Original Article

Jahanfar S, Lye MS, Rampal L
Correspondence: Dr Shayesteh Jahanfar, jahanfar2000@yahoo.com

ABSTRACT
Introduction The aim of this study was to investigate the knowledge, attitudes and behaviour of university students regarding acquired immunodeficiency syndrome (AIDS) and the human immunodeficiency virus (HIV).
Methods A randomised controlled trial of 530 university students was done using peer-adult facilitators. Participants completed a questionnaire before and after the intervention, which was a four-hour group session. A prevention programme was developed by local experts, health educators and peer facilitators. The peer-adult-led programme was designed to provide a conceptual model of HIV risk reduction through information, motivational and behavioural skills, a harm reduction module and health promotion theme.
Results The main outcome measured was the level of knowledge, attitudes and behaviour scores. The results suggest that relative to the control group, participants in the intervention group had higher levels of knowledge (30.37 vs. 25.40; p-value is 0.001) and a better attitude (12.27 vs. 10.84; p-value is 0.001). However, there was no difference in the behavioural score (9.47 vs. 9.41; p-value is 0.530). The correlation between the level of knowledge and age and the level of education was found in the intervention group, but not in the control group (p-value is 0.01). Attitude and gender were found to be correlated in the intervention group only (p-value is 0.01).
Conclusion Our programme was successful in increasing knowledge and improving attitudes towards AIDS and HIV. However, it did not improve risk-taking behaviour. Peer-adult-led educational programmes for youth using various interactional activities, such as small group discussions, poster activity and empathy exercises, can be successful in changing the prevailing youth perceptions of AIDS and HIV.

Keywords: acquired immunodeficiency syndrome, health education, human immunodeficiency virus, sexually-transmitted disease
Singapore Med J 2009; 50(2): 173-180

Tian HH, Ong WS, Tan CL
Correspondence: Dr Tian Ho Heng, roger_tian@cgh.com.sg

ABSTRACT
Introduction Nutritional supplements used by athletes can be classified as sports food, dietary supplements and ergogenic aids. The aim of this study was to examine the use of such supplements among university athletes in Singapore.
Methods 82 athletes from 16 sport disciplines completed a questionnaire which sought information on demographical parameters, type of supplements, frequency of use, motivations, knowledge, expenditure and side effects.
Results The prevalence of supplement use was 76.8 percent and 20 different products were used. Each individual consumed a mean and standard deviation of 3.18 ± 1.7 products over a 12-month period. The mean number of products consumed daily was 2.1 ± 1.2. Popular products included sports drinks, vitamin C, multivitamins and traditional/herbal preparations such as essence of chicken, bird’s nest and ginseng. Before using a product, 65.9 percent sought information, usually from the media, the Internet, coaches and fellow athletes. However, many did not know where to obtain reliable information and 86.4 percent were also unaware that supplementation can have adverse effects.
Conclusion Although there is a high prevalence of supplement use in our study population, many do not have accurate information about these products. Hence, there is an urgent need to provide athletes with education and access to scientific and unbiased information.

Keywords: dietary supplements, ergogenic aids, nutritional supplements, sports food
Singapore Med J 2009; 50(2): 165-172

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

ABSTRACT
Introduction The Written Asthma Action Plan (WAAP) educates patients on the early recognition and treatment of deteriorating asthma. It has been adopted in Singapore polyclinics and restructured hospitals in the past few years as recommended by the Singapore National Asthma Programme. Local asthma patients can choose to be treated by family physicians at public polyclinics or by private general practitioners (GPs). In a previous study, half of the physicians in primary care self-reported that they formulated an asthma action plan for their patients, but little is known about their actual practices. This qualitative study explored family physicians’ views of WAAP and its implementation in primary care in Singapore.
Methods Qualitative data was obtained for 29 participants from polyclinics, GP clinics or locum doctors at five separate focus group discussions. The data was coded using NVivo-7 software, audited and analysed to identify emergent themes.
Results The participants generally perceived the usefulness of WAAP. While WAAP was widely used in polyclinics, GPs rarely used it. Even in polyclinics, usage varied and was associated with participants’ training and practice of WAAP and task substitution to nurses. They perceived that WAAP would benefit only selected motivated patients who could understand and use it. They were hampered by language barriers in educating their multiracial patients and the perceived lack of time related to patient loads in polyclinics. The GPs lacked training and practice, role models and relied on verbal instructions as a personalised form of care delivery.
Conclusion Family physicians generally perceived WAAP as useful, but implementation was hampered by lack of training and practice, language barriers and perceived benefits for patients.

Keywords: asthma, family physician training, Written Asthma Action Plan
Singapore Med J 2009; 50(2): 160-164

Boo NY
Correspondence: Prof Nem-Yun Boo, nemyun_boo@imu.edu.my

ABSTRACT
Introduction The neonatal resuscitation programme (NRP) published by the American Academy of Paediatrics and American Heart Association was launched in Malaysia in 1996. This study aimed to review the outcome of NRP in Malaysia during the first eight years.
Methods Information on basic demographical data and training activities of NRP providers were collected prospectively from NRP instructors from all over Malaysia during the eight years following the inception of the NRP. The national perinatal and neonatal mortality data during the five-year period before and eight years following implementation of the NRP were compared.
Results During the eight years following the launch, 14,575 personnel were trained. 40 percent of NRP-certified personnel worked in areas where delivery services were provided, viz. labour room, operation theatre, obstetric ward, emergency department and maternal and child health clinic. There were very few NRP-certified providers working in emergency departments and most of them were medical assistants. Most of the providers working in neonatal intensive care units (NICUs) and labour rooms were nurses while those in paediatric wards were doctors. All NRP-certified doctors working in NICUs and labour rooms obtained full certificates. Only 80 percent of NRP-certified nurses in these two areas obtained full certificates. There was further serial decrease in perinatal mortality and neonatal mortality rates in Malaysia during the years following the launch of the NRP programme.
Conclusion The launch of the Malaysian NRP was associated with further improvement in perinatal and neonatal mortality rates.

Keywords: neonatal mortality rates, neonatal resuscitation programme
Singapore Med J 2009; 50(2): 152-159

Sumathi B, Ramalingam S, Navaneethan U, Jayanthi V
Correspondence: Dr Udayakumar Navaneethan, navaneur@ucmail.uc.edu

ABSTRACT
Introduction Stomach cancer is the third most common cancer in South India. A higher incidence has been reported from certain states in northern India, where potential risk factors have been identified. Similar data is available only to a limited extent from southern India. The aim of this case-control study was to evaluate the effects of lifestyle habits and dietary factors on the risk of gastric cancer in South Indians.
Methods A hospital-based case-control study of matched pairs was conducted in Chennai, India, from 2002 to 2006 in a large tertiary care referral centre in South India. We studied 89 gastric cancer patients and 89 age- and gender-matched healthy controls of the same socioeconomic status. All subjects were interviewed face-to-face by a trained interviewer using a structured questionnaire to collect data about lifestyle habits, such as cigarette smoking, alcohol consumption, tobacco chewing and dietary factors, with special attention to known factors like salted fish, smoked and pickled foods as well as intake of vegetables and fruits.
Results The response rate was 100 percent. There were 64 male and 25 female patients. The male to female ratio was 2.6:1. The demographic characteristics were similar in the case and control populations. Less than ten percent of patients were below the age of 30 years. Approximately 50 percent were between 30 and 60 years of age, and the rest were over 60 years of age. Multivariate logistic regression models indicated that alcohol consumption (odds ratio [OR] 2.3, 95 percent confidence interval [CI] 1.1–4.9, p-value is 0.04) and consumption of pickled food (OR 1.8, 95 percent CI 1.2–3.9, p-value is 0.05) are independent risk factors for the development of gastric cancer. A protective effect of the consumption of pulses (OR 0.4, 95 percent CI 0.2–0.9, p-value is 0.05), showing a 55 percent reduction in risk, was also identified; this could be of use for possible control and prevention of this cancer. Tobacco chewing and cigarette smoking did not emerge as high risk factors for stomach cancer.
Conclusion The study showed alcohol and pickled food consumption as independent risk factors for the development of gastric cancer, while consumption of pulses were protective. Cigarette smoking did not predict an increased risk of contracting the disease.

Keywords: cancer risk factors, dietary factors, gastric cancer, stomach factors
Singapore Med J 2009; 50(2): 147-151

Manoharan S, Balakrishnan S, Menon VP, Alias LM, Reena AR
Correspondence: Dr Shanmugam Manoharan, sakshiman@rediffmail.com

ABSTRACT
Introduction Oral carcinoma accounts for 40–50 percent of all cancers in India. Tobacco chewing, smoking and alcohol consumption are the major risk factors associated with the high incidence of oral cancer in India. Our aim was to investigate the chemopreventive potential of curcumin and piperine during 7,12-dimethylbenz[a]anthra-cene (DMBA)-induced hamster buccal pouch carcinogenesis.
Methods Oral squamous cell carcinoma was developed in the buccal pouch of Syrian golden hamsters, by painting them with 0.5 percent DMBA in liquid paraffin, three times a week for 14 weeks. The tumour incidence, tumour volume and burden were determined in the buccal pouches. The status of phase II detoxification agents, lipid peroxidation and antioxidants were estimated by specific colorimetric methods.
Results We observed 100 percent tumour formation in DMBA-alone painted hamsters. Disturbances in the status of lipid peroxidation, antioxidants and phase II detoxification agents were noticed in DMBA-alone painted hamsters. Oral administration of curcumin (80 mg/kg body weight) and piperine (50 mg/kg body weight) to DMBA-painted hamsters on alternate days to DMBA painting for 14 weeks completely prevented the formation of oral carcinoma. Also, curcumin and piperine restored the status of lipid peroxidation, antioxidants and detoxifying agents in DMBA-painted hamsters.
Conclusion The chemopreventive efficacy of curcumin and piperine is probably due to their antilipidperoxidative and antioxidant potential as well as their modulating effect on the carcinogen detoxification process.

Keywords: 7,12-dimethylbenz[a]anthracene, antioxidants, buccal pouch carcinogenesis, curcumin, lipid peroxidation, oral carcinoma, piperine
Singapore Med J 2009; 50(2): 139-146

Sim HL, Seah M, Tan SM
Correspondence: Dr Tan Su-Ming, su_ming_tan@cgh.com.sg

ABSTRACT
Introduction The incidence of breast cancer in Asia is rapidly rising. Knowledge and perception often influence attendance at screening programmes. However, there has not been any survey to assess the level of knowledge of breast cancer in an Asian population. Singapore has a multiracial population and is the only Asian country with a national screening programme. We conducted a survey on 1,000 women to assess their level of knowledge and screening practices.
Methods A self-administered questionnaire was used, where one point was given for a correct answer and zero for an incorrect / “not sure” response. The maximum knowledge score was 19. The women were also surveyed for their screening practices. Points were not assigned to questions on practice.
Results The response rate was 100 percent. The mean score was 11.4 and the median was 12 (range 0–19). The scores were high for general knowledge and disease progression, but poor for risk factors, screening, symptoms and treatment. Several myths and misconceptions were prevalent. Only 53 percent did regular breast self-examination (BSE), while 57 percent of women aged 40 years and above had gone for a screening mammogram. Increasing age, Malay race, lower educational level, lower socioeconomic class and not knowing anyone with breast cancer were significant independent predictors of poor knowledge. Higher educational level and knowledge scores were significant independent predictors of BSE practice and screening mammogram attendance.
Conclusion Knowledge affects practice. Public education is required to correct misconceptions and focus on women with poor knowledge. This would help to improve screening attendance rates.

Keywords: breast cancer knowledge, breast self examination, public education, screening mammogram
Singapore Med J 2009; 50(2): 132-138

Cheng CL, Saw SM, Pang CE, Chee C
Correspondence: Dr Bobby CL Cheng, bobby_cheng@snec.com.sg

ABSTRACT
Introduction This study aimed to describe the morphology of age-related macular degeneration (AMD) as well as to obtain an estimate of the population-based incidence rate in Singapore.
Methods This is a retrospective hospital-based study of AMD cases seen in 1991 and 1992 at the Singapore National Eye Centre (SNEC), a tertiary eye centre. All case notes recorded with the International Classification of Diseases, ninth revision, clinical modification code ‘362.5’, which is ‘degenerations of the macula’, were retrieved and analysed. Only case notes of patients who were aged 50 years and above and with documented AMD were included in the study.
Results There were 41 (21.8 percent) patients with drusen alone, 39 (20.7 percent) with dry AMD and 108 (57.5 percent) with exudative AMD. The morphology of the disease was similar among the Chinese and non-Chinese and there were no gender differences. A significant majority of patients with dry and exudative AMD had legal blindness at presentation (p-value is less than 0.0001). Notably, 27 (33.3 percent) patients with exudative AMD had improved vision with time. In comparison, the majority of patients with dry AMD or drusen alone tended to have the same or worsening visual acuity over time. The two-year SNEC hospital incidence rate of AMD in 1991–1992 was 0.38 percent or equivalent to 3.8 per 1,000 new cases seen at SNEC. The estimated population-based incidence rate of exudative AMD was 0.02 percent.
Conclusion The population incidence of exudative AMD is lower but comparable to the Western population. Patients with exudative AMD tend to have poorer vision as compared to patients with geographical atrophy or drusen. The proportion of exudative AMD to geographical atrophy appears to be higher than in the West.

Keywords: age-related macular degeneration, drusen, dry age-related macular degeneration, exudative age-related macular degeneration, macular degeneration
Singapore Med J 2009; 50(2): 126-131

Lim LH, Lee SY, Ang CL
Correspondence: Dr Ang Chong Lye, ang.chong.lye@snec.com.sg

ABSTRACT
Introduction This study aims to evaluate the factors affecting the accuracy of biometry assessment using the SRK II formula in predicting the refractive outcome after uneventful cataract surgery by phacoemulsification for eyes within the normal range of axial lengths.
Methods A retrospective review of 100 consecutive cases of uncomplicated phacoemulsification surgery performed by two surgeons from January to September 2005 in a single centre was done. Eyes with axial length greater than or equal to 22.5 mm and less than 24.5 mm were included in the study. The error of prediction was calculated by actual postoperative refractive error minus the refraction target. A comparison was made between the low predictability (prediction error more than 0.50 dioptres [D]) and high predictability (prediction error less than or equal to 0.50 D) groups of eyes. Statistical analysis was performed.
Results A total of 267 case notes were reviewed, of which 100 met the inclusion criteria. The mean age was 68.3 years, with a mean keratometric reading of 43.94 +/- 1.27 D and mean axial length of 23.38 +/- 0.51 mm. The mean IOL power used was 21.77 +/- 1.50 D. The mean error was +0.25 +/- 0.67 (range -1.58 to +1.80)D, with the standard error of mean 0.669. 45 percent of the patients were within 0.5 D of the predicted refractive error and 83 percent were within 1.0 D. There was no difference in preoperative corneal astigmatism, mean keratometry, axial length, age or gender of the patient, laterality of the operated eye and intraocular lens power between the low and high predictability groups. There was a negative correlation between the axial length and prediction error.
Conclusion SRK II is reliable in the prediction of the refractive outcome in normal axial length eyes. The findings in our study are comparable to those found in previous studies. We found a negative correlation between axial length and prediction error, even within the range of normal axial length eyes.

Keywords: biometry, cataract surgery, eye axial length, phacoemulsification surgery, SRK II formula, target refraction
Singapore Med J 2009; 50(2): 120-125

Shobeiri E, Khalatbari MR, Taheri MS, Tofighirad N, Moharamzad Y
Correspondence: Dr Yashar Moharamzad, yasharpop@hotmail.com

ABSTRACT
Introduction This study aimed to compare the characteristics of magnetic resonance (MR) imaging in patients with low back pain (LBP) and those with sciatica.
Methods Clinical examination and MR imaging were performed on 100 sciatic and 100 LBP patients who were matched by age and gender. Different findings, including spinal canal stenosis, spondylolisthesis, the degree of disc herniation (bulge, protrusion, and extrusion) and nerve root compression, were documented. MR imaging findings were compared using the chi-square and Mann-Whitney U tests.
Results 11 percent of LBP patients and 37 percent of sciatic patients had spinal canal stenosis (p-value is less than 0.001). Spondylolisthesis was found in 12 percent of LBP patients and 14 percent of sciatic patients (p-value is 0.6). Disc extrusion was more common in patients with sciatica as compared to LBP patients at the L4–L5 level (29 percent vs. 4 percent; p-value is less than 0.001) and at the L5–S1 level (24 percent vs. 3 percent; p-value is less than 0.001). Nerve root compression was also more common in sciatic patients in the thecal sac (58 percent vs. 20 percent; p-value is less than 0.001) and in the lateral recess (73 percent vs. 19 percent; p-value is less than 0.001) than in LBP patients.
Conclusion Patients with sciatica were more likely to have spinal canal stenosis, disc extrusion (at L4–L5 and L5–S1 levels) and nerve root compression in the thecal sac and lateral recess.

Keywords: disc extrusion, low back pain, magnetic resonance imaging, nerve root compression, sciatica, spinal canal stenosis
Singapore Med J 2009; 50(1): 87-93