During induction of general anaesthesia, the act of laryngoscopy and tracheal intubation stimulates the sympathetic
nervous system resulting in an increase in blood pressure and heart rate which may be harmful especially in elderly
patients with pre-existing ischaemic heart disease. Several drugs have therefore been used to obtund this increase
including esmolol, nicardipine, magnesium sulphate and lignocaine. This prospective, double blind randomised
clinical trial compared the efficacy of magnesium sulphate and esmolol in attenuating haemodynamic responses to
laryngoscopy and tracheal intubation. One hundred and twenty six ASA I-II patients scheduled for elective surgery
requiring general anaesthesia with tracheal intubation were enrolled and randomised into two groups: Group 1 (n =
67) received MgSO4 40 mg/kg diluted in 100 ml normal saline administered over ten minutes, whereas Group 2 (n =
59) received a bolus of esmolol 1.0 mg/kg diluted to 10 ml. Systolic and diastolic blood pressures and heart rate were
recorded every minute for subsequent 10 minutes following laryngoscopy and tracheal intubation. Attenuation of the
mean systolic and diastolic blood pressures following laryngoscopy and tracheal intubation was significantly larger
in Group 2 compared to Group 1. Patients in Group 2 had significantly better suppression of heart rate response
compared to Group 1 during the first four minutes after laryngoscopy and tracheal intubation (p
A 55-year-old healthy lady with history of regular contact lens (CL) use presented with 10 days history of
progressive left eye blurring of vision, redness and pain. There was good CL hygiene practiced with no history of
swimming, trauma or contact with domestic pets. Left eye vision was hand movement and right eye was 1/60,
pinhole 6/18. On the left eye, there was a central, oval-shaped corneal infiltrate with an overlying large epithelial
defect and stromal oedema, with significant anterior chamber cells and fibrin. B-mode ultrasound showed no vitritis.
Intensive topical benzylpenicillin 10000iu/ml and topical gentamycin 1.4% hourly, homatropine 2% three times
daily, oral doxycycline and oral ascorbic acid were started. The gram stain results showed gram positive cocci
growth. Her ulcer improved with the treatment and preservative-free dexamethasone 0.1% once daily was
commenced to reduce inflammation and scarring. Interestingly, culture was reported as Pasteurella maltocida, a
gram negative bacilli sensitive to penicillin, and so treatment was continued until the ulcer completely healed. She
had central corneal scarring with best corrected vision of 6/24 in the left eye but was not keen on further surgery to
improve her vision. Although it has not been previously reported, Pasteurella multocida can cause CL related
corneal ulcer with severe anterior chamber inflammation. This diagnosis should be considered even if there is trivial
contact or no history of exposure to domestic animals.
Orbital cellulitis is a relatively common disease affecting predominantly the paediatric population. Most cases occur as a result of spread from the nearby sinuses. Other causes include penetrating trauma or extension from infected adjacent structures.If left untreated, this condition may result in devastating sequelae such as orbital apex syndrome, cavernous sinus thrombosis, meningitis, cranial nerve palsies, intracranial abscess formation and even death. A 47 year old immunocompetent Burmese lady presented with left eyelid swelling of 2 days duration associated with eye redness, blurring of vision and diplopia. Previously, there was history of right maxillary sinusitis and parapharyngeal abscess 9 months prior to presentation. On examination, she was afebrile with vision of 1/60 for the left eye with positiverelative afferent pupillary defect (RAPD). The eye was proptosed and swollen with restricted extraocular movements in all gazes. Conjunctiva was injected with chemosis and there was corneal epithelial bedewing. Otherwise anterior chamber was quiet and intraocular pressure was 51mmHg. Bilateral fundus examination was normal. Computed tomography (CT) scan of the orbit and paranasal sinus showed dense sinusitis and periosteal abscess at the lateral orbital wall.She was started on intravenous (IV) Cefuroxime and Metronidazole and underwent Functional Endoscopic Sinus Surgery (FESS) and orbital decompression. Intra-operatively there was pus and debris at the left anterior ethmoid, maxillary and sphenoid air sinuses and cultures revealed Klebsiella pneumoniae which was sensitive to Cefuroxime. Despite medical and surgical treatment, left orbital swelling only reduced minimally. However after starting intravenous Dexamethasone the swelling dramatically improved. She completed 10 days of intravenous Dexamethasone. Upon discharge, she was given oral Dexamethasone 2mg daily for 2 weeks and completed 2 weeks of oral Cefuroxime and Metronidazole. Intraocular pressure normalised and vision recovered to 6/9. A repeat CT orbit 3 weeks later showed resolving preseptal and periorbital collection.
Mycobacterium tuberculosis (MTB) is a rare cause of prosthetic joint infection. The diagnosis is challenging
especially in cases of latent tuberculosis. QuantiFERON-TB Gold (QFT®) is an interferon-gamma relative assay
(IGRA) which is highly specific and sensitive for detection of MTB infection. We report a case of 76-year-old lady
diagnosed with tuberculous prosthetic joint infection following total knee replacement. Histological examination of
abnormal synovial tissue taken intraoperatively reveals chronic granulomatous lesion and raised suspicion of
tuberculous infection in otherwise asymptomatic patient. The tuberculin skin test, MTB acid-fast stain and
tuberculosis polymerase chain reaction were negative. The diagnosis dilemma was solved with positive result of
QuantiFERON TB Gold Test. The patient was treated with anti-tuberculous drug without any surgical intervention.
At five months follow-up, patient was clinically well with no symptoms and signs of infection.
Strabismus is one of the most common ocular problems affecting the preschool population and the aim of strabismus surgery is to correct abnormal alignment of the eyes. A 5-year-old girl with strabismus underwent an uneventful surgery and was discharged on the same day with topical medications. Two days later, she returned with a painful right lower eyelid swelling, eye discharge and fever which started 1 day post-surgery. She was admitted for intravenous (IV) antibiotic. Symptoms initially improved after 24 hours of treatment, but later she had worsening eyelid swelling. An urgent CT scan of the orbit showed a right lower lid abscess with orbital cellulitis. Subsequently an examination under anaesthesia (EUA) and incision and drainage (I&D) of the lower lid abscess were performed. Culture from the pus grew Community Acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA), sensitive to Vancomycin. At day 2 post I&D she subsequently developed another episode of localised right lower lid swelling. Another EUA was done but showed the lower lid and wound was free of pus. She was later found to have a toxic reaction to topical Gentamicin and hence this medication was stopped. She responded well to treatment and was discharged after completing her IV antibiotics. At 14 months outpatient follow up, she was well and orthophoric in primary gaze. While treating a disease, we should be opened to all possibilities and not to treat with multiple antibiotics once susceptibility is known
Endometrial stromal sarcoma (ESS) is a rare malignant tumour of the endometrium, accounts for less than 1% of all
uterine malignancies. Routinely, it is diagnosed morphologically, supported by immunomarkers of CD10 and
vimentin. CD56 is used widely in neuroendocrine tumour. In our current practice, CD56 is not used to support the
diagnosis of ESS. We present a case of a postmenopausal lady with advanced ESS who had expression of CD56
upon immunohistochemical study
We report on a rare case of a child with persistent right upper lid eversion with conjunctival prolapse since birth that
failed various attempts in repositioning the right superior fornix at other centre. He was found to have a right superotemporal
orbital mass above the prolapsed area. Computerized tomography (CT) scan of orbit confirmed a right
lacrimal gland tumour with thinning of the right lesser wing of sphenoid. An excision biopsy of the tumour via
anterior orbitotomy and eyelid reconstruction were performed. Histopathology report reviewed plexiform
neurofibroma of the lacrimal gland. Further physical examination confirmed presence of multiple café-au-lait spots.
He was diagnosed as Neurofibromatosis Type 1.
Hypervirulent Klebsiella pneumoniae strain is a major cause of liver abscess and this bacteria has metastatic properties. This distinct liver abscess syndrome has been increasingly reported in Asia over the past two decades, but is emerging as a global disease. We described an 81-year-old lady, who presented to the emergency department with 1-week prior duration of fever and right eye swelling. She had been admitted for recurrent liver abscess prior to this. Hence, she was initially treated as sepsis secondary to recurrent liver abscess. Meanwhile, she was managed concurrently by ophthalmology team for endophtalmitis. Despite the initiation of treatment with antibiotics, she did not show any improvement and required right eye evisceration to treat the sepsis. Invasive liver abscess syndrome with metastatic endophthalmitis should be screened in patient with Klebsiella liver abscess. They should be monitored for ocular symptoms as early recognition can prohibit delays in treatment, which has debilitating consequences.
Thyroidectomy for benign and malignant diseases has progressed dramatically over the last two decades. Moving from large collar incision to no scar is a very good news to the patient with neck swellings. The morbidity of the surgery remains low regardless of the technique and approaches used but scarless surgery is still limited to benign diseases and small cancers. Further study and future refinement of the technique might make these techniques also applicable to large tumours.
Perioperative intravenous (IV) dexamethasone is administered prophylactically for post operative nausea and vomiting. However, its glucocorticoid property which raises blood glucose is of concern, especially among diabetic patients. The surgical stress response also contributes to increased perioperative blood glucose. Prior studies showed higher glucose levels with dexamethasone 8 mg compared to 4 mg, hence we studied the effect of the lower dose amongst diabetic patients. This prospective, single blinded, randomised study recruited forty-six type 2 diabetes mellitus patients planned for surgery under general anaesthesia. They received IV dexamethasone 4 mg or saline (placebo) after induction of anaesthesia. Capillary blood glucose levels were recorded preoperatively, and subsequently at recovery (T0), and at 6, 12, 18 and 24 (T6, T12, T18, T24) hours post-operatively. Median glucose levels were higher at 9.0 [10.5-7.7] mmol/l in the dexamethasone group, versus 7.4 [9.2-5.9] mmol/l in the placebo group at T0, p = 0.022. Similarly at T6, the dexamethasone group recorded higher glucose levels of 11.2 [15.0-9.3] mmol/l, versus 7.7 [9.0-6.2] mmol/l in the placebo group, p = 0.001. This corresponded to a significant difference between the groups, in the change of glucose levels from baseline values, p = 0.042. Subsequent readings at T12, T18, and T24 were comparable between the groups. In conclusion, IV dexamethasone 4 mg in type 2 diabetic patients, resulted in higher glucose levels immediately postoperative and 6 hours later. The change in blood glucose from baseline levels was significant between the groups at 6 hours postoperatively. Glucose levels however remained within acceptable range of approved guidelines in both groups at all recorded intervals.
We compared the analgesic profile between patient-controlled analgesia (PCA) using oxycodone and morphine in post total abdominal hysterectomy patients. Eighty-four ASA I or II patients, aged 18 to 65 years who underwent total abdominal hysterectomy were recruited into this prospective, double blind, randomised controlled study. They were randomised to receive either PCA oxycodone 0.7 mg per bolus or PCA morphine 1 mg per bolus for postoperative pain relief. At the end of surgery, all patients received IV morphine 0.1 mg/kg and skin incision was infiltrated with 20 mls of bupivacaine 0.25%. Post-operative pain scores, opioids consumptions, sedation scores and side effects were assessed upon arrival and at 30 minutes after arrival to recovery area, as well as at 6 hours and 24 hours after the operation in the ward. Patients’ overall satisfaction was also assessed 24 hours postoperatively.No significant differences were observed in terms of postoperative pain scores, opioids consumption, sedation scores, side effects as well as patient’s overall satisfaction between the PCA oxycodone and PCA morphine group. Oxycodone was comparable to morphine as PCA in terms of total opioid consumption, pain scores and satisfaction level for patients undergoing total abdominal hysterectomy and therefore may be an alternative to morphine in postoperative pain management as PCA.
Traumatic injury to the eye can occur due to various causes, most of which are avoidable. Here we report three cases of intrastromal corneal foreign bodies (FB) which required surgical removal. Most corneal FBs are removed easily at the slit lamp, however, these cases required surgical intervention due to the mechanism of which the FB penetrated into the stroma. Although the mechanism of injury was similar, with all three cases occurring at high velocity, we observed that the entry and level of penetration differed in each case. In the first case, the corneal FB penetrated the cornea and was embedded in the anterior stroma, whereas in the second case, the FB was embedded in the posterior stroma, but with an intact endothelium. In the third case, the FB caused a full thickness, self-sealed laceration wound but remained embedded in the stroma. Through further evaluation, we noted that several factors contribute towards the severity of the injury, namely, anatomy of the cornea, area affected, shape, size, mass and velocity of the object. We speak in depth about the mechanism of injury and physics associated with these injuries and why the penetration differed in each case.
Microperforate hymen is a rare vaginal anomaly that is usually reported in childhood due to recurrent urogenital infections. Unlike imperforate hymen where the presenting complaints are classical due to complete vaginal obstruction, the less profound and varied presentation of microperforate hymen may go unnoticed. We report a case of a 39-year-old, with a background history of amenorrhea, who presented with acute abdomen suggestive of tubo-ovarian abscess, and was finally diagnosed to have microperforate hymen. She underwent hymenectomy to correct the anomaly. To our knowledge, this is the oldest age of presentation of a congenital form of microperforate hymen. A high index of suspicion and early detection of microperforate hymen and properly timed intervention is essential to prevent acute symptoms and long term detrimental sequalae to women’s reproductive and psychosexual health.
Surgical training worldwide has been reformed from
the since 19th century until the present era. It started as
a trade which eventually was transformed into a
profession that acquires skills and knowledge. The
apprenticeship model was introduced amongst the
Western surgeons as the standard approached for
surgical training. The surgery was learned through
direct observation without any formal and structured
education. William S Halstead had introduced the new
approach of training the surgeons in America
following his landmark lecture at Yale University in
1904 (1). His principle was based on direct the
German Surgical training which emphasized on basic
sciences in the curriculum and Sir William Ossler
concepts of bedside rounds. This has lead to the
development of Halsted principals of surgical training
which included intense and repetitive exposure in
managing surgical patients under the supervision of
skilled surgeons, acquiring the knowledge of scientific
basis of surgical diseases and as the surgical trainee
received enhanced responsibility and independence
with each advancing year (2). Since then, Halsted
principle of surgical training has become the
foundation of most established surgical training
worldwide. The principles have been expanded and
upgraded and since then six cores competencies have
been identified for the surgical residents to achieve
and master during the training course (3). There were
medical knowledge, patient care, interpersonal and
communication skills, professionalism, practice-based
learning and improvement and system based practice.
From the Malaysia perspective, surgical training was
done through the overseas Royal colleges after the
independence in 1957. The local programme started in
1982 through the initiative of local universities that
initially offered surgical training programme in
General surgery, Orthopedics and otorhinolaryngology
(4). Since then through the collaborations of Ministry
of Health and other professional bodies various
surgical training programme has been established to
provide training opportunities which will eventually
serving the nation. The subcommittee of the National
Conjoint Board for General Surgery was the
consultative body to oversee and manage the
implementation of the surgical training. Since the
establishment, the subcommittee was responsible in
streamlined the training curriculum for all the
universities that offered the course, centralized and
standardized the intake of the trainees, coordinating
the national exit examination and advising new
application for graduate training in general surgery.
The important milestone of the subcommittee was the
task given to develop the national surgical
postgraduate curriculum for the doctors who are
interested in becoming a surgeon in the country. The
curriculum is being developed to create a pathway for
surgical training from the internship until subspecialty
training. The development encompasses the
governance, the curriculum development, the training
process and learning outcome according to the latest
evidence based on post graduate training. The
programme should be the foundation in producing well
trained surgeons towards 2050 through TN50.
The pathophysiology of systemic inflammatory response syndrome (SIRS) had been described to involve various strong oxidative reactions affecting the status and progress of the patients. Antioxidant therapy had been suggested in many studies involving SIRS management. The objective of this study was to compare the role of vitamin E Tocotrienol and vitamin E Tocopherol combined with vitamin C as antioxidant therapy in the management of critically ill patients diagnosed with SIRS, admitted to the intensive care unit and high dependency wards of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). It was a single blind randomized clinical trial with a total of 72 patients in which 44.4% Malays, 34.7% Chinese, 19.4% Indians and 1.4% others with 59.7% males and 40.3% females were recruited. Patients in TRI E group received Tocotrienol with Vitamin C while TOCO group received Tocopherol with Vitamin C and a control group did not receive any antioxidant. The clinical parameters (heart rate, respiratory rate, systolic blood pressure) showed improvements with significant difference at the end of study (post-intervention) as compared to admission (pre-intervention).Whereas, the sepsis (temperature, PCT, CRP and WBC) and oxidative stress (8-OHdG/Creatinine) parameters showed improvements with significant difference at the end of study (post-intervention) as compared to admission (pre-intervention). The TRI E group showed obvious improvement in clinical, sepsis and oxidative stress parameters, as compared to TOCO and control groups. This study showed that Vitamin E Tocotrienol and Vitamin E Tocopherol in combination with Vitamin C demonstrated significant improvement in the clinical and laboratory parameters during the management of SIRS. Therefore, Vitamin E in combination with Vitamin C had therapeutic benefits in the treatment of critically ill patients with SIRS.
Phacoemulsification (PEA) is currently the procedure of choice for most cataract extraction. However, intra-operative complications may require the procedure to be converted to extracapsular cataract extraction (ECCE). We have evaluated the indications for conversion and visual outcomes in cases converted from phacoemulsification to ECCE. A retrospective review was performed on 33 eyes in which phacoemulsification was initiated and then converted to ECCE. The main parameters evaluated were indications for conversion and visual outcomes at 3 months. Thirty-three cases out of 1448 operations were identified from January 2013 to February 2014.The incidence of PEA converted to ECCE was 2.2%. The indications for ECCE conversion were posterior capsular rupture (PCR) in twenty-two cases, combined capsulorhexis extension with PCR in three cases, capsulorhexis extension and zonular dialysis in two cases respectively. Combined zonular dialysis with PCR, corneal toxicity, Descemet’s tear and obscured edge of capsulorhexis had one case each. Twenty-six (78%) cases had gain in vision, one (3%) case had unchanged vision and six (18%) cases had worsening of vision. The incidence of complicated phacoemulsification surgery requiring intra-operative conversion to ECCE was low in our study (2.2%). Seventy-eight percent of cases achieved final VA of 6/12 or better. Therefore, early recognition of complications and timely intra-operative conversion of PEA to ECCE may result in good visual outcome.
A 42-year-old Chinese man, known case of renal cell carcinoma with lung metastasis, was referred to Universiti
Kebangsaan Malaysia Medical Centre for left eye blurring of vision for one month duration, which was worse upon
waking up in the morning and cleared up after 1-2 hours. On examination, visual acuities were 6/6 in both eyes. No
relative afferent pupillary defect. Left fundus showed inferonasal retinal detachment without macular involvement.
No retina break, no retinitis and no choroidal lesion seen. Right eye examination was normal. Optical coherence
tomography (OCT) of left eye showed subretinal fluid temporal and inferior to optic disc. Fundus fluorescein
angiography (FFA) left eye showed hypofluoresence in early phase but hyperfluorescence with pin point leakage in
late phase over inferonasal quadrant. Indocyanine green (ICG) showed early hypofluoresence with late pin point
hyperfluoresence in the same quadrant. A clinical diagnosis of exudative retinal detachment due to choroidal
metastasis secondary to renal cell carcinoma was made. The patient was planned for cyber-knife radiotherapy of his
left eye but unfortunately we lost the follow up. High index of suspicion and relevant investigation are needed for
patients with visual complaints and history of renal cell carcinoma to diagnose choroidal metastasis.
Congenital peritoneal band is an extremely rare condition, but may induce small bowel obstruction (SBO) at any age, predominantly in childhood and rarely in adults. We report a case of extensive bowel ischaemia following caesarean section, due to trapping of an intestinal loop between a congenital peritoneal band and the mesentery. A 42-year-old, Gravida 2 Para 1, who has no history of prior abdominal surgery or trauma, presented in spontaneous labour and underwent an uncomplicated emergency lower segment caesarean section, for fetal distress. Postoperatively, she had worsening abdominal distension and pain, followed by vomiting. Computed Tomography Scan of the abdomen showed gross fluid retention with marked small bowel dilatation and fluid filled bowel loops. An emergency exploratory laparotomy was performed which revealed a congenital band, extending between the right fimbrial end and the small bowel mesentery, looping over the small bowel, causing extensive small bowel ischemia. Post-operative course was uneventful. In conclusion, congenital peritoneal band causing small bowel obstruction, although rare, should be considered in the differential, especially for patients with virgin abdomen.
A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. Ocular examination showed that visual acuity on the right was 6/60 and on the left was 6/24. Both optic disc were swollen with extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortuous vessels with macular oedema. Systemic examination revealed blood pressure of 176/111 mmHg, malar rash and alopecia. Diagnosis of grade 4 hypertensive retinopathy secondary to SLE was made. The diagnosis was confirmed by positive ANA/ dsDNA, low C3/ C4 and renal biopsy showed lupus nephritis. She was treated with oral prednisolone, hydroxychloroquine and cyclosporin A. Throughout the monitoring for hydroxychloroquine toxicity, vision over both eyes were 6/9, but serial visual fields showed non-progressive left superior and inferior scotoma while right eye showed inferior scotoma. The intraocular pressure was normal with pink optic disc and cup disc ratio of 0.3. Optical coherence tomography (OCT) showed temporal and nasal retinal nerve fiber layer thinning bilaterally. However, macula OCT, fundus fluorescein angiography and autofluorescence were normal. The visual field defect was concluded secondary to CWS indicating microinfarction of the retinal nerve fiber secondary to previous hypertensive retinopathy. Non-progressive visual field defects may occur after the appearance of CWS in hypertensive retinopathy and it should not be overlooked when diagnosing glaucoma or hydroxychloroquine toxicity.
Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break.
However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of
retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical
repair as well as the possible measures to treat the complications.