Original Article

Rohana J, Hasmawati J, Zulkifli SZ
Correspondence: Dr Rohana Jaafar, drohana@mail.hukm.ukm.my

ABSTRACT
Introduction We report part of the findings of a study conducted to determine the correlation between bone mineral content (BMC) and biochemical bone markers in very low birth weight (VLBW) infants.
Methods This was a cross-sectional study, carried out between August 2001 and June 2004 in the neonatal intensive care unit of Hospital Universiti Kebangsaan Malaysia. Whole body BMC was measured by dual energy X-ray absorptiometry in 41 VLBW infants.
Results The mean BMC/kg body weight was 25.8 (standard deviation [SD] 11.2) g per kg. The BMC of these infants had significant negative correlation with their birth weight (r equals -0.31, p-value equals 0.048). There was no significant difference in the mean BMC between different races and gender. The infants were divided into two groups based on the course of prematurity: "non-complicated" and "complicated" groups because of the lack of "healthy reference population" data for normal BMC values in premature infants. The "non-complicated" group (30) had received ventilator assistance for less than seven days, tolerated full enteral nutrition before the age of two weeks, had no sepsis or necrotising enterocolitis and did not receive regular diuretic or steroid treatment. The cut-off level for a desirable BMC per kg in VLBW infants was obtained from a value corresponding to one SD below the mean of the "non-complicated" group, i.e., 17.4 g per kg. Eight (19.6 percent) infants had BMC less than this value. Multilinear regression analysis of demographical characteristics, maternal factors, neonatal complications and nutrition received revealed that heavier birth weight (p-value equals 0.007) and longer duration of parenteral nutrition (p-value equals 0.03) were associated with lower BMC.
Conclusion VLBW infants who required parenteral nutrition for longer periods were at higher risk to having poorer bone mineralisation.

Keywords: bone mineral content, dual energy X-ray absorptiometry (DEXA), parenteral nutrition, very low birth weight infants
Singapore Med J 2007; 48(3): 191–194

Chan GCT, Koh D
Correspondence: Dr Gregory Chan, gregchan@nus.edu.sg

ABSTRACT
Introduction This study aims to understand the physical and psychosocial work environment, expectations and the perceived levels of stress encountered of medical students in Singapore.
Methods A cross-sectional study employing a self-administered work environment questionnaire was applied over a one-week period to the entire 2003/2004 medical school cohort (1,069 students, response rate 85 percent) from the first to fifth (final) years at the National University of Singapore.
Results 3.3 percent had at least one needlestick injury within the academic year. The majority (especially the clinical students) also had musculoskeletal complaints (neck and back mainly) within the last three months. Using the General Health Questionnaire, it was found that 49.6 percent encountered significant stress and 64.6 percent reported that more than 60 percent of their total life stress was due to medical school. The most important psychosocial stressors were: too much work and difficulty in coping. The clinical students were particularly concerned about being good medical students and doctors. The reasons for choosing Medicine as a career and social health (health, study and sleep habits) were also studied.
Conclusion The health risks of a medical student are primarily psychosocial in nature. The biggest challenges are work demands, maintaining a work-life balance and managing the psychosocial work environment.

Keywords: medical students, musculoskeletal complaints, needlestick injury, physical work environment, psychosocial health, stress
Singapore Med J 2007; 48(2): 166–171

Mahendran R, Subramaniam M, Chan YH
Correspondence: Dr R Mahendran, rathi_mahendran@imh.com.sg

ABSTRACT
Introduction Insomnia is a common complaint associated with psychiatric disorders. Detection and diagnosis of insomnia can be a challenge at the primary care level. Patients often present with various kinds of psychological symptoms. Therefore, a high index of suspicion and careful assessments are crucial in eliciting signs and symptoms and making an accurate diagnosis of primary insomnia or a psychiatric disorder.
Methods This study was undertaken at the end of 2005, and is a retrospective review of all patients referred to the Insomnia Clinic and seen by the principal author in a three-year period between 2002 and 2005. Relevant data was collected from the medical records of patients who attended the clinic during this period.
Results In this study of 141 patients seen at an Insomnia Clinic, 47.5 percent had primary insomnia, while 52.5 percent had a primary diagnosis of a psychiatric disorder. 41.1 percent of those diagnosed with a primary psychiatric disorder had comorbid psychiatric disorders and 4.3 percent had substance abuse problems.
Conclusion The various psychiatric disorders present in this group of patients highlight the need for careful assessment and recognition of these associations.

Keywords: insomnia, insomnia clinic, psychiatric disorders, sleep disorders
Singapore Med J 2007; 48(2): 163–165

Seah M, Tan SM
Correspondence: Dr Su-Ming Tan, su_ming_tan@cgh.com.sg

ABSTRACT
Introduction Health professionals are a direct source of medical information to the public. Hence, it is crucial that their knowledge is accurate and aids in building awareness. Our aim was to ascertain the level of breast cancer knowledge and screening practices among nurses in a general hospital.
Methods Between January and April 2004, all registered nurses in a general hospital were surveyed by a self-administered questionnaire for their knowledge of breast cancer and screening practices. One point was given for a correct knowledge answer and zero for wrong/"not sure" answer. The maximum knowledge score was 19.
Results There were 716 (79.4 percent) respondents. The median score was 16 (range 2-19). The scores were high for general knowledge and natural disease progression, fair for knowledge of symptoms and treatment, but dropped when it came to knowledge of risk factors and screening. Nurses also held several common misconceptions held by the public. Those who had managed breast cancer patients had higher total scores (15.7). Only 63 percent did regular breast self-examination (BSE) and only 35 percent had gone for a screening mammogram. Chinese nurses who had managed breast cancer patients were more likely to do regular BSE.
Conclusion Nurses working in a general hospital had good knowledge of breast cancer progression, average understanding of symptoms and treatment, but lacked knowledge in risk factors and screening. They had low BSE and mammographic screening rates. Experience in managing breast cancer patients improved their knowledge and practices.

Keywords: breast cancer knowledge, breast screening, breast self-examination, health professionals, nursing knowledge
Singapore Med J 2007; 48(2): 158–162

Teoh WHL, Shah MK, Mah CL
Correspondence: Dr Wendy HL Teoh, teohwendy@yahoo.com

ABSTRACT
Introduction We prospectively investigated the incidence of ileus, nausea/vomiting, and hospital course of non-labouring women fed immediately after Caesarean delivery under regional anaesthesia.
Methods 196 patients were randomised into either the early-fed group (250 ml clear fruit juice 30 minutes postoperatively, and unlimited solid food thereafter) or the control group (clear feeds allowed after two hours, advanced to solids as tolerated).
Results Both groups had similar baseline demographics and operative characteristics. Bowel sounds were present immediately postoperatively in 90.8 percent (early group) versus 95.9 percent (control). The early-fed group had reduced time to first drink (0.86 +/- 0.6 hours versus 14.4 +/- 18.2 hours) and solid food intake (4.2 +/- 2.7 hours versus 20.0 +/- 6.8 hours), earlier passage of flatus (14.4 +/- 9.4 hours versus 21.0 +/- 10.4 hours) and first stool (44.4 +/- 18.7 hours versus 65.6 +/- 25.4 hours), shorter duration of intravenous hydration (12.8 +/- 7.5 hours versus 22.4 +/- 5.8 hours), and earlier removal of intravenous cannulae (20.5 +/- 6.7 hours versus 24.7 +/- 7.8 hours), with all p-values less than 0.001. Early-fed mothers also mobilised (23.1 +/- 6.8 hours versus 27.4 +/- 7.6 hours), commenced breastfeeding (26.5 +/- 14.1 hours versus 38.8 +/- 21.8 hours), and were ready for discharge earlier (44.3 +/- 10.4 hours versus 62.0 +/- 12.7 hours), compared to the control group, with all p-values less than 0.001. There was no difference in mild ileus symptoms (3.1 percent). Earlier solid intake resulted in more nausea (10.2 percent versus 2 percent, p-value is 0.033), which was self-limiting. Maternal satisfaction rated higher in the early-fed group (90 versus 60, on visual analogue scale score 0-100, p-value is less than 0.001).
Conclusion This prospective randomised trial showed no increase in ileus with early feeding post-Caesarean delivery under spinal anaesthesia, with added benefits of earlier intravenous cannulae removal, ambulation, breastfeeding initiation and potential for shorter hospitalisation. Despite increased nausea in those taking solids earlier (but not feeds), maternal satisfaction rated higher in the early-fed group.

Keywords: Caesarean delivery, Caesarean section, early feeding, ileus, regional anaesthesia
Singapore Med J 2007; 48(2): 152–157

Abalkhail A, Satti MB, Uthman MAE, Al Hilli F, Darwish A, Satir A
Correspondence: Dr Ali Abalkhail, wagi47@yahoo.com

ABSTRACT
Introduction Rhinoscleroma is a chronic progressive inflammatory disease of the upper respiratory tract. We report a clinicopathological series from the Gulf region.
Methods The clinical and pathological features of patients diagnosed with rhinoscleroma at three main hospitals in Saudi Arabia and Bahrain over a 20-year period are presented. Archived glass slides and paraffin blocks from these patients were retrieved from the pathology files for review. Special stains were performed whenever indicated. Biopsy material and clinical data from 25 patients formed the basis of this study.
Results Most of the patients were young females with a median age of 24 years. The nose was involved in all cases with frequent extension to other parts of the upper respiratory tract. The provisional clinical diagnoses included syphilis, midline granuloma and malignancy. The histological differential diagnoses included leprosy, malakoplakia and metastatic renal cell carcinoma.
Conclusion Rhinoscleroma is rare in Saudi Arabia and Bahrain. Awareness of possible clinical presentations and early diagnosis will significantly reduce the morbidity caused by this disease.

Keywords: Klebsiella rhinoscleromatis, nasal inflammatory disease, nose, respiratory tract infection, rhinoscleroma, upper respiratory tract
Singapore Med J 2007; 48(2): 148–151

Olukoga A
Correspondence: Dr A Olukoga, aolukoga@yahoo.com

ABSTRACT
Introduction This study aims to estimate the unit costs of inpatient days in five district hospitals in South Africa.
Methods The study is based on a costing exercise carried out in five district hospitals in South Africa. The hospitals were purposely selected to reflect those providing most of the services included in the district hospital package, the availability of good quality data, and the rural/urban variations in the country. The study calculated costs from the perspective of the healthcare facility. The ingredients approach was used, combining a top-down and step-down allocation of overhead costs of the six final cost centres. The measures of inpatient care used were: admissions, inpatient days and average length of stay.
Results The unit costs of inpatient days were between US dollars (USD) 65.31 and USD 212.09 for maternity patients, USD 37.23 and USD 93.55 for surgical patients, USD 37.23 and USD 70.86 for medical patients, and USD 38.37 and USD 139.60 paediatric patients. The unit costs per inpatient days were between USD 38.04 and USD 103.68 in the five hospitals. Personnel costs were the major cost component and ranged from 73 percent to 82 percent of the unit costs.
Conclusion There was considerable variation in the unit costs of inpatient days in the hospitals studied. The average unit cost for maternity patients was more than double the average unit cost for medical patients. The very low bed occupancy rates in these hospitals are indicative of inefficiency in their operations. Measures need to be instituted to improve the efficiency of these hospitals in the provision of quality and effective healthcare services.

Keywords: district hospitals, healthcare cost, healthcare resources, hospital cost, inpatient days, inpatient unit costs
Singapore Med J 2007; 48(2): 143–147

Surekha RH, Srikanth BBMV, Jharna P, Ramachandra RV, Dayasagar RV, Jyothy A
Correspondence: Dr A Jyothy, jyothycell@rediffmail.com

ABSTRACT
Introduction Coronary artery disease is caused by the additive and interactive effects of inherited and environmental factors. Substantial evidence shows that reactive oxygen species (ROS) play a vital role in the aetiopathogenesis of atherosclerosis. Our study has been designed to evaluate the oxidative stress due to ROS and assess the antioxidant protection against ROS, in addition to the major risk factors, like lipid profiles, habit of smoking and conditions such as diabetes mellitus and hypertension, in myocardial infarction (MI) patients.
Methods World Health Organisation criteria were followed in the selection of the subjects. 150 patients with MI were included in the study along with equal number of age- and gender-matched controls. Malondialdehyde (MDA) and nitrite/nitrate levels were measured as markers of oxidative stress of free radical induced injury, and total antioxidant status was determined to assess the antioxidant protection against ROS, along with the lipid profiles.
Results The levels of total cholesterol, low density lipoprotein cholesterol, triglycerides, MDA and nitrite/nitrate were found to be significantly high, while high density lipoprotein cholesterol and total antioxidant capacity were significantly low in MI patients compared to controls.
Conclusion Our study revealed the importance of determining the total antioxidant status in MI, in addition to the markers of oxidative stress and lipid profiles to enable the formulation of specific antioxidant therapies for an early intervention and better management of the disease. The study also suggests initiating lifestyle modifications as a preventive measure to reduce the burden of the disease.

Keywords: lipid peroxidation, lipid profiles, myocardial infarction, oxidative stress, total antioxidant status
Singapore Med J 2007; 48(2): 137–142

Soon CY, Chan WX, Tan HC
Correspondence: Dr Soon Chao Yang, sooncy@gmail.com

ABSTRACT
Introduction The importance of time-to-primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction has been controversial. We examine the relationship between time-to-treatment and short- to medium-term clinical outcomes.
Methods In a prospective observational study of data collected from our institution's angioplasty database between June 2001 and May 2003, 208 consecutive patients (mean age 56.0 [range, 28-90] years; 88.5 percent men; 23.6 percent with diabetes mellitus) with ST-segment elevation myocardial infarction (STEMI) and who underwent primary PCI without antecedent fibrinolytic therapy were analysed. With adjustments for appropriate covariates, logistic regressions were performed to assess the relationship between symptom-to-balloon time, door-to-balloon time and the studied outcomes, which were mortality and major adverse cardiac event (MACE) defined as death, myocardial infarction and repeat target vessel revascularisation.
Results Prolonged symptom-to-balloon time (median time, 3 hours 55 minutes) significantly increased the MACE rate at one month (odds-ratio [OR], 1.45; 95 percent confidence interval [CI], 1.09-1.92; p-value is 0.011) and six months (OR, 1.19; 95 percent CI, 1.01-1.41; p-value is 0.046) but not mortality (at one month, p-value is 0.25; at six months, p-value is 0.87) after adjusting for relevant covariates. However, door-to-balloon time (median time, 110 minutes) did not significantly influence mortality (mortality at one month, p-value is 0.73; six months, p-value is 0.64) and MACE (MACE at one month, p-value is 0.71; six months, p-value is 0.08) at one and six months.
Conclusion Symptom-to-balloon time is an important predictor of MACE in the short- and medium-term in contrast to door-to-balloon time. Improving public awareness and accessibility of health services to patients with STEMI is essential in reducing poor outcomes.

Keywords: angioplasty, balloon angioplasty, ischaemic heart disease, myocardial infarction, percutaneous coronary intervention
Singapore Med J 2007; 48(2): 131–136

Kalpana C, Sudheer AR, Rajasekharan KN, Menon VP
Correspondence: Dr Venugopal P Menon, cmrana@sify.com

ABSTRACT
Introduction Tobacco consumption is one of the leading preventable causes of death and disease worldwide. Nicotine, a major toxic component of tobacco, has been identified as an important risk factor for lung-related diseases. Increasing evidence demonstrates that oxidative stress plays a crucial aetiological role in the development of lung-related diseases. The present study aims at evaluating the protective role of curcumin and a synthetic analogue of curcumin (BDMC-A) on nicotine-induced oxidative stress.
Methods Male albino rats of Wistar strain were used for the experimental study. Lung toxicity was induced by subcutaneous injection of nicotine at a dose of 2.5 mg/kg body weight (five days a week, for 22 weeks) and curcuminoids were given simultaneously by intragastric intubation for 22 weeks. Measurement of lipid peroxidation indices, thiobarbituric acid reactive substances and hydroperoxides, nitric oxide and antioxidants, such as superoxide dismutase, catalase, glutathione peroxidase, reduced glutathione, vitamin E and vitamin C, were used as biomarkers for testing the antioxidant potential of the drugs.
Results Oxidative stress, as evidenced by lipid peroxidation indices, was significantly increased in nicotine-treated groups. Administration of curcumin and BDMC-A abrogated this effect. The antioxidant status which was decreased in nicotine was effectively modulated by both curcumin and BDMC-A treatment. However, the reduction in oxidative stress was more pronounced in BDMC-A treatment groups compared to those treated with curcumin.
Conclusion The present study suggests that BDMC-A exerts its protective effect by modulating the extent of lipid peroxidation and augmenting the antioxidant defence system.

Keywords: antioxidants, curcumin, curcumin analogue, lipid peroxidation, lung toxicity, nicotine
Singapore Med J 2007; 48(2): 124–130