Original Article

Khan MMH, Kraemer A
Correspondence: Dr MMH Khan, mobarak.khan@uni-bielefeld.de

ABSTRACT
Introduction Extremes of body mass index (BMI), viz.underweight,overweight and obese categories, are associated with a variety of adverse health outcomes such as diabetes mellitus, cardiovascular diseases, low birth weight, poor quality of life and higher mortality. In Bangladesh, the prevalence of underweightness is very high with an increasing trend of overweightness and obesity. This is a serious public health concern as it indicates a dual burden of disease. The present study assessed the associations of being underweight, overweight and obese with socioeconomic, demographical and migration variables among ever-married non-pregnant urban Bangladeshi women aged 13–49 years.
Methods The data was extracted from the Bangladesh Demographic and Health Survey 2004. Bivariable, factor and multinomial logistic regression analyses were performed in this study.
Results The prevalence of being underweight, overweight and obese among ever-married non-pregnant urban women in Bangladesh was 25.2 percent, 15.7 percent and 3.9 percent, respectively. Age, education, region of residence, marital status, current use of contraception and type of occupation were significantly associated with BMI categories. Adjusted multinomial logistic regression analysis indicated that women with a high socioeconomic status were significantly negatively associated with being underweight (odds ratio [OR] 0.55, 95 percent confidence interval [CI] 0.48–0.63) but positively associated with being overweight (OR 1.70, 95 percent CI 1.48–1.96) and obese (OR 2.48, 95 percent CI 1.89–3.26), as compared to the women with normal BMI. In contrast, women who migrated from rural to urban areas showed a significantly positive association with being underweight (OR 1.15, 95 percent CI 1.04–1.27) but negative associations with being overweight (OR 0.80, 95 percent CI 0.71–0.89) and obese (OR 0.75, 95 percent CI 0.62–0.92), when compared with women who did not migrate.
Conclusion Suitable interventions based on further studies are needed to reduce the prevalence of being underweight and overweight among ever-married non-pregnant urban women in Bangladesh. Factors, viz. socioeconomic status, rural-urban migration and education, should be considered while developing interventional strategies to reduce the prevalence of extreme BMIs among women living in urban areas of Bangladesh.

Keywords: obesity, overweight, rural-urban migration, socioeconomic status, underweight
Singapore Med J 2009; 50(8): 804-813

Mathew AJ, Antony J, Eremenco S, Paul BV, Jayakumar B, Philip J
Correspondence: Dr Ashish Jacob Mathew, ashishjacobmathew@gmail.com

ABSTRACT
Introduction Assessment of health-related quality of life (HRQL) has been gaining much importance in the care of rheumatoid arthritis (RA). This study was aimed at assessing the HRQL of patients with RA in South India.
Methods HRQL of consenting RA patients, on disease-modifying anti-rheumatoid drugs (DMARDs) and attending a rheumatology clinic, was assessed using a self-filled Malayalam version of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) version 4 questionnaire.
Results 50 patients were assessed out of 58 responses. The mean duration of the disease was 7.29 years. 46 patients (79.3 percent) had tried complementary and alternative medicines (CAM). The HRQL score in patients who were put on DMARDs within six months of symptoms was significantly higher (p-value is equal to 0.008).
Conclusion HRQL in patients treated early by DMARDs is significantly higher in this region, where a good proportion of patients seek the CAM for treatment of RA.

Keywords: complementary medicine, disease-modifying anti-rheumatic drugs, quality of life, rheumatoid arthritis
Singapore Med J 2009; 50(8): 800-803

Dahlui M, Hishamshah MI, Rahman AJA, Aljunid SM
Correspondence: Dr Maznah Dahlui, maznahd@ummc@edu.my

ABSTRACT
Introduction The quality of life of transfusion-dependent thalassaemia patients is affected by the disease itself and iron overload complications from repeated blood transfusion. Desferrioxamine has been used to remove the excess iron, resulting in decreased mortality and morbidity. In Malaysia, a significant proportion of the transfusion-dependent thalassaemia patients are not prescribed desferrioxamine, due to its high cost, especially as it is not subsidised by the government. The aim of this study was to measure the quality of life of thalassaemia patients on desferrioxamine treatment.
Methods A cross-sectional study was performed on all transfusion-dependent thalassaemia patients on follow-up at two tertiary hospitals in Kuala Lumpur, Malaysia, in 2005. Quality-of-life scores were measured by using the translated MOS SF-36 questionnaires, while diseases related to iron overload complications were obtained from the medical records. Use of desferrioxamine was elicited through interviews and validated by drug records. Quality-adjusted life-years (QALYs) presented were formulated from residual life-years and quality-of-life scores.
Results A total of 112 transfusion-dependent thalassaemia patients were recruited, with 54 (48 percent) and 58 (52 percent) patients on sub-optimum and optimum desferrioxamine treatments, respectively. QALYs were higher in patients on optimum desferrioxamine (9.04, standard deviation [SD] 2.46) than patients on sub-optimum desferrioxamine (5.12, SD 2.51). QALYs were associated with the level of serum ferritin, iron overload complications and total family income.
Conclusion Optimum desferrioxamine usage reduces iron overload complications and provides a better quality of life.

Keywords: desferrioxamine treatment, iron overload complications, quality of life, quality-adjusted life-years, transfusion-dependent thalassaemia
Singapore Med J 2009; 50(8): 794-799

Mamishi S, Mashoori N, Mahboobi N, Pour Akbari B
Correspondence: Ms Negar Mashoori, negar_1400@yahoo.com

ABSTRACT
Introduction The Shigella spp. is an organism with an ongoing changing resistance pattern to different antibiotics, thus making its appropriate treatment difficult. Nalidixic acid has been one of the most common agents used for the treatment of shigellosis. Recently, some studies have reported an emerging resistance to this agent.
Methods In this study, we compared the resistance of Shigella isolates during the period 2001–2003 with the period 2004–2006.
Results Shigella spp. resistance was increased totally and in each subgroup, except for Shigella sonnei.
Conclusion Our results showed an increasing resistance of the Shigella spp., thus identifying an emergent need for an alternative agent for the treatment of shigellosis in future.

Keywords: antimicrobial resistance, dysentery, nalidixic acid, Shigella spp., shigellosis
Singapore Med J 2009; 50(8): 791-793

Ng KW, Chow A, Win MK, Dimatatac F, Neo HY, Lye DC, Leo YS
Correspondence: Dr Angela Li Ping Chow, angela_chow@ttsh.com.sg

ABSTRACT
Chikungunya is a re-emerging mosquito-borne viral infection that has spread from East Africa to Indian Ocean islands and re-emerged in India since 2004. In Malaysia, chikungunya re-emerged after a hiatus of seven years, causing a localised outbreak in a north-western coastal town in 2006 and subsequently widespread outbreaks in 2008. Since the first local outbreak of chikungunya in Singapore in January 2008, chikungunya infections have been increasingly reported in Singapore. In this case series, five patients aged 37–62 years, with chikungunya infection confirmed in August 2008, were reported. Three of the five were male, and only one had medical comorbidities. Two had a travel history to Johor, Malaysia, where local outbreaks of chikungunya had been reported. Fever, arthralgia and rash were the most common symptoms. Fever lasted four to five days while viraemia lasted four to 11 days, persisting two to three days after defervescence in three patients. A biphasic pattern of fever was observed in two patients. Leucopenia was noted in all patients, while mild thrombocytopenia and transaminitis occurred in three of five patients. Two patients had persistent polyarthralgia at two to three weeks after the onset of symptoms. Fever, arthralgia and rash should prompt consideration of acute chikungunya in Singapore. While taking the travel history, doctors should be mindful that indigenous chikungunya cases can occur.

Keywords: arbovirus, arthralgia, chikungunya, infection outbreaks, mosquito-borne viral infection
Singapore Med J 2009; 50(8): 785-790

Agarwal AK, Gupta S, Bhattacharya N, Guha G, Agarwal A
Correspondence: Dr Akhilesh Kr Agarwal, akhil2u@rediffmail.com, akhil_g_2002@yahoo.com

ABSTRACT
Introduction Block dissection of inguinal lymph nodes is done in cases of malignant inguinal lymphadenopathy, which requires the removal of skin where it is involved, or elevation of the flaps which have precarious blood supply leading to necrosis. Thus, wound closure presents a big challenge. It can be done either by primary closure which is frequently complicated by necrosis, or by split thickness skin graft which is complicated by rejection on radiotherapy. Another option is to cover the wound by a vascularised pedicled graft. This prospective study was conducted after obtaining clearance from the ethical committee. The results were compared with the accepted complication rates of the operation.
Methods  We presented our experience of coverage of wounds after block dissection of inguinal lymph nodes for malignant deposits in 15 patients (with median age of 46 years) by pedicled tensor fascia lata thigh flap.
Results The results following the surgery were good. Healing was satisfactory in all 15 cases. There were two cases of marginal flap necrosis, and three cases developed lymphoedema which was managed by stockings. There were two cases of infection which were settled by antibiotics. There were three cases of loss of a small area of skin graft at the donor site. There was no reported case of recurrence in the inguinal region.
Conclusion This technique of coverage of the defect after inguinal block dissection is easy with predictable good results.

Keywords: groin malignancy, inguinal block, dissection, tensor fascia lata flap, vascularised pedicled graft
Singapore Med J 2009; 50(8): 781-784

Low SW, Ng YJ, Yeo TT, Chou N
Correspondence: Dr Low Shiong Wen, swlow@singnet.com.sg

ABSTRACT
Introduction The aim of this study was to evaluate the outcome of Osteoplug^TM, a novel biodegradable polymer burr-hole cover implant, used in patients with burr holes done for drainage of chronic subdural haematoma.
Methods 12 patients with chronic subdural haematoma had Osteoplug^TM implants inserted into their burr holes after evacuation of the haematoma. Osteoplug^TM is a biodegradable polycaprolactone implant with a mushroom-button shape, designed specifically to fit into a 14-mm diameter burr hole. It has an upper rim of 16-mm diameter and a body diameter of 14 mm, with a honeycomb-like architecture of 400-600 µm pore size. The Osteoplug^TM snaps onto the 14-mm diameter burr hole snugly after the evacuation of the liquefied haematoma is done. All 12 patients were followed up for a period ranging from ten months to two years (mean 16 months) postoperatively. They were evaluated for their clinical, radiological and cosmetic outcomes.
Results Osteoplug^TM provided good cosmesis by preventing unsightly depressions over the skull postoperatively in all the 12 patients. Postoperative computed tomography, done at one year, showed signs of good osteointegration into the surrounding calvarial bone, with multifoci mineralisation throughout the scaffold in one patient. There was no case of infection or any adverse systemic reaction noted. Patient satisfaction was high.
Conclusion The Osteoplug^TM polycaprolactone burr-hole covers are suitable, biodegradable implants with good medium-term results. They provide an ideal scaffold for osteogenesis and excellent cosmesis. There were no adverse events in all 12 patients, with a mean follow-up of 16 months.

Keywords: biodegradable polymer, burr-hole covers, osteoconduction, osteogenesis, Osteoplug^TM, polycaprolactone implants
Singapore Med J 2009; 50(8): 777-780

Leong BDK, Chuah JA, Kumar VM, Rohamini S, Siti ZS, Yip CH
Correspondence: Dr Benjamin Dak Keung Leong, bleongdk@yahoo.com

ABSTRACT
Introduction Sabah, formerly known as North Borneo, is part of East Malaysia. 52.2 percent of patients with breast cancer in Sabah presented at advanced stages and up to 20.4 percent of patients defaulted proper treatment, opting for traditional therapy. We performed a two-year prospective study looking at the treatment trends of breast cancer in Sabah.
Methods Our subjects were all newly-diagnosed breast cancer cases seen at the hospital in 2005 and 2006. Type of surgery, chemotherapy, radiotherapy, hormonal therapy and surgical complication for each patient were studied.
Results Out of 186 newly-diagnosed cases, 152 (81.7 percent) had surgery, 126 (67.7 percent) had chemotherapy, 118 (63.4 percent) had radiotherapy and 92 (49.5 percent) had hormonal therapy. 18.3 percent did not have surgery either due to refusal of treatment or advanced disease. They were more likely to be non-Chinese (91.1 percent, p-value is 0.02). Only 15.8 percent had breast-conserving surgery. The most frequent surgical complication was seroma formation (15.0 percent). The commonest chemotherapy regime and hormonal therapy were anthracycline-based regime (88.1 percent) and tamoxifen (95.8 percent), respectively.
Conclusion The proportion of breast-conserving surgery and usage of modern adjuvant therapies are low in Sabah. This can be attributed to lack of breast cancer awareness leading to late presentation and refusal of treatment, coupled with insufficient health service funding.

Keywords: advanced cancer, breast cancer, cancer awareness, cancer treatment
Singapore Med J 2009; 50(8): 772-776

Gill SS, Sebastian MG, Tan SG, Chia KH, Tan BS, Tay KH
Correspondence: Dr Mathew George Sebastian, mathewg.sebastian@sgh.com.sg

ABSTRACT
Introduction Endovascular aortic repair (EVAR) has gained prominence as a means of treating aortic disease, with lower perioperative morbidity and mortality compared to open surgery. This article aimed to describe the experience of two tertiary hospitals in a Southeast Asian population.
Methods A retrospective review of 100 consecutive patients undergoing EVAR in two hospitals in Singapore was conducted. This included patients undergoing elective as well as emergency repair.
Results The mean duration of follow-up was 31.8 months. The mean aneurysm size was 6.3 cm and the mean length of stay was 12.1 days. 64 percent of the patients were of American Society of Anesthesiologists class III or above. The deployment success was 98 percent. Major complications (acute myocardial infarction, pneumonia, cerebrovascular accidents, renal failure, colonic infarction and spinal cord infarction) occurred in 18 patients. Perioperative mortality occurred in six percent of cases. The endoleak rate was 28 percent. Both patients with colonic infarction had a single patent internal iliac artery post-procedure, and end-stage renal failure.
Conclusion Our results are comparable to published experiences in aortic stenting. Our population possibly had a higher incidence of short common iliac arteries. Revascularisation of internal iliac arteries should be considered for patients with end-stage renal failure and a single patent internal iliac artery.

Keywords: aorta, aortic aneurysm, aortic stent, endovascular aortic repair
Singapore Med J 2009; 50(8): 768-771

Ng KH, Lim YK, Ho KS, Ooi BS, Eu KW
Correspondence: Prof Eu Kong Weng, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction The use of robotics in colorectal surgery is relatively new. The first few cases of colonic surgery using da Vinci Surgical System were reported in 2002. Since then, several centres had reported on their experience, with favourable outcomes. Our department started to embark on robotics in colorectal surgery in December 2007. The aim of our paper was to share our early experience with robotics in colorectal surgery and provide an update on the current status of robotics.
Methods Preparations included formal training with the da Vinci Surgical System, certification of the surgeons, and obtaining Hospital Ethics committee approval. We used a hybrid technique of laparoscopic and robotic assistance in the resection of mid- to low-rectal cancer (total mesorectal excision). Laparoscopic approach was used to isolate the inferior mesenteric artery and for mobilisation of the left colon. The da Vinci robot was used in the dissection of the rectum down to the pelvic floor. We reviewed the outcomes of our early experience with emphasis on feasibility and safety.
Results Over a period of three months, we performed eight cases of robotic-assisted colorectal surgery for cancer. The median age of the patients was 55 (range 42–80) years. The median operating time was 192.5 (range 145–250) minutes. There were no intraoperative or postoperative complications related to the use of robotics. The median length of hospital stay was five (range 4–30) days.
Conclusion Robotic-assisted laparoscopic colorectal surgery is a safe and feasible procedure.

Keywords: da Vinci robotics, laparoscopic surgery, rectal cancer, robotic surgery, total mesorectal excision
Singapore Med J 2009; 50(8): 763-767