This paper summarises our experience of twenty one patients with degenerative arthritis treated by bilateral simultaneous total knee replacement (BSTKR) in Tawakal Hospital in a period of twenty two months vis. January 1994 to November 1995. The results were analysed according to the scoring system of Hospital for Special Surgery. The preliminary observations were encouraging, 90% excellent, 8% good and 2% fair results. The benefits, safety and cost effectiveness of the procedure as compared to the unilateral staged knee replacement are discussed. We recommend that BSTKR be routinely practised for appropriate situations in all institutions where the expertise and facilities are available.
Quality of life outcome (QOL) on dialysis is important. We determined the measurement properties of Spitzer's QL-index, a QOL measure, in our patients on chronic haemodialysis. The QL-index measures 5 dimensions of QOL (activity, daily activities, general health, social support and psychological outlook). 59 haemodialysis (HD) patients from 2 centres were rated by 5 raters. Inter-rater agreement for the total score was good with a mean intra-class correlation coefficient 0.66 (range 0.47-0.81). That for dimension scores however was poor (weighted kappa range 0.07-1). Systematic differences between raters were also observed. Intra-rater agreement was generally better than inter-rater agreement. Significant gradients in scores were observed by age, serum albumin, comorbid disorders, previous hospitalisation, capacity for self care HD and rehabilitation status thus providing evidence for construct validity. The distribution of total scores was skewed indicating poor discriminatory ability. Nevertheless, QL-index has acceptable measurement properties for application in dialysis patients.
The method of backcalculation estimates past HIV infection rates from available AIDS incidence data and an estimate of the incubation period. The method is used on the Malaysian data to model the AIDS epidemic because it makes use of the Malaysian AIDS incidence data which is fairly reliable and is more reflective of the trend of the epidemic as compared to the HIV infection rate recorded. An application is made on the monthly AIDS incidence data in Malaysia from January 1995 until August 1996 released by the Ministry of Health, Malaysia using the backcalculation program from Bacchetti et al and the incubation period distribution from Brookmeyer to generate the current HIV infection rate for Malaysia (until August 1996).
A survey of specialisation choices was conducted for two batches of medical officers applying to the local medical schools for specialisation in Malaysia. A total of 359 doctors responded, giving a response rate of 71%, with 169 male (44.4%) and 187 female (55.6%) respondents. Surgery ranked highest among the male doctors followed by orthopaedic surgery and internal medicine. Family medicine ranked highest among female doctors followed by public health and anaesthesiology. Among the other specialties, the male doctors preferred otorhinolaryngology while female doctors preferred Pathology. Both male and female doctors chose to be a clinical consultant in a general hospital as the first choice. They prefer to work in or near their hometowns.
We present a case of cervical necrotising fasciitis in a 56 year old man, secondary to a rare mastoid infection. The patient had coexisting diabetes mellitus and hypertension. He was treated with early surgical debridement followed by neck and chest reconstruction and radical mastoidectomy. Aggressive antibiotic therapy and supportive care was given. He recovered well with minimal residual functional deficit.
A seroepidemiological study carried out on 800 stored serum samples collected between January 1999 to December 2000 derived from an urban population in Malaysia showed that the overall seropositive rate of human paravovirus B19 infection was 37.6%, with an overall geometric mean titre (GMT) of 18.3 IU. The seropositive rates of B19 among the male and female populations were 39.0% and 36.3% respectively. The seropositive rates among the racial groups were 37.2%, 38.2%, 38.1% and 29.4% respectively for the Malays, Chinese, Indians and other races. There was no statistical significant gender and racial differences in the B19 seropositive rates. When compared with the seroprevalence of B19 infection in other Asian countries, the seropositive rate of B19 in Malaysia was low in the younger age group and increased steadily with age. The unusual finding in this study was the presence of a high seropositive rate in those between six months to five years of age, especially in children in the one year old age group.
This study was conducted to determine the prevalence of household food insecurity and its potential risk factors and outcomes among the Orang Asli (Temuan) households. Socioeconomic, demographic and food security information of the households and anthropometric measurements and dietary intakes of preschoolers (n = 64) were obtained using a structured questionnaire. Food security was assessed using the Radimer/Cornell hunger and food insecurity instrument. Diet quality was based on 24 hour recall and analyzed according to the Malaysian RDA and Food Guide Pyramid. Majority of the households (82%) reported some kind of household food insecurity. The prevalence of significant underweight, stunting and wasting were 45.3%, 51.6% and 7.8%, respectively. Dietary intakes were less than 2/3 RDA levels for calories, calcium and iron. However, the intakes of protein, vitamin A, vitamin C and niacin exceeded the RDA and the sources for these nutrients were mainly rice, fish and green leafy vegetables. Among the five food groups, only the number of servings from cereals/cereal products/tubers group was achieved while that of the milk/diary products was the worst. Majority of the children (68.7%) had poor, 31.3% had fair and none with excellent diet quality. In general, diet quality and nutritional status of the children decreased as household food insecurity worsened. It is recommended that the nutritional problems of Orang Asli children be addressed through health, nutrition and economic programs and further studies should be carried out on determinants and consequences of household food insecurity.
Postal surveys are becoming an increasingly popular method of conducting research in Malaysia. However, the response rates from these surveys have not been well studied. All postal surveys published in the Medical Journal of Malaysia between 1991-2000 were therefore reviewed to provide an overview of the response rates that may be expected, and to assess if this is a valid method of conducting research here. The response rates of postal surveys ranged from 30-87.5%. Seven of 13 postal surveys (54%) had a response rate of less than 50% and only 2 of 13 (15.4%) had a response rate of more than 70%, raising doubts on the use of postal surveys as a research tool.
A 49 year-old Indian housewife was diagnosed with Hodgkin's disease in 1995. She was given combination chemotherapy comprising Chlorambucil, Vincristine, Procarbazine and Prednisolone. Unfortunately she defaulted after two courses of chemotherapy. One year later, she developed progressive right knee swelling and pain, associated with loss of appetite, loss of weight, intermittent fever, night sweats and pruritus. The right knee swelling measured 15 cm x 20 cm and was warm and tender. A plain radiograph of the right knee revealed osteolytic lesions at the distal end of the right femur and the proximal ends of the right tibia and fibula, associated with gross periosteal reaction and soft tissue swelling. Apart from left cervical lymphoadenopathy, examination of other systems was unremarkable. Pelvic bone marrow biopsy was inconclusive. An open biopsy of the lower end of the right femur was consistent with Hodgkin's disease. She was given salvage combination therapy comprising Chlorambucil, Vincristine, Procarbazine, Prednisolone, Doxorubicin, Bleomycin and Vinblastine. She tolerated the treatment well and responded with significant reduction in the swelling and pain of the right knee. Unfortunately, she again defaulted treatment after 2 courses of chemotherapy. This case illustrates an unusual presentation of Hodgkin's disease in relapse.
A case of spontaneous rupture of uterine artery in the second trimester of pregnancy is described. Haemorrhage from rupture of uterine artery during pregnancy was discovered at laparotomy. This was an unusual but serious complication of pregnancy. This condition is extremely rare and one must consider it in cases of incomprehensible abdominal pain with or without haemodynamic collapse. A review of the literature revealed only four similar cases so far. This pregnancy continued till 37 weeks pregnancy and had a spontaneous vaginal delivery. Immediate institution of effective resuscitative measures and early surgical intervention were essential to both foetal and maternal survival.
We report three cases of large occipito-encephaloceles that were managed in the Neurosciences Unit, Hospital Universiti Sains Malaysia over the last 5 years. All patients had pre-operative MRI (magnetic resonance imaging) evolution and mapping of the sagittal sinus tract. The cerebrospinal fluid (CSF) of all three patients were initially diverted by means of ventricular shunt two weeks prior to shunt removal. The slow drainage of CSF prevented electrolyte and volume disturbances due to sudden decompression during their definitive occipital encephalocele operations. After 3 years follow-up, all these patients are progressing well.
A case of giant cell arteritis with systemic and panocular involvement is reported here. This elderly Indian male presented with symptoms of unilateral temporal headache and intermittent jaw claudication for a month followed by diplopia and blurring of vision and later loss of vision in the right eye. The right eye showed some limitation of ocular movements, presence of relative afferent pupil defect, anterior segment ischaemic changes and anterior ischaemic optic neuropathy. Visual evoked potential showed an absent P1 wave while the left eye with normal 6/6 vision sowed a prolonged P1 wave. Fundus fluoresceine angiography showed delay in choroidal perfusion. His erythrocyte sedimentation rate (ESR) was 120 mm/hr and he was started on oral prednisolone. Superficial temporal artery biopsy obtained one week after starting steroids was positive for giant cell arteritis. Steroids led to the resolution of optic disc swelling, disappearance of anterior segment signs, full recovery of right ocular movements and no further deterioration of the fellow eye. On steroids, he developed insomnia and progressive myopathy which resolved and is now symptom free at lower doses of steroids.
Bleeding into the rectus sheath is an uncommon but a well-recognised condition that mimics several other diagnoses of acute abdomen. A wide range of etiology has been proposed in association with this condition. It is often self-limiting, but can lead to unnecessary laparotomy if the diagnosis is not recognised.
Since January 1999, ten patients had undergone surgical treatment for metastatic bony lesions of proximal femur at this centre. Seven of these patients were treated for complete pathological fractures, one for impending fracture and one for revision of internal fixation and loosening of hemiarthroplasty. Primary malignancies were located in breast in four cases, prostate in three and one in lung, thyroid and neurofibrosarcoma. Two patients had died within six months after surgery, four after 1 year while the remaining four were still alive. The mean duration of survival was eleven months. Nine patients had been ambulating pain free and there were no failure of reconstruction.
The concept of 'unwanted pregnancy' is a recent in human history and is associated with social stresses of modern life. The purposes of the law, maqasid al shari'at, and its principles, qawa'id a shari'at, focus on preventing 'unwanted pregnancy', protecting the rights of the fetus and infant, and mitigating the adverse effects of 'unwanted pregnancy' by social measures. 'Unwanted pregnancy' is associated with general social determinants (hedonistic life styles, sexual transgression, addiction to drugs, fear of poverty, and low female status) and specific antecedent causes (sexual crimes, egoistic greed, maternal/fetal disease, and gender discrimination). It is prevented by sexual hygiene, marriage, contraception, deterring sexual crimes, and raising the status of women. The adverse sequelae of 'unwanted pregnancy' (feticide, infanticide, or child abuse and neglect) can be prevented by defending the basic human right of the fetus and infant to life, promoting social institutions for child welfare (nuclear family, extended family, foster care, and open adoption). Closed adoption is forbidden by Law but care in a foster home is allowed and is encouraged if the nuclear and extended families are unwilling or are unable to care for children. Abortion at any stage of pregnancy is a crime against humanity. It is not a solution to the problem but is part of the problem. It will encourage more 'unwanted pregnancies'.
Historical perspective of terminations of unwanted pregnancies in the UK. Moral and ethical considerations imposed by established church's teachings becoming increasingly in conflict with the wishes and expectations of a more secular society. Recognition that illegal abortion was, as a matter of fact available, at great risk to vulnerable girls and women. Eventually public demand and a radical and reforming government led to the current Statutory Framework. Statutory provisions: Offences against the Person Act 1861, Sections 58 and 59; Infant Life Preservation Act 1929 Section 1. Recognition of the limited flexibility allowed by the law in the original restrictive statutory framework. The direction to the jury in July 1938 by Macnaghten J in the case of R. v. Bourne [1939] 1 KB 687, where an eminent obstetrician was acquitted after carrying out an abortion on a young rape victim. Then the modern statutory provisions: Abortion Act 1967, amended by the Human Fertilisation and Embryology Act 1990. The statutory framework provides for healthcare professionals not to have to take part in terminations if they have a conscientious objection to doing so. While there are still fierce challenges from moral pressure groups when any changes in the detail of the law are proposed--such as reducing the maximum gestation period for a lawful termination--as a whole society seems to have accepted the current law. Issues affecting doctors who consider and provide terminations; current medico-legal problems relating to wanted pregnancies that have been lost by reason of clinical negligence, and unwanted children that have been born by reason of clinical negligence.
Globally, abortion mortality accounts for approximately 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high maternal mortality and morbidity from abortion tend to occur together. Unplanned and unwanted pregnancies constitute a serious public health responsibility. While fertility has declined by half in developing countries, the motivation to control and space births has risen faster than the rate of contraceptive use. Preventing maternal mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives. A range of positive steps has been taken to reduce deaths and morbidity from abortion in a growing number of countries over the past 15 years. Making abortion legal is an essential prerequisite in making it safe. In this respect, changing the law does matter and assertions to the contrary are ill conceived and unsupported in practice. Although, in many countries, trends towards safer abortion have often occurred prior to or in the absence of changes in the law, legal changes need to take place if safety is to be sustained for all women. Religious laws may also require attention when legal change is being contemplated. There are three main ways of approaching this problem: liberalizing the existing law within the penal or criminal code; partially or fully legalizing abortion through a positive law or a court ruling; and decriminalising abortion by taking it out of the law. Women's health groups and other advocates, parliamentarians and health professionals, can work together to support the right of women not to die from unsafe abortions and to ensure they receive treatment for complications. Committed doctors can make a difference by providing treatment for abortion complications, interpreting the law in a liberal way and providing safe services where these are legal as well as training providers in the safest techniques to reduce mortality and morbidity. Although law, policy and women's rights are central to this issue, making abortions safe is above all a public health responsibility of governments. Moreover, reducing maternal mortality by making abortions safe is also an important part of the international commitment made in Cairo in 1994 at the ICPD and reaffirmed at the Cairo meeting in 1999.
When a doctor is required to go to court, he does so with some amount of trepidation. The degree of trepidation increases in direct proportion as to whether he is required to be a witness or a defendant. The practice of medicine on the other hand requires the patient to have full confidence and open out his secrets to the doctor. If you hold back vital information, the diagnosis may be entirely different to the disease that you have. Lawyers who enter hospitals may also do so with some trepidation, maybe even more so than doctors who enter courts, as their lives are at stake. There is a perception that medico-legal matters are on the rise. We may put forward a few reasons for this: 1. A better educated and increasingly assertive public with greater awareness of the medical and legal systems; 2. Rising expectations of medical results; 3. Commercialization of medical care with erosion of the doctor-patient trust relationship. This paper will discuss the reasons for and the ways to address medical errors as well as explore the reasons for defensive medicine. The argument is put forward that public education programs on the risks inherent in some of the new advances in treatment modalities and surgery and professional education programs on the need for obtaining the patient's informed consent to such treatment is needed. Public advocacy programs to demonstrate the problems in medicine and the delivery of health care resulting from strict cost containment limitations should be carried out. There is also the need to enhance the level and quality of medical education for all physicians, including improved clinical training experiences. Doctors' must manage their clinical affairs in a professional manner without being dictated to by the legal system. However, it would be wise to take note of the views expressed by learned counsel and judges in their courts. The middle road is always the best and we must never be extreme in our viewpoints. We must always remember the patient is why we are here and the patient must never suffer in the process while we formulate our responses to the medico-legal challenges that lie ahead.