Original Article

Nidugala H, Bhargavi C, Avadhani R, Bhaskar B
Correspondence: Dr Bhagya Bhaskar, bagyabs@gmail.com

ABSTRACT
INTRODUCTION To the best of our knowledge, the sexually dimorphic characteristics of the craniofacial region among the South Indian population are not available in the current literature. We aimed to determine these characteristics using discriminant function analysis.
METHODS A total of 80 recent skulls (40 male, 40 female) from the Department of Anatomy, Yenepoya Medical College, Yenepoya University, Karnataka, India, were analysed. Ten craniofacial parameters were measured and subjected to univariate and multivariate statistical analyses using the Statistical Package for the Social Sciences version 13.0.
RESULTS Statistical analyses revealed that the differences in the bizygomatic, orbital and biorbital breadths of males and females were significant (p < 0.05). Direct method gave an accuracy of 68.8% for sex determination. In stepwise analysis, bizygomatic breadth and upper facial height were selected, giving a 65.0% accuracy for sex prediction.
CONCLUSION Craniofacial parameters are sexually dimorphic. The present study established several features of craniofacial morphometry that can be used for sex determination among the South Indian population. The findings of the present study serve as a foundation for future studies that aim to compare craniofacial parameters among various ethnic groups in South India.

Keywords: craniofacial region, discriminant function analysis, metric parameters, sexual dimorphism, South Indian population 
Singapore Med J 2013; 54(8): 458-462; http://dx.doi.org/10.11622/smedj.2013154

REFERENCES

Yang J, Ji S, Zhang Y, Wang J
Correspondence: Dr Jiangbin Wang, sciencel122@126.com

ABSTRACT
INTRODUCTION Helicobacter (H.) hepaticus infection causes chronic active hepatitis and induces hepatocellular tumours in A/JCr mice, but evidence of this in humans is scarce. This study aimed to demonstrate the correlation between H. hepaticus and human primary hepatocellular carcinoma (HCC).
METHODS The sera of 50 patients with primary HCC were tested for the presence of anti-H. pylori and anti-H. hepaticus immunoglobulin G (IgG) antibodies. The liver tissues of patients who tested positive for serum antibody were analysed for H. hepaticus-specific 16S rRNA, H. hepaticus cdtB, H. pylori cagA, H. pylori vacA and H. pylori ureC genes using polymerase chain reaction.
RESULTS After the anti-H. pylori antibodies in the serum samples were absorbed by H. pylori antigen, the anti-H. hepaticus IgG serum antibody detection rate was 50.0% in patients with primary HCC. This was significantly higher (p < 0.001) than the detection rate in the benign liver tumour (7.7%) and normal liver tissue (6.3%) groups. Of the 25 primary HCC samples that tested positive for anti-H. hepaticus IgG serum antibody, the H. hepaticus-specific 16S rRNA gene was detected in nine (36.0%) samples. Sequencing showed that the polymerase chain reaction-amplified product exhibited 95.5%–100% homology to the H. hepaticus-specific 16S rRNA gene. Among these nine primary HCC tissue samples, the H. hepaticus cdtB gene was detected in four (44.4%) samples, while no such expression was observed in the benign liver tumour or normal liver tissue groups.
CONCLUSION The present study identified the presence of H. hepaticus infection in patients with primary HCC using serological and molecular biological detection, suggesting that H. hepaticus infection may be involved in the progression of HCC.

Keywords: Helicobacter hepaticus, Helicobacter pylori, primary hepatocellular carcinoma
Singapore Med J 2013; 54(8): 451-457; http://dx.doi.org/10.11622/smedj.2013153

REFERENCES

Yang YH, Wang YR, Jiang SD, Jiang LS
Correspondence: Prof Sheng-Dan Jiang,  jiangsd@126.com

ABSTRACT
INTRODUCTION Proximal femoral nail antirotation (PFNA) and third-generation Gamma nail (Gamma 3) are widely used in the treatment of intertrochanteric fractures. However, it remains unclear which device achieves better clinical and radiographic outcomes when treating intertrochanteric fractures.
METHODS This study comprised 239 patients with intertrochanteric fractures treated with either PFNA or Gamma 3 for a minimum of 12 months. During surgery, the operative time, image intensifier time and amount of blood loss were recorded. Following surgery, we assessed reduction quality and implant position. At the final follow-up, postoperative complications, including femoral shaft fracture, cutout, reoperation, pneumonia, urinary tract infection, cerebral infarction, cardiac infarction and decubital ulcer, were recorded. In addition, walking ability was assessed using the Parker-Palmer mobility score.
RESULTS No difference was found in the operative time, image intensifier time and amount of blood loss between patients treated with PFNA and those treated with Gamma 3. The reduction quality of fractures treated with Gamma 3 was better than those treated with PFNA. However, there were no significant differences in implant position, walking ability and postoperative complications between the two groups. Although Gamma 3 resulted in better reduction quality, it did not provide any advantages in walking ability and postoperative complications when compared with PFNA.
CONCLUSION Therefore, we conclude that both PFNA and Gamma 3 are safe and reliable devices for the treatment of intertrochanteric fractures.

Keywords: intertrochanteric fractures, intramedullary fixation
Singapore Med J 2013; 54(8): 446-450; http://dx.doi.org/10.11622/smedj.2013152

REFERENCES

Kaliya Perumal AK, Balasubramanian K
Correspondence: Dr Arun Kumar Kaliya Perumal, dr.arunkumar.orth@gmail.com

ABSTRACT
INTRODUCTION Indications for flexible intramedullary nailing, as well as advancements in this technique, have evolved considerably with time and individual experience. We implemented and studied a simplified version of the technique. Functional outcome, osseous union and related issues are discussed.
METHODS A total of 15 patients aged 5–15 years with diaphyseal femur fracture were selected for the study. The patients’ fractures were stabilised with flexible intramedullary nails through lateral entry alone. After a minimum follow-up period of six months, the outcomes were analysed.
RESULTS The mean patient age was 8.7 years, and patients were followed up for a mean duration of 12 months. Radiological union was achieved within a mean duration of 7.5 weeks. The outcomes were excellent in most of the cases.
CONCLUSION Adequate fixation was achieved through the use of flexible nails as intramedullary splints. The results were comparable to that of the original technique. Further study is obligatory.

Keywords: elastic stable intramedullary nailing, flexible intramedullary nailing, paediatric femur fracture
Singapore Med J2013; 54(8): 441-445; http://dx.doi.org/10.11622/smedj.2013151

REFERENCES

Randhawa NK, Tan EK, Sabnis MA
Correspondence: Dr Nau’shil Kaur Randhawa, naushil_randhawa@yahoo.com.sg

ABSTRACT
INTRODUCTION Current international Royal College of Obstetricians and Gynaecologists (RCOG) guidelines list maternal obesity (body mass index [BMI] ≥ 30.0 kg/m²) as a risk factor for venous thromboembolism (VTE). Although the World Health Organization (WHO) has recommended lower BMI cutoff points for Asians when risk stratifying for diseases associated with obesity, this has not been extended to maternal obesity. In the present study, we compared the difference in using Asian-specific BMI cutoff points as opposed to those in international guidelines in determining the population at risk for VTE, as defined by RCOG guidelines.
METHODS All spontaneous deliveries (n = 94) and Caesarean sections (n = 41) over a three-week period, and instrumental deliveries (n = 15) over a two-month period, were reviewed and risk stratified based on Asian-specific, as well as international, BMI cut-off points.
RESULTS For the group that underwent spontaneous vaginal delivery, the percentage of patients at risk for VTE nearly doubled (from 8.5% to 16.0%) with the revised risk stratification, while that of patients who had instrumental delivery had more than a two-fold increase (250%). In the initial risk stratification of the post-Caesarean patients, none were at high risk of VTE. However, when the lower cut-off points of 27.5 kg/m² and 23.0 kg/m² were used, one and three patients were respectively identified to be at high risk.
CONCLUSION Further research and consideration regarding the adjustment of international risk stratification guidelines to accommodate population-specific differences are required so that at-risk patients are not missed.

Keywords: ethnicity, pregnancy, puerperium, risk assessment, thromboembolism
Singapore Med J 2013; 54(8): 437-440; http://dx.doi.org/10.11622/smedj.2013150

REFERENCES

Lee SY, Tan KH
Correspondence: Dr Lee Shu Yi Sonia, sonia.lee@mohh.com.sg

ABSTRACT
INTRODUCTION We aimed to investigate the epidemiology, diagnosis, prognostication, follow-up care and outcomes of antenatally diagnosed congenital diaphragmatic hernia (CDH) in KK Women’s and Children’s Hospital (KKH), Singapore. The objective of this study was to identify trends in current practice, and evaluate and improve the management of CDH.
METHODS We retrospectively reviewed cases of antenatally diagnosed CDH from 2006 to 2010.
RESULTS A total of 22 cases of CDH were found, bringing its incidence in KKH to 3.6 per 10,000 live births. The mean gestational age at diagnosis was 22.7 weeks, with 14 (63.6%) cases diagnosed at < 22 weeks and 8 (36.4%) diagnosed at ≥ 22 weeks. All cases were left-sided – 15 (68.2%) were isolated CDH and 7 (31.8%) were associated with other anomalies. Of the 22 cases, counselling about the prognosis of pregnancy based on the lung-to-head ratio was provided in 9 (40.9%). Overall, 10 (45.5%) cases resulted in termination of pregnancy (TOP), 9 (40.9%) resulted in live birth and 1 (4.5%) in stillbirth; 2 (9.1%) cases were lost to follow-up prior to delivery. Of the 9 live births, 3 (33.3%) resulted in neonatal death. In the 10 births, 5 (50.0%) were delivered by normal vaginal delivery, 4 (40.0%) by emergency Caesarean section and 1 (10.0%) by elective Caesarean section.
CONCLUSION CDH is a challenging perinatal problem with a low overall survival rate. Almost half of the cases opt for TOP. The data in this study can help clinicians better undertake the task of adequately counselling parents with qualitative and quantitative prognostic factors, using an evidence-based approach.

Keywords: antenatal diagnosis, congenital diaphragmatic hernia, epidemiology, outcome, prognosis
Singapore Med J 2013; 54(8): 432-436; http://dx.doi.org/10.11622/smedj.2013149

REFERENCES

Kouk LJ, Neo GH, Malhotra R, Allen JC, Beh ST, Tan TC, Østbye T
Correspondence: Prof Truls Østbye, truls.ostbye@duke-nus.edu.sg

ABSTRACT
INTRODUCTION The present study aimed to assess the demographic, socioeconomic, medical and lifestyle factors associated with the progression of a threatened miscarriage to a complete miscarriage in the first trimester.
METHODS A prospective cohort study was conducted on 157 women who presented with vaginal bleeding in the fifth to tenth week of gestation. Cox regression analysis was used to determine the risk factors for progression to a complete miscarriage within 16 weeks of gestation.
RESULTS Of the 139 women included for data analysis, 36 (25.9%) had a miscarriage, mostly within two weeks of presentation. The results of our study showed that women aged ≥ 34 years were more likely to miscarry (hazard ratio [HR] = 1.95). Compared to women whose partner was 20–30 years of age, women whose partner was ≥ 41 years of age also had a higher likelihood of experiencing a miscarriage (HR = 8.33). However, the presence of nausea (HR = 0.33) and a high stress score (i.e. ≥ 17) on the Perceived Stress Scale (HR = 0.49) were associated with a reduced likelihood of miscarriage.
CONCLUSION Older pregnant women experiencing a threatened miscarriage should be counselled about their higher risk of miscarriage, especially if they have an older partner.

Keywords: maternal age, nausea, paternal age, Southeastern Asia, threatened abortion
Singapore Med J 2013; 54(8): 425-431; http://dx.doi.org/10.11622/smedj.2013148

REFERENCES

Jian WX, Jin J, Qin L, Fang WJ, Chen XR, Chen HB, Su Q, Xing HL
Correspondence: Prof Hui-Li Xing, dr_huilixing@126.com

ABSTRACT
Introduction Hypothyroidism and subclinical hypothyroidism may be associated with hypertension and metabolic syndrome. The aim of this study was to investigate the relationship between thyroid-stimulating hormone (TSH) and blood pressure, as well as the relationship between thyroid function and insulin resistance in middle-aged and elderly Chinese.
Methods This was a cross-sectional, community-based study. Serum TSH, fasting glucose and insulin were measured in 2,988 subjects aged 35–80 years. Logistic regression analysis was used to identify the risk factors for hypertension. Analysis of variance and multiple linear regression analysis were performed to characterise the relationship among TSH, insulin resistance and blood pressure.
Results Higher serum TSH concentration was found to be an independent risk factor for hypertension in females (odds ratio 1.4, 95% confidence interval 1.02–1.93; p-value = 0.039). The female group with subclinical hypothyroidism and high normal TSH (2.5–4.8 mIU/L) were more susceptible to high blood pressure than those with low normal TSH (0.3–2.5 mIU/L) (p-value < 0.05). After adjustment for waist-hip ratio and body mass index, neither the correlation between blood pressure and homeostasis model assessment of insulin resistance (HOMA-IR) nor the correlation between TSH and HOMA-IR were found to be significant in this study.
Conclusion This study provides evidence that both subclinical hypothyroidism and high normal TSH are independent risk factors for hypertension in middle-aged and elderly Chinese women.

Keywords: hypertension, hypothyroidism, insulin resistance, thyrotropin
Singapore Med J 2013; 54(7): 401-405; http://dx.doi.org/10.11622/smedj.2013142

REFERENCES

Fatima A, Khawaja KI, Burney S, Minhas K, Mumtaz U, Masud F
Correspondence: Dr Faisal Masud, dr.faisalmasud@gmail.com

ABSTRACT
Introduction With advancement in the understanding of the pathogenesis underlying diabetes mellitus (DM), the boundary between type 1 and type 2 DM (T1DM and T2DM) does not seem to be as clear cut as previously thought. This study was designed to test the possibility of overlap between the spectra of immune-mediated DM and insulin resistance.
Methods To test for the possibility of overlap, we looked for autoantibodies typical of T1DM in patients with classical T2DM, and insulin resistance in patients with T1DM. Autoantibodies against islet cell antigen, glutamic acid decarboxylase-65 and insulinoma-associated antigen-2 were tested in 82 patients with T2DM and 27 patients with T1DM. The patients had been diagnosed on clinical criteria using standard laboratory techniques. Clinical parameters of diagnostic importance were noted, and homeostatic model assessment of insulin resistance (HOMA-IR) was calculated using fasting insulin and fasting blood glucose ratio.
Results Autoantibodies against one or more beta cell antigens were detected in 12.19% of patients clinically diagnosed to have T2DM, and insulin resistance (HOMA-IR > 2.5) was diagnosed in 37.03% of patients with T1DM. It was not possible to identify any combination of clinical or biochemical markers that could predict autoantibody positivity in T2DM patients. T1DM patients with insulin resistance had a significantly higher body mass index than their insulin-sensitive counterparts (p = 0.02).
Conclusion Autoantibodies against beta cell antigens are detectable in insulin-resistant T2DM patients, and insulin resistance may be present in relatively overweight T1DM patients. No differentiating clinical features that might predict autoantibody positivity in T2DM patients were found.

Keywords: autoantibodies, insulin resistance, type 1 diabetes mellitus, type 2 diabetes mellitus
Singapore Med J 2013; 54(7): 396-400; http://dx.doi.org/10.11622/smedj.2013141

REFERENCES

Mastura I, Teng CL, Mimi O, Ho BK, Kusiar Z, Hasim R
Correspondence: Dr Mastura Ismail, drmi68@yahoo.com

ABSTRACT
Introduction Self-monitoring of blood glucose (SMBG) has been underutilised. We conducted an open-label, randomised controlled trial to assess the feasibility of introducing SMBG in primary care clinics in Malaysia.
Methods This was an open-label, randomised controlled trial conducted in five public primary care clinics in Malaysia. Patients with type 2 diabetes mellitus (age range 35–65 years) not performing SMBG at the time of the study were randomised to receive either a glucometer for SMBG or usual care. Both groups of patients received similar diabetes care from the clinics.
Results A total of 105 patients with type 2 diabetes mellitus were enrolled. Of these, 58 and 47 were randomised to intervention and control groups, respectively. After six months, the glycated haemoglobin (HbA1c) level in the intervention group showed a statistically significant improvement of 1.3% (p = 0.001; 95% confidence interval 0.6–2.0), relative to the control group that underwent usual care. The percentages of patients that reached the HbA1c treatment target of ≤ 7% were 14.0% and 32.1% in the control and intervention groups (p = 0.036), respectively.
Conclusion The usage of a glucometer improved glycaemic control, possibly due to the encouragement of greater self-care in the intervention group.

Keywords: diabetes mellitus, Malaysia, primary care, randomised controlled trial, self-monitoring of blood glucose
Singapore Med J 2013; 54(7): 391-395; http://dx.doi.org/10.11622/smedj.2013140

REFERENCES