Hickman catheters have previously been conventionally placed by surgical dissection. This usually performed by experienced surgeons and is carried out under general anaesthesia. We report our preliminary experience in Hickman catheter placement by percutaneous technique in twenty patients. We outline the implantation methods and complications encountered by this technique. The procedure is relatively simple provided the operator is skilled in central venous cannulation. The chief advantages are that the procedure can be done under local anaesthesia and results in less trauma compared with surgical dissection. Such an alternative in catheter insertion would promote wider usage of Hickman catheters in cancer patients.
A study to determine contamination of diluted disinfectants at different points in preparation and use in 6 Malaysian hospitals was done using the in-use test. A growth of > or = 250 organisms/ml was taken as an indication of contamination. A total of 342 (7.9%) of the 4316 freshly diluted samples collected from disinfectant bottles in the pharmacy were found to be contaminated. The bacterial isolates obtained were Pseudomonas spp. (42.4%), Moraxella spp. (22.0%), Flavobacterium spp. (11.6%) and Enterobacter spp. (4.2%). Three hundred and sixty seven out of 2278 ward stock were contaminated. The isolates were Pseudomonas spp. (48.6%), Moraxella spp. (17.8%), Acinetobacter spp. (8.9%) and Flavobacterium spp. (7.0%). Of the 9265 disinfectants in-use, 1519 (16.4%) were contaminated. Among the organisms isolated were Pseudomonas spp. (44.3%), Bacillus spp. (13.0%), Enterobacter spp. (9.5%) and Acinetobacter spp. (7.3%). The results indicated a high level of contamination of diluted disinfectants prepared in the pharmacy, stored and used in the wards. This gave a high index of suspicion that recommendations for cleaning of disinfectant containers before refilling, handling of diluted stock solutions and using of disinfectants were not closely adhered to. Standard disinfection procedures outlined in the disinfection and sterilization policy by the Ministry of Health should therefore be followed.
A retrospective study was carried out on 42 patients (38 males, 4 females, mean age 25.9) with liver injury at the University Hospital, Kuala Lumpur from 1994 through to 1991. Prognostic factors that might help to identify those patient survival was related to pulse rate on arrival ( < or = 120 beats per minute, p = 0.027), systolic blood pressure at induction of anaesthesia ( > or = to 80 mmHg, p = 0.003) and intraoperative blood transfusion of < or = to 4 units (p = 0.05). This data were supported by the 95% confidence interval suggesting that these factors may be strong prognostic indicators individually. Increased mortality was also associated with increased total blood transfused (p = 0.002) and grade of liver injury (p = 0.02). Although the factors we have identified reflect both the severity of injury and resuscitative and surgical efforts, further studies using a prospective design are required to confirm these findings.
This study evaluated the efficacy and safety of endoscopic pneumatic balloon dilatation as the initial treatment for achalasia of the cardia. 15 patients with achalasia underwent a total of 19 dilatations using the new polyethylene dilator (Microvasive Rigiflex Balloon Dilator) over the last 6 years. An overall treatment success rate of 93% was achieved. 11 patients (73.3%) have not required a further dilatation and 3 patients (20%) required between 1 and 2 further dilatations. Elective surgery was necessary in 1 patient. The mean follow-up period was 31.5 months. There was no complication or death attributable to the procedure. Endoscopic pneumatic balloon dilation is a safe and effective treatment for achalasia and should be considered as the initial treatment of choice in most patients with achalasia.
Five cases of spontaneous pneumothorax were treated with video-assisted thoracoscopic surgery (VATS). These included four cases of recurrent pneumothorax and one case of persistent pneumothorax. The mean age was 33 years. The identified bullae were eliminated with either endoloop ligation (in one patient) or stapled excision (in four patients). There were no recurrences reported in a mean follow-up of 9.4 months. In conclusion, VATS offers an equally effective and less morbid alternative to open thoracotomy in the management of primary spontaneous pneumothorax.
Phenylephrine in concentrations of either 2.5% or 10% is widely used as a mydriatic agent in ophthalmic surgery. Its potential cardiovascular effects are seldom recorded as ophthalmic surgery is not usually monitored by an anaesthetist. A prospective randomised double blind study was carried out in 89 consecutive cases of uncomplicated cataract surgery in the presence of an anaesthesiologist ensuring the continuous monitoring of blood pressure, heart rate, electrocardiography and pulse oximetry. All these patients were given a drop of either normal saline, 2.5% or 10% phenylephrine in addition to mydriacyl prior to surgery. Blood pressure readings were found to be significantly higher in non-hypertensive patients receiving phenylephrine at the start of the operation and at five, 10, 15 and 20 minutes intra-operatively and the first three hours post-operatively. Blood pressure readings in hypertensive patients, on the other hand, were also found to increase after phenylephrine administration, though not statistically significant. 10.3% of the 10% phenylephrine group and 3% of the 2.5% phenylephrine group required intraoperative intravenous hypotensive agent to control the blood pressure. There were no arrhythmias or ischaemic changes observed intraoperatively. None of the patients complained of palpitation, headache or chest discomfort. There was no oxygen desaturation observed. We concluded that significant hypertensive effects can arise after phenylephrine eye drop administration. Hence, it should be used cautiously with intraoperative monitoring of the cardiovascular status during cataract surgery.
A total of 209 randomly selected Malaysian university students (128 from Universiti Kebangsaan Malaysia, 81 from the University of New South Wales) completed a self-filled questionnaire enquiring about their smoking behaviour and psychosocial characteristics. The prevalence of smoking was 26.6 per cent among students in Malaysia and 18.8 per cent among students in Australia (average 23.4%). Both samples have similar patterns in terms of age of starting smoking, time of the day when they smoked, family and peer history of smoking, and whether or not they inhaled deeply during smoking. The smokers tend to be male, studying beyond the first year, staying with peers outside the hostel, having financial sources other than a scholarship, and abnormal mental health score. However, the smokers from the Australian samples were noted to smoke less and made fewer attempts at quitting the habit.
Three millilitres of plain 0.5% bupivacaine were injected intrathecally at two different spinal interspaces (L2/3 and L4/5) and at two different speeds (15 and 30 sec) in four groups of ten patients. Injection at L2/3 over 15 sec produced a significantly higher mean maximum spread of analgesia (T6.4) when compared to injection at L4-5 over 15 sec (T10.3) (P < 0.05). Over the same interspace L2/3, injection over 15 sec also produced a higher level of spread as compared to the 30 sec group (p < 0.05). At 15 min there was a greater fall in blood pressure in the L2/3 15 sec group when compared to the other groups (p < 0.01). There was a further decrease in the blood pressure in L2/3 15 sec and L4/5 30 sec groups after 30 minutes of blockade (p < 0.01). Therefore close monitoring of cardiovascular parameters must be continued for at least 30 min in spinal anaesthesia with bupivacaine.
The intraoperative localisation of small intestinal bleeding lesions identified at pre-operative angiography has always been difficult, resulting in extensive resections in doubtful cases. We report two patients in whom, at angiography, a small intestinal lesion was noted to be the cause of gastrointestinal haemorrhage. They then underwent superselective mesenteric arterial cannulation at a second angiographic procedure and were operated upon with the angiographic catheter left within the branch responsible for the bleeding. This superselective catheter placement facilitates precise localisation of the bleeding site intraoperatively, enabling limited segmental resection of bowel. Both patients have had no recurrent bleeding episodes.
We report a case of left pulmonary artery sling in a child who also had duodenal atresia. He was admitted for respiratory failure requiring prolonged respiratory support due to a bronchiolitis-like illness at two months of age. Diagnostic procedures confirmed the presence of left pulmonary artery sling. He had a corrective procedure which relieved the compression. However postoperatively he had intermittent episodes of severe bronchospasm in addition to a persistent airway obstruction. Finally one such episode of severe bronchospasm did not respond to medical and resuscitative therapy and the baby succumbed. To our knowledge no case of left pulmonary artery sling has been described previously in a Malaysian child. This case also highlights the postoperative airway problems that may be encountered.
Primary lymphangiomyomatosis is a benign tumour of lymphatic channels and lymph nodes, clinically manifested by chylous ascites. This disease is usually progressive and unresponsive to surgery, chemotherapy or irradiation. A case of a 36-year-old lady with chylous ascites due to underlying primary lymphangiomyomatosis is reported.
A 10-year-old girl presented with progressive dystonia with diurnal fluctuation. Response to low dose L-Dopa was dramatic and sustained with no complications. Recurrence of symptoms was observed on attempted withdrawal. Because of the dramatic response to therapy, dopa-responsive dystonia must be considered in the differential diagnosis of disorders presenting as gait disorders in childhood.
A cross-sectional study on a normal clinical myopic population reveals that there is a difference in the pattern of myopic progression between Malays and Chinese in Malaysia. It shows that while myopia in Malays stays relatively constant throughout 10 to 50 years of age, myopia in Chinese progresses rapidly from 10 to 20 years of age, after which it starts to show hyperopic shift, reaching a level of myopia similar to that of Malays at around 35 years of age. In view of the above finding it is postulated that the difference in myopia between the two races may be due to excessive accommodation in Chinese, causing a temporary increase in crystalline lens power and hence an increase in myopia. Because the magnitude of myopia for both races for 10 +/- 1 years age group is relatively high, i.e. about -2.00 D, it is postulated that myopia in these ethnic groups may start much earlier than 10 years of age.
Circumstances surrounding accidental ingestion of poisons were investigated in families of 70 hospitalised children. Indian children were more likely to be hospitalised for poisoning. Poor safety measures directly contributed to poisoning incidents. Poisons had not been stored safely and only in 12.9 per cent of families were the poisons allegedly kept in cupboards. Kerosene had been ingested from soft drink containers in 70 per cent of instances. Medications had been taken mainly from plastic envelopes (57.9%) or bottles (31.6%). Safety practices in the homes of cases and 140 controls were compared. As a whole parents of victims had poor safety practices when compared with parents of controls. Poisoning incidents were discovered by mothers in 75.0 per cent of the cases. Vomiting was induced by parents in 32.3 per cent of cases involving medications and non-volatile items, and in 41.6 per cent of kerosene ingestions. Before hospitalisation 59.4 per cent were brought to general practitioners and 22.7 per cent to government clinics. Mothers were the main attendants when children were brought for medical care. This study highlights the need for measures to prevent childhood poisoning and reduce its morbidity. Household products and medications should be made safer to children through improved packaging, prescribing instructions and education. Safety and first aid education may be directed towards parents, particularly mothers, through the media and health facilities.
2,124 cases of cancer diagnosed and/or treated in Penang between 1987-1990 were reported to the National Cancer Registry of Malaysia by hospitals in Penang. 1,762 met the criteria for Penang incident cases first diagnosed between 1987-1990, and were the subjects on which all subsequent analyses were based. 85 per cent of case notifications were from Mount Miriam Hospital. Among males, all-site cancer incidence rates (age-standardised) were highest among Chinese, and lowest among Malays. Among females, the Indian female incidence rate was highest, higher than that of any other ethnic-gender sub-group. Site-specific cancer rates varied according to ethnicity and gender, but overall the four most frequent cancers reported from Penang were breast, lung, cervix and nasopharynx cancers. It needs to be emphasised that all these results are highly tentative since they are based on notified cancer occurrences and hence are very uncertain proxies for true cancer incidence. Based on incidence rates from the Singapore Cancer Registry (1978-1982), the expected number of incident cases in 1989 for Penang (Malays, Chinese and Indians combined) was 1,561. The number notified to the National Cancer Registry was 496. This underlines the tentative nature of this analysis of the returns for 1987-1990 from Penang.
A total of 250 hepatitis B surface antigen positive sera were screened for antibody to hepatitis B surface antigen. It was found that seven (3%) sera showed concurrently circulating surface antigen and surface antibody to hepatitis B virus. The level of antibody to surface antigen was not affected by HBeAg and most of the cases were found in chronic hepatitis B carriers.
A case report of an ingested fish bone migrating to the subcutaneous tissue in the neck is presented. During its course of migration there was no significant morbidity. The usual management is to locate the foreign body and remove it. A review of the literature indicates that this is evidently a rare case.
The overall mean birth weight of the total deliveries (1986-1988) in Lundu Hospital was 2.96 kg. The mean birth weight for the male babies was 2.94 kg. The Chinese babies had a significantly higher mean birth weight (3.12 kg) than the other ethnic groups (p < 0.05). The overall incidence of low birth weight (LBW) in this study was 11.84 per cent. The Chinese again had a lower incidence of LBW of 6.73 per cent compared to Ibans who had the highest incidence of LBW, 13.59 per cent, with the Bidayuhs 12.97 per cent and Malays, 12.45 per cent. It was also noticed that of the 14.9 per cent preterm deliveries, 37.5 per cent were LBW. The very young mothers (15-19 years) and older mothers (> 40 years) seem to have a higher incidence of LBW. Mothers who had medical conditions like anaemia, hypertension, pre-eclampsia also had a higher incidence of LBW when compared to mothers who did not have a medical condition. Special emphasis should be given to mothers who have medical conditions, and to very young and very old mothers during antenatal care, to prevent incidence of LBW.
Comment in: Chia CP. Low birth weight babies. Med J Malaysia. 1995 Mar;50(1):120