Original Article

Hassan A, Khealani BA, Shafqat S, Aslam M, Salahuddin N, Syed NA, Baig SM, Wasay M
Correspondence: Dr Mohammad Wasay, mohammad.wasay@aku.edu

ABSTRACT
Introduction Pneumonia is a common complication after acute stroke. It affects the outcome adversely. However, data regarding microbiology of stroke-associated pneumonia and its effect on outcome is scarce.
Methods Stroke-associated pneumonia was identified through chart review of all ICD-9 identified adult stroke patients admitted to our hospital over a period of four years (1998-2001). The demographical, laboratory, radiological, microbiological data and outcome of patients with stroke-associated pneumonia were recorded and analysed.
Results 443 patients with stroke were admitted over the four-year period and 102 (23 percent) had stroke-associated pneumonia. Their ages range from 28 to 100 (mean 64+/-14) years. 69 (68 percent) were men. Median length of stay was nine days compared to four days for all stroke patients. 68 (67 percent) patients manifested pneumonia within 48 hours and 34 (33 percent) after 48 hours of admission. Yield of tracheal aspirate cultures was 38 percent and that of chest radiographs was 25 percent. Pseudomonas aeruginosa and Staphylococcus aureus were the most common organisms (12 percent each) followed by Streptococcus pneumoniae and Klebsiella pneumoniae (4 percent each). Patients with infiltrates on chest radiographs were more likely to have positive tracheal aspirate cultures (p-value is 0.003). 35 patients (34 percent) expired during hospital stay. Positive chest radiographs and tracheal aspirates were independent predictors of prolonged hospital stay (p-value is less than 0.005).
Conclusion Pneumonia is a common medical complication of stroke. It is associated with a high mortality and prolongs the hospital stay. The yield of chest radiographs and tracheal aspirates is low. However, these are independent predictors of prolonged hospital stay. Pseudomonas aeruginosa and Staphylococcus aureus are most common organisms in stroke-associated pneumonia.

Keywords: cerebrovascular accident, pneumonia, Pseudomonas aeruginosa, Staphylococcus aureus, stroke
Singapore Med J 2006; 47(3): 204-207

Parmar H, Golay X, Lee KE, Hui F, Sitoh YY
Correspondence: Dr Hemant Parmar, parurad@hotmail.com

ABSTRACT
Introduction Recent advances in magnetic resonance (MR) diffusion tensor imaging technique enable evaluation of the anisotropy of white matter tracts in-vivo, as well as the integrity of fibre tracts and their orientation. We describe our initial experiences with diffusion tensor imaging and MR tractography techniques to evaluate the structural degeneration of white matter tracts following stroke.
Methods Diffusion tensor imaging data were acquired in 11 cases with stroke on a 3T MR imaging scanner, with three-dimensional diffusion tensor imaging-based colour maps and MR tractography performed offline. We evaluated the spatial relationships of the eloquent white matter tracts to the infarcts and areas of haemorrhage, and classified therewith the tracts as either disrupted or displaced. We compared these with the clinical severity of the neurological deficits and prognosis.
Results A good correlation was found between tractography findings and patient's clinical recovery. All the patients with disruption of white matter tracts had residual deficits on clinical follow-up, whereas the patients with displaced tracts had near complete neurological recovery.
Conclusion Diffusion tensor imaging and MR tractography provide a novel and useful method to directly visualise changes in the white matter tracts in stroke. This can potentially allow clinical-imaging correlation with prognostic potential.

Keywords: cerebrovascular accident, diffusion magnetic resonance imaging, echo planar imaging, magnetic resonance imaging, magnetic resonance tractography, stroke
Singapore Med J 2006; 47(3): 198-203

Man K, Kareem AMM, Ahmad Alias NA, Shuaib IL, Tharakan J, Abdullah JM, Prasad A, Hussin AM, Naing NN
Correspondence: Prof Jafri Malin Abdullah, deptneurosciencesppspusm@yahoo.com

ABSTRACT
Introduction Computed tomography (CT) perfusion is a new method to diagnose ischaemic stroke especially in developing countries. It identifies the area and is useful to predict the size of final infarction. The aim of this study was to assess cerebral ischaemia with CT perfusion (CTP) among patients with acute ischaemic stroke in Hospital Universiti Sains Malaysia, a tertiary referral centre in a rural setting.
Methods 42 consecutive unenhanced CT and CTP examinations of the brain in adult patients were evaluated prospectively. Unenhanced CT images were divided into normal, suspicious or frank infarction. CTP images was classified as normal or ischaemic. Subgroup analysis was carried out with a limit of six hours from time of ictus.
Results Out of 42 patients, 20 had frank infarction on unenhanced CT, 15 had suspicious CT studies, while seven were normal. There was no significant association of demographical, clinical and radiological parameters to CTP in the whole group among acute stroke patients without frank infarction. Among the subgroup of patients without frank infarction, there was no significant association between unenhanced CT and CTP in patients who were studied less than six hours after stroke (p-value is 0.063) as well as those after six hours (p-value is 0.317). The prevalence of a normal unenhanced CT and positive CTP for ischaemia was 22.7 percent (95 percent confidence interval 7.8, 45.4).
Conclusion CTP may be a useful imaging tool for determining cerebral infarction in a rural-based community population, especially in cases where the unenhanced CT is normal. Thrombolysis is a therapeutic option, even when the history of onset of stroke is unclear.

Keywords: brain, cerebrovascular accident, computed tomography, ischaemic stroke, stroke
Singapore Med J 2006; 47(3): 194-197

Al-Hathlol K, Al-Madani A, Al-Saif S, Abulaimoun B, Al-Tawil K, El-Demerdash A
Correspondence: Dr Khalid Al-Hathlol, kdalhathlol@yahoo.com

ABSTRACT
Introduction Cholestasis associated with long-term total parenteral nutrition (TPN) occurs commonly in very low birth weight (VLBW) infants. Indeed, the majority of infants with TPN-associated cholestasis (TPNAC) respond very well to TPN withdrawal and full enteral feeding, yet some of them do not respond and have the potential for development of intractable cholestasis. It has been demonstrated that ursodeoxycholic acid (UDCA) has beneficial effects in treating TPNAC in various age groups. Nevertheless, the clinical data of UDCA use in VLBW infants, the most vulnerable group, are limited. We report the results of administration of UDCA therapy to VLBW infants with intractable TPNAC.
Methods Medical records of VLBW infants who were treated with oral UDCA, at dose of 15-20 mg/kg/day, for intractable TPNAC were reviewed from 1999-2001. Treatment effectiveness was evaluated by monitoring the biochemical hepatic markers, including total bilirubin, direct bilirubin, alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transferase (GGT).
Results A total of 13 infants were identified with the diagnosis of intractable TPNAC and they were treated with UDCA therapy. There was a significant reduction in serum levels of direct bilirubin, total bilirubin (p-value equals 0.0001) and AST (p-value equals 0.001). However, the serum levels of ALP, ALT and GGT showed a trend of improvement, yet none of them was statistically significant. Serum direct bilirubin was noted as the first marker to respond to UDCA therapy. It declined steadily during the course of therapy except in two intervals at the sixth and twelfth week of therapy that apparently associated with severe sepsis. There were no serious side effects noted.
Conclusion Our series data suggest that UDCA is safe and may be a potential treatment for intractable TPNAC if used within two weeks after TPN withdrawal and full enteral feeding. Sepsis may alter the effectiveness of UDCA therapy.

Keywords: cholestasis, intractable cholestasis, total parenteral nutrition, ursodeoxycholic acid, very low birth weight infants
Singapore Med J 2006; 47(2): 147-151

Chen HMK, Tan WH, Tan WC, Yu CKE, Lim THJ, Tay MH, See HT
Correspondence: Dr See Hui Ti, dmosht@nccs.com.sg

ABSTRACT
Introduction The National Cancer Survivors Day Foundation defines a cancer "survivor" as anyone living with a history of cancer--from the moment of diagnosis through the remainder of life. Little is known about the size and make-up of this population or about the medical care experience of and social implications for patients who have had a diagnosis of cancer in Singapore. An opportunistic survey was undertaken to understand how members of the public believe about this population.
Methods A sample of the general public was undertaken during the "CancerVive" event in 2004. Questionnaires regarding employment as well as attitudes towards cancer and cancer survivorship were distributed.
Results Members of the public held certain misconceptions about cancer survivors. They also have certain negative attitudes toward cancer survivors. Beliefs and attitudes about cancer are similar for cancer survivors and the general public. Although members of the public had positive attitudes towards working with cancer survivors, the majority felt that cancer survivors should not be given equal opportunities at work, by not employing cancer survivors if they were in the position to hire.
Conclusion Further research with larger and more representative samples needs to be undertaken to extend the understanding into cancer survivorship issues.

Keywords: attitude towards cancer, cancer, cancer survivors
Singapore Med J 2006; 47(2): 143-146

Jayaranee S, Sthaneshwar P
Correspondence: Dr S Jayaranee, jayaranee@um.edu.my

ABSTRACT
Introduction The objective of this study was to assess the clinical significance of soluble transferrin receptor (sTfR) in hypochromic microcytic anaemia.
Methods Serum sTfR was determined on 91 blood samples with haemoglobin less than 110 g/L and MCV less than 76 fl or MCH less than 27.0 pg. The samples were classified as iron deficiency anaemia (IDA), anaemia of chronic disease (ACD) and thalassaemia. ACD was further divided into groups 1 and 2, based on the serum ferritin level.
Results The sTfR level in the control was 1.53+/-0.8 mg/L. In IDA, the sTfR level was 5.53+/-8.76 mg/L and this was significantly higher compared with the control (p-value is less than 0.0001). sTfR levels in ACD (3.32+/-3.94 mg/L) and the thalassaemia group(1.64+/-1.02 mg/L) were not significantly different from that of the control (p-value is more than 0.05). In ACD, the sTfR level in group 1 was significantly higher when compared with the control (p-value is less than 0.001) and group 2 (p-value is less than 0.01). A significantly higher sTfR/ferritin ratio was observed in IDA (2,368.98+/-7,236.4 microg/microg) compared to the control (37.6+/-43.7 microg/microg) (p-value is less than 0.001). No significant difference was noted between ACD, thalassaemia and control (p-value is greater than 0.05). sTfR/ferritin ratio was significantly higher in group 1 of ACD when compared with that of control and group 2 (p-value is less than 0.001).
Conclusion Serum sTfR and sTfR/ferritin ratio are useful parameters in hypochromic microcytic anaemia to diagnose iron deficiency particularly when associated with chronic inflammation. sTfR can be done selectively in ACD patients when ferritin levels are more than 60 microg/L and there is a diagnostic dilemma. If sTfR level is raised, a trial of iron therapy is suggested for these patients.

Keywords: anaemia, hypochromic microcytic anaemia, iron deficiency anaemia, thalassaemia, transferrin receptor
Singapore Med J 2006; 47(2): 138-142

Mohd Zain Z, Fathelrahman AI, Ab Rahman AF
Correspondence: Dr Ab Rahman A F, abfatahmy@yahoo.com

ABSTRACT
Introduction Paracetamol is available as an over-the-counter medication in many countries including Malaysia. This drug has been implicated in many poisoning cases admitted to hospitals throughout the country.
Methods We conducted a three-year retrospective review of 165 medical records of patients admitted to the Penang General Hospital for acute paracetamol poisoning. Cases were identified according to the discharge diagnosis documented in their medical records.
Results Acute paracetamol poisoning occurred in all major ethnic groups. About 70 percent of our patients were female. There was minimal involvement of children. Admissions were more likely to be due to deliberate ingestions rather than accidental poisoning. In most cases, serum concentrations data plotted on the Rumack-Matthew nomogram predicted the majority of cases to be unlikely to be hepatotoxic, which were consistent with their mild clinical courses. Patients who acutely ingested more than 140 mg/kg or predicted to be hepatotoxic, based on their serum concentrations, had a significantly longer hospital stay.
Conclusion Although acute paracetamol poisoning was common, the outcome was generally good.

Keywords: acute poisoning, drug ingestion, paracetamol, poisoning
Singapore Med J 2006; 47(2): 134-137

Zilfalil BA, Sarina S, Liza-Sharmini AT, Oldfield NJ, Stenhouse SA
Correspondence: Dr Zilfalil Bin Alwi, zilfalil@kb.usm.my

ABSTRACT
Introduction Cystic fibrosis (CF) is one of the common genetic disorders in the western world. It has been reported to be very rare in Asian populations. According to the Cystic Fibrosis Genetic Analysis Consortium, more than 1,000 mutations of the CF gene have been identified. The CF gene, named the cystic fibrosis transmembrane conductance regulator (CFTR), is located on chromosome 7 and composed of 27 exons. This study aims to detect possible CFTR gene mutations in Malays.
Methods We analysed 50 blood samples from healthy Malays with no symptoms of CF. DNA was extracted from blood using commercially available extraction kits (Eppendorf, Germany). Identification of CFTR gene mutation was performed using the CF OLA (Oligonucleotide Ligation Assay) kit (Applied Biosystems, USA). The PCR-ligation products were electrophoresed on eight percent sequagel using an ABI PRISM 377 genetic analyser (Applied Biosystems, USA). Electrophoresis data was analysed using the Genotyper software and a report of the CF genotype for all loci tested was created using the CF Genotyper Template software. Out of 50, one sample (two percent) was detected to have the F508del mutation (3bp deletion at exon 10), which is one of the most common CFTR gene mutations in Caucasians.
Results The F508del mutation allele was detected in one subject. This indicates that she was a CF carrier.
Conclusion We report the finding of a carrier of the F508del mutation of the CFTR gene in the Malay population. Our finding revealed that CF could also affect the Malay population. Larger studies are necessary to determine the exact gene frequency of this population.

Keywords: cystic fibrosis, F508del mutation, gene mutation, transmembrane conductance regulator
Singapore Med J 2006; 47(2): 129-133

Ong VYK, Habibah AK, Lee FCY
Correspondence: Dr Victor Ong Yeok Kein, victor_ong@alexhosp.com.sg

ABSTRACT
Introduction This article aims to study work-related injuries through the eyes of the foreign workers and correlate the findings with their perception of job safety and their level of training received.
Methods A prospective questionnaire-based survey was conducted between April and October 2002 in the Emergency Department of a secondary level hospital. 285 consecutive foreign workers with work-related injuries were enrolled.
Results The majority of the foreign workers were of Asian origin, male, and 20-30 years of age. 66 percent had prior working experience. 83 percent of those surveyed rated the safety training received as "just enough" or better. There was a positive correlation between job skills and safety training (rs equals 0.733). 82 percent said that safety equipment were available, though only one-half made use of them. 67 percent of the injured received some form of first aid at scene, mainly bandaging. 17 percent did not receive any first aid because of lack of equipment or first aid training. The two most common injuries were wounds to the limbs (33.2 percent) and foreign body (FB) entry into the eyes (17.7 percent). Correspondingly, toilet and suture and removal of FB in the eye were the two most common procedures done.
Conclusion In this study, the foreign workers generally felt that the safety and work skills training were adequate. However, there are some problems that still need to be addressed.

Keywords: emergency medicine, first aid, industrial accidents, migrant workers, worker safety
Singapore Med J 2006; 47(2): 121-128

Wai CT
Correspondence: Dr Chun-Tao Wai, mdcwct@nus.edu.sg

ABSTRACT
Introduction Drug-induced liver injury (DILI) is an important clinical problem. However, although traditional Chinese medicines (TCM) are widely consumed in Asia, most cases of TCM-DILI are reported as case reports or case series. We aimed to evaluate the clinical course of DILI at an Asian tertiary liver centre.
Methods All patients with DILI seen by one hepatologist from July 2003 to June 2004 at a local liver centre were prospectively collected and reviewed.
Results 29 cases of DILI were seen by the hepatologist over the 12-month period. Median age was 51 (range 18-76) years, 20 (69 percent) were female, and 24 (83 percent) were Chinese. TCM were the commonest group of drugs implicated as 15 (52 percent) of the patients had presumed DILI from TCM, while four (14 percent) were from anti-tuberculosis drugs. 18 (62 percent) presented as hepatitic picture, seven (24 percent) as cholestatic, and four (14 percent) as mixed picture. Extrahepatic manifestations were seen only in ten percent of patients. Three (ten percent) died and one (3 percent) underwent liver transplant for liver failure.
Conclusion DILI is a common clinical problem with significant mortality. TCM is an important cause of DILI in Asia. Further studies on DILI from TCM or other complementary medicines are needed.

Keywords: drug-induced liver injury, drug toxicity, herbal medicine, liver failure, traditional Chinese medicine
Singapore Med J 2006; 47(2): 116-120