI, Nazrun AS, Ima-Nirwana S
Correspondence: Dr Norazlina Mohamed, azlina@medic.ukm.my

ABSTRACT
Introduction Nicotine has been shown to exert negative effects on bone. This study determined whether vitamin E supplementation is able to repair the nicotine-induced adverse effects in bone.
Methods 24 male rats were divided into three groups. The first group was the baseline control and killed untreated at the beginning of the study. Groups 2 and 3 received nicotine at 7 mg per kg for three months but during the second and third months, group 2 was supplemented with alpha-tocopherol (N+ATF) while group 3 was given palm tocotrienol mixture (N+TT). Serum interleukin-1 (IL-1), serum interleukin-6 (IL-6), serum osteocalcin, urine deoxypyridinoline (DPD) and bone calcium content were measured.
Results Palm tocotrienol mixture was able to prevent the increment of IL-1 and IL- 6 due to nicotine treatment. No changes were seen in the osteocalcin levels, but the N+ATF group had lower urine DPD levels after treatment. However, bone-remodelling index revealed no significant changes. No significant differences were seen in the femoral bone calcium content results, although the fourth lumbar bone calcium content was reduced in both groups with 66.5 percent reduction in the N+ATF group and 59.6 percent reduction in the N+TT group.
Conclusion Palm tocotrienol mixture was better than alpha-tocopherol in reversing the effects of nicotine on IL-1 and IL-6. Both forms of vitamin E were not able to restore the nicotine-induced bone calcium loss, but the N+ATF group suffered a greater loss. Tocotrienol seemed to be superior to alpha-tocopherol in combating against the adverse effect of nicotine.

Keywords: alpha-tocopherol, bone remodelling, nicotine, tocotrienols, vitamin E
Singapore Med J 2007; 48(3): 195–199