Modern anaesthesia carries a definite although small risk. The risk from general and regional anaesthesia is reviewed, the causes explored, and preventive strategies discussed. Although anaesthesia may never be 100% safe, a knowledge of the risk and causes enables us to work towards this goal.
Refractory peptic ulceration refers to ulcers which are slow to heal despite active treatment for at least three months. Oxygen-derived free radicals are cytotoxic and promote tissue injury. Twelve consecutive patients with refractory peptic ulceration (eight with duodenal ulcers and four with solitary pre-pyloric gastric ulcers) were treated using the radical scavengers allopurinol or dimethyl sulphoxide. This treatment was well tolerated by all patients and produced no adverse effects. Endoscopic examination four weeks later demonstrated complete healing (an intact gastric or duodenal mucosa without any breaches) in all patients. The results suggest that oxygen-derived free radicals perpetuate the process of peptic ulceration and exert an adverse effect on healing. Scavengers of these radicals stimulate the healing of refractory gastric and duodenal ulceration.
From January 1980 to August 1992, there were 125 deaths occurring in the operating theatre at the University Hospital Kuala Lumpur. Out of these 125, six were judged to have been mainly 'due to anaesthesia.' In the same time period, there were a total of 155,000 anaesthetics given in the hospital. This gives an anaesthetic death rate (in the operating theatre) of six out of 155,000 or 0.39:10,000.
We report a retrospective review of 12 medical students with a peculiar erythemato-vesicular dermatitis entomologically caused by an endemic beetle Paederus fuscipes. The clinical features, outcome in these cases and treatment are discussed. The students were residents of hostels in the USM campus in Kubang Kerian, Kelantan. The causative agent in all these cases were found to be Paederus fuscipes (rove beetle). The most common site of involvement in all these cases was the face, followed by the neck. The average duration of symptoms was two days and pruritus was a common symptom. About 83% of the patients made a complete recovery. However two patients (16%) had residual pigmentation.
A retrospective study of 95 patients with retinal vein occlusion was carried out to determine the clinical presentation and pattern of distribution in the local Malaysian population. There was no significant difference found in its distribution with regards to sex. In comparing branch retinal vein occlusion with central retinal vein occlusion, no significant differences were found in its racial distribution. Branch retinal vein occlusion occurred more commonly among the older patients whereas the converse is true for central retinal vein occlusion. Reduced vision represents the commonest mode of presentation. Hypertension, diabetes mellitus, hyperlipidaemia and haematological disorders are important associated systemic conditions.
Between January 1990 and December 1991, 100 cases of extrapulmonary tuberculosis were identified at the General Hospital Kota Bharu representing 11% of all the newly diagnosed tuberculosis. It was commonest in the third decade of life and the sites involved were the lymph nodes (34%), osteoarticular (14%), miliary (12%) and pleura (10%). Tuberculous lymphadenitis appears to be more common in females and younger patients. Fourteen patients had concurrent active pulmonary tuberculosis and in 36 others the chest X-rays showed satisfactory response to standard chemotherapy. Six patients died and six were lost to follow-up.
Realtime ultrasonography with general purpose sector transducer was used to guide 87 percutaneous biopsies on 82 patients with lesions suspected to be mediastinal masses on plain chest radiographs. In seven patients who had dyspnea the biopsies were done in erect or semi-erect sitting positions. Definitive diagnosis was obtained from 66 lesions (80.5%) where 46 (70.0%) were mediastinal and the remaining 20 lesions (30.0%) arising from the lung. Of the 46 mediastinal lesions where specific diagnosis were made, 42 (91.0%) were anterior and four (0.9%) posterior mediastinal lesions. The majority of these anterior mediastinal masses were lymphomatous nodes followed by germ cell tumours whereas all four posterior mediastinal masses were neurogenic. Of the lung lesions, 19 were primary malignancies. The remaining lung lesion which was located posteriorly was cryptococcus infection. One patient developed massive hemothorax, but subsequently recovered. No significant complications were encountered in the remaining patients. Surgery was carried on 11 patients. There is correlation between definitive diagnosis from percutaneous biopsy and final diagnosis after surgery in 80% of patients. It is proposed that all percutaneous biopsies for thoracic masses which abut the chest wall and cause mediastinal widening on a plain chest radiograph be guided by ultrasound. It can be effectively accomplished with ease and safety even without the use of dedicated biopsy ultrasound probes or biopsy attachments, and on patients in erect or semi-erect positions.
From March 1986 to June 1992, 100 primary total knee arthroplasties were done in 69 patients. The demographic data and complications were analysed in these 69 patients. The first 50 knees with a minimal follow-up of one year (range 1-6 years) were analysed in more detail according to the International Knee Society Rating System. Detailed radiological evaluation was also carried out to assess positioning of the components. There were 79 knees with osteoarthritis, 20 knees with rheumatoid arthritis and one with Systemic Lupus Erythromatosus (SLE). The knee score was poor in all knees pre-operatively. Post-operatively 78% had good to excellent score and the other 22% had fair knee score. However the functional score remained poor in 50% of the knees. Ideal tibio-femoral alignment was obtained in 68% of the knees. Twenty four percent of the knees had 0.4 degrees of varus and eight percent had 10-12 degrees valgus. Complication rate was low with 1% of infection (one knee). Overall early results were satisfactory.
Study site; University Hospital Kuala Lumpur (University Malaya Medical Centre)
Pain of psychogenic origin can be as frequently related to the musculoskeletal system as it is to the cardiovascular and gastrointestinal systems. We report here two patients who presented with rheumatic pains. Both were subsequently found to have an underlying psychogenic disorder though they were initially diagnosed to have a distinct rheumatic disease. It is easy for doctors to create nondisease when diagnosis is based mainly on investigative results. The practical points in recognising such patients are briefly discussed.
Acquired arteriovenous fistula is an unusual complication of lumbar disc surgery. Diagnosis is often late because of the lack of awareness of this complication and also because it may simulate other vascular diseases. A case diagnosed initially as deep vein thrombosis of the leg is described.
We report a case of idiopathic portal hypertension (IPH) in association with autoimmune thyroiditis occurring in a 39 year old woman. Ultrasonography revealed a normal liver echotexture. Spleno-portogram confirmed portal hypertension and liver biopsy showed features in keeping with IPH. She was also found to be biochemically hypothyroid with markedly elevated thyroid autoantibodies. These findings may suggest an autoimmune link in the pathogenesis of IPH.
We report a 14 year old Indian-Muslim girl who developed a fulminant, disseminated and fatal varicella infection while receiving steroids for nephrotic syndrome. The terminal phase of her illness was complicated by a bleeding dyscrasia and circulatory collapse. Varicella infection in healthy children is a benign disease. However in neonates and immunosuppressed patients it may be severe and often fatal. There are many reports of fatalities occurring in cancer patients receiving chemotherapy, patients on immunosuppressives for asthma, haemolytic anaemia, rheumatic fever, and renal and bone marrow transplantation. Patients with nephrotic syndrome receiving cyclophosphamide treatment are at particular risk of developing severe chickenpox infection. To our knowledge, there has been only one report of fatal chickenpox infection in a child who received steroids for nephrotic syndrome. We report here a case of fatal haemorrhagic chickenpox complicating nephrotic syndrome.
Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma to the surgeons faced with this problem. Two such cases and their outcome are presented. The first case was caused by tracheal rupture during emergency intubation and was treated by observation until complete resolution. The second case was caused by barotrauma during positive pressure ventilation and was treated by laparotomy. Both patients died for reasons unrelated to the pneumoperitoneum. The passage of air from the chest cavity into the abdominal cavity was along the great vessels in the first case and through the diaphragm in the second. A compilation of other aetiologies of pneumoperitoneum without peritonitis as extracted from the literature is presented. In the presence of pneumoperitoneum without peritonitis and when the clinical history does not suggest visceral perforation, an abdominal tap or lavage should be attempted. If negative, continued observation is advised.
To our knowledge extraosseous osteosarcoma has not been reported in the Malaysian literature. We report a case of extraosseous osteosarcoma which was treated by intra-arterial chemotherapy, embolization, wide resection of tumour and salvage of limb with good functional result.
A case of marked penile skin loss following an adult circumcision is presented. The surgical requirement is to provide a soft and flexible cover for the penis to facilitate return of sensation and function. The two stage bilateral dartos musculocutaneous flaps offer an acceptable surgical alternative.
In this study we examined the incidence of hypercalcaemia among patients with tuberculosis in Malaysia. Serum calcium concentration and other calcium metabolism parameters were studied in 43 newly diagnosed tuberculous patients from the Kuala Lumpur General Hospital and the National Tuberculosis Centre. Forty-four patients admitted to the medical wards of the General Hospital, Kuala Lumpur were recruited as controls. The incidence of hypercalcaemia was found to be only 1/43 (2.3%). There was no significant difference between the mean serum calcium and other calcium metabolism parameters between the patients and the controls. Despite earlier reported incidences of 30-50%, this study showed that hypercalcaemia in tuberculosis is uncommon in Malaysia.
A bilingual version of the Khatena-Torrance Creative Perception Inventory was given to 70 Malaysian students. The two 50-item subscales, 'Something About Myself' and 'What Kind of Person Are You?", require the respondent to choose one of two alternatives. Test-retest reliability and criterion validity indices for this version suggest the bilingual form is suitable to assess the creative perception of these students. Replication with other groups is recommended.
The authors report 4 Oriental cases of total occlusion of the left main coronary artery (LMCA) with differing presentations. The first patient had a twelve-year history of stable angina pectoris. The second patient had angina for a year, which became unstable two months prior to diagnosis. The third patient had myocardial infarction seven years ago and presented with a one-month history of rest angina. The fourth patient had stable effort angina for six years but presented with accelerated angina three months prior to diagnosis. The incidence of total occlusion of the LMCA is rare and survival depends on the existence of collateral circulation. In LMCA disease, there is usually disease in other parts of the coronary arterial tree, and hence, the need for urgent coronary bypass surgery.