Original Article

Chua AC, Leo YS, Lee CC
Correspondence: Dr Arlene C Chua, arlene_chua@nuhs.edu.sg

ABSTRACT
Introduction Batam is one of the islands comprising the Riau Province in Indonesia, and is closest to Singapore. It is a popular destination of many Singaporeans. Surveillance reports among commercial sex workers conducted in Batam showed the prevalence rate of human immunodeficiency virus (HIV) is 16.2 percent. At the end of 2006, the total number of HIV-infected Singaporeans was 3,060, the majority being infected via heterosexual transmission. The aim of the Indonesian government is to rapidly scale up HIV treatment to those needing it. One of the factors critical to the rapid scale-up is healthcare worker training.
Methods An intersectoral collaboration addressing the issue of HIV care and treatment with a hospital in Batam was created. The first activity of the collaboration was a two-day HIV training course conducted in February 2007. The aim of the course was to provide a basic understanding of HIV, as well as knowledge on common opportunistic infections that may present to a general hospital or clinical setting.
Results 34 doctors from 23 institutions in Batam and three doctors from two hospitals in the Riau Islands attended the two-day HIV training course. The participants found the training very useful and highly relevant.
Conclusion This first HIV training provided a foundation to build on further HIV education. It is our belief that through the HIV training programme, there will be more awareness of HIV among the various medical institutions in Batam. As the HIV epidemic knows no borders, working with neighbouring countries is one strategy that deserves attention.

Keywords: acquired immunodeficiency syndrome (AIDS), health education, human immunodeficiency virus (HIV), infectious disease, sexually transmitted disease
Singapore Med J 2008; 49(5): 376-379

Luman W 
Correspondence: Dr Widjaja Luman, wijluman@singnet.com.sg

ABSTRACT
Introduction Gastroscopy is an excellent technique for investigation of upper gastrointestinal pathology. However, patients frequently request for conscious sedation as the procedure causes pain, pharyngeal reflex and nausea. Administration of conscious sedation incurs additional medical expenditure and risks. Transnasal gastroscopy, which became commercially available in 2005, does not induce pharyngeal reflex. The aim of this study was to examine patients' perception and satisfaction with transnasal gastroscopy performed in an office setting.
Methods Questionnaires were administered to consecutive patients after the performance of transnasal gastroscopy. Patients received topical ten percent xylocaine spray to the nasal and pharyngeal cavities 1-2 minutes before the procedure. The transnasal endoscope used was a narrow upper gastrointestinal endoscope (EG270N5 [Fujinon, Saitama City, Japan]).
Results Transnasal gastroscopy was attempted in 96 patients. The procedure failed in one patient due to a narrow nasal passage and had to be converted to oral route of intubation. Questionnaires were completed by 96 patients. There were 52 males (54 percent) with the median age of 43 (range 11-85) years. None of them received conscious sedation. 53 patients (56 percent) reported that there was no pain/discomfort during the procedure. On the Lickert visual analogue scale for pain from 0 to 10 points, 91 patients (96 percent) reported severity of pain of below 5 points. 85 patients (89 percent) reported they were satisfied or more than satisfied with the procedure. 84 patients (88 percent) were happy to undergo similar repeat procedure without sedation. 25 patients (26 percent) had undergone previous oral gastroscopy; 22 of these patients reported that transnasal route was definitely more comfortable than the oral route. There were two incidents of nosebleed which were self-limiting.
Conclusion Transnasal gastroscopy with a thin endoscope was found to be safe. The procedure is well-tolerated by patients without conscious sedation. Patients reported better preference for transnasal endoscopes in comparison to conventional transoral gastroscopy.

Than TH, Swethadri GK, Wong J, Ahmad T, Jamil D, Maganlal RK,  Hamdi MM, Abdullah MS
Correspondence: Dr Than Than Htwe, ltthtwe@yahoo.com 

ABSTRACT
Introduction It has been suggested that Galectin-3 (Gal-3) and Galectin-7 (Gal-7) are potential tumour markers for differentiating thyroid carcinoma from its benign counter part. Galectins are beta-galactoside-binding proteins with Gal-3 being a redundant pre-mRNA splicing factor. They are supposed to be p53-related regulators in cell growth and apoptosis, being either anti-apoptotic or pro-apoptotic. Although the value of Gal-3 has been studied extensively, there is little knowledge regarding the expression of Gal-7 in thyroid malignancy.
Methods We initiated an immunohistochemical (IHC) study on the expression of Gal-3 and Gal-7 on various thyroid lesions. Formalin-fixed paraffin embedded thyroid tissues were stained for IHC expression of Gal-3 and Gal-7 using monoclonal anti-human Gal-3 antibody and anti-human Gal-7 antibody (R&D Systems Inc, MN, USA). Gal-3 and Gal-7 expressions were measured semiquantitatively on their distribution and staining intensity.
Results A total of 95 cases were collected, including 32 benign and 63 malignant thyroid lesions. These contained 37 cases of papillary thyroid carcinoma, nine cases of papillary thyroid carcinoma follicular variant, 16 cases of follicular carcinoma, one case of anaplastic carcinoma, 14 cases of follicular adenomas and 18 cases of nodular goitre. Gal-3 expression was significantly strong in cancer cases compared to non-cancer cases (p-value is 0.000), while no significant difference was noted with Gal-7 expression (p-value is 0.870).
Conclusion Our findings suggested that the IHC localisation of Gal-3 is a useful marker in conjunction with routine haematoylin and eosin staining in differentiating benign from malignant thyroid lesions, while there is no significant adjunct diagnostic value in Gal-7 for thyroid malignancy.

Tiong TS 
Correspondence: Dr Tiong Thung Sing, ytiong27@hotmail.com 

ABSTRACT
Introduction In medical practice, some patients consult doctors for reassurance of normality, e.g. patients with throat discomfort. Therefore, medical graduates should be competent in diagnosing clinical normality. One way to assess clinical competence is by the objective structured clinical examination (OSCE).
Methods In 2002-2006, five batches of medical students who completed their otorhinolaryngology posting in Universiti Malaysia Sarawak were examined with the same OSCE question on clinically normal vocal cords. There were five subquestions concerning structures, clinical features, diagnosis and management. All students had prior slide show sessions regarding normal and abnormal laryngeal conditions.
Results The total number of students in 2002, 2003, 2004, 2005 and 2006 was 25, 41, 20, 30 and 16, respectively, and 100 percent responded. The average percentage of students with correct answers was 19.4, 2.4, 2.2, 21.2, and 2.4, in the subquestions 0.1 to 0.5, respectively, leaving the remaining relatively larger percentages with incorrect answers of various clinical abnormalities. A reason for these findings is examination fever by the students, who also assumed that all the stations had clinical abnormalities and required differentiating abnormalities from abnormalities, and not from normality. Without clinical normality OSCE questions, the assessment of the undergraduates' clinical competence in real life would seem incomplete.
Conclusion This study showed that a significantly large percentage of students answered incorrectly in the clinical normality OSCE. This may mean that more clinical normality OSCE questions should be included in the undergraduate medical examination to help undergraduates practise the need to look for, and become competent in, clinical normality in real life.

Jayaraman T, Kannappan S, Ravichandran MK, Anuradha CV
Correspondence: Prof CV Anuradha, cvaradha@hotmail.com

Hefny AF, Ahmed I, Branicki FJ, Ramadan K, Czechowski J, Abu-Zidan FM 
Correspondence: Prof Fikri Abu-Zidan, fabuzidan@uaeu.ac.ae

ABSTRACT
Introduction The aim of this study was to evaluate our recent clinical management of mesenteric vascular occlusion (MVO) at Al-Ain Hospital, United Arab Emirates.
Methods A retrospective study was performed including all patients who were diagnosed to have MVO from December 2001 to May 2005. The records were studied with regard to clinical features, risk factors, diagnosis, treatment, and outcome.
Results Of the 14 patients studied, seven patients experienced mesenteric venous thrombosis (MVT), five patients mesenteric arterial occlusion (MAO), and two patients were found to have both MVT and MAO. The main risk factor for MAO was ischaemic heart disease with atrial fibrillation in four patients (80 percent). No predisposing factors were identified in three patients with MVT (primary MVT 43 percent). Contrast-enhanced computed tomography was performed in all patients and was diagnostic in 12 (86 percent) patients. Seven patients (50 percent) underwent surgery. One patient died on the ninth postoperative day (overall mortality rate 7 percent). Seven patients (50 percent) were successfully managed conservatively, five of them had only MVT, one had combined MVT and MAO, and one had only MAO.
Conclusion Early diagnosis and prompt initiation of anticoagulation therapy, with operative intervention when indicated, are essential for a favourable outcome.

Chan SC, Lee TW, Teoh LC, Abdullah ZC, Xavier G, Sim CK, Ng AC, Ong ICH, Begum R, Leong CC 
Correspondence:Prof Chan Sook Ching, csching@rcmp.unikl.edu.my

Keywords: cardiovascular disease preventive care, cardiovascular risk factors, disease prevention, general practice
Singapore Med J 2008; 49(4):311-315

Lee YY, Tee MH, Zurkurnai Y, Than W, Sapawi M, Suhairi I 
Correspondence: Dr Lee Yeong Yeh, yylee@kck.usm.my

ABSTRACT
Introduction This study was primarily aimed to determine the failure rate of thrombolysis with streptokinase in acute myocardial infarction using electrocardiogram criteria and its association between various independent variables and outcome parameters.
Methods A total of 192 subjects were recruited into this retrospective observational study. Thrombolysis failure with streptokinase was defined using electrocardiogram criteria of less than 50 percent reduction in ST elevation in the worst infarct lead. Multivariate analysis was used to test association with study outcome.
Results A total of 109 patients (56.8 percent) failed thrombolysis using streptokinase. The failures were associated with five variables in multiple logistic regression analysis (backward stepwise method) including anterior location of myocardial infarct (odds-ratio [OR] 0.07, 95 percent confidence interval [CI] 0.03-0.16; p-value is less than 0.001), longer door-to-needle time (OR 1.01, 95 percent CI 1.00-1.02; p-value is 0.02), diabetes mellitus (OR 3.13, 95 percent CI 1.13-8.69; p-value is 0.03), hypertension (OR 2.06, 95 percent CI 0.92-4.60; p-value is 0.08) and high total white cell count (OR 1.12, 95 percent CI 1.01-1.24; p-value is 0.03). Thrombolysis failure with streptokinase was associated with recurrent acute coronary syndrome (crude OR 2.49, 95 percent CI 1.16-5.32; p-value is 0.02) and death after one year (crude OR 7.61, 95 percent CI 0.95-61.24; p-value is 0.04).
Conclusion This study showed that streptokinase had a failure rate of 56.8 percent. History of diabetes mellitus, history of hypertension, anterior location of myocardial infarction, longer door-to-needle time and high total white cell count were highly predictive of thrombolysis failure using streptokinase. This group of patients may benefit from other early reperfusion strategy.

Keywords: electrocardiogram criteria, myocardial infarction, reperfusion failure, streptokinase, thrombolysis failure
Singapore Med J 2008; 49(4):304-310

Rafidah HM, Azizi A, Noriah MN
Correspondence: Dr Rafidah Hanim Mokhtar, Email:rafidahhanim@gmail.com; rafidahh@iiu.edu.my

Keywords: ambulatory blood pressure monitoring,  arterial compliance, blood pressure variability,  coronary artery disease, hyperlipidaemia
Singapore Med J 2008; 49(4): 297-303

Chai J, Chu FCS, Chow TW, Shum NC
Correspondence: Dr Frederick Chu, cschu@hkucc.hku.hk

Keywords: elderly patients, infirmary,  malnutrition, risk factors, stroke 
Singapore Med J 2008; 49(4):290-296