Original Article

Abdullah A, Hazim MYS, Almyzan A, Jamilah AG, Roslin S, Ann MT, Borhan L, Sani A, Saim L, Boo NY
Correspondence: Ms Asma Abdullah, asmaent@yahoo.com

ABSTRACT
Introduction This study aims to determine the prevalence of hearing loss among newborns delivered at Hospital Universiti Kebangsaan Malaysia and to evaluate the usefulness of our hearing screening protocol.
Methods All infants born in the hospital over a nine-month period, between April to December 2003, were screened for hearing loss with a portable otoacoustic emission (OAE) before discharge. At the age of two months, a second OAE test was repeated on newborns who failed the initial test. Those who failed the second test were re-tested at three months of age. When these infants failed the third OAE test, a brainstem evoked response (BSER) test was performed.
Results During the study period, 4,219 infants were born in the hospital, and 3,762 (89.2 percent) underwent OAE screening. 620 (19.7 percent) of them failed the first screening test, and 506 (81.6 percent) of them came for a second stage-screening test. In the third stage screening at three months of age, only 39 (65 percent) patients turned up. Of these, ten infants passed the OAE test and 29 failed. However, when these infants underwent BSER, 13 had normal BSER and 16 have abnormal BSER. The prevalence of hearing loss in this study was 0.42 percent (16/3,762).
Conclusion The large number of defaulters and false-positive results in this study suggest that this pilot hearing-screen programme requires fine-tuning to minimise these problems.

Keywords: brainstem evoked response, hearing loss, newborn screening, otoacoustic emission
Singapore Med J 2006; 47(1): 60-64

Homesh NA, Alsabahi AA, Al-Agmar MH, Alwashaly AA, Valenzuela RE, Alhadid MA, Alkubati SM
Correspondence: Dr Nagi Homesh, nagihomesh@yahoo.com

ABSTRACT
Introduction Cancer of the oesophagus is a major problem in Yemen, where most of the patients present with advanced disease. Curative oesophageal resection for carcinoma may be carried out by either the transhiatal or transthoracic technique. The aims of this study were to compare the morbidity, mortality, short term outcome and long term survival of the two techniques in the treatment of oesophageal carcinoma.
Methods From March 1998 to July 2004,118 patients with cancer of the oesophagus were studied. The tumours in 84 patients were resected by transhiatal oesophagectomy (43) and transthoracic oesophagectomy (41).
Results The two groups were comparable in terms of age, sex, location of the tumours, risk factors and stage of the disease. There was no significant difference in the mean intensive care unit stay, blood transfusion and mean hospital stay. Anastomotic leak was higher in the transhiatal oesophagectomy group than transthoracic group (21 percent versus 12 percent, p-value is equal to 0.001). Recurrent laryngeal nerve lesion was present in 18.6 percent of the transhiatal group and absent in the transthoracic group. The overall hospital mortality was 8.3 percent with no significant difference between the two groups (transhiatal 9.3 percent versus transthoracic 7.3 percent, p-value is equal to 0.742).
Conclusion Transhiatal oesophagectomy was associated with a higher incidence of anastomotic complications and recurrent laryngeal nerve lesions, but there was no significant difference in the mortality between the two groups.

Keywords: oesophageal cancer, oesophagectomy, oesophagus, transhiatal resection, transthoracic resection
Singapore Med J 2006; 47(1): 54-59

Tan KH, Kwek K, Yeo GSH
Correspondence: Dr Kelvin Tan Kok Hian, kh@tan.net

ABSTRACT
Introduction The incidences and characteristics of pre-eclampsia (PE) and eclampsia in KK Women's and Children's Hospital (KKH), a tertiary obstetrical referral centre in Singapore, were studied.
Methods The incidences and types of PE between July 1999 and June 2003 were derived from the pregnancy disease databases. The characteristics of women with PE in relation to the general obstetric population were analysed on the age, race, parity, types of delivery, gestation at delivery and mortality. Case records of eclampsia were analysed.
Results A total of 2,213 (3.6 percent) out of 61,595 deliveries were complicated by PE between July 1999 and June 2003. Incidence rates for mild or unspecified PE, severe PE, eclampsia and PE superimposed on hypertension were 2.47 percent (1,518), 0.97 percent (599), 0.02 percent (10) and 0.14 percent (85), respectively. The incidence increased with multiple pregnancies: from 3.5 percent in singletons to 7.5 percent in twins, 19.4 percent in triplets and 25.0 percent in quadruplets. The Caesarean section rate for PE was 46.1 percent compared with 23.7 percent in the hospital population. The proportion of premature birth (<37 weeks) in PE was 31.0 percent and that of severe prematurity (<32 weeks) was 5.7 percent, while hospital population proportions were 9.8 percent and 1.3 percent, respectively. The perinatal mortality rate (PMR) of PE was 11.0/1,000 births (population PMR was 4.4/1,000 births). There were only ten cases of eclampsia out of 61,595 deliveries (1:6160) giving an incidence of eclampsia of 16.2/100,000 deliveries. There was no stillbirth, neonatal and maternal death among the eclamptic patients.
Conclusion The incidence and outcome of eclampsia in KKH showed a significant reduction over the years due to improved obstetrical care. While PE is still common, eclampsia is now a very rare disease outcome.

Keywords: eclampsia, hypertension, maternal mortality, pre-eclampsia, pregnancy toxemia
Singapore Med J 2006; 47(1): 48-53

Sankaran M, Subramanian P
Correspondence: Dr Perumal Subramanian, psub@rediffmail.com

ABSTRACT
Introduction The influences of chronic administration of low and high doses of melatonin on the characteristics of circadian rhythms of glucose, reduced glutathione, total protein were studied, in order to investigate whether melatonin could modulate these rhythms differently.
Methods Pharmacological doses of melatonin (0.5 mg/kg and 1.0mg/kg body weight) were administered chronically for 45 days to Wistar rats, and 24-hour rhythms of glucose, reduced glutathione (GSH), total protein and melatonin (MLT) were studied under semi-natural (LD 12:12 hours) conditions.
Results Exogenous melatonin administered caused delays in the acrophase of glucose, total protein and melatonin rhythms, whereas advances in the acrophases of reduced glutathione were observed. This indicated that the chronic administration of melatonin could act as the modulated internal zeitgeber and this could be the reason for altered acrophase (peak time of the variable) and other characteristics of rhythms in the melatonin-treated groups. Significant dose-dependent effects of melatonin were absent in the study.
Conclusion The present study demonstrates that the exogenous administration of melatonin could influence the biochemical rhythms.

Keywords: circadian rhythm, glucose, melatonin, reduced glutathione, total protein
Singapore Med J 2006; 47(1): 42-47

Joazlina ZY, Wastie ML, Ariffin N
Correspondence: Dr Joazlina Zaleha Yusof, joazliniazy@yahoo.com

ABSTRACT
Introduction There is an awareness of the increased incidence of splenic abscess in Southeast Asia giving rise to unexplained fever. This study looks at the role of computed tomography (CT) in evaluating focal splenic lesions in patients presenting with fever.
Methods 37 patients presenting with fever of unknown origin underwent CT and this study retrospectively analyses the findings in these patients. 13 patients also had associated abdominal pain. Patients with conditions at high risk for splenic infection include: diabetes mellitus in ten patients, leukaemia in seven patients, human immunodeficiency virus infection in five patients, intravenous drug abuse in six patients, and steroid therapy in two patients. No risk factors could be identified in seven patients.
Results Splenic abscess was diagnosed in 28 patients. A range of infecting organisms was isolated but the most frequent were Staphylococcus aureus (eight), tuberculosis (four), Streptococcus (four), fungal (four) and melioidosis (four). No infecting organism could be identified in ten cases though in patients with leukaemia with multiple low attenuation areas, the cause was presumed to be fungal. Six patients were diagnosed to have splenic infarcts though differentiation from splenic abscess could be difficult; these patients were treated for an abscess and all had endocarditis. Three patients were subsequently diagnosed with lymphoma. Percutaneous abscess drainage was performed in five patients and splenectomy was carried out in six patients.
Conclusion CT proved to be very useful as it not only revealed the size and extent of any splenic abnormality but it assisted with guidance for percutaneous drainage, determined the site for biopsy, and provided follow-up after treatment.

Keywords: computed tomography, pyrexia of unknown origin, spleen, splenic abscess, splenic infarct
Singapore Med J 2006; 47(1): 37-41

Lee KK, Seow WT, Ng I
Correspondence: Ms Lee Kah Keow, kah_keow_lee@nni.com.sg

ABSTRACT
Introduction In Singapore, severe traumatic brain injury (TBI) continues to be a major public health problem and devastating condition, with significant mortality and morbidity. By understanding the incidence, prevalence and implications of severe TBI in Singapore, strategic plans to meet the unique needs of these patients in the local context may be developed.
Methods The demographical profiles of the adult severe TBI patients in Singapore were studied in this retrospective review of 528 patients admitted to the National Neuroscience Institute (NNI) from January 1999 to December 2003.
Results There were 420 male and 108 female patients, age ranging from 15 to 96 years old, with a mean and standard deviation (SD) of 44.6 +/- 19.9 years, admitted to NNI during the study period. Motor vehicle and fall-related accidents were the leading causes of severe TBI. Three high-risk groups identified were young adults, elderly, and foreign workers.
Conclusion Preventive measures targeting at these high-risk groups are important to reduce the incidence of severe TBI.

Keywords: accidents, brain injury, motor vehicle accidents, trauma
Singapore Med J 2006; 47(1): 31-36

Chan MY, Woo KS, Wong HB, Chia BL, Sutandar A, Tan HC
Correspondence: Dr Mark Y Chan, chanyymark@mac.com

ABSTRACT
Introduction Identifying and controlling cardiovascular risk factors at an early age may prevent cases of young myocardial infarction (MI). We studied age-related differences in the cumulative incidence of risk factors and the adequacy of primary prevention by surveying 1,556 patients with a first MI admitted to a tertiary hospital in Singapore.
Methods This is a single centre registry-based study on patients admitted with a first MI to a tertiary hospital in Singapore. We stratified the cohort into younger (45 years of age and younger) and older (older than 45 years of age) groups. The presence of five risk factors, namely: hypertension, diabetes mellitus (DM), smoking, a family history of premature MI, and hyperlipidaemia, was assessed at the point of care by interview and prior medical records when obtainable. We also determined by the same methods, if these patients were receiving active treatment for DM, hypertension or hyperlipidaemia prior to their first MI. Lipid levels were measured within 24 hours of admission.
Results 96 percent of patients 45 years and younger and 92 percent of those older than 45 years had at least one antecedent risk factor. The 45 years and younger age group had a higher incidence of untreated hypertension (odds ratio 2.99, 95 percent confidence interval 2.00-4.46, p-value is less than 0.001) and hyperlipidaemia (odds ratio 1.71, 95 percent confidence interval 1.20 - 2.43, p-value is equal to 0.002).
Conclusion A majority of young patients with a first MI have at least one identifiable antecedent risk factor. There is significant undertreatment of hypertension and hyperlipidaemia in this age group.

Keywords: cardiovascular risk factors, hyperlipidaemia, hypertension, myocardial infarction
Singapore Med J 2006; 47(1): 27-30

Hsu LY, Koh TH, Tan TY, Ito T, Ma XX, Lin RT, Tan BH
Correspondence: Dr Hsu Li Yang, liyang_hsu@yahoo.com

ABSTRACT
Introduction The clinical features and molecular epidemiology of further cases of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection in Singapore are described.
Methods Six cases of CA-MRSA infection that occurred between April and October 2004 are described. The bacterial isolates were tested for the presence of Panton-Valentine leukocidin (PVL) genes and typed via pulsedfield gel electrophoresis, staphylococcal chromosomal cassette mec (SCCmec) and multi-locus sequence typing. The results were compared with that of previously-reported local and international CA-MRSA isolates.
Results There were four cases of cutaneous abscesses and one each of chronic osteomyelitis and endocarditis. CA-MRSA isolates from the last two cases tested negative for PVL genes. Three isolates were identical and related to the Oceanian clone, and one isolate to the predominant Taiwanese clone. The isolate causing osteomyelitis had a novel sequence type.
Conclusion CA-MRSA, though uncommon, is being isolated with increasing frequency in Singapore. A predominant clone (ST30- MRSA-IV) seems to be emerging locally.

Keywords: community infection, Methicillin-resistant Staphylococcus aureus, Methicillin resistance, Panton-Valentine leukocidin, Staphylococcus aureus
Singapore Med J 2006; 47(1): 20-26

Liza-Sharmini AT, Azlan ZN, Zilfalil BA
Correspondence: Dr Liza-Sharmini Ahmad Tajudin, liza@kb.usm.my

ABSTRACT
Introduction Down syndrome was first described as Mongoloid children with European parentage. Although their facial features resemble Orientals or Asians, ocular findings have not been well-documented in Asians, especially Malaysians. Our aim was to identify the ocular findings of Malaysian children with Down syndrome.
Methods A total of 60 children with Down syndrome, aged between one month and 17 years, were examined for ocular findings from January 1995 to January 2004. Ocular examination, which includes visual acuity assessment, slit lamp biomicroscopy, ocular motility, cycloplegic refraction and ophthalmoscopy were performed whenever possible.
Results The ocular findings include epicanthic fold in 96.7 percent (58), nystagmus in 33.3 percent (20), and strabismus in 26.7 percent (16) of children with Down syndrome, all of whom were esotropic. Other findings were bilateral congenital cataract in 13.3 percent (8), blepharoconjunctivitis in 10.0 percent (6), eyelid abnormalities in 6.7 percent (4), glaucoma in 6.7 percent (4), nasolacrimal duct obstruction in 3.3 percent (2), bilateral retinoblastoma in 1.7 percent (1), bilateral retinal detachment in 1.7 percent (1), and chronic uveitis in 1.7 percent (1) of children. Visual assessment showed that 47.3 percent of patients achieved good vision (6/12 to 6/6). Cycloplegic refraction was done in 24 patients (41.7 percent). Out of the 24 patients, 29.2 percent (7) were myopic, 25.0 percent (6) were hyperopic, and astigmatism was observed in 8.3 percent (2).
Conclusion Malaysian children with Down syndrome demonstrated high incidences of epicanthic fold, nystagmus, and strabismus, and absence of Brushfield spots or keratoconus, which are in contrast to the ocular findings in Caucasian patients with Down syndrome. Rare ocular findings, such as bilateral retinoblastoma and retinal detachment, were also observed but their association with Down syndrome is not well-established.

Keywords: Down syndrome, epicanthic fold, eye manifestations, nystagmus, ocular lesions
Singapore Med J 2006; 47(1): 14-19

Saralaya V, Nayak SR
Correspondence: Dr Soubhagya R Nayak, ranjanbhatana@gmail.com

ABSTRACT
Introduction We evaluated the relative position of the greater palatine foramen (GPF) for precise injection of local anaesthetics, for optimal pain control in maxillofacial and dental surgeries.
Methods The study was conducted in 132 adult dried unsexed skulls of the west coast region of Southern India. All the skulls studied were normal with fully erupted third molars and free from any pathological changes.
Results The statistical analysis indicated there was no significant difference in the measurement between the right and left sides with regard to the distance of GPF to the midline, GPF to the incisive fossa, GPF to the posterior border of the hard palate. The angle made by the line joining the GPF to the incisive foramen with the palatal midline (GIM angle) on two sides showed statistical significance. The mean angle on the left side was 21.2 +/- 4.2 degrees and 20.1 +/- 4.2 degrees on the right side. In 74.6 percent of skulls, the GPF was located opposite the third maxillary molars, whereas 24.2 percent showed the GPF between the second and third molars. In 0.4 percent of skulls, the GPF was opposite to the second molar and in 0.8 percent of skulls, the GPF was situated beyond the third molar. 46.2 percent of the GPF was directed forward and medially, whereas 41.3 percent was directed forward, and 12.5 percent as directed forward and laterally.
Conclusion The perpendicular distance of the GPF in Indian skulls was about 15 mm, the distance of GPF to incisive fossa was approximately 37 mm, and the GIM angle was 21 degrees.

Keywords: greater palatine foramen, hard palate, incisive foramen, skull anatomy
Singapore Med J 2007; 48(12): 1143–1146