PURPOSE: To analyse the visual outcomes of cases with posterior capsule rupture (PCR) compared to those without PCR following phacoemulsification. The occurrence of posterior capsule rupture during phacoemulsification surgery for cataract can have serious implications in the visual recovery. However, recognition of PCR and proper management can yield a successful visual outcome. This study analysed the visual outcomes of cases with PCR compared to those without PCR.
METHODS: This is a case-control study. All patients who underwent cataract surgery from 2011 to 2012 in Hospital Melaka were traced from the National Eye Database (NED) of Malaysia. The visual outcomes were classified as good, borderline and poor as per WHO guidelines. The data was analysed with SPSS version 12 IBM.
RESULTS: Out of 80.4% (2519) of eyes that had undergone phacoemulsification (PHACO) type of surgery, 3.06% (77 cases) had posterior capsule rupture complication. There was no significant difference in the visual outcome of borderline between cases with PCR and cases without PCR (Odds Ratio (OR) 0.989; 95% Confidence Interval (CI) 0.382- 2.560). However, cases with PCR were significantly less likely to have good vision compared to those without PCR (OR 0.335; 95% CI 0.157-0.714).
CONCLUSION: The study reveals that a significant number of patients without PCR had good vision, whereas those with PCR did not get good vision. We would like to suggest meticulous care during phacoemulsification surgery to avoid PCR in order to obtain good visual outcomes.
INTRODUCTION: The understanding of the skin's vascular anatomy has improved in the last decade. It has lead to technique modification such as the staged procedure in performing sural flaps and improvement in the flap survival rate. The aim of this study was to evaluate the acute vascular complications (flap necrosis or congestion) of 29 patients who underwent distal base sural flap for coverage of wound around the ankle.
METHODS: Twenty-four males and five females with a mean age of 37.1 years old underwent sural flap surgery to cover wounds at around the ankle. There were 12 cases of open fracture, five infected fractures, four spoke injuries, four degloving injuries and four diabetic foot ulcers. Twentythree cases were done as a single stage procedure while six as a two-stage procedure. The flaps were tunnelled under the skin in three cases.
RESULTS: Twenty one flaps healed uneventfully, seven acute vascular complications occur in a single stage group: five developed partial necrosis, one had congestion with epidermolysis, and one had complete flap necrosis. Complications were treated by dressing or skin grafting and only one required a repeat flap surgery.
CONCLUSIONS: Acute vascular complications may be minimised when sural flap is done in stages for elderly, diabetic, smokers and/or patients with large wound around the ankle. Even if the flap appears necrotic, the underlying structure may still be covered as the fasciosubcutaneous layer of the flap may still survive.
BACKGROUND: The effect of Helicobacter-pylori eradication therapy on the platelet counts in patients with immune thrombocytopenia is still debatable. The aim of this study was to assess the response rates of standard triple eradication therapy in secondary immune thrombocytopenia with Helicobacter pylori infection.
METHODS: From January 2012 to December 2013, 197 patients were diagnosed to have immune thrombocytopenia, out of which 22(11.1%) patients infected with Helicobacter- Pylorus were enrolled in this study. Helicobacter-Pylori infection was documented by Helicobacter-pylori stool antigen enzyme immunoassay method. All positive patients were put on triple eradication therapy. The responses rates to treatment were defined as per International Working Group on ITP.
RESULTS: Mean age of patients was 43.18±12.5 years. There were 10(45.5%) males and 12 (54.5%) females. Of the 22 patients, 7(31.8%) exhibited a complete response (CR) to Hpylori eradication therapy; 10(45.4%) attained a response; and 5(22.7%) had no response. Mean base line platelet counts were 53.36±24.5x109/l, while platelet counts at 4 week following eradication was 80.86±51.0x109/l (P=0.003). The predictive factor of response following eradication therapy was baseline platelet counts. Virtually all responders had baseline platelet counts >30x109/l and all non-responders had <30x109/l of platelet counts.
CONCLUSIONS: Though the prevalence of H-pylori is low, this study confirmed the efficacy of eradication in increasing the platelet counts in H-pylori positive patients with ITP. It is an important measure in short time, safe and very cost effective to achieve platelets increment. We endorse the routine detection and eradication treatment of H-pylori infective ITP patients.
INTRODUCTION: Biomedical research has traditionally been the domain of developed countries. We aim to study the effects of the increased focus on biomedical and medical research on level 1-4 publications in several industrialised and newly industrialised countries endowed with petroleum and gas resources.
METHODS: We identified all level 1-4 publications from 01/01/1994 to 31/12/2013 via PubMed using advanced options. The population and GDP (current US$) data from 1994-2013 were obtained through data provided by the World Bank and the raw data was normalised based on these two indicators.
RESULTS: From 1994-2013, Saudi Arabia and Malaysia were responsible for the highest absolute number of level 1 to 4 biomedical and medical research publications with 2551 and 1951 publications respectively. When normalised to population, Kuwait and Qatar had the highest publication rates, with 7.84 and 3.99 publications per 100,000 inhabitants respectively in a five yearly average. Kuwait produced the largest number of publications per billion (current US$) of GDP, at 2.92 publications, followed by Malaysia at 2.82 publications in a five yearly average.
CONCLUSION: The population size of a country as well as GDP can influence the number of level 1-4 publications in some countries. More importantly, effective government policy which stimulates research as well as a culture which actively promotes research as shown by Malaysia have proven to have a larger influence on the amount of level 1-4 biomedical and medical publications.
INTRODUCTION: Nasal colonisation of S. aureus in healthy children was 18% to 30%. One to three percent of them were colonised by Methicillin-resistant Staphlycoccus aureus (MRSA). Although MRSA infection has become increasingly reported, population-based S. aureus and MRSA colonisation estimates are lacking. The main objective of this study was to determine the prevalence of S. aureus carriage among children.
METHODS: Nasal samples for S. aureus culture were obtained from 250 children from three kindergartens in the Klang Valley, after consent was obtained from the children and their parents. Swabs were transported in Stuart medium, and inoculated on mannitol-salt agar within four hours of collection. Identification and disk diffusion test were done according to guidelines. Polymerase chain reaction was done on MRSA isolates for the presence of mecA and lukS/FPV genes.
RESULTS: Overall prevalence of S. aureus and MRSA carriage were 19.2% (48/250) and 1.6% (4/250) respectively. mecA gene was present in all isolates, 50% isolates carried Panton-Valentine leucocidin (PVL) gene. Sccmec type I was found in 2 isolates and the remaining isolates has Sccmec type V.
CONCLUSION: The prevalence of S. aureus and MRSA carriage were similar to other studies. However, risk of contracting severe infection might be higher due to presence of PVL gene in half of the MRSA isolates.
Zika virus (ZIKV) has re-emerged to cause explosive epidemics in the Pacific and Latin America, and appears to be associated with severe neurological complications including microcephaly in babies. ZIKV is transmitted to humans by Aedes mosquitoes, principally Ae. aegypti, and there is historical evidence of ZIKV circulation in Southeast Asia. It is therefore clear that Malaysia is at risk of similar outbreaks. Local and international guidelines are available for surveillance, diagnostics, and management of exposed and infected individuals. ZIKV is the latest arbovirus to have spread globally beyond its initial restricted niche, and is unlikely to be the last. Innovative new methods for surveillance and control of vectors are needed to target mosquito-borne diseases as a whole.
Peritoneal radionuclide scan is an established imaging modality for evaluating peritoneopleural communications. In this case report, unusual mediastinal lymph node radiotracer uptake is seen in a patient with portal hypertension on peritoneal scintigraphy. This was suspected to be due to marked lymphatic enlargement from longstanding portal hypertension since childhood, permitting passage of the large Tc-99m MAA particle. The nodes were morphologically benign on CT. Mediastinal lymph node uptake on peritoneal scintigraphy is rare but should not raise undue clinical concern, particularly in a patient with chronic portal hypertension. Anatomic correlation with SPECT-CT can provide reassurance.
Staphylococcus Aureus is a Gram-positive cocci bacteria which had been found to be the causative organism in over 88% of patients with primary iliopsoas abscess. We report the case of a 53-year-old diabetic woman with end-stage renal failure diagnosed with left iliopsoas abscess with a catheter-related infection. Computed tomogram (CT) of abdomen and pelvis revealed hypodense lesions of left psoas, iliacus and quadratus lumborum suggestive of psoas abscesses. In addition, osteomyelitis changes at left sacroiliac and hip joint were seen. At surgery, she was found to have abscess at the posterior psoas muscle where she underwent open surgery drainage and percutaneous drain was inserted. A high index of suspicion of iliopsoas abscess should be maintained among haemodialysis patients presenting with intradialytic pelvic and hip pain and treated with optimal antibiotics therapy with appropriate surgical intervention.
We present a rare case of stomach trichobezoar complicated with iatrogenic intussusception noted intra-operatively after failed attempt of endoscopic removal in a 13-year-old girl. At presentation, she had gastric outlet obstruction with anaemia. Endoscopy established the diagnosis of trichobezoar. Surgical removal was warranted after failed endoscopic removal. Her postoperative course was uneventful. Detailed history and careful examination disclosed trichotillomania and associated trichophagia. Psychiatric referral was sought with the intention to prevent future recurrence.
Damage Control Resuscitation and Surgery is the concept of controlled hypotension, haemostatic resuscitation and abbreviated surgical procedures following severe trauma; the practice of which has resulted in improved mortality and morbidity. We describe a rare case of thoraco-abdominal impalement successfully managed based on the concept of Damage Control Resuscitation.
Neuromyelitis optica (NMO) is a rare disorder in children with variable presentation. We report a 7-year-old boy who presented with bilateral retrobulbar optic neuritis and responded very well to treatment. He was also positive for aquaporin 4 (AQP4) antibodies, which is part of an emerging endophenotype within autoimmune neurological disorders in childhood.
Leiomyomas are benign soft tissue swellings of smooth muscle origin, most commonly found in the uterus. Extra uterine leiomyomas presenting as an abdominal mass is often a diagnostic challenge as such occurrence is rare. We present a rare case of primary abdominal wall leiomyoma, and highlight the importance of laparoscopic approach in the diagnosis and treatment of such tumour.
Abdominal pain with dengue fever can be a diagnostic challenge. Typically, pain is localised to the epigastric region or associated with hepatomegaly. Patients can also present with acute abdomen. We report a case of a girl with dengue fever and right iliac fossa pain. The diagnosis of acute appendicitis was made only after four days of admission. An appendicular mass and a perforated appendix was noted during appendectomy. The patient recovered subsequently. Features suggestive of acute appendicitis are persistent right iliac fossa pain, localised peritonism, persistent fever and leucocytosis. Repeated clinical assessment is important to avoid missing a concurrent diagnosis like acute appendicitis.
Chronic Myeloid Leukaemia (CML) is a disease characterised by a distinctive marker that is the Philadelphia Chromosome and an ability to transform into blast phase, which confers a poor prognosis. The median survival was reported to be between three to six months in correlation to blast phase. Extramedullary involvement with CML to sites such as pleural, meningeal and bones have been reported. We report a case of 41-year-old man who was diagnosed with CML in blast phase and presented with ascites. Ultrasound of abdomen showed coarse echotexture of liver suggestive leukaemic infiltration to the liver. The liver profile was severely deranged and associated with coagulopathy. Flow cytometry analysis of the peritoneal fluid revealed presence of myeloblasts consistent with CML in blast crisis with leukaemic ascites. Bone marrow biopsy also confirmed disease transformation. He received standard induction chemotherapy for acute myeloid leukaemia with dose modifications based on liver enzymes performance. Our case highlights an unusual presentation of CML in blast crisis with leukaemic ascites and the challenges in managing cytotoxic treatments due to the liver infiltration.
Chronic diarrhoea in tropical countries may be due to a myriad of causes from infective to non-infective. This case report illustrates the challenges faced in the investigation of a middle-age Chinese gentleman who presented with chronic diarrhoea and weight loss. The diagnosis of type II enteropathy-associated T-cell lymphoma (EATL) was finally made. The diagnosis of EATL was least suspected as the condition is almost unheard of in this part of the world. The epidemiology, presentation, diagnosis, management and prognosis of this rare condition are discussed.
Dialysis disequilibrium syndrome (DDS) is a neurological disorder with varying severity that is postulated to be associated with cerebral oedema. We described a case of DDS resulting in irreversible brain injury and death following acute haemodialysis. A 13-year-old male with no past medical history and weighing 30kg, presented to hospital with severe urosepsis complicated by acute kidney injury (Creatinine 1422mmol/L; Urea 74.2mmol/L, Potassium 6.3mmol/L, Sodium 137mmol/L) and severe metabolic acidosis (pH 6.99, HC03 1.7mmol/L). Chest radiograph was normal. Elective intubation was done for respiratory distress. Acute haemodialysis performed due to refractory metabolic acidosis. Following haemodialysis, he became hypotensive which required inotropes. His Riker's score was low with absence of brainstem reflexes after withholding sedation. CT Brain showed generalised cerebral oedema consistent with global hypoxic changes involving the brainstem. The symptoms of DDS are caused by water movement into the brain causing cerebral oedema. Two theories have been proposed: reverse osmotic shift induced by urea removal and a fall in cerebral intracellular pH. Prevention is the key to the management of DDS. It is important to identify high risk patients and haemodialysis with reduced dialysis efficacy and gradual urea reduction is recommended. Patients who are vulnerable to DDS should be monitored closely. Low efficiency haemodialysis is recommended. Acute peritoneal dialysis might be an alternative option, but further studies are needed.
A 36-year-old lady presented with four episodes of right sided pneumothorax during pregnancy requiring multiple chest drain insertion. It was complicated with persistent air leak despite low pressure high volume suction applied to the chest drainage. She delivered safely through spontaneous vaginal delivery with chest drainage. Further imaging by high resolution computed tomography (HRCT) scan of thorax done revealed bilateral scattered pulmonary cysts and sub pleural bullae and was later followed up with respiratory unit. She had no further episodes of pneumothorax postpartum. This case highlights the vital importance of prompt recognition and management of pneumothorax in pregnancy as the patient involved is at higher risk for acute respiratory failure leading to maternal and/or foetal mortality. It is essential for early involvement of obstetric team and to expedite the delivery for a better perinatal and maternal outcome.
Symptomatic bronchial artery aneurysm warrants urgent intervention. It has a known association with pulmonary infection caused by Staphylococcus aureus. We hereby report an elderly lady with a ruptured left superior bronchial artery mycotic aneurysm. She was in the early stages of treatment for a left lung abscess. She had multiple episodes of haemoptysis following which she underwent a left lower lobectomy. Presentation of lung abscess with a concurrent ruptured mycotic aneurysm warrants early surgical intervention and can be curative as seen in this case.
The present study aimed to investigate the behavior and neuronal morphological changes in the perihaemorrhagic tissue of the mouse intracerebellar haemorrhage experimental model. Adult male Swiss albino mice were stereotactically infused with collagenase type VII (0.4U/μl of saline) unilaterally in to the cerebellum, following anaesthesia. Motor deficits were assessed using open field and composite score for evaluating the mouse model of cerebellar ataxia at 1, 3, 7, 14 and 21 days after collagenase infusion. The animals were sacrificed at the same time interval for evaluation of perihaematomal neuronal degeneration using haematoxylin and eosin staining and Annexin V-FITC/Propidium iodide assay. At the end of the study, it was found that infusion of 0.4U collagenase produces significant locomotor and ataxic deficit in the mice especially within the first week post surgery, and that this gradually improved within three weeks. Neuronal degeneration evident by cytoplasmic shrinkage and nuclear pyknosis was observed at the perihaematomal area after one day; especially at 3 and 7 days post haemorrhage. By 21 days, both the haematoma and degenerating neurons in the perihaematomal area were phagocytosed and the remaining neuronal cells around the scar tissue appeared normal. Moreover, Annexin-V/propidium iodide-positive cells were observed at the perihaematomal area at 3 and 7 days implying that the neurons likely die via apoptosis. It was concluded that a population of potentially salvageable neurons exist in the perihaematomal area after cerebellar haemorrhage throughout a wide time window that could be amenable to treatment.
The treatment of Acanthamoeba infections remains problematic, suggesting that new targets and/or chemotherapeutic agents are needed. Bioassay-guided screening of drugs that are clinically-approved for non-communicable diseases against opportunistic eukaryotic pathogens is a viable strategy. With known targets and mode of action, such drugs can advance to clinical trials at a faster pace. Recently Bortezomib (proteasome inhibitor) has been approved by FDA in the treatment of multiple myeloma. As proteasomal pathways are well known regulators of a variety of eukaryotic cellular functions, the overall aim of the present study was to study the effects of peptidic and non-peptidic proteasome inhibitors on the biology and pathogenesis of Acanthamoeba castellanii of the T4 genotype, in vitro. Zymographic assays revealed that inhibition of proteasome had detrimental effects on the extracellular proteolytic activities of A. castellanii. Proteasome inhibition affected A. castellanii growth (using amoebistatic assays), but not viability of A. castellanii. Importantly, proteasome inhibitors affected encystation as determined by trophozoite transformation into the cyst form, as well as excystation, as determined by cyst transformation into the trophozoite form. The ability of proteasome inhibitor to block Acanthamoeba differentiation is significant, as it presents a major challenge in the successful treatment of Acanthamoeba infection. As these drugs are used clinically against non-communicable diseases, the findings reported here have the potential to be tested in a clinical setting against amoebic infections.