Original Article

Tan SWJ, Ng SW, Tan SH, Teoh LC
Correspondence: Dr Tan Siau Woon Jacqueline, aceug@yahoo.com

ABSTRACT
Introduction Wrist arthroscopy has evolved since its inception to become an essential diagnostic and therapeutic tool for the management of various wrist disorders. Our study aimed to examine the outcomes of arthroscopic debridement in the treatment of scapholunate (SL), lunotriquetral (LT) and triangular fibrocartilage complex (TFCC) tears.
Methods We conducted a retrospective review of 68 consecutive wrist arthroscopies performed at our institution between January 2000 and July 2005. All the patients complained of wrist pain, which often interfered with their daily activities, work or sports. A standard arthroscopic technique was employed in all. Any intercarpal ligament or TFCC tears found were debrided.
Results There were 42 patients with TFCC tears, 58 with SL tears and 49 with LT tears. At a mean follow-up time of 16.6 months, 85.3% of the patients reported an improvement in symptoms and 27.9% had improved range of motion. Grip strength improved by 11.8%. All except two patients returned to their original activities. Outcome following arthroscopic debridement was determined using the Mayo Modified Wrist Score. Based on the postoperative wrist scores of 47 patients, 24 were rated excellent, 17 good, four fair and two poor. By comparing the pre- and postoperative wrist scores of 31 patients, we were able to demonstrate significant improvement in patients who underwent wrist arthroscopies.
Conclusion Our study demonstrated that there is a definite role for arthroscopic debridement in the management of SL, LT and TFCC tears.

Keywords: arthroscopic debridement, ligament, triangular fibrocartilage complex
Singapore Med J 2012; 53(3): 188–191

Audat Z, Moutasem O, Yousef K, Mohammad B
Correspondence: Dr Audat Ziad, ziadaudat@yahoo.com

ABSTRACT
Introduction Lower back pain due to degenerative disc disease is a common problem that requires surgical treatment, such as posterolateral fusion and posterior instrumentation (PLF), posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). This retrospective study aimed to compare the clinical and radiological outcomes of these techniques.
Methods 81 patients were treated between 2003 and 2006. The patients were divided into three groups: Group I (PLF n = 17 [43 levels]); Group II (PLIF n = 27 [52 levels]); and Group III (TLIF n = 37 [70 levels]). All patients underwent the same pre- and postoperative clinical and radiological evaluations (using Oswestry Disability Index [ODI], Stanford score and local criteria). Follow-ups were performed at three months and yearly for three years.
Results There was no significant difference in the rates of intra-operative complications (Group I: 17.6%; Group II: 11.1%; Group III: 18.9%; p = 0.688) and postoperative complications (Group I: 11.8%; Group II: 25.9%; Group III: 13.5%; p = 0.343) among the groups. There was a significant decrease in the ODI scores over time (p < 0.005) but no significant difference among the groups at different follow-up times. Radiographic fusion rates for Groups I, II and III were 88%, 88.9% and 91.9%, respectively.
Conclusion Surgical techniques such as PLF, PLIF and TLIF are equally suitable for treating degenerative disc disease, with no differences observed in complications and clinical outcomes. However, in our study, the best radiological outcome was found in patients treated with TLIF.

Keywords: degenerative, fusion, lumbar interbody, posterolateral, transforaminal
Singapore Med J 2012; 53(3): 183–187

Hey HW, Lau PHB, Hee HT
Correspondence: Dr Hey Hwee Weng Dennis, hwee_weng_hey@nuhs.edu.sg

ABSTRACT
Introduction Degenerative cervical spine diseases are common, and physiotherapy is widely used as an initial form of treatment. We aimed to analyse the effects of the initial sessions of physiotherapy for patients who were newly diagnosed with degenerative cervical spine disorders.
Methods A prospective series of 30 patients with newly diagnosed degenerative cervical spine disease were referred to our department and followed up for the initial two sessions of physiotherapy. The patients were assessed after each session. Outcome parameters studied included pain using a visual analogue scale (VAS), neck range of movements and activities of daily living (ADL).
Results Our study subjects comprised mainly females (60%) in their fifties (46.7%) who worked as clerks or secretaries (53.3%). There was an improvement in the patients’ pain score (VAS) from a median of 8 to 4 after two visits to the physiotherapists. Slight improvement in the neck range of movements was also observed. Marked improvement was seen in ADL, especially in the ability to carry heavy objects.
Conclusion Physiotherapy is an effective initial option for patients with newly presented degenerative cervical spine disease. The results of this study can be used to advise patients on the short-term benefits of physiotherapy.

Keywords: degenerative cervical spine disease, physiotherapy
Singapore Med J 2012; 53(3): 179–182

Yudi M, Omera L, McCubbery N, Dick S, Jayasinghe R, Hamilton-Craig I
Correspondence: Dr Matias Yudi, matiasyudi@hotmail.com

ABSTRACT
Introduction Familial hypercholesterolaemia (FH) is caused by an autosomal dominant mutation of the low density lipoprotein (LDL) receptor gene, resulting in high levels of LDL cholesterol and premature coronary artery disease (P-CAD). Studies have shown low detection rates of FH in patients admitted with P-CAD and suboptimal therapy at discharge.
Methods Males aged = 55 years and females aged = 60 years who were admitted with P-CAD to the Gold Coast Hospital during a 12-month period were included in the study. The demographics, cardiovascular risk factors, examination findings, admission and discharge cardiac medications and provisional diagnoses were recorded. Diagnosis of FH was made according to internationally accepted criteria.
Results 210 patients were included in the study; 60% were male and 40% female (mean age 48 and 50 years, respectively). Only 96 (46%) patients’ fasting lipid levels were documented (LDL-C 2.75 ± 1.0 mmol/L), and FH was considered in three (1%) cases. According to the Dutch Lipid Network criteria, three (1%) patients had probable FH, 50 (24%) had possible FH and 60 (29%) had unlikely FH. Of the 53 patients with probable or possible FH, 12 (23%) were discharged without statin therapy and 13 (25%) on the maximum recommended statin dose.
Conclusion Our study has found inadequate documentation and screening for FH and suboptimal therapy in patients admitted with P-CAD. We propose a simple screening tool that can be applied to all patients admitted with suspected P-CAD in order to improve the detection rate of FH and its management.

Keywords: familial hypercholesterolaemia, LDL cholesterol, premature coronary artery disease, screening
Singapore Med J 2012; 53(3): 174–178

Ruangsetakit C, Chinsakchai K, Wongwanit C, Sermsathanasawadi N, Siriapisith T, Mutirangura P
Correspondence: Dr Khamin Chinsakchai, khaminc@gmail.com

ABSTRACT
Introduction We aimed to study the outcomes of permanent inferior vena cava (IVC) filter implantation in Thai patients.
Methods This was a retrospective study of 28 patients with deep vein thrombosis (DVT) who underwent prophylactic implantation of IVC filters for fatal pulmonary embolism (PE) between January 2005 and June 2008. The patients’ operative records, protocol and follow-up data were analysed. 11 (39%) patients had PE at the initial diagnosis. The mean age of the patients was 62.1 (range 33–83) years. Indications for IVC filter implantation included contraindications to and complications of anticoagulant therapy and floating thrombi in the iliofemoral veins. 
Results No significant technical complication was noted, except for malposition in one patient (3.5%) and failure of the permanent IVC filter to open fully in another. During the follow-up period (mean 17.5 ± 10.9 months), no patients had any episode of PE and nine (32%) died of unrelated causes. Two patients were lost to follow-up. Among the 17 survivors, six (35.2%) had non-recanalised thrombosis vein, four (23.5%) had clinical evidence of chronic venous insufficiency, two (11.7%) had recurrent DVT in the contralateral limb and one (5.8%) developed IVC thrombosis. There was no evidence of migration of the caval filters. No statistical significance was observed in the effects of post-filter anticoagulation drug on current DVT and in the relation between PE at initial diagnosis and death during follow-up.
Conclusion Permanent IVC filter implantation may be effective for preventing symptomatic PE in Thai patients, with no significant sequelae in the lower extremities.

Keywords: outcome, pulmonary embolism, treatment, vena cava filter
Singapore Med J 2012; 53(3): 170–173

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

ABSTRACT
Introduction Baseline renal impairment is the most recognised risk factor for development of contrast-induced nephropathy (CIN) post percutaneous coronary intervention (PCI). We examined the additional risk factors in this high-risk group and aimed to develop a risk model for prediction of CIN.
Methods A cohort of 770 consecutive patients with existing impaired renal function (estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2), who received routine prophylactic saline hydration and oral N-acetylcysteine treatment while undergoing PCI between May 2005 to October 2008 in our centre, were enrolled. The study endpoint, CIN, was defined as > 25% increase from baseline creatinine within 48 hours post PCI. 
Results Despite routine prophylaxis, CIN occurred in 11.4% of the patients. Important clinical predictors for CIN were age (odds ratio [OR] 1.59, 95% confidence level [CI] 1.0–2.52, p = 0.049), anaemia with haemoglobin < 11 mg/dL (OR 2.26, 95% CI 1.41–3.61, p = 0.001), post-procedure creatinine kinase rise (OR 1.12, 95% CI 1.07–1.16 for every 500 u/L increase, p < 0.001), systolic hypotension with blood pressure < 100 mmHg (OR 2.53, 95% CI 1.16 –5.52, p = 0.016) and higher contrast volume. The incidence of CIN was significantly higher in patients with more severe renal failure (6.3%, 17.4% and 40.8% when eGFR was 40–60, 20–40 and < 20 ml/min/1.73m2 respectively, p < 0.001). A prediction model was developed based on these findings. The incidence of CIN could vary from 2% to > 50% depending on these additional risk profiles.
Conclusion Patients with impaired renal function undergoing PCI are at high risk of developing CIN despite traditional prophylaxis. A model of risk prediction could be used to predict its occurrence.

Keywords: contrast-induced nephropathy, renal impairment, risk score
Singapore Med J 2012; 53(3): 164–169

Pande KC, Ishak HL
Correspondence: Dr Ketan C Pande, ketanpande@yahoo.com

ABSTRACT
Introduction Burn injuries are a public health concern across the world, particularly in Southeast Asia, where epidemiological data is lacking. This retrospective study was conducted to assess the epidemiology of patients with burns treated at a major referral hospital in Brunei Darussalam, with particular reference to demographics and aetiology. 
Methods All patients were referred to and treated at the Burns Unit, where data was recorded by the on-duty nurse on a pre-designed form at the first attendance. A total of 211 patients (111 male, 100 female), comprising 10 inpatients and 201 outpatients, were treated during the study period.
Results The average age of the patients was 19.6 ± 20.9 (median 10, range < 1–90) years. 67 (32%) patients were under two years of age. Scalding due to hot liquids was the most common cause (78.2%), followed by flame and contact burns. The majority of burns were sustained indoors either at home or at work (87.2%). The total body surface area (TBSA%) for the whole sample was 3.7% ± 7.9% (median 2%; range 1%–90%). Patients with flame burns (n = 19) were older and had larger TBSA% (p < 0.05). Inpatients had significantly higher TBSA% compared to outpatients (28.2% ± 26% versus 2.5% ± 2.1%; p < 0.005).  
Conclusion Scald burns sustained indoors are the most common across all age groups. Although the TBSA is small, a large number of children are affected. There is a need for burns prevention education programme in Brunei Darussalam.

Keywords: burns, epidemiology, paediatric, prevention
Singapore Med J 2012; 53(2): 124–127

Htwe TT, Sabaridah I, Rajyaguru KM, Mazidah AM
Correspondence: Dr Than Than Htwe, ththan@rcmp.unikl.edu.my

ABSTRACT
Introduction In line with the trend to engage students in active learning, it is imperative to introduce new strategies that make learning more interesting, especially in undergraduate curricula. This study aimed to determine students’ performance and perception in pathology crosswords as an active way of learning and to assess their ability to memorise difficult terms in pathology. 
Methods A crossword competition in pathology was conducted for two batches (year 2009 and 2010) of Phase 2 medical students in Malaysia. Crossword puzzles were prepared using an online application. Two sets of puzzles were prepared, with 20 questions for the assessment of general pathology and 20 for systemic pathology. The purpose was to compare the students’ recent and remote memorising abilities, as general pathology was taught a year before proceeding to systemic pathology teaching. There were 12 groups per batch, with 8–10 students in a group. Survey questionnaires were used to assess the students’ perception of the competition. Descriptive analysis was performed for comparison of performance.
Results The mean score of correctly answered questions in general pathology was 12.75 and 11.50 in batch 2009 and 2010, respectively. The mean score for systemic pathology was 14.50 in 2009 and 13.83 in 2010. Students in the 2009 batch performed better, but this was not statistically significant (p-value > 0.05). A positive response was observed from
the questionnaires.  
Conclusion Applying crossword puzzles as a new strategy is a useful and easy way for undergraduate medical students to learn pathology. 

Keywords: crosswords, learning pathology, undergraduate medical education
Singapore Med J 2012; 53(2): 121–123

Phua J, See KC, Khalizah HJ, Low SP, Lim T
Correspondence: Dr Tow Keang Lim, tow_keang_lim@nuhs.edu.sg

ABSTRACT
Introduction Clinical questions often arise at daily hospital bedside rounds. Yet, little information exists on how the search for answers may be facilitated. The aim of this prospective study was, therefore, to evaluate the overall utility, including the feasibility and usefulness of incorporating searches of UpToDate, a popular online information resource, into rounds.
Methods Doctors searched UpToDate for any unresolved clinical questions during rounds for patients in general medicine and respiratory wards, and in the medical intensive care unit of a tertiary teaching hospital. The nature of the questions and the results of the searches were recorded. Searches were deemed feasible if they were completed during the rounds and useful if they provided a satisfactory answer.
Results A total of 157 UpToDate searches were performed during the study period. Questions were raised by all ranks of clinicians from junior doctors to consultants. The searches were feasible and performed immediately during rounds 44% of the time. Each search took a median of three minutes (first quartile: two minutes, third quartile: five minutes). UpToDate provided a useful and satisfactory answer 75% of the time, a partial answer 17% of the time and no answer 9% of the time. It led to a change in investigations, diagnosis or management 37% of the time, confirmed what was originally known or planned 38% of the time and had no effect 25% of the time. 
Conclusion Incorporating UpToDate searches into daily bedside rounds was feasible and useful in clinical decision-making.

Keywords: beside rounds, clinical decision making, education, electronic information resource, UpToDate
Singapore Med J 2012; 53(2): 116–120

Chow WL, Wang VW, Low YS, Tse DWL, Lim JFY
Correspondence: Dr Chow Wai Leng, chow.wai.leng@singhealth.com.sg

ABSTRACT
Introduction Patients in Singapore can choose their primary care provider on a per-episode basis and pay out-ofpocket for services rendered. The infrastructure of subsidised and private primary care sector facilities differs. Onsite  ancillary services are available in subsidised facilities, allowing for convenience of routine investigations, while private  clinics are usually standalone practices. This study sought to examine the factors influencing patients’ choice of polyclinic.
Methods This was a cross-sectional survey of a convenient sample of 484 random patients who sought treatment at a  polyclinic located in a new housing estate from 24–27 June 2008. 
Results The response rate was 85.4% (n = 409). 38.1% of the patients were male. Mean age was 36.2 years. Only 13.8%  had a regular private family physician, while 37.3% were followed up at polyclinics. Patients on regular polyclinic followup were more likely to be older (p < 0.001), unemployed, retirees or housewives (p < 0.001) and were seeking treatment  for chronic diseases (p < 0.001). Geographical convenience (p = 0.002), low cost of consultation (p = 0.024), and onsite laboratory (p = 0.001) and imaging services (p = 0.018) significantly influenced those on regular polyclinic follow-up to attend the polyclinic.
Conclusion Affordability, convenience of travel and onsite laboratory facilities influence patients’ choice of seeking treatment at polyclinics. Further research examining whether the overall convenience of onsite ancillary services influences patients’ choice of primary care provider would be useful in redesigning private primary care infrastructure to enhance patient convenience and encourage more patients to have a regular private family physician.

Keywords: choice, influencing factors, out-of-pocket payments, primary care
Singapore Med J 2012; 53(2): 109–115