Introduction: The understanding of the skin’s vascular anatomy has improved in the last decade. It has lead to technique modification such as the staged procedure in performing sural flaps and improvement in the flap survival rate. The aim of this study was to evaluate the acute vascular complications (flap necrosis or congestion) of 29 patients who underwent distal base sural flap for coverage of wound around the ankle. Methods: Twenty-four males and five females with a mean age of 37.1 years old underwent sural flap surgery to cover wounds at around the ankle. There were 12 cases of open fracture, five infected fractures, four spoke injuries, four degloving injuries and four diabetic foot ulcers. Twentythree cases were done as a single stage procedure while six as a two-stage procedure. The flaps were tunnelled under the skin in three cases. Results: Twenty one flaps healed uneventfully, seven acute vascular complications occur in a single stage group: five developed partial necrosis, one had congestion with epidermolysis, and one had complete flap necrosis. Complications were treated by dressing or skin grafting and only one required a repeat flap surgery. Conclusions: Acute vascular complications may be minimised when sural flap is done in stages for elderly, diabetic, smokers and/or patients with large wound around the ankle. Even if the flap appears necrotic, the underlying structure may still be covered as the fasciosubcutaneous layer of the flap may still survive.

evere social and psychological problems. Tissueexpansion, although an old concept, provides a surgicalalternative to manage areas of alopecia. We describe a caseof alopecia secondary to repaired occipital encephalocelethat was successfully treated using tissue expansiontechnique.

High failure rate for recurrent palatal fistulas closure pose agreat challenge to plastic surgeons. Tongue and facial arterymusculomucosal (FAMM) flaps are the more commonly usedflaps for closure of these recurrent fistulas. We report a caseof a formerly inset FAMM flap to effectively close apreviously repaired oronasal fistula.

We report our experience of treating two patients with ankle amputation with different presentations. The first case was a clean-cut sharp amputation. The second case was an avulsion injury following a motor vehicle accident in a patient who arrived 8 hours after the injury. Replantation was successful in both cases. In avulsion injuries, a secondary operation for wound coverage is required at a later stage. With good strategy and a support team, encouraging limb survival outcomes are possible post-replantation.

BACKGROUND: Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early results in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft. METHODS: A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty. RESULTS: In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes. CONCLUSIONS Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.

mortality and an important cause of morbidity in Malaysiafor several years. To reduce global cardiovascular (CV) riskin the population, primary preventive strategies need to beimplemented. Hypercholesterolaemia is one of the majorrisk factors for CVD. This paper is an expert review on themanagement of hypercholesterolemia focusing on high andvery high risk individuals. In low and Intermediate riskindividuals, therapeutic lifestyle changes (TLC) and ahealthy lifestyle alone may suffice. In high and very high riskindividuals, drug therapy in conjunction with TLC arenecessary to achieve the target LDL-C levels which havebeen shown to slow down progression and sometimes evenresult in regression of atherosclerotic plaques. Statins arefirst-line drugs because they have been shown in numerousrandomized controlled trials to be effective in reducing CVevents and to be safe. In some high risk individuals, despitemaximally tolerated statin therapy, target Low DensityLipoprotein Cholesterol (LDL-C) levels are not achieved.These include those with familial hypercholesterolaemia andstatin intolerance. This paper discusses non-statintherapies, such as ezetimibe and the newer Proproteinconvertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

BACKGROUND: The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma. METHODS: This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved. RESULTS: Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years. CONCLUSIONS: Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.
Ameloblastoma ; Female ; Fibula ; Follow-Up Studies ; Free Tissue Flaps ; Humans ; Male ; Mandible ; Mandibular Osteotomy ; Mandibular Reconstruction ; Medical Records ; Recurrence ; Retrospective Studies ; Venous Thrombosis

Objective: To determine the etiologies of tropical acute febrile illness (TAFI) in West Pahang, Malaysia and to investigate morbidity and mortality factors in relation to TAFI. Methods: A multicenter prospective cohort study was conducted between January and June 2016 in six district hospitals throughout the western part of Pahang State in Peninsular Malaysia. A total of 336 patients answered a standardized questionnaire and blood samples were collected for laboratory confirmation of infectious etiology. Descriptive analysis and logistic regression were performed to identify factors associated with TAFI. Results: A total of 336 patients were included. The patients were mainly Malays (70.2%), males (61.3%), aged (44.6±17.4) years, with more than half (58.9%) presenting with gastrointestinal symptoms. The majority were diagnosed with dengue (35.7%) while malaria (4.5%) was the least frequent. The in-hospital mortality due to TAFI was 9.2%. Patients with meliodosis had five times higher mortality [Adjusted OR: 5.002, 95% CI: (1.233, 20.286)]. Patients with comorbidities such as cardiovascular symptoms (P <0.001) and renal replacement therapy initiation (P <0.001) were significantly associated with in-hospital mortality in all TAFI. Conclusions: The etiology of TAFI in the western Pahang includes dengue, leptospirosis, malaria and melioidosis, which carry the highest risk of in-hospital mortality. The presence of cardiovascular symptoms may be used to assess the disease severity in TAFI, but more studies are needed in the future.

INTRODUCTIONThe elderly are often underrepresented in clinical trials for acute coronary syndrome (ACS), and cardiologists commonly face management dilemmas in the choice of treatment for this group of patients, particularly concerning the use of invasive revascularisation. This study analysed the characteristics of hospitalised elderly patients with ACS, and compared the outcomes of treatments.

METHODSFrom 29 December 2005 to 26 April 2010, 13,545 patients were admitted for ACS in 16 hospitals across Malaysia. These patients were divided into two groups - elderly (≥ 65 years) and non-elderly (< 65 years). The clinical characteristics, treatment received (invasive or non-invasive) and outcomes (in-hospital and 30-day all-cause mortality) of the two groups were compared. The elderly patients were then grouped according to the type of treatment received, and the outcomes of the two subgroups were compared.

RESULTSElderly patients had a higher cardiovascular risk burden and a higher incidence of comorbidities. They were less likely to receive urgent revascularisation for acute ST-segment elevation myocardial infarction (elderly: 73.9% vs. non-elderly: 81.4%) and had longer door-to-needle time (elderly: 60 minutes vs. non-elderly: 50 minutes, p = 0.004). The rate of cardiac catheterisation was significantly lower in the elderly group across all ACS strata. Elderly patients had poorer outcomes than non-elderly patients, but those who received invasive treatment appeared to have better outcomes than those who received non-invasive treatment.

CONCLUSIONElderly patients with ACS tend to be undertreated, both invasively and pharmacologically. Invasive treatment seems to yield better outcomes for this group of patients.

Acute Coronary Syndrome ; epidemiology ; Age Factors ; Aged ; Cardiovascular Diseases ; epidemiology ; Databases, Factual ; Female ; Humans ; Malaysia ; epidemiology ; Male ; Middle Aged ; Morbidity ; trends ; Registries ; Survival Rate ; trends

Background & Objectives: The National Institute of Health Stroke Scale (NIHSS) provides a valid and quick assessment of stroke severity in hyperacute stroke management. Stroke patients who are eligible for reperfusion therapy require prompt assessment. There is no validated Bahasa Malaysia (BM) version of the NIHSS that allows easier assessment by BM-speaking health professionals. This study aimed to translate and validate a BM version of the NIHSS. Methods: The English NIHSS was translated to BM, then back translated to ensure linguistic accuracy. We also adapted the language assessment of the NIHSS to be more culturally appropriate. Training and certification videos were downloaded from the NIH website and dubbed into BM. We determined intra-class correlation and unweighted kappa as the best measure of reliability. Median scores were used in the analysis for language items. Results: One hundred and one raters participated in the test-retest reliability study. Agreement between the original NIHSS and our translated version of the BM-NIHSS was good (ICC = 0.738, 95% CI: 0.611 to 0.823). Fair to moderate agreement was found on item-by-item analysis (unweighted κ=0.20-0.50) despite high observed agreement. Fifty patients participated in the language assessment arm. Scores were better in BM for reading, naming objects and repetition (Mdn = 100, p < 0.001). There was no difference in the median scores for the description component. Conclusions: The BM-NIHSS is a valid translation of the NIHSS, and may be used in clinical practice by BM-speaking healthcare professionals.