Original Article

Peirovifar A, Gharehbaghi MM, Gharabaghi PM, Sadeghi K
Correspondence: Dr Manizheh Mostafa Gharehbaghi, gharehbaghimm@yahoo.com

ABSTRACT
INTRODUCTION Retinopathy of prematurity (ROP) can lead to severe visual impairment. This study was conducted to determine the levels of biochemical mediators (i. e. vascular endothelial growth f actor [VEGF] and insulin- like growth factor-1 [IGF-1]) in the blood of premature infants with proliferative ROP.
METHODS Blood samples from 71 preterm infants born at or before 32 weeks of gestation were obtained 6–8 weeks after birth. These infants were classified into two groups according to their eye examination results. The control group consisted of 41 infants who had no evidence of ROP, and the study group consisted of 30 infants with  proliferative  ROP  at  stage  III  or  higher.  Blood  VEGF  and  IGF-1  levels  were  measured  using  enzyme-linked immunosorbent assay. 
RESULTS The mean gestational ages of the infants at birth were 28.4 ± 1.6 and 28.8 ± 1.6 weeks in the study and control groups, respectively (p = 0.259). The mean postmenstrual age of the infants at the time of blood sampling was 34.9 ± 1.2 weeks in the study group and 34.6 ± 1.3 weeks in the control group (p = 0.339). The mean blood IGF-1  (18.48 ± 11.79 µg/L and 16.75 ± 13.74 µg/L in the study and control groups, respectively; p = 0.580) and VEGF (267.35 ± 103.43 pg/mL and 237.52 ± 130.92 pg/mL in the study and control groups, respectively; p = 0.305) levels of the infants were not significantly different between the two groups.
CONCLUSION At 6–8 weeks after birth, blood IGF-1 and VEGF levels were not found to be significantly different between premature infants with proliferative ROP and those without. 

Keywords: insulin-like growth factor, retinopathy of prematurity, vascular endothelial growth factor
Singapore Med J2013; 54(12): 709-712; http://dx.doi.org/10.11622/smedj.2013246

REFERENCES

Shariff AH, Ashril Y, Razif MA
Correspondence: Dr Mohamad Shariff A Hamid, ayip@um.edu.my

ABSTRACT
INTRODUCTION The purpose of this study was to investigate the pattern of muscle injuries and the factors that predict the return-to-play duration among Malaysian athletes.
METHODS This is a retrospective review of the case notes of athletes who attended the National Sports Institute Clinic in Malaysia. The medical records of athletes with muscle injury, diagnosed on clinical assessment and confirmed by diagnostic ultrasonography, were included for final analysis.
RESULTS From June 2006 to December 2009, 397 cases of muscle injury were diagnosed among 360 athletes. The  median  age  of  the  athletes  with  muscle  injuries  was  20.0  years.  Muscle  injuries  were  mostly  diagnosed  among national-level athletes and frequently involved the lower limb, specifically the hamstring muscle group. Nearly all of the athletes (99.2%) were treated conservatively. The median return-to-play duration was 7.4 weeks. Athletes who waited more than one week before seeking medical attention, those with recurrent muscle injuries and female athletes were significantly more likely (p < 0.05) to take more than six weeks before returning to the sport.
CONCLUSION Grade 2 lower limb muscle injury was commonly diagnosed among national-level athletes in this study. The frequency of weekly physiotherapy sessions did not affect the return-to-play duration. Factors such as initial consultation at more than one week post injury, recurrent muscle injuries and female gender were significant predictors of return-to-play duration among Malaysian athletes. These predictive factors should be kept in mind during clinical assessment so as to aid in prognosticating recovery after muscle injury.

Keywords: athletes, Malaysia, muscle injury, musculoskeletal, return to play
Singapore Med J 2013; 54(10): 587-591; http://dx.doi.org/10.11622/smedj.2013204

REFERENCES

Sloan RA, Haaland BA, Leung C, Padmanabhan U, Koh HC, Zee A
Correspondence: Dr Robert Alan Sloan, Robert_Alan_Sloan@HPB.gov.sg

ABSTRACT
INTRODUCTION Cardiorespiratory fitness (CRF) is an independent predictor of voluminous health outcomes and can be measured using non-exercise fitness assessment (NEFA) equations. However, the accuracy of such equations in Asian populations is unknown. The objective of this study was to cross-validate the NEFA equation, developed by Jurca et al in 2005, in the adult Singaporean population.
METHODS A total of 100 participants (57 men, 43 women; aged 18–65 years) were recruited, and their maximal oxygen consumption (VO₂ max) was measured in the laboratory by indirect calorimetry. The participants also completed the NEFA questionnaire, which helps to predict VO2 max with the NEFA equation. The relationship between NEFA-predicted and laboratory-measured VO₂ max values was analysed.
RESULTS Overall, our study demonstrated a high correlation between the NEFA-predicted and laboratory-measured VO₂ max values (r = 0.83). The Pearson’s correlation coefficient values for the men and women in the study were 0.61 and 0.77, respectively. To improve the accuracy of the predictive equation, we transformed the original equation developed by Jurca et al into new equations that would allow estimation of VO₂ max with and without resting heart rate as a variable.
CONCLUSION The modified NEFA equations accurately estimated CRF and may be applied to the majority of adult Singaporeans. With this, health practitioners and researchers are now able to assess CRF levels at both the individual and population levels in either the primary care, fitness or research setting.

Keywords: Asian population, cardiorespiratory fitness, non-exercise fitness assessment
Singapore Med J 2013; 54(10): 576-580; http://dx.doi.org/10.11622/smedj.2013186

REFERENCES

Yang SY, Kong KH
Correspondence: Dr Keng He Kong,keng_he_kong@ttsh.com.sg

ABSTRACT
INTRODUCTION The level of participation is an important factor influencing rehabilitation outcome. However, few studies have evaluated rehabilitation participation and its clinical predictors in patients with stroke. This study aimed to establish the level of participation in patients with stroke undergoing inpatient rehabilitation, and define the clinical predictors for participation.
METHODS This was a prospective observational study of first-time patients with stroke admitted to a rehabilitation centre over a 12-month period. The primary outcome measure was the level of rehabilitation participation as measured on the Pittsburgh Rehabilitation Participation Scale (PRPS). PRPS measurements were made one week after admission and one week before planned discharge from inpatient rehabilitation. Other outcome measures evaluated were the National Institute of Health Stroke Scale, Functional Independence Measure (FIM), Elderly Cognitive Assessment Questionnaire (ECAQ), Centre for Epidemiologic Studies-Depression Scale, Fatigue Severity Scale (FSS), Lubben Social Network Scale-Revised, and Multidimensional Health Questionnaire.
RESULTS A total of 122 patients with stroke were studied. The mean PRPS score on admission was relatively high at 4.30 ± 0.90, and this improved to 4.65 ± 0.79 before planned discharge (p < 0.001). On multivariate analysis, the mean PRPS score on admission was predicted by FIM, EACQ and FSS scores on admission, but not by variables such as age, gender, depression, social support, or health attitudes and beliefs.
CONCLUSION Patients with lower levels of participation were more likely to be functionally dependent, cognitively impaired and have more fatigue. We suggest that in addition to cognition, fatigue should be routinely screened in patients with stroke undergoing rehabilitation.

Keywords: patient participation, rehabilitation, stroke
Singapore Med J 2013; 54(10): 564-568; http://dx.doi.org/10.11622/smedj.2013201

REFERENCES

Hossain MG, Saw A, Alam R, Ohtsuki F, Kamarul T
Correspondence: Dr Saw Aik, sawaik@hotmail.com

ABSTRACT
INTRODUCTION Cephalic index (CI), the ratio of head breadth to head length, is widely used to categorise human populations. The aim of this study was to access the impact of anthropometric measurements on the CI of male Japanese university students. 
METHODS This study included 1,215 male university students from Tokyo and Kyoto, selected using convenient sampling. Multiple regression analysis was used to determine the effect of anthropometric measurements on CI. 
RESULTS The variance inflation factor (VIF) showed no evidence of a multicollinearity problem among independent variables. The coefficients of the regression line demonstrated a significant positive relationship between CI and minimum frontal breadth (p < 0.01), bizygomatic breadth (p < 0.01) and head height (p < 0.05), and a negative relationship between CI and morphological facial height (p < 0.01) and head circumference (p < 0.01). Moreover, the coefficient and odds ratio of logistic regression analysis showed a greater likelihood for minimum frontal breadth (p < 0.01) and bizygomatic breadth (p < 0.01) to predict round-headedness, and morphological facial height (p < 0.05) and head circumference (p < 0.01) to predict long-headedness. Stepwise regression analysis revealed bizygomatic breadth, head circumference, minimum frontal breadth, head height and morphological facial height to be the best predictor craniofacial measurements with respect to CI.
CONCLUSION The results suggest that most of the variables considered in this study appear to influence the CI of adult male Japanese students.

Keywords: anthropometric measurements, cephalic index, logistic regression, multiple regression, university students
Singapore Med J 2013; 54(9): 516-520; http://dx.doi.org/10.11622/smedj.2013175

REFERENCES

George JM, Menon M, Gupta P, Tan M
Correspondence: Dr Michelle Tan, michelle.tan.g.e@sgh.com.sg

ABSTRACT
INTRODUCTION The use of opioids in chronic non-cancer pain (CNCP) is controversial, as it presents both benefits and risks. There is currently no available data on the incidence, prescription pattern, functional outcomes and adverse effects of opioids in patients with CNCP in Singapore. This study aimed to address the aforementioned deficit.
METHODS All records of patients who were prescribed strong opioids (for > 3 months per year) for the management of CNCP over a two-year period were retrospectively analysed. Factors including type of opioid, indications for opioid prescription, uncontrolled side effects, functional status, coexisting psychological issues and suspicion of aberrant drug-seeking behaviour were studied.
RESULTS Out of the 1,389 new patients who visited the centre, 42 (3.0%) with CNCP received strong opioids for more than three months a year. The most commonly prescribed opioid was methadone (42.9%). The principal diagnosis for opioid prescription was spinal pain (38.1%). Ten patients had severe side effects. 15 patients saw improvement in activities of daily living scores. Although ten patients returned to work, one stopped following the commencement of opioids. Aberrancy was seen in 5 (11.9%) patients, while 19 (45.2%) had psychological issues and 10 (23.8%) required psychiatric co-management.
CONCLUSION Opioids are not a panacea for chronic pain. Therefore, functional outcomes should be considered more important end points than mere reductions in pain scores. A multidisciplinary team approach is essential for the effective management of patients with CNCP who are on opioids.

Keywords: Asia, chronic pain, non-cancer pain, opioids, Singapore 
Singapore Med J 2013; 54(9): 506-510; http://dx.doi.org/10.11622/smedj.2013173

REFERENCES

Leung GK, Ang SB, Lau TC, Neo HJ, Patil NG, Ti LK
Correspondence: Dr Gilberto KK Leung, gilberto@hkucc.hku.hk

ABSTRACT
INTRODUCTION Undergraduate education in medical schools plays an important role in promoting patient safety. Medical students from different backgrounds may have different perceptions and attitudes toward issues concerning safety. This study aimed to investigate whether patient safety cultures differed between students from two Asian countries, and if they did, to find out how they differed. This study also aimed to identify the educational needs of these students.
METHODS A voluntary, cross-sectional and self-administered questionnaire survey was conducted on 259 students from two medical schools – one in Hong Kong and the other in Singapore. None of the students had received any formal teaching on patient safety. We used a validated survey instrument, the Attitudes to Patient Safety Questionnaire III (APSQ-III), which was designed specifically for students and covered nine key factors of patient safety culture.
RESULTS Of the 259 students, 81 (31.3%) were from Hong Kong and 178 (68.7%) were from Singapore. The overall response rate was 66.4%. Significant differences between the two groups of students were found for two key factors – ‘patient safety training’, with Hong Kong students being more likely to report having received more of such training (p = 0.007); and ‘error reporting confidence’, which Singapore students reported having less of (p < 0.001). Both groups considered medical errors as inevitable, and that long working hours and professional incompetence were important causes of medical errors. The importance of patient involvement and team functioning were ranked relatively lower by the students.
CONCLUSION Students from different countries with no prior teaching on patient safety may differ in their baseline patient safety cultures and educational needs. Our findings serve as a reference for future longitudinal studies on the effects of different teaching and healthcare development programmes.

Keywords: curriculum, medical error, medical student, patient safety, survey
Singapore Med J 2013; 54(9): 501-505; http://dx.doi.org/10.11622/smedj.2013172

REFERENCES

Seng M, Lim JW, Sng J, Kong WY, Koh D
Correspondence: Dr Seng Yi Feng Melvin, melvin_yf_seng@nuhs.edu.sg

ABSTRACT
INTRODUCTION Structured training for the prevention of needlestick injuries (NSIs) among medical students was implemented in Singapore in 1998. In this study, we determined the incidence of NSIs and the knowledge and practice of managing and reporting NSIs among first-year clinical students in a medical school in Singapore, as well as the adequacy of the training provided for these students, 14 years after preventive training was instituted.
METHODS All third-year medical students (n = 257) from the Yong Loo Lin School of Medicine, National University of Singapore, Singapore, who had completed their first clinical year posting were enrolled in this cross-sectional study. A self-administered questionnaire was answered by the students one month after completion of their last clinical posting. Students who repeated their first clinical year were excluded from the study. 
RESULTS 237 students completed the questionnaire. However, 9 of these students were excluded because they repeated their first clinical year. The response rate was 91.9%. Although 8 (3.5%) students reported one NSI each, only 2 (25.0%) of these 8 students reported the incident to the relevant authority. Among the students surveyed, 65.8% reported using gloves at all times during venepuncture procedures, 48.7% felt that improvements could be made to the current reporting system and procedures, and 53.2% felt that the training provided before commencement of clinical posting could be enhanced.
CONCLUSION There was a decrease in the incidence of NSIs among medical undergraduates in their first clinical year when compared to the incidences reported in earlier studies conducted in the same centre (35.1% in 1993 and 5.3% in 2004). The current reporting system could use a more user-friendly platform, and training on NSIs could be improved to focus more on real-life procedures and incident reporting.

Keywords: incident reporting, medical students, needlestick injuries
Singapore Med J 2013; 54(9): 496-500; http://dx.doi.org/10.11622/smedj.2013171

REFERENCES

Ng ZM, Seet MJ, Erng MN, Buendia F, Chang A, Sriram B
Correspondence: Dr Ng Zhi Min, ng.zhi.min@kkh.com.sg

ABSTRACT
INTRODUCTION We aimed to study the profile of nonimmune hydrops fetalis (NIHF) in the local population and identify its outcomes and causes. 
METHODS We carried out a retrospective review of the medical records in KK Women’s and Children’s hospital, a single tertiary referral centre, for pregnancies with an antenatal diagnosis of NIHF in the six-year period from 1 January 2005 to 31 December 2010.
RESULTS A total of 29 cases of NIHF were identified; 19 (66%) cases underwent karyotype evaluation, 17 (59%) underwent intrauterine infection screening, and all underwent antenatal thalassaemia screening. The median gestational age at diagnosis was 27 (range 12–37) weeks, median gestational age at birth was 33 (range 27–37) weeks, and median birth weight of live births was 2,480 (range 1,230–3,900) g. The aetiologies for NIHF were identified in 20 (69%) cases, which included cardiac anomalies (n = 5), haematological problems (n = 4), congenital tumours (n = 4), genetic/metabolic disorders (n = 4) and cystic hygromas (n = 3). The cause of NIHF was not identified in the remaining 9 (31%) cases. There were 19 live births – 8 (42%) survived and 11 (58%) died in the neonatal period – and one stillbirth. Nine women opted for medical termination of pregnancy following the diagnosis of NIHF.
CONCLUSION It is important to thoroughly investigate all cases of NIHF and identify its causes in order to provide appropriate antenatal and postnatal counselling. In our series, almost one-third of NIHF cases had no identified aetiology. The neonatal mortality rate was approximately 58%.

Keywords: aetiology, nonimmune hydrops fetalis, outcome
Singapore Med J 2013; 54(9): 487-490; http://dx.doi.org/10.11622/smedj.2013169

REFERENCES

Luo GC, Foo KT, Kuo T, Tan G
Correspondence: Prof Keong Tatt Foo, foo.keong.tatt@sgh.com.sg

ABSTRACT
INTRODUCTION The objective of this study was to evaluate the accuracy of using intravesical prostatic protrusion (IPP) as a parameter for the diagnosis of prostate adenoma (PA), as well as to determine the relationship between the site of PA and bladder outlet obstruction. IPP was determined with the use of transabdominal ultrasonography (TAUS).
METHODS A total of 77 consecutive adult men aged 30–85 years with haematuria or undergoing checkup for bladder tumour were enrolled. International Prostate Symptom Score (IPSS), and the results of uroflowmetry, TAUS and cystourethroscopy were assessed. All cases of IPP were classified into grades 0 (no IPP), 1 (1–5 mm), 2 (6–10 mm) or 3 (> 10 mm). PA diagnosis was confirmed using flexible cystourethroscopy. The sites of PA were classified as U0 (no adenoma), U1 (lateral lobes), U2 (middle lobe) or U3 (lateral and middle lobes).
RESULTS Of the 77 patients, 11 (14.3%) had no IPP. PA was confirmed using cystourethroscopy for all patients with IPP and for 7 of the 11 patients without IPP. Of the 37 patients with prostate volume < 20 g, 29 (78.4%) had IPP. Sensitivity, specificity, as well as positive and negative predictive values for diagnosing PA using only IPP were 90.4%, 100.0%, 100.0% and 36.4%, respectively. Higher sensitivity (95.9%) and negative predictive value (50.0%) were obtained when PA was used together with peak urinary flow rate (Qmax) < 20.0 mL/s. The mean Qmax of patients classified as U1 (n = 39) was 16.0 mL/s, while the mean Qmax in those classified as U2 (n = 12) and U3 (n = 22) was 11.9 mL/s and 8.9 mL/s, respectively. 
CONCLUSION All patients with IPP had PA, and PA in the middle lobe was more obstructive than those in lateral lobes. Patients without IPP may still have PA.

Keywords: benign prostate hyperplasia, intravesical prostatic protrusion, prostate adenoma, transabdominal ultrasonography
Singapore Med J 2013; 54(9): 482-486; http://dx.doi.org/10.11622/smedj.2013168

REFERENCES