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Successful free omental flap and skin graft reconstruction of scalp avulsion injury

Ramzisham AR, Somasundaram S, Nasir ZM, Ali F, Das S

Clin Ter, 2010;161(5):453-5.
PMID: 20949243

For the management of a full-thickness scalp avulsion injury, thorough wound debridement and immediate primary revascularization or a split-thickness skin graft may be necessary. Graft failure may be common situation thereby predisposing the individuals to unnecessary multiple operations. In the recent times, the use of omental graft has gained much popularity. In the present study, we describe an interesting case of chronic non healing scalp ulcer in a young woman who eventually underwent a free omental flap reconstruction with split-thickness skin graft and had satisfactory outcome.
The transcript level of interleukin-6 in the cartilage of idiopathic osteoarthritis of knee

Moktar NM, Yusof HM, Yahaya NH, Muhamad R, Das S

Clin Ter, 2010;161(1):25-8.
PMID: 20393674

AIMS: The mRNA level for interleukin-6 (IL-6) is an important marker of osteoarthritis (OA). The present study aimed to investigate the level of IL-6 mRNA in the cartilage of OA knee while comparing it to the normal cartilage obtained from the same patient.
MATERIALS AND METHODS: A total of 21 patients who underwent total knee replacement were recruited for this study. Sectioning of the destructive cartilage was performed in the medial part of the proximal tibiofemoral cartilage. The unaffected lateral part of the knee in the same patient, served as a control. The mRNA level for IL-6 was assessed using LightCycler 2.0 quantitative real-time polymerase chain reaction (qRT-PCR). actin mRNA was used as an endogenous control.
RESULTS: Twelve out of 21 patients (57.1%) exhibited up regulation of IL-6 mRNA in the OA cartilage as compared to the normal cartilage. The rest of the patients (42.9%) showed down regulation of IL-6 mRNA. The statistical analysis showed there was insignificant level of IL-6 mRNA in the OA (1.91 +/- 0.45) as compared to the normal cartilage (1.13 +/- 0.44) (p > 0.05). The inter-individual variation in the level of IL-6 mRNA in the cartilage of idiopathic knee was in accordance with previous findings.
CONCLUSIONS: These observations suggest IL-6 could also act as a catabolic agent in some patients or its expression might be influenced by other cytokines.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
The predictive values of urinalysis in intravenous urogram. Is intravenous urography really necessary in mild hydronephrotic patient?

Hamzaini AH, Helmee MN, Masoud S, Suraya A, Nazri MS, Das S

Clin Ter, 2009;160(6):473-5.
PMID: 20198290

BACKGROUND AND AIMS: Many patients who presented to Universiti Kebangsaan Malaysia Medical Centre (UKMMC) with signs and symptoms of urolithiasis had mild hydronephrosis with non visualization of calculus on ultrasound examination. These patients underwent an intravenous urogram (IVU) in order to determine the presence of urolithiasis and most of them had normal IVU. The main aim of this study was to determine the predictive value of urinalysis in this group of patients in determining the need for IVU examinations.
MATERIALS AND METHODS: Retrospectively the ultrasound, urinalysis and intravenous urography reports of 53 patients were reviewed and evaluated.
RESULTS: The positive predictive and negative predictive value of urinalysis was found to be 68% and 96.4%, respectively. CONCLUSIONS; The results indicate that the urinalysis was an excellent negative predictor for IVU. In view of high radiation dose, risk of contrast reaction and contrast induced nephropathy of IVU, we suggest that it should not be performed in patient with non visualization of calculus mild hydronephrosis when the urinalysis is negative for blood.

Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Higher division of the tibial nerve in the leg: gross anatomical study with clinical implications

Norzana AG, Farihah HS, Fairus A, Teoh SL, Nur AK, Faizah O, et al.

Clin Ter, 2013;164(1):1-3.
PMID: 23455733 DOI: 10.7417/CT.2013.1501

Tibial nerve is a branch of the sciatic nerve and it is the main nerve innervating the muscles of the back of the leg. The tibial nerve divides into medial and lateral plantar nerves. The level of division may be important for surgical purpose. The main aim of the present study was to observe the exact level of division of the tibial nerve and discuss its clinical implications.
Arterial embolization of a bleeding gastric Dieulafoy lesion: a case report

Mohd Rizal MY, Kosai NR, Sutton PA, Rozman Z, Razman J, Harunarashid H, et al.

Clin Ter, 2013;164(1):25-7.
PMID: 23455738 DOI: 10.7417/T.2013.1506

Dieulafoy's lesion is one of an unusual cause of upper gastrointestinal bleeding (U GIB). Endoscopic intervention has always been a preferred non-surgical method in treating UGIB including bleeding from Dieulafoy's lesion. Owing to recent advances in angiography, arterial embolization has become a popular alternative in non- variceal UGIB especially in cases with failed endoscopic treatment. However, managing bleeding Dieulafoy's with selective arterial embolization as the first line of treatment has not been exclusively practiced. We hereby, report a case of bleeding Dieulafoy lesion which had been primarily treated with arterial embolization.
Topographical anatomy of the profunda femoris artery and the femoral nerve: normal and abnormal relationships

Choy KW, Kogilavani S, Norshalizah M, Rani S, Aspalilah A, Hamzi H, et al.

Clin Ter, 2013;164(1):17-9.
PMID: 23455736 DOI: 10.7417/T.2013.1504

Femoral nerve (FN) is the largest branch of lumbar plexus. It lies lateral to femoral artery (FA) and it is located outside the femoral sheath. Profunda femoris artery (PFA) is a branch of the FA. The present study aimed to observe the topographical anatomy and relationship of the PFA and the FN.
An interesting case of isolated pancreatic teratoma: lessons to learn

Razman J, Azlanudin A, Eyad AJ, Zahiah M, Das S

Clin Ter, 2012 Nov;163(6):495-7.
PMID: 23306744

Mature cystic teratomas of the pancreas are extremely rare tumours encountered in day-to-day clinical practice. Only few cases have been reported to date involving all age groups. The management, diagnosis and evaluation of this tumor are questionable, with definitive diagnosis taking place intra-operatively. We hereby report the case in a 30 year-old-male who presented with newly diagnosed diabetes mellitus and during the follow up he was noted to have elevated liver enzymes clinically, he was asymptomatic. The computerized tomography revealed a retropancreatic mass and pushing the mesenteric veins anteriorly. The mass was hypodense in nature and there was presence of calcification. Although the patient was asymptomatic, the decision for resecting the mass was made in view of the size and possibility of malignancy. In conclusion, considering the size and approximity of the mass to the pancreas, Whipple procedure's is the most appropriate approach although the histological diagnosis has not been established preoperatively.
Spinal arteriovenous malformation presenting with prolapsed intervertebral disc: a diagnostic dilemma

Farina MY, Harunarashid H, Faridzal F, Jegan T, Das S

Clin Ter, 2012 Nov;163(6):491-3.
PMID: 23306743

The availability of multiple investigating modalities should be utilized to arrive at the correct diagnosis of the spinal arteriovenous malformation (AVM). We hereby report the case of a 21-year-old, obese female, who presented with paraplegia and impaired bowel control two years after an episode of the fall. The Magnetic Resonance Imaging (MRI) of her spine not only revealed disc prolapse at T11-T12, but also tortuous dilated spinal veins and cord oedema. A diagnosis of a spinal arterio-venous fistula was confirmed after a spinal angiogram. The dilemma of treating the right pathology for the clinical signs and symptoms are being discussed.
Absence of the isthmus of the thyroid gland: anatomical and clinical considerations

Taty-Anna K, Farihah HS, Norzana AG, Farida H, Das S

Clin Ter, 2012 Nov;163(6):503-4.
PMID: 23306746

The right and left lobes of the thyroid gland are connected by an isthmus. The isthmus lies at the level of the second and third tracheal rings. Occasionaly, the isthmus may be absent. We hereby, report the absence of isthmus in a 52-year-old male cadaver of unknown origin. Both the right and left lobes were normal but they were separated. Both the right and left lobes of the thyroid gland measured 4.3 cm vertically. The separation distance between right and left glands was noted at the upper, middle and lower parts. The upper end of medial border of both lobes were separated by a distance of 1 cm while the separation distance was 0.7 cm and 1.5 cm at the middle and lower parts, respectively. The anatomical and clinical significance of absence of isthmus is important for medical personnel and the surgeons operating on the thyroid gland. The present case report is a an attempt to highlight such.
The underlying mechanism of action for various medicinal properties of Piper betle (betel)

Haslan H, Suhaimi FH, Thent ZC, Das S

Clin Ter, 2015;166(5):208-14.
PMID: 26550811 DOI: 10.7417/CT.2015.1880

Piper betle (betel) plant belongs to the Piperaceae family. Piper. betle is widely known for its potent medicinal properties. Various active compounds are present in Piper. betle such as allylpyrocatechol, hydroxychavicol, piperbetol, ethylpiperbetol, piperol A, piperol B, chavibetol, and alkaloids which account for these beneficial medicinal properties. In the present narrative review, we looked into the various active compounds present in the Piper betle and attempted to understand their underlying mechanism of action. Proper understanding of the molecular biology involving the mechanism of action may help in better drug formulation and provide better therapeutic actions in the field of alternative and complementary medicine.
Laparoendoscopic Transgastric Enucleation of an awkwardly sited Peri-Cardial Gastrointestinal Stromal Tumour (GIST): A Multi- Modal Approach

Kosai NR, Rajan R, Roslani EJ, Sutton PA, Mustafa M, Das S

Clin Ter, 2015 Nov-Dec;166(6):248-52.
PMID: 26794812 DOI: 10.7417/CT.2015.1896

In the modern era of surgery, minimally invasive surgery is increasingly applied for excision of gastrointestinal stromal tumors. Site, size and tumor location are important factors that affect the surgical approach and excision. We performed a laparoendoscopic transgastric enucleation of a 4-cm pericardial endophytic gastrointestinal stromal tumor (GIST) using an energy device. The surgery was successful and post-operative recovery uneventful. No tumor recurrence was detected on surveillance gastroscopy. In the safe hands of a well-trained laparoscopic upper gastrointestinal surgeon, pericardial GIST can be enucleated safely by this method. The avoidance of surgical staplers is not only cost-effective, but also reduces the risk of associated complications.
Adductor accessorius - an unusual supernumerary adductor muscle of thigh

Goel S, Arora J, Mehta V, Sharma M, Suri RK, Rath G, et al.

Clin Ter, 2015;166(3):114-7.
PMID: 26152618 DOI: 10.7417/CT.2015.1840

The knowledge of variant anatomy of medial compartment of thigh is extremely important in surgical procedures requiring obturator nerve block. The nerve block is also recommended for providing additional analgesia following major knee surgeries and for relieving painful adductor muscle spasm. The interfascial injection technique is commonly followed in ultrasound guided obturator nerve block. For this procedure it is imperative to identify the adductor muscles on sonography to inject the anesthetic solution in the intermuscular fascial planes. The presence of an additional muscle can prove useful in myocutaneous flap surgeries for reconstruction especially of perineum. We hereby report a case of such an anomalous supernumerary adductor muscle present between adductor brevis and proximal part of adductor magnus, in an adult Indian male cadaver, recorded during routine dissection in Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital. The muscle was innervated by the posterior division of obturator nerve. The morphology, embryological basis and clinical aspects are also discussed.
Pregnant and severe acute abdominal pain: A surgical diagnostic dilemma

Kosai NR, Amin-Tai H, Gendeh HS, Salleh S, Reynu R, Taher MM, et al.

Clin Ter, 2015;166(3):110-3.
PMID: 26152617 DOI: 10.7417/CT.2015.1839

Acute abdominal pain in pregnancy remains a surgical conundrum. A 25-year-old primigravid at 29 weeks gestation presented with a two-week history of epigastric pain, nausea and vomiting. She had a distended abdomen consistent with a full term gravid uterus; tender at the epigastric and right hypochondrium suggestive of small bowel obstruction or acute appendicitis. Abdominal ultrasound was inconclusive but abdominal Computed Tomography (CT) suggested small bowel volvulus. An exploratory laparotomy revealed a segmental jejunal volvulus and small bowel diverticulum contributing to the volvulus. A short segmental bowel resection was performed. Histopathology confirmed a Meckel's Diverticulum. The patient recovered well but underwent premature labour 10 days later. Small bowel obstruction secondary to Meckel's diverticulum is rare in pregnancy. In an acute gestational abdomen, clinical examination is key. Radiological imaging may be helpful, whilst surgical intervention is confirmatory and therapeutic in the event of an obstructive volvulus.
Effect of Exercise on Pulmonary Function Tests in Obese Malaysian Patients

Christopher LK, Kosai NR, Reynu R, Levin KB, Taher MM, Sutton PA, et al.

Clin Ter, 2015;166(3):105-9.
PMID: 26152616 DOI: 10.7417/CT.2015.1838

Obesity has taken the 21st century by storm, posing negative effects on of the various facades of health, healthcare and global economy. With regards to pulmonary performance, numerous studies have proven the detrimental effects of obesity while reinstating the positive effects of weight loss on overall pulmonary function. However, effects of exercise on pulmonary function and correlation between changes in pulmonary function test with weight loss have yet to be described. We performed a prospective interventional study to determine the effects of regular exercise on Pulmonary Function Tests (PFT) and ascertain the relationship between weight loss and change in PFT in obese patients.
Rare atypical vascular pattern of subscapular artery: Anatomico-clinical insight

Kumar A, Goel S, Arora J, Mehta V, Pakhiddey R, Suri RK, et al.

Clin Ter, 2015;166(3):118-20.
PMID: 26152619 DOI: 10.7417/CT.2015.1841

The use of muscles of scapular region in transposition and reparative surgery has made the anatomical knowledge of axillary artery and its branches imperative. The subscapular arterial tree is frequently used as a source of microvascular grafts to replace damaged or diseased portion of arteries especially in upper and lower limbs. This investigation is aimed to study the variation in branching pattern of the third part of axillary artery.
Unusual branching pattern of brachial artery - Embryological basis and clinicoanatomical insight

Hansdak R, Arora J, Sharma M, Mehta V, Suri RK, Das S

Clin Ter, 2015;166(2):65-7.
PMID: 25945432 DOI: 10.7417/CT.2015.1817

Variations in the arterial pattern of upper limb are of colossal importance to the surgeons as they are liable to iatrogenic injuries. During routine dissection for undergraduate medical students, an anomaly of brachial artery was discovered. The brachial artery terminated at higher level into ulnar and radial artery. The common interosseus artery took origin arising from radial artery. The ulnar artery did not give any branches in the forearm. Both radial and ulnar artery displayed a superficial course in the forearm. The anatomical knowledge of these variations may be of great help for the clinicians in planning and conducting flap harvesting during reconstructive surgeries and in arteriography.
A prospective cohort study on quality of life after endoscopic thoracic sympathectomy for primary hyperhidrosis

Dharmaraj B, Kosai NR, Gendeh H, Ramzisham AR, Das S

Clin Ter, 2016;167(3):67-71.
PMID: 27424505 DOI: 10.7417/CT.2016.1928

BACKGROUND: Hyperhidrosis is an excessive sweating disorder affecting quality of life. Endoscopic thoracic sympathectomy (ETS), introduced by Kux in 1951, is currently the gold standard surgical treatment for primary hyperhidrosis. 75% of patients with primary hyperhidrosis have seen improvement in quality of life within 30 days after surgery. Compensatory hyperhidrosis and pneumothorax (up to 75%) have been reported in patients after surgery. This study evaluates the functional status, self- esteem, compensatory hyperhidrosis and quality of life among patient with primary hyperhidrosis before and after undergoing ETS.
METHOD: Fifty (n=50) patients between the ages 18 to 30, with primary hyperhidrosis were recruited. Patients answered the quality of life questionnaire and Rosenberg self-esteem questionnaire prior to surgery and 30 days post surgery on follow up. Any post-operative complications were documented. Telephone interviews were held for patients who were unable to attend the clinics for follow-up.
RESULTS: Forty six patients (92%) had symptomatic relieve within 30 days of surgery. The incidence of compensatory sweating was 78% (39 patients), with 6 patients developing severe hyperhidrosis. Two patients who did not experience symptomatic relieve, developed compensatory hyperhidrosis. Pneumothorax was documented in 8 patients (16%), with 6 patients requiring chest tubes. Significant improvement in quality of life and self-esteem was seen among patients after surgery.
CONCLUSIONS: ETS has shown to significantly improve the quality of life and self-esteem of patients with primary hyperhidrosis within 30 days of surgery. However, the rate of compensatory hyperhidrosis still remains high (78%) which requires a long term evaluation.
KEYWORDS: Hyperhyrosis; Quality of life; Thoracoscopic Symphatectomy
Fulltext Foot care strategy for the newly diagnosed DM Type 2 patients with low educational and socio-economic background: a step towards future

Hamidah H, Santhna LP, Ruth Packiavathy RD, Suraya AM, Yap WC, Samsiah M, et al.

Clin Ter, 2012 Nov;163(6):473-8.
PMID: 23306740

BACKGROUND AND AIMS:
Diabetic foot ulcer is one of the major health problems that accounts for increased morbidity among the diabetic patients. Having good knowledge, good attitude and practice of managing the foot prevents the impending chronic co-morbidities of the disease.

MATERIALS AND METHODS:
This cross-sectional study was performed to assess the knowledge, attitude and practice on foot care among the newly diagnosed diabetic type 2 patients with low education and socio economic background. This study was conducted in one of the out patient clinics in a tertiary hospital. A set of questionnaire adopted from The Michigan Diabetes Research and Training Center (MDRTC), was used to assess 109 respondents based on their knowledge of diabetes mellitus, practice and attitude towards the condition and care of the feet.

RESULTS:
The overall finding on knowledge, practice and attitude had shown unsatisfactory result. There was no relationship between the knowledge, practice and attitude with care of the feet. Only 20 (18.3%) respondents had a high score on knowledge, 31 (28.4%) had practiced good habits and 5 (4.6%) showed positive attitude towards care of the feet. However, there was significant finding on the level of education and the knowledge of foot care (p=0.01);

CONCLUSION:
Strategies should be developed to overcome the longterm complications. As for the Muslim patients, ablution, the ritual practice of washing and cleaning both feet prior to the prayers may be a possible means of checking the feet for any diabetic foot complication.
A histological study of the structural changes in the liver of streptozotocin-induced diabetic rats treated with or without Momordica charantia (bitter gourd)

Teoh SL, Latiff AA, Das S

Clin Ter, 2009;160(4):283-6.
PMID: 19795081

Aim: Diabetic liver is associated with biochemical, physiological and pathological changes. The aim of the present study was to evaluate the histological changes following administration of Momordica charantia (MC) in the streptozotocin (STZ) induced diabetic rats.

Materials and methods: Eighteen Sprague-Dawley rats (n=18) were taken for this study. The animals were divided into 3 groups:- non-diabetic (n=6), untreated diabetic (n=6) and diabetic treated with MC extract (n=6). Diabetes was induced in the experimental rats via intravenous injection of streptozotocin (45 mg/kg body weight). MC extract (50 mg/kg body weight) was administered orally to the treated diabetic rats 10 days following induction. The liver tissues were collected on the 10th day following treatment and the histological study was performed using different staining methods which included hematoxylin and eosin (H&E), Verhoeff's van Gieson (VvG) and periodic acid Schiff (PAS).

Results: The liver of the diabetic rats showed involvement of the hepatocytes with features of inflammation. The portal triad in the diabetic liver showed extensive involvement in terms of accumulation of mucopolysaccharide deposits. Liver damage in the diabetic animals showed features of healing with administration of the MC extract.

Conclusions: The MC extract due to its antioxidant role may be helpful in reversing the changes in the liver in diabetes mellitus.
Fulltext Sonographically abnormal placenta: an association with an increased risk poor pregnancy outcomes

Wan Masliza WD, Bajuri MY, Hassan MR, Naim NM, Shuhaila A, Das S

Clin Ter, 2017 10 19;168(5):e283-e289.
PMID: 29044348 DOI: 10.7417/T.2017.2021

BACKGROUND: The placenta is a most interesting but unfortunately often ignored and misunderstood organ. Placental abnormalities, therefore, can be an "early warning system" for fetal problems. A complete prenatal sonographic examination of the placenta is an essential component as its abnormalities can have a direct effect on fetal or maternal outcomes, obstetrical management and future fertility.
OBJECTIVE: To determine whether any association exists between the finding of an increased thickness of placenta, abnormal placenta shape, placental calcification, placental lake and abnormal cord insertion site at 20-22 and 30-32 weeks gestation with an increased risk of uteroplacental complications or a poor pregnancy outcome.
METHODOLOGY: A real-time ultrasound was used at the time of detail scan (at 20-22 weeks gestation) and at 30-32 weeks gestation to look for placenta appearance, fetal growth and anomaly. The main outcome measures were risk of hypertension disease in pregnancy, fetal growth restriction and poor fetal outcomes such as low Apgar score and low cord pH.
RESULT: The majority of the participants were Malay (77.9%). Abnormal placenta found at both gestations were placental lakes and thickness, and only one case had marginal cord insertion. Approximately 6% of the cases were confirmed placenta previa. No abnormal shape or abnormal calcification found at both gestations. About 10% patient developed hypertensive disease in pregnancy, 15% of the fetus was found to have growth restriction and another 16% have low umbilical cord pH. Majority of them delivered at term (90%) and via vaginal delivery (81%). There was no significance between presence of abnormal placental lake and thickness at both gestations with the maternal and fetal outcome.
CONCLUSION: Presence of abnormal placental thickness and lakes at 30-32 weeks scan associated with maternal hypertensive disease, fetal growth restriction and low umbilical cord pH, however these were not statistically significant.

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