Original Article

KH Koh, PH Chew, A Kiyu
Correspondence: Dr Koh Keng Hee, kohkenghee@yahoo.com

ABSTRACT
Aims To study the clinical and demographic aspects as well as the outcomes of severe cases of malaria infections managed in the intensive care unit of the Sarawak General Hospital, Kuching from January 1996 to December 2001.
Methods All cases of malaria admitted to the intensive care unit of the Sarawak General Hospital from January 1996 to December 2001 were identified from the intensive care records and retrospectively reviewed.
Results A total of 31 cases of malaria were managed in the intensive care unit of the Sarawak General Hospital in the six-year period. Twenty-eight cases were P. falciparum infections; two were P. vivax and one was a mixed infection of P. falciparum and P. vivax. Fever with or without chills and rigors, headache, abdominal pain and vomiting were the four commonest presenting complaints for P. falciparum infections. Patients with both abdominal pain and hepatomegaly have significantly higher mortality. The fatal cases, at presentation, had higher parasite counts, higher bilirubin, aminotransferase, potassium and urea levels, but lower haemoglobin and platelet counts, and more deranged coagulation profiles compared to surviving patients. The major complications include acute renal failure, acute respiratory distress syndrome, cerebral malaria and disseminated intravascular coagulopathy, haemolytic anaemia and liver dysfunction. A single case of vivax malaria, which was complicated by septicaemic shock and disseminated intravascular coagulopathy was also documented. Higher mortality rate was documented if the antimalarial medication was not commenced on the day of admission into hospital.
Conclusion Several infections of P. falciparum are still associated with significant mortality. Other confounding factors include the patient's own initiating quinine therapy. Aggressive and appropriate therapy is life saving. Earlier anti-malaria treatment may improve the survival rate for falciparum malaria. The isolated case of death from P. vivax infection argues against complacency in the management of even the "benign" form of the infection.

Keywords: ICU infections, intensive care unit (ICU), malaria, malaria complications, plasmodium falciparum
Singapore Med J 2004; 45(1): 28-36

TO Lim, Z Morad, Hypertension Study Group
Correspondence: Dr T O Lim, limto@crc.gov.my

ABSTRACT
We determined the prevalence of hypertension and the level of awareness, treatment and control of hypertension among Malaysian adults in a population based cross-sectional survey. Twenty-one thousand and three hundred ninety-one adults aged 30 or older in all 13 states of Malaysia in 1996 were sampled using a stratified two-stage cluster sampling design. Thirty-three percent of adults had hypertension with a higher percentage among women. Among hypertensives, 33% were aware of their hypertension, 23% were currently on treatment and a mere 6% had controlled hypertension. There was practically no difference in mean BP between treated and untreated hypertensives. Concerted public health effort is urgently required to improve the detection, treatment and control of hypertension in Malaysia.

Keywords: awareness, blood pressure, control, detection, hypertension, prevalence
Singapore Med J 2004; 45(1): 20-27

AS Devnani
Correspondence: Dr A S Devnani, anandsdevnani@yahoo.com

ABSTRACT
Aim To study the long term result of open reduction of longstanding dislocated elbows with regard to stability, avascular necrosis of the distal humerus and degenerative changes of the joint.
Methods Nine patients, aged between nine and 60 years (average 30 years) with longstanding posterior dislocation of the elbow underwent open reduction. The operative procedure featured a medial and lateral incision, excision of the capsule, fibrous adhesions and the collateral ligaments with no attempt to reconstruct the ligaments, as well as anterior transposition of the ulnar nerve. The procedure was performed on an average eight months after the injury (range 1.5 to 30 months).
Results All elbows had improved flexion at follow-up which ranged from one to eleven-and-half years (average 48 months). The average arc of flexion improved from 11 degrees to 87 degrees. The average flexion at the elbow improved from 32 degrees (range 20 degrees - 50 degrees ) to 111 degrees (range 85 degrees - 140 degrees ). Younger patients with fractures of the articular surface of distal humerus had smaller gain in the range of motion. No patient complained of instability or had recurrence of dislocation. No patient developed avascular necrosis of the distal end of the humerus. The radiographs of the 60-year-old man at 11.5 years follow-up showed extensive degenerative changes of the joint but he still maintained a painless arc of flexion from 10 degrees to 135 degrees.
Conclusion There was improvement in the range of motion and function in all nine patients. The elbows were stable despite excision of the collateral ligaments. There was no evidence of avascular necrosis. Patients with eight or more years of follow-up showed degenerative changes of the joint.

Keywords: collateral ligaments, dislocated elbow, excision of ligaments, open reduction, stability
Singapore Med J 2004; 45(1): 14-19

A Mahadev, MYH Soon, KS Lam
Correspondence: Dr Arjandas Mahadev, arjandas@kkh.com.sg

ABSTRACT
Studies in Caucasian populations have shown that a significant percentage of childhood extremity fractures occur at the playground. There are no comparable studies in Asian populations. Thus this study sets out to determine the pattern of playground related extremity fractures in Asian populations and to suggest modifications to prevent or reduce these injuries. This study involved a retrospective review of 390 patients with these fractures who visited our Department from May 1997 to December 1998. This accounted for 19.5% of all fractures seen in the same period. The largest age group affected were the five through 12-year-old patients with a male to female ratio of 2:1. Monkey bars or upper body devices were the most common cause (66%). The most common fracture was supracondylar fractures (43%). Further studies to determine the actual dimensions of playground equipment will be carried to ascertain with greater certainty the safety of these equipment in our playgrounds.

Keywords: extremity fractures, monkey bars, paediatric fractures, playground, supracondylar
Singapore Med J 2004; 45(1): 9-13

SKY Chang, P Chan
Correspondence: Dr Stephen Chang, stephen_chang@alexhosp.com.sg

ABSTRACT
Recurrent appendicitis is defined when patients with recurring similar right iliac fossa pain had acute appendicitis confirmed at the time of operation and the pain completely subsided after surgery. We conducted a retrospective study on our patients with appendicitis. There were 290 patients with appendicitis over a two-year period and 33 patients (11%) had reported recurring pain prior to the presentation. Majority had one prior episode but 15% had multiple episodes of right iliac fossa pain. Fifty-eight percent of the episode occur within six months of the presentation. We conclude that recurrent appendicitis should be considered as a differential diagnosis in patients with recurrent right iliac fossa pain.

Keywords: appendectomy, appendicitis, pain, recurrent appendicitis, right iliac fossa
Singapore Med J 2004; 45(1): 6-8

KT Lee, S Singh, CH Lai
Correspondence: Dr Lai Choon Hin, choon_hin_lai@ttsh.com.sg

ABSTRACT
Introduction We retrospectively reviewed the results of total elbow arthroplasty in patients with rheumatoid arthritis of the elbow followed for a minimum of two years.
Methods Between September 1999 and March 2001, seven patients with rheumatoid arthritis of the elbow were treated with total elbow arthroplasty using the semi-constrained Coonrad-Morrey elbow replacement prostheses. One patient died 19 months after her surgery and was excluded from the study. Two patients had bilateral total elbow replacements. Eight elbows were thus available for review. The mean age of our patients at the time of surgery was 55.5 years. The indication for surgery was severe pain and stiffness in six elbows, and distal humerus fractures in two elbows.
Results The mean duration of postoperative hospitalisation stay was 6.6 days. The average length of follow-up was 39.4 months. Six elbows had no pain, while two elbows had mild pain. The mean arc of flexion was 101.3 degrees. The mean Mayo elbow performance score was 93.1 points. Excellent results were achieved in six elbows, while two elbows had good outcome. There was one case of intraoperative lateral condylar fracture treated with internal fixation. One patient developed blisters postoperatively but resolved with dressings and antibiotics.
Conclusion Our small study revealed good to excellent short-term outcome with the use of semi-constrained total elbow arthroplasty for the treatment of rheumatoid arthritis of the elbow in Asian patients.

Keywords: arthroplasty, elbow, replacement arthroplasty, rheumatoid arthritis
Singapore Med J 2005; 46(12): 718-722

YL Lim, T Thirumoorthy
Correspondence: Dr Lim Yen Loo, yllim@nsc.gov.sg

ABSTRACT
Introduction Serious cutaneous adverse reactions to traditional medicines are not well described or reported in the literature, despite growing use of these medicines.
Methods This is a case series of four patients who were found to have various serious cutaneous adverse reactions to the traditional Chinese medicines that they had taken.
Results In this series, there was a patient with toxic epidermal necrolysis from traditional Chinese medicine, another with acute generalised exanthematous pustulosis from piroxicam and salicylate-contaminated traditional Chinese medicine, and two patients with drug hypersensitivity syndrome--one from traditional Chinese medicine and the other from phenylbutazone-adulterated traditional Chinese medicine.
Conclusion The series illustrates that serious cutaneous adverse reactions do occur with traditional medicines and emphasises the importance of being aware of such reactions.

Keywords: adverse reaction, cutaneous reaction, drug reaction, traditional Chinese medicine
Singapore Med J 2005; 46(12): 714-717

FS Al-Joudi
Correspondence: Dr Fawwaz Shakir Al-Joudi, fajoudi@hotmail.com

ABSTRACT
Introduction Decreased serum albumin (SA) levels have been used extensively as prognostic indicators in many chronic debilitating diseases. The decrease may be partly compensated by globular proteins. The failure of globulins to compensate may reflect advanced disease. We examined the prognostic value of the level of serum globulins in colorectal and breast cancers.
Methods Data of 80 patients with advanced colon and breast cancers were analysed. Of these, 46 patients died within six months of measurement of their serum proteins, and the rest were followed-up for more than six months after measurements of their serum proteins were taken. A mathematical formula, representing the globulin compensation index (GCI), was recently developed from the measured SA levels and globulins. Patients were then classified into three categories: negative GCI and negative compensation; GCI of 0 to less than 1.0 with partial compensation; and GCI equal or greater than 1.0 with full compensation.
Results Among the deceased patients, 45.7 percent had negative GCI, compared to 26.5 percent of patients in the survivors group. For partial compensation, 30.4 percent of patients were from the deceased group, and 32.4 percent were from the survivors group. For full compensation (elevated GCI), 23.9 percent of patients were from the deceased group, compared to 41.1 percent from the survivors group (p-value equals 0.031).
Conclusion Patients with low GCI are more likely to have bad prognoses, whereas those with higher GCI have more favourable prognoses. Globulin compensation may be a reliable prognostic factor in advanced colorectal and breast cancers, and possibly in other chronic illnesses. The GCI may serve as a useful tool in the measurement of this compensation.

Keywords: breast cancer, colon cancer, globulin compensation index, serum albumin, serum globulin
Singapore Med J 2005; 46(12): 710-713

B Chaiwun, N Sukhamwang, S Lekawanvijit, K Sukapan, S Rangdaeng, M Muttarak, PS Thorner
Correspondence: Dr Benjaporn Chaiwun, bchaiwun@mail.med.cmu.ac.th

ABSTRACT
Introduction This study aims to correlate fine-needle aspiration specimens diagnosed as C3 (atypical, probably benign) and C4 (suspicious, probably malignant) with histology and mammography, and to evaluate these two cytology categories in terms of diagnostic usefulness and patient management.
Methods All fine-needle aspiration (FNA) specimens in categories C3 or C4 at the Maharaj Nakorn Chiang Mai Hospital, Thailand between 2000-2004 were reviewed. Results were correlated with available histological and mammographical studies.
Results 148 FNA specimens were identified, comprising 43 category C3 and 105 category C4. Histology was available in 90 cases. 14 (64 percent) C3 cases showed benign histology on biopsy and eight (36 percent) were malignant. 13 (19 percent) C4 cases were benign on biopsy, whereas 55 (81 percent) were malignant. Mammographical studies were available in 56 of the histologically-proven cases. All seven cases with benign mammograms had benign histology, and all 26 cases called "highly suggestive of malignancy" were malignant on histology (five C3 and 21 C4). Of the 23 cases called "suspicious abnormality" on mammography, 14 turned out to be malignant on biopsy (one C3 and 13 C4).
Conclusion Our study supports maintaining cytology categories C3 and C4. About two-thirds of C3 cases were benign on biopsy whereas 81 percent of C4 cases were malignant (p-value is less than 0.001). There was complete correlation between histological and mammographical studies except those with equivocal mammograms. Our study supports the combined use of clinical, mammographical and cytological findings for optimal patient management. This is especially important for patients with C3 aspiration results, in order to avoid unnecessary surgery for benign lesions.

Keywords: breast biopsy, breast cancer, cytology, fine-needle aspiration, mammography
Singapore Med J 2005; 46(12): 706-709

B Norsa’adah, BN Rusli, AK Imran, I Naing, T Winn
Correspondence: Dr Norsa’adah Binti Bachok, norsaadah@kb.usm.my

ABSTRACT
Introduction Breast cancer is the commonest cancer for females in Malaysia, with a prevalence of 86.2 per 100,000 women in 1996. Breast cancer mortality rate shows an increasing trend in Malaysia from 0.61 in 1983 to 1.8 per 100,000 women in 1992. The aim of this study was to identify the risk factors for breast cancer in women in Malaysia.
Methods A matched case-control study was carried out at referral hospitals in Kelantan from July 2000 to June 2001. A standardised questionnaire that comprised socio-demographical factors, obstetrical and gynaecological histories, anthropometric measurements, and other potential risk factors for breast cancer, was used to interview 147 histologically-confirmed breast cancer patients and 147 controls. Controls were non-breast cancer patients who were matched for age and ethnicity, and excluded those with malignancies, or having gynaecological, hormonal or endocrine problems. Simple and multiple conditional logistic regressions were used for analyses.
Results Factors contributing toward increased risk of breast cancer were nulliparity (odds ratio [OR] of 15.3; 95 percent confidence interval [CI] of 3.2, 72.4), overweight (OR of 2.1; 95 percent CI of 1.1, 3.9), family history of breast cancer (OR of 4.3; 95 percent CI of 1.3, 14.1) and previous use of oral contraceptives (OR of 2.5; 95 percent CI of 1.3, 4.8).
Conclusion This study reconfirmed that similar risk factors identified in Western populations were responsible for the occurrence of breast cancer in Kelantan. It also supported the theory that breast cancer occurrence was related to oestrogen exposure and familial factors. It suggested the importance of having children, maintaining ideal body weight and caution for oral contraceptive users and women with a family history of breast cancer.

Keywords: breast cancer, cancer risk factors, oestrogen exposure, oral contraceptive
Singapore Med J 2005; 46(12): 698-705