Original Article

Subash S, Subramanian P
Correspondence: Dr P Subramanian, annamalai_rhythm@yahoo.co.in

ABSTRACT
Introduction Hyperammonaemia is a major contributing factor to neurological abnormalities observed in hepatic encephalopathy and in congenital defects of ammonia detoxication. Ammonia toxicity results in free radical generation that leads to oxidative stress and tissue damage. Morin is a bioflavonoid, a constituent of many herbs and fruits that are used as herbal medicines and also several biological activities. Our aim was to investigate the effect of morin on circulatory liver markers, lipid peroxidation and antioxidant status in ammonium chloride (AC)-induced hyperammonaemic rats.
Methods Male albino Wistar rats weighing 180-200 g were used for the study. The hyperammonaemia was induced by interaperitonial injection of AC (100 mg/kg body weight). Rats were treated with morin (30 mg/kg body weight) via oral administration. Administration of morin in hyperammonaemic rats reduced the levels of ammonia and urea. The antioxidant property of morin was studied by assessing the activities of thiobarbituric acid reactive substances (TBARS), hydroperoxides (HP) and liver markers (alanine transaminase, aspartate transaminase and alkaline phosphatase) and the levels of glutathione peroxidase, superoxide dismutase, catalase, reduced glutathione, vitamins A, C and E in AC-treated rats.
Results Oxidative stress was effectively modulated by morin administration. Morin significantly improved the status of antioxidants and decreased the levels of ammonia, urea, TBARS, HP and liver markers enzymes, as compared to the AC-treated group.
Conclusion The study offers evidence for the antihyperammonaemic, hepatoprotective and antioxidant effects of morin against oxidative stress induced by AC.

Keywords: antioxidants, hyperammonaemia, lipid peroxidation, liver markers, morin
Singapore Med J 2008; 49(8): 650-5

Balasubramanian T
Correspondence: Prof Thiagarajan Balasubramanian, baradear@gmail.com

ABSTRACT
Introduction Perfusion of rat urinary bladder with uric acid (UA) or 1-methyl uric acid (1-MUA) solution was reported to produce features of metabolic syndrome, viz. hyperglycaemia, hyperinsulinaemia, hypertriglyceridaemia and hypercholesterolaemia. The present study was carried out to confirm that UA or 1-MUA in the bladder can produce insulin resistance, and to demonstrate that an unknown humoral factor from the bladder is possibly involved in producing features of metabolic syndrome.
Methods Wistar rats weighing 200-300 g were used. Two sets of protocols, perfusion study and cross-over study, were followed. For the perfusion study, urinary bladders were perfused with distilled water or solution of UA or 1-MUA, and serum levels of glucose and insulin and insulin resistance during perfusion were compared between groups. For the cross-over study, serum from distilled water or UA perfused rats (donors) was infused intravenously into rats (recipients), and serum levels of glucose, insulin, true triglyceride and total cholesterol and insulin resistance were compared.
Results Perfusion of bladder with UA or 1-MUA solution resulted in an increase in serum levels of glucose and insulin, and insulin resistance, on comparison with distilled water perfused. Infusion of serum from donors perfused with UA resulted in hyperglycaemia, hyperinsulinaemia, hypertriglyceridaemia and hypercholesterolaemia and increase in insulin resistance in recipients when compared with recipients infused with serum from donors perfused with distilled water.
Conclusion The present study confirms that UA and 1-MUA in the bladder produce features of metabolic syndrome and could be the result of an unknown humoral factor released from the bladder mucosa.

Keywords: insulin resistance, metabolic syndrome, methylxanthines, uric acid, urinary bladder
Singapore Med J 2008; 49(8) :644-9

Rajneesh CP, Manimaran A, Sasikala KR, Adaikappan P
Correspondence: Dr Anbazhagan Manimaran, mani267@gmail.com

ABSTRACT
Introduction The present study was undertaken to evaluate the status of lipid peroxidation and antioxidants as biomarkers in human plasma.
Methods The extent of lipid peroxidation as evidenced by the formation of thiobarbituric acid reactive substances (TBARS) and conjugated dienes (CD) as well as the status of the antioxidants superoxide dismutase (SOD), catalase (CAT), reduced glutathione (GSH), glutathione peroxidase (GPx) and glutathione S-transferase (GST) in serum samples of 40 breast cancer patients in and around Coimbatore, India, were studied. Controls consisted of members of the public with no previous history of breast cancer or other cancer-related diseases.
Results The plasma samples of the breast cancer patients showed enhanced level of lipid peroxidation when compared to the corresponding controls. This was accompanied by a significant elevation in both enzymic and non-enzymic antioxidants.
Conclusion These findings indicate the significant increase in lipid peroxidation as evidenced by the level of TBARS and antioxidant status such as elevated SOD, CAT, GPx, GSH and GST in samples from breast cancer patients compared to controls.

Keywords: antioxidants, breast cancer, glutathione peroxidase, lipid peroxidation
Singapore Med J 2008; 49(8): 640-3

Chew KS, Mohd Idzwan Z, Nik Hishamuddin NAR, Wan Aasim WA, Kamaruddin J
Correspondence: Dr Chew Keng Sheng, cksheng74@yahoo.com

ABSTRACT
Introduction Bystander cardiopulmonary resuscitation (CPR) serves as a vital link to improve the chance of survival among the out-of-hospital cardiac arrest (OHA) patients. The frequency of bystander CPR in Malaysia is largely unknown. The aim of this study was to find out how frequently bystander CPR was performed among OHA patients with CPR performed at the Emergency Department (ED), Hospital Universiti Sains Malaysia (HUSM), prior to their arrival to the department.
Methods In this one-year observational study, data was collected from cases of CPR performed in ED, HUSM. In the OHA category, a subanalysis was further performed to look into the frequency and effects of bystander CPR on achieving return of spontaneous circulation and survival to hospital admission. The categorical data collected was analysed using chi-square test or Fisher-exact test.
Results Out of a total of 23 OHA patients that had CPR performed on arrival at the ED, HUSM, from March 2005 to March 2006, only two cases (8.7 percent) had bystander CPR performed. None of these two cases achieved return of spontaneous circulation.
Conclusion Although this study has many limitations, it does indicate that the frequency of bystander CPR is dismally low in our community and the mere fact that bystander CPR was reported to be done does not seem to translate into a higher chance of survival to admission. The quality and effectiveness of the technique is equally important.

Keywords: bystander cardiopulmonary resuscitation, cardiopulmonary resuscitation, out-of-hospital cardiac arrest , return of spontaneous circulation
Singapore Med J 2008; 49(8): 636-9

Anisah A, Chew KS, Mohd Shaharuddin Shah CH, Nik Hisamuddin NAR
Correspondence: Dr Chew Keng Sheng, cksheng74@yahoo.com

ABSTRACT
Introduction Little is known regarding public opinion of prehospital care in Malaysia. This study was conducted to find out the public's perception and expectations of the ambulance services in one of the university hospitals in Malaysia.
Methods A six-month prospective cross-sectional study to look at patients' perception of Hospital Universiti Sains Malaysia's (HUSM) ambulance service was conducted from February 2006 to July 2006. Upon arrival at the hospital, patients or their relatives (who used our hospital's ambulances) were interviewed with a set of questions regarding their perception of the ambulance services and were asked to rate the perception on a Likert Scale from 1 to 10. A convenient sampling method was applied.
Results A total of 87 samples were obtained. Despite the many problems faced by the ambulance service in HUSM, the mean score for each of the questions on patient's perception ranged from 9.33 to 9.70 out of 10. The questions with the highest mean score, which were both 9.70 each, were related to staff attentiveness and staff gentleness.
Conclusion Patients' perceptions can be very subjective, but until further similar studies could be carried out in other parts of Malaysia, this set of data merely represents a numerical measure of public perception of the ambulance services from HUSM.

Keywords: ambulance services, emergency medicine, prehospital care, public perception
Singapore Med J 2008; 49(8): 631-5

Khorasani G, Hosseinimehr SJ, Kaghazi Z
Correspondence: Dr Ghasemali Khorasani, ghkhorasani@mazums.ac.ir

ABSTRACT
Introduction Burn injury is a medical problem as well as a social burden on the national health services in developing countries. Trace elements have important roles in wound healing and act as antioxidants. In this study, zinc (Zn) and copper (Cu) levels in plasma of burned patients and their relationship with the burn surface area and time-related pattern are determined in the admitted patients after burn injury.
Methods 37 patients were divided into two groups: Group 1 consisted of 16 patients with burn injuries less than 20 percent of the total burn surface area, and Group 2 consisted of 21 patients with burn injuries between 20 and 40 percent of the total burn surface area. The control group consisted of 20 subjects. The Zn and Cu levels were determined one, three, seven and 14 days after the occurrence of burn injury. These trace elements were determined using atomic absorption spectrophotometer.
Results These trace elements in plasma significantly decreased on all days after admission and the levels were lower than those of the control group. There was no significant relationship between Groups 1 and 2 in Cu and Zn concentrations on different days. We did not find any difference between burn surface area and Zn and Cu concentrations in these groups.
Conclusion Based on the critical role of plasma's Zn and Cu rate in wound healing and their relationship in decreasing the burn injury, it is important that patients having burn types II and III take Zn and Cu supplements continuously as micronutrients after burn injury.

Keywords: burn injury, copper supplement, trace elements supplementation, wound healing, zinc supplement
Singapore Med J 2008; 49(8): 627-30

Riaz N, Khan MR, Tayeb M
Correspondence: Dr Muhammad Rizwan Khan, doctormrkhan@yahoo.com

ABSTRACT
Introduction Gallstone ileus is responsible for 1-3 percent of cases of mechanical small bowel obstruction. Debate continues regarding choice of optimal surgical procedure. One-stage procedure includes enterolithotomy, cholecystectomy and repair of fistula at the same setting, whereas staged procedure includes enterolithotomy alone, with fistula repair at a later stage. This study aims to determine factors influencing choice of surgical procedure in patients with gallstone ileus.
Methods Data was collected for patients diagnosed with gallstone ileus between 1990 and 2005. Five patients underwent enterolithotomy alone (Group 1), while the remaining five patients underwent enterolithotomy with cholecystectomy and repair of fistula as a single stage procedure (Group 2).
Results In Group 1, patients presented late with deranged physiological parameters and pre-existing comorbidities accounting for an American Society of Anesthesiologists (ASA) score of 3 or above. In Group 2, patients presented early with preserved physiological status accounting for an ASA score of 2. The mean operative time was 126 +/- 23 minutes in Group 1 and 245 +/- 54.4 minutes in Group 2. There was no mortality, three patients in Group 1 had superficial wound infection, and one patient in Group 2 had injury to the common bile duct necessitating hepaticojejunostomy. The mean follow-up period was 3.5 +/- 1.5 years. None of the patients in both groups had recurrent symptoms requiring further intervention.
Conclusion Choice of surgical procedure was largely determined by the clinical status of the patient. Single-stage procedure was performed in haemodynamically-stable patients, while enterolithotomy alone was considered sufficient for unstable patients.

Keywords: biliary-enteric fistula, cholecystoduo-denal fistula, enterolethotomy, gallstone ileus, small bowel obstruction
Singapore Med J 2008; 49(8): 624-6

Sireesh I, Kaman L, Singh R
Correspondence: Dr Lileswar Kaman, kamanlil@yahoo.com

ABSTRACT
Introduction In animal models and human trials, pentoxifylline has shown beneficial pharmacological effects in the treatment of septic shock. We evaluated the role of pentoxifylline in the treatment of perforation peritonitis, as an adjuvant to surgery and standard antibiotic treatment.
Methods A prospective, randomised placebo-controlled trial was conducted on 50 patients with perforation peritonitis. 25 patients were randomised to the test group and 25 patients to the control group. In addition to standard treatment, the test group of patients received pentoxifylline 200 mg per day as an adjuvant for three days. The endpoints of the study were to evaluate the condition of the wound in the postoperative period, APACHE II score and total duration of hospital stay.
Results Both groups were comparable in all aspects. There were 23 male and two female patients in the test group, and 20 male and five female patients in the control group (p-value is 0.021). Mean age was 37.9 +/- 10.5 years in the test group and 33.8 +/- 11.0 years in the control group (p-value is 0.186). The APACHE II score in the test group and in the control group was statistically not significant (p-value is 0.661). In the test group, seven (28 percent) patients had wound infection and in the control group, 13 (52 percent) patients had wound infection (p-value is 0.083). The mean postoperative hospital stay in the test group was 6.8 +/- 2.1 days and in the control group, it was 11.2 +/- 5.2 days (p-value is 0.001).
Conclusion Pentoxifylline improved the outcome by significantly decreasing the length of the hospital stay and the rate of wound infection.

Keywords: pentoxifylline, perforation peritonitis, septic shock, surgical complications, wound infection
Singapore Med J 2008; 49(8): 619-23

Ong CPC, Chan TKN, Chui CH, Jacobsen AS
Correspondence: Dr Caroline CP Ong, caroline.ong.cp@kkh.com.sg

ABSTRACT
Introduction Complicated appendicitis has significant infective postoperative morbidity. There is no universally-accepted antibiotic regime, although traditionally, triple antibiotics are recommended. Our complicated appendicitis clinical pathway recommends ceftriaxone and metronidazole. The study aimed to determine if choice of antibiotics influenced the risk of infective complications.
Methods We reviewed all paediatric appendicectomy patients between January 1, 2005 and December 31, 2005. All patients with intraoperative diagnosis of perforated appendicitis were recruited, excluding infants, immunocompromised patients, and patients allergic to the guideline antibiotics. All operations were performed by registrar/consultant surgeons and were laparoscopic, unless technically not feasible.
Results There were 82 patients with perforated appendicitis. 62 patients (76 percent) followed pathway antibiotics, and 20 patients (24 percent) deviated from the pathway by receiving additional empiric gentamycin. We compared the pathway compliant and deviation groups, and found no significant differences in patient characteristics, clinical presentation, operation, length of stay and infective complications. Overall there was one wound infection and five (six percent) postoperative abscesses. Initial peritoneal cultures and subsequent drainage cultures of patients who developed abscesses were sensitive to treatment antibiotics.
Conclusion In complicated appendicitis, empirical perioperative addition of gentamycin to ceftriaxone and metronidazole did not reduce the risk of developing intra-abdominal abscess, compared to changing antibiotics on clinical grounds. Patients developed postoperative abscesses despite initial peritoneal cultures growing organisms sensitive to treatment antibiotics.

Keywords: appendicitis, complicated appendicitis, perforated appendicitis, postoperative abscess, postoperative infection
Singapore Med J 2008; 49(8): 615-8

Ooi LH, Lo NN, Yeo SJ, Ong BC, Ding ZP, Lefi A
Correspondence: Dr Ooi Lai Hock, lai_hock_ooi@ttsh.com.sg

ABSTRACT
Introduction The study aims to show that total knee arthroplasty using computer-assisted surgical navigation without intramedullary rodding is safer than conventional intramedullary techniques in preventing venous thromboembolism.
Methods 30 patients were grouped into groups of 10. Groups A and B had conventional intramedullary rodding of the femur and/or tibia. Group C had no rodding of the femur and tibia using computer-assisted surgical navigation. The degree, duration and size of the embolic shower were captured by a transoesophageal echocardiography probe. The echogenic emboli were graded according to the Mayo Clinic score. Haemodynamic parameters such as pulse oximetry oxygen saturation, end-tidal carbon dioxide, heart rate and mean arterial pressure were also recorded.
Results There was a significant difference in the size of the emboli and the Mayo Clinic score when comparing the groups with intramedullary rodding and those without. There was also a significant difference in the pulse oximetry oxygen saturation and heart rate when the group without intramedullary rodding was compared with groups with rodding.
Conclusion Surgical navigation total knee arthroplasty may be safer than conventional total knee replacement with intramedullary rodding in preventing venous thromboembolism.

Keywords: intramedullary rodding, surgical navigation, pulmonary embolism, total knee arthroplasty, venous thromboembolism
Singapore Med J 2008; 49(8): 610-4