IIUM Medical Journal Malaysia (IMJM)
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The Perils of Haemorrhoids Treatment
Get PDFTreating problematic haemorrhoids has taken a long turmoil route. Its peak incidence is among 45 to 65 years of age group. Typically, problematic haemorrhoids present in multi-symptoms forms like a prolapsed lump, painless bleeding, discomfort, soiling, or itchiness. Many theories were postulated in the pathophysiology of symptomatic haemorrhoids. The sliding and engorged of anal cushion with hypervascularity is the most popular. This is an updated review of published English-language literature regarding the treatment of haemorrhoids. The treatment includes medical therapy, office procedures, and surgical operations. Merits and demerits of the different modalities of treatment of haemorrhoids are presented. The best treatment options are difficult to ascertain. It should be tailored to individualize treatment according to their presentation and severity. Up till recently, the excisional haemorrhoidectomies are considered the standard procedure for haemorrhoid treatment. These techniques produce significant post-operative pain to the patient, which hinders them from normal daily activity. Recent advancement in surgical intervention has focused on minimising severity of pain and enhances recovery
Trauma to a Hepatoblastoma: A Case Report
Get PDFWe are reporting a case of previously undiagnosed hepatoblastoma in a healthy child, who presented acutely in a post-traumatic setting. We reported a 7-year-old boy, with no previous medical history, presented with gradual worsening abdominal pain following an episode of trivial trauma to the abdomen two weeks prior. He was anaemic at presentation, and had a distended abdomen with a tender enlarged liver. Computed tomography (CT) of the abdomen showed a grossly enlarged left lobe of the liver, within which was an organized hematoma. Serum alphafetoprotein (α-FP) was raised significantly. The liver injury was managed conservatively and the child recovered well. He is set to undergo staging scans and further workup, in anticipation of subsequent systemic therapy. Though exceedingly unlikely in older children, the diagnosis of hepatoblastoma should be entertained in those with an enlarged liver with a clinical presentation masquerading as a ‘straightforward’ liver injury
Traumatic Diaphragmatic Hernia
Get PDFTraumatic diaphragmatic hernia (TDH) is uncommon and it can be a result from both blunt and penetrating trauma. About to 1% to 7% of patients with blunt trauma sustained TDH. Left sided traumatic diaphragmatic hernia are much common compared to right side.TDH can present acutely or delayed with signs of respiratory distress of intestinal obstruction. The diagnosis was made with the aid of chest radiograph and computed topography (CT) abdomen. A coiled nasogastric tube within the hemithorax is a pathognomonic for TDH. We are presenting a case of high impact injury resulting in a TDH in a 19-year-old, malay male with unsure mechanism injury. He presented with generalised abdominal pain and in respiratory distress with a clinical evidence of abdominal tenderness and type 1 respiratory failure. Subsequently, he underwent exploratory laparotomy and repair of left diaphragmatic hernia. Intraoperatively, noted large linear tear of left hemidiaphragm posterolaterally extending medially until the insertion of falciform ligament. Stomach, left lobe of liver, spleen and splenic flexure of colon were herniated into the left hemithorax. The left diaphragmatic tear was repaired in 2 layers using prolene. A left subdiaphgramatic drain and a chest tube were inserted. Post operatively, the patient was nursed in ICU and recovered well. Repeated chest x -ray showed left lung was fully expanded. With aggressive chest physiotherapy and incentive spirometry, he recovered well and was discharged home. In trauma, there should be a high index of suspicion in patients with both respiratory and abdominal symptoms. Conclusion: Prompt recognition and early definitive management can improve patient outcomes
Psychosocial Distress and Blood Pressure among Young Adults: Role of Cortisol as Mediator
Get PDFIntroduction: Hypertension is the most prevalent risk factor of cardiovascular diseases in Malaysia. 17.3% of hypertension cases in Malaysia is attributed to adults aged 18 to 39 years. Psychosocial distress is a possible risk factor for elevated blood pressure in young adults, and cortisol could be the mediating factor. The aim of this study is to evaluate the mediating role of cortisol in hypertension and psychosocial distress in young adults. Methods and materials: A comparative cross-sectional study was conducted in 240 young adults aged 18 to 45 years. The body mass index, waist circumference and blood pressure parameters were recorded. Serum cortisol, creatinine, fasting blood glucose and lipid profile were measured following acute mental stress test. Psychosocial distress was assessed using the DASS-21 questionnaire. Results: Mean (standard deviation) values for SBP, DBP, MAP were 126.0(16.3), 84.1(12.2) and 98.1(13.1) mmHg respectively. Anxiety was significantly associated with systolic blood pressure (β=0.644), diastolic blood pressure (β=0.454) and mean arterial pressure (β=0.516) after adjusting for sex, age and cortisol. However, it was not mediated by cortisol. Depression and stress were not found to have any effect on blood pressure of the young adults studied. Conclusion: The data suggest that there is no elevated risk for psychosocial distress and hypertension that cortisol poses in young adults
Seronegative Occult Hepatitis C Virus Infection (OCI) in a Main Haemodialysis Centre In Pahang, Malaysia
Get PDFIntroduction: Occult HCV infection has a predilection for specific populations such as haemodialysis (HD) patients. The exact natural course, epidemiology, pathogenesis and clinical importance of OCI are unknown. We investigated the existence of OCI among local patients undergoing routine HD at a referral hospital in Pahang, Malaysia. Methods: Serum and peripheral blood mononuclear cells (PMBCs) were collected from peripheral venous blood samples of seropositive (anti-HCV positive) and seronegative (anti-HCV negative) HD patients as well as healthy individuals (negative control group). Inclusion criteria for the seronegative patients included elevated liver enzymes. Both conventional PCR and strand-specific PCR were used to detect the viral RNA and to indicate active viral replication in PBMCs respectively. Direct DNA sequencing was done to confirm the viral HCV RNA and their genotypes. Results: In the majority (90-100%) of seropositive chronic hepatitis C patients, viral RNA was detected in both serum and PMBCs . Meanwhile, out of 22 seronegative patients, 6 (27%) showed active viral replication in PBMCs but no detectable viral RNA presence in the serum. None of the negative control group had detectable viral RNA. All seronegative patients with OCI were infected with HCV genotype 3 and two of them (2/6) had a slight elevation of their liver enzymes. Conclusion: Seronegative OCI does exist among local hemodialysis patients, with normal or persistently abnormal liver enzyme values. Further investigation is needed to study the mode of viral transmission and clinical significance of OCI in HD setting
Can FMA (Noise) 1989 Prevent Occupational NoiseInduced Hearing Loss? An Evaluation using Fault Tree Analysis
Get PDFIntroduction: Factory and Machinery Act (Noise Exposure) Regulation 1989 (FMA [Noise] 1989) has been implemented in Malaysia for nearly 30 years, but noise-induced hearing loss (NIHL) cases is still rising. Fault tree analysis is a top-down approach to analyzing incidences of 'failures', starting with establishing the single top event that will eventually cause NIHL, followed by identification of the contributing factors to the top event which are the immediate or basic events. Through its visual, structural and deductive approach; FTA is able to depict the temporal sequence of events and their interactions in a formal and logical hierarchy. Materials and Methods: Employees with permanent standard threshold shifts (PSTS) underwent further assessment confirming the presence of NIHL. A single common fault tree was constructed based on six cases of PSTS. The top event is the PSTS. Intermediate and basic events were identified and mapped with relevance to the provisions in the FMA (noise) 1989 indicating how failed control measures have resulted in the PSTS cases. Results: The constructed fault tree with its branches illustrated how breach or noncompliance of FMA (Noise) 1989 resulted in the eventual top event (NIHL). Conclusion: FTA provides a standardized perspective of errors within the system in preventing NIHL
Degloving Penile Injury with Urethral Avulsion: A Case Report
Get PDFAccidental male genital injuries represent a serious urological disorder that demands immediate urological treatment due to risk of infection and need for fertility preservation. We reported a 30- year-old gentleman who presented with an extensive penile degloving injury, right open pneumothorax and right thigh laceration following a buffalo attack. Examination under anesthesia (EUA) demonstrated ruptured penis with tearing up to penile base and partially avulsed right testis. Right orchidectomy, wound debridement and suprapubic catheter insertion performed before being referred to Penang General Hospital. Repeated EUA revealed avulsed penile urethra 3cm from the meatus with interposing granulation tissue of 2cm in length. He underwent serial wound debridement and eventually required a split skin graft to the penis. Patient was reported to be able to achieve penile erection by 2 months post-operative and planned for urethroplasty later. This is the first paper that reports an incident of buffalo attack resulting in degloving injury of penis. Management depends on severity of trauma and prompt intervention essential to prevent immediate as well as delayed complication. Urethral injury must be considered in any extensive penile injury. Despite multiple modality for traumatic penile skin loss repair, split thickness skin grafting (SSG) was chosen for this patient. Conclusion: External injuries of the genitals, particularly caused by animal attack, should be followed by immediate operative exploration and if necessary, to reparative measures. Care must be taken with goal of optimizing long term sexual, cosmetic and voiding outcomes
Intra-Abdominal Solid Organ Injury Management in Pediatrics
Get PDFAbdominal trauma is relatively uncommon in children but can leads to a significant morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children. We are reporting a case of a child with multiple solid organ injury that was successfully treated non-operatively at our center. We presented a previously healthy 9-month-old girl, presented with fluctuating GCS secondary to motor vehicle accident with borderline hemodynamic stability. She was intubated, blood transfusion commenced and a single inotrope support started. She subsequently diagnosed with grade III liver injury, grade II splenic injury, right grade IV renal injury with large perinephric and retroperitoneal hematoma and moderate hemoperitoneum, a non-displaced left superior pubic rami fracture and cerebral edema on computed tomography (CT). She was admitted to pediatric intensive care unit (PICU). Her intra-abdominal injury injuries were successfully treated conservatively. She required a right chest tube on post trauma day 2, for right hemothorax. The chest tube was removed 3 days later following adequate drainage. She eventually was weaned off from ventilator on post trauma day 11. Feeding was commenced on day 7 of post trauma. She was discharge home well after 3 weeks post trauma with periodical follow up. Conclusion: Pediatric intra-abdominal solid organ injury is relatively uncommon, but a potential source of significant morbidity. Non-operative management is the standard of care for the majority of these injuries, which have shown successful rate more than 95%, although continued hemodynamic instability mandates operative intervention
Primary Breast Sarcoma in a Middle Age Lady: A Rare Presentation
Get PDFSarcoma is an aggressive, malignant condition of a breast. It is a rare condition, which makes it difficult to diagnose at clinicopathological study. We are reporting a case of a primary breast sarcoma in a 54-year-old menopausal lady that came with painless fast growing right breast lump within 6 months of duration. Clinically, there was a huge mobile painless right breast lump without discoloration of skin noted. Both axilla and supraclavicular lymph node were not palpable. A mammogram showed large lobulated dense mass 8.3cm x 10.0cm in size occupying right upper outer quadrant correspond to BIRADS 4 lesion. A trucut biopsy reported as a papillary lesion. Repeated trucut biopsy reported as mesenchymal lesion with smooth muscle differentiation. With this histopathology report, she was diagnosed with mesenchymal tumor of right breast. She underwent an uneventful mastectomy. Histopathological examination of the surgical specimen reported as tumor with mesenchymal differentiation which requiring further confirmation by breast-endocrine pathologist as primary breast sarcoma. She was subjected to post op radiotherapy to the chest wall followed by adjuvant chemotherapy
Phenotypic and Genotypic Characterization, and Detection of PVL Encoding Gene in Methicillin Resistant Staphylococcus Aureus Strains Isolated From Patients Admitted to a Tertiary Hospital In Kuantan, Malaysia
Get PDFIntroduction: Methicillin-resistant Staphylococcus aureus is globally a major public health threat. Resistance to methicillin originates from a modified protein (PBP2a) encoded by the mecA gene. The PVL gene as an important virulence factor increases the pathogenicity of MRSA. Epidemiology and characteristics of MRSA differ in different geographical regions. This study was conducted to characterize and determine the antibiotic susceptibility profile of MRSA strains isolated from patients in Hospital Tengku Ampuan Afzan, Pahang, Malaysia and to detect the presence of the mecA and PVL genes in the isolates. Materials and methods: In this study a total of 36 isolates of MRSA have been collected during a period of three months (1stFebruary –30thApril 2018). The susceptibility pattern of the isolates to ten different commonly used antibiotics were determined and the target genes were addressed by real-time PCR experiment. Results: Based on the identifying criteria, 44.4% of the isolates were CA-MRSA, and 55.5% were HA-MRSA. Resistance to oxacillin, cefoxitin and penicillin was 100%, gentamicin 88.8%, erythromycin 33.3%, tetracycline 77.7%, trimethoprim-sulfamethoxazole 61.1%, clindamycin 13.8%, chloramphenicol 11.1%, but no resistant strain of vancomycin was detected. Most of the isolates were resistant to more than three groups of antibiotics. Realtime PCR revealed that all the isolates were mecA positive and 4 isolates were PVL-positive. PVL-positive strains were CA-MRSA and susceptible to clindamycin. Conclusion: The study confirms multi-drug resistant MRSA in the study area, and shows that resistance to methicillin is mecA mediated. PVL carrier strains were present and related to CA-MRSA strains of the isolates