Original Article

Gunnal SA, Wabale RN, Farooqui MS
Correspondence: Sandhya Arvind Gunnal, sandhyagunnal@yahoo.com

ABSTRACT
Introduction Papillary muscle rupture and dysfunction can lead to complications of prolapsed mitral valve and mitral regurgitation. Multiple operative procedures of the papillary muscles, such as resection, repositioning and realignment, are carried out to restore normal physiological function. Therefore, it is important to know both the variations and the normal anatomy of papillary muscles.

REFERENCES

Tay EL, Lew PS, Poh KK, Saclolo R, Chia BL, Yeo TC, Tan HC, Yip JW
Correspondence: Dr Edgar Tay, Edgar_Tay@nuhs.edu.sg

ABSTRACT
Introduction The treatment of aortic valve stenosis (AS) is seeing renewed interest mainly due to the availability of transcatheter therapies. However, the number of epidemiological studies of this disease in Singapore is limited. We aimed to describe the aetiology and clinical presentation of AS in Singapore, as well as patients’ attitudes toward it. Our findings may facilitate the future planning and utilisation of resources to better manage these patients.

Aung TH, Go YY, Low LP, Chua T
Correspondence: A/Prof Terrance Siang Jin Chua, terrance.chua.s.j@nhcs.com.sg

ABSTRACT
Introduction Hyperlipidaemia is a major risk factor for coronary artery disease (CAD). Its effective treatment has been shown to reduce the incidence of cardiovascular events, both in secondary and primary prevention. An essential component of risk factor management at the community level is public awareness and knowledge of treatment benefits. However, this data is limited in Singapore.
Methods A cross-sectional survey questionnaire of public perception and knowledge on cholesterol treatment among adult Singaporeans aged 30–69 years was commissioned by the Singapore Heart Foundation and conducted by a professional market survey company. Regional quota sampling was performed to ensure that the sample was representative of the Singapore population. This was followed by random sampling of households and respondents.
Results Of the 365 respondents, 40.9% were male, 70.3% were Chinese, 18.8% Malay and 10.9% Indian. The mean age was 47.5 years. Although 81.9% of respondents had medical check-ups involving blood tests, only 11.0% knew their actual cholesterol levels. A third of the respondents saw herbal medicine as healthier and safer than Western medication. More than 80% of respondents believed that diet and exercise were equally effective at lowering cholesterol as medication. About half of the respondents associated long-term use of statins with damage to the liver and kidney, while a third associated chronic statin use with the development of cancer.
Conclusion There are gaps in the level of public awareness and understanding of cholesterol treatment in Singapore. Common misconceptions should be addressed, as they could potentially impair effective management or treatment compliance.

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Lim CP, Sim KL
Correspondence: Dr Choon Pin Lim, lim.choon.pin@nhcs.com.sg

ABSTRACT
Introduction Peripartum cardiomyopathy (PPCM) is a rare but life-threatening condition. We report 11 patients admitted to the National Heart Centre Singapore with a diagnosis of PPCM over a period of 14 months.
Methods Baseline demographics, pregnancy history, haematology, serum biochemistry and echocardiographic findings of women admitted with a diagnosis of PPCM were analysed.
Results The incidence of PPCM was 0.89 per 1,000 live births in our cohort. 63.6% of the patients were Malay and 27.3% were Chinese. 45.5% of the patients were smokers and 45.5% had a history of pregnancy-induced hypertension or preeclampsia. There was no maternal mortality. Mean left ventricular ejection fractions at diagnosis and at six months were 26.9% ± 9.1% and 51.9% ± 10.6%, respectively. Mean left ventricular internal diameters in end-diastole at diagnosis and at six months were 5.5 ± 0.5 cm and 5.1 ± 0.6 cm, respectively. All patients were treated successfully for the acute episode and all but one patient had returned to New York Heart Association functional class I status at six months.
Conclusion PPCM remains a rare condition and appears to occur more commonly in Malay patients. Smoking and pregnancy-induced hypertension appear to be significant risk factors. While short-term outcome remains excellent, collaborative studies with other tertiary centres will help enhance our understanding of the long-term management of and clinical outcomes in these patients.

Keywords:cardiomyopathy, heart failure, peripartum, pregnancy
Singapore Med J 2013; 54:24-27; http://dx.doi.org/10.11622/smedj.2013006

Ngo CS, Aquino MC, Noor S, Loon SC, Sng CC, Gazzard G, Wong WL, Chew PT
Correspondence: Dr Cheryl SF Ngo, cherylngo@gmail.com

ABSTRACT
Introduction To describe the optic disc, visual field and ocular characteristics of a consecutive cohort of Asian patients with chronic primary angle-closure glaucoma (CPACG), and compare them with those having primary open-angle glaucoma (POAG).
Methods In a prospective comparative case series of new patients with POAG or CPACG in Singapore, all patients underwent visual acuity assessment, slit-lamp examination, tonometry, gonioscopy, refraction, Heidelberg Retina Tomograph (HRT) and Humphrey visual field (HVF) assessment.
Results 98 patients were enrolled (POAG n = 48; CPACG n = 50). CPACG patients were significantly older (66.5 ± 9.2 years vs. 64.1 ± 13.5 years; p = 0.027) and mostly female (p = 0.004). CPACG eyes had significantly higher intraocular pressure (26.9 ± 6.9 mmHg vs. 24.5 ± 3.3 mmHg; p = 0.03), shorter axial length (22.89 ± 0.97 mm vs. 24.26 ± 1.79 mm; p < 0.001) and shallower anterior chamber depth (2.60 ± 0.25 mm vs. 3.16 ± 0.48 mm; p < 0.001). HVF mean deviation or pattern standard deviation (PSD) did not differ significantly between POAG and CPACG eyes, but the latter had a lower PSD for a given mean deviation. HRT parameters between the two groups were not significantly different.
Conclusion In this study, CPACG eyes had significantly higher presenting intraocular pressure than POAG eyes, but there were no significant differences in optic disc topography. A majority of the patients in both groups had moderate field defects at the time of presentation, followed by severe and then mild defects. The field loss in CPACG eyes was more diffuse than that in POAG eyes.

Keywords: field of vision, intraocular pressure, optic nerve
Singapore Med J 2013; 54(3): 140-145; doi:10.11622/smedj.2013049

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Ong C, Biswas A, Choolani M, Low JJ
Correspondence: A/Prof Jeffrey Low, jeffrey_low@nuhs.edu.sg

ABSTRACT
Introduction The risk of malignancy index (RMI) is a scoring system used to triage benign from malignant ovarian masses. We compared the specificity and sensitivity of the four indices (RMI 1, RMI 2, RMI 3 and RMI 4) to discriminate a benign ovarian mass from a malignant one in a Southeast Asian population.
Methods This was a five-year retrospective study of women who were admitted for surgery due to ovarian masses. RMI scores were calculated based on standardised preoperative cancer antigen (CA)-125 levels, ultrasonography findings, menopausal status and tumour size based on ultrasonography. Postoperative histopathologic diagnosis was regarded as the definite outcome. Data were analysed using the Statistical Package for the Social Sciences, and Mann-Whitney U test was used to compare the individual RMI scores between the benign and malignant cases.
Results Out of the 480 patients reviewed, 228 women aged 10–65 years were included in the study. Of these, 17 (7.5%) had malignant disease and 211 (92.5%) had benign pathology. There was no statistical difference in the RMI 1, 2, 3 and 4 scores between the benign and malignant cases. Individual variables that were analysed showed significant differences in median CA-125 level and tumour size (p = 0.044 and p < 0.0005, respectively) between the benign and malignant cases.
Conclusion Our study shows that RMI is not a valuable triage tool for our Southeast Asian population. Further prospective validation, with regard to standardising results in different patient populations and centres, is required.

Keywords: CA125, ovarian cancer, risk of malignancy index, ultrasonography
Singapore Med J 2013; 54(3): 136-139; doi:10.11622/smedj.2013046

REFERENCES

Vanadurongwan B, Siripisitsak T, Sudjai N, Harnroongroj T
Correspondence: Prof Thossart Harnroongroj, tmthr@mahidol.ac.th

ABSTRACT
Introduction The end of medial opening oblique wedge high tibial osteotomy (HTO) points into a narrow area between the articular cartilage of the posterolateral proximal tibia and proximal tibiofibular joint (PTFJ) at the tibial site, which is an anatomical safe zone (ASZ) for osteotomy. We studied the ASZ and its relation to the fibular tip, including the level of posterior cruciate ligament (PCL) insertion, to avoid penetration into the knee and PTFJ, and PCL injury by osteotomy.
Methods Ten pairs of embalmed cadaveric legs were disarticulated at the knee joint and then examined. Soft tissues at the proximal tibia were removed. The posterior capsule of the PTFJ was incised to identify the articular cartilage of the PTFJ at the tibial site. The height of the fibular tip and the thickness of the ASZ were measured and calculated to determine the relationship between the ASZ and fibular tip. The level of PCL insertion was measured from the posterior articular surface of the proximal tibia to the distal attachment of the PCL.
Results The average height of the fibular tip and the thickness of the ASZ were 5.43 ± 1.53 mm and 4.12 ± 1.60 mm, respectively. On average, the fibular tip was 1.31 ± 1.28 mm higher than the ASZ, and the level of PCL insertion was 10.10 ± 1.88 mm.
Conclusion To ensure safety during medial opening oblique wedge HTO, the end of osteotomy should point accurately into the ASZ at a level just below the fibular tip as reference. Proximal osteotomy thickness should not be less than 10 mm at the level of PCL insertion.

Keywords: anatomical safe zone, fibular tip, medial opening oblique wedge high tibial osteotomy, posterior cruciate insertion
Singapore Med J 2013; 54(2): 102–104; http://dx.doi.org/10.11622/smedj.2013033

REFERENCES

Jin AZ, Louange EC, Chow KY, Fock C
Correspondence: Dr Jin Ai Zhen, Jin_ Ai_ Zhen@hpb.gov.sg

ABSTRACT
Introduction A retrospective observational study was performed to evaluate the effectiveness of CervicalScreen Singapore (CSS), a National Cervical Cancer Screening Programmme.
Methods National trends on incidence, mortality of cervical cancer and carcinoma in situof the cervix before and after the launch of CSS were examined. Linear regression was used to calculate the average annual percentage change in age-standardised incidence and mortality rates. We also examined the operational measures of CSS, such as the women who joined the CSS programme and the diagnostic accuracy of Pap smears. The study was confined to women who consented to join CSS at government-funded polyclinics.
Results Nationally, there was a greater decline in the age-standardised incidence and mortality rates in the period 2004–2008 as compared to the period 1987–2003. Under CSS, a total of 99,759 Pap smears were performed on 81,087 women in the period 2004–2008. However, the number of first screens decreased from 18,434 in 2004 to 11,624 in 2008. Among women aged 25–69 years who had their first Pap smear screening and who were recommended for routine rescreen in three years, 10% had a subsequent rescreen within three years. Overall, the CSS programme was able to detect 0.37 invasive cancers per 1,000 screens in women aged 25–69 years.
Conclusion The CSS programme has contributed to a decline in the mortality and incidence of cervical cancer in Singapore. However, the challenges of increasing the screening uptake among eligible women need to be addressed.

Keywords: cervical cancer screening, effectiveness, evaluation
Singapore Med J 2013; 54(2): 96–101; http://dx.doi.org/10.11622/smedj.2013032

REFERENCES

Padhy BM, Yadav R, Gupta YK
Correspondence: Dr Biswa Mohan Padhy, drbisu7@gmail.com

ABSTRACT
Introduction We aimed to assess the efficacy of fixed dose combination of atorvastatin plus ezetimibe in Indian patients with dyslipidaemia.
Methods A double-blind study was conducted to assess the effect of fixed dose combination of ezetimibe 10 mg plus atorvastatin 10 mg on lipid profile, oxidised low-density lipoprotein (ox-LDL), high-sensitivity C-reactive protein (hsCRP) and soluble intercellular cell adhesion molecule (sICAM) in dyslipidaemic patients with or at high risk of coronary artery disease, and compare it with atorvastatin 10 mg monotherapy. 30 patients were randomised to receive ezetimibe plus atorvastatin or atorvastatin once daily for four weeks.
Results Of the 30 patients, 10 men and 5 women (mean age 54.3 ± 1.6 years) received ezetimibe plus atorvastatin, while 13 men and 2 women (mean age 53.7 ± 2.8 years) received only atorvastatin. The combination treatment significantly reduced total cholesterol (percentage treatment difference −14.4 ± 6.5, 95% confidence interval [CI] −1.0 to −27.7; p = 0.041) and LDL cholesterol (LDL-C; percentage treatment difference −19.9 ± 6.1, 95% CI −7.4 to −32.4; p = 0.003) compared to atorvastatin monotherapy. 13 patients on combination treament achieved the National Cholesterol Education Program target for LDL-C as compared to 9 patients on atorvastatin monotherapy (p = 0.032). Significant reductions in very low-density lipoprotein cholesterol, triglyceride, ox-LDL and sICAM were observed with combination treatment compared to atorvastatin monotherapy. However, no significant change was seen in high-density lipoprotein cholesterol or hsCRP levels between the two groups.
Conclusion Combination treatment with atorvastatin and ezetimibe had relatively better lipid-lowering and anti-inflammatory efficacy than atorvastatin monotherapy.

Keywords: atorvastatin, ezetimibe, high sensitivity C-reactive protein, intercellular cell adhesion molecule
Singapore Med J 2013; 54(2): 90–95; http://dx.doi.org/10.11622/smedj.2013031

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Ng PL, Kwok CH, Tsui SH, Tong HK
Correspondence: Dr Pui-Lok Ng, lucypl@yahoo.com

ABSTRACT
Introduction Acute pulmonary embolism (PE) is an uncommon but potentially fatal disease. Acute right ventricular failure, which can be demonstrated by echocardiography, is known to be an adverse prognostic factor in patients with acute PE. However, this diagnostic test is not always available in emergency departments and it is also an operator-dependent investigation. This study aimed to investigate whether cardiac troponin I (cTnI) levels could predict clinical outcomes in Chinese patients with PE.
Methods This was a retrospective cohort study performed in a tertiary regional hospital in Hong Kong. For this study, 100 patients who were diagnosed with acute PE between January 1, 2002 and December 31, 2009 were recruited. Information, including demographic data, presenting symptoms and vital signs at presentation, predisposing factors for PE, results of diagnostic procedures and clinical outcomes, was collected from the medical records of these patients.
Results 71% of recruited patients had elevated cTnI levels. High cTnI levels were associated with haemodynamic instability (odds ratio [OR] 5.30, 95% confidence interval [CI] 1.32–27.71; p = 0.019) and complicated clinical course (OR 6.34, 95% CI 1.76–22.9; p = 0.002).
Conclusion Elevated cTnI level was associated with a complicated clinical course in patients with acute PE. We suggest that measurements of cTnI levels be used for the early risk stratification of patients with PE in the emergency departments of hospitals.

Keywords: cTnI, Chinese, PE, pulmonary embolism, troponin I
Singapore Med J 2013; 54(2): 86–89; http://dx.doi.org/10.11622/smedj.2013030

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