Original Article

Guven HE, Bulak H, Turanli S, Oral S
Correspondence: Dr H Erhan Güven, heguven@gmail.com

ABSTRACT
Introduction According to the revised staging system for breast cancer, the infraclavicular node status has become more important because the involvement of the apical nodes now changes the stage of the disease for all tumour sizes. In this study, we analysed the stage migration among our patients treated with mastectomy for breast cancer.
Methods 44 patients who were treated with modified radical mastectomy for breast cancer in our department during 2003 were reviewed for their clinicopathological features, including the status of the axillary lymph nodes.
Results 11 patients (25 percent) were reclassified as stage IIIC according to the new Tumour, Node and Metastasis (TNM) classification system of American Joint Committee on Cancer that was revised in 2002. The mean age was 40.2 years and the mean tumour size was 5 cm.
Conclusion Patients with breast cancer should be properly staged preoperatively for choosing appropriate individual treatment, and more accurate evaluation of the infraclavicular region for metastatic lymph nodes should be done.

Keywords: apical lymph nodes, axillary lymph nodes, breast neoplasm, infraclavicular lumph nodes, lymphatic metastasis, modified radical mastectomy
Singapore Med J 2007; 48(1): 31–33

Arshad A, Kong KO
Correspondence: Dr Anwar Arshad, anwararshad@hotmail.com

ABSTRACT
Introduction Fibromyalgia syndrome (FMS) is a common but controversial condition. There appears to be different levels of belief of its existence and awareness. We set out to explore the variations of perceptions and awareness of this condition among rheumatologists from Malaysia and Singapore.
Methods 48 rheumatologists from Malaysia (28) and Singapore (20) were approached to participate in this survey by answering a specific questionnaire regarding their belief in FMS. 23 respondents from Malaysia and 20 from Singapore completed the questionnaire.
Results 91 percent of Malaysian rheumatologists and 95 percent of the Singaporean believe that FMS is a distinct clinical entity and that this condition is considered an illness rather than a disease. 87 percent and 90 percent of rheumatologists from Malaysia and Singapore, respectively, believe that FMS is a mixture of medical and psychological illness. However, not many of those in the university setting include FMS in their undergraduate teaching. 87 percent and 80 percent of the respondents from Malaysia and Singapore, respectively, also ordered blood tests to exclude other serious pathologies, and 100 percent of the respondents from both countries also prescribed some form of drugs to their FMS patients.
Conclusion This study confirmed that there was a variation of perceptions and knowledge of FMS among rheumatologists from Malaysia and Singapore. The majority of rheumatologists recognise that FMS is a distinct clinical entity, and is diagnosed by excluding other well-defined clinical diseases through a combination of clinical evaluation and screening tests.

Keywords: fibromyalgia syndrome, musculoskeletal disease, rheumatological disease, rheumatologist survey
Singapore Med J 2007; 48(1): 25–30

Wong CY, Wu E, Wong TY
Correspondence: Dr Wong Chiang Yin, wong.chiang.yin@singhealth.com.sg

ABSTRACT
Introduction Information asymmetry has been offered as a reason for unnecessarily high costs in certain industries where significant information asymmetry traditionally exists between providers and consumers, such as healthcare. The purpose of this paper is to examine the impact of the introduction of publishing of bill size as a means to reduce healthcare costs. Specifically, we aim to examine if this initiative to decrease information asymmetry on healthcare prices between healthcare providers and patients, and between healthcare providers themselves, will lead to lower prices for patients.
Methods Bill size data of 29 commonly occurring diagnosis-related groups (DRGs) for two ward classes (B2 and C) over a 16- month period were studied. Each ward class was studied separately, i.e. involving 58 DRG data sets. The mean bill size data as well as that of 50th and 90th percentile bill sizes were examined. The study involved some 46,000 inpatient episodes which occurred in the five public sector acute general hospitals of Singapore.
Results Mean prices dropped by 4.14 percent and 9.64 percent for B2 and C classes, respectively. 50 out of 58 DRG data sets showed a drop in prices. Bill sizes at the 50th percentile dropped by 7.95 percent and 10.12 percent for B2 and C classes, respectively; while at the 90th percentile, the corresponding figures were decreases of 8.01 percent and 11.4 percent for the two ward classes.
Conclusion The act of publishing bill sizes has led to less information asymmetry among providers, thereby facilitating more competitive behaviour among hospitals and lower bill sizes.

Keywords: diagnosis-related group, health economics information asymmetry, information costs, market failure
Singapore Med J 2007; 48(1): 16–24

Tan KBL, Tan SH, Tan KH, Yeo GSH
Correspondence: Dr Kenny BL Tan, ktbl@pacific.net.sg

ABSTRACT
Introduction Anencephaly is a neural tube defect that is incompatible with life. Previous studies have suggested that there is a racial predilection for this condition. However, local studies have not shown a statistical difference between the races. The aim of this study is to examine the incidence and the demographical trend of this condition over a ten-year period.
Methods Data of patients with anencephaly born from 1993 to 2002 were retrieved from the National Birth Defect Registry and analysed.
Results There were a total of 267 cases of anencephaly in the ten-year period from 1993 to 2002, giving an overall incidence of 0.58 per 1,000 livebirths, with a decreasing trend noted. The incidence was highest among the Malay population, compared with the Chinese population (p-value equals 0.03) and other races. Abortion rates have also increased over the years, causing a reduction in livebirth rates for this condition.
Conclusion The overall incidence and birth incidence of anencephaly has seen a decreasing trend over the last ten years, with the latter being contributed significantly by early termination. More studies should be done to ascertain if improved folate supplementation has contributed to the drop in overall incidence. The incidence in the Malay population is significantly higher than other races and this phenomenon should be further examined.

Keywords: anencephaly, birth defects, neural tube defects, termination of pregnancy
Singapore Med J 2007; 48(1): 12–15

Rozitah R, Nizam MZ, Nur Shafawati AR, Nor Atifah MA, Dewi M, Kannan TP, Ariffin N, Norsarwany M, Setianingsih I, Harahap A, Zilfalil BA
Correspondence: Dr B Alwi Zilfalil, zilfalil@kb.usm.my

ABSTRACT
Introduction Beta-thalassaemia major is an autosomal recessive disorder that results in severe microcytic, hypochromic, haemolytic anaemia among affected patients. Beta-thalassaemia has emerged as one of the most common public health problems in Malaysia, particularly among Malaysian Chinese and Malays. This study aimed to observe the spectrum of mutations found in Kelantan Malay beta-thalassaemia major patients who attended the Paediatrics Daycare Unit, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, the data of which was being used in establishing the prenatal diagnosis in this Human Genome Centre.
Methods This was a cross-sectional study conducted with 35 Kelantan Malay beta-thalassaemia major patients. DNA was extracted from the blood collected from the patients and subjected to polymerase chain reaction (PCR) amplification. Six restriction enzymes were used to digest the PCR products for the detection of mutations.
Results Five out of the six beta-globin gene defects were detected, namely, IVS-1 nt5 (G > C), IVS-1 nt1 (G > T), codon 26 (G > A), codon 41–42 (4 bp del) and codon 19 (A > G). The mutation which was not observed in this study was in codon 15 (G > A). The two most common mutations observed were codon 26 (G > A) and IVS-1 nt5 (G > C), which was detected in 26 and 17 patients, respectively. Two patients did not show any of the six mutations.
Conclusion Our results added to the existing data on the common beta-globin gene defects in Kelantan Malay beta-thalassaemia patients.

Keywords: beta thalassaemia, genetic disease, ß-globin gene, haemolytic anaemia, mutations, polymerase chain reaction, restriction fragment length polymorphism, thalassaemia
Singapore Med J 2008; 49(12): 1046-1049

Su TA, Hoe VCW
Correspondence: Dr Anselm Su Ting, anselmsuting@yahoo.com

ABSTRACT
Introduction Validity and reliability of the information relating to hand-transmitted vibration exposure and vibration-related health outcome are very important for case finding in hand-arm vibration syndrome (HAVS) studies. In a local HAVS study among a group of construction workers in Kuala Lumpur, Malaysia, a questionnaire translated into Malay was created based on the Hand-transmitted Vibration Health Surveillance – Initial Questionnaire and Clinical Assessment, from Vibration Injury Network. This study was conducted to determine the reliability of standardised questions in the questionnaire used in the study.
Methods 15 subjects were selected randomly from the sampling frame of the HAVS study. Test-retest reliability was conducted on all items contained in parts 1–6 of the questionnaire and clinical assessment form, with an interval of 13–14 days between the first and second administration. Kappa coefficient and percentage agreement were calculated for all standardised questions.
Results The kappa coefficient and percentage agreement for all standardised questions varied from -0.174 to 1.000 and 66.7 to 100.0 percent, respectively. The kappa coefficient for important questions related to current vibratory tool usage, tingling, numbness and hand grip weakness were 0.714, 0.432, -0.077 and -0.120, respectively, while the percentage agreement for current vibratory tool usage, finger colour change, tingling, numbness and hand grip weakness were 85.7 percent, 92.8 percent, 79.5 percent, 85.7 percent and 71.4 percent, respectively. Intra-rater reliability on the extent of vibration exposure was good, with the intra-class correlation coefficient (95 percent confidence interval) ranging from 0.786 (0.334–0.931) to 0.975 (0.923–0.992).
Conclusion Critical questions on vascular, neurological and musculoskeletal symptoms of HAVS were found to be reliable. The history on the extent of vibration exposure revealed good reliability when explored by the investigator alone. This questionnaire is considered reliable to be used in the study of HAVS among construction workers working in a construction site.

Keywords: hand-arm vibration syndrome, questionnaire reliability, vibration exposure
Singapore Med J 2008; 49(12): 1038-1045

Banihashemi M, Pezeshkpoor F, Yazdanpanah MJ, Family S
Correspondence: Dr Mahnaz Banihashemi, dr_banihaashemi@yahoo.com

ABSTRACT
Introduction The common wart is a common infectious disease caused by human papilloma virus. A variety of therapeutic modalities are available. Cryotherapy (liquid nitrogen) is one of the most common treatment forms. It freezes the tissue and destroys warts. Phenol is a caustic agent. Our purpose was to evaluate and compare the efficacy of cryotherapy and 80 percent phenol solution on common warts of hands.
Methods This single-blinded clinical trial study was performed on 60 patients with common warts referred to the dermatology clinic of Ghaem Hospital Mashhad, Iran, in 2002. Patients were randomly divided into two groups; 30 patients were treated with cryotherapy and 30 patients were treated with 80 percent phenol, on a once-weekly basis until complete clearance of the lesions or a maximum duration of six weeks.
Results Complete clearance of warts after six weeks was observed in 70 percent of patients who were treated with cryotherapy, and 82.6 percent of patients in the 80 percent phenol group; there was no statistically significant difference between the two methods (p-value is 0.014).
Conclusion Our data indicates that 80 percent phenol and cryotherapy are effective and simple treatments for common warts of hands, and patients do not experience any pain during the treatment.

Keywords: cryotherapy, human papilloma virus, liquid nitrogen, phenol, warts
Singapore Med J 2008; 49(12): 1035-1037

Ramnarayan R, Praharaj MS, Jayakumar PN
Correspondence: Dr Ramnarayan Ramachandran, r_ramnarayan@yahoo.com

ABSTRACT
Introduction A consensus on the ideal surgical procedure for Chiari 1 malformation has not been achieved. The purposes of the study were to report on the experience of treating this condition in an Indian hospital, and to look into the management of this not too uncommon condition with a view to improve the treatment and prognosis.
Methods A retrospective case note study of all cases of Chiari 1 malformations operated over a ten-year period from 1989 to 1999 and followed-up for another two years, were analysed for clinical and radiological features. All patients who underwent posterior fossa decompression were included. Patients who underwent other procedures like shunts were excluded. The data obtained included clinical and radiological features.
Results A total of 51 cases were analysed. All patients had posterior fossa decompression with duroplasty in the majority. Many patients had a delayed improvement noticed during the follow-up period. Headache, neck pain and motor features showed an improvement in the majority of the patients but sensory deficits did not.
Conclusion This study showed the effectiveness of posterior fossa decompression with duroplasty as a procedure, which benefited most patients with Chiari 1 malformations.

Keywords: cerebellar tonsils, Chiari 1 malformations, duroplasty, hindbrain herniation, posterior fossa decompression, syringomyelia
Singapore Med J 2008; 49(12): 1029-1034

Gole L, Adrianne F, Ee AM, Ng BL, Baig S, Koay E, Biswas A, Choolani M
Correspondence: Dr Leena Gole, leenagole@gmail.com

ABSTRACT
Introduction This study aimed to refine the current quantitative fluorescent polymerase chain reaction (QF-PCR) screen to detect X chromosome anomalies for prenatal diagnosis in the major Southeast-Asian populations.
Methods 100 amniotic fluid samples from Chinese, Malay and Indian origins were subjected to QF-PCR using the X chromosome markers, HPRT, X22 and AMXY, along with the autosomal marker D21S1411.
Results Out of the 100 samples tested by markers X22 and HPRT, eight samples were homozygous for both markers, of which seven were resolved by comparison with the autosomal marker D21S1411.
Conclusion 99 percent of samples could be tested for X chromosome copy numbers, increasing the stringency for detection of X chromosome anomalies by QF-PCR. All results were confirmed by cytogenetics.

Keywords: amniotic fluid samples, cytogenetics, prenatal diagnosis, quantitative fluorescent polymerase chain reaction, Turner syndrome, X chromosome abnormalities
Singapore Med J 2008; 49(12): 1025-1028

Orji EO
Correspondence: Dr Ernest Okechukwu Orji, eoorji11@yahoo.com

ABSTRACT
Introduction The impact of previous pregnancy outcome on future fertility in Nigeria has not been appreciated, hence the continued neglect of the adoption of safe motherhood measures in this sub-region. The objective of this study was to compare the past pregnancy outcomes among fertile and infertile patients in a Nigerian population.
Methods An institutional-based comparative case-controlled study of past pregnancy outcomes among infertile and fertile women was conducted. The data was managed using Epi-Info and the Statistical Package for Social Sciences.
Results 708 patients consisting of 472 pregnant women (fertile) and 236 infertile women were investigated. Infertile women were at a significant risk of having an adverse pregnancy outcome, such as induced abortion (p-value is 0.0001), postabortal sepsis (p-value is 0.0001), postpartum infection (p-value is 0.001), manual removal of the placenta (p-value is 0.0005) and prolonged unsupervised labour (p-value 0.0001), compared to pregnant fertile women. Logistic regression analysis of variables at 95 percent confidence intervals showed that the adjusted odds ratio for prolonged labour, prolonged rupture of membranes, postabortal sepsis and postpartum infection still remained significant.
Conclusion Previous mismanaged pregnancies impacted negatively on future fertility. Efforts should be directed towards the prevention of unplanned pregnancies. Motherhood must be made safer in planned pregnancies by prevention of complications, and aggressive and prompt treatment of any complication if and when it occurs.

Keywords: fertility, future fertility, mismanaged pregnancy, past pregnancy outcome, pregnancy outcome
Singapore Med J 2008; 49(12): 1021-1024