Original Article

Juniarto AZ, Goossens K, Setyawati BA, Drop SLS, de Jong FH, Faradz SMH
Correspondence: Dr Sultana MH, sultana@indosat.net.id

ABSTRACT
Introduction Congenital adrenal hyperplasia (CAH) or adrenogenital syndrome is the most common cause of female ambiguous genitalia. Management of such patients involves medical treatment using glucocorticoids such as hydrocortisone, prednisone or dexamethasone. Monitoring is done by measurement of 17-hydroxyprogesterone (17-OHP) or androstenedione in serum, plasma or saliva. The aim of this study was to develop a system of monitoring steroid treatment in CAH patients using only saliva.
Methods We studied the saliva of 24 CAH patients who received glucocorticoid replacement therapy. The patients were asked to collect saliva upon awakening, and in the afternoon and evening. The levels of 17-OHP and androstenedione in the saliva as well as in serum were then measured by immunoassay.
Results There was a significant positive correlation between 17-OHP in serum and in saliva (R equals 0.929, p-value less than 0.01). A significant positive correlation between androstenedione level in saliva and serum was also found (R equals 0.611, p-value less than 0.01). This study also revealed a significant positive correlation between androstenedione and 17-OHP in serum (R equals 0.647, p-value less than 0.01) and saliva (R equals 0.799, p-value less than 0.01). All patients showed increased level of 17- OHP and androstenedione in the sample collected upon awakening.
Conclusion Determination of salivary androstenedione and 17-OHP in CAH patients could be a useful alternative to the measurement of these hormones in serum.

Keywords: 17-hydroxyprogesterone, ambiguous genitalia, androstenedione, congenital adrenal hyperplasia, saliva
Singapore Med J 2011; 52(11): 810-813

Tan AM, Muthusamy L, Ng CC, Phoon KY, Ow JH, Tan NC
Correspondence: Ms Tan Ai Meng, tan.ai.meng@singhealth.com.sg

ABSTRACT
Introduction Type 2 diabetes mellitus is a progressive condition in which the pancreatic beta-cell function deteriorates with increasing duration of the disease. When good glycaemic control is not achieved despite adherence to oral hypoglycaemic drugs, healthy diet and lifestyle, insulin should be initiated. However, this is often delayed due to various reasons. We aimed to determine the issues relating to insulin initiation for diabetic patients managed in primary care polyclinics in Singapore.
Methods Qualitative data was obtained during four focus group discussions, with participation from healthcare professionals (HCPs), including physicians and nurses, and type 2 diabetes mellitus patients. The data was transcribed into text, coded and grouped into themes.
Results Launching the topic and doctor-patient communication on insulin therapy were key issues in insulin initiation. Patient barriers to insulin commencement included: refusal to acknowledge the need for insulin therapy; its perception as a social stigma, an inconvenient mode of treatment or punishment for failure; and fear of needles, side-effects and complications. The HCP’s attitude and experience with insulin therapy were also possible barriers.
Conclusion Our findings highlight that insulin initiation is affected by the complex interaction between the patients and HCPs, and other system factors. Patients may harbour misconceptions about insulin due to the late introduction of insulin therapy by HCPs or the way the therapy is being communicated to them. The key issues to address are the disparity in perceptions of diabetic control between HCPs and patients, and education regarding the need for insulin therapy.

Keywords: diabetes mellitus, insulin
Singapore Med J 2011; 52(11): 801-809

Lee SY, Lim CH, Pasupathy S, Poopalalingam R, Tham KW, Ganguly S, Wai CHD, Wong WK
Correspondence: Dr Shanker Pasupathy, shanker.pasupathy@sgh.com.sg

ABSTRACT
Introduction Morbid obesity is associated with increased morbidity and mortality. Bariatric surgery offers morbidly obese individuals substantial and sustainable weight loss and reduction in obesity-related comorbidities. Laparoscopic sleeve gastrectomy (LSG) is a new restrictive procedure in bariatric surgery. We aimed to evaluate our experience with LSG with regard to its safety and feasibility and early weight loss.
Methods The surgical outcome, complications and early clinical results of all patients who underwent LSG at Singapore General Hospital were studied.
Results 30 patients underwent LSG between December 2008 and October 2010. The mean preoperative weight of the patients was 113.4 (range 91.0–170.0) kg, while the mean body mass index (BMI) was 42.6 (range 33.0–60.0) kg/m2. Diabetes mellitus was present in 39 percent of the patients, hypertension in 43 percent, hyperlipidaemia in 35 percent, obstructive sleep apnoea in 30 percent and osteoarthritis in 22 percent. The majority of patients had two or more obesity-related comorbidities (52 percent). Mean operative time was 142 (range 80–220) minutes and median duration of postoperative stay was three days. At two weeks, one, three and six months post operation, the mean BMI was 38.6 kg/m2, 37.8 kg/m2, 34.5 kg/m2 and 30.8 kg/m2, the mean percentage of excess weight loss was 17.7 percent, 23.3 percent, 40.9 percent and 56.7 percent, and absolute weight loss was 8.00 kg, 11.52 kg, 18.77 kg and 26.85 kg, respectively.
Conclusion LSG is a promising procedure for surgical treatment of obesity, with good early weight loss and low morbidity.

Keywords: bariatric surgery, laparoscopic sleeve gastrectomy, morbid obesity, weight loss
Singapore Med J 2011; 52(11): 794-800

Elvy Suhana MR, Farihah HS, Faizah O, Nazrun AS, Norazlina M, Norliza M, Ima-Nirwana S
Correspondence: Prof Dr Ima-Nirwana Soelaiman, imasoel@medic.ukm.my

ABSTRACT
Introduction Glucocorticoids cause osteoporosis by decreasing bone formation and increasing bone resorption activity. Glucocorticoid action in bones depends on the activity of 11-betahydroxysteroid dehydrogenase type 1 (11ßHSD1) enzyme, which plays an important role in regulating corticosteroids. 11ß-HSD1 is expressed by human and rat osteoblasts. We aimed to investigate the relationship between 11ß-HSD1 dehydrogenase activity and bone histomorphometric changes in glucocorticoidinduced osteoporotic bone in rats.
Methods A total of 30 male Sprague-Dawley rats (aged three months, weighing 200–250 g) were divided into three groups of ten each. Group 1 rats were the baseline control, which were sacrificed untreated at the beginning of the study. Group 2 rats underwent sham operation and were administered with vehicle olive oil intramuscularly at 0.05 ml/kg. Group 3 rats were adrenalectomised and administered with an intramuscular injection of dexamethasone 120 µg/kg body weight/day. The treatment was started two weeks after the operation, for a duration of two months. Plasma osteocalcin, plasma pyrodinoline, plasma corticosterone and 11ß-HSD1 were measured, and bone histomorphometry analysis was performed.
Results Dexamethasone treatment caused an increase in plasma corticosterone level, together with a significant reduction in 11ß-HSD1 dehydrogenase activity of the bone, along with a higher plasma level of the bone resorption marker, pyridinoline. Dexamethasone treatment also caused a reduction in trabecular volume, number and thickness, and an increase in trabecular separation.
Conclusion Long-term glucocorticoid treatment reduces the 11ß-HSD1 dehydrogenase activity in the bone, which can otherwise lead to bone loss due to the increased level of active glucocorticoids.

Keywords: 11-beta-hydroxysteroid dehydrogenase type 1, bone, dexamethasone, glucocorticoids, osteoporosis
Singapore Med J 2011; 52(11): 786-793

Durai R, Mir N, Ng PCH
Correspondence: Dr R Durai, dr_durai@yahoo.com

ABSTRACT
Introduction Needle aspiration and core biopsies are commonly used to assess retroperitoneal lymph nodes. However, the tissue obtained by this method is insufficient to define and type the tumour. This article demonstrates the feasibility and safety of the laparoscopic approach in obtaining an adequate volume of lymph node tissue for typing.
Methods Laparoscopic retroperitoneal lymph node biopsy was performed on 12 patients over a period of five years. A pneumoperitoneum was induced with a Veress needle, and an initial 10-mm trocar was inserted in the sub-umbilical region in order to carry a 30-degree telescope. Two or more 5-mm ports were inserted into the targeted areas under laparoscopic guidance to achieve optimal triangulation in order to access the nodal tissue.
Results The procedure was successful in 11 out of the 12 patients. An average volume of 1.7 cm3 of tissue was harvested for each patient. In one patient with preoperatively undiagnosed portal hypertension, laparoscopy was converted to an open procedure due to bleeding. In all patients, the histology was adequate and contributed to the diagnosis, allowing rapid institution of treatment. The diagnosis was reactive lymphadenopathy in three patients and sarcoidosis in one patient. Seven others suffered from various conditions, including lymphoma, leukaemia, secondary from unknown origin and Castleman’s disease.
Conclusion Laparoscopy allows access to perihepatic and perisplenic areas, and is a procedure of choice when needle biopsy is not possible or fails to provide an adequate sample.

Keywords: laparoscopy, lymph node, lymphoma
Singapore Med J 2011; 52(10): 758-762

Wu MWF, Sevilla EM, Raman L, Consigliere D, Siow WY, Tiong HY
Correspondence: Dr Tiong Ho Yee, cfsthy@nus.edu.sg

ABSTRACT
Introduction This study aimed to evaluate the risk of complications for patients who received periprosthetic nerve block (PPNB) with one percent lignocaine before transrectal ultrasonography (TRUS) biopsy of the prostate.
Methods From 2008 to 2009, data on 526 consecutive patients who underwent prostate biopsy was prospectively recorded and analysed. 475 (90.3 percent) patients received PPNB with 10 ml of one percent lignocaine (Group 1), which was carried out under TRUS-guidance and prior to biopsy. 51 (9.7 percent) patients received diclofenac (100 mg) intramuscular injections or no analgesia (Group 2). Complications were defined as any adverse effects after biopsy. Serious complications were defined as those requiring hospitalisation or invasive/operative procedures for treatment.
Results At baseline, both groups were comparable. The mean prostate-specific antigen level in Group 1 was higher than that in Group 2 (48.6 +/- 13.8 versus 19.0 +/- 4.3 ng/ml; p-value is 0.04). There was no perioperative mortality. Post-procedural complications were reported in 23.4 percent (n is 111) of patients in Group 1 and 25.5 percent (n is 13) in Group 2 (p-value is 0.27). Serious complications were reported in 2.5 percent (n is 12) and 7.1 percent (n is 3) of Group 1 and 2 patients (p-value is 0.10), respectively. Both univariable and logistic regression revealed age below 65 years and pre-procedure complaints of lower urinary tract symptoms as independent predictors for complications (p-values are 0.02 and 0.006, respectively).
Conclusion PPNB with one percent lignocaine is a safe analgesic procedure to perform in patients undergoing TRUS biopsy.

Keywords: complications, periprostatic nerve block, transrectal prostate biopsy
Singapore Med J 2011; 52(10): 752-757

Zhang KY, Xing JC, Chen BS, Liu CX, Lau HW, Sim HG, Foo KT
Correspondence: Dr Foo Keong Tatt, foo.keong.tatt@sgh.com.sg

ABSTRACT
Introduction Transurethral enucleation and resection of the prostate (TUERP) may offer a better treatment for benign prostatic enlargement. We compared the perioperative parameters and outcome following bipolar plasmakinetic transurethral resection of the prostate (TURP) and TUERP.
Methods Data from two independent institutions were reviewed retrospectively. 50 and 45 consecutive patients were enrolled in the TURP and TUERP groups, respectively. Pre- and postoperative parameters, including prostatic specific antigen (PSA), prostate volume (PV), International Prostate Symptom Score (IPSS), quality of life (QOL) score, uroflowmetry and prostate volume (PV), were compared.
Results Age at surgery, preoperative PSA (5.8 +/- 4.0 versus 7.6 +/- 5.9 ng/ml) and PV (55.8 +/- 31.6 versus 53.2 +/- 26.8 g) showed no significant difference (p-value greater than 0.05). However,postoperative PSA (2.8 +/- 3.0 versus 0.8 +/- 0.4 ng/ml; p-value less than 0.05) and PV (15.2 +/- 7.7 versus 10.5 +/- 5.4 g; p-value less than 0.01) differed significantly between the TURP and TUERP groups, respectively. There were no significant differences in IPSS, QOL, and Qmax between the two groups during follow-up (p-value is 0.62, 0.68 and 0.13, respectively). However, for the TUERP group, the postoperative post-void residual urine volume (PVR) was significantly better (13.8 +/- 19.5 versus 25.2 +/- 18.7 ml; p-value less than 0.01).
Conclusion The TUERP technique achieved more complete resection than TURP, with a smaller post procedure PV and lower PSA and PVR after surgery. This may predict better long-term results for patients who had TUERP.

Keywords: benign prostatic enlargement, enucleation, prostate, resection
Singapore Med J 2011; 52(10): 747-751

Ranade AV, Tripathi Y, Rajalakshmi R, Vinodini NA, Soubhagya RN, Nayanatara AK, Rekha DK, Kumari M
Correspondence: Dr Anu V Ranade, anuranade@gmail.com

ABSTRACT
Introduction Testicular torsion is a medical emergency, especially in male neonates and adolescents. It is a common clinical outcome and a significant urological issue. From the literature, it is evident that the use of antioxidants in the prevention of testicular reperfusion injury following detorsion is conflicting. This study was conducted to investigate the role of vitamin E in testicular reperfusion injury following detorsion.
Methods Male Wistar albino rats were divided into Groups I, II, III and IV. Only Group IV rats were pre-treated with vitamin E 100 mg/kg body weight for 30 days. Ischaemia was induced manually by rotating the rat testis to 720 degrees clockwise and counter rotating for reperfusion. The testes were fixed in Bouin’s fluid and processed for histopathological examination.
Results A significant decrease in the standard tubular diameter and epithelial height was observed in Group III rats compared to those in Groups I and II. However, the seminiferous tubules in Group IV rats showed recovery in the standard tubular diameter and epithelial height when compared with the untreated control groups.
Conclusion The results showed that vitamin E, when administered before torsion of the spermatic cord in rats, provided significant protection against acute testicular torsion and detorsion injury.

Keywords: ischaemia, reperfusion, testicular torsion, testis
Singapore Med J 2011; 52(10): 742-746

Obarisiagbon EO, Olagbuji BN, Onuora VC, Oguike TC, Ande ABA
Correspondence: Dr Edwin Obarisiagbon, dredbaris@gmail.com

ABSTRACT
Introduction Urinary tract injuries are known complications of pelvic surgeries. Although a few instances have been noted, they remain a source of great concern to surgeons due to their associated morbidity and occasional mortality. We report our experience with the management of iatrogenic urological injuries that complicated obstetric and gynaecological surgeries over a five-year period.
Methods We reviewed all cases of urological injuries managed in our unit that were deemed to be of obstetric and gynaecological origins within the study period.
Results A total of 16 patients were identified as having iatrogenic urological injuries following obstetric and gynaecological surgeries. Only four patients presented early. Five patients had injuries to the bladder, while 12 had ureteric injuries; one of the 16 patients had both types of injuries. Seven cases of ureteric injuries affected only the left ureter, while three were bilateral and two affected the right ureter. One patient with a vesicovaginal fistula (VVF) was successfully managed by urethral catheter drainage alone. Three patients had transabdominal repair of the VVF, while ten had ureteroureterostomy and one had diversion procedure. Simple nephrectomy was performed for one patient with a non-functioning kidney.
Conclusion Iatrogenic urological injuries are still common in our environment. In order to reduce the risk of injury, adequate preoperative preparation is recommended and meticulous surgical technique based on proper understanding of the anatomy of the urogenital system should be practised by the surgeon.

Keywords: gynaecological surgical procedure, intraoperative complications, obstetric surgical procedure, urinary tract injuries, urology
Singapore Med J 2011; 52(10): 738-740

Rahana AR, Ng SP, Leong CF, Rahimah MD
Correspondence: Dr Rahana Binti Abd Rahman, drrahana@ppukm.ukm.my

ABSTRACT
Introduction This study evaluated the effect of human semen cryopreservation using an ultra-low temperature technique with a mechanical freezer at -85°C as an alternative method to the conventional liquid nitrogen technique at -196°C.
Methods This was a prospective experimental study conducted in the Medically Assisted Conception unit, Department of Obstetrics and Gynaecology, National University Hospital, Malaysia from January 1, 2006 to April 30, 2007. All normozoospermic semen samples were included in the study. The concentration, motility and percentage of intact DNA of each semen sample were assessed before and after freezing and thawing on Days 7 and 30 post freezing.
Results Sperm cryopreservation at -85°C was comparable to the conventional liquid nitrogen technique for a period of up to 30 days in a normozoospermic sample. There was no statistical difference in concentration (Day 7 p-value is 0.1, Day 30 p-value is 0.2), motility (Day 7 p-value is 0.9, Day 30 p-value is 0.5) and proportion of intact DNA (Day 7 p-value is 0.1, Day 30 p-value is 0.2) between the ultra-low temperature technique and conventional liquid nitrogen cryopreservation at Days 7 and 30 post thawing.
Conclusion This study clearly demonstrates that short-term storage of sperm at -85°C could be a viable alternative to conventional liquid nitrogen cryopreservation at -196°C due to their comparable post-thaw results.

Keywords: liquid nitrogen, sperm cryopreservation, ultra-low temperature
Singapore Med J 2011; 52(10): 734-737