Showing papers in "Singapore Medical Journal in 2004"

Cardiac and electrocardiographical manifestations of acute organophosphate poisoning.

Abstract: Introduction To study the extent, frequency and pathogenesis of the cardiac and electrocardiographical manifestations of acute organophosphate poisoning. Methods 37 adult patients admitted over a three-year period with a diagnosis of acute organophosphate or carbamate poisoning were studied prospectively. The clinical features and electrocardiographical finding were recorded. Results Cardiac complications developed in 23 patients (62.2 percent). These were: non-cardiogenic pulmonary oedema in eight cases (21.6 percent), electrocardiographical abnormalities including prolonged Q-Tc interval in 14 cases (37.8 percent), ST-T changes in 11 cases (29.7 percent), and conduction defects in two cases (5.4 percent). Sinus tachycardia occurred in 15 patients (40.5 percent) and sinus bradycardia in seven patients (18.9 percent). Hypertension developed in five patients (13.5 percent) and hypotension in four patients (10.8 percent). Five patients (13.5 percent) needed respiratory support because of respiratory depression of which two patients developed intermediate syndrome. Out of 14 patients with prolonged Q-Tc interval, only one had polymorphic ventricular tachycardia of the torsade de pointes type. Two patients died from non-cardiogenic pulmonary oedema and one from ventricular fibrillation, giving a hospital mortality of 8.1 percent. Conclusion Cardiac complications usually occur during the first hour after exposure. Hypoxemia, electrolyte derangements and acidosis are major predisposing factors for the development of these complications. Intensive supportive treatment, meticulous respiratory care and administration of atropine in adequate doses vary early in the course of the illness will reduce the mortality.

Biostatistics 201: linear regression analysis.

Abstract: Correspondence to: Dr Y H Chan Tel: (65) 6325 7070 Fax: (65) 6324 2700 Email: chanyh@ cteru.com.sg In the 100 series(1-4) the common univariate techniques (summarized in Table I) available for data analyses were discussed. These techniques do not allow us to take into account the effect of other covariates/ confounders (except for partial correlation(4)) in an analysis. In such situations, a Regression Model would be required.

Refractive errors in medical students in Singapore.

Abstract: Introduction Refractive errors are becoming more of a problem in many societies, with prevalence rates of myopia in many Asian urban countries reaching epidemic proportions. This study aims to determine the prevalence rates of various refractive errors in Singapore medical students. Methods 157 second year medical students (aged 19-23 years) in Singapore were examined. Refractive error measurements were determined using a stand-alone autorefractor. Additional demographical data was obtained via questionnaires filled in by the students. Results The prevalence rate of myopia in Singapore medical students was 89.8 percent (Spherical equivalence (SE) at least -0.50 D). Hyperopia was present in 1.3 percent (SE more than +0.50 D) of the participants and the overall astigmatism prevalence rate was 82.2 percent (Cylinder at least 0.50 D). Conclusion Prevalence rates of myopia and astigmatism in second year Singapore medical students are one of the highest in the world.

Breath carbon monoxide as an indication of smoking habit in the military setting.

Abstract: Introduction: The breath carbon monoxide (CO) monitor has been shown to be an effective tool in predicting smoking habits. This study aims to assess whether the breath CO level can be employed to determine a person’s smoking habit in the military setting and to analyse various factors that can influence the breath CO levels. Methods: 155 navy personnel were questioned on their smoking habits in phase one of the study. The subjects were explained the objective of the study and instructed to provide two breaths into the CO monitor (EC-50 Smokerlyser, Bedford Instruments, Kent, UK). In a subsequent singleblind study, 40 trainees were not told of the purpose of the study and were assessed via a questionnaire and smokerlyser estimation. Descriptive statistics were used to examine the data and assess distribution. Depending on the distribution, a two-sample t test or MannWhitney U test were used to test for a significant difference between CO levels among smokers and non-smokers. Results: In phase one, the mean breath CO levels were 11.6 (± 6.2) ppm for smokers and (1.9 ± 0.9) ppm for non-smokers (p-value less than 0.0001). A cut-off level of 5 ppm gave a sensitivity of 96 percent and a specificity of 98 percent. The high CO levels were clustered within five hours of the last cigarette smoked. Therefore, this value may not reliably predict smoking habits if an individual smoked more than five hours before the test. Of the 40 subjects in phase two, five smokers who stated that their last cigarette smoked was 48 hours before the breath test had a mean CO level greater than 5 ppm. (range of 5.5 to 18.0 ppm). On further questioning, all admitted to having smoked on the day of the test. Conclusion: The breath CO monitor has good potential for use as an adjunct in future smoking control assessments and a reading greater than 5 ppm strongly suggests that the military outpatient is a smoker.

A survey of fasting during pregnancy.

Abstract: Introduction: Fasting during the month of Ramadan is compulsory in the Muslim faith. Although pregnant women may be exempted, many still choose to fast while others are more careful in practising it. This survey examines the practice of fasting among pregnant Muslim women in Singapore based on the prevalence in relation to factors such as parity, social and economic circumstances. It also analyses the factors that influence the decision to fast and the successful completion of the fast, and examines their knowledge, belief and attitudes on fasting during the holy month of Ramadan. Methods: This is a retrospective study of all Muslim women who were pregnant and received antenatal care in our hospital during the month of Ramadan from 17 November 2001 to 16 December 2001. A four-page questionnaire was mailed to

Paralytic complications of puffer fish (tetrodotoxin) poisoning.

Abstract: Introduction: Puffer fish is available in Bangladesh and is occasionally eaten by some people. Ignorance regarding its proper cooking process may lead to serious health hazards, including fatality. Methods: An unusual catastrophic event happened recently in Khulna, Bangladesh that drew nationwide attention. Eight families were affected. Results: Thirty-seven patients were admitted with a history of consumption of puffer fish. Peri-oral paraesthesia (24), weakness of both lower limbs (22), paraesthesia all over the body (18), headache (15), difficulty in respiration (14), nausea and vomiting (8), blurring of vision (7), and vertigo (6) were common clinical presentations. Twentytwo patients developed ascending paralysis of limbs and involved the respiratory muscles in 17 patients. Eight patients died due to respiratory failure while the rest improved. Conclusion: Health personnel should have sufficient knowledge regarding the clinical manifestations, complications and management of puffer fish poisoning. During its preparation, organs that contain the highest level of tetrodotoxin should be removed. Since there is no specific treatment, people should be made aware of the potential risk of eating puffer fish, about the warning symptoms and signs of puffer fish poisoning, and when to seek medical help.

Prescription monitoring of anti-hypertensive drug utilisation at the Panjab University Health Centre in India.

Abstract: Introduction The present pilot study was conducted in order to establish the drug-prescribing trend of anti-hypertensive agents at the Panjab University Health Centre in India. Methods A pilot study of six-month duration was conducted at the Panjab University Health Centre. The information was collected from the patients attending the outpatient department through a random sample method. World Health Organisation-based prescription-auditing proforma was used for data collection. Results This study revealed that most of the male patients were on monotherapy (60 percent). In the monotherapy category, four classes of drugs were used. These were calcium channel blockers (48.1 percent), beta-blockers (46.2 percent), ACE inhibitors (3.9 percent) and diuretics (1.9 percent). Among monotherapy drugs, calcium channel blockers were prescribed most whereas diuretics were least used. Among those who were treated with drug combinations, 92.1% received two drugs and 7.9 percent received three drugs. In combination therapy, a two-drug combination consisting of beta-blockers and calcium channel blockers was given to the majority of the patients. Overall, 57.8 percent patients were treated with a single anti-hypertensive drug and 42.2 percent were treated with anti-hypertensive drug combinations. Conclusion The present study represents the current prescribing trend for anti-hypertensive agents and it highlights certain shortcomings in the existing prescribing practice. There is a considerable scope for improvement, particularly the under-utilisation of diuretics in the present prescribing pattern of anti-hypertensive drugs.

A comparison of two surgical strategies for the emergency treatment of gallstone ileus.

Abstract: Introduction Debate currently exists regarding the appropriate surgical strategy for emergency treatment of gallstone ileus. This relates to the need for definitive biliary tract surgery after relief of mechanical obstruction. Our study reviews treatment by enterolithotomy alone and enterolithotomy combined with definitive biliary tract surgery and fistula closure to determine if there is advantage of one treatment option over the other. Methods The clinical, operative and follow-up data on 19 consecutive patients treated by emergency surgery for gallstone ileus from January 1992 to December 2000 was retrospectively reviewed. Results There were 15 women and four men, with a mean age of 74.6 (range 62-91) years. Pre-operative diagnosis was made in only nine of 19 patients. Enterolithotomy alone (E group) was performed in seven patients and enterolithotomy with cholecystectomy and fistula closure (E+C group) in 12 patients. In the E group, more patients had significant co-morbidity as identified by poorer American Society of Anesthesiologists (ASA) status, poorer pre-operative status (shock at presentation) than in the E+C group. Operative time was significantly shorter in the E group. However, there were no significant differences in morbidity, and both groups had zero mortality. Conclusion Both procedures can be carried out safely and with zero mortality. Relief of obstruction remains the mainstay of treatment. The better surgical option in our series is enterolithotomy alone. It is safe in both low and high-risk patients, and requires a shorter operating time as it is technically less demanding. In the longer term, the remnant fistula also does not appear to lead to further complications.

Prevalence, awareness, treatment and control of hypertension in the Malaysian adult population: results from the national health and morbidity survey 1996.

Abstract: We determined the prevalence of hypertension and the level of awareness, treatment and control of hypertension among Malaysian adults in a population based cross-sectional survey. Twenty-one thousand and three hundred ninety-one adults aged 30 or older in all 13 states of Malaysia in 1996 were sampled using a stratified two-stage cluster sampling design. Thirty-three percent of adults had hypertension with a higher percentage among women. Among hypertensives, 33% were aware of their hypertension, 23% were currently on treatment and a mere 6% had controlled hypertension. There was practically no difference in mean BP between treated and untreated hypertensives. Concerted public health effort is urgently required to improve the detection, treatment and control of hypertension in Malaysia.

Adverse drug reactions in Singaporean children

Abstract: Introduction Allergic reactions to drugs are considered rare in the paediatric population. Host genetic and environmental factors influence the reported incidence and characteristics of adverse drug reactions (ADRs), and cause significant variation according to the population described and case definition used. We aimed to define the prevalence and characteristics of reported drug allergies in hospitalised children in Singapore. Methods A retrospective case control study was performed through the hospital's inpatient electronic medical record (EMR) for the period of August 2002 to December 2002. The EMR was used to identify children with a previously reported ADR. The control group was randomly selected from patients hospitalised during the same period. Results Of the 8437 patients hospitalised during the study period, reports of previous ADRs were found in the records of 222 patients. The mean age of the patients was 7.4 years, range 2 months to 17 years (95 percent confidence interval [CI] 6.3 - 8.4). There were 146 males and 160 Chinese. The most commonly-involved medications were betalactam antibiotics (45 percent) and non steroidal anti-inflammatory drug (18.5 percent). Compared to the control group, children with a reported ADR were more likely to be older, with a mean age of 7.4 years versus 4.6 years (p-value less than 0.001), male (odds ratio [OR] 1.7, 95 percent CI 1.2-2.4), of Chinese descent (OR 1.8, 95 percent CI 1.5-5), have an associated chronic illness (OR 3.5, 95 percent CI 2.5-5), and a diagnosis of asthma (OR 2.7, 95 percent CI 1.7-4.5). Conclusion In our paediatric inpatient population, the risk of reported ADRs increases with age, male gender, Chinese descent and the presence of chronic disease. The major drugs involved are betalactam antibiotics and non-steroidal anti inflammatory drugs.

Ethnic differences among Chinese, Malay and Indian patients with type 2 diabetes mellitus in Singapore.

Abstract: Introduction Ethnic differences exist in patients with diabetes mellitus. Not much is known about such differences in Asian populations. The aim of the study was to determine ethnic differences among Chinese, Malay and Indian patients with type 2 diabetes mellitus in Singapore. Methods The study design was cross-sectional, involving 967 patients who were attending follow-up care for type 2 diabetes mellitus at a primary care clinic. Data collection was by patient interview, examination, and from case records. Blood and urine samples were collected for analysis of indicators of diabetic control and albuminuria. Results Malays had the highest mean body mass index (BMI) after controlling for age, gender, duration of diabetes and exercise status. Adjusted mean BMI for Malays was 27.4kg per square metres, Indians 25.7kg per square metres, Chinese 24.9kg per square metres, with the p value being less than 0.01. HbA1c levels were highest among Indians after controlling for age, duration of diabetes, body mass index and treatment. Adjusted mean HbA1c for Indians was 8.3 percent, Malays 8.0 percent, and Chinese 7.7 percent, with the p value being less than 0.01. Compared with Chinese, Indians were more likely to have a positive family history of diabetes (prevalence rate ratio (PRR) of 1.3, 95 percent confidence interval (CI) of 1.0 to 1.7), but were less likely to have associated hypertension (PRR of 0.7, 95 percent CI of 0.5 to 1.0) and microalbuminuria and macroalbuminuria (PRR of 0.6, 95 percent CI of 0.4 to 1.0). Conclusion Ethnic differences exist with regard to BMI, diabetic control as reflected by HbA1c levels, family history of diabetes, presence of associated hypertension, and severity of albuminuria. Indians, while having poorer control of diabetes, are less prone to hypertension and renal complications than Chinese.

A retrospective study of malaria infections in an intensive care unit of a General Hospital in Malaysia

Abstract: Aims: To study the clinical and demographic aspects as well as the outcomes of severe cases of malaria infections managed in the intensive care unit of the Sarawak General Hospital, Kuching from January 1996 to December 2001. Methods: All cases of malaria admitted to the intensive care unit of the Sarawak General Hospital from January 1996 to December 2001 were identified from the intensive care records and retrospectively reviewed. Results: A total of 31 cases of malaria were managed in the intensive care unit of the Sarawak General Hospital in the six-year period. Twenty-eight cases were P. falciparum infections; two were P. vivax and one was a mixed infection of P falciparum and P. vivax. Fever with or without chills and rigors, headache, abdominal pain and vomiting were the four commonest presenting complaints for P. falciparum infections. Patients with both abdominal pain and hepatomegaly have significantly higher mortality. The fatal cases, at presentation, had higher parasite counts, higher bilirubin, aminotransferase, potassium and urea levels, but lower haemoglobin and platelet counts, and more deranged coagulation profiles compared to surviving patients. The major complications include acute renal failure, acute respiratory distress syndrome, cerebral malaria and disseminated intravascular coagulopathy, haemolytic anaemia and liver dysfunction. A single case of vivax malaria, which was complicated by septicaemic shock and disseminated intravascular coagulopathy was also documented. Higher mortality rate was documented if the antimalarial medication was not commenced on the day of admission into hospital. Conclusion: Several infections of P. falciparum are still associated with significant mortality. Other confounding factors include the patient's own pre-morbid general health status and delay in initiating quinine therapy. Aggressive and appropriate therapy is life saving. Earlier anti-malaria treatment may improve the survival rate for falciparum malaria. The isolated case of death from P. vivax infection argues against complacency in the management of even the "benign" form of the infection.

Screening for hearing impairment in a cohort of elderly patients attending a hospital geriatric medicine service.

Abstract: Introduction This study sets out to determine the usefulness of a questionnaire to screen for hearing impairment, assess the psychosocial impact of hearing handicap and survey older persons' attitudes towards hearing aid usage. Methods Subjects were recruited from a Geriatric Medicine unit over a six-month period. A questionnaire was administered, followed by an otoscopic examination and audiometric testing. Results Sixty-three patients were included in the study. Fifty-two (83%) patients had hearing impairment, of which 34 were moderately severe and 18 were mild. Of the six questions used in hearing screening, the question on self-perception was the most specific (91%). Administering the remaining five questions on activities of daily living improved the questionnaire's sensitivity from 58% to 73%, although the specificity was reduced from 91% to 64%. Of the 30 patients with self-perceived and audiometrically-confirmed hearing impairment, about 40% reported negative psychosocial impact as a result of the handicap. 66.7% were not keen to consider using hearing aid, even if recommended. The willingness to use hearing aids was correlated to patients' functional status (p=0.002) but not to the severity of hearing impairment (p=0.157). Conclusion Self-perception of hearing problems in the elderly is a strong indicator of hearing impairment. Introducing additional culturally-relevant questions based on activities of daily living improves the detection rate of hearing impairment. Although hearing loss impacts negatively on psychosocial well-being, most elderly subjects are unwilling to consider the use of hearing aids. There is a need to educate the elderly on the importance of intervention in order to reduce their handicap and improve their quality of life.

Ruptured uterus in South Western Nigeria: a reappraisal.

Abstract: Introduction: Rupture of the gravid uterus is a grave obstetric complication that is associated with high maternal and perinatal mortality rates. In Nigeria, the incidence remains high and continue to increase because of poverty, illiteracy, unavailability of manpower, poor supply of medical equipment and consumables, and dwindling health care funding. Methods: A 10-year retrospective review of all cases of ruptured uterus seen at the Obafemi Awolowo University teaching hospital complex in lle Ife, Nigeria was conducted. Results: A total of 61 cases of ruptured uterus from 16,683 deliveries were recorded, giving a ratio of I in 273. Predisposing or aetiological factors for rupture were: prolonged labour (91.8 percent), grand multiparity (50.8 percent), injudicious use of oxytocin (41.0 percent), uterine scar (26.2 percent), obstetric manipulation (4.9 percent) and abnormal lie (14.8 percent). Fifty-six patients had surgery, of which 14 (25.0 percent) had total abdominal hysterectomy, 16 (28.6 percent) had subtotal hysterectomy, 15 (26.8 percent) had repair of the rupture and bilateral tubal ligation, and 13 (19.6 percent) had repair only. Thirteen maternal deaths occurred with a case fatality rate of 21.3 percent. Conclusion: Ruptured uterus remains a problem in Nigeria, with primary health centres and mission houses being identified as major contributors to this condition. They primarily failed in the recognition of abnormalities in the antepartum and/or intrapartum periods, with delays in referral and the injudicious use of oxytocin.

A stent is not just a stent: Stent construction and design do matter in its clinical performance.

Abstract: The undisputed superiority of stents over conventional balloon angioplasty has resulted in a plethora of stents in clinical use. Recent data, however, have indicated not all stent models are the same. Nuances in stent design and construction have impacted significantly on the immediate and long-term clinical outcome. Among the stainless steel stents, those with multicellular or tubular designs have proven to be superior to coiled or hybrid stent models, and thin-strut stents perform better than thicker-strut stents. Coating stainless steel stents with gold, carbide, phosphorylcholine or heparin do not appear to confer any additional benefit, compared with bare metal stents. In contrast, randomised trials have demonstrated that drug-eluting stents coated with various anti-proliferative drugs, with or without a carrier polymer, afford unparalleled restenosis rates compared with non-drug-eluting stents. Drug-eluting stents, however, are expensive, and their long-term durability and safety remain undefined. Notwithstanding these unresolved issues, it is likely that the majority of percutaneous coronary interventions will involve the use of drug-eluting stents once a more attractive balance between their cost and clinical effects is reached.

Endometriosis of the appendix presenting as acute appendicitis.

Abstract: While endometriosis is fairly common, endometriosis of the appendix is a very rare occurrence. Correct pre-operative diagnosis is uncommon and definitive diagnosis is established by histology of the appendix. We present a case of endometriosis of the appendix that manifested as acute appendicitis in a 40-year-old woman.

Liver injury induced by the non-steroidal anti-inflammatory drug mefenamic acid.

Abstract: Introduction Non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat musculoskeletal disorders, inflammation and to control pain. Virtually all NSAIDs are capable of producing liver injury ranging from mild reversible elevation of liver enzymes to severe hepatic necrosis. Methods Mice were dosed intraperitoneally with mefenamic acid either one day at 100mg/kg and 200mg/kg, or 14 days dosing at 50mg/kg/day and 100mg/kg/day. Plasma was taken for alanine aminotransferase activity. Mice were sacrificed at the end of the study. Livers were removed and weighed. Liver samples were taken for histology. results: One-day doses of mefenamic acid revealed dose-dependent hepatocyte degeneration in the liver parenchyma. There were no significant changes in plasma alanine aminotransferase activity. Interestingly, 14-day daily doses induced hepatocellular necrosis, massive degeneration and inflammation. This was accompanied by a significant increase in plasma alanine aminotransferase activity and significant increase in the liver weight in the 100mg/kg/day mefenamic acid-dosed mice. Conclusion Results from this study suggest that mefenamic acid is capable of producing hepatotoxicity and care should be taken when prescribing or using this drug.

Biostatistics 203. Survival analysis.

Abstract: Since survival time is a quantitative variable, why can’t we just use the usual techniques from Table I? Before we explain the main reason why we use survival analysis, let’ us consider a simple example on the survival times (in months) for 25 lung cancer patients who all died; the timings are : 1, 5, 6, 6, 9, 10, 10, 10, 12, 12, 12, 12, 12, 13, 15, 16, 20, 24, 24, 27, 32, 34, 36, 36, 44 months. Performing a simple descriptive, we have n = 25, mean (sd) = 17.52 (11.48) months and median = 12 months.

The superior gluteal artery perforator flap for the closure of sacral sores.

Abstract: The purpose of this paper is to report the use of the superior gluteal artery perforator (SGAP) flap in the closure of sacral pressure sores here in Singapore. This fasciocutaneous flap is a refinement of the musculocutaneous flap which is popularly used for the closure of sacral sores. There were minimal complications. This is a reliable flap and gives the option of further reconstructive possibilities should a recurrence occur.

Biostatistics 301. Repeated measurement analysis.

Abstract: Common techniques of analyses are(1-3): 1. Mean response over time – Interest in overall treatment effect. No information on treatment effect changes over time. 2. Separate analyses at each time point – This is most common in medical journals. Repeated testing at each time point causes inflated type I error and results in interpretation problems. Treatment standard errors are less accurate as only observations at each time point used. Must be discouraged! 3. Analyses of response features – Area under the curve, minimum/maximum values, time to max values.

Imaging of tuberculosis of the spine.

Abstract: Tuberculosis (TB) is the leading cause of death worldwide that can be attributed to a single infectious agent. With the onset of the AIDS epidemic, there has been a resurgence of TB in recent years. Skeletal TB constitutes 1% to 3% of extrapulmonary cases, and typically involves the spine. TB of the spine should be considered in the differential diagnosis of many spinal conditions affecting patients of all ages. The pathophysiology, clinical and imaging features of TB of the spine are reviewed, with illustrations of findings on radiography, computed tomography and magnetic resonance imaging. Familiarity with the imaging features of TB of the spine may enable a more rapid diagnosis to be made, thereby preventing a delay in diagnosis with its consequent complications.

Peritonsillar infections: local experience

Abstract: Introduction: The disease pattern and management of peritonsillar infections in Singapore General Hospital are studied. Other objectives are to determine if a seasonal variation exists and to examine the role of routine bacterial cultures and interval tonsillectomy. Methods: This is a retrospective review of the management and outcome of patients with peritonsillar infections who were admitted acutely to Singapore General Hospital over a three-year period. Results: Of 185 patients studied, 151 (81.6 percent) had peritonsillar abscess or quinsy and 34 (18.4 percent) had peritonsillar cellulitis. There were 139 males and 46 females, with a racial predisposition among Malays (p value is less than 0.0005). There may be a seasonal variation with a bi-annual trend, though no correlation with upper respiration tract infections was noted. Treatment consisted mainly of incision and drainage (66 percent) or needle aspiration (34 percent). No significant difference in the length of stay was noted in patients receiving penicillin alone, penicillin with metronidazole, or broad-spectrum antibiotics (p value is equal to 0.062). Fourteen (7.6 percent) patients had recurrences, all of which occurred after the first month. Two patients (1 percent) had bilateral quinsy. Conclusion: Peritonsillar infections remain a common admitting diagnosis to the Otolaryngology department. A single episode of infection should no longer be an indication for tonsillectomy as the incidence of recurrence is low.

Imaging of giant breast masses with pathological correlation.

Abstract: Ultrasonography (US) and mammography are the two basic techniques for routine imaging in the diagnosis of breast diseases. A wide variety of breast conditions such as lipoma, hamartoma, cyst, fibroadenoma, phyllodes tumour, haematoma, abscess and carcinoma can result in solitary or multiple giant masses. These conditions may appear similar on physical examination. The clinical significance of these entities is that some lesions necessitate mastectomy but some lesions may require only local excision, aspiration or even conservative management. Imaging has enhanced our ability to characterise these lesions. The purpose of this pictorial review is to illustrate the causes of giant breast masses, and the role of US and mammography in diagnosis of these lesions.

Assessment of maternal anxiety levels before and after amniocentesis.

Abstract: Introduction: To assess anxiety levels in mothers before and after undergoing amniocentesis. The secondary aim was to see how counselling by nurse-counsellors affected maternal anxiety levels. Methods: A prospective study was carried out from February 2000 to August 2000 at the Kandang Kerbau Women’s and Children’s Hospital in Singapore. We used standard statistical analysis and Spielberger’s state-trait anxiety inventory (STAI), that consisted of 40 items, to assess anxiety levels. Anxiety levels were assessed at different stages: before and after counselling; before amniocentesis and after amniocentesis; when results were disclosed; and after the routine 20-week screening ultrasound scan was acknowledged four to six weeks later. Englishspeaking women were recruited for the study as the STAI questionnaire has only been validated for an English-speaking population. 195 at-risk mothers (advanced maternal age, abnormal nuchal translucency on ultrasound scan, previous abnormal baby and high-risk maternal serum screening results) and patients requesting for amniocentesis between 15 to 20 weeks gestation were recruited. Results: 156 mothers agreed to amniocentesis. 38 mothers declined amniocentesis. S-anxiety levels declined significantly after counselling by trained nurse-counsellors in all mothers counselled. S-anxiety levels were highest and significantly higher compared to all other times just prior to amniocentesis despite counselling. Anxiety levels were the lowest and significantly lower compared to all other times at the last assessment stage. Conclusion: High level of anxiety prior to amniocentesis despite counselling is understandable due to the invasive nature of the procedure. There is no long-lasting post- procedural anxiety to the mother.

Ectopic thyroid tissue in the parotid salivary gland.

Abstract: Benign ectopic thyroid tissue within the parotid salivary gland is very rare. A 32-year-old woman presented with a slowly-growing, painless mass in the parotid region. The mass, which was clinically diagnosed as a parotid tumour, was found at surgery to be cystic in nature. Histological examination showed thyroid tissue with secondary changes in the cyst wall and colloid in the lumen. On iodine isotope scan, the thyroid gland was found in its normal location. The possible origin of the ectopic thyroid tissue in the parotid salivary gland could be due to a common evolution of the thyroid and parotid glands, a heteroplasia or a metaplasia.

Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus.

Abstract: Acupuncture is used for some conditions as an alternative to medication or surgical intervention. Several complications had been reported, and they are generally due to physical injury by the needle or transmission of diseases. We report a case of life-threatening necrotising fasciitis that developed after acupuncture treatment for osteoarthritis of the knee in a 55-year-old diabetic woman. She presented with multiple discharging sinuses over the right knee. As the patient did not respond to intravenous antibiotics, extensive debridement was performed. She made a good recovery. Since many old diabetic patients with degenerative joint diseases may consider this mode of treatment, guidelines on cleanliness and sterility of this procedure should be developed and practiced.

Mucinous adenocarcinoma of the renal pelvis associated with lithiasis and chronic gout.

Abstract: Diffusely-infiltrating mucinous adenocarcinoma of the renal pelvis associated with lithiasis and chronic gout is reported in a 61-year-old Malay man. The patient underwent left nephrectomy and vesiculo-lithotomy. This tumour is postulated to arise in response to chronic irritation of the urothelium.

The epidemiology and prevention of drowning in Singapore.

Abstract: INTRODUCTION: The aim of this study was to derive a profile of drowning victims in Singapore in the 10-year period 1992-2001 and determine if there are any patterns, trends or factors which may affect the risk profile of victims. Another objective was to recommend measures for reducing deaths from drowning through a review of some of the current literature and studies on drowning prevention. METHODS: Data for epidemiological analysis were studied and analysed. Data was primarily obtained from the annual drowning statistics reported in the annual reports of the Singapore Life Saving Society, which were in turn obtained from the Registry of Births and Deaths, and the Coroner's Court. The review of current literature and studies on drowning was concentrated on the publications of leading drowning experts and agencies and on the papers presented at two important international conferences, the International Drowning Symposium in May 1996 and the first World Congress on Drowning in June 2002. The review was done with a view to identify successful drowning prevention measures that may be adopted or enhanced in Singapore. RESULTS: The study revealed a few important findings. Firstly, Singapore had a drowning rate per 100,000 population that varied from a low of 0.88 in one year to a high of 1.72 in another in the period 1992-2001. Secondly, the male drowning mortality rate in Singapore was much higher than the female drowning mortality rate. Thirdly, persons in the age group of 20-29 years were at the highest risk. Fourthly, the sea, rivers and swimming pools were the locations with the highest number of drowning victims. The study also showed that the main measures of drowning prevention may be broadly divided into supervision, environmental design changes, legislation, swimming lessons and aquatic safety education. CONCLUSION: The situation in Singapore is generally comparable to that in high income or developed countries although there are some differences. Further studies and research need to be done to provide a better understanding of the epidemiology and prevention of drowning in Singapore. In the meantime, the main measures of drowning prevention should, as far as possible, be followed or enhanced. Language: en