Original Article

LP Tham, I Chan
Correspondence: Dr Tham Lai Peng, sharonlp@kkh.com.sg

ABSTRACT
Introduction Little information is available regarding the outcome of children in our local population who sustained pre-hospital cardiac arrest. This study was performed to determine the survival rate among children after out-of-hospital cardiac arrest, to describe the epidemiology, and to identify predictors of survival.
Methods The records of 85 children who presented to a paediatric emergency department in cardiac arrest, between 1 June 1997 and 31 September 2001, were reviewed. The characteristics of the patients, cardiac arrest circumstances, and the outcomes of arrest were analysed.
Results 85 children presented to the emergency department in cardiac arrest during the 52-month study period. 26 out of 85 children (30.6 percent) with cardiac arrest had return of spontaneous circulation (ROSC) after resuscitation efforts at the emergency department. Only four (4.7 percent) survived to be discharged from hospital and three of them survived beyond one year. Two of the cardiac arrest survivors had no change in the neurological status, with the remaining two sustaining severe neurological deficits. Emergency medical service was activated in only 63.7 percent of the patients. 34 percent of the arrests were witnessed, and only 22.9 percent of the children received bystander cardiopulmonary resuscitation (CPR). The positive predictors for survival to hospital discharge in a bivariate analysis were witnessed arrest (p-value is equal to 0.012), presence of bystander CPR (p-value is equal to 0.003), and duration of resuscitation (p-value is equal to 0.028). None who had more than 30 minutes of resuscitation in the emergency department survived. In a multivariate analysis with a logistic regression model, the only two independent predictors of ROSC were witnessed arrest (odds ratio is 3.049; 95% confidence interval [CI] is 1.101-8.444; p-value is equal to 0.032) and duration of resuscitation (odds ratio is 0.353; 95% CI is 0.146 - 0.854; p-value is equal to 0.021).
Conclusion Out-of-hospital cardiac arrest in children has a poor prognosis and prolonged resuscitation at the emergency department beyond 30 minutes does not improve survival.

Keywords: cardiac arrest, cardiopulmonary resuscitation, emergency medical service, paediatric cardiac arrest
Singapore Med J 2005; 46(6): 289-296

K Lew, PJ Barlow
Correspondence: Dr Philip John Barlow, chmpjb@nus.edu.sg

ABSTRACT
Introduction This study sets out to investigate any differences in dietary practices between adolescents in Singapore and Malaysia.
Methods An adolescent dietary practices survey was conducted in Singapore and Malaysia involving 200 adolescents (100 from each country) aged 11 to 21 years in order to have a better understanding of the adolescents' dietary practices. Dietary practices were assessed by a self-administered dietary practices questionnaire (DPQ).
Results The major differences identified between adolescents' dietary practices in Singapore and Malaysia are related to alcohol consumption and venue for taking of lunch. More Malaysian adolescents have their lunch prepared at home (32.9 percent), compared with 7.2 percent of Singaporean adolescents. More adolescents in Malaysia drink alcohol (49.4 percent), compared with only 21.7 percent of Singaporean adolescents.
Conclusion From the dietary practices survey of adolescents from Singapore and Malaysia, it may be concluded that while general dietary practices are similar, the major differences identified were significantly (p-value is less than 0.05) higher alcohol consumption by Malaysian adolescents and significantly (p-value is less than 0.05) more Malaysians took their lunch at home compared with Singaporeans. The reasons for the differences are discussed in the paper.

Keywords: adolescent dietary practice, diet, food habits, nutritional behaviour
Singapore Med J 2005; 46(6): 282-288

HY Lee, EL Lee, P Pathy, YH Chan
Correspondence: Dr Lee Huei Yen, gdmlhy@sgh.com.sg

ABSTRACT
Introduction Information regarding the clinical features of patients with anorexia nervosa in Singapore is rare and there have not been any large studies published to date. The aims of this paper were to study the clinical characteristics and features of patients with anorexia nervosa in Singapore, and to compare the clinical features of the early versus the classical later-onset cases.
Methods 126 cases presenting to the Child Guidance Clinic and the Eating Disorder Clinic at the Institute of Mental Health between 1994 and 2002 were identified and studied retrospectively. All presented with anorexia nervosa or had a past history of it. Subjects were further classified into early-onset (younger than 14 years) or classical later-onset (14 years and older), and a comparison was done between the two groups.
Results The large majority were female students with a mean presenting age of 17.6 years. 65.1 percent were of the restricting subtype. 84.1 percent were Chinese, 7.9 percent were Indians and 4.8 percent were Malays. Mean presenting body mass index (BMI) was 15.56. Depression was the most common co-morbid condition affecting 25.4 percent of the sample. The number of new cases increased significantly from six in 1994 to 24 in 2002 (p-value equals 0.002). Commonest precipitating factors were comments from others, school and work stress. 11.1 percent were previously members of trim and fit club in school. 42.7 percent of late-onset cases compared to 16.2 percent of the early-onset were of the binge-purge type (p-value equals to 0.005) and had a higher presenting BMI (15.91 +/- 2.90 versus 14.74 +/- 2.14, p-value equals 0.003).
Conclusion The clinical characteristics of patients with anorexia nervosa in Singapore are similar to that reported in western literature. The Malay population appears to be under-represented. There was a significant increase in numbers presenting over the last two years. The early-onset cases tend to be of the restrictive-type and had a lower presenting BMI than the later-onset group.

Keywords: anorexia nervosa, body mass index, depression, eating disorder
Singapore Med J 2005; 46(6): 275-281

V Poulose, P Chiam, WT Poh
Correspondence: Dr Vijo Poulose, vijopoulose@pol.net

ABSTRACT
Introduction Kikuchi's disease is a benign form of cervical lymphadenopathy that commonly affects young adults. We report a case series from our hospital.
Methods The clinical features of 23 cases of Kikuchi's disease diagnosed at Changi General Hospital over a seven year period are presented. The cases were identified from pathology records using the search term histiocytic necrotising lymphadenitis.
Results Most of our patients (78 percent) were young women who presented with cervical lymphadenopathy. The median age was 31 years. In the 18 cases who completed follow-up at the hospital, there was spontaneous resolution of symptoms within a six-month period. One patient demonstrated seropositivity for systemic lupus erythematosus (SLE) and was initially started on steroids. However, the treatment was discontinued shortly afterwards since she did not meet the diagnostic criteria for SLE. Excision biopsy of the affected lymph node was the diagnostic method of choice.
Conclusion Kikuchi's disease is not uncommon in the Singaporean population. Establishing an early diagnosis is crucial since the clinical presentation can mimic tuberculous lymphadenitis or malignant lymphoma. The diagnostic method of choice is excision biopsy.

Keywords: histiocytic necrotising lymphadenitis, Kikuchi’s disease, lymph node, lymphadenopathy
Singapore Med J 2005; 46(5): 229-232

SK Tiwari, AA Khan, KS Ahmed, I Ahmed, F Kauser, MA Hussain, SM Ali, A Alvi, A Habeeb, Z Abid, N Ahmed, CM Habibullah
Correspondence: Prof C M Habibullah, cmhabib@rediffmail.com

ABSTRACT
Introduction Current guidelines that recommend Helicobacter pylori eradication treatment without endoscopy in selected patients underscore the importance of non-invasive testing. The accuracy of saliva as a non-invasive specimen was compared with that of invasive tests in pretreatment diagnosis of H. pylori infection.
Methods One hundred patients undergoing gastroscopy were grouped into 80 symptomatic and 20 asymptomatic subjects and were investigated for the presence of H. pylori in saliva and stomach. Samples tested comprised saliva and gastric biopsies collected from each patient. Exclusion criteria were history of peptic ulcer, bleeding ulcer, cancer or recent use of antibiotics, proton pump inhibitors and non-steroidal anti-inflammatory drugs. Two sets of primers homologous to 534 bp fragment of H. pylori DNA, which have been shown previously to be highly specific and sensitive, were used for the polymerase chain reaction (PCR) amplification.
Results 72 (90 percent) of the symptomatic group and 10 asymptomatic subjects were infected with H. pylori in the stomach as determined by histology and direct PCR amplification of biopsy DNA obtained from each subject. H. pylori DNA was identified in the saliva of 70 (87.5 percent) symptomatic subjects and 12 (60 percent) asymptomatic control subjects.
Conclusion High rates of detection using saliva as a specimen indicate that saliva of the infected person could serve as a reliable non-invasive alternative to detect the presence of H. pylori infection in comparison to the currently available standard diagnostic tests.

Keywords: duodenal ulcer, gastritis, Helicobacter pylori, polymerase chain reaction saliva, 16S ribosomal RNA genes
Singapore Med J 2005; 46(5): 224-228

HC Chan, WAW Aasim, NM Abdullah, NN Naing, JM Abdullah, MHM Saffari, A Osman
Correspondence: Prof Jafri Malin Abdullah, deptneurosciencesppspusm@yahoo.com

ABSTRACT
Introduction Paediatric minor head injuries (MHI) are just as common in both bigger and smaller towns in Malaysia. Urban-based MHI are due more to motor vehicular injuries compared to rural-based MHI which are mainly due to non-motor vehicular injuries. The main objectives of this study were to compare incidence of admitted patients to accident and emergency departments of hospitals in two different settings in Malaysia, namely: Ipoh (urban-based) and Kota Bharu (rural-based); and to correlate to demographical characteristics, types of accident, clinical signs and symptoms, radiological and computed tomography (CT) findings, management; and finally, to determine clinical predictors of intracranial injury in MHI.
Methods A cross-sectional study of 153 paediatric patients aged 2-18 years who were admitted to the Ipoh Hospital, Perak and 112 patients of the same age group admitted to Hospital Universiti Sains Malaysia, Kelantan were included in this study. The study period was between 1 January 1998 and 31 December 2001. Data collection was done prospectively. Chi-square and independent t-tests were applied to compare characteristics of patients admitted to these two hospitals. Backward stepwise multiple logistic regression was applied to determine clinical predictors of intracranial injury.
Results There were significant differences of age, race, types of accidents, clinical signs and symptoms, Glasgow coma scale (GCS), skull fracture and CT findings between two hospitals. Significant clinical predictors were headache (OR 20.8, 95 percent CI 3.9-25.2, p-value is less than 0.001), unequal pupils (OR 8.4, 95 percent CI 4.3-17.9, p-value is equal to 0.0413) and GCS score of 13 (OR =3.8, 95 percent CI 1.9-6.8, p-value is equal to 0.005). Skull fractures and intracranial injuries were more common in Kota Bharu due to children riding motorcycles without helmets than in Ipoh (p-value is less than 0.001).
Conclusion In the rural Malaysian community, both the police and physicians must be alerted to the fact that unhelmeted children riding motorcycles are more likely to sustain morbidity than those in urban areas. More aggressive traffic policing of the village roads should be done by the relevant authorities.

Keywords: childhood injury, craniocerebral trauma, emergency medicine, head injury, minor head injury
Singapore Med J 2005; 46(5): 219-223

HH Tan, R Chan
Correspondence: Dr Tan Hiok Hee, hhtan@nsc.gov.sg

ABSTRACT
Introduction Infections caused by Chlamydia trachomatis (C. trachomatis) is one of the commonest sexually transmitted infections (STI). As there is currently no laboratory in Singapore that offers the chlamydia culture tests, alternative laboratory methods were developed and antigen detection methods such as enzyme immunoassays (EIA) proved to be even less sensitive than cell culture. This study was done to assess the accuracy and sensitivity of pooling five endocervical swabs collected for C. trachomatis testing by polymerase chain reaction (PCR) technology, as compared to the currently used EIA on individual swabs, in female sex workers who were seen at a STI clinic in Singapore.
Methods A total of 1,182 endocervical swab specimens were analysed by EIA as well as in pools of five specimens using PCR. Any pool with a positive PCR result for C. trachomatis infections was subjected to repeat PCR testing of the five individual specimens in the pool.
Results There were a total of 48 confirmed cases of C. trachomatis infection. EIA detected 19 positive samples for C. trachomatis, yielding a prevalence of 1.6 percent among the sex workers tested. Pooled PCR testing showed a higher prevalence rate of 4.1 percent, with 48 PCR positive samples. All cases that were EIA positive were also PCR positive. Individual runs on 200 random samples as well as on 220 individual samples from positive pooled results showed PCR inhibition rates ranging from 1.5 percent to 2.3 percent. However, the PCR inhibition rate was 0 percent with the use of pooling. Sensitivity of EIA was 39.6 percent, with 100 percent specificity. EIA tests had a false negative rate of 60.4 percent. PCR was found to be 100 percent sensitive and specific.
Conclusion C. trachomatis infections among female sex workers attending the clinic were found to be higher using PCR technology. Less sensitive methods such as EIA result in undertreatment of otherwise undetected cases. The pooling strategy using pool sizes of five specimens, with a disease prevalence of 4.1 percent is reliable and cost-effective, and has since been introduced in the current medical surveillance scheme for sex workers in the clinic.

Keywords: Chlamydia trachomatis, enzyme immunoassays, polymerase chain reaction
Singapore Med J 2005; 46(5): 215-218

STA Seah, JA Low, YH Chan
Correspondence: Dr Angeline Seah, James_low@Alexhosp.com.sg

ABSTRACT
Introduction We aimed to study the symptoms and the care of elderly patients dying in an acute hospital in Singapore.
Methods Over a one year period, we retrospectively studied all patients admitted to the Department of Geriatric Medicine and all other patients aged more than 75 years old who were admitted and died during the same admission to all other units in an acute hospital. There were 189 such patients. Demographical data, information on the patients' background and prevailing medical problems, symptoms, intervention and treatment methods were obtained from the patients' medical records and analysed.
Results The patients were frail and old. 17 percent had bedsores and 20 percent had limb contractures noted at the point of admission. 20 percent had known terminal disease. 88 percent of the deaths were expected and 12 percent unexpected. In spite of the deaths being anticipated, 25 percent of them were subjected to cardiopulmonary resuscitation and 17 percent were intubated at the point of collapse. The majority (81 percent) of relatives of the 160 patients whose deaths were anticipated and had family had no acceptance problems. 52 (31 percent) of the 167 expected deaths had input from palliative care. These patients were more dependent, (p-value equals 0.018; odds ratio [OR] = 2.5; 95 percent confidence interval [CI] 1.2-5.2), less likely to undergo resuscitation (p-value is less than 0.001; OR = 0.16; 95 percent CI, 0.06-0.44), and were more likely to be on treatment for their symptoms (p-value is equal to 0.001; OR = 7.7; 95 percent CI, 2.1-28.8).
Conclusion The common symptoms experienced by the elderly at the end of life are difficulty with breathing, fever, pain and respiratory secretions. A number of patients were not on any treatment for these problems though the proportion is less where there is palliative input.

Keywords: aged patients, dying patients, palliative care, terminally ill patients
Singapore Med J 2005; 46(5): 210-214

S Manoharan, AA Baskar, T Manivasagam, P Subramanian
Correspondence: Dr P Subramanian, psub@rediffmail.com

ABSTRACT
Introduction Oral cancer is one of the leading cancers in India accounting for 30 to 40 percent of all cancers. Disturbances in lipid peroxidation and antioxidants status have been implicated in the pathogenesis of several cancers including oral cancer. However, circadian disturbances of oxidants and antioxidants in oral cancer patients were not reported.
Methods The levels of plasma thiobarbituric acid reactive substances (TBARS), reduced glutathione (GSH) and activity of glutathione peroxidase (GPx) in ten oral cancer patients and an equal number of age-matched healthy subjects were assayed at every 6 hour intervals using colorimetric methods and their circadian characteristics were analysed using Cosinorwin computer software programme.
Results Alterations in mesor, amplitude, acrophase and r value of the chosen parameters were noticed.
Discussion The desynchronisation of plasma thiobarbituric acid reactive substances and the altered circadian characteristics of antioxidants observed in this study, may deserve further investigation for the early diagnosis, prognosis and for the efficacy of cancer chronotherapy.

Keywords: oral cancer, lipid peroxidation, antioxidants, circadian rhythms
Singapore Med J 2005; 46(4): 184-188

HW Yuen, YH Goh, WK Low, SK Lim-Tan
Correspondence: Dr Heng-Wai Yuen, yuen_a@yahoo.com.sg

ABSTRACT
Introduction Kimura's disease (KD) is a rare, benign, chronic inflammatory disease with unknown aetiology. Its manifestation is protean. KD has a predilection for the head and neck area, and typically presents as tumour-like lesions that could be easily misdiagnosed. We review our experience with four recent cases.
Methods Over a four-year period, all patients admitted to Singapore General Hospital with KD of the head and neck region were retrospectively reviewed. Biodata, presenting symptoms and clinical parameters, especially serum eosinophil levels, preoperative investigations, type of surgical procedures and outcome were documented.
Results Four patients presented with KD of the head and neck and displayed varied manifestations of the disease. All the patients had raised serum eosinophil levels. None of them had renal involvement. Preoperative computed tomography were performed in two of the patients and showed features suggestive of KD. Fine-needle aspiration cytology that was performed in two patients was not useful in the diagnosis. All the patients underwent surgical excision of the lesions. Only one patient had multiple recurrence, both at the original and remote sites in the head and neck.
Conclusion The clinical presentation and behaviour of KD is very variable. Preoperative imaging is useful in the diagnosis of the disease but the final diagnosis is histological. Surgical excision is the current treatment of choice but recurrence is common. A high index of suspicion and awareness is vital in the early diagnosis and management of KD.

Keywords: angiolymphoid hyperplasia, eosinophilia, immunoglobulin E, Kimura’s disease, lymphadenopathy
Singapore Med J 2005; 46(4): 179-183