Clinical Competence ; Education, Medical, Graduate ; standards ; Education, Medical, Undergraduate ; standards ; Female ; Humans ; Internship and Residency ; standards ; Male

Emphysema is a progressive unrelenting component of chronic obstructive pulmonary disease and a major source of mortality and morbidity globally. The prevalence of moderate to severe emphysema is approximately 5% in Malaysia and likely to increase in the future. Hence advanced emphysema will emerge as a leading cause of hospital admission and a major consumer of healthcare resources in this country in the future. Patients with advanced disease have a poor quality of life and reduced survival. Medical therapy has been largely ineffective for many patients however certain subgroups have disease amenable to surgical palliation. Effective surgical therapies include lung volume reduction surgery, lung transplantation and bullectomy. This article is a comprehensive evidence based review of the literature evaluating the rationale, efficacy, safety and limitations of surgery for advanced emphysema highlighting the importance of meticulous patient selection and local factors relevant to Malaysia.

Synchronous primary non-small cell lung cancers (NSCLC) are rare and may be discovered unexpectedly following lung resection. Discrimination from intrapulmonary metastases is important to guide treatment and prognosis but is difficult solely on clinical or radiological findings. Histopathological evaluation with immunohistochemistry (IHC) markers can prove decisive and should feature in the diagnostic algorithm of such patients. We report a rare case of two synchronous primary NSCLCs diagnosed post operatively following pathological examination of the resected lobe, highlighting the value of IHC and discuss the management of such patients.

Introduction: In the Southeast Asian region where chronic hepatitis B virus (HBV) infection remains prevalent, HBV related disorders comprise a significant proportion of cases managed by the Hepatology clinics. Additionally, non-alcoholic fatty liver disease (NAFLD) is becoming an increasingly common condition referred to Hepatology clinics for management. We prospectively assessed the spectrum of hepatic disorders managed by the Hepatology clinics in RIPAS hospital, the only tertiary referral centre in Brunei Darussalam. Materials and Methods: All patients seen for hepatic disorders (new referral or follow-up) during a 32 working days period were included in this study. Patients attending for non-hepatic disorders were excluded. Results: During this period, hepatic disorders accounted for 32.2% of the cases managed. The mean age of patients with hepatic disorders was 43.3 ± 12.2 years old with more male patients (65.7%). New referrals accounted for 10%. Overall, 49.6% were positive for HBV, 12% for chronic hepatitis C virus (HCV) infection and 42.1% had evidence of NAFLD. There were overlaps of disorders in 15.5% (12.5% HBV/NAFLD, 2.1% HCV/NAFLD and 1.2% HBV/HCV). Nineteen cases (5.75) had cirrhosis, most commonly associated with HBV and HCV. A quarter were cryptogenic. Patients with NAFLD were significantly heavier than those with HBV, HCV/HBV and the ‘Others’ group. There was also a significant trend for elevated serum alanine aminotransferase among those with NAFLD. Conclusion: Chronic HBV infection is still the most common hepatic disorder encountered in our Hepatology clinics. However, NAFLD is becoming an increasingly more common condition.

The incidence of premature multi-vessel coronary artery disease (CAD) is on the rise in Malaysia. The pathogenesis of coronary atherosclerosis is multi-factorial with dyslipidaemia being one such risk factor. Elevated total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and triglycerides (TG) levels are primarily responsible. We analysed the fasting pre-operative lipid profiles of coronary artery bypass graft (CABG) patients with symptomatic severe premature CAD. A majority of patients had an elevated LDL cholesterol level despite being on a statin. Similarly, no patient with an elevated TG level was prescribed a fibrate. Pre-operative control of known dyslipidaemia was suboptimal in young adults with angiographially proven severe symptomatic CAD. This is either due to subtherapeutic dose prescribing or failure to commence appropriate anti-lipid drugs. Collectively, general practitioners, cardiologists and cardiac surgeons must be more diligent in monitoring lipid profiles in such patients and be more meticulous in prescribing therapeutic doses to achieve target control.
Coronary Artery Disease

Introduction: Colonoscopy is an investigation for the evaluation of lower gastrointestinal symptoms. Just like any other conditions, it is important to be aware of the spectrum of findings so that appropriate referral and decisions can be made. Materials and Methods: Patients (mean age 52.3 ± 15.3 years old with almost equal proportion of genders) referred for colonoscopy in RIPAS Hospital over a five year period (January 2003 to December 2007) were retrospectively identified and studied. Results: The most common indication for colonoscopy was bleeding per rectum (22.9%), followed by evaluation of abdominal pain (18.6%), anaemia (11.7%), colorectal cancer screening (11.7%), evaluation of constipation (5.9%) and altered bowel habits (3.8%). A large proportion (58.4%) colonoscopy was normal. The most common positive finding was haemorrhoids (30.3%), majority of which were categorised as grade I. This was followed by colonic polyps (17.6%), diverticular disease (12.1%), non-specific colitis (4.0%), colorectal cancers (4.0%) and ulcers (3.6%), melanosis coli (0.4%) and telangiectasia (0.1%). Colorectal cancer was most common among the Malays (4.4%), followed by the Chinese (4.0%), the indigenous (2.8%) and the others (1.2%). Conclusions: Our study showed that the most common indication was for the evaluation of bleeding per rectum. Majority had normal colonoscopy and the most common positive finding was haemorrhoids. Importantly colorectal neoplasms accounted for one fifth of procedures with colorectal cancers accounting for four percent.
Diabetic Complications ; Diabetic Foot ; Microbiology ; Bacteriology

“Enlarged parietal foramina” is a congenital malformation with autosomal dominant inheritance. The condition is usually self-limiting and doesn’t require any treatment. However, it may also be associated with encephalocele, vascular anomalies or may be a part of syndrome. We present a case of enlarged parietal foramina in a child and discuss its imaging findings and the associated intracranial vascular malformations.
Encephalocele

We describe a case of vitamin-D-deficiency rickets in a young child to highlight its existence in Malaysia where sunlight is abundant throughout the year. The child presented with deformity of both legs. He came from an educated urban family but remained indoors most of the time. Radiographs of knees and wrists showed changes of florid rickets. Low serum 25-hydoxyvitamin-D, high parathyroid hormone, normal serum phosphate and calcium levels, and normal renal function clinched the diagnosis of vitamin-D-deficiency rickets. He improved remarkably after treatment with oral Vitamin-D. We emphasise the importance of exposure to sunlight to prevent rickets.