Original Article

Bhat YR, Kumar V, Rao A
Correspondence: Dr Ramesh Bhat Y, docrameshbhat@yahoo.co.in

ABSTRACT
Introduction Outcome of neonates with congenital diaphragmatic hernia (CDH) varies widely and the data from developing countries is scanty. We aimed to study the management and outcome of CDH. We also aimed to ascertain prenatal and postnatal factors affecting the outcome.
Methods A retrospective review of neonates with CDH admitted to a teaching hospital was conducted. Demographical data, prenatal and postnatal factors, birth details, management and outcomes were studied. Survival was the primary outcome.
Results 16 live-born neonates with diaphragmatic hernia were admitted during the study period. All neonates had hernia on the left side. Mean (standard deviation) gestational age and birth weight were 38.6 (1.5) weeks and 2,616.6 (457) g, respectively. Polyhydramnios was associated in one patient, and additional anomalies in five patients (31.3 percent). Overall survival was 56.3 percent. The CDH was detected prenatally in four and postnatally in 12 patients. 12 neonates underwent surgery and nine survived. Prenatally-detected cases had significantly reduced survival to surgery, overall survival and lower Apgar scores at one minute (p-value is less than 0.04). Median age at surgery was 48 hours. Average duration of mechanical ventilation among survivors was 91.5 hours. Neonatal intensive care unit stay ranged from five to 27 (median nine) days. Six of seven deaths occurred within 72 hours of life. Non-survivors had significantly low Apgar scores and were symptomatic within 12 hours of life (p-value is less than 0.03).
Conclusion Greater than 50 percent survival of neonates with CDH was observed in a centre with conventional ventilation. Poor outcome is likely in neonates who present within 12 hours of life.

Keywords: congenital diaphragmatic hernia, neonatal hernia, neonatal survival
Singapore Med J. 2008; 49(9): 715-8

Tan KBL, Tan KH, Yeo GSH
Correspondence: Dr George Yeo Seow Heong, mfm93b@pacific.net.sg

ABSTRACT
Introduction Cleft deformities, though non-lethal, receive much attention from parents and doctors alike because of their obvious physical disfigurement, social stigma and associated feeding and vocal articulation problems. There is also an association with chromosomal defects for certain cleft deformities. The aim of this study is to examine the incidence, demographic data and epidemiological trend of this condition over a ten-year period, and to compare our data with other local studies, as well as to examine the chromosomal defects associated with this condition.
Methods Data of cleft deformity cases born during the period 1993-2002 was retrieved from the National Birth Defects Registry and analysed.
Results There were a total of 859 cases of cleft deformities in the ten-year period 1993-2002, giving an overall incidence of 1.87 per 1,000 live births, with an increasing trend noted. Incidence was highest among the Chinese and lowest among the Indians. There were more males with cleft deformities compared with females. The risk of aneuploidy rose by about ten-fold in syndromic cleft cases, compared to non-syndromic cleft cases. There were two cases of Trisomy 21 in the non-syndromic cleft lip and palate group, giving an incidence of 1:133.
Conclusion The race-specific and gender-specific differences in cleft incidence suggest genetic and environmental factors which warrant further studies. The increased risk of aneuploidy among syndromic clefts, as well as the finding of Trisomy 21 in non-syndromic cleft lip and palate cases suggest a need for karyotyping in these two groups of antenatally-diagnosed cleft deformities.

Keywords: aneuploidy risk, cleft deformity, cleft lip, cleft palate, non-syndromic cleft, Trisomy 21
Singapore Med J. 2008; 49(9): 710-4

Agarwal A, Fong YF
Correspondence: Dr Anupriya Agarwal, dr_anupriya@yahoo.com

ABSTRACT
Introduction Cutaneous or subcutaneous endometriosis is a rare entity that is an often overlooked because of chronic abdominal pain.
Methods We reviewed the ten cases of cutaneous endometriosis that presented to this hospital over a seven-year period.
Results The mean age of patients at presentation was 36.3 years. All our patients presented with cyclical abdominal pain. There was a considerable delay in the diagnosis and offer of treatment, the mean length of time between onset of symptoms to surgery being 31.7 months (range 1-62 months). The onset was spontaneous in 40 percent of our patients and the rest had scar endometriosis. The patients with spontaneous onset of disease had a more severe pelvic disease compared to those with scar endometriosis. Complete surgical excision was curative but left a large defect requiring polypropylene mesh repair in two patients.
Conclusion Cutaneous endometriosis should be suspected in any female presenting with cyclic or non-cyclic pain emanating from a mass in the vicinity of a previous surgical scar, the umbilicus or in the inguinal region. Surgical excision of the cutaneous endometriotic implants can be easily performed and is curative.

Keywords: cutaneous endometriosis, endometriosis, inguinal scar, scar endometriosis, umbilical scar
Singapore Med J. 2008; 49(9): 704-9

Sarsam DS, Shamden M, Al Wazan R
Correspondence: Dr Samar Daoud Sarsam, samarsarsam4@yahoo.com

ABSTRACT
Introduction Our study aims to compare neonatal and maternal outcomes between expectant (or conservative) and aggressive (or immediate) management in cases with severe preclampsia remote from term.
Methods This is a comparative study conducted at Al-Batool Teaching Hospital in Mosul City, Iraq, from April 2003 to August 2004. A total of 74 singleton pregnancies complicated by severe preeclampsia with gestational age of 24-34 weeks were studied during this period. The criteria used for the diagnosis of severe preeclampsia were in accordance with the guidelines of the American College of Obstetricians and Gynaecologists. All the patients were counselled for expectant management. 39 patients were delivered immediately due to refusal of expectant management either by the patient or the attending physician. The other 35 patients were managed expectantly; this group was followed-up and carefully monitored for a period ranging from 72 hours to 18 days. Neonatal parameters, neonatal outcome and maternal outcome were compared between the two groups.
Results The mean value of pregnancy prolongation was 9.2 days. Median gestational age for the first group was 29 weeks, and for the second group, it was 30 weeks. Regarding neonatal parameters, the expectantly-managed group had a higher Apgar score at one minute (3.56 +/- 1.72 vs. 5.05 +/- 1.77, p-value equals 0.001), lower mean days of hospitalisation in the neonatal intensive care unit (6.83 +/- 5.38 vs. 4.50 +/- 3.46, p-value equals 0.03), with a lower incidence of neonatal and maternal complications.
Conclusion Expectant management is recommended in patients with severe preeclampsia remote from term, after proper selection of patients and careful monitoring.

Keywords: expectant management of pregnancy, maternal complications, neonatal complications, pregnancy complications, severe preeclampsia
Singapore Med J. 2008; 49(9): 698-703

Chen YH, Lau G
Correspondence: Dr Helen Chen, helen.chen.y@kkh.com.sg

ABSTRACT
Introduction Maternal mortality in Singapore, as in other developed countries, has remained low in the past decade. In the United Kingdom and Australia, maternal deaths from suicide and psychiatric causes have been the leading cause of maternal mortality, and there have therefore been comprehensive healthcare programmes to address the mental health needs of mothers.
Methods In this study, we looked at maternal deaths from 2000 to 2004, by linking coronial cases of female suicide in the reproductive age group 15-45 years, with the birth registration database, to identify both early and late maternal deaths.
Results There was only one identified maternal death among 589 female suicides aged 15-45 years, occurring in a teenager within the first month postpartum. There was likely also another case that was unconfirmed and unreported.
Conclusion From this preliminary study, suicide and psychiatric causes are not significant causes of maternal mortality in Singapore. However, given that the epidemiology of postnatal depression statistics mirror that of the other countries, it is possible that maternal suicides have been underreported, and the load may well be higher. There is a need for a similar confidential enquiry into maternal deaths to be set up here, as is already in place in various countries, notably the United Kingdom and Australia, for the past decade.

Keywords: female suicide, maternal deaths, maternal mortality, severe maternal mental illness, suicide
Singapore Med J. 2008; 49(9): 694-7

Marzuki OA, Fauzi ARM, Ayoub S, Kamarul Imran M
Correspondence: Dr Marzuki OA, marz72@gmail.com

ABSTRACT
Introduction Tuberculosis (TB) affects one-third of the world's population. Anti-TB drugs with isoniazid, rifampicin and pyrazinamide are very effective but they can cause hepatotoxicity. Many risk factors have been recognised. Data on prevalence of anti-TB drug-induced hepatitis as well as the contributing risk factors are scarce in Malaysia. This observational case control study was designed to look at the prevalence and the risk factors of drug-induced hepatitis in our population.
Methods We retrospectively examined all the case notes of anti-TB drug-induced hepatitis over a 30-month period from January 2003 to June 2005. They were compared with controls selected by simple random sampling. Both groups were compared in terms of demographical data and risk factors, such as age, gender, body mass index, hepatitis B carrier, human immunodeficiency virus (HIV) infection, sites of TB, and pretreatment liver biochemistries (serum albumin, globulin, aspartate aminotransferase, alanine aminotransferase and bilirubin). Data was evaluated by chi square, independent t-test (univariate) and binary logistic regression analysis (multivariate).
Results Out of 473 TB patients, 46 developed hepatitis and 138 were selected as controls. The prevalence of drug-induced hepatitis was 9.7 percent. On univariate analysis, HIV infection (p-value is 0.005), extrapulmonary tuberculosis (p-value is 0.008), lower serum albumin (p-value is 0.023) and higher serum globulin (p-value is 0.025) were significant risk factors. On binary logistic regression, only HIV infection (p-value is 0.018) and extrapulmonary TB (p-value is 0.017) were significant.
Conclusion The prevalence of hepatitis was 9.7 percent. The presence of HIV infection and extrapulmonary TB were significant risk factors for the development of hepatitis.

Keywords: anti-tuberculosis drugs, drug-induced hepatitis, extrapulmonary tuberculosis, hepatoxicity, isoniazid, pyrazinamide, rifampin, toxic hepatitis
Singapore Med J. 2008; 49(9): 688-93

Tan NC, Cheah SL, Teo EK, Yang LH
Correspondence: Dr Ngiap-Chuan Tan, tan.ngiap.chuan@singhealth.com.sg

ABSTRACT
Introduction Hepatitis B (HBV) is endemic in Singapore. This study aimed to determine the quality of life of patients with chronic HBV infection (HBV carriers) on conservative management. They were reviewed in primary care facilities and in a district hospital in Singapore.
Methods This cross-sectional survey utilised a validated Hepatitis Quality of Life questionnaire, which incorporated the SF-36 health survey, to assess a convenience sample of HBV carriers' quality of life in 14 domains. The mean scores in each domain were determined, with higher scores indicating better health. Wilcoxon-Mann-Whitney test was used in the data analysis to determine statistical significance (p-value is less than 0.05).
Results The mean age of 108 participants was 44.1 (standard deviation 12.5) years. They were predominantly Chinese (90.7 percent), male (58.3 percent) and 50.7 percent of them had family members who were HBV-infected. The latter had higher scores in the hepatitis specific limitation (HLIM) domain. The majority did not have any impaired physical nor mental health. In comparison with the healthy peers in the local population, the Chinese HBV carriers scored significantly lower in the "social functioning" domain (p-value is less than 0.001), regardless of gender.
Conclusion The majority of HBV carriers had good physical and mental health. Physicians should recognise the impact of the chronic infection on the social aspects of daily living of the HBV carriers, and such issues should be addressed appropriately to provide better quality care.

Keywords: chronic hepatitis B infection, hepatitis B carrier, quality of life
Singapore Med J. 2008; 49(9): 682-7

Sedeek SM, Tey IK, Tan AHC
Correspondence: Dr Sedeek Mohamed Sedeek, sedeeko2000@hotmail.com

ABSTRACT
Introduction The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The results continue to improve with the advancements made in instrumentation and technique. This study aims to evaluate the outcome of arthroscopic Bankart repair with the use of suture anchors for cases that were followed-up for at least two years from the date of surgery.
Methods This was a consecutive series of 40 shoulders in 37 patients who underwent arthroscopic Bankart repair with suture anchor. The mean age at the time of operation was 26.3 years. The patients were assessed with two different outcome measurement tools (the University of California at Los Angeles [UCLA] shoulder rating scale and simple shoulder test [SST] score). The mean duration of follow-up was 30.2 months. The recurrence rate, range of motion, and postoperative function were evaluated.
Results The two shoulder scores significantly improved after surgery (p-value is less than 0.05). According to the UCLA scale, 37 shoulders (92.5 percent) had excellent or good scores, one shoulder (2.5 percent) had a fair score, and two (five percent) had poor scores. All 12 components of SST showed improvement, which was statistically significant. Overall, the rate of postoperative recurrence was 7.5 percent (three shoulders). All patients either maintained or demonstrated improvement of range of motion. There was no loss of external rotation range of motion postoperatively.
Conclusion Arthroscopic Bankart repair with the use of suture anchors is a reliable treatment method that can provide a good clinical outcome with excellent postoperative shoulder motion and low recurrence rate.

Keywords: anterior shoulder instability, arthroscopic surgery, Bankart repair, shoulder dislocation, suture anchors
Singapore Med J. 2008; 49(9): 676-81

Hussain A, Mahmood H, Nicholls J, El-Hasani S
Correspondence: Dr Abdulzahra Hussain, azahrahussain@yahoo.com

ABSTRACT
Introduction The optimal technique for gastrointestinal anastomosis is controversial. The three most popular techniques are two layers, one layer and the stapling method. However, there is no universal agreement on the best technique. The aim of this study was to evaluate the safety, feasibility, and efficacy of continuous figure-of-eight suturing in gastrointestinal anastomosis.
Methods This was a retrospective study of 170 patients who underwent gastrointestinal anastomosis using continuous figure-of-eight suturing for the first layer and continuous seromuscular suturing for the second layer from August 1993 to January 2006. All operations were performed by a single consultant surgeon. We assessed each anastomosis by checking the integrity, vascularity and patency, and also ensuring tension-free status. Postoperatively, patients were managed by routine care of intravenous fluids and nasogastric tube until they had active bowel sounds and started absorbing. Imaging was arranged for patients who developed clinical signs and symptoms of leak.
Results 170 patients underwent gastrointestinal anastomosis by continuous figure-of-eight suturing for different pathologies over a two-and-a-half-year period. There were 92 (54.1 percent) men and 78 (45.9 percent) women. The mean age of the patients was 56 (range 20-88) years. The median follow-up was 74 months. There were 124 (72.9 percent) small bowel anastomosis and 46 (27.1 percent) large bowel anastomosis. An important complication after gastrointestinal anastomosis was leakage, which was reported in three (1.8 percent) patients. One of them had gastric cancer, one had Crohn's disease and one had intestinal ischaemia. No mortality was reported in relation to anastomotic failure. Two (1.2 percent) patients developed stenosis and 15 (8.8 percent) patients died because of progression of their disease or other pathologies during the follow-up.
Conclusion Continuous figure-of-eight suturing is a simple, easy to learn, safe and satisfactory upper and lower gastrointestinal anastomosis technique.

Keywords: continuous figure-of-eight suturing, gastrointestinal anastomosis, gastrointestinal tract, suturing techniques
Singapore Med J. 2008; 49(9): 672-5

Lim SA, Goh KY, Tow S, Fu E, Wong TY, Seah A, Tan C, Cullen JF
Correspondence: Dr James F Cullen, jbarrycullen@yahoo.com

ABSTRACT
Introduction Optic neuritis (ON) is the commonest optic neuropathy encountered in the younger group of patients from the Singapore Neuro-Ophthalmology Study Group. Previous surveys in Asia and our study suggest that ON in Singapore differs from that in Western populations where the majority of cases are associated with multiple sclerosis (MS).
Methods Patients satisfying our entry criteria for ON seen between September 2002 and June 2004 were enrolled in the study. The data collected was recorded in a central database and analysed two years later.
Results The majority (60 percent) of our patients had anterior ON with optic disc swelling (papillitis), were idiopathic in 49.1 percent, and associated with MS in only 25.5 percent. Bilateral cases comprised 16.4 percent of our series and were usually of the anterior variety and mostly idiopathic, although it is still essential to rule out secondary causes. Recurrent ON is indicative of an underlying disease process.
Conclusion The pattern of ON as seen in Singapore differs from that reported in Caucasian studies and from the seminal Optic Neuritis Treatment Trial. We found a higher incidence of optic disc swelling, i.e. anterior ON (papillitis), and a lesser association with MS; visual recovery is similarly good but our recurrence rate is lower.

Keywords: optic disc swelling, idiopathic optic neuritis, multiple sclerosis, optic neuritis, papillitis, retrobulbar optic neuritis
Singapore Med J. 2008; 49(9): 667-71