Original Article

Tan VAK, Gerez IFA, Van Bever HP
Correspondence: Prof Hugo P Van Bever, paevbhps@nus.edu.sg

ABSTRACT
Introduction Adverse drug reactions (ADRs) are a common medical problem in children, affecting up to 15 percent of children, according to the literature. However, most studies on ADRs were performed in a hospital setting, and studies in the general population are limited. The current study aims to estimate the prevalence of ADRs in a large number of non-selected Singaporean children.
Methods School children, aged 7–16 years, from 25 random schools were screened via a self-reported questionnaire on ADRs, and parents of the selected children were then followed up with a telephone interview to obtain additional information on specific manifestations, diagnosis and allergy testing.
Results The prevalence of an ADR in children was 5.4 percent, with 56.7 percent of cases reporting an ADR to beta-lactam antibiotics. Dermal manifestations were reported in 60 percent of all ADRs, while multiple drug allergies accounted only for 3.8 percent. Only 6.9 percent of the children who experienced an ADR were referred to a hospital for further investigations.
Conclusion ADRs were associated with a positive history of atopy, increased income level and Chinese and Indian ethnicity, but not with gender or age. It is striking that most children suffering from a clinical ADR were not investigated further or referred for diagnostic tests. Many parents were unaware of the availability of drug allergy tests and feared compromising their children’s health. This certainly could attribute to the high incidence of the over-reporting of ADRs in the general population.

Keywords: adverse drug reaction, antibiotics, beta-lactam antibiotics, drug allergy, skin reactions
Singapore Med J 2009; 50(12): 1158-1161

Asma A, Marina MB, Mazita A, Fadzilah I, Mazlina S, Saim L
Correspondence: Dr Asma Abdullah, asmaent@yahoo.com.

ABSTRACT
Introduction This study aims to review the management and discuss the outcome of patients with iatrogenic facial nerve palsy. 
Methods 11 patients with iatrogenic facial nerve palsy (FNP) were evaluated retrospectively in a tertiary centre between June 1995 and September 2008. All the cases were referred from other centres. 
Results Ten patients had iatrogenic immediate FNP secondary to mastoidectomy and one had FNP secondary to superficial parotidectomy. Of the ten cases, three had concomitant profound sensorineural hearing loss and one had concomitant labyrinthine fistula. Ten patients underwentfacialnerveexplorationandonepatient was managed conservatively. The second genu was the commonest site of injury (60 percent). Facial nerve recoveries were achieved to Grade I House Brackmann classification in five cases, Grade II in two cases and Grade III in two cases postoperatively. One case defaulted follow-up. One patient, managed conservatively, recovered to FNP Grade II after five months post-injury. 
Conclusion Mistakes that most likely occurred during mastoid surgery are drilling towards the antrum, causing injury to the facial nerve at the second genu. Early facial nerve exploration and neurolysis resulted in good facial nerve recovery. 

Tan KK, Yan ZY, Vijayan A, Chiu MT
Correspondence: Dr Ker-Kan Tan, kerkan@gmail.com

ABSTRACT
Introduction Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. We reviewed our institution’s management of patients with diaphragmatic rupture after blunt trauma.
Methods All patients in this study were treated at Tan Tock Seng Hospital, Singapore, from March 2002 to October 2008. Patients with penetrating injuries were excluded. The parameters included age, mechanism of injury, haemodynamic status at admission, Glasgow coma scale (GCS) score, injury severity score (ISS), imaging studies, location of diaphragmatic injuries, associated injuries and outcome.
Results 14 patients with a median age of 38 years formed the study group. Vehicular-related incidents accounted for 71.4 percent of the injuries. The median GCS score on admission was 14 (range 3–15), while the median systolic blood pressure and heart rate were 94 (range 50–164) mmHg and 110 (range 76–140) beats per minute, respectively. The median ISS was 41 (range 14–66). All had chest radiographs performed in the emergency department, six (42.9 percent) had computed tomography performed before surgery, while the remaining eight (57.1 percent) were sent straight to the operating theatre from the emergency department. There were five (35.7 percent) right-sided and nine (64.3 percent) left-sided diaphragmatic ruptures. The mortality rate was 35.7 percent. Some of the associated injuries included eight (57.1 percent) splenic lacerations, five (35.7 percent) haemothorax and lung injuries, four (28.6 percent) bone fractures and three (21.4 percent) liver lacerations. 12 (85.7 percent) patients underwent repair of the diaphragmatic rupture using interrupted polypropylene suture, while the remaining two (14.3 percent) were too haemodynamically unstable to undergo definitive treatment. Advanced age, haemodynamic instability and raised ISS were associated with mortality.
Conclusion An accurate diagnosis of diaphragmatic rupture in trauma patients is difficult, and a thorough examination of both the hemidiaphragms is mandatory during emergency laparotomy for these patients. Those with more severe injuries and decreased physiological reserves usually fare worse.

Keywords: blunt abdominal injuries, diaphragm, diaphragmatic rupture, emergency laparotomy, surgical emergency
Singapore Med J 2009; 50(12): 1150-1153

Hussain A, Mahmood H, Singhal T, Balakrishnan S, El-Hasani S
Correspondence: Mr Abdulzahra Hussain, azahrahussain@yahoo.com

ABSTRACT 
Introduction The correlation between clinical and histopathology findings in appendicitis has been highlighted by many studies. However, the impact of this correlation on the surgical decision to remove a normal-looking appendix is still vague, with no clear definition of positive appendicitis. The aim of this study was to correlate the histological, operative and clinical diagnoses of acute appendicitis (AA). 
Methods 200 patients with a preoperative diagnosis of AA underwent laparoscopic appendectomy. A single consultant surgeon performed all the procedures. The clinical, macroscopical and microscopical outcomes were reported and analysed. Follow-up assessment was performed as an outpatient appointment. 
Results 112 women and 88 men were included in this study. The mean age was 18.8 (range 8–83) years. Macroscopical appendicitis was confirmed in 139 (69.5 percent) patients, while microscopical appendicitis was reported in 147 (73.5 percent) specimens of the appendix. Ten (7.2 percent) out of 139 patients who were macroscopically positive were found to have a normal appendix on microscopical examination. Different pathologies were found in 21 (10.5 percent) patients, and all underwent appendectomy. Microscopical appendicitis was confirmed in10 (25percent) out of 40 patients who had a normal-looking appendix. 
Conclusion The correlation of the clinical, microscopical and macroscopical findings in AA is important in order to understand the natural history of appendicitis, and this may help to formulate a sound surgical decision. These findings are supportive of justifying appendectomy for normal-looking appendices, if no other pathology is found.

Wong TH, Tan YM
Correspondence: Dr Wong Ting Hway, wong.th@iname.com

Shariff AH, George J, Ramlan AA
Correspondence: Dr Mohamad Shariff A Hamid, ayip@um.edu.my 

ABSTRACT 
Introduction The purpose of this study was to investigate the pattern of musculoskeletal injuries sustained by Malaysian badminton players. 
Methods This is a retrospective case notes review of all badminton players who attended the National Sports Institute (NSI) Clinic, Kuala Lumpur, Malaysia, and were diagnosed with musculoskeletal injuries. 
Result In a two and a half year period, from January 2005 to June 2007, 469 musculoskeletal injuries were diagnosed among badminton players at the NSI Clinic. The mean age of the players who attended the clinic was 19.2 (range 13–52) years. Approximately 60 percent of the injuries occurred in players younger than 20 years of age. The majority of injuries (91.5 percent) were categorised as mild overuse injury and mostly involved the knee. 
Conclusion The majority of the injuries sustained by badminton players in this study were due to overuse, primarily in the knee. The majority of the injuries were diagnosed in younger players and occurred during training/practice sessions. There was no difference in terms of incidence and types of injuries between the genders. 

Yong MH, Hwang WS, Knight LA, Fung W, Chan MY, Seow WT, Chui CH
Correspondence: Dr Chui Chan Hon, chchui@surgeryforchildren.com 

ABSTRACT
Introduction Neuroblastoma is the most common extracranial solid tumour in children, accounting for about 5.3 percent of all childhood cancers in Singapore. Several genetic abnormalities have been reported as prognostic markers, including amplification of the MYCN gene, deletion of the short arm of chromosome 1 (1p) and gain of the long arm of chromosome 17 (17q). However, the correlation between tumour histology and these genetic parameters remains to be established in our local population. 
Methods 14 untreated primary neuroblastoma tumours, diagnosed consecutively in our hospital between 2003 and 2007, were included for this study. Tumour tissues were classified histologically as favourable or unfavourable, according to the modification of World Heath Organization Classification of Tumours, by associating the degree of differentiation and mitotic karyorrhectic index of the neuroblastoma to the age of the patient. Fluorescence in situ hybridisation analysis for MYCN, 1p status and 17q status were subsequently performed on tumour touch imprints. 
Results Five tumours with favourable histology were all negative for the three genetic parameters being investigated. The other nine tumours showing unfavourable histology exhibited one or more of the three genetic parameters. All MYCN amplified tumours either had additional 1p deletion and/or 17q gain. 
Conclusion Our limited data suggests that 1p deletion and 17q gain are reliable independent parameters correlating with an unfavourable histology and poor clinical outcome. The use of 1p deletion and 17q gain studies, in addition to MYCN amplification studies, should be considered routinely in predicting prognosis in neuroblastomas. 

Chong VH, Abdullah MS, Telisinghe PU, Jalihal A 
Correspondence: Dr Chong Vui Heng, chongvuih@yahoo.co.uk
 

ABSTRACT
Introduction The incidence of colorectal cancer (CRC) is reported to be increasing. This study assessed the incidence and trend of CRCs in Brunei Darussalam, a developing nation.
Methods All histologically-confirmed CRCs over a 22-year period (1986–2007) were identified from the National Cancer and the Department of Pathology registries and retrospectively reviewed.
Results There was a total of 576 (male 59.0 percent, mean age 59.6 +/- 14.8 years, adenocarcinoma 97.6 percent, rectum 31.4 percent) CRCs diagnosed during this period. There was an increasing trend in the mean age at diagnosis, 55.2 +/- 17.5 years in 1986 to 62.0 +/- 13.0 years in 2007, but this was not significant (p-value equals 0.150, ANOVA). 18.8 percent were diagnosed in patients aged 45 years or below. There was no difference in the age at diagnosis between the genders (p-value equals to 0.432) and tumour sites, colon vs. rectum (p-value equals to 0.279). Overall, there was an increase in the age standardised rate (ASR) from 10.36 (1986–90) to 13.75 (1991–95), 15.90 (1996–2000), 16.87 (2001–05) and 24.31 per 100,000 (2006–07). Among the ethnic groups, the Chinese had higher ASRs (41.44) compared to the Malays (including the indigenous groups) with 15.46 per 100,000. The mean age of the Chinese (62.6 +/- 14.0 years) was significantly higher than that of the Malays (58.2 +/-14.9 years, p-value equals to 0.001) at diagnosis. The age-specific incidence rates for the genders were comparable, except for the age groups of older than 55–59 years, where the rate for males was higher.
Conclusion The incidence of CRC is increasing in our local setting with differences observed among the ethnic groups. The Chinese had a higher incidence but developed CRC at a later age. These have important implications if screening for CRC is to be considered in our local setting.

Menon SK, Sarathi V, Bandgar TR, Menon PS, Goel N, Shah NS
Correspondence: Dr Tushar R Bandgar, drtusharb@gmail.com 

ABSTRACT 
Introduction Autoimmune hypophysitis (AH) is a rare primary autoimmune inflammatory disorder involving the pituitary gland. 
Methods A retrospective analysis of the clinical features and outcome of patients diagnosed with AH between 1988 and 2006, was carried out. 
Results 15 patients (14 females and one male) with AH were identified. Three patients presented in the peripartum period. Headache, vomiting and visual field defects, suggestive of an expanding sellar mass, were the most common presenting symptoms (67 percent). The most common deficient hormone was adrenocorticotropic hormone (ACTH) (67 percent), followed by thyroid stimulating hormone (53 percent) and gonadotropins (40 percent). Imaging revealed a definite, enhancing sellar mass in 87 percent of the patients and stalk thickening in 33 percent of the patients. Three patients underwent surgery. On serial monitoring, the sellar mass regressed or disappeared spontaneously without any immunosuppressive treatment in the other ten patients with a definite sellar mass. 
Conclusion We report a higher female to male ratio and a lower incidence of peripartum cases in our series. Symptoms of mass effect were the most common presentation, while ACTH was the most commonly-deficient hormone. Surgery was rarely needed, and most patients experienced a spontaneous resolution of the mass. 

Abdul Wahab NA, Rashid MFN
Correspondence: Mr Noor Alaudin Abdul Wahab, alaudin@medic.ukm.my 

ABSTRACT 
Introduction The present study aimed to obtain preliminary tympanometric data of young Malay adults and to compare the results between genders. 
Methods 96 undergraduate students (49 males and 47 females), aged 19–25 (mean and standard deviation 21.14 +/- 1.31) years, participated in this study. Otoscopic examination, pure tone audiometry, qualitative tympanogram and ipsilateral acoustic reflex were measured to ensure a clear ear canal, normal hearing and normal middle ear function, prior to tympanometric measurement. As a result, a total of 154 ears (80 ears from males and 74 ears from females) were selected for further statistical analyses. The tympanometric parameters measured were peak compensated static acoustic admittance (Peak Y_tm), tympanometric width (TW) and equivalent ear canal volume (V_ea). 
Results The results showed that the mean Peak Y_tm, V_ea and TW for males were 0.81 mmhos, 1.48 cubic cm and 113.67 daPa, respectively. The mean Peak Y_tm, V_ea and TW for females were 0.63 mmhos, 1.12 cubic cm and 98.04 daPa, respectively. Males were found to have significantly higher mean V_ea and mean Peak Y_tm than females. However no significant gender difference was observed in the mean TW. 
Conclusion The current study suggests that young Malay adults may require gender-specific Peak Y_tm and V_ea values when implementing a quantitative approach in tympanogram interpretation.