Original Article

Lee SY, Goh BK, Tan YM, Chung YF, Cheow PC, Chow PK, Wong WK, Ooi LL
Correspondence: Dr Tan Yu Meng, gsutym@sgh.com.sg

ABSTRACT
Introduction Splenectomy is routinely performed in conventional distal pancreatectomies. Spleen removal with its possible sequelae of infections and haematological complications has prompted the development of spleen-preserving techniques. This study aimed to evaluate the safety and clinical outcomes of distal pancreatectomy with preservation of the spleen.
Methods A retrospective review of 24 consecutive patients who underwent spleen-preserving distal pancreatectomy in a tertiary care hospital was conducted.
Results There were 17 female and seven male patients, and the mean age was 47 (range 14–77) years. Median American Society of Anesthesiologists score was II (range I–III). The indications were as follows: mucinous cystadenoma (n = 7), serous cystadenoma (n = 6), insulinoma (n = 3), intraductal papillary mucinous tumour (n = 2), pseudocyst (n = 3), papillary cystic adenoma (n = 1), neuroendocrine neoplasm (n = 1), and metastatic carcinoma of the thyroid (n = 1). Two patients developed postoperative pancreatic fistula and another two patients developed postoperative ileus with spontaneous resolution. Mean operative time was 172 (range 105–250) minutes. Mean length of postoperative hospital stay was 6.7 (range 5–11) days. There was no perioperative mortality in this series.
Conclusion Spleen-preserving distal pancreatectomy can be safely performed with low morbidity, and should be considered in the surgical management of distal pancreatic disease.

Keywords: distal pancreatectomy, pancreatec-tomy, spleen-preserving distal pancreatectomy
Singapore Med J 2008; 49(11): 883-885

Darwish FM, Haddad WH
Correspondence: Dr Fayeq M Darwish, fayeq_d@yahoo.com

ABSTRACT
Introduction The aim of this retrospective study was to study the clinical presentation, investigations, histopathological findings, and the best ways of treatment of the giant cell tumour of the tendon sheath (GCTTS).
Methods The medical records of all patients diagnosed to have GCTTS during the period 1994-2001 were reviewed, and follow-up was for three to ten years.
Results The total number of patients was 52, of whom 36 were females, and the mean age was 32.4 years. All the tumours except one were located in the hand and wrist area, with the thumb being the most affected finger. Painless swelling was the most common presentation. All of them were treated surgically and the recurrence rate was 24 percent.
Conclusion After reviewing the literature and comparing with our results, we conclude that GCTTS is a true benign tumour with local aggressive behaviour in some cases, and the best way of treatment is wide local excision.

Keywords: giant cell tumour of the tendon sheath, hand tumours, nodular synovitis, pigmented nodular synovitis, synovial tumours, wrist tumours
Singapore Med J 2008; 49(11): 879-882

Ince N, Issever H, Ince H, Özyildirim B, Isik E, Hapçoglu B, Özdilli K, Akçay ME, Çalak B, Agkoç N
Correspondence: Dr Nurhan ?nce, nince@istanbul.edu.tr

ABSTRACT
Introduction Leather tanning may result in various occupational diseases. The aim of this study was to compare the relation between blood pressure levels and vocations in leather tanning.
Methods Our study was conducted in Turkey's leading leather process plant located in Tuzla organised industry zone, between March 11 and May 30, 2005. All leather plants that consented to participate in our study were included. The blood pressure, height and weight of the workers were measured. Their ages, educational levels, smoking habits and hypertension history were obtained via interviewing the subjects. The relation between three main factors, i.e. age, body mass index (BMI), working period, and hypertension were analysed through multiple logistic regression analysis.
Results 40.4 percent (295) of 730 workers' blood pressure values were found to be within normal limits. 59.6 percent (435) were found to be hypertensive. The hypertension correlation remained significant, along with BMI and their working period (p-values were 0.0001 and 0.035, respectively).
Conclusion Our study demonstrated that BMI and working period have a key influence on the increased risk of hypertension, which leads us to consider the importance of occupational exposure. Different hypertension studies to be conducted in various occupational fields would likely be able to confirm our findings.

Keywords: hypertension, leather tanning, occupational exposure, tanning workers
Singapore Med J 2008; 49(11): 874-878

Porapakkham Y, Pattaraarchachai J, Aekplakorn W
Correspondence: Dr Wichai Aekplakorn, rawap@mahidol.ac.th

ABSTRACT
Introduction This study aims to determine the prevalence of hypertension, diabetes mellitus, and both conditions combined, and to examine factors related to awareness, treatment and control among the elderly in Thailand.
Methods Data from a multistaged National Health Examination Survey III of 19,374 individuals aged 60 years and older in Thailand was used. Information on the socioeconomic status was obtained by interview. Blood pressure was measured with a sphygmomanometer. Fasting plasma glucose was obtained. Logistic regression models were used to examine the determinants of awareness, treatment and control of blood pressure and plasma glucose.
Results Age-adjusted prevalence of hypertension was 51.1 percent, diabetes mellitus 14.0 percent, and diabetes mellitus with hypertension 8.0 percent. Overall, the proportion of unawareness for hypertension, diabetes mellitus and both conditions combined were 56.1, 41.2 and 21.9 percent, respectively. For those undergoing treatment for the control of blood pressure (less than 140/90 mmHg) was 12.4 percent, diabetes mellitus (fasting plasma glucose less than 140 mg/ dL) 26.4 percent, and control of both conditions combined was 7.4 percent. Factors associated with unawareness and inadequate controls of the illnesses were subjects from rural areas, with low income, low educational levels, currently working, and the oldest age group.
Conclusion There was a high prevalence of hypertension and diabetes mellitus among the older people in Thailand, with high percentages of unawareness and inadequate control for those treated. Screening programmes for early detection, treatment and control of hypertension and diabetes mellitus need to be improved.

Keywords: diabetes mellitus, disease prevalence, elderly patients, geriatrics, health awareness, health screening, hypertension
Singapore Med J 2008; 49(11): 868-873

Shankar A, Wang JJ, Rochtchina E, Mitchell P
Correspondence: Dr Anoop Shankar, ashankar@hsc.wvu.edu

ABSTRACT
Introduction Self-rated health (SRH) is a consistent predictor of cardiovascular disease and mortality. However, the intermediate biological mechanisms behind this association are not clear. We examined the longitudinal relationship between SRH and incident severe hypertension.
Methods We studied a population-based cohort of 1,298 participants (mean age 62.5 years, range 49-84 years), at the baseline examination (1992-1994) residing in the Blue Mountains region, west of Sydney, Australia, and re-examined after five years (1997-1999). Main outcome-of-interest was incident severe hypertension (systolic blood pressure [BP] 160 mmHg or above, diastolic BP 100 mmHg or above, or a combination of self-reported hypertension diagnosis and use of antihypertensive medications) among baseline individuals without severe hypertension.
Results Among men, those with fair/poor SRH had significantly higher odds of incident severe hypertension, compared to individuals with excellent SRH. Multivariable odds-ratio (OR) (95 percent confidence intervals [CI]) comparing fair/poor SRH to excellent SRH was 1.93 (1.04-3.56) (p-trend was 0.03). This association was not observed in women comparing fair/poor SRH to excellent SRH: OR 0.96, 95 percent CI 0.57-1.62 (p-trend was 0.70). Subgroup analyses stratified by age, smoking, body mass index, diabetes mellitus and BP categories, supported this male gender-specific pattern of association.
Conclusion This data suggests an association between poor SRH and incident hypertension among men, but not among women. These results suggest that at least part of the previously-reported association between poor SRH and mortality may be mediated by its relation to incident severe hypertension.

Keywords: blood pressure, Blue Mountains Eye Study, hypertension, self-rated health, severe hypertension
Singapore Med J 2008; 49(11): 860-867

Eid HO, Lunsjo K, Torab FC, Abu-Zidan FM
Correspondence: Dr Fikri Abu-Zidan, fabuzidan@uaeu.ac.ae

ABSTRACT
Introduction Trauma is a major health problem in the United Arab Emirates, and it is the second leading cause of death. Research can help us find solutions for this problem. We evaluated the published literature on trauma from United Arab Emirates to define research areas which need improvement.
Methods A MEDLINE search for articles on trauma and injury from the United Arab Emirates covering the period 1960-2005 was performed. The content of articles was studied, classified and summarised.
Results 32 articles were found, of which 18 were published in the last six years. 18 articles were on prevention and epidemiology, ten on clinical management and four on education. The first author was affiliated to the university in 19 articles. There were no articles on pre-hospital care, experimental work, trauma systems, trauma registry or post-hospital rehabilitation.
Conclusion There is a need for a strategic plan to support research in areas like pre-hospital care, implementation of trauma systems, trauma registries and post-hospital rehabilitations to reduce the socioeconomic impact of trauma in the United Arab Emirates.

Keywords: injury research, road traffic accidents, strategic planning, trauma research
Singapore Med J 2008; 49(10): 827-830

Singh SP, Gupta SC
Correspondence: Dr Suraya P Singh, suraya9@yahoo.co.uk

ABSTRACT
Introduction This study was performed with the objective of determining the efficacy of naked eye single tube red cell osmotic fragility test (NESTROFT) as a screening test for beta-thalassaemia trait, and to standardise a saline concentration which could give best results with minimum error and maximum sensitivity and specificity.
Methods Five concentrations (0.35 percent, 0.36 percent, 0.37 percent, 0.38 percent and 0.39 percent) of buffered saline solutions were used. NESTROFT was applied to three groups of subjects: 24 normal individuals, 87 subjects with genetically-proven beta-thalassaemia trait and 13 patients with proven iron-deficiency anaemia.
Results The results demonstrated that 0.36 percent was the best saline concentration for NESTROFT. It could detect 97.7 percent of heterozygous beta-thalassaemia patients, compared to 94.25 percent, 91.95 percent, 88.51 percent and 82.76 percent detection rates obtained with 0.35 percent, 0.37 percent, 0.38 percent and 0.39 percent saline concentrations, respectively. Specificity of NESTROFT with 0.36 percent saline was also higher at 83.3 percent, whereas that of 0.35 percent, 0.37 percent, 0.38 percent and 0.39 percent was 79.17 percent, 79.17 percent, 70.83 percent and 62.5 percent, respectively. This test with 0.36 percent saline concentration was also positive for three (23.08 percent) patients with iron-deficiency anaemia.
Conclusion NESTROFT done with 0.36 percent buffered saline solution provides more accurate results compared to the other concentrations tested. Since the test is sensitive, cost-effective, rapid and reliable, it may be considered as the single screening test to be used in areas with limited laboratory facilities and economic resources.

Keywords: anaemia, beta-thalassaemia trait, naked eye single tube red cell osmotic fragility test (NESTROFT), red blood cell osmotic fragility, thalassaemia
Singapore Med J 2008; 49(10): 823-826

Manikandan P, Vidjaya Letchoumy P, Prathiba D, Nagini S
Correspondence: Prof Siddavaram Nagini, s_nagini@yahoo.com; snlabau@gmail.com

ABSTRACT
Introduction We investigated the combinatorial chemopreventive efficacy of Azadirachta indica (AI) and Ocimum sanctum (OS) against N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-induced gastric carcinogenesis, based on changes in oxidant-antioxidant status, cell proliferation, apoptosis and angiogenesis.
Methods Male Wistar rats were assigned to four groups. Rats in groups 1 and 2 received MNNG (150 mg/kg body weight i.g.) three times with a gap of two weeks in between the treatment. Group 2 rats additionally received ethanolic AI (100 mg/kg body weight i.g.) and OS (150 mg/kg body weight i.g.) leaf extract three times per week for 26 weeks. Group 3 animals were given AI and OS leaf extract alone, whereas group 4 served as the control.
Results Lipid and protein oxidation and status of the antioxidants, superoxide dismutases, catalase, reduced glutathione (GSH) and GSH-dependent enzymes together with markers of proliferation (proliferating cell nuclear antigen [PCNA], glutathione S-transferase-Pi [GST-P]), invasion (cytokeratin [CK]), angiogenesis (vascular endothelial growth factor [VEGF]) and apoptosis (Bcl-2, Bax, cytochrome C and caspase-3) were used to biomonitor chemoprevention. Rats administered MNNG developed forestomach carcinomas that displayed low lipid and protein oxidation coupled to enhanced antioxidant activities, and overexpression of PCNA, GST-P, CK, VEGF and Bcl-2 with downregulation of Bax, cytochrome C and caspase-3. Coadministration of AI and OS extract suppressed MNNG-induced gastric carcinomas accompanied by modulation of the oxidant-antioxidant status, inhibition of cell proliferation and angiogenesis, and induction of apoptosis.
Conclusion The results of the present study suggest that chemoprevention by AI and OS combination may be mediated by their antioxidant, antiangiogenic, antiproliferative and apoptosis inducing properties.

Keywords: antioxidants, apoptosis, Azadirachta indica, cell proliferation, chemoprevention, gastric cancer, Ocimum sanctum, oxidant-antioxidant status, rat forestomach carcinogenesis model
Singapore Med J 2008; 49(10): 814-822

Chong FY, Thirumoorthy T
Correspondence: Dr Chong Fei Yoong, feiyon@yahoo.com

ABSTRACT
Introduction Soft tissue infections are common, but erysipelas, especially its blistering feature, is an under-recognised entity. There have been few reports of blistering erysipelas. We aim to describe the clinical characteristics, management and the risk factors for erysipelas in 20 patients admitted in a tertiary hospital in Singapore.
Methods A chart review of all cases of erysipelas, diagnosed by experienced dermatologists and admitted to the Singapore General Hospital during the period January 2006 to August 2006, was conducted.
Results There were 20 patients (11 male, nine female) with an average age of 62.2 (range 31-86) years. The most commonly-involved site was the leg (75 percent), followed by the arm (15 percent) and face (ten percent). The clinical characteristics were well dermarcated (50 percent), erythema (100 percent) and oedema (85 percent), and bullae and vesicles formation (80 percent). Most presented with no pain (40 percent) and minimal signs of systemic toxicity. There was no positive blood culture, but the swab on the blistering erysipelas yielded positive cultures in 67 percent. The most common predisposing factor was disruption in the skin barrier (65 percent), followed by venous insufficiency (20 percent) and lymphoedema (25 percent). All patients received empirical antibiotics, most commonly penicillin and cloxacillin (65 percent), for an average duration of 20.65 (10-41) days, and with local care, there was complete resolution.
Conclusion In our experience, erysipelas is a clinically distinct entity and commonly presents with bullae or vesicles. It has favourable prognosis, and rarely develops any complication with timely and appropriate therapy.

Keywords: bullae, blistering erysipelas, cellulitis, erysipelas, skin infection
Singapore Med J 2008; 49(10): 809-813

Goyal NK, Kumar A, Das SK, Pandey AK, Sharma GK, Trivedi S, Dwivedi US, Singh PB
Correspondence: Prof Pratap Bahadur Singh, pburology@gmail.com

ABSTRACT
Introduction Peyronie's disease is a common cause of sexual dysfunction. We assess the technique of plaque excision and dermal grafting for the treatment of Peyronie's disease.
Methods A total of 11 patients, aged 38-55 years, were operated for Peyronie's disease. All patients had stable plaque on the dorsum or dorsolateral aspect of the penile shaft. All patients had penile curvature, nine (81.8 percent) had painful erections, six (54.5 percent) had penile pain and three (27.3 percent) had erectile dysfunction. All suffered difficulty in intercourse. We performed plaque excision and dermal grafting. Main outcome measures were relief of penile pain, relief of painful erection, performance of satisfactory coitus and straight penis while erection.
Results All patients had relief of penile pain and painful erection. Nine (81.8 percent) patients had straight penis and had satisfactory coitus. Two (18.2 percent) patients suffered postoperative erectile dysfunction which was mild and responded to Sildenafil tabs.
Conclusion Although experience with this technique is limited, the initial results are encouraging. We found this technique feasible with satisfactory results.

Keywords: dermal graft, penile disease, penis, Peyronie’s disease, plaque excision
Singapore Med J 2008; 49(10): 805-808