Melioidosis is a potentially deadly infection that can affect any organ system. Reports of melioidosis of the ENT/head and neck region are relatively uncommon. Four cases are presented: (i) parotid abscess evolving into necrotising fasciitis, (ii) acute sinusitis and parapharyngeal cellulitis resulting in upper airway obstruction, (iii) acute suppurative lymphadenitis (iv) and chronic suppurative otitis media causing meningoencephalitis. Three of the four cases are believed to be unique, as a literature review of melioidosis in ENT/head and neck is also presented. Some practical issues of management are also discussed. Not suspecting melioidosis does not change contemporary empirical broadspectrum antibiotic therapy. The value of suspicion or on confirmation of diagnosis lies in anticipating and planning for rapid change.
The current treatment options for beta thalassaemia major patients include conservative treatment with blood cell transfusions and iron chelation or stem cell transplantation. Regular blood transfusions inevitably lead to multi-organ haemosiderosis and are attended by risks of blood-borne infections. Results from stem cell transplantation are good and suggest that this should be offered as first line therapy when a matched sibling donor is available because the patient is often cured and able to live a normal life. Of 38 Malaysian children who underwent bone marrow or cord blood transplantations using matched sibling donors, 29 (76%) are now cured.
Thromboembolic disease remains an important cause of maternal mortality worldwide. The risk assessments for prevention of thromboembolism in pregnancy are controversial due to lack of large-scale randomised controlled trials. Unfractionated heparin is at present, the anticoagulant of choice during pregnancy. However, it may be superseded by low-molecular-weight heparin in the near future because of its safety and efficacy.
In the setting of transplantation and chronic hepatitis B viral infection there is a unique histological feature termed cholestatic fibrosing hepatitis. The use of nucleoside analogues in the treatment of this condition has been successful. We describe a case of cholestatic fibrosing hepatitis, which occurred after intense immunosuppression for graft versus host disease in a patient with bone marrow transplantations. She was commenced on lamivudine therapy and showed good clinical, biochemical and virological response. However she succumbed due to sepsis.
A case of non-recurrent laryngeal nerve is reported. The non-recurrent laryngeal nerve was found on the right side and was not associated with any vascular abnormalities. The anatomy and surgical implication of this rare condition is discussed
In this prospective, randomized controlled trial, changes in endotracheal tube cuff pressure were studied in 60 patients undergoing elective surgery under general anaesthesia with nitrous oxide and oxygen. The cuffs were inflated with either air or distilled water. The mean pressure in the air-filled cuffs increased steadily throughout the procedure, reaching 47.5 +/- 7.3 cmH2O at one hour compared with 31.6 +/- 2.4 cmH2O mean pressure in the water-filled cuffs. The pressure and the rate of rise in cuff pressure were significantly lower (P<0.05) in the water-filled cuffs throughout the hour of study. When an endotracheal tube cuff is distended with water, the rise in cuff pressure during nitrous oxide anaesthesia is lower than that of an air-filled cuff.
The incidence of ear lobe crease (ELC) was studied in 1576 healthy Malay subjects (566 males and 1010 females), randomly selected from the residents of Kota Bharu, Malaysia. ELC was present in 31.1% of males and in 3.6% of females; this difference in incidence between the two sexes is statistically significant (p > 0.05). In males the incidence of Type I crease was highest (10.1%) while that of Type III crease was lowest (2.3%). In females Type II crease showed the highest incidence (1.9%) and Type III the lowest. The incidence of bilateral presence of all three types of ELC showed an age-related increase in males. The ELC often starts unilaterally and later develops bilaterally and earlier in males than in females.
During the outbreak of Nipah virus encephalitis in Malaysia, stored cerebrospinal fluid (CSF) samples from 84 patients (27 fatal and 57 nonfatal cases) were cultured for the virus. The virus was isolated from 17 fatal cases and 1 nonfatal case. There were significant associations between CSF virus isolation and mortality as well as clinical features associated with poor prognosis. In addition, there was a positive linear correlation of CSF virus isolation with age. There was no significant association between CSF virus isolation and the character of the CSF, presence of Nipah-specific antibody in the serum or CSF, duration of illness before collection of samples, or sex or ethnicity of the patients. This study suggests that high viral replication in the central nervous system may be an important factor for high mortality.
From June 1993 to September 1995, 132 case files of patients who received palliative radiotherapy (RT) for skeletal metastases were reviewed. Majority of the patients (75/132) was in the age range of 41-60 years. Common sites of metastases were the vertebrae (86 patients) and the pelvic bones (40 patients). The major primary tumors encountered were as follows: multiple myeloma (30), breast cancer (25) and prostate cancer (20). Pain was the commonest symptom of presentation. Doses of palliative RT ranged from 8-40 Gy in different fractionation schedules. Ninety-four patients showed more than 50% symptomatic response, 26 had no response and 12 were lost to follow up immediately after the treatment. Single fraction treatments resulted in almost similar responses compared to various multiple fraction treatments. To conclude, short course radiation therapy regimes are optimum in our local circumstances where RT resources are limited and patients have to travel long distances to attend hospital.
Malaria is an infectious disease that remains the main health problem in Tawau, Sabah. A case control study was carried out in the district to determine the influence of seasonal migration on malaria occurrence. Respondents consisted of 142 cases who were randomly selected from the reported cases in 1996 and they were pair-matched with 142 controls from the same villages by age and sex. The results showed that malaria occurrence was significantly associated with movement to the jungle, use of preventive measures during migration and frequency of using treated bednets (p < 0.05). The risk of individuals migrated to the jungle was 6 times as compared to those who do not (unadjusted Odd Ratio = 5.50, 95% CI 1.16-35.89) and they were more likely to get the infection if they did not use bednets (OR = 3.57, 95% CI 1.57-9.06). Health promotion campaign on the use of bednets especially during short term migration should be given priority in any malarial intervention program.
A total of 323 workers from 5 different occupational groups in the telecommunication industry were studied in this cross sectional study, which sought to determine the prevalence of Work Related Upper Limb Disorders (WRULD) in 5 occupational groups; operators using the Video Display Terminals, switchboard operators, clerks, data entry processors and the supervisors. WRULD was also studied with regard to factors such as sex, race, height, age, stress and the discomfort perceived due to the work station design. The possibility of WRULD was determined from a self-administered questionnaire and confirmed by history and physical examination. Psychological stress and the discomfort due to the workstation were measured from the questionnaire. The overall prevalence was found to be 31.2% and the prevalence among the various occupations differed with it being the highest in the switchboard operators and data processors and the lowest in the supervisors. The older workers and the female workers were found to have higher prevalences of WRULD. It was also found that a higher stress score and a higher score of discomfort perceived at the work station were associated with higher prevalences of WRULD.
Penicillium marneffei, a dimorphic fungus is a rare opportunistic pathogen. It is known to cause infection in immunocompromised patients and recently its occurrence in AIDS patients has been well-documented. Disease with Penicillium marneffei is even rarer among previously healthy individuals. The disease is endemic in Southeast Asia and China. Recognition of this rare disease is important because it is amenable to treatment. We report a case of P. marneffei infection in a previously healthy individual.
Although survival rates for childhood cancers have improved steadily over the past two decades, the outcome for advanced stage solid tumours remains poor. Many of these tumours are chemosensitive but most chemotherapeutic regimens are limited by their haematological toxicities. Much attention is now focused on mega-dose chemotherapy followed by stem cell rescue in the treatment of disseminated neuroblastoma, rhabdomyosarcoma, germ cell tumour and brain tumours. There is a preferential shift towards peripheral blood stem cell transplantation instead of bone marrow transplantation because of its advantages of faster engraftment, decreased transfusion and antibiotic usage and shortened hospitalisation. This mode of therapy is dependent on technologies including peripheral blood stem cell harvesting, cell cryopreservation and thawing. These technologies were recently made available in Malaysia and we report our early experience.
Most patients presenting with acute right sided peritonitic pain are diagnosed and managed as acute appendicitis. In a series of 336 patients, eight were found to have caecal diverticulitis. The occurrence of such diverticula appears to be more frequent in Asian populations. The diagnosis can be established at operation on the basis of surgical findings. The aim of this retrospective review is to discuss the management of such patients when acute diverticulitis is found at the time of appendicectomy. It is advocated that management be conservative where possible, with appendicectomy and antibiotics. Where the possibility of a carcinoma remains, investigation after surgery by colonoscopy may be undertaken.
The present study aims to compare the family's social environment, social supports and mental health of Malay women from rural and urban areas. Equal number (n-184) of Malay women from similar socio-economic back grounds were chosen from the rural areas of Kedah and urban areas of Pulau Pinang using the stratified random sampling method. The results indicated significantly higher level of mental health problems among the rural respondents when compared with the urban subjects. Among the family related variables included in the present study, cohesiveness, moral religious emphasis and organization and intellectual and cultural orientation were found to be significantly associated with the mental health problems of rural respondents. Whereas, only one variable, namely, active recreational orientation was found to be having an impact on the mental health of urban respondents. Similarly, deficiencies in the social support perceived from family and other members of the community were found to be significantly associated with the mental health problems of rural samples when compared to the social support perceived from the others for the urban subjects. The implications of these observations are discussed.
We reviewed all documented cases of septicaemia following caesarean deliveries in Kandang Kerbau Hospital between 1st January 1993 to 31st December 1995. There were 22 cases of septicaemia among 8201 caesarean births, and hence the incidence is 2.7:1000. There were 45,412 deliveries, and the overall caesarean section rate was 18.1%. Among the 22 documented cases of septicaemia which came under this study, the most common clinical conditions found were endomyometritis (7 cases), urinary tract infection (6 cases), and wound infection (3 cases). One of the three cases with wound infection also had pneumonia. There was one patient who had mild transient myocarditis. We could not determine with certainty any site of infection in five patients. The most common bloodstream bacterial isolates was Staphylococcus aureus (16), while the uncommon ones were Acinetobacter baumanii (2), Escherichia coli (1), Klebsiella sp. (1), Staphylococcus epidermidis (1), Streptococcus Group F (1), Peptostreptococcus species and Veillonella species (1). There was no mortality and prompt, vigorous treatment had led to uneventful recovery in all the cases.
Cholestatic disorders of infancy (viz neonatal hepatitis and biliary atresia) have not been well studied in Malaysia. In a retrospective study in the Department of Paediatrics, University Hospital, Kuala Lumpur from January 1982 through December 1991, a total of ninety-three infants with such conditions were identified: 35 (38%) had biliary atresia, 58 (62%) neonatal hepatitis. There was a statistically significant male preponderance in the neonatal hepatitis group (P = 0.020). There was no significant difference in the racial distribution and in the proportions of low birthweight infants between the two groups of disorders. When the biliary atresia group was compared with the neonatal hepatitis group, significant differences were observed in the age of presentation (mean +/- SD) 9.8 +/- 6.8 VS 20 +/- 17.3 weeks (P < 0.001), proportion of infants with prolonged jaundice (> seven weeks) 28/35 (80%) VS 20/58 (34.5%) (P < 0.00001), occurrence of alcoholic stools 26/35 (74.3%) VS 27/58 (46.6%) (P = 0.020), liver size (mean +/- SD): 4.3 (1.6 cm VS 3.3 +/- 1.8 cm (P < 0.01) and splenic size: 2.5 (1.8 cm VS 1.4 (1.2 cm (P < 0.001). There was however considerable overlap between the two groups in these features at presentation, making clinical differentiation between the two conditions difficult. Infants with cholestasis tended to present late, compromising the chance of survival. In order to improve the medical care of these patients, these conditions must be emphasised during the training of medical practitioners, and efforts to increase public awareness of these conditions must be created.
From October 1996 to March 1997, 31 children with febrile convulsions were admitted to the University Hospital, Kuala Lumpur. Human Herpesvirus 6 (HHV 6) was virologically and/or serologically confirmed to be the cause of the febrile episode in 5 of these children (16.1%). Age, sex and other associated clinical features (diarrhoea, cough, running nose and type of seizure) were not useful in differentiating cases of febrile convulsion due to HHV 6 from those of other aetiology. However, uvulo-palatoglossal junctional ulcers were noted in children in whom the cause of the seizure could be attributed to HHV 6 but not in the remaining cases in the study group. HHV 6 DNA was detected in peripheral blood mononuclear cells from all patients with febrile convulsions attributed to HHV6, and in patients shown serologically to have already been exposed to the virus by nested polymerase chain reaction amplification. Only genotype HHV 6B was detected from patients with seizure due to HHV 6 but both genotype 6A and 6B were detected in the remaining cases studied.
Fifty-five patients were followed up after day surgery for breast lumpectomy. It was found that local infiltration with bupivacaine significantly decreased analgesic requirement in recovery. Almost half of the patients could not be contacted during the 24 hour post-operative follow-up by telephone. 7.1% complained of severe pain despite oral analgesics. 14.3% of patients had queries regarding wound care and 78.6% of the patients were willing to undergo day surgery again. Ongoing patient education and good post operative analgesia are crucial to enable successful establishment of ambulatory surgery. Post-operative follow-up is encouraged to audit clinical and social outcomes of day surgery.
A case of persistent trophoblastic tissue on the pelvic peritoneum is presented. While most cases are secondary to conservative surgery for tubal ectopic pregnancy, primary implantation can also occur as highlighted by this case. A brief pathophysiology of the condition is presented. The importance of monitoring the serum for beta subunit human chorionic gonadotrophin (HCG) is emphasised.