for Journals by Title or ISSN
for Articles by Keywords

Publisher: Universiti Kebangsaan Malaysia   (Total: 11 journals)   [Sort by number of followers]

Showing 1 - 11 of 11 Journals sorted alphabetically
3L : Language, Linguistics, Literature     Open Access   (Followers: 26, SJR: 0.251, CiteScore: 0)
Akademika : J. of Southeast Asia Social Sciences and Humanities     Open Access   (Followers: 7)
Asia-Pacific J. of Information Technology and Multimedia     Open Access   (Followers: 1)
Asian J. of Accounting and Governance     Open Access   (Followers: 3)
GEMA OnlineĀ® J. of Language Studies     Open Access   (Followers: 1, SJR: 0.306, CiteScore: 1)
Islamiyyat : The Intl. J. of Islamic Studies     Open Access   (Followers: 1)
J. of Surgical Academia     Open Access   (Followers: 1)
Jurnal Ekonomi Malaysia     Open Access   (Followers: 4, SJR: 0.184, CiteScore: 0)
Jurnal Hadhari : An Intl. J.     Open Access   (Followers: 2)
Jurnal Melayu     Open Access   (Followers: 2)
Jurnal Pendidikan Malaysia     Open Access   (Followers: 1)
Journal Cover
Journal of Surgical Academia
Number of Followers: 1  

  This is an Open Access Journal Open Access journal
ISSN (Print) 2231-7481
Published by Universiti Kebangsaan Malaysia Homepage  [11 journals]
  • Recurrent Orbital Cellulitis Secondary to the ‘Forgotten’
           Scleral Buckle: A Case Report

    • Authors: ahlina
      Abstract: Author(s):  Hor SM Noor Aniah A Mushawiahti M Malisa A Bastion MLC Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Mae-Lynn Catherine Bastion. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457207 Fax: +603-91456733 E-mail: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Scleral buckling with exoplant has been an effective method in treating primary rhegmatogenous retinal detachment for more than 50 years (1). Long-term complications include induced myopia, diplopia, strabismus, foreign body sensation, infection, extrusion, intrusion, anterior segment, retinal and choroidal ischaemia (1,2). Complications may present years after surgery with different clinical manifestation (1). Infection of scleral buckle remains a significant complication and can results in orbital infection. Almost all cases are resistant to antimicrobial treatment and removal of buckling elements is required for resolution (3). Anterior segment necrosis is another serious complication of scleral buckle. Wilson et al reported up to 8.2% of eyes had anterior segment necrosis while performing post mortem in eyes with scleral buckle (4).</p> <p> &nbsp;</p> <p> In this case report, we describe a case of recurrent orbital cellulitis with anterior segment ischemia induced by a forgotten and missed silicone scleral tire from previous retinal detachment surgery.&nbsp;</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> An 85-year-old woman presented with one-day history of recurrent painless eye redness, yellowish discharge and swelling of the left eye associated with one-month history of blurred vision. She was treated for left orbital cellulitis, &lsquo;choroidal detachment&rsquo; and was investigated for possible underlying malignancy in another eye center one month prior to presentation.</p> <p> &nbsp;</p></div><p> &nbsp;</p><div> <p align="center"> <img height="140" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="551" /></p> <p> &nbsp;</p> <p> <strong>Figure 1</strong>: a) Anterior segment photograph of the left eye at presentation. Left conjunctiva was injected, chemosed with corneal vascularization nasally. Mucopurulent discharge with left lower lid entropion were noted. Pupil was rigid and could not be dilated beyond the size shown in the photograph; b) Rubeosis iridis was seen in left eye at the pupil margin in this slit anterior segment photograph during presentation; c) Conjunctiva injection and rubeosis iridis of left eye improved one week after removal of scleral buckle with intracameral ranibizumab.</p> <p> &nbsp;</p> <p align="center"> <img height="277" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="385" /></p> <p> &nbsp;</p> <p> <strong>Figure 2</strong>: a) Hyperechoic scleral buckle indenting the globe with vitreous opacity; b) Axial and coronal view computed tomography of the orbit showed hyperdense structures (scleral buckle, arrow) encircling both globes with right pthisical bulbi; c) Encircling scleral buckle (silicone tire with Watzke sleeve) which was removed and sent for culture.</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> She had underlying diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease and dementia. Cataract extraction was done in both eyes 15 years ago. Her right eye was blind which her family members were unsure of the cause. They were unable to provide any other past ocular or surgical history.</p><p> &nbsp;</p><p> Ocular examination revealed her right vision was no perception to light and left vision was hand movement. Her right eye was pthisical. The left eyelids were swollen with lower lid entropion and mucopurulent discharge (Fig. 1a). The conjunctiva was injected, cornea was hazy, rubeosis iridis was seen with anterior chamber cells of 3+ (moderate inflammation in between the cornea and iris). Pupil was rigid with maximum dilatation of 3 mm (Fig. 1b). Le...
      PubDate: Fri, 24 Nov 2017 03:42:51 +000
  • Antenatal Myomectomy: Is It Safe'

    • Authors: ahlina
      Abstract: Author(s):  Nor Amirawati A Anizah A Shafiee MN Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Anizah Ali. Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +60391455960 Fax: +603-91456672 Email: Myomectomy is rarely performed in pregnancy due to risk of miscarriage or pregnancy loss, bleeding and possible hysterectomy. Myomectomy is mainly reserved for unavoidable indications such as rapidly growing fibroid or severe pain with possiblity of red degeneration for which medical treatment failed. However, good outcome had been reported in selective second trimester myomectomies. Full text:  <p> <strong>Introduction</strong></p><p> &nbsp;</p><p> The prevalence of leiomyomas during pregnancy varies from 0.3 to 15% (1). Leiomyomas mostly remains asymptomatic during pregnancy but in 10% of cases, it causes obstetric complications depending on their size, location, and number (2). Pain is the most common symptom reported however it rarely necessitates myomectomy (3). To date, limited literature exists to serve as reference with regards myomectomy in pregnancy. Available literatures are mainly restricted to case reports and retrospective studies. As such, a surgical approach is usually reserved for cases of intractable abdominal pain or persistent gastroenteric and urinary symptoms despite pharmacological treatment (4-6). Majority of the reported myomectomies were performed in second trimester for intractable pelvic pain and had excellent results. We are reporting two cases of unavoidable myomectomies in second trimester with good outcome throughout the pregnancy (7,8).</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> <em>Case 1</em></p><p> &nbsp;</p><p> A 28-year old primigravida presented with severe right iliac fossa pain and mass per abdomen at 13 weeks and 5 days period of amenorrheoa. She experienced it for 2 days prior to presentation. She had sudden onset of pain with pain score of 7/10. There were no aggravating factors and the pain was not radiating. She was unable to sit up for a long time and thus affected her daily activities. Otherwise, there were no urinary or bowel symptoms.</p><p> &nbsp;</p><p> Assessment revealed that she was in pain and distressed. She was tachycardic but remained stable and a febrile. Abdomen was soft but tender with voluntary guarding. Uterus was palpable at 16 weeks size with a right iliac fossa mass measuring 6x6 cm. The mass has normal overlying skin, regular border, firm in consistency and mobile side to side but unable</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> to get below the mass. Vaginal examination revealed normal vulva and vagina, cervix was tubular and os closed. Uterus was at 16 weeks size bimanually and mass was attached to uterus. Other systems were unremarkable.</p><p> &nbsp;</p><p> Investigations showed she had normochromic normocytic anaemia with haemoglobin of 10.8 g/dL, white cell count was normal 7.8x109/L and normal platelet level. A pedunculated fibroid which measured 6.8x6.6cm was seen on transabdominal ultrasound. There were no complex appearance or cystic changes noted. Fetus was viable with parameters corresponded to her gestational age and placenta was posterior not low lying.</p><p> &nbsp;</p><p> Diagnosis of penduculated uterine fibroid was made. She was treated with regular intravenous opiods. However, despite adequate analgesia, her pain score was not reduced. She was then subjected for emergency laparotomy myomectomy due to intractable pain having failed medical management. Upon entry to her pelvis, uterus was noted to be enlarged to 16 weeks size with a subserosal fibroid at right posterolateral wall (Fig. 1). It measured 6 x 8cm and had paper thin stretched subserosal layer covering the tumour. Myomectomy procedure was uneventful, uterine incision was closed with vicryl 1/0. Hemostatic agent also was placed at incision site and estimated blood loss was only 200ml. Symptoms markedly improved post-operatively and she was discharged home the subsequent day. Histopathology report showed interlacing fibers of smooth muscle with spindle shaped cells, bland looking and elongated nuclei with abundant eosinophilic cytoplasm. There were also dilated and congested blood vessels ...
      PubDate: Fri, 24 Nov 2017 03:32:39 +000
  • A Dilemma in Management of Intrauterine Death in Mother with Major
           Placenta Previa

    • Authors: ahlina
      Abstract: Author(s):  Rima Anggrena D Yulianty A Nor Azlin MI Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Rima Anggrena Dasrilsyah. Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455949 Fax: +603 91456672 E-mail: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Placenta previa is a condition when the placental tissue extends over the internal cervical os. Its incidence ranged from 3.5-4.6 per 1000 birth and contributed by combination of factors due to rising number of caesarian sections and increasing maternal age (1,2,3). Placenta previa is associated with maternal and fetal morbidity and mortality. The management is complicated, especially when deals with intrauterine death. It is indeed a challenge in decision making of its management for the best interest of patient and the unborn fetus.</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 30-years-old housewife, gravida 3 para 2 at 33 weeks gestation with underlying gestational diabetes mellitus on diet modification with history of two spontaneous vertex deliveries, was diagnosed with placenta previa major at 28 weeks period of amenorrhea. She never had any per vaginal bleeding or abdominal pain. Unfortunately, at 29 weeks gestation, she was diagnosed with intrauterine death and opted for conservative management with weekly full blood count and coagulation profile.</p> <p> &nbsp;</p> <p> She remained well until 33 weeks gestation when she presented to emergency department with increased vaginal bleeding. On assessment, she was pale, her blood pressure was 132/74mmHg, pulse rate of 114 beats/minute and afebrile. Abdominal examination was soft and non-tender, uterus of 28 weeks size, singleton, longitudinal lie and cephalic presentation five fifth palpable. Speculum examination showed blood clots with cervical os open. Vaginal examination revealed cervical os of 3cm with bulging membrane and placental edge felt.</p> <p> &nbsp;</p> <p> She was admitted and given epidural. The labour was augmented and cervical os was fully dilated after three hours. She was encouraged to bear down after artificial rupture of membrane. However, as anticipated, there was no descend of fetal head due to placenta. In view of increased vaginal bleeding with clots, attending specialist decided to remove the placenta manually</p></div><p> &nbsp;</p><div> &nbsp;</div><p> &nbsp;</p><p> followed by delivery of the fetus.&nbsp; The placenta was removed in one piece and no true knot noted at the umbilical cord. Intravenous carbetocin was given and uterus contracted 20 weeks size. Perineum was intact and no active bleeding. The estimated blood loss was 1000ml.</p><p> &nbsp;</p><p> Patient delivered a macerated baby girl weighing 1.42kg. There was no gross abnormality seen.&nbsp; The histopathology result of the placenta sent showed uteroplacental insufficiency with placenta infarction and atheroma. There was no growth in placental swab culture.</p><p> &nbsp;</p><p> <strong>Discussion</strong></p><p> &nbsp;</p><p> There are only small numbers of reported cases of intrauterine death with placenta previa. These patients were managed differently depending on case to case basis. To date there is still no general consensus the best way to manage such cases. However, in general, placenta previa with fetal death can be managed in 3 main ways.</p><p> &nbsp;</p><p> Approximately about 85% women with intrauterine death will deliver spontaneously within 3 weeks of diagnosis (4). Theoretically, uteroplacental blood perfusion will decrease causing placental atrophy. Thus, it can reduce the blood loss during vaginal delivery (5). Unfortunately, expectant management could have disadvantages as 10% of patient may develop DIVC within one month after fetal demise (6). Therefore, women who delay in labour for periods longer than 48 hours should be advised to have DIVC testing twice weekly (2). Risk of intrauterine infection will also increase in time. Furthermore, keeping dead baby can lead to psychological stress to the mother. A Sweedish study in 1996 shows in interval of 24 hours or more from the diagnosis of death in utero to start of labour, there is increase of moderately severe anxiety or worse (7).</p><p> &nbsp;</p><p>...
      PubDate: Fri, 24 Nov 2017 03:24:58 +000
  • First Trimester Placenta Accreta: A Rare Clinical Entity and Diagnostic

    • Authors: ahlina
      Abstract: Author(s):  Ng BK Wang PY Ng WYL Mohammed F Lim PS Mahdy ZA Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Ng Beng Kwang. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455949 Fax: +603-91456672 E-mail:, Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Morbidly adherent placenta (MAP) or abnormally invasive placenta (AIP) is a potential life-threatening emergency that might lead to significant morbidity and mortality (1). It occurs in 1.32-3.27/ 1000 pregnancies and the incidence have been rising particularly with the increasing trend of caesarean sections (2,3). AIP in the first trimester is rare and more challenging due to difficulty in diagnosis (4). Therefore, most of the cases of first trimester AIP were diagnosed intra-operatively while performing surgical evacuation for miscarriages (5). We report a case of an incidental finding of placenta accreta during evacuation of product of conception (ERPOC) for missed miscarriage. Intra-operatively this was complicated with excessive bleeding requiring hysterectomy and bilateral internal iliac artery ligation.</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 33-year-old Gravida 4 Para 2 + 1 at 15 weeks 3 days period of amenorrhea (POA) was electively admitted for ERPOC. She had a history of surgical evacuation for incomplete miscarriage at 11 weeks of gestation and a previous lower segment caesarean section for oblique lie. She was diagnosed to have a missed miscarriage at 12 weeks POA. Trans-vaginal scan showed an intrauterine pregnancy with a fetal pole measuring 9.6 mm without fetal cardiac activity (Fig. 1). She was then admitted at 14 weeks for medical management. Misoprostol 400mg was given twice per vaginally but was unsuccessful. She opted for surgical evacuation after a week of rest.</p> <p> &nbsp;</p> <p> Intra-operatively, uterus was 8 weeks&rsquo; size and anteverted. During evacuation, there was profuse</p></div><p> &nbsp;</p><div> &nbsp;</div><p> &nbsp;</p><div> <p> vaginal bleeding after 20 cc of product of conception was removed. A decision was made for an exploratory laparotomy and hysterectomy with bilateral internal iliac ligation in view of persistent bleeding. Total estimated blood loss was 6.2 liters. She was transfused with 9 units of packed cells, 4 unit of fresh frozen plasma, 8 unit of platelet and 12 units of cryoprecipitate.&nbsp; She was nursed in the intensive care unit for 2 days without the need of inotropic support. She was discharged well on day 4 post-operatively. Histopathological examination showed products of conception confirmed with evidence of placenta accreta (Fig.2).</p> <p> &nbsp;</p> <p> <strong>Discussion</strong></p> <p> &nbsp;</p> <p> Three degrees of abnormal placental adherence can be distinguished i.e. accreta (superficial invasion), increta (invasion deeper into myometrium) and percreta (invasion into or through the uterine wall); due to a defect in the decidua basalis (6). Predisposing factors include advanced maternal age, multiparity, history of uterine surgery such as caesarean section, uterine curettage or myomectomy (2,3,7). With the advancement in radiological imaging, the diagnosis of AIP can usually be established prenatally between 18-37 weeks (7). However, diagnosis of AIP during first trimester remains challenging as typical findings of AIP might not be present and there may be a low index of suspicion as in this case.</p> <p> &nbsp;</p> <p> Several reports have described the use of ultrasonography in the first trimester to detect AIP. Presence of a well-vascularised hyperechoic lesion, loss of endometrium-myometrium interface, low resistive index and myometrium thinning near the lesion are all suggestive of AIP (6). A study by Rac et al. demonstrated that smaller anterior myometrial thickness measured in the sagittal plane significantly<br clear="all" /> improved prediction of placental invasion; whereas, distance from the gestational sac to the external os, location of the decidual basalis, presence of anechoic areas and uterine-bladder interface irregularity did not (8). Thi...
      PubDate: Fri, 24 Nov 2017 03:20:25 +000
  • Colonic Metastasis from an Invasive Lobular Carcinoma of the Breast

    • Authors: ahlina
      Abstract: Author(s):  norfaidhi akram MN Samuel T Norly S Ros’aini P Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Norfaidhi Akram Mat Nor. Department of Surgery, Hospital Pakar Sultanah Fatimah, Jalan Salleh, 84000 Muar, Johor, Malaysia. Tel: 00-60-17-6886756 Fax: 00-60-6-9526003 E-mail: Breast carcinoma to the colon and rectum is rare type of metastatic spread. We report a case of colonic metastasis from a lobular carcinoma of the breast twelve years after the initial diagnosis. Accurate diagnosis and early treatment of systemic therapy can be done if awareness is increased. Full text:  <p> <strong>Introduction</strong></p><p> &nbsp;</p><p> Regardless of sex in Malaysia, most common cancer is breast cancer (1).&nbsp; The two most common histologic types of breast cancer are invasive ductal and lobular carcinoma. Breast cancers typically metastasize to the lungs, liver and bones. In patients with disseminated disease, few reports of colonic metastasis from breast cancer can be found (2). The risk of developing metastasis is there despite long disease free interval (3). In the present study we report a case of colonic metastasis from a lobular carcinoma of the breast twelve years after the initial diagnosis.</p><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> A 60-years-old lady was diagnosed with left breast invasive lobular carcinoma 12 years prior to current presentation.&nbsp; She underwent a left modified radical mastectomy with level II axillary clearance, followed by 6 cycles of chemotherapy and 15 cycles of radiotherapy.&nbsp; She also completed 5 years of hormonal therapy (tamoxifen).&nbsp; Four years ago she developed metastasis to both her ovaries.&nbsp; She was then subjected to a total abdominal hysterectomy with bilateral salpingo-oopherectomy and omentectomy.&nbsp; Following that she had another 6 cycles of chemotherapy (Doxetaxel).&nbsp; She had been well until September 2016 when she developed lower abdominal pain.&nbsp; A contrast enhanced computed tomography scan of the thorax, abdomen and pelvis revealed a long segment wall thickening involving the whole of the large bowel.&nbsp; A colonoscopy examination was done and it showed inflammed mucosa up to 20 cm from the anal verge.&nbsp; The biopsy of the colon revealed metastatic lobular breast carcinoma (Fig. 1). Following she underwent six cycles of CMF (cyclophosphamide, methotrexate, 5-flurouracil).&nbsp; Currently, she is asymptomatic from the colonic point of view at the moment.&nbsp; Literature review on the management of colonic metastasis from the breast was done and discussed.</p><p> &nbsp;</p><p> <strong>Discussion</strong></p><p> &nbsp;</p><p> Among all breast adenocarcinomas, lobular carcinoma accounts for only 8-14%.&nbsp; The metastatic pattern of lobular carcinoma is more towards unusual locations such as gastrointestinal tract, gynaecological organs and peritoneum. A PubMed review revealed a narrowed number of reports of breast cancer with metastatic spread to the colon and rectum (less than 50 cases).&nbsp;&nbsp;</p><p> &nbsp;</p><p> In reported literature, the duration from the diagnosis of breast cancer to presentation of gastrointestinal metastasis ranged from synchronous presentation to 26 years after the initial diagnosis (4). Our patient presented 12 years after the initial diagnosis. The<br clear="all" /> <img height="219" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 1</strong>: Hematoxylin and eosin stain at 200x magnification showed light microscopy image showing malignant tumour cells dispersed throughout lamina propria of large intestine (yellow arrow), some of which were present in a simple file strands. The image showed fragments of colonic mucosa with no ulcer of dysplasia (red arrow). In further studies, the malignant cells are positive for CK7 and ER (3+, in 90% cells). They are negative for CK20, PR, leucocyte common antigen, TTF-1 and e-cadherin.</p><p> &nbsp;</p><p> clinical presentation is varied and non-specific.&nbsp; It is difficult to differentiate metastatic breast to colon from a primary colon or rectal cancer.&nbsp; This can make the diagnosis difficult and often unexpected.&nbsp; It may also lead to inappropriate management and chemotherapy regime.<...
      PubDate: Fri, 24 Nov 2017 03:08:32 +000
  • Lupus Nephritis with Visual Field Defect Secondary to Hypertensive
           Retinopathy: A Case Report

    • Authors: ahlina
      Abstract: Author(s):  Hor SM Norshamsiah MD Mushawiahti M Hazlita MI Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Norshamsiah Md Din. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457207 Fax: +603-91456733 Email: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Systemic lupus erythematosus (SLE) is an autoimmune disease with a wide range of clinical manifestation which can affect any organ in the body (1). Secondary malignant hypertension resulting from renal parenchymal lesion is part of the disease entity. Malignant hypertension may affect the eye in various ways but grade III or IV hypertensive retinopathy with ischemic retinal injury can be visually disabling. Cotton wool spots seen in grade III and IV hypertensive retinopathy indicates microinfarction of the retinal nerve fibers and neuronal loss which can<br clear="all" /> results in subsequent related scotoma (2). Hereby, we describe a case of lupus nephritis with grade 4 hypertensive retinopathy presenting with multiple peripapillary cotton wool spots which eventually causes permanent visual field defect. &nbsp;&nbsp;</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. The past medical and family history were insignificant.</p> <p> &nbsp;</p></div><p> &nbsp;</p><div> <p align="center"> <img height="506" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="478" /></p> <p align="center"> &nbsp;</p> <p> <strong>Figure 1</strong>: a) Optic disc photo taken in year 2011 showed hypertensive retinopathy as evidenced by hyperemic swollen disc, extensive peripapillary cotton wool spots and flame shape haemorrhages; b) Optic disc photo taken in 2016 showed pink optic disc with cup/disc ratio 0.3, no neuroretinal rim thinning, scant gliosis more on right eye; c) OCT RNFL showed thinning of bilateral temporal quadrant, right nasal quadrant and left infero-nasal quadrant.</p> <p> &nbsp;</p></div><p> &nbsp;</p><div> <p> Ocular examination showed that visual acuity on the right was 6/60 and left 6/24. There was no relative afferent pupillary defect. Anterior segment and intraocular pressure were normal. Fundoscopic examination showed bilateral optic disc swelling with blurred disc margin, extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortous vessels and macular oedema (Fig. 1a). Systemic examination showed blood pressure of 176/111 mmHg, malar rash, discoid rash over the scalp, alopecia and vasculitic lesions over her palms.</p> <p> &nbsp;</p> <p> The blood investigation showed positive ANA/dsDNA, low C3/C4, macrocytic anemia with positive direct coomb&rsquo;s test and raised reticulocyte count. Urinalysis showed proteinuria with microscopic haematuria and renal biopsy revealed diffuse active proliferative and membranous lupus nephritis (WHO class IV &amp; V) with 56% cellular crescent. Otherwise, the renal function test was normal and computed tomography (CT) of the brain did not show features of posterior reversible encephalopathy syndrome (PRES).</p> <p> A diagnosis of SLE with grade IV hypertensive retinopathy secondary to lupus nephritis, autoimmune hemolytic anemia and discoid lupus was made. She was treated with intravenous (IV) methylprednisolone, double-filtration plamapheresis with IV immunoglobulin and IV cyclophosphamide. Subsequently, the prednisolone was tapered off and she was maintained on HCQ 200mg daily.</p> <p> &nbsp;</p> <p> She was seen in Ophthalmology clinic for screening of hydroxychloroquine toxicity. Throughout the follow up, her visual acuity remained stable at 6/9 in both eyes</p></div><p> &nbsp;</p><div> <p align="center"> <img height="759" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="354" /></p> <p> <strong>Figure 2</strong>...
      PubDate: Fri, 24 Nov 2017 03:02:25 +000
  • Congenital Peritoneal Band Causing Bowel Ischaemia Post Caesarean Section:
           A Rare Occurrence

    • Authors: ahlina
      Abstract: Author(s):  Phon SE Ng BK Ng WYL Rahman RA Zainuddin AA Mahdy ZA Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Ng Beng Kwang. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455949 Fax: +603-91456672 E-mail:, Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Early post-operative small bowel obstruction is not uncommon after abdominal surgeries with significant morbidity and mortality rate of 2-5% (1). It remains challenging and puts surgeons around the world in tremendous dilemma, in terms of its diagnosis and management. There are numerous causes of bowel obstruction, including adhesions or strictures. We described a case of post caesarean section small bowel obstruction secondary to a rare congenital anomaly band.</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 42-year-old Gravida 2 Para 1 underwent an uncomplicated emergency lower segment caesarean section for fetal distress. Her antenatal care had been uneventful with no history of prior abdominal surgery or trauma.</p> <p> &nbsp;</p> <p> On day one post operatively, she complained of epigastric discomfort associated with vomiting. On examination, her blood pressure was 124/82 mmHg with pulse rate of 92 beats/minute. She was afebrile. Her abdomen was not distended, soft but tender upon palpation only over the incision site. The uterus was well contracted at 18 weeks&rsquo; size. There was no other mass palpable. Bowel sounds were normal. She was treated symptomatically with anti-emetics and antacids.</p> <p> &nbsp;</p> <p> However, on the following day, her abdominal pain worsened, especially over the right flank, which was</p></div><p> &nbsp;</p><div> <p align="center"> <img height="206" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="393" /></p> <p> <strong>Figure 1</strong>: a) Axial CT scan showing distension of small bowel loops with diffuse wall thickening (*) and extensive mesenteric oedema (arrow); b) Saggital CT image showed abrupt tapering of the dilated small bowel in keeping with transition zone (arrow).</p> <p> &nbsp;</p> <p align="center"> <img height="188" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="393" /></p> <p> <strong>Figure 2</strong>: a) Laparotomy view showing the ischaemic bowel open entering the abdominal cavity; b) Arrow showing the area of constricture due to the congenital anomaly band that loops around the affected small bowel</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> associated with abdominal distension and bilious vomiting. She was tachycardic, but her blood pressure remained normotensive. On examination, the abdomen appeared grossly distended, with tenderness over the right flank.&nbsp; Rebound tenderness was positive and bowel sounds were sluggish. Blood investigations revealed leukocytosis with the total white cells of 11.6 x 10<sup>9</sup>; otherwise, serum electrolytes were within normal limits.</p><p> &nbsp;</p><p> An urgent abdominal CT scan was performed, which confirmed a marked small bowel dilatation with ascites (Fig. 1). An emergency exploratory laparotomy was performed for suspected small bowel obstruction. Intra-operatively there was 160 cm of ischemic small bowel (Fig. 2). A congenital band was found extending between the right fimbria end and the small bowel mesentery, looping over the small bowel and constricting it. The ischemic portion of small bowel was resected and primary anastomosis was performed. The patient was nursed in intensive care unit for 2 days, and was discharged home after 4 days post operatively. Histopathological examination confirmed an ischemic bowel.</p><p> &nbsp;</p><p> <strong>Discussion</strong></p><p> &nbsp;</p><p> Early post-operative small bowel obstruction (EPOSBO) is defined as temporary retu...
      PubDate: Fri, 24 Nov 2017 02:50:46 +000
  • Schwannoma of the Common Peroneal Nerve – A Rare Incidence

    • Authors: ahlina
      Abstract: Author(s):  Tan JA Levin KB Rhani SA Hisam A Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Shaharuddin Abd. Rhani. Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457330 Fax: +603-91726473 E-mail: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Schwannomas are slow growing, well capsulated, benign tumours that arise from neurilemmal cells which form the myelin sheath of peripheral nerves. It occurs more in females and usually in the fourth and fifth decade of life. It is the most common solitary nerve tumour in the body with the most common site being in the head but may also be found in the brachial plexus and the sciatic nerve. Rarely, it presents in the lower extremities, but if it does, it usually arises from the deep layers of the foot (1). Unlike Neurofibromas, Schwannomas are benign and have less than one percent chance to become malignant in the form of a neurofibrosarcoma. Patients presenting with multiple Schwannomas are usually associated with type 2 Neurofibromatosis or Schwannomatosis (2). Traditionally it is believed that Schwannomas do not breech the fascicles of the nerve, instead, it just sits on the myelin sheath. Hence, most patients are asymptomatic until a lump is noted, or when nerve irritation occurs secondary to mechanical compressive effects (3). We report a rare case of a patient presenting with a Schwannoma over the right common peroneal nerve, with the tumour found to be in continuity with the fascicles of the nerve during surgical dissection. The incidence of common peroneal nerve schwannoma is not known, however to date, there are only less than 10 known case reports in the literature since the year 1995 (1,3).</p></div><p> &nbsp;</p><div> <p align="center"> <strong><img height="214" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="382" /></strong></p> <p style="margin-left:142.5pt;"> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (a)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (b)</p> <p> <strong>Figure 1: </strong>a) Sagittal T2-weighted MRI showing a hyperintense lesion along the common peroneal nerve lying between the biceps femoris tendon and lateral head of gastrocnemius muscle (arrow); b) Lesion was not suppressed by fat suppression sequence. (arrow).</p> <p align="center"> <strong><img height="277" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.jpg" width="382" /></strong></p> <p> <strong>Figure 2: </strong>Biphasic tumour composed of compact areas of spindle cells (Antoni A) with palisading Verocay bodies and loosely cellular areas (Antoni B). Maginification of image: 25X</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> A 50-year-old gentleman was referred to the orthopaedic clinic for pain and swelling over the right popliteal fossa which was gradually increasing in size over the past 6 months. It was associated with worsening radicular pain along the anterolateral aspect of the right leg which was more severe on flexion of the knee. Other than that, he also complained of weakness over the right ankle on dorsiflexion. On examination, he was found to have a 3x2 cm lump behind the posterolateral aspect of the right knee. The lump was firm in consistency, deep to the fascia and mobile. Tinel&rsquo;s sign was positive upon tapping of the lump, there was sensory deficit over the anterolateral aspect of the leg and the ankle dorsiflexors had a muscle power of grade 3.</p><p> Magnetic resonance imaging (MRI) of the right leg revealed a well circumscribed, oval lesion located along the pathway of the common peroneal nerve. It is homogenously hypointense on T1-weighted images. and heterogeneously hy...
      PubDate: Fri, 24 Nov 2017 02:37:19 +000
  • Retinal Break Adjacent to the Optic Disc Causing Retinal Detachment in a
           Pathological Myopia

    • Authors: ahlina
      Abstract: Author(s):  Noor Aniah A Bastion MLC Mushawiahti M Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Noor Aniah Azmi. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457207 Fax: 03-91456733 E-mail: Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break. However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical repair as well as the possible measures to treat the complications. Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Retinal detachment is one of the complications of pathological myopia. About 40% of retinal detachment occurs in myopic patients. Rhegmatogenous retinal detachment occurs as a result of a retinal break or lattice degeneration that is commonly associated with pathological myopia. Pathological myopia is defined as axial length more than 26 mm or refractive error of more than &ndash; 6.0 diopters. The common sites of retinal break are in the peripheral retina, however, it can also occur around the optic disc. This case report illustrates the rare incidence of retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical repair as well as the possible measures to treat the complications.</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 74-year-old Malay gentleman with underlying diabetes mellitus, hypertension and chronic myeloid leukemia presented with left eye blurring of vision, central scotoma and floaters for the past two months. He had no metamorphopsia and no recent ocular trauma. He is a known high myope and is bilaterally pseudophakic. His right axial length is 26.84 mm and left eye is 26.82 mm. Visual acuity of the left eye during presentation was 6/36 and N18. His intraocular pressure (IOP) and anterior segment was unremarkable. Posterior pole revealed retinal detachment surrounding the optic disc with vitreomacular traction (Fig. 1) with presence of submacular fluid detected on Optical Coherence &nbsp;</p> <p> &nbsp;</p> <p align="center"> <img height="230" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="257" /></p> <p> <strong>Figure 1</strong>: Fundus photo showing retinal detachment surrounding the optic disc</p></div><p> &nbsp;</p><div> <p align="center"> <img height="132" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="430" /></p> <p align="center"> <strong>Figure 2</strong>: OCT image showing retinal detachment with subretinal fluid and vitreomacular traction (before surgery)</p> <p align="center"> &nbsp;</p> <p align="center"> <img height="140" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image006.gif" width="431" /></p> <p align="center"> <strong>Figure 3</strong>: OCT image showing persistent subretinal fluid 3 months after surgery</p> <p align="center"> &nbsp;</p> <p align="center"> <img height="154" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image008.gif" width="438" /></p> <p align="center"> <strong>Figure 4</strong>: OCT image showing reduction of subretinal fluid 10 months after surgery</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> Tomography (OCT) (Fig. 2). The patient refused surgery at the time of presentation and he came back after 2 months with worsening metamorphopsia, but visual acuity remained the same. Pars plana vitrectomy with internal limiting membrane peeling, endolaser and perfluoropropane (C3F8) gas tamponade was performed. Intraoperatively, we noted that there was a small retinal break superior to the optic disc. Immediately after surgery, his visual acuity was counting finger (CF), which improved to 6/60 3 months after. On OCT, there was persistent subretinal fluid involving the fovea and retinal detachment extending to the edges of the optic disc 360...
      PubDate: Fri, 24 Nov 2017 02:24:41 +000
  • Retinal Redetachment After Pneumatic Retinopexy – The Importance of
           Case Selection

    • Authors: ahlina
      Abstract: Author(s):  Muhammad Najmi K Aida Zairani MZ Mushawiahti M Bastion MLC Amin A Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Amin bin Ahem. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455981 Fax: +603-91456673 E-mail: Pneumatic retinopexy is known as one of the treatment options for a specific type of retinal detachment. It is done in an office setting and may be the most cost-effective means of retinal reattachment surgery. Location and size of the retinal break remain as the major criteria for a successful outcome. We describe a case that fulfilled all except one major criteria for pneumatic retinopexy and underwent multiple procedures but failed. Fluctuation in the resolution of the retinal detachment such as in this particular case suggested possibility of early treatment failure. Full text:  <p> <strong>Introduction</strong></p><p> &nbsp;</p><p> Pneumatic retinopexy is a procedure done to treat retinal detachment. It involves injecting expanding gas bubble into the vitreous cavity and securing retinal tear by using laser and/or cryopexy. The literature reports a variable success rate when compared to other conventional retinal reattachment surgeries. This procedure may be done in office setting thus remained as the most cost effective ways to treat retinal detachments.</p><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> A 58-year-old Chinese gentleman with no known medical illness, presented with two weeks history of right eye superonasal visual field defect which progressed towards the centre, associated with flashes and floaters. There was no history of ocular trauma and patient was emmetropic. Examination revealed visual acuity of 6/60 over the affected side with positive relative afferent pupillary defect. Slit-lamp examination of the right eye revealed normal anterior segment, presence of tobacco dusting with intraocular pressure of 7 mmHg. On fundal examination, there was a right eye rhegmatogeneous retinal detachment (Fig. 1) involving the macula with superior horse-shoe tear at 11 o&rsquo;clock position (2 clock-hours size). The patient underwent right eye pneumatic retinopexy with an injection of 0.4 mls of C3F8 gas (100%) followed by indirect barricade laser around the tear two days later. He was compliant to the positioning instruction which was sit up with head tilt to the left. Fundal examination a week later showed satisfactory reduction in the area of detachment and early scarring of the laser marks. However, at 2 weeks post treatment, residual retinal detachment was still present with small opening of the primary tear. In view of the positive response after the first procedure, he was subjected for a repeat pneumatic retinopexy with additional laser and injection of C3F8 0.4mls (100%) to treat the small opening of the tear. Reattachment of the macula was achieved at 1-week post procedure with residual inferior detachment.&nbsp; This was confirmed by the optical coherence tomography (OCT) (Fig. 2). Unfortunately, at 4 weeks post pneumatic treatment, the macula redetached and the area of detachment remained fairly persistent with no signs of further<br clear="all" /> <img height="262" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 1</strong>: Fundus photograph of right eye showing retinal detachment with macula-off.</p><p> &nbsp;</p><p> <img height="147" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 2</strong>: OCT showing macula reattachment after second pneumatic retinopexy treatment</p><p> &nbsp;</p><p> <img height="146" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image006.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 3</strong>: OCT showing macula re-detachment 4 weeks post pneumatic treatment</p><p> &nbsp;</p><p> resolution (Fig. 3). Eventually, 2 weeks after the redetachment, pars plana vitrectomy was performed with gas tamponade together wit...
      PubDate: Fri, 24 Nov 2017 01:49:48 +000
  • Successful Visual Outcome Following Vitrectomy for Complication of Ocular

    • Authors: ahlina
      Abstract: Author(s):  Norshamsiah MD Muhaya M Bastion MLC Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Tuberculosis is one of the most rapidly spreading communicable diseases worldwide made worse by migration from third world countries and the emergence of diseases requiring immunomodulation or immunosuppression (1,2). While systemic tuberculosis is readily detectable with standard tests, ocular tuberculosis needs a high index of clinical suspicion to diagnose, as it may be the only organ involved. The eye has limited tissue available for biopsy, hence in cases of ocular tuberculosis, collaborative high clinical suspicion and standard tests are crucial (3).</p><p> Ocular tuberculosis often results in good visual outcome but may have high ocular morbidity particularly in highly prevalent areas (4)and immunosuppressed patients (5).&nbsp; We report a healthy young gentleman with presumed ocular tuberculosis who failed to respond to initial treatment with anti-tuberculous drugs. He subsequently required surgical intervention and had a good visual outcome.</p><p> <strong>Case Report</strong></p><p> A 24-year-old Chinese gentleman complained of sudden onset of floaters affecting his right outer visual field for two weeks. Three days later, his vision dropped in that eye. There was no redness, photopsia or pain. There was no recent travel abroad and he denied any high-risk behaviour. He reported a history of cough with bloody sputum for 2 years with recent intermittent pleuritic chest pain. There were no other constitutional symptoms and no history of contact with tuberculosis (TB) patient. He was a former smoker of 20 cigarettes a day but ceased a month ago.</p><p> Examination revealed a thin young man with stable vital signs. Systemic examination was unremarkable with no lymphadenopathy. His vision at presentation was 6/18 ph 6/12 N 18 OD and 6/9 ph 6/6 N 5 OS. There was right relative afferent pupillary defect with good red reflex bilaterally. The anterior segment was quiet. The intraocular pressure was 18 mmHg OU.</p><p> Examination of the posterior segment showed old pigmented anterior vitreous cells of 2 + in the right eye. Funduscopy of the right eye revealed an area of retinitis and vasculitis with flame shaped and preretinal haemorhages at the superonasal arcade. The optic disc was swollen and hyperaemic with a macular star (Fig. 1). Sheathing of the vessels at the periphery was also noted.</p><p> The left vitreous was quiet. The left optic disc was also hyperaemic but not swollen. There was a cluster of dot haemorrhages at the mid-periphery temporal to the arcades. The macula was normal.</p><p> Fundus fluorescein angiogram of the right eye revealed arterial occlusion distal to the vasculitis area with staining of diseased vessels.</p><p> Blood investigations revealed raised total white cell count with neutrophilia. Other blood tests like renal profile, random blood glucose and liver functions, VDRL, retroviral screening and hepatitis screening were all negative. The chest X-Ray and MRI of the thorax and brain was also normal. Mantoux test read 15 mm of induration.</p><p> He was started on a trial of oral rifampicin 300 mg daily for 2 weeks and oral prednisolone 60 mg daily. His vision improved to 6/18 ph 6/9 with improvement of the other ocular lesions. The respiratory team commenced multi-drug anti-TB regime of isoniazid, rifampicin and pyrizinamide.</p><p> After swapping the treatment regime for some traditional Chinese medication, he presented 3 weeks later with sudden drop in vision of the right eye for 3 days. With a vision of counting finger, the right eye had suffered a dense vitreous haemorrhage (VH). Recommencement of the anti TB treatment allowed the VH to resolve slowly.</p><p> Unfortunately, a month later, he developed a dense subhyaloid haemorrhage at the macula. The decision for surgical intervention was made and he underwent 20G trans pars plana vitrectomy, membrane peeling, endolaser and silicone oil injection. Post-operatively, he continued to improve leaving a macular pucker with visual acuity of 6/36.</p><p> A second surgery to remove the silicone oil and epiretinal membrane peeling was done 3 months later.&nbsp; A subsequent posterior subcapsular cataract developed for which cataract surgery was performed. His final visual acuity after 18 months of therapy was 6/9 with stable and quiescent retinopathy (Fig. 2).</p><p> <strong>Di...
      PubDate: Wed, 28 Nov 2012 08:46:36 +000
  • Sub-Brachialis Course of the Median Nerve in the Arm and its Possible
           Clinical Complications: A Case Report

    • Authors: ahlina
      Abstract: Author(s):  Melanie RD Anitha G Naveen K Satheesha BN Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal 576104, Karnataka, India. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Disorders of the peripheral nervous system are common. Among these disorders, entrapment neuropathies, i.e. cases in which the nerve is compressed by adjacent anatomic structures, are frequently encountered by the clinician (1).</p><p> Classically, the median nerve receives fibers from C5, C6, C7, C8 and T1 spinal nerves, and supplies motor, sensory and sympathetic nerve fibers to the upper limb. The median nerve is normally formed by the union of two roots: lateral root of median nerve (LRM) derived from the lateral cord (C5, C6, C7) of brachial plexus and medial root of median nerve (MRM) derived from the medial cord (C8, T1) of brachial plexus. The two roots embrace the third part of the axillary artery, uniting anterior or lateral to it. In the arm, the course of the median nerve is closely related to the brachial artery. It descends along the lateral side of the third part of axillary artery and proximal part of brachial artery. At the middle of the arm opposite the insertion of coracobrachialis the nerve crosses from lateral to medial, usually in front of the artery and then accompanies along the medial side of the brachial artery. It appears in the cubital fossa beneath the bicipital aponeurosis and rests on the brachialis. The nerve leaves the cubital fossa through a gap between the superficial and deep heads of pronator teres.</p><p> <strong>Case Report</strong></p><p> During routine dissections for medical undergraduates, a few variations were found in the anterior compartmentof the arm. The variations were found in the right limb and were unilateral. The median nerve (MN) trunk was found medial to the third part of axillary artery formed by the union of the lateral root (arising from the lateral cord of the brachial plexus) and the medial root (arising from the medial cord of the brachial plexus), the former passing anterior to the artery. After its formation, median nerve trunk continued medial to the brachial artery.</p><p> At the level of the insertion of coracobrachialis muscle, MN crossed the brachial artery from medial to lateral side. The median nerve trunk then received a communicating branch from the lateral cord of brachial plexus, after the latter gave off the musculocutaneous nerve.</p><p> MN then passed deep to the brachialis. It then emerged out just before entering the cubital fossa. In the cubital fossa it was situated medial to the brachial artery as is the normal course of the nerve. Further course and distribution of median nerve in the forearm and hand was observed to be normal. These kinds of variations are vulnerable to damage in surgical operations of the axilla and upper arm.</p><p> <strong>Discussion</strong></p><p> The distribution, course and the branching pattern of the nerves of brachial plexus is significant from the clinical perspective. A more defined knowledge than that found in classical anatomical texts is necessary for clinical investigation and the surgical treatment of peripheral nerve injury(2).</p><p> In the present study, there was a change in relationship of LRM with axillary artery where the LRM has crossed the artery anteriorly from lateral to medial side to join the MRM to form the trunk of the median nerve. The median nerve was medial to the axillary artery, unlike the usual case of MRM crossing the artery from medial to lateral to form the median nerve lateral to axillary artery. This type of variation of formation of median nerve has also been mentioned in literature (3, 4).</p><p> Understanding the embryologic development of the brachial plexus is of importance in explaining such anatomic variations. The change in relationship between cords of brachial plexus and axillary artery might be due to a change in the source of the subclavian artery, from the usual 7<sup>th</sup> segmental artery which is between lateral and medial cords, to 6<sup>th</sup> or 8<sup>th</sup> segmental artery which may cause medial or lateral displacement of cords in relation to artery respectively (5).</p><p> Variations in the formation of median nerve were noted by some earlier workers. The variations related to the formation of median nerve by more than two roots which have been observed in the present study are rare, as revealed by survey of litera...
      PubDate: Wed, 28 Nov 2012 08:42:20 +000
  • Spontaneous Retrobulbar Haemorrhage Secondary to Orbital Varices of
           Inferior Ophthalmic Vein-A Case Report

    • Authors: ahlina
      Abstract: Author(s):  Haizul IM Umi Kalthum MN Mae-Lynn CB Faridah HA Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, 56000 Cheras, Kuala Lumpur, Malaysia. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Orbital varices are uncommon vascular malformations, characterized by rapid protrusion of eyeball induced by elevated orbital venous pressure. The advancement of neuro- radiology studies allow for precise diagnosis, hence better selection of treatment options.</p><p> Orbital varices may manifest with variable degree of proptosis and venous dilatation of the eyelids. Rarely, it presents with acute thrombophlebitis with spontaneous retrobulbar haemorrhage.</p><p> <strong>Case Report</strong></p><p> A 50 year old Chinese gentleman presented with one hour history of sudden onset of right eye proptosis associated with pain, deteriorating vision and diplopia.&nbsp; He is a known case of hypertension and dyslipidaemia on treatment. There was no history of head injury in the past.</p><p> Visual acuity at presentation was hand motion and 6/9 and N14 for the right and the left eyes respectively. There was presence of relative afferent pupillary defect on the right eye with proptosis, tense globe and limited extraocular muscle movements. The proptosis was non-pulsatile and no bruit was noted, but there was subconjunctival haemorrhage. The intraocular pressure was 20 mmHg on the right eye and 14 mmHg on the left eye. Funduscopic examination showed slightly pale optic disc on the right eye compared to the left eye.</p><p> Urgent computed tomography scan showed hyperdense collection occupying intraconal and extraconal space of the right eye consistent with retrobulbar haemorrhage.</p><p> Emergency orbital decompression with lateral canthotomy was done under local anaesthesia followed by medical decompression with intravenous methylprednisolone, and additional antiglaucoma medications.</p><p> Marked improvement in visual acuity from hand motions to 6/24 and lessening of proptosis was noted within an hour after treatment, with reduction in the intraocular pressure. He was eventually transitioned to oral steroid with excellent response and no evidence of recurrence.</p><p> <strong>Discussion</strong></p><p> Orbital varices are rare vascular hamartoma which usually manifest in the 2<sup>nd</sup> and 3<sup>rd</sup> decades of life (1) and affecting both genders equally (2). It is characterized by thin- walled, distensible post- venous capillary vessels with low flow and intravenous pressure (3).</p><p> The patho-mechanism of retrobulbar haemorrhage is thought to arise from vascular wall abnormality coupled with abnormal venous flow resulting in formation of thrombosis. This thrombosis occludes the venous channel, further enlarging the varices which eventuated into venous rupture (4).</p><p> The classification of vascular malformations of the orbit is broadly based on radiological or clinical findings. There is a wide range of clinical manifestations of orbital varices. The clinical classifications described the findings of orbital varices in stages, ranging from variable proptosis in stage 1 to acute thrombophlebitis in stage 5 (5). Acute orbital haemorrhage such as in this case is considered as stage 4, based on this classification.</p><p> Based on radiological findings, orbital vascular malformation is divided into lymphangioma, arterial and venous malformation. This case most probably falls under the orbital varices of the venous malformation category. Furthermore, the rapid onset of painful intermittent proptosis coupled with spontaneous orbital haemorrhage points the diagnosis towards the non- distensible type (6). This particular subtype of orbital varices has minimal communications with surrounding venous system.</p><p> Prompt recognition and management of acute retrobulbar haemorrhage is crucial to prevent visual loss and restore good visual function. Early diagnosis is best done using computed tomography utilizing the coronal and axial cut (5), and three-dimensional reconstruction is not a necessity (6). Orbital compartment syndrome results from relatively narrow space of the intraconal and extraconal regions which only allows limited anterior globe displacement (7). Irreversible retinal ischaemia and optic neuropathy was prevented in this case with surgical orbital decompression and rapid institution of medical therapy. Lateral canthotomy is a relatively...
      PubDate: Wed, 28 Nov 2012 08:36:04 +000
  • Replaced Right Hepatic Artery Associated with Uncommon Triplet Right Renal
           Vein: Embryological Perspective and Clinical Importance

    • Authors: ahlina
      Abstract: Author(s):  Satheesha NB Srinivasa RS Surekha DS Naveen K Anita G Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Anatomy, Melaka Manipal Medical College, Manipal Campus, International Centre for Health Sciences Manipal University, Madhav Nagar, Manipal Udupi District, 576 104 Karnataka State, India. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> The coeliac trunk (CT) supplies the abdominal oesophagus, stomach, duodenum up to major duodenal papilla, liver, pancreas, gall bladder and spleen. The classic branches of CT are the common hepatic, splenic and left gastric arteries. The common hepatic artery after originating from the CT runs downwards to the first part of the duodenum, where it divides into hepatic artery proper and gastroduodenal arteries. The common hepatic artery gives right gastric branch before its termination. The hepatic artery proper runs in the right free margin of lesser omentum and divides into right and left hepatic arteries at or near the porta hepatis.</p><p> The renal veins are the tributaries of the inferior vena cava, and they lie anterior to the renal artery. They open into the inferior vena cava at the level of L2 vertebra. Right renal vein typically receives blood solely from the right kidney. The left renal vein is three times larger than right renal vein and it receives blood from the left kidney, left gonad and left suprarenal gland. Multiple variations in the abdominal vessels are commonly observed and have been reported in the past. Mostly reported variations are that of hepatic artery, coeliac trunk and its branches and renal vessels. However, multiple vascular variations of these vessels in a person are rarely reported in the past. In the present case, we report the vascular variations involving RHA and right renal vein with their embryological aspects and clinical significance.&nbsp;</p><p> <strong>Case Report</strong></p><p> During regular dissections for the medical undergraduates, we found multiple vascular variations, in the retroperitoneal region of an elderly male cadaver. The CT &nbsp;trifurcated into splenic artery left gastric artery and common hepatic artery. The common hepatic artery divided into left hepatic artery and gastroduodenal artery. The right hepatic artery (RHA) arose from the superior mesenteric artery (SMA), close to its origin from the abdominal aorta (AA). This artery was found to be solely supplying the right lobe of the liver, and it was identified as a replaced RHA (Fig. 1).</p><p> The right kidney was drained by three renal veins (Fig. 2). The upper most among the three twisted around the superior branch of right renal artery. It terminated into inferior vena cava by entering through its posterior surface (Fig. 2 and 3). The middle renal vein passed behind, and the inferior renal vein passed in front of the proximal part of the ureter before ending in the inferior vena cava. In addition, the left kidney was supplied by two renal arteries, and drained by a single renal vein.</p><p> <strong>Discussion</strong></p><p> RHA usually arises from the proper hepatic artery, a branch of common hepatic artery and supplies the right lobe of the liver. If it originates from any artery other than hepatic artery proper and replaces the RHA arising from the hepatic artery proper, it is defined as replaced RHA, but if the artery serves as an additional branch it</p><p> is defined as accessory RHA (1). The replaced right hepatic artery may arise from the SMA. Earlier, many studies have documented the incidence of replaced or accessory RHA from the SMA, and the incidence varied from 10.6% to 18% in various groups (2,3,4,5). The persistence of replaced RHA can be explained on the basis of embryonic development of ventral branches of the abdominal aorta. In the fetal life, aorta gives off ventral branches, four of which forms the celiac, splenic, common hepatic and SMA. Later, a longitudinal arterial anastomoses is formed between these segments. Persistent longitudinal arterial segment connecting the SMA may attribute to the development of replaced RHA, in the postnatal life (6).&nbsp;</p><p> In the present case, we report a replaced RHA from the SMA, and the common hepatic artery continued as a left hepatic artery. This anatomical variant is clinically very important, as the occlusion of the SMA by various means invites the necrosis of right lobe of the liver, along with the affected gut. Occlusion of SMA is a common clinical problem because approximately 4% of all a...
      PubDate: Wed, 28 Nov 2012 08:29:53 +000
  • Presence of Additional Head of Pronator Teres Muscle and Associated
           Neurovascular Variations: A Rare Case Report

    • Authors: ahlina
      Abstract: Author(s):  Sushma RK Srinivasa RS Kumar MR Bhat Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Anatomy, Kasturba Medical College, Manipal University, Manipal-576104, Karnataka, India. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> The brachial artery is a continuation of the axillary artery from the distal border of the teres major tendon and ends about a centimeter distal to the elbow joint by dividing into the radial and ulnar arteries. The artery is wholly superficial, covered anteriorly by skin and fascia and crossed superficially by the median nerve from the lateral to medial side. The brachial artery provides the following branches: profunda brachii, muscular and nutrient branches, superior and inferior ulnar collateral arteries, radial and ulnar arteries.</p><p> Normally, the pronator teres muscle arises as two heads, a humeral head arising just proximal to the medial epicondyle from the common tendon of the flexor muscles and an ulnar head from the medial side of the coronoid process. The median nerve enters the forearm between the two heads of the pronator teres.</p><p> Here we report a high division of brachial artery and an unusual fibromuscular tunnel formed by an extensive additional head of pronator teres. The latter finding is extremely rare and not reported elsewhere.</p><p> <strong>Case Report</strong></p><p> Variations were observed in a 60 year old male cadaver during routine dissection in the Department of Anatomy, Kasturba Medical College, Manipal, India. In this arm, the brachial artery was divided in to radial and ulnar artery 3cm above the inter-epicondylar plane. The radial artery was seen descending medial to the biceps brachii and in the cubital fossa below the bicipitial aponeurosis and follows the normal course in the forearm. The median nerve which normally crosses brachial artery from lateral to medial side is not seen and the nerve lies medial to brachial artery and ulnar artery in its course in the distal end of the arm. Then, the ulnar artery and the median nerve were seen to pass through 2cm long tunnel formed by the extensive additional humeral head of the pronator teres muscle.&nbsp; A fibromuscular tunnel was so formed by the humeral head of the pronator teres which was arising from the medial intermuscular septum and also from the fibrous arch between the shaft of the humerus and medial intermuscular septum (Fig. 1). After running in the tunnels for about 2cm, the median and ulnar artery were emerging into the cubital fossa just below the inter-epicondylar plane under the additional head of the pronator teres muscle (Fig. 1).</p><p> Additionally, the profunda brachii artery, arising from the brachial artery immediately divided into middle and radial collateral arteries. Just before these two branches enter the lower triangular space, the superior ulnar collateral artery was found arising from the middle collateral artery and had a normal course with the ulnar nerve (Fig. 2).</p><p> <strong>Discussion</strong></p><p> Muscular and arterial variations in the upper limb have varied clinical and surgical significance. Major variation were found in the brachial artery in about 25% of subjects studied (1). The bifurcation of brachial artery proximal to intercondylar line of humerus is considered a variation (2).&nbsp; The high division is possible at any point in the normal course of the vessel but, is more com&shy;mon in the middle third. The two branches, into which the brachial artery divides, retrace the usual position of the brachial artery. Further, cubital region onwards, these two arteries follow their normal course (2).</p><p> In the present case, we have focused on the morphology of this arterial variation and also discussed its clinical significance and relevance.</p><p> Earlier, it has been shown that the brachial artery divides into radial and ulnar artery in the arm itself after giving rise to profunda brachii artery (3). In another case, it has been reported that the brachial artery divided into superficial and deep branches. The superficial brachial artery was then divided into radial and ulnar arteries, while the deep division continued as interosseous artery and provided a large median artery which then completes the superficial palmar arch with the ulnar artery in the palm (4). An accessory brachial artery which arose from brachial artery 21cm proximal to the intercondylar line was also encountered (5). Thus, high origin of radial and ulnar artery is the most common type of variations in the brachial artery.</p><p> Embryological explanation provided to the higher origin of radial and ul...
      PubDate: Wed, 28 Nov 2012 08:22:08 +000
  • Gastric Outlet Obstruction Due to Extraluminal Compression: An Unusual

    • Authors: ahlina
      Abstract: Author(s):  Chatterjee S Basu A Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of General Surgery, Medical College, Kolkata. 88 College Street, Kolkata - 700073, India. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Ascariasis caused by the nematode Ascaris lumbricoides is a very common disorder amongst the Asian population. Adult roundworms are generally found in the intestine (mainly jejunum). But their agility often takes them through different orifices (1). Hepatobiliary and pancreatic ascariasis (HPA) refers to a group of diseases caused by migration of the Ascaris from the intestine into the biliary tree and pancreatic duct through the ampulla of Vater. In most cases, the nematode moves back into the intestine within 72 hours. Depending on the position of the nematode, HPA has widespread manifestations. We&nbsp;&nbsp; present&nbsp; a&nbsp; case&nbsp;&nbsp; that&nbsp; presented&nbsp; with&nbsp;&nbsp; acute&nbsp; gastric&nbsp; outlet&nbsp; obstruction&nbsp;&nbsp; and&nbsp; obstructive&nbsp; jaundice&nbsp;&nbsp; caused&nbsp; by a ball of ascaris.</p><p> <strong>Case Report</strong></p><p> A fifty year&nbsp; old&nbsp; male&nbsp; patient presented&nbsp;&nbsp; with&nbsp; intermittent colicky&nbsp; pain&nbsp; in&nbsp; right&nbsp; hypochondrium&nbsp; for&nbsp; 1 month, for which he was taking medication as prescribed by his physician. Patient also developed jaundice&nbsp; with&nbsp; passage&nbsp; of&nbsp; high&nbsp; coloured&nbsp; urine, &nbsp;clay&nbsp; coloured,&nbsp; stool,&nbsp;&nbsp; pruritus&nbsp; and&nbsp;&nbsp; anorexia . He gave a history of&nbsp; projectile&nbsp; vomiting&nbsp; of&nbsp; food&nbsp; taken&nbsp; more&nbsp; than&nbsp; 24&nbsp; hours&nbsp; ago&nbsp; for&nbsp;&nbsp; last 5 days .&nbsp; The patient was brought to the emergency in hypovolemic shock. Inspection&nbsp; of&nbsp; abdomen&nbsp; showed&nbsp; visible&nbsp; peristaltic&nbsp; waves&nbsp; from&nbsp; left&nbsp; to&nbsp; right. Right hypochondrium was highly tender with localized rigidity. Auscultopercussionrevealed a dilated stomach. Investigations&nbsp; revealed mild leucocytosis, raised serum urea and creatinine, increase&nbsp; in&nbsp; total (7mg/dl)&nbsp; and&nbsp; direct&nbsp; bilirubin&nbsp; with&nbsp; moderately&nbsp; raised&nbsp; liver&nbsp; enzymes. Patient was resuscitated and haemodynamically stabilized.&nbsp; Further investigations were done to find the cause of gastric outlet obstruction and obstructive jaundice.</p><p> USG&nbsp; &nbsp;revealed&nbsp;&nbsp; dilated&nbsp; intrahepatic biliary radicles (IHBR), an&nbsp; ill defined&nbsp; 7.7 x 7 x 5cm collection with&nbsp; interval&nbsp; echoes&nbsp; and&nbsp; multiple&nbsp; echogenic tiny&nbsp; foci with&nbsp; posterior&nbsp; acoustic&nbsp; shadow&nbsp; in&nbsp; gall bladder (GB) fossa, 13mm dilated common bile duct (CBD) containing&nbsp;&nbsp; multiple&nbsp;&nbsp; calculi&nbsp; and&nbsp; a &nbsp;&nbsp;moving&nbsp;&nbsp; round&nbsp; worm&nbsp;&nbsp; in&nbsp; CBD (Figure 1A).</p><p> Upper GI endoscopy (UGIE) revealed a bulge in antrum of stomach due to extrinsic compression.&nbsp; Duodenum&nbsp; was&nbsp; deformed, ampulla&nbsp; could&nbsp; not&nbsp; be&nbsp; identified&nbsp; due&nbsp; to &nbsp;distorted&nbsp; anatomy (Figure 2). Contrast enhanced CT&nbsp; scan&nbsp;&nbsp; showed&nbsp; dilated IHBRs,&nbsp; irregular GB&nbsp; with&nbsp; increased&nbsp; attenuation&nbsp; in&nbsp;&nbsp; lumen, CBD&nbsp; dilated up to&nbsp; lower&nbsp; end&nbsp; with&nbsp; calculus&nbsp; impaction, and&nbsp; a 6x6cm&nbsp; collection&nbsp; around&nbsp; GB&nbsp; fossa containing linear&nbsp; slender&nbsp; structures, (suspected to be worms), compressing against stomach (Figure 1B). CT guided aspiration from the collection yielded bilious fluid.&nbsp;</p><p> The&nbsp;&nbsp; patient&nbsp;&nbsp; vomited&nbsp;&nbsp; quite a few&nbsp;&nbsp; living round worms&nbsp;&nbsp; two days after admission.&nbsp; He&nbsp; was&nbsp; given&nbsp;&nbsp; piperazine&nbsp; citrate&nbsp; syrup&nbsp; by&nbsp; Ryle&rsquo;s&nbsp; Tube&nbsp; for&nbsp; five&nbsp; consecutive&nbsp; days&nbsp;&nbsp;&nbsp; followed&nbsp; by&nbsp;&nbsp; ivermec...
      PubDate: Wed, 28 Nov 2012 08:17:36 +000
  • ‘Emergency Chemotherapy’ for Bleeding Cervical Cancer: Case

    • Authors: ahlina
      Abstract: Author(s):  Shafiee MN NorAzlin MI Lim PS Trika I Arifuddin D Hatta D Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia. Full text:  <p> &nbsp;</p><p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Even though the incidence of cervical cancer shows a downward trend in many developed countries resulting from effective preinvasive cervical screening and vaccination, yet advanced disease is still not uncommon in developing countries (1).&nbsp;</p><p> Urinary system is commonly affected due to close proximity to cervix and ureters running in the parametrium, approximately two centimeters from the cervix before entering the bladder. Lateral tumour extension -encasing the distal ureter leading to hydroureter, hydroneprosis and finally renal impairment. The prognosis is guarded with median survival of three to seven months(2).</p><p> Bleeding from the tumour can be torrential and difficult to arrest causing haemodynamic instability to the extend of death. Vaginal packing with Monsel solution works temporarily especially in non massive haemorrhage. Radiotherapy and brachytherapy are commonly used not only for definitive treatment in early stage but also palliative measures to stop bleeding. Other options could be embolization of the uterine arteries, ligation of feeding vessels, surgical resection and stereotactic radiosurgery, with varying successful rate and availability(3).</p><p> Generally chemotherapy is administered singly in advanced cervical cancer or as neoadjuvant in inoperable or bulky tumour. Chemotherapy is not particularly used as a rescue measure to stop bleeding as it is theoretically time consuming and relatively contraindicated in anaemic patients. More so, in uropathic patients where poor clearance is anticipated, it is not an advisable option. To date there is no report published on the evaluation of clinical benefits of high dose chemotherapy in emergency situation to arrest bleeding from the tumour.</p><p> <strong>Case Report</strong></p><p> <em>Case 1:</em></p><p> A 48-year-old, grandmultipara presented with prolonged per vagina bleeding for three weeks. It was associated with anaemia and constitutional symptoms. She was previously healthy, with six previous normal vaginal deliveries. She never had any Pap smear done. Assessment revealed a fungating cervical mass 7x8cm with contact bleeding. It has involved the upper half of the vaginal wall and both parametriums were thickened. The renal function was acceptable but she was severely anaemic with haemoglobin of 4 g/dL. She was transfused with four units of blood, but the bleeding persisted. As radiotherapy was not readily available to arrest the bleeding, a course of chemotherapy (cisplatin, vinscristin, bleomycin and mitomycin C) was administered with an excellent result. The bleeding finally stopped and two weeks later, haemoglobin improved to 10 g/dL. The tumour shrunk to 3x5 cm and the second course of chemotherapy was administered before the tumour became operable.</p><p> <em>Case 2:</em></p><p> A 39-year-old, multipara presented with abnormal vaginal bleeding for one month, associated with lower abdominal discomfort. She also had intermittent haematuria. She was pale with haemoglobin of 5 g/dL. There was oozing of blood from the vagina with an exophytic growth occupying the upper half of the vagina. The friable tissue obtained confirmed squamous cell carcinoma with extension to bladder mucosa. The bleeding continued and she was persistently anaemic despite of four units of blood transfusion. Emergency palliative chemotherapy (cisplatin, vinscristin, bleomycin and mitomycin C) was administered with spontaneous remission of the bleeding.</p><p> <em>Case 3:</em></p><p> A 45-year-old, nulliparous, presented with anuria and ureamic symptoms. She had history of persistent per vaginal bleeding since three months prior to the presentation but did not seek any medical advice. She was dehydrated and pale. A contact bleeding of 5x5 cmexophytic growth occupying the upper two third of vagina was confirmed to be adenosquamous cervical carcinoma. The haemoglobin was 4 g/dL and blood gases revealed metabolic acidosis. Serum urea and creatinine was 15 mmol/L and 150 mmol/L respectively. Ultrasound kidney, ureter and bla...
      PubDate: Wed, 28 Nov 2012 07:56:48 +000
  • Eccrine Spiradenoma: An Uncommon Breast Tumour

    • Authors: ahlina
      Abstract: Author(s):  Norly S Ros’aini P Lim HC Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Surgery, Hospital Pakar Sultanah Fatimah, Jalan Salleh, 84000 Muar, Johor. Malaysia Eccrine spiradenoma is a benign tumour of the sweat gland.  Eccrine glands can be found almost everywhere but are mostly concentrated on the palms, soles and the axillae.  Lesions involving the breast are rare.  We present a case of a 13-years-old Malay girl with eccrine spiradenoma of the breast.  The clinical presentation and histological features are being described. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Eccrine spiradenoma was first described by Kersting and Helwig in 1956 (1).&nbsp; It is an uncommon, benign tumour arising from the cutaneous sweat gland.&nbsp; It has no gender predilection and commonly affects young adults.&nbsp; The tumour is usually found on the trunk and extremities.&nbsp; It is usually solitary in nature, about 1-2 cm in size.&nbsp; Occasionally, it may be associated with pain and tenderness.&nbsp;</p><p> Eccrine spiradenoma can be associated with Brooke-Spiegler syndrome, which is an autosomal dominant disorder characterized by a high affinity to form multiple adnexal neoplasms, especially trichoepitheliomas, cylindromas, and spiradenomas.&nbsp; However, in most cases it occurs sporadically.&nbsp;</p><p> Malignant transformation of eccrine spiradenoma was described by Dabska in 1972 (2).&nbsp; It is an extremely rare condition, accounting for 0.005% of all skin tumours (3).</p><p> <strong>Case Report</strong></p><p> Our patient was a 13-year-old Malay girl, who presented with a two years history of left painless<br clear="all" /> breast lump, which slowly grew in size over the years. Otherwise, there was no significant personal or family history. On examination there was a 4x4 cm hard lump in the left upper inner quadrant of the breast.&nbsp; The overlying skin was bluish in colour. The lump felt superficial but a deeper connection to the breast tissue was also felt. Ultrasonography examination of the left breast revealed a well-defined nodule measuring 3.8 x 4.1 x 2.9 cm in size.&nbsp; The nodule has a solid and cystic component with multiple vascular channels seen within the solid component (Fig. 1).&nbsp; Fine needle aspiration yielded 10 cc of brownish fluid which was later sent to the laboratory and interpreted as cystic content.&nbsp; A wide local excision was done and intra-operatively the lesion had a maroon-bluish colour with spots of calcifications on its surface.&nbsp; Histopathological examination revealed lobules of solid and cystic tumour made up of two types of epithelial cells: cells with small dark nuclei and cells with vesicular nuclei and clear cytoplasm.&nbsp; Deposits of hyaline material were noted around the cell islands.&nbsp; No increase in mitosis or nuclear atypia was observed. The histomorphological features were in line with eccrine spiradenoma.&nbsp; The patient recovered well post surgery and was being followed up with yearly ultrasound examination of the breast.&nbsp; There has been no recurrence of the tumour on the latest follow up.</p><p> <strong>Discussion</strong></p><p> Eccrine spiradenoma is a rare tumour of the skin.&nbsp; When the clinical presentation is that of a breast neoplasm, diagnosis can be difficult.&nbsp; Classically eccrine spiradenoma presents as a dermal or subcutaneous nodule.&nbsp; A pink or blue hue overlying the nodule is suggestive, but clinical diagnosis alone cannot give accurate diagnosis.&nbsp;</p><p> Characteristic histological findings of eccrine spiradenoma are the basaloid cells can be composed of two distinct morphologies with one cell type that is larger, pale, and with an ovoid nuclei and the other type that is smaller, dark, and with a compact hyperchromatic nuclei.</p><p> Malignant eccrine spiradenoma is suspected in patients with rapid enlargement of the nodule. Changes in colour and increase in number of nodules are also suggestive.&nbsp; Histological findings may include atypical cells, increased in mitotic counts and loss of typical lobular pattern. Malignant eccrine spiradenoma arising in the breast have been described by few authors (4, 5). &nbsp;&nbsp;</p><p> The mainstay of treatment for both benign and malignant eccrine spiradenoma is surgical excision.&nbsp; Other options, such as radiotherapy, carbon dioxide laser ablation, or chemotherapy, are reserved for cases<br clear="all" /> in multiplicity or that are malignant...
      PubDate: Wed, 28 Nov 2012 07:51:50 +000
  • Bilateral Ossified Pterygospinous Ligament and Its Clinical Significance

    • Authors: ahlina
      Abstract: Author(s):  Raju S Sujatha M Indira Devi B Sirisha B Sri Devi P Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Anatomy, RIMS Medical College, Rajiv Gandhi Institute of Medical sciences, Kadapa- 516002. A.P. India. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> The pterygospinous ligament extends from the lateral plate of pterygoid process of sphenoid bone to the spine of sphenoid. pterygospinous ligament occasionally replaced by muscle fibres which extends between spine of sphenoid and posterior border of lateral pterygoid bone (1). This may sometimes ossified, this can convert into an incomplete or complete ossified bony bar or a foramen. Mandibular nerve branches may passes through this foramen and may get compressed which may leads to clinical conditions like mandibular neuralgia, lingual numbness. Civinini cited by Tebo, 1968 (2) described the pterygospinous ligament this connection was going from the spine of the sphenoid bone to the pterygospinous process that forms the pterygospinous foramen.</p><p> <strong>Case Report</strong></p><p> During routine osteology teaching classes for undergraduate medical students in the department of anatomy we noticed a case of ossified pterygospinous ligament both right (Fig. 1) and left side (Fig. 2) of dried adult skull. A bony bar was arising from the posterior border of lateral pterygoid plate of pterygoid process to the spine of sphenoid bone both sides. This bony bar was thick and consisting of an oval foramen which is related inferior to the foramina ovale. The diameters of variant pterygospinous foramen were 4.25 mm horizontally and 4.55 mm vertically on right side and 4 mm, 4.10 mm on left side. In the present variation the author observed the complete ossified pterygospinous ligament bilaterally<em>.</em></p><p> <strong>Discussion</strong></p><p> The ossification of pterygospinous and pterygoalar ligaments were defined and examined by many previous researchers and also pterygospinous bony bridges incidence were reported by different authors with different results. According to Pinar et al. (3) 0ut of 361 dried adult skulls 12 samples of complete ossified pterygospinous ligaments and 35 samples of incomplete ossified ligaments were observed and also complete ossified pterygoalar ligaments in four samples and incomplete&nbsp; ossified&nbsp; ligaments in 18 samples were observed. Krmpotic et al. (4) observed five ossified pterygospinous ligaments out of 100 skulls.&nbsp; According to Nayak et al. (5) out of 416 dry human skulls 9.61 % of incomplete pterygospinous bony bar, 3.84 % of incomplete pterygospinous foramen and 5.76 % of complete pterygospinous bony bar and foramen were observed. Von Ludinghausen et al. (6) reported the complete pterygospinous bony bar as 1.85 % on cadaver and as 6% on dried skulls. Only a few cases of bilateral complete pterygospinous ligaments were reported yet. Patnaik et al. (7) reported a single case of complete bilateral pterygoalar bar in a dried skull. Suazo et al. (8) conducted a study on 116 skulls and observed 5. 12% of type 2, 1.28% 0f type 3 and 7. 69% of type 4 of bilateral ossified pterygoalar bars. So the present variation is important because bilateral occurrence of this very rare.</p><p> Many researchers were explained regarding the importance and clinical significance of ossified pterygospinous and pterygoalar ligaments. According to Newton and Potts (9) these ossified ligaments can be an obstruction in a radio graphically guided trigeminalganglion blockage. Kapur et al. (10) reportedthat pterygospinous and pterygoalar bony bridges can be 3 to 3.5 cm in depth and may prevent the anesthesia of mandibular nerve at the lateral sub zygomatic approach. According to Das and Paul (11), the pterygospinous and pterygoalar bony bridges have got the great clinical significance to the anesthetic treatment of the mandibular nerve and for therapeutics for the trigeminal ganglion, because their presence may hamper the access to the needle in the vicinity of the oval foramen. The anatomical knowledge of this ossified bridges and their prevalence is important for Surgeons, neurologists and anesthetists.</p><p> <strong>Conclusion</strong></p><p> The knowledge of the anatomical variation like ossified pterygospinous ligament is important because it is very rare finding, which can be produces nerve entrapment syndromes. Ossified pterygospinous ligament is important for surgeons and anesthetists because this can interfere with the surgical...
      PubDate: Wed, 28 Nov 2012 07:44:56 +000
  • Abnormal Intraparotid Termination of Facial Vein and Its Clinical

    • Authors: ahlina
      Abstract: Author(s):  Satheesha Nayak B Srinivasa Rao S Sapna M Ashwini LS Jyothsna P Ashwini Aithal P Swamy Ravindra S Abhinitha P Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Anatomy, Melaka Manipal Medical College, Manipal Campus, International Centre for Health Sciences, Manipal University, Madhav Nagar, Manipal.Karnataka State, India. 576104. Full text:  <p> &nbsp;</p><p> <strong>Case Report</strong></p><p> During routine dissection classes for medical undergraduates in Melaka Manipal Medical College, Manipal University, we observed a variant course and termination of the facial vein in the right side of the face of an adult male cadaver approximately aged 60 years. While dissecting the face, it was noted that the facial vein had a normal origin. It descended down along the side of the nose and reached the surface of buccinator muscle. It then coursed transversely on the masseter muscle with slight upward inclination. It crossed the parotid duct from below upwards, being superficial to the duct and then entered the substance of the parotid gland. Within the parotid gland, it received the transverse facial vein and finally terminated into the superficial temporal vein just above the termination of the maxillary vein (Fig. 1 and Fig. 2). The facial artery had a normal course and branching pattern.</p><p> <strong>Discussion</strong></p><p> The venous variations of the face are more common on the right side of the face (2). The facial vein normally joins with the anterior division of the retromandibular vein to form the common facial vein, which drains into the internal jugular vein. It shows frequent variations in its termination. It may terminate into the external jugular vein (3, 4) or into subclavian vein (5). Its high termination into the retromandibular vein within the parotid gland has also been reported (6). So far only one case has been reported where the facial vein terminated into the superficial temporal vein (7). There is no report on termination of the transverse facial vein into the facial vein. According to our knowledge for the first time in the literature, we report the abnormal intraparotid course of facial vein associated with the termination of transverse facial vein into it.</p><p> Knowledge of venous variations is important for the surgeons performing head and neck micro vascular surgeries to avoid unnecessary bleeding during intra operative trial and error procedures (8). Intraparotid course and termination of the facial vein may result in bleeding during parotid surgeries. The vein might get compressed by the parotid duct where it crosses the parotid duct or it might compress the parotid duct. If the vein compresses the parotid duct, this might result in improper drainage of saliva, resulting in enlargement of the gland, which might be mistaken for the presence of a sialolith. The varied course and termination may result in complications during removal of skin flaps for plastic surgery also.</p><p> <strong>Conclusion</strong></p><p> The abnormal intraparotid course of the facial vein is clinically very important due to its rarity. It might bleed significantly in the transverse incisions while draining the parotid abscess. Knowledge of its close relationship with the parotid duct is also of importance for the surgeons removing the sialoliths.</p> References:  1. Standring S, Borley NR, Collins P, Crossman AR, Gatzoulis MA, Healy JC, et al. Gray’s Anatomy- The Anatomical Basis of Clinical Practice. London: Elsevier Churchill Livingstone, 2008, pp-492.2. Mehra S, Kaul JM, Das S. Unusual venous drainage pattern of face: a case report. J Anat Soc India 2003; 52(1): 64-65.3. Choudhry R, Tuli A, Choudhry S. Facial vein terminating in the external jugular vein: an embryologic interpretation. Surg Radiol Anat 1997; 19(2): 73-77.4. Prakash R, Prabhu LV, Kumar J, Nayak V, Singh G. Variations of jugular veins: phylogenic correlation and clinical implications. South Med J 2006; 99(10): 1146-1147.5. Prakash BB, Bhagath KP. A rare termination of left common facial vein into left subclavian vein: a case report. Int J Morphol 2007...
      PubDate: Wed, 28 Nov 2012 07:33:19 +000
  • Vitrectomy for Breakthrough Bleeding in Age Related Macular Degeneration
           and Polypoidal Choroidal Vasculopathy in a Malaysian Hospital

    • Authors: ahlina
      Abstract: Author(s):  Bastion MLC Amelah MAQ Wong HS Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, 56000 Cheras, Kuala Lumpur, Malaysia. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Age related macular degeneration (AMD) is one of the most common causes of reduced visual acuity in the aged population. Exudative AMD is characterized by the presence of subretinal neovascularisation with subretinal haemorrhages, exudation and pigment epithelial detachments. Recently, a disease that has clinical features similar to AMD has been found to have a higher prevalence in Asian populations, namely polypoidal choroidal vasculopathy (PCV) (1). Unlike cataract and glaucoma in which there are effective treatments which can completely cure or control the disease, AMD and PCV remain diseases that carry heavy financial burdens for those afflicted and may result in persistent, poor central vision despite treatment.</p><p> Subretinal haemorrhage following choroidal neovascular membrane secondary to age-related macular degeneration or idiopathic polypoidal choroidal vasculopathy (PCV) is an important sight-threatening condition (1).A massive intraocular haemorrhage in the course of age-related macular degeneration (AMD) is a devastating event which often requires immediate surgical intervention. It can also be a diagnostic and treatment dilemma. There is evidence that anticoagulant therapy prescribed for vascular or cardiac indications plays a role in the development of a massive haemorrhage (2-4).</p><p> The aim of this retrospective review was to review the ocular and systemic risk factors and clinical outcomes of patients undergoing pars planar vitrectomy (PPV) for breakthrough bleeding (BTB) from age related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV).</p><div> <p> <strong>Materials and methods</strong></p> <p> A retrospective review of 346 patients operated by the vitreoretinal unit in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in Kuala Lumpur from January 2008 - June 2011 was conducted to detect all cases of vitreous haemorrhage secondary to breakthrough bleeding (BTB) from AMD or PCV which underwent pars planar vitrectomy for clearance of the haemorrhage. The study was conducted in accordance with the Declaration of Helsinki. All patients had signed an informed consent form prior to vitrectomy surgery. Pars planar vitrectomy was performed by one surgeon and was either 20G or 23G pars planar vitrectomy using the Millenium<sup>TM</sup> (Bausch and Lomb, London, UK) or Accurus<sup>TM</sup> (Alcon laboratories, Texas, USA) vitrectomy machines. Patients underwent subsequent fundus fluorescein and indocyanine green angiography with Heidelberg Retinal Angiogram<sup>TM</sup> (Heidelberg Engineering, USA) if angiography had not been performed prior to the bleed or for better localization of the membrane or polyp or if the lesions looked active and were not fibrotic.&nbsp; The patient medical records were reviewed to collect information on the demographics, the fundus photography and the angiography confirming diagnosis of AMD and PCV. The data was analysed by SPSS version 16.</p> <p> <strong>Results</strong></p> <p> Eight eyes of 8 patients with AMD/PCV-related BTB who underwent PPV were included. Table 1 shows the demographics and clinical data of the patients. The mean age of patients was 64.4 years (range 41-80 years). Males just outnumbered females. The majority of patients were Chinese (n=5).</p> <p> Photodynamic therapy (PDT) was performed previously in two eyes including one eye with previous PDT and anti-VEGF. Five cases out of the eight had components of idiopathic polypoidal choroidal vasculopathy (PCV) and three of them were<br clear="all" /> macular in location. (Patient 6, Figure 1) Three cases with features of AMD were all macular in location and had fibrotic elements. (Table 1)&nbsp; (Patient 5, Figure 2 and Patient 7, Figure 3) Only one case of PCV with BTB was in fibrotic stage. (Patient 2, Figure 4) Four cases of PCV were in the active stage. Small gauge (23G) vitrectomy was used in all cases except one. Two cases were combined with phacoemulsification. Vision at presentation was poor in all cases (counting finger or worse).&nbsp; The vision in all patients improved after vitrectomy. However, only half achieved 6/60 or better vision. Two patients achieved vision better than 6/12 who were the two patients with extramacular PCV. (Patient 3, Figure 5) Mean follow up was 60 weeks (range 4-28 months). &nbsp;</p> <p class="...
      PubDate: Wed, 28 Nov 2012 07:20:32 +000
      DOI: 10.1038/sj.eye.6700706
  • Sedation with Dexmedetomidine versus Propofol during Regional Anaesthesia:
           Comparing Haemodynamic Parameters, Respiratory Rates and Offset Times

    • Authors: ahlina
      Abstract: Author(s):  Nadia MN Samsul Johari MA Muhammad M Raha AR Nurlia Y Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Anaesthesiology & Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, 56000 Cheras, Kuala Lumpur, Malaysia Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> Sedation is given during regional anaesthesia to enhance patient comfort. Patients may feel uncomfortable and become restless especially if they need to remain immobile during a procedure. Sedation has been shown to increase patient satisfaction and acceptance of regional anaesthesia (1). The selection<br clear="all" /> of sedative agents depends on physician preference and the patient<sup>&rsquo;</sup>s premorbid status. Ideally, the sedated patient should be able to respond to physical and verbalstimuli,and also maintain their airway independently.&nbsp;&nbsp; A wide variety of centrally-acting drugs such as propofol, midazolam, clonidine and dexmedetomidine have been used to provide sedation and anxiolysis (1,2).</p><p> Propofol (2,6-diisopropylphenol) is an intravenous sedative-hypnotic agent used for induction and maintenance of general anaesthesia, as well as for sedation in patients undergoing surgery under regional anaesthesia. It acts by facilitating the inhibitory neurotransmission mediated by gamma amino butyric acid (1). The advantages of propofol are its rapid onset of action, easy titration, rapid emergenceas well as antiemetic property (3-6). Propofol for intraoperative sedation can be delivered via target control infusion (TCI) with target plasma concentrations ranging between 1.0 - 3.0 &mu;g/ml (2,4).</p><p> Dexmedetomidine is a selective &alpha;-2 receptor agonist, with potent sedative, anxiolytic and analgesic properties. Unlike propofol, it acts primarily on the postsynaptic &alpha;-2 receptor causing sedation and sympatholytic effects (1).Patients receiving dexmedetomidine at infusion rates ranging between 0.3 - 0.7 &mu;g/kg/hour are effectively sedated, yet easily aroused with minimal respiratory depression (1,2).&nbsp;Its short half-life enables patients to have a rapid recovery with minimal hangover effect (2,7).&nbsp; It was licensed for use in the intensive care unit as a sedative for a maximum of 24 hours only (1,2,8).&nbsp;However, in 2008, the U.S Food and Drug Administration (FDA) approved the use of dexmedetomidine in non-intubated patients requiring sedation prior to and/or during surgical and other procedures. Studies have reported the use of dexmedetomidine for sedation in non-intubated patients during regional anaesthesia, radiological imaging and other procedures (7,9,10).</p><p> Both drugs provide effective sedation, but have slightly different cardiorespiratory effects, especially if a rapid loading dose was given (7-9). Propofol may be associated with cardiovascular depression, resulting in hypotension due to a reduction in systemic vascular resistance and cardiac contractility, and respiratory depression leading to apnoea (2,9,10). Although dexmedetomidine causes cardiovascular depression due to decreases in sympathetic outflow, it has only minimal effects on respiration (2,9). However, studies have shown that there were no significant haemodynamic effects when dexmedetomidine was used for sedation without a loading dose (11,12).</p><p> The aim of this study was to compare dexmedetomidine versus propofol, in terms of haemodynamic parameters, respiratory rates and offset times, when used for sedation in patients undergoing elective orthopaedic and surgical procedures under regional anaesthesia.</p><p> <strong>Materials and Methods</strong></p><p> <em>Subjects</em></p><p> This was a prospective, randomised, single-blind study. After obtaining institutional ethics committee approval and informed consent, patients of American Society of Anesthesiologists (ASA) physical status I or II, aged 18-70 years, planned for orthopaedic or surgical procedures requiring central neuraxial blockade were recruited into the study. Patients with allergies to the study drugs, potential airway difficulties, body mass index (BMI) &ge; 35 kg/m<sup>2</sup>, on sedative medications and with conditions associated with low cardiac output, bradyarrhythmias, conduction defects and renal impairment were excluded from the study.</p><p> <em>Methodology</em></p><p> Patients were fasted from midnight and given oral midazolam 3.75 mg t...
      PubDate: Wed, 28 Nov 2012 06:43:24 +000
  • A Comparative Study on Prognostic Relevance of Various Severity Scoring
           Systems of Acute Pancreatitis in Present Day Surgical Practice

    • Authors: ahlina
      Abstract: Author(s):  Shamita C Arghya B Soumika B Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  7 Bepin Pal Road, Kolkata 700026, India. Full text:  <p> &nbsp;</p><p> <strong>I</strong><strong>ntroduction</strong></p><p> <em>&ldquo;Acute pancreatitis&nbsp;&nbsp; stings&nbsp; like&nbsp; a&nbsp; scorpion,&nbsp; drinks like&nbsp; a&nbsp; fish , eats&nbsp; like&nbsp; a&nbsp; wolf , burrows&nbsp; like&nbsp; a&nbsp; rodent&nbsp; and&nbsp; kills&nbsp; like&nbsp; a&nbsp; leopard.&rdquo; &ldquo;Acute Pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera. The suddenness of its onset, the illimitable agony which accompanies it, and the mortality attendant upon it, all render it most formidable of catastrophies.&rdquo; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</em>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<em>(Berkeley Moynihan, 1865-1936)</em></p><p> Acute Pancreatitis refers to pancreatic inflammation which may be followed by clinical and biological restitution of the gland, if the primary cause is eliminated. It may involve the entire gland, may present as vasomotor collapse, hypotension, shock and even death (1). It has various modes of presentation, varied laboratory test result and different forms of treatment, ranging from conservative treatment to surgery and both high mortality and morbidity. Males are generally affected more than females in third world countries (2). Severe acute pancreatitis refers to the presence of organ failure and/or local complications (pancreatic necrosis, abscess or pseudocyst) with unfavorable prognostic signs (Ranson&rsquo;s criteria &ge;3 or Acute Physiology and Chronic Health Evaluation [APACHE] II score &ge;8)(3). Early severe acute pancreatitis is characterized by development of organ dysfunction within 72 hours of onset and progressive multi organ dysfunction score (MODS) , early hypoxemia, high CT score, increased incidence of necrosis, infection and abdominal compartment syndrome (4, 5).</p><p> Prior assessment of severity is very important in the management of acute pancreatitis. It helps us to identify high risk&nbsp;&nbsp; patients and to transfer them to an intensive care unit for closer supervision and early interventions. No single parameter, blood test or clinical recording has been found to be consistently accurate in predicting the severity of acute pancreatitis(6). A variety of predictive systems have been developed to meet this goal, but&nbsp; still&nbsp; there is no such sensitive and specific test or severity scoring system that can accurately measure prognosis at admission . The purpose of our study was to compare the predictive efficacy of various severity scoring systems for acute pancreatitis.</p><p> The main aim of the study was to compare&nbsp; association and&nbsp; prognostic relevance of various severity scoring systems - Ranson&rsquo;s criteria, Acute Physiology and Chronic Health Evaluation [APACHE II], BalthazarComputed Tomography Severity Index (BCTSI)&nbsp; and&nbsp; Goris Multi Organ Failure Score (GMOFS) and&nbsp; to&nbsp; determine&nbsp; the&nbsp; most&nbsp; accurate&nbsp; scoring&nbsp; system.</p><div> <p> <strong>Materials and Methods</strong></p> <p> The study was conducted with patients admitted with acute pancreatitis in Medical College, Kolkata between January 2011 to November 2011.&nbsp; Fifty consecutive patients admitted with acute pancreatitis were selected and relevant data studied prospectively, as per the study protocol...
      PubDate: Wed, 28 Nov 2012 04:25:51 +000
  • A Comparative Study of Conventional Wound Irrigants and Their
           Effectiveness in Wound Healing

    • Authors: ahlina
      Abstract: Author(s):  Chatterjee S Basu A Choudhury TK Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  7 Bepin Pal Road, Kolkata – 700026, India Full text:  <p> &nbsp;</p><div> <p> <strong>Materials and methods</strong></p> <p> &nbsp;</p> <p> Over a period of 20 months from May 2010 to December 2011, a total number of 180 patients<br clear="all" /> underwent wound debridement at Medical College, Kolkata, India in Department of General Surgery.</p> <p> &nbsp;</p> <p> Inclusion criterion - Patients with wounds with slough or pus.</p> <p> Exclusion criterion &ndash; Immunocompromised patients.</p> <p> &nbsp;</p> <p> Data on the following aspects were compiled&ndash; History, co morbid factors, past medical history, history of any addiction, antibiotic exposure, type of antibiotic used, investigations (Hematology, Biochemistry, Microbiology), peri-operative management, presence of infective discharge, presence&nbsp; of systemic symptoms, complications, and final outcome&nbsp; after debridement.</p> <p> &nbsp;</p> <p> Types of irrigant and categorization of patients:</p> <p> &nbsp;</p> <p> 1. Every 1<sup>st</sup> case - NS irrigation</p> <p> 2. Every 2<sup>nd</sup> case - sterile water irrigation</p> <p> 3. Every 3<sup>rd</sup> case - H2O2 irrigation</p> <p> 4. Every 4<sup>th</sup> case - PI irrigation</p> <p> 5. Every 5<sup>th</sup> case - nSOS irrigation</p> <p> 6. Every 6<sup>th</sup> case - hypochlorite irrigation</p> <p> &nbsp;</p> <p> The patients were selected from the patients admitted at our hospital for debridement of infected wounds. Linezolid and clindamycin were initially administered to all patients, and then necessary changes made depending on wound culture report. In diabetic patients the blood glucose level was controlled using regular human insulin (soluble). Patients with eczematous lesions near wound site were treated with antibiotic&ndash;steroid ointment locally and anti-histaminics. Patients with local fungal infections were given local clotrimazole ointment with systemic fluconazole.</p> <p> &nbsp;&nbsp;&nbsp;&nbsp;</p> <p> After discharge the patients were reviewed at weekly&nbsp;&nbsp; intervals till two months from the date of last debridement.</p> <p> &nbsp;</p> <p> <strong>Results</strong></p> <p> &nbsp;</p> <p> Over a period of 20 months from May 2010 to December 2011, a total number of 180 patients were<br clear="all" /> followed up who underwent debridement at our Department. Of these, 138 patients were male and 42 patients were females. The age of the patients ranged from 36-82 yrs.</p> <p> &nbsp;&nbsp;&nbsp;</p> <p> We followed a distinct protocol to determine the candidate and irrigant material used as stated above. Thirty patients were included in each group of irrigation.</p> <p> &nbsp;</p> <p> <em>I. Complication rates in presence of co morbid factors </em></p> <p> &nbsp;</p> <p> In contaminated and infected wounds in patients with co morbid factors (diabetes, presence of fungal infection /eczema or any other localized or systemic skin disorder) nSOS remained the irrigant of choice followed by H<sub>2</sub>O<sub>2</sub> and PI. Hypochlorite was not found</p> <p> &nbsp;</p> <p> to be a very useful irrigant, but it gave&nbsp;&nbsp; good results in cases where repeated debridement and sloughectomy was required. NS and sterile water came up to be poor quality irrigants with high complication rates in infected or contaminated wounds (Table 1).</p> <p> &nbsp;</p> <p> Complications included persistence of systemic symptoms, thick pus for more than seven days, osteomyelitis, septicemia, renal or cardiorespiratory failure, amputation or death. &nbsp;</p> <p> &nbsp;</p> <p> Statistical&nbsp; analysis (by&nbsp; Student t-test)<strong>- </strong>Incidence&nbsp; of&nbsp; complications&nbsp; was&nbsp; highest&nbsp; with&nbsp; the&nbsp; use&nbsp; of&nbsp; sterile water&nbsp; irrespective&nbsp; of&nbsp; the&nbsp; presence or absence&nbsp; of&...
      PubDate: Wed, 28 Nov 2012 03:55:44 +000
  • Surgeons as Mentors

    • Authors: ahlina
      Abstract: Author(s):  Sharaf Ibrahim Issue:  Vol. 2 No. 2 : 2012 Correspondance Address:  Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Full text:  <p> The Oxford dictionary defines a mentor as an experienced person in a company or educational institution who trains and counsels new employees or students. For medical students, their initial exposure to surgery were during their clinical years. Although most surgeons were not formally appointed as mentors, they were nevertheless role models for many undergraduates considering a future surgical career. What are the hallmarks of an excellent surgical teacher' A master teacher is passionate and enthusiastic with the ability to make the subject interesting and easily understood by simplifying complex issues. How do we further stimulate the interest of medical students' We can do this by allowing them to assist in surgery. This hands-on approach has a positive influence and may encourage a future career in surgery. Our legacy for the future generation of surgeons is by mentoring trainees and junior surgeons. Mentees work with their mentors and learn surgery not only through formal knowledge but also from tacit knowledge by observing, imitating, and practising (1). As mentors, we expect our mentees to progress both personally and professionally. We should rejoice when they have surpassed our achievements as this is a sign of progress. It takes wisdom and maturity to ensure that there is no professional rivalry between the mentor and the mentee. An Indonesian orthopaedic colleague recently remarked that as mentors we must demonstrate and uphold not only the highest professional values but personal values as well. In many ways, the relation between a mentor and mentee is similar to that between a parent and a child. Teaching and learning are like the two sides of a coin. It is always a two-way process as mentors also benefit by the critical questioning from their mentees leading to further clarity in their own thinking and understanding (2). An old English proverb states that a good surgeon has an eagle&rsquo;s eye, a lion&rsquo;s heart and a lady&rsquo;s hand. To these qualities we must add compassion, sound clinical judgement and mentoring.</p> References:  1. Lam, A. Tacit knowledge, organizational learning and societal institutions. An integrated framework. Organization Studies. 2000; 21(3): 487-513. 2. Rombeau J, Goldberg A, Loveland-Jones C. Surgical mentoring. Building tomorrow’s leaders. New York: Springer; 2010: 15-28 read more
      PubDate: Wed, 31 Oct 2012 09:06:28 +000
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
Tel: +00 44 (0)131 4513762
Fax: +00 44 (0)131 4513327
Home (Search)
Subjects A-Z
Publishers A-Z
Your IP address:
About JournalTOCs
News (blog, publications)
JournalTOCs on Twitter   JournalTOCs on Facebook

JournalTOCs © 2009-