Original Article

Golestan M, Akhavan Karbasi S, Fallah R
Correspondence: Dr Fallah Razieh, fallah@ssu.ac.ir

ABSTRACT
Introduction Low birth weight (LBW) is a major health problem and a significant contributor to neonatal death in both industrialised and developing countries. This study examined the prevalence and risk factors for LBW in Yazd, a central city of Iran.
Methods In this cross-sectional study, we evaluated all births that were registered in all the maternity hospitals in Yazd, Iran in 2008. LBW neonates were compared with neonates whose birth weight exceeded 2,500 g.
Results The overall prevalence of LBW was 8.8 percent. Univariate analysis using chi-square test showed that the risk factors associated with LBW were first and second pregnancies, teenage pregnancy, maternal diseases (pregnancy-induced hypertension, chronic hypertension and urinary tract infection), childbirth interval of less than three years, especially less than one year from the previous birth, preterm labour and working mothers. In multivariate analysis, preterm labour (odds ratio [OR] 5.2, 95 percent confidence interval [CI] 4.8–6.11), working mothers (OR 2.7, 95 percent CI 1.25–3.1) and pregnancy-induced hypertension (OR 1.5, 95 percent CI 1.2–2.22) were found to be risk factors for LBW.
Conclusion Screening for high-risk pregnancies, such as teenage pregnancies and those with short birth intervals and maternal disease, as well as making provisions for attentive prenatal care and facilities are essential to reduce the incidence of LBW.

Keywords: extremely low birth weight, low birth weight, neonate
Singapore Med J 2011; 52(10): 730-733

Wijeweera O, Ng SBA
Correspondence: Dr Olivia Wijeweera, honliang.olivia@gmail.com

ABSTRACT
Introduction Congenital tracheal stenosis is a rare but life-threatening obstructive airway disease. It usually presents in early infancy and requires surgical intervention. This study is a review of our experience in the management of congenital tracheal stenosis in children at KK Women’s and Children’s Hospital, Singapore.
Methods All children who had undergone tracheoplasty for congenital tracheal stenosis between January 1999 and December 2008 were included. The patients’ medical records were retrieved from our database, and the demographic data, comorbidities, clinical presentation and management, surgery performed, postoperative complications, final outcomes and follow-up were reviewed.
Results A total of 11 children aged 12 days to six years underwent surgery for congenital long-segment tracheal stenosis, of which ten (90.9 percent) had associated cardiac and vascular anomalies and nine (81.8 percent) had left pulmonary artery sling predominance. Five (45.4 percent) children had associated bronchopulmonary abnormalities. All the patients underwent slide tracheoplasty with concomitant repair of congenital heart defects. Overall mortality was 45.4 percent (n is 5), including one late mortality due to an unrelated cause. With the exception of one, the follow-up of all patients was complete at this writing. One patient had mild residual tracheal stenosis and another had bilateral bronchomalacia.
Conclusion This is the largest case series of congenital long-segment tracheal stenosis reported in Southeast Asia to date. Slide tracheoplasty with concomitant repair of cardiac lesions is currently the preferred management for long-segment stenosis. Management of such patients remains a challenge for clinicians and the patients’ families, and requires a multidisciplinary approach.

Keywords: airway obstruction, congenital tracheal stenosis, infant, Southeast Asia, trachea
Singapore Med J 2011; 52(10): 726-729

Sindhwani G, Verma A, Biswas D, Srivastava M, Rawat J
Correspondence: Dr Girish Sindhwani, girish_sindhwani@rediffmail.com

ABSTRACT
Introduction Pulmonary rehabilitation is now an accepted modality of care in the management of chronic obstructive pulmonary disease(COPD) patients. However, in resource-limited settings, conventional pulmonary rehabilitation may not be feasible due to the high cost involved and the extensive infrastructure requirement. In view of these constraints, we designed a domiciliary pulmonary rehabilitation programme and evaluated its usefulness in the management of severe COPD.
Methods A total of 20 patients suffering from severe COPD (ten patients each in the experimental and control groups) were enrolled in the study. The experimental group was subjected to domiciliary pulmonary rehabilitation along with medical management, while the control group underwent only conventional medical management. During the six-month study period, both groups were assessed for quality of life (clinical COPD questionnaire), exercise capacity (six-minute walk distance) and spirometry values (forced expiratory volume in one second and forced vital capacity).
Results Statistically significant differences were observed in clinical COPD questionnaire scores in both groups from the fourth month (p-value is 0.002 and 0.001 at the end of four and six months, respectively). The results of the six-minute walk distance showed a similar trend (p-value is 0.009 and 0.001 at the end of four and six months, respectively). No significant difference was observed in either of the spirometry values.
Conclusion The domiciliary pulmonary rehabilitation programme improves the quality of life and exercise endurance of patients with severe COPD, and thereby acts as a substitute for conventional pulmonary rehabilitation programmes in resource-limited situations.

Keywords: chronic obstructive pulmonary disease, domiciliary, pulmonary rehabilitation
Singapore Med J 2011; 52(9): 689–693

Arora R, Jha KN, Sathian B
Correspondence: Dr Reema Arora, reemaoph@yahoo.com

ABSTRACT
Introduction This study aimed to evaluate the retinal changes associated with altitude illness in young soldiers.
Methods A total of 50 young soldiers with altitude illness, who were referred to a tertiary care hospital between October 2003 and January 2006, were included in the study.
Results All the soldiers were male. The mean age of the subjects was 30.3 (range 20–44) years. Nine (18 percent) soldiers had acute mountain sickness (AMS), nine (18 percent) had high-altitude pulmonary oedema (HAPE) and 20 (40 percent) had high-altitude cerebral oedema (HACE). Retinal haemorrhages were observed in 29 soldiers (58 percent). Among these 29 cases, two also had symptoms of AMS, five had symptoms of HAPE and twelve had symptoms of HACE. High-altitude retinal haemorrhage alone as a sign of altitude illness was seen in ten cases. Severe grades of high-altitude retinopathy were found mostly in soldiers who suffered from HAPE and HACE. Visual recovery was complete in 22 (76 percent) soldiers. High-altitude retinal haemorrhage was associated with partial visual impairment in five (17 percent) soldiers and permanent visual loss in two (seven percent) soldiers.
Conclusion Retinal haemorrhages were noticed in 58 percent of soldiers with altitude illness. The association of severe grades of high-altitude retinopathy with HAPE and HACE was statistically significant. Branch retinal vein occlusion with macular oedema is an additional finding in our study, which has not been previously reported.

Keywords: altitude, cerebral oedema, pulmonary oedema, retinal haemorrhage
Singapore Med J 2011; 52(9): 685–688

Jamaluddin S, Sulaiman AR, Kamarul Imran M, Juhara H, Ezane MA, Nordin S
Correspondence: Dr Abdul Razak Sulaiman, abdrazak@kb.usm.my

ABSTRACT
Introduction The aim of this study was to determine the reliability and accuracy of the tape measurement method (TMM) with a nearest reading of 5 mm in assessing leg length discrepancy (LLD).
Methods This was a cross-sectional study conducted on 35 patients with LLD and 13 patients without LLD. Two blinded surgeons measured the lower limbs from the anterior superior iliac spine to the medial malleolus using TMM with a nearest reading of 5 mm. Computed tomography (CT) scanograms of the lower limbs of 22 patients were conducted by two blinded radiologists. Intraclass correlation coefficient (ICC) with 95 percent confidence interval was calculated to assess the interobserver reliability of TMM. The accuracy of TMM was assessed by comparison with CT as the gold standard.
Results The interobserver reliability of LLD measurement using both TMM and CT scanogram was high, with ICCs of 0.924 and 0.971, respectively. No significant mean difference on paired sample t-test was observed for both TMM and CT scanogram. Compared to CT scanogram, TMM had good accuracy, with an ICC of 0.805. When the mean TMM readings by two observers were compared to those derived from CT scanogram, the ICC was found to be 0.847, with a mean difference of 1.95 (range -3.17 to 7.07) mm.
Conclusion There was excellent agreement in the LLD measurements between the two surgeons using TMM, between the two radiologists using CT sonogram, and between the TMM and CT measurements. This study showed that one TMM with the nearest reading of 5 mm was reliable and accurate in measuring LLD.

Keywords: leg length discrepancy, tape measurement method
Singapore Med J 2011; 52(9): 681–684

Ang CL, Singh G, Goh ASW, Shen L, Tay BK
Correspondence: Dr Ang Chia Liang, med80199@yahoo.com

ABSTRACT
Introduction Bisphosphonates have been shown to be effective in reducing the risk of fragility fractures in several landmark clinical trials conducted in Western populations. However, limited studies on bone mineral densitometry (BMD) trends have been conducted in Asian women. We conducted a retrospective review of electronic records to determine the actual BMD trends in a local population of postmenopausal women on bisphosphonate treatment.
Methods The electronic records of all women over 50 years of age who had undergone BMD at Singapore General Hospital in 2004 were examined. Patients who were later started on bisphosphonates and continued the treatment for at least two years were selected for the study. Their subsequent BMD results were recorded, and longitudinal analysis was applied to determine the BMD trends as a cohort.
Results A total of 254 postmenopausal women were included for analysis. Their mean BMD T-score was -2.70 before treatment, and improved to -2.56 and -2.27 one and two years after treatment, respectively. However, the score deteriorated to -2.50 and -2.62 three and four years after treatment, respectively. The difference between each year’s results and those of the baseline was statistically significant.
Conclusion In our study, the BMD scores in our local population showed improvement in the first two years of bisphosphonate treatment but declined subsequently. Our findings contrasted with those of studies conducted in Western populations. Further prospective studies are suggested so as to elucidate the actual BMD trends and fracture risk reduction in Asian women on bisphosphonate treatment.

Keywords: Asian, bisphosphonates, bone mineral density, postmenopausal, women
Singapore Med J 2011; 52(9): 677–680

Sharma A, Kumar A, Singh P
Correspondence: Dr Anu Sharma, anuashwani2003@yahoo.com

ABSTRACT
Introduction Detailed anatomical knowledge of the distal end of the ulna plays a pivotal role in understanding post-injury instability and painful conditions at the distal radioulnar joint (DRUJ), which can be due to avulsion of the ulnar styloid process or ulnar styloid triquetral impaction syndrome. With this in mind, data on the morphological features of distal ulnae in the Indian population was collected.
Methods The distal end of 100 human ulnae (50 right-sided and 50-left sided) of unknown gender from the anatomy department’s bone bank were studied with regard to the seat (articular circumference of the head of ulna), ulnar styloid process, fovea and pole (articular surface for articulation of triangular fibrocartilaginous complex of the wrist on the head of ulna).
Results The average length of the styloid process was 5.2 mm in the right-sided ulnae and 5 mm in the left. The mean maximum height of the seat was noted to be 5.9 mm and 6.9 mm on the right-and left-sided ulnae, respectively. The maximum width of the pole was calculated to be 5.4 mm (right-sided ulnae) and 6.1 mm (left-sided ulnae). The shapes of the pole and styloid process were also noted. Extensor carpi ulnaris groove was more commonly found on the left-sided ulnae.
Conclusion The study provides an anatomical database of the morphometry of parts of the distal end of the ulna in the Indian context, which will aid in the early management of DRUJ injuries.

Keywords: distal end of ulna, distal radioulnar joint, head of ulna, styloid process of ulna
Singapore Med J 2011; 52(9): 673–676

Nawfar SA, Yacob NBM
Correspondence: Dr Abdul Nawfar Sadagatullah, nawfar@kb.usm.my

ABSTRACT
Introduction Peripheral diabetic neuropathy, which is a cause of increasing morbidity and mortality following foot ulcers and amputations, is a burden to health and the economy. Various adjunct treatments to improve neuropathy have been introduced into the market; one such treatment is monochromatic infrared energy (MIRE) therapy, which claimed to produce promising results. This study aimed to evaluate the effects of MIRE on diabetic feet with peripheral neuropathy.
Methods A randomised controlled, single-blinded study was conducted at Hospital Universiti Sains Malaysia from February 2008 to October 2008. A total of 30 feet from 24 patients were studied. Neuropathy was screened using the Michigan neuropathy scoring instrument, followed by an assessment of the current perception threshold using a neurometer at frequencies of 2,000 Hz, 250 Hz and 5 Hz. The feet were randomised to receive either daily MIRE or sham treatment for a total of 12 treatments. Each foot was then reassessed using the neurometer at six weeks and three months following treatment.
Results The data obtained was analysed using a non-parametric test to compare the pre- and post-treatment groups. No significant difference was found between the neuropathic foot of diabetic patients in both the MIRE and sham groups.
Conclusion No improvement of neuropathy was observed following MIRE treatment in the neuropathic feet of diabetic patients.

Keywords: diabetes complications, diabetic foot, infrared therapy, peripheral neuropathy
Singapore Med J 2011; 52(9): 669–672

Tan MLM, Feng J, Gordois A, Wong ESD
Correspondence: Dr Mark Tan Ming Long, minglong@starhub.net.sg

ABSTRACT
Introduction The aim of the study was to determine the cost-effectiveness of the Lower Extremity Amputation Prevention (LEAP) strategy in comparison to standard clinical practice for treating patients with critical limb ischaemia (CLI).
Methods A retrospective cost-effectiveness analysis of the LEAP programme relative to pre-LEAP practice was performed from the perspective of Singapore hospitals. The cost incorporated in the analysis included direct medical costs incurred during the admission. Outcomes included the number of amputations, number of deaths and length of hospital stay after the initial treatment.
Results During the study period, the LEAP group had a lower amputation rate (29 percent versus 76 percent, p-value is 0.00001), lower related death rate (one percent versus 19 percent, p-value is 0.00001) and fewer in-hospital days per patient (17.8 days versus 23.16 days,  p-value is 0.048) as compared to the standard clinical practice group. The implementation of the LEAP strategy generated cost savings of S$2,566 per patient during admission when compared with the pre-LEAP approach. The results were robust to variations in input parameters.
Conclusion The LEAP strategy dominated standard practice in the management of patients with diabetes mellitus and CLI. The implementation of the LEAP strategy significantly improved patient outcomes and reduced hospital costs.

Keywords: cost-effectiveness, critical limb ischaemia, hospital cost savings, limb salvage, percutaneous angioplasty
Singapore Med J 2011; 52(9): 662–668

Ong HS, Tan G, Chew WYC
Correspondence: Dr Ong Hang Shyan, hang_shyan_ong@ttsh.com.sg

ABSTRACT
Introduction The purpose of this paper is to share the outcome of cases of scaphoid non-union treated with 1,2 intercompartmental supra-retinacular artery (1,2 ICSRA) vascularised graft at our institution, as well as to identify the possible factors for the failure of the procedure.
Methods This was a retrospective review of 13 cases of scaphoid fracture non-union treated with 1,2 ICSRA vascularised bone grafting from October 2000 to March 2003. A clinical and radiological review was conducted. Linear regression was performed in order to identify the factors associated with a negative outcome.
Results Out of the 13 patients with scaphoid non-union, ten (77 percent) had avascular necrosis of the proximal pole. The patients were followed up for a mean duration of 13 (range 3–28) months. Ten out of the 13 (77 percent) patients achieved union.
Conclusion Our results are comparable to those reported by other studies and indicate that avascular necrosis was associated with failure to achieve union.

Keywords: avascular necrosis, bone grafting, non-union, scaphoid
Singapore Med J 2011; 52(9): 658–661