C-reactive Protein, Albumin, Urea, CRP/Albumin Ratio, and Urea/Albumin Ratio: A Retrospective Evaluation in COVID-19 Patients

@#Introduction: C-reactive protein (CRP), urea, albumin, CRP/albumin ratio (CAR) and urea/albumin ratio (UAR) could be valuable biomarkers for determining the severity of illness in patients with COVID-19. This study aimed to determine the association between these markers and disease severity in COVID-19 patients on admission and days five to seven after admission. Methods: This retrospective study includes 153 adult COVID-19 patients admitted to Hospital Raja Perempuan Zainab II and Hospital Ampang from January 2021 to December 2021. Patients’ serum CRP, urea, albumin and creatinine levels were recorded on admission and on days five to seven after admission. The patients were categorised based on the Annex 2e guidelines published by the Ministry of Health, Malaysia and further classified as mild to moderate disease (stages 1-3) and severe to critical illness (stages 4-5). Results: On admission, urea, creatinine, CRP, UAR and CAR were significantly higher in the severe to critical group (p<0.001). The optimal cut-off value for the UAR was 0.16; the area under the curve (AUC) was 0.760, and sensitivity and specificity were 63.6% and 85.7%, respectively. The AUC of the CAR was 0.752, with 54.2% sensitivity and 91.4% specificity at an optimal cut-off value of 1.63. In severe to critical COVID-19 patients, albumin levels decreased significantly on days five to seven after admission, while urea levels remained significantly higher in this group (p<0.001, p<0.05, respectively). Conclusion: CRP, urea, albumin, CAR and UAR are promising biomarkers for predicting the severity of disease in COVID-19 patients.

The Level of N-Carboxymethyllysine and C-Reactive Protein in Type 2 Diabetes Mellitus and it’s Association with HbA1c in Diabetic Nephropathy

@#Introduction: N-Carboxymethyllysine (CML) is involved in diabetic nephropathy (DN) via production of oxidative stress, growth factors and cytokines. C-reactive protein (CRP) is an inflammatory marker associated with diabetes risk. This study is to determine the level of serum CML and CRP in Type 2 diabetes mellitus (T2DM) patients and healthy subjects and to determine the correlation between CML and CRP with glycated haemoglobin (HbA1c) in T2DM patients. Methods: This is a case-control study on 73 T2DM patients without nephropathy, 74 T2DM patients with nephropathy and 73 healthy subjects, aged from 18 to 65 years old. Fasting venous blood was taken and analysed for CML, CRP, HbA1c, and creatinine. The comparisons of serum CML and CRP among the three groups and the correlation between CML and CRP with HbA1c (in T2DM patients) were determined. Results: The differences in CML [median (Interquartile Range) (IQR)] between healthy subjects [131.80 (73.56) ng/ml] and T2DM patients without nephropathy [188.80 (55.95) ng/ml]; between healthy subjects and T2DM patients with nephropathy [237.70 (439.04) ng/ml] were statistically significant (P<0.001). The differences in CRP [median (IQR)] between healthy subjects [1.64 (1.91) ng/ml] and T2DM patients without nephropathy [2.15 (5.64) ng/ml]; between healthy subjects and T2DM patients with nephropathy [4.75 (6.91) ng/ml] were statistically significant (P<0.001). Logistic regression showed CML and CRP are independent predictors of diabetic groups. There was no correlation between HbA1c with CML and CRP in T2DM groups. Conclusion: Since serum CML and CRP are independent predictors of DN, their levels can be used to identify high-risk diabetic patients prone to developing DN.

Serum Procalcitonin (PCT) - Is there a Role as an Early Biomarker in Infected Diabetic Foot Ulcer (IDFU) Patients?

@#Introduction: Infected diabetic foot ulcers may lead to serious complications if not recognised in the early stage. Diagnosis of infection is particularly challenging at that stage; thus, a sensitive inflammatory biomarker may be helpful. We aimed to evaluate the role of procalcitonin (PCT) as an early biomarker for infected diabetic foot ulcers (IDFU). Materials and method: This cross-sectional study was conducted at Klinik Rawatan Keluarga (KRK), Orthopedic clinic and wards in Hospital Universiti Sains Malaysia (USM) from May 2020 to December 2020. A total of 264 participants were recruited and divided into three groups: 50 diabetic patients with no ulcers (control), 107 patients with non-infected diabetic foot ulcers (NIDFU), and 107 patients with infected diabetic foot ulcers (IDFU). The level of PCT was taken for all patients. Total white count (TWC) and Creactive protein (CRP) were taken only for IDFU patients. Diagnosis of infection was based on the Infectious Disease Society of America-International Working Group of Diabetic Foot (IDSA-IMWGDF), and the severity of infection was graded according to the Wagner Classification. Results: The level of PCT was higher in IDFU than in NIDFU and diabetic patient, with a median (IQR) of 0.355 (0.63) ng/mL, 0.077 (0.15) ng/mL and 0.028 (0.02) ng/mL, respectively. PCT and CRP showed moderate positive correlations in IDFU patients (p<0.001). The sensitivity and specificity were 63.6% and 83.2%, respectively, at the best cut-off at 0.25 ng/mL. Conclusion: PCT is a valuable biomarker for the diagnosis of infection; however, it adds little value in the early diagnosis of IDFU in view of its low sensitivity.

A Systematic Review of the Role of Mitochondria in Cleft Pathology: A Forgotten General?

ABSTRACT@#Orofacial clefts (OFC) are one of the most common birth defects that affects the lip, palate, or lip and palate of an infant. The deterioration of clefts is multifactorial involving multiple genes, various interactions from environmental factor and most forgotten, mitochondrial abnormality. The aim of this review is to highlight the importance of mitochondrial activity related to non-syndromic OFC deformity. Despite its important role in cells, the study on mitochondrial activity in cleft pathology was scarce and almost forgotten compared to other genetic investigations. This systematic review was completed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. The literature search was done via the following databases: Google Scholar, Pubmed and Scopus with a total of nine studies of mitochondrial abnormalities were included. We hypothesise that mitochondria play an important role in early craniofacial development. A decreased in its function or activity may result in cleft lip formation. Hence, we would like to shed light on the remarkable role of mitochondria activity in the pathogenesis of non-syndromic OFC.

The Frequency and Cost of Redundant Biochemistry Test in Tertiary Teaching Hospital

@#Introduction: Laboratory tests account for 66% of clinical decision making and reducing inappropriate test utilisation is a step towards optimising patients’ care and hospital cost savings. This study aims to identify the rate and cost of redundant test requests in our centre. Methods: A cross-sectional study comprising laboratory results of 14 analytes in renal function test (RFT) and liver function test (LFT) were made. Data involved blood results from adult patients admitted to Hospital Universiti Sains Malaysia from January to December 2018. The redundant test is defined as test results consecutively normal twice and requested within 26 hours for analytes in RFT and 50 hours for analytes in LFT. Cost contributions were estimated by multiplying cost-per-test with total redundant requests. The test redundancy in different wards and disease groups were also evaluated. Results: Equal distribution of RFT and LFT requests were observed in both genders (50% respectively), with the most requests seen in the 60 – 79 years age group. More than 20% redundancy rate was observed for seven analytes (ALT, total bilirubin, sodium, urea, potassium, AST, Chloride), and overall redundancy was 19.7%, equals to Malaysian Ringgit (MYR) 669,105.00. Oncology wards and genitourinary diseases contribute to the highest redundancy rate. Conclusion: This study estimated MYR 600 thousands of saving if test redundancy were to be eliminated. The finding is hoped to serve as a platform for future intervention and policymaking. Future planning to optimise the current laboratory request system and collaboration among physicians and laboratory professionals can minimise test inappropriateness.

Lower eyelid fornix deepening: A new indication for the facial artery myomucosal flap

Eye socket contracture is a well-known late complication of enucleation surgery, and the additional insult of radiotherapy at an early age causes even further fibrosis and scarring of the socket. Management of the contracted socket is challenging, and several methods have been proposed. We report a case of eye socket contracture after enucleation and radiotherapy in which multiple reconstructive procedures failed. The recurrent contracture caused difficulty in housing and retaining the eye prosthesis. We reconstructed the lower eyelid with a facial artery myomucosal flap and nasolabial flap, and the upper eyelid with a Fricke flap following reconstruction of the orbital rims (supraorbital and infraorbital rims with a calvarial bone graft, and further augmentation of the infraorbital rim with a rib bone graft). Cosmesis post-reconstruction was acceptable and the prosthesis was retained very well.

Inappropriate Positioning of Separator Gel in Blood Collection Tube: A Case Report

@#Blood collection tubes containing separator gel are widely used in many clinical laboratories because of easy to use, convenience and several other advantages. However, they are not void of limitation. We describe an unusual case with a floating separator gel in the primary blood collection tube. The blood sample was collected into a BD Vacutainer SST II Advance tube, from a 51 years old man admitted for community acquired pneumonia and had history of hyperproteinaemia. Inappropriate positioning of the separator gel was observed after centrifugation, whereby the separator gel floated above the serum. Detection of abnormal separator gel floatation pattern in this patient’s sample before analysis had prevented potential technical problem and production of erroneous result caused by aspiration of separator gel. The limitation of blood collection tube with separator gel especially in patients with hyperproteinaemia should be made aware among laboratory personnel and physicians.

Acute Suppurative Thyroiditis Secondary to Tuberculosis with Superimposed Bacterial Infection: A case report / Journal of the ASEAN Federation of Endocrine Societies

@#Acute suppurative thyroiditis is a rare and potentially fatal condition. We present a case of an 18-year-old Malay female who presented with one-week history of painful right sided neck swelling, fever and odynophagia. Neck CT confirms ruptured multiloculated abscess with posterosuperior extension into prevertebral space. Pus and tissue cultured Streptococcus anginosus and Eikenella corrodens with positive TB PCR. She responded well to ampicillin/sulbactam and anti-tuberculosis treatment with no evidence of residual collection from ultrasound.

Epidemiology of surgically treated patient in road traffic accident with lower extremity vascular injury from a single centre in Kelantan

@#Introduction: Lower extremity vascular injury can result in either temporary or permanent disability. Methods: This is a clinical audit involving all patients admitted to our institution from January 2008 to June 2018 of those who had undergone revascularization surgery for lower limb trauma. Results: Fifty-nine patients were in this study with a mean age of 28.1 years. Most of the patients were motorcyclist involved in road traffic accidents with cars (n=30, 50.8%). The popliteal artery was most commonly seen injury (n=41, 69.5%). The mean duration of ischaemia was 14.1 hours. The limb salvage rate was 89.8%. Conclusion: Lower extremity vascular injury caused by RTA treated in our institution predominantly involved young patients aged between 18–30 years associated with long bone fractures causing contusion and thrombosis of the popliteal artery.

Successful ankle replantation in two cases with different presentations

We report our experience of treating two patients with ankle amputation with different presentations. The first case was a clean-cut sharp amputation. The second case was an avulsion injury following a motor vehicle accident in a patient who arrived 8 hours after the injury. Replantation was successful in both cases. In avulsion injuries, a secondary operation for wound coverage is required at a later stage. With good strategy and a support team, encouraging limb survival outcomes are possible post-replantation.

A 20-year experience of immediate mandibular reconstruction using free fibula osteocutaneous flaps following ameloblastoma resection: Radical resection, outcomes, and recurrence

BACKGROUND: The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma. METHODS: This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved. RESULTS: Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years. CONCLUSIONS: Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.

Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate

BACKGROUND@#Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early results in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft.@*METHODS@#A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty.@*RESULTS@#In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes.@*CONCLUSIONS@#Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.

Functional Outcome after Treatment of Aggressive Tumours in the Distal Radius: Comparison between Reconstruction using Proximal Fibular Graft and Wrist Fusion

@#Introduction: Restoration of a functional hand is the ultimate goal following a distal radius tumour resection. The early outcomes of mobile wrist reconstruction are satisfactory; however, long-term results are unpredictable due to late wrist instability and degenerative arthritis. Our aim is to compare mobile wrist reconstruction with wrist fusion (pan-carpal fusion) in our cohort of patients. Materials and Methods: A retrospective cohort study was performed for functional outcomes of all patients who underwent resection for distal radius tumour and treated with either fusion or reconstruction of the wrist in a single institution from years 2000-2013 with a minimum of three years follow-up. Results: Eleven patients were included in the study, six of whom had wrist reconstruction with proximal fibula graft and the remaining five wrist fusion, with a mean follow-up of 6.3 years. The mean Musculoskeletal Tumour Society (MSTS) score was 82.78%, ranging from 70% to 93.3%. Average grip strength compared to the normal contralateral hand was 60.0% for total wrist fusion, which was better than wrist reconstruction with 58.07%. There was no difference in the functional outcome between fusion and mobile reconstruction in our study. Osteoarthritis changes and subluxation of the wrist joint were the most common findings in the long-term follow-up for this group. Conclusion: There was no difference in the functional outcome of the long-term follow-up between the two groups.

Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction

mortality and an important cause of morbidity in Malaysiafor several years. To reduce global cardiovascular (CV) riskin the population, primary preventive strategies need to beimplemented. Hypercholesterolaemia is one of the majorrisk factors for CVD. This paper is an expert review on themanagement of hypercholesterolemia focusing on high andvery high risk individuals. In low and Intermediate riskindividuals, therapeutic lifestyle changes (TLC) and ahealthy lifestyle alone may suffice. In high and very high riskindividuals, drug therapy in conjunction with TLC arenecessary to achieve the target LDL-C levels which havebeen shown to slow down progression and sometimes evenresult in regression of atherosclerotic plaques. Statins arefirst-line drugs because they have been shown in numerousrandomized controlled trials to be effective in reducing CVevents and to be safe. In some high risk individuals, despitemaximally tolerated statin therapy, target Low DensityLipoprotein Cholesterol (LDL-C) levels are not achieved.These include those with familial hypercholesterolaemia andstatin intolerance. This paper discusses non-statintherapies, such as ezetimibe and the newer Proproteinconvertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

The use of facial artery musculomucosal (FAMM) readvancement flap in closure of recurrent oronasal fistula

High failure rate for recurrent palatal fistulas closure pose agreat challenge to plastic surgeons. Tongue and facial arterymusculomucosal (FAMM) flaps are the more commonly usedflaps for closure of these recurrent fistulas. We report a caseof a formerly inset FAMM flap to effectively close apreviously repaired oronasal fistula.

Alopecia secondary to repaired occipital encephalocele - role of tissue expander in hair restoration

evere social and psychological problems. Tissueexpansion, although an old concept, provides a surgicalalternative to manage areas of alopecia. We describe a caseof alopecia secondary to repaired occipital encephalocelethat was successfully treated using tissue expansiontechnique.

Early Vessels Exploration of Pink Pulseless Hand in Gartland III Supracondylar Fracture Humerus in Children: Facts and Controversies

The management of pink pulseless limbs in supracondylar fractures has remained controversial, especially with regards to the indication for exploration in a clinically well-perfused hand. We reviewed a series of seven patients who underwent surgical exploration of the brachial artery following supracondylar fracture. All patients had a non-palpable radial artery, which was confirmed by Doppler ultrasound. CT angiography revealed complete blockage of the artery with good collateral and distal run-off. Two patients were more complicated with peripheral nerve injuries, one median nerve and one ulnar nerve. Only one patient had persistent arterial constriction which required reverse saphenous graft. The brachial arteries were found to be compressed by fracture fragments, but were in continuity. The vessels were patent after the release of obstruction and the stabilization of the fracture. There was no transection of major nerves. The radial pulse was persistently present after 12 weeks, and the nerve activity returned to full function.

Inconspicuous Nasoethmoidal Encephalocele Might Be Wrongly Diagnosed

No abstract available.

Acute coronary syndrome in the elderly: the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry

<p><b>INTRODUCTION</b>The elderly are often underrepresented in clinical trials for acute coronary syndrome (ACS), and cardiologists commonly face management dilemmas in the choice of treatment for this group of patients, particularly concerning the use of invasive revascularisation. This study analysed the characteristics of hospitalised elderly patients with ACS, and compared the outcomes of treatments.</p><p><b>METHODS</b>From 29 December 2005 to 26 April 2010, 13,545 patients were admitted for ACS in 16 hospitals across Malaysia. These patients were divided into two groups - elderly (≥ 65 years) and non-elderly (< 65 years). The clinical characteristics, treatment received (invasive or non-invasive) and outcomes (in-hospital and 30-day all-cause mortality) of the two groups were compared. The elderly patients were then grouped according to the type of treatment received, and the outcomes of the two subgroups were compared.</p><p><b>RESULTS</b>Elderly patients had a higher cardiovascular risk burden and a higher incidence of comorbidities. They were less likely to receive urgent revascularisation for acute ST-segment elevation myocardial infarction (elderly: 73.9% vs. non-elderly: 81.4%) and had longer door-to-needle time (elderly: 60 minutes vs. non-elderly: 50 minutes, p = 0.004). The rate of cardiac catheterisation was significantly lower in the elderly group across all ACS strata. Elderly patients had poorer outcomes than non-elderly patients, but those who received invasive treatment appeared to have better outcomes than those who received non-invasive treatment.</p><p><b>CONCLUSION</b>Elderly patients with ACS tend to be undertreated, both invasively and pharmacologically. Invasive treatment seems to yield better outcomes for this group of patients.</p>

Acute vascular complications (flap necrosis and congestion) with one stage and two stage distally based sural flap for wound coverage around the ankle

Introduction: The understanding of the skin’s vascular anatomy has improved in the last decade. It has lead to technique modification such as the staged procedure in performing sural flaps and improvement in the flap survival rate. The aim of this study was to evaluate the acute vascular complications (flap necrosis or congestion) of 29 patients who underwent distal base sural flap for coverage of wound around the ankle. Methods: Twenty-four males and five females with a mean age of 37.1 years old underwent sural flap surgery to cover wounds at around the ankle. There were 12 cases of open fracture, five infected fractures, four spoke injuries, four degloving injuries and four diabetic foot ulcers. Twentythree cases were done as a single stage procedure while six as a two-stage procedure. The flaps were tunnelled under the skin in three cases. Results: Twenty one flaps healed uneventfully, seven acute vascular complications occur in a single stage group: five developed partial necrosis, one had congestion with epidermolysis, and one had complete flap necrosis. Complications were treated by dressing or skin grafting and only one required a repeat flap surgery. Conclusions: Acute vascular complications may be minimised when sural flap is done in stages for elderly, diabetic, smokers and/or patients with large wound around the ankle. Even if the flap appears necrotic, the underlying structure may still be covered as the fasciosubcutaneous layer of the flap may still survive.