Original Article

Sarbolouki S, Javanbakht MH, Derakhshanian H, Hosseinzadeh P, Zareei M, Hashemi SB, Dorosty AR, Eshraghian MR, Djalali M
Correspondence: Dr Mahmoud Djalali, mjalali87@yahoo.com

ABSTRACT
Introduction Diabetes mellitus is the most common metabolic disorder in humans, and its incidence is increasing rapidly worldwide. Although polyunsaturated fatty acids have beneficial effects on diabetes mellitus, previous data regarding the possible positive effects of n-3 fatty acids on glycaemic indices were inconclusive. We conducted a double-blind randomised clinical trial to determine the effects of eicosapentaenoic acid (EPA), an n-3 polyunsaturated fatty acid, on overweight patients with type 2 diabetes mellitus (T2DM).
Methods This double-blind, placebo-controlled randomised clinical trial was conducted on a total of 67 overweight patients with T2DM for a duration of three months. Of these 67 patients, 32 received 2 g purified EPA daily, while 35 received a placebo of 2 g corn oil daily. The patients’ fasting plasma glucose (FPG), serum insulin, glycated haemoglobin (HbA1c) and insulin sensitivity indices were assessed.
Results After three months of EPA supplementation, the group that received EPA showed significant decreases in FPG (p < 0.001), HbA1c (p = 0.01) and homeostasis model assessment of insulin resistance (HOMA-IR) (p = 0.032), when compared to the placebo group. EPA supplementation resulted in decreased serum insulin levels, with the levels between the EPA and placebo groups showing a significant difference (p = 0.004).
Conclusion The results of our study indicate that EPA supplementation could improve insulin sensitivity. It was able to decrease serum insulin, FPG, HbA1c and HOMA-IR. EPA could have beneficial effects on glycaemic indices in patients with T2DM.

Keywords: diabetes mellitus, eicosapentaenoic acid, insulin sensitivity
Singapore Med J 2013; 54(7): 387-390; http://dx.doi.org/10.11622/smedj.2013139

REFERENCES

Lee PC, Tham KW, Tan HC, Pasupathy S
Correspondence: Dr Kwang Wei Tham, tham.kwang.wei@sgh.com.sg

ABSTRACT
Introduction Obesity is a risk factor for type 2 diabetes mellitus (T2DM). Metabolic-bariatric surgery (MBS) results in significant weight loss with dramatic improvement in T2DM. This study analysed the effects of MBS on patients with T2DM in a tertiary centre in Singapore.
Methods Individuals with T2DM who underwent MBS in a single centre from September 2008 to May 2012, with at least 12 months of regular follow-up, were included in our study. The primary outcome measure was good glycaemic control (glycated haemoglobin [HbA1c] < 6.5%, with or without medications) 12 months after surgery. Secondary outcome measures were partial DM remission (fasting blood glucose [FBG] < 7.0 mmol/L and HbA1c < 6.5% without DM medications), complete DM remission (FBG < 5.6 mmol/L and HbA1c < 6.0% without DM medications), weight, body mass index, blood pressure, and fasting serum lipid, serum glucose and serum insulin levels.
Results Of the 19 patients who met the inclusion criteria, 14 underwent gastric bypass and 5 underwent sleeve gastrectomy. At 12 months postoperatively, 17 (89.5%) patients achieved good glycaemic control. DM remission was achieved in 14 (73.7%) patients, with 10 (52.6%) attaining complete remission.
Conclusion In Singapore, MBS is an effective treatment modality for obese patients with T2DM. Despite the small sample size and lack of matched controls, the present study suggests that MBS is effective in achieving significant weight loss and eliciting a significant and sustainable improvement in the glycaemic control of patients with T2DM, for up to 12 months. 

Keywords: bariatric surgery, diabetes mellitus, metabolic, obesity, remission
Singapore Med J 2013; 54(7): 382-386; http://dx.doi.org/10.11622/smedj.2013138

REFERENCES

Shakiba M, Iranmanesh MR
Correspondence: Dr Mehrdad Shakiba, shakiba@ssu.ac.ir

ABSTRACT
Introduction The exact amount of vitamin D required for pregnant women to adequately supply the foetus during pregnancy is still unclear. This randomised trial attempted to determine the optimal dose of vitamin D necessary during pregnancy in order to attain a vitamin D level > 20 ng/mL in neonates.
Methods A total of 51 healthy, pregnant women in Yazd, Iran, were recruited in 2009. Of these, 34 were randomised to receive either 50,000 IU (Group A) or 100,000 IU (Group B) of vitamin D3 per month from the second trimester of pregnancy. The remaining 17 pregnant women, who formed the third group (Group C) and were found to have vitamin D deficiency, were initially treated with 200,000 IU of vitamin D3, following which the dose was adjusted to 50,000 IU per month. 25-hydroxyvitamin D (25[OH]D) in cord blood was measured by chemiluminescence immunoassay, and a serum 25(OH)D level < 20 ng/mL was defined as deficiency.
Results All the pregnant women had a vitamin D level < 30 ng/mL at the beginning of the second trimester. The neonates of 76% of women from Group A had sufficient levels of 25(OH)D. All the neonates born to women in Groups B and C had 25(OH)D > 20 ng/mL. No side effects were observed in our participants during the period of vitamin D supplementation.
Conclusion A vitamin D3dose > 50,000 IU/month is required during the second and third trimesters of pregnancy for vitamin D-deficient pregnant women in order for their neonates to achieve serum 25(OH)D levels > 20 ng/mL. Supplementation with < 50,000 IU/month is insufficient to ensure a vitamin D level > 20 ng/mL in all neonates born to vitamin D-deficient pregnant women.

Keywords: 25-hydroxyvitamin D, neonate, pregnancy, vitamin D
Singapore Med J 2013; 54(5): 285-288; http://dx.doi.org/10.11622/smedj.2013110

REFERENCES

Subramanian P, Choy KL, Gobal SV, Mansor M, Ng KH
Correspondence: Dr Pathmawathi Subramanian, pathmawathi@um.edu.my

ABSTRACT
Introduction Ventilator-associated pneumonia (VAP) is a common risk among critically ill ventilated patients. This study aimed to investigate the effects of nurse-led education on: (a) knowledge of and compliance with ventilator care bundle (VCB) practices among intensive care unit (ICU) nurses; and (b) reduction in the rates of VAP post intervention.
Methods A quasi-experimental design with pretest-posttest evaluation and observation was used to investigate nurses’ knowledge of and compliance with VCB practices, and the incidence of VAP. The study was conducted among 71 nurses, and the intervention involved structured education on VAP and its prevention using VCB in an ICU setting. Data were analysed using descriptive and inferential statistics.
Results Nurse-led education significantly increased nurses’ knowledge of (t[70] = −36.19; p < 0.001) and compliance with (t[65] = −21.41; p < 0.001) VCB practices. The incidence of VAP, which was 39 per 1,000 ventilator days during the two-month period before intervention, dropped to 15 per 1,000 ventilator days during the two-month period following intervention.
Conclusion Our findings show that nurse-led education on VAP and VCB significantly increased knowledge of and compliance with VCB practices among ICU nurses, and was associated with a reduction in the incidence of VAP among intubated and mechanically ventilated ICU patients. Inclusion of recent knowledge and evidence-based VCB guidelines for VAP prevention when educating anaesthetists, nurses, physiotherapists and other healthcare providers in the critical care setting is recommended.

Keywords: compliance, intensive care, knowledge, ventilator-associated pneumonia, ventilator care bundle
Singapore Med J 2013; 54(5): 281-284; http://dx.doi.org/10.11622/smedj.2013109

REFERENCES

Jaovisidha S, Siriapisith R, Chitrapazt N, De Zordo T, Woratanarat P, Subhadrabandhu T, Sirikulchayanonta V, Siriwongpairat P
Correspondence: Dr Suphaneewan Jaovisidha, rasjv@yahoo.com

ABSTRACT
Introduction This study aimed to evaluate radiological findings in patients with chondroblastoma (CB) in tubular and non-tubular bones (NTBs).
Methods We retrospectively reviewed the medical records of patients with CB. Data collected included patients’ gender and age, type, size and location of bone involved, and imaging findings regarding border, lobulation, calcification, trabeculation, cortical expansion and destruction, periosteal reaction, soft tissue component and fractures. Magnetic resonance imaging and/or multidetector computed tomography were used to determine the presence of any internal cystic space or secondary aneurysmal bone cyst that may have affected the radiological appearance of CB.
Results All 31 lesions (18 tubular bones, 13 NTBs) exhibited geographic bone destruction and did not involve the adjacent joints. Univariate analysis showed that NTB lesions were found in older patients and were associated with thin trabeculation (p < 0.01) and well-defined margins (p < 0.05), whereas tubular bone lesions correlated with thick trabeculation and partially ill-defined margins. On multivariate analysis, age and type of bone involvement were significantly correlated. An increase in age by one year reduced the risk of having tubular bone involvement by about 27% when compared with NTBs (p = 0.011). Thin trabeculation was also significantly correlated with NTB lesions.
Conclusion Age was the most significant parameter, as increased age was found to reduce the risk of tubular bone involvement. Patients with NTB lesions were significantly older than those with tubular bone lesions. Based on imaging alone, thin trabeculation showed significant correlation with CB occurring in NTBs on both univariate and multivariate analyses.

Keywords: chondroblastoma, flat bone, non-tubular bone, radiograph, tubular bone
Singapore Med J 2013; 54(5): 275-280; http://dx.doi.org/10.11622/smedj.2013108

REFERENCES

Wong TH, Tay KH, Sebastian MG, Tan SG
Correspondence: Dr Ting Hway Wong, wong.th@doctors.org.uk

ABSTRACT
Introduction The gold standard for evaluation of the lower extremity arterial tree is catheter angiography. Duplex arterial-occlusive imaging or duplex ultrasonography arteriography, a noninvasive technique, is used as the first-line investigation in patients with peripheral vascular disease at our centre. Based on the results of duplex imaging, patients who require angiographic intervention then proceed with simultaneous catheter arteriography and intervention. This study aimed to compare the results of duplex imaging alone as the first-line investigation against the eventual results of catheter angiography, and to assess the impact of the former on patients’ clinical outcomes.
Methods All cases involving patients who underwent duplex imaging followed by angiographic intervention, from May 2008 to February 2009, were discussed at weekly interdisciplinary meetings. Only patients who underwent lower limb imaging were included in the study. Those who were involved in grafts and stent surveillance studies, as well as those with incomplete duplex images were excluded.
Results During the study period, 113 duplex imaging studies of the lower limb followed by percutaneous transluminal angioplasty were performed at our hospital for peripheral vascular disease. The iliac artery was visualised in 40 images, but could not be visualised in 73 images. There was a potential change in management in three cases due to radiological differences between the duplex images and angiography films.
Conclusion In our series, duplex imaging was found to be accurate enough to guide initial clinical management of patients with peripheral vascular disease. This modality is the preferred first-line investigation for such patients at our centre.

Keywords: arterial-occlusive imaging, duplex ultrasonography, peripheral vascular disease
Singapore Med J 2013; 54(5): 271-274; http://dx.doi.org/10.11622/smedj.2013107

REFERENCES

Klaipetch A, Namwongprom S, Ekmahachai M, Lojanapiwat B
Correspondence: Dr Alisa Klaipetch, aklaipet@med.cmu.ac.th

ABSTRACT
Introduction This study aimed to ascertain whether nonopacified kidney on excretory urography (also known as intravenous urography [IVU]) indicates nonsalvageability.
Methods We retrospectively reviewed 45 adult patients with chronic unilateral urinary tract obstruction, in whom IVU revealed nonopacified kidney on one side but normal excretion on the contralateral side. Affected kidneys with split glomerular filtration rate (GFR) < 10 mL/min/1.73 m² on 99mTc-diethylenetriaminepentaacetic acid diuretic renal scintigraphy were considered nonsalvageable. Non-function was defined based on cutoff points (< 15% and < 20%) to determine the sensitivity and specificity of differential renal function. Differences in IVU and renal scintigraphy findings, with respect to the duration of delayed filming on IVU, were analysed for significance.
Results The results of IVU and renal scintigraphy findings for 34 (75.6%) nonopacified kidneys matched, representing nonsalvageable kidneys. Sensitivity and specificity of differential renal function were 76% and 100%, respectively, when the cutoff point for non-function was set at < 15%. Sensitivity and specificity were 97% and 82%, respectively, when the cutoff point was < 20%. There was no significant difference between renal scintigraphy findings and IVU with 2-hour and > 2-hour delayed films (p = 0.96).
Conclusion Although most nonopacified kidneys on IVU were nonsalvageable, a quarter of them were found to be salvageable on renal scintigraphy. Besides split GFR, differential function at cutoff point < 15% could be used to determine non-function of a chronic obstructed kidney when the contralateral kidney is normal. Delayed filming beyond two hours appears unnecessary in ensuring non-excretion on IVU.

Keywords: chronic obstruction, differential renal function, excretory urography, nonsalvageable, renal scintigraphy
Singapore Med J 2013; 54(5): 267-270; http://dx.doi.org/10.11622/smedj.2013106

REFERENCES

Alam S, Hussain A, Daiwajna R, Tan J
Correspondence: Dr Sartaj Alam, drsartajalam@hotmail.com

ABSTRACT
Introduction Sevelamer hydrochloride (Renagel) is frequently used as a second-line phosphate binder in patients on renal replacement therapy. Many studies have shown that sevelamer can improve vascular calcification, serum uric acid and low-density lipoprotein (LDL) cholesterol levels. The main objectives of this study were to assess the efficacy of sevelamer against calcium-based phosphate binders, as well as its tolerability and side-effect profile.
Methods This was a retrospective study that included all patients on renal replacement therapy (between 2008 and 2011) who had previously received calcium-based binders for ≥ 6 months and were subsequently switched to sevelamer. Data collected from the patients’ medical records included demographics, as well as renal parameters three months prior to sevelamer treatment, and at three and six months post treatment. The study excluded patients on multiple, concomitant phosphate binders or with functioning renal transplants, and those who were noncompliant or had inadequate follow-up blood investigations.
Results A total of 39 patients were included in the study. No major side effects were reported by any of the patients. There were improvements in calcium, phosphate, uric acid and LDL cholesterol levels at three and six months post-sevelamer treatment.
Conclusion We found sevelamer to be superior to calcium-based phosphate binders in reducing serum calcium, phosphate, uric acid and LDL cholesterol levels in our patient population with advanced renal bone disease. Sevelamer also appears to be well tolerated with no significant side effects.

Keywords: calcium-based binders, dialysis, phosphate binders, renagel, sevelamer
Singapore Med J2013; 54(5): 263-266; http://dx.doi.org/10.11622/smedj.2013105

REFERENCES

Sim A, Ng LG, Cheng C
Correspondence:  Dr Allen Sim, allen_sim@hotmail.com

ABSTRACT
Introduction The incidence of lymphoceles – lymphatic collections around a transplanted kidney – can be as high as 20%. We aimed to review the presentation, treatment and outcome of patients with lymphoceles.
Methods We reviewed a prospective database of 154 patients who underwent renal transplantation at our hospital from January 2005 to November 2008.
Results The mean age of the patients in our cohort was 46 (range 34–58) years. The incidence of lymphoceles in our series was 5.8% (n = 9). The median onset was 19 (range 6–28) days post-transplantation, while the median size of the lymphoceles was 5 (range 1.5–8) cm. Lymphoceles were most commonly found at the lower pole of the transplanted kidney. Eight patients with lymphoceles had received cadaveric transplants. While a majority of these patients did not have hydronephrosis on presentation, four had markedly elevated creatinine. Of the nine patients with lymphoceles, six were on macrolides (tacrolimus, sirolimus or everolimus), two were successfully managed conservatively, three were managed percutaneously and four required surgical drainage via either laparoscopic marsupialisation (n = 1) or open drainage (n = 3). There was no graft loss.
Conclusion It remains unknown whether the choice of immunosuppressants increases the risk of lymphocele formation. Intervention is necessary in the case of impaired drainage of the pelvicalyceal system in these patients. Minimally invasive intervention, while effective in treating lymphoceles, does not provide definitive treatment. Surgical intervention should be considered early for the treatment of post-transplantation patients with lymphoceles, so as to shorten hospital stay and prevent further complications.

Keywords: lymphocele, renal transplant
Singapore Med J 2013; 54(5): 259-262; http://dx.doi.org/10.11622/smedj.2013104

REFERENCES

Kao YH, Goh CR
Correspondence: Dr Yung Hsiang Kao, yung.h.kao@gmail.com

ABSTRACT
Introduction The traditional family-centred approach to cancer management in Singapore often leads to nondisclosure of diagnosis to patients with advanced cancer. This study aimed to determine the rate of nondisclosure to such patients in Singapore, and compare it against the rate of nondisclosure to patients’ families and that of a study conducted in 1992.
Methods Consecutive patients (n = 100) with advanced cancer who were referred to a palliative home care service in 2004 were studied retrospectively. Comparison between the 1992 and present study groups was performed using chi-square and Fisher’s exact tests. Multivariate logistic regression was applied to patient age, Eastern Cooperative Oncology Group (ECOG) performance status, gender and ethnicity to identify factors associated with nondisclosure.
Results The overall nondisclosure rate among patients with advanced cancer was 23% (23/100), compared to only 2% (2/99) among their families (p < 0.001). The nondisclosure rates among ECOG 0–2 and ECOG 3–4 patients were 11% (7/62) and 42% (16/38), respectively (p < 0.001). There was no significant improvement in the nondisclosure rate among ECOG 3–4 patients when compared to the 1992 study (p = 0.94). It was more likely for nondisclosure to occur among patients aged ≥ 70 years (p < 0.001; odds ratio [OR] 14.77, 95% confidence interval [CI] 3.68–59.26) and those with poor ECOG performance status (p = 0.019; OR 4.0, 95% CI 1.26–12.73). There was no significant association between nondisclosure and gender or ethnicity (p > 0.05).
Conclusion Disclosure of diagnosis to patients with advanced cancer remains a challenge in Singapore. The relationship between nondisclosure and advanced age, as well as nondisclosure and poor ECOG performance status, needs to be clarified with further studies.

Keywords: cancer, diagnosis disclosure, family-centred, palliative, Singapore
Singapore Med J 2013; 54(5): 255-258; http://dx.doi.org/10.11622/smedj.2013103

REFERENCES