It is well known that diagnostic accuracy of the clinical cause of death has not improved despite advances in diagnostic techniques. We aimed to investigate the accuracy of the clinical cause of death compared with the autopsy cause of death and to see if the Coroner's autopsy can play a role in clinical audit. Our study population consisted of all autopsies where the deceased was hospitalised or resuscitated at the Accident and Emergency Unit of the University of Malaya Medical Centre before death, performed during the period July 1998 to June 2000. The cases were subdivided according to natural and unnatural causes of deaths. Natural deaths were further subdivided in relation to the main organ systems involved while unnatural deaths were subcategorised into trauma, poisoning and burns. The rate of agreement between clinical and autopsy cause of death was further compared with duration of survival in the hospital. Of 132 autopsies included in this study, 115 were Coroner's autopsies. 78% of cases showed agreement between clinical and autopsy cause of death. The agreement rate in Coroner's cases was 80.0%. For natural and unnatural causes, the agreement rate was 56.7% and 84.3% respectively. There were 6 cases (4.5%) where an initial accurate diagnosis might have altered the prognosis of the deceased. In general, the rate of agreement increased with duration of survival of patients. However, this was no longer observed after a survival of more than 28 days. Our findings agree with other similar studies. The diagnostic accuracy of cause of death has not improved despite the modernisation in medical technology. The autopsy still plays an important role in clinical audit and medical education.
Clinical ; Cause of Death ; Autopsy ; agreement ; seconds

Visual conditions such as anisometropia, monovision and monocular undercorrection affect the combination of visual input from both eyes. This study investigated the effects of monocular blur, in binocularly normal participants, on stereoacuity and binocular contrast sensitivity. Fifteen young adults (age range between 19 and 23 years old) with normal visual acuity and binocular vision participated in this study. Stereopsis was measured using the TNO test with a series of positive spherical lenses placed before the dominant eye. The procedure was repeated using the Titmus Stereotest on five participants as a control experiment. Monocular and binocular contrast sensitivities were also measured using the Pelli-Robson Contrast Sensitivity Chart. Blur was induced monocularly with a series of positive spherical lenses placed before the dominant eye and binocular contrast sensitivity was re-measured. Stereopsis scores decreased significantly when monocular blur was imposed. Across blur levels, absolute stereopsis scores measured with TNO test were worse than those measured with Titmus stereotest (all p < 0.05). However, the ratio of scores obtained without blur and under monocular blur appeared to be similar for both tests. Stereopsis without blur was between 6.82× to 8× better than that obtained with the highest level of imposed monocular blur. Binocular contrast sensitivity score decreased significantly with increasing level of monocular blur (p < 0.01). Binocular contrast sensitivity score without blur was 1.62× better than that obtained under binocular viewing with highest level of imposed blur. Stereopsis tests are more sensitive than measurements of binocular contrast sensitivity as an indicator of interocular acuity discrepancies which could occur in anisometropic or monovision patients. However, the choice of stereopsis test is crucial, as the TNO test appears to be more sensitive to monocular blur than the Titmus stereostest.
Depth Perception

Mitochondrial DNA (mtDNA) deletions are a major cause of chronic progressive external ophthalmoplegia (CPEO) and Kearns-Sayre syndrome (KSS). We analyzed single mtDNA deletions in 11 CPEO and one KSS patients by means of Southern blot and long polymerase chain reaction (PCR) assays. The deletion sizes ranged from 3.4 kb to 6.9 kb whereas the heteroplasmy level varied from 18.8% to 85.5%. Two unique deletions sized 4320 bp and 4717 bp were found. This study represents the first genetic screen of mtDNA disorders in Malaysia, and it follows the data seen in other published reports on CPEO and KSS genetic aetiology.

A cohort of Malaysian patients with clinico-pathological diagnosis of three specifi c mitochondrial encephalomyopathy syndromes comprising of mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS), myoclonus epilepsy with ragged-red fi bers (MERRF) and Leigh syndrome were studied to determine the frequency of their common mitochondrial DNA mutations. The ‘hot-spot’ point mutations for MELAS, MERRF and Leigh syndrome were screened. In the absence of common point mutations, screening of large-scale deletions as well as sequencing of tRNALeu and tRNALys genes were performed. Of 22 patients studied, nine m.3243A>G mutations, four m.8344A>G mutations, one m.8993T>G mutation and one deletion were identifi ed (65% detection rate). While the m.3243A>G mutation was closely associated with MELAS, the m.8344A>G was more heterogenous, being seen in one MERFF, two isolated mitochondrial myopathies and one Leigh syndrome patient. Screening for m.8993T>G in Leigh syndrome has a low yield as unsurprisingly Leigh syndrome has considerable genetic heterogeneity.

INTRODUCTIONNecrotising fasciitis is a disease associated with high morbidity and mortality, and multi-focal necrotising fasciitis is uncommon. We present 2 cases of concurrent necrotising fasciitis of contralateral upper and lower limbs.

CLINICAL PICTUREBoth presented with pain, swelling, bruising or necrosis of the affected extremities. Traditional medical therapy was sought prior to their presentation.

TREATMENTAfter initial debridement, one patient subsequently underwent amputation of the contralateral forearm and leg. The other underwent a forearm amputation, but refused a below-knee amputation.

OUTCOMEThe first patient survived, while the second died.

CONCLUSIONTraditional medical therapy can cause bacterial inoculation, leading to necrotising fasciitis, and also leads to delay in appropriate treatment. Radical surgery is needed to optimise patient survival.

Aged ; Amputation ; Debridement ; Fasciitis, Necrotizing ; diagnosis ; drug therapy ; surgery ; Fatal Outcome ; Female ; Hand ; microbiology ; surgery ; Humans ; Leg ; microbiology ; surgery ; Male ; Medicine, East Asian Traditional ; Middle Aged ; Risk Factors

Diabetes Mellitus is a disease due to reduced insulin sensitivity and secretion in the body which associated with obesity and hypertension. This study aimed to determine the influence of family support and self-motivation towards dietary compliance and glycaemic control among Type 2 Diabetes Mellitus (T2DM) outpatients. This cross-sectional study involved 35 subjects selected from Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in Cheras and Ampangan Health Clinic in Seremban. Anthropometric measurements and fasting blood glucose have been obtained. Face-to-face interview session was done to obtain socio-demographic and diet intake. Further, dietary compliance, social support and self-motivation were assessed using Summary Diabetes Self Care Activities (SDSCA), Diabetes Social Support Questionnaire Family version (DSSQ-Fa) and Treatment Self-Regulation Questionnaire (TSRQ), respectively. Only 8.6% of subjects complied with dietary counselling. Fasting blood glucose for both men (7.93 ± 1.99 mmol/L) and women (8.77 ± 3.08 mmol/L) were higher than normal range. Self-motivation (r = 0.358, p < 0.05) and family support (r = 0.460, p < 0.01) significantly correlated with dietary compliance. Self-motivation and family support are important factors which can increase compliance towards dietary counseling. Further investigation should be carried out to determine factors that may influence dietary compliance and family support towards achieving desirable glycaemic control among T2DM patients.
Diabetes Mellitus

Purpose: Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored. Methods: We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed. Results: Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36–65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1–67). Mean specimen weight was 458.75 g (range 242–800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92–198), and the average ischemic time was 37.3 minutes (range 22–50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nippleareolar complex ischemiaecrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed. Conclusion ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an “aesthetically scarless” mastectomy and reconstruction through minimal incisions.

Chronic Limb-Threatening Ischemia ; Factor Xa Inhibitors/adverse effects* ; Humans ; Platelet Aggregation Inhibitors/adverse effects* ; Rivaroxaban/adverse effects* ; Singapore ; Treatment Outcome

Introduction: Awareness for paediatric palliative care has resulted in the impetus for paediatrician-led palliative care services across Malaysia. However, there is paucity of local data on patients receiving hospital-based paediatric palliative care. We aim to review the clinical spectrum of patients referred to these services. Methods: An observational study of children aged between 0-18 years receiving palliative care at 13 hospitals between 1st January and 31st December 2014 was carried out. Results: There were 315 patients analysed, 90 (28.6%) and 46 (14.6%) were neonates and adolescents respectively. The main ICD-10 diagnostic categories for all patients were identified to be ‘Congenital malformations, deformations and chromosomal abnormalities’ 117 (37.1%), ‘Diseases of nervous system’ 76 (24.1%) and ‘Neoplasms’ 60 (19.0%). At referral 156 (50%) patients had holistic needs assessments. Patients with ‘Diseases of nervous system’ were assessed to have significantly more physical needs than the other two diagnostic categories. Majority of patients who knew of their diagnosis and prognosis were those with malignancy. Over a fifth of referrals were at their terminal admission. Of 144 who died, 111 (77.1%) had advanced care plans. There was bereavement follow-up in 98 (68.1%) patients. Conclusion: Patients referred for palliative care have varied diagnoses and needs. To ensure all paediatricians are competent to deliver quality care to all children, further education and training initiatives is imperative.
Palliative Care

OBJECTIVETo identify the phenotype and immune function of dendritic cells derived from HBV-related HCC patients's peripheral blood monocytes pulsed with soluble tumor antigen, and their relation to immune escape.

METHODSPeripheral blood monocytes were isolated from 18 HBV-related hepatocellular carcinoma (HCC) patients, 11 HBV-related liver cirrhosis patients (LC) and 10 health blood donors; DCs were induced in the completed medium containing GM-CSF and IL-4. The morphology of DCs was studied using a confocal microscope and scanning electronic microscope, and the phenotype of DCs were detected by flow cytometric analysis. The mixed leucocyte reaction test was employed to determine the stimulatory capacity of DCs before and after being pulsed with soluble tumor antigen (prepared from HCCLM6 cell line). IL-12 ELISA kit was used to investigate IL-12 secretion of DCs in the supernate of MLR.

RESULTSThe amount of PBMC and DCs was significantly lower in LC and HCC compare to those in the healthy subjects; the expression levels of HLA-DR, CD1a, CD80 and CD86 on DC surfaces were lower in LC and HCC patients than those of the healthy group; the stimulating capacity of DC in MLR and levels of IL-12 in supernate of MLR were also lower in LC and HCC, but were enhanced after tumor antigen pulsed in all three groups, particularly in the LC group; the secretion of IL-12 in MLR supernate was still lower than that of the healthy group.

CONCLUSIONThe phenotype and function defects of DC derived from PBMC of LC and HCC patients might play a key role in immune escape in HBV infection and HCC. The function of DC of LC patients can be enhanced after the tumor was antigen-pulsed.

Antigens, Neoplasm ; immunology ; Carcinoma, Hepatocellular ; immunology ; virology ; Dendritic Cells ; immunology ; virology ; Granulocyte-Macrophage Colony-Stimulating Factor ; pharmacology ; Hepatitis B ; complications ; immunology ; Humans ; Interleukin-4 ; pharmacology ; Liver Neoplasms ; immunology ; virology ; Lymphocyte Culture Test, Mixed