A method of treating tracheostomal stenosis post-laryngectomy is described. The carbon dioxide (CO2) laser is used to fashion and ablate two triangular areas lateral to the stenosed stoma to provide an immediate enlarged stoma for comfortable breathing. This simple procedure is done under local anaesthesia, is almost bloodless, safe and takes just 10 minutes. Over the last five years eight patients underwent this procedure and seven had a satisfactory stoma without the need to use a tracheostomy tube.
Actinic prurigo is a chronic familial photodermatitis found predominantly among the Amerindians. It has been reported from North and South America, Britain and Japan. We report a case of actinic prurigo seen in Singapore. A 20-year-old Malay female presented with a persistent pruriginous eruption in the sun-exposed parts and on her abdomen. She also had lower lip cheilitis and thinning of the outer eyebrows, features often seen in actinic prurigo. The minimal erythema dose to ultraviolet A (UVA) and UVB were persistently lowered. We propose that this condition be called actinic prurigo, tropical (South-East Asian) variant.
Publication year=1992-1993
From 1988 to 1990, eighty operations on eighty knees of seventy-nine patients with a clinical diagnosis of meniscal tear was entered into a prospective study. The clinical diagnosis was correct in 76% of patients. Excellent or good results were achieved in 90% of knees which had only meniscal lesions but dropped to 70.5% when other intraarticular pathologies coexisted with the meniscal lesions. Excellent or good results were achieved in 71% of the knees in the presence of Anterior Cruciate Ligament (ACL) deficiency.
Open reduction of the radial head and reconstruction of the annular ligament has been advocated for the Monteggia fracture dislocation in children who present more than a month after injury. Three patients with an anterior Monteggia lesion were treated by open reduction of the radial head which was held in place by a Kirschner wire passed from the humerus to the radius. No attempt was made either to repair or reconstruct the annular ligament. The patients were aged between 2 and 6 years, the delay between injury and reduction was between 6 and 8 weeks, and the length of follow up was 5 years for two patients and 1 year for the third. All three patients were free of pain, had no deformity and the radial head had not subluxated. All had nearly full flexion at the elbow. The forearm had full supination but restricted pronation.
A case of symptomatic polycystic liver disease treated by fenestration and segmental liver resection is reported. The intraoperative use of ultrasound to define the plane of liver resection is emphasised. No significant post-operative complication was encountered. The clinical presentation, management and treatment are discussed.
All post-neonatal children with acute non-traumatic coma admitted over an 8-month period were analysed and followed up for 18-24 months to determine the aetiology and outcome of their coma. One hundred and sixteen children, 72 boys and 44 girls, were recruited. Half the children were under 1 year of age and only 16 (14%) were more than 6 years of age. Eighty cases (69%) were due to infection, 15 (13%) to toxic metabolic causes, six (5%) to hypoxic ischaemic insults, four (3.5%) had intracranial haemorrhage, nine (7.8%) were due to miscellaneous causes and in two (1.7%) the cause was unknown. Seven cases were lost to follow-up. Of the remainder, 39 (35.7%) died, 32 (29.3%) developed permanent neurological deficit, and 38 (35%) were discharged well. The outcome was worst in the infectious group. Age of onset and sex did not significantly affect outcome. Our findings are similar to experience in Japan, where infection accounts for 74% of non-traumatic coma, but differ considerably from Western data on childhood coma where only a third of cases are due to infection.
Thoracic oesophageal perforation, a life-threatening condition, is a therapeutic challenge. A 20 year old male developed a lower oesophageal perforation following an abdominal cardiomyotomy for achalasia of the lower oesophagus. The resulting suppurative mediastinitis and left empyema thoracis were treated by decortication. The oesophageal perforation was closed using a transposition pedicle left latissimus dorsi muscle flap.
We review our experience with 27 cases of pulmonary and meningeal cryptococcosis at the University Hospital, (Kuala Lumpar, Malaysia) where this is the most common cause of adult meningitis in patients without debilitating illnesses. Of the 27 cases analysed, six presented primarily with pulmonary symptomatology which usually were mainly cough, chest pain and low grade fever. The rest presented with primarily central nervous system (CNS) symptomatology of which headaches and fever were the most consistent symptoms although a third of these patients also had pulmonary lesions noted on chest radiographs. Treatment in all cases was with amphotericin B and 5-fluorocytosine and usually till a total cumulative dose of 1.5 g of amphotericin had been reached (an average of 10 weeks). Primary pulmonary presentations, if symptomatic, were treated as per CNS cryptococcosis due to the high likelihood of CNS dissemination. Incidental pulmonary cryptococcoma found on routine chest radiographs were confirmed by biopsy under ultrasound or fluoroscopy guidance and booked for surgical resection. Death usually occurred early in patients who presented late. Once patients responded to therapy, mortality was usually avoided. The only cause of morbidity in survivors was visual impairment or blindness, and this was attributed mainly to intracranial hypertension with residual deficits determined by the measures taken to lower intracranial pressures. Our experience suggests that: (i) symptomatic patients should have combination therapy with 5-fluorocytosine and amphotericin B till at least a cumulative dose of 1.5 g amphotericin B is reached irrespective of whether they have primary CNS or pulmonary symptomatology; (ii) non-symptomatic pulmonary cryptococcoma could be treated primarily by surgical resection; (iii) visual failure or papilloedema should be treated aggressively; and (iv) prognosis is good with adequate therapy and early presentation.
To evaluate the effects of simple compensated fixed-dose iodine-131 therapy for thyrotoxicosis, the long-term results for 74 patients treated with a fixed dose of iodine-131 ranging from 5 to 12 mCi (185 to 444 MBq) were evaluated in the first 2 years of a trial. The dose selected was loosely based on the gross size of the thyroid gland. Routine antithyroid drug therapy was given for a minimum of 3 months after iodine-131 therapy. The mean (+/- SD) duration of follow-up was 74.5 +/- 42 months. The results indicated that roughly 25% of patients treated in this way will become hypothyroid after 5 years and that 85% are cured (need no further therapy during the follow-up period) using a single dose of iodine-131. Of those cured using a single iodine-131 dose, 81% were no longer receiving drugs after 6 months and 85% after 1 year. Such a regimen seems currently to be among the best available where prolonged periods of medication-free euthyroidism after therapy are sought.
Our experience from 1968 to 1985 in 12 women requiring closed mitral valvotomy during pregnancy is reviewed. All patients had severe mitral stenosis and were in functional class 3 (2 patients) or class 4 (10 patients). Mitral valvotomy was performed between the 18th and the 30th week of pregnancy using a transventricular dilator. Improvement in functional class was noted in all patients postoperatively. One patient had postvalvotomy mitral regurgitation and heart failure, which responded to diuretics; the subsequent course was uneventful. Eleven patients had normal deliveries; whilst one patient had a Caesarean section for an obstetric indication. All babies were normal and there was no maternal death. This series confirms that closed mitral valvotomy can be performed with an acceptable degree of safety during pregnancy, when indicated.
The clinical response and the histological changes in the mucosa of the small bowel in response to continued feeding with cows' milk protein were assessed over a period of 2-6 weeks in 24 infants who had shown histological changes without immediate clinical symptoms after challenge with a diet containing cows' milk protein. Twenty of the 24 infants (83%) thrived well on cows' milk protein. Jejunal biopsy specimens taken six to eight weeks after the initial biopsy showed histological improvement in all 20 infants compared with biopsy specimens taken soon after the challenge, which had shown mucosal damage. The mucosa had returned to normal in 12, was mildly abnormal in seven, and moderately abnormal in one. Corresponding improvements in the activities of mucosal enzymes were seen. In four of the 24 infants (17%) symptoms developed between three and six weeks. Histological examination of the jejunal biopsy specimens showed that mucosal damage had progressed in two, and remained the same in two; moreover, the disaccharidase activities remained depressed. The present study shows that most infants with enteropathy caused by sensitivity to cows' milk protein but without clinical symptoms develop tolerance to the protein and the mucosa returns to normal despite continued feeding with cows' milk protein.
From 1981 to 1989, 12 patients of the University Hospital, Kuala Lumpur, were diagnosed to have Evans syndrome based on direct antiglobulin test (DAT) positive haemolytic anaemia and immune thrombocytopenia occurring either simultaneously (7 patients) or consecutively (5 patients). Their mean age at presentation was 24.8 years with a marked female preponderance. All 12 patients were given high dose steroid after diagnosis. Subsequently, other modalities including intravenous immunoglobulin (1 patient) and high dose methylprednisolone (1 patient) were given. Three patients died of intracranial haemorrhage during the first admission while 1 patient died of pulmonary embolism six months after diagnosis. Three patients had splenectomy because of thrombocytopenia. Six patients tested positive for antinuclear factor and antibodies to double stranded DNA and four of them died. Positive serology appeared to be associated with a poorer prognosis. Follow up observations indicate that patients who survive the acute attacks fare reasonably well.
This prospective study was performed to quantify glucose-6-phosphate dehydrogenase (G6PD) enzyme activity in deficient males and female heterozygotes. The methods used in the study were the fluorescent spot test, G6PD enzyme electrophoresis on cellulose acetate and quantitative assays. Forty-seven children who had been detected as spot screen deficient at birth were rescreened. Their first degree relatives were also included in the study. The mean enzyme activity of deficient males was 0.74 iu/g Hb (s.d. +/- 0.8), of female heterozygotes was 6.5 iu/g Hb (s.d. +/- 3.2) and of normal males was 12.1 iu/g Hb (s.d. +/- 3.5). The mean activity in deficient males was 6.1% of normal males. Most (35 of 47) of these fell into class 2 in Beutler's classification of G6PD variants. This indicates a population which may be susceptible to favism. Female heterozygotes had an intermediate enzyme activity with a wide scatter. Using a cut off point of enzyme activity of below 9.0 iu/g Hb gave sensitivity and specificity of 87% and 84% in detecting female heterozygotes. This group could be defined more accurately by combining quantitative assays with family studies.
The objectives of this Malaysian study were to investigate the relationship between severity of trauma and interval before treatment, and the effect of delayed treatment on prognosis. A total of 123 traumatized permanent incisors were observed over a 24-month period. Results of this study suggest that the interval between trauma and emergency treatment is directly related to the severity of injury and the level of dental awareness of the patients. However, prognosis of these teeth is greatly influenced by the interval between trauma and initial treatment. Pathological pulp changes in these teeth can occur as late as two years after injury and this justifies the necessity for a long observation period following treatment.
45 patients (50 eyes) were treated for juvenile rhegmatogenous retinal detachments between August 1979 and July 1984. A review of these cases revealed high myopia and trauma to be the main aetiological factors. Eight-six per cent detachments were successfully reattached. Visual acuity of 6/36 or better was present in 16% preoperatively and in 52% postoperatively, some of the characteristics of juvenile rhegmatogenous retinal detachments in Malaysian population are discussed.
The sexual identity of 65 Malaysian male medical students was investigated by anonymous questionnaire. Of these students, 40% were aware of homosexual feelings prior to age 15 years, and 16% were so aware currently. There were correlations between current homosexual feelings and feminine sex dimorphic behavior during childhood and between current homosexual feelings and feminine gender identity. The results are discussed in light of results of a similar questionnaire completed by 138 male medical students in Sydney, Australia.
Study site: National University of Malaysia (Universiti Kebangsaan Malaysia), Kuala Lumpur, Malaysia
From 1st January 1986 till 31st December 1986; 273 patients were treated in the Intensive Care Ward. The mortality in the Intensive Care Unit was 24.5%, mortality of patients 60 years and above was 35%. Of 187 patients who had survived, only 105 (56.2%) responded to the questionnaire, 39 (20.9%) did not respond and 43 (23.0%) could not be traced. Of the total discharged alive, 95 (51.9%) survived two years and eight (4.6%) died over the two years. Forty (41%) have returned to normal routine and are satisfied with their life style; 57 (59%) were not satisfied with their life style for various reasons, ill health being one. As regards patients above 60 years; 21 (53.8%) are alive and 10 (47.6%) are happy and satisfied with their life style.