Original Article

Umeora OUJ, AneziOkoro EA, Egwuatu VE
Correspondence: Dr Ouj Umeora, oujair@yahoo.com

ABSTRACT
Introduction Higher-order multiple births have implications for perinatal and maternal morbidity and mortality. This study aimed to determine the incidence and outcomes of higher-order multiple pregnancies in a rural area in Southeast Nigeria.
Methods The study reviewed the data on all higher-order multiple deliveries conducted in two tertiary health institutions in Abakaliki over a seven-year period from January 2000 to December 2006.
Results Higher-order multiple births constituted 0.13 percent of the 16,968 deliveries at the two institutions. There were 21 triplet births and one quadruplet delivery. Mothers with higher-order multiple pregnancies had more antenatal admissions for preterm uterine contractions and had more preterm deliveries. The vaginal route was the preferred method of delivery. Stillbirth was recorded in 12.7 percent of the triplets, with 25.5 percent involving triplets I, II and III, who suffered birth asphyxia. The perinatal mortality rate was 276 per 1,000.
Conclusion The Igbo women of Ebonyi State, Nigeria, have a high rate of higher-order multiple births. These are attended by increased obstetric and perinatal complications. Abdominal delivery is therefore recommended in order to reduce the rate of intrapartum stillbirth and birth asphyxia among triplets.

Keywords: Igbo, perinatal, quadruplets, special care, triplets
Singapore Med J 2011; 52(3): 163-167

Zhang RF, Chandran M
Correspondence: Dr Manju Chandran, manju.chandran@sgh.com.sg

ABSTRACT
Introduction Knowledge about osteoporosis and its related risk factors may be lacking among nurses in Singapore. The objective of this study was to assess the various aspects related to nurses’ knowledge and attitudes regarding osteoporosis.
Methods The Facts on Osteoporosis Quiz was used to survey 100 nurses who attended an osteoporosis nursing symposium at the largest hospital in Singapore.
Results No respondent scored 100 percent on the quiz. One-way ANOVA showed that tertiary hospital respondents had a lower mean score at 14.26 +/- 2.571 compared to the scores of staff from polyclinics and rehabilitation hospitals at 15.71 +/- 1.704 and 16.67 +/- 1.211, (p-value is 0.029), respectively. Respondents had good knowledge regarding certain aspects of osteoporosis. The majority (94.6 percent) knew that without preventive measures, 20 percent of women older than 50 years would have a fracture due to osteoporosis in their lifetime, that bone loss speeds up after menopause (92.9 percent) and that smoking increases the risk of osteoporosis (91.1 percent). However, only one (1.8 percent) respondent knew that the statement “walking has a great impact on bone health” is false. Knowledge about the required calcium intake in growing children was also poor, with 39.3 percent believing that a glass of milk provided enough calcium to prevent osteoporosis in this age group.
Conclusion Although this was a small pilot study, it does highlight the fact that knowledge of osteoporosis among nurses in Singapore may be insufficient. More osteoporosis outreach programmes for nursing professionals are warranted.

Keywords: Facts on Osteoporosis Quiz, knowledge of osteoporosis, nurses, Singapore
Singapore Med J 2011; 52(3): 158-162

Chong PH, Poon WH
Correspondence: Dr Chong Poh Heng, chongpohheng@gmail.com

ABSTRACT
Introduction Homecare nurses had been and still are the backbone of palliative care services in Singapore. Although extensively documented by overseas researchers, the local perspective of their identity has not been evaluated. We aimed to uncover the lived experience of palliative homecare nurses so as to understand the meaning and interpretation of their experience of being homecare nurses.
Methods The research methodology was underpinned by the tenets of hermeneutic phenomenology. Two focus group discussions were held to gather responses from a purposive sample of ten nurses who belonged to five agencies that provide palliative homecare in Singapore. The discourses were audiotaped and transcribed verbatim for qualitative analysis.
Results The common themes that emerged were organised into six domains: Introduction to palliative care; Initial experiences; Challenges; Working in a team; Working with the doctor; and Support. Despite the different settings, most of the experiences were consistent with those described elsewhere.
Conclusion The palliative homecare nurse assumes a prominent role as part of a team, since she often has in-depth connections with her patients. Although it can be depressing and trying at times, she grows to see this role as both a privilege and a calling.

Keywords: nurses, palliative care, qualitative research
Singapore Med J 2011; 52(3): 151-157

Ramezani H, Bozorgi SH, Nooranipour M, Mostajeri A, Kargar-Fard H, Molaverdikhani S, Mazdaki A, Alavian SM
Correspondence: Prof Seyed Moayed Alavian, alavian@thc.ir

ABSTRACT
Introduction The hepatitis A virus (HAV) is a major global health problem, especially in developing countries. Althrough children aged 5–14 years are the most infected age group, all age groups are equally affected in an HAV epidemic. The aim of this study was to determine the prevalence and related risk factors of HAV among blood donors in Qazvin, central Iran.
Methods A cross-sectional study was performed in April 2008 on a total of 351 blood donors aged 17 to 60 years. Information on demographic variables and probable risk factors was recorded. The blood samples were investigated for antibodies to HAV (HAV Ab). Data was analysed using the t-test, chi-square test and Fisher’s exact test to examine the factors related to HAV Ab positivity.
Results Out of the 351 blood donors, 49.0 percent (n is 172) were regular blood donors, 94.0 percent (n is 330) were male and 71.0 percent (n is 248) were married. HAV Ab was found in 94.9 percent (n is 333) of the total sample. The prevalence of HAV Ab was higher among married and older participants. It was lower among those with a high school or vocational level of education (p is less than 0.05) than among those with a lower level of education.
Conclusion This study reveals a high prevalence of HAV Ab among adult blood donors in Qazvin, which indicates a high level of childhood contact with HAV in the area.

Keywords: blood donors, hepatitis A virus, Iran, prevalence, risk factors
Singapore Med J 2011; 52(2): 107-112

Wongpakaran T, Wongpakaran N, Wannarit K
Correspondence: A/Prof Tinakon Wongpakaran, tchanob@med.cmu.ac.th

ABSTRACT
Introduction This study aimed to investigate the psychometric properties of the Thai version of the Experiences of Close Relationships-Revised (Thai ECR-R) questionnaire.
Methods 400 students from a university in northern Thailand were randomly selected to complete the Thai ECR-R, the extraversion scale for 16 personality factors, the self-esteem scale and the trait anxiety scale. A retest of the Thai ECR-R was conducted at four-week intervals. Exploratory and confirmatory factor analyses were performed to test the validity of the construct.
Results The Thai ECR-R showed good internal consistency and satisfactory test-retest reliability. The avoidance and anxiety subscales demonstrated a convergent validity with the extraversion, self-esteem and trait anxiety scales. An exploratory analysis yielded a two-factor structure. Confirmatory factor analysis also provided general support for the hypothesised two-factor model, although there was a slight lack-of-fit.
Conclusion The overall psychometric properties of the Thai ECR-R were acceptable. In order to render it more congruent with Thai culture, a revision of some items was considered. Further research on other age groups should be conducted in future.

Keywords: adult, attachment, Experiences of Close Relationships, Thai
Singapore Med J 2011; 52(2): 100-106

Iyer US, Koh KF, Chia NCH, Macachor J, Cheng A
Correspondence: Dr Uma Shridhar Iyer, uma_shridhar@rediffmail.com

ABSTRACT
Introduction Morbid obesity and obstructive sleep apnoea (OSA) are increasingly encountered in anaesthetic practice today. Difficult intubation may be seen more frequently in our practice. This high-risk group may also be more prone to complications in the postoperative period.
Methods We reviewed a consecutive series of patients who had undergone laparoscopic gastric banding at our institution from 2001 to 2006. The incidence of difficult intubation, early postoperative complications and its attendant risk factors were studied.
Results Severe OSA and neck circumference greater than 44 cm were factors associated with difficult intubation in morbidly obese patients who presented for bariatric surgery. Asthma and increasing age may be associated risk factors for adverse events in the postoperative period.
Conclusion It is important to anticipate and prepare for a difficult intubation scenario in patients with severe OSA and a larger neck circumference. Close monitoring is recommended for patients with respiratory comorbidities and advanced age.

Keywords: bariatric surgery, difficult postoperative complications, morbid obesity, obstructive intubation, sleep apnoea
Singapore Med J 2011; 52(2): 94-99

Chong VH, Telisinghe PU, Yapp SKS, Chong CF
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk

ABSTRACT
Introduction Tuberculous appendix is surprisingly rare, even in countries where this infection is common. We report our experience with tuberculous appendix over a 15-year period.
Methods A search for cases of tuberculous appendix was conducted from January 1995 to December 2009 on the databases of the National Tuberculosis Centre and the Departments of Pathology and Surgery of Raja Isteri Pengiran Anak Saleha Hospital.
Results There were five cases of tuberculous appendix, giving a cumulative incidence of 0.08 percent of all appendectomies (n is 6,593), 0.2 percent of tuberculosis (TB) cases (n is 2,876) and 8.6 percent of abdominal TB (n is 58). Three patients were male and two were female, with a median age of 27 (range 25–48) years. Four patients presented with symptoms of acute appendicitis and one with an appendiceal mass following treatment for acute gastroenteritis. Only one patient had constitutional symptoms. Four patients had appendectomies (one laparoscopic and three open) within the same admission and one had interval appendectomy. Operative findings included perforated appendix (n is 1), appendiceal mass (n is 1) and acute appendicitis (n is 3). In all cases, the diagnoses were made only after review of the histology. None of the patients had pulmonary TB. Delay in initiating anti-TB treatment in one patient resulted in the development of an ileocutaneous fistula following appendectomy. This was resolved by excision, followed by anti-TB treatment.
Conclusion Tuberculous appendix can present as acute appendicitis, and the diagnosis is often made after surgery. Any delay in treatment can lead to significant complications.

Keywords: appendectomy, appendicitis, gastrointestinal tuberculosis, granuloma, tuberculosis
Singapore Med J 2011; 52(2): 90-93

Hassan MR, Mustapha NRN, Zawawi FM, Earnest BSP, Voralu K, Pani SP
Correspondence: Dato’ Dr Muhammad Radzi bin Abu Hassan, radzi@crc.gov.my

ABSTRACT
Introduction This study was conducted to compare the genotype and markers of disease severity of chronic hepatitis C (CHC), namely viral load, alanine transaminase (ALT) levels and histopathological findings on liver biopsy, in patients with and without end-stage renal disease (ESRD).
Methods This was a cross-sectional retrospective comparative study that included ESRD patients on haemodialysis and non-ESRD patients with CHC who underwent liver biopsy between January 2004 and December 2006. Blood tests for viral load (VL) (hepatitis C virus, ribonucleic acid, polymerase chain reaction), genotyping and ALT were administered. VL was grouped into low (less than 5 log10) and high (more than or equal to 5 log10) VL, genotype into G1 and 2, 3, 4, and ALT into normal and elevated ALT. Necroinflammatory activity was grouped into mild (G0–6) and moderate/severe (G7–18) activity, and fibrosis into mild (S0–2) and moderate/severe (S3–6) fibrosis. These variables were compared between the two groups.
Results Genotype 1 was significantly higher in ESRD patients than in non-ESRD patients, in whom genotypes 2, 3 and 4 were higher. Although the proportion of patients with high VL was greater and the duration of CHC was longer in the ESRD group, the ALT levels were lower and the histopathological grading of necroinflammatory activity and stages of fibrosis were less severe in ESRD compared to non-ESRD patients.
Conclusion The lower levels of ALT observed in CHC patients with ESRD translate to histopathological benefits.

Keywords: dialysis, end-stage renal disease, genotype, hepatitis C, liver fibrosis
Singapore Med J 2011; 52(2): 86-89

Theerawit P, Kiastboonsri S, Ingsathit A, Tanwattanathavorn K
Correspondence: Dr Pongdhep Theerawit, pongdhep@live.com

ABSTRACT
Introduction We analysed the parameters associated with mortality outcome in shock patients.
Methods The databases of intensive care unit patients were retrieved, and shock patients were selected for further analysis. Logistic regression was used to identify the predictors of mortality outcome. The area under curve (AUC) of receiver operating characteristic (ROC) curve was calculated for the power of prediction model.
Results A total of 467 patients were recruited, of which 183 patients were diagnosed with shock. The variables predicting mortality outcomes were heart rate above 130 beats/minute (p-value is 0.015, odds ratio [OR] 4.38, 95 percent confidence interval [CI] 1.338–14.321), pH less than or equal to 7.24 (p-value is 0.001, OR 6.11, 95 percent CI 2.17–17.18), creatinine more than 1.5 mg/dl (p-value is 0.048, OR 3.05, 95 percent CI 1.01–9.19), and Glasgow Coma Score less than 7 (p-value is 0.038, OR 3.476, 95 percent CI 1.07–11.27). The sensitivity, specificity and AUC of ROC of this model was 82.5, 60.5 and 0.826 percent, respectively. The positive and negative predictive values and AUC of ROC at a score below 2 was 82.8, 67.3 and 0.81 percent, respectively. The results revealed a significant improvement in survival in shock patients with a score below 2 (p-value less than 0.001). We prospectively validated the score in 107 shock patients and found very high AUC of ROC.
Conclusion Acidosis, tachycardia, renal impairment and impaired consciousness within the first 24 hours are the main predictors of shock state, and should be used for assessment of survival outcome in shock patients.

Keywords: intensive care units, mortality, outcome assessment, prognosis, shock
Singapore Med J 2011; 52(2): 81-85

Koh JSB, Goh SK, Png MA, Ng ACM, Howe TS
Correspondence: Dr Joyce SB Koh, joyce.koh.s.b@sgh.com.sg

ABSTRACT
Introduction Some authors have hypothesised that atypical femur fractures occur due to tensile mechanism of failure. We studied the  distribution of such lesions along the femur shaft to determine if they concentrate in regions that are subject to tensile loading.
Methods From May 2004 to March 2010, radiological reviews of 48 patients aged 69 +/- 10.4 (range 47–92) years with atypical femoral fractures and lesions were performed. The absolute distance of each lesion from the greater trochanter and the ratio of the distance of each lesion from the greater trochanter expressed as a percentage of the entire femur length were measured.
Results All periosteal reactions and cortical stress lesions occurred in the lateral cortex. There were 35 right femoral lesions (28 complete fractures and seven cortical stress reactions), with a median distance of 108.3 +/- 54.0 (range 67.0–270.4) mm from the greater trochanter and a median ratio of 23.9 +/- 11.7 (range 15.7–58.6) percent of the entire femoral length. There were 38 left femoral lesions (27 complete fractures and 11 cortical stress reactions), with a median distance of 109.9 +/- 43.1 (range 73.6–246.2 ) mm from the greater trochanter and a median ratio of 24.4 +/- 9.1(range 16.3–51.1) percent of the entire femoral length.
Conclusion Based on previously established femoral shaft loading characteristics, atypical lesions were clustered at the region of maximal tensile loading. No lesion occurred in regions that were subject to compressive loading. This unique distribution supports a tensile mechanism of failure in such lesions.

Keywords: advanced glycation end products, atypical fracture, lateral periosteal reaction, tension failure
Singapore Med J 2011; 52(2): 77-80