2009

Lim BL, Lim GH, Heng WJ, Seow E
Correspondence: Dr Lim Beng Leong, beng_leong_lim@ttsh.com.sg

ABSTRACT
Introduction While non-contrast computed tomography (CT) of the brain can be used to rapidly identify patients with altered mental status (AMS) in the emergency department (ED), with an acute intracranial bleed or infarct, a wide variation in its use exists. The aim of this pilot study was to identify the clinical predictors of an abnormal CT result in ED patients with AMS.
Methods We conducted a retrospective study of patients aged 15 years and older presenting with undifferentiated AMS in a busy urban ED over one year. Data collected included demographical, clinical, laboratory and radiological features. The primary outcome of interest was the presence of an abnormal CT result defined as an acute infarct or intracranial bleed. Secondary outcomes were clinical predictors of an abnormal CT result. The data was analysed using descriptive statistics. Logistic regression was used to identify clinical predictors of an abnormal CT result. Odds ratios (ORs) were reported with 95 percent confidence intervals (CIs).
Results 578 patients were recruited, of which 284 (49.1 percent) were males. 327 (56.6 percent) patients underwent CT of the brain. 128 scans (39.1 percent) were abnormal. Logistic regression revealed seven clinical features that were associated with an abnormal CT result. They were mean age greater than or equal to 73 years (OR 1.03; 95 percent CI 1.015–1.045), drowsiness or unresponsiveness (OR 1.73; 95 percent CI 0.17–17.72), previous cerebrovascular accident (OR 2.03; 95 percent CI 0.82–5.02), previous epilepsy (OR 1.63; 95 percent CI 0.63–4.19), tachycardia [greater than 120/min] (OR 1.16; 95 percent CI 0.38–3.54), bradycardia [less than 60/min] (OR 1.35; 95 percent CI 0.19–9.59) and exposure to drugs (OR 1.90; 95 percent CI 0.58–6.26).
Conclusion We identified seven clinical predictors of an abnormal CT result in AMS patients. Future research in prospective studies is needed to validate these findings.

Keywords: altered mental status, brain infarction, cerebral computed tomography, intracranial haemorrhage
Singapore Med J 2009; 50(9): 885-888

Wang E, Lim BL, Than KY
Correspondence: Dr Etienne Wang, etiennewang@gmail.com

ABSTRACT
Introduction In Singapore, a significant proportion of patients receive specialist dermatological services via referrals from points of primary care, such as polyclinics and emergency departments (ED). The study hospital, Tan Tock Seng Hospital, is an acute care general hospital with a large catchment area, and has the busiest ED in Singapore. The aim of this paper was to describe the types of dermatological conditions presented at the ED in the year 2007. This information is useful for the future education of junior doctors working in the department, as well as for the allocation of future resources in the treatment of the more common conditions.
Methods The ED patient database was searched for all dermatological conditions by ICD-9 code and by keywords in the diagnosis description. The two lists were merged and duplications were eliminated. The consultation notes of the patients were reviewed in cases where the diagnosis was ambiguous. Patient demographics were then filtered and analysed.
Results A total of 4,061 patients were seen in the ED with a primary dermatological complaint, out of a total of 157,527 attendances in 2007. The commonest conditions seen were chickenpox and herpes zoster (20.8 percent). Dermatitis/eczema (11.6 percent) and urticaria (11.4 percent), nail conditions including trauma and infections (10.2 percent) and drug rashes (9.7 percent) were also common. Venereal diseases (1 percent) were uncommonly seen in the ED. Interestingly, men (65.3 percent) were seen in the ED for dermatological conditions twice as often as women (34.7 percent).
Conclusion The recognition and management of the common conditions should be core modules in the training of doctors and nurses.

Keywords: chickenpox, dermatitis, dermatological conditions, rash, skin conditions
Singapore Med J 2009; 50(9): 881-884

Özgür BC, Özgür S, Dogan V, Örün UA
Correspondence: Dr Berat Cem Özgür, bcemozgur@hotmail.com

ABSTRACT
Introduction Monosymptomatic nocturnal enuresis (MNE) is a frequent problem in children older than five years of age. Of the various treatment options, the enuresis alarm has been widely advocated for treating nocturnal enuresis. This study was designed to evaluate the success rates of the enuretic alarm device in patients with MNE.
Methods 40 patients who had significant MNE (three or more wet nights per week)were included. They used an enuretic alarm for 12 weeks initially. If a relapse was observed, reusage of the device was provided. A success criterion was defined as “14 consecutive dry nights” and a relapse criterion was “more than one wet night a week”.
Results The patients’ mean age was 8.1 (range 6–16) years and the mean follow-up time was 10.2 (range 6–19) months. 27 patients became dry at night at the end of three months. In the follow-up period, a relapse was observed in 66.7 percent of the initial responders. For recovery, 14 patients started to reuse the device, and seven of them responded positively. At the end of the treatment, a total of 13 of the patients had benefited from the enuretic alarm.
Conclusion During the follow-up, the enuretic alarm device provided acceptable initial and long-term complete dryness in patients with primary nocturnal enuresis. Without the need for expensive pharmacological intervention, the alarm treatment is an effective choice for children with nocturnal enuresis.

Keywords: enuresis alarm, monosymptomatic nocturnal enuresis, nocturnal enuresis, primary nocturnal enuresis
Singapore Med J 2009; 50(9): 879-880

Hemmati F, Pishva N
Correspondence: Dr Fariba Hemmati, hemmatif@sums.ac.ir

ABSTRACT
Introduction Previous studies report the spectrum of thyroid function abnormalities in critically-ill neonates. In this study, we evaluated the thyroid status in critically-ill neonates, and determined whether thyroid function abnormalities are more common in sick neonatal infants.
Methods In a prospective cohort study, 67 critically-ill infants from the Neonatal Intensive Care Unit (NICU), affiliated to Shiraz University of Medical Sciences, were entered into our study. Of all the included neonates, 33 were premature and seven were under 28 weeks of gestation. In addition to the routine thyroid-stimulating hormone (TSH)-screening (capillary specimen), serum free triiodothyronine (FT3), free thyroxine (FT4) and TSH were checked using radioimmunoassay kit twice (during critical illness and before discharge from the NICU).
Results It was observed that abnormal TSH levels (screening test) were about 40-fold higher in critically-ill neonates compared with healthy neonates, while more than four-fifths of them were detected in the second sampling done after recovery. The mean FT3 was significantly lower during the critical illness and it increased after recovery (2.537 and 3.232 pg/ml, respectively). Mean FT4 and mean TSH during the illness and after recovery did not have any significant difference.
Conclusion Thyroid function abnormalities are more common in infants under intensive care and most of them manifested as “euthyroid sick syndrome”; abnormal screening tests may be due to the transient elevation of TSH during recovery from illness. Therefore, only in cases in which TSH rises more than 15–20 mIU/L or TSH remains high for a month or longer, that treatment is needed, while other cases must be followed up by serial determination of TSH and FT4. The levels of FT3 and FT4 during the illness were not affected by the duration and severity of the illness.

Keywords: euthyroid sick syndrome, neonatal intensive care unit, neonatal screening, thyroid function tests, thyroid status
Singapore Med J 2009; 50(9): 875-878

Singh JK, Vasudevan V, Bharadwaj N, Narasimhan KL
Correspondence: Dr Kannan Laksmi Narasimhan, narasimhankl@gmail.com

ABSTRACT
Introduction Foreign body aspiration in the airway of children is a life-threatening clinical situation. Endoscopic retrieval alone is successful in the majority of patients. Occasionally, open surgical intervention in the form of tracheostomy, thoracotomy and bronchotomy and/or pulmonary resection is needed. We analysed the specific indications for tracheostomy during the removal of airway foreign bodies in our study.
Methods The records of four patients who needed tracheostomy, out of 342 cases of foreign body airway obstruction managed by the senior author, were analysed. These patients underwent an additional tracheostomy for open removal of the foreign body and/or to secure the airway to facilitate the foreign body removal.
Results Rigid bronchoscopy was successful in retrieving the foreign bodies in 338 (98.8 percent) cases, while four (1.2 percent) cases required additional tracheostomy, either to protect the airway during the procedure or to assist in removing the foreign body. The indications for tracheostomy were subglottic foreign bodies of long duration, sharp subglottic foreign bodies and foreign bodies that were larger than the glottic chink. There was no mortality or long-term complication because of the tracheostomies.
Conclusion Tracheostomy is occasionally indicated in foreign body extraction, when they are subglottic in location and impacted, or are large foreign bodies that get obstructed at the glottic chink during removal.

Keywords: airway obstruction, bronchoscopy, foreign body, tracheostomy
Singapore Med J 2009; 50(9): 871-874

Mantoo SK, Mak K, Tan TJ
Correspondence: Dr Surendra Kumar Mantoo, skmantoo@yahoo.co.in

ABSTRACT
Introduction Obturator hernia is a rare variety of abdominal hernia that nonetheless is a significant cause of morbidity and mortality, especially in the elderly age group. This article aimed to review the diagnosis and management of obturator hernia by describing the anatomy, clinical presentation, predisposing factors, diagnostic modalities and management in the modern era.
Methods We managed six cases of obturator hernia between 2003 and 2006. Five out of six cases were diagnosed by a preoperative computed tomography (CT) and the sixth case was diagnosed by ultrasonography. All except one were managed by an exploratory laparotomy and repair of the hernia, and one was treated with laparoscopic repair.
Results Correct preoperative diagnosis was made in five out of five (100 percent) patients by clinical signs and CT of the abdomen and pelvis, and the sixth patient was operated on the basis of an ultrasonographical diagnosis and strong clinical suspicion.
Conclusion We conclude that the rapid evaluation by CT of the abdomen and pelvis and surgical intervention are possible, thereby reducing the morbidity and mortality of patients with obturator hernia. An algorithm for the management of obturator hernia is proposed.

Keywords: abdominal hernia, obturator hernia, strangulated hernia
Singapore Med J 2009; 50(9): 866-870

Lim YK, Kam MH, Eu KW
Correspondence: Prof Eu Kong Weng, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction The role of carcinoembryonic antigen (CEA) in screening has been previously investigated and found to be inefficient because of its low sensitivity and specificity. Nevertheless, it is still used as a tumour marker in health screening packages, often for asymptomatic patients. We aimed to review all asymptomatic patients who were referred to our department for raised CEA, to determine if this was indeed associated with significant pathology, and to what extent the asymptomatic patients should be investigated.
Methods All patients with no gastrointestinal symptoms, and whose only indication for endoscopy was a raised CEA level, were entered into the study group. All the investigations were retrospectively reviewed and any pathology was noted.
Results There were 217 asymptomatic patients who presented for endoscopy and further  evaluation due to raised CEA,from December 1998 to August 2004. After the initial investigations, a total of 20 primary and eight metastatic cancers were found. The malignancies detected included 11 colorectal cancers, two stomach cancers, five lung cancers, one periampullary carcinoma and one ovarian teratoma. There were two cases of metastasis in the lungs and six with liver metastasis. In the subsequent median follow-up period of 13 (range 6–97) months, an additional 16 (7.4 percent) primary cancers were detected.
Conclusion Asymptomatic average -risk patients who present with raised CEA should be investigated endoscopically and radiologically for commonly-associated cancers, and thereafter followed up for at least two years, as up to 7.4 percent present with a subsequent malignancy.

Keywords: cancer screening, carcinoembryonic antigen, colorectal cancer, tumour marker
Singapore Med J 2009; 50(9): 862-865

Ng YCS, Tan MH
Correspondence: Dr Ng Yung Chuan Sean, seanng31@gmail.com

ABSTRACT
Introduction Liposarcoma is one of the more common types of soft tissue sarcomas, presenting with a wide spectrum of clinical behaviour. However, there is little information on the outcome, management and survivability of patients with extremity liposarcoma in Singapore.
Methods A retrospective review of all the patients with extremity liposarcoma, diagnosed between 1997 and 2007, was performed. Univariate and multivariate statistics were used on the data to evaluate the clinical presentations, treatment, outcome and survivability of patients seen.
Results Over a ten-year period, 30 patients were seen for primary liposarcoma of the extremities. Three patients dropped out and 27 were managed and followed-up. Management included surgery and/or radiotherapy. Histological subtypes included 14 (51.9 percent) well-differentiated, five (18.5 percent) myxoid, four (14.8 percent) de-differentiated, and two (7.4 percent) each of round cell and pleomorphic variants. Four patients (14.8 percent) developed local or metastatic recurrent disease. The mean follow-up was 53 months, and the survival rate with primary disease at 53 months was 92.6 percent. The recurrence-free survival for primary disease at 53 months was 85.2 percent.
Conclusion Liposarcoma of the extremities is relatively rare compared to other major soft tissue tumours. It is a highly pleomorphic disease, whose outcome is dependent on the histological subtype. Limb-sparing management includes wide resection of the tumour with/without radiation postoperatively.

Keywords: dedifferentiated liposarcoma, limb-sparing surgery, lipomatous tumour, liposarcoma, musculoskeletal tumour, soft tissue sarcoma
Singapore Med J 2009; 50(9): 857-861

Peh WCG, Ng KH
Correspondence: Prof Wilfred CG Peh, smj.editor@sma.org.sg

ABSTRACT
Processing of a submitted manuscript is a complex and time-consuming process. Authors should be aware of items in the editorial office checklist. The journal editors and peer reviewers are an essential part of the manuscript processing system. Copy editors serve as a link between authors and the printer/publisher, and aim to adapt the accepted manuscript to the journal house style and to improve readability of the article.

Keywords: manuscript processing, manuscript submission, medical writing, scientific paper
Singapore Med J 2009; 50(9): 853-856