Coronary artery disease (CAD) is the most common cause of death in the industrialized world. Obesity is one of the risk factor for developing CAD and also postoperative morbidity and mortality. However, in published articles the relationship between body mass index (BMI) and outcome of coronary artery bypass graft surgery depict conflicting results. This study evaluated the relationship between BMI and outcome of isolated coronary artery bypass graft performed in Hospital Universiti Sains Malaysia (HUSM). Cardiothoracic Unit HUSM is a referral centre for east coast of West Malaysia. Data was retrospectively collected from the medical records retrieved from the hospital record office. All patients who underwent isolated CABG in Cardiothoracic Unit, Hospital Universiti Sains Malaysia Kubang Kerian, Kelantan from November 2001 till October 2004 were identified and their demographic and clinical data were collected. Patients were divided into non overweight (BMI= or <25 kg/m2) and overweight (BMI>25 kg/m2) group. Data was then analyzed using SPSS version 12.0. There were 141 patients who underwent isolated CABG over the three year period. There were 80 patients with BMI < or =25 kg/m2 and 61 patients with BMI of >25 kg/m2. The demographic data of the two groups were similar. There was no statistical significant differences in the outcome of isolated coronary artery bypass graft. In conclusion, body mass index does not influence the outcome of isolated coronary artery bypass graft.

Refractory ascites is difficult to treat by restriction of salt and repeated paracentesis which have been the mainstay of treating it for a long time. Sapheno-peritoneal shunts have been performed in patients with refractory ascites . Here, we evaluated the use of saphenous vein to be anastomosed to the peritoneam to drain the refractory ascites. Nine patients (7 male, median age 45 years, range 17 - 69) with tense refractory ascites associated with liver cirrhosis, perioprtal fibrosis and end stage renal diseases underwent sapheno-peritoneal anastomosis by mobilizing and rotating the proximal vein in order to be anastomosed to peritoneum in the lower abdomen . All procedures were performed under local anaesthesia. Thirty-day mortality was 22% (2) patient. Morbidity included fluid leakage in 1 (11%), and wound infection in 1 (11%). Hospital stay (median) was 16 days (range 11 to 23). In the short term (median of 2 months) significant reduction in body weight and abdominal girth was seen in 9 (90%), 6 (60%) were not on diuretics while 3 (30%) continued to remain on reduced doses of diuretic. Furthermore, 7 (70%) did not require paracentesis. At 2-year follow-up, 5 (45%) patients died and 3 succumbed during follow-up. The remaining 3 were all in active employment, 1 was off diuretics, and 2 were on reduced doses. All 3 patients maintained reduced body weights and abdominal girths compared with preoperative values. Saphenous-peritoneal shunt appears a simple, safe, and cost effective method of achieving long-term control of refractory ascites. The use of autogenous shunt is an added advantage over prosthetic shunts for drainage of ascitic fluid.

Primary tumors of the heart are rare. However, among them cardiac myxoma is the most common tumor accounting for half of the primary cardiac neoplasms. About 75% of cardiac myxomas are located in the left atrium, and 25% are located in the right atrium. These are thought to be arising from remnants of subendocardial vasoformative reserve cells or multipotential primitive mesenchymal cells in the fossa ovalis and surrounding endocardium, which can differentiate along a variety of cell lineages including epithelial, hematopoietic, and muscle cells. Although some cases are discovered incidentally by echocardiographic examination, it was recognized in most of the patients by various symptoms caused by the release of inflammatory cytokines such as interleukin-6 (IL-6), obstruction of intracardiac blood flow, or embolization. Cardiac myxoma has many undetermined interesting issues regarding its origin, nature as a tumor, varying clinical manifestations, and the presence of both sporadic and familial types. Recent evidence revealed that cardiac myxomas are benign neoplasms and slowly proliferating lesions. The existence of its malignant counterpart is controversial. However, recurrence after surgical excision or metastasis has been reported. We hereby present a case report of a young gentleman who presented with history of sudden onset of weakness and cerebellar signs. Urgent CT scan revealed hypodensities of bilateral occipital lobes and cerebellum suggestive of infarcts. Urgent echocardiography denoted large left atrial myxoma. The tumor was excised and the patient recovered well.

Colonic diverticula is observed in over 60% of the western population aged over 80 where up to 30% will eventually be symptomatic and may develop complications. The natural history and etiology of colonic diverticula have been well described. However, predictive indicators of complicated diverticular disease are not known thus preventing the prophylactic treatment of this subset of patients,. The aim of this study was to observe patients with complicated diverticular disease in order to identify common factors associated with recurrent complications. All hospital admissions from January 2005 to December 2008 for complications of diverticular disease were recruited. Using logistic regression, demographic data and factors such as clinical presentation, nature of complication, lifestyle, concomitant medical illness and medications that may be associated with recurrent episodes of complications were analyzed. A total of 121 patients were diagnosed with complicated diverticular disease during the study period with 24 patients having recurrent complications. Logistic regression analysis performed after controlling for confounders found active smoking (p=0.006) and alcohol consumption (p=0.036) along with underlying diabetes (p=0.031) and dyslipidemia (p=0.039) significantly associated with an increased risk of recurrent complications. We therefore concluded that smoking, alcohol consumption, diabetes mellitus and dyslipidemia are associated with recurrent complicated colonic diverticular disease. As these are modifiable risk factors, they should be sought for during the presentation of the first attack. Aggressive control of these factors will help in reducing the risk of recurrent complications.

Acute appendicitis is one of the most common differential diagnoses for acute abdominal pain made by emergency doctors. Suspected cases require surgical referral for observation or definitive intervention to prevent complications. A high index of suspicion and good clinical skills with the aid of scoring systems allows early decision making, which includes optimal pain control. The objective of this study was to identify the pain score and is relationship to the cut-off points of the Alvarado scoring system so that justifies early surgical referral or discharge for suspected acute appendicitis from the Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a cross sectional study of acute abdominal pain from June 2007 to September 2008. All patients who fulfilled the criteria and consented to the study were assessed for Alvarado score, verbal numerical pain score (VNRS) and their subsequent management. Patients with an Alvarado score of ≥7 were likely to have acute appendicitis (80.1% sensitivity and 52.63% specificity) and those with the score of ≤3 were unlikely to have acute appendicitis. The median pain score was 7.00 (IQR: 5.00-8.50) but 72.5% did not receive any analgesia. There was no direct relationship between the pain score with Alvarado score. Oligoanalgesia in patients with acute appendicitis still exist in Emergency Department of UKMMC.

Dermoid cyst in a kidney is rarely seen. We report a case of intrarenal dermoid cyst which mimics malignant renal tumour and discuss the dilemma in managing this disease.

Patients with end-stage renal disease typically require catheter hemodialysis during the time required for fistula or graft maturation or after other methods of hemodialysis are exhausted. When patients requiring indwelling catheters develop central venous occlusions, unconventional routes to the central veins are used. Translumbar catheterization of inferior vena cava is considered as one of the options for central venous access. We highlight a case of Translumbar central venous tunelled catheterization performed under Computed Tomography (CT) guidance combined with fluroscopy in a 40-year-old lady with end-stage renal failure.

Extra-gonadal germ cell tumours (EGGCT) are rare. Therefore further investigations of the testis is aimed at sourcing a possible primary origin of gonadal tumour. Over the years, various case series on EGGCT have been reported questioning its true nature as in a majority of them, a primary source is found in the testis, thus representing a metastatic gonadal tumour. The testis pathology could be either a true germ cell foci, an intra-tubular epithelial neoplasia or an area of fibrosis, indicating a ‘burnt out tumour’. We report a 39-year-old male who underwent laparotomy and excision of a retroperitoneal tumour. Histopathological examination revealed retroperitoneal lymph node of mixed germ cell tumour origin. Clinical and ultrasound examination of bilateral testis was normal. The patient refused orchidectomy or a testicular biopsy. He underwent four cycles of bleomycin, cisplatin, and etoposide with no evidence of tumour recurrence on follow up and remains disease free after 12 months of diagnosis. A literature review of EGGCT, its relation and factors relating with future testicular tumour is presented.

Pseudohyperkalemia is a spuriously high serum potassium measurement in a patient with no clinical evidence of hyperkalemia. It has been reported to occur in patients with leukocytosis and thrombocytosis. Only a few cases of pseudohyperkalemia have been reported in patients after splenectomy. Two cases of pseudohyperkalemia occurring after emergency splenectomy for abdominal trauma are presented to highlight their clinical presentation and sequalae. Consecutive patients who underwent emergency splenectomy for trauma and subsequently developed pseudohyperkalemia were monitored in Universiti Kebangsaan Malaysia Medical Centre for their clinical sequalae. Both the patients developed leukocytosis, thrombocytosis and high serum potassium level within 2-weeks of their splenectomies. They did not demonstrate any symptoms and signs of hyperkalemia. Their conditions resolved spontaneously without any specific treatment. Pseudohyperkalemia should be suspected in a similar clinical scenario to avoid unnecessary treatment that could lead to severe hypokalemia.

Management of pain plays an important role during prostate biopsy. Various types of management of pain plays an important role during prostate biopsy. Various types of anaesthetic methods have been used. The present study aimed to compare the efficacy and complication rate between periprostatic lidocaine infiltration and transrectal lidocaine gel in transrectal ultrasound guided prostate biopsy. All prostate biopsy patients were included except those with lidocaine, allergy, haemorrhagic diathesis, anticoagulation therapy, the inability to rate a visual analogue scale and inability to obtain consent. They were randomized into two groups. Group 1 received 20ml 2% transrectal lidocaine gel. Group 2 received 5ml 1% lidocaine infiltration for each periprostatic nerve block with 23-gauge spinal needle. After three minutes, prostate biopsy was performed with an 18 gauge 7-inch spring-loaded biopsy gun. Six biopsies were taken for each lobe. Pain during probe insertion, biopsy and immediately after the procedure was assessed using the Visual Analogue Scale. Any complication immediately after procedure, one day or after one week, was recorded. Mean pain score was lower after periprostatic lidocaine infiltration compared to transrectal lidocaine gel (3.1 + 1.9 versus 4.9 + 2.4, p = 0.027). There was no statistically significant difference in the complication rate. Transrectal ultrasound prostate biopsy using periprostatic lidocaine infiltration provides better anaesthesia as compared to the transrectal lidocaine gel application with no significant difference in complication. Thus, the use of periprostatic lidocaine infiltration in TRUS guided prostate biopsy is recommended.