Original Article

Sakallioglu O, Musabak U, Kalman S
Correspondence: Onur Sakallioglu, onursakallioglu@hotmail.com

ABSTRACT
Introduction This study assessed the role of procalcitonin (PCT) in the differentiation of minimal-change nephropathy (MCN) relapses from infections co-existent with proteinuria flares in children.
Methods Data on the PCT levels of patients with MCN who were on follow-up were retrospectively gathered at relapse (Group I), during proteinuria attacks co-existent with intercurrent infection (Group II) and at remission (Group III). The results of these three groups were then prospectively compared with nephrologically healthy patients who had infections that were similar to those in Group II (Group IV), and controls (Group V).
Results Significant differences in PCT level were noted between patients of Groups I, II and IV and the other two groups. A 93% reduction in proteinuria was achieved for Group II patients following an antibiotic regimen. The difference in PCT level between Groups I and II was significant. PCT showed a higher diagnostic predictability than C-reactive protein (CRP) in Group I patients, and was as good as CRP for those with infection and infection-related proteinuria. Sensitivity × specificity in relapse and infection-related states for PCT were 0.472 and 0.628, respectively, and those for CRP were 0.183 and 0.762, respectively.
Conclusion A combined approach with CRP and PCT readings may be beneficial in discriminating proteinuria attacks co-existent with intercurrent infection from sole relapses of nephrotic syndrome. PCT may be a part of the wide spectrum of immune abnormalities seen in patients with MCN.

Keywords: C-reactive protein, children, infection, minimal change nephropathy, procalcitonin, proteinuria
Singapore Med J 2012; 53(5): 353–356

Razieh F, Sedighah AK, Motahhareh G
Correspondence: Dr Akhavan Karbasi Sedighah, sakarbasi@ssu.ac.ir

ABSTRACT
Introduction Febrile seizure (FS) is the most common paediatric neurological problem. The purpose of this study was to determine the frequency of afebrile seizures subsequent to FS in children with initial FS and to evaluate its risk factors.
Methods A prospective study was conducted on all children (age 6 months to 6 years) referred with initial FS to the Shahid Sadoughi Hospital, Yazd, Iran, between August 2004 and March 2006, who were followed up for at least 15 months for the occurrence of subsequent afebrile seizures.
Results 161 boys and 120 girls (mean age 2.12 ± 1.33 years) were followed up for 34.1 ± 7.8 months. 87 (31%) patients had complex FS and 19 (6.7%) patients had subsequent afebrile seizure, with a mean occurrence time of 10.6 ± 6.4 months. Univariate analysis using chi-square test showed that initial FS within one hour of developing fever (p = 0.0001), neurodevelopmental delay (p = 0.0001), family history of epilepsy (p = 0.0001), recurrent FS (p = 0.003) and focal FS (p = 0.04) were risk factors for subsequent afebrile seizure. On multivariate analysis, neurodevelopmental delay (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.3–3.4), initial FS within one hour of developing fever (OR 1.7, 95% CI 1.2–2.1) and family history of epilepsy (OR 1.5, 95% CI 1.1–1.9) were significant factors.
Conclusion Special attention should be paid to children with FS during history-taking and developmental assessments to identify high-risk patients and those who might need prophylactic anticonvulsants.

Keywords: afebrile seizure, complex febrile seizure, epilepsy
Singapore Med J 2012; 53(5): 349–352

Tan SY, Narasimhalu K, Ong S
Correspondence: Dr Simon YK Ong, drmooyk@nccs.com.sg

ABSTRACT
Introduction Communication between patients and physicians is crucial in the disclosure of cancer diagnosis. Although westernisation of Asian societies has resulted in increased awareness of patient autonomy, the family continues to play an important influencing role in the disclosure process. Therefore, in this study, we aimed to characterise the experience of physicians with the disclosure of cancer diagnosis in a westernised Asian population.
Methods Oncologists at a tertiary hospital were approached to participate in this study. Information pertaining to the extent and approach to disclosure was collated. Logistic regression analysis was performed to characterise factors pertaining to the willingness of physicians to fully disclose a diagnosis of cancer.
Results In all, 25 oncologists (mean age 38 years; 72% men) responded to the survey. A majority of oncologists disclosed a cancer diagnosis directly to the patient over the first few visits. The main reason behind partial or nondisclosure was family objection. Ordinal logistic regression analysis showed that family resistance was the only significant predictor of reluctance to disclose a cancer diagnosis (p = 0.01).
Conclusion In this pilot study, contrary to previous reports, we found that oncologists were more likely to disclose a diagnosis of cancer to the patient first, that they do not accede fully to the family’s request for non-disclosure and that family resistance was the only significant predictor of reluctance to disclose a diagnosis of cancer.

Keywords: Asia, cancer, consent, disclosure, ethics
Singapore Med J 2012; 53(5): 344–348

Ghadimi MR, Mahmoodi M, Mohammad K, Rasouli M, Zeraati H, Fotouhi A
Correspondence: Mahmood Mahmoodi, mahmoodim@tums.ac.ir

ABSTRACT
Introduction Oesophageal cancer is one of the most common causes of cancer mortality in developing countries, including Iran. This study aimed to assess factors affecting survival of patients with oesophageal cancer using parametric analysis with frailty models.
Methods Data on 359 patients with oesophageal cancer was collected from the Babol Cancer Registry for the period 1990–1991. By 2006, the patients had been followed up for a period of 15 years. Hazard ratio was used to interpret the risk of death. To explore factors affecting the survival of patients, log-normal and log-logistic models with frailty were examined. The Akaike Information Criterion (AIC) was used for selecting the best model(s). Cox regression was not suitable for this patient group, as the proportionality assumption of the Cox model was not satisfied by our data (p = 0.007).
Results Multivariate analysis according to parametric models showed that family history of cancer might increase the risk of death from cancer significantly. Based on AIC scores, the log-logistic model with inverse Gaussian frailty seemed more appropriate for our data set, and we propose that the model might prove to be a useful statistical model for the survival analysis of patients with oesophageal cancer. The results suggested that gender and family history of cancer were significant predictors of death from cancer.
Conclusion Early preventative care for patients with a family history of cancer may be important to decrease the risk of death in patients with oesophageal cancer. Male gender may be associated with a lower risk of death.

Keywords: AIC, inverse Gaussian frailty, oesophageal cancer, survival analysis
Singapore Med J 2012; 53(5): 336–343

Ozardili I, Guldur ME, Ciftci H, Bitiren M, Altunkol A
Correspondence: Dr Halil Ciftci, halilciftci63@hotmail.com

ABSTRACT
Introduction Lymphangiogenesis has been reported to be important in the prognosis of several tumours. The aim of this study was to assess the correlation between lymphangiogenesis and clinicopathological prognostic parameters in patients with clear cell renal cell carcinoma.
Methods 62 patients with renal cell carcinoma were included in the study. The D2-40 antibody, assessed immunohistochemically for each patient, was used as a marker. Light microscopy was used to determine the presence of intratumoral lymphatic vessels (ILVs) and the number of peritumoral lymph vessels (PLVs)/mm2 or PLV density (PLVD). Correlation between the numbers and the Fuhrman nuclear grade, tumour stage, distant metastasis status, presence of lymph node metastasis and lymphovascular invasion was assessed.
Results A significant correlation was found between the presence of ILVs and distant metastasis (p = 0.033) and lymph node metastasis (p = 0.024). However, no significant correlation was found between the Fuhrman nuclear grade (p = 0.553), tumour stage (p = 0.464) and lymphovascular invasion (p = 0.242). Mean PLVD was 20.8, and no significant difference was found between the patients with PLVD below average and those with PLVD above average in terms of distant metastasis (p = 0.337), lymph node metastasis (p = 0.792), the Fuhrman nuclear grade (p = 0.566), tumour stage (p = 0.795) and lymphovascular invasion (p = 0.942).
Conclusion We found a significant correlation between ILVs and lymph node and distant metastases in patients with renal cell carcinoma.

Keywords: D2-40, lymphangiogenesis, renal cell carcinoma
Singapore Med J 2012; 53(5): 332–335

Prakash, Rajini T, Mokhasi V, Geethanjali BS, Sivacharan PV, Shashirekha M
Correspondence: Dr Prakash, prakashrinku@rediffmail.com

ABSTRACT
Introduction Knowledge of anatomical variations of the great vessels of the abdomen, including the coeliac trunk, is important for clinicians planning surgical intervention and radiological imaging. The present study aimed to record the prevalence of variations in the vascular pattern of branches of the coeliac trunk in cadavers.
Methods A total of 50 properly embalmed and formalin-fixed cadavers from the Indian population were selected for the study. Dissection included surgical incision, followed by mobilisation of the anatomical viscera, to observe and record the branching pattern of the coeliac trunk.
Results The left gastric, common hepatic and splenic arteries were found to arise from the coeliac trunk in 86% of cadavers. In 76% of cadavers, the origin of the gastric artery was proximal to the bifurcation of the coeliac trunk into the common hepatic and splenic arteries. In one case, all three branches arose directly from the abdominal aorta, and the origin of the splenic artery was 1 cm distal to the origin of the left gastric and common hepatic arteries. In another case, the common hepatic and left gastric arteries arose from the coeliac trunk, and the origin of the splenic artery was 1.5 cm distal to the abdominal aorta.
Conclusion Vessel ligation and anastomosis are important in surgical procedures like liver transplantation, and background knowledge of the different vascular patterns of branches of the coeliac trunk is vital. The findings of our study could help to minimise complications related to abdominal surgery, including bleeding and necrosis, and facilitate better and more accurate radiological interpretations.

Keywords: anatomy, aorta, cadaver, coeliac trunk, dissection
Singapore Med J 2012; 53(5): 329–331

Lorchirachoonkul T, Ti LK, Manohara S, Lye ST, Tan SA, Shen L, Kang SC
Correspondence: A/Prof Ti Lian Kah, lian_kah_ti@nuhs.edu.sg

ABSTRACT
Introduction Complications occur in over 15% of central venous cannulations, often a result of anatomical variations. This study aimed to determine the anatomical variations of the internal jugular vein (IJV), demonstrate the likely success of cannulation and assess the risk of carotid artery (CA) injury when catheterising the IJV using the external landmarks technique at various degrees of head rotation in the local population.
Methods 100 elective cardiac surgical patients were prospectively enrolled. Simulated catheterisations were performed with patients placed in the Trendelenburg position. The standard landmark technique was used to identify anatomy. Simulations were done at six different degrees of rotation of the head: 0°, 30° and 60° for both right and left IJVs. Difficult catheterisation was defined as an IJV diameter < 7 mm.
Results There was no thrombosed or absent IJV in any patient. Catheterisation was potentially difficult in 15% of patients at 30° head rotation and more difficult for the left IJV than the right (20% vs. 10%; p < 0.05). The simulated needle hit the IJV in 82% of the attempts, but the needle was in the middle 80% of the vein only 70% of the time. Neck rotation increased the degree of overlap of the CA relative to the IJV from 20%–30% to 50%.
Conclusion Anatomical variations play a significant role in determining the success of IJV catheterisation as well as the incidence of catheterisation-associated complications. This study emphasises the importance of using ultrasonography to guide IJV catheterisation, even in patients with seemingly normal neck anatomy.

Keywords: carotid arteries, central venous catheterisation, jugular veins, ultrasonography
Singapore Med J 2012; 53(5): 325–328

Chooi EY, Chen HM, Miao Q, Weng YR, Chen XY, Ge ZZ, Xiao SD, Fang JY
Correspondence: Dr Fang Jing-Yuan, jingyuanfang@yahoo.com

ABSTRACT
Introduction We aimed to examine the turnover of chronic atrophic gastritis (CAG) pathologically and endoscopically and explore its potential causes.
Methods A retrospective analysis was conducted of prospective data collected from 1,592 patients who underwent gastroscopy three times or more during the period 1985–2009 at Renji Hospital, Shanghai, China. Pathological and endoscopic findings were analysed. Data collected included gender, age, length of follow-up period, family history, past medical history, history of Helicobacter (H.) pylori infection, drug history for the use of proton pump inhibitors (PPIs), antacids and non-steroidal anti-inflammatory drugs [NSAIDs], and lifestyle history, including the patients’ eating habits.
Results 23 (1.44%) patients presented with gastric cancers resulting from CAG and 349 (21.92%) patients had dysplasia. Pathological and endoscopic findings suggested that the proportion of patients with worsening gastric mucosa during the atrophic and intestinal metaplasia (IM) phases was over 35% with increasing age. Gastric mucosa was found to be pathologically aggravated by carbonated drinks and fast food, and pathologically degenerated by H. pylori infection. Smoking deteriorated the gastric mucosa. Side dishes of vegetables may benefit the gastric mucosa even in the atrophic and IM phases.
Conclusion Our findings support the consensus that CAG is a progressive disease. Potential factors that were found to affect the state of the gastric mucosa in our patient group were gender, H. pylori infection, use of PPIs or NSAIDs, and intake of vegetable side dishes, spicy food, carbonated drinks and fast food.

Keywords: chronic atrophic gastritis, clinical pathological characteristics, gastric endoscopy, prognosis
Singapore Med J 2012; 53(5): 318–324

Shelat VG, Chan CY, Liau KH, Ho CK
Correspondence: Dr Vishal G Shelat, vishalkumar.shelat@nathealthgroup.com

ABSTRACT
Introduction Conventionally, patients who failed endoscopic removal of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreaticography (ERCP) would be treated with open cholecystectomy and common bile duct exploration. Laparoscopic common bile duct exploration (LCBDE) is an established option for treating CBDS. The aim of this paper was to look at the feasibility of LCBDE as a salvage procedure after failed endoscopic stone extraction (ESE). The secondary endpoint was to examine the short-term outcomes of our LCBDE series.
Methods We retrospectively reviewed a prospective database to study the feasibility of LCBDE as a salvage procedure for failed ERCP.
Results Since its inception in 2006, 43 patients had undergone LCBDE at our centre. This was achieved via a transcystic approach in 25 patients and laparoscopic choledochotomy in 15 patients. There were three conversions. Of these 43 patients, 21 had a pre-operative attempt at ESE, but only six patients had their ducts cleared endoscopically. The 15 patients who failed ESE underwent LCBDE, of which 14 achieved successful stone clearance and one required open conversion. One patient developed a bile leak, which resolved spontaneously. The median length of stay (LOS) for these 15 patients was three days, while the median LOS for the whole cohort was two days.
Conclusion LCBDE has been shown to be a safe and effective method for treating CBDS, with the added bonus of a short hospital stay. Where the expertise is available, LCBDE is a safe option as a salvage procedure for failed ESE.

Keywords: bile duct exploration, cholecystectomy, common bile duct stones, endoscopic stone extraction, laparoscopy
Singapore Med J 2012; 53(5): 313–317

Jaovisidha S, Leerodjanaprapa P, Chitrapazt N, Nartthanarung A, Subhadrabandhu T, Siriwongpairat P
Correspondence:  Dr Suphaneewan Jaovisidha, rasjv@yahoo.com

ABSTRACT
Introduction We aimed to retrospectively review the ultrasonography (US) findings of patients with clinically suspected soft tissue infection of the legs and to determine whether there is a correlation between US diagnosis and further clinical management.
Methods We reviewed the US findings of consecutive patients with clinically suspected soft tissue infection of the legs who were referred for emergency US during a consecutive two-year period. The indications for US were recorded and the findings evaluated. The effect of the US findings on further clinical management (medication alone versus medication with surgical intervention [SI]) was reviewed.
Results A total of 51 legs from 38 patients were enrolled in the study. The most common indication for US was to rule out necrotising fasciitis (35.3%). The most frequent US diagnosis was isolated cellulitis (21.6%). Both groups of patients (with and without abscess) were treated with medication with or without SI. There was no statistically significant correlation between the presence or absence of abscess and further clinical management (p = 0.216), between the size (length and thickness) of the abscess and the type of SI (p = 0.687 and 0.243, respectively). 
Conclusion In our study, the most frequent US diagnosis was isolated cellulitis, and we found no significant correlation between US findings and clinical management (medication or SI). Our results should encourage sonologists to evaluate in detail patients with clinically suspected soft tissue infection of the legs and to provide information regarding each layer of tissue studied.

Keywords: emergency, infection, leg, soft tissue, ultrasonography
Singapore Med J 2012; 53(4): 277–282