Intestinal parasites of importance to man are Enterobius vermicularis, the soil-transmitted helminthes (STH)--Ascaris lumbricoides Tricburis trichiura, bookworms (Necator americans/Ancylostoma duodenale) and Strongyloides stercoralis and the protozoa Entamoeba histolytica and Giardia duodenalis. Other protozoa such as Cryptosporidium sp. and Isopora sp. are becoming important in causing prolonged diarrhea in immunocompromised patients. It is estimated that almost 1 billion, 500 million and 900 million people worldwide are infected by the major nematode species--A. lumbricoides, T. trichiura and hookworms respectively. Most of the infections are endemic and widely distributed throughout poor and socio-economically deprived communities in the tropics and subtropics. Environmental, socio-economic, demographic and health-related behavior is known to influence the transmission and distribution of these infections. In giardiasis, one study indicates that age < or = 12 years and the presence of family members infected with Giardia were risk factors for infection. Most of the infections occur in children and both genders are equally affected. Epidemiological studies of STH infections have shown that the prevalence and intensity of infection are highest among children 4-15 years of age. The frequency of distribution of STH infections is over-dispersed and highly aggregated. areas reinfection can occur as early as 2 months post-treatment, and by 4 months, almost half of the population treated become reinfected. By 6 months the intensity of infection was similar to pretreatment level.
One hundred primary TKR surgeries done between January 1994 and December 1999 were reviewed after a mean follow-up of 37.4 months. The rate of superficial and deep wound infection were 2% and 9% respectively. The most common organism in wound infection was Staphylococcus aureus. The factors that were significantly associated with superficial wound infection were diabetes mellitus (p = 0.005) and rheumatoid arthritis (p = 0.0000). The factors that were significantly associated with deep wound infection were diabetes mellitus (p = 0.000). There was no significant difference between duration of surgery, and the mean age among patients with and without wound infections.
A cross-sectional study to determine the prevalence of Human Immunodeficiency Virus (HIV) and HIV-associated risk behavior was conducted in February 1998 among 6,324 drug users in 26 drug rehabilitation centres in Malaysia. The majority of respondents were males (97.3%) and Malays (77.8%), administered drugs intravenously (64.6%) and of these 65.4% shared needles. About 78.1% had sexual exposure, of which 55.1% had sex with girl friends, 31.3% with prostitutes and 4.6% with male partners. The HIV prevalence rate in the group was 12.1% and significantly high among injecting drug users (IDU); those sharing needles; those who started addiction at a young age (10-15 years); those who had sexual exposures and had sex with prostitutes.
There is an increasing trend for Shigella isolates worldwide to be resistant to commonly prescribed antibiotics. The species distribution and antibiotic resistance of Shigella species isolated from children in Kuala Lumpur, Malaysia from 1978 to 1997 was reviewed. Three hundred and eighty six isolates were positive for Shigella species, representing 1.4% (95% CI: 1.3%-1.6%) of the 26320 total stool specimens and 13% (95% CI: 11.8%-14.2%) of 2986 isolates positive for bacterial pathogens. Shigella flexneri, constituting 74% of all isolates in the first five years of the study, decreased by 40% during the last five years (95% CI of decrease: 22.1%-57.9%), p-value < 0.0001) to 34%. There was a significant reduction (chi2 for linear trend = 77.6, p-value < 0.001) in the number of Shigella isolates as a percentage of total stool isolates obtained. 58% of the 241 isolates tested for antibiotic sensitivity were resistant to at least one antibiotic, and 42% wEre multi-resistant to three or more antibiotics. Shigella species was not a common pathogen among children admitted with diarrhoea in Kuala Lumpur, and was more likely to be resistant to commonly prescribed antibiotics.
The carriage and antibiotic susceptibility patterns of Staphylococcus aureus in the community were determined. Nasal, throat and axillary swabs were taken from 100 healthy adults and 90 disabled nursing home inmates. Antibiotic disc susceptibility testing was conducted following the NCCLS method. Staphylococcus aureus carriage was noted in 29% of healthy adults and 47.7% of nursing home inmates. Out of 79 strains, resistance to antibiotics were as follows; penicillin (92.4%), genetamicin (2.5%), tetracycline (6.3%), fusidic acid (11.3%), erythromycin (3.8%), pefloxacin (5.1%), mupirocin (3.8%), amikacin (3.8%), ciprofloxacin (2.5%) and chloramphenicol (2.5%). Methicillin-resistant Staphylococcus aureus was not isolated. Multiple colonizations and multi-antibiotic resistant Staphylococcus aureus were shown to occur in healthy individuals without risk factors and not previously hospitalized.
Allogeneic haemopoietic stem cell transplantation was initially considered as a means of delivering supralethal doses of chemotherapy with or without total body irradiation for the treatment of malignancy. However, it has become clear that this mode of therapy does not eradicate the malignancy in many patients and its benefit is largely due to the immune mediated graft versus malignancy effect. This has led to development of alternative strategy to utilize a less intensive preparative regimen pre-transplantation that provides sufficient immunosuppression to achieve engraftment of an allogeneic stem cell graft, thus allowing the evolution of a graft versus malignancy effect post-transplantation. Since September 1999, we had carried out 10 cases of allogeneic peripheral blood stem cell transplantation: one case of aplastic anaemia, four cases of acute myeloid leukemia (AML) in first remission, and five cases of chronic myeloid leukemia (CML) in chronic phase. The preparative regimen was non-myeloablative comprising Fludarabine with Cyclophosphamide or Busulphan. Recovery from transplantation was rapid with no or brief period of neutropenia or thrombocytopenia. Engraftment was established by determining donor's short tandem repeats in the recipient's bone marrow at day 30, 60 and 100 post-transplantation. Seven cases (70%) show partial or complete donor's chimerism by day 30 indicating successful engraftment. No treatment mortality was noted at day 100. Graft versus host disease was generally limited. Up to the date of reporting, two patients with CML had graft failure, one was successfully re-transplanted later. Two patients with AML had since relapsed and passed away. The others remain alive and well. The cost of transplantation on average was estimated to be about a quarter of that using a myeloablative regimen. It appears that this treatment strategy is a promising approach for the management of blood disorders.
The role of husband-wife communication in the practice of family planning was studied among the rural Malay couples in Mukim Rusila, Terengganu. It was a cross-sectional study in which a cluster sampling was used to select the study sample. A total of 193 (100.0%) wives and 74 (38.3%) husbands responded to a face-to-face interview. Visual Analogue Scale was used to measure the level of husband-wife communication. Husband-wife communication score was lower on family planning compared to other matters. There was a significant fair agreement on the scores between the husbands and the wives (p > 0.05) on family planning. There was a significant association between husband-wife communication on family planning and the current practice of family planning (p = 0.002). The 'likelihood' that couples who had had good husband-wife communication to practice family planning was about 2.8 times higher compared to those couples with poor husband-wife communication (95% C.I.: 1.4, 5.3). Further research need to be carried out, as the study was limited by certain constraints.
A prospective randomised study was done to assess the effect of supplemental oestradiol in addition to progesterone on the luteal steroid profiles and pregnancy outcome in stimulated cycles with and without pituitary down regulation. Women undergoing stimulated cycle IVF with GnRH-a and FSH (Group A, n = 63) or stimulated intrauterine insemination using CC and FSH (Group B, n = 55) were studied. These subjects were randomly allocated to receive either 400 mg daily of vaginally administrated Cyclogest (progesterone) alone or in combination with 2 mg daily of oral Oestradiol Valerate (E2V) during the luteal phase. Significant lower concentrations of plasma progesterone were observed in those subjects supplemented with both E2V and progesterone compared to those in whom progesterone only was given during the luteal phase (P < 0.05). Exogenous E2V had a minimal impact on plasma oestradiol concentrations and did not disguise the characterised mid luteal decline in oestradiol secretion. The suppressive effect of E2V on plasma progesterone was lost if implantation occurred normally because any small change in steroid concentrations was reversed by the rapidly increasing concentrations of HCG. Similar pregnancy rates were observed among subjects supplemented with or without oestradiol. The addition of oestradiol to the luteal supplement suppresses endogenous corpus luteum progesterone secretion irrespective of the type of assisted conception cycle and that its use is unlikely to be beneficial to the process of implantation.
Differentiating between Cushing's disease of pituitary origin and ectopic ACTH syndrome of extra-pituitary origin remains a major challenge to the clinician because of limitations in the diagnostic accuracy of the high-dose dexamethasone suppression test. Routine use of inferior petrosal sinus sampling (IPSS) is therefore advocated by some authors for these patients. We present our preliminary experience of IPSS in 7 consecutive patients with Cushing's disease and discuss how the results impacted on the patients' management.
This study was done to ascertain the knowledge and practice of medical officers on spirometry and management of COPD in a medical department of a state hospital. A total of 81 questionnaires with nine items were distributed to medical officers in the medical department (MD) and in other departments (controls). Eight incomplete questionnaires were rejected. In all 15 (21%) respondents were analysed from MD and 58 (79%) from the control group. The respondents from MD were aware that spirometry was important in COPD (100% versus 69%, P < 0.01) but in practice both groups were as likely to use peak expiratory flow rate. Respondents from MD were more likely to treat mild COPD (73% versus 12%, P < 0.001) according to Malaysian Thoracic Society COPD guidelines and also more likely to perform steroid trial (93% versus 37%, P < 0.001). Only 9 (60%) from MD and 33(57%) would refer patients for home oxygen assessment. This preliminary survey suggests that there was lack of translation of knowledge into practice particularly in terms of use of spirometry in COPD as well as lack of awareness for home oxygen assessment. A bigger survey involving all doctors in the state to answer issues raised in this preliminary survey is being conducted.
Epstein-Barr virus (EBV) is believed to have a pathogenic role in lymphomas of the upper-aerodigestive tract. This study aims to elucidate the virus association pattern in nasal and nasal-type NK/T-cell lymphomas, and in sequential biopsies of these tumours. A total of 31 cases of previously diagnosed as lethal midline granuloma. Stewart's granuloma, nasal T-cell non-Hodgkin's lymphoma (T-NHL) and NK/T-cell lymphomas from all anatomical sites were retrieved from the files for the study. Reviews of these cases confirm 8 nasal T-NHL, 19 nasal and 4 extranasal lymphomas of NK/T-cell phenotype from 10 Malays, 18 Chinese, 2 Indian and 1 Kadazan. The male: female ratio was 2.4: 1. All T- and NK/T-cell lymphomas strongly expressed TIA-1 and 63% expressed CD2. The majority of NK/T-cell lymphoma occurred in Chinese (13/23), of which 12/13 (92%) of these cases were associated with EBV. Of the 15 nasal and 9 tonsillar B-cell lymphomas included for a comparison study, only 3 (20%) of the nasal cases were associated with EBV (1 male Chinese, 1 female Chinese and 1 male of other ethnic group). Eight cases of NK/T-cell tumours with sequential biopsies show persistence of EBV, irrespective of the interval and sites of subsequent presentations. This study confirms the cytotoxic nature of NK/T-cell tumour and that EBV is strongly associated with the disease regardless of the anatomical site of presentation and ethnicity. However, nasal and paranasal lymphomas of all phenotypes appear to show higher predilection of EBV association in the ethnic Chinese when compared to non-Chinese.
The missense mutation of the methylenetetrahydrofolate reductase (MTHFR) gene 677C-->T is associated with modest elevation of homocysteine levels. The bio-ecogenetics factors of total homocysteine levels (tHcy) were investigated in a cross sectional study involving 53 randomly selected healthy Malay subjects. Results indicated that the prevalence of the homozygous 677T/T was 3.8% and heterozygous 677C/T was 17.0%. The levels of tHcy was higher in subjects aged more than 50 years (n = 7, 11.53 +/- 4.45 mumol/l) and in males (10.99 +/- 3.77 mumol/l) especially smoking males (12.19 +/- 3.62 mumol/l). THcy levels were low in the 3 pregnant subjects (4.44 mumol/l, p = 0.036) who were under folate supplementation.
This is the first investigation performed to detect the presence of the p53 mutation in Malay patients with gliomas. The p53 gene was amplified using polymerase chain reaction (PCR) from 33 fresh-frozen tumour tissues from patients histologically confirmed as glioma. Four hot spot areas that lie between exon 5 to 8 were screened for mutation by mean of non-isotopic "cold" single strand conformation polymorphism (SSCP) analysis and direct sequencing. The frequency of p53 gene mutation in gliomas examined was 33% (11 of 33). Five (45.5%) cases had mutation in exon 7, four (36.4%) had mutation in exon 8 and two (18.1%) had mutation in exon 6. Seven (63.6%) of 11 mutations were single nucleotide point mutations of which 5 were missense mutations, 1 was nonsense mutation and 1 was, silent mutation. Three (27.3%) showed insertion mutation and 1 (9.1%) showed deletion mutation. Of the point mutations, 57.1% were transitions and 42.9% were transversions. These results suggested that p53 mutations frequently occur in gliomas and this gene does play an important role in the tumourigenesis process of Malay patients with brain tumours.
Aerodigestive amyloidosis is a rare disorder characterized by fibrillar protein deposition in the aerodigestive tree. We present a case of a 19-year-old Chinese gentleman whose diagnosis was initially missed as he presented with features suggestive of severe bronchial asthma and was intubated and ventilated. He subsequently presented 2 years later with severe stridor and required emergency tracheostomy. Current literature is reviewed for the histopathology, common clinical features, radiological findings and treatment options for aerodigestive amyloidosis.
A six-week-old male infant was admitted for investigation of cholestasis and pale stools. He became lethargic and apnoeic with prolonged seizures after a percutaneous liver biopsy. Subsequent investigations showed conjugated hyperbilirubinaemia, elevated liver enzymes, and hypoglycaemia. The radinuclide hepatobiliary scintigraphy was non-excretory. After an operative cholangiogram, the infant developed Addisonian-like crisis with bradycardia, hypotension, respiratory distress, metabolic acidosis, hypoglycaemia, hyponatraemia, and hyperkalaemia. Blood investigations confirmed congenital hypopituitarism. Hormone replacement therapy with L-thyroxine and cortisone acetate resulted in dissolution of jaundice and the reduction of the liver size.
A series of 31 consecutive parotidectomies was evaluated. FNAC could differentiate tumour from non tumour in 72.8% of cases. For actual histology, FNAC was correct in 66.6%. Frozen section was correct in differentiating between benign, malignant and inflammatory conditions in all cases. Eighty-eight percent of frozen section histology concurred with final histology. The immediate postoperative period had 13 cases of facial nerve dysfunction, but only 3 cases had residual weakness. The branch most commonly affected was the mandibular branch (92.3%). Two patients had Frey's syndrome and one had a traumatic neuroma. FNAC and CT scans improve preoperative planning, providing histological evidence and the extent of the lesion.
Two patients who had acute pancreatitis subsequently developed characteristic appearance on urography of smooth extrinsic narrowing and medial deviation of the right ureter suggestive of retroperitoneal fibrosis (RPF) resulting in ureteric obstruction. Both these patients had clinical, biochemical and sonographic evidence of acute pancreatitis. CT scan of the abdomen performed on the second patient also documented acute pancreatitis. Intravenous urograms were consistent with ureteric obstruction due to retroperitoneal fibrosis. Both cases were treated conservatively. They were well after an average of 20 months. These 2 cases illustrate the uncommon association between pancreatitis and RPF.
Rhinosporidiosis is a chronic granulomatous disease of the mucous membrane, predominantly of the nose and nasopharynx. It is uncommon in Malaysia but has been seen in immigrant workers from endemic areas like India and Sri Lanka. A case seen in Johor is reported here to highlight the need of awareness among clinicians at a time where there is increasing numbers of immigrant workers in our country. The causative organism of this disease is Rhinosporidium seeberi, which is found in stagnant waters. Sporangia and endospores of R. seeberi are seen in the granulomatous polypoidal lesions. The patients commonly present with epistaxis and nasal blockage. Complete excision is the treatment of choice for this disease. Recurrences are common despite anti-microbial treatment.