History of severe hypoglycemia in Type 2 Diabetes Mellitus Unmasked Significant Atherosclerotic Coronary Artery Disease: A comparative case control study / Journal of the ASEAN Federation of Endocrine Societies

Objectives@#A history of severe hypoglycemia (SH) is associated with cardiovascular (CV) events among patients with type 2 diabetes mellitus (T2DM). In this study, we compared the severity of atherosclerotic coronary artery disease (ACAD) in T2DM patients with and without a history of SH.@*Methodology@#We conducted a comparative case-control study involving 28 T2DM patients with a history of SH within the last 5 years with no documented ACAD, and matched them with 28 T2DM patients with no history of SH. All subjects underwent coronary artery calcium scoring (CACS) with or without coronary computed tomographic angiography (CCTA) to evaluate the severity of ACAD.@*Results@#A history of SH in T2DM was associated with a higher prevalence of significant ACAD (79% versus 46%, p=0.026). A high CACS (≥100) was seen in a greater number of patients with a history of SH compared to those without (75% versus 43%, p=0.029). Similarly, there was a higher prevalence of obstructive CAD in those with a history of SH compared to those without (72% versus 39%, p=0.036). Median C-reactive protein level was also higher among patients with a history of SH (0.41 mg/dL versus 0.16 mg/dL, p=0.029).@*Conclusion@#In patients with T2DM, a history of SH is significantly associated with ACAD compared to those without SH. A history of SH warrants screening for ACAD.

Sonographic nomogram of paediatric renal size in Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)

@#Introduction: A person’s childhood is an important period of growth, and also one’s most vulnerable, as one can be exposed to various pathologies, for example those that could affect the growth of one’s kidney. Asians are physiologically different from Caucasians, and the nomogram renal size obtained from a Western population (mostly of Caucasians) is not be suitable for representing Asian children. As such a nomogram on paediatric renal size derived from Malaysia is needed. Methods: A total of 109 (64 males and 45 females) aged 0-12 in Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM) took part in this study. They underwent ultrasonography of both kidneys, and their demographic and anthropometric data were collected. The mean and standard deviations of the renal length and renal volume according to their age groups was calculated, and the final data was compared to the ones reported by Rosenbaum et al. (1984). Result: Body weight and Body Surface Area (BSA) of the children reported the strongest correlation with renal size. Significant differences were found between local and the data from Rosenbaum et al (1984). A nomogram on paediatric renal size based on children in PPUKM was then created. Discussion: Ultrasonography is regarded as the standard method for determining renal size. Body weight and BSA were both strongly correlated with renal size. It was shown that the widely used nomograms derived from data obtained from Caucasian was not suitable to represent the population of Malaysian children.

Image Quality of Coronary CT Angiography (CCTA) using 640-slice Scanner: Qualitative and Quantitative Assessments of Coronary Arteries Visibility (Kualiti Imej Tomografi Berkomputer Angiografi Koronari Menggunakan Mesin Pengimbas 640 Hirisan: Penilaian Kualitatif dan Kuantitatif ke atas Keterlihatan Arteri Koronari) / Jurnal Sains Kesihatan Malaysia

@#The purpose of this study was to evaluate the image quality and diagnostic accuracy of coronary computed tomography angiography (CCTA) using 640-slice scanner. Advancement of multidetector computed tomography (MDCT) technology with higher spatial, temporal resolution, and increasing detector array have improved the image quality and diagnostic accuracy of CCTA. A total of 25 patients (12 men and 13 women) underwent CCTA examination was chosen and data was acquired by 640-slice scanner. All 16 segments of coronary arteries were evaluated by two reviewers using a 4-likert scale for qualitative assessment. In quantitative assessment, the evaluation of 4 main coronary arteries were analysed in terms of signal intensity (SI), image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). All 25 patients with a mean age of 52.88 ± 14.75 years old and body mass index (BMI) of 24.24 ± 3.28 kg/m2 were analysed. In qualitative assessment, from the total of 400 segments, 379 segments (95%) had diagnostic value while 21 segments did not have diagnostic value, which means 5% artefact was detected. In quantitative assessment, there was no statistical differences in gender, race, and BMI (p>0.05). Overall evaluation showed that higher SI at the left main artery (LM) at 393.7 ± 47.19. Image noise was higher at right coronary artery (RCA) at 39.01 ± 13.97. SNR and CNR showed higher at left anterior descending (LAD) with 12.73 ± 5.17 and LM 9.14 ± 4.2, respectively. In conclusion, this study indicates that 640-slice MDCT has higher diagnostic value in CCTA examination with 95% vessel visibility with 5% artefact detection.

Radiation Dose Comparison in CT Thorax, CT Abdomen and CT Thorax-Abdomen-Pelvis (TAP) Using 640-and 160-Slice Computed Tomography (CT) Scanners (Perbandingan Dos Sinaran dalam Pemeriksaan Tomografi Berkomputer (CT) Toraksik, Abdomen dan Toraksik-Abdomen-Pelvis (TAP) antara 640 dan 160 Hirisan) / Jurnal Sains Kesihatan Malaysia

@#This study was carried out to compare the effective dose, size specific dose estimation (SSDE) and scan length between genders and between CT scanner with different slice number. A total of 245 set data of radiation dose and scan length for CT scanning procedure involving thorax, abdomen and pelvis regions were obtained retrospectively for comparisons. 111 patients (60 males and 51 females) were scanned using 160-slices CT scanner while 134 patients (71 males and 63 females) were scanned using 640-slices CT scanner. Generally, there were no significant differences in the radiation dose and scan length among genders. However, differences for SSDE in CT thorax and CT thorax-abdomen-pelvis (TAP) protocols exist whereby in CT thorax protocol, 640-slices CT scanner had a significantly higher value of SSDE (9.06±2.67 mGy) than that in 160-slices CT scanner (7.82±1.33 mGy). Similarly to the CT TAP protocol, whereby 640-slices CT scanner had a significantly lower value in SSDE (9.17±1.59 mGy) than that in 160-slices CT scanner (10.76±3.72 mGy). In conclusion, there was no significant difference in the radiation dose and scan length between genders but significant difference was only observed in SSDE due to the presence of body size variation among the study population especially in different CT scanners.

Radiation Dose Management in Fluoroscopy Procedures: Less is More? / Jurnal Sains Kesihatan Malaysia

The aims of this study are (1) to determine the scattered radiation dose levels in routine fluoroscopy procedures and (2) to compare them with the equivalent chest x-rays and also (3) to monitor common techniques and radiation safety measures taken by the medical officers. The study covered a sample of 105 fluoroscopic procedures performed by 18 medical officers. Each officer wore a personal pocket dosimeter inside the lead gown during each procedure. A digital dosimeter was placed near the detector of the fluoroscopy unit while a survey meter was positioned at the control panel area to record the dose levels. There were 14 types of examination included in this study. The total number of images captured was found to be the highest in barium swallow examination with 115 images, almost five times higher compared to the common practices. The longest screening time was observed in barium enema examination which is 9.15 seconds. The median of the scattered dose level was the highest in barium meal examination (165.50 μSv) which is equivalent to 8.28 times of average dose impart by chest x-ray examinations. The number of images and the length of screening time depend on the competency levels of the medical officers. They capture as many images as possible to avoid missing any abnormalities, therefore it will always be better if the fluoroscopist is consulted during each case. They should also consistently practice essential protection by minimizing exposure time, maximizing distance from the source tube and utilizing the radiation shielding.

Association of Cobb angle progression and neuraxial abnormality on MRI in asymptomatic Adolescent Idiopathic Scoliosis

Background: Detection of neuraxial abnormality in neurologically asymptomatic adolescent idiopathic scoliosis (AIS) is crucial prior to surgery. It can only be detected on magnetic resonance imaging (MRI), which was not routinely done in this group of patient. On the other hand, whole spine radiographs for measurement of Cobb angle have been routinely included during clinic follow-up. This study aimed to determine the correlation between Cobb angle progression and neuraxial abnormality finding on MRI in asymptomatic AIS. Methods: A retrospective study was conducted in the Orthopaedic department of a tertiary hospital. Patients with asymptomatic AIS aged 10-20 years who attended scoliosis clinic from year 2007 to 2010 was reviewed. Patients who had whole spine MRI and two vertebral radiographs at least one year apart were further selected. Statistical analysis was done to see the association between Cobb angle progression and neuraxial abnormality on MRI. Results: The mean age at first presentation was 14.4 years old. Female (n=249) to male (n=50) ratio was 5:1. Only 19 patients fulfilled the selection criteria. There were 5 patients (26.3%) who had neuraxial abnormalities. The mean curve progression was 7.05° (range from -5° to 28°). Patients with and without neuroaxial abnormality showed mean curve progression of 0.6º and 9.36° respectively. There was no significant association between Cobb angle progression and neuroaxial abnormality (p=1.000). Conclusion: Cobb angle progression is not a reliable indicator for predicting neuroaxial abnormality in patients with asymptomatic AIS. However, this study stressed the need to perform MRI prior to operation to document any associated neuraxial abnormality in clinically asymptomatic AIS patients.

Polyps! Polyps! And More Polyps! - The First Case of Cronkhite-Canada Syndrome in Malaysia

Cronkhite-Canada Syndrome (CCS) is a syndrome characterised by a constellation of signs including but not limited to onychodystrophy of the finger and toe nails, skin hyperpigmentation and alopecia. Endoscopic features showed hamartomatous polyps involving all segments of the gastrointestinal tract with the characteristic exception of being oesophageal sparring. These polyps show confirmation by the presence of eosinophils and mast cells at the lamina propria upon histological studies.

Renal doppler assessment in differentiating obstructive from non-obstructive hydronephrosis in children

background: to determine the usefulness of Doppler ultrasound measurement of resistive index (RI) in differentiating obstructive from non-obstructive hydronephrosis in children. Methods: From August 2011 to November 2012, renal Doppler assessments of the intra-renal renal arteries were performed on 16 children (19 kidneys) with congenital hydronephrosis. the independent t-test was used to assess for significant difference in RI values between those with obstructive hydronephrosis (6 kidneys) and those with non-obstructive hydronephrosis (13 kidneys) as determined by dynamic renal scintigraphy. the assessor was blinded to the clinical findings and scintigraphy results. Results: RI was significantly different between obstructive and non-obstructive hydronephrosis. Obstructive hydronephrosis returned higher RI values, with mean RI of 0.78. Mean RI in non-obstructive hydronephrosis was 0.70, and the difference was significant (p <0.05). the sensitivity and specificity of Doppler ultrasound were 100% and 53% respectively. conclusion: Doppler ultrasound measurement of resistive index is useful in differentiating obstructive from nonobstructive hydronephrosis and provides an alternative non-ionizing investigation other than dynamic renal scintigraphy.

Contrast enhanced Voiding Urosonography (ce-VUS) as a radiation-free technique in the diagnosis of vesicoureteric reflux: Our early experience

Objective: Contrast-enhanced ultrasound has become increasingly utilised as an alternative imaging modality for the diagnosis of vesicoureteric reflux (VUR) in paediatric patients. The study objective is to evaluate the efficacy of contrast enhanced Voiding Urosonography (ce-VUS) compared with fluoroscopic micturating cystourethrography (MCU) in the detection of VUR. Methods: This prospective study was carried out between July 2011 and January 2013 on paediatric patients who underwent MCU. All consented patients would undergo ceVUS prior to MCU. We documented the epidemiology details, the number of Kidney-Ureter (K-U) unit studied, baseline renal and bladder sonogram, as well as presence of VUR on ce-VUR. The technique for ce-VUS was standardized using normal saline to fill the bladder prior to administration of SonoVue® (2.5 ml) to assess the kidney-ureter (K-U) unit. Dedicated contrast detection software was used to discern the presence of microbubbles in the pelvicaliceal system (PCS). The findings were then compared with MCU. Results: 27 paediatric patients were involved in the study [17 males (63%) and 10 females (37%)] involving 55 K-U units (one patient had a complete duplex system). MCU detected VUR in 10 K-U units while ce-VUS detected VUR in 8 out of the 10 K-U units. There were 2 false negative cases (both Grade 1) with ce-VUS. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of ce-VUS were 80%, 98%, 95%, 89% and 96%, respectively. Conclusion: ce-VUS is a sensitive and specific radiation-free alternative for the detection of VUR in the paediatric population.

Radiation Dose Comparison between Intravenous Urography (IVU) and Unenhanced Helical Computed Tomography (UHCT) Urography / Jurnal Sains Kesihatan Malaysia

Intravenous urography (IVU) and unenhanced helical computed tomography (UHCT) urography are the two main procedures performed in the radiological investigation for urolithiasis (urinary stone). However, exposure to ionizing radiation is the main concern in both procedures. Therefore, a dose comparison study was conducted between IVU and UHCT urography procedures to determine the optimum exposure parameters in this study. An anthropomorphic whole body phantom was used following the exact procedure of UHCT urography and series of imaging for IVU with an administration of contrast media. Three different exposure parameters were used for IVU with 75 kVp, 80 kVp and 85 kVp while 100 kVp, 120 kVp and 140 kVp for UHCT urography respectively. As a result, the radiation doses for IVU were 1.40 mSv, 2.10 mSv and 2.79 mSv corresponding to 75 kVp, 80 kVp and 85 kVp. On the other hand, the radiation doses for UHCT urography were 0.76 mSv, 1.32 mSv and 1.82 mSv for 100 kVp, 120 kVp and 140 kVp, respectively. However the optimum image was obtained at 85 kVp for IVU and 120 kVp for UHCT urography. In conclusion, the doses obtained from IVU were consistently higher than UHCT urography but not signifi cantly different

Observation of Ureteric Diameter in Negative Intravenous Urogram in Hospital Universiti Kebangsaan Malaysia

Background: This study observed the widest ureteric diameter in negative intravenous urogram (IVU) examinations using low osmolar contrast media. Methods: We reviewed a total of one hundred and eighty four ureters from 92 negative IVUs. Results: The results show a mean diameter for the abdominal ureter of 4.19 mm with an SD of 1.27 mm and a mean pelvic ureteric diameter of 4.45 mm with an SD of 1.37 mm. The upper limits for abdominal ureter and pelvic ureter based on a confidence interval of 95% were 4.37 mm and 4.64 mm, respectively. Conclusions: There was no significant difference between the right and left ureteric diameter in both female and male subjects. There was no significant correlation between ureteric diameters and the age of subjects, from the second to the eighth decades.