2005

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

KL Ho, WS Teo
Correspondence: Dr Ho Kah Leng, Ho_Kah_Leng@nhc.com.sg

ABSTRACT
A 70-year-old Chinese woman developed breathlessness, tachycardia and hypotension on the fourth day after total hip replacement. 12-lead electrocardiogram (ECG) showed sinus tachycardia with ST depression in I, II, V5 and V6. The ECG changes of sinus tachycardia along with a typical history is suggestive of pulmonary embolism. Diagnosis, treatment and the use of IVC filter for pulmonary embolism are discussed.

Keywords: acute pulmonary embolism, warfarin
Singapore Med J 2005; 46(3): 144-147

VTW Lee, M Magnaye, HW Tan, CH Thng, LLPJ Ooi
Correspondence: Dr Victor Lee Tswen Wen, vicklee@singnet.com.sg

ABSTRACT
Sclerosing haemangioma is a rare variant of hepatic haemangioma. The radiological features on computed tomography and magnetic resonance imaging may not be typical for haemangioma and can be confused with hepatocellular carcinoma. We report sclerosing haemangioma occurring in a 65-year-old woman where the radiological features raise the possibility of hepatocellular carcinoma.

Keywords: computed tomography, hepatocellular carcinoma, magnetic resonance imaging, sclerosing haemangioma
Singapore Med J 2005; 46(3): 140-143

K Sheah, MA Png
Correspondence: Dr Kenneth Sheah, radioround@yahoo.com

ABSTRACT
Meniscal cysts causing bone erosions are rare. The majority of meniscal cysts are associated with tears of the menisci and magnetic resonance (MR) imaging appearances are usually diagnostic. The MR images of a 34-year-old man showed a well-defined cystic mass that communicated with a horizontal cleavage tear of the posterior horn of the lateral meniscus and caused pressure erosion of the lateral tibial condyle. We believe this to be the first locally reported case of tibial erosion related to a meniscal cyst. This entity should be included in the differential diagnosis for a well-defined periarticular erosion.

Keywords: magnetic resonance imaging, meniscal cyst, meniscus, tibia, tibial erosion
Singapore Med J 2005; 46(3): 137-139

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