Original Article

Teo EY, Lew PS, Foo CS
Correspondence: Dr Eng Yee Teo, calebey@gmail.com

ABSTRACT
Introduction Obesity is a real and dangerous problem with rising incidence. This study aimed to examine public  perceptions of obesity as a disease, as well as the community’s impression of the various modalities in the management  of obesity, particularly bariatric surgery, in Singapore.
Methods Volunteers from the public were approached in 2010 to complete a questionnaire that collected both their  demographic data and perceptions on obesity, management of obesity and bariatric surgery. The perceptions of the respondents were analysed based on various demographic factors. 
Results The incidence of obesity was 16.8%. Consistent with previous studies in developed countries, the highest mean  body mass index was noted in the age range of 41–50 years. 95.6% of the population surveyed were aware that obesity  was related to significant medical conditions. 60% of the population surveyed had attempted weight loss in the past, with  41.7% expressing lack of success, and 58.4% expressed that they had not heard of surgery as a modality. 
Conclusion This study shows that the majority of the population understands the significance of obesity as a medical problem and would take steps to combat it. However, there is suboptimal knowledge of the various modalities of managing obesity as a disease, especially with regard to surgical options. More education on the modalities available and access to them would help in the combat of this obesity epidemic.

Keywords: bariatric surgery, obesity, public perception
Singapore Med J 2012; 53(2): 104–108

Tan CM, Lee VJ, Chang GH, Ang HX, Seet B
Correspondence: Dr Clive Tan, cmtan@jhsph.edu

ABSTRACT
Introduction This paper provides an overview of cases seen by the Singapore Armed Forces (SAF) medical and surgical teams in the 2009 Sumatra earthquake and discusses the role of militaries in the acute phase of a disaster.
Methods Two SAF primary healthcare clinics prospectively collected patient medical information for comparison. Descriptive analysis of the Emergency Department (ED) and surgical case records was performed. 
Results 1,015 patients were seen by the two primary healthcare clinics. In both Koto Bangko and Pariaman, respiratoryrelated conditions were the most common diagnoses (47.2% and 30.6%, respectively), followed by musculoskeletal/joint conditions (31.6% and 20.6%, respectively). In the ED, 55% and 27% of the 113 patients had trauma-related and infectiverelated diagnoses, respectively. Lacerations and contusions were the most common forms of trauma. Lung infection was the most common infective diagnosis seen at the ED. The number of ED cases was high during the first week and gradually declined in the second week. 56% of the 102 surgical procedures were performed on dirty or infective wounds. Fractures requiring fixation comprised 38% of surgical procedures.
Conclusion Medical aid remains an important component of the overall humanitarian response. Militaries could play an important role in disaster response due to their ability to respond in a timely fashion and logistic capabilities. Pre-launch research on the affected area and knowledge on disaster-specific injury patterns would impact the expertise, equipment and supplies required. The increasing evidence base for disaster preparedness and medical response allows for better planning and reduces the impact of disasters on affected populations.

Keywords: disaster, earthquake, health needs, Indonesia, military
Singapore Med J 2012; 53(2): 99–103

Pai AU, Chakrapani  M, Bhaskaran U, Kamath P
Correspondence: Dr Chakrapani M, chakrapani.m@manipal.edu

ABSTRACT
Introduction 24-hour ambulatory blood pressure (BP) monitoring is a well-validated tool that can reveal the patient’s nocturnal dipping pattern. However, to the best of our knowledge, the role of home BP monitoring in identifying nocturnal dipping has not been studied.
Methods We evaluated the nocturnal BP of 30 treatment-naive subjects using a home BP monitoring device. BP measurements were taken once during the daytime and once at night (three hours after sleep) by a blinded observer. Readings were correlated with left ventricular mass index.
Results Night BP measurements were significantly lower in subjects without left ventricular hypertrophy (LVH) as compared to those with LVH, while the daytime readings were not significantly different between the two. The mean dips in nocturnal systolic and diastolic BP were 1.92% ± 6.89% and −0.55% ± 14.31%, respectively, in subjects with LVH. The corresponding values were 12.96% ± 6.16% and 11.36% ± 11.90% in those without LVH.  The correlation between left ventricular mass index and night BP readings was statistically significant (systolic r = 0.66, p < 0.001; diastolic r = 0.496, p < 0.005).  
Conclusion  Nocturnal BP measurement using a home BP monitoring device may be a reliable and cost-effective  method for detecting early signs of end-organ involvement such as LVH in hypertensives, especially in a resource-limited setting.

Keywords: ambulatory blood pressure monitoring, home blood pressure monitoring, left ventricular hypertrophy
Singapore Med J 2012; 53(2): 95–98

Tan VKM, Abidin SZ, Tan SG
Correspondence: Dr Veronique Tan, vquetan@gmail.com

ABSTRACT
Introduction We previously reported our technique of ultrasonography-guided, catheter-assisted foam sclerotherapy of the long saphenous vein for treatment of primary varicose veins. In this study, we present the technical results, based on follow-up duplex images, and patient-reported symptom improvement and satisfaction.
Methods All patients treated with ultrasonography-guided, catheter-assisted foam sclerotherapy between March 2006 and August 2007 were included in this review. Prospectively collected clinical data and follow-up postoperative duplex examinations at one day, six months and 12 months were reviewed. Telephone interviews with a standard questionnaire were conducted.
Results During the study period, 66 lower limbs in 62 patients were treated using the described technique. The median follow-up period was 12 months (range one day to 38 months). Successful occlusion rate was 98% at six months and 80% at 12 months for patients who attended follow-up duplex imaging. Seven patients underwent a second procedure. Patient satisfaction was good, with 96% reporting symptom improvement.
Conclusion Ultrasonography-guided, catheter-assisted foam sclerotherapy is safe, minimally invasive and yields good medium-term occlusion rates of the treated veins.

Keywords: catheter-guided foam sclerotherapy, varicose vein
Singapore Med J 2012; 53(2): 91–94

Cullen JF, Chung SHR
Correspondence: Dr James F Cullen, jbarrycullen@yahoo.com

ABSTRACT
We report the six months follow-up findings in relation to visual acuity and visual field defects in a series of Singaporean patients with non-arteritic anterior ischaemic optic neuropathy seen in the neuro-ophthalmology service of the Singapore National Eye Centre. 90% of the patients were Chinese, and the most common vascular risk factor was hypertension. Visual acuity was normal at the outset in 40% of cases and unchanged in 85%, and the assessment of visual acuity alone was not found to be a satisfactory method to determine prognosis. Visual field defects were found in all the  affected patients, the most common being in the inferior fields. After six months, visual field defects were found to be unchanged in 77% of cases,  improved in 15.5% and worse in 7.5%. Overall visual function (visual acuity plus visual field)  was unchanged in 81% of cases, and no patient had complete recovery.

Keywords: anterior ischaemic optic neuropathy, hypertension, vascular risk factors, visual acuity, visual field
Singapore Med J 2012; 53(2): 88–90

Rosman M, Zheng Y, Lamoureux E, Saw SM, Aung T, Tay WT, Wang JJ, Mitchell P, Tai ES, Wong TY
Correspondence: Prof Wong Tien Yin, ophwty@nus.edu.sg

ABSTRACT
Introduction This study highlights the key epidemiological findings from the Singapore Malay Eye Study (SiMES-1).
Methods SiMES-1 was a cross-sectional, population-based epidemiological study on eye diseases. It was performed on 3,280 randomly selected Malay adults living in the south-western part of Singapore. All study participants underwent various validated questionnaires and detailed eye examinations. A review of all papers published from SiMES-1 was performed.
Results A total of 24.6% of the study population had myopia, while 35.3% had hyperopia and 39.4% had astigmatism. 20.4% of the population had under-corrected refractive error. 1,338 (45.7%) participants were diagnosed to have cataracts in at least one eye. 8.6% of the study population had undergone cataract surgery in either eye, while 4.7% had bilateral cataract surgery. 150 (4.6%) participants were diagnosed to have glaucoma, of which primary open angle glaucoma was the most common type (3.2% of the study population), followed by secondary glaucoma (0.8%) and primary angle closure glaucoma (0.2%). Pterygium was diagnosed in 508 out of 3,266 study participants, giving a prevalence rate of 15.6%. The presence of diabetic retinopathy was observed in 421 (12.9%) out of 3,265 study participants. 183 (5.6%) study participants had some degree of age-related macular degeneration (AMD), of which 23 (0.7%) were classified as having late AMD.
Conclusion This paper provides a summary of the prevalence of common eye diseases among the Singaporean adult Malay population and provides data useful for public health education and disease prevention.

Keywords: eye diseases, prevalence, Singaporean Malays
Singapore Med J 2012; 53(2): 82–87

Gupta C, Ray B, Dsouza AS, Nair N, Pai SR, Manju M
Correspondence: Dr Chandni Gupta, chandnipalimar@gmail.com

ABSTRACT
Introduction Coronary artery bypass grafting is an established means of treating advanced coronary artery disease. In recent years, there has been an increased interest in the radial artery as an entry route during coronary angiography. Accurate knowledge of the branching pattern of this artery and its relation to surrounding structures is of great importance in the care of surgical patients.
Methods This study was conducted on 75 formalin-fixed upper limbs in order to note the variations in the branching pattern and termination of the radial artery.
Results The radial artery divided into three branches in 2.7% of cases and into two branches in 52.0% of cases. The radial recurrent artery originated from the brachial artery instead of the radial artery in 12.0% of cases. The radial recurrent artery, palmar carpal artery, first dorsal metacarpal artery and superficial palmar artery were absent in 1.3%, 26.7%, 9.3% and 5.3% of cases, respectively. 6.7% of cases had a high origin of the superficial palmar artery.
Conclusion The rich photographic documentation of the variation of branching pattern and termination of radial artery is not only of academic interest but also useful to surgeons and radiologists working in the same area.

Radha Krishna LK, Poulose VJ, Goh C
Correspondence: Dr Lalit Kumar Radha Krishna, lalit.krishna@nccs.com.sg

ABSTRACT
Introduction This study aimed to describe the patterns of sedative use among terminally ill cancer patients who were referred to a hospital-based specialist palliative care service for symptom management. It also aimed to examine whether sedative use among terminally ill cancer patients during the last two days of life had any impact on their survival.
Methods A retrospective review of case notes was carried out for patients with a diagnosis of terminal cancer, who died in a 95-bedded oncology ward between September 2006 and September 2007. Data was collected on patient characteristics, duration of palliative care, indications and doses of sedatives used at 48 hours and 24 hours before death.
Results A total of 238 patients died while receiving specialist palliative care, 132 of whom (55.5%) were female. At 48 hours and 24 hours before death, 22.6% and 24.8% of patients, respectively, were on sedatives like midazolam, haloperidol or both. The median dose of midazolam was 5 mg/day while the haloperidol dose at 48 hours and 24 hours before death was 3 mg/day and 4 mg/day, respectively. The indications for midazolam were anxiety, breathlessness and stiffness, while those for haloperidol were confusion agitation and nausea. Survival analysis showed no significant difference in survival between patients who were on sedatives and those who were not. The p-value for log-rank test was 0.78.
Conclusion The results showed that the doses and overall frequency of sedative use in this patient population tended to be low and that usage of sedatives had no deleterious influence on survival.

Keywords: midazolam, palliative care, sedatives, survival analysis, terminal cancer
Singapore Med J 2012; 53(1): 62–66

Bee PC, Gan GG, Tai YT, Haris AR, Chin E, Veera SN
Correspondence: Dr Bee Ping Chong, bpingchong@yahoo.com

ABSTRACT
Introduction The introduction of imatinib mesylate in 1998 has changed the management of chronic myeloid leukaemia. It is now the first-line therapy for newly diagnosed chronic myeloid leukaemia patients worldwide. However, its long-term survival benefit still needs to be established in clinical setting among Asian patients.
Methods All chronic myeloid leukaemia patients in the chronic phase who were on imatinib mesylate therapy were retrospectively reviewed. Data was collected through a review of case notes, which was then processed, managed and analysed.
Results A total of 44 patients were included in the study. The cumulative rates of complete haematological response, major cytogenetic response and major molecular response were 93.2%, 75.0% and 34.2%, respectively. The overall survival and event-free survival at five years were 86.0% and 84.9%, respectively. 31.8% of the patients developed anaemia, 29.5% neutropenia and 27.3% thrombocytopenia. A total of 43.2% of patients developed non-haematological side effects. Higher dosage (> 600 mg) and smaller body size (< 60 kg) were risk factors for haematological side effects. Patients with major cytogenetic response and absence of thrombocytopenia had better survival.
Conclusion The majority of our chronic myeloid leukaemia patients did well with imatinib therapy. The adverse effects in our patients were tolerable, and no patient had to stop treatment permanently.

Keywords: chronic myeloid leukaemia, chronic phase, imatinib mesylate, major cytogenetic response, overall survival
Singapore Med J 2012; 53(1): 57–61

Chan CMH, Azman WA
Correspondence: Caryn Chan Mei Hsien, caryn.chan@yahoo.com

ABSTRACT
Introduction Findings in the area of patient-physician relationship are riddled with inconsistencies. Although patient-centredness has been found to have special relevance in chronic illnesses, no study in the Southeast Asian region has so far examined role orientation and its implication for patient-centred outcomes in the cancer context. This study aimed to examine role orientation in cancer patients and their physicians, doctor-patient fit and how this congruence relates to patient satisfaction.
Methods The participants were 80 cancer patients and 12 physicians from a single academic medical centre. All participants completed the Patient-Practitioner Orientation Scale, while only the patient participants completed the self-administered Patient Satisfaction Questionnaire.
Results The cancer patients and their oncologists were found to be patient-centred and thus showed a high doctor-patient fit. Our findings also support the hypothesis that patient-centredness (overall mean = 4.66 ± 0.585) and patient-physician congruence (overall mean = 4.95 ± 0.088) are significantly associated (t(90) = -1.75, p = 0.084) with patient satisfaction (r = 0.56, p < 0.01).
Conclusion To our knowledge, this study is the first in the Southeast Asian context to examine congruence using role orientations of cancer patients and their oncologists as well as the resultant patient satisfaction in an actual clinical setting. The finding that strong doctor-patient fit is linked to higher patient satisfaction is unexpected and differs from the results of other studies from the USA. Further studies are required in order to examine how this may be influenced by differences in socio-cultural norms and expectations.

Keywords: cancer care, doctor-patient fit, patient-centeredness, patient-physician relationship, patient satisfaction
Singapore Med J 2012; 53(1): 52–56