Knowledge of local antimicrobial resistance patterns of bacteria is a valuable guide to empirical antimicrobial therapy. This paper reports the resistance patterns of more than 36,000 bacteria isolated between August 1991 and July 1992 in six Malaysian hospitals and discusses the implications of the results. A customized menu driven software programme was developed to analyse the results. Generally, resistance to the commonly used antibiotics like ampicillin, cloxacillin, cephalosporins, gentamicin, cotrimoxazole and tetracycline was high. Some differences in resistance rate amongst the six hospitals were also noted. Continuous surveillance of antimicrobial resistance in hospitals is encouraged for the effective control of the emergence of antimicrobial resistance.
Background: Based on studies and some clinical practice pneumatic dilatation utilizing the widely available wire guided polyethylene pneumatic dilator system using a 30mm balloon inflated for 15 seconds upon loss of waist noted (during fluoroscopy) at 7 to 10psi obtains optimal disruption of the lower esophageal sphincter. We employed this technique till August 2001 without any complications (notably perforation) with good clinical outcome and durability.
Aims: To study the efficacy of pneumatic dilatation with the pneumatic balloon dilated only till loss of waist.
Materials and Methods: A total of 10 treatment naïve achalasia patients enrolled from August 2001 till July 2002 were dilated till loss of waist and the outcome and durability was compared with our historical controls.
Findings: A total of 10 patients with age 45±18 (range 22-67) years with 8 females: 2 males and 5 Malays: 5 Chinese with 3 patients with megaoesophagus underwent pneumatic dilatation using a 30 mm Rigiflex® pneumatic dilator till loss of waist was noted during fluoroscopy at 7psi and the balloon deflated immediately. All the patients reported symptomatic improvement in dysphagia, regurgitation and demonstrated a 3-12 month post procedural weight gain of 6±5 (range: 1-15) kg. One patient required a second dilatation only after 13 months. All the remaining patients remain well till today after the initial single dilatation. The durability of the dilatation was 27±7 months (range: 13-33) months. There were no complications noted. There were no complaints of excessive reflux. This data was compared with our historical control (patients before August 2001), i.e. the pneumatic dilator inflated for 15 seconds upon loss of waist, and there was no difference in clinical outcome, or the durability of dilatation or the duration of stay post procedure.
Conclusion: Forceful disruption of the lower esophageal sphincter utilizing the pneumatic dilator is effective but is associated with a 1-5% risk of perforation. We obtained identical results without loss of clinical improvement or durability utilizing our technique compared to the traditional method. Since August 2001 all our dilatations were performed in our unit utilizes this simplified method. We have yet to report a perforation after pneumatic dilatation.
Introduction: Megaesophagus is defined as an esophagus measuring 8cm or larger on the barium swallow examination in a patient with Achalasia cardia. Its existence defines a late stage of achalasia and therapy will include an esophagectomy in its management. The latter carries a high morbidity and mortality.
Materials and Methods: We reviewed retrospectively all treatment naïve patients with Achalasia from 1st January 2000 and identified 10 patients with megaesophagus and these patients were analysed.
Findings: The average presenting age is 52±15 (range 20-73) years with 4 males: 6 females with 5 Malays:3 Chinese:2 Indians. The duration of illness before diagnosis was 7±5 (range 1-16) years. All patients had dysphagia, regurgitation and weight loss. All 10 patients demonstrated aperistalsis but interestingly 8 patients failed Lower Esophageal Sphincter (LES) intubation during Standard Esophageal Manometry due to coiling of the catheter. Failure to elicit Failure of LES relaxation translates as a high technical failure of manometry (80%) in the diagnosis of Achalasia. A confident diagnosis of Achalasia was made on barium swallow in 9 cases (90%). All 10 patients underwent pneumatic dilatation. Eight patients required only single dilatation. However two patients required two dilatations. The durability of the twelve pneumatic dilatation 27±13 (Range: 9-44) months with good symptomatic relieve and an objective post procedural weight gain of 10±6 (range:1-19) kg over a period of 3-12 months. There was no complications noted post procedure.
Conclusion: In advanced cases of achalasia, barium swallow is superior to manometry for obtaining the diagnosis. Pneumatic dilatation is an effective and safe procedure for patients with megaesophagus.
Objectives: To assess the feasibility of a computer-based Standard Gamble (SG) visual prop whilst measuring utilities of different asthma health states at the same time.
Methods: Twenty adult asthma patients literate in either Malay or English language were conveniently sampled from a public hospital in Penang, Malaysia. They were interviewed by two trained interviewers using a bilingual script. Each patient was requested to value the given health states using Visual Analogue Scale (VAS) prior to SG exercise. There were three chronic health states (C1-C3) for 10 years, three temporary states (T1-T3) for 3 months, and two anchor states (healthy and dead). During the SG exercise, the visual prop was fully operated by the interviewers. The probability of being in a worse state was changed in a ‘ping-pong’ fashion until the indifference point was reached.
Results: All patients understood the SG exercise and rated SG easier than VAS. Around 85% (n=17) completed SG within 30 minutes. There was 90% (n=18) who ranked T3 as the worst temporary health state during VAS. Two patients provided logical inconsistency data in SG. The preferences by SG were higher than VAS. Preferences were also higher in temporary states measured by chained SG than other states by conventional SG. The mean utilities for C1=0.56 (SD 0.38), C2=0.47 (SD 0.33), C3=0.53 (SD 0.38), T1=0.65 (SD 0.31), T2=0.53 (SD 0.35), and T3=0.38 (SD 0.38).
Conclusions: The SG methods including the props are feasible for utilities measurement in asthma, based on the agreements achieved with other studies on the pattern of utilities measured in this preliminary study.
PURPOSE: Extravasation with intravenous chemotherapy is a common complication of chemotherapy which carries the risk of devastating complications. This study aims to determine the rate of extravasation with intravenous chemotherapy in a major hospital where chemotherapy is delivered in various departments other than the oncology department.
PATIENTS AND METHODS: All patients who underwent intravenous chemotherapy in the oncology department and surgical wards in Penang General hospital from 1st February 2008 till 31st June 2008 were recruited retrospectively for this study to look at the rate of extravasation.
RESULTS: A total of 602 patients underwent intravenous chemotherapy during this period. Fifty patients received chemotherapy in the general surgical ward while another 552 patients received chemotherapy in the oncology department. There were 5 cases of extravasation giving an overall extravasation rate of 0.8% (5/602). however, 4 of these cases occurred in the general surgical ward giving it a rate of 8% (4/50).
CONCLUSION: The rate of extravasation in our hospital was 0.8%. however, this rate can be significantly increased if it is not done under a specialized unit delivering intravenous chemotherapy on a regular basis. Preventive steps including a standard chemotherapy delivery protocol, staff and patient education must be put in place in all units delivering intravenous chemotherapy.
INTRODUCTION: Maternal mortality and morbidity from eclampsia continues to be seen around the globe. Local Key Performance Index on recurrence of eclamptic fits did not meet targets, thus this raised the issue whether the care provided adhered to the standard management for eclampsia.
METHODS: This clinical audit was conducted to assess and improve the quality of the service being offered to patient, particularly in managing eclampsia cases. It was conducted according to the audit cycle. It begins with the development of 12 standardized criteria for eclampsia management. First audit was conducted by retrospectively reviewing eclampsia cases from year 2008 till 2012. Strategies for changes were formulated and implemented following the results of the first audit. Second audit was conducted six months after the changes.
RESULTS: The overall incidence rate of eclampsia was 9.17 per 10,000 deliveries. A first seizure occurred during the antepartum period in 52.9% of cases (n=27), intrapartum in 24% (n=11) and postpartum in 21% of cases (n=13). Suboptimal care was mainly on delay of activation of Red Alert system and no treatment for uncontrolled blood pressure. Several strategies were implemented, mainly on improving working knowledge of the staffs and reengineering hospital Red Alert system. Positive achievements observed during the second audit, shown by a reduction in the number of patients with recurrence eclamptic fits and perinatal mortality rate.
CONCLUSION: Conducting an audit is essential to evaluate local performance against the standardized criteria. Improvement can be achieved with inexpensive solutions and attainable within a short period of time.
Study site: Sultan Abdul Halim Hospital, Sungai Petani, Kedah, Malaysia
Background: Achalasia cardia is an uncommon disease that is often detected late and is associated with significant morbidity. It is a primary esophageal motility disorder diagnosed based on a good history, barium swallow, upper endoscopy and a standard esophageal manometry.
Materials and Methods: We reviewed complete available records of treatment naïve patients with achalasia cardia from 1st January 2000 till April 2004.
Results: A total of 40 patients, with average presenting age at 44±16 (range 19-73) years with 14 males: 26 females with 20 Malays: 15 Chinese: 5 Indians, were suitable for further analysis. The classical symptom of dysphagia to liquids and solids were noted in all cases (100%). These patients learnt that water and sometimes-aerated drinks aid in flushing food down. Symptoms of regurgitation (36 patients-90%), heartburn (15 patients-37.5%), weight loss (10 patients–25%), nocturnal cough (16 patient-40%), retrosternal chest discomfort (2 patient-5%) and hemetemesis (2 patient-5%) was noted. One patient had aspiration pneumonia and another had concomitant active pulmonary tuberculosis and 8 had concomitant constipation (20%). In this series the duration of illness before diagnosis was 5±6 (range
0.3- 30) years and their presenting weight was 53±13 (range 33-82) kg. Barium swallow diagnosed achalasia in 27 patients (67.5%) and a dysmotility disorder in 7 cases (17.5%). There were 10 patients with mega-esophagus and two had epiphrenic diverticulum. There was no pseudoachalasia. Standard esophageal manometry, performed in 36 cases, demonstrated aperistalsis with one vigorous achalasia. The manometric assembly failed to pass through the sphincter in 14 cases and hence LOS assessment was not possible. Four cases demonstrated normal LOS pressure but demonstrated incomplete relaxation (normotensive achalasia). Pneumatic dilatation was performed in 38 newly cases without any complications with excellent symptomatic relief and a 3-12 month post procedural weight gain of 7±5 (range: 0-19) kg. Six patients required a second dilatation and another required two further dilatation. The durability of the total 45 pneumatic dilatations during this short study period was excellent at 24±12 (range 2-48) months.
Conclusion: A primary esophageal motility disorder must be excluded in any patients who present with dysphagia, with or without regurgitation and a "normal" upper endoscopy. Achalasia is not uncommon, often delayed in diagnosis and has a varied presentation. Although there is no cure for achalasia, but early detection and treatment certainly relieves symptoms and prevents complications. Pneumatic dilatation in our center has excellent durability without any complications.
Background: Achalasia cardia, not an uncommon disease, is diagnosed based on a good history, upper endoscopy, barium swallow, and standard esophageal manometry, is often diagnosed late and best care is delayed.
Materials and Methods: Complete records of treatment naïve patients with achalasia from 1st January 2000 till 20th November 2004 were reviewed.
Results: A total of 42 patients, with average presenting age at 45±17 (range 19-83) years with 15 males:27 females with 22 Malays:15 Chinese:5 Indians, were analysis. Compared to our upper endoscopy attendees, there is a trend towards a younger age group (p>0.05) but clearly demonstrating a female preponderance (p<0.005) and towards the Malays but sparing the Indians (p< 0.05). The classical symptom of dysphagia was noted in all cases (100%). Regurgitation in 37 patients (88%), heartburn in 15 patients (36%), weight loss in 10 patients, nocturnal cough in 16 patient, retro-sternal chest discomfort in 2 patients and hemetemesis in 2 patient. One patient presented with aspiration pneumonia and another had concomitant active pulmonary tuberculosis and 9 had concomitant constipation (21%). The duration of illness before diagnosis was 66±90 (range 3-360) months and their presenting weight was 52±12 (range 33-82) kg. Barium swallow examination confidently diagnosed achalasia in 28 patients (67 %). The remaining was marked as dysmotility disorder (7 cases), possible carcinoma of the esophagus (in 2 patients) and dysmotility with possible achalasia (in 5 patients). Ten had mega-esophagus and two had epiphrenic diverticulum with no pseudo-achalasia. Standard esophageal manometry, performed in 39 cases, all demonstrated aperistalsis with one vigorous achalasia. The manometric assembly failed to pass through the
sphincter in 14 cases (36%), includes 8 patients with mega-esophagus, and LES assessment was not possible. Four cases demonstrated normal LES pressure but demonstrated incomplete relaxation (normotensive achalasia). Dilatation was performed with a 30 mm Rigiflex pneumatic dilator under fluoroscopy at 7psi for 3-30 seconds after loss of waist in 40 patients without complications and excellent symptomatic relief with 3-12 months post procedural weight gain of 7±5 (range: 0-19) kg. Six patients required a second dilatation and another required two further dilatation. The pneumatic dilatations durability during this short study was excellent at 29±11 (range 8-48) months. Similar efficacy and safety profile was noted in patients with mega-esophagus.
Conclusion: Barium swallow (especially in advanced disease) and manometry (especially in early disease) serve as essential tools for the diagnosis of achalasia and they complement each other. We report two patients presenting with hemetemesis. We obtained excellent results with pneumatic dilatation without any
complications and this extends to advanced cases of achalasia with mega-esophagus.
We performed a prospective study of all hospitalized patients with a diagnosis of Gout in Sarawak General hospital from 1st July 2011 to 1st July 2012. There were a total of 126 patients in our study of which 112 (88.9%) were males. The majority of our patients were from the indigenous populations (71.7%). They have a mean age of 60.0 ± 14.2 years. Most of our patients were overweight (68%) with comorbities of hypertension (78.6%), Chronic Kidney Failure (48.4%), Type II diabetes Mellitus (30.2%), dyslipidemia (27.8%) and Ischaemic heart disease (11.9%). Polyarticular gouty arthritis was the main presenting pattern during hospitalization (88.1%). The mean length of stay for our patients was 9.8 ± 6.0 days which was significantly longer than the mean length of stay for other patients without gout (p<0.05). Only 17 patients had gout on admission and the majority developed gout during hospitalizations. Our patients were admitted respectively for medical problems (45.4%), surgical problems (28.6%) and orthopaedic problems (9.2%). Colchicine (73.8%) and steroid (40.5%) were the main stays of treatment for our patients. Our hospitalized gout patients were complicated patients with multiple comorbidities.