2005

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

M Muttarak, B Chaiwun
Correspondence: Prof Malai Muttarak, mmuttara@mail.med.cmu.ac.th

ABSTRACT
Scrotal swelling may be due to extratesticular and intratesticular lesions. The majority of extratesticular lesions are benign while the majority of intratesticular lesions are malignant. Ultrasonography (US) is helpful in separating extra- from intratesticular lesions. US can show whether a mass is cystic, solid or complex, and also features such as associated calcifications, epididymal involvement, scrotal skin thickening and colour Doppler flow pattern. Extratesticular lesions include hydrocoele, spermatocoele, varicocoele, epididymal cyst, hernia and tumours of the epididymis and cord structures. Intratesticular lesions include primary tumour, metastases, lymphoma and leukaemia. Tuberculous epididymitis or epididymo-orchitis may also present with painless scrotal swelling. US features of these disease patterns, with pathological correlation, are presented in this pictorial essay.

Keywords: scrotum, testis, testicular abnormalities, testicular neoplasms, ultrasonography
Singapore Med J 2005; 46(4): 196-202

SM Tavangar, M Ghafouri
Correspondence: Dr Seyed Mohammad Tavangar, mtavangar@yahoo.com

ABSTRACT
Pigmented villonodular synovitis is a rare benign disorder and usually affects young and middle-aged adults. It occurs either as a localised pedunculated form or more common diffuse form, and is almost always unifocal. Only few cases of multifocal involvement have been reported, all of them in children. Multifocal pigmented villonodular synovitis occurring in a 5-year-old girl is presented. Both her knees and left elbow were involved. All three lesions were of localised pedunculated type and were completely excised. She is believed to be one of the youngest patients reported.

Keywords: juvenile joint disease, multifocal pigmented villonodular synovitis, pigmented villonodular synovitis, synovitis
Singapore Med J 2005; 46(4): 193-195

AHC Tan
Correspondence: Dr Andrew H C Tan, goothc@sgh.com.sg

ABSTRACT
Posterior dislocation of the shoulder is a rare and commonly missed injury. While prompt diagnosis and treatment is important to prevent untoward sequelae, it is often diagnosed and treated too late. The first reported case of a posterior fracture-dislocation of the humeral head following a domestic electrocution accident in Singapore is described in a 52-year-old man. The injury was missed by several doctors before a humeral head replacement was done. The diagnostic pitfalls and management of this injury and ways to avoid a missed or delayed diagnosis are discussed.

Keywords: electrocution accident, fracture-dislocation, missed dislocation, posterior shoulder dislocation
Singapore Med J 2005; 46(4): 189-192

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

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