A Ten-Year Review of Ruptured Sinus of Valsalva: Clinico-Pathological and Echo-Doppler Features

Share this Article

Singapore Med J 2001; 42(10): 473-476
A Ten-Year Review of Ruptured Sinus of Valsalva: Clinico-Pathological and Echo-Doppler Features

RP Shah, ZP Ding, ASH Ng, SSS Quek
Correspondence: Dr R P Shah, dr_rajesh_shah@hotmail.com

ABSTRACT
Rupture of the sinus of valsalva (RSOV) is an uncommon condition with a variety of manifestations ranging from an asymptomatic murmur to cardiogenic shock. This retrospective 10-year review (1985-1995) of 18 patients from a single institution revealed that 6 (33%) were female and 12 (67%) were male with a mean age of 37.6 +/- 13.4 years and that 72% were Chinese by ethnic descent with the remaining 28% being Malay. Eight patients (44.4%) presented with an asymptomatic murmur, 4 (22.2%) with acute chest pain, 4 (22.2%) with mild heart failure, 2 (11.1%) with severe heart failure, and 2 (11.1%) with cardiogenic shock. Rupture of the right aneurysmal coronary cusp (RCC) made up 15 (83.3%) while those of the non-coronary cusp (NCC) made up the remaining. Most of the RCC ruptures were directed into the right ventricle and all of the NCC ruptures were into the right atrium. Ventricular septal defects (VSDs) were found in 9 (50%) of the patients, (although detected by echocardiography in only one third of those patients), aortic regurgitation in 6 (33.3%) and aortic valve vegetations in 2 (11.1%). Echocardiography was found to be accurate in diagnosing RSOVs with 100% diagnostic accuracy after 1990 with four misdiagnoses before 1990. Of these four patients, two were misdiagnosed as having VSDs, one as having a coronary arteriovenous fistula and one as having a patent ductus arteriosus. The anatomical structure of the "windsock" was seen in 64% of the patients who were correctly diagnosed. The pattern of colour flow and spectral Doppler was seen in all patients and helped to localise the site of rupture and the direction of flow. In summary, echocardiography is a simple and accurate way of diagnosing and defining RSOVs and is the imaging modality of choice.

Keywords: echocardiogram, Doppler, ruptured sinus of valsalva
Singapore Med J 2001; 42(10): 473-476

Falls Amongst Institutionalised Psycho-Geriatric Patients

Share this Article

Singapore Med J 2001; 42(10): 466-472
Falls Amongst Institutionalised Psycho-Geriatric Patients

KD Lim, KC Ng, SK Ng, LL Ng
Correspondence: Dr K D Lim, dominic.lim@chmeds.ac.nz

ABSTRACT
Falls are common among the elderly patients in the psycho-geriatric wards and yet they have been understudied. A fall is a multi-factorial syndrome involving the patient and the environment. Psycho-geriatric patients who fall may suffer serious physical injuries that result in morbidity, further institutionalisation or even mortality. This study aims to examine the contributing factors to, and morbidity and outcome of falls among institutionalised psycho-geriatric patients so that preventive strategies can be refined. Data of patients who fell over a year's period in four psycho-geriatric wards were collected retrospectively and compared with those who had not fallen within the same period. The general profile of the psycho-geriatric patient who falls is one who is: above seventy-five years old; on three or more medications; and having recent changes in medication and mental status. About one in three fallers fell repeatedly. The rate of serious injury and mortality was low. In conclusion, while many factors are attributable to the common effects of aging and physical illnesses; psychotropic medication, change in mental state and specific environmental factors also play significant contributory roles to falls in this group of patients.

Keywords: falls, factors, outcome, psycho-geriatric wards, prevention
Singapore Med J 2001; 42(10): 466-472

Percutaneous Endocopic Gastrostomy - Indications and Outcome of Our Experience at the Singapore General Hospital

Share this Article

Singapore Med J 2001; 42(10): 460-465
Percutaneous Endocopic Gastrostomy - Indications and Outcome of Our Experience at the Singapore General Hospital

W Luman, KR Kwek, KL Loi, MA Chiam, WK Cheung, HS Ng
Correspondence: Dr W Luman, gm2wid@sgh.gov.sg

ABSTRACT
Introduction
 Percutaneous endoscopic gastrostomy (PEG) is widely used for patients with dysphagia from neurological causes and head and neck malignancy. We examined the indications, complication rates and long term outcome of PEG inserted in our department.
Methods We performed a study of PEG inserted in our department between January 1995 to March 2000. Consecutive patients with PEG inserted during this period were identified from our database that contained demographic data, primary and secondary underlying medical conditions, and immediate complications after the procedure. Casenotes were reviewed and caregivers (relatives or staff at nursing homes) were contacted for information on long term outcome at the time of this study between April 2000. Data was collected in standard form designed for this study.
Results 181 cases of PEG insertion were performed during the study period. 174 patients were successfully followed up and reviewed. The median age was 70.5 (range 24 to 93) years old and there were 111 males. Indications for PEG insertion were: cerebrovascular diseases (60.4%), Parkinson's disease and other neuromuscular disorders (10.9%), nasopharyngeal carcinoma and other upper gastrointestinal malignancies (24.7%), and head injury (4%). Superficial wound infection (22.4%) and granuloma formation (31%) were common minor complications. Major complications were infrequent: peritonitis (2.3%) and gastrointestinal bleeding (0.6%). The mortality rates were 11.5% and 28.2% at one and six months respectively. Only one death from peritonitis was directly attributed to the procedure, most deaths were due to underlying co-morbidities with pneumonia being the most common cause. The proportion of the first PEG tubes removed or replaced were 12.2% and 35.5% at one and six months respectively. Thirty tubes were replaced due to blockage at median interval of 9.6 months. 9.7% of PEG tubes functioned longer than 24 months.
Conclusion Our results confirm the safety of PEG tubes in elderly patients with multiple co-morbidities. Major complications of the procedure were infrequent but produced grave consequences in these elderly patients with multiple co-morbidities. As such, patients considered for PEG feeding should have reasonable prognosis and the procedure is inappropriate for patients with rapidly progressive and incurable diseases.

Keywords: gastrostomy, tubes
Singapore Med J 2001; 42(10): 460-465

The Role of Spiral Computed Tomogram in the Diagnosis of Acute Pulmonary Embolism

Share this Article

Singapore Med J 2001; 42(10): 455-459
The Role of Spiral Computed Tomogram in the Diagnosis of Acute Pulmonary Embolism

J Lingamanaicker, JJ Mukherjee, KM Fock, TK Khoo
Correspondence: Dr Jayaram Lingamanaicker, jayaram_lingamanaicker@cgh.com.sg

ABSTRACT
Acute pulmonary embolism is associated with considerable morbidity and mortality. Early diagnosis and prompt treatment is essential. A number of non-invasive diagnostic tools are available for its detection. However, each one of these tests has its limitations and the invasive pulmonary angiography remains the gold standard. We describe the use of spiral volumetric computerised tomogram in the diagnosis of acute pulmonary embolism in six patients in our centre where ventilation-perfusion scan facility is not available. This safe, simple and non-invasive test has an excellent sensitivity and specificity for the detection of central and segmental pulmonary embolism and may replace the conventional invasive pulmonary angiography for the diagnosis of pulmonary embolism.

Keywords: Pulmonary embolism, Computed tomography (CT), Ventilation-Perfusion Scan
Singapore Med J 2001; 42(10): 455-459

Intermediate Probability Lung Scans (IPLS): Retrospective Review of 82 Cases

Share this Article

Singapore Med J 2001; 42(10): 450-454
Intermediate Probability Lung Scans (IPLS): Retrospective Review of 82 Cases

WY Wong, DCE Ng, ES Ang, ASW Goh, FX Sundram
Correspondence: Dr W Y Wong

ABSTRACT
Objective
 In the light of a reported 30-40% prevalence of pulmonary embolism (PE) in intermediate probability lung scans (IPLS) based on results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study, we examined the frequency of documented PE in 82 patients with IPLS, the management strategy employed in these patients with regards to additional imaging (e.g. further evaluation with venous sonography or spiral computed tomographic angiography (CTA)), anticoagulation therapy, and subsequent follow-up outcomes.
Method Retrospective review of the medical records of 82 patients with intermediate probability ventilation-perfusion (V/Q) lung scans from January 1998 to July 1999.
Results 14.1% of V/Q scans were reported as having an intermediate probability of PE. 72% of IPLS were subject to further evaluation with venous Doppler ultrasound and/or CTA, and 39% of these patients had evidence of thrombo-embolic disease. All patients with imaging evidence of thromboembolic disease were started on anticoagulation therapy. In addition, 19 patients were treated based on clinical judgement. Amongst the 35 patients who were not treated, 17 (49%) were based on clinical findings without further imaging. There was no mortality on follow-up of 28 cases of untreated IPLS.
Conclusion The majority of IPLS will have further imaging, out of which over one-third will have thrombo-embolic disease. Approximately half of IPLS cases will receive anticoagulation therapy. No mortality or PE was found on follow-up of patients who were not treated.

Keywords: pulmonary embolism, V/Q scan, intermediate probability, spiral CTA, Doppler ultrasound
Singapore Med J 2001; 42(10): 450-454

Flank Pain: Is Intravenous Urogram Necessary?

Share this Article

Singapore Med J 2001; 42(9): 425-427
Flank Pain: Is Intravenous Urogram Necessary?

HS Teh, MBK Lin, TK Khoo
Correspondence: Dr Teh Hui Seong, cyber_xray@yahoo.com

ABSTRACT
Aims
 To determine the diagnostic yield of Intravenous Urogram (IVU) and the values of plain radiograph of kidney, ureter and bladder (KUB) and urinalysis as screening tests, with the objective to improve the cost effectiveness, in the management of patients presenting with flank pain due to urinary lithiasis.
Patients and Methods All Intravenous Urogram (IVU) request forms and reports for the month of February 1998 were audited. The case notes, urinalysis, KUB and IVU films were traced and reviewed.
Results There were 110 patients investigated, 61.8% (68) had normal IVU, 38.2% (42) had abnormal IVU. The sensitivity and specificity of KUB alone was 79.4% and 90%. The sensitivity using urinalysis alone was 90.9% and its specificity 33.8%. The sensitivity of combined KUB and urinalysis was 100% and its specificity 26%, with a negative predictive value of 100%. All the patients with both negative KUB and urinalysis in our study were found to have negative IVU.
Conclusion Our study shows that in patients with both negative KUB and urinalysis, the yield of IVU is very low and may not be necessary. This is important, as an IVU examination is not without risk. A combination of KUB with urinary analysis and careful evaluation of clinical symptoms will improve the cost-effectiveness of patient management.

Keywords: Flank pain, Intravenous Urogram, Plain radiograph of kidney, ureter and bladder (KUB), Urinalysis
Singapore Med J 2001; 42(9): 425-427

Hepatitis B Seroprevalence Study 1999

Share this Article

Singapore Med J 2001; 42(9): 420-424
Hepatitis B Seroprevalence Study 1999

L James, CW Fong, BH Foong, MK Wee, A Chow, E Shum, SK Chew
Correspondence: Dr L James, Lyn_JAMES@moh.gov.sg

ABSTRACT
Hepatitis B is a disease of public health importance in Singapore. A study was conducted in 1999 to estimate the overall and gender-, age- and ethnic-specific prevalence of hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and antibody to hepatitis B surface antigen in the Singapore population. A cross-sectional sample of the Singapore population constituting 4,698 Singapore residents aged 18-69 years was surveyed. This was the first time a large-scale study has been conducted to assess the hepatitis B seroprevalence rates in the Singapore population. The overall prevalence of the HBsAg in the general population was estimated to be about 4%. About 13% of the HBsAg carriers were also HBeAg positive. Only about 40% of the population had immunity to hepatitis B virus either through immunisation or from previous exposure to the virus. There was still a large proportion (60%) of the population who had no immunity, especially the younger age group of 18-29 years where only 28% had immunity. There is a need to strengthen the hepatitis B immunisation programme to reach out to those who have no immunity, especially the young adults.

Keywords: Hepatitis B, Seroprevalence, Control, Immunisation, Singapore
Singapore Med J 2001; 42(9): 420-424

An Audit of Morphine Prescribing in a Hospice

Share this Article

Singapore Med J 2001; 42(9): 417-419
An Audit of Morphine Prescribing in a Hospice

SH Neo, EC Loh, WH Koo
Correspondence: Dr Koo Wen Hsin, whkoo@doverpark.org.sg

ABSTRACT
Aim of Study
 This audit was designed to investigate the morphine prescribing pattern in a hospice.
Method A review of 358 medical charts of all existing patients was conducted with a set of questionnaire. The prevailing practice was compared with an established standard guideline.
Result One-third (35%) of patients were receiving morphine. Several deficiencies in morphine prescribing were identified. These include omission of breakthrough morphine dosing, use of morphine as p.r.n. (when necessary) alone for chronic pain, absence of review after prescribing treatment, and lack of double dosing at night. Prophylactic laxative and anti-emetics were often not co-prescribed.
Conclusion Despite much of what is known about the pharmacology and therapeutic use of morphine, there is much variation and even inappropriate prescription in a palliative care institution. Implementation of recommended European guidelines and education may improve morphine prescribing habits. However, such guidelines may have to be validated in future studies to see if they need to be revised to suit our local population.

Keywords: pain, symptom, opioid, guidelines
Singapore Med J 2001; 42(9): 417-419

Autogenous Osteochondral Morselised Grafts for Full Thickness Osteochondral Defects in the Knee Joints of Pigs

Share this Article

Singapore Med J 2001; 42(9): 410-416
Autogenous Osteochondral Morselised Grafts for Full Thickness Osteochondral Defects in the Knee Joints of Pigs

Arjandas Mahadev, Deepak P Mahara, P Chang, AK Mitra, BK Tay, CS Sim
Correspondence: Dr Arjandas Mahadev, arjandas@yahoo.com

ABSTRACT
The aim of this study is to firstly ascertain the survival of autogenously grafted morselised cartilage for full thickness osteochondral defects in knee joints of pigs. Secondly, it is to determine the quality of the grafted cartilage that survives and to score to it based on a recognised and tested system of indices and thirdly, to recognise, if any, the potential for reconstitution of the osteochondral junction. Two groups of five pigs were followed up for six and 12 weeks. Similar osteochondral defects were created in the medial condyles of both knees with the right medial femoral condyle defect filled with graft and the left used as control and filled with gel foam. At the end of the study period, an independent pathologist assessed the defects macroscopically and microscopically with an accepted and comparable histological scoring system. Macroscopically, there was better filling of the defect and restoration of bony contour in the grafted group compared to the control. Microscopically, at six weeks, filling of the defect, nature of predominant tissue, matrix staining and nature of cells all showed significantly better histological score than the control using the Mann-Whitney U test at the level of significance of p<0.05. At 12 weeks, in addition to the above, the reconstitution of osteochondral junction also showed a significantly better score. Comparing the test groups at six and 12 weeks, the reconstitution of the osteochondral junction was significantly better at 12 weeks. In conclusion, the autogenous osteochondral morselised graft persisted as mature hyaline cartilage with good histological score at six weeks with significantly better reconstitution of osteochondral junction occurring at 12 weeks. The use of morselised graft allows for the inclusion of bone graft which possibly allows for larger amounts of donor tissue and thus the possibility of treating larger defects. In the human model the donor site would be the non-weight bearing surfaces of the knee such as the intercondylar notch as described by Walgenbach A and Stone KR at the 1997 Annual Meeting of the American Academy of Orthopaedic Surgeons in San Francisco.

Keywords: Autogenous osteochondral grafts, Morselised grafts, Osteochondral defects, Hyaline cartilage, Articular cartilage
Singapore Med J 2001; 42(9): 410-416

MRI of the Hypothalamus and Pituitary Gland in Patients with Hyperprolactinaemia Following Radiotherapy for Nasopharyngeal Carcinoma

Share this Article

Singapore Med J 2001; 42(9): 406-409
MRI of the Hypothalamus and Pituitary Gland in Patients with Hyperprolactinaemia Following Radiotherapy for Nasopharyngeal Carcinoma

KY Lau, WT Fung, PO Chan, WM Sze, AWM Lee, TK Yau
Correspondence: Dr K Y Lau, drkylau@yahoo.com

ABSTRACT
Purpose
Neuroendocrine dysfunction is a known complication of cranial radiation. While growth hormone deficiency is the most common laboratory finding, hyperprolactinaemia is one of the most common symptomatic dysfunction in adult female patients with nasopharyngeal carcinoma (NPC) following radiotherapy. This analysis aims to study the magnetic resonance imaging (MRI) features of the hypothalamus and the pituitary gland in affected patients.
Methods MRI was performed in 24 patients NPC with hyperprolactinaemia detected 10-52 months following one course of radical radiotherapy. The region of study included the nasopharynx, the hypothalamus and the pituitary gland in 20 patients, while in the remaining four patients, this was limited to the pituitary gland. The estimated radiation dose to the hypothalamus and the pituitary gland was 66 Gy, and six patients also had adjuvant chemotherapy. There was no clinical evidence of tumour recurrence in all 24 patients when hyperprolactinaemia was detected.
Results None of the 24 patients showed any MRI evidence of structural abnormality in the hypothalamic-pituitary region.
Conclusion MRI did not reveal any structural abnormality in the hypothalamic-pituitary region of patients who developed hyperprolactinaemia following radiotherapy for NPC.

Keywords: Magnetic resonance imaging, Nasopharyngeal carcinoma, Hyperprolactinaemia, Radiation-induced complication
Singapore Med J 2001; 42(9): 406-409