Hand-assisted laparoscopic nephrectomy (HAL-N) and nephroureterectomy (HAL-NU) were introduced to bridge the gap between open and laparoscopic surgery. This newer technique has the benefits of both laparoscopic and open surgical approaches but has a shorter learning curve and decreased operative time compared to laparoscopic surgery. A review of our 2-year experience showed that for the seventeen cases of HAL-N that was performed, the mean operative time was 187.8 minutes while the mean length of hospital stay was 4.1 days. For the two HAL-NU cases, the mean operative time was 415 minutes while the mean length of hospital stay was 5.5 days. Only one complication occurred and it was an incisional hernia at the hand-port site. There was no recurrence for the carcinoma cases. Our experience shows that this technique is feasible and safe.
The aim of this study was to determine the prevalence and association of speech disorders among operated cleft lip and palate children (CLP) in Northeast Malaysia. A comparative cross sectional study was performed on 98 operated CLP and 109 non-cleft subjects that aged between 3- 12-years-old. Data collection was done clinically and also by recording speech samples of each subject from both groups using a portable cassette recorder. Results showed that the prevalence of speech abnormality was 61.2% (95% CI: 51.41-71.04) and the risk of having speech abnormality was 174.5 times (95% CI: 23.04, 1320.67; P value < 0.001) in CLP children compared to non-cleft children. Therefore it was found that children with appropriately repaired CLP in Northeast Malaysia failed to have normal speech.
We report a male patient of Graves' Disease with bilateral exophthalmos who had undergone bilateral transnasal endoscopic orbital decompression with subsequent improvement of 3 mm in orbital proptosis bilaterally without any complications. Transnasal endoscopic orbital decompression is recommended as an alternative to traditional decompression techniques especially for purely cosmetic reasons.
Tolerance to colonoscopy varies between populations and data from the South East Asian region is lacking. We aimed to determine tolerance and safety with to colonoscopy; conscious sedation and identify risk factors for complications in Malaysian adults. Consecutive outpatients undergoing colonoscopy were enrolled prospectively. A combination of pethidine and midazolam were used and tolerance to colonoscopy assessed three hours post-procedure using a validated scale. All patients were monitored for cardiorespiratory depression and risk factors for complications were identified. Two hundred and eight patients (mean age 57.2 +/- 14.8 years, 48% female) were enrolled. The population ethnicity consisted of 45 (21.63%) Malays, 101 (48.56%) Chinese and 56 (26.92%) Indians. Conscious sedation was achieved with 5.0 +/- 1.1 mg of midazolam and 43.3 +/- 14.0 mg of pethidine. Thirty (14.4%) patients tolerated the procedure poorly and independent predictors included female gender (OR 2.93, 95% CI = 1.22 to 7.01) and a prolonged duration of procedure (OR 2.85, 95% CI = 1.08 to 7.48). Hypotension occurred in 13 (6.25%) patients, with age > 65 years as the only risk factor (OR 13.17, 95% CI = 1.28 to 137.92). A prolonged duration was the main cause of hypoxia (OR 5.49, 95% CI = 1.54 to 19.49), which occurred in 6 (2.88%) patients. No major complications occurred during the study period. The current practice of conscious sedation is safe and tolerated well by most adults in our population. However, poor tolerance in a notable minority may have significant clinical implications.
Study site: Division of Gastroenterology, Department of Medicine, University Malaya Medical Centre (UMMC)
The clinical outcome of bacteraemic patients is influenced by many factors. It is vital to know one's own local hospital epidemiological data so as to provide optimal care to the affected patients. This was a prospective, observational study carried out in the said patient population over a period of four months in the year 2005. One hundred and ninety one patients presented with bacteraemia over the study period. Fifty-two (27%) of the patients died. Mechanical ventilation, inappropriate empirical antibiotic usage, Chinese ethnicity and low serum albumin levels independently affected prognosis. These factors should alert physicians to those patients who require more intensive monitoring and care.
KEY WORDS:
Bacteraemia, Blood Culture Positive, Outcome, Risk factors, Kuala Lumpur, Malaysia
Empty Nose Syndrome (ENS) is a rare and controversial sequelae from previous radical turbinate surgery. We report on a 50-year-old Chinese gentleman with long-standing nasal problems who has had radical turbinate surgery many years prior to presenting at the ENT clinic with mucoid nasal discharge and chronically blocked nose. His nasal cavities were ironically very patent and there were only minor remnants of his turbinates bilaterally. We treated him medically for several years with nasal steroids, antihistamines and leukotriene receptor antagonists and his nasal symptoms have reduced significantly.
Study site: ENT clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
This study described the practice profile of an open access exercise stress test (EST) service to the primary care physicians at a teaching hospital in 2000. We performed a retrospective review of all ESTs ordered and conducted by the primary care physicians. A total of 145 ESTs were conducted, of which 80.7% were referred for assessment of chest pain. Proportions of positive, negative, uninterpretable and inconclusive ESTs were: 22.1%, 52.8%, 18.1% and 6.9%. Typical chest pain was independently associated with a positive EST in this study (p = 0.008, OR 5.50, 95% CI 1.56-19.37). Although referral to the open access EST service seemed appropriate, there is a need to reduce the number of uninterpretable and inconclusive results.
We aimed to determine the outcome of nutritional intervention in children with moderate to severe malnutrition following persistent diarrhoea (PD), referred to a tertiary referral unit in Malaysia. Thirty-one (44%) of the 71 children (median age 19 months) with PD had moderate to severe malnutrition on admission. Fifty-three (75%) required dietary modification and 15 (21%) needed parenteral nutrition (PN, median duration 96 days). Of the 70 patients in whom remission of diarrhoea could be ascertained, 64 (91%) achieved remission. Three required home PN. At three months after discharge, there was a significant improvement in the mean weight-for-height z-score as compared to the original score at initial presentation (from -1.83 +/- -1.77 to -0.80 +/- -1.17; p < 0.001), although 12 (22%) of the 55 patients in whom nutritional status could be ascertained still had moderate to severe malnutrition. In conclusion, moderate to severe malnutrition was a common complication following PD resulting from diverse causes. With appropriate therapy, remission can be achieved in majority of patients, although a small number of patients needed home PN because of persistence of diarrhoea.
Adolescent Idiopathic Scoliosis is a spinal deformity which affects patients' self image and confidence. Surgery is offered when the curve is more than 50 degrees based on its likelihood of progression. Studies on the radiological outcome of scoliosis correction are abundant. Therefore, it is the objective of this study to evaluate the health related quality of life in scoliosis patients who had undergone surgical correction in University Malaya Medical Center, Kuala Lumpur, Malaysia using Scoliosis Research Society-22 (SRS-22) patient questionnaire. This is a prospective evaluation of SRS-22 scores of thirty eight patients operated in our center over the past five years with a minimum follow up of one year. There were thirty two females and six males. Twenty six (68.4%) were Chinese, eight (21.1%) Malay and four (10.5%) Indian patients. The age of the patients ranged from twelve to twenty eight years, with a mean age of 18.4 +/- 3.5. Based on the King and Moe's classification, sixteen patients had King's 3 curve. The mean pre-operative Cobb angle was 68.6 degree and post-operative Cobb angle was 35.8 degree. The average curve correction was 48.5%. The overall score for SRS-22 was 4.2. The SRS-22 scores were highest for the pain domains and lowest for the functional domains. Satisfaction domain scored 4.3. The function domain scored significantly higher in those who have twenty four months or less follow up duration. Curve magnitude and the amount of correction did not significantly alter the SRS scores. In conclusion, patients were satisfied with the outcome of their operation. Although pain was common, the intensity of the pain was minimal. The amount of curve correction did not correlate with the quality of life after operation.
The study was designed to assess retrospectively clinical pattern of insulinoma at a national referral center in the Kingdom of Saudi Arabia. All cases of insulinoma recorded at King Khalid University Hospital Riyadh between January 1987 and December 2006 were reviewed. During the 20-year period five patients were seen comprising three females (ages 38, 40, and 70 years) and two males (17 and 34 years). The duration of symptoms prior to diagnosis ranged between one and eight years. The commonest mode of presentation before diagnosis was inability to observe Ramadan fasting. Other notable symptoms included dizziness and loss of consciousness. All the five patients proceeded to operation. At surgery all were found to be benign tumors. Post-operatively, three of the patients developed pseudocyst, which resolved upon undergoing second surgery. Though clinical presentation of insulinoma in Saudi subjects is similar to those reported in the literature, our study revealed prominent symptoms occurring during yearly ramadan religious fast could be a useful information in history taking. Further studies on a larger population are needed to further characterize our findings.
The use of laryngeal mask airway (LMA) as an alternative to the endotracheal tube (ETT) is becoming more popular in the practice of anesthesia. It is undeniable that this device has numerous advantages over endotracheal tube, however it does not provide an airtight seal between the airway and atmospheric gases. This may lead to pollution of the operating room environment with nitrous oxide. One hundreds adult patients undergoing general anaesthesia were divided into two groups. The airway in Group I was maintained with LMA with spontaneous ventilation and ETT with intermittent positive pressure ventilation (IPPV) was used for Group II. The result demonstrated that the ETT group recorded concentrations of nitrous oxide that were well above the NIOSH recommended eight hour time weighted average of 25ppm throughout the duration of surgery when compared to patients using LMA.
Subclinical cerebral infarcts (SCI) have been increasingly shown to cause a significant clinical impact. However, there are limited data available on Asian patients. The objectives of this study were to determine the prevalence of SCI in ischaemic stroke patients seen in the Hospital Universiti Kebangsaan Malaysia (HUKM) and to identify its associated risk factors. We evaluated the brain computed tomography (CT) evidence of subclinical infarcts in ischaemic stroke patients. The patients were selected from those who were on regular follow up in the neurology clinic following an ischaemic stroke. The risk factors associated with subclinical infarct were documented. The brain CTs were done during acute admission and reviewed for SCI. Sixty-one patients were enrolled in this study. Twenty-two (36.1%) out of the 61 patients had SCI. The risk factors for SCI in our study were hypertension (OR 14.16 CI 2.04-97.89), diabetes mellitus (OR 12.48; CI 1.95-79.77) and leukoaraiosis (OR 28.39; CI 2.33-284.16). Subclinical cerebral infarcts were present in about one third of our ischaemic stroke patients. This finding is higher than in previous studies done on Caucasians. Hypertension, diabetes mellitus and leukoaraiosis independently predict SCI.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.
Study site: primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
An anaesthetist-led outpatient pre-operative assessment (OPA) clinic was introduced in our unit in an effort to improve patient care and cost-effectiveness. To assess the efficiency of the clinic, 112 patients who attended the OPA clinic (attendance rate 98%) during the first year were assessed prospectively and compared with 118 patients who did not undergo OPA the year before. There were fewer cancellations among those who attended the OPA clinic (13.6% compared to 3.6%), and the hospital stay was shortened from an average of 10.7 days to 7.0 days. This has resulted in more efficient utilization of operating theatre, reduced hospital costs and improved patient satisfaction. More extensive use of the pre-admission clinic is recommended and should be explored in other clinical settings.
Study site: Outpatient Preoperative Assessment (OPA) clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
The p53 gene is a tumour suppressor gene that encodes a 393-amino-acid nuclear DNA-binding phosphoprotein. The significance of p53 detection is that p53 mutation is linked with chemo-resistance and transformation to more aggressive disease in a large number of tumour types and it was confirmed that mutant p53 is involved in neoplastic transformations. In addition, the expression of p53 has been closely correlated with clinicopathological findings. Since breast cancer has been reported as one of the most frequent malignancies in women in Malaysia, the expression of p53 was studied in 382 cases of invasive ductal carcinoma of the breast, obtained from three major hospitals in the North-East States of Malaysia. The study utilized an enzyme immunohistochemistry assay for the detection of p53. It was found that p53 was expressed in 29.6% of all the study cases. Furthermore, its expression was significantly correlated with the age and the clinical grading of the disease. No significant statistical correlations were depicted with lymph node status, tumour size, side of tumour, and expression of estrogen and progesterone receptors. Nevertheless, knowledge of the p53 status may be valuable in making clinical decisions regarding diagnosis, prognosis and therapy.
Epilepsy patients have a higher mortality rate than the general population. Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality for these patients. The possibility of cardiac involvement in the pathogenesis of SUDEP has been suggested by many previous studies. This study compared the QT interval in epilepsy patients and normal controls, and identified the factors that affected the QT interval. Standard 12-lead ECGs were recorded from 70 consecutive epilepsy patients from the neurology clinic of HUKM and 70 age, race and gender matched controls. The mean QT interval corrected for heart rate (QTc) was calculated and compared. The mean QTc among the epilepsy patients was 0.401 +/- 0.027s. It was significantly shorter than the QTc (0.420 +/- 0.027s) in the control group (p<0.0005). Thirty five epilepsy patients (50%) and 17 matched controls (24.3%) had a mean QTc shorter than 0.40s (p=0.001). Among the epilepsy patients, the mean QTc did not significantly differ between patients in the duration (F=0.836, p=0.438) of the epilepsy, frequency (F=0.273, p=0.845) and types of seizures (p=0.633). There was no significant difference in the mean QTc between the epilepsy patients on different number of antiepileptic agents (F=0.444, p=0.643). Patients with cryptogenic epilepsy had a mean QTc of 0.392 +/- 0.029s, which was significantly shorter than patients with symptomatic epilepsy (QTc = 0.410 +/- 0.027s, p = 0.015). The mean QTc of the same subjects showed no significant interobserver difference (p=0.661). This study, for the first time, demonstrates that epilepsy patients have a significantly shorter QTc than controls, particularly in the subgroup of patients with cryptogenic epilepsy.
Study site: Neurology clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Thrombocytopaenia is often relied upon as an important criterion for the diagnosis of dengue infection among patients presenting with an acute non-specific febrile illness. This study was aimed to assess usefulness of thrombocytopaenia in the diagnosis of acute dengue virus infection. This was a clinic based prospective cohort study from May to November 2003. Consecutive patients presenting with acute non-specific febrile illness of less than two weeks were selected from two urban primary care centres. We did full blood count examination (FBC) on the day of visit and dengue serology on day five of illness for all patients enrolled. We repeated the FBC examination for patients who had initial normal platelet counts. Thrombocytopaenia was defined as platelet count < 150 X 10(9)/L. Eighty-seven patients enrolled in the study. Complete data was available for 73 patients. The prevalence of acute dengue virus infection was 27.6%. The sensitivity and specificity were 88% and 71% respectively. The likelihood of acute dengue infection in the presence of thrombocytopaenia was 2.52 and likelihood of not having dengue infection in normal platelet count patients was 5.22. Thrombocytopaenia has fair predictive value in diagnosing acute dengue virus infection. It was more useful to exclude than to diagnose dengue infection.
Study site: Primary Care Centre of Hospital Universiti
Kebangsaan Malaysia (HUKM) and Batu 9 Health Clinic Hulu Langat,
Anaemia of chronic disease (ACD) is a frequent complication of rheumatoid arthritis (RA). A diagnostic difficulty in RA is the distinction between iron deficiency anaemia (IDA) and ACD. The aim of our study was to evaluate the usefulness of serum soluble transferrin receptor (sTfR) and sTfR/log ferritin (TfR-F) index to diagnose iron deficiency in RA patients with anaemia. Routine laboratory indices of anaemia and sTfR were measured in 20 healthy persons to form the control group, 30 patients with iron deficiency anaemia and 28 RA patients with anaemia. Serum sTfR levels were significantly elevated above the cut-off value in patients with IDA and those in the iron depleted RA subgroup (ferritin < 60 microg/L) compared with those in the control and iron repleted RA subgroup (ferritin > 60 microg/L). The same was observed for TfR-F index. However, five patients in the iron repleted RA sub group had an elevated sTfR level, of which two had increased TfR-F index. Serum sTfR correlated well with the markers of anaemia and not with ESR. Ferritin had no correlation with markers of anaemia but correlated well with ESR. Measurement of sTfR and TfR-F index are good indicators of iron deficiency in RA patients with anaemia. To be cost effective, sTfR can be estimated in RA patients with anaemia when the ferritin level is more than 60 microg/L.
This is a cross-sectional study to determine the prevalence of insulin resistance and its associated factors in Hospital UKM patients with schizophrenia using the Homeostatic Model Assessment (HOMA) model. Fasting glucose and insulin from 85 patients were obtained. Fasting glucose revealed 15% of the patients were diabetic, while another 15% had impaired fasting glucose. Using the HOMA model, 68% of the patients had insulin resistance. Univariate analyses found BMI (p < 0.001) and waist circumference (p < 0.001) to be associated with insulin resistance. The statistical significance disappeared after multivariate analyses. All patients with schizophrenia should be screened and managed as a group at high risk for development of diabetes with emphasis on body weight management.
Study site: inpatient and outpatients, Psychiatric department, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
This study was carried out to determine the association between body mass index and age related cataract among patients attending eye clinic. We conducted a case control study. The outcome of clinical eye assessment determined the patient's status. Mean body mass index among the cases was shown to be higher (25.4 +/- 4.5) than the control group (24.4 +/- 3.9) (p < 0.01). Crude analysis showed that only obese respondents were 2.4 times more likely to develop age related cataract, however this association was not seen in the multivariate analysis after adjusting for other determinants (aOR 1.81; 95% CI 0.91 - 3.62). We conclude that there is no association between body mass index and age related cataract.
Study site: Eye clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia