Original Article

C Vu, YY Ng
Correspondence: Dr Charles Vu, Charles_Vu@notes.ttsh.gov.sg

ABSTRACT
Introduction High Helicobacter pylori (H. pylori) prevalence is well documented among peptic ulcer patients. However, there have been recent reports of declining H. pylori infection rates in developed countries. Based on previous local data in a different hospital, H. pylori prevalence was 66% in gastric ulcer, 86% in duodenal ulcer and 75% in combined gastric and duodenal ulcers. Our present study aims to review the recent H. pylori prevalence in peptic ulcer patients in a Singapore hospital. H. pylori infection rate in relation to sex, age, non-steroidal anti-inflammatory drug (NSAID) use and race were also examined.
Methods Over a 6-month period, patients diagnosed with peptic ulcer by oesophagogastroduodenoscopy were selected. Relevant information was obtained from case notes retrieved from the Medical Records Office. H. pylori status was assessed by rapid urease test (CLOtest) and/or histology. Exclusion criteria were(1) history of peptic ulcer(2), active bleeding(3), cancer or(4) recent use of antibiotics or proton pump inhibitors.
Results 107 peptic ulcer patients were selected; 53 gastric ulcer, 47 duodenal ulcer and 7 with combined gastric and duodenal ulcers. Overall H. pylori prevalence was 67.9%(36/53), 85.1%(40/47) and 85.7%(6/7) respectively. Except for the gender variable in gastric ulcer group, age, race and NSAID use was not found to influence H. pylori prevalence.
Conclusion The prevalence of H. pylori among our peptic ulcer patients is slightly lower compared to overseas studies but the local trend,when compared indirectly to another previous local study did not appear to have changed much. Reasons for the lower H. pylori infection rate in comparison to overseas studies are discussed. The lower H. pylori prevalence among female gastric ulcer patients may be due to the higher prevalence of NSAID use.

Keywords: Helicobacter pylori, peptic ulcer, prevalence, Singapore
Singapore Med J 2000; 41(10): 478-481

CK Low, AWM Lam
Correspondence: Dr Low Chee Kwang

ABSTRACT
Aim of Study A retrospective review on the outcomes of four floating shoulder, ipsilateral scapular neck and clavicular fractures, treated with open reduction and internal fixation of the clavicle alone using plate and screws.
Methods All patients were evaluated by interview, physical examination and radiological examination at an average follow up period of 3.3 years (range: 2-4 years). Functional outcomes were rated using Rowe's score.
Results Radiological union of both fractures occurred at an average of 2.8 months (range: 8-12 weeks). Excellent result was seen in three cases and good in one.
Conclusion Plating of clavicle alone restored stability of shoulder and allowed early range of motion exercises. All cases gained good and excellent function.

Keywords: Ipsilateral scapular neck and clavicular fractures, Rowe’s score
Singapore Med J 2000; 41(9): 452-453

G Chee, P Mok, R Sim
Correspondence: Dr Gerard Chee, entv3@nus.edu.sg

ABSTRACT
Squamous cell carcinoma of the external ear canal is an uncommon condition that is associated with a poor outcome. The development of an accepted staging system has not been forthcoming and this has inhibited the formation of an evidence-based therapeutic protocol. We report the findings in 14 patients with squamous cell carcinoma of the external ear canal treated in our institutions. The most common presenting symptoms were otorrhoea and otalgia. Four patients had a history of chronic ear discharge and one had previous radiotherapy for nasopharyngeal carcinoma. Five patients had facial palsy which was a poor prognostic sign. Only one patient had clinical neck disease. Pre-operative imaging with CT or MRI scans was accurate in determining the extent of tumour involvement. The initial T-staging relied heavily on these findings. With combination treatment involving surgery, radiotherapy and chemotherapy, disease free survival achieved was 69% (9 of 13) over a mean follow-up period of 24.7 months. One patient absconded treatment. Patients with early stage tumours faired better than patients with advanced tumours (100% vs 33%). There was low incidence of involvement of the parotid gland (1 of 7 patients). Patients with facial nerve involvement had a significantly poorer outcome (p = 0.035).

Keywords: Squamous Cell Carcinoma, external ear canal, carcinoma staging system
Singapore Med J 2000; 41(9): 441-446,451

AS Devnani
Correspondence: Dr A S Devnani, devnani@kb.usm.my

ABSTRACT
Aim To study the outcome of gradual reduction by skin traction of supracondylar fracture of the humerus in children with swollen elbow, who seek treatment two days or longer after the injury.
Method Fifteen children aged between 4 and 11 years (average 7 years 11 months), who had initially consulted a traditional practitioner, reported between 2 and 21 days (average 7.5) after the injury were treated by skin traction with the elbow kept straight and the forearm in position of comfort.
Results The average duration of stay in hospital was 14 days. All fractures healed; there was no incidence of myositis ossificans or neurovascular deficit. All patients had functional range of movements at the elbow within 6 months. Five patients developed cubitus varus deformity greater than 5 degrees, they were classified as poor result. Four out of these 5 patients had sought treatment after a delay of 7 days or longer. There were 9 good (60%), 1 fair (7%) and 5 poor (33%) results.
Conclusion Gradual reduction by skin traction is safe. It is possible to achieve satisfactory reduction if the delay is up to 7 days. The results with regards to deformity and function were comparable with those obtained following open or closed Kirschner wire fixation.

Singapore Med J 2000; 41(9): 436-440

P Damodaran, R Subramaniam, SZ Omar, P Nadkarni, M Paramsothy
Correspondence: Dr Premitha Damodaran, premita@pc.jaring.my

ABSTRACT
The object of this study is to determine the status of an urban Malaysian woman in her menopause age group with reference to her menopausal symptoms, lipid profile, breast, pelvis and bone. One hundred and sixty four women attending the Menopause Clinic of University Hospital, Kuala Lumpur who had not previously been on hormone replacement therapy were studied. Forty nine women were perimenopausal, 74 women were in early menopause (within 5 years of menopause) and 41 women were in late menopause (after 5 years of menopause). The most common symptoms were hot flushes (56%) and generalised tiredness (49%). Eighty four percent (84%) of women had high cholesterol levels. Serum triglycerides were highest in the late menopause group. There were 2 cases of intraductal carcinoma diagnosed on routine mammography, with 8 cases of fibrocystic breast disease and 7 cases of suspicious breast lumps. Routine ultrasound (pelvic and abdominal) revealed two women with ovarian cysts, 6 women with an endometrial thickness of more than 5 mm and 8 women with uterine fibroids. Eighty five women (51.8%) had mild osteoporosis while four women had moderate osteoporosis on dual photon measurements for bone mineral density. Menopause clinics should aim at investigating a woman in her menopause as a whole. Vasomotor symptoms were common in the urban Malaysian menopausal woman. There was a high incidence of lipid abnormalities. Routine mammography, pelvic ultrasound examinations and bone mineral density tests detected significant pathology and abnormalities.

Keywords: menopause, Malaysia, symptoms, cholesterol, triglycerides, bone mineral density, mammogram, pelvic ultrasound
Singapore Med J 2000; 41(9): 431-435

JTS Theng, TY Wong, Y Ling
Correspondence: Julian Theng

ABSTRACT
Aim In Caucasian populations, premature infants with retinopathy of prematurity (ROP) have been reported to have higher risks of developing refractive errors and strabimus. The purpose of this study is to evaluate the rate of these complications in Asian premature infants with and without ROP.
Methods A retrospective case review of all premature infants referred to the Singapore National Eye Centre for ophthalmology screening. These included all neonates born earlier than 34 weeks gestational age and less than 1500 grams in birth weight. Standardized ophthalmology examinations including cycloplegic refraction and fundus examination at regular intervals were performed to determine the presence of ROP, refractive errors, squints and other ocular abnormalities until the patients were 3 years old.
Results During 1991 to 1993, a total of 113 neonates were reviewed. Of these, 16 (14.2%) developed ROP. The risk of ROP was higher with lower birth weights and earlier gestational ages. At 1-year follow-up, the rate of myopia was 33.3% in babies with ROP compared to 3.7% in babies with no ROP (p < 0.001). The higher rates of myopia in babies with ROP remained with longer follow-up (33.3% and 25% in ROP group versus 3.4% and 3.8% in no ROP group, at 2 and 3 years respectively). There was no difference in rates of astigmatism or hyperopia throughout the 3 years. At 1 year follow-up, the rate of strabismus was 20% in the ROP group compared to 4.9% in the no ROP group (p = 0.07). However, this difference in rates of strabismus was not significant at 2 and 3 years of follow-up.
Conclusion Premature babies with ROP had higher rates of myopia and strabismus than those without ROP. Long-term follow-up of these babies is important for early detection and treatment of these ocular problems.

Keywords: ROP, myopia, astigmatism, strabismus, amblyopia
Singapore Med J 2000; 41(8): 393-397

ELHJ Teo, K Tan, SL Lam, CL Ong, CS Wong
Correspondence: E L H J Teo

ABSTRACT
Aim To evaluate the roles and effectiveness of US and CT in a clinical algorithm for the evaluation of children with suspected appendicitis.
Methods Patients with suspected appendicitis were prospectively evaluated with ultrasound (US), and in some cases with CT, after they were graded to have high, intermediate or low clinical likelihood for appendicitis. Imaging findings were made known to clinicians who then decided on a line of management. Patho-histological examination and clinical follow-up established the final diagnoses, which were correlated with the imaging findings. The effect of imaging on the management of patients was examined.
Results Overall, the sensitivity of US was 92.9%, specificity 96.9%, accuracy 96.0%, positive predictive value 89.7% and negative predictive value 97.9%. Imaging did not affect the decision to operate in 13/14 (92.9%) patients in the high likelihood subgroup. Imaging guided the clinicians to the right management pathway in 26/30 (86.7%) patients in the intermediate group. 77/82 (93.9%) of US was truly negative in the low likelihood group. CT was performed in 12 patients because of unsatisfactory US scans or incompatibility between the US and the clinical findings. CT correctly diagnosed the presence or absence of appendicitis in all 12 patients.
Conclusion US and CT are accurate modalities in the diagnosis of acute appendicitis in children. US is most useful in patients with equivocal clinical findings. US should be the first modality used to evaluate children with suspected appendicitis. CT should be reserved for cases where US is sub-optimal or where the findings are inconsistent with the clinical findings.

Keywords: acute appendicitis, ultrasound, computed tomography, children
Singapore Med J 2000; 41(8): 387-392

CJL Khor, KM Fock, TM Ng, EK Teo, CS Sim, AL Tan, A Ng
Correspondence: Dr Christopher Khor, ckhor@bigfoot.com

ABSTRACT
We aimed to determine the rate of Helicobacter pylori (HP) recurrence and duodenal ulcer relapse in patients of a hospital in Singapore over a period of at least one year from the time of eradication. Ninety-six consecutive duodenal ulcer patients with biopsy-proven HP eradication and healed ulcer were seen at 3-month intervals, and follow-up endoscopy was performed when dyspepsia recurred, at the end of one year after eradication, or at the time of recall if the patient had been lost to follow-up. HP status was determined by antral and corpus biopsies and by antral cultures. Sixty-five had been given triple therapy, and 31 received dual therapy with omeprazole + amoxycillin or clarythromycin. Median time to follow-up endoscopy was 12 months. Six patients (6.25%) were positive for HP infection after eradication. Recurrence of HP infection was detected at 9 and 10 months after confirmation of HP eradication in two patients, and at between 13 and 20 months in the remaining four. Two of these had recurrent duodenal ulcer; all but one had erosive duodenitis. Two other patients had recurrent duodenal ulcer despite absence of HP reinfection; they admitted to taking low-dose aspirin. It was concluded that the recurrence of HP infection is low at the end of one year after successful eradication therapy in this urban East Asian population. Ulcer relapse occurred in 4.17% (4/96) of patients, and was associated with recurrent HP infection or NSAID exposure.

Keywords: Helicobacter pylori, Drug Therapy, Combination, Peptic Ulcer, Follow-up studies, Recurrence
Singapore Med J 2000; 41(8): 382-386

YY Sitoh, A Lee, SY Phua, PK Lieu, SP Chan
Correspondence: Dr Yih Yiow Sitoh, syympc@pacific.net.sg

ABSTRACT
Aim Dysphagia is common in the elderly and is associated with increased morbidity and mortality. We undertook a prospective study to determine the usefulness of a simple bedside swallowing test in terms of (1) detecting previously undiagnosed dysphagia, (2) agreement of the doctor's assessment with that of the speech therapist, (3) impact on subsequent feeding modality, (4) predicting risk of subsequent pneumonia.
Method Patients in an acute geriatric ward who had no contra-indications to oral feeding were subjected to a bedside swallowing assessment by a geriatrician within 24 hours of admission. All patients found to be dysphagic were subsequently re-assessed by a speech therapist within 48 hours. In addition, every fifth patient deemed to have normal swallowing by the doctor was assessed by the speech therapist.
Results Sixty-five patients were studied. The doctor's assessment was in very good agreement with the assessment of the speech therapist (kappa = 0.87). Patients found to have dysphagia using the doctor's assessment protocol had an increased risk of developing pneumonia during their hospitalization (relative risk R.R.: 9.9 confidence interval C.I.: 1.2-81.2). Cough on swallowing and delayed swallowing were both found to be associated with an increased risk of developing pneumonia during the period of hospitalization (R.R.: 4.2, C.I.: 1.2-14.4; R.R.: 5.3, C.I.: 1.1-26.3 respectively).
Conclusion A simple bedside swallowing test can be used as an effective screening tool in detecting hitherto undiagnosed dysphagia. The validity of this tool in the diagnosis of aspiration requires further investigation.

Keywords: dysphagia, bedside swallowing assessment, screening tool, geriatrics
Singapore Med J 2000; 41(8): 376-381

WY Sekhar, EH Soo, V Gopalakrishnan, S Devi
Correspondence: Dr Shamala Devi, shamala@medicine.med.um.edu.my

ABSTRACT
The aim of the study was to look into the epidemiology of serodiagnosed cases of leptospirosis at the University Hospital and compare two commercial ELISA Assays to the Microscopic Agglutination Test (MAT). Demographic data for all serodiagnosed cases for the years 1991-1997 were collected. From this data, 104 sera (n = 104) were selected as samples for comparative evaluation of the commercial ELISAs (INDX Dip-S-Ticks and PanBio ELISA) to the MAT test. Thirty two (n = 32) negative control sera were selected from serodiagnosed cases of other differential diagnosis of leptospira infection. The MAT test is a standard test that detects agglutination antibodies to leptospira biflexa, while the INDX Dip-S-Ticks is an ELISA dot test assaying for total anti-leptospira antibodies. The PanBio ELISA is a colorometric assay in test well strips to detect anti-leptospira IgM. The sensitivity, specificity, and efficiency of tests were calculated at a MAT cut-off value of 1:320. Demographic data showed that leptospirosis peaks during March-May and Aug-Nov coinciding with the inter-monsoon period with more men being infected than women and more adults than children. The sensitivity, specificity, and efficiency of test for the INDX Dip-S-Ticks were 83.3%, 93.8% and 87.5% while the values for the PanBio ELISA were 54.2%, 96.9% and 71.3%. The suboptimal PanBio result could be related to the blocking effect of high IgG titres or could be related to the diagnostic MAT cut-off values used in this study. The data hence reflects a pattern of transmission that is related to "wet" occupational risk factors. The commercial assays evaluated, are easier to perform but interpretation of results should be based on level of endemicity. The INDX Dip-S-Ticks allows this flexibility and is a practical alternative to the MAT test.

Keywords: leptospira, epidemiology, diagnostic assay, ELISA, Dipsticks
Singapore Med J 2000; 41(8): 370-375