2005

CT Wai, G Lau, CJL Khor
Correspondence: Dr Chun-Tao Wai, waict@nuh.com.sg

ABSTRACT
An 89-year-old woman was admitted for intestinal obstruction. Her abdominal radiograph showed typical features of sigmoid volvulus. Decompression was done successfully through careful flexible sigmoidoscopy with minimum air insufflation. The patient's symptoms were relieved and she was discharged two days post-procedure. No recurrence was noted at extended follow-up. Rapid diagnosis and early decompression are key to optimal management of sigmoid volvulus.

Keywords: air insufflation, intestinal obstruction, sigmoid colon, sigmoidoscopic decompression, volvulus
Singapore Med J 2005; 46(9): 483-488

P Chiam, V Kwok, BA Johan, C Chan
Correspondence: Dr Paul Chiam, paul_chiam@nhc.com.sg

ABSTRACT
The current treatment of massive pulmonary embolism (PE) has been either thrombolysis or surgical embolectomy. Recently, percutaneous rheolytic thrombectomy has emerged as an alternative treatment in patients with contraindications to thrombolysis. We describe a 45-year-old woman who developed major PE post-operatively, who was treated successfully with the AngioJet system. The principles of percutaneous rheolytic thrombectomy, its effectiveness and potential complications are discussed.

Keywords: percutaneous rheolytic thrombectomy, pulmonary embolism, rheolytic thrombectomy catheter, thrombolysis
Singapore Med J 2005; 46(9): 479-482

R Zuzarte, CC Khong
Correspondence: Dr Khong Chit Chong, dkhong@kkh.com.sg

ABSTRACT
An unusual case of a second ipsilateral ectopic pregnancy following a partial (proximal) salpingectomy for ectopic gestation is presented in a 32-year-old woman with a history of secondary infertility. This occurred in the distal remnant of the left fallopian tube. It is postulated that the pregnancy was conceived following migration of spermatozoa or the fertilised egg from the endometrial cavity to the distal remnant of the left fallopian tube or by passage of spermatozoa through the intact right fallopian tube and the pouch of Douglas. Consequent to the maintenance of a high index of suspicion of ectopic pregnancy, there was early diagnosis and expedient surgical intervention on both occasions.

Keywords: ectopic pregnancy, laparoscopy, salpingectomy, tubal pregnancy
Singapore Med J 2005; 46(9): 476-478

P Nyiri
Correspondence: Dr Polly Nyiri, pollybrandon@btinternet.com

ABSTRACT
Introduction The World Health Organisation has identified schools as key players in the global effort to reduce the rising incidence of skin cancer. Singapore lies 70 miles from the Equator, with one of the world's highest ultraviolet (UV) index scores. It is a multi-ethnic society, with many expatriates. Children in Singapore are likely to be exposed to high levels of UV radiation, and represent a variety of skin types. This study aimed to assess sun protection measures in schools, the frequency of reported sunburn in schoolchildren of different ethnic groups, the level of parental and school concern about sun exposure, the sun-protective measures currently in place, and the parental and school support for public education and "sunsmart" school programmes.
Methods Questionnaires were sent to principals and parents of primary schoolchildren in 20 local and eight international schools in January 2003.
Results The majority of children in all ethnic groups in Singapore were reported to suffer to some degree from sunburn during their first ten years. Over 50 percent of parents and head teachers predicted an increased risk of skin cancer in their children. Some protective measures were in place. But teachers and parents were concerned, and most favoured the promotion of more active measures.
Conclusion The reported incidence of sunburn among Singaporean school children is higher than expected across all ethnic groups. Given the current level of sun protective measures in place, more could be done to educate parents and schools regarding "sunsmart practice", and reducing their future risk of skin cancer and eye damage.

Keywords: cataract, melanoma, school children, skin cancer, sunburn
Singapore Med J 2005; 46(9): 471-475

CS Foo, KH Tay, T Ravintharan
Correspondence: Dr Chek Siang Foo, foo.chek.siang@singhealth.com.sg

ABSTRACT
Introduction Laparoscopic adjustable gastric banding (LAGB) has been used for the treatment of obesity, being shown in western populations to be a safe and effective option. We present the results of our experience in the use of LAGB in the treatment of obesity.
Methods A retrospective review of all patients who underwent LAGB from February 1999 to June 2004 was made from a prospectively collected database. Pre-operative comorbidities, height, weight and body mass index (BMI) were recorded and compared with post-operative results. Operative times, length of stay and complications were also noted.
Results 38 consecutive patients underwent LAGB. The 16 male and 22 female patients had a mean age of 37.6 years (range 19 to 62 years) and a mean BMI of 42.7 kg per square metre (range 28.8 to 78.4 kg per square metre). Nine were done utilising the perigastric approach, and the other 29 with the pars flaccida approach. There were no open conversions. Overall peri-operative morbidity was encountered in two (5.3 percent) patients, with a minor liver laceration and a capsular splenic laceration in separate patients. There were no post-operative complications. One (2.7 percent) patient had the band removed at 29 months post-operatively on request. There were no mortalities. Mean follow-up period was 13 months (range one to 56 months). Mean BMI decreased to 40.7, 38.7, 37.4, 34.1 and 32.9 kg per square metre, respectively, at one week, one, six, 12 and 18 months post-operatively.
Conclusion LAGB is a feasible modality in the multifaceted approach to treatment of morbid obesity. The results from our follow-up are comparable to larger series in western populations, with a similar safety profile.

Keywords: bariatric surgery, gastric banding, laparoscopic adjustable gastric banding, laparoscopic surgery, obesity
Singapore Med J 2005; 46(9): 465-470

S Misbah, H Hassan, MY Yusof, YA Hanifah, S AbuBakar
Correspondence: Prof Sazaly AbuBakar, sazaly@um.edu.my; sazaly@ummc.edu.my

ABSTRACT
Introduction This study aims to identify Acinetobacter of clinical isolates from the University of Malaya Medical Centre (UMMC), Kuala Lumpur, to the species level by 16S rDNA sequencing.
Methods 12 representative Acinetobacter isolates of the UMMC inpatients were randomly picked and used for the study. The 16S rDNA sequences were determined and phylogenetic relationships to all known Acinetobacter species were established.
Results Based on the 16S rDNA sequences, all the UMMC isolates were identified as Acinetobacter baumannii. The isolates shared a common ancestral lineage with the prototypes Acinetobacter baumannii DSM30007 and DSM30008 with 99-100 percent sequence similarities. The isolates could be differentiated into two groups by a single nucleotide difference (thymine-cytosine) within the 16S rRNA sequence. Three different genotypes, 1, 3 and 4, were recognised using REP-PCR.
Conclusion The previously uncharacterised Acinetobacter isolates from the UMMC were identified by their 16S rDNA sequences as Acinetobacter baumannii. The isolates were distinguished into at least three different genotypes by REP-PCR genotyping. These findings confirmed for the first time the presence of Acinetobacter baumannii of different genotypes among patients at UMMC.

Keywords: Acinetobacter, genomic species identification, genotyping, 16S ribosomal RNA
Singapore Med J 2005; 46(9): 461-464

ZE Astal
Correspondence: Dr Zakaria El Astal, zalastal@yahoo.com

ABSTRACT
Introduction This study aims to assess common organisms causing urinary tract infection (UTI) in the Gaza Strip, Palestinian Authority and to examine the incidence of ciprofloxacin resistance in the strains of bacteria isolated from patients suspected with UTI over a six-month period.
Methods Ciprofloxacin was evaluated along with other commonly-used antibiotics against a total of 480 clinical isolates obtained from urine samples. The samples were collected from community patients from different parts of the Gaza Strip. Susceptibility tests were done by the Kerby Bauer method.
Results Among the tested drugs, the percent resistance rate to ciprofloxacin was 15.0 percent. However, high resistance to ciprofloxacin was detected among Acinetobacter haemolyticus (28.6 percent), Staphylococcus saprophyticus (25.0 percent), Pseudomonas aeruginosa (20.0 percent), Klebsiella pneumonia (17.6 percent) and Escherichia coli (12.0 percent). Minimal inhibitory concentration of ciprofloxacin was measured for all resistant UTI isolates.
Conclusion This study indicates emerging ciprofloxacin resistance among most UTI bacterial pathogens. Increasing resistance against ciprofloxacin demands coordinated monitoring of its activity and rational use of the antibiotics.

Keywords: antibiotic resistance, ciprofloxacin, urinary tract infection
Singapore Med J 2005; 46(9): 457-460

WJ Chng, C Sum, P Kuperan
Correspondence: Dr Chng Wee Joo, chngwj@nuh.com.sg

ABSTRACT
Introduction To determine the causes of isolated prolonged activated partial thromboplastin time (APTT) in an acute care general hospital setting so as to rationalise fresh frozen plasma usage.
Methods A prospective study of consecutive patients with isolated prolonged APTT presenting to our hospital between February 2002 and January 2004 was performed. All patients had normal prothrombin time and thrombin time. For all patients, an initial 50:50 correction with plasma was done and a standard panel of tests was performed. These included detection of lupus anticoagulant using two different sensitive tests; measurement of coagulant factors VIII (FVIII), IX, XI and XII, which are involved in the intrinsic arm of haemostasis; von Willebrand factor antigen (vWF:Ag) levels and for those with FVIII levels less than 10 percent, an inhibitor assay using the Nijmegen modification of the Bethesda method.
Results 177 patients were included in the study. The cohort was typical of an acute care general hospital patient population in Singapore in terms of age, sex and racial distribution. The most common cause of an isolated prolonged APTT in our study was the presence of lupus anticoagulant (53.1 percent of cases). In 31.6 percent of cases, obvious cause could be detected after our panel of tests. These patients mostly had mildly prolonged APTT that could be both correctable and non-correctable by normal plasma. Prolonged APTT due to factor deficiency was relatively rare with those that may potentially cause haemorrhagic problems only accounting for 4.5 percent of cases.
Conclusion Our study suggests that most of the causes of isolated prolonged APTT do not lead to haemorrhagic complications. In fact, in a majority, it may signify an underlying thrombophilic condition. As a result, prolongation of APTT should be fully investigated and correction with fresh frozen plasma should be used only when appropriate.

Keywords: coagulation factors, fresh frozen plasma, lupus anticoagulant, prolonged activated partial thromboplastin time
Singapore Med J 2005; 46(9): 450-456