Original Article

Ozgencil E, Yalcin S, Tuna H, Yorukoglu D, Kecik Y
Correspondence: Dr Enver Ozgencil, geno6700@hotmail.com

ABSTRACT
Introduction Gabapentin and pregabalin have been compared in studies conducted on management of neuropathic and postoperative pain. In neuropathic pain studies, the analgesic effects of the two drugs were compared, and pregabalin has been found to be more potent. However, in postoperative pain studies, the effects of each drug were examined separately. This study compared the analgesic effects of pregabalin (300 mg day-1), gabapentin (1,200 mg day-1) and a placebo in managing postoperative pain following laminectomy and discectomy.
Methods 90 patients were randomly assigned to three groups (pregabalin, gabapentin and placebo) of 30 patients each. Pregabalin 150 mg, gabapentin 600 mg and a placebo were administered every 12 hours, two times pre- and post surgery. Study data collected included morphine consumption, Visual Analogue Scale records, preoperative anxiety, patient satisfaction, adverse effects and observation notes.
Results In the gabapentin and pregabalin groups, overall morphine consumption, preoperative anxiety, pruritus, postoperative shivering were significantly lower (p-value less than 0.05 for all), and patient satisfaction was significantly higher than those in the placebo group (p-value less than 0.05).
Conclusion This study showed that both pregabalin 300 mg day-1 and gabapentin 1,200 mg day-1 have more analgesic, anxiolytic and opioid-sparing effects, higher patient satisfaction and are more effective for preventing postoperative shivering than the placebo following lumbar laminectomy and discectomy. The findings revealed that pregabalin 300 mg day-1 had equivalent analgesic, adverse and opioid-
sparing effects and patient satisfaction as gabapentin 1,200 mg day-1.

Keywords: discectomy, gabapentin, laminectomy, postoperative pain, pregabalin
Singapore Med J 2011; 52(12): 883-889

Panah Khahi M, Yaghooti AA, Marashi SH, Nadjafi A
Correspondence: Dr Panah Khahi, panahkha@sina.tums.ac.ir

ABSTRACT
Introduction Gabapentin has demonstrated efficacy in clinical trials as a pre-emptive analgesic and in acute postoperative pain management. However, our experience with the drug is still limited. The present study was conducted in order to evaluate the effect of gabapentin on reduction of postoperative pain in the first 24 hours after internal fixation of the tibia under spinal anaesthesia.
Methods In a double-blind, randomised controlled clinical trial, 64 American Society of Anesthesiologists Class I or II patients, who underwent internal fixation of the tibia, were administered 300 mg of gabapentin or a placebo two hours before surgery. The postoperative pain was assessed using Visual Analogue Scale two, 12 and 24 hours after surgery. The time from the end of surgery until the first bolus dose of morphine on demand (pain score > 4) and the total morphine requirement were recorded. Patients were also asked about the possible side effects of gabapentin.
Results The pain score was significantly lower in the gabapentin group at two hours post surgery (p-value is 0.004), while the scores at 12 and 24 hours post surgery were not significantly different between the two groups. No side effect of gabapentin was observed.
Conclusion Pre-emptive use of gabapentin 300mg orally significantly decreases postoperative pain two hours after surgery.

Keywords: gabapentin, morphine demand, orthopaedic surgery, postoperative pain, pre-emptive analgesia
Singapore Med J 2011; 52(12): 879-882

Sharma R, Dua CK, Saxena KN
Correspondence: Dr Rajeev Sharma, rajeevkrsharmaji@gmail.com

ABSTRACT
Introduction Classic laryngeal mask airway (LMA) has long been used for airway management. General anaesthesia has been associated with a significant decrease in pulmonary functions during the postoperative period. The decrease in pulmonary functions has been found to be greater with the use of a tracheal tube (TT). In this study, we compared the effects on pulmonary functions during the early postoperative period when the airway was managed using an LMA versus a TT.
Methods A total of 20 patients in each group received either LMA or TT for airway management. Postoperative pulmonary functions were recorded at 30 and 60 minutes after removal of the airway device in patients undergoing peripheral limb surgeries. Forced vital capacity (FVC), forced expiratory volume during the first second (FEV1), vital capacity, FEV1/FVC, peak expiratory flow rate and percentage saturation of oxygenated haemoglobin were compared. Postoperative coughing and hoarseness were also recorded.
Results Pulmonary functions were significantly decreased in both groups at 30 and 60 minutes postoperatively. The decrease in the TT group was significantly greater than that in the LMA group at both 30 and 60 minutes. The FEV1/FVC was not significantly changed, indicating a restrictive pattern. Patients in the TT group had a significantly higher incidence of coughing at both 30 and 60 minutes.
Conclusion The use of LMA instead of TT for airway management during peripheral limb surgeries causes less depression of pulmonary functions during the early postoperative period. The incidence of coughing is also significantly lower.

Keywords: classic laryngeal mask airway, early postoperative period, pulmonary functions, tracheal tube
Singapore Med J 2011; 52(12): 874-878

Chiu CK, Low TH, Tey YS, Singh VA, Shong HK
Correspondence: Dr Chiu Chee Kidd, cheekidd_chiu@imu.edu.my

ABSTRACT
Introduction Chronic, nonspecific low back pain is a difficult ailment to treat and poses an economic burden in terms of medical expenses and productivity loss. The aim of this study was to determine the efficacy and safety of intramuscular metylcobalamin in the treatment of chronic nonspecific low back pain.
Methods This was a double-blinded, randomised, controlled experimental study. 60 patients were assigned to either the methylcobalamin group or the placebo group. The former received intramuscular injections of 500 mcg parenteral methylcobalamin in 1ml solution three times a week for two weeks, and the placebo group received 1 ml normal saline. Patients were assessed with Oswestry Disability Index questionnaire Version 2.0 and Visual Analogue Scale pain score. They were scored before commencement of the injections and at two months interval.
Results Of the 60 patients, 27 received the placebo injections and 33 were given methylcobalamin injections. A total of 58 patients were available for review at two months (placebo: n is 26; methylcobalamin: n is 32). There was a significant improvement in the Oswestry Disability Index and Visual Analogue Scale pain scores in the methylcobalamin group as compared with the placebo group (p-value less than 0.05). Only minor adverse reactions such as pain and haematoma at the injection sites were reported by some patients.
Conclusion Intramuscular methylcobalamin is both an effective and safe method of treatment for patients with nonspecific low back pain, both singly or in combination with other forms of treatment.

Keywords: methylcobalamin, nonspecific low back pain, vitamin B12
Singapore Med J 2011; 52(12): 868-873

Khanna A, Agrawal A
Correspondence: Prof Anuradha Khanna, dr_anuradhakhanna@yahoo.co.in

ABSTRACT
Introduction Although genital tuberculosis is a condition that is prevalent worldwide, it is still a diagnostic dilemma. This study aimed to find an effective diagnostic modality for the condition.
Methods A total of 100 infertile women were clinically evaluated with haemoglobin estimation, total and differential count, Mantoux test, tubercle bacilli enzyme-linked immunosorbent assay (TB ELISA), hysterosalpingography, pelvic ultrasonography, laparohysteroscopy, premenstrual endometrial biopsy for histopathology, culture and tubercle bacilli polymerase chain reaction (TBPCR). The womens’ Day 2 hormonal profile (luteinising, follicle-stimulating, prolactin and thyroid-stimulating hormones) and their husbands’ semen analysis were also conducted.
Results A total of 58 women had primary infertility and 42 had secondary infertility. Female factor infertility was present in 63 percent of the cases (mostly tubal; 45.97 percent). 26 women tested positive for endometrial TBPCR. Erythrocyte sedimentation rate, Mantoux test, TB ELISA and hysterosalpingography were found to have high negative predictive value (greater than 80 percent), while the positive predictive value was 35–45 percent. Laparoscopy findings were suggestive of tuberculosis in 13 percent of the women, out of which 83.3 percent were positive for endometrial TBPCR. Hysteroscopy revealed intrauterine adhesions in 34.8 percent of the women, with 68.8 percent being positive for tubercular bacilli.
Conclusion Our study established that in cases of genital tuberculosis, the use of expensive endometrial TBPCR tests may be avoided with a detailed workup, which would also help in the institution of anti-tubercular treatment in early disease, thus enhancing the chance of pregnancy.

Keywords: genital, infertility, markers, polymerase chain reaction, tuberculosis
Singapore Med J 2011; 52(12): 864-867

Wong CS, Lye DC, Lee CC, Leo YS
Correspondence: Dr Wong Chen Seong, wongchenseong@gmail.com

ABSTRACT
Introduction The incidence of human immunodeficiency virus (HIV) infection in Singapore is on the rise. We aimed to study the clinical epidemiology of acute HIV infection in Singapore.
Methods All patients that fulfilled the criteria for definite and probable acute HIV infection were prospectively identified from January 1, 2003 to June 30, 2006. Demographic, clinical and laboratory data were recorded.
Results A total of 16 out of 34 patients had definite acute HIV infection, and 68 percent of the entire cohort comprised men who have sex with men (MSM). Ten percent of the patients were co-infected with hepatitis B and C viruses, while 27 percent were infected with syphilis. Signs and symptoms were nonspecific, with fever, rash and diarrhoea being the three most common symptoms. Only 35 percent of the patients required hospitalisation.
Conclusion Men who have sex with men account for the majority of patients with acute HIV infections in Singapore, many of them also being co-infected with syphilis. Safer sex campaign among MSM should be implemented or intensified.

Keywords: acute HIV infection, HIV transmission, men who have sex with men, seroconversion, Singapore
Singapore Med J 2011; 52(12): 860-863

Xie CB, Chan MY, Teo SG, Low AF, Tan HC, Lee CH
Correspondence: A/Prof Lee Chi-Hang, mdclchr@nus.edu.sg

ABSTRACT
Introduction There is a paucity of data on acute myocardial infarction (AMI) in young Asian women and of comparative data among various ethnic groups with respect to risk factor profile and clinical outcomes. We present a comprehensive overview of the clinical characteristics of young Asian women with AMI and a comparative analysis among Chinese, Malay and Indian women in a multiethnic Asian country.
Methods We studied 45 Asian female patients aged 50 years and below who were admitted to our hospital with a diagnosis of ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI).
Results Overall, diabetes mellitus, hypertension and hyperlipidaemia were prevalent in the study population. Hyperlipidaemia was more prevalent among Indian patients, while diabetes mellitus was more common among Malay patients. Only a minority of the study patients were current smokers. Among the 20 patients admitted with STEMI, 17 (85 percent) received urgent reperfusion therapy. The mean symptom-to-balloon time and door-to-balloon time for the Malay patients were longer compared to those for other ethnic groups. Among the 25 patients admitted with NSTEMI , 12 (48 percent) underwent coronary revascularisation therapy. The average duration of hospital stay was 4 +/− 4.1 days, with no significant difference observed among the various ethnic groups.
Conclusion Many young Asian women with AMI have identif iable risk factors that are different from those found in the Western population. There seems to be an ethnic effect on the prevalence of these risk factors and door-to-balloon time.

Keywords: ethnicity, myocardial infarction, women, young
Singapore Med J 2011; 52(11): 835-839

Woo KT, Lau YK, Chan CM, Zhao Y, Tan HB, Liu FE, Fook-Chong S, Wong KS
Correspondence: Prof Woo Keng Thye, woo.keng.thye@sgh.com.sg

ABSTRACT
Introduction Association studies with single nucleotide polymorphisms (SNPs) have been contradictory. Haplotypes may be more helpful. With gene sequencing, all SNPs can be found for construction of haplotypes.
Methods The ACE gene was sequenced in four healthy Chinese subjects and 20 patients with IgA nephropathy (IgAN) to observe if differences exist among SNPs and haplotypes. 20 patients on angiotensin 1-converting enzyme inhibitor/angiotensin receptor antagonist(ACEI/ATRA) therapy were then compared with another 20 patients not treated with ACEI /ATRA to determine their renal outcome in response to ACEI/ATRA therapy and whether their genetic profile of ACE gene could play a role in determining their outcome to ACEI /ATRA therapy and progression to end-stage renal failure (ESRF).
Results IgAN patients had 53 variants, of which 17 were unique, whereas normal subjects had 38 variants, of which two were unique (p less than 0.005). No unique variant was a significant risk factor for IgAN. Significant genotype and allele frequency differences in five variants were observed between IgAN patients with renal impairment and those with ESRF (p less than 0.02).
Conclusion Our data suggests that at least in the ACE gene, haplotyping SNPs within a single gene seems to have no added advantage over genotyping the individual component SNPs. The D allele and haplotype 3 confer an adverse prognosis, while the I allele and haplotype 5 appear to be renoprotective. The data suggests that genotypes of the ACE gene are linked to certain haplotypes, which could influence IgAN patients’ response to ACEI/ATRA therapy.

Keywords: haplotypes, IgA nephropathy, renal failure, single nucleotide polymorphism
Singapore Med J 2011; 52(11): 824-834

Hossain MG, Saw A, Ohtsuki F, Lestrel PE, Kamarul T
Correspondence: Prof Saw Aik, sawaik@hotmail.com

ABSTRACT
Introduction Secular changes in the head and body dimensions of the Japanese population were recorded during the last century, but studies on Japanese adult facial shape were poorly documented. This study aimed to document the secular changes in facial shape and their association with craniofacial measures of Japanese adult female students.
Methods Data were collected from 1998–2001 and 1975–1979 from institutions in Tokyo and Kyoto. The prosopic index (PI) was derived from morphological facial height (n-gn) and bizygomatic breadth (zy-zy). Multiple regression analysis was used to determine the association between PI (facial form) and craniofacial measures.
Results Larger mean values for morphological facial height (n-gn) and for PI, but smaller values for bizygomatic breadth (zy-zy) and bigonial breadth (go-go) were observed in the current sample compared to their predecessors 21 years ago. The most prevalent facial shapes were mesoprosopic (30.53 percent) and euryprosopic (45.14 percent) for the current and previous series, respectively. There was a significant positive relationship between the PI and head length (g-op) (p less than 0.01), head breadth (eu-eu) (p less than 0.01) and head height (v-po) (p less than 0.05), and a negative relationship between the PI and head circumference (g-g) (p less than 0.01) and minimum frontal breadth (ft-ft) (p less than 0.01).
Conclusion Our results suggest that a narrowing of facial shape has been occurring for approximately 21 years in adult Japanese females. The best predictor variables for PI were head length, head circumference, head breadth, minimum frontal breadth and head height.

Keywords: craniofacial measures, facial shape, Japanese females, multiple regressions, proscopic index
Singapore Med J 2011; 52(11): 818-823

Chan SWY, Tan KY, Cheng AKS, Mak KSW, Aye AT, Pang M
Correspondence: Dr Tan Kok Yang, kokyangtan@gmail.com

ABSTRACT
Introduction The HpOne test is a new five-minute rapid urease test developed for the rapid detection of Helicobacter pylori infection during gastroscopy. However, evidence in the literature supporting its use clinically is scarce. The most commonly used rapid urease test remains the Campylobacter-like organism (CLO) test, which generates accurate readings only after 24 hours. The aim of this study was to evaluate the efficacy of the HpOne test in our local population.
Methods From August 2007 to May 2008, consecutive patients undergoing gastroscopy for various indications were recruited into this prospective study. Patients who were pregnant, lactating, on proton pump inhibitors, antibiotics, immunosuppressants or had previous gastric surgery were excluded. During gastroscopy, six gastric mucosal biopsies were taken; three from the body and three from the antrum. One body and one antral biopsy were used for each of the HpOne test, CLO test and histology. Results of the HpOne and CLO tests were then compared against the gold standard of histology.
Results Of the 149 patients recruited, 82 (55 percent) were men and 67 (45 percent) were women. The prevalence of Helicobacter pylori infection was 38.9 percent (n is 58) . The sensitivity and specificity of the HpOne test were 65.5 percent and 85.7 percent, respectively, while those for the CLO test were 63.8 percent and 84.6 percent, respectively.
Conclusion The HpOne test is as efficacious as the CLO test, with the added advantage of yielding results faster. It is thus a superior alternative and should be considered for clinical use.

Keywords: CLO test, diagnosis, Helicobacter pylori, HpOne, rapid urease test
Singapore Med J 2011; 52(11): 814-817