Original Article

EHL Lim, EHC Liu
Correspondence: Dr Evangeline Lim, ducktai@singnet.com.sg

ABSTRACT
Introduction Pre-operative Chest X-ray (CXR) and electrocardiograms (ECG) are routinely ordered locally for patients above a certain age. This study examines the usefulness of such a practice and its clinical impact.
Methods Prospective audit of 875 consecutive anaesthetic patients over a one-month period, assessing the proportion and impact of abnormal CXR or ECG findings.
Results The proportion of patients with abnormal CXR or ECG increased with worsening ASA status. There was little impact of routine pre-operative CXR and ECG on anaesthetic management. Only 11/324 CXR and 13/375 ECG affected anaesthetic technique or choice of therapeutic procedure.
Conclusion Targeted investigations should be performed as indicated by clinical findings rather than on the basis of arbitrary age cut-offs.

Keywords: Electrocardiogram, chest X-ray, pre-operative test, audit
Singapore Med J 2003; 44(7): 340-343

KO Kong, S Vasoo, NSWT Tay, HH Chng
Correspondence: Dr K O Kong, Kok_Ooi_Kong@ttsh.com.sg

ABSTRACT
Introduction Relapsing polychondritis (RPC) has been described mainly in Caucasian populations. Reports from other ethnic groups are few.
Objectives To describe the clinical characteristics, management and outcome of RPC patients seen in an Oriental population in Singapore.
Methods The case records of RPC patients treated in our department from 1989 to 2001 were reviewed. Only 12 fulfilled the McAdam-Michet-Damiani-Levine diagnostic criteria and these were studied.
Results The female-to-male ratio in our series was 3:1. There were 10 ethnic Chinese and two Malay patients. The age of onset of symptoms ranges from three to 65 years, with a mean of 34 years. A diagnosis was made from two weeks to three years after onset, with a median of 4.5 months. There were 10 patients with pinna, nine articular, eight ocular, six laryngotracheal, five inner ear, four nasal and one cardiac involvement. Five presented with fever. None of them had cutaneous, renal or central nervous system involvement. Ten had raised ESR at presentation. One patient developed discoid lupus erythematosus two years later. All 12 patients received prednisolone with eight of them requiring additional immunosuppressants. Two patients had resistant disease failing to respond adequately to various immunosuppressants together with prednisolone. There was no mortality amongst the nine patients who had remained on follow-up at the time of this report. Five of the six patients with laryngotracheal involvement had tracheostomy and one of them had airway stenting as well.
Conclusion Our series suggests that although the clinical manifestations of RPC are similar in the Oriental and the Caucasian populations, Oriental patients may have less cutaneous, renal or nervous system involvement and more serious airway complications.

Keywords: polychondritis, oriental, obstruction, airway, stent
Singapore Med J 2003; 44(4): 197-200

V Nissapatorn, CKC Lee, AA Khairul
Correspondence: Dr Veeranoot Nissapatorn, nissapat@hotmail.com

ABSTRACT
Four hundred and six AIDS patients were recruited in this retrospective study. The seroprevalence of toxoplasmosis among 406 AIDS patients was 208 (51.2%). Their age ranged from 17 to 74 years with a median of 35 years. The majority of patients were males 172 (82.6%), Malays 99 (47.5%), single 109 (52.4%), unemployed 99 (47.6%) and heterosexual with commercial sex workers (CSW) 97 (46.6%) as the risk marker to HIV infection. Thirty-one (14.9%) of 208 AIDS-related toxoplasmosis were diagnosed as active toxoplasmic encephalitis. The most common clinical manifestation was headache (67.7%). The CT scan findings showed most lesions to be multiple (87.5%), hypodense (66.7%), and in frontal region (41.7%). Twenty-two (71%) patients had chronic (latent) Toxoplasma infection as evidenced by seropositivity for anti-Toxoplasma (IgG) antibody. They were statistically significant in the association between CD4 count and toxoplasmic encephalitis (P = 0.019; OR = 2.6; 95% CI = 1.14-6.02). After the initial six weeks of anti-TE therapy, relapsing toxoplasmic encephalitis was detected in 9.7% in this study.

Keywords: AIDS, Toxoplasmosis, Toxoplasmic encephalitis (TE)
Singapore Med J 2003; 44(4): 194-196

SC Peh, J Shaminie, S Poppema, LH Kim
Correspondence: Peh Suat Cheng, pehsc@ummc.edu.my

ABSTRACT
Background Castleman's disease is an uncommon disease and the histopathogenesis is poorly understood. This study aims to investigate their clinicopathological and immunophenotypic profile.
Materials and Methods Castleman's disease was reconfirmed in biopsy tissue from 10 patients in a period of 17 years. Immunohistochemical staining was performed on the archival materials, with antibodies to lymphoid antigens and oncogene products, Bcl-6 and Bcl-2. Six reactive hyperplastic lymph nodes and three tonsils were used for comparative study of the phenotypic expression.
Result There were three cases of plasma-cell and seven of hyaline-vascular variant. The ages of patients ranged from eight to 60 years (median 30 years). The three patients with plasma-cell variant were older, all females. Two of the plasma-cell variant had multicentric lesions associated with systemic disease. All patients with hyaline-vascular variant had localised disease. Atrophic follicle centres were present in all the diagnostic tissue of both subtypes, with loss of Bcl-6 follicular centre B-cells and presence of relatively few CD57 T-cells. These follicle centres stained strongly with anti-CD21. In the mantle zone, CD5 expression was observed in only two cases and Bcl-2 expression similar to reactive follicles was present in six.
Conclusion Loss of Bcl-6 B-cells in the atrophic follicle centres, characteristic CD21 network patterns, low rate of CD5 and Bcl-2 expression in the mantle-zone lymphocytes are present in both variants of Castleman's disease, differ distinctly from reactive follicles. The phenotypic similarity in these two variants suggests possibility of closely related pathogeneses.

Keywords: Castleman’s disease, hyaline-vascular, phenotype, plasma-cell type
Singapore Med J 2003; 44(4): 185-191

MH Kam, YH Tan, MYC Wong
Correspondence: M Y C Wong, gurwyc@sgh.com.sg

ABSTRACT
Introduction Vesicovaginal fistulae are largely iatrogenic and represent therapeutic dilemmas in surgical approach and timing of repairs.
Aim We have reviewed our surgical management of vesicovaginal fistulae over a 12-year period to determine whether the outcome is dependent on surgical approach and timing of repair.
Patients and Methods From January 1990 to September 2001, 23 patients were referred to our department of whom 20 have retrievable records. Fourteen of these 20 patients had gynaecological operations as the primary cause for their fistulas whilst the remaining six had varied causes ranging from forceps delivery to recurrent pelvic malignancies.
Results Of 20 patients, four underwent transvaginal repair, seven transvesical repair, eight supravesical repair and one required an ileal conduit diversion. There was an 85% success after first repair with only three fistula recurrences, two of whom underwent a successful second repair and one was treated conservatively and successfully with urethral catheterisation. There were no further recurrences at mean follow-up of 23 months for our cohort. Earlier repair seemed to be associated with a higher recurrence rate (33% of six patients within six weeks) compared with delayed operations (7% of remaining 14 operated after six weeks).
Conclusion Vesicovaginal fistulae can be successfully managed surgically. Although the type of approach did not affect outcome, the timing of the repair may affect the success of the operation.

Keywords: Vesicovaginal, fistula, genitourinary, iatrogenic, surgical management
Singapore Med J 2003; 44(4): 181-184

HT Hee, HK Wong
Correspondence: A/Prof Wong Hee Kit, doswhk@nus.edu.sg

ABSTRACT
Purpose To evaluate the surgical results of spinal stenosis in the elderly and to investigate which factors may contribute to a poor outcome.
Methods This is a retrospective study of 68 patients aged 60 and above who had decompression laminectomy for lumbar spinal stenosis between 1989 and 1991. They were evaluated at an average of eight years after surgery. The mean age at surgery was 68 years. Twenty-eight had co-existing illnesses. Twenty-one had concomitant degenerative spondylolisthesis. Thirty-two (47%) had decompression laminectomy performed at one level. Eleven (16%) had arthrodesis. Seven had spinal instrumentation, of which six were Hartshill rectangles. Functional result was graded using modified Paine classification. Multivariate analysis with logistic and linear regression was used to determine predictors of poorer outcomes.
Findings There were 68% excellent and good, 22% fair and 10% poor results. Back pain was relieved in 91% of the patients. Leg pain was relieved in 76% of the patients. Numbness was relieved in 87% of the patients. Five patients had re-operations. Multivariate analysis revealed that age, sex, co-morbidity score, number of levels decompressed, and degenerative spondylolisthesis did not predict worse outcomes. However, Hartshill rectangle instrumentation and pre-operative leg numbness predicted less favourable results.
Conclusion The surgical results of spinal stenosis in the elderly are favourable and comparable to those reported for the general population at an eight-year follow-up.

Keywords: Decompression laminectomy, elderly, Fusion, Hartshill rectangles, Spinal stenosis
Singapore Med J 2003; 44(4): 175-180

HC Gan, EJC Lee, MM Tay, Norashidah Yusuf
Correspondence: Dr Gan Hwa Chau, ganhwachau@yahoo.com

ABSTRACT
Objective To study the incidence of peritonitis in CAPD patients in their first six months on CAPD.
Patients and Methods All patients who started on CAPD between 1 January 1999 and 31 December 1999 were included in the study. All of them were followed for six months for development of peritonitis.
Results Four episodes of CAPD related peritonitis occurred in four different patients during this period. Patient One was an elderly man with diabetes mellitus who had Streptococcal peritonitis two months after he started on CAPD. Patient Two was an elderly woman with diabetes who developed Streptococcal peritonitis four months after she was on CAPD. Patient Three was a 51-year-old lady with diabetes who suffered Pseudomonas peritonitis at four months on CAPD. Patient Four was a young man without diabetes. He had peritonitis after he was on CAPD for four months. The culture showed no bacteria growth. For the first six months of CAPD the peritonitis rate was calculated as one episode for every 51 patient months. The average peritonitis rate of all patients on CAPD at the National University Hospital in 1999 was calculated as one episode for every 27 patient months. The CAPD related peritonitis involving new CAPD patients was lower.

Keywords: early onset, peritonitis, CAPD
Singapore Med J 2003; 44(3): 138-140

MB Bahari, N Md Nur, AF Ab Rahman
Correspondence: M B Bahari, baidi@usm.my

ABSTRACT
A survey was carried out among primary school teachers in the district of Kota Bharu, Malaysia to assess the level of knowledge on asthma and its management. Our findings revealed that primary school teachers were less informed about the management and treatment of asthma. They were relatively more knowledgeable about the causes and symptomatology of asthma. The majority of respondents had misunderstanding regarding the effect of rain, smoking and cold weather on asthma. It is important that teachers should be able to recognise symptoms of an asthmatic attack or take the necessary precautions to avoid such an attack. Many teachers agreed on the need to have an asthma education programme in their teaching curriculum.

Keywords: teachers, primary school, knowledge, asthma, Malaysia
Singapore Med J 2003; 44(3): 131-135

R Poopalalingam, MYH Chow, LT Wong
Correspondence: R Poopalalingam, rumini@bigfoot.com

ABSTRACT
Background Epidural sufentanil can relieve postoperative pain after thoracic and upper abdominal surgery but it has some unwanted side effects. Patient-controlled epidural analgesia (PCEA) allows patients to titrate and reduce their analgesic requirements.
Objective The study aims to assess the use of demand-only PCEA after thoracotomy and upper abdominal surgery using sufentanil with or without bupivacaine in terms of pain control, amount of analgesic required and side effect profile.
Methods After the Hospital Ethics Committee approval and written informed consent, 34 ASA I and II patients were enrolled in this prospective, randomised, double-blinded controlled study. Post-operatively, after achieving adequate analgesia in the recovery, the patients were randomised to receive either sufentanil 1 microg/ml in normal saline (Group S) or sufentanil 1 microg/ml with bupivacaine 0.125% (Group SB) in a demand-only PCEA programme. Pain scores, side effects and amount of analgesia used were reviewed every hour.
Results The demographic profile of both groups was similar. The amount of sufentanil used was higher in Group S than in Group SB but it was not statistically significant. The numbers of patients with high pain scores at rest and during movement were not significantly different between the two groups. The side effect profiles of both groups were similar.
Conclusion The PCEA demand-only programme using sufentanil 1 microg/ml with and without bupivacaine 0.125% was satisfactory after thoracotomy and upper abdominal surgery in our patient population. The addition of bupivacaine to sufentanil did not significantly reduce the amount of sufentanil required, the pain scores or the side effects.

Keywords: patient-controlled epidural analgesia, sufentanil, local anaesthetics, bupivacaine, thoracic and upper abdominal surgery
Singapore Med J 2003; 44(3): 126-130

N Prepageran, Gopala Krishnan
Correspondence: N Prepageran, prepageran@yahoo.com

ABSTRACT
Objective To present our experience of endoscopic electrocoagulation of sphenopalatine artery for persistent posterior epistaxis despite conservative measures.
Methods Seven endoscopic electrocoagulation of sphenopalatine artery was done for four patients from early 2001 till the present for recalcitrant epistaxis despite conservative treatment. The basic principle of this surgical method is to identify the sphenopalatine artery via endonasal endoscopy and to electrocoagulate the vessel.
Results Seven procedures were carried out in four patients. Endoscopic coagulation of sphenopalatine artery was carried out unilaterally in one patient and bilaterally in three patients. The artery was identified in all cases with successful postoperative results.
Conclusion This method is an effective surgical technique for persistent posterior epistaxis with low morbidity.

Keywords: epistaxis, endoscopic coagulation of sphenopalatine artery
Singapore Med J 2003; 44(3): 123-125