A prospective study was made of 40 consecutive patients who presented with peripheral arterial embolism to the Vascular Surgical Service in UKM. Atrial fibrillation was the most common source of the embolus. Twelve patients did not present until the affected limb(s) were in established gangrene. Thirty-two embolectomies were performed on 25 patients. Only 10 of these patients were discharged well with their limbs intact. Four patients required amputation because embolectomy did not restore viability of the limbs. Eleven patients died following embolectomy. The overall mortality for arterial embolism was 50%. Among the survival (n = 20), only 11 patients were discharged with their limbs intact. The cause of the poor result was related to the delay in definitive treatment and the poor general state of the patients. It was concluded that the prognosis for arterial embolism was very poor. This result needs to be improved and recommendations are made to achieve this.
A prospective study of acute nephritis in children was conducted at the Universiti Sains Malaysia Hospital, Kubang Kerian between July 1987 and June 1988. One hundred and twenty four children were admitted with acute glomerulonephritis. The aim of the study was to determine the clinical pattern of the nephritis as well as its aetiology. The majority of our patients came from the lower socio-economic group and 54% of the families had incomes below the poverty line. Preceding skin infection was much more common than throat infection. The children showed a high incidence of complications: severe hypertension (43.6%), hypertensive encephalopathy (11.3%), clinical pulmonary oedema (36.3%), severe azotaemia (10.5%), and prolonged gross haematuria (13.7%). By using immunologic indices such as ASOT, anti-DNase B and complement 3, it was concluded that 121 of the 124 patients had post-streptococcal nephritis.
In a 30-month prospective study, between January 1987 and June 1989, 101 of 64,424 Malaysian neonates (1.6 per 1000 livebirths) born in the Maternity Hospital, Kuala Lumpur were found to have subaponeurotic haemorrhage shortly after delivery. The incidence was highest in neonates weighting 4000 gm or more. There was no significant difference in incidence of this condition in neonates of different ethnic origins. Hypoprothrombinemia was present in only 5/101 (5.0%) of the affected neonates. Sixty seven (66.3%) of the neonates with subaponeurotic haemorrhage had history of trial of vacuum extraction. The incidence of subaponeurotic haemorrhage was significantly higher in neonates delivered by vacuum extraction than by other modes of delivery in this hospital (41.4 per 1000 livebirths in neonates delivered by vacuum extraction versus 1.0 per 1000 livebirths in neonates delivered by other modes). Those neonates who developed subaponeurotic haemorrhage without trial of vacuum extraction had a history of either prolonged labour or difficult delivery. Thirty-three (32.7%) of the neonates with subaponeurotic haemorrhage developed anaemia which required blood transfusion and 3/33 (9.1%) were in shock. Fifty seven (56.4%) of the neonates with subaponeurotic haemorrhage developed hyperbilirubinemia due to the haemorrhage. Four (7.0%) of them had severe unconjugated hyperbilirubinemia which required exchange transfusion. The results of this study suggest that subaponeurotic haemorrhage in Malaysian neonates was commonly associated with vacuum extraction and was not a benign condition.
A pilot epidemiologic study of all cases of Reye and Reye-like syndromes was undertaken at 8 representative major hospitals in Peninsular Malaya from January 1st to December 31st 1986. The cases were classified as definitive Reye's syndrome, clinical Reye's syndrome and encephalo-hepatopathies. Less than 50% of cases reviewed fulfilled the National Center for Disease Control criteria for clinical Reye's syndrome. Causes of Reye-like syndromes/encephalo-hepatopathies included fulminant hepatitis, Japanese B encephalitis, dengue, septicaemia, and complex febrile fits. It was not possible to differentiate clinical Reye's syndrome from the other encephalo-hepatopathies by either the clinical features (except for jaundice) or biochemical parameters. Liver biopsy is necessary for a definitive diagnosis of Reye's syndrome in Malaysia, because of the high prevalence of Reye-like diseases. The mortality rate in the 2 groups of patients is similar. Ingestion of salicylates was not found to be significantly associated with Reye and Reye-like syndromes in this study.
Cardiac complications comprise as much as 50% of perioperative vascular surgical morbidity and mortality. Using the Goldman multifactorial index for evaluating cardiac risk pre-operatively, 53 consecutive patients who underwent abdominal aortic aneurysm surgery were prospectively studied. Forty patients (75.5%) were also evaluated with echocardiography for assessment of left ventricular function. There were 14 (23.7%) peri-operative events, of which nine (17.0%) were acute myocardial infarctions--two of whom died (3.8%). The minor complications included three with hypovolaemic renal failure, and one each with acute respiratory failure and cerebrovascular accident. Patients with Goldman cardiac risk index (CRI) classes III and IV were associated with significantly higher risks of peri-operative complications (p less than 0.001), i.e. 77.8% and 66.7% respectively, compared with class II (22.7%) and class I (nil). Echocardiographic left ventricular shortening fraction (LVFS) of less than 28% helped identify high risk groups in all classes, although its positive predictive value was low (42.3%). Combining LVFS less than 28% with Goldman CRI categories II to IV improved the sensitivity to 91.7% and the positive predictive value to 61.1%. Careful pre-operative assessment using the simple Goldman index and echocardiography is helpful in identifying higher risk patients who would benefit from pre-operative stabilisation and more rigorous perioperative hemodynamic monitoring preferably including intensive care (ICU) management, so as to reduce cardiac complications.
A prospective study was done to determine the incidence of cardiovascular malformations in neonates with Down's syndrome. 17/34 (50%) of the babies with Down's syndrome born at the Maternity Hospital, Kuala Lumpur, Malaysia had congenital heart defects. These included 7 cases of ventricular septal defect (VSD), 3 cases of patent ductus arteriosus (PDA), 2 cases of atrio-ventricular canal defect, 2 cases of ventricular septal defect with patent ductus arteriosus, 1 case of hypertrophic cardiomyopathy, 1 case of hypertrophic obstructive cardiomyopathy and 1 case of complex cyanotic heart. Only 8/17 (47%) of these babies had any clinical signs suggesting underlying cardiac defects. In view of the common occurrence of cardiac anomalies, it is recommended that echocardiographic screening should be carried out on all neonates with Down's syndrome.
Thirty-six asymptomatic infertile women undergoing laparoscopic examination as part of their infertility investigations, were included in this study on chlamydial infection. Patients were tested for chlamydial antigen in the cervix and peritoneal fluid. The serum of twenty-five of these patients was titrated for evidence of chlamydial antibodies. Fifty women attending a family planning clinic were used as a control group. The study showed a strong relationship between chlamydial infection and infertility due to tubal pathology. The incidence of chlamydial infection in asymptomatic infertile women was 33.3%. The results indicate that Chlamydia trachomatis should be sought in patients presenting with infertility and, if detected, appropriate medical treatment be given.
The occurrence of post-operative wound infection was studied respectively over an eight month period in the University Hospital, Kuala Lumpur. One hundred and seventy four (3.4%) surgical wounds out of 5129 operations became infected. The clean wound infection rate was 2.9%, rising to 5.4% and 12.2% for clean-contaminated and contaminated surgical wounds respectively. Of the wound infections, 80.8% occurred within the first two weeks post-operatively. Bacteriological studies revealed that the commonest bacterial isolates were Staphylococcus aureus (36.1%), Pseudomonas aeruginosa (15.4%) and Klebsiella species (10.1%).
Though peripheral arterial disease is not as common as in the Western countries, abdominal aorit aneurysm (AAA) is the most frequent arterial problem in Malaysia. A prospective study was made of 100 consecutive patients who presented with AAA to the author between January 1986 to September 1988 (31 months' period). There were 88 males and 12 females. The age range was 47-90 years, mean = 68.7. All the major ethnic rates were equally affected. The sizes of the AAA were documented by ultrasonography and the diameters ranged from 3-10 centimetres, mean = 5.8. Aneurysmectomy was performed on 58 patients, 17 of which were emergencies for ruptured AAA. The operative mortality for elective surgery was 2 percent, but that for emergency surgery was 47 percent. Ten patients refused surgery and 28 were not offered an operation. The true incidence of AAA is likely to be much higher than the number of patients referred for treatment. Many cases are not diagnosed or referred for treatment. Many cases of ruptured AAA died at home or in peripheral hospitals without a diagnosis being made. It is estimated that an AAA is present in 17,000 persons in Peninsular Malaysia. The risk of elective surgery is significantly lower than that of emergency. The overall mortality for ruptured AAA is even higher at about 99 percent. Furthermore, AAA is a benign disease and after surgery the patients return to their normal life expectancy. It is recommended that patients with AAA of five centimetres or more should be advised surgery if premature death is to be avoided.
A prospective study of 100 consecutive patients with basal skull fracture admitted to the University Hospital, Kuala Lumpur between July 1986 and October 1988 was carried out to study its epidemiological pattern, clinical and radiological presentations, mechanisms of injury, time interval between accidents and neurosurgical referrals, complications and outcomes. Two-thirds of the patients were between 20 and 50 years old and 79% were male. Half of the injured were motorcyclists and 22% were pedestrians. Three-quarters of the patients were seen within an hour after injury. Thirty-two patients had intracranial haematomas: 14 subdural, 9 extradural and 9 intracerebral. Three patients developed meningitis (two after operations) and six developed epilepsy. Eighteen patients died, but good recovery resulted in 70 patients at follow-up of 1 to 28 months. A small subgroup of 15 patients with severe ear and nose bleeding as a result of basal venous sinus tear died within a few hours despite aggressive resuscitation, probably due to underlying severe brain stem injury. The implication of the high incidence of basal skull fractures in motorcyclists, despite the enforcement of crash helmets is discussed, with possible mechanisms proposed.
In this study 24 patients who had conventional erect lateral X-ray pelvimetry had a CT pelvimetry done after delivery to complete the pelvimetry views. The erect lateral pelvimetry was read independently by a Consultant Radiologist, Consultant Obstetrician and a Medical Officer training in Obstetrics and Gynaecology. Using CT pelvimetry as the 'gold standard' (as the error of measurement was known with the machine used) the 3 readings were compared. There was no statistical difference in the values suggesting that X-ray pelvimetry is comparable to CT pelvimetry. However CT pelvimetry is preferred, if available, because of the lower dose of radiation involved, more comfort for the patient and shorter time in performing the procedure. Measurements done are easily read directly from the CT console.
Undetected hypertension is an obstacle to effective blood pressure control in the community. A study was done to assess the justification of screening in the outpatient department. Only 13% of all visits to the outpatient department resulted in an attempt to detect hypertension. The common reasons leading to blood pressure measurement were headache and dizziness. Current practice of hypertension detection appeared inadequate and irrational. Nine per cent of all visits to the outpatient department were already accounted for by hypertensives. A screening survey found that 30% of all non-hypertensive patients attending outpatient department aged 30 years or more had blood pressure greater than or equal to 140/90 mmHg. The drop out rate among these newly diagnosed hypertensives was 100%. Existing resources are already inadequate and existing hypertension care has also been shown to be inadequate. Screening can only be expected to considerably increase hypertensive patient load without however any assurance that effective long term care can be delivered. Labelling people as hypertensives in this manner may be harmful. The question of screening cannot be considered individually, separate from the entire problem of hypertension control. Detection must be linked to treatment in a programme designed to promote compliance and capable of delivering adequate care before it can be justified.
A prospective study was carried out on 26,176 Malaysian neonates born in the Maternity Hospital, Kuala Lumpur over a 12-month period to determine the incidence and associated risk factors of brachial plexus injuries. This condition was found in 42/26,176 neonates (1.6 per 1000 livebirths). Multiple logistic regression analysis of affected and control neonates from a nested case-control study showed that increasing birth weights and breech deliveries were the significant risk factors. Our study suggests that to reduce the occurrence of this condition, there is a need for: (i) better assessment of fetal size and maternal pelvimetry to enable earlier diagnosis of cephalo-pelvic disproportion, and (ii) review of the indications and techniques of breech delivery.
In a study to test the association between soil transmitted intestinal helminthiasis and abdominal symptoms in a non-paediatric age group, 242 randomly selected patients (137 males, 105 females, median age 45 years) were asked specific questions pertaining to abdominal symptoms at the time of admission to the adult medical wards. Stool examination on all patients revealed a round worm prevalence rate of 21%. A larger proportion of stool positive female patients were symptomatic than stool negative females (68% vs 30%, p = 0.04). There was no significant difference in symptoms between stool positive and stool negative male patients (34.6% vs 31%, p = 0.91). The results suggested an association between intestinal nematode infection and abdominal symptoms in females but not in males.
A prospective study of 92 children with poisoning admitted to University Hospital, Kuala Lumpur is reported. Majority of the affected children were below 3 years of age and belonged to low income families. Household items, especially kerosene, and medications were most often implicated. All children recovered completely. Preventive strategies are discussed.
We conducted a prospective longitudinal study to determine the nature and prevalence of cardiac abnormalities in systemic lupus erythematosus and to study their natural history and relationship with disease activity. Forty consecutive inpatients with systemic lupus erythematosus were studied during their admission and subsequently 6 to 12 months later. On each occasion a clinical cardiovascular examination was carried out, disease activity was scored using the "Lupus Activity Criteria Count" and a Doppler echocardiographic examination was carried out. 72.5% of patients had an abnormal echocardiogram in the first study while 51.7% were abnormal during the follow-up study. Valvar disease occurred in 37.5% of patients. The mitral valve was most commonly affected. Libman-Sacks endocarditis was rare (2.5%). Pericardial effusions were seen in 36.2% of echocardiograms. The majority (76.0%) of these were associated with hypoalbuminaemia. 80.0% of patients had active disease during the first examination and 41.4% at follow-up. There was no correlation between activity of disease and prevalence of cardiac abnormalities at either examination. We conclude that cardiac disease is common in systemic lupus erythematosus. Prevalence of cardiac abnormality did not correlate with disease activity.
Between January 1989 to April 1990 (16 months), a prospective observational study was carried out on 329 consecutive very low birthweight (VLBW) less than or equal to 1500 grams) Malaysian neonates born in the Maternity Hospital, Kuala Lumpur before their first discharge from the hospital. The objectives of the study were to determine the common causes of early morbidity and mortality of this group of Malaysian neonates. The study shows that the incidence of Malaysian VLBW neonates was 9.9 per 1000 livebirths (95% confidence intervals 9.0 to 10.8). The mean duration of stay in the hospital was 19.3 days (SD = 21.4). One hundred and ninety-six (59.6 percent) of the VLBW neonates died. They accounted for 60 percent (196/334) of all neonatal deaths in the hospital during the study period. Mortality was significantly higher in neonates of birthweight less than 1000 grams (p less than 0.01) and of gestation of less than 33 weeks (p less than 0.001). The three most common clinical problems were respiratory distress syndrome (RDS) (72.6 percent), septicemia (28.0 percent) and intraventricular haemorrhage (IVH) (21.9 percent). Death occurred in 71.1 percent of the septicemic patients. The most common causative organisms of septicemia were multiresistant klebsiella (52.3 percent) and multiresistant acinetobacter (14.7 percent). RDS (33.2 percent), septicemia (29.6%) and IVH (17.9 percent) were the three most common causes of death. Improvement in the nursing staff situation and basic neonatal care facilities in this hospital and prevention of premature delivery could help to decrease morbidity and mortality in this group of neonates.
Spinal anaesthesia was performed on 101 patients with a 25-Gauge (0.52 mm) needle. We found a 13.9% overall incidence of postdural puncture headache (PDPH) in an orthopaedic population whose mean age was 33.6 years. This incidence is too high and an alternative technique may be needed.
A prospective study was carried out in the Maternity Hospital, Kuala Lumpur in 1989 to determine the morbidity and mortality of infants of diabetic mothers. Out of 24,856 neonates born during the study period, 54 neonates (2.2 per 1000 livebirths) were born to mothers who were diagnosed to have diabetes mellitus before the current pregnancy or who had impaired glucose tolerance test during the current pregnancy. Almost a third (29.6 percent) of these infants of diabetic mothers had birthweight of 4000 grams and above, and 37.0 percent of the 54 babies were large-for-gestational age. Hypoglycemia occurred in 9/54 (16.7 percent) of the neonates, respiratory distress syndrome in 5/54 (9.3 percent), shoulder dystocia in 7/54 (13.0 percent), and congenital abnormalities in 4/54 (7.4 percent). Three (5.6 percent) neonates died during the neonatal period. The results of this study suggest a need to intensify control of maternal diabetes mellitus during pregnancy in order to reduce the rates of morbidity and mortality of their infants.
A prospective study of temperature drop in 141 normal term newborn infants delivered vaginally at the labour ward, University Hospital, Kuala Lumpur were studied. The effect of various manoeuvres on the temperature drop were also studied. They were randomized into 3 study groups, 63 cases where the babies were wiped with dry cloth alone, 37 cases where the babies were put into a plastic bag immediately after birth and lastly 41 cases where the babies were wiped with dry cloth and then inserted into a plastic bag. There was significant temperature drop in all the 3 groups maximum in the first 15 minutes and the fall continued for 1 hour after delivery (p less than 0.001). This shows that in an air-conditioned labour ward in a tropical country the temperature fall in newborn infants can be significant. This study also showed that plastic is a poor insulator against significant temperature drop.