Original Article

Kumar P, Kaman L, Singh G, Singh R
Correspondence: Dr Lileswar Kaman, kamanlil@yahoo.com

ABSTRACT
Introduction Nonoperative measures using an oral water soluble contrast agent is a significant development in the management of patients with postoperative small bowel obstruction.
Methods In this prospective randomised trial, patients were randomised into two groups: Group A patients were given an oral water soluble contrast agent and Group B patients were managed conventionally. Surgery was performed as and when indicated. The end-points of the study were to evaluate the time interval between admission and relief of obstruction, the length of hospital stay and the need for surgery.
Results Of a total of 41 patients, 21 were in Group A and 20 were in Group B. The mean age of Group A patients was 40.48 +/- 14.96 years and it was 43.40 +/- 16.33 years for Group B patients (p-value is 0.553). There were 17 males and four females in Group A, and 14 males and six females in Group B (p-value is 0.441). In Group A, 14 patients had relief of obstruction after administration of the contrast material, and the mean time for relief of obstruction was 7.47 hours. In Group B, 18 patients had relief of obstruction and the time interval was 35.20 hours (p-value is less than 0.001). The mean length of hospital stay was 3.43 +/- 1.08 days for Group A and 5.33 +/- 2.95 days for Group B (p-value is 0.029). Seven patients in Group A and two in Group B were operated on (p-value is 0.071).
Conclusion Administration of an oral water soluble contrast agent in postoperative small bowel obstruction helps in the earlier resolution of the obstruction and decreases the length of hospital stay.

Keywords: intestinal obstruction, nonoperative management of bowel obstruction, postoperative small bowel obstruction, small bowel obstruction
Singapore Med J 2009; 50(4): 360-364

Wang E, Kow AWC, Chan CY, Liau KH, Ho CK
Correspondence: Mr Ho Choon Kiat, choon_kiat_ho@ttsh.com.sg

ABSTRACT
Introduction Laparoscopic hepatectomy has been performed in many overseas centres. By avoiding long incisions associated with open hepatectomies, patients suffer less pain, recover faster and enjoy a shorter hospital stay. In Singapore, many centres have recently embarked on this approach. We believe that careful patient selection can facilitate scaling the learning curve. The aim of this study was to review our centre’s initial outcome with laparoscopic anatomical liver resection when stringent selection criteria were applied.
Methods For our initial experience, we based our patient selection on criteria recommended by centres more experienced with laparoscopic hepatectomy. We selected only patients with small lesions confined to Couinaud’s liver segments of II, III, IVB, V and VI. The surgical technique was similar in all cases, including intraoperative ultrasonography for localisation, ultrasonic shears and surgical staplers for parenchymal transection, and delivery of the specimen via a Pfannenstiel incision. No hand ports were used. Patients’ records were retrospectively reviewed.
Results Between July 2006 and August 2007, we had five consecutive patients. Their median age was 50 (range 36–66) years. Four of these patients had hepatocellular carcinomas and one had a liver abscess. The median operation time was 275 (range 250–290) minutes, and median intraoperative blood loss was 400 (range 200–700) ml. The median hospital stay was four days.
Conclusion At the initial stages of a laparoscopic hepatectomy programme, we propose that a stringent patient selection criteria coupled with the proper surgical expertise can ensure favourable outcomes, comparable to more established centres.

Keywords: hepatectomy, laparoscopic hepatectomy, laparoscopy, liver surgery, liver tumour
Singapore Med J 2009; 50(4): 354-359

Chew MH, Suzanah N, Ho KS, Lim JF, Ooi BS, Tang CL, Eu KW
Correspondence: Prof Kong Weng Eu, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction Colorectal cancer (CRC) is a leading cause of morbidity and mortality with human and financial costs. Screening by faecal occult blood test (FOBT) has proven to be effective in decreasing mortality from CRC in both randomised trials and case-control studies. We report on the results of a CRC screening event using quantitative FOBT (QFOBT) held in Singapore.
Methods The mass screening event was held over two days, and participants 40 years or older without prior screening performed in the preceding year were eligible. Those with significant symptoms or medical comorbidities were excluded. Stool sampling was done with two issued immunochemical QFOBT kits, and participants with positive stool samples with equal or greater than 100 ng haemoglobin/ml sample solution in any two samples were advised to have a colonoscopy screening conducted.
Results A total of 1,048 participants took part in the screening event. 222 (21 percent) of the participants claimed to have some abdominal symptoms prior to screening. 49 participants (26 males, 23 females) tested positive for QFOBT and 47 were evaluated. 10 (21 percent) had polyps and one case of colorectal cancer was detected. Seven of these cases had significant neoplasia (lesions 1 cm or larger) and were treated. Two patients required surgery.
Conclusion Our study demonstrates wide variation in the attitudes of participants who turned up for screening. In addition, the number of significant colorectal neoplasia patients (14 percent) in those with positive QFOBT provides further evidence of the importance of screening with a potential reduction in CRC mortality. Continuous education of the public in events such as this, is essential to improving attitudes towards screening.

Keywords: cancer screening, colorectal cancer, faecal occult blood test, quantitative faecal occult blood test
Singapore Med J 2009; 50(4): 348-353

Tan NC, Tay IH, Ngoh A, Tan M
Correspondence: Dr Tan Ngiap-Chuan, tan.ngiap.chuan@singhealth.com.sg

ABSTRACT
Introduction Little is known about the decision pathway that family physicians (FP) take in considering drug therapy for their asthma patients. This study aimed to explore the factors that influence FPs’ decisions in prescribing medications for their asthma patients.
Methods A qualitative method using focus group discussions (FGD) was used to gather qualitative data based on a semi-structured topic guide from FPs of different training backgrounds and practices. 29 Singapore FPs working as private general practitioners (GP), polyclinic doctors and locums were recruited into five FGDs.
Results The FPs’ asthma drug prescription decisions were related to the FPs’ medical training and acquisition of asthma-related information and updates. Uncertainty of disease diagnosis, patients’ beliefs and their perceptions of the disease and treatment, as well as the FPs’ concerns about drug side effects, were significant considerations for the participants. Costs related to differential subsidies in the consultation fees and drugs between public polyclinics and GP clinics in the local primary healthcare system, was a key factor in influencing the FPs’ asthma drug treatment decisions.
Conclusion FPs’ asthma drug prescribing behaviour is influenced by their medical training, disease definition, patient factors and drug costs in the context of the local primary healthcare system and policy.

Keywords: asthma, qualitative research, family physician, drug prescription
Singapore Med J 2009; 50(3): 312-319

Khor GL, Zalilah MS, Phan YY, Ang M, Maznah B, Norimah AK
Correspondence: Prof Khor Geok Lin, khorgl@medic.upm.edu.my

ABSTRACT
Introduction Body image concerns are common among adolescents as they undergo rapid physical growth and body shape changes. Having a distorted body image is a risk factor for the development of disordered eating behaviours and eating disorders. This study was undertaken to investigate body image concerns among Malaysian male and female adolescents aged 11–15 years.
Methods A total of 2,050 adolescents (1,043 males and 1,007 females) with a mean age of 13.1 +/- 0.8 years from secondary schools in Kedah and Pulau Pinang were included in the study. Questionnaires were used to collect socioeconomic data and body image indicators.
Results The majority (87 percent) of the adolescents were concerned with their body shape. While the majority of underweight, normal weight and overweight male and female subjects perceived their body weight status correctly according to their body mass index (BMI), a noteworthy proportion in each category misjudged their body weight. About 35.4 percent of the males and 20.5 percent of the females in the underweight category perceived themselves as having a normal weight, while 29.4 percent and 26.7 percent of the overweight males and females respectively also perceived that they had a normal weight. A higher proportion of the females (20 percent) than males (9 percent) with a normal BMI perceived themselves as fat. Most of the male (78–83 percent) and female subjects (69–74 percent) in all the BMI categories desired to be taller than their current height. An appreciable proportion of both the males (41.9 percent) and females (38.2 percent) preferred to remain thin, or even to be thinner (23.7 percent of males and 5.9 percent of females). Females had a significantly higher mean body dissatisfaction score than males, indicating their preference for a slimmer body shape. More males (49.1 percent) preferred a larger body size while more females (58.3 percent) idealised a smaller body size. Compared to normal weight and underweight subjects, overweight males and females expressed lower confidence and acceptance levels, as well as expressed greater preoccupation with and anxiety over their body weight and shape.
Conclusion As having a distorted body image may lead to negative effects such as unhealthy eating habits and disordered eating behaviours, it is recommended that appropriate educational efforts on body image be incorporated into school health activities for adolescents.

Keywords: adolescents, body image, eating habits, school health
Singapore Med J 2009; 50(3): 303-311

Nivethetha M, Jayasri J, Brindha P
Correspondence: Dr Pemiah Brindha, brindhajana@yahoo.com

ABSTRACT
Introduction This study was designed to scientifically evaluate the effects of an aqueous extract of Muntingia calabura L. (M. calabura), a medicinal herb, on isoproterenol-induced myocardial infarction (MI) in rat models.
Methods Six groups of Wistar albino rats, each comprising six animals,were selected for this study.Group I served as a control,Group II rats were given isoproterenol (20 mg/100g, subcutaneously), and Group III rats were given M. calabura leaf extract (300 mg/kg). Groups IV, V and VI rats were given M. calabura leaf extract (100 mg/kg, 200 mg/kg and 300 mg/kg, respectively) and isoproterenol (20 mg/100g subcutaneously) prior to MI induction. The transaminases (aspartate transaminase and alanine transaminase), lactate dehydrogenase (LDH) and creatine phosphokinase (CK), were estimated in both the serum and heart tissues, and the serum uric acid level was also estimated.
Results Isoproterenol significantly increased the activities of CK, LDH and the transaminases in serum with a concomitant decrease in these enzymes in tissue. Pretreatment with the aqueous leaf extract of M. calabura at a dose of 300 mg/kg body weight for 30 days had a significant effect on the activities of marker enzymes compared to the other groups. Serum uric acid level, which increased on isoproterenol administration, registered near normal values on treatment with the leaf extract under study.
Conclusion The study confirms the protective effects of M. calabura leaf extract against isoproterenol-induced biochemical alterations in rats.

Keywords: isoproterenol, leaf extract, Muntingia calabura, myocardial infarction, uric acid
Singapore Med J 2009; 50(3): 300-302

Amran AA, Zaiton Z, Faizah O, Morat P
Correspondence: Dr Zaiton Zakaria, zaitonz@medic.ukm.my

ABSTRACT
Introduction The fruit extract of Garcinia atroviridis (G. atroviridis) contains hydroxycitric acid and flavonoids, which have been reported to have a hypolipidaemic property. This extract with solvent methanol was used to investigate its effects on serum lipid profiles of guinea pigs fed a high cholesterol diet.
Methods 24 male Dunkin Hartley guinea pigs were randomly divided into four groups. The first group served as controls and was fed with commercial rabbit chow. The second group was given only G. atroviridis by oral gavage (50 mg/body weight). The third group was fed a one percent cholesterol diet in food pellets in order to induce atherosclerosis. The fourth group was administered G. atroviridis with cholesterol. All the treatments were given daily for eight weeks, after which the animals were sacrificed, and the blood and aorta were taken for biochemical analysis and histological studies.
Results The supplementation of G. atroviridis with a cholesterol diet decreased the level of lipid profile in the serum. Histological studies showed a reduction in fat deposition in the aorta of high cholesterol diet animals given G. atroviridis as compared to the high cholesterol diet group.
Conclusion This study has shown that dietary intake of G. atroviridis has a tendency to decrease lipid composition levels in the serum and reduce fat deposition in the aorta of high cholesterol diet animals.

Keywords: atherosclerosis, cholesterol, Garcinia atroviridis, lipid profile
Singapore Med J 2009; 50(3): 295-299

Lamri-Senhadji MY, El Kebir B, Belleville J, Bouchenak M
Correspondence: Prof M Bouchenak, mbouchenak@netcourrier.com

ABSTRACT
Introduction During the month of Ramadan, fasting is obligatory for all healthy adult Muslims, with the only exempted adults being those who have to travel or are sick. The aim of this study was to see whether changes in food intake and meal patterns during Ramadan fasting could modify serum lipid and lipoprotein parameters in healthy Algerian young men and women volunteers. The time-course prospective study was done in order to investigate at what time eventual changes to these parameters occur during Ramadan and their disappearance after Ramadan.
Methods Subjects were interviewed by trained interviewers using the method of the “seven day recall and record”, before, during and after Ramadan. The serum lipid and lipoprotein contents were analysed at different times.
Results The total energy intake was higher during Ramadan (13 and 11 MJ/day) than before and after Ramadan (11 and 9 MJ/day) in men and women, respectively. In the second week of Ramadan, carbohydrate intake was elevated by 22 percent and 24 percent in men and women, respectively, compared to before and after Ramadan. At the end of Ramadan, the low density lipoproteins (LDL) percentages decreased by 20 percent in women and 55 percent in men compared to the values obtained before Ramadan. In both groups, the amount of serum high density lipoproteins (HDL) was 1.4-fold higher, in particular on day 28 of Ramadan, in comparison with the period before and after Ramadan. Indeed, a progressive decrease in LDL-C was noted in women and was particularly drastic in men. In contrast, HDL-C had increased by 30 percent on day 15 of Ramadan, compared to before Ramadan.
Conclusion This study shows that striking changes in nutritional habits during Ramadan may be useful in reducing LDL levels and in increasing HDL levels. The young Muslim’s diet during Ramadan may contribute to favourable modifications of the serum lipoprotein profile related to cardiovascular protection.

Keywords: cholesterol, dietary consumption, lipids, lipoproteins, Ramadan
Singapore Med J 2009; 50(3): 288-294

Tan VKM, Tan SG
Correspondence: Dr Veronique KM Tan, vquetan@gmail.com

ABSTRACT
Introduction The aim of this study was to describe an original technique of using ultrasound-guided foam sclerotherapy in the long saphenous veins (LSV) for the treatment of varicose veins, and report the early results.
Methods Only patients with lower limb varicose veins and demonstrable incompetent saphenofemoral junction with reflux down the LSVs underwent ultrasound-guided injection of foam sclerosant into the LSV. Foam sclerosant was made by the Tessari’s method using three percent sodium tetradecyl sulphate to air in a 1:3 ratio. The LSV was accessed below the knee with a micropuncture set. A Headhunter angiographic catheter was cut to length and advanced over a guide wire to the saphenofemoral junction (SFJ). With the patient in the Trendelenburg position and the leg raised, the SFJ was manually compressed and foam was injected into the Headhunter catheter while the tip was withdrawn. Direct ultrasound visualisation ensured accurate catheter placement.
Results 66 lower limbs in 62 patients were treated in the manner described above. The diameter of the treated LSV ranged from 4 to 13.4 mm. Ultrasound duplex assessment one day post-treatment showed complete occlusion in 62 veins (94 percent). Early complications included superficial thrombophlebitis, skin pigmentation, cellulitis and thrombosis of the superficial femoral vein.
Conclusion Immediate results using our method of ultrasound-guided foam sclerotherapy showed a high obliteration rate of the LSV.

Keywords: foam sclerotherapy, long saphenous vein, ultrasound-guided sclerotherapy, varicose veins
Singapore Med J 2009; 50(3): 284-287

Yeo YYC, Lee SK, Lim CY, Quek LS, Ooi SBS
Correspondence: Dr Cindy Yeo Ying Ying, cindy.yeo@nathealthgroup.com

ABSTRACT
Introduction The elderly population in Singapore is steadily increasing, thus increasing the stress on healthcare provision and financing. Elderly injuries result in significant mortality and morbidity. This study aimed to identify the injury patterns, specific risk factors involved and needs of the elderly so that the current emergency model of care for the injured elderly can be improved and injury prevention strategies devised.
Methods We conducted a retrospective study of all elderly aged 65 years and older seen for trauma in an emergency department over six months. Data captured in the real-time computer system was studied with regard to patient profile, mechanism of injury and patient disposition.
Results 720 patients aged 65 years and older were seen for trauma in the first six months of 2005, accounting for 10.4 percent of the total attendance for that age group. Home injuries (67.9 percent) were the most common, followed by road-related injuries (21.2 percent). 85.3 percent of the injuries were due to falls. 49.9 percent of the patients were admitted to hospital. We also examined the underlying causes of the injuries and the common injuries sustained.
Conclusion Injuries in the elderly is a significant problem. Most of the injuries occur at home and falling is the commonest cause. Many of the injuries are potentially preventable. Several possible injury prevention strategies and improvements to the current emergency model of care of the injured elderly are discussed. The establishment of a national elderly injury surveillance database is advocated.

Keywords: elderly injuries, emergency department, falls, geriatric injuries, trauma
Singapore Med J 2009; 50(3): 278-283