Tuberculosis (TB), once a disease confined to undeveloped or developing nations is currently in resurgence due to pandemic human immunodeficiency virus infection and immigration from endemic areas. TB is also known as the ‘great mimicker’. Extra-pulmonary tuberculosis affecting the knee is rare in all forms of TB (0.1-0.3%). Here, we report a case of isolated highly erosive TB knee in a previously fit Burmese migrant worker. He presented with after a history of fall into a drain. The patient also reported pain and swelling over his left knee for the previous three years. He had been treated for a bacterial infection of the knee in another hospital but defaulted due to financial constraints. Arthrotomy of the knee was performed including washout. Diagnosis of TB of the knee was made based on the synovial fluid and tissue culture. Treatment with antituberculosis drugs was then initiated.

INTRODUCTIONWhile benign prostatic hyperplasia (BPH) incidence has been shown to vary by race and ethnicity, data is lacking among Asians. This study aimed to describe the baseline symptom profile and response to medical therapy in a multiracial Singaporean cohort with BPH.

MATERIALS AND METHODSInternational Prostate Symptom Score (IPSS), uroflowmetry and prostate specific antigen (PSA) levels were retrospectively analysed for 887 men at presentation and on follow-up 1 year later. Following diagnosis, 150 men were managed conservatively and 586 men with drugs; 151 received surgery.

RESULTSOverall median IPSS scores were 9.0 at baseline. Malay men most often had severe symptoms (17.3%), compared to other groups (Chinese 11.7%, Others 11.1%, Indians 10.7%). Indians most frequently showed improvement in the Quality of Life (QOL) score following intervention (64.3%). Malays had the poorest initial mean peak-flow rates (9.6 mL/s) and Chinese, the highest (12.0 mL/s). Initial post-void residual urine volume was highest in Malays (100.1 mL) but showed greatest reduction with medical treatment. Median IPSS scores decreased from 10.5 below 50 years old to 7.0 above 80 years old. Peak-flow rates were 12.6 to 7.2 mL/s respectively, with a corresponding upward trend in RU. Treatment with a combination of 5-alpha-reductase inhibitor and alpha-blocker yielded the greatest improvement in IPSS and QOL scores, and residual urine volume (71.4%, 60% and 68.8%, respectively). Indians had the lowest initial and follow-up PSA (1.5 and 1.2, P = 0.8 and 0.6, respectively).

CONCLUSIONSInter-ethnic differences in symptom perception and quantitative assessment of BPH were evident among our multiracial urban study cohort, as well as varied degrees of response to the medical treatments instituted.

Aged ; Cohort Studies ; Humans ; Male ; Middle Aged ; Prostate-Specific Antigen ; analysis ; Prostatic Hyperplasia ; ethnology ; physiopathology ; Severity of Illness Index ; Singapore

INTRODUCTIONPaediatric laparoscopic choledochal cyst excision has increasingly gained acceptance as an alternative to open excision. Laparoscopic excision is feasible and safe in the short term, but long-term outcomes are not as well established. KK Women's and Children's Hospital started performing laparoscopic choledochal cyst excision in children since 2007. In this paper, we report our experience with the laparoscopic approach, and the early and mid-term outcomes in comparison with the conventional open approach.

MATERIALS AND METHODSThirty-five consecutive cases by a single surgeon between May 2006 and April 2012 were retrospectively reviewed. Patient characteristics and surgical outcomes were analysed.

RESULTSThere were 13 laparoscopic and 22 open cases. Baseline patient characteristics were similar. Operative time was longer in the laparoscopic group. Three cases in the laparoscopic group were converted to open in our early experience. There were no differences in time to feeds or length of hospitalisation. One laparoscopic case developed minor bile leak that resolved on conservative management. There were no complications in the laparoscopic group on median follow-up of 35 months. In the open group, there was 1 case of pancreatitis, cholangitis, and hypertrophic scarring respectively. There were 3 cases of suspected adhesive colic that resolved without surgery.

CONCLUSIONLaparoscopic choledochal cyst excision enjoys excellent early and mid-term outcomes compared to open excision, even in centres with smaller patient volume. It should be the approach of choice where technical expertise is available.

Child, Preschool ; Choledochal Cyst ; surgery ; Digestive System Surgical Procedures ; methods ; Female ; Hospitals, Pediatric ; Humans ; Laparoscopy ; Male ; Retrospective Studies ; Tertiary Care Centers ; Time Factors ; Treatment Outcome

Background: Large population surveys in Malaysia have consistently shown minimal improvement of blood pressure control rates over the last 10 years. Poor adherence to antihypertensive medication has been recognized as a major reason for poor control of hypertension. This study aimed to describe the prescribing pattern of antihypertensive agents in 2 public primary care clinics and assess its appropriateness in relation to current evidence and guidelines. Methods: A cross-sectional survey to describe the prescribing pattern of antihypertensive agents was carried out in 2 public primary care clinics in Selangor from May to June 2009. Hypertensive patients on pharmacological treatment for ≥1 year who attended the clinics within the study period of 7 weeks were selected. Appropriate use of antihypertensive agents was defined based on current evidence and the recommendations by the Malaysian Clinical Practice Guidelines (CPG) on the Management of Hypertension, 2008. Data were obtained from patients’ medical records and were analysed using the SPSS software version 16.0. Results: A total of 400 hypertensive patients on treatment were included. Mean age was 59.5 years (SD ±10.9, range 28 to 91 years), of which 52.8% were females and 47.2% were males. With regards to pharmacotherapy, 45.7% were on monotherapy, 43.3% were on 2 agents and 11.0% were on ≥3 agents. Target blood pressure of <140/90mmHg was achieved in 51.4% of patients on monotherapy, and 33.2% of patients on combination of ≥2 agents. The commonest monotherapy agents being prescribed were β-blockers (atenolol or propranolol), followed by the short-acting calcium channel blocker (nifedipine). The commonest combination of 2-drug therapy prescribed was β-blockers and short-acting calcium channel blocker. Conclusion: This study shows that the prescribing pattern of antihypertensive agents in the 2 primary care clinics was not in accordance with current evidence and guidelines. β-blockers and short-acting preparations were commonly used both as monotherapy and combination treatment. Thiazide diuretics, ACE inhibitors and long acting calcium channel blockers were underutilised in this study, despite robust evidence to support their use. Evidence have also shown that simplifying the number of daily doses is effective in improving adherence, therefore a wider use of generic once daily preparation should be strongly advocated in public primary care clinics.

Bone marrow stem cells (BMSC), known for its multipotency to differentiate into various mesenchymal cells such as chodrocyte, osteoblasts, adipocytes, etc, have been actively applied in tissue engineering. BMSC have been successfully isolated from bone marrow aspirate and bone marrow scraping from patients of various ages (13-56 years) with as little as 2ml to 5ml aspirate. BMSC isolated from our laboratory showed the presence of a heterogenous population that showed varying prevalence of surface antigens and the presence of telomerase activity albeit weak. Upon osteogenic induction, alkaline phosphatase activity and mineralization activity were observed.
Bone Marrow Cells/cytology ; *Bone Marrow Transplantation ; Bone Regeneration/physiology ; *Bone Transplantation ; Cell Differentiation/physiology ; *Mesenchymal Stem Cell Transplantation ; Telomerase/metabolism ; *Tissue Engineering

The strategy used to generate tissue-engineered bone construct, in view of future clinical application is presented here. Osteoprogenitor cells from periosteum of consenting scoliosis patients were isolated. Growth factors viz TGF-B2, bFGF and IGF-1 were used in concert to increase cell proliferation during in vitro cell expansion. Porous tricalcium phosphate (TCP)-hydroxyapatite (HA) scaffold was used as the scaffold to form 3D bone construct. We found that the addition of growth factors, greatly increased cell growth by 2 to 7 fold. TCP/HA proved to be the ideal scaffold for cell attachment and proliferation. Hence, this model will be further carried out on animal trial.
Bone Regeneration/*physiology ; *Bone Transplantation ; Cell Division/physiology ; Collagen/metabolism ; *Mesenchymal Stem Cell Transplantation ; Organ Culture Techniques ; Periosteum/*cytology ; Tissue Engineering/*methods

INTRODUCTIONGrade 4 cystoceles are among the most challenging to achieve a successful repair for gynaecologists. The high rate of recurrence of severe prolapse encouraged surgeons to use meshes. Only recently have meshes been used transvaginally for pelvic organ prolapse. The aim of our pilot study was therefore to determine the effectiveness of transvaginal anterior colporrhaphy reinforced with prolene mesh in the treatment of severe or recurrent cystoceles by looking at their primary surgical outcomes as well as their complications.

MATERIALS AND METHODSThis was a retrospective study conducted by the urogynaecology unit at KK Women's and Children's Hospital (KKWCH) in Singapore based on operations performed from April 2002 to December 2003. The inclusion criterion was that women had to have at least a grade 4 or recurrent grade 3 cystocele and had undergone a vaginal anterior colporrhaphy reinforced with prolene mesh. The women were further subdivided into 3 groups depending on whether vaginal hysterectomies were performed or not as well as the absence or presence of the uterus.

RESULTSThirty-seven patients with severe cystoceles underwent this procedure. The 3 mean follow-up times for the 3 groups ranged from 14.4 to 19.2 months (range, 2 to 32). Overall for the 3 groups, 75.7% were cured with no or grade 1 cystocele, 18.9% had asymptomatic grade 2 cystocele while 5.4% developed grade 3 or 4 cystocele. There were no mesh erosions.

CONCLUSIONTransvaginal anterior colporrhaphy reinforced with a tension-free prolene mesh in the treatment of severe or recurrent cystoceles is simple, safe, easily performed and is associated with a low failure rate and morbidity.

Adult ; Aged ; Aged, 80 and over ; Biocompatible Materials ; Cystocele ; surgery ; Female ; Humans ; Middle Aged ; Pilot Projects ; Polypropylenes ; Postoperative Complications ; epidemiology ; Retrospective Studies ; Surgical Mesh ; Treatment Outcome ; Urologic Surgical Procedures ; adverse effects ; methods ; Vagina ; surgery

Trauma is a major cause of death, and haemorrhage represents an important target for improving outcomes after severe injury. Volume replacement with crystalloids in resuscitation might become harmful in large amounts because of coagulopathy. A fine balance must be achieved between haemodynamic and haemostatic resuscitation. Permissive hypotension refers to permitting some degree of hypotension in such adult patients in an attempt to attain this fine balance. For patients who require a significant volume of blood product resuscitation, the term 'massive transfusion protocol' (MTP) is used. There is very little data on transfusion protocols for paediatric trauma patients, and children respond to hypovolemic shock in a different physiological manner compared to adults. Hence, concepts such as permissive hypotension may not be appropriate when treating children involved in major trauma. We recently embarked on a plan to streamline the management of blood transfusion in massive bleeding during paediatric trauma, to reduce the logistical problems associated with the transport of blood products from the blood bank to the patient. From this, we evolved a MTP for paediatric major trauma. Nonetheless, further studies will be needed to see if there is indeed improved outcome after MTP in paediatric major trauma as current evidence is extrapolated from adult studies.
Adult ; Blood Coagulation Disorders ; complications ; therapy ; Child ; Clinical Protocols ; Evidence-Based Medicine ; Fluid Therapy ; standards ; Humans ; Injury Severity Score ; Resuscitation ; methods ; Wounds and Injuries ; complications ; therapy

After-Hours Care ; Attitude of Health Personnel ; Attitude to Health ; Child ; Cross-Sectional Studies ; Emergency Service, Hospital ; utilization ; Humans ; Medical Overuse ; Parents ; Pediatrics ; Primary Health Care ; Singapore ; Surveys and Questionnaires