Original Article

Gaur DS, Talekar M, Pathak VP
Correspondence: Dr Dushyant Singh Gaur, dugaur@yahoo.com

ABSTRACT
Introduction Defective sperm quality is a significant cause of infertility. It is known that cigarette smoking affects semen quality. Our aim was to compare the semen of infertile cigarette smokers with infertile non-smokers to study the effect of smoking on semen quality.
Methods Semen samples of 100 cigarette smokers and 100 strictly non-smoking primary infertility patients were included in the study, following stringent exclusion criteria. Smokers were categorised as light, moderate and heavy smokers. Semen samples were examined for asthenozoospermia, oligozoospermia and teratozoospermia, according to World Health Organisation guidelines.
Results 39 percent of non-smokers showed normozoospermia, while only three percent of smokers were normozoospermics. Light smokers predominantly showed asthenozoospermia. Heavy smokers showed asthenozoospermia, teratozoospermia and oligozoospermia. Statistical analysis using Fisher's exact test showed that the incidence of both isolated asthenozoospermia (p-value is 0.0015) and asthenozoospermia with teratozoospermia (p-value is 0.0106) among smokers was significant, in comparison to non-smokers. Overall impact of asthenozoospermia (p-value is less than 0.0001) and teratozoospermia (p-value is 0.0328) but not of oligozoospermia was observed on the semen quality in smokers, compared with non-smokers.
Conclusion Asthenozoospermia, the most common semen variable in our study, can be an early indicator of reduction in quality of semen, as seen in light smokers. In addition, heavy smoking produces teratozoospermia, which further reduces semen quality. Oligozoospermia may be due to factors other than smoking.

Keywords: asthenozoospermia, cigarette smokers, male infertility, semen quality, teratozoospermia
Singapore Med J 2007; 48(2): 119–123

Srilatha B, Adaikan PG, Chong YS
Correspondence: Prof P Ganesan Adaikan, obgadaik@nus.edu.sg

ABSTRACT
Introduction The ageing process in man is accompanied by a number of endocrine changes including decline in testosterone (T), physiological imbalance between androgen and oestradiol (E2) and changes in the E2-T ratio. In this study, hormone profile data from a group of erectile dysfunction (ED) patients were reviewed to evaluate its impact on ED, with emphasis on oestradiol derangement.
Methods 30 ED patient case notes with a record of hormone profiles were retrospectively reviewed. Laboratory investigation included levels of total testosterone, total oestradiol, prolactin, luteinising and follicle stimulating hormones, in addition to lipid profile and glucose, based on specific history. These patients were divided into two groups based on the history of presence (Group A) or absence (Group B) of adequate sexual desire.
Results In Group B patients, the E2-T derangement with increasing age was statistically significant with lower serum T level (2.6 ng/ml; range, 1.6-3.7 ng/ml) and elevated E2 level (60 pg/ml; range, 40-120 pg/ml).
Conclusion In this preliminary report, although low total testosterone level is seen together with impaired libido and erectile impairment, the accompanying significant increase in E2 indicates the possible role for oestrogen in causation and/or persistence of ED in this group of patients.

Keywords: erectile dysfunction, hormone imbalance, oestradiol, oestradiol-testosterone balance, testosterone
Singapore Med J 2007; 48(2): 114–118

Gamanagatti S, Vashisht S, Kapoor A, Chumber S, Bal S
Correspondence: Dr Shivanand Gamanagatti, shiv223@rediffmail.com

ABSTRACT
Introduction To compare the accuracy of graded compression ultrasonography (US) and unenhanced spiral computed tomography (CT) in the diagnosis of acute appendicitis.
Methods This prospective study comprised 58 consecutive patients with high clinical suspicion of acute appendicitis. After careful clinical assessment and laboratory investigations, all the patients were independently evaluated by graded compression US followed by unenhanced spiral CT, in order to establish the diagnosis. CT was performed from the level of the third lumbar vertebral body to the pubic symphysis, and no patient was given oral, rectal or intravenous contrast agents. The results were compared with operative findings and clinical follow-up.
Results Out of the 58 patients evaluated, surgical confirmation was obtained in 52 patients and the remaining six patients were managed conservatively. Statistical analysis was based on the 52 patients who were surgically confirmed. 48 of the operated patients had evidence of appendicitis and four patients had negative findings. In our study, 90 percent of patients were adults and the following results were more applicable to the adult age group. Analysis of the data for US and CT, respectively, revealed a sensitivity of 67.3 percent versus 95.8 percent, specificity of 100 percent versus 75 percent, accuracy of 71.2 percent versus 90.3 percent, positive predictive value of 100 percent versus 97.8 percent, and negative predictive value of 15.8 percent versus 60 percent. Out of the operated patients, four patients did not have acute appendicitis and alternative diagnosis was suggested by US and CT in one patient. Of the six patients managed conservatively, an alternative diagnosis was reached both by US and CT in two patients.
Conclusion We conclude that unenhanced spiral CT is more sensitive than US in detecting appendicitis, especially in adult patients.

Keywords: acute appendicitis, appendicitis, computed tomography, ultrasonography
Singapore Med J 2007; 48(1): 80–87

Mshelia DS, Akinosun OM, Abbiyesuku FM
Correspondence: Dr D S Mshelia, msheliads@yahoo.co.uk

ABSTRACT
Introduction Diabetes mellitus remains a significant universal health problem. Globally, the prevalence of diabetes mellitus is projected to grow from 135 million in 1995 to 300 million in 2025. Due to inadequate healthcare facilities and providers, poverty, and illiteracy coupled with increasing prevalence of diabetes mellitus, there is limited patient-physician contact time. As a result, patients with diabetes mellitus develop complications and die early in life due to poor management. This has grave economic implications as diabetes mellitus principally affects people in their most productive years of life. A cross-sectional and longitudinal study on patients with type 2 diabetes mellitus was carried out to demonstrate how diabetic management objectives can be achieved in a resource-poor environment by increasing patient-physician contact time and with health education.
Methods One group of 105 consecutive patients with type 2 diabetes mellitus were recruited and managed in the metabolic research unit (MRU), where health education was emphasised for five years, served as the intensively-treated cohort (ITC). Another group of 115 patients with type 2 diabetes mellitus were also recruited and managed over the same five-year period in the medical outpatient department (MOPD) of the same hospital, where there was patient congestion at the clinic, served as the control cohort (CC). The CC also reported to the MRU during their follow-up for measurement of their blood pressure and urinalysis. Other measurements for the CC were obtained from the MOPD on the same day of their visit to the MRU. Morbidities were recorded on recruitment, at each visit, and at the end of the study in each cohort.
Results There was a marked reduction of morbidity at the end of the study in the ITC (222 versus 106, p-value is 0.0013), compared to the CC (138 versus 130, p-value is greater than 0.05). There was also a significant reduction in the number of patients with individual morbidities in the ITC, while significant reduction was only noticed in hypertension, eye problems, neuropathies, infections/boils, and ulcer/blisters in the CC. In 85 percent of the ITC, plasma glucose clustered around the target of the study as compared to only 58 percent of the CC.
Conclusion Diabetes mellitus management objectives can be achieved by increasing both patient-physician contact time and health education in addition to other conventional forms of treatment, especially in a resource-poor environment.

Keywords: diabetes mellitus, health education, management objectives, patient-physician contact time, resource-poor environment
Singapore Med J 2007; 48(1): 74–79

Abbas Z, Jafri W, Rasool S, Abid S, Hameed I
Correspondence: Dr Zaigham Abbas, zaigham@akunet.org

ABSTRACT
Introduction Rhino-orbito-cerebral mucormycosis is a rapidly progressive and fatal disease that mostly occurs in patients with diabetes mellitus and immunocompromised status. Antifungal therapy with surgical debridement is the standard of care. Patients with cirrhosis of liver are more prone to develop different infections. Many of these also show glucose intolerance or frank diabetes mellitus. Little is known about the clinical presentation and outcome of mucormycosis in patients with cirrhosis. Treatment is difficult due to underlying coagulopathy and hepatic dysfunction.
Methods Medical records of the past five years were searched for the cirrhotic patients admitted with associated diagnosis of mucormycosis or fungal infection. Six patients with mucormycosis were identified.
Results Out of six patients, five were male. Age range was 15-57 years. Cause of cirrhosis was hepatitis C in four patients, hepatitis B in one patient and autoimmune hepatitis in one patient. Two patients had hepatocellular carcinoma. Four patients had diabetes mellitus, of which one patient was also on steroids for the autoimmune liver disease. Four patients had spontaneous bacterial peritonitis at the time of admission. All six patients presented with rhino-orbitocerebral mucormycosis with nasal discharge and upper motor neuron signs. Diagnosis of mucormycosis was made by culture of biopsy and scrapings taken from the palate and nasal sinuses. These patients received amphotericin B. Four patients died while in the hospital, while two patients died within next few days after discharge.
Conclusion Mucormycosis in cirrhosis is not very common and has a poor prognosis. Patients with advanced cirrhosis and diabetes mellitus are at risk of developing infection.

Keywords: cirrhosis, diabetes mellitus, hepatocellular carcinoma, mucormycosis, oculo-rhino-cerebral mucormycosis
Singapore Med J 2007; 48(1): 69–73

Thia EWH, Vo Thanh LA, Loh SKE
Correspondence: Dr E W H Thia, edwintwh@gmail.com

ABSTRACT
Introduction Undergoing in vitro fertilisation (IVF) treatment is an emotional and physical burden. Couples rate the experience of waiting for the outcome of the IVF treatment and an unsuccessful IVF treatment cycle as the most stressful. The outcome of treatment would affect how they feel about their IVF experience. Our survey aimed to increase understanding of how couples feel about the experience of IVF before and during IVF treatment so that strategies to improve their experience can be devised.
Methods A prospective self-comparative study on the psychosocial aspects and support of patients undergoing an IVF programme was done. The questionnaire compared their responses before and during the IVF treatment.
Results A total of 50 couples (100 respondents) participated in our survey. 78 percent were Chinese, 11 percent Malay and ten percent Indian. 64 percent have had tertiary education. 39 percent were married for three to five years, while 38 percent were married for six to nine years. 83 percent have no children prior to IVF treatment. Prior to counselling, 55 percent had some medical knowledge on types of treatment procedures, the treatment options and the risks of IVF. This increased to 81 percent after counselling. 80 percent found the medical counselling helpful. 80 percent found psychosocial counselling helpful in understanding the emotional issues involved in undergoing IVF treatment. 70 percent of couples felt that ongoing psychosocial counselling was useful, especially during the most stressful stage of IVF.
Conclusion This study increased our understanding of the emotional aspects of IVF. Current strategies of providing medical and psychosocial counselling before IVF help prepare couples psychologically. Emotional support and psychosocial counselling before and during IVF were identified as important areas, particularly while waiting for the pregnancy test result.

Keywords: counselling, in vitro fertilisation, psychosocial support
Singapore Med J 2007; 48(1): 61–68

Ang D, Luman W, Ooi CJ
Correspondence: Dr Ooi Choon Jin, ooi.choon.jin@sgh.com.sg

ABSTRACT
Introduction Double balloon enteroscopy (DBE) is a novel procedure that allows complete visualisation, biopsy and treatment of small intestinal disorders. We describe our early experience with the use of DBE, evaluating the indications, diagnostic rates and complications. A secondary aim of the study was to compare the findings from DBE with wireless capsule endoscopy (WCE).
Methods Retrospective study of patients referred to the Department of Gastroenterology and Hepathology at the Singapore General Hospital for evaluation of suspected small bowel diseases between February 2005 and May 2006 was done. A total of 34 procedures were conducted on 30 patients. A standardised data collection form was used.
Results DBE was carried out via the oral approach (19 patients), anal approach (eight patients), and both approaches (three patients). Mean age was 53 (range 16-79) years. 12 procedures (35.3 percent) had one endoscopist and 22 (64.7 percent) procedures had two. The overall diagnostic input from DBE was 73.3 percent (22 of 30 patients). A positive diagnosis was achieved in 19 patients: jejunal gastrointestinal stromal tumour (GIST) (one), jejunal sarcoma (one), jejunal adenocarcinoma (one), duodenal adenocarcinoma (one), malignant lymphangioma (one), eosinophilic enteritis (one), pseudomembranous ileitis (one), tuberculous ileitis (one), jejunitis/ileitis (seven), lymphangiectasia attributed to relapsed Non-Hodgkins lymphoma (one), combination of angiodysplastic lesions and apthous jejunal/ileal lesions (one), and focal villous atrophy (two). Small intestinal pathology was excluded in three patients with abnormal computed tomography (CT) findings. Endoscopy time for antegrade DBE was 46.1 (+/- 20.1) minutes and for retrograde DBE was 70.8 (+/- 11.0) minutes. The findings of WCE correlated with DBE findings in nine of 12 (75 percent) patients. Apart from the first three DBE procedures, all subsequent cases were performed without fluoroscopy. When stratified into antegrade and retrograde DBEs respectively, procedural duration, sedative use and diagnostic yield were comparable for one and two endoscopist DBEs. No complications were recorded.
Conclusion Our early experience with DBE shows it to be safe and effective in imaging the small intestine, and it may soon become a standard mode of investigation for the gastroenterologist.

Keywords: double balloon enteroscopy, obscure gastrointestinal bleeding, small intestinal disorders, wireless capsule endoscopy
Singapore Med J 2007; 48(1): 50–60

Tiong TS
Correspondence: Dr Tiong Thung Sing, ytiong27@hotmail.com

ABSTRACT
Introduction This retrospective review evaluates the prognostic indicators in the management of sudden sensorineural hearing loss (SSNHL) in otorhinolaryngology patients admitted to Brunei RIPAS Hospital.
Methods The review covered data collected from 1996 to 1998, and included patients who were treated with naftidrofuryl and dexamethasone. Their hearing improvement (more than 20 dB) in relation to pure tone audiogram patterns, hearing loss severity, vertigo, age of the patients and duration from symptom onset to time of treatment, were evaluated.
Results After exclusion of three patients with known causes of hearing loss, 50 patients with idiopathic SSNHL were reviewed. Six audiogram patterns were observed with good prognostic indicators in patterns 1 and 4, where respectively, 95 percent and 100 percent of the patients improved. The hearing improvement was noted in the majority of the patients with mild or moderate degree of hearing loss, especially noticeable in audiogram patterns 1 and 4. Initial vertigo gave poor prognosis in hearing (more than 33 percent patients with vertigo improved versus 88 percent patients without vertigo improved). Patients aged between 21 and 60 years appear to have better prognosis of hearing improvement compared to those who are outside of this age range. 92 percent patients whose treatment started within the first week of onset of hearing loss experienced hearing improvement compared to 84 percent patients whose treatment started in the second week after onset.
Conclusion Fairly consistent with the previously-reported prognostic indicators are hearing loss severity, vertigo, age and duration of onset to treatment, though there was reasonably good prognosis when the patients were treated in the second week from hearing loss onset. Further findings of note were the six audiogram patterns and the good prognostic indicators in patterns 1 and 4.

Keywords: diagnosis, hearing loss, otorhino-laryngology, sudden sensorineural hearing loss, therapy
Singapore Med J 2007; 48(1): 45–49

Akere A, Otegbayo JA
Correspondence: Dr Jesse Abiodun Otegbayo, otegbayoa@comui.edu.ng

ABSTRACT
Introduction The p53 antigen is oncoprotective and when damaged, leads to production of anti-p53. It also predisposes to various cancers, including hepatocellular carcinoma (HCC). Serum anti-p53 has been proven to have prognostic and other values in patients with HCC. The objectives of this study were to determine the serum pattern, prevalence, diagnostic and prognostic utility of serum anti-p53 in Nigerians with HCC.
Methods 41 subjects with HCC and 45 apparently-healthy controls were matched for age and sex. Serum anti-p53 was determined using p53-autoantibody ELISA kit.
Results The mean age of the patients was 48.9 (+/- 13.8) years, and that of controls was 49.4 (+/- 13.7) years. There was male predominance among the patients, 31 men (75.6 percent) versus ten women (24.4 percent), with a male-to-female ratio of 3.1:1. Similar values among controls were 33 men (73.3 percent) versus 12 women (26.7 percent), with a male-to-female ratio of 2.75:1. Anti-p53 was detectable in the sera of five (12.2 percent) patients and four (8.9 percent) of controls (p-value is greater than 0.05). All the patients with positive sera were males, while one of the controls was a female. Three (60 percent) of the positive patients were in the age range 40-49 years, while in the control group, they were in the age range 50-59 years.
Conclusion There is a low prevalence of serum anti-p53 in our study population, and this is commoner in men. It is also present in the control group and therefore may not be useful as a diagnostic tool in this study population.

Keywords: anti-p53, hepatocellular carcinoma, serum anti-p53
Singapore Med J 2007; 48(1): 41–44

Leong HSS, Heng R, Emmanuel SC
Correspondence: Dr Leong Soh Sum Helen, helen_leong@nhgp.com.sg

ABSTRACT
Introduction Breast cancer is the commonest female cancer in Singapore. It is steadily rising with an incidence of 53.1 cases per 100,000 persons per year among women. Screening for detection of early lesions which are highly curable helps to reduce mortality.
Methods Over three afternoon sessions in December 2003, 224 female patients aged 40-65 years, participated in interviews conducted by the National Healthcare Group Polyclinics, Singapore. The survey sought information on mammographic screening history, the time interval since the previous mammographic screening, and the reasons for not going for the screening.
Results The survey found that only 26.4 percent (28 out of 106) among those aged 40 to 49 years had mammographic screening done within the past one year, and 43.2 percent (51 out of 118) among those aged 50 to 65 years had screening done within the last two years. Chinese women were twice more likely than Malay women to have a mammogram done. The commonest reasons for not wanting to have mammographic screening among women who did not have a mammogram done or had mammogram done more than two years ago, were lack of time (42.5 percent), fear of pain during the procedure (26.9 percent), and the belief that cancer would not happen to them (24.6 percent).
Conclusion Despite publicity on breast cancer being the commonest cancer among women in Singapore and cure being possible if the malignancy was detected early, close to half of the women aged 40-65 years old who attended the National Healthcare Group Polyclinics did not have mammographic screening done. One-quarter of the women who did not have mammogram screening did not do so as they did not think cancer would happen to them.

Keywords: breast cancer, cancer screening, mammographic screening, mammography
Singapore Med J 2007; 48(1): 34–40