Original Article

Omolase CO, Adekanle O, Owoeye JFA, Omolase BO
Correspondence: Dr Omolase Charles Oluwole, omolash2000@yahoo.com

ABSTRACT
Introduction This study was designed to determine the prevalence of diabetic retinopathy among diabetic patients attending the medical outpatient department of the Federal Medical Centre, Owo, Ondo State, Nigeria.
Methods This study was conducted between November 2007 and February 2008. Ethical clearance was obtained from the ethical committee of the hospital prior to carrying out the study. 100 diabetic patients selected by simple random sampling were interviewed with the aid of a semi-structured questionnaire. All the respondents had fundoscopy conducted at the eye clinic with the aid of a direct ophthalmoscope. The data was collated and analysed.
Results The majority of the respondents (85 percent) had type 2 diabetes mellitus, while the rest (15 percent) had type 1 diabetes mellitus. 15 percent of the respondents had varying degrees of diabetic retinopathy. The duration of diabetes mellitus was significantly associated with the development of diabetic retinopathy at a p-value of 0.002.
Conclusion A few of the respondents had diabetic retinopathy. There is a need to create awareness among diabetic patients on the need for routine ocular examinations.

Keywords: diabetes mellitus, diabetic retinopathy, retinopathy
Singapore Med J 2010; 51(1): 56-59

Hasnan J, Yusoff MI, Damitri TD, Faridah AR, Adenan AS, Norbaini TH
Correspondence: Dr. Mohd Imran Yusof, drimran@kb.usm.my

ABSTRACT
Introduction Bax is essential for apoptosis in normal cells. However, overexpression of Bcl-2 enhances cell survival by suppressing apoptosis in cells subjected to apoptosis-inducing stimuli. The aim of this study was to examine the expression of apoptotic (Bax and Bcl-2) and biochemical markers in type 2 diabetics mellitus.
Methods A test group comprising 41 type 2 diabetes mellitus patients and a control group comprising 36 non-diabetic patients were enrolled in this study. Skin biopsy tissue samples were stained immunohistochemically for Bcl-2 and Bax expressions. Fasting plasma glucose (FPG), triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDLC) and glycosylated haemoglobin A1c (A1C) were analysed. Low-density lipoprotein cholesterol (LDLC) was calculated.
Results Bcl-2 expression was significantly higher (p-value is less than 0.001) in the control group. Bax expression was significantly higher (p-value is 0.018) in the diabetic group. Positive Bcl-2 expression was observed in 18 of 36 (50 percent) controls. Positive Bcl-2 expression was found in 5 of 41 (12.2 percent) diabetics. There was a significant difference (p-value is less than 0.001) between the two groups for mean FPG, HDLC and A1C. There was no significant difference for TC, LDLC and triglycerides between the two groups. Positive Bax expression was found in 11 of 35 (31.4 percent) controls. The odds of developing Bcl-2 among non-diabetics were 12.67 times compared to diabetics (p-value is less than 0.001).
Conclusion Prolonged hyperglycaemia induces apoptosis in the endothelial cells of diabetic ulcers, which aggravates microvasculopathy and delays tissue healing and regeneration.

Keywords: type 2 diabetes mellitus, apoptosis, biochemical markers
Singapore Med J 2010; 51(1): 50-55

Shin YH, Kim MH, Ko JS, Park JA
Correspondence: Dr Myung Hee Kim, mhsmc.kim@samsung.com

ABSTRACT
Introduction The safety of simultaneous bilateral total knee arthroplasty (SBTKA) remains controversial. This study aimed to compare the postoperative outcomes of SBTKA versus unilateral total knee arthroplasty (UTKA) performed by a single surgeon at a tertiary teaching hospital in Korea.
Methods 629 female patients with total knee arthroplasty (308 patients for SBTKA and 321 for UTKA) performed under combined spinal epidural anaesthesia (CSE) were selected, and their medical records during admission and follow-up visits for a duration of six months after discharge were reviewed.
Results Although significantly higher incidences of postoperative confusion and hypoxia during hospitalisation and a longer hospital stay were demonstrated in the SBTKA group, the rates of serious postoperative complications, such as myocardial infarction and deep venous thrombosis, were not different between the groups during the hospital stay and six months afterwards. No death associated with the surgery was encountered in both groups.
Conclusion It was concluded that SBTKA under CSE may be considered to be relatively safe in Korean female patients.

Keywords: perioperative complications, simultaneous bilateral total knee arthroplasty, total knee arthroplasty, unilateral total knee arthroplasty
Singapore Med J 2010; 51(1): 44-49

Sucak A, Kanat-Pektas M, Gungor T, Mollamahmutoglu L
Correspondence: Dr Mine Kanat-Pekta, minekanat@hotmail.com

ABSTRACT
Introduction This study was carried out to investigate changes in the plasma leptin concentrations during preeclampsia treatment and to determine whether antihypertensive treatments, aimed at decreasing leptin levels, would improve foetal outcomes.
Methods A prospective study was undertaken in 57 pregnant women with preeclampsia (37 with mild and 20 with severe preeclampsia) and 46 normal pregnant women who were matched in maternal and gestational age and body mass index. The mild preeclampsia group was treated with alpha-methyldopa, while the severe preeclampsia group was treated with a combination of alpha-methyldopa and nifedipine.
Results The severe preeclampsia group had significantly lower platelet counts, higher systolic and diastolic blood pressures and elevated serum uric acid concentrations. Pre-treatment plasma leptin levels were significantly increased in the severe preeclampsia group (range 18.3–49.5) compared to the the mild preeclampsia group (range 20.7–45.4) and normal controls (range 8.6–19.2). Post-treatment plasma leptin levels in both the mild and severe preeclampsia groups (range 10.2–23.5 and 11.3–24.4, respectively) were statistically similar to those of the control group(range9.1–20.7). Estimated foetal weight, intrauterine growth retardation and demise were statistically similar in the three study groups.
Conclusion Plasma leptin concentrations were found to be elevated in women diagnosed with severe preeclampsia. However, the exact mechanism underlying the increased plasma leptin levels in preeclampsia and the functional role of leptin in the development of hypertension need to be further clarified. Leptin has a promising future as a valuable marker to identity women with a high risk for preeclampsia.

Keywords: antihypertensive, leptin, placenta, preeclampsia, pregnancy
Singapore Med J 2010; 51(1): 39-43

Kadowa I
Correspondence: Dr Kadowa Isaac, kadisaac@yahoo.com

ABSTRACT
Introduction A ruptured uterus is a life-threatening obstetric complication that remains a major public health concern in low-income countries, particularly in Africa. It is a significant cause of maternal and perinatal morbidity and mortality. In Uganda, the prevalence remains high largely because most women do not deliver in health facilities. Further review of this problem may be helpful in the development of appropriate preventive strategies.
Methods A five-year retrospective review of all cases of ruptured uterus admitted to Mityana Hospital, Uganda from January 1, 2003 to December 31, 2007 was conducted.
Results Out of 14,656 deliveries, 73 cases of ruptured uterus were recorded, resulting in a ratio of 1 in 200. The highest incidence was in patients aged 20–24 years old, of parity 1–4 and residing in the Kassanda sub-county. Other predisposing factors included not attending antenatal care (67.1 percent), which was associated with rupture at home or with traditional birth attendants (TBAs) (Odds Ratio [OR] 6.29; 95 percent confidence interval [CI] 2.01–19.67), obstructed or prolonged labour (68.5 percent), which increased the likelihood of rupture before admission (OR 3.28; 95 percent CI 1.05–10.26), residing more than 10 kilometres from the hospital (64.4 percent), which increased the likelihood of rupture before admission (OR 3.62; 95 percent CI 1.16–11.32) and the existence of previous scars (19.2 percent), which decreased the likelihood of rupture before admission (OR 0.24; 95 percent CI 0.07–0.81). All the women had surgery, of which 14 percent had a total hysterectomy, 22 percent had a subtotal hysterectomy, 25 percent had a repair and bilateral tubal ligation, and 39 percent had a repair only. Eight percent of the women died, while seven percent of the babies were born alive.
Conclusion Uterine rupture is a disturbing problem in Uganda. There is a need to put in place a functional referral system for pregnant women that links the community and TBAs to the hospital, and a need to intensify information, education and communication programmes to encourage women and their partners to use the reproductive health services that are available to them. In addition, greater accessibility to equipped health facilities, the use of a partogram to monitor labour and timely interventions will go a long way to reducing uterine rupture.

Keywords: ruptured uterus, Kassanda, traditional birth attendants, previous scar, parity 1– 4, prolonged labour
Singapore Med J 2010; 51(1): 35-38

Shankar PR, Upadhyay DK, Subish P, Bhandari RB, Das B
Correspondence: Dr P Ravi Shankar, ravi.dr.shankar@gmail.com

ABSTRACT
Introduction The proportion of the elderly population in Nepal, though low, is steadily increasing. Studies on drug utilisation among geriatric patients in Western Nepal, a region with the highest proportion of the elderly in all of Nepal, are lacking. The present study was carried out at the Manipal Teaching Hospital, a 700-bed teaching hospital in Pokhara, Western Nepal.
Methods The study was carried out from June 1, 2005 to May 31, 2006 using case records of discharged patients aged 60 years and older. This was an observational study that utilised a retrospective case notes review methodology. The microorganisms isolated on culture and their antibiotic sensitivity patterns were studied. Drug consumption was measured by the defined daily dose (DDD) per 100 bed-days. The mean cost of the drugs was calculated. The percentage of drugs prescribed by generic name and the percentages of fixed-dose combinations used were noted. The basic demographic information of older inpatients, drug utilisation patterns, drug consumption using DDD, organisms isolated and their antibiotic sensitivity patterns, and the mean cost of the drugs were studied.
Results A total of 548 patients were admitted. Hypertension, acute exacerbation of chronic obstructive pulmonary disease and cancer were the most common illnesses among the patients. The mean number of drugs consumed by each patient was 7.73. Escherichia coli and Pseudomonas aeruginosa were the most common microorganisms isolated. Ranitidine, multivitamins, amlodipine, ipratropium and dextrose normal saline were most commonly prescribed. The DDD per 100 bed-days of ranitidine and omeprazole (highest values) was 33.48 and 3.51, respectively. The mean cost of drugs was USD26.6, and antibiotics accounted for around 40 percent of the cost.
Conclusion The use of a high number of drugs, and of parenteral drugs and intravenous fluids, is a common problem. The prescription of generic drugs is low. Guidelines for the use of drugs in the elderly are required and further studies are needed on this issue.

Keywords: drug utilisation, geriatric drugs, prescribing guidelines
Singapore Med J 2010; 51(1): 28-34

Hasan SS, Bahari MB, Babar ZU, Ganesan V
Correspondence: Mr Syed Shahzad Hasan, shahzad_pharmacy@yahoo.com

ABSTRACT
Introduction The primary purpose of this study was to evaluate the utilisation pattern and seizure outcome of newer and older antiepileptic drugs in paediatric clinical practice in a Malaysian hospital setting.
Methods Over a two-month period, all paediatric epilepsy patients from Penang General Hospital, Malaysia who were diagnosed according to the classification of the International League Against Epilepsy were followed up prospectively, and the patients’ information was gathered with the help of a validated data collection form. This included demographic characteristics, monotherapy and polytherapy of antiepileptic drugs, as well as the number of seizures experienced.
Results Partial seizures, including complex and simple partial seizures (47.2 percent), followed by generalised seizures (40 percent), were the most common seizure types found in this study. An average of 1.51 antiepileptic drugs per patient was prescribed, with 54.3 percent of the patients on monotherapy and 45.7 percent on polytherapy. Overall,sodium valproate was the most frequently prescribed antiepileptic drug (36.8 percent), followed by carbamazepine (30.2 percent) and lamotrigine (10.4 percent). Carbamazepine was the most frequently prescribed monotherapy (28.6 percent), followed by sodium valproate (17.1 percent). The newer antiepileptic drugs were also found to be used as monotherapy in 7.2 percent of the cases. Moreover, a significant difference was observed between the older and newer antiepileptic drugs in terms of the number of seizures experienced (p = 0.027). Most (75 percent) of the seizure-free patients were on carbamazepine monotherapy.
Conclusion Monotherapy was  the most frequently used remedy in all forms of epilepsy. Overall, sodium valproate was the most commonly used drug, while carbamazepine was found to be more frequently used as monotherapy. There was a significant difference found between the older and newer antiepileptic drugs, with 87.5 percent of seizure-free patients on older antiepileptic drugs.

Keywords: antiepileptic drugs, benzodiazepine, drug utilisation, generalised seizure, partial seizure, monotherapy, polytherapy
Singapore Med J 2010; 51(1): 21-27

Afifi M
Correspondence: Dr Mustafa Afifi, afifidr@gmail.com

ABSTRACT
Introduction This study aimed to examine Egyptian ever-married women’s beliefs and attitude toward the discontinuation of female genital cutting (FGC). We also examined the significant sources of information which the women with positive attitude were exposed to the year prior to the survey.
Methods In a national representative community-based sample of 15,573 ever-married Egyptian women, the intention to continue the practice of FGC and other socio-demographical variables were collected from the 2000 Egypt Demographic and Health Survey data. A secondary in-depth analysis was conducted on the data in order to investigate the women’s attitude and its associated factors.
Results Only 12.4 percent of the sample intended to discontinue the practice. The logistic regression models showed that women with a positive attitude to discontinue the practice believed that FGC was not an important part of religious traditions, that husbands did not prefer a cut wife, and that FGC reduced sexual desire. The most significant sources of information related to a positive attitude to discontinue the practice were community discussions, the mosques or churches and the newspapers.
Conclusion The aforementioned sources of information are related to the social and religious aspects of women in the Egyptian community. In order to change women’s attitude toward the discontinuation of this unhealthy practice, communication rather than passive learning is needed.

Keywords: attitude, beliefs, female circumcision, female genital cutting, health survey
Singapore Med J 2010; 51(1): 15-20

Bu XN, Yang T, Thompson MA, Hutchinson AF, Irving LB
Correspondence: Dr Bu Xiao-NingTel, xiaoningbu@gmail.com

ABSTRACT
Introduction We investigated the relationship between frequency of exacerbation and duration and change in functional status, as measured by the BODE index in chronic obstructive pulmonary disease (COPD) patients.
Methods This was a longitudinal cohort study of 56 patients with moderate to severe COPD. Body mass index, spirometry, Modified Medical Research Council (MMRC) dyspnoea score and six-minute walk distance (6MWD) were measured annually when the patients were clinically stable. Data on frequency and duration of COPD exacerbations occurring in the community and requiring hospitalisation were collected prospectively. Early stage exacerbations were identified through the use of individualised patient action plans and further reinforced by fortnightly phone contact.
Results At the two-year follow-up, the BODE index increased in 33 patients, remained stable in 18 and decreased in five patients. Patients
with increased BODE index had significantly higher hospital presentation rates and longer total bed-days compared to those with stable
BODE index. Among the 33 patients with increased BODE index, 20 had lower 6MWD and higher MMRC scores, indicating deteriorating
functional status, and 13 had higher levels of airway obstruction. Between these two subgroups, patients with deteriorating functional status had higher exacerbation frequency, longer exacerbation duration and higher inpatient bed-days. Linear regression showed that total annual duration of exacerbation was predictive of change in 6MWD.
Conclusion Change in the BODE index is a sensitive measure of deteriorating functional status in COPD patients. Duration of exacerbation has greater impact on functional status than frequency of exacerbation episodes.

Keywords: BODE, chronic obstructive pulmonary disease, exacerbation, functional status, hospitalisation
Singapore Med J 2011; 52(12): 894-900

Bhadada SK, Bhansali A, Shah VN, Rao DS
Correspondence: Dr Sanjay KumarBhadada, bhadadask@gmail.com

ABSTRACT
Introduction Primary hyperparathyroidism (PHPT) is considered a state of insulin resistance. However, it is unclear whether the state of insulin resistance and adverse levels of adipocytokines are reversed in PHPT patients who have undergone curative parathyroidectomy.
Methods Ten consecutive patients with PHPT were studied at baseline and three months after curative parathyroid surgery in this prospective interventional study. Fasting blood calcium, intact parathyroid hormone (PTH), glucose, insulin, adiponectin and leptin concentrations were measured. Insulin resistance was assessed using the homeostasis model assessment of insulin resistance (HOMA-IR) and insulin sensitivity, by the quantitative insulin sensitivity check index (QUICKI).
Results Four out of the ten patients were male. The mean age of the patients was 32.40 +/-11.42 years, and the mean body mass index
was 23.70 +/- 5.19 kg/m2. The HOMA-IR value was found to be higher, while the QUICKI value was significantly lower before surgery in patients with PHPT compared to the published reference ranges. Serum leptin concentrations were higher in patients with PHPT than in normal healthy individuals; however, there was no difference in the adiponectin concentrations. There was no statistical difference in the mean values of fasting plasma glucose, plasma insulin, leptin, adiponectin, as well as the HOMA-IR and QUICKI estimates three months postoperatively, as compared to the preoperative measures.
Conclusion Peripheral insulin resistance/sensitivity and the concentrations of leptin and adiponectin did not change three months after curative parathyroidectomy.

Keywords: adiponectin, hyperparathyroidism, insulin resistance, leptin, parathyroidectomy
Singapore Med J 2011; 52(12): 890-893