Original Article

Tan WS, Lim JF, Tang CL, Eu KW
Correspondence: Dr Jit Fong Lim, drlimjitfong@gmail.com

ABSTRACT
Introduction With improvements in surgical techniques, instrumentation and perioperative care, Hartmann’s procedure is now less frequently performed. Restoration of intestinal continuity after Hartmann’s procedure has traditionally been viewed to be technically demanding and associated with significant morbidity and mortality. This is a study of outcomes after the reversal of Hartmann’s procedure in an Asian population. 
Methods A prospectively collected database showed that 255 patients had undergone Hartmann’s procedure from October 1989 to October 2005. Patients who subsequently underwent Hartmann’s reversal were identified and their records reviewed retrospectively. 
Results Hartmann’s reversal was attempted in 49 patients. The most common indication for Hartmann’s procedure was colorectal carcinoma (49.0%).  The median interval between resection and reversal was 23 weeks. Reversal was successful in 46 (93.9%) patients, with 79.6% experiencing no intraoperative complications. Failure of reversal was significantly associated with prior radiotherapy to the pelvis (p-value = 0.007). Anastomotic leak rates and re-bleeding rates were both 0.0%. 79.6% of patients made an uneventful recovery with no postoperative complications. There was no significant increase in the complication rate in older patients or patients with higher American Society of Anesthesiologists status. The overall incidence of 30-day morbidity and mortality was 20.4% and 0.0%, respectively. 
Conclusion In our population, Hartmann’s procedure is more commonly performed for colorectal cancer rather than for diverticular disease, resulting in lower rates of stoma reversal. Hartmann’s reversal could be performed with acceptable morbidity and minimal mortality, although prior radiotherapy and shorter rectal stump may pose challenges during reversal surgery.

Wiratkapun C, Treesit T, Wibulpolprasert B, Lertsithichai P
Correspondence: Dr Cholatip Wiratkapun, racwr@mahidol.ac.th

ABSTRACT
Introduction This study aimed to assess the diagnostic accuracy of ultrasonography (US)-guided core needle biopsy (CNB) for breast lesions. 
Methods We performed US-guided CNB of 733 lesions in 674 women from January 2003 to December 2005. Surgical excision was performed on 331 lesions. We compared the histopathologic findings of the CNB specimens with those of surgical specimens or with patients’ long-term follow-up images. We also calculated the agreement, underestimation, sensitivity and false-negative rates. 
Results The CNB results showed 334 breast cancers (46%), 28 high-risk lesions (5%) and 367 benign lesions (50%). Four (1%) lesions  were categorised as inconclusive. The final diagnosis was breast cancer in 348 lesions. The kappa measure of agreement between the US-guided CNB results and surgical excision findings or follow-up results was 0.861 (p-value < 0.001). The underestimation rate was 40% (10 out of 25) for atypical ductal hyperplasia and 47% (14 out of 30) for ductal carcinoma in situ (DCIS). The CNB false negative rate and sensitivity for malignant lesions was 4% (14 out of 348) and 96% (334 out of 348), respectively. 
Conclusion US-guided CNB is an accurate diagnostic alternative to surgical biopsy in patients with breast lesions detected via US, although the high underestimation rates in DCIS and high-risk lesions are still a concern.

Keywords: breast cancer, diagnosis, needle biopsy, ultrasonography
Singapore Med J 2012; 53(1): 40–45

Yusoff N, Low WY, Yip CH
Correspondence: Nasir Yusof, nasirff@kk.usm.my

ABSTRACT
Introduction The Breast Module (BR23) is increasingly being used worldwide in breast cancer research. This study evaluates the appropriateness of the translated version (i.e. BR23-Malay version) as a useful tool for the Malaysian population who could understand Malay, and examines the reliability and validity of the BR23-Malay version. 
Methods This was a prospective study involving 68 Malaysian women who could understand Malay very well. They answered the BR23-Malay version at two evaluation points – three and ten weeks following surgery for breast cancer. Internal consistency, test-retest intraclass correlation coefficients (ICC), effect size index, sensitivity and discriminity of the scale were calculated. 
Results Internal consistencies were acceptable for the functional domains (0.87 for body image; 0.84 for sexual functioning) and symptomatology domains (0.82 for systemic therapy side effect; 0.82 for breast symptoms; 0.70 for arm symptoms). Test-retest ICC ranged from 0.26 to 1.00. Sensitivity of the scale was observed in all domains except sexual functioning. 
Conclusion The Malay version of BR23 is a suitable tool to measure the functional and symptomatology domains of women diagnosed with breast cancer.

Keywords: BR23, Cronbach’s alpha, intraclass correlation coefficient, Malay version, test-retest reliability and validity
Singapore Med J 2012; 53(1): 36–39

Chang SKY, Hlaing WW, Yu RQ, Lee TWV, Ganpathi IS, Madhavan KK
Correspondence:  Dr Stephen Chang Kin Yong, cfscky@nus.edu.sg

ABSTRACT
Introduction The aim of this study was to establish the value of alpha-foetoprotein (AFP) for the screening of recurrences in hepatocellular carcinoma (HCC) in patients who have undergone curative hepatic resection. 
Methods 72 HCC patients who had curative resection/liver transplant in 2000–2006 were monitored for recurrence by evaluating the three- or six-monthly AFP and computed tomography images. Patients without recurrence were followed up for a mean duration of 7.27 years. 
Results Out of the 72 patients, 34 (47.2%) suffered from HCC recurrence. 65.4% of recurrent cases had AFP values showing an upward trend. Patients with recurrence had higher AFP values than those without at last follow-up (119.45 μg/L vs. 3.1 μg/L, p < 0.001). AFP at recurrence was independent of gender, race, history of alcohol consumption and hepatitis C or cirrhosis status. Patient with hepatitis B or those with tumours larger than 5 cm had higher AFP values. The best cut-off AFP indicative of HCC recurrence was 5.45 μg/L (sensitivity 84.4%; specificity 77.1%). High preoperative AFP was associated with high AFP at recurrence (correlation coefficient 0.553, p = 0.01). 
Conclusion AFP alone is an inadequate screening test for HCC recurrence since only about two-thirds of patients showed upward AFP trend on recurrence. Our study found a relatively low cut-off point for detection of recurrence (5.54 μg/L). Patients with high preoperative AFP tended to have high AFP on recurrence. Imaging is recommended for patients with AFP levels > 5.45 μg/L, especially when AFP shows a rising trend.

Zulhabri O, Rahman J, Ismail S, Isa MR, Wan Zurinah WN
Correspondence: Dr Zulhabri Othman, zulhabri_othman@yahoo.com

ABSTRACT
Introduction K-ras gene mutations in codons 12 and 13 are one of the earliest events in colon carcinogenesis. 
Methods DNA was extracted from 25 mg of tumour tissue (n = 70) that were taken from tumour mass and pairs with normal epithelial tissue distant from the tumour of colorectal cancer patients. Exon 1 and exon 2 of the K-ras gene were amplified. Hotspot mutations were detected using polymerase chain reaction-based single-strand conformation polymorphism method and confirmed by direct DNA sequencing analysis.
Results Mutations were identified in 14 out of the 70 (20%) colorectal carcinoma tissues. Single-base transition from GGT to GAT (glycine to aspartate) in codon 12 was detected in nine samples, while three samples presented with GGC to GAC transition in codon 13. Patients with large adenoma had a 12-fold higher likelihood of K-ras mutations (odds ratios [OR] 12.31; 95% confidence intervals [CI] 1.81–83.76). Tumours located at the left colon were more likely to present with K-ras mutations (OR 4.54; 95% CI 0.96–21.54). 
Conclusion Our study showed a high frequency of G to A transition of codon 12 mutation of the K-ras gene, withsignificant correlation with tumour size and tumour location.

Keywords: codon 12, colorectal cancer, Dukes’ B, K-ras gene, mutation
Singapore Med J 2012; 53(1): 26–31

Tan C, Sabai SM, Tin  AS, Quah TC, Aung L
Correspondence: Dr LeLe Aung, aung.lele@kkh.com.sg

ABSTRACT
Introduction Neuroblastoma is the most common extracranial solid tumour in childhood. We report our experience at National University Health System (NUHS), Singapore. 
Methods We performed a retrospective chart review of 43 patients diagnosed with neuroblastoma, who were seen and  treated at the Department of Paediatrics, NUHS from November 1987 to November 2008. 
Results The median age of the patients at diagnosis was 1.9 (range 0.1–20.2) years. The majority (70.1%) of primary tumours were of abdominal and/or adrenal origin. According to the International Neuroblastoma Staging System, six (14.0%) patients were in stages 1 and 2, 11 (25.6%) in stage 3, 19 (44.2%) in stage 4, and seven (16.2%) in stage 4s. Therapy for all patients included surgery and/or chemotherapy and/or radiation therapy. Patients with stage 4 disease also underwent autologous stem cell transplant. The median follow-up for the cohort was 2.5 (range 0.4–21.0) years. At the time of analysis, 29 (67.4%) patients were alive. The two- and five-year overall survival for the cohort was 65.0% (95% confidence interval [CI] 51.0%–80.0%) and 62.0% (95% CI 45.0%–79.0%), respectively. The five-year overall survival rates according to risk status were 100.0% for low-risk, 75.0% for intermediate risk and 28.2% for high-risk neuroblastoma. 
Conclusion The prognosis for those with advanced stage neuroblastoma remains poor. A collaborative effort, with an emphasis on research in detecting biologic characteristics of aggressive disease and tailoring therapy, needs to be strengthened in order to further our understanding of this disease.

Keywords: neuroblastoma, Singapore, survival, treatment
Singapore Med J 2012; 53(1): 19–25

Kong QX, Xia M, Liang RQ, Li L, Cu X, Sun ZX, Hu J
Correspondence: Dr Qingxia Kong, qingxiakong56@126.com

ABSTRACT
INTRODUCTION The present study aimed to investigate the possible associations between serum levels of visfatin, an adipokine, and atherosclerosis in patients with ischaemic cerebrovascular disease.
METHODS A total of 95 participants were recruited for this study. Group A comprised 35 individuals with no history of cerebrovascular disease (control group) and Group B comprised 60 patients with ischaemic cerebrovascular disease. Group B was further categorised into two subgroups based on the ultrasonographic findings of the common carotid artery intima-media thickness (CCA-IMT) – Group B1 consisted of 21 patients with no atherosclerosis (i.e. CCA-IMT ≤ 0.9 mm) and Group B2 consisted of 39 patients with atherosclerosis (i.e. CCA-IMT > 0.9 mm). The body mass index, fasting blood total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and glucose levels of each patient were measured. Serum visfatin levels were determined using enzyme-linked immunosorbent assays. Visfatin levels were compared between groups, and stepwise logistic regression analysis was used to identify risk factors for atherosclerosis, including visfatin levels.
RESULTS The mean serum visfatin level of the patients in Group B was higher than that in Group A (75.5 ± 77.80 ng/mL vs. 8.6 ± 4.69 ng/mL; p < 0.05) and the level was higher in patients from Group B2 than those from Group B1 (89.0 ± 80.68 ng/mL vs. 50.4 ± 72.44 ng/mL; p < 0.05). Multivariate regression analysis showed that CCA-IMT values were not significantly associated with visfatin levels. However, logistic regression analysis showed that serum visfatin was an independent risk factor for atherosclerosis (odds ratio 37.80; p = 0.004).
CONCLUSION Serum visfatin may be an independent risk factor for cerebral infarction, as high serum visfatin levels are positively associated with the underlying pathogenic mechanisms of ischaemic cerebrovascular disease.

Keywords: adipocytokine, atherosclerosis, cerebral infarction, ischaemic cerebrovascular disease, visfatin
Singapore Med J 2014; 55(7): 383-387; http://dx.doi.org/10.11622/smedj.2014091

REFERENCES

Gupta R, Pruthi M, Kumar A, Garg S
Correspondence: Dr Manish Pruthi, manishpruthi@gmail.com

ABSTRACT
INTRODUCTION No single study has established the superiority of one treatment of Kienböck’s disease over the other. Pooled outcome data is presently considered the best way to add to the knowledge and understanding of Kienböck’s disease.
METHODS A total of 12 patients (9 male and 3 female) with Kienböck’s disease were included in the present case series. The mean age of the 12 patients was 28 years. One patient presented in Lichtman stage I, five in Lichtman stage II, five in Lichtman stage IIIa, and one in Lichtman stage IV. Univariate and multivariate analyses of the obtained data were performed to identify any correlations.
RESULTS The mean follow-up time was 62 months, and the mean modified Mayo wrist score improved from the preoperative value of 29.5 to the final value of 89.6. Lichtman stage at presentation showed moderate positive correlation with the duration of symptoms (r = 0.56), and a strong negative correlation with the preoperative and final modified Mayo scores (r = –0.89 and r = –0.77, respectively). The final modified Mayo score showed moderate negative correlation with the duration of the symptoms (r = –0.55). There was a significant difference in the preoperative modified Mayo scores of patients who presented in stage II and those of patients who presented in stage IIIa (p = 0.03). However, the difference in the final modified Mayo scores of the patients in these stages was not significant (p = 0.14).
CONCLUSION Lichtman’s stage is moderately related to the duration of symptoms, suggesting natural progression of the disease. The final outcomes of stages II and IIIa were the same irrespective of the surgical treatment (radial shortening and/or vascularised bone grafting).

Keywords: Kienböck’s disease, lunate, wrist
Singapore Med J 2014; 55(11): 583-586; http://dx.doi.org/10.11622/smedj.2014155

REFERENCES

Hong CC, Hey HW, Murphy D
Correspondence: Dr Hong Choon Chiet, choonchiet@gmail.com

ABSTRACT
INTRODUCTION New knowledge, and improved surgical hardware and fi xation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures.
METHODS Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital’s electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications.
RESULTS In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12–85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30–39 years vs. 70–79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001).
CONCLUSION Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.

Keywords: complication, epidemiology, minimally invasive plate osteosynthesis, Neer’s classification, proximal humerus fracture
Singapore Med J 2014; 55(11): 574-578; http://dx.doi.org/10.11622/smedj.2014153

REFERENCES

Souza CS, Resende FS, Rodrigues MP
Correspondence: Prof Dr Marcelo Palmeira Rodrigues, pmarcelo27@gmail.com

ABSTRACT
INTRODUCTION Acute pulmonary embolism (APE) is an urgent clinical condition that can progress in a wide variety of ways. Therefore, we sought to develop an easy-to-apply algorithm, to be based on readily available clinical indicators, effective in predicting unfavourable outcomes.
METHODS This was a retrospective cohort study based on systematically collected data in a database. The study included 102 patients with APE who were admitted to a tertiary care hospital. The following outcomes were defined as unfavourable: shock, the need for mechanical ventilation, the use of thrombolytics, and death. Logistic regression analysis was used to explore variables significantly associated with outcome and to calculate post-test probabilities.
RESULTS The prevalence of unfavourable outcomes was 25.5% (26 of the 102 patients with APE). The risk of an unfavourable outcome was reduced to 7.0% for patients with APE who were aged ≤ 40 years. In patients with APE who were aged > 40 years, the presence of hypoxaemia (i.e. peripheral oxygen saturation < 90%) alone increased the risk of an unfavourable outcome to 57.0%. A recent history of trauma and the presence of pre-existing lung or heart disease were significantly associated with unfavourable outcomes. The inclusion of those variables in the logistic regression model increased the post-test risk of an unfavourable outcome to 65.0%–86.0%.
CONCLUSION Advanced age (i.e. > 40 years), the presence of hypoxaemia, a recent history of trauma and the presence of pre-existing lung or heart disease are risk factors for unfavourable outcome in patients with APE.

Keywords: anoxia, logistic models, prognosis, pulmonary embolism, wounds and injuries
Singapore Med J 2014; 55(9): 483-487; http://dx.doi.org/10.11622/smedj.2014118

REFERENCES