Dural exposure may occur during the course of thinning the tegmen tympani and tegmen mastoideum in mastoid procedure. If large area of dura is exposed or lacerated, cerebrospinal fluid and brain herniation may enter the mastoid cavity. We report a case of a patient with injured dura mater and tegmen mastoideum during mastoidectomy for chronic suppurative otitis media with cholesteatoma managed by using DuraGen. The dura mater and tegmen defect healed totally showing the success of the procedure. A collagen matrix like DuraGen is an option for repairing dural tear in mastoid region.
Proteus Syndrome is a rare congenital hamartomatous disorder that typically manifests itself in overgrowth, vascular malformation and disregulation of fatty tissue. The tissues affected are commonly the limbs but can be of any tissue. Vascular anomalies are common and appear at random sites on the body. Diagnosis is often difficult leading to wrong treatment. We describe a case of a 17-year-old girl with Proteus syndrome presented with symptomatic anaemia secondary to chronic rectal bleeding. Computed Tomography Angiogram of Abdomen and Pelvis confirmed the presence of rectal vascular malformations.
The complexities of the anatomy of the nose and paranasal sinuses, as well as its variations may create technical difficulties during surgery. The significance of these anatomical variations in pathogenesis of rhinosinusitis, which is the commonest disease in the region, is still unclear.
Transforming growth factor beta-1 (TGF-beta-1) is a multifunctional cytokine involved in the regulation of growth and differentiation of both normal and transformed cells. The main aim of this study was to determine whether TGF-beta-1 or alpha fetoprotein (AFP) or the combination of the two is a better indicator for hepatocellularcarcinoma (HCC). Serum TGF-beta-1 and AFP were measured by ELISA in 40 healthy subjects, 23 patients with hepatocellular carcinoma (HCC), 70 patients with hepatitis B, 26 patients with hepatitis C and 16 patients with liver cirrhosis (LC). Patients with liver diseases showed significantly higher serum TGF-beta-1 values (> 3 fold) compared to control subjects. As for serum AFP, significant elevation was only observed for HCC cases. Serum TGF-beta-1 exhibited higher percent sensitivity compared to serum AFP in all liver diseases. Combination of serum TGF-beta-1 and AFP increased specificities in all cases studied. In conclusion, serum TGF-beta-1 is a more sensitive marker for HCC when compared to serum AFP and its specificity is increased when combined with serum AFP.
The third National Health Morbidity Survey was conducted in 2006 on a nationally representative sample of population in Malaysia in order to obtain community-based data and information on the prevalence of chronic illness. Of 57,500 eligible respondents 56710 (98.6%) participated in the study. Estimated overall prevalence of chronic illness in the Malaysian population within a recall period of one year was 15.5% (95% CI 15.1% - 15.9%). Chronic illness was reported significantly higher among the females, 16.8% (16.3 - 17.3). The most common chronic illness was hypertension (7.9%, 7.6 - 8.2), followed by diabetes mellitus (4.0%, 3.8 - 4.2) and highest reported by the Indians (19.7%, 18.4 - 21.0). Among the respondents who had sought treatment for chronic illness from government health facilities, Malays (65.8%) and those with monthly household income of less than RM400 (76.6%) were the highest. Chinese (44.5%) and those with household income of RM5000 and above (54.3%) were the highest groups who sought treatment from the private health facilities. Most of the respondents reported mild illness was the main reason for not seeking treatment for their chronic illness. It is hoped that the results of this survey will help the Ministry of Health Malaysia to enhance health programmes and planning resource allocation in order to improve health status of the population.
Study name: National Health and Morbidity Survey (NHMS-2006)
Treatment for chronic respiratory failure has advanced since the introduction of domiciliary non-invasive ventilatory devices. This has given a new light of hope for patients with chronic respiratory failure secondary to various causes. We report a series of patients with respiratory failure of different origins and types of management that they received. Four patients received bilevel positive airway pressure (BiPAP) and one patient received continuous positive airway pressure (CPAP).
When specifically asked, about one third of people report recurrent upper abdominal discomfort, and irritable bowel syndrome (IBS) and chronic gastritis (CG) maybe the most frequently diagnosed ones among all. Consecutive patients with upper abdominal discomfort applying to the Internal Medicine Polyclinic were included into the study. IBS was diagnosed according to Rome II criteria and CG was diagnosed histologically. All cases with IBS were compared with the age and sex-matched randomly selected cases without IBS. One hundred and fifty-six patients with IBS and 179 patients without IBS were studied. CG was detected in 72.4% (113 cases) of cases with IBS, and only 36.3% (65 cases) in patients without IBS (p < 0.001). IBS probably is a cascade of many physiological events, being initiated by infection, inflammation, psychological disturbances-like many stresses and eventually leading to dysfunctions of gut and other systems of the body via a low-grade inflammatory process. CG may be one of the terminating points of the physiological events' cascade, IBS. This may explain the high prevalence of IBS in society. Keeping in mind this association will be helpful during prevention, treatment, and follow up of these common pathologies in Primary Health Centers and Internal Medicine and Gastroenterology Polyclinics for physicians.
This is a cross sectional study of 40 patients diagnosed with chronic rhinosinusitis using the Lanza Kennedy diagnostic criteria based on nasal endoscopy (NE), and on computer tomography (CT) of the paranasal sinuses. The purpose of the study is to demonstrate the effectiveness and limitations of CT, and NE in the assessment of chronic rhinosinusitis. This study shows that CT was superior in detecting OMC involvement, presence of concha bullosa, paradoxical turbinate and nasal septal deviation. NE was better at detecting polyps.
Evidence-based heart failure management now includes beta-blockers and spironolactone in addition to diuretics and angiotensin-converting enzyme inhibitors. We aim to determine if these recommendations had been applied in practice for acute and chronic stable heart failure, and what difficulties there might be. Data from 80 consecutive patients hospitalized for decompensated heart failure ('acute') between May and July 2003 were analyzed at admission, upon discharge and at 12 weeks follow-up; along with 74 cardiology clinic out-patients with stable congestive heart failure ('chronic'- no decompensation or admission in previous six months). Less than half of study patients with prior left ventricular dysfunction were on ACE-inhibitors (47%), diuretics (39%), ATII antagonists, spironolactone or digoxin (5% each). All 'acute' patients were commenced on diuretics and ACE-inhibitors in hospital. Six patients died or transferred to another center. Compliance with clinic appointment at 12 weeks was 85% despite telephone reminders. Drug prescription at 12 weeks was significantly lower for diuretics and ACE-inhibitors compared to prescription at discharge (all p < 0.05) but higher compared to patients with chronic HF. Diuretics and ACE inhibitors remain under-utilized for patients with recurrent heart failure. Use of spironolactone and beta-blocker is slow due to limited medical experience and funding. Clinic non-attendance is significant and due to patient factors.
Posterolateral corner (PLC) laxity of the knee results in rotatory instability, in association with posterior cruciate ligament (PCL) laxity led to a grossly unstable knee. This is a series of eight patients with chronic PLC and PCL laxity treated with arthroscopic quadriceps tendon PCL reconstruction and extraarticular hamstring PLC reconstruction. Seven cases had high tibial osteotomy to address associated genu varus deformity. With prospective pre- and post-operative assessments, there was a significant improvement in the 2000 International Knee Documentation Committee (IKDC) subjective assessment and knee examination, Lysholm-Gillquist and Tegner activity scores, as well as KT-1000 arthrometry measurement after one year in all knees. Surgical treatment of PLC laxity must address coexisting problems of the PCL and mechanical alignment for a successful outcome.
Perianal mucinous adenocarcinoma is a rare tumor which may be associated with long-standing chronic perianal sepsis. Early diagnosis is challenging and is based on a high index of clinical suspicion and specific histological features. Definitive treatment is surgical, in the form of an abdomino-perineal resection. We hereby describe a case of a perianal mucinous adenocarcinoma arising from long-standing recurrent perianal fistula and complement this with a brief review of the literature pertaining in particular to the management of this condition.
Chronic ruptures of the extensor mechanism of the knee are uncommon injuries, and previously reported literature assumes the presence of an intact patella for repair. We present a case of chronic rupture following patellectomy done twelve years previously. The defect in the extensor apparatus was extensive (18cm), and this was bridged using a large fascia lata graft from the opposite thigh, with reasonably successful results.
We report a case of a previously healthy 53-year-old man who developed an intra-operative catastrophic event occurring in association with the use of hydrogen peroxide for wound irrigation following surgical debridement of a chronic osteomyelitis lesion of the humerus. It is our intention to highlight this potentially fatal consequence of hydrogen peroxide irrigation as part of bone debridement procedure. This case will serve as a reminder to orthopaedic surgeons who frequently use hydrogen peroxide in their surgical practice.
Post-traumatic chronic osteomyelitis and infected non-unions of the tibia following severe type-III open fracture are difficult to treat Refractoy cases often necessitate amputation despite attempts to salvage the limb. We report our experience in treating such difficult cases with an alternative surgical option using free osteocutaneous fibular graft. Eight consecutive patients with post-traumatic chronic osteomyelitis/infected non-union were treated surgically with free vascularized osteocutaneous fibular graft. Outcomes in term of graft-host union and complication were evaluated. Four patients had anastomotic venous thrombosis requiring anastomotic revision. Five patients developed surgical site infections needing extended antibiotic therapy to achieve resolution at an average of 15.2 weeks. Fibular graft fracture occurred in three patients but all grafts survived and united after a mean time to union of 42.3 weeks (range 31 to 82 weeks). At the final follow-up, union of host-graft junction and control of infection were achieved in all patients except one who required a secondary amputation. Free vascularized osteo-cutaneous fibular graft is a viable limb salvage option for refractory chronic osteomyelitis or infected non-union following treatment of grade-III open tibial fractures.
Skin is the largest organ in human system and plays a vital role as a barrier against environment and pathogens. Skin regeneration is important in tissue engineering especially in cases of chronic wounds. With the tissue engineering technology, these skins equivalent have been use clinically to repair burns and wounds. Consented redundant skin samples were obtained from patients aged 9 to 65 years old. Skin samples were digested with dispase, thus separating the epidermis and the dermis layer. The epidermis layer was trypsinized and cultured in DKSFM in 6-well plate at 37 degrees C and 5% CO2. Once confluent, the culture were trypsinized and the cells were pooled. Cells were counted using haemacytometer. Doubling time and viability were calculated and analysed. From the result, we conclude that doubling time and viability of in vitro keratinocytes cultured in DKSFM media is not age dependant.
Chronic pancreatitis is a difficult disease to treat. Worldwide, alcohol is the most common aetiology but based on recent studies it is clear that genetic susceptibility plays an important role in determining disease. Several important genetic mutations have been identified. The prevalence of chronic pancreatitis appears to be lower in Asia although very high rates have been reported in parts of India. Severe intractable pain is the predominant presenting complaint of patients. The natural history of the disease and the onset of exocrine and endocrine insufficiency depend on the classification of disease as early onset, late-onset or alcohol associated. Complications of chronic pancreatitis are important and include pseudocyst formation, bile duct and duodenal strictures.
Four to 6 months of conventional interferon alpha (IFN-alpha) (5MU daily or 10MU three times weekly) resulted in HBeAg loss in approximately 33% of HBeAg positive patients (controls: 12%). Longer treatment duration improved HBeAg seroconversion. Children with chronic HBV infection and high ALT respond to IFN-a at similar rates. Good end-of-treatment (ET) biochemical and virological response were also achieved with IFN-alpha in HBeAg negative, HBV-DNA positive hepatitis patients. Sustained response (SR) however, was disappointing, but improved with longer duration of treatment: (10-15% SR with 4/6 months treatment: 30% SR with 24 months treatment). Weekly pegylated IFN-alpha2a (PegIFN-alpha2a) for 24 weeks gave a significantly higher HBeAg conversion rate (33%) than conventional IFN-alpha2a (25%). Fifty-two weeks of PegIFN-alpha2b gave a sustained HBeAg loss in 35% patients and HBeAg seroconversion in 29% patients. Similar results were obtained with 48 weeks of weekly PegIFN-alpha2a. PegIFN-alpha2a monotherapy was found to be superior to lamivudine monotherapy in affecting a 6-month SR (normal ALTs and HBV DNA < 20,000 copies/mL) in HBeAg negative/anti-HBe positive chronic hepatitis B patients. There is a tendency for IFN-a and lamivudine combination to result in better sustained response than lamivudine monotherapy. This tendency is also observed with PegIFN-a and lamivudine combination although the combination did not appear to be better than PegIFN-alpha monotherapy. IFN induced HBeAg seroconversion is durable, could increase over time and resulted in better overall survival and survival free of hepatic decompensation or hepatocellular cancer. The main advantage of IFN-a therapy is that a course of finite duration may achieve sustained off-therapy response in a proportion of both HBeAg positive and HBeAg negative chronic hepatitis B patients. However, IFN treatment is usually associated with side-effects, especially flu-like symptoms, fatigue, neutropenia, thrombocytopenia and depression. These are usually tolerable but may require dose modification and premature cessation of treatment (5%). Interferon therapy induced hepatitis flares may lead to decompensation in patients with cirrhosis and can be dangerous in patients with decompensated liver function despite dose reduction.
Spontaneous intracranial haemorrhage (ICH) is a rare complication of chronic immune thrombocytopenic purpura (ITP) in children. We report four patients with cITP who developed ICH. The latency between onset of ITP and ICH varied from 1-8 years. All our patients were profoundly thrombocytopenic (platelet count of <10 x 109/l) at the time of their intracranial bleed. The presenting features and management are discussed. All patients survived, three had complete neurological recovery while one had a minimal residual neurological deficit.