Characteristics and Microbiological Profile of Patients with Diabetic Foot Infections in Kuantan, Pahang

@#Introduction: The number of people suffering from diabetic foot infection (DFI) has increased precipitously over the years in Malaysia, owing to increased population, urbanisation, the surge of number of people with obesity and physical inactivity. As one of the most dreaded complications of diabetes mellitus, DFI is associated with high morbidity and mortality. We aim to study the microbiological profile of patients with DFI at a university hospital in Kuantan, Pahang. Materials and methods: This retrospective study was carried out at at Sultan Ahmad Shah Medical Centre @IIUM (SASMEC @IIUM) from 1 January 2018 to 30 April 2019. Patients’ demographic data, types of infection and surgical intervention, and the microbiological profile were obtained from the medical records. Results: A total of 142 causative pathogens were cultured from 130 tissue samples, with an average of 1.09 pathogens per lesion. Majority of the pathogens were gram-negative pathogens (52.8%). Staphylococcus sp. was the most common pathogen isolated (22.5%). This was followed by Streptococcus sp. (10.6%), Pseudomonas sp. (9.2%), Morganella sp. (5.6%), Klebsiella sp. (4.9%), Enterobacter sp. (4.9%), and others. Among the 142 pathogens, there were 9 multidrug-resistant strains observed. Most of the antibiotics were effective against the gram-positive pathogens except benzylpenicillin, tetracyclin, fusidic acid and ciprofloxacin. Meanwhile, cefotaxime, amoxicillin and ampicillin-sulbactam were also not suitable against gramnegative pathogens. Oxacillin and sulfamethoxazole/ trimethoprim can be used as empirical antibiotics against gram-positive pathogens, while vancomycin should be reserved for patients with septic shock or suspected multidrug resistant strain infection. Piperacillin/tazobactam and ceftazidime can be used as empirical antibiotics against gram-negative pathogens. Conclusion: Early initiation of empirical antibiotic(s) is paramount to stymie the infection from getting worse while waiting for the identification of causative pathogens in the management of DFI. This study provides a guide for treating physicians to initiate the most appropriate empirical antibiotic in DFI.

Surgical Management of Distal Tibia Fracture: Towards An Outcome-based Treatment Algorithm

@#Introduction: Distal tibia fractures are frequently associated with an extensive soft tissue injury which then leads to a higher risk of complications such as infection, non-union and eventually poor overall outcome. The purpose of this study is to measure the outcome of distal tibia fractures treated with internal fixation, external fixator or Ilizarov external fixator(IEF). We aim to propose an algorithm for management of distal tibia fractures by evaluating the treatment options, outcomes and risk factors present. Material and Methods: This study is a cross-sectional study of all distal tibia fractures treated surgically in Tengku Ampuan Rahimah Hospital, Klang from 1st January 2016 till 30th June 2018. Patient records were reviewed to analyse the outcomes of surgical treatment and risk factors associated with it. Results: Ninety-one patients were included with a mean age of 41.5 years (SD = 16.4). Thirty-nine cases (42.9%) were open fractures. Thirty-eight patients (41.8%) were treated with internal fixation, 27 patients (29.7%) were treated with IEF and 26 patients (28.6%) were treated with an external fixator. Among open fractures cases, no significant finding can be concluded when comparing each surgical option and its outcome, although one option was seen better than the other in a particular outcome. Initial skeletal traction or temporary spanning external fixator in close fractures reduced the risk of mal-alignment (p value=0.001). Internal fixation is seen superior to IEF and external fixator in close fractures in term of articular surface reduction (p value = 0.043) and risk of mal-alignment (p value = 0.007). Conclusion: There is no single method of fixation that is ideal for all pilon fractures and suitable for all patients. This proposed algorithm can help surgeons in deciding treatment strategies in the challenging management of distal tibia fractures to reduce associated complications.

Neonatal Clavicle Fracture: A Review of Fourteen Cases in East Coast Peninsular Malaysia

Introduction: The purpose of this study is to identify the incidence of clavicle fractures in newborn associated with fetal, maternal and process of deliveries in Kuantan General Hospital from June 2012 until January 2014. This study is to determine epidemiological data of clavicle fractures, maternal and baby risk factors associated with clavicle fractures of newborn and its’ outcome. Methods: This is a prospective study. 13 patients were identified to fulfill the inclusion criteria of the study. The data of sociodemographic, associated fetal and maternal risk factors and the outcomes were recorded using proforma. The statistical data analysis was done using SPSS 12.0. Results: Out of 20,257 live births at our centre during the study period, 13 infants were diagnosed to have clavicle fractures, giving an incidence of 0.64 per 1000 live births. There were 5 (38.5%) left, 7 (53.8%) right and one (7.7%) bilateral fracture. All fractures located at the mid shaft of the clavicle and none have associated brachial plexus injuries. All infants were delivered through vaginal delivery (61.5%); five through assisted delivery (instrumental); 2 (15.4%) forcep and 3 (23.1%) vacuum. Two of the babies developed shoulder dystocia. The average birth weight was 3371 grams (SD 0.269) and mean gestational age was 38.7 weeks (SD 1.16). Five of the mothers (38.5%) were primigravida and eight (61.5%) were multigravida in which,7 (53.8%)were healthy without other co-morbidty, 5 (38.5%) having gestational diabetis and one (7.7%) hypertension. The average maternal weight was 62.0 kg and height 1.58 metres with average BMI of 24.16 (3.29SD). All eventually had a complete recovery at 6 weeks with clinical and radiological evident of fracture union. Conclusions: In conclusion, all patients with clavicle fractures were found following vaginal delivery. There were no associations between neonatal clavicle fractures with maternal or baby risk factors. All fractures healed without any complications.

Surgical Reconstruction in Chronic Posterior Cruciate Ligament Injuries of the Knee

This is a cross-sectional study to evaluate the outcome of posterior cruciate ligament reconstruction in chronic injuries using ipsilateral Bone-patella tendon-Bone graft in nine patients, between January 2000 and January 2003 at our institution. Methods: Eight male and one female patient; their ages ranged from 18 to 36 years old. The surgery was done at an average of 17.2 months (range from 3 and 40 months) post injury. All patients were followed up for a minimum of two years period. The assessment was done at twelve and twenty-four months using Lysholm knee score, IKDC knee examination evaluation score and arthrometric measurement with KT-2000. Results: The result showed only moderate success in restoration of ligament stability with 73.4% satisfactory objective results. However, the functional improvement and patient satisfaction is only 55%. The incidences of degenerative changes were 89% at the time of operation. Conclusion: Surgical reconstruction of chronic Posterior Cruciate Ligament restored satisfactory stability of the knee but the functional outcome was only moderate.