Original Article

Chew CP, Lee KH, Koh SB, Howe TS
Correspondence: Dr Chew Chee Ping, bobchew_79@hotmail.com

ABSTRACT
INTRODUCTION The fabella, a sesamoid bone sometimes found in the lateral head of the gastrocnemius muscle, often articulates directly with the lateral femoral condyle. This study aimed to determine the incidence of fabellae in an Asian population and to characterise the radiological features of the fabella.
METHODS Electronic radiographs and magnetic resonance imaging films of 80 consecutive patients who underwent knee arthroscopy between May 2005 and October 2009 were reviewed to determine the presence and characteristics of the fabella. 
RESULTS The incidence of fabellae was 31.25% in our study cohort. The median length, thickness, width and distance of the fabella from the lateral femoral condyle were 7.06 mm, 4.89 mm, 6.12 mm and 33.19 mm, respectively. The fabella was consistently bony and located in the lateral head of the gastrocnemius, with 52% of the fabellae having an articulating facet. Fabellae in men were found to be larger than in women, although the difference was not statistically significant. The presence of an articulating groove was associated with increased size of the fabella, but not with the distance between the fabella and its insertion onto the lateral head of the gastrocnemius.
CONCLUSION The incidence of fabellae in our population was lower than that in regional studies. They were consistently bony and not all had articulating grooves on the lateral femoral condyle. We found that the larger the fabella, the higher the chances of it having an articulating groove. By defining the radiological characteristics of the fabella, we provide objective parameters to help differentiate the fabella from other loose bodies or calcifications in the knee.

Keywords: fabella, knee joint, sesamoid bones
Singapore Med J 2014; 55(4): 198-201; http://dx.doi.org/10.11622/smedj.2014052

REFERENCES

Cheong KX, Lo HY, Neo JX, Appasamy V, Chiu MT
Correspondence: Dr Cheong Kai Xiong, kaixiong.cheong@mohh.com.sg

ABSTRACT
INTRODUCTION We aimed to report the outcomes of inguinal hernia repair performed at Tan Tock Seng Hospital and compare them with those performed at dedicated hernia centres.
METHODS We retrospectively analysed the medical records and telephone interviews of 520 patients who underwent inguinal hernia repair in 2010. 
RESULTS The majority of the patients were male (498 [95.8%] men vs. 22 [4.2%] women). The mean age was 59.9 ± 15.7 years. Most patients (n = 445, 85.6%) had unilateral hernias (25.8% direct, 64.3% indirect, 9.9% pantaloon). The overall recurrence rate was 3.8%, with a mean time to recurrence of 12.0 ± 8.6 months. Risk factors for recurrence included contaminated wounds (odds ratio [OR] 50.325; p = 0.004), female gender (OR 8.757; p = 0.003) and pantaloon hernias (OR 5.059; p = 0.013). Complication rates were as follows: chronic pain syndrome (1.2%), hypoaesthesia (5.2%), wound dehiscence (0.4%), infection (0.6%), haematoma/seroma (4.8%), urinary retention (1.3%) and intraoperative visceral injury (0.6%). Most procedures were open repairs (67.7%), and laparoscopic repair constituted 32.3% of all the inguinal hernia repairs. Open repairs resulted in longer operating times than laparoscopic repairs (86.6 mins vs. 71.6 mins; p < 0.001), longer hospital stays (2.7 days vs. 0.7 days; p = 0.020) and a higher incidence of post-repair hypoaesthesia (6.8% vs. 1.8%; p = 0.018). However, there were no significant differences in recurrence or other complications between open and laparoscopic repair.
CONCLUSION A general hospital with strict protocols and teaching methodologies can achieve inguinal hernia repair outcomes comparable to those of dedicated hernia centres.

Keywords: complications, inguinal hernia repair, laparoscopic, open, recurrence
Singapore Med J 2014; 55(4): 191-197; http://dx.doi.org/10.11622/smedj.2014051

REFERENCES

Sim SW, Moey KS, Tan NC
Correspondence: Ms Shin Wei Sim, simshinwei@gmail.com

ABSTRACT
INTRODUCTION Acute respiratory infections are prevalent and pose a constant threat to society. While the use of facemasks has proven to be an effective barrier to curb the aerosol spread of such diseases, its use in the local community is uncommon, resulting in doubts being cast on its effectiveness in preventing airborne infections during epidemics. We thus aimed to conduct a literature review to determine the factors that influence the use of facemasks as a primary preventive health measure in the community.
METHODS A search for publications relating to facemask usage was performed on Medline, PubMed, Google, World Health Organization and Singapore government agencies’ websites, using search terms such as ‘facemask’, ‘mask’, ‘influenza’, ‘respiratory infection’, ‘personal protective equipment’, ‘disease prevention’, ‘compliance’ and ‘adherence’. Findings were framed under five components of the Health Belief Model: perceived susceptibility, perceived benefits, perceived severity, perceived barriers and cues to action.
RESULTS We found that individuals are more likely to wear facemasks due to the perceived susceptibility and perceived severity of being afflicted with life-threatening diseases. Although perceived susceptibility appeared to be the most significant factor determining compliance, perceived benefits of mask-wearing was found to have significant effects on mask-wearing compliance as well. Perceived barriers include experience or perception of personal discomfort and sense of embarrassment. Media blitz and public health promotion activities supported by government agencies provide cues to increase the public’s usage of facemasks.
CONCLUSION Complex interventions that use multipronged approaches targeting the five components of the Health Belief Model, especially perceived susceptibility, are needed to increase the use of facemasks in the community. Further studies are required to evaluate the effectiveness of implemented interventions.

Keywords: facemask, Health Belief Model, prevention, respiratory infection
Singapore Med J 2014; 55(3): 160-167; http://dx.doi.org/10.11622/smedj.2014037

REFERENCES

Saha A, Mandal S, Chakraborty S, Bandyopadhyay M
Correspondence: Dr Anubha Saha, saha.anubha@yahoo.com

ABSTRACT
INTRODUCTION The sternocleidomastoid (SCM) muscle is a major muscle of the neck. Classically, this muscle is attached below the sternum and clavicle, although the mode of attachment might vary. As the SCM is related to numerous important neurovascular structures, its variable anatomy is clinically relevant, particularly for neck surgeries. A cadaveric study was performed to establish the variations present in the mode of attachment of the SCM muscle in an Indian population.
METHODS We studied the variations in the attachment of the SCM muscle during the dissection of 18 cadavers for undergraduate teaching in two medical colleges in West Bengal, India. 
RESULTS Variations in the attachment of the SCM muscle were found in 5 (27.8%) specimens. Of these five specimens, three had unilateral variations and two had bilateral variations. In each specimen, the modes of presentation of the SCM and its fusion with the major bulk were also different.
CONCLUSION In this study, we found variations in the attachment of the SCM muscle in more than a quarter of the specimens dissected. Surgeons should bear in mind such variations when performing neck surgeries.

Keywords: anatomical variations, extraclavicular head, sternocleidomastoid muscle
Singapore Med J 2014; 55(1): 45-47; http://dx.doi.org/10.11622/smedj.2013215

REFERENCES

Tan NC, Aw LF, Khin LW, Thirumoorthy T, Lim SH, Tai BC, Goh LG
Correspondence: Dr Tan Ngiap Chuan, Tan.Ngiap.Chuan@singhealth.com.sg

ABSTRACT
INTRODUCTION Not much is known regarding how primary care physicians (PCPs) in Singapore keep themselves healthy and mitigate ill health. This study aims to determine the health-seeking behaviour of local PCPs and to identify the predictors of local PCPs attaining the recommended level of exercise.
METHODS This study was a cross-sectional questionnaire survey, which included questions on the demographic characteristics, practice profiles and health-seeking behaviour of PCPs. The sampling frame was the 1,400 listed members of the College of Family Physicians Singapore. The anonymised survey was executed in two phases: a postal survey, followed by a web-based survey on the College of Family Physicians Singapore website. The two data sets were collated; the categorical variables, summarised; and the differences between subgroups (based on exercise engagement), compared using Fisher’s exact test. The effect of each risk factor on exercise duration was quantified using odds ratio (OR) estimate and 95% confidence interval (CI). Multivariate logistic regression analysis was performed to identify significant predictors of exercise engagement.
RESULTS A total of 631 PCPs participated in the survey – 26% were ≤ 34 years old, 58% were male, 21% were single, 34% were singleton practitioners, and 56% were private practitioners. The percentage of PCPs who exercised ≥ 2.5 hours weekly was 29%, while 28% exercised < 0.5 hours weekly. Of the PCPs surveyed, 1% currently smoke, 0.8% drink more than 14 units of alcohol weekly, 60% undertook health screening, 65% had blood investigations done, and 64% had taken preventive measures such as getting influenza vaccination.
CONCLUSION While local PCPs generally did not have undesirable habits such as smoking and alcohol abuse, they could further increase their exercise intensity and undertake more preventive measures such as getting vaccinated against various diseases.

Keywords: exercise, health, primary care physicians, vaccination 
Singapore Med J 2014; 55(3): 155-159; http://dx.doi.org/10.11622/smedj.2014036

REFERENCES

Tan WJ, Wong TK
Correspondence: Dr Tan Woei Jen Michelle, tan.michelle.wj@alexandrahealth.com.sg

ABSTRACT
INTRODUCTION Weight management programmes (WMPs) can help overweight individuals lose weight, and thus prevent complications associated with obesity. Herein, we describe the demographic profile, clinical characteristics, motivations and expectations, and outcomes of patients enrolled in a nonsurgical WMP.
METHODS This was a retrospective study of consecutive patients with a body mass index (BMI) of > 23 kg/m² enrolled in the four-month WMP at the Health For Life Clinic, Alexandra Hospital, Singapore, between 1 and 31 August 2009. Demographic data, medical history and source of referral were recorded. Details on personal motivations and weight loss goals were obtained from the completed self-administered questionnaires of the WMP participants. Weight, waist circumference, fat percentage and BMI were measured at the start and end of the WMP. A weight loss of ≥ 5% was deemed as a successful outcome.
RESULTS A total of 58 patients (mean age 37.2 years) were included in our study. Of these 58 patients, 58.6% were of Chinese ethnicity and 55.2% were male. Many patients (32.8%) attributed their weight gain to work- or study-related stress, and a minority to poor eating habits (12.1%) or a lack of exercise (10.3%). Patients’ motivations included a desire for better health (53.4%) and better fitness (15.5%). However, only 53.4% patients scored their motivation as high (i.e. a score of > 7). The mean expected weight loss was 9.9 kg at 4 months, and 14.1 kg at 12 months. Among the 40 patients (69.0%) who completed the programme, the mean percentage weight loss was 1.8 ± 4.3%. A weight loss of ≥ 5% was achieved by 8 (13.8%) patients.
CONCLUSION Although the patients in our study cohort were young and educated, only a portion of them appeared to be highly motivated to lose weight, despite joining the WMP. There is a need for patients to be guided on how to set realistic weight loss goals.

Keywords: demographics, obesity, results, Singapore, weight management
Singapore Med J 2014; 55(3): 150-154; http://dx.doi.org/10.11622/smedj.2014035

REFERENCES

Ng LP, Goh P
Correspondence: Dr Ng Lai Peng, ng.lai.peng@singhealth.com.sg

ABSTRACT
INTRODUCTION The incidence of cough induced by angiotensin-converting enzyme (ACE) inhibitors has been reported to be 5%–20%, with less than half of affected patients requiring discontinuation due to persistent cough. However, the incidence in the local Asian population has not been studied. This study aimed to objectively evaluate the incidence of discontinuation of ACE inhibitors due to cough, in a primary healthcare centre in Singapore.
METHODS We retrospectively reviewed the medical records, both electronic and written, of patients who attended Tampines Polyclinic to identify those who were newly prescribed ACE inhibitors. The written medical records were analysed to identify patients who discontinued the use of ACE inhibitors and to find out the reasons for discontinuation.
RESULTS A total of 424 patients were identified during the study period. Out of the 424 patients, 129 (30.4%) discontinued the use of ACE inhibitors due to cough. Overall, 90 (21.2%) patients who were initially started on ACE inhibitors were eventually switched to angiotensin receptor blockers (ARBs).
CONCLUSION In our cohort, the incidence of discontinuation of ACE inhibitors due to cough is higher than most other studies. The relationship between ethnicity and tolerance of medications should not be underestimated. As there is a high incidence of discontinuation of ACE inhibitors due to cough in the local population, ARBs may be a reasonable substitute as a first-line medication, if clinically indicated.

Keywords: ACE inhibitors, cough, incidence
Singapore Med J 2014; 55(3): 146-149; http://dx.doi.org/10.11622/smedj.2014034

REFERENCES

Chia P, Lian WB
Correspondence: Dr Lian Wee Bin, wblian@specialkidsclinic.com.sg

ABSTRACT
INTRODUCTION Out-of-hospital cardiopulmonary arrest (CPA) in children is rare but significant, with poor survival rates and high morbidity. Asystole is the most common dysrhythmia, and cardiopulmonary resuscitation (CPR) is of great importance in such cases. We aimed to survey the knowledge, attitudes and perceptions of parents in Singapore regarding infant basic life support (IBLS).
METHODS A questionnaire survey was administered to parents of children managed at the Neonatal Department of Singapore General Hospital, Singapore, between 1 September and 31 December 2008. The questionnaire consisted of three sections – section A collected demographic data, section B included questions on knowledge, and section C explored attitudes and perceptions. Knowledge T-scores were analysed for the entire cohort and subanalysed with respect to prior IBLS training.
RESULTS In our study cohort (n = 375), the median Basic Knowledge (BK) T-score was 7 (range 1–9) and the pass rate was 55%. Median BK T-scores were significantly different between untrained (6; range 3 –9) and previously trained (8; range 3–9) participants. A majority of the trained participants obtained pass marks. Median Total Knowledge T-score, involving advanced questions, for previously trained participants was 11 (range 3–14), but pass rate was low (35.7%). Higher educational qualification was a significant factor impacting all scores. Untrained participants indicated interest in attending IBLS courses, while trained participants were interested in refresher courses.
CONCLUSION IBLS training, as part of basic cardiac life support training, is important given that CPR can significantly alter the outcome in children with CPA. Our survey revealed knowledge gaps that could be bridged through formal training. Refresher courses to regularly update parents’ knowledge are recommended.

Keywords: cardiopulmonary resuscitation, infant basic life support
Singapore Med J 2014; 55(3): 137-145; http://dx.doi.org/10.11622/smedj.2014033

REFERENCES

Soo WF, Tan NC
Correspondence: Dr Soo Wern Fern, soo.wern.fern@singhealth.com.sg

ABSTRACT
INTRODUCTION Asthma is a common childhood disease, and paediatric patients with asthma rely on caregivers to administer domiciliary asthma care. This study aimed to explore the knowledge, understanding, perceptions and main concerns of caregivers and its influence on their home management of children with asthma.
METHODS Data from 14 caregivers of children with asthma was collected during three focus group discussions held in two polyclinics in Singapore. The collected data was analysed using standard content analysis and classified into themes.
RESULTS The caregivers’ main concerns included the perceived effects of infection, food and exercise on children with asthma. Several caregivers considered the disease to be infectious and had a lower threshold for physician consultation, as they believed that any delay in treating the infection would be detrimental to the child’s health. Some also perceived asthma to be episodic and self-limiting, and that their children could ‘outgrow’ it. Many caregivers believed that asthma could be modified by abstinence from, or intake of, certain foods. Others had the perception that sports, including swimming, would worsen asthma. These perceptions resulted in unnecessary restrictions of the children’s diet and activities. Most caregivers were unaware of influenza vaccination as a preventive measure to reduce triggers due to respiratory viral infections.
CONCLUSION We found that the caregivers’ perceptions of asthma aetiology, its triggers and preventive measures affected their help-seeking behaviour and care of children with asthma. Healthcare professionals managing paediatric patients with asthma should recognise such caregiver misperceptions, and take a proactive approach to rectify and bridge the gaps in caregivers’ knowledge and understanding of the disease.

Keywords: asthma, caregiver, knowledge, understanding
Singapore Med J 2014; 55(3): 132-136; http://dx.doi.org/10.11622/smedj.2014032

REFERENCES

Saha R, Saha I, Sarkar AP, Das DK, Misra R, Bhattacharya K, Roy RN, Bhattacharya A
Correpondence: Dr Rajib Saha, dr.rajsaha@gmail.com

ABSTRACT
INTRODUCTION The introduction of highly active antiretroviral therapy (HAART) for the treatment of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) has led to the reduction of mortality and the improvement of the quality of life of people living with HIV/AIDS (PLWHA). The present study was conducted to determine the pattern of adherence to HAART among PLWHA, and to assess the factor(s) affecting nonadherence, if any.
METHODS This study was a hospital-based analytical, cross-sectional epidemiological study conducted between July and October 2011. A total of 370 adult HIV-positive patients registered in the Antiretroviral Therapy Centre of Burdwan Medical College and Hospital, West Bengal, India, were included. Nonadherence was defined as missing at least a single dose of medicine within the last four days. Data was analysed using the Statistical Package for the Social Sciences version 19.0 (IBM Corp, Armonk, NY, USA). 
RESULTS A total of 87.6% of patients were found to be adherent to HAART. Principal causes of nonadherence were forgetting to take medicine (70.2%), being away from home (65.2%), and busyness with other things (64.7%). Multivariate logistic regression analysis revealed that nonadherence was significantly associated with a positive family history of HIV/AIDS (odds ratio [OR] 16; 95% confidence interval [CI] 2.2–114.3; p = 0.01), occurrence of side effects with HAART (OR 9.81; 95% CI 1.9–51.7; p = 0.01) and employment (OR 5.93; 95% CI 1.5–23.2; p = 0.01).
CONCLUSION Although overall adherence was high, the factors that affect nonadherence can be addressed with proper counselling and motivation of patients and their family members. Adherence to HAART could delay the progression of this lethal disease and minimise the risk of developing drug resistance.

Keywords: adherence to HAART, ART Centre, nonadherence to HAART, PLWHA
Singapore Med J 2014; 55(2): 92-98; http://dx.doi.org/10.11622/smedj.2014021

REFERENCES