Thoracic oesophageal perforation, a life-threatening condition, is a therapeutic challenge. A 20 year old male developed a lower oesophageal perforation following an abdominal cardiomyotomy for achalasia of the lower oesophagus. The resulting suppurative mediastinitis and left empyema thoracis were treated by decortication. The oesophageal perforation was closed using a transposition pedicle left latissimus dorsi muscle flap.
Congenital chloride diarrhoea is a rare disorder mainly reported in Finland. A Malay child with congenital chloride diarrhoea presenting at six months of age with watery stools from birth and failure to thrive is reported.
A 66-year-old man sustained an injury to his right foot while gardening. Despite receiving tetanus toxoid one hour later and adequate wound toilet, he developed severe tetanus complicated with autonomic dysfunction six days later. He died 20 days after admission. This case shows that tetanus toxoid alone may not be sufficient to prevent tetanus in wounded patients. Careful consideration must be given to the immune status of the patient and to the nature of the wound sustained. Incompletely immunised patients or patients with unknown immune status who sustain a tetanus prone wound should be protected with both tetanus toxoid and tetanus immunoglobulin.
In view of controversial reports about the role of prelabour rupture of foetal membranes (PROM) in neonatal morbidity and to study the association of PROM with infections and meconium aspiration syndrome (MAS), a prospective case control study was conducted in a level II nursery of Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan. Of the 111 neonates with PROM studied, 18 developed clinical problems (septicaemia and other specific problems such as pneumonia, omphalitis, skin infection and MAS) while 5/56 of the control group developed similar problems. The difference between the two groups was not significant (p < 0.30). There was no neonatal death. It is concluded that PROM is not associated with neonatal morbidity. Neonates with this problem alone do not need to be admitted to the neonatal nursery.
A prospective study of 486 high risk neonates admitted to a level II nursery in a relatively poor and rural area of Malaysia was carried out to determine the incidence, the spectrum of micro-organisms and predisposing factors in relation to early onset septicaemia. The incidence of proven or probable septicaemia was 57.61 per 1000 high risk newborns over 1.5 kg. The case fatality was 10.71 per cent. Coagulase negative staphylococci, Streptococcus Group B and Klebsiella species were the most commonly isolated organisms. Meconium staining of liquor was the most common risk factor for admission to the nursery, and prematurity was the most significant risk factor for early neonatal infection (P < 0.005) followed by small for gestational age (P < 0.04). Although the incidence of septicaemia was quite high in the level II nursery, the mortality rate was comparable to established figures.
Between August 1990 to November 1991, 905 of 2583 (35.4%) isolates of Staphylococcus aureus were found to be methicillin-resistant in a general hospital in Malaysia. A detailed study of 539 of these isolates showed a high prevalence of methicillin resistant Staphylococcus aureus (MRSA) in the surgical/orthopaedic wards, paediatric wards and the special care unit. The yield of MRSA was highest from wounds/ulcers/skin swabs accounting for 64.2 per cent followed by 6.9 per cent in blood cultures. Vancomycin remains the drug of choice with no resistance detected. The resistance to ciprofloxacin was 6.7 per cent, rifampicin 4.5 per cent and fusidic acid 2.0 per cent. Most isolates were resistant to aminoglycosides. In view of the high prevalence of MRSA in this hospital, the authorities must introduce more effective measures to control its spread as a nosocomial pathogen. Otherwise it may seriously disrupt the efficient delivery of health care services in the country.
Primary varicella-zoster virus infection in children with haematological malignancy is a life threatening disease. In one year, there were 10 cases of varicella and 2 cases of zoster among these children as well as 5 mothers who were accompanying their children who developed varicella in the oncology ward. Two children died of fulminating disease despite aggressive antiviral and supportive treatment. Acyclovir can be used in treatment and prophylaxis in exposed susceptible children. Varicella -zoster immune globulin is not available in this country. Vaccination with live virus has been shown to be protective in immunocompromised children and needs consideration.
Functional renal reserve is a measure of the capacity of the kidney to increase the glomerular filtration in response to the stimulus of a protein meal or amino acid infusion. The aim of this study was to evaluate the usefulness of protein meal test to measure functional renal reserve in normal subjects and various groups of renal patients. One hundred and twenty five subjects from the Nephrology Clinic, Kuala Lumpur General Hospital were subjected to a protein loading test to measure their renal reserve. Each subject had to eat a 100 gram cooked chicken meat and timed 2 hours urine collections before and after the test meal were done to measure the creatinine clearances. The 62 healthy subjects showed a mean renal reserve (creatinine clearance after protein loading-baseline creatinine clearance) of 31.0 ml/min. The 31 subjects with various kidney diseases showed a mean renal reserve of 13.5 ml/min. The 19 renal transplant recipients showed renal reserve of 13.2 ml/min. The 12 nephrectomised donors showed renal reserve of 5.4ml/min. Renal reserve may be used to assess suitability of living related transplant donor for nephrectomy.
Study site: Nephrology Clinic, Kuala Lumpur General Hospital
An open prospective descriptive pilot study was undertaken to assess the effectiveness and experience in the use of ExosurfNeonatal, a synthetic surfactant, on preterm infants with respiratory distress syndrome in the neonatal intensive care unit of the Paediatric Institute. Of 10 infants treated, seven (70%) survived with no major handicap on discharge. The mean duration of ventilation for these survivors was 6.4 days, mean duration of oxygen therapy 9.1 days and mean length of hospital stay 38.3 days. A comparison was made with a retrospective analysis of 15 neonates who were admitted during an eight month period prior to the pilot study. These infants were mechanically ventilated for respiratory distress syndrome but not given surfactant therapy. Of these, nine (60%) survived (P > 0.1 compared to Exosurf treated infants), but two developed post haemorrhagic hydrocephalus requiring shunting. For these nine survivors, the mean duration of ventilator therapy was 12.6 days, the mean duration of oxygen therapy 20.7 days and the mean length of hospital stay 70.8 days. This difference was statistically significant (P < 0.05). Of the three ExosurfNeonatal treated infants who died, two were extremely premature. Both developed grade IV periventricular haemorrhage while the third infant was admitted in shock and hypothermia and died from intraventricular haemorrhage and pulmonary interstitial emphysema. Except for the very sick and extremely premature infants, surfactant therapy is useful in reducing the mortality and morbidity of premature infants with respiratory distress syndrome in our neonatal intensive unit.
The common investigations done were pure tone audiometry, electronystagmography, X-ray of the internal auditory meatus, CT-scan of the internal auditory meatus and X-ray of the cervical spine. After the examinations and investigations only 52 patients out of the 107 could be given any diagnosis. The most common diagnosis for the vertigo was Meniere's disease.
The clinical course of 18 patients with Wilson's disease is reported. There were 13 males and five females of whom one is Malay. The prevalence of Wilson's disease in Malaysia is probably the same as elsewhere. Being a genetic syndrome, the genetic carrier rate for Wilson's disease is probably lower amongst the Malays. At diagnosis, the clinical signs were predominantly hepatic in 10 patients, neurological in five patients with three asymptomatic cases. All patients were commenced on penicillamine but poor compliance was observed in many patients. Two patients defaulted follow-up and seven patients died. Out of the nine surviving patients, only four are well with no clinical symptoms.
Obstetric pulmonary embolism forms the most serious vascular problem during pregnancy. The following report is a retrospective study into maternal deaths in Malaysian mothers probably due to obstetrical pulmonary embolism. Obstetric pulmonary embolism can be divided into amniotic fluid embolism and obstetric blood clot embolism. There were 37 maternal deaths attributable to this cause -9.9 per cent of all maternal deaths to blood clot embolism and 6.7 per cent to amniotic fluid embolism. Most cases were diagnosed clinically because a postmortem examination was not done. Eleven cases of embolism were associated with Caesarean delivery. The typical profile of a Malaysian mother dying from obstetrical pulmonary embolism is that of a Malay mother in the "non-risk" parities of one to four and usually aged between 31-35 years. In the management of these patients, there should be an urgency in diagnosis and improvement in diagnostic procedures. Health staff at all levels should be trained to pick up patients who present with features of deep vein thrombosis.
A closed enteral delivery system consisting of a cardboard tetrapack containing the sterile ready-to-use liquid feed and an independent sterile administration set, has been devised. We found bacterial contamination within 24 hours in this system in patients on ventilatory support in intensive care. This emphasises the need for meticulous care in handling enteral feeding systems to prevent environmental contamination.
MeSH terms: Asepsis/methods; Bacteria/isolation & purification*; Enteral Nutrition/instrumentation*; Equipment Contamination/prevention & control; Equipment Contamination/statistics & numerical data*; Evaluation Studies as Topic; Hand Disinfection/methods; Humans; Intensive Care Units; Respiration, Artificial; Time Factors; Infection Control/methods
This is a study of 13 Malaysian patients with clinically definite Multiple sclerosis (MS) subjected to a hot bath test with VEPs, BAEPs, median nerve SSEPs before and after heating. Five patients (38%) developed neurological changes with the rise in body temperature. There was an average of 0.46 new sign per patient. Four patients had motor disturbances attributed mainly to aggravation of spinal cord dysfunction. Two patients had additional visual deterioration, one patient has associated VEP change. This study shows that though Uhthoff's phenomenon has not been noted in the reports of Asian MS patients, when subjected to rigorous testing, Asian MS patients also show sensitivity to body temperature change. However, the percentage of positivity of the hot bath test is much lower than that reported for Caucasians. Thus this study shows further differences between Asian and Caucasian MS patients.
MeSH terms: Adult; Baths*; Body Temperature*; Evaluation Studies as Topic; Female; Hot Temperature*; Humans; Malaysia/epidemiology; Male; Middle Aged; Motor Skills*; Multiple Sclerosis/diagnosis*; Multiple Sclerosis/genetics; Multiple Sclerosis/epidemiology; Multiple Sclerosis/physiopathology*; Sensitivity and Specificity
Cervico-vaginal smears from 350 IUCD users were analysed to ascertain the range of abnormalities induced in the genital tract of these women. Alteration of the microbial environment, inflammatory, degenerative, reparative and proplastic epithelial changes were the salient cytological findings. The clinical implications of these are briefly discussed.
A cross sectional study to determine the prevalence of hearing loss and hearing impairment was conducted on 286 male subjects from a rural area. The sample was chosen by using a simple random sampling method. Prevalence of symptoms of tinnitus, ear disease, ear drum perforation and infection of external auditory meatus was 19.0 per cent, 6.7 per cent, 3.5 per cent and 0.4 per cent respectively. Air conduction audiometry tests showed the prevalences of hearing impairment of the left, right and both ears (aged 15-30 years) were 5.9%, 8.8% and 0% respectively. The prevalence of hearing loss increased with age. The higher frequencies (> 4KHz) appeared to be more affected than the lower frequencies.
A case of symptomatic polycystic liver disease treated by fenestration and segmental liver resection is reported. The intraoperative use of ultrasound to define the plane of liver resection is emphasised. No significant post-operative complication was encountered. The clinical presentation, management and treatment are discussed.
Vasomotor rhinitis is a common condition in Malaysia. Patients' dissatisfaction with medical treatment of this recurring condition leads them to seek other forms of traditional cures. This paper highlights the complications in such patients who seek traditional cures for their chronic condition.
MeSH terms: Tissue Adhesions; Adult; Chronic Disease; Female; Fibrosis; Follow-Up Studies; Humans; Male; Medicine, Chinese Traditional*; Moxibustion/adverse effects*; Nasal Cavity/injuries*; Nasal Cavity/pathology; Patient Acceptance of Health Care; Recurrence; Rhinitis, Vasomotor/therapy*; Wounds and Injuries/etiology; Wounds and Injuries/pathology; Wounds and Injuries/surgery; Patient Satisfaction
A 7-year old female child was admitted for recurrent bronchopulmonary since one week of life. She was diagnosed to have ventricular septal defect and was treated conservatively. At seven years of life, repeat echocardiogram revealed a large perimembranous ventricular septal defect, absent pulmonary valve with overriding of aorta, narrow pulmonary artery annulus, and dilated main pulmonary artery and its branches. She was treated conservatively, discharged and follow-up at the National Heart Institute Kuala Lumpur, for corrective surgery.
MeSH terms: Child; Cough/etiology; Echocardiography; Failure to Thrive/etiology; Female; Follow-Up Studies; Humans; Pulmonary Valve/abnormalities*; Pulmonary Valve/surgery; Pulmonary Valve/ultrasonography; Respiratory Sounds/etiology; Tetralogy of Fallot/complications*; Tetralogy of Fallot/surgery; Tetralogy of Fallot/ultrasonography*
Three children with cardiac tumors are described: a 12-year-old female child who had left atrial myxoma, and two males having rhabdomyoma of the right ventricle associated with tuberous sclerosis. The child with left atrial myxoma was symptomatic and the tumour was subsequently excised. The other two children with rhabdomyoma were managed conservatively.