Practising transoral robotic surgery in a middle-income country: surgical outcomes and early challenges

Transoral robotic surgery is a minimally invasive surgical technique that recently debuted in Malaysia. However, there are concerns over its cost, practicality, and feasibility in local settings. Our study aims to evaluate the surgical outcomes of transoral robotic surgery and discuss its learning curves. The clinical records of all patients who underwent transoral robotic surgery in a university hospital were reviewed. 25 patients were identified with a mean age of 43.9 years. The commonest indication was obstructive sleep apnoea (OSA) (76%), followed by base of tongue carcinoma (16%), recurrent tonsilitis and Wharton's duct cyst (4% each). For excision of tongue base in obstructive sleep apnoea without epiglottectomy, the mean operating time was 2.3(±0.9) hours with an average of 2.8(±0.4) days of hospital stay. The success rate for OSA surgery was seen in 78.9% of cases. The mean operating time for transoral excision of tongue base carcinoma was 4.3(±2.5) hours, whereas the mean hospital stay was 9(±3.6) days. All surgical margins were cleared with no recurrence except for one patient. The recurrent tumour was successfully excised via transoral robotic surgery, and he remained disease free after one year. The most frequent post-operative complaints were dysphagia, post-nasal drip, and hypogeusia. Transoral robotic surgery in Malaysia is in the commencement phase, where some pitfalls are expected. Opportunities should be given for more surgeons to acquire this technique so that minimally invasive surgery for head and neck diseases is readily available for patients in middle-income countries.

Validation study of the Parent Attitudes About Childhood Vaccines (PACV) questionnaire: the Malay version

Vaccine hesitant parents are linked with re-emergence of vaccine preventable diseases, but evidence is scarce locally. The Parent Attitudes about Childhood Vaccines (PACV) questionnaire was validated and used in the USA to identify vaccine hesitant parents. This study aimed to adapt and translate the 15-item PACV questionnaire from English into the Malay language, and to examine its validity and reliability. The sample population was parents of children aged 0-24 months, recruited at an urban government health clinic between November 2016-June 2017. During content validation, two items from the "Behavior" subdomain were identified as items with formative scale and excluded from exploratory factor analysis (EFA) but retained as part of demography. A total of 151 parents completed the questionnaire with response rate of 93.3%. Test-retest reliability was tested in 25 respondents four weeks later and the intra-class correlation was between 0.53 and 1.00. EFA of the 13 items showed possibility of two to four factor domains, but three domains were most conceptually equivalent. Two of the domains were similar to the original and one factor was identified de novo. One item was deleted due to poor factor loading of < 0.3. Therefore, the validated final PACV-Malay consisted of 12 items framed within three-factor domains. The PACV-Malay was reliable with total Cronbach alpha of 0.77. In conclusion, the PACV-Malay is a valid and reliable tool which can be used to identify vaccine hesitant parents in Malaysia. Confirmatory factor analysis and predictive validity are recommended for future studies.

Tsukamurella tyrosinosolvens intravascular catheter-related bacteremia in a haematology patient: a case report

Tsukamurella spp. are a rare but important cause of intravascular catheter-related bacteremia in immunocompromised patients. The organism is an aerobic, Gram-positive, weakly acid-fast bacillus that is difficult to differentiate using standard laboratory methods from other aerobic actinomycetales such as Nocardia spp., Rhododoccus spp., Gordonia spp., and the rapid growing Mycobacterium spp. We report a case of Tsukamurella tyrosinosolvens catheter-related bacteremia in a 51-year-old haematology patient who responded to treatment with imipenem and subsequent line removal. 16srRNA sequencing allowed for the prompt identification of this organism.

Case-controlled review of Clostridium difficile-associated diarrhoea in southern Tasmania

AIM

While the incidence of Clostridium difficile-associated diarrhoea (CDAD) has increased sharply over the last 15 years, its risk factors are still not well defined. The aim of this study was to review cases of CDAD at the major teaching hospital in Tasmania, Australia, to identify risk factors for CDAD and their association with prognosis.

METHODS

A retrospective review of the medical records of adult patients admitted to the hospital between January 1994 and December 1996 was performed. Sixty-four patients who developed CDAD prior to or during their admission, and an additional 120 diarrhoea-free patients (the control group) were studied. An extensive range of demographic and clinical variables were recorded, and the differences between the control group and patients with CDAD were evaluated.

RESULTS

The CDAD patients had a median age of 66 years (range 22-95 years), with females accounting for 52% of cases. There were no significant demographic differences from the control group. Identifiable risk factors for developing CDAD were severe underlying disease, renal impairment, exposure to antibiotics or antineoplastic agents, and the use of total parenteral nutrition or nasogastric feeding. Cephalosporins were the most frequently used antibiotics in both CDAD and control patients, with cefotaxime being the only antibiotic which was identified as being significantly associated with an increased risk of CDAD. The median length of diarrhoea episodes was 9 days (range 1-60 days). The mortality rate was 17.2%, and factors associated with a poor prognosis were older age, severe underlying disease, renal impairment and failure to treat with metronidazole or vancomycin. Delay in starting specific treatment and use of codeine were related to prolonged CDAD.

CONCLUSION

CDAD is a growing contributor to hospital morbidity and costs. Severely ill patients with compromised immune function are particularly susceptible, with antibiotic use being a major risk factor. Prompt diagnosis and initiation of treatment are important factors in the improvement of prognosis.