Pneumomediastinum and pneumopericardium following blunt chest trauma are rare. Diagnosis is by chest radiograph and CT Scan. They have to be identified and treated accordingly. Usually, pneumomediastinum and pneumopericardium are self-limiting requiring no specific therapy. However, vigilance and a continuous monitoring of the vital signs are necessary.
Melioidosis is caused by the gram-negative bacillus, Burkholderia pseudomallei. It is endemic in tropical Australia and in Southeast Asian countries. The overall mortality from this infection remains extremely high despite recent advancement in its treatment. This review discuss about clinical manifestations, diagnosis and management of melioidosis.
A retrospective review was performed on 11 patients who had undergone the transcolumellar transsphenoidal hypophysectomy in our center. There were eight females and three males with age ranging from 17 to 72 years (mean 50 years). Ten patients had pituitary macroadenomas and one had suprasellar cyst. The mean follow-up duration for these 11 patients post-surgery was 7.2 months. Complications included two cerebrospinal leaks, one post-operative sphenopalatine bleed, one septal perforation and one patient developed numbness of the tip of the nose. We found that this approach is a preferred alternative technique especially in smaller Oriental noses with lower complication rate and better aesthetic result.
Surgery for pituitary tumours at our institution was performed by rhinosurgical route by combined procedure by otolaryngologist and neurosurgeons. A retrospective review of case records of patients who had endonasal endoscopic transsphenoidal approach for pituitary tumours from September 1998 to December 2004 was performed. A total of 81 transphenoidal surgeries were performed during this study period. Only 68 case records with adequate information were available for review, 56 patients were included in the study and 12 were excluded. There were 24 males (42%) and 32 females (58%). The ethnic distribution were 29 Malays, 24 Chinese, 2 Indians and 1 other. The age ranged from 16 years to 76 years, with a mean of 46 years. The majority of our patients presented with visual symptoms (38), headache (28), menstrual cycle disturbance or impotence (14) and acromegalic features (16). Fourty patients had macroadenoma (71%) and 16 had microadenomas (29%). Thirtysix patients out of 40 macro-adenoma had suprasellar extensions (90%). Only 11 patients had lumbar drain inserted prior to commencement of the surgery and the majority of these were macroadenomas. The common complications encountered were diabetes insipidus (4), cerebrospinal fluid leak (2), meningitis (3), epistaxis (2), septal perforation (2), intercavernous sinus haemorrhage (3) and anterior pituitary insufficiency (2). Our study reveals that endonasal transsphenoidal approach is a safe and effective method of management of pituitary adenomas.
We assessed the effectiveness of an educational intervention in reducing antibiotic prescribing in public primary care clinics in Malaysia. Twentynine medical officers in nine clinics received an educational intervention consisting of academic detailing from the resident Family Medicine Specialist, as well as an information leaflet. The antibiotic prescribing rates were assessed for six months - three months before and three months after the intervention. A total of 28, 562 prescriptions were analyzed. Among participating doctors, general antibiotic prescribing rates for pre- and post-intervention phases were 14.3% and 11.0% (post-intervention vs preintervention RR 0.77, 95% CI 0.72 to 0.83). The URTI-specific antibiotic prescribing rates for pre- and post-intervention phases were 27.7% and 16.6%, respectively (post-intervention vs pre-intervention RR 0.60, 95% CI 0.54 to 0.66). No significant change in antibiotic prescribing rates was observed among primary care practitioners who did not participate in the study. This low cost educational intervention using both active and passive strategies focusing on URTI produced a statistically significant (and clinically important) reduction in antibiotic prescribing.
A retrospective data of 29 patients who underwent various types of maxillectomy from January 1998 till January 2004 in UKM hospital were reviewed. There were 21 males (72%) and 8 females (28%) with mean age of 42 years. Malays were the majority of patients 17 (59%), Chinese 11 (38%) and Indian 1 (3%). Seventeen patients (59%) presented with malignant tumours while 12 patients (41%) with benign tumours. Inverted papilloma (50%) was the commonest benign tumour and squamous cell carcinoma (36%) was the commonest malignancy. Medical maxillectomy was performed in 10 patients (35%), total maxillectomy in 7 patients (24%), 3 patients (10%) had near total, 3 patients (10%) had partial maxillectomy and 6 patients (21%) underwent inferior maxillectomy.
Cholesterol granuloma in the paranasal sinuses is rare. It is more common in the mastoid antrum and temporal bone air cells in chronic middle ear disease. A case of bilateral maxillary sinus cholesterol granuloma that mimics chronic maxillary sinusitis is reported. This is the first reported case of cholesterol granuloma of the maxillary sinus in the Malaysian Literature.
Thalassaemia is an inherited blood disorder and is a significant public health problem in Malaysia, with many not knowing they are carrying the genes for thalassaemia. The two major forms are alpha and beta thalassaemia. An individual can co-inherent both the alpha and beta thalassaemia genes. This study determined the frequency of concurrent carriers of alpha thalassaemia in 231 beta thalassaemia carriers. Gap-PCR was done on extracted DNA of the beta thalassaemia samples to check for alpha thalassaemia 1 molecular defect. 8 (3.5%) samples were found to have concurrently inherited the alpha thalassaemia 1(--SEA}) deletion. The significant carrier rate for alpha thalassaemia 1 indicates the need for the implementation of DNA analysis to complement thalassaemia screening in high-risk populations.
This article describes the communication skills programme of the International Medical University, which adopts an integrated medical curriculum. The programme, implemented in February 2005, is based on a systematic framework aimed at teaching students basic interpersonal communication skills progressively and continuously throughout the preclinical phase.
MeSH terms: Communication; Curriculum; Students; Universities; Social Skills
Indication for paediatric tracheostomy has changed. Upper airway obstruction secondary to infectious disorders is no longer for commonest indication. The aim of this study was to establish data on indications, outcome and complications of paediatric tracheostomy. A retrospective analysis of paediatric tracheostomy carried out between March 2002 to March 2004 was done. 18 patients were identified. The commonest indication was prolonged ventilation (94.5%) followed by pulmonary toilet (5.5%). None was performed for upper airway obstruction. Post-operative complications were encountered in 6 patients (33.3%), the commonest being accidental decannulation notably in children less than six years of age. 12 patients (66.6%) were successfully decannulated. The mortality rate was 16.6%. All death were non-tracheostomy related. The commonest indication for tracheostomy was prolonged ventilation and tracheostomy in children is relatively safe despite complications.
Malaysia's mammography QA practice was surveyed based on the Malaysian Ministry of Health and the American College of Radiology (ACR) requirements. Data on mammography unit, processor, image receptor, exposure factors, mean glandular dose (MGD), sensitometry, image quality and viewbox luminance were obtained. Mean developer temperature and cycle time were 34.1 ± 1.8°C and 107.7 ± 33.2 seconds. Mean base + fog level, speed index and contrast index were 0.20 ± 0.01, 1.20 ± 0.01 and 1.33 ± 0.26 respectively. 86% of the fifty centres passed the image quality test while 12.5% complied with ACR recommended viewbox luminance. Average MGD was 1.0 ± 0.4 mGy. Malaysia is on the right track for QA but with room for total quality improvement.
MeSH terms: Malaysia; Mammography; Surveys and Questionnaires; Temperature; United States; Quality Improvement
The national clinical practice guideline had recommended that prophylactic antibiotic be given in orthopaedic surgery involving joint replacements and internal fixation of fractures. The aim of this study is to assess the current antibiotics prophylaxis practice in a state level hospital. 183 patients (68 males, 35 females; mean age 41.6 ± 22.2 years) undergoing internal fixation for closed fractures and joint replacement surgery were included in this prospective study. The choice of pre- and post-operative antibiotics, their dosages and duration of administration were recorded. The pre-operative antibiotics were only deemed to have been given if it was documented in the case notes and in the case of post-operative antibiotics if it was signed on the drug chart. 88% were given pre-operative prophylactic antibiotics and 92% were given post-operative antibiotics. For patients undergoing internal fixation of fractures, the most commonly used antibiotic is intravenous cefoperazone. The duration or number of doses of postoperative antibiotics was highly variable. It was not stated in 56% of the post-operative instructions. Post-operative antibiotic was ordered for 48 hours or longer in 10%. In conclusion, prophylactic antibiotics appear to be widely practiced. The first line antibiotics as recommended by the present guideline were not given in any of the patients. Second generation followed by third generation cephalosporins are the most popular antibiotics, with a trend towards using third generation cephalosporins in arthroplasty patients. Single dose prophylaxis was rarely practiced.
Pre-eclampsia or pregnancy induced hypertension (PIH) affects 6-8% of all pregnancies. Although the underlying mechanism of PIH is still unknown, it is widely believed that the placenta plays an important role. It was thought than an ischemic placenta due to poor perfusion can precipitate the signs and symptoms of PIH. This study aims to investigate the possible role of Type 1 (AT1) and Type 2 (AT2) angiotensin II receptor subtypes in the mechanism of PIH. AT1 receptor stimulation causes vasoconstriction and AT2 receptor stimulation causes vasodilation. Investigating the interactions of these two receptors in the placenta provides an insight as to the balance that may exist between AT1 and AT2 receptors in normal pregnancy. Any disruption to the balance might cause a disruption of the blood flow in the placenta, leading to PIH. Placentas were collected from 11 PIH patients and 11 normal patients. Immunohistochemistry techniques were performed on the placental tissue to determine the distribution of AT1 and AT2 receptors in the placental tissue qualitatively and quantitatively. It was observed that in normal patients, the balance between AT1 and AT2 receptors is that the level of AT2 receptors is higher than the level of AT1 receptors. However, in the PIH patient, it was observed that the normal balance was disrupted. In PIH patients, the level of AT1 receptors were observed to be higher than the level of AT2 receptors. This study suggests that disruption of the balance between AT1 and AT2 receptors observed in PIH placentas might cause a decrease in blood flow to the placenta, causing it to be poorly perfused. This may cause placental ischaemia which may lead to PIH.
The purpose of this study is to assess whether the newly developed laryngeal tube (LT) VBM™ is easy, simple to use and able to provide adequate ventilation and oxygenation to a patient with an unstable neck who required airway management. We compared the LT to the laryngeal mask airway (LMA) as alternative airway management tool in adult patient with unstable neck who underwent intubation with manual in-line neck stabilization. A randomized single-blinded prospective study was conducted involving a total of 40 ASA I and II pre-medicated patients who were divided into two groups with 20 patients for each group; either LT or LMA group for airway management during elective surgery. After pre-oxygenation, anaesthesia was induced and neuromuscular blockade was produced with intravenous drugs. The LT or LMA was inserted after neuromuscular blockade was confirmed using a peripheral nerve stimulator (TOF 1). A size 3, 4 or 5 LT OR a size 3 or 4 LMA was inserted while the patient's head and neck were being stabilized by an assistant who held the sides of the neck and the mastoid processes (manual in-line stabilization). If it was not possible to ventilate the lungs, or if endotrachial carbon dioxide (ETCO2 and/or chest movement did not indicate a patent airway, the LT or LMA was removed. After three failed attempts, the study was terminated and the airway was secured in the most suitable manner determined by the Anaesthetist. There was a statistically significant difference for both groups in the time required for successful insertion (time required for LT was 24.8 ± 7.7 seconds and LMA was 36.1 ± 17.3 seconds) (p = 0.01). There was no statistical differences (p > 0.05) in number of attempts needed to achieve a patent airway although we were able to achieve a clear airway in all patients in LT group at the first attempt compared with 85% in LMA group. The successful insertion rate was 100% for both groups. We conclude that the LT is easier to insert and is a suitable alternative to the LMA for airway management when the patient's head and neck are stabilized by manual in-line method.
We analyzed 36 patients who presented with neck abscess in our hospital from January 1999 to December 2003. The most commonly involved space was the parapharyngeal and superficial anterior triangle followed by submandibular, retropharyngeal, posterior triangle and submental spaces respectively. 33% of patients had diabetes mellitus as a predisposing factor. More than half of them had no known aetiological cause for the neck abscess. We encountered one mortality in an elderly patient with diabetes who succumbed to overwhelming septicaemia despite early abscess drainage and intensive medical treatment.
Surgery induces a 'stress' state leading to post-operative hyperglycaemia. To investigate this effect on patients with Type 2 Diabetes Mellitus, we reviewed the records of 50 diabetic patients who underwent surgery without intra- operative insulin. Demographic features together with pre-operative and post-operative blood glucose readings were noted, 27.3% of patients with well controlled pre-operative blood glucose levels developed post-operative hyperglycaemia. In contrast, 84.6% of patients with poorly controlled levels developed the same. Poor control of blood glucose and duration of operation were the only significant predictors of post-operative hyperglycaemia.
MeSH terms: Blood Glucose; Demography; Diabetes Mellitus, Type 2; Humans; Hyperglycemia; Insulin; Postoperative Period
A 60-year-old man who presented with nasopharyngitis developed uncontrollable epistaxis following a punch biopsy of the nasopharynx, QuickClot® was successfully used to arrest the haemorrhage under general anaesthesia after the usual methods employed to secure haemostasis failed. The haemostatic plug was successfully removed a week later after control of the infection. This case represents the first reported intranasal use of QuickClot. We describe our experience and a literature review on this haemostatic agent.
Reported cases of acquired posterior choanal atresia are very few in the English literature. A case of acquired posterior choanal atresia post radiotherapy is reported which was treated by endonasal endoscopic repair using microdebrider with untoward effect.
Haemophagocytic syndrome (HPS) should be included in the differential diagnosis of pyrexia of unknown origin (PUO). The hallmark of HPS is the accumulation of activated macrophages that engulf haematopoietic cells in the reticuloendothelial system. We describe a patient with unexplained fever in which a final diagnosis of HPS was established in a bone marrow study.
MeSH terms: Bone Marrow; Diagnosis, Differential; Fever of Unknown Origin; Humans; Macrophages; Mononuclear Phagocyte System; Lymphohistiocytosis, Hemophagocytic
Ovarian cancer accounts for approximately 4% of all cancers occurring in women and ranks the fourth most frequent cause of cancer-related death in women. Despite aggressive treatment modalities, the 5-year survival rate remains less than 30%. Almost 2.5% of all live births/year result from Assisted Reproductive Techniques (ART). Concern has been expressed that exposure to fertility drugs (FD) might be associated with a risk of ovarian tumours. Given the grave prognosis of ovarian cancer and the increasing use of ART for the past several years, this has been a subject of much scientific debate. The likely magnitude of risk may be 2-3 times that of the general population, which is at most 4-5% in a woman's lifetime. Several case control and cohort epidemiological studies have attempted to address this issue but failed to specifically look at drug treatment as risk factor and research to date demonstrates conflicting results.