Original Article

Jahanshahi M, Golalipour MJ, Heidari K
Correspondence: Dr Mehrdad Jahanshahi, mejahanshahi@yahoo.com

ABSTRACT
Introduction The evaluation and measurement of human body dimensions are achieved by physical anthropometry. Cephalometery is a branch of anthropometry science in which the head and face anatomical dimensions are measured. This research was conducted in view of the importance of anthropometric indices of the face in forensic medicine, surgery, paediatrics and medical imaging.
Methods This descriptive and cross-sectional study was set up to determine and compare the face shapes in Fars and Turkman ethnic groups of 808 normal 17-to 20-year-old males and females in Gorgon, North Iran (Fars group 407, male 200 and female 207; Turkman group 401, male 198 and female 203). The length and width of faces were determined by using classic cephalometery technique with Martin spreading callipers, and the shape of faces in the ethnic group of Fars and Turkman in both sexes was compared.
Results The dominant type of face shape in both the native Fars and Turkman females was euryprosopic (37.7 and 51.7 percent, respectively). The dominant type of face shape in the native Fars and Turkman males was mesoprosopic (44 and 38.4 percent, respectively).
Conclusion This study determined the possible effect of ethnicity on the diversity of face shapes in young males and females in this region.

Keywords: cephalometry, facial anthropometry, prosopic index
Singapore Med J 2008; 49(11): 940-943

Pandit NB, Choudhary SK
Correspondence: Dr Niraj B Pandit, drniraj74@gmail.com

ABSTRACT
Introduction The objective of this study was to obtain comprehensive data on injection practices, especially about safety issues, among health services providers and residents in the Anand district of Gujarat, India.
Methods The study was a cross-sectional study. Stratified random sampling method was used to select primary healthcare facilities, and the field method of randomisation was used to select families in the general population in the catchment areas of the selected health facilities. Thus, 182 health facilities and 510 families (2,080 population) were covered in the study.
Results Almost 77 percent of service providers had unsafe injection practices, including the use of a boiling pan for sterilisation, recapping of needles and exposure to body fluids. The proportion of unsafe injection practices was higher among Government health service providers. The prevalence of needle stick injuries (NSI) among service providers was 52.2 percent and the annual incidence of NSI was 19 percent. 21.6 percent of the population studied had received one or more injections in the past one year, and the average number of injections per head per year in the present study was 0.2.
Conclusion The study revealed a high proportion of unsafe injection practices in the district studied, but a low average number of injections per head per year in the community. Serious issues regarding injection safety need to be addressed urgently. There is a need to develop local guidelines for injection usage and implement a community-based educational programme for the people.

Keywords: needle stick injury, patient safety, unsafe injection practices
Singapore Med J 2008; 49(11): 936-939

Nimmonrat A, Na-ChiangMai W, Muttarak M
Correspondence: Prof Malai Muttarak, mmuttara@mail.med.cmu.ac.th

ABSTRACT
Introduction The clinical manifestation of urachal abnormalities may mimic many intraabdominal or pelvic diseases. We present clinical, imaging and pathological findings of a spectrum of complicated urachal abnormalities and determine whether imaging can be used to differentiate tumour from infection.
Methods From January 1993 to December 2006, seven patients with surgically-proven complicated urachal abnormalities had their clinical, imaging and pathological features reviewed.
Results There were three men and four women, aged 12–73 years. Four patients had infected urachal remnants and three had urachal carcinoma. The main clinical findings in infected urachal remnants were dysuria, abdominal pain and mass. The patients of urachal carcinoma presented with abdominal mass and haematuria. Computed tomography (CT) was performed in all cases, and ultrasonography (US) was performed in four cases. CT in all cases showed a mass located extraperitoneally in the midline just beneath the rectus abdominis muscle and extending from the umbilicus to the dome of the urinary bladder. There were one well-defined cystic mass and six ill-defined solid masses. US showed one cystic mass and three echogenic masses. Cystography was performed in one patient and it showed indentation to the dome of the urinary bladder with mucosal irregularity. The cystic mass and one ill-defined solid mass were pathologically-proven to be xanthogranulomatous inflammation. The other five solid masses were found to be adenocarcinoma in three and chronic non-specific inflammation in two cases.
Conclusion Preoperative diagnosis of urachal abnormalities may be suggested by clinical presentation and imaging features. However, it is difficult to differentiate tumour from infection based on imaging features alone.

Keywords: infected urachal remnants, urachal abnormalities, urachal carcinoma, urachus
Singapore Med J 2008; 49(11): 930-935

Draman CR, Kong NCT, Gafor AH, Rahman AFA, Zainuddin S, Mustaffa WMW, Radzi AM, Shamsul AS
Correspondence: Dr Che Rosle Bin Draman, cherosle@gmail.com

ABSTRACT
Introduction Angiotensin-converting enzyme (ACE) gene polymorphism, especially the deletion/deletion (DD) genotype, is associated with the disease progression of immunoglobulin A (IgA) nephropathy patients in various studies from both Asia Pacific and European populations. However, recent studies within the same populations were unable to reproduce the same results. Hence, we had studied the distribution of the DD genotype, the association between ACE gene polymorphism and the disease progression, and the factors (other than ACE gene polymorphism) which were involved in the disease progression of our local patients.
Methods This was a cross-sectional study of biopsy-proven IgA nephropathy patients attending the Nephrology Clinic, Hospital Universiti Kebangsaan Malaysia. Both biochemical and urine tests at the time of first presentation were compared to those at the time of the study, and the disease progression was analysed. The ACE gene polymorphism was identified via PCR-amplification technique, and patients were then categorised into the DD and the non-DD groups for detailed analysis. Histological severity of each renal biopsy was scored according to the predetermined criteria and medications used were recorded. The association between the gene polymorphism and disease progression was then determined. The patients who were stable or had renal function deterioration, were respectively regrouped into Groups 1 and 2, to identity those factors (other than ACE gene polymorphism), which were involved in the disease progression.
Results 60 patients with adequate renal histopathological examination were recruited. Their mean age was 40.9 +/- 12.3 years and the follow-up duration was 4 +/- 3 years (range 6 months–20 years). More than two-thirds of them were treated with ACE inhibitors or angiotensin receptor blockers and 8.3 percent received the combination treatment. The DD genotype was noted in 13.3 percent of study patients, insertion/insertion in 48.3 percent and insertion/deletion genotype in 38.3 percent. Although the estimated glomerular filtration rate (eGFR) of both groups were the same during their initial presentation, the DD patients had more severe disease compared to the non-DD patients at the time of the study. Their serum creatinine and eGFR was 178 (IQR 31.3) µmol/L and 42.1 +/- 31.1 ml/min/1.73 square metres, whereas the non-DD patients had serum creatinine and eGFR of 79 (IQR: 88.3) µmol/L and 76.6 +/- 42.1 ml/min/1.73 square metres, respectively (p-value is less than 0.01). The DD patients were also found to have more severe vascular damage in their renal biopsies compared to the non-DD patients. The annual rate of decline in eGFR was not significantly different between the two groups. It was -5.7 +/- 2.2 ml/min/1.73 square metres/year for the DD group and -4.8 +/- 2.0 ml/min/1.73 square metres/year for the non-DD group (p-value is equal to 0.5). They also had severe proteinuria with UPCI of 0.09 (IQR 0.2) g/mmol creatinine vs. 0.04 (IQR 0.10) g/mmol creatinine (p-value is less than 0.01). The study also confirmed that patients who had higher systolic blood pressure, greater proteinuria and longer follow-up duration had significant renal function deterioration compared to those who did not.
Conclusion The DD genotype, although found in a minority of the patients, might have adversely affected the disease progression of our IgA nephropathy patients. Higher systolic blood pressure, greater proteinuria and longer follow-up duration were the other prognostic factors in IgA nephropathy patients. However, appropriate treatment, especially prompt use of renin-angiotensin-aldosterone system blockade, should stabilise the disease regardless of their genotype.

Keywords: angiotensin-converting enzyme gene polymorphism, deletion/deletion genotype, gene polymorphism, immunoglobulin A nephropathy, nephropathy, renin-angiotensin-aldosterone system
Singapore Med J 2008; 49(11): 924-929

Makhlough A, Jamshidi M, Mahdavi MR
Correspondence: Dr Atieh Makhlough, makhlogh_a@yahoo.com

ABSTRACT
Introduction Patients on maintenance haemodialysis are known to have an elevated risk of acquiring hepatitis C virus (HCV) infection. The reported prevalence among haemodialysis patients in the United States ranges from eight percent to ten percent, and is considerably higher in many European and Middle Eastern countries. Therefore, a reliable diagnosis of HCV infection is essential in order to prevent the spread of the disease in dialysis units.
Methods All haemodialysis patients were interviewed in two dialysis units in Sari and Ghaemshahr, Iran, in 2006. Blood samples were collected and serum samples screened for anti-HCV antibodies by enzyme-linked immunosorbent assay (ELISA). All samples were retested for confirmation with polymerase chain reaction (PCR).
Results A total of 186 haemodialysis patients (mean age 58.86 +/- 16.9 years) were studied. Mean duration of haemodialysis was 3.07 +/- 0.3 years. Mean of SGOT and SGPT were 30.64 +/- 6 and 32.01 +/- 8, respectively. Among the 186 patients, 39 (21 percent) were seropositive by ELISA and 21 (11.3 percent) were PCR positive. All PCR positive patients also had positive ELISA. Association between the duration of haemodialysis and HCV seropositivity was statistically significant (p-value is 0.0001), but there was no significant correlation between number of transfusions and HCV seropositivity.
Conclusion Despite the growing demand for cost-effectiveness in the health system, tight control of HCV infection by PCR and ELISA examination must remain an essential part of the routine screening in haemodialysis patients.

Keywords: enzyme-linked immunosorbent assay, haemodialysis, hepatitis C virus, polymerase chain reaction, serological methods
Singapore Med J 2008; 49(11): 921-923

Chong VH, Zinna HS
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk

ABSTRACT
Introduction Hepatitis C virus (HCV) infection is prevalent among patients undergoing haemodialysis (HD). This study assessed the characteristics and outcomes of HCV infections among patients undergoing regular HD in a small dialysis centre.
Methods All patients (total 71, male 52 percent) who had HD were identified from the dialysis register and retrospectively reviewed.
Results The mean age was 48.0 (+/– 14.7) years at the start of HD and the overall incidence of HCV IgG seropositivity (+) was 31 percent (22 patients). Ten patients were documented to have acquired HCV infection after starting HD, and nine cases before the institution of control measures. HCV RNA was detected in 14 of 17 (82.4 percent) patients who had RNA testing. Genotyping was done for seven patients; genotype 1a (two), genotype 1a/b (one) genotype 2b (one) and genotype 3a (three). HCV IgG (+) patients were younger, had longer duration of HD and had more transaminitis (all p-values less than 0.05) compared to HCV IgG (–) patients. Five patients had interferon treatment and three had sustained viral response (HCV RNA undetected at six months post-completion). At a mean HD duration of 54.8 (+/– 40.3) months, 25 patients (35.2 percent) died, with similar proportion from those HCV IgG (+) (31.8 percent) and those HCV IgG (–) (36.7 percent), respectively (p-value equal to 0.688). There were no difference in age (p-value equal to 0.444) and duration of HD (p-value equal to 0.534) between these two groups. None of the deaths were due to liver disease.
Conclusion HCV infection is common among patients attending HD and sharing of dialysis machines is an important factor. HCV infection was not a significant factor on the mortality in this study but longer follow-up is required.

Keywords: end-stage renal failure, genotypes, haemodialysis, hepatitis C
Singapore Med J 2008; 49(11): 916-920

Shukla VK, Chauhan VS, Mishra RN, Basu S
Correspondence: Prof Vijay K Shukla, vkshuklabhu@satyam.net.in

ABSTRACT
Introduction Lifestyle and dietary habits play an important role in carcinogenesis. Carcinoma of the gallbladder is no different. The present study was carried out to evaluate the roles of lifestyle, menstrual and reproductive factors in gallbladder cancer.
Methods A prospective case-control study involving 78 newly-diagnosed cases of carcinoma of the gallbladder and 78 age- and gender-matched controls with cholelithiasis were investigated for their lifestyle history, with an emphasis on habits with chewing betel nut and tobacco, alcohol consumption and smoking. Besides this, female patients were investigated for their menstrual and reproductive factors. Odds-ratio and significance were calculated.
Results A Hindu preponderance was seen. About half of the patients with carcinoma of the gallbladder and gallstone were either illiterate or had a very low level of education (primary or below). Religion, education, family income, chewing of tobacco as well as smoking were comparable. But numbers of chewing tobacco and smoking per day differed significantly. Alcohol was consumed by 11.6 percent of carcinoma and 4.1 percent of gallstone patients. Lower age of menarche, higher number of pregnancies and higher age at menopause had a significantly increased risk of gallbladder carcinogenesis. A significant difference in carcinogenesis was seen in the postmenopausal women compared with the menopausal group.
Conclusion Carcinoma of the gallbladder was common in tobacco chewers. Females with lower age at menarche, higher number of pregnancies and childbirths and higher age at last childbirth had an increased risk of gallbladder cancer.

Keywords: biliary tract cancer, carcinogenesis, gallbladder carcinoma, lifestyle, reproductive factors
Singapore Med J 2008; 49(11): 912-915

Kuru B, Camlibel M, Dinc S, Gulcelik MA, Gonullu D, Alagol H
Correspondence: Dr Bekir Kuru, bekirkuru@hotmail.com

ABSTRACT
Introduction The present study was undertaken to define the prognostic factors for overall survival subsequent to definitive surgery, and for survival after the development of distant metastasis in breast cancer patients who developed distant metastasis subsequent to definitive surgery.
Methods The records of 470 breast cancer patients with T1-3 tumours and distant metastasis following surgery were reviewed. Prognostic factors were compared to the first metastatic sites as solitary skeletal, multiple skeletal, and visceral metastases, and were analysed for overall survival following surgery and survival after metastasis. Survival curves were generated by the Kaplan-Meier method, and multivariate analysis was performed by the Cox proportional hazard model.
Results 79 patients (17 percent) had a solitary skeletal metastasis, 105 (22 percent) had multiple skeletal metastases, and 286 (61 percent) had a visceral metastasis. The five-year overall survival was significantly better for patients with a solitary bone metastasis (73 percent) compared to patients who had multiple bone metastases (46 percent), or a visceral metastasis (22 percent) (p-value is less than 0.0001). Pathological lymph node status 3, stage IIIC, grade 3, oestrogen receptor negativity, and visceral metastases were found to have independent detrimental influence on overall survival following surgery and survival after metastasis. A long-term metastasis-free interval affected post-metastatic outcome favourably. Radiotherapy improved overall survival.
Conclusion Pathological lymph node status, stage, grade, and oestrogen receptor status predicted survival after surgery as well as after the development of metastasis. Solitary bone metastasis has a more favourable prognosis than multiple bone metastases, and compared to visceral metastasis, skeletal metastasis has a more favourable prognosis.

Keywords: apex axillary invasion, breast cancer, oestrogen receptor, skeletal metastasis, stage IIIC breast cancer
Singapore Med J 2008; 49(11): 904-911

Parsa P, Kandiah M, Mohd Nasir MT, Hejar AR, Nor Afiah MZ
Correspondence: Dr Parisa Parsa, pparsa2003@yahoo.com

ABSTRACT
Introduction Breast cancer is the leading cause of cancer deaths in Malaysian women, and the use of breast self-examination (BSE), clinical breast examination (CBE) and mammography remain low in Malaysia. Therefore, there is a need to develop a valid and reliable tool to measure the beliefs that influence breast cancer screening practices. The Champion's Health Belief Model Scale (CHBMS) is a valid and reliable tool to measure beliefs about breast cancer and screening methods in the Western culture. The purpose of this study was to translate the use of CHBMS into the Malaysian context and validate the scale among Malaysian women.
Methods A random sample of 425 women teachers was taken from 24 secondary schools in Selangor state, Malaysia. The CHBMS was translated into the Malay language, validated by an expert's panel, back translated, and pretested. Analyses included descriptive statistics of all the study variables, reliability estimates, and construct validity using factor analysis.
Results The mean age of the respondents was 37.2 (standard deviation 7.1) years. Factor analysis yielded ten factors for BSE with eigenvalue greater than 1 (four factors more than the original): confidence 1 (ability to differentiate normal and abnormal changes in the breasts), barriers to BSE, susceptibility for breast cancer, benefits of BSE, health motivation 1 (general health), seriousness 1 (fear of breast cancer), confidence 2 (ability to detect size of lumps), seriousness 2 (fear of long-term effects of breast cancer), health motivation 2 (preventive health practice), and confidence 3 (ability to perform BSE correctly). For CBE and mammography scales, seven factors each were identified. Factors for CBE scale include susceptibility, health motivation 1, benefits of CBE, seriousness 1, barriers of CBE, seriousness 2 and health motivation 2. For mammography the scale includes benefits of mammography, susceptibility, health motivation 1, seriousness 1, barriers to mammography seriousness 2 and health motivation 2. Cronbach's alpha reliability coefficients ranged from 0.774 to 0.939 for the subscales.
Conclusion The translated version of the CHBMS was found to be a valid and reliable tool for use with Malaysian women. It can be used easily to evaluate the health beliefs about breast cancer, BSE, CBE and mammography and for planning interventions. For greater applicability, it is recommended that this tool be tested among ethnically diverse populations.

Keywords: breast cancer, breast cancer screening, breast self-examination, Champion Health Belief Model, clinical breast examination, health belief model
Singapore Med J 2008; 49(11): 897-903

Azarisman SMS, Hadzri HM, Fauzi RA, Fauzi AM, Faizal MPA, Roslina MA, Roslan H
Correspondence: Dr Azarisman Shah Mohd Shah, risman1973@hotmail.com; drrisman@iiu.edu.my

ABSTRACT
Introduction Malaysia has a high rate of smoking prevalence and the figure is increasing. Although there has been many local and regional studies on the prevalence and symptomatology of chronic obstructive pulmonary disease patients, data is lacking on the degree of compliance to national management guidelines in the treatment of chronic obstructive pulmonary disease.
Methods 86 patients who attended the respiratory outpatient clinic of the Hospital Universiti Kebangsaan Malaysia were enrolled into a prospective, observational study.
Results 88 percent of the patients were male and the majority was ethnically Chinese (65 percent). The majority of patients were in the moderate to very severe categories, with a mean FEV1 of 0.97 +/- 0.56 L/sec and predicted mean FEV1 percentage of 43.1 +/- 21.3 percent. 58 percent of the patients were on long-acting beta-agonist, 65 percent were on inhaled steroids, and only 16 percent were on scheduled pulmonary rehabilitation.
Conclusion The low uptake rate for long-acting beta-agonist and pulmonary rehabilitation could be attributed to several factors. Financial cost, the need for strict compliance to a structured rehabilitation regime, lack of significant social support and clear up-to-date guidelines are possible reasons.

Keywords: chronic obstructive pulmonary disease, lung disease, management guidelines, patient compliance, pulmonary rehabilitation
Singapore Med J 2008; 49(11): 886-896