Original Article

Metin M, Yeginsu A, Sayar A, Alzafer S, Solak O, Ozgul A, Erkorkmaz U, Gürses A
Correspondence: Dr Ali Yeginsu, yeginsu@hotmail.com

ABSTRACT
Introduction The purpose of this study was to investigate the results of minimally invasive treatment modalities in early stage multiloculated empyema thoracis.
Methods The minimally invasive treatment modalities of 114 patients with Class 5 thoracic empyema were retrospectively reviewed. The patients’ demographics, symptoms, diagnostic studies, treatment options and complications were evaluated.
Results A total of 47 patients underwent tube thoracostomy, 23 patients underwent fibrinolytic therapy with streptokinase and 44 patients underwent video-assisted thoracoscopic surgery (VATS) deloculation and debridement. No statistical differences were found in the patients’ age, gender, Gram stain and antibiotherapy before intervention among the groups. Illness days before intervention was significantly longer in the tube thoracostomy group than in the others. The VATS group had a shorter drainage time and hospital stay than the others. The VATS and fibrinolytic therapy groups had lower complication rates and less open decortication requirements than the tube thoracostomy group. Success rates were 66, 95 and 100 percent in the tube thoracostomy, fibrinolytic therapy and VATS groups, respectively. In total, there were 35 patients with complications. The most frequent complication was air space. Two in-hospital mortalities occurred.
Conclusion In patients with early stage multiloculated empyema, VATS deloculation and debridement is superior to tube thoracostomy alone and fibrinolitic therapy in reducing drainage time and hospital stay. It has a relatively high success rate without significant morbidity. Therefore, VATS decortication may be recommended as a first-line therapy in early stage multiloculated empyema thoracis.

Keywords: decortication, fibrinolytic therapy, empyema, tube thoracostomy, VATS
Singapore Med J 2010; 51(3): 242-246

Shahrulazua A, Ariff Sukimin MS, Tengku Muzaffar TMS, Yusof MI
Correspondence: Dr. Shahrulazua Ahmad, drshahahmad@hotmail.com

ABSTRACT
Introduction The purpose of this study was to evaluate the early functional outcome following the use of a bioabsorbable suture anchor to simplify the repair of injured lateral ankle structures as a variation of an established technique known as the Brostrom-Gould procedure.
Methods This was a prospective study of 30 ankles with chronic lateral instability that underwent a modified Brostrom-Gould surgery using a bioabsorbable suture anchor, performed by a single surgeon. A total of 29 patients, aged 15 to 52 (mean is 33) years, were enrolled in the study. The follow-up period ranged from three to six (mean is four) months. The function of the patients’ ankles was scored using the Kaikkonen Functional Scale, both preoperatively and postoperatively.
Results Preoperatively, all ankles had poor scores (less than 50). Postoperatively, 28 ankles showed excellent scores and two ankles showed good scores, while none obtained a fair or poor score. The difference in the overall means between the postoperative and preoperative scores was statistically significant (p-value is 0.001). Post surgery, 24 ankles had no symptoms, while six had only mild ankle tightness with extreme inversion movement at the last review. All patients were able to walk normally, and 29 ankles regained their normal running capability. There was marked improvement in the ability to descend stairs, to rise on heels and toes, to perform a single-limb stance, and in range of motions of the ankle dorsiflexion as well as in ankle laxity.
Conclusion The modified Brostrom-Gould procedure using a bioabsorbable suture anchor allowed for early ankle rehabilitation and offered a reproducible and excellent early functional outcome with minimal complications.

Keywords: bioabsorbable, Brostrom-Gould, functional outcome, joint instability, suture anchor
Singapore Med J 2010; 51(3): 235-241

Ibraheem NK, Ahmed JH, Hassan MK
Correspondence: Dr Jawad H Ahmed, jawadahmed_basmed@yahoo.com

ABSTRACT
Introduction Various drugs have been investigated in the treatment of sickle cell disease (SCD), such as hydroxyurea, piracetam and calcium antagonists. Most of these drugs are potentially toxic and are not suitable for long-term therapy. Recently, Nigella sativa (NS) has been reported to have calcium antagonist and antioxidant activities, both of which play a role in the management of the disease. This study aimed to investigate the in vitro antisickling effect of extracts from NS.
Methods Thirty-two patients with SCD, aged 7–47 years old, were recruited for the study. A total of 3 ml of venous blood was collected from each patient and divided into six tubes with heparin. The blood was mixed with 0.5 ml of either 0.1 percent, 0.05 percent or 0.01 percent v/v of the oil extract of NS. A slide was prepared by spreading a drop of treated blood, covered with a cover slide to ensure the complete deoxygenation condition. The separation of irreversibly sickled cells (ISCs) was performed on eight patients by a density gradient (Percoll-Renografin) centrifugation method.
Results The 0.1 percent v/v concentration of the oil extract of NS resulted in an approximately 80 percent reduction in the formation of sickle cells. The 0.05 percent v/v concentration of NS produced an intermediate effect, while the 0.01 percent v/v concentration had no effect on the formation of sickle cells. The 0.1 percent v/v concentration of the fixed oil of NS led to a considerable reduction in the formation of ISCs.
Conclusion The fixed oil extracted from NS seeds has an in vitro antisickling activity.

Keywords: antioxidant, antisickling, fixed oil extract, Nigella sativa
Singapore Med J 2010; 51(3): 230-234

Sahu S, Mohanty NK, Rath J, Patnaik SB
Correspondence: Dr Samir Sahu, samirsahu_kal@yahoo.co.in

ABSTRACT
Introduction Malaria remains a major health concern in tropical and subtropical countries. A large number of cases of malaria have been reported from the State of Orissa, India. Severe malaria cases are reported throughout the year, but they are more common during the high transmission season. The last decade has witnessed a changing pattern of presentations and complications across the country. Severe falciparum malaria is an important cause of multiple organ failure in Indian intensive care unit (ICU) patients.
Methods All patients with severe falciparum malaria above the age of 14 years admitted to the ICU were included in this study. The clinical spectrum of severe falciparum malaria in a tertiary care level III ICU was analysed from December 1998 to June 2008. In all, there were 301 patients with severe malaria admitted to the ICU during that period.
Results Most patients (66.9 percent) had a history of fever for less than seven days. The age distribution of the patients was 38.24 +/- 14.24 years. The Sequential Organ Failure Assessment score at admission to the ICU was 10.44 +/- 4.26. The median duration of ICU stay was three days (range 0–15 days) and 42 percent of the patients required ventilator support. Approximately 48 percent and 42 percent of patients required blood component transfusion and renal replacement therapy, respectively. The rate of single organ involvement was relatively low and multi-organ dysfunction was very common. Jaundice with acute renal failure (ARF) was the most common presentation (13.28 percent), followed by cerebral malaria with jaundice and ARF (6.37 percent), and jaundice, ARF and acute respiratory distress syndrome (ARDS) (5.31 percent). The overall mortality rate was 35.4 percent. Multivariate logistic regression analysis was conducted to estimate the association of the complications with mortality. Shock, ARF, seizure and ARDS were associated with higher mortality.
Conclusion Severe falciparum malaria is a common cause of multi-organ failure in the ICUs in eastern India. There has been no change in the pattern of presentations over the last ten years in the east Indian state of Orissa. Apart from early diagnosis and treatment, good supportive care is the mainstay for better outcome in these cases.

Keywords: clinical spectrum, ICU, malaria complications
Singapore Med J 2010; 51(3): 226-229

Chong CF, Adi MIW, Thien A, Suyoi A, Mackie AJ, Tin AS, Tripathi S, Jaman NH, Tan KK, Kok KY, Mathew VV, Paw O, Chua HB, Yapp SK
Correspondence: Mr Chong Chee Fui, chong_chee_fui@hotmail.com

ABSTRACT
Introduction Acute appendicitis is one of the most common surgical emergencies. The Alvarado and modified Alvarado scores have been developed to aid diagnosis, but both scoring systems have poor sensitivity and specificity when applied in Middle Eastern and Asian populations. The aim of this study was to develop a new scoring system that is suitable for the local population.
Methods Clinical data from 312 patients who had undergone an emergency appendicectomy was retrospectively collected and used to generate 15 parameters. The probability was calculated and a score of 0.5, 1.0 or 2.0 was allocated to each parameter. The receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived using the StatsDirect statistical software.
Results The 15 parameters and the scores generated were age (less than 40 years is 1 point; greater than 40 years is 0.5 point), gender (male is 1 point; female is 0.5 point), right iliac fossa (RIF) pain (0.5 point), migration of pain to RIF (0.5 point), nausea and vomiting (1 point), anorexia (1 point), duration of symptoms (less than 48 hours is 1 point; more than 48 hours is 0.5 point), RIF tenderness (1 point), guarding (2 points), rebound tenderness (1 point), Rovsing’s sign (2 points), fever (1 point), raised white cell count (1 point), negative urinalysis (1 point) and foreign national registration identity card (1 point). The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 88 percent, a specificity of 67 percent, a PPV of 93 percent and an NPV of 53 percent. The negative appendicectomy rate decreased significantly from 16.3 percent to 6.9 percent, which was a 9.4 percent reduction (p is 0.0007).
Conclusion The new appendicitis scoring system looked promising when applied to our settings, and had a better sensitivity and specificity than the Alvarado score when applied to Asian populations. A significant reduction in the negative appendicectomy rate was also predicted. A prospective evaluation of this new appendicitis scoring system, referred to as the RIPASA score, is ongoing.

Keywords: acute appendicitis, appendicectomy, diagnostic techniques, surgical, symptoms
Singapore Med J 2010; 51(3): 220-225

Chitra R
Correspondence: Dr Ramasamy Chitra, vjwchitra@yahoo.co.in

ABSTRACT
Introduction Vascular patterns are important in the planning and performance of all upper abdominal surgical procedures. The coeliac trunk arises from the abdominal aorta and supplies the supracolic organs. Knowledge of variations of the coeliac trunk is important in procedures such as liver transplants for appropriate vascular ligation and anastomosis.
Methods The branching patterns of the coeliac trunk of 50 cadavers (40 male, 10 female) were recorded and analysed during routine dissection by undergraduate students from the Department of Anatomy, NRI Medical College and Siddhartha Medical College, India, from 2003 to 2008. Observations on clinically important variations of the coeliac trunk were noted.
Results The patterns of branching of the coeliac trunk were observed to vary from classical trifurcation to abnormal trifurcation, bifurcation, quadrifurcation, pentafurcation and even hexafurcation of the trunk. The additional branches of the trunk included the inferior phrenic artery, gastroduodenal artery, middle colic artery, dorsal pancreatic artery, jejunal or duodenal branch. Clinically relevant variations of the coeliac trunk were noted in many cases.
Conclusion Variations of the coeliac trunk must be carefully understood in anastomosing the proper arteries in liver transplant surgeries. Knowledge of the variations of the branches of the coeliac trunk, such as the left gastric artery, gastroduodenal artery and middle colic artery, is important when performing surgery of the stomach, duodenum and pancreas.

Keywords: bifurcation, coeliac trunk, hexafurcation, pentafurcation, quadrifurcation, trifurcation
Singapore Med J 2010; 51(3): 216-219

Baral P, Lobo SW, Menezes RG, Kanchan T, Krishan K, Bhattacharya S, Hiremath SS
Correspondence: Dr Kewal Krishan, gargkk@yahoo.com

ABSTRACT
Introduction Facial anthropometry has well-known implications in health-related fields and has been utilised for forensic purposes in the past. It provides an indication of the variations in facial shape in a population. The facial anthropometric profile of a population can characterise the distinctive features of a likely face in that population. The present study aimed to examine the differences in facial height proportions and facial growth patterns in different communities in the Sunsari district of Nepal.
Methods The upper facial height (UFH) and lower facial height (LFH) proportions of 857 subjects (429 male and 428 female) aged between three and 18 years old from four communities (Brahmin, Chhetri, Rai and Limbu) in the Sunsari district of Nepal were calculated, and comparisons were made.
Results Significant differences (p is less than 0.05) in the UFH and LFH percentages were observed between the Brahmin and Rai, Brahmin and Limbu, Chhetri and Rai, and Chhetri and Limbu communities.
Conclusion The study concluded that there is evidence of statistically significant differences of the upper and lower face height proportions among the different racial groups. A change in the facial height proportions of the various age groups was evident. However, differences in facial height proportions between male and female were found to be insignificant.

Keywords: anthropometry, cephalometry, facial ergonomics, Nepal, upper and lower face height
Singapore Med J 2010; 51(3): 212-215

Afolabi EO, Kuti O, Orji EO, Ogunniyi SO
Correspondence: Dr Ernest O Orji, eoorji11@yahoo.com

ABSTRACT
Introduction Although the third stage of labour is usually uneventful, several significant complications may be encountered that may lead to maternal morbidity and mortality, especially primary postpartum haemorrhage. The objective of this study was to compare 400 µg oral misoprostol with 10 IU intramuscular oxytocin in the active management of the third stage of labour.
Methods This was a prospective randomised controlled clinical trial in which 200 parturients at term who had vaginal delivery were randomly assigned into two groups: oral misoprostol and intramuscular oxytocin, after the delivery of the baby and the clamping of the umbilical cord. The primary outcome was the incidence of primary postpartum haemorrhage. Secondary outcomes included a drop in haemoglobin concentration 48 hours after delivery, the need for extra oxytocics, duration of the third stage of labour and side effects of the oxytocics. These results were subjected to statistical analysis using chi-square test or student’s t-test.
Results No occurrence of primary postpartum haemorrhage or significant difference in the drop in haemoglobin concentration levels was reported after delivery (p-value is 0.49), and no significant differences were observed in other secondary outcome measures with the exception of nausea, which occurred solely in the misoprostol group (4 percent, p-value is 0.04).
Conclusion Oral misoprostol appeared to be as effective and as safe as intramuscular oxytocin in the active management of the third stage of labour.

Keywords: intramuscular oxytocin, oral miso-prostol, third stage of labour
Singapore Med J 2010; 51(3): 207-211

Dey A, Bhuniya S, Datta Chaudhuri A, Pandit S, Saha-Dutta Chowdhury M, Sengupta A, Saha I, De P
Correspondence: Dr Atin Dey, dratindey@yahoo.co.uk

ABSTRACT
Introduction The management of recurrent pleural effusion or pneumothorax has always been a cause for serious concern among chest physicians. Among the wide variety of agents that are available for pleurodesis, povidone iodine is now perhaps the most sought after agent as it is cheap, easily available, effective and safe. This study was conducted to establish the efficacy and safety of povidone iodine as an agent for pleurodesis in patients with recurrent pleural effusion and pneumothorax.
Methods A total of 38 consecutive patients with symptomatic malignant or recurrent pleural effusion and pneumothorax received povidone iodine for pleurodesis over a period of 18 months. The mean follow-up period was 10.2 months, with a standard deviation of 2.9 months.
Results Out of the 38 patients, 29 had malignant pleural effusion, eight had recurrent pneumothorax and one had tubercular pleural effusion which was nonresponsive to anti-tubercular therapy. A complete response with no recurrence during follow-up was obtained in 34 (89.5 percent) patients. All the cases of failure had malignant pleural effusion. Three (7.9 percent) patients experienced intense chest pains after the installation of sclerosing agent, but they recovered with immediate symptomatic management.
Conclusion Recurrent pleural effusion or pneumothorax due to any cause may be managed effectively and safely by chemical pleurodesis with povidone iodine. It may be considered as the agent of choice to achieve pleurodesis, especially in resource constrained countries like India, as it is inexpensive and easily available.

Keywords: malignant pleural effusion, pleurodesis, pneumothorax, povidone iodine
Singapore Med J 2010; 51(2): 163-165

Kamarul Imran M, Ismail AAA, Naing L, Wan Mohamad WB
Correspondence: Dr Kamarul Imran Musa, drkamarul@kb.usm.my

ABSTRACT
Introduction This study aimed to compare the quality of life based on the Short Form-36 (SF-36) between two different groups of type 2 diabetes mellitus patients with glycaemic control: those with a glycosylated haemoglobin (HbA1c) level at or below 7.5 percent and those above 7.5 percent.
Methods In this cross-sectional study, a generic SF-36 questionnaire was self-administered to patients with type 2 diabetes mellitus. Based on the HbA1c level, the mean SF-36 scale scores were compared. The analysis of covariance was used to obtain the adjusted mean scores of the SF-36 scales while controlling for age and duration of type 2 diabetes mellitus.
Results 150 patients with type 2 diabetes mellitus were analysed. There were 63 (42 percent) women and 87 (58 percent) men, and their mean HbA1c level was 8.9 percent (SD 2.4 percent). When comparing the two groups of patients with different HbA1c levels, the adjusted means of four scales: physical health functioning, general health, social functioning and mental health, differed significantly between the two. The SF-36 scale scores in type 2 diabetes mellitus patients were also lower than those of the SF-36 norms for the Malaysian population.
Conclusion Type 2 diabetes mellitus patients with poor glycaemic control had lower mean SF-36 scores in physical functioning, general health, social functioning and mental health, and the SF-36 scores in these patients were also lower than the SF-36 norms of the Malaysian population.

Keywords: diabetes mellitus, glycaemic control status, HbA1c level, quality of life, short form 36, type 2 diabetes mellitus
Singapore Med J 2010; 51(2): 157-162