A 35-year-old Jordanian gentleman presented with worsening right iliac fossa pain of three-day durations with vomiting, loose stool and intermittent fever. He later underwent laparoscopic surgery, which was subsequently converted to open laparotomy. Intraoperatively, there was thickened bowel with multiple mesenteric lymph nodes, and also thrombosis of the small bowel vein supplying the affected bowel lesion, the diagnosis which was later confi rmed with the histopathological report. Resection with end-to-end anastomosis was done during the surgery. Within one-week post laparotomy, he developed another progressive abdominal pain and distension, vomiting and no bowel opening. He was sent for another exploratory laparotomy. Intraoperatively, there was a gangrenous small bowel segment measuring 130 cm, with an intact large bowel and previous anastomotic site. Resection of 150 cm of the small bowel was subsequently done.
It is important to provide effective postoperative analgesia following a Caesarean section because mothers wish to be pain-free, mobile and alert while caring for their babies. The role of regular oral diclofenac as postoperative analgesia was evaluated in a randomized controlled study and it was compared to the established method of parenteral pethidine. Forty healthy women scheduled for elective Caesarean section under spinal anaesthesia with 2-2.5 mg of heavy bupivacaine 0.5% were randomized to receive either 75 mg of oral diclofenac twice daily or 1 mg/kg of subcutaneous pethidine every 8 hourly. Efficacy of pain relief (visual analogue score), patients' satisfaction and side effects such as sedation, nausea and vomiting were recorded for three days. The demographic variables were similar in both groups. Pain relief was adequate and comparable in both groups with similar mean visual analogue score during the second and third day of the study period. However, on the first postoperative day, 60% of the diclofenac group population required rescuemedication consisting of subcutaneous pethidine in order to achieve the same pain scores as those in the pethidine group who did not require any rescue medications. Women who received oral diclofenac reported lower sedation and higher overall satisfaction. The incidence of nausea and vomiting was similar in both groups. This concluded that although oral diclofenac 75mg twice daily may not be superior to the traditional method of subcutaneous pethidine for pain relief following caesarean section, it can still be used alone as an alternative, as it has other benefits of a non-opioid analgesia.
Tumour-induced or oncogenic osteomalacia (OOM) is a rare paraneoplastic syndrome characterized by bone pain and muscle weakness. A biochemical profile consisting of normocalcaemia, hypophosphataemia, phosphaturia, increased serum alkaline phosphatase and inappropriately low serum levels of 1, 25-dihydroxyvitamin-D is diagnostic. OOM is usually caused by an osseous or soft-tissue tumour of mesenchymal origin that secretes phosphaturic substances leading to increased urinary phosphate wasting. These tumours are small and slow growing. The diagnosis continues to be easily missed and when eventually made, localization of the tumour can be difficult. We describe the case of a young man who presented with severe generalized pain associated with muscle weakness. He was extensively investigated and eventually diagnosed to have OOM 3 years after initial presentation. Specialized investigations were necessary to localize the offending tumour.
Acute appendicitis is an infrequent yet the commonest surgical emergency in pregnancy occurring in about 1:1500 pregnancies. The classical abdominal pain in the right lower quadrant of the abdomen is the only reliable clinical sign. Delay in diagnosis is attributed to presence of symptoms commonly seen in pregnancy like nausea and vomiting and difficulty in localizing abdominal pain due to displacement of the appendix with advancing gestation. Perforated appendix and generalized peritonitis impacts adversely on pregnancy contributing to increases in miscarriage, pre-term delivery, fetal loss and even maternal mortality. Imaging studies like abdominal ultrasonogram, helical computerized tomography and magnetic imaging have been utilized to complement clinical suspicion and decrease ‘negative appendectomies’ but robust data on their routine use is awaited. Although the laparoscopic approach is a useful diagnostic and therapeutic tool in early pregnancy, its use as the primary approach for appendicectomy in pregnancy requires further evaluation as increases in the incidence of fetal loss of 5.6% has been reported compared to 3.1% in open access surgery
The aim of this retrospective study was to study the clinical patterns of oro-facial infections presented and their management (or trends of management) at the Department of Oral and Maxillofacial Surgery, Dental Faculty, University of Malaya. These included the predisposing factors, presentations and management. This study reviewed the oro-facial infection cases over 15 years. The data was obtained from case note reviews of patients using specially designed proforma. A total number of 409 samples were included in this study. Majority of the patients were generally healthy with about 6.6% having diabetes mellitus. The common presentations were pain (47.4%), pus discharges (16.9%) and limitation of mouth opening (12.5%). The major site was in the submandibular region (18.9%) followed by cheek (13.2%). Most of the infections were from odontogenic source (63.2%). Other sources includes cysts (15.4%) and tumours (6.7%). Incision and drainage were the treatment of choice performed on 57.55% of patients. Monoantimicrobial therapy was the treatment instituted in 20.8% of cases.
Substantial studies reported musculoskeletal disorders among the working population in the developed country, however, a limited number of studies were conducted in Malaysia. The objective of this cross sectional study was to determine the physical activity risk factors for low back pain among automotive workers in Selangor. Modified Risk Factors Questionnaire (RFQ) was used to assess physical activity with the occurrence of low back pain. The significant physical activities associated with the 12 months point prevalence are lifting weight (
Ewing's sarcoma is a rare tumor first discovered by James Ewing in 1921. It is more common in bone or skeletal component compared to soft tissue or extraosseous Ewing's sarcoma. Among soft tissue Ewing’s, spinal cord involvement is rarer with only nine cases reported. We report a case of nine-year-old Malay girl who presented with low back pain for two months following a fall with progressive neurological deficits of bilateral lower limb. Magnetic resonance imaging was suggestive of a well-defined margin of intradural extramedullary tumor. With nerve sheath tumor in mind, surgical excision with laminectomy L2-S1 was performed. Intraoperative finding was an extradural mass from L3-L5 with extension to bilateral neuroforamen. Histopathology report defined a round cell tumour of Ewing’s sarcoma from the mass.
Impact of health care on the population health has been measured in terms of morbidity and mortality but this measurement doesn’t distinguish between children, adults and the elderly. It does not also take into account the losses that occur because of handicap, pain, or other disability. Therefore, measures of population health which combine information on mortality and non-fatal healthboutcomes to represent the health of a particular population as a single number was introduced. QALYs and DALYs are both common outcome measures in economic evaluations of health interventions. QALYs is the comprehensive measure of health outcome because it can simultaneously capture gains from reduced morbidity (quality gains) and reduced mortality (quantity gains) and combine these into a single measure. DALYs is primarily a measure of disease burden where it combines losses from premature death and loss of healthy life resulting from disability. Although QALYs and DALYs are almost similar in their basic concept but there are few distinct differences which must be paid attention to in order to correctly utilize these measures.
Introduction and Objectives: The intensive care unit (ICU) is an uncomfortable and stressful environment for patients. The use of adequate sedation and analgesia is important to reduce stress to patients. The aim of this study was to compare a relatively new sedative agent, dexmedetomidine to current sedative agent used, propofol in the provision of sedation and analgesia, their effects on haemodynamic and respiratory parameters and cost involved on post open heart surgery patients. Materials and Methods: A prospective, randomized single-blinded trial was conducted on post open heart surgery patients in the ICU of the Hospital Universiti Sains Malaysia (HUSM). Thirty two patients were randomized to dexmedetomidine or propofol groups. Analgesic requirement, haemodynamic and respiratory parameters, and extubation time were measured and compared. Mean rate of infusion to achieve adequate sedation were used to calculate the cost involved in the use of these two agents. Results: Patients sedated with dexmedetomidine required significantly lower dose of morphine compared to propofol [mean (sd): 12.80 (2.61) versus 15.86 (1.87) mg/kg/min, p=0.00]. Mean heart rate was also significantly lower in dexmedetomidine group compared to propofol group [mean (CI): 74.48 (70.38,78.59) versus 83.85 (79.61,88.09) per minutes, p=0.00]. However there were no significant differences in the other parameters between the two groups. Cost involved the use of dexmedetomidine was slightly higher compared to propofol (RM 9.57 versus RM8.94 per hour). Discussion and Conclusions: Dexmedetomidine is comparable to propofol in the provision of sedation, and its effect on haemodynamic and respiratory parameters. However it has added advantages in the provision of analgesia, and caused a significant reduction in heart rate. This is beneficial in these patients by reducing myocardial oxygen demand, and hence subsequent ischaemia and infarction. However, further larger studies are needed to evaluate the effect of dexmedetomidine on perioperative cardiac morbidity and mortality.
A 65-year-old lady with cholelithiasis underwent an elective laparoscopic cholecystectomy (LC) and was discharged on post-operative day 2. She was re-admitted after five days with right hypochondriac pain and fever. Investigations revealed a drop in hemoglobin. Computed tomography showed a large intrahepatic subcapsular collection without intra-abdominal collection. She was treated with intravenous antibiotics. Percutaneous aspiration of intrahepatic subcapsular collection under ultrasound guidance revealed old blood. Hence diagnosis of intrahepatic subcapsular hematoma (ISH) was made. She improved and was discharged after a two weeks' hospital stay. Follow-up ultrasonography examination two months later revealed complete resolution of the hematoma. We report this case due to its rarity and review the previously documented cases of this complication.
To evaluate the functional outcome of patients who underwent endoscopic carpal tunnel release (ECTR). This was a prospective study in 24 patients with idiopathic carpal tunnel syndrome undergoing ECTR. Patient assessment entailing both subjective and objective tests at intervals of two and six weeks, three, six and nine months and finally at one year postoperatively. Our assessment results showed overall improvement in symptoms. As early as two weeks post-operatively, there was a low incidence of pillar pain and scar tenderness, allowing patients to return to work early. There were no serious complications. ECTR can be effectively performed with a low perioperative and late postoperative rate of complications. This minimally invasive method can be an option of surgical treatment for patients with carpal tunnel syndrome, who intend to return to work soon after surgery.
Adolescent idiopathic scoliosis is a spinal deformity that affects patients’ self image and confidence. Surgery is offered when the curvature is greater than 50 degrees based on the likelihood of curvature progression. Outcome measures for scoliosis correction can be described in terms of radiological improvement or improvement of health related quality of life scores. The Scoliosis Research Society 22 (SRS-22) and Scoliosis Research Society 24 (SRS-24) questionnaires are widely accepted and used to characterize clinical results. Therefore, this prospective study of 38 patients aims to investigate how the SRS-24 and SRS-22 questionnaires compare to each other in terms of scoring when the same group of patients is evaluated. The SRS-22 questionnaire tends to give an inflated value in the overall score, pain and self image domain compared to the SRS-24 questionnaire.
The computer is well known as one of the important tools in the office that gives a lot of benefits but silently leads to musculoskeletal pain. There are many different kinds of musculoskeletal complaints pain but the most common seen among computer users in developed countries is the complaint of arm, neck and shoulder (CANS). Despite this, definite factors that can be associated with the prevalence of CANS have not been established. This study was conducted to identify the prevalence and factors associated with work-related complaints of arm, neck and shoulder (CANS) among office workers in Selangor and Kuala Lumpur. A survey study design was conducted where 110 (n=110) office workers were recruited from around the Selangor and Kuala Lumpur area for 5 months periods. Participants were required to answer the Maastricht Upper Extremity Questionnaire (MUEQ) and the Level of Ergonomic Knowledge Questionnaire. The study showed the highest percentage of CANS reported was at neck region (53.6% of participants), followed by shoulders with 53.0%. The majority of participants have low level of computer ergonomic awareness where only 19.09% (n=21) from government sector and 10% (n=11) office workers from private sector reported knowledge of ergonomics. Majority of the participants did not have the know-how in implementing correct computer ergonomics. However there was a weak association (r=
Congenital partial aplasia of the atlas with a posterior arch remnant is rare. It may be found as an incidental radiological finding or patients can present with neurological signs and symptoms after head or neck trauma. A 36-year-old female presented with a 3-day history of right sided neck pain radiating down the right arm. Radiographs of the cervical spine showed a radiolucent area in the region of the posterior arch of the atlas. Computed tomography subsequently revealed partial absence of the posterior arch of the atlas with a defect at the anterior ring. Her clinical condition subsequently improved with rest, analgesia and physiotherapy. This case report illustrates a situation where congenital defect of the posterior arch of the atlas was revealed in a patient with neck pain. Awareness of the existence of this condition will help clinicians avoid misdiagnosis and excessive investigations.
The health related quality of life (HRQoL) of chronic obstructive pulmonary disease (COPD) patients is greatly influenced by their health status. The Health Index Questionnaire - Short Form 36 (SF-36) and St George Respiratory Questionnaire (SGRQ) are commonly used to assess the HRQoL of COPD patients. Objective: This study investigates differences in HRQoL following sessions of pulmonary rehabilitation program (PRP) with a control group (CG) that had no intervention. Method: This quasi-experimental study involving 17 subjects assigned to the CG and 16 subjects in the intervention group (IG). Ethical approval was obtained from the relevant authority. Both groups were given the health index questionnaires- SF-36 and SGRQ prior and 5 weeks after the intervention. The CG only had medication while the IG performed exercises (cycling, treadmill walking, upper limb strengthening exercise and stair climbing exercise). Results: Data analysis using SPANOVA demonstrated significant improvement in HRQoL measured from SF-36 in domains of bodily pain (p=0.005), vitality (p=0.021) and mental health (p=0.002) in IG unlike the CG. Similarly, SGRQ, also shows improvement in symptom (p=0.028), activity (p=0.004) and total score (p=0.012. Conclusion: The 5 weeks pulmonary rehabilitation program demonstrated improvement in HRQoL among COPD
patients.
Life (QOL) of patients with childhood leukaemias presenting at the Hospital Universiti Kebangsaan Malaysia (HUKM). The objectives of this pilot study were 1) To assess the feasibility and applicability of assessing quality of life in leukaemia patients using the adult-based SF-36 questionnaire. 2) To compare the differences of QOL scores among patients based on gender and treatment status. The Short-Form-36 Health Survey (SF36) was used. The items in SF-36 were drawn from the original 245-item MOS questionnaire, which includes multi-item scales that measured the eight dimensions of quality of life namely physical function, role limitations (physical problems), bodily pain, general health, vitality, social functioning, role limitations (emotional problems) and mental health. Patients with acute leukaemias were chosen to participate in the study. Twenty-eight patients were recruited, twelve were males and 16 were females. Ten patients had completed therapy whilst 18 others were still undergoing treatment. The results showed that those patients off treatment have a better quality of life than those on chemotherapy. However, this was only significant with respect to the role limitation pertaining to physical problems. Although the use of the SF-36 was feasible, there were limitations especially in the younger age group.
The aim of this study was to identify the position of impacted mandibular third molars based on the classifications of Pell & Gregory and Winter, the indications for extraction, and the relation of post-operative complications and position. Records of patients who attended Hospital Universiti Sains Malaysia between January and December 2007 for surgical removal of mandibular third molars were reviewed. The angulation type, width and depth of impaction were determined by reviewing the orthopantomograms. The indications of extraction and occurrence of any post- operative complications were recorded. A total of 238 impacted teeth were surgically extracted from 194 patients (97 males, 97 females). The reasons for extraction include recurrent pericoronitis (43.1%) followed by prophylactic purposes (33.5%). Mesioangular impactions accounted for 52.3% and Class IIA position of impaction accounted for 45.7% of extractions. The most common post-operative complication was persistent pain and swelling (14.7%) followed by trismus (4.1%) and dry socket (3.0%). There was no significant relationship between the angulation, width and depth of impaction and the occurrence of complication. Mesioangular type and Class IIA position of impaction were the most common impaction. Although the association was not significant, high frequency of post-operative complications was observed in mesioangular, horizontal, IIA and IIC positions.
Acute appendicitis is one of the most common differential diagnoses for acute abdominal pain made by emergency doctors. Suspected cases require surgical referral for observation or definitive intervention to prevent complications. A high index of suspicion and good clinical skills with the aid of scoring systems allows early decision making, which includes optimal pain control. The objective of this study was to identify the pain score and is relationship to the cut-off points of the Alvarado scoring system so that justifies early surgical referral or discharge for suspected acute appendicitis from the Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a cross sectional study of acute abdominal pain from June 2007 to September 2008. All patients who fulfilled the criteria and consented to the study were assessed for Alvarado score, verbal numerical pain score (VNRS) and their subsequent management. Patients with an Alvarado score of ≥7 were likely to have acute appendicitis (80.1% sensitivity and 52.63% specificity) and those with the score of ≤3 were unlikely to have acute appendicitis. The median pain score was 7.00 (IQR: 5.00-8.50) but 72.5% did not receive any analgesia. There was no direct relationship between the pain score with Alvarado score. Oligoanalgesia in patients with acute appendicitis still exist in Emergency Department of UKMMC.
A 64-year-old lady presented with a brief history of abdominal pain associated with obstructive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a short segment stricture with contact bleeding and the brush cytology confirmed presence atypical cells. Ca 19.9 levels were markedly elevated. She was planned for a Whipple’s procedure but was instead subjected to a total pancreatectomy based on intraoperative findings of a diffusely hard and nodular pancreas. Histopathological examination confirmed our diagnosis of diffuse pancreatic adenocarcinoma. This rare presentation of a locally contained and fully resectable diffuse pancreatic adenocarcinoma is being discussed.
Living with epilepsy is equally demanding for both patients and their caregivers. The caregivers’ tasks are not limited to caring for the patients only but also the need to improve their awareness, knowledge and attitude (AKA) level as lack of understanding has a major impact on health-related quality of life (HRQoL). Little is known about the influence of AKA on family caregivers’ HRQoL. Objective: Therefore, this study aimed to assess and relate the AKA and HRQoL profiles of epilepsy carers. Methods: This prospective, cross-sectional study included a sample of 32 epilepsy family caregivers who were recruited from the Neurology and Paediatric Clinics of Hospital Sultanah Nur Zahirah (HSNZ), Kuala Terengganu. Results: Majority were Muslims (93.8%), married (65.6%), housewives (31.2%), who earning monthly income of not more than RM 1000 (34.4%) and was the patients’ mothers (40.6%). The Total AKA score was generally good (mean=123.4±16.8, median 122.5) with awareness being good, knowledge moderate and attitude positive whereas HRQoL score for Disruptiveness was the highest (good) compared to other domains. There were significantly higher scores for Sexual Functioning (p = 0.039) among Poor AKA group and Pain Management (p = 0.040) among Good AKA. Conclusion: The overall outcomes signified that family caregivers with Good AKA experienced better well-being compared to those with Poor AKA while carrying out their roles as caregivers. Consequently, carers clearly require constant epilepsy education to enhance skill-building in order to understand and keep updates with the disease, thus indirectly sustaining their desired HRQoL status from time to time.
Study site: Neurology and Paediatric Clinics of Hospital Sultanah Nur Zahirah (HSNZ), Kuala Terengganu