PURPOSE: To investigate whether topical insulin improves healing rate of corneal epithelial erosions induced during vitreoretinal surgery in diabetics.
METHODS: We retrospectively reviewed case notes and serial post-operative photographs of 15 eyes of 14 patients who had corneal epithelial debridement performed during various vitreoretinal surgeries to improve one surgeon's view over a 10 month period in 2010.
RESULTS: Three groups were identified: DTI, comprising diabetics who received topical insulin 1 unit qds postoperatively (n=5); DCT comprising diabetics treated with conventional post-operative medications only (n=5) and NDCT comprising non diabetic patients on conventional post operative therapy (n=5). Only eyes in which the corneal epithelial defect had been serially photographed at time, t= 0, 12, 24, 36, 48, 60, 72 and 120 hours following commencement of topical medications were included. The size of the defect was calculated using local software. DTI eyes had a significantly smaller defect size at t= 24 (p=0.009), 36 (p=0.009), 48 (p=0.015) and 60 hours (p=0.005) compared to DCT eyes and had no statistical difference from NDCT eyes at all times in the Mann Whitney U analysis (p>0.05). In the diabetic operated bilaterally, the insulin treated eye re-epithelialised by 48 hours whereas fellow eye treated conventionally re-epithelialised in 72 hours.
CONCLUSIONS: Topical insulin or insulin eye drops 1 unit qds may be applied to the corneal surface to normalize the rate of healing of epithelial defects in diabetic patients undergoing epithelial debridement to improve the surgeon's view.
A canal wall down mastoidectomy (CWDM) is an effective technique for eradication of advanced chronic otitis media or cholesteatomas. A retrospective study was conducted at a Malaysian Tertiary Medical Center between June 1996 to December 2003 to evaluate the outcome of Modified Radical Mastoidectomy(MRM), a form of CWDM for patients with chronic active otitis media (OM) with cholesteatoma, chronic mastoiditis or chronic active OM with cholesteatoma and mastoiditis. All new cases of MRM which fulfilled the selection criteria were reviewed. The main outcome measures were the hearing outcome and status of dry ear postoperatively. A total of 84 patients had undergone CWDM. However only 63 patients (26 male, 37 female) were included for analysis. The age of the patients ranged between 5 months to 72 years (mean, 31years). The majority of the patients (86%) were adults and 9 (14%) were children. The ossicular chain was eroded in 91% (57 cases). There were 33 patients (53%) who showed no improvement of Air Bone Gap (ABG) closure while 16 patients (25%) had a post-operative improvement. The presence or absence of stapes suprastructure was found to be the major factor in determining the amount of ABG (Chi squared test, P = 0.025 preoperatively and P = 0.031 postoperatively). A dry ear was achieved in 78% of patients with 3% recurrence rate. In conclusion, the study showed that a proper MRM gave high percentage of dry ear and this procedure did not worsen the hearing.
With the advent of new technology, the treatment for ureteric stricture has moved from open surgery to endoscopic procedures. Our goals were to review and determine the prognostic factors for success of laser endoureterotomy for ureteric stricture. This is a cross sectional study for all cases that underwent laser endoureterotomy in a single centre from 2002 to 2009. Standard treatment in this centre utilizes holmium laser. The fiber used was 365nm, setting as 1J and frequency 8 Hz; power output 8 W. Confirmation of adequacy of incision wss by either visualization of extra-ureteric fat or extravasations of contrast on fluoroscopic imaging. Success or recurrence of the endoureterotomy was confirmed objectively with evidence of improvement from imaging. Of these 77 patients, 42 cases (61.8%) of the strictures were from upper ureter. Eight cases (11.7%) of mid-ureteric while lower ureter had 18 cases (26.5%). Length of stricture has been grouped into two groups; Short (<1cm) and long (≥1cm) and their distributions were 47.1% and 26.5% respectively. Follow-up duration ranged from six months to 88 months with an average of 19.6 months. Success rate was 76.5% (52 patients) while 16 patients (23.5%) developed recurrence. Stone disease, positive presenting symptoms and short length of the stricture were identified as variables with good predictor. This study achieved a 76.5% of success rate for this treatment modality for benign ureteric stricture in wellselected patients. Success is more likely if patient is symptomatic (earlier treatment) and previous stone disease present as a risk factor.
Study site: Hospital Selayang, Kuala Lumpur
Emergency lung resection for chest trauma is a rare event with a reported incidence of 0.08-1.3% but is associated with a high morbidity and mortality especially if a pneumonectomy is required, if due to blunt chest trauma or when concomitant injuries are present. We report three cases of young adult males with penetrating chest injuries that required emergency thoracotomy (ET) and anatomical lung resection to achieve definitive control of life threatening pulmonary haemorrhage. All patients survived to hospital discharge and remained well on follow-up. Indications for an ET and what constitutes the optimal operative management of such patients is discussed.
Helicobacter Pylori has been implicated with a possible link to immune thrombocytopenia purpura (ITP) and studies have shown contradicting results in platelet recovery after eradication of H pylori infection.
Gastro-oesophageal reflux disorders (GORD) are common in Western countries and has been reported to be increasing in the East. This study assessed the prevalence of GORD among the Nepalese residing in the Brunei Darussalam.
This study determined the outcome of combining home based and clinic based amblyopia therapy among preschool children. A total of 479 preschool children were randomly selected for vision screening. Amblyopic therapy was prescribed to children whose visual acuity (VA) could not be improved to <0.1 LogMAR after a 6 week adaptation period with glasses. Intensive near work activities were conducted daily at home for 12 weeks, monitored by parents while weekly therapy was conducted at the optometry clinic by an optometrist. Six preschool children were diagnosed with refractive amblyopia, spherical equivalent (SE) was -11.25D to +0.75D. Significant improvement was found in the VA of right eye, t(6) = 3.07, left eye t(6) = 3.07 and both eyes t(6) = 3.42) p<0.05, at the end of the 12 week therapy. Combining home based and clinic based amblyopia therapy among preschool children showed a positive improvement in VA after 12 weeks of therapy.
Study site: kindergarten, optometry clinic, Perak (site unclear)
Efavirenz is a non-nucleoside reverse transcriptase inhibitor used in combination with other drugs for the treatment of patients with HIV infection. Efavirenz has been reported to cause a positive urine cannabis test reaction which may create problems between HIV-infected patients on Efavirenz and law enforcement agencies. Doctors are at loss whether to issue documents certifying the potential false positive urine cannabis test with Efavirenz to patients. We investigated if the urine of HIV-infected patients on Efavirenz caused a positive urine cannabis test using the AxSYM Cannabinoids Assay®. Urine samples from 51 eligible patients on Efavirenz were tested for cannabis. All tested negative except for one who had used cannabis the day before. Efavirenz does not cause false positive urine cannabis test with the AxSYM Cannabinoids Assay®. Certification documents from doctors are therefore unnecessary.
MeSH terms: Cannabis*; Humans; HIV Infections*; Reverse Transcriptase Inhibitors; Antiretroviral Therapy, Highly Active
This study reviews surgery on acoustic neuromas by the second author using retrosigmoid approach from January 2000 to June 2010 in the state of Sarawak. There was a total of 32 patients in this study. The commonest presenting symptom was hearing loss (81.3%), followed by headache and tinnitus (each 37.5%), ataxia (34.4%) and facial numbness (21.9%). Twenty-seven patients (84.4%) had large tumor (≥ 3cm) while 5 patients (15.6%) had medium size tumor (1.5-2.9cm). The mean tumor size was 3.6 cm. Facial nerve outcome was good to moderate in 93.7% (House and Brackmann Grade I-IV). The most common complications were CSF leak with 3 patients(9.4%) and facial numbness with 2 patients(6.3%). All either resolved with treatment or improved. There was no mortality. Excision of acoustic neuromas using retrosigmoid approach could achieve acceptable facial nerve outcome with a low incidence of morbidity without mortality.
We report a case of two babies with absence of pericardium and patent ductus arteriosus (PDA). The absence of pericardium was found coincidentally during PDA ligation. The PDA was successfully ligated but the pericardium was not reconstructed. Postoperatively, the agenesis of the pericardium did not interfere with cardiac function.
Chylous leakage after mastectomy & axillary clearance is a rare complication. The incidence is less than 0.5%. Anatomical variations in the termination of thoracic duct can occur, rendering it susceptible to injury during axillary dissection. Most chyle leaks in the axilla are managed through conservative measures. Surgical intervention is required in high output chylous leaks. We encountered a case of chylous leak post mastectomy with axillary clearance, which was successfully treated conservatively.
Pituitary apoplexy is a well-known complication of a pituitary adenoma. However, an ischaemic event caused by pituitary apoplexy is rare. We reported a case of pituitary apoplexy with middle cerebral artery infarction in a 44-year old man who presented with a sudden onset of altered sensorium. Vasospasm is the most likely underlying cause of the infarction in this case secondary to transdiaphragmatic rupture of the sella tumour into the subarachnoid space.
A 60-year old Malay man presented with an intermittent lowgrade fever for 3 days and worsening of right ankle ulcers. He was known to have ischaemic heart disease, diabetes mellitus type 2, hypertension and end stage renal failure and was on regular haemodialysis. The organisms isolated from the peripheral and central blood specimens were identified as Ochrobactrum anthropi, a rarely encountered gramnegative bacillus with a unique antibiotic susceptibility profile. His condition improved after removal of the catheters and administration of antibiotic therapy. This case report highlights the importance of being wary of such rare, opportunistic pathogens and good communication between the microbiologists and the clinicians.
Primary lacrimal sac lymphoma is rare. The common clinical features are epiphora and medial canthal swelling which mimic nasolacrimal duct obstruction. Histological examination is therefore important to avoid delay in diagnosis and treatment. We report a case of primary lacrimal sac lymphoma in a 72-year-old female who developed a metachronous tumour at the hard palate one year after excision of the lacrimal sac tumour.
A bleeding pseudoaneurysm of the peripancreatic artery can present with massive upper gastrointestinal hemorrhage. History of pancreatitis and urgent imaging are crucial in the making of the diagnosis. Here, we report a patient with alcoholic chronic pancreatitis presented with ruptured pseudoaneurysm of gastroduodenal artery (GDA). He was treated with percutaneous angiographic embolisation.
Pancreatic pseudocyst is a well recognized complication of acute or chronic pancreatitis. Active treatment (surgical or endoscopic) has been recommended if the pseudocyst persists for more than 6 weeks after the diagnosis. Open trans-abdominal drainage was initially the mainstay treatment for it. However, over the past decade, laparoscopic techniques have been developed to provide patient with minimal access alternative. We report a case of a large symptomatic pseudocyst which developed following attack of severe gallstone pancreatitis. Laparoscopic cholecystectomy and cysto-gastrostomy were done at the same sitting. The operative technique is briefly explained.
Stomach and esophageal cancers are both deadly and difficult to diagnose early. Stomach cancer is the second most common cancer in Asia. Both these are one of the most common causes of cancer related death in the world.
MeSH terms: Cross-Sectional Studies; Esophageal Neoplasms*; Humans; Prognosis; Stomach Neoplasms; Early Detection of Cancer*
The diabetic foot with its many associated complications and presentations can provide a challenge in diagnosis and subsequent treatment. MRI, being increasingly available commonly, is now the main investigative modality. In particular, it is helpful in differentiating between neuroarthropathy and osteomyelitis and in cases where the latter is superimposed on the former. By being well versed in the interpretation of the images, the radiologist can make crucial contribution to the care and management of these patients.