Primary cardiac tumours in the foetuses and neonates are uncommon. Foetuses with cardiac tumour have risk for heart failure and hydrops fetalis. Therefore, an early decision for delivery should be made in the evidence of foetal compromise. Early neonatal care varies on tumour size, type, location and obstructive features. Antenatal detection of foetal cardiac tumours ensures better prenatal and postnatal management. We describe our 5- year experience in managing 5 cases of primary cardiac tumours from 1st January 2006 to 31st December 2010.
Pancytopenia can rarely complicate Grave's disease. It can be due to uncontrolled thyrotoxicosis or as a result of rare side effect of antithyroid medication. Pernicious anemia leading to Vitamin B12 deficiency is another rare associated cause. We report a case of a patient with Grave's disease and undiagnosed pernicious anemia whom was assumed to have antithyroid drug induced pancytopenia. Failure to recognize this rare association of pernicious anemia as a cause of pancytopenia had resulted in delay in treatment and neurological complication in our patient.
Chronic discharging ear, mostly due to middle or external ear infection, is one of the leading causes for seeking healthcare among the paediatric population in a developing country. However, a long-standing forgotten middle ear foreign body forms a rare cause for such presentation demanding a high index of suspicion from the clinicians. Most of them are iatrogenic or accidental, and are removed by conventional permeatal approach; need for tympanotomy is rarely documented in the recent literature. We report the first case where a large stone was introduced into the middle ear through a pre-existing tympanic membrane perforation by the child himself, and only the second documentation of removal of a middle ear foreign body by tympanotomy in a child.
In patients with an elbow fracture dislocation the incidence of radial head fracture is 36%, where as coronoid process fractures occur in 13%, and olecranon fractures in 4% of patients. Combination of all these fractures with a 'terrible triad' is rarely reported in the literature. We describe a 40 year old lady involved in a polytrauma who had head injury, pnuemothorax and an open fracture dislocation of the left elbow. The Injury Severity Score initially on admission was 44. She presented with chronic elbow instability with pain 1 year later. A semi constrained total elbow arthroplasty (TEA) with a Coonrad-Morrey prosthesis was performed in this complex injury involving fractures of the coronoid, olecranon, proximal third of the ulna and radial head malunion with heterotrophic ossification around the elbow joint. Although the survivorship of total elbow replacements has improved, it is still a procedure reserved to older patients with low functional demand. At 1-year follow-up, the patient had full range in flexion and extension. The Mayo Elbow Performance Score (MEPS) was 100. TEA is a procedure which gains function and stability in a terrible triad elbow.
Oncologic outcomes following laparoscopic abdomino-perineal resection (APR) for distal rectal cancer are infrequently reported. This study aims to compare the long term outcomes between laparoscopic and open APR in distal rectal cancers.
Resistance to antifungal agents has increased in Candida spp., especially in non-albicans species. Recent findings reported a strikingly low susceptibility in Candida spp. towards itraconazole in Malaysia. In this study, a colorimetric broth dilution method was utilized to determine the susceptibility of Candida spp. isolated in Kuala Lumpur Hospital within a six month period. A total of 82 isolates from blood, peritoneal and other fluids were tested against 8 antifungal agents using the Sensititre Yeast One method. These comprised of 32 (39%) C. albicans, 17 (20.7%) C. glabrata, 15 (18.3%) C. tropicalis, 13 (15.9%) C. parapsilosis, two (2.4%) C. sake and 1 (1.2%) each of C. pelliculosa, C. rugosa and Pichia etchellsii/carsonii. Overall, susceptibility of all isolates to caspofungin was 98.8%, amphotericin B, 97.6%; 5-flucytosine, 97.6%; voriconazole, 97.6%; posaconazole, 87.8%; fluconazole, 82.9%; ketoconazole, 79.3%; and itraconazole, 56.1%. A total of 18 Candida spp. isolates (22 %) were resistant to at least one antifungal agent tested, and half of these were resistant to three or more antifungal agents. C. glabrata was the most frequently identified resistant species (10 isolates), followed by C. tropicalis (4 isolates), C. parapsilosis (3 isolates) and C. albicans (1 isolate). Resistance was highest against ketoconazole (20.9%), followed by itraconazole (13.4%). However, 30.5% of isolates were susceptible-dose dependent towards itraconazole. Long-term usage of itraconazole in Malaysia and a predominance of nonalbicans species may account for the results observed in this study. In conclusion, susceptibility to antifungal drugs is species-dependent among Candida spp.; reduced susceptibility to itraconazole is concomitant with the high number of non-albicans Candida species isolated in Malaysia.
Although a vital test, blood culture is often plagued with the problem of contamination and false results, especially in a chaotic emergency department setting. The objectives of this pilot study is to find out the level of understanding among healthcare staffs in emergency department, Hospital Universiti Sains Malaysia (HUSM) regarding good blood culture sampling practice.
Traumatic Brain injury (TBI) is one of the most common causes of death and disability worldwide, with recent interest in the use of cholinomimetics in the treatment of TBI patients for cognitive impairments. Our patient who suffered TBI was started on a trial of an acetylcholinesterase inhibitor (Donepezil) for five weeks. Cognitive and memory testing with the Mini-Mental State Examination (MMSE) and Functional Independence Measurement (FIM) showed some degree of improvement: The three item recall component of MMSE improved and the FIM Memory score increased from 1 (Complete dependence) to 6 (Functional independence). Subjective assessment of his behaviour in the ward also showed improvement. This suggests that donepezil may help improve memory and behaviour of moderately severe traumatic brain injury patients, although more research in this direction should be undertaken.
Breastmilk protects the infant from many diseases and many short- term and long- term benefits accrue. At the same time it is also known that breastfeeding acts as a vehicle for some infective agents. It is now accepted that breastmilk transmission of Human Immunodeficiency Virus- 1 (HIV-1) is an important mode of paediatric infection . Despite this fact, many researchers have observed that corresponding to the volume of milk consumed by the infant, maternal transmission via breastmilk is still comparatively low. Some have noted the long latency period of breastmilk HIV transmission with evidence of numerous anti-HIV factors in breastmilk. Although there are accepted standard guidelines on infant feeding in mothers who are HIV positive in many countries, it maybe equally important to realize gaps in our knowledge of mother- to -child HIV transmission. From an evolutionary perspective, the role of the mammary epithelial cell (MEC) and of breastmilk , in contributing to and possibly in influencing HIV-1 transmission is intriguing. The presence of HIV-1 or of other viruses in maternal milk seem to be a requisite to spur immunological defenses to optimize necessary protection to the infant. This article reviews some aspects of the science of HIV transmission through breastmilk and reflects the concept -based understanding of current policies on HIV and breastfeeding. At the same time, it highlights uncertainties in this field and the urgency for future research in this direction. Accepting current notions of breastmilk HIV transmission, greater deliberation by research may throw more light on why breastfeeding with its abundant advantages is fraught with the hazards of transmission of a deadly disease.
Emergency lung resection for chest trauma is a rare event with a reported incidence of 0.08-1.3% but is associated with a high morbidity and mortality especially if a pneumonectomy is required, if due to blunt chest trauma or when concomitant injuries are present. We report three cases of young adult males with penetrating chest injuries that required emergency thoracotomy (ET) and anatomical lung resection to achieve definitive control of life threatening pulmonary haemorrhage. All patients survived to hospital discharge and remained well on follow-up. Indications for an ET and what constitutes the optimal operative management of such patients is discussed.
With the advent of new technology, the treatment for ureteric stricture has moved from open surgery to endoscopic procedures. Our goals were to review and determine the prognostic factors for success of laser endoureterotomy for ureteric stricture. This is a cross sectional study for all cases that underwent laser endoureterotomy in a single centre from 2002 to 2009. Standard treatment in this centre utilizes holmium laser. The fiber used was 365nm, setting as 1J and frequency 8 Hz; power output 8 W. Confirmation of adequacy of incision wss by either visualization of extra-ureteric fat or extravasations of contrast on fluoroscopic imaging. Success or recurrence of the endoureterotomy was confirmed objectively with evidence of improvement from imaging. Of these 77 patients, 42 cases (61.8%) of the strictures were from upper ureter. Eight cases (11.7%) of mid-ureteric while lower ureter had 18 cases (26.5%). Length of stricture has been grouped into two groups; Short (<1cm) and long (≥1cm) and their distributions were 47.1% and 26.5% respectively. Follow-up duration ranged from six months to 88 months with an average of 19.6 months. Success rate was 76.5% (52 patients) while 16 patients (23.5%) developed recurrence. Stone disease, positive presenting symptoms and short length of the stricture were identified as variables with good predictor. This study achieved a 76.5% of success rate for this treatment modality for benign ureteric stricture in wellselected patients. Success is more likely if patient is symptomatic (earlier treatment) and previous stone disease present as a risk factor.
Study site: Hospital Selayang, Kuala Lumpur
A canal wall down mastoidectomy (CWDM) is an effective technique for eradication of advanced chronic otitis media or cholesteatomas. A retrospective study was conducted at a Malaysian Tertiary Medical Center between June 1996 to December 2003 to evaluate the outcome of Modified Radical Mastoidectomy(MRM), a form of CWDM for patients with chronic active otitis media (OM) with cholesteatoma, chronic mastoiditis or chronic active OM with cholesteatoma and mastoiditis. All new cases of MRM which fulfilled the selection criteria were reviewed. The main outcome measures were the hearing outcome and status of dry ear postoperatively. A total of 84 patients had undergone CWDM. However only 63 patients (26 male, 37 female) were included for analysis. The age of the patients ranged between 5 months to 72 years (mean, 31years). The majority of the patients (86%) were adults and 9 (14%) were children. The ossicular chain was eroded in 91% (57 cases). There were 33 patients (53%) who showed no improvement of Air Bone Gap (ABG) closure while 16 patients (25%) had a post-operative improvement. The presence or absence of stapes suprastructure was found to be the major factor in determining the amount of ABG (Chi squared test, P = 0.025 preoperatively and P = 0.031 postoperatively). A dry ear was achieved in 78% of patients with 3% recurrence rate. In conclusion, the study showed that a proper MRM gave high percentage of dry ear and this procedure did not worsen the hearing.