Original Article

Poulose V, Bin Mohd I
Correspondence: Dr Vijo Poulose, vijo_poulose@cgh.com.sg

ABSTRACT
Introduction Prolonged cough is a common reason for referral to a respiratory physician. Some cases of prolonged cough can be a diagnostic challenge, especially when it is not accompanied by features that suggest common aetiologies. The current study examined this group of patients so as to ascertain the final aetiological and clinical outcomes.
Methods We performed a chart review of cases that had been prospectively identified. The inclusion criteria were cough lasting more than three weeks, normal chest radiograph, non-smoking status, no history of angiotensin-converting enzyme inhibitor use, normal physical examination and absence of suggestive features of asthma, gastroesophageal reflux disease and postnasal drip syndrome. We classified the final diagnoses into three categories: likely diagnosis; possible diagnosis; and no diagnosis established, and traced the clinical outcomes.
Results A total of 54 patients met the study criteria. The median duration of cough was 16 weeks (range four weeks to five years), while the median age of the patients was 38 (range 18–73) years. A likely diagnosis was reached in 23 patients and a possible diagnosis, in 12 patients. Gastroesophageal reflux disease and postnasal drip syndrome were the commonest diagnoses. There were no cases of asthma. The cough improved completely in 44 patients. Three cases were lost to follow-up before an outcome could be documented.
Conclusion In most of these cases, a diagnosis could be achieved. The cough improved in the majority of patients, including those in whom a diagnosis could not be made.

Keywords: chronic cough, prolonged cough, subacute cough
Singapore Med J 2011; 52(4): 267-270

Assadi M, Akrami A, Beikzadeh F, Seyedabadi M, Nabipour I, Larijani B, Afarid M, Seidali E
Correspondence: Dr Majid Assadi, assadipoya@yahoo.com

ABSTRACT
Introduction Fasting evidently influences a variety of physiological parameters that can impact the ocular system. Among these modifications are alterations in insulin secretion, sympathetic activity, free fatty acids, lipid profile, melatonin, cortisol, electrolytes and catecholamines. In this study, we investigated the possible alterations in intraocular pressure (IOP), visual acuity and refractive errors during Ramadan fasting.
Methods IOP, visual acuity and refractive errors of both eyes of volunteers were measured on the first and last days of Ramadan (once in the morning and evening). Body weight was measured so as to estimate the amount of dehydration. Data from the two examinations was analysed using one-way analysis of variance. A p-value of less than 0.05 was considered statistically significant.
Results 58 healthy, fasting male volunteers with a mean age of 40.7 +/- 7.1 years participated in the study. Statistical analysis demonstrated no difference in IOP, visual acuity or refractive errors on the first and last days of Ramadan, or within a single day (from morning to evening).
Conclusion Our results reveal that Islamic Ramadan fasting does not profoundly affect physiological IOP, refractive error or visual acuity values in healthy volunteers. However, more detailed investigations using animal models should be designed to evaluate whether fasting has a pivotal influence on pathological conditions.

Keywords: body weight, intraocular pressure, Ramadan fasting, refractive errors, visual acuity
Singapore Med J 2011; 52(4): 263-266

Chow J, Tan CH, Ong SH, Goh YS, Gan HW, Tan VH, Chai SC
Correspondence: Dr Tan Chong Hiok, chong_hiok_tan@cgh.com.sg

ABSTRACT
Introduction Primary transradial percutaneous coronary intervention (TRI) is shown to be efficacious in stable patients with acute coronary syndrome. We aimed to evaluate the application of primary TRI for acute ST elevation myocardial infarction (STEMI), including among high-risk patients from our registry.
Methods This was a single-centre case series comprising 138 patients who underwent primary TRI for STEMI between May 2007 and June 2008. TRI was attempted with a 6-Fr guiding catheter in all patients regardless of Killip class status. Outcome measures were success rates of primary TRI, door-to-balloon time, procedure duration and volume of contrast used. All patients were followed up for major adverse cardiac events in-hospital, at 30 days and six months.
Results A total of 138 patients had primary TRI attempted for STEMI. Four patients failed primary TRI and required a femoral approach. The remaining 134 patients underwent primary TRI. The mean patient age was 56.4 years. Most patients with acute STEMI presented in Killip class I and II (91.8 percent). Only 8.2 percent were in Killip class III or IV on admission. 50 percent of patients presented with anterior STEMI. The median door-to-balloon time for this group was 92 (interquartile range [IQR] 77–121) minutes, with a median procedure time of 39 (IQR 29–51) minutes. The success rate of primary TRI was 97.1 percent.
Conclusion Success rate, procedural and radiation time for TRI are comparable to those achieved via the femoral approach. Primary TRI is therefore a feasible and effective approach for acute STEMI, even in high-risk patients.

Keywords: acute ST elevation myocardial infarction, feasible approach, high-risk patients, Ikari left catheter, primary transradial percutaneous coronary intervention
Singapore Med J 2011; 52(4): 257-262

Chew KS, Tan TW, Ooi YT
Correspondence: Dr Chew Keng-Sheng, cksheng74@yahoo.com

ABSTRACT
Introduction In a multiethnic nation, it is not uncommon for doctors to encounter patients of different cultural backgrounds. Often, patients’ cultural beliefs influence their perception of health and illnesses, and their treatment option. Many Chinese cultural beliefs are influenced by the Taoist concept of yin-yang balance.
Methods We interviewed 50 Malaysian Chinese from the general public of a suburban population in order to unravel the impact of Chinese cultural health beliefs on their decision-making, and this was compared with the opinions of 50 Chinese medical students from second to final year. Convenience sampling was then applied.
Results From the survey, 78 percent of the general public believed that ‘too much heat’ or ‘too much coldness’ in the body could cause diseases. Compared to the medical students, a significantly higher number of the respondents held such beliefs, including the beliefs that abdominal colic is due to excessive ‘wind’ in the abdomen, consuming certain food can dispel wind from the body, and the importance of observing taboos during the confinement period after delivery. The majority of respondents from both groups believed that it is acceptable to combine both traditional Chinese medicine and modern medicine.
Conclusion There is a discrepancy in the extent to which these beliefs influence the perception of health and illnesses among the general public and among medical students. Healthcare providers need to be aware of such beliefs and practices regarding traditional Chinese medicine among their Chinese patients.

Keywords: cultural background, Malaysia, modern medicine, traditional Chinese medicine
Singapore Med J 2011; 52(4): 252-256

Chew MH, Quah HM, Teh KL, Loi TTC, Eu KW, Tang CL
Correspondence: Dr Hak-Mien Quah, quah.hak.mien@sgh.com.sg

ABSTRACT
Introduction The Singapore Polyposis Registry (SPR) was established in 1989 at the Singapore General Hospital. This initiative was aimed at providing a central registry service to facilitate identification, surveillance and management of families and individuals at high risk of colorectal cancer. The aim of the present study was to provide a comprehensive review of all patients with familial adenomatous polyposis (FAP) syndrome in the SPR.
Methods All patients diagnosed with FAP in 1989–2009 were analysed. Data was extracted from a prospectively collected database.
Results 122 patients from 88 families were analysed. The median age of this cohort was 29 (range 10–68) years. 97 percent of the cases were FAP and 3 percent were attenuated FAP. 92 patients tested positive for adenomatous polyposis coli gene. 42 percent of patients were diagnosed with colorectal cancer, of which 78 percent were diagnosed at an advanced stage. 73 percent of patients underwent restorative proctocolectomy and 21 percent had total colectomy. The median age at operation was 30 years. At median follow-up of 98 months, ten-year overall survival was 75.6 percent (95 percent confidence interval 67.0–84.2) and the median age at death was 40 years. For cancer cases, the overall recurrence was 13.5 percent. Recurrence and disease-free survival were not significant for the type of surgery performed (p-value is 0.486).
Conclusion The SPR plays an important and integral part in counselling patients and families with FAP. Improved surveillance programmes may be required to detect the development of cancers in these patients at an earlier stage.

Keywords: colorectal cancer, familial adenomatous polyposis, outcomes
Singapore Med J 2011; 52(4): 246-251

Khan MR, Bari H, Raza SA
Correspondence: Dr Muhammad Rizwan Khan, doctormrkhan@yahoo.com

ABSTRACT
Introduction Colorectal cancer is uncommon in the Indian subcontinent, so there is a paucity of outcome data from this region. The aim of our study was to identify risk factors for early postoperative morbidity and mortality following curative colorectal cancer surgery in our set-up.
Methods The data on patients with pathologically confirmed colorectal cancer who underwent curative surgery at Aga Khan University Hospital, Karachi, Pakistan, between January 1999 and December 2008 were recorded. Patients who developed early postoperative morbidity or mortality were compared with those who followed a healthy course after surgery.
Results A total of 250 consecutive patients underwent colorectal cancer surgery during the study period. Postoperative complications were found in 34.8 percent of the patients, out of which four deaths occurred. Serum albumin level less than 3.5 g/dl (odds ratio [OR] 3.75, 95 percent confidence interval [CI] 1.37–10.23) and tumours involving the left colon (OR 2.60, 95 percent CI 1.02–6.64) were identified as independent risk factors for early postoperative complications on multivariate analysis.
Conclusion A low serum albumin level and the presence of a left-sided colonic tumour were significant risk factors for early postoperative complications. Information on these complications and the risk factors for early postoperative outcome is an important consideration for patients and surgeons.

Keywords: colorectal cancer, outcome, risk factors
Singapore Med J 2011; 52(3): 195-200

Lopes G, Chopra A, Kukutschka J, Portillo P, Bharwani L, Chang A
Correspondence: Dr Gilberto Lopes, glopes@imc.jhmi.edu

ABSTRACT
Introduction This study aimed to examine the efficacy and toxicity of pemetrexed in Singapore.
Methods We conducted a retrospective review of patients treated with pemetrexed between July 2005 and November 2007. RECIST was used to assess the efficacy independent of the treating physician’s assessment, and NCI CTC-AE version 3.0 was used to describe adverse events.
Results 37 patients had non-small-cell lung cancer (NSCLC) and six had malignant pleural mesothelioma. Those with NSCLC had a median age of 60 and an ECOG PS of 0–1, and they were predominantly male, ethnic Chinese and smokers. A median of two cycles were delivered (total 95; range 1–12). Grade 3/4 toxicity was rare. Five (14 percent) patients had an objective response (one complete, four partial) and 13 (35 percent) had stable disease. Median time to treatment failure was 1.86 months (95% confidence interval [CI] 0–6.5). Median overall survival was 18.6 months (95% CI 12.6–27.7). Median age of patients with mesothelioma was 46.5 (range 29–73) years. Five men and one woman received a median of four (total 30, range 1–15) cycles of pemetrexed in combination with cisplatin. Three patients had a partial response, two had stable disease and one had disease progression. Grade 3/4 toxicities were as follows: leucopenia, neutropenia and thrombocytopenia in one patient.
Conclusion The results of this retrospective study and literature review show that pemetrexed is safe and efficacious in the treatment of Asian patients with NSCLC and mesothelioma.

Keywords: Asian, Chinese, efficacy, pemetrexed, toxicity
Singapore Med J 2011; 52(3): 190-194

Masala S, Guglielmi G, Petrella MC, Mastrangeli R, Meschini A, Anselmetti GC, Bartolucci DA, Mammucari M, Manenti G, Simonetti G
Correspondence: Prof Giuseppe Guglielmi, g.guglielmi@unifg.it

ABSTRACT
Introduction The aim of this study was to examine the role of palliative percutaneous secondary lesions bone treatment by comparing the visual analogue scale (VAS) scores of cryoablation plus vertebroplasty versus radiofrequency (RF) plus vertebroplasty so as to determine their feasibility, reliability and efficacy in a short-term series.
Methods Combined RF thermal ablation plus osteoplasty or cryoablation plus osteoplasty was performed in osteolytic secondary bone localisations in 30 consecutive patients who were suffering from pain refractory to conservative therapies. We evaluated pain with the VAS during the preoperative period and at four hours, 24 hours, one week, one month, three months and six months post procedure.
Results There were no statistically significant differences in the VAS score between patients treated with cryoablation plus osteoplasty and those treated with RF ablation plus osteoplasty at one week (p-value is 0.34), one month (p-value is 1), three months (p-value is 0.68) and six months (p-value is 0.65) post procedure. Patients treated with cryoablation plus vertebroplasty have less pain at four hours (p-value less than 0.001) and 24 hours (p -value less than 0.001) than patients treated with RF ablation plus vertebroplasty.
Conclusion Both RF ablation and cryoablation are optimal techniques in the treatment of painful bone metastatic cancer. Cryoablation achieves less treatment-related pain during the early period of follow-up and better volume control by real-time depiction of ablation margins.

Keywords: bone metastases, cryoablation, percutaneous therapies, radiofrequency, vertebroplasty
Singapore Med J 2011; 52(3): 182-189

Das SK, Mukherjee S, Vasudevan DM, Balakrishnan V
Correspondence: Dr Subir Kumar Das, drsubirkdas@gmail.com

ABSTRACT
Introduction Readily available laboratory tests are extremely useful in achieving a better understanding of diseases, and thereby, allow thoughtful management decisions to be made. The examination of peripheral blood smears usually provides excellent clues to the cause of the disease. The main objective of this study was to compare the haematological parameters of patients with non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD), and assess whether these tests have any discriminant value between the two conditions.
Methods The haematological parameters were investigated in 105 NAFLD patients, 40 ALD patients, 32 alcoholics and 77 normal participants.
Results The haemoglobin, red blood cell, haematocrit, lymphocyte count and platelet count were significantly reduced, while the mean corpuscular volume, mean corpuscular haemoglobin and prothrombin time expressed as an international normalised ratio (PT/INR) were significantly elevated in ALD patients compared to the other groups. The platelet count was significantly reduced, while the PT/INR and erythrocyte sedimentation rate (ESR) were significantly elevated in alcoholics compared to normal participants. ESR was also significantly elevated in ALD patients compared to normal participants and NAFLD patients. Compared to the control group, the NAFLD patients have significantly higher haematocrit and significantly lower platelet count.
Conclusion Chronic alcoholism is associated with inflammation and haematotoxic effects, while NAFLD has limited effect on haematological parameters.

Keywords: alcoholic liver disease, fatty liver, haemoglobin, mean corpuscular volume, platelet count
Singapore Med J 2011; 52(3): 175-181

Rajesh H, Lee WY, Fook-Chong S, Yu SL
Correspondence: Dr Hemashree Rajesh, hemashreerajesh@yahoo.com

ABSTRACT
Introduction We aimed to identify the variables associated with ovarian hyperstimulation in Asian patients and compare them with western standards.
Methods This is a retrospective case record analysis of 79 patients with ovarian hyperstimulation at a tertiary restructured hospital.
Results Gonadotropin doses resulting in hyperstimulation did not vary between long and antagonist cycles in women less than 35 years with polycystic ovaries (PCO). Mean oestradiol levels at hyperstimulation were not different between PCO and non-PCO patients in a long cycle. Hyperstimulation was mostly due to higher starting doses. Total follicle counts of more than 20 on Day 5–7 after stimulation may be predictive of subsequent hyperstimulation. Hyperstimulation tended to be more severe in lean PCO patients, and prophylactic albumin helped to reduce its severity.
Conclusion Gonadotropin doses at stimulation should start at 150 iu or less in women below 35 years of age, with a step up of 37.5 iu, as necessary. Transfer should be abandoned in the presence of high oestradiol levels (more than 5,000 pg/ml), when the total number of intermediate and large follicle count exceeds 30 on the day of oocyte retrieval, or when more than 19 eggs are retrieved.Variables in the Asian population appear to be similar to those in the western population.

Keywords: oestradiol level, follicle count, gonadotropin dose, in vitro fertilisation, ovarian hyperstimulation syndrome
Singapore Med J 2011; 52(3): 168-174