Original Article

Kushtagi P, Kulkarni KKA
Correspondence: Prof Pralhad Kushtagi, pralhadkushtagi@hotmail.com

ABSTRACT
Introduction This paper aimed to study the ability of the “ovarian crescent sign” to predict the nature of adnexal masses and to validate the “ovarian crescent” as an ultrasonographical marker for malignancy.
Methods A prospective study was carried out in 60 consenting women with an undiagnosed adnexal mass, attending the gynaecology service and requiring operative intervention. An ovarian crescent sign at pelvic ultrasonography was considered to be present if normal ovarian tissue was seen adjacent to the tumour area. The ultrasonographer was blinded to the reports of CA 125, and if applicable, the ascitic fluid cytology and needle aspiration biopsy. Histopathological examination report of the tumour obtained at surgery (laparotomy/laparoscopy) was considered as the gold standard.
Results 11 of 60 biopsy specimens were positive for malignancy. Normal ovarian tissue could be identified (positive crescent sign) in nearly two-thirds of cases (65 percent) scanned. Presence of normal ovarian tissue was identified in 97 percent of the benign masses. The sign was not seen in ten of the 11 cases with malignancy.
Conclusion The ovarian crescent sign as a method in prejudging the adnexal masses was found to have high sensitivity (90.9 percent) and high negative predictive value (97.4 percent).

Keywords: adnexal mass, ovarian cancer, ovarian crescent sign, ultrasonography
Singapore Med J 2008; 49(12): 1017-1020

Chong VH, Rajendran N, Wint Z
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk

ABSTRACT
Introduction Complementary and alternative medicine (CAM) use is common among patients with chronic disorders. CAM use is also reported to be common among the general population. This cross-sectional study assessed the prevalence, types of ingested CAM use and the factors predictive of their use in Brunei Darussalam.
Methods 568 visitors (male 41.4 percent, mean age 40.2 +/- 15.1 years) to the medical wards were randomly approached and invited to participate in this study. Demographical data (gender, age and racial groups), comorbidities, smoking history, use of prescribed medications and psychosomatic symptoms of depression (anxiety, backache, depression, headache and insomnia) and CAM use were collected.
Results Overall, 21.1 percent had used CAM in the last 12 months, comprising traditional remedies (35.8 percent), vitamins/minerals supplements (19.2 percent), non-vitamins/non-minerals supplements (30 percent) and herbal remedies (3.3 percent). 11.7 percent were unsure of the CAM they had taken. On univariate analysis, older age (40 years and above) and presence of psychosomatic symptoms of depression particularly backaches, depression, headache and insomnia, were predictive for CAM use. On multivariate analysis, only the presence of any psychosomatic symptoms of depression remained significant for CAM use (odds ratio 1.7, 95 percent confidence interval 1.1–2.6). Among those using prescribed medications, 21.9 percent were cousing CAM. 21 percent of subjects without any comorbidities reported using CAM. There was no report of any adverse events.
Conclusion CAM use is not uncommon. One-fifth of our subjects have used CAM within the past 12 months, even in those who do not have any comorbidity. Presence of any psychosomatic symptom of depression was predictive for CAM use. Most importantly, a proportion of the users were not even sure of what they had taken.

Keywords: alternative medicine, complementary medicine, health supplements, herbs, traditional medicine, vitamins
Singapore Med J 2008; 49(12): 1012-1016

Phua DSK, Leong WM, Yoong CS
Correspondence: Dr Darren Phua Shing Kuan, darren_phua@cgh.com.sg

ABSTRACT
Introduction The management of postoperative pain is an increasingly important aspect of healthcare, leading to the establishment of acute pain services in major surgical centres worldwide. The acute pain service (APS) was established in most Singapore hospitals in the 1990s. We analysed data collected in our institution over a ten-year period (1998–2007), documenting our experiences, outcomes and complications encountered by our APS.
Methods Data was chronologically divided into two groups for analysis: years 1998–2003 (3,248 cases) and 2004–2007 (2,466 cases). Analysis included a comparison of patient profiles, modalities of analgesia used, effectiveness of pain relief, adverse effects, complications and patient satisfaction. Results were also compared to published audits and proposed standards in medical literature.
Results The patient profile served by the APS remained unchanged over the years, but a move away from central neuraxial blocks was noted with an increased utilisation of patient-controlled analgesia. There was no clinically significant change in pain scores over the two periods of analysis (0.9 vs. 1.0 at rest, 3.0 vs. 3.0 on movement). There were also no statistically significant changes in the prevalence of patients reporting severe pain while on the APS (1.5 percent vs. 1.6 percent at rest, p-value is 0.66; 8.5 percent vs. 9.4 percent on movement, p-value is 0.25). Complication rates remained well within international standards and no major complications were reported. Patient satisfaction remained high (94.3 percent vs. 94.6 percent, p-value is 0.6).
Conclusion The move away from invasive and less targeted analgesic modalities has not compromised the quality of analgesia provided. Major morbidity remains extremely rare and incidence of complications has been reduced over the years. Patient satisfaction remains well in excess of 90 percent, and the side effects are largely well controlled. With further advancements in the provision of acute postoperative analgesia, the APS will continue to play an important role in the holistic convalescence of the surgical patient.

Keywords: acute pain service, analgesics, pain relief, patient satisfaction, postoperative pain
Singapore Med J 2008; 49(12): 1007-1011

Koosha A, Hashemifesharaki R, Mousavinasab N
Correspondence: Dr Ali Koosha, koosha@doctor.com

ABSTRACT
Introduction Breast-feeding is a major determinant of infants’ health and survival. The aim of this study was to examine breast-feeding patterns and the role of some factors on exclusive breast-feeding.
Methods The study was done at the Health Centre of Community Oriented Medical Education of Zanjan City, Iran. Mothers of 650 infants younger than one year of age were interviewed directly by healthcare providers. The necessary information was recorded on pre-structured questionnaires, and the feeding patterns of all infants were determined.
Results The rate of breast-feeding was greater than 92 percent during the first year of life. Exclusive breast-feeding rate in the first five days of life was 82 percent, but it declined to 44 percent at the first month. The chance of exclusive breast-feeding was higher in infants who were on demand feeding (odds ratio [OR] 2.6), breastfed more than eight times per day (OR 2.23), and their birth weight ranged from 2.5 to 4 kg (OR 2.16). This chance was less among infants exposed to pacifiers (OR 2.62) and with the numbers of deliveries equal to or more than three (OR 2.25).
Conclusion The rates of breast-feeding initiation and its duration at six and 12 months were higher than the national goal. The rate of exclusive breast-feeding was nearly 44 percent. It seems necessary to elucidate the role of other factors, such as socioeconomic status, on exclusive breast-feeding.

Keywords: breast-feeding, exclusive breast-feeding, infant health
Singapore Med J 2008; 49(12): 1002-1006

Bhasker S, Bajpai V, Turaka A
Correspondence: Dr Suman Bhasker, bhaskersuman@rediffmail.com

ABSTRACT
Introduction Providing effective palliative treatment in childhood malignancies is a challenging task. This study evaluated the role of palliative radiotherapy in the management of incurable paediatric malignancies.
Methods Records of 40 paediatric patients treated between January 2003 and November 2005 were reviewed and analysed retrospectively. All had received palliative external beam radiotherapy for symptom control either as a single modality or in addition to surgery, chemotherapy and drugs for symptomatic relief.
Results Predominant symptoms noticed were swelling with or without pain, bleeding, and weakness of limbs. Median duration of symptoms was 90 days. Malignant round cell tumours were most common followed by retinoblastoma, neuroblastoma, Ewing’s sarcoma and acute myeloid leukaemia with chloromas. 45 percent of children had disseminated disease at presentation. Nine underwent surgery, while 32 patients received chemotherapy, and all but two received drugs for symptomatic relief in addition to palliative radiotherapy. Dose schedules were either 5 Gy or 8 Gy in single fraction, while for fractionated radiotherapy, the range was 20 Gy in five fractions to 30 Gy in ten fractions. With regard to symptomatic relief, four patients had complete relief, 20 showed good relief, 15 had little and one did not have any relief. On completion of multimodality treatment, tumour response was complete in two patients, 18 had partial response, eight had stable disease, eight had progressive disease, and the disease status of four was unknown.
Conclusion The role of radiotherapy as a palliative modality in children with locally-advanced lesions provides better symptomatic relief in combination with other treatment modalities.

Keywords: advanced malignancy, cancer treatment, childhood malignancy, paediatric malignancy, palliative radiotherapy, radiotherapy
Singapore Med J 2008; 49(12): 998-1001

Thambidorai CR, Aman Fuad Y
Correspondence: Dr Thambidorai CR, thambidorai@gmail.com

ABSTRACT
Introduction The place of laparoscopic appendicectomy in the management of complicated appendicitis remains unsettled with reports of a higher incidence of postoperative intraperitoneal abscess. Most studies on laparoscopic appendicectomy in children have been done in the Western population. This retrospective review was done to compare laparoscopic appendicectomy with open appendicectomy in children with complicated appendicitis in a hospital in Malaysia.
Methods The laparoscopic appendicectomies were done by a single surgeon, while the open appendicectomies were performed by surgical trainees with at least three years of surgical experience. There was no selection of cases for laparoscopic appendicectomy. Both procedures were done by standard techniques. The operative time, duration of postoperative stay, wound infection rate, incidence of intraperitoneal abscess and postoperative fever were compared.
Results Based on the intention to treat analysis, there were 51 and 61 children in the laparoscopic and open appendicectomy groups, respectively. Conversion from laparoscopy to open technique was done in six children. Distribution of age, gender and pathology of appendicitis was similar for the two groups. With laparoscopic appendicectomy, the mean operative time was longer (112 vs. 72 minutes, p-value is less than 0.005), while severe wound infection (2.1 vs. 21 percent, p-value is less than 0.05) and mean postoperative hospital stay (5.7 vs. 7.4 days, p-value is less than 0.005) were significantly lower. The incidence of postoperative intraperitoneal abscess (12 vs. 11.5 percent) and postoperative fever (20 vs. 11.5 percent) were not significantly different (p-value is greater than 0.05).
Conclusion This review has confirmed that the longer the operating time, the lower the incidence of wound infection and the shorter the postoperative stay for laparascopic appendicectomy. There was no increased risk of postoperative intraperitoneal abscess.

Keywords: children, complicated appendicitis, laparoscopic appendicectomy, open appendicectomy
Singapore Med J 2008; 49(12): 994-997

Jawaid A, Zafar AM, Naveed A, Sheikh S, Waheed S, Zafar MA, Syed EU, Fatmi Z
Correspondence: Mr Ali Jawaid, alijawaid84@gmail.com

ABSTRACT
Introduction Attention deficit hyperactivity disorder (ADHD) and learning disorder (LD) remain prevalent globally and are also speculated to have a high occurrence in Pakistan. An early diagnosis and intervention in these disabilities is imperative for achieving good clinical and functional outcomes. This can be ensured by an effective screening at the level of primary paediatric care in the developing countries. We aimed to explore the ability of general practitioners (GPs) and paediatricians in Pakistan to screen for ADHD and LD based on their awareness regarding the risk factors and symptomatology of ADHD and LD.
Methods A total of 96 paediatricians and 98 GPs practising in Karachi, Pakistan were included in the study. Data was collected employing a self-administered questionnaire.
Results Only 13.7 percent of the GPs and 21.6 percent of the paediatricians were shown to have knowledge sufficient to effectively screen for / diagnose ADHD. Alarmingly, not a single GP was adequately familiar with the established risk factors and clinical symptoms of LD. The level of knowledge was not influenced by age, gender, and clinical practice attributes of the physicians. Doctors who regularly read medical journals and attend medical education seminars showed slightly better trends.
Conclusion We hypothesise that this demonstrated lack of knowledge at the level of primary care in Pakistan prevents an early screening of ADHD and LD. A multipronged strategy targeted at the provision of objective screening tools for primary paediatric care providers, regular continuing medical education seminars and an emphasis on paediatric mental health in undergraduate and postgraduate curricula may ensure an early detection of ADHD and LD in Pakistan.

Keywords: attention deficit hyperactivity disorder, learning disorder, primary paediatric care provider, structured screening tools
Singapore Med J 2008; 49(12): 985-993

Lee YHD, Lim YW, Lam KS
Correspondence: Dr Dave Lee Yee Han, davelyh@singnet.com.sg

ABSTRACT
Introduction The incidence of osteoporotic hip fractures in Singapore as well as in Asia will gradually increase with an ever ageing population. The objectives of this study were to understand the costs of hip fractures in our community and to analyse the various factors that lead to higher inpatient costs for hip fractures.
Methods We prospectively reviewed 80 elderly patients with osteoporotic hip fractures. The relevant patients’ clinical data was correlated with the inpatient hospitalisation costs. We reviewed the cost and management practices of hip fractures published in the literature and compared them with our findings.
Results We found that our patients treated surgically incurred lower costs and had a shorter inpatient stay compared to those treated conservatively. The mean hospitalisation cost for patients treated surgically was S$10,515 and the mean length of stay was 16 days. We found that the length of stay, a longer delay to surgery, male gender, having ASA 3 score, and development of postoperative complications led to higher inpatient hospital costs.
Conclusion With the identification of various clinical factors that are associated with high inpatient costs, we can further shorten our hip fracture patients’ stay as well as reduce the hospitalisation costs.

Keywords: cost-effective treatment, economic cost, hip fractures, hospitalisation costs, osteoporotic hip fractures, proximal femoral fractures
Singapore Med J 2008; 49(12): 980-984

Taweevisit M, Wisadeopas N, Phumsuk U, Thorner PS
Correspondence: Dr Mana Taweevisit, dr.mana4@gmail.com

ABSTRACT
Introduction Haemorrhoids are an abnormal, tortuous dilatation of the arteriovenous plexus of the anus. Although increased resting anorectal pressure is deemed to be a major initiating factor, a thorough understanding of the pathogenesis is still lacking. Mast cells, through release of granules, can affect local vessels with respect to changes in calibre, changes in permeability and thrombosis. Thus, mast cells could play a role in haemorrhoid pathophysiology, although this has not been previously investigated.
Methods 48 cases of haemorrhoids were retrospectively collected at King Chulalongkorn Memorial Hospital, with normal anorectal tissue from surgically-removed colorectal cancer serving as controls. Mast cells were identified by toluidine blue staining and quantitated around venous vessels.
Results Mast cells around haemorrhoidal vessels were significantly more numerous than in normal specimens (p-value is less than 0.001). Similar values were found for haemorrhoids showing chronic changes and those in a more acute stage.
Conclusion These findings support the hypothesis that mast cells may play a role in the pathophysiology of haemorrhoids. Mast cells appear to participate equally in the early and later stages of these lesions. Mast cells are known to affect local vascular conditions through release of their chemical mediators and cytokines, and may influence haemorrhoid symptomatology and progression at this level.

Keywords: anorectal tissue, cytokines, haemorrhoids, haemorrhoid pathophysiology, inflammatory mediators, mast cells
Singapore Med J 2008; 49(12): 977-979

Sumathi B, Navaneethan U, Jayanthi V
Correspondence: Dr Udayakumar Navaneethan, udhaykumar81@yahoo.co.in

ABSTRACT
Introduction Guidelines for an upper gastrointestinal endoscopy have been outlined for the Western population, but not yet for India. The study aimed to assess the appropriateness of upper gastrointestinal endoscopy for patients with dyspepsia and to identify the cut-off age for endoscopy from an Indian perspective.
Methods Patients referred for upper digestive endoscopy to a university clinic in India were prospectively studied between January 2004 and June 2005. Patients who presented with dyspepsia and those with isolated alarm symptoms without dyspepsia who underwent endoscopy were included. The cut-off age for the detection of upper gastrointestinal tract carcinoma in dyspepsia was derived.
Results A total of 3,432 endoscopies were performed during the study period. There were 2,068 men and 1,364 women. The overall mean age was 41.6 +/- 15 (range 7–85) years. 18.3 percent of 284 patients with malignancy were between 25 and 45 years of age. Using the receiver operator characteristic curve, the cut-off age for malignancy was between 35 and 44 years; specifically, the optimal cut-off age was 38 years for females and 43.5 years for males.
Conclusion In the south Indian population with dyspepsia, there were more normal and benign lesions at endoscopy. The optimal cut-off ages for detecting malignancy for both genders were also determined.

Keywords: dyspepsia, endoscopy, malignancy, upper gastrointestinal endoscopy
Singapore Med J 2008; 49(12): 970-976