Extracorporeal life support for cardiac arrest in a paediatric emergency department

The initiation of extracorporeal membrane oxygenation (ECMO) in the emergency department (ED) is a rare event. Herein, we report a case of acute fulminant myocarditis in a nine-year-old girl who was successfully resuscitated by early initiation of ECMO support in the paediatric ED of KK Women’s and Children’s Hospital, Singapore. The patient had rapidly progressed into a witnessed pulseless ventricular tachycardia on presentation, and ECMO was started in the ED following the failure of standard resuscitation measures to establish spontaneous circulation. ECMO was continued for nine days. The patient recovered well with normal neurocognitive function. The initiation of ECMO in the ED is potentially life-saving in the resuscitation of children with witnessed in-hospital cardiac arrest due to a reversible cause.     

Recurrent abdominal pain in children: a clinical approach

The term ‘recurrent abdominal pain’, or RAP, refers mainly to the duration of painful period and frequency of pain. The commonly accepted duration is at least three months in the preceding period, and over this three-month period, there are at least three episodes of pain that are severe enough to affect the daily activities of the affected patients. Over the years, with advances in medical technology and better understanding of the pathophysiology of abdominal pain, more and more organic causes have been identified. However, the most common cause of RAP in children is still functional in origin.     

Wheeze in childhood: is the spacer good enough?

Max was treated with SABA using an MDI and spacer with facemask and responded well to the initial treatment. You explained to the parents that nebulisers are neither required nor recommended in the treatment of wheezing in their child’s situation. You advised the parents on the proper technique of MDI use with spacer and facemask, as well as care of the equipment. You also gave them a clearly written action plan regarding the efficient management of the next episode of wheeze with MDI and spacer. You further explained the side effects of oral bronchodilators and nebulisers, and why you refrained from using them. Max was given a follow-up appointment to assess his progress, and his parents were advised on the situations when they should go to a doctor or the emergency department.     

Pneumococcal glomerulonephritis in a healthy child: a case report and literature review

Pneumococcal glomerulonephritis is rarely described in the literature. We report a four-year-old boy who developed acute glomerulonephritis following pneumococcal bacteraemia and submandibular lymphadenitis, and review the published literature. Two weeks after developing acute glomerulonephritis, the patient developed broncho- pneumonia with left pleural effusion. However, by the fourth week of admission, his renal function had normalised and lung involvement resolved.     

Recurrent wheeze and cough in young children: is it asthma?

A clinical diagnosis of asthma is often considered when a child presents with recurrent cough, wheeze and breathlessness. However, there are many other causes of wheeze in a young child. These range from recurrent viral infections to chronic suppurative lung disease, gastro-oesophageal reflux disease and rare structural abnormalities. Arriving at a diagnosis includes taking into consideration the symptomatology, triggers, atopic features, family history, absence of red flags and therapeutic trial, where indicated.     

Cerebellar strokes: a clinical outcome review of 79 cases

INTRODUCTION

Cerebellar infarcts and haemorrhages are relatively uncommon, accounting for less than 10% of all strokes. The objective of the present study was to quantify and compare the outcomes of patients with cerebellar infarct and those of patients with cerebellar haemorrhage, as well as to identify the risk factors that predict poor outcome in patients with cerebellar stroke.

METHODS

We retrospectively reviewed the medical records of consecutive patients admitted to National University Hospital, Singapore, between 2004 and 2006, within one week of cerebellar stroke onset. Baseline data included demographics, concomitant comorbidities, and the presence or absence of brainstem compression and hydrocephalus (on computed tomography or magnetic resonance imaging). The Glasgow Outcome Scale and modified Rankin Score were used to assess outcome at discharge and at six months after discharge.

RESULTS

A total of 79 patients with cerebellar stroke were admitted during the study period. Of these 79 patients, 17.7% died and 31.6% had poor outcomes at six months after discharge. Patients with cerebellar haemorrhage were found to be more likely to have poor outcomes as compared to patients with cerebellar infarct, both at discharge (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.3–14.1) and at six months after discharge (OR 5.2, 95% CI 1.6–17.2). When compared to small lesions (< 5 cm³), lesions > 20 cm³ were significantly associated with poorer outcomes and the development of hydrocephalus and brainstem compression.

CONCLUSION

Cerebellar strokes are a significant cause of morbidity and mortality. The outcomes of patients with cerebellar haemorrhage are more likely to be worse than those of patients with cerebellar infarct.     

Infant lumbar and thoracic epidurals for abdominal surgeries: cases in a paediatric tertiary institution

INTRODUCTION

There is strong evidence that epidural analgesia provides good postoperative pain relief in adults, but its use in infants is less established. In this retrospective study, we present our experience with managing infant epidural analgesia for abdominal surgeries in a tertiary paediatric institution.

METHODS

The records of 54 infants who had received a thoracic or lumbar epidural as perioperative analgesia for abdominal surgeries were included. The mean age of the infants was 6.1 (standard deviation [SD] 3.8) months and their mean weight was 6.8 kg (SD 1.8). Most (63%) had an ASA (American Society of Anesthesiologists) status of 2 and all underwent elective gastrointestinal, urogenital, hepatobiliary or retroperitoneal surgeries. 20 catheters (37.0%) were inserted in the thoracic region and 33 (61.1%) in the lumbar region.

RESULTS

A total of 52 (96.3%) catheters provided adequate intraoperative analgesia and 36 (66.7%) provided effective analgesia for the postoperative period. Active management of epidural analgesia, such as through epidural top-ups and infusion rate adjustment, was necessary to optimise analgesia in 22 (44%) of the 50 patients postoperatively. Reasons for premature catheter removal were mainly technical issues such as catheter disconnection, leakage and blockage.

CONCLUSION

Our data suggests that in experienced hands, specialised settings and active management, the success rate of epidural analgesia in infants undergoing major abdominal surgeries is high and without major incident.     

Penile cancer: a local case series and literature review

INTRODUCTION

Penile cancer is an uncommon disease affecting only about one in 100,000 men worldwide in a year. The diagnosis of the condition is frequently delayed, and the disease and its treatment frequently result in significant morbidity in patients.

METHODS

We herein describe seven cases of penile tumours: six cases of squamous cell carcinomas and one case of B-cell lymphoma that presented to our hospital’s urology department between March 2011 and October 2012. We reviewed the literature to discuss the clinical presentation, natural history and current management of penile cancer.

RESULTS

The patients were followed up for 1–24 months. They were managed according to their disease stage and lymph node status. Four out of seven patients showed disease progression during the follow-up period.

CONCLUSION

The accurate staging of inguinal nodes in cases of low-risk disease is important to prescribe appropriate surgery for the inguinal nodes. Aggressive management of inguinal and pelvic lymph nodes remains the cornerstone in the treatment of high-risk disease cases.     

The influence of caregivers’ knowledge and understanding of asthma aetiology on domiciliary management of children with asthma

INTRODUCTION

Asthma is a common childhood disease, and paediatric patients with asthma rely on caregivers to administer domiciliary asthma care. This study aimed to explore the knowledge, understanding, perceptions and main concerns of caregivers and its influence on their home management of children with asthma.

METHODS

Data from 14 caregivers of children with asthma was collected during three focus group discussions held in two polyclinics in Singapore. The collected data was analysed using standard content analysis and classified into themes.

RESULTS

The caregivers’ main concerns included the perceived effects of infection, food and exercise on children with asthma. Several caregivers considered the disease to be infectious and had a lower threshold for physician consultation, as they believed that any delay in treating the infection would be detrimental to the child’s health. Some also perceived asthma to be episodic and self-limiting, and that their children could ‘outgrow’ it. Many caregivers believed that asthma could be modified by abstinence from, or intake of, certain foods. Others had the perception that sports, including swimming, would worsen asthma. These perceptions resulted in unnecessary restrictions of the children’s diet and activities. Most caregivers were unaware of influenza vaccination as a preventive measure to reduce triggers due to respiratory viral infections.

CONCLUSION

We found that the caregivers’ perceptions of asthma aetiology, its triggers and preventive measures affected their help-seeking behaviour and care of children with asthma. Healthcare professionals managing paediatric patients with asthma should recognise such caregiver misperceptions, and take a proactive approach to rectify and bridge the gaps in caregivers’ knowledge and understanding of the disease.     

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.     

Imaging of the spleen: what the clinician needs to know

The spleen is considered ‘the forgotten organ’ among radiologists and clinicians, although it is well visualised on abdominal computed tomography and magnetic resonance imaging. Moreover, the spleen is commonly involved in a wide range of pathologic disorders. These include congenital anomalies, infectious and inflammatory diseases, vascular disorders, benign and malignant tumours, and systemic disorders. In this review, we focus on the key imaging findings of the normal spleen, its variants, as well as relevant congenital and acquired abnormalities. It is of utmost importance to recognise and correctly interpret the variable spectrum of abnormalities that may involve the spleen, in order to avoid unnecessary invasive procedures and to guide adequate treatment.     

Reactivity of allergy skin test in healthy volunteers

INTRODUCTION

Healthy individuals may be exposed and sensitised to allergens, and have a positive response to a skin prick test despite being asymptomatic. The objectives of this study were to evaluate the prevalence of atopic sensitisation and identify the reactivity of healthy volunteers to common aeroallergens.

METHODS

Healthy volunteers with no known allergic symptoms were recruited in this study. All volunteers were scheduled to undergo a skin prick test with 16 common aeroallergens that were previously identified among atopic patients.

RESULTS

A total of 100 volunteers (mean age 28 years) were enrolled in this study. 42 volunteers had positive skin prick tests for at least one allergen. The median number of sensitised allergen was 2 (range 1–7). Volunteers with positive skin tests (n = 42) were younger than those with negative skin tests (n = 58) (mean age 25.5 vs. 29.2 years; p < 0.05). The group with positive skin tests also had a higher proportion of males (57.1% vs. 31.0%; p < 0.01) and first-degree relatives with a history of atopic diseases (31.0% vs. 10.3%; p < 0.05). The most common sensitised allergens in these healthy asymptomatic volunteers were mite (n = 33), house dust (n = 23) and American cockroach (n = 20).

CONCLUSION

In this study, up to 42% of healthy volunteers, particularly those with a family history of atopy, were sensitised to allergens. Reactivity of the skin test without allergic symptoms, however, does not indicate allergic disease. Therefore, the skin test should only be indicated in atopic symptomatic individuals.     

Post-thyroidectomy neck ultrasonography in patients with thyroid cancer and a review of the literature

The importance of routine neck ultrasonography for the detection of unsuspected local or nodal recurrence of thyroid cancer following thyroidectomy (with or without neck dissection) is well documented in many journal articles and international guidelines. Herein, we present a pictorial summary of the sonographic features of benign and malignant central neck compartment nodules and cervical lymph nodes via a series of high-quality ultra-sonographic images, with a review of the literature.     

Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting at the emergency department. Early diagnosis and recognition of associated complications, though challenging, are essential for timely management. Imaging studies, including ultrasonography, computed tomography and magnetic resonance imaging, are increasingly utilised for the evaluation of suspected cases of cholecystitis. These investigations help in diagnosis, identification of complications and surgical planning. Imaging features of acute cholecystitis have been described in the literature and are variable, depending on the stage of inflammation. This article discusses the spectrum of cholecystitis-associated complications and their imaging manifestations. We also suggest a checklist for the prompt and accurate identification of complications in acute cholecystitis.     

The use of facemasks to prevent respiratory infection: a literature review in the context of the Health Belief Model

INTRODUCTION

Acute respiratory infections are prevalent and pose a constant threat to society. While the use of facemasks has proven to be an effective barrier to curb the aerosol spread of such diseases, its use in the local community is uncommon, resulting in doubts being cast on its effectiveness in preventing airborne infections during epidemics. We thus aimed to conduct a literature review to determine the factors that influence the use of facemasks as a primary preventive health measure in the community.

METHODS

A search for publications relating to facemask usage was performed on Medline, PubMed, Google, World Health Organization and Singapore government agencies’ websites, using search terms such as ‘facemask’, ‘mask’, ‘influenza’, ‘respiratory infection’, ‘personal protective equipment’, ‘disease prevention’, ‘compliance’ and ‘adherence’. Findings were framed under five components of the Health Belief Model perceived susceptibility, perceived benefits, perceived severity, perceived barriers and cues to action.

RESULTS

We found that individuals are more likely to wear facemasks due to the perceived susceptibility and perceived severity of being afflicted with life-threatening diseases. Although perceived susceptibility appeared to be the most significant factor determining compliance, perceived benefits of mask-wearing was found to have significant effects on mask-wearing compliance as well. Perceived barriers include experience or perception of personal discomfort and sense of embarrassment. Media blitz and public health promotion activities supported by government agencies provide cues to increase the public’s usage of facemasks.

CONCLUSION

Complex interventions that use multipronged approaches targeting the five components of the Health Belief Model, especially perceived susceptibility, are needed to increase the use of facemasks in the community. Further studies are required to evaluate the effectiveness of implemented interventions.     

A review of perioperative anaphylaxis at a Singapore tertiary hospital

INTRODUCTION

Perioperative anaphylaxis is an anaesthetic emergency, but its incidence is not well described in the local literature. This retrospective study aims to look at a group of patients who had perioperative anaphylaxis in our institution.

METHODS

We conducted a retrospective review of electronic databases and clinical case sheets, and identified 34 patients who had possible perioperative anaphylaxis during anaesthesia in our institution between 1 January 2007 and 30 April 2012.

RESULTS

After reviewing clinical and biochemical data, we found that 16 out of 151,876 patients who underwent surgery had confirmed perioperative anaphylaxis, an incidence of 1:10,000. Neuromuscular blockers were identified as the most common causative agent for perioperative anaphylaxis. The offending agent could not be identified in seven patients.

CONCLUSION

To the best of our knowledge, this is the first study in Southeast Asia on the incidence of perioperative anaphylaxis. Having a preoperative history of allergy did not seem to predispose patients to the subsequent development of perioperative anaphylaxis.     

The ‘problematic’ asthma patient

Asthma is a reversible chronic inflammatory disorder of the airways that can be effectively controlled without causing any lifestyle limitation or burden on the quality of life of the majority of asthma patients. However, persistently uncontrolled asthma can be frustrating for both the patient and the managing physician. Patients who fail to respond to high-intensity asthma treatment fall into the category of ‘problematic’ asthma, which is further subdivided into ‘difficult’ asthma and ‘severe refractory’ asthma. Establishing the correct diagnosis of asthma and addressing comorbidities, compliance, inhaler technique and environmental triggers are essential when dealing with ‘problematic’ asthma patients. A systemic approach is also crucial in managing such patients. This is pertinent for general practitioners, as the majority of asthma patients are diagnosed and managed at the primary care level.     

A review of oral food challenges in children presenting to a single tertiary centre with perceived or true food allergies

INTRODUCTION

The prevalence of perceived food allergies exceeds that of true food allergies. Unnecessary food avoidance may increase parental and patient anxiety, reduce quality of life and increase the risk of nutritional deficiency. An oral food challenge (OFC) can provide an objective measure regarding the presence or absence of food allergies in a child. This study reviews the indications for and outcomes of OFCs performed on children.

METHODS

A retrospective review was performed on all children who underwent OFCs at the Allergy Unit of the National University Hospital, Singapore, over a three-year period.

RESULTS

A total of 197 OFCs were performed among 58 patients (34 male, 24 female). Most of the tests were for allergies to tree nuts (n = 107). Among the OFCs, 43.1% were for foods that were avoided and never eaten due to perceived food allergies, 25.9% were for foods that had previously resulted in positive skin prick tests (SPTs) and/or immunoassay results, 16.2% were for foods thought to worsen eczema and 14.7% were for foods thought to have caused a previous reaction. Of all the OFCs, 5% were positive, although adverse reactions were mostly cutaneous. Challenge-positive patients had either positive SPTs (wheal > 3 mm) or raised serum immunoglobulin E levels to specific foods that they reacted to during the challenges. No episodes of anaphylaxis were reported after the challenge. Most of the patients were able to safely introduce the avoided foods into their diets.

CONCLUSION

OFCs provide an objective assessment for suspected food allergies.     

Food allergy in Singapore: opening a new chapter

With the exception of shellfish, the overall food allergy rates in Singapore have not reached the epidemic proportions of the West. The rates of egg, milk and fish allergies remain low. However, the patterns of some food allergies in Singapore have changed over the last decade. For example, peanut allergy, once rare in Singapore, is now the most common cause of anaphylaxis in children. Studies analysing lifestyle practices, particularly with respect to prevention of food allergy, are necessary in order for practitioners to understand global differences and maintain this low prevalence.     

Imaging features of an intraosseous arteriovenous malformation in the tibia

Primary intraosseous arteriovenous malformations (AVMs) are rare and have only been occasionally reported. We herein report a histologically proven case of primary intraosseous AVM in the tibia, which mimicked a fibrous tumour on radiography. This presentation carries a risk of triggering acute large haemorrhage through unnecessary biopsy. In intraosseous AVM, the magnetic resonance (MR) imaging features typical of a soft tissue AVM are absent, making diagnosis difficult. In this report, peculiar MR features in the presence of a connecting vessel between the normal deep venous system of the lower extremity and the tumour provide a clue for the early diagnosis of primary intraosseous AVM.