Extrahepatic bile ducts constitute a significant anatomic site for surgeons when performing hepatobiliary operations from minor procedure such as cholecystectomy to major operation such as hepatectomy. The challenges for surgeon in performing such cases increase when congenital variance of biliary tree occurs which may lead to unintentional bile duct injuries. We reported a case of a lady who presented with obstructive jaundice secondary to huge distal common bile duct stone. The presence of right posterior segmental hepatic duct, which rarely occurs, was discovered during intraoperative cholangiogram before common bile duct exploration. The operation was successful without incidence of biliary duct injury

Intraductal Papillary Mucinous Neoplasm (IPMN) of the pancreas in association with Autosomal Dominant Polycystic Kidney Disease (ADPKD) is extremely rare, even though 10% of ADPKD patients may develop simple pancreatic cyst. The first case report was published by Yasunori Sato from Japan in 2009. Since then less than 10 case reports are available worldwide to describe about this condition. We reported such a rare case of a 67-year-old man with ADPKD who was referred to our centre because of chronic abdominal pain and diagnosed as IPMN based on the serial imaging procedures. Despite of the high risk comorbidities, he successfully underwent pylorus preserving total pancreaticoduodenectomy with splenectomy.

A 24-year-old man presented to the casualty department with a history of left-sided, colicky abdominal pain for one day. It was associated with an inability to pass flatus or motion within the same duration. There was no history of vomiting. On examination, the vital signs were within normal limits, and he was afebrile. His abdomen was soft, but a hard mass was palpable on the left side of his abdomen. There was no peritonitis. The bowel sounds were sluggish.

In Malaysia, dengue fever is a common vector-borne disease. Most cases of dengue fever are reported in residential areas. Children are at high risk to be infected because they spend a lot of time around their housing area for outdoor activities. Such areas may have a high number of Aedes mosquitoes. As schools are equipped with infrastructure and medium for effective educational purposes, school represent the most suitable facilities for learning and teaching process. A cross-sectional study was conducted to determine the level of knowledge among students in Hulu Langat on Aedes mosquitoes, dengue fever, and Zika virus. The study also reported on the demographic factors which affected the knowledge level. Based on sample size calculation using G*Power v3.1 software, a total of 171 respondents were needed from the two primary schools involved in the study. Data collection was conducted using a pre-tested questionnaire that consisted of two main sections on demography and knowledge about Aedes mosquitoes, dengue fever and Zika virus. From the total score of 55, the mean knowledge score is 34.2 ± 8.38. Based on the median value of 36.0, about 50.9% of respondents had satisfactory knowledge. From the study, it was found that students from School A, students who had been watching video related to Aedes mosquito, and those with history of dengue infection among family members had a significantly better knowledge score (p < 0.01). In conclusion, knowledge about Aedes mosquitoes and related illnesses need to be enhanced through a comprehensive module and effective educational materials that can serve as a reliable source of information for primary school students.

Extracranial aneurysms are a rare presentation accounting for only less than 5% of all peripheral artery aneurysms. The left common carotid artery aneurysm is considered even rarer. We present a case of a 46-year-old gentleman who presented to casualty unit with a neck mass, stridor and acute respiratory distress. Prior to this admission patient was being investigated for Takayasu arteritis (TA). Patient was subsequently intubated due to respiratory compromise. A CT angiography of the thorax was done showed a proximal left common carotid artery aneurysm with contained leakage of aneurysm with severe compression of the trachea. Patient was subsequently transferred to the vascular team in National Heart Institute for further management.
Aneurysm

Frantz’ tumour of the pancreas is also known as solid pseudopapillary tumour (SPT) of the pancreas. It is a rare pancreatic neoplasm and represents about 3% of all the pancreatic cystic neoplasm. It occurs predominantly in young woman in 2nd to 3rd decade of life. These tumours exhibit indolent behaviour and very often reach considerable size before the first symptoms appear. Despite this presentation these tumours have low malignant potential and complete surgical resection render excellent prognosis. We reported a case of a 16-year-old girl who presented with upper abdominal mass with symptoms of gastric outlet obstruction for 7 months duration. Clinical examination revealed a huge epigastric mass measuring 10 x 12 cm in size. CT scan showed presence of mass arising from the body of the pancreas which was hypervascular, well-encapsulated with mixed cystic and solid components. She then underwent successful distal pancreatectomy and splenectomy and recovered uneventfully.
Pancreatic Neoplasms

Hypopygiopsis violacea, a species of fly of forensic importance, was recovered from a corpse and described for the first time. The morphological structures of the second and third instar larvae of four specimens were examined using light microscope. Observations were focused on three main morphological characters: cephalopharyngeal skeleton, anterior and posterior spiracles. Cephalopharyngeal skeleton of second instar larva is darkly pigmented and without accessory sclerite below the mouth hook. The anterior spiracles of second and third instar larvae have 8-9 papillae each, arranged in a single row. The posterior spiracle of second instar larva has two spiracular slits with no thickening of peritreme. This differentiates it from the third instar, whereby the latter has three slits for each posterior spiracle. Cephalopharyngeal skeleton of third instar larva is heavily pigmented. An accessory sclerite is found below the hook part of third instar larva but is absent in second instar. Peritreme of the posterior spiracle of third instar larva is thick almost complete encircling a button. The intersegmental spines of the cuticular surface are dome-shaped and unicuspid. Third instar larva of this species is large with size approximately 15 mm long. These findings provide important identification features of immature stages of Hy. violacea which could be useful in forensic entomology.

Background: Non-adherence is a major hindrance to treatment success in any disease. In chronic diseases, adherence to long term treatment is about 50% but existing data on adherence to topical treatment in dermatological diseases are limited. In atopic eczema (AE), adherence to topical therapy is essential to control inflammation and maintain adequate moisturization but these treatment aims will not be achieved without optimal adherence. Objectives: To assess the frequency of treatment adherence among our patients with AE and to identify the influencing factors. Methods: We carried out a questionnaire-based study involving dermatology outpatients with AE. Demographic data were collected and patients or carers were interviewed to assess steroid phobia, knowledge, perception on treatment and use of alternative treatment. Results: Out of 75 patients included in the study, only 14.7% were adherent to treatment. 58.7% of patients had steroid phobia but this did not significantly affect adherence. 41% of patients who use alternative treatment had poor adherence compared to patients who did not. Conclusion: Adherence to topical treatment is poor among our AE patients and multi-pronged intervention is needed to improve adherence. For clinicians, non-adherence should be considered when managing patients who appear ‘resistant’ to optimized treatment.

Aims: Accurate diagnosis and proper treatments of osteomyelitis are often difficult and ineffective due to several reasons such as less sensitive sample collected and the formation of biofilm following prosthetic use. Thus, our goal of this study is to identify suitable sample for laboratory diagnosis and also microbial species that cause osteomyelitic infection and discriminate between biofilm and non-biofilm producing strains in patients at Hospital Tengku Ampuan Afzan, Kuantan. Methodology and results: Samples of bone, prosthetic material, tissue and swab were collected from patient with suspected osteomyelitis at the hospital. Bacteria were isolated from sample using methods such as homogenization, direct transfer, and sonication. Then, species identification was done by colony characterization, biochemical test and the API identification system. Once species identified, tissue culture plate method was performed to discriminate the biofilm-producing strain from the non-biofilm-producing strain. The total number of 57 samples were collected from 17 cases of suspected osteomyelitis with 34 samples were found positive bacterial growth. Prosthetic samples produced highest positive growth with 81.3%, following by bone samples with 66.7% while swab and tissue samples with 46.2% and 43.8% respectively. We found that 14 from total 16 pathogens identified were biofilm producing-strains. Conclusion, significance, and impact of study: Prosthetic and bone samples produced higher bacterial growth, in contrast to other type of samples. Sonication method improves bacterial detection. Biofilm producing-bacteria were also the most common isolated strains from osteomyelitic infection. These have underscored the need to revise current clinical and laboratory practice as proper identification biofilm bacteria may influences management an outcome.
Biofilms ; Osteomyelitis

Introduction: Thyroid enlargement is one of the common surgical presentations in the Department of Surgery, Hospital Universiti Sains Malaysia (HUSM). Among them, benign non-toxic multinodular goiter constitutes one third (30%) of patients who underwent thyroidectomy. Common complications of thyroidectomy include recurrent laryngeal nerve (RLN) injury, hypocalcaemia, and recurrence of the thyroid lesion. Objective & Methods: This is a retrospective study of patients diagnosed with multinodular goiter treated in HUSM between January 1996 and December 2005. A total of 111 patients were studied and 52 of them underwent subtotal thyroidectomy while 59 underwent total thyroidectomy. The outcome in terms of RLN injury, hypocalcaemia and mass recurrence were analyzed. Results: Post operative complications were studied in both groups. Permanent recurrent laryngeal nerve injury occurs in 2.4% (1 case) in subtotal thyroidectomy group compared to total thyroidectomy group (3.6%, 2 cases). Five cases from total thyroidectomy group suffered from permanent hypocalcaemia but none in the other group. 70.7% (29 cases) from subtotal thyroidectomy group have functional remnant of thyroid tissue. Recurrence rate post subtotal thyroidectomy after 5 years is only 4.9% (2 cases). Conclusion: The post operative outcome in patients who underwent subtotal thyroidectomy in HUSM from January 1996 to December 2005 was better than total thyroidectomy with significant functional thyroid remnant.