Original Article

A Ngo, KC Ng, TP Sim
Correspondence: Dr Adeline Ngo, adeline_ngo@singhealth.com.sg

ABSTRACT
Introduction Accidents with foreign bodies are common in the paediatric population. It is impossible to mandate that all foreign bodies (FB) in the ear, nose and throat (ENT) of children should be removed by the specialty-trained physicians. This study evaluates the management of ENT FB removal in children achieved by emergency physicians not trained in otolaryngology in an urban tertiary care paediatric emergency department.
Methods A retrospective study was conducted on consecutive paediatric patients presenting with suspected foreign body in the ear, nose or throat to the children's emergency department (ED) of KK Women's and Children's Hospital over a 10-month period. Removal methods, foreign body types, rates of successful removal and associated complications were evaluated.
Results There were 353 patients, most of whom presented after office hours. An attempt at removal of FB by the emergency physician was made in 76.8 percent of the cases. ENT specialist referral in the ED was made in 1.7 percent of the cases. 50.1 percent of cases were discharged after successful removal of FB in the ED. 4.2 percent of cases were admitted for removal of FB and 44.8 percent of cases were referred to the ENT specialist clinic for further assessment.
Conclusion The emergency physician managed most cases in the ED and urgent referral to ENT specialists was not required. Complications and morbidity often occur from repeated attempts at removal of the FB. ENT opinion should be sought whenever there is doubt. The ED physician should be skilled in techniques of FB removal, especially throat FB, which had the lowest rate of success in our study.

Keywords: ear, foreign bodies, oropharynx, paediatrics
Singapore Med J 2005; 46(4): 172-178

IHG Escudero, MI Chen, YS Leo
Correspondence: Dr Ian Herman G Escudero, Ian_Escudero@ttsh.com.sg

ABSTRACT
Introduction This retrospective one-month survey evaluated the practicality of post-severe acute respiratory syndrome (SARS) surveillance recommendations in previously SARS-affected countries, namely Singapore. These included staff medical sick leave for febrile illness, inpatient fevers, inpatient pneumonia, atypical pneumonia, febrile illnesses with significant travel history and sudden unexplained deaths from pneumonia/ adult respiratory distress syndrome (ARDS).
Methods Surveillance data on medical sick leave of staff, all inpatient fevers, all febrile (temperature greater than or equal to 38 degrees Celsius) inpatient pneumonia, including atypical pneumonia, and deaths from pneumonia were collected from sick leave reports, ward reports, isolation room rounds and mortuary reports from 1 to 28 September 2003.
Results Baseline results show 167 (1.4/1000 staff-days) observed in staff sick leave for febrile illnesses, and 1798 (71.3/1000 bed-days) observed for inpatient fever. There were 40, 31 and 12 instances, respectively, of staff having temperatures of high fever (greater than or equal to 38 degrees Celsius), prolonged sick leave (3 days or more), and repeated sick leave (within 7 days) for febrile illnesses. An average of 4.6 wards a day potentially fulfilled the World Health Organisation SARS alert criteria. Of 27 cases with fever, pneumonia and a total white count of less than 10,000 cells per cubic mm as per Ministry of Health, Singapore criteria for the diagnosis of atypical pneumonia, only five were identified by clinicians.
Conclusion Surveillance is time-consuming and current recommendations are not specific enough to be used practically. Surveillance indicators for inpatients must overcome a high degree of background noise.

Keywords: atypical pneumonia, infectious disease, severe acute respiratory syndrome (SARS), surveillance
Singapore Med J 2005; 46(4): 165-171

WCC Chong, KY Tham, HK Goh, E Seow
Correspondence: Dr Hsin Kai Goh, hsin_kai_goh@ttsh.com.sg

ABSTRACT
Introduction On 22 March 2003, the Ministry of Health, Singapore, designated Tan Tock Seng Hospital as the nationwide severe acute respiratory syndrome (SARS) hospital and its Emergency Department (ED) took over the role as the screening center for SARS on 26 March 2003. We describe the initial clinical characteristics of probable or suspect SARS patients that presented to the ED.
Methods A retrospective study of patients who were admitted through the ED and subsequently diagnosed to have probable SARS and suspect SARS was done. The data of these patients from the ED log were reviewed and analysed.
Results From 13 March 2003 to 31 May 2003, 11,461 patients were screened for SARS and 1,386 patients were admitted. Of these, 117 patients were diagnosed to have probable SARS and 146 suspect SARS. Their mean age was 36.7 years (range 1-80). Among these patients, there were 122 men (46.4 percent), and 205 were Singaporeans (77.9 percent). 13 patients had no initial contact history upon presentation to the ED. The mean duration between onset of symptom to presentation to the ED was 3.1 days. Travel history was less common in probable SARS cases than in suspect SARS cases as the epidemic was due mainly to local transmission. Fever was the most common presenting symptom (91.6 percent), and gastrointestinal symptoms were the least (6.9 percent). In the ED, 249 (94.7 percent) patients had chest radiographs and 86 (32.7 percent) had full blood count done. 22.2 percent of probable SARS patients had normal chest radiographs when they first presented to the ED.
Conclusion The World Health Organisation criteria were important screening tools and admission guides, but should not be strictly followed. It was difficult to differentiate between probable and suspect SARS patients in the ED.

Keywords: emergency department, infectious disease screening, pneumonia, severe acute respiratory syndrome (SARS)
Singapore Med J 2005; 46(4): 161-164

SW Seng, CT Yeong, SF Loh, N Sadhana, SKE Loh
Correspondence: Dr Seng Shay Way, seng.shay.way@kkh.com.sg

ABSTRACT
Introduction To compare the results of in-vitro fertilisation (IVF) in women aged less than 40 years with those aged 40 years and above with baseline follicle-stimulating hormone (FSH) levels less than 15iu and using their own oocytes.
Methods A total of 2179 fresh IVF cycles were started in KK Women's and Children's Hospital IVF Centre from 1997 to 2002, of which 247 cycles were done in women 40 to 45 years with FSH levels less than 15iu. The remaining 1932 cycles were performed in another group of women aged less than 40 years old. All couples were treated using our hospital's IVF protocol, and the same clinical and embryological team was involved in all treatments. The medical records of patient outcomes were retrospectively reviewed. The main outcomes measured were clinical pregnancy, miscarriage and delivery rates.
Results The total number of fresh cycles performed in women over 40 years was 247 cycles. Of these, 186 (75.3 percent) cycles reached oocyte collection, and 179 (72.5 percent) cycles reached embryo transfer. The total number of pregnancies was 22 (12.3 percent). The number of cancelled cycles was 61 (24.7 percent). Women less than 40 years of age demonstrated higher rates in cycles reaching oocyte collection (89.2 percent), embryo transfer (84.6 percent), pregnancy rates (32.9 percent) and live-birth rates (24.0 percent). They also reported a lower miscarriage (36.1 percent) and cancellation rate (10.9 percent) as compared to the group of older women.
Conclusion As older women seek IVF treatment, it is necessary for them to understand that chances of pregnancy decrease with increasing age. Our results show that as women exceed 40 years old, pregnancy and live-birth rates fall with concurrent rising miscarriage and cycle cancellation rates.

Keywords: delivery rate, follicle-stimulating hormone, in-vitro fertilisation outcomes, miscarriage rate, pregnancy
Singapore Med J 2005; 46(3): 132-136

GC Chan
Correspondence: Dr Giin-Cherng Chan, dr_changc@yahoo.com

ABSTRACT
Introduction A study was conducted at primary healthcare level in the Melaka Tengah district of Malaysia to determine whether hypertension in patients with type 2 diabetes mellitus were managed according to guidelines.
Methods A cross-sectional study involving 517 patients with diabetes mellitus from August to October 2003 was performed.
Results All the subjects had type 2 diabetes mellitus. 350 (67.7 percent) patients had hypertension and about 25.7 percent of them were associated with microalbuminuria. The Malay ethnic group form the majority (54.6 percent), followed by Chinese (37.7 percent) and Indian (7.4 percent). Only 11 (3.1 percent) patients with type 2 diabetes mellitus and hypertension achieved the target blood pressure of less than 130/80 mmHg. For those who had not achieved the target goal, 39.5 percent of them were not on any antihypertensive drugs. 38.6 percent were on monotherapy and only 21.8 percent were on two or more antihypertensive drugs. Metoprolol was the most commonly used antihypertensive drug (22.4 percent), followed by Nifedipine (16.2 percent) and Prazosin (13.5 percent). Only 18.3 percent of patients with type 2 diabetes mellitus and hypertension were prescribed with angiotensin converting enzyme (ACE) inhibitors and 0.3 percent with angiotensin receptor blockers. For patients with type 2 diabetes mellitus, hypertension and microalbuminuria, only 14.1 percent of them were prescribed with ACE inhibitors.
Conclusion A significant proportion of patients with type 2 diabetes mellitus had associated hypertension but they were not managed optimally according to guidelines. More intensive management of hypertension among patients with diabetes is essential to reduce the morbidity and mortality at primary healthcare level.

Keywords: clinical practice guidelines, diabetes mellitus, hypertension, primary healthcare
Singapore Med J 2005; 46(3): 127-131

MM Thein, BW Lee, PY Bun
Correspondence: Dr Myint Myint Thein, mmthein@pacific.net.sg

ABSTRACT
Introduction Childhood injuries are the leading cause of death for children between 5 to 14 years of age in Singapore. There have been no studies done on primary caregivers' knowledge, attitude and practices on childhood injuries and its prevention in Singapore. Thus there is a need to conduct this type of study in order to develop appropriate educational programmes.
Methods A cross-sectional nationwide study with a two-stage stratified random sampling was conducted to obtain a representative sample of the Singapore population. Families that had children younger than 15 years of age were selected for the study. Parents and caregivers were interviewed at their homes.
Results The primary caregivers had good knowledge of road safety but poor knowledge on home safety and first aid. The higher the education of the mother, the more likely it is that she would possess the correct knowledge and practice on childhood injuries and its prevention. The media plays an important role on information on child safety of the caregivers. Only 38 percent said they obtained information from doctors and other health personnel.
Conclusion There is a need to educate parents and caregivers on home safety and first aid. Doctors and nurses should take a more active role in giving advice on child safety.

Keywords: caregiver attitude, caregiver knowledge, childhood injuries, child safety, home safety
Singapore Med J 2005; 46(3): 122-126

MM Thein, BW Lee, PY Bun
Correspondence: Dr Myint Myint Thein, mmthein@pacific.net.sg

ABSTRACT
Introduction Childhood injuries are the leading cause of death for children between 5 to 14 years of age in Singapore. However, there is no information or data on childhood injuries in the community in Singapore. There was a need to conduct a nationwide study on childhood injuries in Singapore in order to estimate the prevalence rate, types of injuries, and to identify the hazards in the homes of the children.
Methods A cross-sectional nationwide study with a two-stage stratified random sampling was conducted to obtain a representative sample of the Singapore population. Families that had children younger than 15 years of age were selected for the study. Parents and caregivers were interviewed at their homes.
Results There were 2322 children in the study, of which 452 had one or more injuries in the past one year, giving an overall prevalence rate of 19.5 percent. Of the children who had injuries, the home was the commonest place where injuries occurred (45 percent) and falls were the leading cause of injuries (77 percent). There were many hazards identified in the homes studied and it was found that the more hazards present in the homes, the more likely it is for the child to get injuries.
Conclusion There is a need for educational and interventional programmes to help Singaporeans understand the need to make the home environment safe for children and to prevent home injuries.

Keywords: childhood injuries, community, home hazards, home injuries
Singapore Med J 2005; 46(3): 116-121

ATA Nandhini, V Thirunavukkarasu, MK Ravichandran, CV Anuradha
Correspondence: Dr Carani Venkatraman Anuradha, cvaradha@hotmail.com

ABSTRACT
Introduction The present study was designed to investigate whether taurine mitigates fructose-induced oxidative stress in rat tissues such as heart and kidney.
Methods Male Wistar rats of body weight 170-190 g were divided into four groups containing six rats each. Control animals received the control diet containing starch while fructose-fed animals received a fructose-enriched diet (greater than 60 percent of total calories). Fructose and taurine rats received the fructose diet and two percent taurine solution to drink. Control and taurine rats received the control diet and two percent taurine solution. After the treatment period of 30 days, insulin resistance index, by homeostasis model assessment (HOMA) was determined. The levels of lipid peroxidation markers, the enzymatic and non-enzymatic antioxidants status in heart and kidney tissues were measured.
Results Fructose rats showed high values of HOMA, increased lipid peroxidation and impaired antioxidant status. Taurine treatment to fructose rats attenuated the increased lipid peroxidation, enhanced the levels of antioxidants and improved insulin sensitivity.
Conclusion Inhibition of peroxidation markers and upregulation of antioxidant activity in rat tissues by taurine signify the potential utility of taurine as an adjunct in treatment of insulin resistance.

Keywords: antioxidants, fructose diet, insulin, lipid peroxidation, taurine
Singapore Med J 2005; 46(2): 82-87

M Rajadurai, PSM Prince
Correspondence: Dr P Stanely Mainzen Prince, p_smprince@yahoo.co.in

ABSTRACT
Introduction We demonstrate the effect of Aegle marmelos leaf extract (AMLEt) and alpha-tocopherol on plasma lipids, lipid peroxides and marker enzymes in rats with isoproterenol (ISO)-induced myocardial infarction.
Methods Rats were pre-treated orally for 35 days with different doses of an aqueous AMLEt (50 mg/ kg, 100 mg/kg and 200 mg/kg) prior to ISO-induced myocardial infarction. The effects on creatine kinase, lactate dehydrogenase, plasma thiobarbituric acid reactive substances, lipid hydroperoxides, serum lipids and lipoproteins were studied.
Results Pre-treatment with AMLEt at doses of 100 mg/kg and 200 mg/kg bodyweight for 35 days showed a significant effect on the activities of marker enzymes, lipid peroxides, lipids, lipoproteins and antioxidant enzymes in ISO-treated rats. The effect of AMLEt 200 mg/kg was found to be equal to the effect of alpha-tocopherol 60 mg/kg.
Conclusion Aegle marmelos leaves possess antihyperlipidaemic effect in rats with ISO-induced myocardial infarction.

Keywords: Aegle marmelos, isoproterenol, lipids, lipoproteins, myocardial infarction
Singapore Med J 2005; 46(2): 78-81

V Hufana, JSH Tan, KK Tan
Correspondence: Dr Tan Siah Heng James, siah_heng_tan@nni.com.sg

ABSTRACT
Introduction Although spinal tumours are amenable to total surgical excision, the factors determining the outcome are diverse. This study re-evaluates aspects of the disease that contribute to their outcome.
Methods Ninety-three consecutive patients with spinal cord tumours that underwent microsurgical excision between February 1992 and February 2002 were retrospectively studied. All patients underwent magnetic resonance imaging and had histological confirmation of spinal tumours.
Results There were 44 men and 49 women with a mean age of 49.05 years (range 6 to 83 years). The location of the tumours was cervical in 37 cases, thoracic in 41 cases, lumbosacral in 13 cases, and multilevel in two cases. The mean tumour size was 2.2 cm (range 0.8 to 7 cm) and mean duration of symptoms was 10.8 months. Complete excision was achieved in 72 cases and incomplete removal in 15 cases. The mean follow-up period was 21.45 months (range 3 days to 8 years). Immediate post-operative improvement was noted in 40 (43 percent) patients, 24 (25.4 percent) improved within six months, 13 (14 percent) improved after six months, 12 (12.9 percent) had no improvement and four patients died. The duration of symptoms and the completeness of excision were factors that correlated with post-operative improvement (p-value is less than 0.05). Age, gender, size, histological type, presenting symptoms, spinal level affected and axial location of tumour did not correlate with the outcome.
Conclusion Microsurgical excision of spinal cord tumours is a safe and effective procedure, and post-operative outcome is correlated to duration of symptoms and the extent of tumour resection.

Keywords: primary spinal cord neoplasm, spinal cord neoplasms, spinal neoplasms, spinal surgery
Singapore Med J 2005; 46(2): 74-77