Original Article

WS Teo, R Kam, LF Hsu
Correspondence: W S Teo, Teo_Wee_Siong@nhc.com.sg

ABSTRACT
Objective Patients with heart failure may have conduction abnormalities in up to 30%, further aggravating cardiac output. Drugs worsen these abnormalities and resynchronisation therapy with biventricular pacing improves cardiac function by effecting a more coordinated and efficient ventricular contraction. We report here the technique of biventricular pacing and its results.
Methodology Patients with NYHA Class III to IV heart failure, widened QRS (> or = 130 ms) complex on the ECG and impaired LVEF < or = 40% were enrolled.
Results Biventricular pacing was performed in 29 patients (26 males, three females) from August 1999 to December 2001. The mean age of the patients was 59.6 +/- 12.8 years and 62% had underlying ischemic heart disease. All were in NYHA class III or more. Twenty-three had LBBB, four RBBB and two had widened paced QRS complex. The QRS duration was 161 +/- 21 ms and LVEF was 22 +/- 8%. All the left ventricular leads were implanted successfully. The procedure time was 167.0 +/- 79.6 mins and the fluoroscopy time was 43.8 +/- 41.4 mins. There were no significant complications. The NYHA class improved from a mean of 3.1 to 2.0 and exercise time from 252 +/- 95 seconds to 392 +/- 152 seconds at six months post implant (p=0.049). On follow-up (one month to 28 months), 25 (86%) patients had improvement in heart failure symptoms and 26 (90%) of the patients remained alive.
Conclusion Biventricular pacing can be safely performed and results in improvement in symptoms and exercise tolerance in heart failure patients with ventricular dyssynchrony not responding to drug therapy.

Keywords: biventricular pacing, pacemaker, defibrillator, heart failure, arrhythmia
Singapore Med J 2003; 44(3): 114-122

CY Chen, K Kwek, KH Tan, GSH Yeo
Correspondence: Dr Chen Chern Yi, DrChenCY@hotmail.com

ABSTRACT
Aim To assess the incidence, epidemiological factors, preceding symptoms and signs, management regimens and obstetric outcomes of eclampsia in a tertiary care hospital in Singapore.
Method A retrospective study of all obstetric patients who suffered one or more eclamptic seizures in our hospital between January 1994 and December 1999.
Result There were 62 cases of eclampsia among 92,305 deliveries (6.7 per 10,000 deliveries). The incidence was highest among Indians. Those aged between 25 and 34 had the lowest incidence, while women younger than 25 or older than 34 had a significantly higher incidence. Forty (64.5%) patients had symptom or sign of impending eclampsia of which headache was the most common. Most of the patients (81.6%) who received antenatal care with us suffered their first eclamptic seizure in hospital, compared to 50% of the unbooked patients. There was one maternal death (mortality rate 1.6%), and 15 (24.2%) women had significant morbidity. There were 61 singleton pregnancies and one twin pregnancy. There were six intrauterine deaths and 57 livebirths. The perinatal mortality rate was 95.2 per 1,000 births.
Conclusion Eclampsia is still a major cause of maternal and foetal mortality and morbidity in Singapore. Race and age appear to be risk factors for eclampsia with Indian women and those at the extremes of reproductive age at greater risk. Antenatal care is important in reducing perinatal mortality and possibly maternal complications.

Keywords: eclampsia, incidence, symptom, mortality, Singapore
Singapore Med J 2003; 44(2): 88-93

PH Chandrawansa, Y-C Giam
Correspondence: Y-C Giam, ycgiam@nsc.gov.sg

ABSTRACT
Folliculitis decalvans is a rare condition affecting mainly the scalp leading to scarring alopecia. Aetiology of the condition is still unknown, abnormal host response to Staphylococcus aureus has been postulated. We present a retrospective analysis of six cases of folliculitis decalvans presented to National Skin Centre (NSC), Singapore for the past five years, 1995-2000. The mean age of presentation was 39 years and ages ranged from 17 to 62 years. There were five male patients and one female patient. Duration of symptoms at presentation varied from six months to seven years. Occipital and vertex areas of the scalp were the only regions involved. Staphylococcus aureus was isolated in three patients; in one patient culture yielded negative results and no culture was done in the other two patients. All our patients were treated with several separate courses of systemic antibiotics which include doxycycline, erythromycin, minocycline, co-trimoxazole, cloxacillin, erythromycin, rifampicin and clindamycin. In addition one patient was treated with fucidic acid and zinc sulphate. The disease ran a protracted course with temporary improvement while on antibiotic and flare up of disease when antibiotics were stopped. The effectiveness of early treatment with rifampicin has been highlighted in some case reports in the past. We did use rifampicin in one of our patients. Our concern over emergence of antibiotic resistance, if used widely, may not permit us to use rifampicin on a wide scale.

Keywords: folliculitis decalvans, tufted folliculitis, Staphylococcus aureus
Singapore Med J 2003; 44(2): 84-87

KC Ng
Correspondence: Dr K C Ng, keech@kkh.com.sg

ABSTRACT
This is a three-year retrospective review of 96 cases of paracetamol ingestions seen by KK Children's Emergency Department. Paracetamol is the commonest substance (23%) involved in childhood poisonings. More than 60% occurred in children aged one to three years old with an equal gender distribution. Eighty-six percent were accidental ingestions and the intentional ones had a significant female bias, all occurring in children aged 12 and above. These older children ingested higher doses of paracetamol (average dose of 233 mg/kg) and had potentially serious serum paracetamol levels. There was no significant morbidity and no mortality in this series.

Keywords: Childhood poisonings, Paracetamol Ingestion, Intentional Ingestions, Teenage paracetamol poisoning
Singapore Med J 2003; 44(2): 79-83

SK Mak, CK Loo, PN Wong, KY Lo, GMW Tong, EKM Lam, AKM Wong
Correspondence: Dr Siu Ka Mak, maksk@ha.org.hk

ABSTRACT
Objective The efficacy of short-course triple eradication therapy has been documented in patients with Helicobacter pylori infection and normal renal function. We have evaluated a one-week proton-pump inhibitor-based triple therapy for Helicobacter pylori eradication in a retrospective review of patients with chronic renal failure.
Methods We studied 25 patients (mean age 65.1 +/- 2.4 years) with creatinine clearance <30 ml/min/1.73 m2 or serum creatinine level >200 micromol/L (13 on dialysis), who had Helicobacter pylori infection, documented by histological examination or rapid urease test, together with either peptic ulcer disease or severe gastritis. The combination of Omeprazole 20 mg BID or Lansoprazole 30 mg BID, amoxicillin 1 gm BID and clarithromycin 500 mg BID was given for one week, in addition to therapy for peptic ulcers. All patients were re-endoscoped four weeks later.
Results All but one patient (96%) had successful eradication. On repeat endoscopy, all 13 patients with peptic ulcers had healed ulcers. For the 12 gastritis patients, three became normal and nine had persistent gastritis. For patients not on dialysis, the serum creatinine level and creatinine clearance remained stable at two weeks after treatment (303 +/- 37 vs. 330 +/- 36 micromol/l, p=ns; 23.6 +/- 3.4 vs. 26.0 +/- 3.9 ml/min/1.73 m2, p=ns, respectively).
Conclusion The short course triple therapy was highly efficacious for Helicobacter pylori eradication in patients with chronic renal failure, with no adverse effect on renal function.

Keywords: Chronic renal failure, Eradication, Helicobacter pylori, Triple therapy
Singapore Med J 2003; 44(2): 74-78

LKP Yap, SYL Au, YH Ang, KY Kwan, SC Ng, CH Ee
Correspondence: Dr L K P Yap, philip_yap@alexhosp.com.sg

ABSTRACT
Aim of Study To describe the residents of a nursing home for the elderly in terms of their socio-demographic profile, mental and physical attributes, functional abilities and existing medical problems.
Method A random sample of 120 subjects was obtained from a total of 350 residents in a voluntary welfare nursing home. Two subjects were excluded as they did not satisfy inclusion criteria (age > or = 60 years). The subjects' biodata, social background, medical problems and functional status at the time of admission were obtained by a review of the case records. Each of the subjects was examined with attention to their general condition, hearing and vision, presence of postural hypotension, cognition and ability to perform basic activities of daily living (ADL).
Results Results were available for 106 out of the 118 subjects as the rest were either discharged in the course of the study or had died. Single (36%), widowed (41%), female (71%) and age > or = 75 years (73%) consisted the majority. Most subjects (43%) were admitted because of both medical and social factors. Twenty-two percent appeared undernourished and of those who could be assessed, 14% had postural hypotension, 18% were hearing impaired and 53% had visual impairment. Fifty-two per cent suffered from mental problems while 46% and 40% had been diagnosed with hypertension and stroke respectively. Forty-eight percent had probable cognitive impairment (according to ECAQ scores) and 41% were very severely disabled (according to Barthel Index). Fifty-five percent were dependent in bathing, 50% dependent in dressing, 50% incontinent of urine (and requiring diapers), 48% were non-ambulant and 21% dependent in feeding.
Conclusion With a significant proportion of the population requiring nursing home care in the future, a closer review of the situation is needed. This study has identified malnutrition, urinary incontinence, falls, functional decline and impaired vision/hearing as issues that deserve greater attention and, where necessary, intervention. Whether implementing recognised effective interventions will truly benefit our nursing home residents would warrant more local studies.

Keywords: nursing home, elderly, ECAQ (Elderly Cognitive Assessment Questionaire), Barthel index, ADL (Activities of Daily Living)
Singapore Med J 2003; 44(2): 65-73

YM Low, YH Goh
Correspondence: Dr Low Yin Mei, hushbwn@yahoo.com.sg

ABSTRACT
This is a retrospective review of otolaryngology patients who underwent intra-arterial embolisation in a tertiary hospital over a four-year period. Thirty patients were reviewed. Seven (23.3%) were embolised electively before resection of hypervascular head and neck tumours. Of the emergency indications, nine patients (30%) had intractable epistaxis from non-oncologic causes, 14 (46.7%) had bleeding of oncologic origin from the head and neck. In all, six patients required further procedures within the first week, 2 (6.7%) suffered permanent cranial nerve deficits. Our results show that intra-arterial embolisation is both useful and safe in elective and emergency settings in otolaryngology, with complication rates comparable to previous publications. The survival of oncology patients with otherwise fatal haemorrhage was significantly prolonged.

Keywords: Pre-operative embolisation, endovascular treatment, epistaxis, nasopharyngeal carcinoma, carotid rupture
Singapore Med J 2003; 44(1): 35-38

DK Lim
Correspondence: Dr D K Lim, dominic.lim@chmeds.ac.nz

ABSTRACT
Ketamine, a dissociative anaesthetic in use since 1970, produces prominent psychoactive effects in humans. Its non-medical use has raised concerns in many countries, including Singapore. This paper narrates the psychedelic and psychotic effects of ketamine in two ketamine dependent patients who have presented to the psychiatric service. These effects were dose-related and comprised multimodal hallucinatory experiences, a sense of slowing, paranoid ideation and enhancement of sexual, musical and sensory enjoyment. In both ketamine users the psychotic symptoms resolved quickly with symptom-targeted treatment. However, breaking the ongoing addiction cycle seemed more difficult. The neuro-pharmacological mechanisms of these phenomena are largely due to its complex multi-receptors actions, notably through the excitatory amino acids through mainly the N-methy-D-aspartate (NMDA) receptors. The detection of ketamine abuse requires a high index of suspicion and needs to be considered when there is an acute presentation with multi-modal hallucinations and psychosis.

Keywords: Ketamine, psychedelic effects, psychosis, dependence, management
Singapore Med J 2003; 44(1): 31-34

JL Soon, HC Chang, CS Sim, LC Teoh, CO Low
Correspondence: H C Chang, haw_chong_chang@cgh.com.sg

ABSTRACT
We report a case of Bizarre Parosteal Osteochondromatous Proliferation (BPOP) of the hand that was initially misdiagnosed as an osteochondroma. BPOP, although a benign lesion, behaves aggressively with rapid growth and high risk of local recurrence after local resection. The distinguishing features of BPOP as opposed to an osteochondroma are discussed.

Keywords: Nora’s lesion, differential diagnosis, histopathology
Singapore Med J 2003; 44(1): 27-30

JK Tan, CY Hong, DJC Png, LCH Liew, ML Wong
Correspondence: Dr James K Tan, james_tan_kn@ttsh.com.sg

ABSTRACT
Purpose To study the prevalence of erectile dysfunction (ED) in Singapore males aged 30 and above and its association with demographic, medical and other risk factors.
Methodology A population based cross sectional study of 729 men aged 30 and above in Singapore was conducted using the abridged, five-item version of the International Index of Erectile Function (IIEF-5). Presence of erectile dysfunction was defined as IIEF-5 score of less than 21. Erectile dysfunction was further categorised into mild (IIEF-5: 16-20), moderate (IIEF-5: 11-15) and severe (IIEF-5: <11). A logistic regression model was used to identify significant independent risk factors for ED.
Results Overall, 51.3% of respondents (n=374) reported some degree of erectile dysfunction. Of these, 23.2% have mild ED, 8.8% have moderate ED and 19.3% had severe ED. The prevalence of ED increased from 42.8% for men in their forties to 77.4% in their sixties. The prevalence of severe ED increased from 9.1% in men in their forties to 43.5% in their sixties and 77.0% in those aged 70 and above. Age above 50 years is the single most significant risk factor on multivariate analysis when adjusted for all confounding factors. Other important risk factors include Indian ethnic group, lower household income, physical inactivity, diabetes mellitus and cardiac diseases.
Conclusion Erectile dysfunction is common amongst Singaporean men. Age is the single most important physiologic factor affecting erectile function. The prevalence and severity increased significantly with age after 50 years old. With an ageing population, erectile dysfunction may become a significant health problem. Health care providers should plan their resources accordingly.

Keywords: erectile dysfunction, prevalence, population-based study
Singapore Med J 2003; 44(1): 20-26