Original Article

Rasool N, Safdar CA, Ahmad A, Kanwal S
Correspondence: Major Naima Rasool, dr_naima_r@yahoo.com

ABSTRACT
Introduction Enteric duplication (ED) is an anomaly with varied presentations and possible involvement of the alimentary tract. Once diagnosed, resection of the lesion and the involved part of the gut is usually required. The aim of this study was to evaluate the clinical presentations, diagnostic investigations, management and outcomes of patients with ED.
Methods This was a descriptive case study conducted at the Department of Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January 2005 to January 2011. The medical records of all patients diagnosed with ED were retrospectively analysed with respect to age, presentation, investigations, site and type of lesion, surgical procedures, histological findings and complications.
Results A total of nine patients were managed during the study period. The patients’ ages ranged from three months to five years. Four out of nine EDs were rectal duplications. Three EDs were of the cystic type, five were of the tubular type and one was a complex mixed anomaly. Patients presented with varied symptoms, with the two most common being the presence of an abdominal mass and bleeding per rectum. Diagnosis was mainly achieved based on magnetic resonance imaging and computed tomography, although Meckel’s scan provided accurate diagnosis in three of the nine patients. All the cysts were resected without any major complications, and patients were event-free during the five-year follow-up.
Conclusion EDs should be kept in mind when examining patients with an abdominal mass and bleeding per rectum. Meckel’s scan can provide accurate diagnosis of EDs with bleeding. Prompt diagnosis and management results in satisfactory outcomes.

Keywords: gastrointestinal diseases, gastrointestinal haemorrhage
Singapore Med J 2013; 54(6): 343-346; http://dx.doi.org/10.11622/smedj.2013129

REFERENCES

Chan LG, Bharat S, Dani SK
Correspondence: Dr Lai Gwen Chan, lai_gwen_chan@ttsh.com.sg

ABSTRACT
Introduction In Singapore, theft and related crimes constitute more than 50% of all reported crime, and are the most common offences committed by accused persons remanded to the Institute of Mental Health (IMH), Singapore. There is a need for better understanding of the forensic psychiatric aspects of such offenders. This study aimed to determine the prevalence of psychiatric disorders among theft offenders remanded or referred for forensic assessment in 2010, compare the differences between first-time and repeat theft offenders, and identify the factors associated with reoffence. 
Methods Forensic evaluations of inpatient and outpatient theft offenders that were conducted at IMH in the year 2010 were retrieved and reviewed. The sociodemographic and clinical data of first-time and repeat theft offenders were collected and compared using Student’s t-test and chi-square test for continuous and categorical variables, respectively. Multivariate regression was used to identify the factors that were predictive of repeat offence. 
Results Overall, 10% of offenders had no mental illness. Substance use disorders, mood disorders and psychotic disorders were the most common diagnoses. Psychotic disorders were significantly less common in repeat offenders. Repeat offenders also tended to have a history of conduct problems in childhood. Noncompliance with psychiatric treatment was positively associated with repeat offence, while psychotic disorders were negatively associated. 
Conclusion The pattern of psychiatric morbidity among theft offenders in Singapore has changed over the last ten years. Kleptomania remains rare. Significant differences between first-time and repeat offenders have implications on the treatment, follow-up and rehabilitation of theft offenders in Singapore.

Keywords: forensic psychiatry, kleptomania, recidivism, remand, theft
Singapore Med J 2013; 54(6): 339-342; http://dx.doi.org/10.11622/smedj.2013128

REFERENCES

Koh KM, Ng Z, Low SY, Chua HZ, Chou N, Low SW, Yeo TT
Correspondence: Dr Sharon Low Yin Yee, sharon.yy.low@gmail.com

ABSTRACT
Introduction The results of the International Subarachnoid Aneurysm Trial (ISAT) in 2002 have significantly influenced the management of ruptured intracranial aneurysms. There is now an established shift worldwide toward endovascular coiling as the initial treatment of choice. We assessed the outcomes of patients admitted to our institution for aneurysmal subarachnoid haemorrhage (SAH), comparing the outcomes of patients (World Federation of Neurosurgical Societies [WFNS] grades 1–3) who underwent surgical clipping versus those who underwent endovascular coiling.
Methods We retrospectively reviewed patients admitted to the National University Hospital for SAH secondary to ruptured intracranial aneurysm in 2005–2009. Patients were divided into two groups – clipping and coiling. Data on individual demographics, comorbidities, Fisher grading and Glasgow Outcome Scale scores were collected for the two groups and subjected to relevant statistical analyses.
Results Of the 133 patients admitted for nontraumatic SAH, 89 had ruptured aneurysms. Among the 56 patients classified as WFNS grades 1–3, 23 underwent coiling while the remaining 33 underwent clipping. A significant association was found between Fisher grade and the likelihood of developing hydrocephalus in these patients.
Conclusion Although we acknowledge the presence of management bias in our institution, our findings were similar to those of the ISAT trial. Upon correlation between our results and current evidence-based findings, our findings show that clipping provides similar long-term outcomes as endovascular coiling. In the event that an aneurysm is deemed unsuitable for coiling, clipping remains an effective option.

Keywords: endovascular coiling, intracranial aneurysm, subarachnoid haemorrhage, surgical clipping
Singapore Med J 2013; 54(6): 332-338; http://dx.doi.org/10.11622/smedj.2013127

REFERENCES

Chen L, Yu SL, Rajesh H
Correspondence: Dr Lihang Chen, lihang_chen@126.com

ABSTRACT
Introduction This study aims to evaluate whether an increased polymorphonuclear leucocyte (PMN) count in semen is a good predictor of male genital tract infection, which is detected by semen culture.
Methods A retrospective cross-sectional study examining the semen of 388 men was conducted at the in vitro fertilisation centre of a tertiary hospital. We compared the culture results of 109 men with increased semen PMN count against those of 279 men with normal semen PMN count.
Results There was no significant difference in the percentage of positive cultures between men with increased PMN count in their semen and those without PMN count elevation (original sensitivity 20.8%, specificity 70.3%; p = 0.1289). The overall percentage of positive semen cultures among all 388 patients was 18.6%.
Conclusion Based on the positive cultures of significant organisms in the semen of our cohort, an increased semen PMN count is not a good predictor of genital tract infection in men.

Keywords: bacteriospermia, infertility, male genital tract infection, polymorphonuclear leucocytes, sperm analysis
Singapore Med J 2013; 54(6): 328-331; http://dx.doi.org/10.11622/smedj.2013126

REFERENCES

Candemir M, Semiz S, Yonguc GN, Ozdemir MB, Abban-Mete G, Adiguzel E
Correspondence: Dr Esat Adiguzel, esatadiguzel@yahoo.com

ABSTRACT
Introduction The hippocampus is an important region of the brain that regulates cognitive and emotional functions. In this study, we examined the impact of perinatal administration of testosterone propionate (TP) on the number of pyramidal neurons in the CA1 and CA3 regions of the hippocampi of female rats.
Methods Five groups of rats were used in this study. Three groups of female rats were administered TP in either both the prenatal and the postnatal periods (Group 1), only the prenatal period (Group 2) or only the postnatal period (Group 3). The other two groups of rats included control females (Group 4) and control males (Group 5). The rats were sacrificed on postnatal Day 120 and their brains were analysed for hippocampal pyramidal neuron number using stereological methods.
Results Control male rats (Group 5; p = 0.043) and TP-treated female rats in Groups 1 (p = 0.012) and 2 (p = 0.037), but not Group 3 (p > 0.05), had a significantly higher number of pyramidal neurons than control female rats (Group 4). The rats in Group 1 had the highest number of pyramidal neurons among the female rats.
Conclusion Perinatal TP treatment has an augmenting effect on the number of pyramidal neurons in the hippocampi of female rats. We also found gender-based differences in the hippocampi of male and female rats, with a higher number of pyramidal neurons seen in male rats. Continuous TP administration during the prenatal and postnatal periods is more effective than administration only in the prenatal or postnatal period.

Keywords: androgens, female, perinatal, rat, stereology
Singapore Med J 2013; 54(6): 315-320; http://dx.doi.org/10.11622/smedj.2013124

REFERENCES

Pakpour AH
Correspondence: Dr Amir H Pakpour, Pakpour_Amir@yahoo.com

ABSTRACT
Introduction The objective of this study was to assess the feasibility, reliability and validity of the Iranian version of the Pediatric Quality of Life Inventory™ 4.0 Short Form 15 Generic Core Scales (PedsQL™ 4.0 SF15) in a sample of Iranian schoolchildren and children with chronic health conditions.
Methods A total of 1236 schoolchildren and 1183 parents of schoolchildren participated, and 52 children with chronic health conditions and their parents were recruited from an outpatient clinic. Feasibility, internal consistency reliability, test-retest reliability, known-groups discriminant validity and construct validity of the PedsQL™ 4.0 SF15 were determined.
Results The Iranian version of PedsQL™ 4.0 SF15 evidenced minimal missing responses for child self-report and parent proxy-report (0.4% and 0.6%, respectively), generally demonstrated no significant floor or ceiling effects, and achieved acceptable internal consistency reliability for the Total Scale Score (α = 0.82 child self-report, 0.84 parent proxy-report) and acceptable test-retest reliability. Schoolchildren and their parents reported significantly higher PedsQL™ 4.0 SF15 scores than paediatric patients with chronic health conditions. Child self-report and parent proxy-report showed poor to good agreement. A four-factor model was confirmed among child self-report and parent proxy-report in the confirmatory factor analyses.
Conclusion This study supports the feasibility, reliability and validity of the Iranian version of the PedsQL™ 4.0 SF15 among Iranian children and their parents.

Keywords: children, health-related quality of life, Iran, PedsQL™, short form
Singapore Med J 2013; 54(6): 309-314; http://dx.doi.org/10.11622/smedj.2013123

REFERENCES

Liu SY, Yang CP, Wei TS, Chen YC, Liang CH, Wu CH, Chen CL, Wu JJ
Correspondence: Dr Tsung-Ju Wu, liusenyong111@yeah.net

ABSTRACT
Introduction The exposed section of a traditional nasogastric (NG) tube can interfere with patients’ social activities and thereby result in distress. This study was conducted to evaluate the feasibility and safety of a novel two-piece NG tube for patients with dysphagia.
Methods Ten patients with dysphagia were recruited between November 2011 and May 2012. Patients who were unconscious or in critical condition, had a traditional NG tube < 50 cm or > 60 cm in fixed length, or were unable to follow instructions or sign consent forms were excluded. The two-piece NG tube, which was placed in the patients for one week, comprised a removable external tube that can be joined to an internal tube via a T-connector, which was placed close to the naris. Events related to safety (e.g. nasal pressure sores, number of unplanned extubation, displacement and spontaneous migration of the NG tube, other unpredictable injuries) and effectiveness (e.g. liquid food spills, tube obstruction, perfusion rate, other adverse circumstances) were assessed daily.
Results All patients received feeding without complication using the two-piece NG tube and none experienced premature removal of the tube. No serious NG tube complications or malfunctions were observed.
Conclusion The results of this study indicate that the two-piece NG feeding tube is a feasible option for patients with dysphagia. Future improvements to the connector may help enhance its performance. A rigorous randomised controlled trial to examine the effects of the two-piece NG tube on patients’ quality of life and quality of medical care is being planned.

Keywords: dysphagia, feeding tube, nasogastric, quality of life, rehabilitation
Singapore Med J 2013; 54: 227-230; http://dx.doi.org/10.11622/smedj.2013079

REFERENCES

Chu HP, Logarajah V, Tan N, Phua KB
Correspondence: Dr Chu Hui Ping, chu_huiping@rafflesmedical.com

ABSTRACT
Introduction This study examined the characteristics and trends in the incidence of inflammatory bowel disease (IBD) among children in Singapore.
Methods We retrospectively reviewed all patients under 18 years diagnosed with IBD over a 14-year period. Information on demographics, disease presentation, laboratory findings, radiological investigations, and endoscopic and histological findings were obtained from the patients’ medical records.
Results 32 patients were diagnosed with IBD, 30 of whom had Crohn’s disease and 2 had ulcerative colitis. The incidence of IBD rose from an initial rate of 2.2 per 100,000 patients in the year 2000 to a peak of 11.4 patients per 100,000 patients by 2008. Median age of onset of symptoms was 10.5 years. There were more boys (63%) than girls in the group and a higher representation of Indians (34.4%). The most common presenting symptoms were abdominal pain (87.5%), diarrhoea (75.0%) and weight loss (71.9%). Extraintestinal manifestations such as fever and arthralgia were found in over 50% of patients. The most common physical findings were perianal abnormalities (56.3%), mouth ulcers (37.5%) and growth failure (15.6%). Abnormal laboratory findings such as low albumin, raised erythrocyte sedimentation rate, anaemia, thrombocytosis and high C-reactive protein were found in nearly half of the patients. Endoscopic and histological findings showed that a majority of patients (90.6%) also had evidence of inflammation in the upper gastrointestinal tract.
Conclusion Paediatric IBD is on the rise. The higher occurrence in Indians, earlier onset and more florid presentation may suggest different genetic and environmental influences specific to Asian children.

Keywords: Asian races, Crohn’s disease, paediatric IBD, ulcerative colitis
Singapore Med J 2013; 54: 201-205; http://dx.doi.org/10.11622/smedj.2013073

REFERENCES

Hsu KY, Lin JR, Lin MS, Chen W, Chen YJ, Yan YH
Correspondence: Dr Jr-Rung Lin, jr@mail.cgu.edu.tw

ABSTRACT
Introduction Health-related quality of life (HRQoL) is an important patient-centred outcome in chronic obstructive pulmonary disease (COPD). The aim of the current study is to compare the discriminative capacity of the modified Medical Research Council (mMRC) dyspnoea scale and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric classification of COPD on HRQoL, as well as determine other factors that are simple and determinative of HRQoL.
Methods In this cross-sectional observational study, a total of 328 patients with COPD were enrolled from the pulmonology outpatient clinic. HRQoL was measured using the St George’s Respiratory Questionnaire (SGRQ) and the World Health Organization Quality of Life-BREF (WHOQOL-BREF). HRQoL scores were compared between the four GOLD stages and the five grades of the mMRC scale. Significant differences were determined using analysis of variance with Scheffe post-hoc test. Multiple linear regression was applied to explore the major determinants of HRQoL and exclude confounding factors.
Results Signi?cant differences were found in many more domains of the two questionnaires between mMRC grades than between GOLD stages. In the multiple linear regression model, the mMRC scale was the only factor that remained determinative of all the domains of SGRQ and WHOQOL-BREF. Patients with chronic productive cough, sleep disorders and frequent exacerbations had poorer HRQoL, as reflected by higher scores in SGRQ or lower scores in WHOQOL-BREF.
Conclusion The mMRC dyspnoea scale is a concise and practical tool to assess the HRQoL of patients with COPD in daily clinical practice.

REFERENCES

Cheang HK, Wong HT, Ho SC, Chew KS, Lee WS
Prof Way Seah Lee, leews@um.edu.my

ABSTRACT
Introduction This study aimed to assess the immune response in infants who received the three-shot hepatitis B vaccine in Malaysia.
Methods Consecutive infants born between March 2002 and April 2010 who received three doses of hepatitis B vaccine at a community clinic in Malaysia were enrolled in the study. Screening for hepatitis B surface antigen (HBsAg) and antibody against HBsAg (anti-HBs) was performed after the completion of primary immunisation, at approximately one year of age.
Results A total of 572 infants (median age 9.3 ± 2.7 months; range 6.3–48 months) were screened for immune response to hepatitis B vaccination – 553 (96.7%) infants had adequate levels of anti-HBs (≥ 10 IU/L). Of the 440 mothers whose HBsAg status was known, 14 (3.2%) were positive for HBsAg. None of the 14 infants who were born to HBsAg-positive mothers were positive for HBsAg, and all but one infant had anti-HBs level ≥ 10 IU/L. Gender, gestational age and maternal HBsAg status were not found to significantly affect the subsequent immune response in infants following vaccination.
Conclusion The proportion of Malaysian mothers who are positive for HBsAg remains high. The three-shot hepatitis B vaccine, given as part of universal vaccination against hepatitis B, provides adequate anti-HBs in the vast majority of infants in a community setting in Malaysia.