Original Article

Narayanan S, Kalra N, Bhatia A, Wig JD, Rana S, Bhasin D, Vaiphei K, Khandelwal N
Correspondence: Dr Naveen Kalra, navkal2004@yahoo.com

ABSTRACT
INTRODUCTION Preoperative staging is essential for the optimal treatment and surgical planning of colorectal cancers. This study was aimed to evaluate the accuracy of colorectal cancer staging done using contrast-enhanced multidetector computed tomographic colonography (CEMDCTC).
METHODS We recruited 25 patients with 28 proven colorectal cancers. A 16-slice multidetector computed tomography scanner was used to generate two-dimensional multiplanar reformatted sagittal, coronal and oblique coronal images, and three-dimensional virtual colonography (endoluminal) images. Axial and reformatted views were analysed, and TNM staging was done. Patients underwent surgery and conventional colonoscopy, and surgical histopathological correlation was obtained.
RESULTS The diagnostic accuracies for TNM colorectal cancer staging were 92.3% for T staging, 42.3% for N staging and 96.1% for M staging using CEMDCTC. There was excellent positive correlation for T staging between CEMDCTC and both surgery (κ-value = 0.686) and histopathology (κ-value = 0.838) (p < 0.0001), and moderate positive correlation for N staging between CEMDCTC and surgery (κ-value = 0.424; p < 0.0001). The correlation between CEMDCTC and histopathology for N staging was poor (κ-value = 0.186; p < 0.05); the negative predictive value was 100% for lymph node detection. Moderate positive correlation was seen for M staging between CEMDCTC and both surgery (κ-value = 0.462) and histopathology (κ-value = 0.649). No false negatives were identified in any of the M0 cases.
CONCLUSION CEMDCTC correlated well with pathologic T and M stages, but poorly with pathologic N stage. It is an extremely accurate tool for T staging, but cannot reliably distinguish between malignant lymph nodes and enlarged reactive lymph nodes.

Keywords: colonography, colorectal cancer, contrast-enhanced multidetector computed tomographic colonography
Singapore Med J 2014; 55(12): 660-666; http://dx.doi.org/10.11622/smedj.2014182

REFERENCES

Teo BW, Koh YY, Toh QC, Li J, Sinha AK, Shuter B, Sethi S, Lee EJ
Correspondence: Dr Teo Boon Wee, mdctbw@nus.edu.sg

ABSTRACT
INTRODUCTION Clinical practice guidelines recommend using creatinine-based equations to estimate glomerular filtration rates (GFRs). While these equations were formulated for Caucasian-American populations and have adjustment coefficients for African-American populations, they are not validated for other ethnicities. The Chronic Kidney Disease-Epidemiology Collaborative Group (CKD-EPI) recently developed a new equation that uses both creatinine and cystatin C. We aimed to assess the accuracy of this equation in estimating the GFRs of participants (healthy and with chronic kidney disease [CKD]) from a multiethnic Asian population.
METHODS Serum samples from the Asian Kidney Disease Study and the Singapore Kidney Function Study were used. GFR was measured using plasma clearance of 99mTc-DTPA. GFR was estimated using the CKD-EPI equations. The performance of GFR estimation equations were examined using median and interquartile range values, and the percentage difference from the measured GFR.
RESULTS The study comprised 335 participants (69.3% with CKD; 38.5% Chinese, 29.6% Malays, 23.6% Indians, 8.3% others), with a mean age of 53.5 ± 15.1 years. Mean standardised serum creatinine was 127 ± 86 μmol/L, while mean standardised serum cystatin C and mean measured GFR were 1.43 ± 0.74 mg/L and 67 ± 33 mL/min/1.73 m2, respectively. The creatinine-cystatin C CKD-EPI equation performed the best, with an estimated GFR of 67 ± 35 mL/min/1.73 m2.
CONCLUSION The new creatinine-cystatin C equation estimated GFR with little bias, and had increased precision and accuracy in our multiethnic Asian population. This two-biomarker equation may increase the accuracy of population studies on CKD, without the need to consider ethnicity.

Keywords: Asian, chronic kidney disease, creatinine, cystatin C, glomerular filtration rate
Singapore Med J 2014; 55(12): 656-659; http://dx.doi.org/10.11622/smedj.2014181

REFERENCES

Teo BW, Bagchi S, Xu H, Toh QC, Li J, Lee JC
Correspondence: Dr Teo Boon Wee, mdctbw@nus.edu.sg

ABSTRACT
INTRODUCTION Clinical practice guidelines recommend dietary sodium restriction in chronic kidney disease (CKD) patients. Compliance with this recommendation in a multiethnic Asian population is not clear. This study assessed the urinary sodium excretion profile of a multiethnic Asian population to estimate the population’s dietary sodium intake.
METHODS Data on the urinary sodium excretion of 335 participants were obtained from the Asian Kidney Disease Study and Singapore Kidney Function Study. Standard statistical tests and linear regression were used to assess the association between various continuous variables and sodium excretion.
RESULTS Our study cohort consisted of 335 participants (232 with CKD, 103 healthy) – 51.0% were male; 38.5% were Chinese, 29.6% were Malay, 23.6% were Indian; and 57.3% were hypertensive. The mean age was 53.5 ± 15.1 years and mean urinary sodium excretion was 124.9 ± 68.3 mmol/day. The mean blood pressure of the healthy participants was lower than that of the patients with CKD (p < 0.001). Patients with CKD stages 1–3 excreted an average of > 100 mmol sodium/day. Overall, 40.1% patients with CKD excreted < 100 mmol sodium/day. Indians had higher urinary sodium excretion than the Chinese (p = 0.016) and Malays (p = 0.002). The distribution of urinary sodium excretion in the healthy participants (37.9% excreted < 100 mmol sodium/day) was similar to that seen in the patients with CKD.
CONCLUSION Although patients with CKD stages 4–5 achieved sodium restriction, healthy persons and patients with early-stage CKD need to increase their efforts in reducing their sodium intake, especially for patients of Indian ethnicity.

Keywords: Asian Continental Ancestry Group, chronic diet, hypertension, kidney failure, sodium
Singapore Med J 2014; 55(12): 652-655; http://dx.doi.org/10.11622/smedj.2014180

REFERENCES

Low JM, Tan M, Garcia A, Aw M, Quak SH
Correspondence: Dr Tan Li Nien Michelle, michelle_ln_tan@nuhs.edu.sg

ABSTRACT
INTRODUCTION Although childhood autoimmune hepatitis (AIH) has been extensively investigated in the West, data on AIH in the East is lacking. We aimed to investigate AIH’s clinical, biochemical and histological features, as well as its outcomes, in one of Singapore’s two major paediatric units.
METHODS This was a retrospective study of children diagnosed with AIH in the paediatric unit of National University Hospital, Singapore, over the last 12 years. Children with de novo AIH after liver transplantation were excluded. The demographic and clinical features of the patients, and their laboratory, treatment and clinical outcomes were reviewed.
RESULTS This study comprised ten patients (six females, four males), with a median age of 5.1 (range 2.1–13.8) years at diagnosis. Five patients had inflammatory bowel disease (IBD). Seven patients had type 1 AIH, and three had autoimmune sclerosing cholangitis (ASC) and IBD; none had type 2 AIH. The median level of aspartate aminotransferase at diagnosis was 183 (range 45–2,649) U/L. Prednisolone 1 mg/kg/day was prescribed at diagnosis for eight patients. Two patients were lost to follow-up and were treated symptomatically when they re-presented with end-stage liver disease. Azathioprine or mycophenolate mofetil was prescribed after 3–7 months of treatment. Normalisation of aminotransferase levels took an average of 5.3 (range 1–39) months.
CONCLUSION AIH is a rare but important cause of liver pathology. Children in this region with elevated aminotransferases or unexplained hepatomegaly should be screened for AIH.

Keywords: aminotransferases, childhood autoimmune hepatitis, hepatomegaly, immunosuppressant therapy, liver pathology
Singapore Med J 2014; 55(12): 648-651; http://dx.doi.org/10.11622/smedj.2014179

REFERENCES

Wong AS, Ching SS, Long AS
Correspondence: Dr Wong Siang Yih Andrew, andrew_wong@cgh.com.sg

ABSTRACT
INTRODUCTION The use of an additional biopsy from the gastric body may help improve the detection of Helicobacter pylori during endoscopy. This study aimed to determine whether such an additional biopsy is necessary in routine rapid urease test (RUT), and whether acid suppression and antibiotic therapy affect RUT results.
METHODS Patients recruited had two gastric mucosal biopsies taken – one from the gastric antrum and the other from the gastric body. Each biopsy was placed into separate RUT kits. Information on previous or current use of proton-pump inhibitors, H2 receptor antagonist, bismuth and antibiotics was obtained. Patients on any of those drugs one week prior to endoscopy were considered to have a positive drug history (PDH).
RESULTS Of the 400 patients recruited, 311 had negative RUTs and 89 had at least one positive RUT. Between the PDH and negative drug history (NDH) groups, there was a significant difference in the distribution of the location of the biopsies that yielded positive RUTs (p = 0.023). The NDH group had a higher proportion of patients who had positive RUTs for both locations, whereas the PDH group had a higher proportion of patients who had positive RUTs for only one location.
CONCLUSION As RUT results are significantly affected by the use of acid suppression and antibiotic therapies, biopsies for RUT should be taken from both the gastric antrum and body to minimise false negative results.

Keywords: gastric body biopsy, Helicobacter pylori, rapid urease test
Singapore Med J 2014; 55(12): 644-647; http://dx.doi.org/10.11622/smedj.2014178

REFERENCES

Lim WM, Heng C, Wong MT, Tang CL
Correspondence: Dr Mark Wong, mark.wong@sgh.com.sg

ABSTRACT
INTRODUCTION Faecal incontinence (FI) is a stigmatised condition that remains a silent affliction for many populations. To date, no local study has been performed to determine its prevalence in our population. The existing literature from the West has shown highly variable rates, ranging from 0.8% to 18.0%. The aim of this study was to determine the cross-sectional prevalence of FI in Singapore and to identify at-risk groups.
METHODS A door-to-door questionnaire survey was performed between February and March 2013. We randomly selected 1,000 individuals from the electoral roll to be surveyed using the validated Comprehensive Fecal Incontinence Questionnaire.
RESULTS A total of 381 participants agreed to be enrolled in the study. The mean age of the participants was 52 (range 21–86) years, and slightly more than half of the participants were female (52.8%). Among the female participants, 73.1% had children (78.8% underwent normal vaginal delivery). The overall prevalence of FI in our study population was 4.7%. The prevalence of FI was observed to be significantly associated with increasing age (p = 0.004) and female gender (p = 0.029); women were three times more likely to suffer from FI than men.
CONCLUSION With the ageing population of Singapore, the results of the present study provide further impetus to continue public outreach efforts as well as develop clinical programmes that address the growing need for specialist treatments for people with FI.

Keywords: asian, faecal incontinence, prevalence, quality of life, questionnaire
Singapore Med J 2014; 55(12): 640-643; http://dx.doi.org/10.11622/smedj.2014177

REFERENCES

Goh MH, Chew MH, Au-Yong PS, Ong CE, Tang CL
Correspondence: A/Prof Tang Choong-Leong, tang.choong.leong@sgh.com.sg

ABSTRACT
INTRODUCTION Severe perianal sepsis is often difficult to manage after surgical debridement due to faecal contamination. Diversion of the faecal stream has been attempted with faecal pouches and rectal tubes, and in some cases, a diverting stoma is created. However, reversal of the stoma may be delayed due to prolonged sepsis and this is not without risks. Herein, we review the use of a flexible faecal management system in patients with severe perianal sepsis.
METHODS We retrospectively evaluated 15 patients who made use of the ConvaTec Flexi-Seal® Fecal Management System (FMS) between 1 January 2007 and 31 December 2010. The demographics and comorbidities of the patients, as well as the treatment received, were recorded and reviewed.
RESULTS None of the patients required the creation of a stoma to divert the faecal stream. Nursing requirements and wound care were found to be improved with the use of the Flexi-Seal® FMS (fewer changes were needed). No severe complications were observed in our series. Two deaths were encountered, but the cause of death was not directly due to the initial perianal sepsis. Overall, the wound healing rate was 80.0%, with one graft failure (11.1%).
CONCLUSION The use of the Flexi-Seal® FMS in patients with perianal sepsis following extensive debridement is feasible and can be considered before stoma creation.

Keywords: faecal diversion, faecal management system, flexiseal, perianal sepsis
Singapore Med J 2014; 55(12): 635-639; http://dx.doi.org/10.11622/smedj.2014176

REFERENCES

Han ER, Chung EK, Oh SA, Woo YJ, Hitchcock MA
Correspondence: Dr Eun-Kyung Chung, ekcmedu@chonnam.ac.kr

ABSTRACT
INTRODUCTION Effective mentoring helps interns in the early stages of their medical career to reach personal and professional goals. This study investigated the mentoring experience of Korean interns during medical internship and evaluated mentoring effects to facilitate the development of future mentoring programmes.
METHODS Participants were interns being trained at Chonnam National University Hospital, South Korea, in 2011. Interns were asked to complete a questionnaire about their mentoring experiences and job satisfaction.
RESULTS A total of 61 medical interns participated in the study, giving a response rate of 70.1%. Among these interns, 26 (42.6%) had mentoring experiences, with an average of 2.3 ± 1.9 mentors per mentee. Mentees usually discussed career planning and concerns regarding their personal and social lives with their mentors. Perceived quality of the mentor was signifi cantly more important for male mentees than for female mentees. Female interns without a mentor made signifi cantly less effort to seek a mentor than their male counterparts. Having and not having a mentor resulted in significant differences in the interns’ job satisfaction.
CONCLUSION Fewer than half of the medical interns had mentoring experiences. Results suggest that the mentoring relationship may be less satisfying and more challenging for female interns. Effective mentoring may not only help interns plan their medical career, but also increase job satisfaction. Mentoring programmes during medical internship should be expanded and supported, as it is the initial step in a medical career.

Keywords: career counselling, internship, job satisfaction, mentorships
Singapore Med J 2014; 55(11): 593-597; http://dx.doi.org/10.11622/smedj.2014157

REFERENCES

Rezaeian A, Ghayour-Mobarhan M, Mazloum SR, Yavari M, Jafari SA
Correspondence: Mrs Mehri Yavari, yavarim@mums.ac.ir

ABSTRACT
INTRODUCTION Iron deficiency, associated with a decline in cognitive function, is the most common nutritional deficiency globally. The present study aimed to identify the impact of weekly iron supplements on the attention function of female students from a high school in North Khorasan Province, Iran.
METHODS This was a blind, controlled, clinical trial study, involving 200 female students who were chosen using the stratified randomised sampling method. First, laboratory studies were performed to detect iron consumption limitations. Next, the 200 students were divided randomly and equally into case and control groups. The case group was treated with 50 mg of ferrous sulfate twice a week for 16 weeks. We compared both groups’ data on attention, iron status and erythrocyte indices. Questionnaires were used to collect demographic data, while clinical data was collected using complete blood count and Toulouse-Piéron tests. Data was analysed using descriptive statistics, as well as paired and independent t-tests.
RESULTS The mean attention scores of the case and control groups were 104.8 ± 7.0 and 52.7 ± 9.6, respectively (p < 0.001). The mean haemoglobin levels of the two groups were 12.5 ± 0.9 and 11.2 ± 1.0, respectively (p < 0.001). Compared to the control group, the attention scores and haemoglobin concentrations of the case group were found to be improved by approximately 90% and 10%, respectively.
CONCLUSION Oral iron supplements (50 mg twice a week for 16 weeks) were able to improve the attention span and haematologic indices of female high school students.

Keywords: attention, erythrocyte indices, haemoglobin, iron, oral supplement
Singapore Med J 2014; 55(11): 587-592; http://dx.doi.org/10.11622/smedj.2014156

REFERENCES

Yoshino Y, Wakabayashi Y, Suzuki S, Seo K, Koga I, Kitazawa T, Okugawa S, Ota Y
Correspondence: Dr Yusuke Yoshino, yoshinosuke0618@gmail.com

ABSTRACT
INTRODUCTION Early detection of catheter-related candidemia is necessary to ensure that patients receive prompt and appropriate treatment. The aim of the present case-control study is to investigate the clinical features of catheter-related candidemia at disease onset, so as to determine the clinical indications for empiric antifungal therapy.
METHODS All 41 cases of catheter-related candidemia from September 2009 to August 2011 at a teaching hospital were included in the present study. To determine the characteristics that were risk factors for developing catheter-related candidemia, we compared all cases of catheter-related candidemia with all 107 cases of catheter-related blood stream infection (CRBSI) caused by non-Candida spp.
RESULTS In comparison with CRBSI due to non-Candida spp., the duration of catheter use was significantly longer in cases of catheter-related candidemia (13.9 ± 9.0 days vs. 23.2 ± 25.2 days). There was also a significant difference in the frequency of pre-antibiotic treatment between catheter-related candidemia and CRBSI due to non-Candida spp. (97.6% [40/41 cases] vs. 44.9% [48/107 cases]). Patients with catheter-related candidemia also had significantly more severe clinical statuses (measured using the Sepsis-related Organ Failure Assessment score) than patients with CRBSI due to non-Candida spp. (7.63 ± 3.65 vs. 5.92 ± 2.81).
CONCLUSION When compared to patients with CRBSI caused by non-Candida spp., patients with catheter-related candidemia had significantly more severe clinical backgrounds, longer duration of catheter use and more frequent prior administration of antibiotic agents.

Keywords: candidemia, catheter-related bloodstream infection, clinical feature
Singapore Med J 2014; 55(11): 579-582; http://dx.doi.org/10.11622/smedj.2014154

REFERENCES