Characteristics of children with newly diagnosed type 1 diabetes mellitus in Brunei Darussalam / Journal of the ASEAN Federation of Endocrine Societies

Objective@#This study aims to characterize the presentation, biochemical status of children with T1DM at diagnosis, the type of subcutaneous insulin regimens initiated, and to determine the incidence of T1DM in Bruneian children aged 18 years and younger.@*Methodology@#A retrospective electronic and paper medical chart review was performed on patients aged 18 years and younger diagnosed with T1DM from 2013 to 2018 in Brunei Darussalam.@*Results@#A total of 31 children with a mean age of 10.2 ± 3.6 years old were diagnosed with T1DM, of which 66.7% presented with diabetic ketoacidosis (DKA), a majority in severe DKA with an intercurrent illness (p=0.021). The mean HbA1c was 13.6 ± 2.7% with a mean serum glucose of 37.0±14.9 mmol/L at diagnosis. In the majority of the children (67.7%), multiple daily injections of subcutaneous insulin were initiated. The incidence of T1DM in children aged 18 years and younger was 4.9 per 100,000 for the year 2018.@*Conclusions@#The majority of the patients in this study presented with severe DKA with an intercurrent illness. This highlights the importance of childhood T1DM awareness among the public and healthcare providers. The incidence of childhood T1DM in Brunei Darussalam is similar to other countries in the Asian region, being relatively low, compared to the rest of the world.

A Rare Case of Dysphagia Secondary to a Large Oesophageal Lipoma

Dysphagia is considered a warning symptom that requires exclusion of significant pathology such as oesophageal cancer, especially in elderly patients. Benign neoplasms of the oesophagus are rare. We report the case of a 69-year-old lady who presented with a five years history of infrequent intermittent dysphagia that had rapidly progressed over one month. This was associated with globus sensation, weight loss, intermittent episodes of stridor and aspiration pneumonia. Investigations revealed a large oesophageal lipoma in the proximal oesophagus extending down to the lower oesophagus. This was successfully resected via a left cervical approach. She remained well two years after the surgery.

Right atrial myxoma: An unusual cause of clinical right heart failure

Myxomas are the most common type of primary cardiac tumour with 86% occurring in the left atrium. Right atrial myxomas is far less common. Patients usually present with progressive dyspnoea, fever, weight loss, right-sided heart failure, or pulmonary embolisation. We report the case of a 55-year-old man who presented with progressive dyspnoea and signs of right heart failure secondary to a large right atrial myxoma, which was diagnosed with a bedside transthoracic echocardiogram. This was successfully removed surgically.

Anabolic steroids induced acute myocardial infarction

Androgenic anabolic steroids are commonly abused by athletes and body-builders to help develope lean body mass and muscular strength to enhance their performance. However, at doses which are much higher than recommended therapeutic dosage, abuse of these drugs is commonly associated with cardiovascular side-effects that can lead to acute myocardial infarction and sudden death. We report here three cases of acute myocardial infarction in local young bodybuilders who were using Stanazolol, an androgenic anabolic steroid, and discuss the pathophysiological mechanisms behind the observed cardiovascular side effects.

Ruptured right atrial appendage secondary to blunt chest trauma

Rupture of one or more cardiac chambers following domestic blunt chest trauma is rare. A positive outcome depends on high level of suspicion and early surgical intervention. We report here an interesting case of a ruptured right atrial appendage in a four year old boy following a blunt crushing injury to the chest and abdomen by a heavy porcelain sink which was successfully repaired. Therefore, accurate diagnosis is very important for appropriate management.

Use of Heartstring aortic seal device with selective epiaortic scanning in OPCAB

Introduction: Excessive manipulation of the aorta in conventional on-pump coronary artery bypass (ONCAB) is associated with postoperative neurological complications. We assessed the results of a protocol of 'minimal-aortic manipulation' in off-pump-CABG (OPCAB) using Guidant Heartstring aortic-seal with selective epiaortic scanning. Materials and Methods: A protocol of 'minimal-aortic manipulation OPCAB' using Heartstring aortic-seals was introduced in patients undergoing OPCAB from January 2005. Data were prospectively collected for one year. Intra-operative epiaortic scanning was selectively used. Mean graft flow and pulsatility index (PI) were routinely measured. Results: Sixty-nine Heartstring aortic-seals were used in 31 patients (23 Male; 8 Female). Mean age and left ventricular ejection fraction (LVEF) were 62.5 ± 10.8 years and 57.8 ± 14.2% respectively. Five patients had intra-operative epiaortic scanning performed. Left internal thoracic artery (LITA) to left anterior descending (LAD) artery was achieved in 100% with mean LITA graft flow and PI of 32.09 ± 19.48 ml/min and 3.26 ± 1.74 respectively. Mean flow and PI in radial artery graft (RAG) and saphenous venous graft (SVG) were 20.47 ± 5.37 ml/min; 1.97 ± 0.31 and 22.84 ± 16.88 ml/min; 3.93 ± 2.83 respectively. There were no postoperative neurological complications or death. Conclusions: Routine use of Heartstring aortic-seals with selective epiaortic scanning in a protocol driven 'minimal-aortic manipulation OPCAB' is safe. The avoidance of partial aorta cross-clamping may translate to a reduction in post-operative neurological complications.

Routine chest drainage after patent ductus arteriosis ligation is not necessary

Introduction Chest drain insertion after surgical patent ductus arteriosus (PDA) ligation creates significant morbidity in terms of pain, pleural space infection, reduced mobility as well as prolonged hospital stay. We investigated the safety and efficacy of performing drainless thoracotomy closure following PDA ligation in a paediatric population. Materials and Methods Retrospective analysis of data collected from 13 paediatric patients undergoing PDA ligation at RIPAS hospital by a single surgeon over a period of five years (2001 to 2006) was performed. All continuous data were presented as mean ± standard deviation. Results PDA ligation was performed via a left thoracotomy in 13 paediatric patients with a mean age of 2.24 ± 2.03 years (ten females and three males). Mean duration of the procedures was 67 ± 12 minutes. There was minimal blood loss and no transfusions were required. Postoperatively, ten patients required only oral paracetamol for pain relief. Two patients required additional non steroidal anti-inflammatory drugs (NSAIDs). One patient had one dose of pethidine immediately post-operatively. Post-operative chest radiographs confirmed full expansion of the left lung except in one patient who had a small apical pneumothorax. Two other patients developed mild surgical emphysema despite full expansion of the left lung. All three complications resolved spontaneously after a day. Median post-operative stay was two days. There were no cases of left recurrent nerve injury and no mortality. Conclusion Routine chest drainage is not necessary following uncomplicated surgical PDA ligation and patients recovered more quickly and were discharged earlier.

Brunei International Medical Journal: Achieving standards with indexing and open access journal status

It has only been six month since the relaunch of the face lifted Brunei International Medical Journal (BIMJ) together with free open online access platform at www.bimjonline.com, BIMJ has made great strides in its aim of achieving high standards. We would like to share some of these achievements with our contributors and readers.

Evaluation of the RIPASA Score: a new appendicitis scoring system for the diagnosis of acute appendicitis

Introduction: We recently developed a scoring system for diagnosis of acute appendicitis. This study prospectively evaluates the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score for the diagnosis of acute appendicitis in patients presenting to the Accident & Emergency department or the Surgical wards with right iliac fossa pain. Materials and Methods: From November 2008 to April 2009, consecutive patients presenting to the Accident & Emergency department or the surgical wards with right iliac fossa pain were recruited for the study. The RIPASA score was applied but the decision for radiological investigations or emergency appendicectomy was made based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived. Ethical approval for the study was obtained from the Medical & Health Review Ethics Committee. Results: Within six months, 144 consecutive patients with a mean age of 29.5 ± 13.3 yrs were recruited to the study. Ninety-eight patients underwent emergency appendicectomy of which 79 were confirmed histologically for acute appendicitis. The observed negative appendicectomy rate was 19.4%. The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. The predicted negative appendicectomy rate was 13.5%, which is a 5.9% reduction from the observed rate of 19.4% (p=0.3). Conclusion: The RIPASA score is a more suitable appendicitis scoring system developed for our local settings with a population that is reflective of our region in South-east Asia and has high sensitivity, specificity and diagnostic accuracy.