Eventration of the diaphragm is caused by weakened musculature of the diaphragm. This can occur in one or both hemidiaphragms. Symptoms may be minimal and it is usually detected incidentally on chest radiograph which would show an elevation of the diaphragm. We report and discuss a case of eventration of right diaphragm in a patient presented with a lobulated lung mass on chest radiograph.

Methicillin-resistant Staphylococcus aureus (MRSA) infection is important among vas-cular surgical patients. Its effect can be devastating resulting in limb amputation and mortality. We performed a retrospective patients record analysis to determine the pat-tern of MRSA infection among vascular surgical patients in Hospital Kuala Lumpur from January 2005 to December 2007. We also attempted to identify the factors asso-ciated with poor clinical outcome after such infection. There were 999 patients who underwent vascular surgeries in HKL within the analysis period. Of these 24 patients (2.4%) were detected to have MRSA surgical site infection. The infection was commoner among cigarette smokers, patients with diabetes melitus and those who had previous vascular surgery. Most infections occurred in the emergency surgery category and manifested as wound breakdown. Fifty-four percent of the infected pa-tients ended with graft removal, amputations or death. MRSA infection complicating vascular surgery resulted in poor clinical outcome. This serious threat requires intensified preventive measures.

INTRODUCTIONWhile opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed.

MATERIALS AND METHODSA multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions.

RESULTSAvailable data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour.

CONCLUSIONDue to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as secondor third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required.

Analgesics, Opioid ; therapeutic use ; Chronic Pain ; drug therapy ; etiology ; Evidence-Based Medicine ; Humans

INTRODUCTION: To evaluate the mid-term outcomes of regular surveillance venography with or without percutaneous transluminal angioplasty (PTA) in haemodialysis patients presenting with central venous occlusive disease. MATERIALS AND METHODS: A single-centre retrospective analysis of haemodialysis patients who presented with central vein occlusion (CVO) and central vein stenosis (CVS) between January 2008 and December 2011 was performed. CVO and significant CVS were defined as 100% and >50% luminal narrowing, respectively. Upon successful angioplasty on first presentation, patients were followed up with regular surveillance venography within 3-6 months of the intervention and were re-treated when a significant stenosis or occlusion was demonstrated. Data on patient's demographics, comorbidities, presenting symptoms, type of upper limb dialysis access, lesion characteristics and complications were collected. Technical success, primary patency and primary assisted patency were analysed. RESULTS: Thirty-five patients with CVO and 77 patients with CVS were enrolled. The technical success of initial PTA was 77% and 73% for the CVO and CVS groups, respectively. The primary patency at 3 months was 65% and 55% for the CVO group and CVS group, respectively ( = 0.32). The primary assisted patency at 1 year was 88% and 99% for the CVO group and CVS group, respectively ( = 0.009). At 2 years, the primary assisted patency were 77% and 90%, respectively ( = 0.07). There was significant difference in the overall primary assisted patency ( = 0.048) between the CVO and CVS groups. CONCLUSION CVOs are more difficult to treat than CVS. High primary assisted patency rates can be achieved with surveillance venography, albeit at the expense of increased number of interventions. Further cost effectiveness studies need to be performed to study the true benefit of our surveillance programme.