Original Article

Aljohari A, Althani H, Elmabrok G, Hajaji K, Taha I
Correspondence: Dr Hisham Aljohary, dr.johary@hotmail.com

ABSTRACT

REFERENCES

Pruksakorn D, Tirankgura P, Luevitoonvechkij S, Chamnongkich S, Sugandhavesa N, Leerapun T, Pothacharoen P
Correspondence: Dr Dumnoensun Pruksakorn, dumnoensun@hotmail.com

ABSTRACT
INTRODUCTION To prevent long-term unfavourable consequences to the articular cartilage of weight-bearing joints, serum biomarkers can be used to identify optimum loading of activities. This study aimed to investigate the circulation pattern of serum cartilage biomarkers in healthy adults in response to an uphill walk.
METHODS This study recruited 58 healthy participants for the experimental group and 24 matched participants for the control group. Participants in the experimental group walked continuously for 14 km on a pathway with a 5.97° incline, while participants from the control group walked on a horizontal pathway. Serum was collected from both groups preactivity (i.e. T1), immediately after activity (i.e. T2) and 24 hours after T1 (i.e. T3). The serum cartilage oligomeric matrix protein (COMP), chondroitin sulfate-WF6 (WF6) and hyaluronic acid (HA) levels at each time point were quantified using enzyme-linked immunosorbent assays, and the results analysed. 
RESULTS Both groups shared similar demographic characteristics and activity duration. At T2, the serum COMP level of the experimental group was significantly higher than that of the control group, but the serum HA level of the experimental group was significantly lower than that of the control group. No significant difference between the serum WF6 levels of the experimental and control groups was observed at T2.
CONCLUSION Increasing levels of serum COMP demonstrate articular cartilage susceptibility to the increasing load. An unsustainable, high serum COMP level and an undetectable change in WF6 level were considered to be a reversible physiological change of the car tilage. A change in ser um HA level could be related to intensive physical activity and dynamic clearance rather than a change in cartilage structure.

Keywords: biomarkers, cartilage, COMP, exercise, uphill walk
Singapore Med J 2013; 54(12): 702-708; http://dx.doi.org/10.11622/smedj.2013245

REFERENCES 

Nik Farid ND, Che’ Rus S, Dahlui M, Al-Sadat N
Correspondence: Dr Nik Daliana Nik Farid, daliana@ummc.edu.my

ABSTRACT
INTRODUCTION This study aimed to investigate the determinants of sexual intercourse initiation among incarcerated adolescents aged 12–19 years in Malaysia.
METHODS This was a sequential mixed-method research project that was conducted in two phases. Quantitative and qualitative methods were used in the first and second phases, respectively. Data was collected via a survey using self-reported questionnaires from 1,082 adolescents, and from in-depth interviews and the written essays of 29 participants. The participants were recruited from 22 welfare institutions in peninsular Malaysia. 
RESULTS Among the study participants, 483 were male and 599 were female. Overall, 62.3% of the incarcerated adolescents had initiated sexual intercourse at least once. The mean age at first sexual intercourse for both genders was 14.0 years. Individual factors found to be associated with previous sexual intercourse were the female gender (odds  ratio  [OR]  1.75;  95%  confidence  interval  [CI]  1.11–2.74),  previous  alcohol  use  (OR  1.80;  95%  CI  1.10–2.94), previous illicit drug use (OR 1.85; 95% CI 1.07–3.22), permissive attitude toward premarital sex (OR 4.34; 95% CI 2.17–8.70), and sexual abuse during childhood (OR 5.41; 95% CI 3.52–8.32). Qualitative findings revealed that the reasons for initiation of sexual intercourse among these adolescents were partner influence, inability to control sex drive, family issues, and the perception of sex as an expression of love.
CONCLUSION The determinants of sexual intercourse initiation among incarcerated Malaysian adolescents are comparable to those of developed countries. However, in Malaysia, sexual and reproductive health programmes for such adolescents should be tailored to address their specific needs.

Keywords: incarcerated adolescents, sexual intercourse initiation, welfare institutions
Singapore Med J2013; 54(12): 695-701; http://dx.doi.org/10.11622/smedj.2013244

REFERENCES

Wang HB, Yang CX, Zhang B, Xia Y, Liu HZ, Liang H
Correspondence: Dr Hua Liang, lhlh2003@126.com

ABSTRACT
INTRODUCTION Sedation or anaesthesia is recommended for all patients undergoing bronchoscopy unless absolute contraindications exist. However, the widely used combination of propofol and opiates for moderate sedation (MS) in bronchoscopy results in a high incidence of hypoxaemia and a relatively high cough score during the procedure. In this study, we evaluated the efficacy and safety of target-controlled infusion (TCI) of propofol and remifentanil, together with the use of high frequency jet ventilation (HFJV), to achieve general anesthesia (GA) in diagnostic fibre-optic bronchoscopy.
METHODS A total of 92 consecutive patients scheduled for flexible bronchoscopy were randomly assigned to receive either MS using TCI-delivered propofol and remifentanil (n = 46), or GA using TCI-delivered propofol and remifentanil with HFJV (n = 46). The following were compared between the MS and GA groups: incidence of hypoxaemia, cough score, haemodynamic parameters, partial pressure of carbon dioxide in arterial blood, duration of bronchoscopy and patient satisfaction score. 
RESULTS The average and minimum oxygen saturation values in the MS group were lower than those in the GA group. The MS group showed a higher incidence of hypoxaemia. There was no significant difference in the partial pressure of carbon dioxide between the two groups. Cough score and duration of the bronchoscopy were markedly lower in the GA group, and patient satisfaction score was higher in the GA group.
CONCLUSION GA, achieved via TCI-delivered propofol and remifentanil with HFJV, provides better conditions for diagnostic bronchoscopy – it decreases the occurrence of hypoxaemia, shortens the duration of bronchoscopy and increases patient satisfaction.

Keywords: bronchoscopy, target-controlled infusion, ventilation
Singapore Med J 2013; 54(12): 689-694; http://dx.doi.org/10.11622/smedj.2013243

REFERENCES

Lim YK, Chia YN, Yam KL
Correspondence: Dr Lim Yong Kuei Timothy, yongkuei@hotmail.com

ABSTRACT
INTRODUCTION For many decades, Wertheim’s radical hysterectomy via laparotomy, also known as Wertheim’s radical abdominal hysterectomy (RAH), has been the traditional surgical approach for operable stage IB cervical cancer. However, many established cancer centres worldwide have recently shown total laparoscopic Wertheim’s radical hysterectomy (TLRH) to be a safe and feasible alternative to the conventional abdominal route for early cervical cancer management. This technique was introduced in Singapore in 2009.
METHODS This was a prospective pilot study comparing TLRH with RAH in a single large tertiary institution in Singapore. Inclusion criteria included surgically fit patients with early cervical cancer and no radiological evidence of regional or distant metastases. 
RESULTS From November 2009 to February 2011, a total of 18 TLRHs and 30 RAHs were performed. The median blood loss in the TLRH group was significantly lower than that in the RAH group (300 mL vs. 500 mL; p = 0.04). However, there was no statistically significant difference found between the two techniques in terms of operative time, hospital stay, bladder recovery, total lymph node yield or adjuvant treatment. No intraoperative bladder, ureteric or bowel complications were observed in the two groups. Postoperative complications occurred in 2 (11.1%) TLRH patients and 4 (13.3%) RAH patients. With a median follow-up of 37.3 (range 10–68) weeks, the rate of recurrence was found to be 5.6% for the TLRH group and 10.0% for the RAH group.
CONCLUSION The results of our study suggest that with appropriate patient selection and increased experience, TLRH can be a safe and effective procedure for the management of early cervical cancer in Singapore.

Keywords: cervical cancer, laparoscopic radical hysterectomy
Singapore Med J 2013; 54(12): 683-688; http://dx.doi.org/10.11622/smedj.2013242

REFERENCES

Nathan AM, Tang JP, Goh AE, Teoh OH, Chay OM
Correspondence: Dr Jenny Tang PL, jenny.tang.pl@gmail.com

ABSTRACT
INTRODUCTION This study aimed to determine compliance with noninvasive home ventilation in children with obstructive sleep apnoea and the factors affecting this compliance.
METHODS We retrospectively reviewed 51 children who were prescribed noninvasive home ventilation for the management of obstructive sleep apnoea from 1 January 2000 until 31 May 2008. Noninvasive ventilation was started based on positive polysomnogram, i.e. obstructive apnoea hypopnea index ≥ 1/hr. Compliance was defined as the use of noninvasive ventilation ≥ 4 days/week.
RESULTS Noninvasive home ventilation was started at a median age of 11.5 years. In all, 21 (41.2 %) children were reported to be compliant with treatment. Univariate analysis revealed that the female gender (p = 0.017), presence of  asthma (p = 0.023), presence of genetic syndromes (p = 0.023), use of bi-level ventilation versus continuous positive airway pressure (p = 0.027), and funding from the social work department (p = 0.049) were associated with compliance with noninvasive home ventilation. Logistic regression revealed the presence of asthma (p = 0.008) and female gender (p = 0.047) to be significantly associated with compliance with treatment. However, factors such as counselling prior to initiation of treatment, severity of obstructive sleep apnoea before initiation of treatment, obesity, use of humidification, and polysomnogram indices were not found to be associated with treatment compliance.
CONCLUSION Only 41.2% of the children in this study were reported to be compliant with noninvasive home ventilation. The female gender and the presence of asthma were associated with treatment compliance. Future research focusing on effective methods to improve compliance with noninvasive home ventilation in children should be undertaken.

Keywords: children, compliance, continuous positive airway pressure, home ventilation, obstructive sleep apnoea
Singapore Med J 2013; 54(12): 678-682; http://dx.doi.org/10.11622/smedj.2013241

REFERENCES

Terzi O, Sisman A, Canbaz S, Dündar C, Peksen Y
Correspondence: Dr Ozlem Terzi, ozlemzelterzi@hotmail.com

ABSTRACT
INTRODUCTION The location of ambulance stations are of great importance, as location is a determining factor of whether ambulances are able to respond to emergency calls within the critical period. The aim of the present study was to determine whether the ambulance stations in the provincial centre of Samsun, Turkey, were able to cover their entire operational area within 10 mins of receiving an emergency call.
METHODS This study was based on emergency calls received by the emergency medical services of the study area. Detailed address data from the calls was used to produce thematic maps using the geographic information system (GIS). Buffer analysis was used to determine the adequacy of the stations’ locations in relation to the time taken to respond to the emergency calls.
RESULTS In the study area, there were a total of 11,506 emergency ambulance calls made in 2009, which revealed a call density of 0.7 calls per ha and 23.8 calls per 1,000 population. A total of 75.8% of the calls were made due to medical reasons, while 11.6% were related to traffic accidents. The GIS-based investigation revealed that the 10-min coverage areas for the four ambulance stations in the provincial centre of Samsun served 76.9% of the area and 97.9% of its population. Of the 10,380 calls for which detailed address data were available, 99.2% were within the stations’ 10-min coverage areas.
CONCLUSION According to the buffer analysis, the ambulance stations in the provincial centre of Samsun are able to reach 97.9% of the population within the critical 10-min response time. This study demonstrates that GIS is an indispensable tool for processing and analysing spatial data, which can in turn aid decision-making in the field of geographical epidemiology and public health.

Keywords: ambulance, coverage area, geographic information system, station
Singapore Med J 2013; 54(11): 653-658; http://dx.doi.org/10.11622/smedj.2013228

REFERENCES

Ozdemir H, Akinci E, Coskun F
Correspondence: Dr Emine Akinci, emineakinci@yahoo.com

ABSTRACT
INTRODUCTION We aimed to compare the effectiveness of intravenous piracetam with that of intravenous dimenhydrinate in the treatment of acute peripheral vertigo in the emergency department.
METHODS This double-blind study comprised a total of 200 patients, aged between 18 and 70 years, who had presented to the emergency department of Ankara Training and Research Hospital and were diagnosed with peripheral vertigo. Evaluation of the severity of the patients’ vertigo was performed using a visual analogue scale, before and after drug administration.
RESULTS Both drugs were found to be effective (p < 0.001) and had comparable effects (p < 0.474). Dimenhydrinate was also found to have about two times the side effects of piracetam. Drowsiness was found to be the most common side effect of these two drugs. 
CONCLUSION Dimenhydrinate and piracetam have similar levels of effectiveness with regard to acute vertigo. We conclude that piracetam, which has fewer side effects than dimenhydrinate, better vestibular compensation, and is effective for both acute and chronic vertigo, could be more frequently used in the emergency treatment of acute vertigo.

Keywords: dimenhydrinate, emergency department, peripheral vertigo, piracetam
Singapore Med J 2013; 54(11): 649-652; http://dx.doi.org/10.11622/smedj.2013225

REFERENCES

Feng SY, Song YQ, Zhang YL, Li Y
Correspondence: Dr Shun Yi Feng, shunyi1058@hotmail.com

ABSTRACT
INTRODUCTION According to the findings of some studies, instability due to inertia during changes in speed may negatively impact the quality of chest compressions performed during cardiopulmonary resuscitation (CPR) in a moving environment. This study thus aimed to introduce a simple device that maintains the balance of a person performing CPR in a moving environment, such as an ambulance. We also sought to evaluate the effectiveness of this device in the improvement of the quality of chest compressions.
METHODS The experiment comprised a total of 40 simulated cardiopulmonary arrest scenes (20 in the experimental group and 20 in the control), in which CPR was conducted by eight paramedics. Each simulation involved two paramedics randomly selected from the eight. The ambulance took the same route from the simulated site to the hospital, and continuous CPR was performed on a manikin in the ambulance with or without the aid of our proposed novel device.
RESULTS The average number of chest compressions per simulation in the experimental and control groups was 1330.75 and 1266.60, respectively (p = 0.095). The percentage of chest compressions with adequate depth achieved in the experimental and control groups was 72% ± 4% and 50% ± 3%, respectively (p < 0.0001).
CONCLUSION By maintaining the balance of the CPR performer, our proposed novel device can offset the negative impact that instability (due to a moving environment) has on chest compressions. The device may also lead to an increase in the percentage of chest compressions that achieve adequate depth.

Keywords: ambulance, cardiopulmonary resuscitation, chest compression, instability, quality
Singapore Med J 2013; 54(11): 645-648; http://dx.doi.org/10.11622/smedj.2013226

REFERENCES

Wu RS, Chan JX, Chong SL, Ong GY, Ng KC
Correspondence: Dr Ryan Song Lian Wu, ryan.wu@mohh.com.sg 

ABSTRACT
INTRODUCTION Toy-related injuries, a common reason for emergency department visits in the paediatric population, constitute a significant health burden in Singapore. Although government regulations imposed on toys and childcare-related items are in place, parents and caregivers still play a pivotal role in ensuring toy safety in children. We hypothesised that deficiencies in knowledge surrounding toy safety issues exist in our adult population. 
METHODS We conducted a cross-sectional questionnaire study at KK Women’s and Children’s Hospital, Singapore, to examine the current attitudes, knowledge and practices of the local population regarding toy safety. Hypothetical questions on toy selection were included in the questionnaire to assess respondents’ ability to identify appropriate toys and discern potentially dangerous toys for a specified age group. 
RESULTS The scores of the 93 respondents showed that they were less able to identify appropriate toys for children in the 1–2 years (66.7%; 95% confidence interval [CI] 61.4%–72.0%) and 2–3 years age groups (69.9%; 95% CI 65.5%–74.3%) than for children in the 0–1 year (82.8%; 95% CI 79.9%–85.7%) and 3–5 years age groups (85.2%; 95% CI 81.2%–89.2%). Our survey also identified key areas for improvement (e.g. educational efforts and government regulation) in current practices in order to attain a higher level of toy safety. 
CONCLUSION Our study highlights the current knowledge deficit in toy safety issues and the need for improvements in regulation, education and surveillance in order to minimise the risk of toy-related injuries in children.

Keywords: emergency, Singapore, survey, toy-related injuries, toy safety
Singapore Med J 2013; 54(11): 639-644; http://dx.doi.org/10.11622/smedj.2013227

REFERENCES