CASE PRESENTATION: We report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients.
CONCLUSIONS: Cardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.
METHODOLOGY: A retrospective study on IOL using the CRB in women with previous caesarean section or grandmultiparity between January 2014 and March 2015. All cases were identified from the Sarawak General Hospital CRB request registry. Individual admission notes were traced and data extracted using a standardised proforma.
RESULTS: The overall success rate of vaginal delivery after IOL was 50%, although this increases to about two-thirds when sub analysis was performed in women with previous tested scars and the unscarred, grandmultiparous woman. There was a significant change in Bishop score prior to insertion and after removal of the CRB. The Bishop score increased by a score of 3.2 (95% CI 2.8-3.6), which was statistically significant (p<0.01) and occurred across both subgroups, not limited to the grandmultipara. There were no cases of hyperstimulation but one case of intrapartum fever and scar dehiscence each (1.4%). Notably, there were two cases of change in lie/presentation after CRB insertion.
CONCLUSION: CRB adds to the obstetricians' armamentarium and appears to provide a reasonable alternative for the IOL in women at high risk of uterine rupture. Rates of hyperstimulation, maternal infection and scar dehiscence are low and hence appeals to the user.
METHODS: A 10-year retrospective analysis of SCARs cases in Penang General Hospital was carried out from January 2006 to December 2015. Data collection is based on the Malaysian Adverse Drug Reactions Advisory Committee registry and dermatology clinic records.
RESULTS: A total of 189 cases of SCARs were encountered (F:M ratio; 1.2:1.0; mean age of 45 year). The commonest manifestation was Stevens-Johnson Syndrome [SJS] (55.0%), followed by toxic epidermal necrolysis [TEN] (23.8%), drug rash with eosinophilia and systemic symptoms [DRESS] (12.7%), acute generalised exanthematous pustulosis [AGEP] (4.8%), SJS/TEN overlap syndrome (2.6%) and generalised bullous fixed drug eruptions [GBFDE] (1.1%). Mean time to onset for TEN/SJS/Overlap syndrome was 10.5±13 days; AGEP, three days; GBFDE, 2.5±0.7 days, and DRESS, 29.4±5.7 days. The most common drugs implicated were antibiotics (33.3%), followed by allopurinol (18.9%) and anticonvulsant (18.4%). Out of 154 cases of SJS/TEN/overlap syndrome, allopurinol was the commonest causative agents (20.1%). In DRESS, allopurinol accounts for 45.8% of the cases. The mortality rate in SJS, TEN and DRESS were 1.9%, 13.3% and 12.5% respectively. No mortality was observed in AGEP and GBFDE.
CONCLUSION: The commonest manifestations of SCARs in our setting were SJS, TEN and DRESS. Allopurinol was the most common culprit. Thus, judicious allopurinol use is advocated and pre-emptive genetic screening for HLAB *5801 should be considered.
MATERIALS AND METHODS: We conducted a 6-year retrospective cross-sectional study from the 1st January 2016 until 31st December 2021. Clinical, demographic characteristics, perioperative parameters, operative indications, blood loss, maternal/neonatal outcomes and complications were analysed. Patients were subdivided, analysed and studied in two subgroups- emergency hysterectomy (EH) and planned hysterectomy (PH).
RESULTS: There were 65 cases of peripartum hysterectomy out of total 100,567 deliveries, with a prevalence rate of 0.06%. Overall, the majority of patients were multiparous (96.9%), having previous caesarean scar (73.8%) or diagnosed with placenta praevia (75.4%). More than half of the total patients (61.5%) have both previous caesarean scar and concomitant placenta praevia. EH was carried out in 39(60%) patients while 26(40%) patients underwent PH. The only indication for surgery in the PH group (100%) was abnormal placentation while the most common indication for surgery in the EH group (53.8%) was postpartum haemorrhage related to abnormal placentation. Patients who underwent EH were more likely to have massive blood loss (p=0.001), require ICU admissions (p=0.001), have DIVC cycles transfused (mean [SD] regime: 1.35 [0.95] vs 0.54 [0.99]; p=0.002), have lower postoperative haemoglobin level (mean [standard deviation, SD] haemoglobin: 9.23g/l [SD1.8] vs. 10.8 g/l [SD1.86]; p=0.001) and have higher difference between pre/post operative haemoglobin level (mean [SD] haemoglobin difference: 1.78g/l [SD6.34] vs 0.32g/l [SD1.7]; p=0.008) compared to patients with PH. Red blood cell transfusion, operating time, length of stay, weight of babies and Apgar score between two groups showed no significant differences. A significant reduction of blood loss between the first and the second half duration of the study (mean [SD] blood loss: 6978 ml [SD 4999.45] vs. 4100ml [SD2569.48]; p=0.004) was also observed. In the emergency group, 'non-placental cause' EH required significantly more red blood cell transfusion than 'placental cause' (p<0.05) while in the PH group, no significant difference was observed between the occlusive internal iliac artery 'balloon' and 'no balloon' subgroup in terms of operating time, total blood loss or blood transfusion. Overall complications showed more cases of post operative fever and relaparotomy in the EH group (18.4% vs. 7.6%) while urinary tract injuries including injuries to bladder and ureter occurred only in the PH group (9.4% vs. 0%).
CONCLUSION: The majority of peripartum hysterectomy cases are due to placenta accreta spectrum disorders. Planned peripartum hysterectomies have a lower morbidity rate compared to emergency hysterectomies. Therefore, early identification of placenta accreta spectrum disorders and timely planning for elective procedures are crucial to minimise the need for emergency surgery.
Methodology: A total of 123 patients were recruited into this study, comprising 82 patients who underwent a pterional approach and 41 patients who underwent a supraorbital approach. Computed tomography angiograms, the modified Rankin Scale, and the visual analogue scale were administered at 6 months to look for residual aneurysm, functional outcomes, scar tenderness, and cosmetic satisfaction. Complication data were collected from patients' case notes.
Results: The mean operating time for the pterional group was 226 min, compared to supraorbital group, which was 192 min (P = 0.07). Cosmetic satisfaction was significantly higher (P = 0.001) in the supraorbital group. There was no significant difference between the supraorbital and pterional groups' scar tenderness (P = 0.719), residual aneurysm (P = 0.719), or functional outcomes (P = 0.137), and there was no significant difference between the groups in terms of intra-operative and post-operative complications.
Conclusions: The supraorbital group had better cosmetic outcomes and shorter operating times compared to the pterional group.
Methods: A total of 126 patients were randomised into two groups. The patients in Group A underwent mesotherapy (n = 66) and those in Group B underwent surgery (n = 60). The patients in Group A group received six sessions of mesotherapy treatment at 2-week intervals. Both groups were followed up for 12 weeks, during which they were assessed for complications arising from treatment, reduction of the size of the lipoma and cosmetic outcomes.
Results: The overall mean age of the patients was 32.93 (± 10.1) years old and the mean volume of the lipomas was 2.29 (± 3.8) mL. A 55.86% (P = 0.0032) mean reduction in the volume of lipomas was noted in the patients who received mesotherapy, while one patient showed a gain of 16% by volume. The patients in Group A (cosmetic score ≥ 4: 63%) were happier with the treatment than those in Group B (cosmetic score ≥ 4: 21%).
Conclusion: Our findings indicate that mesotherapy modestly reduces the volume of lipomas with very few and minor complications and excellent cosmetic outcomes.