Demographics and outcome of patients with congenital haemophilia in Sarawak, Malaysia

INTRODUCTION

Sarawak has a population that is geographically and characteristically widely varied. This study aimed to determine the demographic profile of patients in Sarawak, Malaysia. Materials and Methods - A cross-sectional study was conducted in 2019 at four major haemophilia treatment centres in Kuching, Sibu, Bintulu and Miri Hospitals, Sarawak. Demographic and clinical data were collected with consents from patients.

RESULTS AND DISCUSSION

Ninety-six haemophilia patients were identified - 79(82.3%) haemophilia A(HA) and 17(17.7%) haemophilia B(HB). Severe haemophilia patients were noted in 45.6% (36/79) of HA and 64.7% (11/17) of HB. In all 44.3% of the HA and 52.9% of the HB population had no identifiable family history of haemophilia. Two-thirds of the patients with severe HA were on prophylaxis [24/36 (66.7%)] and only onethird [4/11 (36.4%)] in severe HB. Inhibitors developed in 9/79 (11.4%) of the HA population [3/79 (3.8%) high responders]. The median inhibitor titre was not significantly different between the different treatment groups - on demand versus prophylaxis (1.0BU versus 2.0BU; z statistic -1.043, p-value 0.297, Mann-Whitney test). None of the patients developed inhibitory alloantibodies to factor IX. Four HA patients (5.1%) underwent immune tolerance induction where one case had a successful outcome. Three severe HA patients received emicizumab prophylaxis and showed remarkable reduction in bleeding events with no thromboembolic events being reported. One female moderate HA patient received PEGylated recombinant anti-haemophilic factor. Eleven patients underwent radiosynovectomy. One mild HB patient succumbed to traumatic intracranial bleeding. Our data reported a prevalence (per 100,000 males) of 5.40 cases for all severities of HA, 2.46 cases for severe HA; 1.16 cases for all severities of HB, and 0.75 cases for severe HB. The overall incidence of HA and HB was 1 in 11,500 and 1 in 46,000, respectively.

CONCLUSION

This study outlines the Sarawakian haemophilia landscape and offers objective standards for forward planning. Shared responsibilities among all parties are of utmost importance to improve the care of our haemophilia population.

Clinical spectrum of children receiving palliative care in Malaysian Hospitals

INTRODUCTION

Awareness for paediatric palliative care has resulted in the impetus for paediatrician-led palliative care services across Malaysia. However, there is paucity of local data on patients receiving hospital-based paediatric palliative care. We aim to review the clinical spectrum of patients referred to these services.

METHODS

An observational study of children aged between 0-18 years receiving palliative care at 13 hospitals between 1st January and 31st December 2014 was carried out.

RESULTS

There were 315 patients analysed, 90 (28.6%) and 46 (14.6%) were neonates and adolescents respectively. The main ICD-10 diagnostic categories for all patients were identified to be 'Congenital malformations, deformations and chromosomal abnormalities' 117 (37.1%), 'Diseases of nervous system' 76 (24.1%) and 'Neoplasms' 60 (19.0%). At referral 156 (50%) patients had holistic needs assessments. Patients with 'Diseases of nervous system' were assessed to have significantly more physical needs than the other two diagnostic categories. Majority of patients who knew of their diagnosis and prognosis were those with malignancy. Over a fifth of referrals were at their terminal admission. Of 144 who died, 111 (77.1%) had advanced care plans. There was bereavement follow-up in 98 (68.1%) patients.

CONCLUSION

Patients referred for palliative care have varied diagnoses and needs. To ensure all paediatricians are competent to deliver quality care to all children, further education and training initiatives is imperative.

Frequent occurrence of gastric cancer in Asian kindreds with Li-Fraumeni syndrome

Type of cancer and age of onset in individuals with inherited aberrations in the tumour suppressor gene TP53 are variable, possibly influenced by genetic modifiers and different environmental exposure. Since 2009, the modified Chompret criteria (MCC) have been used to identify individuals for TP53 mutation screening. Using the TP53 mutation database maintained by the International Agency for Research on Cancer (IARC), we investigated if the MCC, mainly developed for a Caucasian population, was also applicable in Asia. We identified several differences in Asian families compared with similar Caucasian cohorts, suggesting that identification and management of Li-Fraumeni syndrome in Asia do not completely mirror that of North America and Western Europe. Early gastric cancer (<40 years) may be considered a new addition to the MCC especially for Asian families.

Mild autosomal recessive osteopetrosis: successful treatment with bone marrow transplant

We describe a 5 1/2 year old boy who was diagnosed with mild autosomal recessive osteopetrosis based on the presence of bony sclerosis, extramedullary haematopoeisis, leukoerythroblastosis and visual impairment who had an allogeneic bone marrow transplant from a matched sibling donor. Conditioning regime was busulphan 16 mg/kg and cyclophosphamide 200 mg/kg. Apart from transient hypercalcaemia, there were no major post transplant complications. Four years post transplant, the extramedullary haematopoeisis has resolved completely with normal blood counts. Apart from a fracture after a trivial fall two months after transplant, he has not suffered any fracture related limb deformities.

Early presentation of right adrenal mass, hepatoblastoma and hepatic cavernous haemangioma in Beckwith-Wiedemann Syndrome

Beckwith-Wiedemann Syndrome (BWS) is associated with early development of embryonal tumours usually in the first four years of life. We describe a patient who presented with a right adrenal cyst in the first month of life and hepatoblastoma in the third month of life. A cavernous haemangioma was subsequently found in the resected tumour.

Chromosome 13q deletion with Cornelia de Lange syndrome phenotype

A 3-year-old girl with facial dysmorphic features suggestive of Cornelia de Lange syndrome was seen in the ophthalmology unit for a right leukocoria. The leukocoria was found to be caused by a large retinoblastoma and the right eye was enucleated. Chromosomal analysis revealed partial chromosome 13q deletion involving band 14 which is associated with a high risk of retinoblastoma. This case shows that patient with chromosome 13q deletion syndrome cannot be diagnosed based on dysmorphic features only. Chromosomal analysis is warranted in all infants with facial dysmorphism suggestive of Cornelia de Lange syndrome so that those with chromosome 13q deletion can be referred early for early detection of retinoblastoma.

Moulded cement-prosthesis for osteosarcoma of the proximal humerus

We report a case of an 11-year-old boy with osteosarcoma of the proximal humerus treated with wide excision and reconstruction with a cement spacer-prosthesis. After seven years of follow-up, the patient is now almost a young adult. We present his current physical and functional status, which seems to defray the initial doubts regarding long-term problems when we chose this method of reconstruction.

New abdominal retractor for exposure of subphrenic region

A new abdominal retractor for good exposure of the subphrenic space is described. It can be used either with subcostal incision for extensive hepatic resection or with upper midline incision for total gastrectomy. Because of the centrally placed winch and simple design, it withstands strong pulling and is very reliable. In more than 100 laparotomies done, the retractor was used in extensive hepatic resection or total gastrectomy without complications.

Hepatolithiasis in East Asia. Retrospective study

Hepatolithiasis is a major disease in Asia but differences in operative incidence between countries have not been examined. A retrospective study was conducted in Taiwan, Hong Kong, and Singapore, and the results were compared with those in Japan with the aim of defining factors involved in the etiology of the condition. In order to ensure uniformity of the data collected, the same form was used throughout the study and was completed by the same personnel after reviewing the patient's record and radiographs in each case. The years 1976-1980 were chosen for the study, since the newer methods of diagnosis such as ultrasound, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography became available during that period. The most significant finding was the difference in the relative prevalence of hepatolithiasis as a proportion of all gallstone cases in Taiwan, Hong Kong, and Singapore, where the majority of the population consisted of patients of Chinese descent. The highest prevalence, 53.5%, was found in Taiwan, while in Hong Kong it was 3.1% and in Singapore 1.7%. Environmental rather than ethnic factors are implicated in the cause of hepatolithiasis.

Pyloric function five to eleven years after Ramstedt's pyloromyotomy

Pyloric function after Ramstedt's pyloromyotomy was assessed in seven patients aged five to eleven years and compared to that in sixteen normal children. Gastric emptying (T 1/2) of liquid, as measured by the double sampling test, was faster in patients than in normal children. Duodenal reflux was calculated from the sodium content in gastric aspirates. At rest, it was greater in patients than in normal children. In the poststimulatory state, there was no difference. Gastric acid secretion was similar in both groups. Rapid gastric emptying might explain the high incidence of peptic ulcer reported in several series of long-term follow-up patients. Increased duodenal reflux at rest might account for a similar increased incidence in gastritis and dyspepsia.

Recovery of malignant tumor cells from the right atrium during hepatic resection for hepatocellular carcinoma

Tumor cells were recovered from the right atrium in three of five patients during hepatic resection for hepatocellular carcinoma. Mechanical factors during blunt mobilization and rotation of the hepatic tumor appeared to be responsible for tumor dislodgement into the venous circulation. Tumor embolization to the lungs may be one of the important reasons for the poor results of surgery in this disease. Two possible technical and therapeutic modifications are suggested to prevent or neutralize this phenomenon.

Effects of gastrocystoplasty on serum gastrin levels and gastric acid secretion

Hypersecretion of gastric acid and hypergastrinaemia occur when the antrum of the stomach is transposed as a diverticulum to the colon. Thus, when an antral pouch is transposed to increase bladder capacity or to replace the bladder as a gastrocystoplasty, similar pathophysiological disturbances can be anticipated. However, previous studies in our laboratories in dogs have shown that acid overproduction and stomal ulcerations do not occur. This paper reports the results of gastrocystoplasty in 13 patients followed up from 1 to 6 years. Gastric acid hypersecretion and hypergastrinaemia did not occur.

Acute subdural haematoma: better results with neurosurgeons than general surgeons

During an eleven year period, 123 patients with acute subdural haematoma were treated in our unit. The first 63 patients were managed by general surgeons with a mortality rate of 80.9 per cent. Good recovery among survivors was 4.7 per cent. The subsequent 60 patients were managed by neurosurgeons. The mortality rate then dropped to 60 per cent and the rate of good recovery rose to 21.6 per cent. This improvement in outcome is statistically significant (P less than 0.02 and P less than 0.05 respectively). Early operation plus thorough evacuation of haematoma by craniectomy or craniotomy were the main factors found responsible for the improvement.

Epidural hygroma of the posterior fossa. Case report

A case of posttraumatic epidural hygroma is reported. This child presented with occipital injury. Slowly but progressively he developed bilateral Wallenberg's syndrome and retrocollis. Correct preoperative diagnosis was made with the aid of computerized tomography. The case is discussed with emphasis on the mechanism of formation of an epidural hygroma and its clinical presentation.

Disseminated tuberculosis in a renal transplant recipient

A case of disseminated tuberculosis in a renal transplant recipient is presented. Tuberculosis can occur in the early postoperative period and is potentially curable. It should be vigilantly looked for in every case of post-transplant infection.

Biliary atresia before and after the introduction of the Kasai-type procedure

The apparent cure rate of infants with biliary atresia is compared before and after the introduction of the Kasai-type procedure. While the operation has been criticized for many of its postoperative problems, it still compares favourably in terms of the apparent cure rate, i.e. an improvement from 4.5% to 35.3%.

Proximal gastric vagotomy, truncal vagotomy with drainage, and truncal vagotomy with antrectomy for chronic duodenal ulcer. A prospective, randomized controlled trial

The relative merits of proximal gastric vagotomy (PGV), truncal vagotomy with drainage (TV + D), and truncal vagotomy with antrectomy (TV + A) in the treatment of chronic duodenal ulcer were evaluated and compared in 152 patients in a prospective, randomized and controlled clinical trial. One death occurred after TV + A, resulting in an operative mortality of 2% after gastrectomy and 0.7% for the entire series. After one to six years, stomal and duodenal ulcers proven by endoscopy occurred in eight patients after PGV (16%) and in six patients after TV + D (11.8%); the difference was not statistically significant (p greater than 0.5). One additional patient developed a gastric ulcer nine months after PGV. There was so far no ulcer recurrence after TV + A. Majority (13 patients) of the recurrent ulcers were discovered within three years after surgery. Patients after PGV experienced significantly less unwanted side effects than those after either TV + D or TV + A; particularly, dumping, epigastric fullness, and diarrhea. When the functional status was graded according to a modified Visick system that excluded ulcer recurrence, significantly more PGV patients were placed in the near-perfect grade (82.1%) than TV + A patients (58%). Patients after TV + D fared better than patients after TV + A; but the differences were not significant. However, when ulcer recurrence was included in the functional assessment, the advantage of PGV was lost.

Surgical management of benign oesophago-pleural fistula

Three cases of oesophago-pleural fistula are presented. Two resulted from foreign body perforation of the oesophagus and one followed left lower lobectomy for bronchiectasis. All three presented late; the time lapse ranged from 6 days to 2 months. An initial course of conservative treatment was given to all three patients. Alimentation via nasogastric tube feeding, gastrostomy or total parenteral nutrition was carried out. The pleural fluid grew the anaerobe, Bacteriodies melaninogenicus, in all three cases. Gram-negative aerobes, Escherichia coli and Proteus mirabilis, were also cultured. Closed intercostal drainage and a course of appropriate antibiotics were instituted. The patients were subjected to surgery after the infection had been brought under control. Simple repair was performed in two patients. Exclusion of the oesophageal leak with drainage and later reconstruction was carried out in the third patient. Although all three patients recovered, the morbidity was considerable. The duration of hospital stay ranged from 2 to 4 months.

Analysis of mortality of extradural haematoma in a general surgical unit

Extradural haematoma complicating head injury still has a formidable mortality despite recent advances in neurological surgery. The experience of 60 cases of extradural haematoma treated in a general surgical unit was reviewed retrospectively. The mortality was 35%. Analysis of the 21 deaths showed that 13 (62%) of them were possibly avoidable. Lack of index of suspicion, delay in instituting surgical treatment and inadequate surgical intervention were the main causes of the avoidable mortality.

Tracheostome construction during laryngectomy--a method to prevent stenosis

A new technique for construction of the tracheostome at the time of total laryngectomy is described. It involves making an X-shaped incision on the lower skin flap and four slits on the divided trachea. The result is a serrated suture line at the tracheocutaneous junction. The incidence of stenosis in 116 patients who did not have this method of construction was 31%. Sex difference and previous irradiation was not found to be related to the occurrence of stenosis. Of 25 patients who had the new method of tracheostome construction, only one patient had to wear a tube until she died at 7 months. The rest, followed up for at least 9 months, did not have stenosis. It is concluded that this new method of tracheostome construction will reduce the incidence of stenosis.

Percutaneous sump drainage: a palliation for oft-recurring intracranial cystic lesions

Eleven cystic lesions comprising four craniopharyngiomas, six astrocytomas, and one pinealoma, which at operation were presumed to be unamenable to radical excision, were treated by partial resection, insertion of a sump drainage, and postoperative radiotherapy. As a consequence of this relatively simple operative procedure there were no serious complications, and every patient recovered fully from preoperative neurologic deficit. Whenever the symptoms recurred the subcutaneous reservoir provided a readily available access for needle puncture to relieve the raised intracranial pressure. On each occasion, after aspiration of the accumulated cyst fluid, each patient showed marked improvement within 48 hours. Pertinent literature is reviewed and possible other applications of sump drainage are discussed.

Oestrogen receptor status and survival in Chinese females with breast cancer

Oestrogen receptor assay was performed on one hundred and sixty-eight patients with proven breast cancer. Fifty-two per cent were positive for receptors; there was a lower incidence of positives in both the pre- and postmenopausal women, when compared with corresponding figures for American women. Patients were randomized into different modes of treatment. It was found that oestrogen receptor positive patients fared better than the negative ones irrespective of the stage of the disease or the treatment received, and this difference was statistically significant in patients with early disease (stages one and two). In patients assigned to some form of endocrine manipulation, 77% of receptor positive, and 7% receptor negative patients showed a response to treatment; in those receiving chemotherapy, receptor negative patients fared better than the positive ones, though the difference was not statistically significant.

Caseating regional lymphadenitis complicating BCG vaccination: a report of 6 cases

Six infants had caseating regional lymphadenitis complicating BCG vaccination. There was a delayed onset and a lack of immediate vaccination complications. Three infants had frank abscesses. Additional affected nodes undetected clinically were found at operation in all cases. All lymph nodes contained tubercles, 3 showing acid-fast bacilli, 2 of which grew Mycobacterium bovis. Complete excision followed by antiuberculous chemotherapy produced satisfactory results.

Epidermoid carcinoma of the anus

Twenty five patients with epidermoid carcinoma of the anus, representing 1.5% of all large bowel malignancies, were seen over a 33 year period. Most patients presented with an advanced lesion which gave rise to a fungating mass, bleeding or pain. Nearly all patients who received either palliative irradiation or refused treatment died within a year of diagnosis. Abdominoperineal resection in 12 patients yielded an encouraging five year survival rate of 68.5%. Therapeutic groin node dissection performed on six occasions led to only one late recurrence. The surgical literature on sphincter saving local excision and therapeutic radiotherapy is reviewed. Currently, radical resection remains the most appropriate treatment for the majority of patients with epidermoid anal cancer.

Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial

A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.

Perforations in acute duodenal ulcers

To determine the clinical characteristics and outcome of perforated acute ulcers of the duodenum, we prospectively studied 60 patients, 28.3 per cent of all perforations, after closure only. Patients with acute ulcers were significantly older and had a higher hospital mortality than did those with perforated chronic ulcers. Within the first three years following closure, chronic ulcers recurred significantly more often than did acute ulcers. Nevertheless, relapses in patients with acute ulcers were usually symptomatic and, on occasion, necessitated reoperation for complications. Among the acute ulcer group, individuals who had perforated ulcers by the age of 30 years had a significantly increased risk of early recurrence. Due to the higher risk, we suggest that an immediate, definitive operation be evaluated in younger patients with a perforated acute ulcer of the duodenum.

Oesophagoplasty for malignant obstruction of the oesophagus following previous partial gastrectomy

The management of 19 patients with malignant obstruction of the oesophagus who previously had undergone partial gastrectomy was reviewed. With stomach unavailable for oesophagoplasty, the jejunum was used in 12 patients, and the colon in seven patients, for reconstruction or bypass. The technique recommended is jejunal oesophagoplasty. Surgical intervention to restore swallowing in this group of patients has been associated with a 52% hospital mortality and a considerable morbidity. Because of the late stage of the disease, survival beyond two-three years after a successful operation has not been possible so far.

Mucoepidermoid carcinoma of the bile duct

Three patients with mucoepidermoid carcinoma of the bile duct are described. In two patients the tumor arose from the common hepatic duct. Mucoepidermoid carcinoma of the extrahepatic bile duct has not been previously reported. The clinical features and pathologic behavior of this rare type of tumor are similar to the usual biliary adenocarcinoma. The coexistence of Clonorchis sinensis infestation and primary pyogenic cholangitis raises the possibility of an etiologic association.

Interposing fascial pedicle flap for the repair of urethral fistulae after hypospadias surgery

A one-stage technique for the repair of urethral fistulae after urethroplasty for hypospadias is reported. A pedicle flap prepared from the facial layers of the scrotum is interposed between the urethra and the overlying skin. In the nine patients operated on, there was one failure, and it was due to postoperative hematoma formation. This technique is especially recommended for patients with multiple small urethral fistulae.

Extraperitoneal sphincteroplasty for residual stones: an update

Sphincteroplasty was done via the extraperitoneal transduodenal approach in 42 patients. The indications were residual stones in 34 patients, stricture at Oddi's sphincter in seven patients, and relapsing pancreatitis in one patient. Seven patients suffered operative complications, with one death. Sphincteroplasty was successfully performed in all patients, and the residual stones were removed in 31. Thirty-three of the 36 patients followed up for a mean of seven years were asymptomatic. Extraperitoneal sphincteroplasty has a role in supplementing endoscopic papillotomy and percutaneous extraction through the T-tube tract in the treatment of patients with residual stones.

Choledochojejunostomy in the treatment of primary cholangitis

Choledochojejunostomy was performed upon 128 patients with primary cholangitis with an operative mortality of 2.3 per cent. Evaluation of 106 patients at a median of eight years reveals that 78 patients or 73.6 per cent have good, 14 or 13.2 per cent have fair and 14 or 13.2 per cent have poor results. All 14 patients with poor results required reoperation, and the findings showed that the two most common causes of recurrent symptoms are the reformation of stones, despite a patent choledochojejunostomy and the stricturization of the choledochojejunostomy. When performed with the proper indications, choledochojejunostomy is a safe and effective procedure for managing patients with primary cholangitis.

Survival after surgery for advanced carcinoma of the stomach other than the cardia

The survival of 103 patients operated on for advanced carcinoma of the stomach other than the cardia was assessed. The median duration of survival for patients subjected to palliative partial gastrectomy, total gastrectomy, gastrojejunostomy, and biopsy only was 24, 22, 11, and 10 weeks, respectively. All of these patients had definite residual tumor. In the 27 patients with preoperative signs of incurable tumor, the high operative mortality rate (19 percent), the low rate of resectability (26 percent), and the short duration of survival in the patients who had resection (median 11 weeks) combined lead to the conclusion that exploration for the possibility of resection is not worthwhile.

Fine-needle aspiration versus drill-needle biopsy of thyroid nodules: a controlled clinical trial

Percutaneous needle biopsy by two different methods was evaluated in a prospective controlled study of 167 consecutive patients with dominant thyroid nodules. Fine-needle aspiration was superior to high-speed drill-needle biopsy because of its higher diagnostic yield (93.9%). When a sample sufficient for diagnosis was obtained, the accuracy rate for both methods was comparable. Diagnostic errors were due to inadequate samples, difficulties in interpreting hypercellular adenomas, and geographic sampling problems. In the detection of thyroid cancer, neither technique alone appears completely adequate because of occasional false negative errors. The selection of patients for operation should depend on clinical parameters as well as the findings on fine-needle aspiration of thyroid nodules.