We present a case of a middle-aged man who was incidentally found to have right renal solid mass while investigating for his left eye proptosis. Computerised tomography (CT) scan confirmed the diagnosis of renal cell carcinoma and the tumour was successfully excised via open surgery. The histopathology examination revealed the 10x7x8 cm mass to be a clear cell type renal cell carcinoma. The rare presentation of this metastatic renal cell carcinoma, its diagnosis and management will be discussed.
Chlorhexidine is labelled as hidden allergen as the health care professionals (HCPs) are unaware of the wide range of products containing chlorhexidine. Adverse events from chlorhexidine allergy can be reduced by appropriate perioperative management especially heeding on positive history during preoperative assessment, awareness regarding this hidden allergen, and educating HCPs on possible chlorhexidine-containing products. The regulatory agencies all over the world have issued recommendations regarding safety and risk of hypersensitivity reactions with chlorhexidine-containing products. The onus lies on HCPs to disseminate this knowledge to the stakeholders. We present a brief update to combat chlorhexidine allergy in perioperative setting.
The aim of this study was to examine the relationship between the level of stress experienced by rescue workers after the collapse of a 13 story condominium in Kuala Lumpur, and other probable risk factors. Within a month of the incident, 123 firefighters filled up the Impact of Life Event score (Horowitz) and the General Health Questionnaire (GHQ). The results indicated that 7 (6%) firemen could be classified as possible 'cases' on the GHQ, and significantly 5 from this group also scored highly on the impact of events score. No other risk factors were identified in the firemen. On conclusion, the GHQ can be used to screen those with high impact scores to pick up possible cases early enough, so that intervention can be successful.
A total of 356 doctors responded to a survey on the timing and stability of choice of medical specialty. The majority of doctors made their final decision while working as a medical officer. One hundred (48.5%) of the doctors had made an earlier choice as medical students, 63 (30.6%) during their internship and 43 (20.9%) made their final choice while they were medical officers. Working experience in the specialty was the most important factor in determining final choice of specialty. Advice from consultants/seniors, better financial prospects and parental influence were more important for the male doctors while marriage and family considerations were more important for the female doctors in making their final choice.
There is a resurgence of tuberculosis globally but lesions affecting the skull are rare. Cases reported are of single, focal lesions as seen on plain x-rays. We report a 34 yearold patient with tuberculosis of the skull where multiple punched out lesions are seen, mimicking that of multiple myeloma.
We report a case of a previously healthy 38-year old lady who presented with prolonged fever and hepatosplenomegaly. Intensive investigations were performed for pyrexia of unknown origin which revealed negative. CT scan of the abdomen showed multiple hypodense lesions which did not respond to broad-spectrum antibiotics. Percutaneous biopsy of the splenic lesion revealed granuloma formation and Langhan's giant cells suggestive of TB. She responded well with anti- TB medication but required extended treatment duration of 24 months due to persistence of the splenic lesion on repeated CT scans. This case illustrates a very rare clinical entity of isolated splenic TB with a therapeutic dilemma following incomplete resolution, despite prolonged treatment.
AIM: This study was performed to determine the accuracy of ultrasound (USG) as compared to mammography (MMG) in detecting breast cancer.
METHODS: This was a review of patients who had breast imaging and biopsy during an 18-month period. Details of patients who underwent breast biopsy were obtained from the department biopsy record books and imaging request forms. Details of breast imaging findings and histology of lesions biopsied were obtained from the hospital Integrated Radiology Information System (IRIS). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of USG and MMG were calculated with histology as the gold standard.
RESULTS: A total of 326 breast lesions were biopsied. Histology results revealed the presence of 74 breast cancers and 252 benign lesions. USG had a sensitivity of 82%, specificity of 84%, PPV = 60%, NPV = 94% and an accuracy of 84%. MMG had a sensitivity of 49%, specificity of 89%, PPV = 53%, NPV = 88% and an accuracy of 81%. A total of 161 lesions which were imaged with both modalities were analyzed to determine the significance in the differences in sensitivity and specificity between USG and MMG. Sensitivity of USG (75%) was significantly higher than sensitivity of MMG (44%) (X(2)1=6.905, p=0.014). Specificity of MMG (91%) was significantly higher than specificity of USG (79%) (X(2)1=27.114, p<0.001). Compared with MMG, the sensitivity of USG was 50% (95% CI 10%-90%) higher in women aged less than 50 years (X(2)1=0.000, p=1.000) and 27% (95% CI 19%-36%) higher in women aged 50 years and above (X(2)1=5.866, p=0.015). Compared with MMG, the sensitivity of USG was 40% (95% CI 10%-70%) higher in women with dense breasts (X(2)1=0.234, p=0.628) and 27% (95% CI 9%-46%) higher in women with non-dense breasts (X(2)1=4.585, p=0.032).
CONCLUSION: Accuracy of USG was higher compared with MMG. USG was more sensitive than MMG regardless of age group. However, MMG was more specific in those aged 50 years and older. USG was more sensitive and MMG was more specific regardless of breast density. In this study, 20% of breast cancers detected were occult on MMG and seen only on USG.
OBJECTIVE: Contrast-enhanced ultrasound has become increasingly utilised as an alternative imaging modality for the diagnosis of vesicoureteric reflux (VUR) in paediatric patients. The study objective is to evaluate the efficacy of contrast enhanced Voiding Urosonography (ce-VUS) compared with fluoroscopic micturating cystourethrography (MCU) in the detection of VUR.
METHODS: This prospective study was carried out between July 2011 and January 2013 on paediatric patients who underwent MCU. All consented patients would undergo ce- VUS prior to MCU. We documented the epidemiology details, the number of Kidney-Ureter (K-U) unit studied, baseline renal and bladder sonogram, as well as presence of VUR on ce-VUR. The technique for ce-VUS was standardized using normal saline to fill the bladder prior to administration of SonoVue® (2.5 ml) to assess the kidney-ureter (K-U) unit. Dedicated contrast detection software was used to discern the presence of microbubbles in the pelvicaliceal system (PCS). The findings were then compared with MCU.
RESULTS: 27 paediatric patients were involved in the study [17 males (63%) and 10 females (37%)] involving 55 K-U units (one patient had a complete duplex system). MCU detected VUR in 10 K-U units while ce-VUS detected VUR in 8 out of the 10 K-U units. There were 2 false negative cases (both Grade 1) with ce-VUS. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of ce-VUS were 80%, 98%, 95%, 89% and 96%, respectively.
CONCLUSION: ce-VUS is a sensitive and specific radiation-free alternative for the detection of VUR in the paediatric population.
AIM: To determine the (i) sensitivity and specificity of ultrasound (USG) in the detection of urinary tract calculi, (ii) size of renal calculi detected on USG, and (iii) size of renal calculi not seen on USG but detected on computed tomography urogram (CTU).
METHODS: A total of 201 patients' USG and CTU were compared retrospectively for the presence of calculi. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value of USG were calculated with CTU as the gold standard.
RESULTS: From the 201 sets of data collected, 59 calculi were detected on both USG and CTU. The sensitivity and specificity of renal calculi detection on USG were 53% and 85% respectively. The mean size of the renal calculus detected on USG was 7.6 mm ± 4.1 mm and the mean size of the renal calculus not visualised on USG but detected on CTU was 4 mm ± 2.4 mm. The sensitivity and specificity of ureteric calculi detection on USG were 12% and 97% respectively. The sensitivity and specificity of urinary bladder calculi detection on USG were 20% and 100% respectively.
CONCLUSION: This study showed that the accuracy of US in detecting renal, ureteric and urinary bladder calculi were 67%, 80% and 98% respectively.
Study site: Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
OBJECTIVE: The aim of this study was to compare the use of semi-automated (Medax Velox 2; Poggio Rusco, Italy) and automated (Bard Magnum Biopsy Instrument; Covington, GA, USA) core biopsy needles, for ultrasound guided breast biopsy.
MATERIALS AND METHODS: A 14G semi-automatic spring loaded core biopsy needle with a 22-mm-throw (Medax Velox 2; Poggio Rusco, Italy) and 14-gauge automated needle device with a 22-mm-throw biopsy gun (Bard-Magnum Biopsy Instrument, Covington, GA, USA) were used for breast biopsies under ultrasound guidance on alternate months during the study period between July 2009 and May 2011. One hundred and sixty lesions were biopsied and specimens were sent for histological evaluation.
RESULTS: The automated needle obtained a higher number of histology reports at 84% (67/80) as compared with the semiautomated needle at 60% (48/80) (Fisher exact test, p value=0.023). Inadequate samples with the automated needle were much less at 9% (7/60) than with the semiautomated needle at 23% (18/60) (Fisher exact test, p value=0.028). The semi-automated needle showed slightly less fragmented samples. However, the number of fragmented samples with definitive diagnosis was slightly higher with the automated compared with the semiautomated needle, at 16% (13/80) and 13% (10/80) respectively. Compared with histology of 29 lesions that were excised, the semi-automated needle had higher sensitivity (100%) but lower specificity (75%) and accuracy (90%) compared with the automated needle (88% sensitivity, 100% specificity, 95% accuracy).
CONCLUSION: Definitive diagnosis from the study samples slightly favours the use of automated core biopsy needle as compared to semi-automated core biopsy needle.
Study site: Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
BACKGROUND: to determine the usefulness of Doppler ultrasound measurement of resistive index (RI) in differentiating obstructive from non-obstructive hydronephrosis in children.
METHODS: From August 2011 to November 2012, renal Doppler assessments of the intra-renal renal arteries were performed on 16 children (19 kidneys) with congenital hydronephrosis. the independent t-test was used to assess for significant difference in RI values between those with obstructive hydronephrosis (6 kidneys) and those with non-obstructive hydronephrosis (13 kidneys) as determined by dynamic renal scintigraphy. the assessor was blinded to the clinical findings and scintigraphy results.
RESULTS: RI was significantly different between obstructive and non-obstructive hydronephrosis. Obstructive hydronephrosis returned higher RI values, with mean RI of 0.78. Mean RI in non-obstructive hydronephrosis was 0.70, and the difference was significant (p <0.05). the sensitivity and specificity of Doppler ultrasound were 100% and 53% respectively.
CONCLUSION: Doppler ultrasound measurement of resistive index is useful in differentiating obstructive from nonobstructive hydronephrosis and provides an alternative non-ionizing investigation.
Study site: Universiti Kebangsaan Malaysia
Medical Centre, Kuala Lumpur, Malaysia
Acute respiratory distress syndrome (ARDS) is the final outcome of a common pathway of a variety of unrelated but massive insults to the lung. It is commonly seen in adults but also occurs in the paediatric age group. A prospective study was carried out to determine the incidence, predisposing conditions, clinical course and outcome of children with ARDS admitted to a paediatric intensive care unit (PICU). Six patients (aged 0.8 to 11 years) who fulfilled the strict criteria for ARDS were identified prospectively during a one year study period. The incidence was 1.7% of all PICU admission. The most common underlying conditions were septicemia and pneumonia. The mortality rate was 83%. Death most often occurred during the early phase of the disease. Treatment of ARDS included elimination of the cause of ARDS, early institution of mechanical ventilation with PEEP, prompt recognition and treatment of superimposed infection and careful management of additional organ failure.
A child with a post-tramatic pancreatic pseuodocyst developed pancreatic fistula, following percutaneous drainage of the cyst. The fistula output was about 120ml/day and lasted for a month. A diagnostic ERCP revealed main pancreatic duct disruption. The fistula output ceased over the next two days following the ERCP. The patient has been well for the past four years. This patient's immediate recovery after ERCP could possibly be due to dislodgement of a mucus plug by the contrast injected during ERCP. Such a mechanism can explain the previous sporadic reports of spontaneous cure of persistent pancreatic fistulae in children.
We describe a case of acute disseminated encephalomyelitis in a child. This case is unusual in that the illness was characterised by recurrent episodes rather than a monophasic course and that the choice of treatment was intravenous immunoglobulin over corticosteroids. The rapid and remarkable recovery is highlighted and a review of the treatment for this rare condition is discussed.
Posterior sagittal anorectoplasty (PSARP) is preferred by most pediatric surgeon and intermediate types of anorectal anomalies (ARA) in infants. In this report, we describe two girls who presented in their late teens with ARA and were treated by PSARP. Prior to this report, only two adult females with congenital rectovaginal fistulae treated by PSARP have been reported. Megarectum is a feature in late presentation of ARA and requires rectal tapering during PSARP. The functional outcome in late presentation of ARA is discussed.
The aim of the study was: to obtain the profile of patients (with regards to age and family history of breast cancer) with a palpable breast mass. To determine the validity of ultrasound in the assessment of the palpable breast mass by determining the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasound in distinguishing a malignant mass. To determine the most discriminating ultrasound characteristics for differentiating benign and malignant masses. Seventy patients who had fine needle aspiration cytology of a palpable breast mass were subjected to an ultrasound assessment of the mass. The ultrasound findings were classified as benign, indeterminate or malignant. These findings were then compared with either the cytology or histology results in cases that eventually had surgical excision. The age of the patients ranged from 15 to 66 years old The majority was in the third and fourth decades with an average age of 25 years. The 8 patients with a proven malignant breast mass were aged between 39 and 66 years old. They did not have any family history of breast cancer. Only 4 patients had a family history of breast carcinoma and all proved to have a benign breast lesion. Ultrasound had a sensitivity of 100%, specificity of 85.7%, positive predictive value of 50%, negative predictive value of 100% and accuracy of 87.5% for distinguishing a malignant mass. For benign masses: 93.7% had well-defined margins, 81.3% had homogenous internal echoes, 91.7% had depth-width ratio of less than 1.0 and 89% were compressible. For malignant masses: 87.5% had either ill-defined or irregular margins, 87.5% had inhomogenous internal echoes and mixed posterior echoes, and 100% were incompressible. The majority of patients with a palpable breast mass were aged below 40 years old. Most of the patients with a malignant breast mass were aged 40 years and older. Neither a positive nor a negative family history of breast cancer had any significance on outcome. Ultrasound had high sensitivity, specificity and accuracy in distinguishing a malignant mass. The most discriminating benign ultrasound characteristic was compressibility. The most discriminating malignant ultrasound characteristic was ill-defined and irregular margins.