Liver disease is an important and serious condition in pregnancy. The Confidential Enquiries Into Maternal Deaths in Malaysia showed that there were 23 maternal deaths attributed to liver disease between 1991-1994. Over the same period, there were 1066 reported maternal deaths with 929 of them being due to direct and indirect causes. Thus 2.15% of such deaths were due to liver disease in Malaysia. The three main causes of maternal deaths due to liver disease in pregnancy were hepatitis (6 cases), acute fatty liver in pregnancy (6 cases) and septicaemia (4 cases). Liver disease is common at a mean of thirty weeks of gestation with a preponderance to women of low parity. Only two patients in this series had no antenatal care. The majority of cases (45.8%) presented between 28-37 weeks of gestation. All cases delivered by spontaneous vaginal delivery. Remediable factors that were identified included failure to appreciate the severity of disease. Case summaries of all the cases of maternal deaths due to liver disease are discussed and a guideline to management of liver disease in pregnancy presented.
MeSH terms: Adult; Cause of Death; Female; Humans; Liver Diseases/ethnology; Liver Diseases/mortality*; Liver Diseases/physiopathology; Malaysia/epidemiology; Maternal Mortality/ethnology; Maternal Mortality/trends*; Pregnancy; Young Adult
Background: Urinary excreton of low molecular weight proteins such as beta2-microglobulin and retinol binding protein (RBP), and enzymes such as N-acetyl-beta-D-glucosaminidase (NAG), may be useful as indicators of renal tubular dysfunction in diabetes mellitus.
Objective: To describe the profile of urinary protein and enzyme excretion in 240 Chinese patients with type 2 diabetes mellitus in Singapore.
Materials and Methodology: Cross-sectional study of consecutive patients presenting for follow-up at a Government primary care clinic. Information was obtained from interview, physical examination and laboratory analysis. Data analysis included descriptive statistics on urinary protein and enzyme excretion, comparison of unadjusted and adjusted means of these among patient subgroups, as well as correlation with control of diabetes and other clinical parameters.
Results: Albuminuria correlated with urine B2-microglobulin (r=0.34, p<0.01) and RBP (r=0.46,p<0.01). hypertensive patients had significantly higher mean urine albumin (geometric mean 15.13mg/gCr) and B2-microglobulin (363.18ug/gCr) levels compared to patients without hypertension (7.07mg/gCR; 219,20ug/gCr; p<0.05). Patients with complications of diabetes also had higher albumin (15.55 vs 6.20mg/gCr), B2-microglobulin (344.47 vs 288.83ug/gCr) and RBP excretion (152.02 vs 94.54mg/gCr). Two-hour postprandial sugar correlated with B2-microglobulin (r=0.33, p<0.01), RBP (r=0.35, p<0.01) and NAG (r=0.28, p<0.01). Urinary protein excretion did not correlate with HbA1c, fasting blood sugar, age of patient or duration since diagnosis.
Conclusion: These results among 240 Chinese patients in Singapore were consistent with reports from other study populations.
MeSH terms: Acetylglucosaminidase/urine; Adult; Aged; Aged, 80 and over; Ambulatory Care Facilities; China/ethnology; Cross-Sectional Studies; Diabetes Mellitus, Type 2/physiopathology*; Enzymes/urine; Female; Humans; Male; Middle Aged; Proteinuria/urine*; Singapore; Renal Insufficiency/diagnosis
One hundred consecutive newly diagnosed patients with nasopharyngeal carcinoma (NPC) since January 1994 were the subjects for studying various factors that contribute to the delay in the confirmation of the diagnosis. Seventy-nine of them were males and the peak age of incidence was the fifth decade. Ninety two percent were Chinese, 7% Malay and 1% Indian. Seventy six percent were agriculture workers or labourers with 66% having either no formal education (16%) or only primary level education (50%). In 50% of patients neck swelling was the first presenting symptom, 26% had nasal symptoms, 12% ear symptoms and 11% has symptoms due to intracranial extension of tumour. As many as 80% were at UICC Stage IV at the time of diagnosis. While the median delay, on the part of patients, in consulting a doctor was 2.5 days, the median delay on the part of the doctors to confirm the diagnosis of NPC was 127 days, the delays was particularly worse when the patients presented with ear symptoms (266 days) followed by those with neck swelling (94 days). For those patients who were required to undergo more than one nasopharyngoscopy and biopsy the median doctor's delay was 144 days. Since 82% of patient's had first consulted general practitioners, it is suggested that their level of awareness with regards to the diagnosis of NPC be significantly raised so that the delay on their part be greatly minimized.
Sixty inpatients with diabetic foot were studied prospectively at the Orthopaedic wards of Hospital Kuala Lumpur. Data was evaluated to document the patient profile and the factors that were associated with a major amputation (either above knee or below knee) of the lower limb. Factors that were associated with increased risk of amputation were a low education level, manual occupation, poor foot care, peripheral vascular insufficiency of the lower limb, insulin dependence, anaemia and leucocytosis. However only anaemia, leucocytosis and hyperglycaemia were statistically significant in predicting a more adverse surgical procedure. This study recommends that foot care awareness and practice is important. This can be effectively dealt with at specially organised, multi disciplinary Diabetic Foot Clinics.
Fifteen cases of insulinoma were managed at HUKM over a period of 20 years. Although all patients presented with neurological symptoms, the diagnosis was delayed in all. Fasting hypoglycaemia and the measurement of C-peptide levels eventually made the diagnosis. Pre-operative localization investigations were not particularly useful. Intraoperative ultrasound (IOUS) detected 72% of the insulinomas, while 93% of the insulinomas were identified intraoperatively by palpation. All the insulinomas were detected intraoperatively with the combination of the two techniques. Twelve of 15 patients had benign adenomas including one patient with MEN-1 syndrome. Two patients had malignant insulinomas. One patient refused surgery. Nine patients underwent pancreatic resections and the remaining 5 patients had the adenomas enucleated.
A prospective analysis of 500 consecutive patients undergoing colonoscopy at the endoscopy unit of Hospital UKM under the care of the surgical unit was analysed. All colonoscopies were supervised by one of two consultant surgeons. The bowel preparation was graded from grade 1 to 4 according to established criteria. All patients had 3 litres of colonic lavage solution as bowel preparation. One hundred and two patients (20.4%) were considered to have poor bowel preparation, while 398 patients (79.6%) had good bowel preparation. Statistically significant factors that resulted in poor bowel preparation included age <20 years and >60 years (p<0.0001), and inpatients (p<0.0193). There was no significant difference in respect to sex, ethnic groups and the indication for colonoscopy. We conclude that young adults and the elderly as well as inpatients are more likely to have a poor bowel preparation using the standard regime.
This paper highlights two cases of paediatric familial hyperlipidaemia (hypercholesterolaemia and hypertriglyceridaemia). The first case was an 11 year old Chinese boy, a "homozygous" (Type II) hypercholesterolaemic patient. He had extremely high blood cholesterol level (19.4 mmol/l), severe multiple xanthoma and abnormal resting electrocardiogram. He had repeated heart attacks and died at the age of 15 in spite of early intervention, treatment and follow up. The second case was a 2 1/2 years old girl who had severe hypertriglyceridaemia. She had raised cholesterol (6.2 mmol/l) and extremely high triglycerides (14.8 mmol/l). The patient did not resemble Type I lipoproteinaemia which is classically seen in childhood. On the contrary, the patient exhibited clinical and biochemical manifestations of a Type V lipoproteinaemia which often occurs in adults. Apart from a Type V lipoprotein pattern, the patient had low post hepatic lipase activity (PHLA), Apo C II and Apo E2/E3 phenotype. In addition, the lipid profile of her family members (both the parents and brothers) had raised triglycerides and thus ruled out the Type I lipoprotein inheritance pattern, which is an autosomal recessive condition. The issue of paediatric hyperlipidaemia, their management and treatments are discussed.
Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. Although uncommon, it should be considered among the list of important opportunistic infections in severely immunocompromised patients. Patients living with AIDS are at particular risk of disseminated histoplasmosis. Diagnosis requires a high level of clinical suspicion. The infection is best confirmed by demonstration of the organism in tissue specimens or by culture. Amphotericin B is the most effective drug for severe disseminated histoplasmosis. Response is good but life-long maintenance is required to prevent relapse.
An asymptomatic subject with radiographic changes due to welders' siderosis is described. This condition has not been well recognized and described in our community. Siderosis of the lung is generally considered to be a benign condition not associated with respiratory symptoms. However, recent reports have associated welding with various disorders of pulmonary function as well as lung cancer. There is a need for future epidemiological studies to better define the risk of long term welding.
A rare combination of a segmental ulnar fracture with fracture dislocation of the head of the radius and intraarticular fracture of the distal radius concomitant with an ipsilateral scaphoid, lunate and coronoid process fractures is presented. The mechanism of injury could possibly be a tremendous impact on the outstretched hand with a dorsiflexed wrist, fracturing the carpal bones and the distal radius. Transmitted axial forces on the ulna in a pronating forearm resulted in the other fractures. To the best of our knowledge, no such case has been reported. Open reduction with screw fixation of the scaphoid, plating of the proximal ulna and Kirschner wiring of the distal radius and radial head dislocation were done.
A neurologically impaired child who had fundoplication and gastrostomy done for gastroesophageal at the age of three, presented two years later with intestinal obstruction. She underwent laparotomy and was found to have antegrade jejuno-jejunal intussusception. Intussusception is an unusual but recognised complication of gastrostomy tube placement.
A case report of adenoid cystic carcinoma of the trachea is presented. A high index of suspicion is required to make the diagnosis of tracheal tumours early since the patients tend to have normal chest radiographs which on closer examination may show an abnormality of the tracheal column. Adenoid cystic carcinoma is the most common malignant tumour of the trachea. Locoregional control of this disease is achieved by a combined modality therapy of surgery and postoperative radiotherapy. Despite this, it still has a prolonged clinical course and the tendency for delayed onset of distant metastases.
Acute promyelocytic leukemia (APL) in pregnancy poses serious danger to both the mother and fetus. Cytotoxic chemotherapy may cause teratogenicity to the fetus. APL is unique because it is usually associated with a coagulopathy that markedly increases the risk for the mother and fetus. A 21 year old lady with APL in her third trimester of pregnancy was treated with oral tretinoin. Tretinoin reversed the coagulopathy and normalised her blood counts without causing cytotoxic damage associated with cancer chemotherapy. Fetal distress occurred at 37 weeks of gestation and an emergency caesarean section was performed without complications and no blood transfusion support was needed as her coagulopathy and thrombocytopenia had resolved. A remission was achieved with only tretinoin induction. She subsequently had consolidation and maintenance chemotherapy. The mother and baby remain well at 4 years from completion of chemotherapy. A total of 10 pregnancies associated with APL have been reported in the current literature. Premature delivery and a fetal arrhythmia were the only complications. Although retinoin is considered teratogenic, its use so far in second and third trimester has been safe.
The obstetric flying squad has been used in obstetric practice since 1933 to manage obstetric emergencies occurring in domicilliary practice. It has often been criticised in such situations as only delaying effective treatment to the patient. We have introduced the obstetric flying squad in an urban setting to cater for obstetric emergencies occurring in private practice. This service has been used on ten occasions since its inception without any maternal deaths being recorded or any delay in the provision of emergency care. The flying squad has led to closer cooperation between the government and private sectors in providing obstetric care.
MeSH terms: Emergency Medical Services*; Female; Humans; Patient Care Team/organization & administration*; Pregnancy; Air Ambulances*; Delivery, Obstetric*
A nutritional status study was carried out among a group of young Chinese adults, aged between 19 and 25, in Kuala Lumpur, Malaysia. Subjects comprised 108 young adults (55 women, 53 men) who were students at two institutes of higher learning. Physical characteristics were evaluated by anthropometric measurements while food intake was determined with a 3-day food record. Blood cholesterol and triglyceride were assessed using the Reflotron analyser. Birthweight was obtained from birth certificates or by proxy. The results showed that the mean body mass index (BMI) for men and women was 21.4 ± 3.3 and 20.0 ± 2.0, respectively, indicating normal weight. Further analysis of BMI classification demonstrated that 28% of men and 39% of women were underweight, 11% of men and 2% of women were overweight while 2% of men were obese. Mean waist-to-hip ratio showed that the subjects had a low risk of developing cardiovascular disease (0.72 ± 0.03 women; 0.81 ± 0.05 men). Mean energy intake was 8841 ± 1756 kJ per day for men and 6426 ± 1567 kJ per day for women. Closer analysis of energy intake of the subjects showed that 86% of men and 91% of women were consuming below the Malaysian recommendation for energy. Nutrients found to be deficient in at least one third of women were calcium, vitamin A, niacin and iron. Mean cholesterol intake in the diet was 278.7 ± 108.7 mg in men and 207.0 ± 82.5 mg in women and there was a significant difference between genders. Blood cholesterol and triglyceride levels were 3.88 ± 0.76 mmol/L and 1.08 ± 0.33 mmol/L, respectively in men, while these levels were lower in women, 3.87 ± 0.80 mmol/L for cholesterol and 0.99 ± 0.29 mmol/L for triglyceride. A general trend of higher mean blood cholesterol and triglyceride levels was shown in adults who were born with lower birthweights.
The present study is unique in the Malaysian context on two counts; first, it employs for the first time a functional group approach (groups based on occupational or economic activity) in the assessment of community nutritional status. Second, the study provides on a nationwide-sampling basis, information on total blood cholesterol (TC) levels in rural children (7.0-12.9 years; n = 1921) and adolescents (13.0-17.9 years; n = 753) which were hitherto unavailable. Total blood cholesterol measurements were performed on 7184 subjects ranging from 7 to 75-years-old (males = 3151; females = 4033) from households in 69 rural villages and seven estates in peninsular Malaysia, which were based on selected multistage random sampling according to the household's involvement in the following economic activities: rice farming, rubber smallholding, coconut smallholding, fishing and employment in estates. In all functional groups, TC values increased with age and there was a distinct gender effect, namely females had higher TC values than males throughout the age spectrum analyzed. Mean TC levels for children and adolescents were in the range 3.85-4.37 mmol/L, rising markedly during adulthood to an overall mean of 4.91 ± 1.13 mmol/L for men and 5.17 ± 1.11 mmol/L for women. In adults (>= 18.0 years), there was marked disparity in mean TC values among the functional groups; males and females from rice households had the lowest mean TC values (4.58 and 4.99 mmol/L, respectively). Individuals at 'high risk' (TC > 6.20 mmol/L) averaged 16.0% in women and 11.6% in men, with women from the fishing, rubber and coconut households particularly affected (17.1-21.1%). When compared to earlier rural TC data reported for closely similar rural communities in the peninsula, the present findings suggest a 'hypercholesterolemic shift' approximating 0.39 mmol/L (15 mg/dL) in the adult population; however, this was not apparent in the children and adolescents from these rural communities.
A cross-sectional nutritional survey was carried out on 350 elderly Malays aged 60 and above from 11 randomly selected villages in a rural area on the east coast of Malaysia. The findings indicated that the mean intakes of energy and of all of the nutrients investigated were below the Malaysian Recommended Dietary Allowances, except for protein and vitamin C. With respect to dietary habits, almost all of the subjects reported that they had breakfast (99.3%), lunch (97.9%) and dinner (90.4%) daily or almost daily (5-6 times/week). However, approximately half of the subjects, especially women, had particular beliefs and prohibitions about specific foods. Most of the subjects usually ate their meals at home, particularly dinner, with 99.3% always having dinner in their own home. Thus, although the rural elderly Malays studied had regular meal intakes, the dietary intake was inadequate. There is a need to plan community-based intervention programmes in order to prevent the subsequent consequences of malnutrition that lead to increased morbidity and mortality.