Original Article

VKG Lim
Correspondence: V K G Lim, bizlimv@nus.edu.sg

ABSTRACT
Aim This study examined the level of knowledge of SARS transmission among Singaporeans and their willingness to disclose their health condition to others. We also examined respondents' perceived effects of SARS on work and organisations and their attitudes toward issues of privacy and disclosure of medical information.
Methods Respondents comprised MBAs (Master of Business Administration students) and human resource managers who attended classes in a local tertiary institution. Data were collected via an email survey. A total of 101 completed surveys were received and included in data analyses.
Results Results suggest that despite rather intensive efforts to generate awareness about SARS transmission, a certain level of uncertainty about how SARS can be transmitted still prevails. This is not surprising, given that SARS is a relatively new medical problem. Our findings also suggest that while respondents unanimously agreed that they would inform their parents, spouse, siblings and employers if they were tested positive for SARS, they were more ambivalent about disclosing such information to their neighbours and colleagues. Findings also suggest that having a SARS or probable SARS case in the company would disrupt the flow of work and affect employees' morale.
Conclusion Results of this study have significant implications for efforts to educate Singaporeans about the disease and the management of SARS at the workplace.

Keywords: Severe Acute Respiratory Syndrome (SARS), Singapore, work, organisations, knowledge of transmission
Singapore Med J 2003; 44(9): 457-463

S-K Goh, CH Chui, AS Jacobsen
Correspondence: C H Chui, chanhon@kkh.com.sg

ABSTRACT
Objective To analyse the cases of acute pancreatitis presented to a children's hospital in Singapore.
Methods Clinical charts of all children, aged under 18 years, who presented to our hospital for the first time with pancreatitis (ICD search criteria = 577.x) between the period of 1998 and mid-2002 were reviewed. Parameters analysed included presenting features, aetiology of the acute pancreatitis, length of hospital stay, complications, treatment and outcome.
Results There were 12 cases in the review period, and the attributable causes in these cases were, in descending order, trauma, drug-induced, anatomical anomalies, poisoning and idiopathic. Of interest were two patients whose pancreatitis were results of child abuse. The most common symptoms were abdominal pain (n=11) and vomiting (n=7), though only five patients localised the pain to the epigastrium. Abdominal tenderness could be elicited in all the patients. Eleven had evidence of acute pancreatitis from computerised tomography (CT) whilst the twelfth was diagnosed with ultrasonography. The peak amylase levels amongst these patients were not high, with a median of 512.5 U/L. In the acute stage, only one patient required operative intervention whilst the remainder were managed conservatively. The mean length of hospital stay was 12.41 +/- 4.54 days. The complications encountered included pseudocyst formation, ascites, hypocalcaemia, pleural effusion and coagulopathy.
Conclusion The diagnosis of acute pancreatitis in children can be difficult. This is often due to ambiguous symptoms, signs and laboratory results. CT and ultrasound are essential investigations in the diagnosis and subsequent follow-up.

Keywords: acute pancreatitis, children, child abuse, paediatrics
Singapore Med J 2003; 44(9): 453-456

SKE Gan, CY Loh, B Seet
Correspondence: Samuel Gan Ken En, 383838@starhub.net.sg

ABSTRACT
Aim To study the prevalence of hypertension and "white coat hypertension" in young adult Asian males, and identify the associated risk factors.
Methods Population-based descriptive analysis of 3,352 Singapore military conscripts presenting consecutively for medical screening, followed by case-control study of subjects with elevated blood pressure. A standard protocol for assessing elevated blood pressure, 24-hour ambulatory monitoring and detailed interviews were performed. Main study outcomes are prevalence rate of hypertension and "white coat hypertension", mean blood pressure readings, and adjusted odds ratios for associated variables.
Results Prevalence of hypertension and "white coat hypertension" was 1.6% (95% CI 1.2, 2.0) and 2.0% (95% CI 1.5, 2.5) respectively. Twenty-four-hour ambulatory monitoring was required to differentiate the two conditions, with a fall of 22.5 mmHg (95% CI 19.7, 25.3) observed between first visit and day-time ambulatory mean systolic blood pressures. There was strong association between hypertension and obesity (adjusted odds ratio using Body Mass Index: 1.19, p<0.001). Other important variables included parental history of hypertension, Malay ethnicity and low socio-economic status, although there was no significant correlation in our regression model.
Conclusion This study provides population-based data on hypertension in young Asian adults. While the prevalence of hypertension is low compared to older age groups, it remains important to detect cases early, as appropriate treatment may mitigate long-term cardiovascular risks and reduce target organ damage. There is a clear role for ambulatory blood pressure monitoring for differentiating true hypertension from "white coat hypertension". There may be a role for targeted screening of high-risk groups, particularly the obese.

Keywords: hypertension, white coat hypertension, screening, blood pressure, ambulatory monitoring
Singapore Med J 2003; 44(9): 448-452

VC Woon, KH Lim
Correspondence: Dr Woon Voon Ching, Voon_Ching_Woon@cgh.com.sg

ABSTRACT
Objectives The aim of the study was to determine the differences in presentation, complications, management and outcome of elderly patients with acute myocardial infarction (AMI) compared to young patients.
Materials and Methods All case-notes with a discharge or death diagnosis of AMI between January and July 1999 at a restructured hospital in Singapore were reviewed retropectively. Patients were categorised into those younger than 65 years (young) and those 65 years or older (elderly). Data on the demographic and clinical profile of patients were collected.
Results There were 112 young and 101 elderly AMI patients. Chest pain was the most common presentation in both age groups, but more likely in the young than the elderly (89.3% vs 66.3%; p < 0.001). Atypical presentations were more likely in the elderly, with shortness of breath as the most common presentation (20.8% vs 5.4%; p < 0.001). The elderly were more likely to have complications of cardiac failure (65.3% vs 25%; p < 0.001) and cardiogenic shock (8.9% vs 0.9%; p = 0.006). The elderly were less likely to receive thrombolytic therapy (35.8% vs 64.8%; p < 0.001) as they were more likely to have contraindications (34.5% vs 6.8%; p = 0.002). The elderly were also less likely to receive beta-blockers (21.8% vs 60.7%; p < 0.001). In-hospital mortality was higher in the elderly (20.8% vs 2.7%; p < 0.001). Cardiogenic shock complicating AMI was associated with high in-hospital mortality.
Conclusion In AMI patients, chest pain was the most common presentation in both age groups, though less frequently in the elderly. Atypical presentations were more likely in the elderly, with shortness of breath as the most common atypical presentation. In elderly AMI patients, prevalence of cardiac failure was higher, use of beta-blockers was lower and in-hospital mortality was higher than young patients.

Keywords: atypical, cardiac failure, cardiogenic shock, presentation, shortness of breath
Singapore Med J 2003; 44(8): 414-418

N Kohno, Y Ohno, S Kitahara, E Tamura, T Tanabe, Y Murata, M Kawaida
Correspondence: Prof Naoyuki Kohno, sukohno@kyorin-u.ac.jp

ABSTRACT
This study aims to treat locally-advanced nasopharyngeal cancer by concurrent conventional irradiation at 2.0 Gy/day five days per week up to a total dose of 68 Gy, and daily intra-arterial infusion of cisplatin 3 mg/m2 plus 24 hours intravenous drip infusion of 5-fluorouracil 150 mg/m2 per day, five days per week. All of five enrolled patients completed the schedule, and treatment compliance was considered to be identical. Of the five patients evaluable for response, four with complete response (80%) and one with partial response (20%), with an overall response rate of 100% was achieved. The median survival time was 26 months. Two-year survival of the patients was 80%. This regimen showed marginal mucositis but well tolerated. We concluded that this treatment option is safe and effective for the locally-advanced nasopharyngeal cancer.

Keywords: chemoradiotherapy, low dose intra-arterial cisplatin, 5-fluorouracil, stage IV nasopharyngeal cancer
Singapore Med J 2003; 44(8): 410-413

KY Tan, HC Lee, D Chua
Correspondence: Dr David Chua, david_chua@cgh.com.sg

ABSTRACT
Introduction It is now widely accepted that open reduction and internal fixation of displaced acetabular fractures should be the standard of care. This paper reports a case series of acetabular fracture fixation performed at the Changi General Hospital by a single trauma surgeon.
Patients and Methods A retrospective study was conducted of 15 consecutive cases of displaced acetabular fracture fixation between February 1996 and September 1999. Outcome was assessed radiologically and functionally with the use of a hip scoring system used by Matta.
Results The patients' age had a mean of 34.9 years. All fractures were a result of high energy trauma. The median duration to operation upon admission was eight days. The mean hospital stay was 24.9 days and the mean medical hospitalisation leave was 159 days. Bony union was achieved in all patients. Two patients (13.3%) had a residual displacement of 1 mm. Four patients (26.6%) had a residual displacement of 2 mm. Of these four patients with 2 mm displacement, two eventually developed osteoarthritis. Subsequently, one of the two with OA required revision to a total hip arthroplasty two years post fracture. Other complications include 1 (6%) wound infection and 2 (13%) deep vein thrombosis. There were no complications of heterotopic ossification or sciatic nerve injury. Functional scores with a minimum follow up of one year and a mean of 22.6 months follow-up were excellent in 13.3%, good in 66.7%, fair in 13.3% and poor in 6.7%.
Conclusion The number of cases in this paper is insufficient to produce any statisticallly significant outcome predictors but accuracy of reduction is an important factor. A good to excellent result was attained in 80% of the patients which confirms that open reduction and internal fixation is the treatment of choice for displaced and acetabular fractures.

Keywords: acetabulum, fracture, fixation, open reduction
Singapore Med J 2003; 44(8): 404-409

WB Lian, SKY Ho, CL Yeo, LY Ho
Correspondence: Dr Lian Wee Bin

ABSTRACT
Introduction Childhood developmental and behavioural disorders are increasingly being recognised, with high demands for earlier diagnosis and intervention. In Singapore, referrals to the Child Development Unit, KK Women's and Children's Hospital, originate mainly from primary health care practitioners, who therefore should have adequate baseline knowledge of normal development as well as common developmental and behavioural disorders.
Methodology A pilot study, using a questionnaire survey, was conducted, with the aim of assessing existing knowledge in childhood developmental and behavioural paediatrics amongst a cohort of general practitioners (GPs) in Singapore. True/False questions on normal development as well as developmental disorders such as autistic spectrum disorder (ASD), attention deficit/hyperactivity disorder (ADHD) and learning disability, were structured. These disorders were selected because of their relatively higher prevalence.
Results A total of 48 GPs were surveyed, representing 2% of non-specialists practising in the private sector. The median total score (T-score) was 9 (range 6 to 13) of a possible 14. Only just over a-third of the group achieved the pass rate (defined arbitrarily as 75%) for T-score, with two-thirds replying correctly to all questions on normal development. Scores for factual ASD/ADHD questions were also not ideal, with some myths being believed as truths.
Conclusion The scores reflect knowledge and educational deficits in developmental paediatric medicine amongst the study cohort. Expected to provide holistic care and counselling, these GPs are currently insufficiently equipped with the necessary knowledge and skills to support families of special-needs children. Education and training programmes in this aspect of paediatric medicine are clearly needed, through the organisation of CME lectures and incorporation of various developmental topics into the training curriculum. This will enable early identification and diagnosis of childhood developmental and behavioural disorders, which will in turn allow greater optimisation of potential and functionality in these special-needs children.

Keywords: childhood, developmental, behavioural, knowledge, special-needs
Singapore Med J 2003; 44(8): 397-403

PR Shankar, P Kumar, AM Theodore, P Partha, N Shenoy
Correspondence: Dr P R Shankar, mcoms@mos.com.np; pathiyilravi@rediffmail.com

ABSTRACT
Background In Nepal, self-treatment is common and complementary medicine practitioners play an important role in providing health services. Previous studies on drug use patterns have been mainly carried out in the Kathmandu valley. Studies in the Pokhara valley, western Nepal are lacking. The objectives of our study were to obtain: 1) baseline information on drug use patterns in the preceding six-month period, 2) reasons for using complementary and self-medication and 3) any association of drug use patterns with demographic variables.
Methods Health workers of the community medicine department carried out the study in Pokhara city and Bedabari village using a semi-structured questionnaire. Differences in the proportion of patients using self-medication and complementary medicines according to sex, age, place of residence and socioeconomic status of the family were analysed by the z test of proportions (p < 0.05).
Findings and Conclusion One hundred and twenty individuals from 112 households had used prescribed allopathic or complementary remedies. Seventy-one point six percent of the respondents had used allopathic medicines. The commonest allopathic medicines prescribed were antibiotics and paracetamol. Complementary medicine use was more common among older respondents (> 30 years). Thirty-nine families practiced self-medication with home remedies accounting for 18.9% of the drugs used. Self-medication was more common among rural households. Complementary practitioners should be integrated into the health care system to provide health care in the rural areas. Studies on drug use patterns and on factors influencing drug use in the remote areas of Nepal are urgently required.

Keywords: drugs, drug-monitoring-methods, non-prescription-therapeutic use, self-medication-statistics
Singapore Med J 2003; 44(7): 352-356

CW Peng, BK Tay, BPH Lee
Correspondence: Prof Tay Boon Keng, goctbk@sgh.com.sg

ABSTRACT
Introduction A prospective trial was carried out in simultaneous bilateral total knee replacement to compare the outcome of resurfaced versus non-surfaced patella.
Methods Thirty-five patients between 1997 and 2002 had simultaneous bilateral total knee replacement with resurfaced patella on the left and non-resurfaced patella on the right knee using the same implant in both.
Results There were 29 females and six males with a mean age of 65.3 years. Mean follow-up was 3.18 years. There was no significant difference between the resurfaced and non-resurfaced knees with respect to the overall Knee Society clinical score (p = 0.093 preoperative, 0.310 postoperative) or the pain (p = 0.715 preoperative, 0.395 postoperative) or function subscores (p = 0.126 preoperative, 0.317 postoperative). The postoperative range of motion was 109 and 110 degrees for the resurfaced patella and non-resurfaced patella respectively (p = 0.894). The post-operative knee scores between patients with or without pre-operative anterior knee pain (p = 0.238) and between those who were obese and non-obese (p = 0.387) were not significantly different. 82.9% of patients felt that the resurfaced knee and 80% felt that the non-resurfaced knee were much better than before. There was no major preference for either knee for climbing stairs and getting out of chair.
Conclusion The functional and symptomatic outcome of total knee replacement with or without patella resurfacing is the same in the local population. Also, the present study demonstrated no evidence that the weight of the patient or the presence of preoperative anterior knee pain should be considered as factors in the decision to resurface the patella.

Keywords: total knee arthroplasty, patella, knee score, patella thickness, patella tracking
Singapore Med J 2003; 44(7): 347-351

BB Hamidon, AA Raymond, MI Norlinah, SB Jefferelli
Correspondence: Dr Hamidon Bin Basri, hamidon@mail.hukm.ukm.my

ABSTRACT
Background and Purpose Infection is a frequent complication after an acute stroke and may affect stroke outcome. We identified predictors of early infection, type of infection, their relation to initial disability, and the eventual outcome during the inpatient period.
Methods This was a study of patients with acute ischaemic stroke admitted to Universiti Kebangsaan Malaysia Hospital from June 2000 to January 2001. A single observer, using pre-defined diagnostic criteria recorded information on demography, the type, time of onset, and frequency of infections that occurred during the inpatient period.
Results One hundred and sixty three patients with acute ischaemic stroke were enrolled in the study. Early infection was observed in 26 (16%) patients. The infections observed were pneumonia (12.3%), and urinary tract infection (3.7%). Using multivariate analysis, the independent predictors of early infection were Barthel index (BI) less than 5 (OR 4.23; 95% CI 1.70 to 5.11), middle cerebral artery (MCA) territory infarcts (OR 4.91; 95%CI 1.57 to 8.82), and a Glasgow coma score (GCS) less than 9 (OR 5.12; 95% CI 2.98 to 15.52). The presence of early infection increased mortality (OR 14.83; 95% CI 4.31 to 51.07).
Conclusion Severe disability, large MCA infarct and poor GCS independently predict the development of early infection.

Keywords: early infection, ischaemic stroke, mortality
Singapore Med J 2003; 44(7): 344-346