Original Article

BP Khoo, YC Giam
Correspondence: Dr B P Khoo

ABSTRACT
Background Pitted nails is a non-specific entity seen in children that is often associated with various underlying skin disorders such as atopic dermatitis, psoriasis, alopecia areata and lichen planus; and those without such associations are labelled as idiopathic pitted nails. Spontaneous resolution is common but may take several years. Treatment options so far have not been encouraging. This pilot study sought to determine the safety and efficacy of intralesional steroid in the treatment of pitted nails in children.
Method Children with pitted nails below the age of 12, seen between January 1994 and December 1997, were invited to participate in this study. Symmetrically affected fingernails were selected, topical anaesthetic cream applied and a single dose of triamcinolone acetonide was introduced intralesionally to the proximal nailfold while the contralateral nail acted as control. The degree of pitting of nail surface was documented at months 0, 2 and 4.
Results Four children were enrolled, and their ages ranged from 4 to 9 years. The degree of pitting was reduced to a mean of 15% of the nail surface in the second month, and 42% in the fourth month. The procedure was fairly well tolerated and no adverse effects were noted.
Conclusion Intralesional steroid is a safe and acceptable method of treating pitted nails in children with a maximum effect seen in 2 months. In order to sustain a continuous therapeutic effect, a bimonthly treatment is suggested.

Keywords: pitted nails, trachyonychia, intralesional steroid, bimonthly treatment
Singapore Med J 2000; 41(2): 66-68

HY Wong, HY Lee, WS Pang, PL Lieu
Correspondence: Dr H Y Lee

ABSTRACT
Wegener's granulomatosis classically involves the upper respiratory tract, lungs and kidneys. Rarely, it also affects the skin and heart. Cardiac involvement is uncommon in Wegener's granulomatosis and myocardial infarction is seldom highlighted. It can be a difficult diagnosis to make in the elderly who often have multiple co-existing illnesses. We present a case of a 75-year-old Chinese woman with interesting cardiac and dermatological manifestations of Wegener's granulomatosis.

Keywords: pustules, aged, cutaneous, vasculitis
Singapore Med J 2000; 41(2): 64-65

GD Bishop, HML Oh, HY Swee
Correspondence: A/Prof G D Bishop

ABSTRACT
Aim of Study This study examines the beliefs and attitudes of Singapore doctors, dentists, and nurses concerning HIV/AIDS and persons living with HIV/AIDS (PWAs).
Method A mail survey was done of all doctors and dentists in Singapore as well as a random sample of 1,500 nurses from the Singapore Nursing Board Register.
Results The results showed that respondents held accurate beliefs concerning transmission of HIV via sex and needle sharing but a significant proportion also expressed belief in transmission via everyday social contact. Respondents were aware of universal precautions when treating persons with HIV/AIDS but tended to be overly cautious in low/no risk situations. A substantial proportion of respondents indicated little or no knowledge or experience with AIDS-related conditions and the majority believed that most health care professionals are unprepared to care for PWAs. Further, there was evidence of substantial stigmatisation and fear of treating PWAs, both of which were significantly and negatively correlated with accuracy of beliefs about HIV transmission and universal precautions.
Conclusion These results point to important misconceptions about HIV/AIDS held by Singapore health care professionals as well as stigma towards and fear of treating PWAs. These are areas that need to be addressed through better professional education concerning HIV/ AIDS. This education needs to address both the factual misconceptions about HIV/AIDS as well as the stigma associated with this disease and the fears that health care professionals have of treating PWAs.

Keywords: AIDS, HIV, attitudes, health care professionals, Singapore
Singapore Med J 2000; 41(2): 55-63

S Nadarajah, NKY Leong
Correspondence: S Nadarajah

ABSTRACT
Aim of Study The aim was to analyse the pregnancy outcome among girls, aged 17 and below, at KK Hospital.
Methodology This is a retrospective study. A total of 108 adolescent pregnancies were analysed with regards to pregnancy order, antenatal complications, mode of delivery and pregnancy outcome.
Results The 2 most common antenatal complications were anaemia and preterm labour. The repeat pregnancy rate was 15.7%. Vaginal delivery was achieved in 7.2%; 21.2% of babies born weighed less than 2.5 kg.
Conclusion Adolescent pregnancies accounted for only a small proportion of all deliveries in our hospital. Late or non-existent antenatal care was a feature in most pregnancies. The incidence of repeat pregnancies reflects the need for a more effective counselling on contraception.

Keywords: adolescent pregnancy, teenage pregnancy
Singapore Med J 2000; 41(1): 29-31

CL Goh
Correspondence: C L Goh

ABSTRACT
Background This is a report of a prospective study on the treatment outcome of 94 Asian skin Types III and IV patients with port-wine stains with the 585 nm flashlamp-pumped pulsed dye laser in Singapore.
Patients All patients had completed at least 1 year of follow-up post treatment and had received treatment at 8-12 weekly intervals under topical lodocaine-prilocaine anaesthesia. Our patients received an average of 4 treatments sessions. At the end of each treatment (8-12 weeks after the last laser treatment/before the next laser treatment) and on completion of the last treatment (8-12 weeks after the final laser treatment), patients were assessed for response based on a subjective scoring system where excellent = > 75% improvement, good = 50% to 75% improvement, fair = 25% to 49% improvement and poor = < 25% improvement and the same = no observable improvement. The dermatologist also recorded scores after each treatment in a similar way. On completion of the final treatment, patients were asked to score (8-12 weeks after the final laser treatment) the overall response to the treatment themselves using the same scoring system. The mean age was 26.4 years (range 1 year to 58 years). The mean initial treatment energy density dose was 6.24 J/cm2. Eighty percent of our patients experienced excellent or good response to treatment after the initial treatment and further improvements were observed with each subsequent treatment.
Results The author scored 86% of our patients having "excellent" or "good" response while 83% of our patients scored "excellent" or "good" response upon completion of their treatment. The dermatologist generally recorded better improvement scores than the patients. The dermatologist scored 36% and 50% of our patients having "excellent" and "good" response respectively. The corresponding treatment response scores by our patients were 22% ("excellent") and 61% ("good").
Conclusion Macular lesions appear to respond better than papular/nodular lesions, but the difference was not statistically significant probably due to the small study cohort. Light coloured port-wine stains tended to respond better to treatment than darker lesions (not statistically significant), but overall, all colour lesions responded well to treatment. Patients' expectation of improvements was generally higher than the dermatologist's.

Keywords: capillary malformation, capillary haemangioma, cosmetic laser treatment
Singapore Med J 2000; 41(1): 24-28

KC Ong, V Indumathi, WT Poh, YY Ong
Correspondence: Dr K C Ong

ABSTRACT
Background The development of a pleural effusion in a patient with a known malignancy often raises the possibility that the effusion is due to malignant involvement of the pleura. Accurate diagnosis of the cause of the pleural effusion in such a patient is essential as the treatment and prognosis may vary. Currently, thoracentesis and cytologic analysis of pleural fluid cytology is usually the initial diagnostic step.
Aim To assess the diagnostic yield of pleural fluid cytologic examination in patients with suspected malignant pleural effusions seen at our centre.
Methods Retrospective review of the results of pleural fluid cytologic examination performed on 103 patients who presented with suspected malignant pleural effusions.
Results The underlying malignancies in these patients were as follows: bronchogenic carcinoma (51.5%), breast carcinoma (29.1%), hepatocellular carcinoma (1.9%), carcinoma of the stomach (1.9%), malignant mesothelioma, nasopharyngeal carcinoma, renal cell carcinoma, carcinoma of the oesophagus, lymphoma, carcinoma of the colon (1% each), unknown (9.7%). Initial pleural fluid cytology was positive for malignancy in 48.5% of patients. The yield of this diagnostic procedure was improved with repeated pleural fluid cytologic specimens and when combined with a percutaneous pleural biopsy. There was no statistically significant difference in the clinical features and pleural fluid characteristics of patients with malignant pleural effusions and those in whom the pleural effusions were paramalignant.
Conclusion Pleural fluid cytologic examination is a useful initial step in the diagnostic work-up of patients with suspected malignant pleural effusions. The diagnostic yield of such examination is improved with repeated pleural fluid cytologic specimens and when combined with a percutaneous pleural biopsy. Clinical presentation and pleural fluid characteristics were inadequate in differentiating between malignant and paramalignant effusions.

Keywords: thoracentesis, paramalignant pleural effusions, cell blocks, cytologic examination, pleural biopsy
Singapore Med J 2000; 41(1): 19-23

TK Ti
Correspondence: T K Ti

ABSTRACT
Aim of Study This paper attempts to determine the appropriate surgical procedure in relation to the pathological types of adenocarcinoma of the gastro-oesophageal junction in Singapore.
Methods Data on population characteristics, clinical presentation, pathology, surgical procedures and results of treatment were gathered from the case records of a personal series of 32 patients resected for adenocarcinoma of the gastro-oesophageal junction.
Results The 32 patients with adenocarcinoma of the gastro-oesophageal junction (Type I, 9; II, 20 and III, 3), presented at a late stage (Stage I-II, 5; III, 14; IV, 13). In 19 patients with Stages I-III disease, attempted curative surgery was performed--extended total gastrectomy for Types II and III disease (13 patients) and oesophagectomy for Type I (6 patients). There was one operative mortality following curative resection. Palliative resection was performed on 13 patients with Stage IV disease with one operative mortality. The main operative morbidity was anastomotic leakage, occurring in 5 patients; both operative deaths were associated with this complication. The actuarial 5-year survival was 20%.
Conclusion Although gastro-oesophageal cancer presents late, it can be resected safely by extended total gastrectomy for Types II and III disease and oesophagectomy for Type I disease, taking precautions to minimise anastomotic leakage. Although usually palliative, Stages I and II and to a lesser extent Stage III, are curable by these surgical procedures which ensure a tumour free surgical margin and adequate lymphadenectomy.

Keywords: adenocarcinoma, oesophagus, oesophagectomy, oesophago-gastrectomy, Singapore
Singapore Med J 2000; 41(1): 14-18

XF Zhang, BKH Tan
Correspondence: A/Prof B K H Tan

ABSTRACT
Aim of Study The aim was to demonstrate the effects of the leaves of Gynura procumbens (Lour.) Merr. on blood sugar and lipid levels in experimental animals.
Methodology We obtained an ethanolic extract of the leaves of G. procumbens and monitored the effects of an oral administration of (i) different single doses of the extract on oral glucose tolerance in streptozotocin-induced diabetic and normal rats and (ii) fourteen doses over 7 days on serum cholesterol and triglyceride levels in streptozotocin-induced diabetic rats. Metformin and glibenclamide were used as positive control drugs.
Results The extract, at single doses of 50, 150 and 300 mg/kg orally, significantly suppressed the elevated serum glucose levels in diabetic rats; 150 mg/kg was found to be the optimum hypoglycaemic dose. The extract however did not significantly suppress the elevated serum glucose levels in normal rats, unlike glibenclamide. Metformin, but not glibenclamide, improved glucose tolerance in the diabetic rats. When the optimum dose was given to diabetic rats for 7 days, the extract significantly reduced serum cholesterol and triglyceride levels in these rats.
Conclusion These results indicate that the leaves of G. procumbens may have biguanide-like activity.

Keywords: Gynura procumbens, diabetic rat, cholesterol, triglyceride, oral glucose tolerance test
Singapore Med J 2000; 41(1): 9-13

TYT Tan, KP Teo, KH Tan
Correspondence: Dr D H C Su

ABSTRACT
Background/Aim of Study The results of primary total knee arthroplasties have improved over the years but some still fail, requiring revision. Revision total knee arthroplasty is technically more difficult and has not enjoyed the same success rates as the index operation. The aim of this retrospective study was to review the results of revision total knee arthroplasties carried out at our centre. This is the first study in Singapore on revision total knee arthroplasty.
Methods A retrospective study where 17 patients (18 knees) had been followed up since their revision operations were clinically assessed. Based on the Knee Society Clinical Scoring System, they were assigned separate knee and function scores (each having a maximum possible 100).
Results The mean knee score was 76 (range 35-93), which rates as good. Of the 18 knees, 67% had excellent or good knee scores. By comparison, the mean function score was 56 (range 0-90) which rates as poor and 33% had excellent or good function scores.
Conclusion Revision total knee arthroplasty achieves good and excellent results in spite of technical difficulties often associated with the revision operation. The difference in mean knee and function scores emphasises that many other factors such as physical strength and stamina affect function. Nevertheless, 15 patients were able to walk out of their house and around their neighbourhood for varying distances. This satisfied their expectations and the poor mean function score may reflect different expectations of patients overseas from whence this scoring system originated.

Keywords: total knee arthroplasty
Singapore Med J 2000; 41(1): 6-8

KL Tong, YS Lau, WS Teo
Correspondence: Dr W S Teo, Teo_Wee_Siong@nhc.com.sg

ABSTRACT
Introduction Torsade de Pointes (Tdp) is a form of polymorphic ventricular tachycardia in the setting of prolonged QT interval. Any drug that prolongs repolarisation, and hence QT interval, may cause Tdp. Predisposing factors of drug-induced Tdp include female sex, bradyarrhythmia and hypokalaemia.
Methods We retrospectively analysed the case notes of 13 patients with drug-induced LQTS from 1991 to 2000 from National Heart Centre and Changi General Hospital.
Results Causative drugs in the series were amiodarone (seven patients, 54%), sotalol (two patients), quinidine (one patient), phenothiazine (two patients) and astemizole (one patient). There were eight females and all were Chinese. The mean age was 72 +/- nine years. The patients commonly present with syncope (38%) and cardiac arrest (38%). The mean corrected QTC interval was 545 ms. The most common precipitating factor was hypokalaemia (31%). Nine patients require cardiopulmonary resuscitation and two patients (15%) died. Nine patients (69%) had underlying structural heart disease such as ischaemic heart disease, valvular heart disease and hypertensive heart disease. The left ventricular ejection fraction was normal in six patients. The onset of Tdp ranged from Day 2 to Day 5 in the seven patient with amiodarone-induced LQTS. These were inpatients who were given intravenous loading doses of amiodarone. Both patients with sotalol-induced LQTS were females on sotalol 80 mg and 240 mg per day with Tdp occurring on Day 2 and 10 months respectively.
Conclusion Tdp is a potentially life-threatening arrhythmia. The list of torsadogenic drugs is ever expanding. Physicians need to know the drugs which can lead to Tdp. Careful assessment of risk-benefit ratio is important before prescribing such drugs. Amiodarone-induced Tdp is not uncommon in our local population. Initiation of a class III agent, especially amiodarone, should be done judiciously, with monitoring of the QT interval and avoidance of hypokalaemia.

Keywords: drug-induced long-QT syndrome, Torsade de Pointes, class III agent, torsadogenic drugs
Singapore Med J 2001; 42(12): 566-570