Monitoring treatment response in sputum smear positive pulmonary tuberculosis patients: comparison of weight gain, sputum conversion and chest radiograph.

BACKGROUND: Monitoring treatment response to anti-tuberculous therapy remains unsatisfactory in resource-limited countries where sophisticated and expensive tests are not readily available. Sputum culture for mycobacterium is desirable, but not obtainable in many developing countries. Sputum acid-fast bacilli (AFB) smear alone can be misinterpreted in the presence of unviable bacilli or non-tuberculous mycobacteria. Hence the search for a cheaper but reliable monitoring tool, or a combination of several tools, continues. Interesting reports from studies in third world nations have considered weight gain/loss as one such monitoring tool. Since pulmonary tuberculosis is endemic in this country, we take the opportunity to evaluate weight gain and chest radiograph, compared to sputum AFB smear in monitoring patient's response. METHODS: This was a retrospective study of confirmed positive sputum AFB smear patients from January 1999 to December 2004 who attended the Chest Clinic at Hospital Tengku Ampuan Afzan, Kuantan, Malaysia. Data on weight, chest radiograph and sputum AFB smear from initiation of therapy to end of treatment and follow-up were collected and analyzed. RESULTS: 201 patients were included. At week-4 of anti-tuberculous treatment, only 14.7% had positive sputum smear. At completion of therapy 93.1% had improved chest radiographs. 90% had weight gain, 5% had weight loss and the remaining had no change in weight. Amongst patients with weight loss, there were no significant differences in the underlying illnesses (p=0.376), sputum smear at 4 weeks (p=0.697) and chest X-ray changes (p=0.731). Three patients who initially showed sputum smear conversion had reappearance of positive smear results towards the end of treatment. One of them was diagnosed as treatment failure while the other two remained well after discontinuation of therapy. CONCLUSION: Weight gain is very common among smear-positive tuberculosis patients after treatment even though weight gain does not correlate well with underlying disease, sputum conversion and chest X-ray changes. Reappearance of smear-positive sputum must be interpreted with caution and not to be regarded as treatment failure without other evidence.

Defaulters among lung cancer patients in a suburban district in a developing country.

INTRODUCTION: This study was carried out to determine the prevalence, patient's characteristic and reasons for defaulting follow-up and treatment among patients with lung cancer. METHODS: Patients with histologically confirmed lung cancer were recruited. Patient's detailed demographic data, occupation, socioeconomic status, and educational level of both the patients and their children were recorded. Defaulters were classified as either intermittent or persistent defaulters. By using Chi-square test, defaulter status was compared with various demographic and disease characteristic factors. The reasons for default were determined. RESULTS: Ninety five patients were recruited. Among them, 81.1% patients were males; 66.3% were Malays. The mean age (SD) was 60 ± 10.5 years. About 46.3% of the patients had Eastern Cooperation Oncology Group (ECOG) functional status 0/1 and 96.8% of the patients presented with advanced stage (Stage 3b or 4). Overall, 20 patients (21.1%) were defaulters (35.0% intermittent defaulters; 65.0% persistent defaulters). Among the intermittent defaulters, 8 patients defaulted once and one patient defaulted 3 times. Among the 20 defaulters, only 2 (10%) patients turned up for the second follow-up appointment after telephone reminder. Two main reasons for default were 'too ill to come' (38.5.5%) and logistic difficulties (23.1%). No correlation was found between patient education, children education, income, ECOG status, stage of the disease, race, and gender with the defaulter rate. CONCLUSION: Defaulter rate among lung cancer patients was 21.1%. Children education level is the only significant factor associated with the defaulter rate.

The man with the boggy head: cranial melioidosis.

Melioidosis is known to cause abscesses in various organs, including the cranium, though less commonly. We present a patient with scalp abscess and subdural empyema that was visible on computed tomography of the brain. The neurosurgical drainage grew Burkholderia pseudomallei. Despite our best effort to treat the patient using parenteral antibiotics and surgical drainage, the patient did not survive.

Hospitalised patients' awareness of their rights: a cross-sectional survey from a tertiary care hospital on the east coast of Peninsular Malaysia.

INTRODUCTION: Optimal patient care varies considerably from place to place and is influenced by scientific as well as social developments. The purpose of this study was to investigate awareness and pertinent issues regarding informed consent among hospitalised patients and to determine lapses, in order to improve the standard of care. METHODS: A questionnaire-based cross-sectional survey was conducted among inpatients at a tertiary care level hospital. RESULTS: 90 percent of patients were aware of their rights, and 85 percent had enough information regarding their illness and modality of treatment. However, treatment options were discussed with 45 percent of cases only, and 65 percent of patients were informed of their duration of treatment. Most of the patients from the surgical group, haemodialysis unit and those with minor ailments were very satisfied with the doctors (92 percent, 86 percent and 96 percent, respectively), as opposed to only 36 percent of cancer patients and 70 percent of acquired immunodeficiency syndrome (AIDS) patients (p-value is less than 0.0001). Almost all patients (99 percent) said that their religious beliefs were respected by the staff and they had no problems in accessing them in times of need. Informed consent was obtained by the doctor in 98 percent of cases and by the nurse in two percent. 98 percent of the patients mentioned that their treatments/examinations were conducted in an atmosphere of privacy and that their personal information was kept confidential by their doctors. CONCLUSION: Patients were reasonably informed about their illness. Their privacy and religious beliefs were duly respected. Treatment options and the duration of treatment were not discussed with all patients. Cancer and AIDS patients were less satisfied with the attending staff. The results suggest that there is a need for periodic surveys of patient satisfaction with the quality of care.

Invasive rhinocerebral mucormycosis with orbital extension in poorly- controlled diabetes mellitus.

Rhinocerebral mucormycosis is an invasive fungal sinusitis with a high mortality rate, especially in immunocompromised patients. A 70-year-old woman, with uncontrolled type 2 diabetes mellitus, presented with a one-month history of non-specific headaches associated with progressive swelling of her left eye. Computed tomography of the brain and orbits showed the extensive involvement of bilateral intranasal sinuses, orbits, extraocular muscle and soft tissues. The diagnosis of invasive mucormycosis was confirmed from a tissue biopsy taken from the internasal septum. Despite the extensive mucormycosis invasion, she was successfully treated with intranasal and systemic amphotericin B and minimal adjunctive intranasal sphenoidotomy.

Influences on bone mineral density in Malaysian premenopausal systemic lupus erythematosus patients on corticosteroids.

The aim of this study was to assess the bone mineral density (BMD) of premenopausal patients with systemic lupus erythematosus (SLE) on corticosteroids (CS) and to determine the influence of CS and other risk factors on BMD. A total of 98 premenopausal patients with SLE were recruited from outpatient clinics in two teaching hospitals. Risk factors for osteoporosis were determined, and BMD was measured using dual-energy x-ray absorptiometry. The mean age of the patients was 30.05 +/- 7.54 years. The mean dose of prednisolone at time of BMD measurement was 18.38 +/- 10.85 mg daily. Median duration of CS use was 2.5 years (range 0-20). Median cumulative dose of CS was 9.04 g (range 0.28-890.0). Six patients (6.1%) had osteoporosis, 41 (41.9%) had osteopenia and 51 (52.0%) had normal BMD. Lumbar spine T score correlated with cumulative CS dose (P = 0.019). Duration of CS intake correlated with femoral neck T score (P = 0.04) and trochanter T score (P = 0.008). There was no correlation between BMD and race, SLE Disease Activity Index score, smoking and self-reported calcium intake or exercise. Only 52% of these patients had normal BMD. The duration and cumulative dose of CS intake was significantly correlated to BMD, but not the other commonly assessed risk factors. These findings suggest that premenopausal patients with SLE on CS should have their BMD measured at regular intervals to fully assess their osteoporosis risk.

A mimicry of melioidosis by Klebsiella ozaenae infection.

Klebsiella ozaenae is a Gram negative bacillus. It has been described as a colonizer of oral and nasopharyngeal mucosa and is a cause of atrophic rhinitis. Klebsiella ozaenae has seldom been isolated from serious infections. However, several reports have stated that Klebsiella ozaenae may cause invasive infections and even mortality. We report a 55-year-old man with Klebsiella ozaenae infection causing abscesses involving the right eye and left kidney and possibly also in the brain, lungs and prostate. The isolates were sensitive to ceftazidime, ciprofloxacin, chloramphenicol, gentamicin and sulfamethoxazole-trimethoprim but resistant to ampicillin. He responded well to 4 weeks of i.v. ceftazidime and i.v. amoxycillin-clavulanic acid. To our knowledge, such a multiorgan infection has not been reported previously for this organism.

Transbronchial needle aspiration of mediastinal lymph node.

In Malaysia, transbronchial needle aspiration (TBNA) is a relatively new procedure performed only in a handful of respiratory centres. We reviewed TBNA of mediastinal lymph node performed in Hospital Tengku Ampuan Afzan (HTAA) to determine the yield and its complications. Data was retrieved from endoscopy databases and patients' records, CT thorax images and all cytological and histological slides were reviewed. Twenty-five patients had TBNA performed. TBNA was positive in 15 patients (60%). Overall, 80% had confirmed malignancy after bronchoscopy. Only four patients had documented bleeding after TBNA and in two of them, bleeding stopped spontaneously and another two patients required diluted adrenaline to stop the bleed. No mortality was reported from this procedure. Hence, TBNA is a safe procedure.

Transbronchial needle aspiration of mediastinal lymph node.

In Malaysia, transbronchial needle aspiration (TBNA) is a relatively new procedure performed only in a handful of respiratory centres. We reviewed TBNA of mediastinal lymph node performed in Hospital Tengku Ampuan Afzan (HTAA) to determine the yield and its complications. Data was retrieved from endoscopy databases and patients' records, CT thorax images and all cytological and histological slides were reviewed. Twenty-five patients had TBNA performed. TBNA was positive in 15 patients (60%). Overall, 80% had confirmed malignancy after bronchoscopy. Only four patients had documented bleeding after TBNA and in two of them, bleeding stopped spontaneously and another two patients required diluted adrenaline to stop the bleed. No mortality was reported from this procedure. Hence, TBNA is a safe procedure.

Prevalence and risk factors of anti-tuberculosis drug-induced hepatitis in Malaysia.

INTRODUCTION: Tuberculosis (TB) affects one-third of the world's population. Anti-TB drugs with isoniazid, rifampicin and pyrazinamide are very effective but they can cause hepatotoxicity. Many risk factors have been recognised. Data on prevalence of anti-TB drug-induced hepatitis as well as the contributing risk factors are scarce in Malaysia. This observational case control study was designed to look at the prevalence and the risk factors of drug-induced hepatitis in our population. METHODS: We retrospectively examined all the case notes of anti-TB drug-induced hepatitis over a 30-month period from January 2003 to June 2005. They were compared with controls selected by simple random sampling. Both groups were compared in terms of demographical data and risk factors, such as age, gender, body mass index, hepatitis B carrier, human immunodeficiency virus (HIV) infection, sites of TB, and pretreatment liver biochemistries (serum albumin, globulin, aspartate aminotransferase, alanine aminotransferase and bilirubin). Data was evaluated by chi square, independent t-test (univariate) and binary logistic regression analysis (multivariate). RESULTS: Out of 473 TB patients, 46 developed hepatitis and 138 were selected as controls. The prevalence of drug-induced hepatitis was 9.7 percent. On univariate analysis, HIV infection (p-value is 0.005), extrapulmonary tuberculosis (p-value is 0.008), lower serum albumin (p-value is 0.023) and higher serum globulin (p-value is 0.025) were significant risk factors. On binary logistic regression, only HIV infection (p-value is 0.018) and extrapulmonary TB (p-value is 0.017) were significant. CONCLUSION: The prevalence of hepatitis was 9.7 percent. The presence of HIV infection and extrapulmonary TB were significant risk factors for the development of hepatitis.

Medical thoracoscopy: Pahang experience.

Medical thoracoscopy has gain its popularity in Malaysia recently. This paper presents our early experience in thoracoscopy using semi-rigid fiberoptic thoracoscope. All thoracoscopy records since October 2006 were retrieved. The patients' records, thoracocentesis investigations results, thoracoscopic findings and all pleural biopsy results were reviewed. Twenty-four thoracoscopic procedures on 22 patients in whom two patients had repeated thoracoscopy. Ten patients were confirmed carcinoma. Eight patients had inconclusive thoracoscopic pleural biopsy results. Three patients underwent pleurodesis for malignant effusion. One patient had adhesiolysis for empyema. There was no procedure-related deaths or intraoperative accidents. Thoracoscopy is a relatively safe procedure.

An unusual cause of haemoptysis and headache: cryptococcosis.

Pulmonary cryptococcosis can be clinically silent in non-HIV infected patients but can also present as nodules and masses on the chest radiograph, which can be mistaken for tuberculosis or lung cancer. Common symptoms include fever and cough, and uncommonly haemoptysis. This report illustrates a non-HIV infected patient whose main complaint was haemoptysis and headache. He was diagnosed with pulmonary cryptococcosis from biopsy of an endobronchial mass found on flexible bronchoscopy. Disseminated cryptoccoccal infection should be considered as a differential diagnosis in non-HIV infected patients presenting with haemoptysis and headache. Early recognition and administration of appropriate therapy will improve clinical outcome in these patients.

Awareness, knowledge and attitude toward informed consent among doctors in two different cultures in Asia: a cross-sectional comparative study in Malaysia and Kashmir, India.

INTRODUCTION: Informed consent is now accepted as the cornerstone of medical practice, with reasonable patient standards typically considered to be appropriate in the developed countries; however it is still challenged in many developing countries. The objective of this descriptive study was to evaluate the perceptions and practices among attending medical professionals in matters relating to informed consent in selected hospitals. METHODS: A questionnaire-based cross sectional survey among doctors in the two tertiary care hospitals, one in Malaysia and the other in Kashmir, was performed. RESULTS: Awareness on informed consent was universal with "reasonable physician standard" as the most popular choice. As compared to doctors in Malaysia, doctors from Kashmir showed a tendency to reservedly disclose medical information (p-value equals 0.051) and withhold it, if it was deemed potentially harmful (p-value is less than 0.001) or requested so by relatives (p-value is less than 0.023). They also withheld some information from female patients (p-value is less than 0.001). When consent was refused despite needing lifesaving intervention, the majority of both respondents (73 percent versus 80 percent) considered intervention without consent to be justified. Respondents from Malaysia felt that parents could refuse treatment on their children's behalf on the basis of their beliefs (p-value is less than 0.001). CONCLUSION: Despite a very high awareness of informed consent, the model chosen reflected age-old medical paternalism. Doctors' opinions are accorded a larger role in clinical decision-making in Kashmir. The results emphasise the need for doctors to change their attitude and acknowledge the patient's autonomy, which is the basis of modern medical ethics, and yet still be aware of the cultural and religious views of the local population.

Molar pregnancy and glomerulonephritis.

A 17-year-old, sexually active, single, nulliparous young woman presented to us with one week history suggestive of nephrotic syndrome. She was found to have a benign hydatidiform mole confirmed by histopathological examination after suction and curettage. Renal biopsy revealed focal segmental glomerulosclerosis. The renal pathology was most probably due to molar pregnancy due to the close temporal relationship. To our knowledge, this is the first case of focal segmental glomerulosclerosis associated with a gestation trophoblastic disease described in the literature.

AMSAN variant of Guillain Barre syndrome progressing to chronic inflammatory demyelinating polyneuropathy in a patient with Marfan's syndrome and pulmonary tuberculosis.

We report a 40-year-old man who has Marfan's syndrome and was recently diagnosed to have pulmonary tuberculosis when he presented with chronic cough. He was admitted with bilateral lower limb weakness which was ascending in nature. He eventually required ventilation. It was initially thought to be isoniazid-neuropathy. However, stopping the drug did not improve the condition and the patient developed bilateral lower motor neuron 7th cranial nerve palsy. Nerve conduction, MRI and CSF studies were done to confirm a first case report of AMSAN variant progressing to CIDP in a patient with Marfan's syndrome and pulmonary tuberculosis.

Risk factors for anti tuberculous drugs induced hepatitis: a prospective survey from a chest clinic in a general hospital.

A prospective survey on 14 consecutive cases with tuberculous drug induced hepatitis was done at our chest clinic in a state general hospital over a period of 15 months. There were 30 controls chosen randomly from the chest clinic register. The cases had lower mean body mass index (P<0.008), serum albumin (P<0.005) and higher serum globulin (P<0.04). Serum liver transaminases and total bilirubin rose significantly during the acute episode of drug induced hepatitis. Among the risk factors studied, only chronic hepatitis B carrier status was found to be more prevalent among the cases. There was one death (7.1%) over the whole study period.

Antibodies in systemic lupus antineutrophil cytoplasmic erythematosus: prevalence, disease activity correlations and organ system associations.

Systemic Lupus Erythematosus (SLE) is a disease with multiorgan involvement and multiple autoantibody production including antineutrophil cytoplasmic antibodies (ANCA). Despite its reported prevalence in more than one third of SLE patients, the role of ANCA in the pathogenesis or otherwise in SLE remains unresolved. 131 SLE patients had been previously studied for various serologic parameters of disease activity. Their cumulative organ involvement in the course of their disease had also been determined and the Lupus Activity Index (LAI) calculated. Their stored sera were then screened for the presence of ANCA by two methods viz Indirect immunofluorescence (IIF) and also enzyme-linked immunosorbent assay (ELISA). ANCA was present in 24.8% of these SLE patients. The atypical ANCA pattern was predominant and accounted for an overall of 20.6%. Anti-MPO and anti-PR3 were detected in 1.5% of patients respectively. No association was found between ANCA positivity and disease activity. There was also no association of ANCA with specific organ involvement. Despite the high prevalence of ANCA especially the atypical variant in SLE, they probably represent only one of the wide repertoire of autoantibodies found in this disease. Routine testing for ANCA in lupus patients is therefore not recommended.

Knowledge and practice of medical doctors on chronic obstructive pulmonary disease: a preliminary survey from a state hospital.

This study was done to ascertain the knowledge and practice of medical officers on spirometry and management of COPD in a medical department of a state hospital. A total of 81 questionnaires with nine items were distributed to medical officers in the medical department (MD) and in other departments (controls). Eight incomplete questionnaires were rejected. In all 15 (21%) respondents were analysed from MD and 58 (79%) from the control group. The respondents from MD were aware that spirometry was important in COPD (100% versus 69%, P < 0.01) but in practice both groups were as likely to use peak expiratory flow rate. Respondents from MD were more likely to treat mild COPD (73% versus 12%, P < 0.001) according to Malaysian Thoracic Society COPD guidelines and also more likely to perform steroid trial (93% versus 37%, P < 0.001). Only 9 (60%) from MD and 33(57%) would refer patients for home oxygen assessment. This preliminary survey suggests that there was lack of translation of knowledge into practice particularly in terms of use of spirometry in COPD as well as lack of awareness for home oxygen assessment. A bigger survey involving all doctors in the state to answer issues raised in this preliminary survey is being conducted.

Brachiocephalic vein stenosis in a patient with end-stage renal disease without prior central vein cannulation.

Central vein stenosis is usually associated with previous cannulation or trauma to the affected vein. This pathology may present as ipsilateral arm swelling in patients in whom a recent arteriovenous fistula has been prepared for chronic hemodialysis. The presence of central vein stenosis without prior trauma or cannulation is not hitherto reported to the best of our knowledge. We herewith report a patient with end-stage renal disease who was initiated on chronic dialysis using an arteriovenous fistula, who was noted to have central vein stenosis. This was despite her never having had any central vein cannulation or previous known trauma. Venogram confirmed the presence of brachiocephalic vein stenosis. The patient underwent venographic stenting of the involved vein with good success.

Usefulness of cytological specimens from bronchial brushings and bronchial washings in addition to endobronchial biopsies during bronchoscopy for lung cancer: 3 years data from a chest clinic in a general hospital.

A retrospective review of all bronchoscopy cases for investigation of lung cancer between January 1997 and December 1999 was done. The cases were included if endobronchial mass was visible (Group A) or when there was an abnormal mucosa and/or bronchial narrowing in the absence of a mass (Group B). All patients in Group A (n = 177) underwent endobronchial biopsy (EB) bronchial brushings (BB) and bronchial washings (BW). All cases in Group B underwent transbronchial biopsy (TBB), BB and BW. Only a small increase in the positive results for cancer was seen when cytology specimens (BB and BW) were added to EB (85.3% vs 88.1%, McNemar's P = 0.06) in Group A but there was a significant increase in Group B (37.3% vs 54.2%. McNemar's, P = 0.001). Therefore although cytology specimens did not significantly add to overall yield of positive results when endobronchial lesions were visible, when mass lesions were not visible, cytology specimens increased the yield by 16.9%.