Acute coronary syndrome (ACS) patients with positive troponin T (TnT) test are at higher risk for death and myocardial reinfarction. They would significantly benefit from early aggressive pharmacologic and invasive therapy. However, TnT test is not widely available. This retrospective study of 173 patients with ACS showed: that prolonged or repetitive episodes of angina at rest in the previous 24 hours (p = 0.01) and evidence of myocardial ischaemia on ECG (p < 0.001) were associated with positive TnT tests (> or = 0.1 ng/mL). The two variables in combination showed 100% positive predictive value, facilitating early identification and streamlining of therapy.
A cross-sectional survey of 400 medical students of multicultural backgrounds at the University of Malaya was conducted to understand their attitudes towards euthanasia and factors related to medical decisions and ethical reasoning concerning the prolongation of life, the right to die and euthanasia. The student respondents completed self-administered questionnaires that comprised of twelve questions with multiple stems addressing personal perceptions, knowledge, attitudes, and decisions about euthanasia and the relief of suffering. The majority of respondents (52%) were for the withdrawal of active therapy in a patient suffering from a terminal painful disease while 48% of them were against it. Seventy-one percent of the students involved in the study were against the idea of active euthanasia i.e. the administration of a lethal injection. However, 27% of the respondents felt that there was a moral justification to assist patients to die. Thirty-two percent of the respondents favoured the legalization of euthanasia in Malaysia while 67% of them were strongly against it. The majority (61%) of respondents would not practice euthanasia as a doctor nor would they have performed on themselves if or when it became legal. The main issue surrounding euthanasia that concerned the respondents was the misuse of it by unethical practitioners and they felt that further debate on the matter was essential, both within the local and international communities.
Adhesive small bowel obstruction (ASBO) is an annoying postoperative complication. Though the diagnosis can be made easily, the role of conservative management in children is controversial. Hence a study was conducted to determine the role of conservative management, and to identify the factors that can predict / influence the outcome of conservative treatment in children with ASBO. Children admitted with ASBO from 1980 to 2002 (22 year period) formed the material for this study. The data was analyzed with respect to the influence of age at the time of presentation, primary disease for which original laparotomy was done, time interval between the primary surgery and the development of ASBO and the number of laparotomies prior to the development of ASBO on the outcome of conservative management. There were 74 episodes of ASBO in 69 children (Five children had two episodes). Out of 74 episodes, 5 episodes (6.75%) needed immediate laparotomy for suspected gangrene. All others were managed conservatively. Of the 69 episodes managed conservatively, 36 responded to conservative treatment (2-5 days) while 33 required subsequent surgical intervention, with 11 of them requiring bowel resection (two for gangrene and 9 for bowel damage during adhesiolysis) and in the rest 22 cases adhesiolysis. A substantial number of children with ASBO respond well to conservative treatment. Majority of the children developed ASBO within three months after the primary laparotomy. Children below the age of one year (at the time of presentation with ASBO) responded poorly to the conservative management. Children who had primary surgery for Hirschsprung's disease and intussusception also appeared to have responded poorly to conservative management, but statistically not significant. Time interval between the primary surgery and the number of laparotomies before the child developed ASBO did not influence the outcome of conservative management.
Tonsillectomy is the single most common operation performed in Ear Nose and Throat Department. Various methods of tonsillectomy have been practiced over the century aimed at reducing or eliminating intraoperative and postoperative morbidity. Due to various blood supplies received, intraoperative bleeding is the most difficult problem and securing it is time-consuming. The time taken to control the bleeding would invariably determine the length of operation. Common postoperative complications are bleeding and pain. This study evaluated the operative time, intraoperative blood loss, postoperative pain and other postoperative complications of tonsillectomy performed by laser as compared to conventional dissection technique. This is a prospective randomized study whereby sixty patients were divided into two groups of equal number. In one group, the tonsillectomy performed by laser and in the other group the tonsillectomy performed by conventional dissection technique. Operative time and amount of blood loss is significantly reduced in the laser group. Total postoperative pain and post operative complications were not significantly different between the two groups. Tonsillectomy by using laser have shown less intraoperative bleeding and shortened the operative time. In the hospital where laser machine and expertise are available, it is justifiable to use this technique as effective method of performing tonsillectomy.
The study of apoptosis in endometrium of women with irregular uterine bleeding and its predictive value in endometrial malignancy. Analyze apoptotic and mitotic indices and their relevance in irregular uterine bleeding. To determine the expression of Bcl-2 oncoprotein in endometrial glands from patients with irregular uterine bleeding. Department of pathology in a Government Hospital serving a varied socio-economic population in Chennai. Random samples of endometrial currettings from dysfunctional uterine bleeding (DUB) patient who underwent endometrial curettage as therapeutic and diagnostic procedure during the year 2000. Of 50 cases of endometrial samples from patients diagnosed as cases of DUB, the apoptotic and mitotic indexing was carried out and histological categorization revealed 13 cases as Anovulatory. 14 as simple hyperplasia, 5 as early secretory endometrium, 4 as mid secretory and 4 as late secretory endometrium and 7 as endometrium showing features of hormonal imbalance. Three cases were not included, due to sub-optimal processing. A good correlation of the Bcl-2 expression and the apoptotic cell morphology/indices, in the different categories of the endometria of DUB cases is observed. This preliminary study gives an insight to the existence of a correlative pattern of apoptosis in DUB cases. A prospective study on a larger number of cases may substantiate the hypothesis that the Apoptotic and Mitotic indices are useful screening methods with predictive values on development of endometrial carcinoma. It is observed that an increased apoptotic index correlating with high Bcl-2 expression, reflecting the actual cell burden. This prolonged cell survival resisting cell deletion is associated with irregular uterine bleeding endometria.
Health-related quality of life (HRQoL) assessment is important in healthcare outcomes. This study aimed to determine the feasibility, reliability and validity of the Malay McGill Quality of Life Questionnaire--Cardiff Short Form (MMQOL-CSF) in advanced cancer population. Patients either completed the MMQOL-CSF alone or in addition to its long version. The study recruited 116 participants (average age = 44 years old). On average, MMQOL-CSF was completed in 5.4 minutes. Most domains showed evidence of reliability (Cronbach's alpha = 0.76-0.92). Correlation with its long version was moderate to strong (r(s) = 0.54-0.87). The MMQOL-CSF was a feasible, reliable and valid HRQoL instrument in this population.
The tarsometatarsal (Lisfranc) joint suffers a spectrum of injuries ranging from solely ligamentous injury to fracture dislocation. The authors evaluated eighteen consecutive patients who underwent surgery for tarsometatarsal joint injuries, utilising 4.5 mm cancellous screws and 1.6 mm K-wires. The outcome of function and anatomical reduction were assessed by AOFAS (American Orthopedic Foot and Ankle Society) midfoot score and radiography. Patients with only ligamentous injury scored poorer partly due to delay in diagnosis and the nature of the injury. The technique used maintained anatomical reduction at the time of review.
Pulmonary disease is sometimes treated empirically as tuberculosis (TB) in the absence of microbial confirmation if the clinical suspicion of active TB is high. In a country of relatively high TB and low HIV burden, we retrospectively studied 107 patients (69.2% male; mean age (SD): 45 (17) years) who received empirical anti-TB treatment for intrapulmonary opacities or pleural effusions suspected of active TB in our hospitals between 1998 and 2002. The diagnosis of definite or probable 'smear-negative' pulmonary TB was made based on treatment outcome at two months with rifampicin, isoniazid, pyrazinamide and ethambutol (or streptomycin). At this end-point, 81 patients (84.4%) had both clinical and radiological improvement (definite cases), 12 (12.5%) had clinical improvement alone and 3 (3.1%) had radiological improvement alone (probable cases). Confirmation of acid-fast bacilli was subsequently obtained in 12 patients (all definite cases) from culture of initial pulmonary specimens. Eleven patients (10.5%) were diagnosed as 'non-TB' based on absence of both clinical and radiological improvement or discovery of another cause for the pulmonary condition at or before this two-month study end-point. In the 'non-TB' group, 2 had carcinoma, 2 had HIV-related pulmonary diseases, 1 had bronchiectasis, while in 6 causes were indeterminate. Six (6.3%) and 3 (27.3%) patients reported adverse effects from anti-TB drugs from the 'TB' and 'non-TB' groups respectively. Our findings suggest that empirical anti-TB treatment is an acceptable practice if clinical suspicion is high in patients coming in our region.
Early identification and management of hearing impairment is very valuable. The goal standard measurement of hearing loss is by brainstem evoked response (BSER). This prospective study was conducted in Hospital University Kebangsaan Malaysia (HUKM) to determine the sensitivity and specificity of transient evoked otoacoustic emission (TEOAE) as a screening tool for hearing impairment from February 1999 to February 2000. One hundred and thirty-three newborns from postnatal ward and seventy-eight newborns from neonatal intensive care unit (NICU) were screened for possible hearing loss using portable TEOAE. This study showed that TEOAE is a very sensitive but moderately specific screening tool.
The radiographs of 115 anterior shoulder dislocations (100 patients; 74 males, 26 female were reviewed to assess the radiographic views used in the management of this dislocation. Eighty-eight patients (88%) had only the anteroposterior (AP) view, 10 patients had 2 radiographic views taken and only 2 patients had three radiographic views. Hill-Sachs lesions were found in 18%, and glenoid rim fractures in 3% of the patients. A greater tuberosity fracture was found in 18% of the patients. Therefore, the current practice in the management of an acute anterior shoulder dislocation appears to be to perform a single view (AP) pre-reduction radiograph to confirm the diagnosis and a single view (AP) post reduction radiograph to confirm reduction after a close manipulative reduction has been performed. This practice is likely to result in an underestimate of associated Hill Sachs lesion and glenoid rim fractures, but not greater tuberosity fractures.
The resurging interest in diagnostic laparoscopy has witnessed its increasing application in trauma surgery. Such unbridled enthusiasm has at times overlooked its shortcoming in the diagnosis and management of certain in abdominal injuries. We report and discuss one such conspicuous limitation and advocate that the use laparoscopy in abdominal trauma should be tempered with caution.
Complications that arise from self-cleaning the external ear canal are common. This is a prospective study using standard questionnaire on the practice of ear cleaning in 50 subjects. A loose tip cotton bud was also shown to them to assess if it was acceptable to replace their current cotton bud. Thirty six percent of them clean their ears by introducing an object into the ear canal once or more a day. The commonest reason to clean the ears was the presence of earwax. Only 6% used a cotton bud to mop fluid from the ear canal. Almost all (92%) the subjects used a cotton bud to clean the ear. A complication rate of 2% was noted. A loose tip cotton swab was shown to the subjects. Despite explaining that it is safer and better, only 24% of the subject were willing to change to this loose tip cotton bud. Seventy four percent of the subjects cleaned their ear regularly because of earwax. The misconception of needing to clean the ear canal by introducing an object into the ear is rampant. This practice should be avoided and health care providers can play an important role in this.
ALLHAT study is the biggest randomized clinical trial in hypertension ever conducted. Its objective was to ompare the efficacy of newer (calcium channel blocker amlodipine and angiotensin-converting enzyme inhibitor inopril) to the older (diuretic chlorthalidone) antihypertensive agents in the treatment of patients with hypertension. After enrolling 42,000 patients who were followed for an average of 4.9 years, ALLHAT did not find significant differences in the primary end-points between these antihypertenive agents. ALLHAT however found significant differences in the secondary end-points such as heart failure and strokes between chlorthalidone and amlodipine or lisinopril. Based on these and on economic reasons, the investigators unequivocally recommended diuretics as the first line therapy for hypertension. Since its publication, ALLHAT has been much discussed, debated A and opined. The choice of drugs for study, the study design, the conduct of the study and the conclusions drawn by the investigators had all been criticised or controversial. Yet ALLHAT has been widely quoted, commented upon or referred to and it has been instrumental in initiating the JNC VII Guidelines. Thus a thorough understanding of ALLHAT is necessary for clinical practice and in designing and evaluating clinical trials in the future. Moving Points: in Medicine will capture the essence of ALLHAT, discusses its implications to clinical trials and explores its possible impact on the practice of medicine in this country.
A patient with duodenal ulcer who developed iatrogenic perforation post endoscopy is presente. We present t is case that was treated successfully treated by jejunal serosal patch.
The efficacy of Virkon S, a commercial disinfectant as a virucidal spray against human enterovirus 71 (HEV71), the causative agent of the fatal form of hand, foot and mouth disease was examined. At least one log10 reduction of HEV71 titer was achieved when one spray of Virkon (1% or 2%) with ten minutes of contact time was applied. The infectivity was completely lost when four sprays of 1% or 2% Virkon were applied, suggesting that at least four sprays of 1% Virkon to the surface bound HEV71 was necessary to completely inactivate the virus. These findings suggest that Virkon S at the proper concentration is suitable to be used as an effective and easy to use disinfectant against HEV71.
Hepatitis A, an acute usually self limiting infection of the liver is one of the most common vaccine-preventable infectious disease in the world. Effective vaccines which provide long term immunity against hepatitis A have been available since 1992. They are of known good quality, well tolerated with no serious adverse events and have been successfully used to protect different populations from infection as well as interrupt outbreak in closed communities. Mathematical models estimate the long term persistence of antiHAV antibodies to be more than 25 years. Vaccination efforts should be supplemented by health education and improved sanitation. Planning for large scale immunization programmes against hepatitis A should take into consideration epidemiological and cost benefit studies.
The liver biopsy has a unique place in the investigation of liver disease because the concepts and classification of liver disease are rooted in morphology. Today, the use of the liver biopsy has extended beyond that of diagnosis, to the assessment of disease progression, response to therapy and transplant rejection. To get the best out of the liver biopsy, it is necessary to appreciate the usefulness and limitations of the biopsy specimen. Aspects to consider include: (1) minimizing sampling errors, and appreciating that the changes in the biopsy may not be representative of the primary pathology, (2) good laboratory quality practices to avoid processing artifacts, which may render a biopsy undiagnosable, (3) the appropriate use of special stains and other laboratory techniques, (4) adoption of a systematic and algorithmic approach in the microscopic examination of the biopsy, and (5) good clinicopathological correlation.