Original Article

A Kuruvilla, JD Pandian, M Nair, VV Radhakrishnan, S Joseph
Correspondence: Dr Abraham Kuruvilla, akuruvilla@doctor4u.com

ABSTRACT
Objectives Little has been published on Neurocysticercosis (NCC) in the State of Kerala, South India. This study was conducted to describe the clinical and radiological features of NCC in Kerala and also to study the frequency of NCC as seen in a tertiary referral setting.
Materials and Methods We evaluated retrospectively 11 patients who were admitted with a diagnosis of NCC from 1986 to 1998. A pre-abstracted proforma containing detailed demographic data, dietary habits, clinical features and history of travel outside Kerala and neuroimaging findings were obtained from patient records and the data was tabulated and analysed. Follow up assessment was made three months after treatment.
Results There were a total of 11 patients, including nine males and two females in the age range of 24 to 62 years and a mean age of 35.2 years. All were nonvegans, only 36% were pork eaters while 18% claimed consumption of salads and uncooked vegetables. 55% of patients were migrants. Migrants were defined as those who lived outside the state of Kerala for more than six months. Seizure was the most common presenting complaint and occurred in all patients (100%). Multiple ring enhancing lesions were seen on computerised tomography (CT) and magnetic resonance imaging (MRI) scans in 60%. Calcified lesions were noted in two patients. An isolated instance of miliary or disseminated cysticercosis with subcutaneous nodules and multiple brain lesions in MRI scan was observed. All patients received anticysticercal therapy besides anticonvulsants.
Conclusion It appears that NCC is rather uncommon in Kerala. Better socioeconomic status, high literacy rate, improved sanitation and health care in the state of Kerala could be reasons for this observation. A prospective case-control study of NCC in Kerala is needed to study these factors.

Keywords: Neurocysticercosis, Kerala, India, Epilepsy, Neuroimaging
Singapore Med J 2001; 42(7): 297-303

N Shamini, EH Tay, TH Ho
Correspondence: Dr Nair Shamini, sham@kkh.com.sg

ABSTRACT
Introduction Vulvar cancer is uncommon in Singapore and to date there have been no local reports on this rare cancer. This is a descriptive study that aims to evaluate our patients' profiles, their management and their outcomes.
Materials and Methods Between January 1981 and December 1998, there were 35 patients with vulvar cancer treated at KK Women's and Children's Hospital. The case records of these patients were reviewed. Survival was calculated using the Kaplan-Meier method.
Results The modal age at diagnosis was 74.0 years (range 17.0-89.0 years). Chinese patients accounted for 88% of the study group, Malays for 6%, Indians for 3% and other races made up 3% of the study group. The most common presenting symptom was an ulcer or lump (83.8%). Squamous cell carcinoma was the most common histological type (80.0%). Vulvar intraepithelial neoplasia III was found in 20% of the cases. There were five patients with other lower genital tract malignancies. Surgery was the most common treatment modality and wound breakdown was the most common complication. The overall five year survival was 75.9%. For stage 1&2 disease, the five year survival was 90.0%. For stage 3&4 disease, the five year survival was 26.0%.
Conclusion The rarity of vulvar cancer makes it best treated in a tertiary centre. There is a definite survival advantage in early diagnosis and treatment of vulvar cancer. Lymph node surgery was associated with a longer operating time and a higher chance of wound breakdown.

Keywords: vulvar cancer, squamous cell carcinoma, lymph node surgery, surgery, radiotherapy
Singapore Med J 2001; 42(7): 292-296

SG Ling
Correspondence: Dr S G Ling

ABSTRACT
Objectives To determine the frequency of complex features in febrile convulsion, association of complex febrile convulsion with neurological findings and risk factors associated with complex febrile convulsion.
Methodology Retrospective review of clinical records of 379 patients admitted for their first febrile convulsion over a two-year period.
Results Complex features occurred in 37.2% patients. Focal seizures tended to be prolonged as well. There was also significant association between prolonged or focal seizures with presence of neurological abnormalities. The longer the duration of the seizure, the higher was the likelihood of neurological abnormalities. Risk factors associated with a complex first febrile convulsion were: 1) Age of 15 months or less, 2) Birth weight of 2 kg or less and 3) initial temperature of 38 degrees C or less.
Conclusion Any acute febrile convulsion should be abbreviated soonest possible as neurological abnormalities, which may be signs of cerebral insult become more likely with increasing duration of seizures. The risk factors found associated with complex febrile convulsion underline the propensity of the immature, developing brain to abnormal seizure discharges in response to a lower temperature threshold.

Keywords: complex febrile seizure, risk factors, neurological abnormalities
Singapore Med J 2001; 42(6): 264-267

F Lateef, AB Storrow, BW Gibler, T Liu
Correspondence: Dr F Lateef, gaefal@sgh.gov.sg

ABSTRACT
Objectives To compare the 30-day cardiac event rate between patients aged at least 60 years (geriatric group) with those younger than 60 (younger group), who were enrolled in an Emergency department-based chest pain centre management protocol.
Methodology This was a retrospective, cohort study done at the Centre for Emergency Care at the University of Cincinnati, from 1 Oct 1991 to 31 March 1999 (from Oct 1991 to Dec 1998: 9-hour protocol in use; from Jan 1999 to March 1999: 6-hour protocol in use). Patients, at least 25 years, with the chief complaint of non-traumatic chest pain were eligible for management in the unit. Exclusion criteria included acute ST-elevation or depression > 1 mm in 2 contiguous leads, haemodynamic instability or clinical syndrome consistent with unstable angina. Outcomes studied were disposition and cardiac events at 30-days (defined as acute myocardial infarction, congestive heart failure, ventricular fibrillation / tachycardia arrest, coronary artery bypass surgery or percutaneous transluminal coronary angioplasty). The protocol was the standard of care and enrolled patients underwent continuous ECG and ST-segment trend monitoring, serial CK-MB draws at 0, 3, 6 and 9 hours, followed by either a graded exercise stress test or a sestamibi myocardial perfusion scan (from Oct 1998). With the 6-hour protocol the 9-hour draws were omitted and the GXTdone 3 hours earlier.
Results A total of 2491 patients were enrolled; 304 (12.2%) in the geriatric age-group. The mean age was 66.8+/-5.9 and 41.3+/-8.6 years respectively. There were 133 (43.8%) female patients in the geriatric group and 1170 (53.5%) in the younger group. There were no statistically significant differences between the groups in terms of prevalence of risk factors, but there was significant (p < 0.001) and ECG changes from the baseline (p = 0.0015). The geriatric patients were also not different from the younger ones in terms of GXT positive for ischaemia (10, 5.3% vs 42, 2.7%; p = 0.124), admission rates (61, 20.1% vs 321, 14.7%; p = 0.312), coronary care unit admissions (8, 2.6% vs 63, 2.9%; p = 0.418 and 30-day complication rate (10, 3.6% vs 46, 2.4%; p = 0.303).
Conclusion The ED-based chest pain unit represents an effective way for the risk-stratification and management of both geriatric and young patients with low-to-moderate risk of acute coronary events.

Keywords: geriatric patients, chest pain, coronary events
Singapore Med J 2001; 42(6): 259-263

JSP Yuen, SW Yung, MK Wong
Correspondence: Dr J S P Yuen, spyuen@hotmail.com

ABSTRACT
Aim To review the results of open reduction and temporary rigid screw fixation of Lisfranc fracture-dislocations performed in Singapore General Hospital (SGH) from 1996 to 1998.
Methods A retrospective review of II cases of Lisfranc injuries treated with temporary rigid internal screw fixation with a minimum follow up of six months was carried out. Radiological assessment was made at follow up to ascertain the anatomical reduction achieved and complications such as post-traumatic arthritis. In addition, the patients were evaluated with a functional assessment with relation to pain, interference to usual activities and the time to resumption of work.
Results Anatomical reduction was achieved in all cases. None of the cases showed loss of reduction at follow up after the temporary implants were removed. No longitudinal arch collapse or other deformities were seen. All the patients had good or excellent functional outcomes.
Conclusion Results of treatment of Lisfranc injuries are related to anatomical correction. Temporary screw fixation allows rigid internal fixation with stability to allow anatomical correction. Screws also maintain their stability longer, allowing ligamentous injuries the longer period necessary for healing. In conclusion, temporary rigid screw fixation of Lisfranc fracture maintains anatomical reduction and gives excellent functional outcomes for the patients.

Keywords: Lisfranc injuries, AO Screw fixations
Singapore Med J 2001; 42(6): 255-258

CL Cheng, SP Chee, DTH Tan
Correspondence: Dr C L Cheng

ABSTRACT
Purpose To evaluate patient's reliability in the administration of eyedrops.
Method The study is based on a randomised, controlled clinical trial in which a steroid-containing drug delivery system (DDS) was directly compared to conventional steroid eyedrops after cataract surgery. 32 eyes undergoing extracapsular cataract extraction with intra-ocular lens insertion received a DDS, while 31 eyes received 0.1% dexamethasone eyedrops q.d.s for 30 days. Patients with DDS were given a placebo eyedrop in the form of 0.9% sodium chloride, while all 63 eyes received topical chloramphenicol eyedrops q.d.s for 30 days. At the conclusion of the 30 day visit, the eyedrop containers were collected and the residual volume of medication remaining in each bottle was then measured to the nearest 10 microlitre using a pipette.
Results 31 patients returned the complete set of eyedrop containers. There was no statistical significant difference in the volume used between the types of eyedrops, sex and diabetic status. All the patients used more than the prescribed amount. Older patients tended to use less medication.
Conclusion The amount of medication that patients actually administered in this trial varied widely according to the individual, and patient age may be a factor affecting compliance in using eyedrops.

Keywords: Eyedrops, Reliability
Singapore Med J 2001; 42(6): 252-254

SW Hwang, YS Leo
Correspondence: Dr Leo Yee Sin, yee_sin_leo@notes.ttsh.gov.sg

ABSTRACT
The introduction of antiretroviral therapy has led to a significant decrease in the mortality and morbidity associated with human immunodeficiency virus (HIV) infection. Nucleoside reverse transcriptase inhibitors (NRTI) have been widely used as part of the antiretroviral therapy against HIV. However, one recently recognised serious complication of NRTI is the development of lactic acidosis. We report two cases of fatal NRTI-induced lactic acidosis, which occurred within five months of each other. Both were being treated with didanosine (ddI) and stavudine (d4T). Physicians involved in the care of HIV patients should recognise and be alert to the possibility of this highly fatal complication.

Keywords: HIV infection, lactic acidosis, nucleoside reverse transcriptase inhibitors, anti-retroviral therapy
Singapore Med J 2001; 42(6): 247-251

L Chua, SA Chong, E Pang, VPY Ng, YH Chan
Correspondence: Lyn Chua, lyn_chua@imh.com.sg

ABSTRACT
Objective To evaluate the effect of risperidone treatment on the cognitive functioning in a group of Asian patients with schizophrenia
Method Patients with DSM-IIIR schizophrenia were recruited from Woodbridge Hospital. Several domains of cognitive functions were assessed at baseline before washout, at 8 weeks and 6 months after initiation of treatment on risperidone. Clinical outcome was assessed on the Positive and Negative Syndrome Scale (PANSS).
Results Significant improvements were found in verbal fluency and certain aspects of memory 8 weeks after risperidone treatment. There were significant improvements in executive and memory functioning after 6 months. Improvements were also noted in attention and perceptual/motor processes although these did not reach significant levels. Treatment on risperidone also resulted in significant reduction in the PANSS score.
Conclusion Our results are consistent with those found in other studies in which risperidone was shown to be effective in improving several aspects of cognitive functioning. There were corresponding effectiveness in treating positive and negative symptoms of schizophrenia. Such improvements can have positive implications on vocational and social functioning.

Keywords: risperidone, cognitive functioning, schizophrenia, Asian
Singapore Med J 2001; 42(6): 243-246

S Shahar, J Earland, Abd Rahman S
Correspondence: Dr Suzana Shahar

ABSTRACT
Aim To evaluate the social and health functions of rural elderly Malays.
Method A survey was carried out on 350 elderly Malays aged 60 and above using a set of socio and health questionnaires.
Results The majority of elderly people in the study were married (64%), unemployed with no pension (76%), relied on children for their main economic resources (62%) and perceived that they have sufficient money to buy the food they require (61%). Most of the subjects felt healthy, contented and satisfied with their everyday life, were able to do most of the Activities of Daily Living (ADL) tasks and were actively involved in community activities. However, most of the subjects (60%) had either one or two diagnosed chronic diseases. Thus, only 15% of the subjects had not taken any type of medicines during the previous 12 months.
Conclusion Although the majority of the elderly in this study were able to perform all the ADL tasks and perceived their health as good, physical impairments (eg. sight, hearing and chewing difficulties) are prevalent and the use of medicines is widespread. It is expected that in future a greater proportion of rural elderly Malays will live alone and will face economic and health problems because of the lack of sufficient and satisfactory programmes for this age group.

Keywords: social, health, elderly, rural, Malays
Singapore Med J 2001; 42(5): 208-213

ISY Chua, KT Tan, SK Lim-Tan, TH Ho
Correspondence: I S Y Chua

ABSTRACT
Introduction Granulosa cell tumour (GCT) represents the largest group of sex-cord stromal tumours and comprises 1.5-3% of ovarian malignancy. The aim is to determine the incidence of the disease, study the profile of local patients, and assess the use of imaging studies in the diagnosis of the tumour.
Materials and Methods Clinical records of 19 patients diagnosed with GCT between October 1988 and July 1997 in Kandang Kerbau Hospital (KKH) were reviewed.
Results GCT accounts for 3.5% of ovarian malignancy (54 out of 1552) in Singapore, of which 94.7% are adult GCT. In our study, patients are mainly peri/postmenopausal women (63.2%) in their 50s who experience post-menopausal bleeding. There is a high incidence of association with endometrial hyperplasia (40%). Ultrasound scans are able to predict the size and involvement of the tumour rather accurately. In our study sample, 13 patients (68.4%) presented with Stage 1 of the disease, none with Stage 2, 1 with Stage 3 (5.3%) and none with Stage 4. The other 5 patients (26.3%) were unstaged. Only one patient required adjuvant chemotherapy.
Conclusion The local data with regards to GCT is congruent with those found in foreign literature. However, in our study, there were no patients with recurrence whereas GCTs are known to be late recurring in up to 20% of patients 10-20 years after diagnosis. This is probably attributed to the relatively short period of follow-up in this study. Thus, despite the fact that there is no evidence of recurrence of disease in our current study, we still recommend a vigilant follow-up protocol on all patients as literature has proven that with early detection of recurrences, it is possible to achieve complete cure.

Keywords: granulosa cell tumours, recurrence, ultrasound studies
Singapore Med J 2001; 42(5): 203-207