Original Article

Mazita A, Wan Fazlina WH, Abdullah A, Goh BS, Saim L
Correspondence: Dr Mazita Ami, mazitaami@yahoo.com 

ABSTRACT 
Introduction The purpose of this study was to review the results of our patients with congenital canal atresia after implantation of bone-anchored hearing aids (BAHA). The occurrence of complications was also reviewed. 
Methods This was a retrospective analysis of the first 16 patients who had BAHA implantation at Universiti Kebangsaan Malaysia Medical Centre, Malaysia. Audiometric assessment was done preoperatively and postoperatively for each patient using the standard procedure. The surgical procedure was described and its complications discussed. 
Results The 16 patients consisted of 11 male and five female patients. Their mean age was 8.9 years at the time of the surgery. The main indication was bilateralcanal atresia.11patients had implantation of BAHA performed in two stages, while the other five patients had it as a single-staged procedure. The complications that occurred were failure of osseointegration (one patient), granulation tissue overgrowth into the abutment (two patients) and cellulitis surrounding the abutment (three patients). The average preoperative unaided air conduction threshold was 64.9 dB and the average postoperative aided hearing threshold was 29.7 dB. The overall mean functional gain was 35.2 dB. 
Conclusion BAHA has many advantages over the conventional hearing aid in the form of cosmesis, discomfort and hearing gain. It is a reliable hearing rehabilitation tool with good predictable hearing outcome in patients with bilateral canal atresia, especially those unsuitable for canalplasty. Despite its higher cost and the need for surgical implantation, its use is justifiable in properly selected patients. 

Kuan WS, Mahadevan M
Correspondence: Dr Kuan Win Sen, kuanwinsen@hotmail.com 

Tan PC, Yow CM, Omar SZ 
Correspondence: Prof Peng Chiong Tan, pctan@um.edu.my

ABSTRACT
Introduction Coitus and orgasm in late pregnancy are believed to facilitate the onset of labour. We aim to evaluate the relationship at term of reported coitus and orgasm with spontaneous labour. 
Methods Women at term scheduled for non-urgent labour induction were asked to keep a coitus and orgasm diary. These women were recruited for a randomised trial on the effect of coitus to promote spontaneous labour. For this analysis, the women were categorised into coitally-active and abstinent groups according to their coital diary. Spontaneous labour prior to the date of scheduled labour induction was the primary outcome. Labour, delivery and neonatal outcome were also evaluated. Multivariable logistic regression analysis was used to control for significant variables.
Results On univariate analysis, the inverse association of coitus with spontaneous labour was borderline (odds ratio [OR] 0.6; 95 percent confidence interval [CI] 0.3–1.0; p-value is 0.052). Orgasm was not associated with spontaneous labour (p-value is 0.33). After adjustment, coitus (adjusted OR 0.4; 95 percent CI 0.2–0.8; p-value is 0.009) displayed a significant inverse association with spontaneous labour. Coitus and orgasm were not associated with any other adverse pregnancy outcome.
Conclusion Women who reported coitus were less likely to go into spontaneous labour prior to their scheduled labour induction. Reported coitus and orgasm were not associated with adverse pregnancy outcome.

Thia EWH, Loi K, Wang JJ, Siow A 
Correspondence: Dr Anthony Siow, anthonysiow@gmail.com

ABSTRACT
Introduction Ectopic pregnancy is an acute emergency in the first trimester where surgery is the mainstay of treatment. With the advent of improved diagnostic techniques like high-resolution transvaginal ultrasonography and expedient serum human chorionic gonadotrophin (HCG) assay, ectopic pregnancy is now diagnosed early. At this stage, the conceptus is often small, causing minimal or no symptoms. Medical management may then present an appealing alternative to surgery. Methotrexate has been widely used to treat ectopic pregnancy. A methotrexate ectopic treatment protocol was introduced by the Minimally Invasive Surgery Centre at KK Women’s and Children’s Hospital, Singapore. We present the results of this treatment.
Methods A prospective review of 110 cases of medical management of ectopic pregnancy since the implementation of the treatment protocol was undertaken. Demographical data, clinical presentation, treatment progress and outcome were captured using a computer database. All patients were managed as outpatients, and a telephone call-out service was provided to ensure that treatment side effects were monitored and potential treatment failures were identified early.
Results From August 2003 to October 2006, 93 (84.5 percent) patients with ectopic pregnancy were successfully treated with intramuscular methotrexate. 16 patients eventually required surgery and only one patient defaulted on follow-up. There was no major side effect detected in this cohort. The minor side effects reported included mucositis (19.1 percent) and abdominal pain (28.2 percent).
Conclusion Methotrexate treatment of ectopic pregnancy is safe. Our treatment protocol enabled us to achieve a reasonable treatment success rate of 84.5percent.

Wee WW, Kanagalingam D 
Correspondence: Dr Wei-Wei Wee, wcube@hotmail.com 

ABSTRACT 
Introduction The development of anti-D antibodies results from foetomaternal sensitisation occurring in rhesus (Rh) negative blood group women who carry an Rh-positive foetus. Despite guidelines on Rh immunoprophylaxis, isoimmunisation continues to occur, suggesting that the guidelines are not being fully applied by obstetricians. This study aims to establish the adequacy of knowledge on Rh immunoprophylaxis among obstetricians and trainees in obstetrics and gynaecology in Singapore, and their usual practice in the care of an Rh-negative mother; and hence to audit their practice in accordance with evidence-based guidelines. 
Methods An anonymous questionnaire survey auditing obstetricians’ knowledge of guidelines on anti-D prophylaxis and their usual practice in the clinical setting. 
Results The mean score achieved on the questionnairewas75.9percent.Manyobstetricians did not know that anti-D immunoglobulins (Ig) should be given within 72 hours of a sensitising event for successful immunoprophylaxis. In clinical practice, all the obstetricians who participated in the questionnaire would offer anti-DIg prophylaxis to Rh-negative women both antenatally and postnatally. However, only 12.7 percent of them would routinely perform a Kleihauer test in Rh-negative women following delivery. 
Conclusion The knowledge on anti-D prophylaxis among obstetricians can be improved. A continual system of education to raise awareness of evidence-based practices as well as clinical audit has been implemented to address this. 

Geeta A, Jamaiyah H, Safiza MN, Khor GL, Kee CC, Ahmad AZ, Suzana S, Rahmah R, Faudzi A
Correspondence: Ms Geeta Appannah, geeta@crc.gov.my

ABSTRACT
Introduction The Third National Health and Morbidity Survey Malaysia 2006 includes a nutritional status assessment of children. This study aimed to assess the inter- and intra- examiner reliability, the technical error of measurement and the validity of instruments for measuring weight, height and waist circumference.
Methods A convenience sample of 130 adults working in a selected office setting was chosen to participate in the study, subject to the inclusion and exclusion study criteria. Two public health nurses, trained to follow a standard protocol, obtained the weight, height and waist circumference measurements. The weight was measured using the Tanita HD-318 digital weighing scale to the nearest 0.1 kg, and Seca Beam Scale to the nearest 0.01 kg. The height was measured using the Seca Bodymeter 206 and Stadiometer, both to the nearest 0.1 cm. The waist circumference was measured using the Seca circumference measuring tape S 201, to the nearest 0.1 cm.
Results The intra-examiner reliability in descending order was weight and height followed by waist circumference. The height measurement, on average, using the test instrument, reported a recording of 0.4 cm higher than the reference instrument, with the upper and lower limits at 2.5 cm and 1.6 cm, respectively. The technical error of measurement and coefficient of variation of weight and height for both inter-examiner and intra-examiner measurements were all within acceptable limits (below five percent).
Conclusion The findings of this study suggest that weight, height and waist circumference measured in adults aged 18 years and above, using the respective abovementioned instruments, are reliable and valid for use in a community survey. Limiting the number of examiners, especially for waist circumference measurements, would yield a higher degree of reliability and validity.

Keywords: anthropometry, height measurement, nutritional status assessment, waist circumference measurement, weight measurement
Singapore Med J 2009; 50(10): 1013-1018

Pal S, Ma SO, Norhasimah M, Suhaida MA, Siti Mariam I, Ankathil R, Zilfalil BA
Correspondence: Dr Zilfalil Bin Alwi, zilfalil@kb.usm.my

ABSTRACT
Introduction This study was done to determine the prevalence of chromosomal abnormalities and the subsequent reproductive outcome in couples who had two or more miscarriages.
Methods 56 couples with a history of at least two previous miscarriages were evaluated for prevalence and types of chromosomal abnormalities from their karyotype records. The study was a retrospective one, and subsequent reproductive outcome after a period of 12-24 months from the time of karyotyping was obtained by telephone interviews and scrutiny of the case records. The comparison of reproductive outcome was done by chi-square statistics.
Results Five couples (8.9 percent) had a chromosomal abnormality in one partner. Three cases of reciprocal translocations t(5;11), t(9;14), dup(9q); one Robertsonian D/D translocation 13/14; and one mosaic Down syndrome male karyotype were found. Among the 32 couples available for follow-up, there was a lower incidence of subsequent live healthy births among chromosomally-normal couples (35.7 percent) compared to chromosomally-abnormal ones (25 percent). However, the difference was not statistically significant (p-value is 1.0). There was a lower incidence of subsequent abortions in chromosomally-normal couples (42.8 percent) compared to chromosomally-abnormal ones (50 percent), but the difference was also not statistically significant (p-value is 1.0).
Conclusion Chromosomal abnormalities were seen in 8.9 percent of the couples, and translocations were the commonest abnormality found. The frequencies of subsequent live healthy births and subsequent abortions showed no significant difference between couples having normal karyotypes and those having chromosomal abnormality in one partner.

Keywords: chromosomal abnormalities, karyotype, miscarriages, reproductive outcome, translocations
Singapore Med J 2009; 50(10): 1008-1012

Saththasivam P, Umadevan D, Ramli N, Voralu K, Naing NN, Ilias MI, Shuib N, Tan BG, van Rostenberghe H
Correspondence: Dr Hans van Rostenberghe, hansvr@kb.usm.my

ABSTRACT
Introduction The aim of this study was to determine whether there was a difference in the pain indicators and effectiveness between venipuncture (VP) and heel prick (HP) for blood glucose monitoring in term neonates (recently, venipuncture was shown superior for the Guthrie test).
Methods 66 term neonates undergoing blood glucose monitoring underwent VP or HP. Primary outcome measures included the Neonatal Facial Scoring System (NFCS) score, duration of the first cry, total duration of cry and duration of procedure. Secondary outcome measured was the number of skin punctures needed to obtain blood.
Results The NFCS score was not significantly different between the two groups and the duration of the procedure was significantly longer for the VP than the HP group (median 27 s vs. 7 s; p-value is less than 0.001). The differences between the two groups in the duration of the first cry, total duration of cry and number of skin punctures needed to obtain blood were not statistically significant, but these parameters displayed a trend, favouring the HP.
Conclusion The HP is still the preferred method of drawing blood in neonates for blood glucose monitoring, as only one drop of blood is required.

Keywords: blood glucose monitoring, heel prick, Neonatal Facial Scoring System score, venipuncture
Singapore Med J 2009; 50(10): 1004-1007

Goh KP, Chew K, Koh A, Guan M, Wong YS, Sum CF
Correspondence: Dr Goh Kian Peng, kian_peng_goh@alexhosp.com.sg

ABSTRACT
Introduction The aim of this study was to analyse the association between the ACE ID polymorphism and aerobic capacity in a homogeneous cohort of national Asian rugby players.
Methods 17 subjects recruited during active training had their maximal oxygen uptake (V0_2max) and ventilatory threshold (VT) measured during maximal exercise testing. ACE genotyping was performed for all players.
Results The likelihood of having a V0_2max above the 80th percentile of a gender-specific reference range for a normal population was 14.3-fold greater among subjects with the II genotype as compared to the ID genotype (p-value is 0.030). Similarly, subjects with the II genotype were 29.4 times more likely to have a VT above the gender-specific median value compared to the ID genotype (p-value is 0.019). The results suggest that the I allele confers an advantage in aerobic capacity as measured by the V0_2max and VT.
Conclusion It is likely that the same physiological mechanisms mediated by the ACE gene are responsible for aerobic capacity in both Asians and Caucasians.

Keywords: aerobic capacity, angiotensin converting enzyme, exercise physiology, gene polymorphism
Singapore Med J 2009; 50(10): 997-1003

Panesar NS, Goggins W
Correspondence: Dr Nirmal Singh Panesar, nspanesar@cuhk.edu.hk

ABSTRACT
Introduction Historical anecdotes suggest human beings can postpone death around important occasions. Some formal studies have claimed that elderly Jewish men and Chinese women in America postponed death around the Passover and Harvest Moon (or Mid-Autumn) Festival (HMF), respectively.
Methods We examined deaths from cancer, cerebrovascular and heart diseases in the Chinese around four important holidays celebrated in Hong Kong. From computerised data in 1995–2000, the expected weekly deaths for 12 weeks before and after Lunar New Year, Ching Ming, HMF and Chung Yeung holidays were calculated using a polynomial regression model for the three diseases in men and women, under and over the age of 75 years. The differences in the observed deaths one week before and one week after the four holidays were tested by the binomial test.
Results There were significantly fewer deaths overall in men before the holidays than after (p-value equals 0.0081), with most of the difference being due to cancer deaths, particularly among men over 75 years of age. For women, there were actually more deaths before the holidays than after. The data, stratified according to age, gender, disease and holiday, yielded only five out of 48 variables with a p-value of less than 0.05, which was slightly above chance, considering the large number of comparisons made. In four of the five situations, there were significantly fewer deaths before than after the holidays; but after Bonferroni correction, only the finding of fewer cancer deaths for men aged over 75 years before HMF was significant.
Conclusion Other than cancer deaths in males, we found little evidence in this dataset of death postponement until after important holidays in the Hong Kong Chinese population.

Keywords: deaths, holidays, postponement, psychological stress
Singapore Med J 2009; 50(10): 990-996