Original Article

Tan F, Mukherjee JJ, Lee KO, Lim P, Liew CF
Correspondence: Dr Florence Tan, ftanhs@yahoo.co.uk

ABSTRACT
Introduction Blockade of the renin-angiotensin-aldosterone system (RAAS) by either the angiotensin converting enzyme inhibitor (ACE-I) or the angiotensin II receptor blocker (ARB) has been shown to reduce albuminuria and delay the progression of diabetic nephropathy. This study evaluated the effect of dual blockade of the RAAS by adding an ACEI or an ARB to the administration of either drug alone on albuminuria in Asian type 2 diabetic patients with nephropathy.
Methods 34 patients were randomly assigned to receive either enalapril 20 mg or losartan 100 mg once daily for eight weeks. Following this, all patients received a combination of enalapril 10 mg and losartan 50 mg daily for eight weeks, followed by enalapril 20 mg and losartan 100 mg daily for another eight weeks. The blood pressure and 24-hour urinary albumin excretion (UAE) were monitored.
Results Following monotherapy with enalapril, there was a mean and standard error (SE) reduction in the UAE and mean arterial pressure (MAP) of 9.8 (SE 6.8) percent (p-value is 0.061) and 5.3 (SE 2.2) mmHg (p-value is 0.026), respectively; the reduction in UAE and MAP following monotherapy with losartan was by 10.9 (SE 14.1) percent (p-value is 0.053) and 4.5 (SE 1.9) mmHg (p-value is 0.034), respectively. Combination therapy with enalapril and losartan further reduced the UAE (11.2 [SE 8.7] percent, p-value is 0.009] despite there being no significant change in the MAP (-1.2 [SE 1.47] mmHg, p-value is 0.42). The adverse effects included dry cough (seven [19.4 percent] patients, resulting in the withdrawal of medication in two patients), and transient hyperkalaemia (two [six percent] patients).
Conclusion Dual blockade of the RAAS is safe and effective in reducing albuminuria in Asian type 2 diabetic patients with nephropathy.

Keywords: ACE inhibitor, albuminuria, angiotensin receptor blocker, diabetic nephropathy, renin-angiotensin system
Singapore Med J 2010; 51(2): 151-156

Boo NY, Rohana J, Yong SC, Bilkis AZ, Yong-Junina F
Correspondence: Professor Nem-Yun Boo, nemyun_boo@yahoo.com

ABSTRACT
Introduction The aim of this study was to compare the response and survival rates of term infants with persistent pulmonary hypertension of the newborn (PPHN) on high frequency oscillatory ventilation (HFOV) treated with either inhaled nitric oxide (iNO) or intravenous magnesium sulphate (MgSO₄).
Methods This was a randomised controlled study. The inclusion criteria were infants with respiratory distress, oxygen index equal to or greater than 25 despite HFOV support, and echocardiographic evidence of PPHN. Infants in the MgSO₄ group (n is 13) were loaded with MgSO₄ 200 mg/kg infused over half an hour, followed by continuous infusion at 50–150 mg/kg/hour to attain a serum magnesium level of 5.0–7.0 mmol/L. Infants in the iNO group (n is 12) were administered nitric oxide at an initial concentration of 20 ppm. Analysis was done on an intention-to-treat basis.
Results There was no significant difference in the median age when the vasodilators were commenced (MgSO₄ group: 14.0 hours, interquartile range [IQR]: 7.5, 27.0; iNO group: 14.8 hours, IQR: 12.5, 35.3, p is 0.8). There was no significant difference in the proportion of infants who responded primarily to either vasodilator (MgSO₄: 23.3%, iNO: 33.3%, p is 1.0). After switching over to iNO following a failed MgSO₄ therapy, a significantly higher proportion (9 out of 10) of the non-respondents in the MgSO₄ group recovered from PPHN and survived compared to the non-respondents in the iNO group (one out of eight) who switched over to intravenous MgSO₄ (p is less than 0.03).
Conclusion Infants who were administered iNO following a failed MgSO₄ therapy were associated with a better outcome than those who were administered MgSO₄ following a failed iNO therapy.

Keywords: inhaled nitric oxide, intravenous magnesium sulphate, PPHN
Singapore Med J 2010; 51(2): 144-150

Öztürk A, Özkan Y, Akgöz S, Yalçýn N, Özdemir RM, Aykut S
Correspondence: Dr Alpaslan Öztürk, ozturkalp@mynet.com

ABSTRACT
Introduction Hip fractures in the elderly are associated with significant mortality. This study aimed to investigate the risk factors for mortality in elderly patients with hip fractures during a one-year period.
Methods This was a prospective study which included consecutive isolated nonpathologic hip fractures in 74 (52 female, 22 male) patients in a level-1 trauma centre. These patients were 65 years or older and were ambulatory before the fracture. The patients were treated with hemiarthroplasty. The factors investigated were age, gender, nutritional status determined by blood albumin and total lymphocyte count, haemoglobin levels on the day of admission, mobilisation time after surgery, length of hospital stay, comorbidities, American Society of Anaesthesiologists (ASA) rating of operative risk, and the time period between injury and surgery. The patients were followed up for one year after surgery, or until death.
Results In total, 15 patients died during the one-year period. Patient survival was 94.6 percent at 3 months, 81.1 percent at 6 months and 79.7 percent at 12 months. There were two in-hospital deaths. The factors significantly associated with mortality were patients with more than two comorbidities, an ASA score of III–IV, a blood albumin level of less than 3.5 g/dl and a total lymphocyte count of less than 1500 cells/ml on admission. Hovewer, after the multivariate analysis, an ASA score of III–IV, low total lymphocyte count, female gender and low haemoglobin levels on admission remained the independent and significant risk factors associated with a one-year mortality.
Conclusion This study confirms that a high ASA score, female gender, a lower lymphocyte count and low haemoglobin levels on admission are significant factors in assessing the one-year mortality in elderly patients with hip fractures. Predicting these risk factors improves the case management.

Keywords: ASA, hip fracture, mortality risk factors
Singapore Med J 2010; 51(2): 137-143

Jaouad IC, Cherkaoui Deqaqi S, Sbiti A, Natiq A, Elkerch F, Sefiani A
Correspondence: Dr Cherkaoui Jaouad Imane, imane_cj@yahoo.fr

ABSTRACT
Introduction Trisomy 21 or Down syndrome is the most common type of autosomal chromosome abnormality, with an incidence of one out of 700 live births. Down syndrome is associated with psychomotor delay, characteristic facial features, and sometimes, cardiac, digestive and ocular malformations. The aim of this study was to estimate the proportions of various cytogenetic types of trisomy 21, and to study the link between maternal age and trisomy 21 in the Moroccan population, in order to provide data on the cytogeneticity and epidemiology of Down syndrome in Morocco.
Methods A retrospective analysis was performed on the case records of 852 patients who were confirmed as Down syndrome by cytogenetic analysis at the Department of Medical Genetics, National Institute of Health, Morocco.
Results Among the 852 cases of Down syndrome presenting over a period of 15 years, free trisomy 21 was present in 820 cases (96.24 percent). 27 patients had translocation and five cases were mosaics. The median maternal age of the Moroccan mothers at the birth of the affected child was 35.39 years.
Conclusion The identification of specific types of chromosomal abnormalities in Down syndrome children is important as it assists with patient management and family counselling.

Keywords: cytogenetic analysis, Down syndrome, karyotype pattern
Singapore Med J 2010; 51(2): 133-136

Boo NY, Chia GJQ, Wong LC, Chew RM, Chong W, Loo RCN
Correspondence: Prof Nem-Yun Boo, nemyun_boo@yahoo.com

ABSTRACT
Introduction This study aimed to determine the prevalence of obesity among medical students and its relationship with their dietary intake and physical activities.
Methods This observational study was carried out on 240 medical students during the clinical phase of their medical course in a private medical school. Their body weight and height were measured, and a standardised questionnaire was used to collect information on their physical activities and dietary intake.
Results The median body weight of the participants was 59.0 kg (interquartile range: 51.3–66.8), the mean body height was 166.1 cm (standard deviation [SD] 8.5 cm), and the mean body mass index (BMI) was 21.8 kg/m2 (SD 3.4 kg/m2). Based on the World Health Organization BMI cut-offs for the Asian population, 30.1 percent (n is equal to 72) of the students were overweight or obese, with a BMI that was equal to or greater than 23.0 kg/m2. Logistic regression analysis showed that, after controlling for various potential confounders, the only significant risk factors associated with overweight/obesity among these students were: male gender (adjusted odds ratio [OR] 2.1; 95 percent confidence intervals [CI] of 1.1 and 4.1; p is equal to 0.03), Malay ethnic group (adjusted OR 2.4; 95 percent CI 1.0 and 5.7; p is equal to 0.04), Indian ethnic group (adjusted OR 3.6; 95 percent CI 1.5 and 8.9; p is equal to 0.005), and the number of soft drinks consumed per week (adjusted OR 1.3; 95 percent CI 1.0 and 1.5; p is equal to 0.02). Skipping breakfast, the frequency of physical exercise per week, the number of hours of sleep per day, and eating noodles or roti canai (a type of Malaysian pancake) for breakfast were not significant risk factors.
Conclusion Obesity remains a common problem among medical students in their clinical years.

Keywords: medical students, obesity, risk factors, soft drinks
Singapore Med J 2010; 51(2): 126-132

Ruamsup S, Wiratkapun C, Wibulpolprasert B, Lertsithichai P
Correspondence: Dr Panuwat Lertsithichai, raplt@mahidol.ac.th

ABSTRACT
Introduction The aim of this study was to compare the short-interval and regular-interval follow-up in women with Breast Imaging Reporting and Data System (BI-RADS) category 3 screen imaging studies. The image stability, rate of image-detected breast cancer and stage of cancer are studied.
Methods Women who had BI-RADS 3 screen imaging studies (mammography and ultrasonography) conducted between the period January 2003 and December 2005 were retrospectively identified using the computerised database at the Department of Radiology, Ramathibodi Hospital, Thailand. Women who had known breast cancer status at two years after screening were included in the study and divided into two groups: short-interval (six months after screening) or regular-interval (one year after screening) follow-up. The two groups were compared in terms of the baseline clinicoradiologic characteristics and outcomes, including the image stability, image-detected breast cancer and the cancer stage at detection.
Results A total of 10,086 women underwent screen imaging studies within the study period. Of these, 1,541 (15 percent) were categorised as BI-RADS 3. Only 1,036 women (67 percent) had follow-up images done six to 12 months after screening, and 846 (82 percent of 1,036 women) also had known cancer status two years after the screening. Breast cancer was noted in seven women (a positive predictive value of 0.7 percent). There were no significant differences between the two groups of women in terms of their baseline characteristics, image stability at the initial follow-up, the rate of image-detected breast cancer and the stage of cancer at detection.
Conclusion There were no significant differences in the effectiveness of short-interval versus regular-interval follow-up in women with BIRADS 3 screen imaging studies.

Keywords: BI-RADS category 3, breast cancer, regular-interval follow-up, screen imaging studies, short-interval follow-up
Singapore Med J 2010; 51(2): 120-125

Shams S, Asheri H, Kianmehr A, Ziaee V, Koochakzadeh L, Monajemzadeh M, Nouri M, Irani H, Gholami N
Correspondence: Dr Sedigheh Shams, shamss@sina.tums.ac.ir

ABSTRACT
Introduction Female adolescents and adults are among the population groups who are most affected by iron deficiency. Thus, the aim of this study was to investigate the prevalence of iron deficiency and iron deficiency anaemia in female students aged 18 to 25 years old from the Tehran University of Medical Sciences, Iran.
Methods 295 female university students participated in the study. The mean corpuscular volume (MCV) and haemoglobin (Hb), serum ferritin, serum iron and total iron binding capacity (TIBC) levels were measured. Iron deficiency anaemia was defined as a situation where Hb is less than 12 g/dL, MCV is less than 78 µm3, ferritin is less than 12 ng/ml or transferin saturation (TS) (iron/TIBC × 100) is less than 15 percent, Iron deficiency (ID) was defined as a situation where Hb is greater than or equal to 12 g/dL, MCV is greater than or equal to 74 µm3, ferritin is less than 12 ng/ml or TS is less than 15 percent.
Results The complete data was available for 237 students. The prevalence of ID was 40.9 percent and that of IDA was 3.8 percent. Normal iron status was found in 49.8 percent of the subjects. The remaining (5.5 percent) had other kinds of anaemia or required confirmatory tests.
Conclusion ID is common among 18 to 25-year-old Iranian female university students. Iron supplementation is thus required for the target group.

Keywords: adult females, iron deficiency, iron deficiency anaemia, medical students
Singapore Med J 2010; 51(2): 116-119

Ahmad R, Tripathi AK, Tripathi P, Singh R, Singh S, Singh RK
Correspondence: Dr Raj Kumar Singh, singhrk23a@hotmail.com

ABSTRACT
Introduction Chronic myeloid leukaemia (CML) is a myeloproliferative disorder of the haematopoietic cell. Free radicals can be important causative agents of a number of human diseases, including cancer and leukaemia. Thus, antioxidants, which control the oxidative stress state, represent a major line of defense for regulating the overall true state of health. The relationship between non-enzymatic antioxidant status and the levels of well-known markers of oxidative stress that are measured as lipid peroxides reflects better health indices. The aim of this study was to evaluate the plasma levels of lipid peroxidation products and non-enzymatic antioxidant status as indices of oxidative stress, disease progression and early responses to chemotherapeutic agents in chronic myeloid leukaemia patients.
Methods The study included 128 CML patients and 50 age-and gender-matched healthy control volunteers. Indices of oxidative stress were evaluated as lipid peroxidation and non-enzymatic antioxidant status using the spectrophotometric method.
Results There was a significant increase in the plasma levels of lipid peroxidation products in CML patients as compared to the healthy volunteers. The plasma levels of lipid peroxidation products continued to rise significantly as the disease progressed. The non-enzymatic antioxidant status was found to be significantly decreased in CML patients as compared to the healthy participants. The plasma levels of non-enzymatic antioxidant status continued to decrease significantly during the disease progression.
Conclusion It can be concluded that plasma lipid peroxidation and non-enzymatic antioxidant status reflect oxidative stress in CML patients, and may be used as indices for oxidative stress, disease progression and early responses to different therapeutic modalities.

Keywords: chronic myeloid leukaemia, oxidative stress, response marker
Singapore Med J 2010; 51(2): 110-115

Golden N, Darmadipura S, Bagiada NA
Correspondence: Prof Nyoman Golden, nyoman_golden@yahoo.co.id

ABSTRACT
Introduction Clinical studies have shown that the incidence of early post-traumatic seizures is higher in children than in adults. It has been proposed that iron-induced lipid peroxidation plays an important role in the development of epileptogenic foci. This study examined some of the hypothesised reasons for the difference in the incidence of early post-traumatic seizures between children and adults.
Methods 12 young rats and 12 adult rats were randomised into four groups. Groups 1 and 2 were control groups, comprising six young rats and six adult rats, respectively, and they were administered an intracortical injection of saline. Groups 3 and 4 were injury groups, comprising six young rats and six adult rats, respectively, and they were administered an intracortical injection of FeCl₃. All the rats were observed for six hours post-injection for the occurrence of seizures, and were then killed. The injected hemispheres were extirpated and tested for the malondialdehyde (MDA) levels and superoxide dismutase (SOD) activity as indices of oxidative damage.
Results Seizures were observed only in Group 3. Increased MDA levels and decreased SOD activity were observed in Group 3 (ANOVA, p-value is less than 0.001). Increased MDA levels and decreased SOD activity were significantly higher in rats with seizures (Group 3) than in those without seizures (independent t-test, p-value is less than 0.001).
Conclusion Different levels of lipid peroxidation induced by an intracortical ferric chloride injection may account for the different incidence rates of seizures between young and adult rats.

Keywords: early post-traumatic seizures, epileptogenesis, lipid peroxidation
Singapore Med J 2010; 51(2): 105-109