One hundred consecutive newly diagnosed patients with nasopharyngeal carcinoma (NPC) since January 1994 were the subjects for studying various factors that contribute to the delay in the confirmation of the diagnosis. Seventy-nine of them were males and the peak age of incidence was the fifth decade. Ninety two percent were Chinese, 7% Malay and 1% Indian. Seventy six percent were agriculture workers or labourers with 66% having either no formal education (16%) or only primary level education (50%). In 50% of patients neck swelling was the first presenting symptom, 26% had nasal symptoms, 12% ear symptoms and 11% has symptoms due to intracranial extension of tumour. As many as 80% were at UICC Stage IV at the time of diagnosis. While the median delay, on the part of patients, in consulting a doctor was 2.5 days, the median delay on the part of the doctors to confirm the diagnosis of NPC was 127 days, the delays was particularly worse when the patients presented with ear symptoms (266 days) followed by those with neck swelling (94 days). For those patients who were required to undergo more than one nasopharyngoscopy and biopsy the median doctor's delay was 144 days. Since 82% of patient's had first consulted general practitioners, it is suggested that their level of awareness with regards to the diagnosis of NPC be significantly raised so that the delay on their part be greatly minimized.
Background: Urinary excreton of low molecular weight proteins such as beta2-microglobulin and retinol binding protein (RBP), and enzymes such as N-acetyl-beta-D-glucosaminidase (NAG), may be useful as indicators of renal tubular dysfunction in diabetes mellitus.
Objective: To describe the profile of urinary protein and enzyme excretion in 240 Chinese patients with type 2 diabetes mellitus in Singapore.
Materials and Methodology: Cross-sectional study of consecutive patients presenting for follow-up at a Government primary care clinic. Information was obtained from interview, physical examination and laboratory analysis. Data analysis included descriptive statistics on urinary protein and enzyme excretion, comparison of unadjusted and adjusted means of these among patient subgroups, as well as correlation with control of diabetes and other clinical parameters.
Results: Albuminuria correlated with urine B2-microglobulin (r=0.34, p<0.01) and RBP (r=0.46,p<0.01). hypertensive patients had significantly higher mean urine albumin (geometric mean 15.13mg/gCr) and B2-microglobulin (363.18ug/gCr) levels compared to patients without hypertension (7.07mg/gCR; 219,20ug/gCr; p<0.05). Patients with complications of diabetes also had higher albumin (15.55 vs 6.20mg/gCr), B2-microglobulin (344.47 vs 288.83ug/gCr) and RBP excretion (152.02 vs 94.54mg/gCr). Two-hour postprandial sugar correlated with B2-microglobulin (r=0.33, p<0.01), RBP (r=0.35, p<0.01) and NAG (r=0.28, p<0.01). Urinary protein excretion did not correlate with HbA1c, fasting blood sugar, age of patient or duration since diagnosis.
Conclusion: These results among 240 Chinese patients in Singapore were consistent with reports from other study populations.
Liver disease is an important and serious condition in pregnancy. The Confidential Enquiries Into Maternal Deaths in Malaysia showed that there were 23 maternal deaths attributed to liver disease between 1991-1994. Over the same period, there were 1066 reported maternal deaths with 929 of them being due to direct and indirect causes. Thus 2.15% of such deaths were due to liver disease in Malaysia. The three main causes of maternal deaths due to liver disease in pregnancy were hepatitis (6 cases), acute fatty liver in pregnancy (6 cases) and septicaemia (4 cases). Liver disease is common at a mean of thirty weeks of gestation with a preponderance to women of low parity. Only two patients in this series had no antenatal care. The majority of cases (45.8%) presented between 28-37 weeks of gestation. All cases delivered by spontaneous vaginal delivery. Remediable factors that were identified included failure to appreciate the severity of disease. Case summaries of all the cases of maternal deaths due to liver disease are discussed and a guideline to management of liver disease in pregnancy presented.
We determine the prevalence and determinants of clustering of hypertension, abnormal glucose tolerance, hypercholesterolaemia and overweight in Malaysia. A national probability sample of 17,392 individuals aged 30 years or older had usable data. 61% of adults had at least one risk factor, 27% had 2 or more risk factors. The observed frequency of 4 factors cluster was 6 times greater than that expected by chance. Indian and Malay women were at particular high risk of risk factors clustering. Individuals with a risk factor had 1.5 to 3 times higher prevalence of other risk factors. Ordinal regression analyses show that higher income, urban residence and physical inactivity were independently associated with risk factors clustering, lending support to the hypotheses that risk factors clustering is related to lifestyle changes brought about by modernisation and urbanisation. In conclusion, risk factor clustering is highly prevalent among Malaysian adults. Treatment and prevention programme must emphasise the multiple risk factor approach.
Study name: National Health and Morbidity Survey (NHMS-1996)
Our preliminary experience of Somatostatin Receptor Positive Tumour Scintigraphy (SRPTS) in the management of some rare neuroendocrine tumours is highlighted. Six patients were evaluated using SRPTS. A single patient each with Zollinger-Ellison syndrome, recurrent medullary carcinoma of thyroid and Stage IV neuroblastoma. Two patients with phaeochromocytoma, and one patient with suspected insulinoma were evaluated. SRPTS was useful in three of the six patients studied i.e. patient with gastrinoma, recurrent medullary carcinoma of thyroid and metastatic neuroblastoma. SRPTS although expensive is a useful and cost-effective approach of rare endocrine tumours and it role as a first line tool in the diagnosis is discussed.
A total of 37,152 patients attended the Accident & Emergency (A&E) Department of Hospital Universiti Kebangsaan Malaysia (HUKM) from 1st January to 31st December 1998. Attendance during early hours (midnight to 0659 hrs.) constituted only 10.4% (3853 cases) whereas that for three other time periods of 0700-1159 hrs., 1200-1759 hrs., and 1800-2359 hrs. was 29.4% (10,927 cases), 30.8% (11,448 cases), and 29.4% (10,924 cases) respectively. Two hundred and fifty-one patients were direct admissions from other hospitals into our hospital wards and they attended the A&E department for registration purposes only. Of the remaining 36,901 that were triaged, 196 (0.5%) were resuscitation cases [Triage 1], 3648 (9.9%) were emergency cases [Triage 21, 18,935 (51.3%) were urgent cases [Triage 3], and 14,122 (38.3%) were non-urgent cases [Triage 4]. Despite fluctuations in monthly patient attendance, the proportions of patients according to time of attendance, age group, gender and triage categories remained similar throughout. As majority of patients attended during convenient hours (89.6% from 0700-2359 hrs.) and a high proportion of patients (38.3%) belonged to the non-urgent Triage category, we feel that public emergency services are possibly being abused.
Fifteen cases of insulinoma were managed at HUKM over a period of 20 years. Although all patients presented with neurological symptoms, the diagnosis was delayed in all. Fasting hypoglycaemia and the measurement of C-peptide levels eventually made the diagnosis. Pre-operative localization investigations were not particularly useful. Intraoperative ultrasound (IOUS) detected 72% of the insulinomas, while 93% of the insulinomas were identified intraoperatively by palpation. All the insulinomas were detected intraoperatively with the combination of the two techniques. Twelve of 15 patients had benign adenomas including one patient with MEN-1 syndrome. Two patients had malignant insulinomas. One patient refused surgery. Nine patients underwent pancreatic resections and the remaining 5 patients had the adenomas enucleated.
Sixty inpatients with diabetic foot were studied prospectively at the Orthopaedic wards of Hospital Kuala Lumpur. Data was evaluated to document the patient profile and the factors that were associated with a major amputation (either above knee or below knee) of the lower limb. Factors that were associated with increased risk of amputation were a low education level, manual occupation, poor foot care, peripheral vascular insufficiency of the lower limb, insulin dependence, anaemia and leucocytosis. However only anaemia, leucocytosis and hyperglycaemia were statistically significant in predicting a more adverse surgical procedure. This study recommends that foot care awareness and practice is important. This can be effectively dealt with at specially organised, multi disciplinary Diabetic Foot Clinics.
An asymptomatic subject with radiographic changes due to welders' siderosis is described. This condition has not been well recognized and described in our community. Siderosis of the lung is generally considered to be a benign condition not associated with respiratory symptoms. However, recent reports have associated welding with various disorders of pulmonary function as well as lung cancer. There is a need for future epidemiological studies to better define the risk of long term welding.
Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. Although uncommon, it should be considered among the list of important opportunistic infections in severely immunocompromised patients. Patients living with AIDS are at particular risk of disseminated histoplasmosis. Diagnosis requires a high level of clinical suspicion. The infection is best confirmed by demonstration of the organism in tissue specimens or by culture. Amphotericin B is the most effective drug for severe disseminated histoplasmosis. Response is good but life-long maintenance is required to prevent relapse.
This paper highlights two cases of paediatric familial hyperlipidaemia (hypercholesterolaemia and hypertriglyceridaemia). The first case was an 11 year old Chinese boy, a "homozygous" (Type II) hypercholesterolaemic patient. He had extremely high blood cholesterol level (19.4 mmol/l), severe multiple xanthoma and abnormal resting electrocardiogram. He had repeated heart attacks and died at the age of 15 in spite of early intervention, treatment and follow up. The second case was a 2 1/2 years old girl who had severe hypertriglyceridaemia. She had raised cholesterol (6.2 mmol/l) and extremely high triglycerides (14.8 mmol/l). The patient did not resemble Type I lipoproteinaemia which is classically seen in childhood. On the contrary, the patient exhibited clinical and biochemical manifestations of a Type V lipoproteinaemia which often occurs in adults. Apart from a Type V lipoprotein pattern, the patient had low post hepatic lipase activity (PHLA), Apo C II and Apo E2/E3 phenotype. In addition, the lipid profile of her family members (both the parents and brothers) had raised triglycerides and thus ruled out the Type I lipoprotein inheritance pattern, which is an autosomal recessive condition. The issue of paediatric hyperlipidaemia, their management and treatments are discussed.
A prospective analysis of 500 consecutive patients undergoing colonoscopy at the endoscopy unit of Hospital UKM under the care of the surgical unit was analysed. All colonoscopies were supervised by one of two consultant surgeons. The bowel preparation was graded from grade 1 to 4 according to established criteria. All patients had 3 litres of colonic lavage solution as bowel preparation. One hundred and two patients (20.4%) were considered to have poor bowel preparation, while 398 patients (79.6%) had good bowel preparation. Statistically significant factors that resulted in poor bowel preparation included age <20 years and >60 years (p<0.0001), and inpatients (p<0.0193). There was no significant difference in respect to sex, ethnic groups and the indication for colonoscopy. We conclude that young adults and the elderly as well as inpatients are more likely to have a poor bowel preparation using the standard regime.
A neurologically impaired child who had fundoplication and gastrostomy done for gastroesophageal at the age of three, presented two years later with intestinal obstruction. She underwent laparotomy and was found to have antegrade jejuno-jejunal intussusception. Intussusception is an unusual but recognised complication of gastrostomy tube placement.
A rare combination of a segmental ulnar fracture with fracture dislocation of the head of the radius and intraarticular fracture of the distal radius concomitant with an ipsilateral scaphoid, lunate and coronoid process fractures is presented. The mechanism of injury could possibly be a tremendous impact on the outstretched hand with a dorsiflexed wrist, fracturing the carpal bones and the distal radius. Transmitted axial forces on the ulna in a pronating forearm resulted in the other fractures. To the best of our knowledge, no such case has been reported. Open reduction with screw fixation of the scaphoid, plating of the proximal ulna and Kirschner wiring of the distal radius and radial head dislocation were done.
Sixty-one patients with biliary atresia, who underwent portoenterostomy (PE) between 1992 to 1998 in the Institute of Pediatrics, Kuala Lumpur and were followed for a period of one year, were studied to analyze the factors associated with jaundice clearance and cholangitis following PE. Sex distribution was equal. Majority of patients were Malays. Mean age in days at admission to the surgical ward was 66.90 +/- 23.36 and mean age at PE was 75.85 +/- 24.05. At the end of one-year follow-up, six patients (10%) had died, 35 (57%) developed one or more attacks of cholangitis, 35 (57%) had portal hypertension, eight (13%) liver failure and six patients had esophageal variceal bleeding. Thirty-three patients (54%) had jaundice clearance with a mean clearance time of 85 days after PE. The study shows that when the ductules in the porta hepatis were < 150 mu in size, persistence of jaundice after PE and the incidence of cholangitis in the first post-operative year were higher; patients with cholangitis in the first year had lower rate of jaundice clearance. Jaundice clearance was achieved in more patients when their postnatal age at the time of PE was lower but the relationship was not linear. Age at PE also did not have a linear temporal relationship to the incidence of cholangitis and the size of portal ductules. Prospective, multi-center based local studies on a bigger patient population are needed to identify other indicators of successful outcome following PE. This would help to define the indications for primary liver transplantation in the local population.
The prevalence of HFMD as well as the causative agents was unknown in peninsular Malaysia prior to May 1997. From May 1997 to June 2001, 585 patients suspected to have enterovirus infections, with 467 patients clinically diagnosed as having HFMD, were investigated in the diagnostic virology unit of the University Malaya Medical Centre. Data from this study showed that HFMD is endemic in Malaysia with the occurrence of two outbreaks during the study period. In each outbreak, a number of viruses were isolated but enterovirus 71 was the main virus isolated in both outbreaks. Echovirus 7 (Eo7) was isolated from 5 patients with HFMD in the second outbreak, a clinical entity that has not been attributed to it previously. Children aged 4 years and below, particularly those between 1 and 2 years of age, were in the main group of patients affected by the illness. HFMD by itself and without neurological involvement was relatively benign and self-limiting. There was no significant difference in the virus isolation rate with respect to gender and ethnic groups. Virus isolation was attempted in a total of 764 clinical specimens consisting of 342 stool specimens, 285 oral secretions specimens and 137 vesicular fluid specimens. Oral specimens gave the highest virus isolation rate (33.3%) followed by vesicular specimens (27.0%). Stool specimens only yielded an isolation rate of 14.0%.
Diabetes mellitus is an important risk factor for the development of coronary artery disease. The presence of microalbuminuria, which indicates renal involvement in diabetic patients, influences the progression of coronary artery disease. New coronary risk factors such as C-reactive protein (CRP), Lipoprotein a [Lp (a)] and fibrinogen are increasingly being recognized as important cardiovascular prognostic factors. These new coronary risk factors could account for the worse cardiovascular prognosis in diabetic patients with microalbuminuria. Our cross sectional study was to compare the prevalence of elevated CRP and the levels of Lp (a) and fibrinogen between diabetic patients with microalbuminuria and those without microalbuminuria. Diabetic patients with overt coronary artery disease were excluded from the study. A total of 108 patients were recruited of which 57 patients had microalbuminuria and 51 were without microalbuminuria. There was no difference in the number of patients with elevated CRP between these two groups. There were also no significant differences in the mean values of Lp (a) and fibrinogen between diabetic patients with and without microalbuminuria. The inflammatory marker CRP and coagulopathy markers i.e. Lp (a) and fibrinogen seem not to be perturbed in diabetic patients with microalbuminuria.
The authors made a 3-year retrospective study of cases of tubo-ovarian abscess surgically treated in KK Women's and Children's Hospital. In the period studied (1998 through 2000), there were 36 such cases. A total of 11 patients underwent laparoscopic treatment while 25 patients underwent laparotomy. The study demonstrates the differences in the patient profile and the short term morbidity in each mode of surgical treatment and the changing trends in the surgical treatment of tubo-ovarian abscess.