Computed tomography (CT) is widely used in assessing clinically stable patients with blunt abdominal trauma. In these patients, liver is one of the commonest organs being injured and CT can accurately identify and assess the extent of the injury. The CT features of blunt liver trauma include laceration, subcapsular or parenchymal haematomas, active haemorrhage and vascular injuries. Widespread use of CT has notably influenced the management of blunt liver injury from routine surgical to nonsurgical management. We present pictorial illustrations of various liver injuries depicted on CT in patients with blunt trauma.
Muslim diabetics who fast during Ramadan are at risk of hypoglycaemia, and previous consensus guidelines have highlighted certain risk factors. This prospective cohort study aims to determine the relative risk (RR) of hypoglycaemia during Ramadan fasting compared with a non-fasting period of equivalent length, and to ascertain which risk factors are clinically significant. From the results, Ramadan fasting carries a RR of hypoglycaemia of 1.60 (95% CI 1.05 to 2.43). Good metabolic control (HbAlc < 8%) and old age (> 60 years) increased RR more than twice, while taking breakfast prior to fasting reduces RR to less than half.
In a short period of two months, the novel influenza A/H1N1 virus has circumnavigated the entire planet leaving behind in its wake approximately 3000 reported deaths worldwide. Fortunately, in many areas around the world, September 2009 brought a lull in the number of new H1N1 infections. This brought welcomed relief in many countries that had earlier experienced high respiratory disease activity in their communities. However, based on previous influenza pandemics, this reprieve may well be short-lived. As the Northern hemisphere approaches its winter months, many experts are now predicting a second wave of influenza A/H1N1 infections. This prediction maybe well placed as all 3 influenza pandemics in the last century reported second or even subsequent waves of new infections, all of which appeared to be more severe than the primary event (ref). The timing of these second waves have varied from 6 months to 3 years and invariably seemed to be linked to the winter months. It is unclear precisely what changes caused the increased severity seen during the second waves; one possibility is the progressive adaptation of the novel influenza virus to its new human host . Molecular analysis, for example, suggests that the 1918 Spanish influenza virus that emerged during the second wave had undergone changes in the hemagglutinin binding site that increased the binding specificity for human receptors. This is thought to have increased the replicative capacity and hence, the pathogenicity of the virus. It is also evident that as the H1N1 2009 pandemic virus continues to spread, opportunities for adaptation that increases virulence will also increase. Nonetheless, the changes needed for such adaptation and for increased virulence are unpredictable and by no means inevitable
Since its discovery in the 1940s, retinal photocoagulation has evolved immensely. Although the first photocoagulators utilised incandescent light, it was the invention of laser that instigated the widespread use of photocoagulation for treatment of retinal diseases. Laser permits choice of electromagnetic wavelength in addition to temporal delivery methods such as continuous and micropulse modes. These variables are crucial for accurate targeting of retinal tissue and prevention of detrimental side effects such as central blind spots. Laser photocoagulation is the mainstay of treatment for proliferative diabetic retinopathy amongst many other retinal conditions. Considering the escalating prevalence of diabetes mellitus, it is important for physicians to grasp the basic principles and be aware of new developments in retinal laser therapy.
Massive goiter with retrosternal extension may impose additional risk such as difficult intubation, tracheomalacia, and possibility of different incision and approach including sternotomy. We would like to report a case of massive goiter encasing major neck structures and how it was managed.
Recovery from chikungunya is previously considered universal and mortality due to the virus is rare and unusual. Findings from recent chikungunya outbreaks occurred in Reunion Island and India have since challenged the conventional view on the benign nature of the illness. Malaysia has experienced at least of 4 outbreaks of chikungunya since 1998. In the present on-going large outbreak due to chikungunya virus of Central/East African genotype, a previous healthy sixty six years gentleman without co-morbidity was noted to have severe systemic infection by the virus and involvement of his liver. He subsequently passed away due to cardiovascular collapse after 5 days of illness.
A retrospective study was conducted to investigate 183 serologically-confirmed cases of dengue fever (DF) admitted from October 2004 to March 2005 in a large hospital in Pahang. Clinical and laboratory features, progress and outcome of these patients were analysed in order to identify risk factors associated with development of dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Individually, we found that older patients, secondary dengue infection, high baseline haematocrit levels, low platelet levels and prolonged activated partial thromboplastin time (APTT) ratio were significant associations with bleeding tendencies. Of these risk factors, haematocrit and APTT ratio were two independent significant risk factors on multivariate analysis. Older patients with primary infection and younger patients with secondary infection had significant bleeding tendencies. We also verified the validity of the haematocrit levels suggested as cut-off levels for plasma leakage for the Malaysian population by Malaysian Clinical Practice Guidelines for Dengue Infection in Adults (2003).
This was a cross-sectional study to determine the prevalence and characteristics of mother-infant bed-sharing practice in Klang district, Malaysia. Data was collected by face-to-face interview using a structured questionnaire for a four month period in 2006. A total of 682 mother-infant pairs attending government health clinics were included in the study. Data regarding socio-demographic characteristics of the mothers, information on the infants, bed-sharing and breastfeeding practices were collected. The mean maternal age was 28.4 +/- 5.1 years while the mean infant gestational age was 38.8 +/- 1.8 weeks. The study showed the prevalence of bed-sharing was 73.5% (95% CI: 70.0, 76.7). In multivariate analysis; area of interview, maternal occupation, family income, breastfeeding and infant birth weight were associated with bed-sharing after adjusted for maternal ethnicity, age, marital status, educational level, parity, infant gender and infant gestational age. In conclusion, bed-sharing is a common practice in Klang district, Malaysia, not specific to ethnicity, but strongly associated with low family income and breastfeeding.
Patients with isolated severe head injury with diffuse axonal injury and without any surgical lesion may be treated safely without cerebral resuscitation and intracranial pressure (ICP) monitoring. Seventy two patients were divided into three groups of patients receiving treatment based on ICP-CPP-targeted, or conservative methods either with or without ventilation support. The characteristics of these three groups were compared based on age, gender, Glasgow Coma Scale (GCS), pupillary reaction to light, computerized tomography scanning according to the Marshall classification, duration of intensive care unit (ICU) stays, Glasgow Outcome Score (GOS) and possible complications. There were higher risk of mortality (p < 0.001), worse GCS improvement upon discharge (p < 0.001) and longer ICU stays (p = 0.016) in ICP group compared to Intubation group. There were no significant statistical differences of GOS at 3rd and 6th months between all three groups.
Spirometry data of 869 individuals (males and females) between the ages of 10 to 60 years were analyzed. The analysis yielded the following conclusions: 1. The pattern of Forced Vital Capacity (FVC) and Forced Expiratory Volume in One Second (FEV1) for the selected subgroups seems to be gender dependant: in males, the highest values were seen in the Chinese, followed by the Malay, and then the Dayak; in females, the highest values were seen in the Chinese, followed by the Dayak, and then the Malay. 2. Smoking that did not produce respiratory symptom was not associated with a decline in lung function, in fact we noted higher values in smokers as compared to nonsmokers. 3. Prediction formulae (54 in total) are worked out for FVC & FEV1 for the respective gender and each of the selected subgroups.
Endoscopic examination and removal of foreign body under general anaesthesia are recommended for persistent symptomatic patient with or without significant findings on radiological examination. This report evaluates the management outcome of surgical removal of foreign body ingestion in upper gastrointestinal tract. A total of 70 cases with full documentation were reviewed retrospectively from June 1998 until December 2007. There were 32 male and 38 female with age range from 6 months to 87 years old (mean: 36.9 years). Sixty five patients (93%) were adults and 15 (7%) were below 13 years. Fish bones were the most common foreign body found (44.3%). Radiologically, foreign bodies were highly suspicious in 51 cases (76.1%). Intraoperatively, thirty six cases (70.6%) were positive. From 16 cases (23.9%) with normal radiograph, 10 cases (62.5%) were found to have foreign bodies. Therefore the plain radiograph is helpful, but clinical presentation is more reliable to determine surgical removal under general anaesthesia.
To evaluate the perinatal outcome of premature babies according to the mode of delivery. A total of 113 pregnant women and 124 neonates who delivered from 30 to 35 weeks of gestation were enrolled and outcomes of 70 neonates born vaginally were compared to 54 neonates born by caesarean. Neonatal mortality rate was 20 percent for infants in caesarean group as compared to 10 percent for vaginal group. There was no significant difference in the neonatal morbidity among both the groups. Caesarean delivery cannot be routinely recommended, unless there are obstetric indications.
The aim of this study is to evaluate the clinical risk factors, accuracy of antenatal ultrasound for diagnosis, and the effect of these on pregnancy outcome. It is a retrospective study looking at cases which had hysterectomy following vaginal or caesarean section deliveries from 1993 to 2005. Data regarding the maternal demographic characteristics, number of previous CS, number of previous termination/curettage, antenatal scan findings (state features) and the gestation at which accreta was first suspected/diagnosed, MRI scan findings, pregnancy outcome (need for hysterectomy, amount of blood loss, amount of transfusion, length of ICU and hospital stay, other maternal complications, and neonatal outcome) were collected and evaluated. There were a total of 40 cases diagnosed to have abnormal placental attachment and majority of these were actually diagnosed antenatally by sonography. Visualisation of an absence or thinning of hypoechoic myometrial zone had the highest sensitivity to detect placenta accreta followed by intraplacental lacunae, focal mass tissue elevation and disruption of uterine serosal bladder wall.
Acoutic neuromas operated at UMMC from 2001 to 2006 were retrospectively reviewed. There were a total of 27 cases. All tumors were large, measuring more than 2 cm. Hearing loss was the most common presenting symptom (63%), followed by headache (52%), dysequilibrium (30%), facial numbness (30%), tinnitus (26%) and gait disturbances (15%). Eleven (41%) of patients had hydrocephalus at the time of presentation, for which a shunt procedure was required. The translabrynthine (TL) approach was used for 12 patients and the retrosigmoid (RS) with or without presigmoid clearance for the remaining 15. Major complications included one mortality and three cerebrovascular accidents (CVA's). The one-year facial nerve outcome was good to acceptable in 62% (House-Brackmann Grade I - IV) of patients. A literature review of current management of acoustic neuromas is presented.
This study looked at the causes of vision loss, levels of distance, near vision and the use of low vision devices (LVDs) in children studying at special schools in Malaysia. A total of 139 children from two special education schools took part. Visual acuity was measured with and without LVDs. Those who required further assessment were referred to Low Vision Clinic. Near visual acuity in 71 children ranged from N4 to N64. Sixty eight children could not read the N64 chart or they were totally blind. Only eight students were using LVDs before intervention. Seventy one children were referred for low vision assessment and 48 were found to benefit from the LVDs prescribed. The major cause of visual impairment was cataract (17%). Hand held magnifier was the most preferred LVD. Majority of the children attending the blind schools had residual vision but did not have LVDs. LVDs are able to significantly improve near visual acuity and hence there is a need to prescribe and train the children to use the LVDs.
The incidence of Non-Hodgkin's lymphomas (NHL) is rising worldwide and if not adequately treated carries a high mortality rate. The pattern and frequency of NHL vary in different populations and geographical regions. It has considerable biologic and clinical heterogeneity and a definitive diagnosis can be made only after histopathogical examination. The histology and the extent of the lymphoma are the major determinants of optimal therapeutic regimen and treatment outcome. Additionally, the overall treatment strategies should be tailored according to medical status and preference of the patient. A holistic approach provided by a multi-disciplinary team of health care professionals is the cornerstone of ensuring successful treatment outcome. Importantly, therapy should be expedited and where possible performed in experienced centers. Patients achieving remission would require long-term monitoring for disease recurrence and late effects of cytotoxic chemotherapy and radiotherapy. Hence, clinicians should have a fundamental understanding in the biology and the principles of treatment of NHL. This review provides an evidence-based and systematic approach in designing therapeutic strategies for individual patients with newly diagnosed and relapsed NHL focusing on the common types of NHL with particular reference to the current practice within the local settings. The role of standard and novel therapeutic modalities in treatment will be summarized.
We report a case of a 52 year-old dentist who had stent implantation for a left subclavian artery stenosis. However, this was later complicated by a stent fracture within one week of stent placement. A chest radiograph showed two pieces of the fractured stent, which was confirmed by computed tomographic angiogram (CTA) of the affected artery. We then discuss the occurrence of stent fractures, which are not uncommon but serious complications of endovascular therapy.
We report on an 11 year-old boy with dyskeratosis congenita who presented with dystrophic nails, dysphagia, hyperpigmentation and oral leukoplakia. He had a brother who died 14 years earlier with similar presenting symptoms and aplastic anaemia. Genetic studies of our patient demonstrated the presence of a DKC1 mutation and confirmed our diagnosis. Further genetic screening revealed that his mother and one of his four sisters are heterozygous for the same mutation.
We describe a 5 1/2 year old boy who was diagnosed with mild autosomal recessive osteopetrosis based on the presence of bony sclerosis, extramedullary haematopoeisis, leukoerythroblastosis and visual impairment who had an allogeneic bone marrow transplant from a matched sibling donor. Conditioning regime was busulphan 16 mg/kg and cyclophosphamide 200 mg/kg. Apart from transient hypercalcaemia, there were no major post transplant complications. Four years post transplant, the extramedullary haematopoeisis has resolved completely with normal blood counts. Apart from a fracture after a trivial fall two months after transplant, he has not suffered any fracture related limb deformities.
A 14 year old boy underwent a 7 hour long spinal surgery for scoliosis in the prone position. In the immediate postoperative period, he developed right proptosis, periorbital swelling, chemosis and total ophthalmoplegia. The vision in his right eye was only counting fingers and the intraocular pressure was 68 mmHg. Fundus examination revealed occlusion of the right central retinal artery. A rare manifestation of both vein and artery occlusion was possible in this patient as a result of external ocular compression due to a prolonged period in the prone position. This report highlights the importance of being aware of the possible complications of external ocular compression in non-ocular surgery.