o The HIV epidemic in Malaysia is slowing down but has now spread to spouses and sexual partners of traditional at risk populations, via heterosexual transmission. o The WHO 2009 guideline advocates starting HAART at CD4 level of 350 cells/mm3, marking a significant departure from starting at CD4 level of 200 cells/mm3 previously. o The WHO 2009 guideline recommended replacing stavudine with either zidovudine or tenofovir as part of the first line HAART regimen due to the former’s adverse effects. o Early detection of HIV infection and earlier initiation of HAART translates into better quality of life and lower risk of Tuberculosis co-infection. o Earlier detection of HIV infection requires picking up on subtle signs of the infection as well as employing a host of available diagnostic tests in cases where HIV infection is strongly suspected. o HIV test should be offered as a part of a routine health check screening. This facilitates early detection of HIV infection and early referral to the hospital for further management. o Collaboration and communications with non-governmental organizations involved in care of HIV infected people can be a good mean of providing support and counselling to newly diagnosed HIV infected individuals. o Asymptomatic undiagnosed HIV infected patients may pose a risk for disease transmission to health care workers in the primary care setting. Steps must be taken to minimize the risk of transmission and easy access to post-exposure prophylaxis. o The primary care physician should be well versed with the many possible drug interactions between HAART and other commonly used medications for other illnesses in order to avoid potentially fatal adverse reactions or treatment failure in patients taking HAART.

A 19-year-old man presented with sudden onset of right eye ptosis, diplopia and giddiness. He had no previous medical illnesses with negative history of exertional dyspnoea, epistaxis, haemoptysis, palpitations, chest pain and chronic cough. Examination revealed central cyanosis, digital clubbing, polycythaemia, partial ptosis of right eye, diplopia on right gaze and dilated right pupil. Examination of the chest revealed pectus excavatum but no cardiac murmurs were heard. Investigations revealed a solitary right pulmonary arteriovenous malformation with two feeder vessels which were successfully embolized surgically.

The influences of lactic/hydrochloric acidosis on pulmonary vasoconstriction and gas exchanges were investigated in 36 dogs. The tv infusion of lactic or hydrochloric acid reducing arterial pH to 7. 00 could elicit significant changes of pulmonary hemodynamics, including the consistent increase of pulmonary arterial pressure and the decrease of arterial oxygen saturation. It is suggested that pulmonary vasocostriction is related to arterial PH but not to arterial lactic acid levels.

Primary tuberculosis (TB) of the hard palate is very rare. A 74-year-old man was presented with 6-month history of dysphagia along with an irregular mass in the hard and soft palate. Magnetic resonance imaging (MRI) revealed thickened and increased signal intensity within hard and soft palate. Tissue biopsy showed focal caseating granulomatous-like lesion and the histochemical staining using Ziehl–Neelsen stain for acid-fast bacilli was positive. Positive histochemical studies provided evidences that the hard palate mass was most likely due to TB. Thus, the patient was started on antituberculous therapy

Phantom limb pain may reduce ambulation and mobility in amputees, resulting in diminished quality of life. We conducted a prospective study to compare the perioperative analgesic use of intravenous morphine infusion in 27 patients (Group A) and intramuscular diclofenac sodium in 28 patients (Group B) in patients undergoing lower limb amputation. All patients underwent amputation under spinal anaesthesia and reported a Modified Verbal Numerical Pain Score of less than two prior to the procedure. Presence of phantom pain was assessed on the first, second, third and seventh day as well as at the third month and sixth month post-operatively. Twelve (44 %) patients from group A and 21 patients (75 %) from group B developed phantom limb pain following amputation, a statistically significant difference between groups (p<0.05). We conclude that intravenous morphine infusion is more effective than intramuscular diclofenac sodium in preventing the occurrence of phantom limb pain following amputation.

Subcutaneous emphysema is the presence of gas or air in the subcutaneous tissue plane. The term is generally used to describe any soft tissue emphysema of the body wall or limbs, it can result from benign causes, most commonly secondary to trauma or from a life-threatening infection by gas gangrene or necrotising fasciitis. A case of subcutaneous emphysema involving the upper limb resulting from a trivial laceration to the elbow is reported and the importance of distinguishing between the two causes of subcutaneous emphysema is highlighted.
Subcutaneous Emphysema

one hundred and five Wistar rats were randomized into 3 groups and heterogenous decalcified bone matrix (HDBM) + CaCl_2+Na_2HPO_4+KH_2PO_4, HDBM + CaSO_4+Na_2HPO_4+KH_2PO_4, and HDBM + NaCl were implanted into the quadriceps muscle of both thighs of the animals respectively. They were monitored with ~3H-TdR and ~(45)Ca tracing to evaluate the efficacy of the 3 delivery systems to enhance osteogenesis. It was found that coadministration of CaSo_4, Na_2HPO_4, and KH_2PO_4 could significantly enhance the osteogenesis induced by HDBM. It is concluded that HDBM and the coadministration of Na_2HPO_4, KH_2-PO_4, and CaS0-4/CaCl_2 together will be much more effective to induce osteogenesis than HDBM is used singly.

Temporal bone squamous cell carcinoma (TBSCC) is rare and poses difficulties in diagnosing, staging and management. We describe a case series with six patients who were diagnosed TBSCC, from January 2009 to June 2014, with median age of 62 years old. All patients presented with blood-stain discharge and external auditory canal mass, showing that these findings should highly alert the diagnosis of TBSCC. Three patients staged T3 and another three with T4 disease. High-resolution CT (HRCT) temporal findings were noted to be different from intraoperative findings and therefore we conclude that MRI should be done to look for middle ear involvement or other soft tissue invasion for more accurate staging. Lateral temporal bone resection (LTBR) and parotidectomy was done for four patients with or without neck dissection. Patients with positive margin, perineural invasion or parotid and glenoid involvement carry poorer prognosis and postoperative radiotherapy may improve the survival rate. One patient had successful tumor resection via piecemeal removal approach in contrast with the recommended en bloc resection shows that with negative margin achieved, piecemeal removal approach can be a good option for patients with T2-3 disease. In general, T4 tumor has dismal outcome regardless of surgery or radiotherapy given.

Following a week after a jellyfish sting, a young man presented with regional cyanosis and threat of distal gangrene secondary to vascular spasm in the forearm. The patient also suffered from transient paresis and numbness of the affected upper limb. Contrasted imaging revealed unopacified vessels in the distal forearm and worsening swelling warranted emergency surgical fasciotomy for impending compartment syndrome. This case highlights the occurrence of jellyfish envenomation and the need for early treatment.
Wounds and Injuries

We present fi ve cases of severe brainstem-spinal encephalomyelopathy suggestive of neuromyelitis optica (NMO) spectrum disorders treated with or without intravenous immunoglobulin (IVIG). The result shows that early IVIG is probably effective in preserving neurological function in cases with severe brainstem-spinal encephalomyelopathy suggestive of NMO spectrum disorders.