Original Article

Tor PC, Poon LY
Correspondence: Dr Tor Phern Chern, torphernchern@gmail.com

ABSTRACT
Introducion Schizophrenia is a severe, chronic mental illness with a worldwide prevalence of about one percent. It is possible to define at-risk mental states (ARMS) that predict conversion to schizophrenia in up to 40 percent of help-seeking individuals within a year of screening. Treatment of ARMS is controversial due to difficulties with diagnosis and uncertainties of treatment effectiveness. There is currently no consensus among psychiatrists in Singapore or internationally, regarding the diagnosis of ARMS, or its treatment. This survey was conducted to assess current attitudes of Singaporean psychiatrists towards ARMS.
Methods An anonymous survey containing a clinical vignette and questions related to the diagnosis and management of ARMS was sent out to all registered psychiatrists and psychiatric trainees in Singapore.
ResultsThere was a response rate of 62.1 percent (87/140). 60.9 percent of respondents were fully-trained psychiatrists. 44.8 percent versus 43.7 percent of respondents diagnosed ARMS versus psychosis, respectively. 74.4 percent (29/39) of respondents who diagnosed ARMS would treat the patient with active management rather than watchful waiting. 64.4 percent felt that there was no consensus regarding the management of ARMS. There was no significant relationship between responses and age, gender, training or place of practice.
Conclusion There is currently clinical equipoise with regard to both diagnosis and management of ARMS in Singapore. Most psychiatrists would manage ARMS actively rather than with watchful waiting.

Keywords: at-risk mental states, chronic mental illness, clinical equipoise, psychosis, schizophrenia
Singapore Med J 2008; 49(1):37-41.

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

ABSTRACT
Introduction Two of the most common malformations of the anterior abdominal wall include gastroschisis and omphalocele, both of which are associated with high morbidity and mortality. Studies have shown an increase in both conditions worldwide. These two  conditions are considered separate entities because of their differences in epidemiology, physical characteristics and associations with other structural anomalies and chromosomal aberrations. This is the first local study to examine these two conditions.
Methods Data of anterior abdominal wall defect cases of patients born during the period 1993-2002 were retrieved from the National Birth Defects Registry and analysed. 
Results There were a total of 121 cases of anterior abdominal wall defects in the tenyear period from 1993 to 2002, giving an overall
incidence of 2.63 per 10,000 livebirths. The individual incidences of gastroschisis (n = 21) and omphalocele (n = 100) were 0.46 and 2.17per 10,000 livebirths, respectively. 33 percent of women with foetal gastrochisis were younger than 25 years of age, and 31 percent of women with foetal omphalocele were older than 35 years of age. This was statistically significant when compared to the general obstetric population. Incidence of omphalocele was lowest among the Indian population. Total aneuploidy rate was 14.9 percent (18/121 cases), with omphalocele having a higher aneuploidy rate than gastroschisis (17 percent versus 4.8 percent). Omphaloceles are also more likely to be associated with cardiac defects (p-value equals 0.02).
Conclusion Our studies are consistent withthe worldwide trend of an increasing prevalence of anterior abdominal wall defects. The racespecific differences suggest genetic and environmental factors that warrant further studies.

Hamidah A, Rizal A M, Nordiah A J, Jamal R
Correspondence: Dr Hamidah Alias, midalias@mail.hukm.ukm.my

ABSTRACT
Introduction We evalutated piperacillin-tazobactam in association with amikacin in the initial empirical therapy of febrile neutropenic children.
Methods An open-labelled, non-randomised, prospective trial to assess the efficacy and safety of this association was conducted from June 1, 2001 to December 31, 2002. Children and adolescents were treated for a haematological  mal ignancy or  a primary, refractory or relapsed solid tumour, and presented with febrile neutropenia. Patients received intravenous piperacillin-tazobactam (90 mg/kg/dose every eight hours) plus a single daily dose of  amikacin at 15 mg/kg/day, maximum 250 mg. If fever persisted, second line therapy with carbapenem was  administered. Teicoplanin was added for grampositive isolates or for unremitting fever after 48 hours, if clinically indicated. Amphotericin B was added at 96 hours, if fever and neutropenia persisted.
Results 155 episodes of fever and neutropenia in 76 patients were evaluable. 40 (25.8 percent) episodes were a microbiologically-documented infection, 30 (19.4 percent) were clinicallydocumented,  and 85  (54.8 percent) were unexplained fever. 77 (49.7 percent) episodes responded to piperacillin-tazobactam plus amikacin without a need for tretment modification. A higher success rate (63.5 percent) was observed in episodes with unexplained fever. The predominant pathogens isolated in our study were gram-negative organisms (70.7 percent). A mild gastrointestinal intolerance occurred in 35 out of 155 (22.6 percent) episodes.
Conclusions This study suggests that piperacillin-tazobactam plus amikacin presents a satisfactory efficacy and a good tolerance as initial empirical therapy for febrile neutropenic children.

Keywords: amikacin, childhood cancer, febrile neutropenia, piperacillin-tazobactam
Singapore Med J 2008; 49(1): 26-30

Siassakos D, Gourgiotis S, Moustafellos P, Dimopoulos N, Hadjiyannakis E
Correspondce: Dr Stavros Gourgiotis, drsgourgiotis@tiscali.co.uk; goustav@otenet.gr

Howe T C, Padhy A K, Loke K, Magsombol B, Ng D, Goh A
Correspondence: Dr Howe Tse Chian, howe_tsechiang@rafflesmedical.com

ABSTRACT
Introduction Medullary thyroid carcinoma (MTC) is a rare disease. Serum calcitonin levels and Tc-99m DMSA(V) scans are used in the follow-up of these patients after surgical resection.  We present our experience in the follow-up of these patients at a tertiary institution.
Methods A retrospective review of the medical records was performed. Patients with histologically -proven MTC, and who had serum
calcitonin assays and DMSA (V) scans in their postoperative follow-up, were included. 
Results There were 17 patients with 56 DMSA (V) scans. Four out of seven patients with elevated preoperative calcitonin measurements had calcitonin normalisation within six months of surgery, and have remained disease-free. Two patients had persistently elevated calcitonin levels after six months, which predated positive DMSA (V) scans. Results of DMSA (V) scans and serum calcitonin levels were concordant in 38 of 48 instances (79.2 percent) and discordant in 10 of 48 instances (20.8 percent). Sensitivity of DMSA (V) scans for detecting  recurrence was 71.4 percent.There were no false-positive scans.
Conclusion Serum calcitonin level is a sensitive and specific indicator of disease recurrence in postoperative follow-up of patients with MTC. Early (within six months) normalisation of calcitonin  level s  pos t surgery may predict subsequent disease-free status. Discordant results between serum calcitonin levels and DMSA (V) scans may be due to undetectable lesions and follow-up scans or alternative radionuclide imaging may be required.

Noraini AR, Gay E, Ferrara C, Ravelli E, Mancini V, Morra E, Muti P, Tahir A, Abdul Jalil N, Rossetti C
Correspondence: Dr Noraini Abdul Rahim, norainichoo2@hotmail.com

ABSTRACT
Introduction To establish the role of positron-emission tomography (PET)-computed tomography (CT) in post-transplant lymphoproliferative disorder (PTLD) patients, compared to conventional imaging (ultrasonography/CT/magnetic resonance imaging) in relation to its accuracy, sensitivity and specificity.
Methods 30 patients (26 males and 4 females), with a median age of 49.5 (range 18–74) years, were retrospectively evaluated. In 29 cases, the diagnosis was confirmed by histopathology. Malignant lymphoma was detected in 20 cases, polymorphic lymphoproliferative disorder in six cases, multiple myeloma in two cases and Hodgkin’s disease in one case. A total of 49 PET-CTs (13 studies for staging at diagnosis and 36 studies at follow-up as assessment post-therapy) were compared to conventional imaging. Imaging results in accordance with disease status were assessed at a median follow-up of 17.8 (range 1.5–42.2) months post-PET-CT. 
Results In 41 of 49 examinations performed for staging and on follow-up, PET-CT and conventional imaging findings were concordant. Compared to conventional imaging, PET-CT showed comparable sensitivity (75 percent vs. 83 percent), similar specificity (100 percent in both modalities) and comparable accuracy (77 percent vs. 85 percent) during staging at diagnosis. PET-CT was found to be superior to conventional imaging modalities at follow-up, with greater sensitivity (100 percent vs. 81 percent), specificity (80 percent vs. 100 percent) and accuracy (97 percent vs. 83 percent). 
Conclusion PET-CT is an accurate diagnostic tool for staging and for the follow-up of PTLD patients. It represents a good alternative imaging method to avoid contrast-related nephrotoxicity in patients who often develop impaired renal function secondary to chronic immunosuppressive therapy. However, further studies are recommended before considering PET-CT as a routine diagnostic tool in PTLD.

Taneja M, Tay KH, Sebastian M, Pasupathy S, Lin SE, Teo T, Low R, Irani FG, Chng SP, Dewan A, Tan BS
Correspondence: Dr Manish Taneja, manish.taneja@sgh.com.sg

ABSTRACT
Introduction This study aims to evaluate our experience with self-expanding nitinol stent- enabled recanalisation of long-length occlusions (30 cm or more) of the superficial femoral artery (SFA). 
Methods 573 patients underwent 842 lower limb interventions from August 2006 to December 2008. A retrospective review of patients undergoing recanalisation of long-length SFA occlusions with self-expanding nitinol stents and an evaluation of their patency and impact on limb salvage, were done. 
Results 22 patients (mean age 62.5 years, male: female ratio 11:11) underwent 22 long-length SFA stenting procedures. The spectrum of critical limb ischaemia included rest pain (five), ulcer (six) and gangrene (11). Length of occlusions varied from 30 cm to 45 cm (average length 36.4 cm). Five patients had stents placed through the ipsilateral popliteal artery approach, and the rest had stents placed through the femoral artery approach. All patients were followed up over an average duration of 12 months. One patient died due to associated medical conditions during this period. Six out of 21 (28.6 percent) of the stents thrombosed completely on one year follow-up. Of these, two patients underwent amputation, one patient had a bypass, and the stent in two patients were recanalised with balloon angioplasty. All remaining patent stents showed varying degrees of stenoses at one year. The overall limb salvage rate at one year following stent placement was 81 percent. 
Conclusion Our experience showed the beneficial result of long-length SFA stent placement with good limb salvage outcome. Repeat interventions may be required to maintain the patency of stents in these patients. 

Shirafkan A, Motahari M, Mojerlou M, Rezghi Z, Behnampour N, Gholamrezanezhad A
Correspondence: Dr Ali Gholamrezanezhad, gholamrezanejhad@razi.tums.ac.ir 

ABSTRACT
Introduction It has been suggested that hypertension (HTN) is associated with certain target organ damage (TOD) and related clinical conditions. On the other hand, left ventricular hypertrophy (LVH) has been considered as an independent risk factor of cardiovascular events and death. The aim of this study was to examine the relationship between HTN-induced LVH and TOD (retinopathy and renal failure). 
Methods We assessed 102 hypertensive subjects (43 males and 59 females) with a mean age of 60.2 +/- 8.8 (range 35–81) years. LVH was defined as a left ventricular mass index (LVMI) of more than 51 and 47 g/(m [to the power of 2.7]), in men and women, respectively. The degree of retinopathy on ophthalmological examination was defined according to the Keith-Wagener classification. Serum creatinine, blood urea nitrogen and urine protein concentrations were also measured. 
Results Hypertensive retinopathy was found in 94 (92.2 percent) cases (Grades I 55.9 percent; II 28.5 percent; III 3.9 percent; IV: 3.9 percent). The mean systolic and diastolic blood pressures and serum creatinine concentration showed significant correlation with the severity of LVH. There was no significant relationship between LVH severity and retinopathy or proteinuria. 
Conclusion The tight control of systolic and diastolic blood pressures in the first step of essential hypertension can assist to postpone LVH. Furthermore, routine measurement of serum creatinine can predict the risk of cardiovascular complications in the hypertensive patient.

Yeap R, Low WY
Correspondence: Dr Reiko Yeap, reiko_yeap@imu.edu.my

ABSTRACT 
Introduction This study examines the general public’s knowledge of mental health and explores effective tools to promote good mental health through a household survey of a representative sample of the Malaysian population residing in Klang Valley, Malaysia. 
Methods A total of 587 respondents, aged 18 years and older, responded to a series of questions in relation to mental health issues. Respondents were requested to specify how they learned about the information. Following that, an attitude scale was presented to the participants, and they were requested to rate how much they agreed to the statements. 
Results The findings indicated that the majority of the respondents did not have good knowledge of mental health. However,all respondents displayed a neutral attitude towards mental health issues. It was found that ethnic background, religion, educational level and residential location were the few demographic characteristics found to be significantly related to either the respondent’s knowledge or attitude towards mental health issues. With regard to seeking help, while the respondents’ ethnic background influenced their decisions, younger respondents and respondents with better attitude towards mental health were more willing to seek help. 
Conclusion This study has implications for promoting the understanding of the general mental well-being as well as the importance of seeking help for mental health in the local population. Steps should be taken to improve the public’s understanding of, and attitude towards mental health. These include the presentation of a positive image and the dissemination of accurate information by the mass media, the primary source for information on mental health.

Loh CH 
Correspondence: Dr Loh Chee Hong, seanchloh@gmail.com

ABSTRACT
Introduction In a country dominated by western healthcare, interest in traditional Chinese medicine (TCM) is growing. The increasing popularity of TCM, occasionally used with conventional medicine, needs to be assessed, especially in a vulnerable paediatric population. This paper sought to evaluate the use of TCM in children, mainly to determine the common conditions they seek TCM, the pattern of acupuncture or herbal usage for various age groups, the extent of concurrent usage of TCM and conventional medicine, and the reasons for TCM use. Paediatricians’ perceptions of TCM will allow us to gauge the acceptability of TCM by those who practise conventional medicine. These are assessed in another arm of this study, with a set of predictive characteristics for their personal TCM use, their perceptions of herb/acupuncture safety, and their own referral to TCM eventually determined.
Methods An anonymous questionnaire was administered on 300 parents awaiting consultation at a large TCM clinic. Next, a separate qualitative questionnaire survey form was posted to 100 paediatricians.
Results Herb usage in children is very common (84.3 percent) and 80 percent of parents admitted concurrent usage of TCM and conventional medicine for their children. Drug-herb interactions was an issue of concern for paediatricians. Paediatricians with a higher level of self-reported TCM knowledge were more likely to refer for a cure.
Conclusion This was the first study to determine the characteristics of children attending a large TCM clinic in a country which is dominated by western healthcare. It also provided insight into the perceptions of TCM among paediatricians in Singapore. Specifically, it gave us an idea of the predictor traits that determine their referral patterns to TCM and their perceptions of herb and acupuncture safety.