We describe the outcomes on haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) provided by the Ministry of Health (MOH). The assessment was based on data from the Malaysian Dialysis Registry on 2480 HD and 732 CAPD patients who commenced dialysis between 1980 and 1996. Young patients (age < 40) have remarkable long term survival (life expectancies of 16 years on HD, 18 years on CAPD). Adjusting for background mortality, relative survival of older patients was as good as younger ones. Diabetics did poorly. 52% of HD and 26% of CAPD patients were employed in 1996. 71% of HD patients scored 10(normal) on QL index (a measure of quality of life) while 60% of CAPD patients have similar score. Differences in rehabilitation and QL index scores by age, gender and diabetes were also observed. Outcomes of dialysis in the MOH programme are reassuring.
Severe, persistent back pain following back surgery is often referred to as Failed Back Surgery Syndrome (FBSS). Conservative measures such as physiotherapy, back strengthening exercises, transcutaneous electrical nerve stimulation and epidural steroids may be inadequate to alleviate pain. Spinal Cord Stimulators were implanted into two patients suffering from FBSS. Both patients responded successfully to spinal cord stimulation with reduction of pain and disability.
Much has been said in various anaesthetic journals about the need to teach medical undergraduates in areas such as basic life support skills and resuscitation. Anaesthesiology as a specialty can contribute significantly in this aspect of teaching. The question is how should it be incorporated into the existing curriculum, given the fact that anaesthesiology constitutes a minor role in the undergraduate medical curriculum? This article attempts to answer this question and proposes the possible integration of anaesthesiology with the other major clinical specialties. This curriculum forms the basis of anaesthesiology curriculum at the Kulliyah of Medicine, International Islamic University Malaysia (IIUM).
The management of a case of antenatally diagnosed meconium peritonitis (MP) due to intrauterine intestinal perforation secondary to bowel atresia is reported. The literature is reviewed with reference to the significance and outcome of antenatally diagnosed MP.
There are a number of differential diagnoses for crystal deposits in the cornea. With the presence of a corneal epithelial defect, the differential diagnosis can be narrowed down to either infective causes or deposits from topical medications. This report describes a case of crystal deposits in the cornea from the use of Vitamin C eye drops.
Pericardial rupture after blunt chest trauma is described in the literature. This case report summarises our experience with a 22-year old male patient who suffered blunt chest trauma during a motor vehicle accident. On admission no serious injuries could be detected, but 3 hours later, displacement of the heart to the right hemithorax combined with sudden cardiac failure appeared. Emergency thoracotomy revealed a right-sided rupture of the pericardium with complete herniation of the heart into the right pleural cavity and consequent strangulation by the margins of the pericardial defect.
Swyer-James-MacLeod syndrome is a rare complication of respiratory tract infection occurring in early childhood. We report two children with chronic cough and recurrent wheezing who fulfilled the diagnostic criteria for this disorder: 1) Unilateral loss of lung volume with hyperlucency on chest x-ray. 2) Unilateral reduction in vascularity on CT scan of the chest. 3) Unilateral loss of perfusion on Technetium 99c lung scan.
A 56-year-old Chinese lady with valvular heart disease and atrial fibrillation was referred to us from a private hospital for further management of autoimmune haemolytic anaemia. Physical examination and laboratory investigations did not support the diagnosis of haemolytic anaemia. However, direct antiglobulin test (DAT) was strongly positive with anti-IgG and negative with anti-C3d. There was also mild anaemia and reticulocytosis, which was attributable to persistent haematuria. The DAT became positive after commencing Unasyn and cessation was associated with decreasing reactivity of the positive DAT. We believe that the positive DAT in this patient was most likely due to the Unasyn therapy.
This is a case report of an unusual case of a patient with dextrocardia and "situs inversus totalis" who presented with unstable angina. Coronary angiography revealed severe main stem and severe triple vessel coronary artery disease. The patient later underwent successful emergency coronary artery bypass graft surgery. To the authors' knowledge this is the first reported case in Malaysia and also, the first ever report in the literature of multiple vessel coronary artery grafting, including the use of the right internal mammary artery.
A 52 year old hypertensive Malay man, a smoker who presented with a one month history of mild chest discomfort not related to exertion and had a positive stress test with ST segment depression in the lateral leads. Coronary angiography showed stenosis in the right coronary artery and a coronary aneurysm in the proximal segment of his left anterior descending. The aneurysm was situated just distal to a stenotic lesion. The aneurysm is most likely related to atherosclerotic coronary artery disease. The patient was treated with oral nitrates, aspirin, angiotensin converting enzyme inhibitor and warfarin to prevent thromboembolism related to the coronary aneurysm. He remains asymptomatic one year after diagnosis.
A two years retrospective analysis of patients diagnosed as contact allergic dermatitis with positive patch test attending the Dermatology clinic was performed. Of the 346 patients with a positive patch test, 14% had occupational dermatitis. This condition affected mainly young and inexperienced workers. An inverse relationship was seen between age and prevalence of occupational allergic dermatitis. Allergic hand dermatitis was the commonest presentation in occupational allergic dermatitis. This was followed by dermatitis of the exposed skin (face, neck, hands and forearms). The common sensitising agents identified were rubber chemicals and nickel. The two main groups at risk were factory workers and medical personnel. The common allergens found in factory workers were epoxy resin, pewter, nickel and rubber chemicals. Exposure dermatitis occurred in patients working in the pewter industry. Two thirds of medical personnel with hand dermatitis were allergic to rubber gloves. One year follow up after patch testing showed that 19% of patients still suffered from chronic dermatitis. Dermatitis improved in 34% of patients. Forty-seven percent were cured and stopped attending the clinic after patch testing and adequate counselling.
Study site: Dermatology Clinic, Hospital Kuala Lumpur
Patients with upper airway obstruction from malignant disease are difficult to manage. A 62 year old patient presented with stridor and was found to have an upper tracheal tumour. Bronchoscopy, dilatation and stenting were performed successfully. The techniques and indications for the use of dynamic airway stent are discussed.
We describe a 2 year-old non-immunocompromised girl with disseminated histoplasmosis who presented with a 2-month history of fever and bloody diarrhoea. On presentation, she was severely wasted and anaemic. There were gross hepatosplenomegaly and multiple lymphadenopathy. A septic screen was negative. A subsequent stool culture isolated Salmonella enteriditis. Serial Widal-Weil Felix (WWF) titres showed serological response after 2 weeks of Ceftriaxone. However, she continued to have spiking fever, bloody diarrhoea and weight loss. She developed pancytopaenia and disseminated intravascular coagulation. A bone marrow aspirate and trephine, and lymph node biopsy showed the presence of Histoplasma capsulatum, confirmed by Gomori-Methenamine Silver staining. She responded to intravenous amphotericin B followed by fluconazole (intravenous then oral) for 6 months after discharge. Human Immunodeficiency Virus screening tests were negative. Complement and immunoglobulin levels were normal. T and B enumeration tests showed gross leucopaenia with very low T cell function with defective phagocytic function. A repeat T and B cell enumeration test and phagocytic function tests done 3 months later were normal.
We surveyed parents of school-aged hearing impaired children to investigate their awareness and knowledge of the special needs of their child, especially in the area of the usage of hearing aids and methods of communication. Questionnaires were distributed to parents of hearing impaired children at 13 special schools for the deaf in Malaysia. Out of 1,267 questionnaires given out, 787 (62.1%) were completed and returned. Results of the survey indicated the majority of parents (68.6%) suspected hearing loss late, that is after their child's first birthday, and there was a significant time lag before the suspicion was confirmed. Over 82.8% of the children were diagnosed only after 1 year of age, with 41.3% being diagnosed after 3 years of age. Hearing aids were fitted late (mean = 5.32 years; SD = 2.66). Hearing aid ownership was influenced by the factors of socio-economic level and ethnic group (p < 0.01) whereas knowledge of use and proper care of the aids was influenced by socio-economic level (p < 0.01). Communication methods were generally inappropriate with 41.3% of the mothers and 48.5% of the fathers reporting ignorance of Bahasa Malaysia Kod Tangan, the sign language that is commonly used by their children. The parents' choice of communication method was not significantly influenced by socio-economic level or ethnic group. The study revealed the present inadequate state of services available for the rehabilitation of children with congenital hearing impairment.
Ignorance is not bliss when it comes to sexuality. Psychosexual problems lead to shame, fumbling, needless fears, low-self esteem and even subfertility. The demands for help appears to be increasing; as the general population become more aware of its presence and the treatment options available through the mass media and better health education. Sex therapy has traditionally been the realm of the psychiatrist but with the gynaecologist as the first contact for most women, the number of women seeking advice directly from their doctors will only increase with time. A total of 243 new cases of sexual dysfunction were treated at the sexual problem clinic in Kandang Kerbau Hospital between January 1994 and November 1996; majority of which were self-referrals (48.5%). The patient pool consisted of more males than females although the clinical setting is in an obstetrics and gynaecology teaching institute. Vaginismus and erectile problems constituted the main complaints. Erectile problems are more common in the patients above 40 years old (p < 0.001). We report here our experience of such a sexual problem clinic and hope to provide insight into this area of medicine from the perspective of a practising gynaecologist.
A 10-year follow-up of children having exanthem subitum (ES) seen in an outpatient paediatric clinic, Kuala Lumpur, Malaysia shows that uvulo-palatoglossal junctional (UPJ) ulcer is a reliable early clinical sign of ES. During this period, 1,977 children (1,086 males, 891 females) had adequate follow-up from the age of 3 months to 24 months old. 897 children (478 males, 419 females) were noted to have UPJ ulcers. Of these 897 children, 855 (459 males, 396 females) presented with the classical clinical features of ES of maculopapular rash following 3 to 4 days of fever. The positive predictive value and the negative predictive value of UPJ ulcers in the clinical diagnosis of ES are 95.3% and 100% respectively. Among the 855 children with clinical features of ES, a provisional diagnosis of ES could be made in 781 children during the pre-eruptive phase by the presence of the UPJ ulcers. The other 74 children already had the rash at the time of consultation at the clinic. The peak age of occurrence of ES was 6 months old with 98.2% of the total cases of ES seen between the age of 4 and 12 months. There was no significant gender difference in the incidence of ES nor any seasonal variation. Mild to moderate diarrhoea was the other commonly associated clinical feature which usually presented from the third febrile day onwards.
Study site: Paediatric clinic, Assunta Hospital, Petaling Jaya, Selangor, Malaysia
From January to December 1992, 92 babies weighing 1000-1499 gm here to referred as very low birth weight (VLBW) were admitted to NICU (Neonatal Intensive Care Unit), Hospital University Sains Malaysia (HUSM). Sixty babies were inborn giving a VLBW rate of 7.5 per 1000 live births. Incidence of nosocomial sepsis was 32.6% (30/92) of whom 43.3% (13/30) died. Eighty percent (24/30) of the septic babies had blood culture positive for gram negative organisms of which 40% (12/30) were sensitive only to imipenem. Ventilator support within 24 hours of life was required in 41.3% (38/94) babies of whom 42% (16/38) babies developed nosocomial sepsis. Delayed initiation of feeding was significantly associated with nosocomial sepsis. A strict asepsis policy and early feeding of the VLBW infant are essential components of any strategy to prevent of sepsis due to nosocomial infection.
A total of 155 consecutive anaesthetics in three public Malaysian hospitals were prospectively studied to assess preoxygenation practices by their anaesthesia providers. Preoxygenation was practised in 96.1% of patients. Specialist and non-specialist anaesthesiologist did not preoxygenate 8.8% and 2.3% of their patients, respectively. Overall incidence of arterial oxygen desaturation during induction was 15.5%. Arterial oxygen desaturation occurred more frequently with emergency surgery (30.2%) in comparison to elective surgery (9.8%). Arterial oxygen desaturation occurred more frequently with non-specialist (18.9%) than specialist anaesthesia providers (3.0%).