Mechanical thrombolysis as an adjunct therapy to management of portal vein thrombosis following Radio Frequency Ablation.

Radiofrequency ablation (RFA) has evolved to become the treatment of choice for non-resectable recurrent colorectal liver metastasis. It is however, not without complications. Portal vein thrombosis following RFA is rare but can be fatal to the outcome of the patient. Here, we present a case of a 66-year-old man who developed portal vein thrombosis following RFA. CT scan revealed a left portal vein thrombosis. This case report highlights the challenges and multimodal treatment of portal vein thrombosis following Radiofrequency ablation (RFA) in a cirrhotic patient.

Resolution of Acanthosis Nigricans Following Curative Gastric Carcinoma Resection.

We discuss a 48-year old, who presented with upper epigastrium pain associated with early satiety and significant weight loss. Physical examination revealed a thickening and darkening of skins around the skin folds, scalp, back and front of abdomen. A diagnosis of gastro-esophageal junction adenocarcinoma was confirmed by oesophagogastroduodenoscopy (OGDS) and biopsy. The biopsy of the skin lesion revealed a diagnosis of acanthosis nigricans, He underwent a total gastrectomy followed by adjuvant chemo-radiotherapy. Recovery is unremarkable. Interestingly, the skin lesions disappear following our therapy. We believe this may be attributed to the treatment of the malignancy. We highlight the interesting association, pathophysiology and therapy.

Training exposure and confidence level among medical officers: Does an Emergency Physician make a difference?

BACKGROUND AND PURPOSE: The training of emergency medical officers has always been informal. Only recently, the presence of emergency physician may have a positive influence in their training and development. This study aims to determine the effect of Emergency Physician (EP) presence on the training exposure and confidence level of medical officers in their practice. MATERIALS AND METHODS: Questionnaires were mailed to all ED (emergency department) medical officers working in 130 Malaysian Ministry of Health hospitals. They were required to answer the 14-item questionnaire, which includes demographic section, training modalities available and confidence score of listed clinical scenarios related to their work practice. RESULTS: The response rate was 41.3% (n=217). Only 210 questionnaires were complete for analysis. There were more responses gathered from ED medical officers with EP (123 vs 87). ED medical officers working with in-house EP were exposed to more training modalities as compared to their counterparts in ED with absence of EP. All five responses (100%) that stated that there was no training available in their department came from ED without EP. Total confidence score was found to be significantly higher among ED medical officers in ED with EP presence (mean score 132.5 versus 120.45; p<0.001; 95%CI: 6.526-17.58). CONCLUSIONS: Presence of EP in the ED have positive influences on medical officers training exposure and hence confidence level in performing their clinical duties.

Novel usage of fresh frozen plasma in hereditary angioedema.

Hereditary angioedema (HAE) is a rare and potentially life threatening autosomal dominant disease characterized by recurrent episodes of cutaneous and mucosal oedema. It results from reduced expression or loss of function of CI-esterase inhibitors (C1-INH). As opposed to the more common histamine-mediated angioedema, HAE does not respond well to conventional treatments with anti-histamines, steroids and adrenaline. Early recognition and timely intervention with the correct treatment are crucial particularly preventing airway obstruction. New disease specific treatment including plasma derived or recombinant C1-INH, ecallantide and icatibant have recently emerged and its appropriate use can reduce HAE-associated mortality and morbidity. However due to its costs, these disease specific treatments have yet to reach Malaysia. Despite that no randomized clinical trial on FFP has been performed, its efficacy in treating acute attacks of HAE is only demonstrated in case studies. This case report illustrates the successful treatment of acute HAE episode with FFP in a Malaysian government hospital setting.

Male ductal carcinoma in situ (DCIS): treatment strategies in this rare entity.

Ductal carcinoma in situ (DCIS) in females is a recognized premalignant disease. However, its occurrence in males is rare. Articles describing this disease are scarce with documented occurrence is less than 7% worldwide. We report a case of 52 year-old gentleman presented with 6 months history of left breast lump. It was painless with no nipple discharge. Despite an inconclusive biopsy, lumpectomy was performed in view of the suspicion of malignant disease. Histopathology confirms DCIS. He underwent mastectomy and sentinel lymph nodes. Most treatment strategies are based on evidence on female breast malignancy and modifications are needed due to the different pathological pathway in male.

Randomized Controlled Trial Comparing Daycare and Overnight Stay Laparoscopic Cholecystectomy.

BACKGROUND: This present study sought to review the feasibility and patients' satisfaction of laparoscopic cholecystectomy to be perform as daycare procedure. MATERIAL AND METHODS: Sixty-two patients with symptomatic gallstones were recruited within a year. They were randomized into overnight stay and daycare groups. The outcomes and post-operative complications were analyzed. RESULTS: Fifty-eight patients were eligible for analysis and four patients were excluded because of conversion to open cholecystectomy. All patients in daycare group reported no fever but two patients in the overnight stay group complaint of post-operative fever (p=0.150). The mean pain score using Visual Analogue Score (VAS) in daycare group was 2.93 but in the overnight stay was recorded as 3.59 (p=0.98). Five patients had post-operative nausea and vomiting (PONV) in daycare group compared to 2 patients in the overnight stay group (p=0.227). Patient's satisfaction were higher in the daycare group (p=0.160). All patients in daycare group were back at work within a week but in overnight stay, 11 patients had to stay off work for more than one week (p=0.01). CONCLUSIONS: Daycare laparoscopic cholecystectomy is safe and feasible. The satisfaction of daycare surgery is higher than overnight stay group. Patients' selection is an important aspect of its success.

White gauze test: a novel technique in preventing post-hepatectomy bile leak.

BACKGROUND: Post-hepatectomy bile leak may lead to undesired morbidity. Multiple methods have been employed to identify this leak but can be inconclusive and taxing. This novel white gauze test is a simple and reliable method. MATERIALS AND METHODS: This is a prospective study performed from January 2010 until March 2011. All open hepatic resection were included. Dry white gauze is compressed onto the transected surface and observed for bile staining. The leaking duct is repaired immediately upon detection. The process is repeated until negative. Drain was removed on postoperative day-5. Post-operative bile leak is defined as: 1. Bilirubin concentration of the drain fluid is 3 times or higher than serum; 2. Presence of intra-abdominal bile collection on imaging and upon drainage; 3. Bile leak demonstrated on postoperative cholangiography. RESULTS: 42 patients were recruited. Seven (16.7%) patients were cirrhotic with Child-Pugh A. White gauze test were positive for intra-operative bile leaks in 29 patients (70%), which were primarily repaired. As a result, there was no postoperative bile leak in this series. One mortality was detected in this series due to postoperative pancreatic fistula and multi organ failure. CONCLUSIONS: The White Gauze Test is a useful method for the prevention of bile leakage after hepatic resection. It is safe, quick and cheap.

Pancreatic pseudopapillary tumour: A rare misdiagnosed entity.

INTRODUCTION: Solid pseudo papillary pancreatic tumour is a rare entity. The atypical presentation causes a delayed or misdiagnosis of these pathology. It commonly affects the female population in the 2nd and 3rd decade of life. The presentation varies from non-specific abdominal pain to incidental findings in asymptomatic patients. It is a low-grade premalignant condition that is curable by excision of the tumour. PRESENTATION OF CASE: This paper presents a 17-year-old girl with intra-abdominal mass diagnosed with solid pseudo papillary tumour that underwent Whipple's procedure. DISCUSSION: We discuss the presentations, diagnosis and pathology findings of this rare pathology. CONCLUSION: The diagnosis remains an enigma in view of the nature and location of the tumour. Resection is still the best choice remains for this condition.

An evaluation of knowledge and skill on cricoid pressure among emergency personnel.

BACKGROUND: Cricoid pressure (CP) is a step during rapid sequence induction. Previous studies showed a poor clinical application of CP despite a reasonable theoretical knowledge of CP. This study aims to evaluate the proficiency and knowledge retention on CP among the emergency staff in the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre. MATERIALS AND METHODS: This is questionnaire-based observational comparative study. Once the questionnaire is filled, the application of CP is tested on an airway model and competency level is documented. An education hand out is passed to all participants after the procedure. The improvement and knowledge retention were assess after 2 month. RESULTS: A total of 81 completed surveys were returned comprises of of 34 medical officers, 23 staff nurses and 24 assistant medical officers. 75.3% subjects have work experience more than a year but only 59.3% of them were trained in CP application. A total of 69.1% participants passed the pre educational handout test and 100% passed the post educational handout test. However, for pre educational handout phase, 81.5% participants passed the theory part while only 42% passed the practical component. In post educational handout phase, the number of respondents who passed both components was 97.5% and 63% respectively. There are positive correlation between designation and working experience with overall passes in this study. CONCLUSIONS: The theoretical knowledge of CP is satisfactory but clinical application is poor especially in the pre educational handout phase. The educational handout is proved to improve the knowledge transfer and retention with regards to CP.

MMP-9: biomarker for abdominal aneurysm.

INTRODUCTION: Matrix Metalloproteinase 9 (MMP-9) has been shown to express significantly on organ tissue culture in Abdominal Aortic Aneurysm (AAA) patients. Prior studies have shown the correlation between MMP-9 concentration levels with AAA raising the probability of its usage as a biomarker in AAA disease. However, results of previous studies have been conflicting. The purpose of this study is to identify the correlation between MMP-9 concentration levels with AAA disease and further define the utility as a biomarker for our center population. MATERIALS AND METHODS: This is prospective controlled trial. Peripheral venous blood sample is obtained from 20 patients with AAA and 36 normal control subjects. MMP-9 concentration levels were determined by an enzyme-linked immunosorbent assay and compared with subjects abdominal ultrasonography or computed tomography of abdomen. RESULTS: Mean (± SE) MMP-9 was 23.94 ± 0.60 ng/mL in normal control subjects and 21.39 ± 1.03 ng/mL in patients with AAAs (p ← 0.05 versus normal control subjects). MMP-9 correlate significantly with AAA (p=0.004). There was no correlation of MMP-9 levels with age, gender, or other risk factors. The cutoff point is 12.54 for aorta size <3.0 cm. The sensitivity and specificity of MMP-9 were 60% and 64% respectively. CONCLUSIONS: MMP-9 levels correlate significantly with AAA with a cutoff point of 12.54. However, the utility of MMP-9 as a diagnostic test is limited due to low sensitivity and specificity. An elevated MMP-9 has limited use to predict the presence of AAA (positive predictive value: 60%) and a normal MMP-9 level was insufficient to determine the absence of AAA (negative predictive value: 36.1%).