METHODS: The patients were evaluated clinically and FNP was graded using the House Brackmann (HB) scale. High resolution computerized tomography (HRCT) of the temporal bone was used to evaluate temporal bone fractures. Transmastoid facial nerve decompression was performed and the facial nerve function was re-evaluated in subsequent follow ups.
RESULTS: There were five cases with immediate onset and four with delayed onset of FNP. Only three cases had pure temporal bone fractures, the others were associated with other life threatening injuries. The sensitivity and specificity of HRCT temporal bone to detect the obvious facial canal fracture line were 50% and 40% respectively. 75% of patients with immediate onset of HB grade VI FN palsy who were operated within a month recovered completely. Surgeries for the delayed onset FNP were performed at a mean of 70 days (range 51-94). All recovered to HB grade II-III from severe FNP.
CONCLUSIONS: Our study demonstrated that transmastoid FN decompression surgery was beneficial to traumatic nerve injury. Early intervention resulted in better outcomes. However, FN function could still be salvaged even in delayed FN decompression.
METHODS: We retrospectively reviewed the case records of patients with positive serology findings for syphilis in University Malaya Medical Center (UMMC) from January 2010 to December 2015. Serological positivity was defined as having a positive rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) with a confirmatory positive Treponema pallidum particle agglutination assay (TPPA). Treatment outcomes were divided into two, success or failure. Demographic and clinical characteristics associated with predictors of treatment failure were assessed using statistical package for the social science (SPSS). This study also included a neurosyphilis descriptive sub-study.
RESULTS: There were 637 patients identified with positive syphilis serology, but 258 patients were excluded as they did not meet the inclusion criteria. 379 patients were then taken for the demographic study; 14 patients (3.7%) were treated for neurosyphilis; 170 patients with complete data were included. In all 42/170 (24.7%) failed treatment, 12/170 (7.1%) had reinfection and 116/170 (68.2%) had treatment success. A final number of 158 patients were then taken and analyzed for predictors of treatment failure after excluding the 12 reinfection patients. Only low baseline RPR (<1:16) was found to be significant on multivariate logistic regression analysis (p value: 0.007, 95% CI: 1.42, 9.21).
CONCLUSION: Most of the patients were HIV positive and from the MSM (Men who have sex with Men) population. Low baseline RPR titre is a predictor of treatment failure.
OBJECTIVE: We aimed to examine the delays in the diagnosis of RA in patients presenting to the Rheumatology Unit, Sarawak General Hospital (SGH).
METHODS: Data on demographics and various delays were collected from the medical records from January 2015 until March 2018. Patient delay is defined as from the time onset of symptom to the first primary care presentation. Primary care delay is defined as from the first primary care presentation to referral to rheumatology. Rheumatology delay is defined as from rheumatology referral to appointment at the rheumatology clinic. Disease modifying anti-rheumatic drugs (DMARDS) delay is defined as from the rheumatology clinic appointment to starting DMARDS. Total delay is from symptom onset to starting DMARDS.
RESULTS: There were 84 new patients diagnosed with rheumatoid arthritis, out of which 66 were females (78.6%). The mean age was 54.1±12.0 years. Only 19 patients (22.6%) were treated with DMARDS within 12 weeks of symptom onset. The median time for patient delay was four weeks (Interquartile range (IQR) 2-20 weeks), while the median time primary care delay was 11 weeks (IQR 4-24 weeks). The median time for rheumatology delay was zero weeks (IQR 0- 1 week) and the DMARDS delay was zero week (IQR 0). The median time from symptom onset to DMARDS initiation was 23.5 weeks (IQR 13.25-51 weeks).
CONCLUSION: The delays in the diagnosis of rheumatoid arthritis were mainly from the patient and primary care.
METHODS: In this retrospective study, we reviewed the cases diagnosed with CVST admitted to our centre from January 2011 until November 2015.
RESULTS: A total of 15 patients were included in this review. The patterns of imaging findings as well as risk factors for CVST is discussed with a review of the literature and current management practices. One year followed-up showed full recovery (Glasgow Outcome Scale (GOS) of 5) in 10 cases (66.7%), whereas 4 cases (26.7%) with GOS of 4 (three cases with neurological deficits, and 1 case with mild symptom. There was one case of mortality in this study secondary to sepsis during hospitalisation. The presenting symptoms were mainly headache, focal neurology deficits, seizure and altered sensorium. Risk factors identified were oral contraceptive pills usage, chronic sinuses or ear infections, and obesity. Initial computed tomography (CT) scan showed various findings and haemorrhagic infarct was one of the common findings. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) revealed majority of the patients had occlusion at two or more venous sinus sites. No patients had new or recurrent intracranial haemorrhage following initiation of anticoagulation therapy.
CONCLUSION: Thus it is considerable safe to start anticoagulation therapy in CVST patients including those with intracranial haemorrhage. We propose further neuroimaging to avoid missed diagnosis of CVST in patient presented with recent onset headache and CT evidence of unusual cerebral infarction.
METHODS: A retrospective study was conducted on 20 patients who had suffered from ISSHL from January 1, 2012, to December 31, 2017. ISSHL is defined as a rapid decline in hearing over three days or less affecting three or more frequencies by 30dB or greater. Comparison between the mode of steroid therapies and improvement in patients was done. At least 15dB improvement in pure tone audiogram (PTA) was considered as successful therapeutic intervention.
RESULTS: Twenty male and female patients who fit the inclusion and exclusion criteria were included. The mean age of the patients was 41.4 years with a range from 13 to 72 years. Ninety percent patients presented with unilateral ISSHL involvement. Eight ears of patients who received systemic steroid therapy alone had improved hearings (75%). Out of seven ears from six patients who received salvage therapy, four ears (57.1 %) had improvement in PTA. Seven ears showed improvement in PTA from a total of eight patients who primarily received IT injections.
CONCLUSIONS: IT steroid therapy promises a favourable outcome in the improvement of the hearing, as compared to systemic steroid administration. Its usage is recommended not only for salvage therapy but should be used as primary treatment especially in those with co- morbidities.
METHODS: We reviewed the medical records of BA patients who underwent Kasai procedure at the Dr. Sardjito Hospital, Indonesia from August 2012 to December 2018. The cut-off values of TB7/TB0, GGT7/GGT0, and ALT7/ALT0 for prediction of patients' survival were determined by receiver operating characteristics (ROC) curves. Log-rank tests were utilised to test the association between cut-off values and overall survival.
RESULTS: In all 46 BA patients (23 males and 23 females) after Kasai procedure were included, consisting of one type 1, 17 type 2A, seven type 2B, and 21 type 3. The cut-off values of TB7/TB0, ALT7/ALT0 and GGT7/GGT0 for overall survival was 0.455 (sensitivity 87.5%, specificity 22.7%, area under curve (AUC) 0.59; 95% Confidence Interval (95%CI): 0.42, 0.75), 0.481 (sensitivity 87.5%, specificity 18.2%, AUC 0.49; 95%CI: 0.31, 0.65), and and 0.31 (sensitivity 79.2%, specificity 9.1%, AUC 0.34; 95%CI: 0.18, 0.50), respectively. However, these cut-off values were not significantly associated with overall survival, with p-values of 0.18, 0.49, and 0.56, respectively.
CONCLUSION: The TB7/TB0, ALT7/ALT0, and GGT7/GGT0 might not predict the overall survival of BA patients after Kasai procedure. Further multicentre studies with a larger sample size is needed to clarify our findings.
METHODS: Medical records of patients who were treated for LM in the Paediatric Surgical Centre Universitas Gadjah Mada from January 2015 to January 2019 were reviewed. Scoring systems were used to assess the outcomes, including reduction of size, problems of aesthetics, functional problems, complications, necessity of further interventions, and interventions' frequencies.
RESULTS: During the four-year study, we included 31 children, consisting of 6, 5, and 20 patients in Groups I, II, and III, respectively. The total score did not significantly differ between Groups I, II, and III (14.67±2.80 vs. 13.40±2.07 vs. 12.50±1.47, respectively; p=0.056). Group II scored better in aesthetic problems than other groups (p=0.001), Group III scored higher in necessity of further interventions compared to the other groups (p=0.026), and Group I was higher in interventions' frequencies than the other groups (p<0.001). However, there were no significant differences in reduction of size, functional problems, and complications among groups (p=0.554, 0.151, and 0.076, respectively).
CONCLUSIONS: There is no significant different effect of the three modalities treatment for LM, although one group might have more beneficial effects compared with the other groups due to different scoring system parameters. Further multicentre and prospective cohort studies with a larger number of patients are necessary to establish the existence and extent of our findings.
METHODS: The medical records and clinical outcomes of 35 patients who underwent endoscopic thoracic sympathectomy for primary hyperhidrosis from 2008 to 2018 in Department of Cardiothoracic Surgery were reviewed.
RESULTS: The mean age of the patients was 27±10.1years, with male and female distribution of 18 and 17, respectively. Fifty-one percent of patients complained of palmar hyperhidrosis, while 35% of them had concurrent palmaraxillary and 14% had palmar-plantar-axillary hyperhidrosis. Our data showed that 77% (n=27) of patients were not investigated for secondary causes of hyperhidrosis, and they were not counselled on the non-surgical therapies. All patients underwent single-staged bilateral endoscopic thoracic sympathectomy. There was resolution of symptoms in all 35 (100%) patients with palmar hyperhidrosis, 13(76%) patients with axillary hyperhidrosis and only 2 (50%) patients with plantar hyperhidrosis. Postoperatively 34.3% (n=12) of patients reported compensatory hyperhidrosis. There were no other complications such as pneumothorax, chylothorax, haemothorax and Horner's Syndrome.
CONCLUSION: Clinical evaluation of hyperhidrosis in local context has not been well described, which may inadvertently result in the delay of appropriate management, causing significant social and emotional embarrassment and impair the quality of life of the subjects. Detailed clinical assessment and appropriate timely treatment, be it surgical or non-surgical therapies, are crucial in managing this uncommon yet distressing disease.
OBJECTIVES: This is an audit project aiming to evaluate the proportion of misdiagnosis among hospitalised communityacquired pneumonia (CAP) patients in the Respiratory wards of Penang General Hospital based on their initial presentation data, and their associated outcomes.
METHODS: We reviewed the medical notes and initial chest radiographs of 188 CAP patients who were admitted to respiratory wards. Misdiagnosis was defined as cases which lack suggestive clinical features and/or chest radiograph changes. In-hospital mortality and length of stay (LOS) were the outcomes of interest.
RESULTS: The study found that 38.8% (n=73) of the hospitalised CAP patients were misdiagnosed. The most common alternative diagnosis was upper respiratory tract infection (32.8%, n=24). There was no statistical difference between misdiagnosis and CAP patients in the demographic and clinical variables collected. In terms of outcomes, misdiagnosed patients were discharged earlier (mean LOS= 3.5±3.28 days vs. 7.7±15.29 days, p=0.03) but the in-hospital mortality difference was not statistically significant (p=0.07).
CONCLUSIONS: One third of our CAP admissions were misdiagnosed. Although initial misdiagnosis of CAP in our study did not show any increase in mortality or morbidity, a proper diagnosis of CAP will be helpful in preventing inappropriate prescription of antibiotics and unnecessary admission.
AIMS: This project aimed to review the impact on antimicrobial treatment and clinical outcome in the NICU setting, of the introduction of the Xpert MRSA/SA BC test (Cepheid, USA) for the identification of staphylococci in blood cultures.
METHODS: A retrospective audit was carried out of the pre- and post-intervention periods; the intervention was the introduction of the Xpert MRSA/SA BC test.
RESULTS: In total, 88 neonates had positive blood cultures with Staphylococcus spp., comprising 42 neonates in the pre-intervention and 46 in the post-intervention groups. The pre-intervention group had a higher birth weight (1.541 kg vs. 1.219 kg, p = 0.05) and higher platelet count (288 vs. 224 × 109/L, p = 0.05). There was a trend towards a shorter duration of antimicrobial therapy in term infants and in the length of admission; however, this was not statistically significant (p = 0.2). All of the nine infants post-intervention with significant bacteraemia (S. aureus =3, CoNS =6) were changed to the optimal antimicrobial at the time the result was available.
CONCLUSIONS: This study shows that the introduction of the Xpert MRSA/SA BC test can lead to a reduction in the length of admission and duration of antimicrobials in term infants; however, the difference was not statistically significant. All nine infants with clinically significant bacteraemia were treated with the appropriate antimicrobial when the Xpert MRSA/SA BC test result was available.
METHODS: A retrospective cohort study of 200 patients on dabigatran and warfarin from January 2009 till September 2016 was carried out. Data were collected for 100 patients on dabigatran and 100 patients on warfarin.
RESULTS: The mean follow-up period was 340.7±322.3 days for dabigatran group and 410.5±321.2 days for warfarin group. The mean time in therapeutic range (TTR) was 52±18.7%. The mean CHA2DS2 -VASc score for dabigatran group was 4.4±1.1 while 5.0±1.5 for warfarin group. None in dabigatran group experienced ischemic stroke compared to one patient in warfarin group (p=0.316). There was one patient in dabigatran group suffered from ICH compared to none in warfarin group (p=0.316). Four patients in warfarin group experienced minor bleeding, while none from dabigatran group (p=0.043).
CONCLUSION: Overall bleeding events were significantly lower in dabigatran group compared to warfarin group. In the presence of suboptimal TTR rates and inconveniences with warfarin therapy, non-vitamin-K antagonist oral anticoagulants (NOAC) are the preferred agents for stroke prevention in elderly Asian patients for nonvalvular AF.
OBJECTIVE: To describe the clinical spectrum and identify risk factors for chronicity of cutaneous vasculitis.
METHODS: Retrospective data analysis of 275 patients diagnosed with cutaneous vasculitis from January 2008 to December 2013.
RESULTS: The mean age was 33.7 (±17.89) years, with female predominance. The majority of patients were Malays (67.3%). Skin biopsy was performed in 110 (40%) patients. The commonest sign was palpable purpura (30.6%). The aetiology remained elusive in 51.3% of patients. Common identifiable causes include infection (19.7%) and connective tissue disease (10.2%). Extracutaneous features were noted in 46.5% of patients. Erythrocyte sedimentation rate and antinuclear antibody were raised in 124 of 170 and 27 of 175 patients with documented results respectively. Cutaneous vasculitis was the presenting symptom in seven patients with newly diagnosed systemic lupus erythematosus. Anti Streptolysin O Titre was positive in 82 of 156 patients with documented results. Despite antibiotics, 31.7% of them had chronic lesions. Prednisolone alone was used in 20% of patients while 16.4% needed steroid-sparing agents. Most patients who needed systemic therapy (62%) had unidentifiable aetiology. Among the 155 patients who remained under follow up, 36.4% had chronic disease, one patient succumbed due to septicaemia, and the rest fully recovered within three months. The presence of ulcerative lesion was significantly associated with developing chronic vasculitis (p=0.003).
CONCLUSION: The clinical spectrum of cutaneous vasculitis in our population was similar to other studies. Ulcerative lesion predicts a chronic outcome.
MATERIALS AND METHODS: During the period from 16 to 21 March 2007, outbreak investigations and active case finding were carried out among residents and nursing staff at the welfare home. Interviews and medical notes review were conducted to obtain epidemiological and clinical data. Hospitalised patients were tested for respiratory pathogens. Further genetic studies were also carried out on positive respiratory samples.
RESULTS: The overall clinical attack rate was 9.4% (17/180) in residents and 6.7% (2/30) in staff. All infected residents and staff had received influenza immunisation. Fifteen residents were hospitalised, with 2 developing severe complications. Genetic sequencing revealed that the outbreak strain had an 8.2% amino acid difference from B/Malaysia/2506/2004, the 2006 southern hemisphere influenza vaccine strain, which the residents and staff had earlier received.
CONCLUSIONS: A mismatch between the vaccine and circulating influenza virus strains can result in an outbreak in a highly immunised LTCF resident population. Active surveillance for acute respiratory illness in LTCFs could be implemented for rapid detection of antigenic drift. Enhanced infection control and other preventive measures can then be deployed in a timely manner to mitigate the effect of any outbreaks.
PATIENTS AND METHODS: With concern over its rising microbial resistance, we explored the association of empiric antibiotics choices with the hospital outcomes of patients treated for microbial proven K. pneumoniae pneumonia in an urban-based teaching hospital.
RESULTS: In 313 eligible cases reviewed retrospectively, hospital mortality and requirement for ventilation were 14.3% and 10.8% respectively. Empiric regimes that had in vitro resistance to at least one empiric antibiotic (n = 90) were associated with higher hospital mortality (23.3% vs. 10.8%, P = 0.004) with risk increased by about two-fold [Odds ratio (OR), 2.5; 95% confidence interval (CI), 1.3 to 4.8]. Regimes (n = 84) other than the commonly recommended "standard" regimes (a beta-lactam stable antibiotic with or without a acrolide) were associated with higher ventilation rates (16.7% vs. 8.8%, P = 0.047) with similar increased risk [OR, 2.0; 95% CI, 1.0 to 4.3].
CONCLUSIONS: Our findings reiterate the clinical relevance of in vitro microbial resistance in adult K. pneumoniae pneumonia and support empiric regimes that contain beta-lactam stable antibiotics.