Original Article

Olasinde AA, Oluwadiya KS, Adegbehingbe OO
Correspondence: Prof Oluwadiya Kehinde Sunday, oluwadiya@gmail.com

ABSTRACT
Introduction Brodie’s abscess is not a common variant of subacute osteomyelitis; however, when it does occur, the presentation is atypical and usually late. This study aimed to describe the mode of presentation of Brodie’s abscess and evaluate the results of surgical treatment in a resource-poor setting.
Method Over a five-year period, we retrospectively reviewed 20 patients who presented to two tertiary health institutions in south western Nigeria with clinical and radiological features of Brodie’s abscess.
Results Brodie’s abscess accounted for just 2 percent of all patients with osteomyelitis. Most patients were adults (mean age 21.5 +/- 7.8 years) and males (75 percent). In the series, the tibia was involved in 50 percent of the cases, the femur in 30 percent, and the radius and fibula each in 10 percent. The diaphyseal part of the long bones was affected in 65 percent of the patients and the metaphysis, in the remaining patients. The average size of the cavities was 3.0 +/- 0.8 cm. 65 percent of the isolates yielded Staphylococcus aureus. All patients were treated by curettage of the abscess cavities, cancellous bone grafting and antibiotics. All patients had satisfactory outcomes, with complete incorporation of the grafts and new bone formation in the cavities. No patient reported any recurrence.
Conclusion Patients with Brodie’s abscess respond well to surgical curettage of the abscess, cancellous bone grafting and antibiotic therapy.

Keywords: Brodie’s abscess, developing countries, osteomyelitis, treatment
Singapore Med J 2011; 52(6): 436-439

Shadangi BK, Garg R, Pandey R, Das T
Correspondence: Dr Bijaya Kumar Shadangi, drrgarg@hotmail.com

ABSTRACT
Introduction Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. Intrathecal midazolam produces antinociception and potentiates the effect of local anaesthetics. We compared intrathecal bupivacaine with and without midazolam to assess its effect on the duration of sensory block, motor block and pain relief.
Methods A total of 100 patients scheduled for elective lower abdominal, lower limb and gynaecological procedures were selected to participate in this prospective, randomised, double-blind study. Patients were randomly allocated into two groups for intrathecal drug administration. Group B received 3 mL 0.5 percent bupivacaine with 0.4 mL saline, and group BM received 3 mL 0.5 percent bupivacaine and 0.4 mL (2 mg) midazolam mixture. The onset, duration of sensory/motor block, time to first rescue analgesia and side effects were noted.
Results Demographic profile and duration of surgery were comparable between the two groups. The onset of sensory (4.8 versus 4.6 min) and motor block (5.9 versus 6 min) was also comparable between the groups. The duration of sensory blockade was prolonged in the midazolam group (90.8 versus 115.8 min, p-value is 0.001), while the duration of motor blockade was comparable (151.8 versus 151.3 min, p-value is 0.51). The duration of effective analgesia was significantly longer in the midazolam group compared to the control group (121.3 versus 221.1 min, p-value is 0.001). Sedation score was comparable in the two groups.
Conclusion The addition of preservative-free midazolam to bupivacaine intrathecally resulted in prolonged postoperative analgesia without increasing motor block.

Keywords: analgesia, hyperbaric bupivacaine, intrathecal, midazolam
Singapore Med J 2011; 52(6): 432-435

Lee KM, Guo S, Manning V, Thane K, Wong KE
Correspondence: Dr Victoria Manning, victoria_manning@imh.com.sg

ABSTRACT
Introduction The expansion in gambling activities over the past decade has made gambling more accessible than ever. This could bring changes in the sociodemographic and clinical profiles of those seeking treatment for pathological gambling.
Methods This study examined the differences between two cohorts of 150 patients each, treated at the National Addictions Management Service between 2001 and 2006 (cohort-1) and between 2006 and 2008 (cohort-2), respectively.
Results Compared to cohort-1, cohort-2 was significantly younger (p-value less than 0.01), comprised fewer Chinese and were more highly educated (p-value less than 0.05), with no significant difference in gender or marital status. Regarding the type of gambling activities, cohort-2 was more likely to engage in soccer betting (p-value less than 0.01). Although the proportion presenting with any comorbidity remained unchanged, alcohol use disorders had increased more than three-fold and suicide risk was slightly elevated, although not significantly.
Conclusion Clinicians should undertake routine screening and assessment of alcohol misuse and suicide risk, offering brief interventions, where necessary, for this vulnerable population.

Keywords: alcohol misuse, clinical, pathological gambling, Singapore, sociodemographic profile
Singapore Med J 2011; 52(6): 428-431

Mazlina M, Julia PE
Correspondence: Dr Mazlina Mazlan, drmazlina@gmail.com

ABSTRACT
Introduction Medical ethics issues encountered in rehabilitation medicine differ from those in an acute care setting due to the complex relationships among the parties involved in rehabilitative care. The study examined the attitudes of Malaysian rehabilitation doctors toward medical ethics issues commonly encountered during patient care.
Methods We surveyed 74 rehabilitation physicians and residents in Malaysia using a self-administered descriptive questionnaire. The questions covered medical ethics issues on allocation of resources, patient confidentiality, discharge planning, goal-setting, reimbursement documentation, decision-making capacity and withdrawal of life support.
Results The overall response rate was 69 percent. More than 80 percent of respondents would disclose confidential information to their team members if it would affect the rehabilitation process. More than two-thirds of respondents would not allocate scarce rehabilitation resources if the functional outcome is marginally positive. Issues involving patients’ autonomy in decision-making, both in life-threatening and non-life-threatening situations, showed mix responses. The least common response was on the issue of discharge planning, where 51 percent of respondents would send a patient back to a nursing home with suboptimal care if there were no other alternatives.
Conclusion The attitude of Malaysian rehabilitation doctors toward ethical issues is reflective of the level of maturity of rehabilitation medicine in Malaysia. Issues on allocation of resources, discharge planning and decision-making capacity are significantly influenced by limited rehabilitation facilities in parts of the country. The lack of influence from external factors, such as a developed health insurance system, contributes to the difference in attitude between rehabilitation doctors in Malaysia and those in developed countries.

Keywords: attitude of health personnel, autonomy, bioethics, medical ethics, rehabilitation
Singapore Med J 2011; 52(6): 421-427

Bahadin J, Teo SSH, Mathew S
Correspondence: Dr Juliana Bahadin, juliana.bahadin@singhealth.com.sg

ABSTRACT
Introduction Antibiotic resistance among uropathogens causing urinary tract infection (UTI) is increasing worldwide. In most cases of UTI, family physicians can provide empirical treatment without the benefit of a pre-therapy urine culture. Knowledge of the aetiology and antimicrobial susceptibility patterns of uropathogens is important in order to determine the best empiric treatment option. This study aimed to determine the aetiology and antimicrobial susceptibility of uropathogens in culture-positive, community-acquired UTIs over a one-year period.
Methods This is a retrospective analysis of medical case records. All patients who were diagnosed and coded with UTI and had urine culture done were analysed. The prevalence of the UTI-causing organism and its antibiotic susceptibility was tabulated. Results were analysed with descriptive statistics. The chi-square and Fisher’s exact tests were applied for categorical variables.
Results The commonest organism isolated for all age groups and gender was Escherichia coli (74.5 percent) and Klebsiella spp. (8.7 percent). Among the oral antibiotics widely used in primary care in Singapore, the Enterobacteriaceae family was most susceptible to amoxicillin/clavulanate. There was no significant difference in the susceptibility of common oral antibiotics when tested against the Enterobacteriaceae for both male and female patients and between patients older than 65 years and those 65 years and below.
Conclusion Empirical treatment of community-acquired UTI with cotrimoxazole, ciprofloxacin, cephalothin and ampicillin is inadequate. Amoxicillin/clavulanate should be the drug of choice for empirical treatment instead.

Keywords: aetiology, antimicrobial susceptibility, community-acquired urinary tract infection, empirical treatment, uropathogens
Singapore Med J 2011; 52(6): 415-420

Sen T, Esmer AF, Acar HI, Karahan ST, Tuccar E
Correspondence: Dr Ali Firat Esmer, alife76@yahoo.com

ABSTRACT
Introduction The arteries of the anterior perforated substance (APS) are important due to their role in supplying blood to important internal structures such as the internal capsule, putamen and caudate nucleus. The purpose of this study was to investigate in detail the arteries of the APS.
Methods The arteries of the APS were investigated in 60 cerebral hemispheres from 30 adult cadaveric brains. The internal carotid arteries were cannulated and perfused with coloured latex. The branches of the middle cerebral artery (MCA) penetrating the APS were investigated. These arteries, known as the lateral lenticulostriate arteries and originating from the M1 segment, early temporal and early frontal branches of the MCA, were recorded.
Results The branches of the anterior choroidal artery, which reached the APS, were seen in all specimens. We found one to three branches that arose from the A2 segment of the anterior cerebral artery (ACA) to the APS in all hemispheres, and one to three branches that originated from the A1 segment of the ACA in 48 hemispheres. In addition, two accessory MCAs that originated from the A2 segment of the ACA were recorded as variations, and perforating branches to the APS were observed.
Conclusion Serious complications like motor deficits can occur as a result of injury to the arteries of the APS. Hence, neurosurgeons performing operations such as aneurysm or insular tumour surgeries must be aware of the importance of preserving these arteries.

Keywords: anatomy, anterior cerebral artery, anterior perforated substance, middle cerebral artery
Singapore Med J 2011; 52(6): 410-414

Siow TR, Ngoi CLF, Tan WKT
Correspondence: Dr Siow Tian Rui, siow.tian.rui@singhealth.com.sg

ABSTRACT
Introduction This study aimed to analyse the inter-fraction prostate motion and setup error during intensity-modulated radiotherapy for prostate cancer at the National Cancer Centre Singapore.
Methods Gold seeds were implanted as fiducial markers. Daily portal films were taken and displacements of the gold seeds from the isocentre in each axis were recorded. Random and systematic errors were used to derive a margin recipe for each axis based on the van Herk formula.
Results 1,077 fractions from 36 patients were analysed. 89.8 percent, 85.2 percent and 83.6 percent of the setup errors were within +/- 2 mm for the right-left (RL), superior-inferior (SI) and anterior-posterior (AP) axes, respectively. The population systematic errors were 0.71 mm, 0.84 mm and 0.87 mm; the population random errors were 1.32 mm, 1.59 mm and 1.70 mm; the overall population mean setup errors were -0.14 (range -2.27 to 1.15) mm, 0.11 (range -2.32 to 1.69) mm and 0.08 (range -1.33 to 1.46) mm; and the van Herk margin recipes were 2.69 mm, 3.22 mm and 3.37 mm for the RL, SI and AP axes, respectively.
Conclusion The setup errors and inter-fraction prostate movements were small. Gold seed implantation is a feasible and easy method of verifying the prostate position.

Keywords: fiducial markers, intensity-modulated radiotherapy, inter-fraction motion, prostate cancer
Singapore Med J 2011; 52(6): 405-409

Chong E, Shen L, Poh KK
Correspondence: Dr Eric Chong, ericchong80@hotmail.com

ABSTRACT
Introduction Ezetimibe at full dose (10-mg) is used for lipid lowering. We hypothesised that ezetimibe at half dose is effective in achieving percentage improvement in lipid profile among Asian patients with severe hyperlipidaemia.
Methods This was a prospective cohort study conducted between 2006 and 2008. 105 patients with hyperlipidaemia not reaching target level with statin treatment alone were given add-on ezetimibe 5-mg daily treatment. Lipid profiles were compared at pre- and post-ezetimibe therapy.
Results The mean age of the patients was 56.0 +/- 10.3 years. 79.0 percent were male and 62.9 percent had hypertension, 39 percent had diabetes mellitus with a mean HBA1c of 7.7 percent. 58.1 percent had a history of myocardial infarction. The median simvastatin equivalent dose was 40 (range 5–80) mg. Duration of ezetimibe treatment was 102 +/- 60 days. We observed improvements in total cholesterol (TC) (from 5.31 +/- 1.02 to 4.33 +/- 1.11 mmol/l, 16.4 percent reduction, p-value less than 0.0005), low density lipoprotein (LDL) (from 3.43 +/- 0.87 to 2.52 +/- 0.95 mmol/l, 24.0 percent reduction, p-value less than 0.0005) and TC to LDL ratio (from 4.92 +/-1.42 to 4.03 +/-1.16, 16.2 percent reduction, p-value less than 0.0005). The percentage improvement of lipid profile was comparable to that of the published data based on 10-mg dosing.
Conclusion A 5-mg dose of daily ezetimibe add-on treatment is effective in improving lipid profiles in Asian patients with severe hyperlipidaemia not reaching target with statin monotherapy.

Keywords: Asian, ezetimibe, half-dose, lipid, statin
Singapore Med J 2011; 52(6): 400-404

Shaikh MU, Ali N, Adil SN, Khurshid M
Correspondence: Dr Natasha Ali, natasha.ali@aku.edu

ABSTRACT
Introduction Acute lymphoblastic leukaemia (ALL) is a heterogeneous group of lymphoid neoplasm resulting from the proliferation of malignant lymphoid cells. We aimed to study the outcome of adult patients with ALL receiving the Medical Research Council UKALL XII protocol.
Methods This was a retrospective study conducted at Aga Khan University Hospital from January 2001 to December 2008. The medical records of all adult patients were reviewed and analysed for clinical, morphological and immunological features at presentation and impact on treatment outcomes. Multivariate analysis and survival studies were performed using Kaplan-Meier statistics.
Results The total number of patients was 54, with a male to female ratio of 3.4:1 and a median age of 28 years. Common presenting symptoms were fever (n is 49) and bleeding (n is 14). 38 patients had haemoglobin less than 10 gms/dl, 21 had white blood cell (WBC) count of 50 × 10E9/L or more, and 35 had lactate dehyrogenase more than 1,000 IU. Morphologically, FAB-L2 was the commonest subtype, with 38 patients with B-ALL and eight with T-ALL. Multivariate analysis showed that age above 30 years, male gender, WBC count above 50 × 10E9/L and T-ALL subtype were independent risk factors for poor survival. 46 (85 percent) patients achieved complete remission. The median survival was 12.3 months. At the end of five years, 16 patients were alive, two were alive with disease and 14 were in complete remission.
Conclusion Overall survival and relapse rates in our study were comparable to those reported internationally.

Keywords: acute lymphoblastic leukaemia, adults, MRC UKALL XII protocol, Philadelphia chromosome, treatment outcome
Singapore Med J 2011; 52(5): 370-374

AL-Rousan HO, Meqdam MM, Alkhateeb A, Al-Shorman A, Qaisy LM, Al-Moqbel MS
Correspondence: Prof Mamdoh M Meqdam, m.harahsha@uoh.edu.sa

ABSTRACT
Introduction This study was aimed at investigating the prevalence of human bocavirus (HBoV) among Jordanian children hospitalised with lower respiratory tract infection (LRTI) as well as the clinical feature associated with HBoV infection, the seasonal distribution of HBoV and the DNA sequencing of HBoV positive samples.
Methods A total of 220 nasopharyngeal aspirates were collected from children below 13 years of age who were hospitalised with LRTI in order to detect the presence of HBoV using real-time polymerase chain reaction assay and direct HBoV sequencing.
Results HBoV was detected in 20 (9.1 percent) patients, whose median age was four (range 0.8–12) months. Children under the age of 12 months were more susceptible to HBoV infection (p-value is 0.016). The main clinical diagnoses of patients infected with HBoV were bronchopneumonia (35 percent) and bronchiolitis (30 percent). Coughing (100 percent), wheezing (82.7 percent) and fever (68.2 percent) were the most prominent symptoms in infected patients. HBoV infections were seasonal; increasing in cooler months, diminishing in the summer and peaking in March (45 percent). Direct DNA sequencing revealed that three out of 20 (15 percent) specimens were identical to Stockholm 1 and 2 isolates, and single base pair substitution (A to T) at codon 92 was found in 17 out of the 20 (85 percent) specimens that were positive for HBoV, resulting in a threonine-to-serine substitution.
Conclusion More attention should be given to diagnosing HBoV in patients with LRTI using molecular techniques.

Keywords: bocavirus, Jordan, real-time PCR, sequencing
Singapore Med J 2011; 52(5): 365-369