Anti-hypertensive prescription practices in private hospitals in Malaysia: a prospective, non-interventional, observational study

INTRODUCTION

In managing hypertension, monotherapy and sometimes a combination of more than one agent are used to achieve blood pressure (BP) control. The objective of this prospective, observational, multi-centre study was to assess the level of BP control in patients receiving one or more anti-hypertensive drugs in private medical centres in Malaysia according to the treatment regimens (monotherapy, free drug combinations and single pill combinations).

MATERIALS AND METHODS

Data were collected through medical records and interview sessions with patients on current pharmacotherapy for hypertension management at baseline and 2-3 months later. Results are expressed as mean ± SD for continuous data and as frequencies and percentages for categorical data.

RESULTS

Among 182 recruited patients, 89 (49%) achieved BP control by the end of the study. Majority (62/89) patients were on single-pill (monotherapy or SPC) antihypertensives. Majority (63/89) required more than two antihypertensives to achieve BP control.

CONCLUSION

Both SPC and free drug combination antihypertensives reduced BPs, but physicians preferred SPC to improve BP control and increase treatment compliance.

Complications of extra-anatomic aortic bypass for complex coarctation and aortic arch hypoplasia

BACKGROUND

We have adopted the extra-anatomic bypass graft as the procedure of choice for the treatment of coarctation and aortic arch hypoplasia in the adult-sized patient. However, we have experienced prolonged chest drainage and have decided to investigate this complication and the morbidity related to this procedure.

METHODS

Between 1996 and 2010, 15 extra-anatomic bypass grafts of the aorta were performed in 14 patients. Their hospital records and follow-up data were retrospectively reviewed and compared with those of 14 consecutive patients operated with other conventional techniques over the same time period.

RESULTS

There was no hospital mortality. After the extra-anatomic bypass procedure, patients had longer hospital stay because of prolonged pleural effusions. Four patients developed complications related to persistent effusions leading to reinterventions, which led to mediastinitis in 2 instances. At last follow-up, 2 of 14 patients with extra-anatomic bypass remained hypertensive, while 8 of the 14 patients who underwent other types of repair had arch obstruction, were hypertensive, or both.

CONCLUSIONS

In the adult-sized patient extra-anatomic bypass of the aortic arch relieves arch obstruction more effectively than conventional techniques. However, this technique is fraught with complications related to prolonged effusion drainage that may lead to mediastinitis and reintervention. Its indication should be weighted carefully.

Awareness of diastolic heart failure as a disease entity among Malaysian doctors -- a questionnaire survey from three general hospitals

The concept of diastolic heart failure (DHF) is not new. However awareness and understanding on this subject may remains uncertain among medical practitioners. We wished to examine the extent of awareness of such entity among doctors in Malaysia. A questionnaire was designed and distributed randomly during hospital Continuous Professional Development (CPD/CME) sessions and also in the respective outpatient departments (OPD) between July to October 2008. This cross-sectional survey in three urban-based general hospitals showed that there are a significant proportion of doctors who are lack of understanding and awareness of diastolic heart failure.

Severe colonic diverticulitis in an adolescent with Williams syndrome

Williams Syndrome (WS) is a condition with multisystemic involvement caused by a genetic deletion in chromosome 7. Colonic diverticulosis has been described in adults with WS; however, it has not previously been reported in adolescents with WS. We report an adolescent boy with WS who developed complicated colonic diverticulitis and briefly review the possible aetiology of diverticular disease.

Prospective comparison of costs and short term health outcomes of surgical versus device closure of atrial septal defect in children

OBJECTIVE

To compare surgical and device closure of isolated secundum atrial septal defect (ASD) in terms of hospital costs, clinical outcome, and impact on the patient and family.

DESIGN

Prospective, observational study.

SETTING

Paediatric tertiary referral centre.

PATIENTS

Consecutive local children with a secundum ASD, admitted between 1 May 1999 and 1 May 2001.

METHODS

Parents completed a standardised questionnaire at recruitment (on admission), at discharge, and one month after the procedure. Clinical and hospital generated cost data were collated at discharge.

RESULTS

62 children were included in the analysis: 19 who underwent surgical repair and 43 who underwent device closure with the Amplatzer septal occluder. Median procedure times and hospital stay were significantly longer for surgical patients (170 (147 to 180) v 92 (70 to 115) minutes and 88 (78 to 112) v 29 (28 to 30) hours, respectively; p < 0.01). There was no difference in the complication rate. No device patients required intensive care or blood products. The median values for postoperative pain score, analgesia use, and convalescence time were greater for surgical patients. The median cost of each procedure was similar, but higher nursing and laboratory costs contributed to a slightly greater total cost for surgical repair (Aus$12 969 ($11 569 to $14 215) v Aus$11 845 ($10 669 to $12 555), p = 0.03).

CONCLUSIONS

Device closure of ASD involves a shorter hospital stay, causes less discomfort and familial disturbance, and carries less cost than surgical closure. However, there should be guarded acceptance of this technique until long term data are available.

Rashkind and Clamshell Device Closure of Ventricular Septal Defect

This report discusses the worldwide experience of transcatheter and intraoperative closure of ventricular septal defects (VSDs) using the Rashkind and Clamshell devices, including the author's personal experience and communications. This report also provides a detailed description with illustrations of the devices, catheters, techniques, and various modifications of techniques used in deploying the devices.

New interventional therapeutic approach for dual drainage of the scimitar vein

A patient with scimitar syndrome and dual drainage of a right-sided scimitar vein into the inferior vena cava and the left atrium underwent coil occlusion of the right aortopulmonary collateral artery and device occlusion of the lower scimitar vein drainage, leaving it flowing solely into the left atrium.

Common congenital heart defects. The value of early detection

BACKGROUND

Congenital heart disease forms the largest group of congenital anomalies and therapy is available for all conditions. The main challenge is the early detection and referral of such cases.

OBJECTIVE

The important features of the commonest congenital heart defects are reviewed with an emphasis on the diagnostic features. The pivotal role of the general practitioner in the early detection and referral of these patients is emphasised.

DISCUSSION

A high index of suspicion, general understanding of transitional changes, haemodynamic aspects, good listening skills and examination techniques with the appropriate use of investigative tools, especially echocardiography will enable the practitioner to have a higher success with early detection and screening of patients. Rapport with institutions and parents is of great importance.

Device closure of an atrial septal defect following successful balloon valvuloplasty in a neonate with critical pulmonary valve stenosis and persistent cyanosis

Persistent cyanosis after successful balloon valvuloplasty for neonatal critical pulmonary valve stenosis is often related to poor right ventricular compliance and right-to-left shunting at the atrial level. A successful catheter closure of an atrial septal defect was performed with a dramatic increase in systemic oxygen saturation alleviating the need for a surgical systemic-to-pulmonary artery shunt.

Incipient left ventricular rupture complicating anomalous left coronary artery

A 4-month-old girl presented with 2 weeks of symptoms and physical signs of heart failure. Echocardiography demonstrated marked left ventricular dilation, thinning of the myocardium with anterolateral akinesis, mitral regurgitation, a moderate pericardial collection, and an anomalous left coronary artery from the pulmonary artery. At operation there was a tense hemopericardium and a site of imminent rupture through a transmural anterior infarction. The anomalous artery was reimplanted in the ascending aorta, and an extensive infarct resection and ventricular repair performed. Support with a left ventricular assist device was required for 3 days, but the infant subsequently made a satisfactory recovery. Left ventricular rupture is a very rare complication of this lesion, but should be considered if there is evidence of a pericardial collection.

Pulmonary valve annulus grows after balloon dilatation of neonatal critical pulmonary valve stenosis

BACKGROUND

Neonates with critical pulmonary valve stenosis often demonstrate small or hypoplastic right ventricular structures. Relief of the obstruction enhances forward flow across the right ventricle and reduces its pressure load. Growth of the right ventricle and especially of the pulmonary valve annulus was evaluated after balloon dilatation.

METHODS

Ten consecutive neonates with critical pulmonary valve stenosis who underwent balloon valvuloplasty were studied by serial echocardiography to assess growth of right ventricular structures at follow-up.

RESULTS

The mean diameter of the pulmonary valve annulus increased from 6.1 +/- 1.4 mm to 12.6 +/- 3.5 mm (z scores from -2.9 +/- 1.0 SD to - 1.3 +/- 1.2 SD, p < 0.0001) after a mean follow-up period of 2.7 +/- 2.0 years. The mean diameter of the tricuspid valve annulus increased from 12.9 +/- 3.8 mm to 19.0 +/- 3.1 mm; however, the respective z score did not change significantly (from 0.5 +/- 2.4 SD to -0.5 +/- 1.0 SD). Right ventricular cavity size was hypoplastic in four patients initially and normal in all patients at latest follow-up.

CONCLUSIONS

Balloon dilatation of critical pulmonary valve stenosis encourages catch-up growth of the pulmonary valve, and surgery may be avoided even in a hypoplastic pulmonary valve annulus.

Early clinical experience with use of the 'Amplatzer Septal Occluder' device for atrial septal defect

Device closure of oval fossa atrial septal defects with the Amplatzer Septal Occluder was performed in 26 patients ranging in age from 0.89 to 60.44 years. In eight additional patients no device implant was performed because of the presence of multiple defects or because the defect was of a size unsuitable for closure with the devices currently available. The stretched diameter of the defects that were closed ranged from 4 to 23 mm (mean 14+/-5.4 mm) and device sizes ranged from 4 to 24 mm. Two devices were unstable, of which one embolized to the right atrium after release. Both devices were retrieved at the same procedure. One of these patients subsequently underwent a successful device closure of his defect using a larger (24-mm) device. Three patients had multiple defects, which were successfully closed with a single device. At 1-month follow-up 23/26 (88%) and at 3-month follow-up 22/24 (92%) patients had complete closure of their defects, while two had residual shunts. One further patient who had complete closure of his defect at 1-month post-implant had his device removed and his atrial septal defect patched surgically 8 weeks after device closure. This was done as a result of the development of a vegetation affecting the device after an episode of septicaemia, which was not related to the cardiac problems. There was no procedure-related morbidity or mortality and all patients remain well at the present time.

Treatment of critical pulmonary valve stenosis by balloon dilatation in the neonate

Critical pulmonary valve stenosis represents an emergency, and immediate treatment is mandatory. The purpose of this study was to evaluate the immediate and medium-term results of pulmonary valve dilatation. We report 18 neonates in whom pulmonary valvuloplasty was attempted. The procedure could be accomplished in 14 patients. The angiographically determined diameters of the pulmonary and tricuspid valve at the time of procedure were 5.6 +/- 1.5 mm and 14.0 +/- 5.4 mm. The mean Doppler gradient decreased from 71 +/- 27 mm Hg to 27 +/- 14 mm Hg. Perforation of the right ventricular outflow tract was the major complication in three patients with one fatal event. Infusion of prostaglandin E1 could be discontinued 1 to 5 days after the procedure. On follow-up three children required a second balloon dilatation with good results. Seven patients monitored for more than 9 months with a mean follow-up time of 34.4 +/- 16 months had a residual gradient of 11.6 +/- 6.7 mm Hg. In spite of a hypoplastic pulmonary valve annulus in seven of the patients, results were good and surgery could be avoided.

Long-term follow-up after two coronary repair of anomalous left coronary artery from the pulmonary artery

A retrospective analysis of ten patients with anomalous left coronary artery arising from the pulmonary artery operated between 1979 and 1990 was undertaken. All presented with evidence of left ventricular dysfunction and "ischemic" mitral regurgitation. Surgical repair consisted of an aortopulmonary tunnel (Takeuchi) procedure in eight and direct left coronary artery reimplantation in two. Two patients required postoperative support with a left ventricular assist device. There were no operative or late deaths (CL 0% to 17%) for a follow-up of over 670 patient months. All patients are in New York Heart Association Class I or II, though two patients are still receiving anticongestive medications. One patient has required further surgery for pulmonary artery stenosis, and another has had a mitral valve replacement because of severe mitral regurgitation. One additional patient has moderate-to-severe residual mitral regurgitation and two have a trivial left coronary to main pulmonary artery fistula. All have a patent, nonstenotic left coronary artery and much improved left ventricular function and perfusion as assessed by echocardiography, thallium scan, gated blood pool scan, and angiography. There have been no documented arrhythmias, clinically or on Holter monitoring. The ECGs have shown resolution or improvement of the initial changes of ischemia/infarction in all patients. Chest X-rays have shown normalization of cardiothoracic ratio in eight of ten patients. Excellent early and late results can be achieved following timely surgical repair. Marked improvement in left ventricular function has been observed in patients with poor preoperative left ventricular function, even in the presence of extensive ischemia/infarction.

Serological screening for syphilis during pregnancy in a multiethnic Asian population

Out of 14,841 women who were serologically examined for syphilis at the antenatal booking clinic, University Hospital, Kuala Lumpur in Malaysia, 1.78% were VDRL positive and 1.05% TPHA positive with significant differences between the Malays, Indians and Chinese. These rates are higher than published series and were attributed to childhood yaws infection among the Malays. As differentiation between yaws and syphilitic infection in the clinic is difficult, all TPHA-reactive women were treated as for syphilis. Congenital syphilis was not diagnosed in those women who had been effectively treated before delivery.

Surgical excision of primary cardiac tumours in infancy

Six cases of primary cardiac tumour have been operated upon in a 7 year period from 1 June 1979 until 1 June 1986. All patients were under 6 months of age at the time of operation and two of the patients were in their first week of life. The principal indication for surgery was obstruction mainly at the right or left ventricular outflow tract level. More recently echo evaluation alone has been adequate to define the problem prior to surgery. Surgical excision has been performed without mortality or significant complications. In most cases resection has been complete, although in one case residual tumour has been left because of attachment of the tumour to vital structures. Follow-up of this case has not resulted in further surgery being required because of regrowth of the tumour. In one case, with co-existent congenital heart disease, the tumour was brought to notice after palliative systemic to pulmonary artery shunt had been performed. From the cardiac view point gratifying results have been obtained both in the short and long term following surgical resection. However, for patients with rhabdomyoma, later development of symptomatic tuberosclerosis should be anticipated in 50% of cases.

Evaluation of aortic valve prolapse in ventricular septal defect

Angiographic criteria for the recognition of aortic valve prolapse in isolated ventricular septal defect were based on the degree of aortic cusp deformity and the presence or absence of aortic regurgitation. Ninety eight consecutive patients with isolated perimembranous or infundibular ventricular septal defects who were catheterised and had aortography performed were reviewed. They included five with postoperative ventricular septal defects and three with additional mild right ventricular outflow tract obstruction. Eighteen were found to have aortic valve prolapse. Although eight of the 18 were noted to have aortic regurgitation angiographically, only three had an early diastolic murmur. Only eight of the 18 patients had cross sectional echocardiographic findings suggestive of prolapse. All of these had at least moderate prolapse angiographically. Cross sectional echocardiography was found to be insensitive in diagnosing mild degrees of aortic valve prolapse. A trend towards a decreasing left to right shunt was noted as the degree of aortic valve prolapse increased. Spontaneous decrease in the size of a ventricular septal defect may be due to unrecognised aortic valve prolapse without clinical evidence of aortic regurgitation.

Patterns of copper loss--a comparison of the multiload Cu250, TCu-220C and Cu7 IUDs

The rate of copper loss from 329 IUDs (Multiload Cu250, TCu-220C and Cu7) which had been terminated for various reasons after 0.5-46 months in-utero were determined. All 3 IUDs showed a wide scatter of release rates with no significant differences between the ML Cu250 and the Cu7. The TCu-220C showed the highest rates and in contrast to the ML Cu250 and Cu7, the decrease with time was not significant. Its rate of copper loss was significantly higher than the ML Cu250 in the 1st year, but comparable after that. The TCu-220C had a similar rate to the Cu7 in the 1st year and significantly higher rates subsequently. The relevance of these findings to observed pregnancy rates and area of copper on the IUDs is discussed.

Chronic supraventricular tachycardia. A curable cause of congestive cardiomyopathy

Two cases of congestive cardiomyopathy were proved to be due to chronic atrial automatic-focus tachycardia. Surgical elimination of the tachycardia resulted in normalization of cardiac function in both cases. We suggest that patients with congestive cardiomyopathy be carefully screened for supraventricular tachycardia. Patients with chronic supraventricular tachycardia should be treated aggressively to prevent myocardial dysfunction.

A multicenter randomized comparative investigation of ML Cu250, TCu-220C and Cu7 IUDs

The final analysis of 1725 interval insertions of the 3 IUDs is presented. The earlier observations were confirmed at: at 24 months, no significant differences were found between the TCu-220C and ML Cu250 IUDs though the TCu-220C had a lower gross pregnancy rate (2.0 versus 2.9) and the ML Cu250 had a lower expulsion rate (2.3 versus 4.1). Expulsions were more common with the Cu7 when compared to the ML Cu250 (p 0.001) and T-220C (p 0.01); pregnancy rates were also higher with p values of 0.05 and 0.01 respectively. Other use-related terminations were not significantly different among the 3 IUDs and continuation rates at 24 months were: Cu7, 69, TCu-220C, 73, and ML Cu250, 74.

Anaemia and menstrual blood loss studies in women using multiload Cu250 and progestasert IUDs

Two to 9 months following insertion of the ML Cu250 (n = 54) and Alza T (n = 30) IUDs, mean menstrual blood losses (MBL) were 46.3 ml and 32.7 ml, respectively (p less than 0.005). Significantly more of the Alza T users had losses below 40 ml and they also perceived their menses to be lighter. Based on a haemoglobin level of 12gm/dL, the upper normal limit of MBL was about 40 ml. These findings are consistent with earlier observations that during the first year, ferritin levels fall in ML Cu250 users whereas they are unaltered in Alza T users.

Surgical treatment of absent pulmonary valve syndrome in infants: relief of bronchial obstruction

Congenital absence of the pulmonary valve is usually associated with a malalignment type of ventricular septal defect as well as right ventricular outflow obstruction and aneurysmal dilatation of the pulmonary arteries. Symptomatic infants primarily have severe tracheobronchial obstruction caused by aneurysmal dilatation of the proximal pulmonary arteries; pulmonic and systemic blood flow are usually balanced. Surgical intervention to relieve the obstruction by plicating the pulmonary artery and its branches under deep hypothermia and circulatory arrest, together with patch closure of the ventricular septal defect, is advocated.

Effect of laparoscopic sterilization and insertion of Multiload Cu 250 and Progestasert IUDs on serum ferritin levels

Blood haemoglobin and serum ferritin levels were measured at the initial visit and 12 months following sterilization and IUD insertion. Ferritin levels were unaltered in Progestasert users after 12 months but haemoglobin values increased though not significantly. Ferritin levels fell in Multiload Cu 250 users and in sterilized women; haemoglobin levels were also observed to fall but significantly only in the latter group. Iron-deficiency anaemia was prevalent at initial contact and there appeared to be an increased risk subsequently in Multiload Cu 250 users and in those who were sterilized. Screening and monitoring for anaemia is indicated. From the viewpoint of iron status, the Progestasert is preferable to the Multiload Cu 250 but it suffers the major disadvantages of needing frequent replacement and of causing menstrual disturbances which might compromise its acceptability. Menstrual blood loss studies may help explain why anaemia develops after sterilization.

A randomised comparative evaluation of the copper 7, multiload copper 250 and T copper-22OC IUDs

Two new Cu-IUDs, the TCu-22OC and Multiload Cu250, were evaluated against the Cu7 in 1,199 subjects in a randomised, multicentric trial using a common study protocol. During the 2 years following insertion, cumulative first-segment rates for total use-related terminations showed no significant differences between the 3 devices; however, the Cu7 had a significantly higher termination rate for accidental pregnancy compared to the TCu-22OC and its expulsion rate was significantly higher than the ML Cu250. The rate of accidental pregnancy was higher and the expulsion rate lower with the ML Cu250 compared to the TCu-22OC but these differences were not significant. The results are discussed in relation to IUD design and their application in family planning.

Iron-deficiency anemia and long-term use of copper-bearing IUDs

The increase in menstrual blood loss (MBL) caused by IUDs may result in iron deficiency anemia. 60 women completing 2 years of Cu-IUD use were investigated for this risk, using hemoglobin concentration serum iron indices. No significant differences were found compared to a control group of women requesting interval Cu-IUD insertion. A decrease in the MBL increment with time following insertion, self-selection of the study population, and increased dietary iron absorption are suggested explanations for these results. 15.4% of patients suffered from iron deficiency anemia. Measurement of serum ferritin is advocated to identify these women for treatment, in order to enhance maternal health.

Screening for gonorrhea in a prenatal clinic in Southeast Asia

Screening by culture of endocervical specimens revealed four cases of gonorrhea among 744 pregnant women attending the prenatal clinic at the University Hospital in Kuala Lumpur, Malaysia. The observed prevalence of gonorrhea (0.54%) in pregnant women is similar to that in Great Britain (0.2-0.7%), but lower than the prevalences reported for North America (2.5-7.5%) and Thailand (11.9%). The results indicate that routine screening of pregnant women attending prenatal clinics in Malaysia would aid in the control of gonorrhea in that country.

Primary peritoneal pregnancy implanted on the uterine fundus

A case of primary peritoneal implanted on the uterine fundus is presented. The differential diagnosis and aetiology of this condition is briefly discussed together with a review of recent literature.

A longitudinal study of serum iron indices and haemoglobin concentration following copper-IUD insertion

The increase in menstrual blood loss associated with copper-bearing IUDs may cause or aggravate pre-existing anaemia. In order to evaluate this risk, 84 Malaysian women wearing copper-IUDs were studied longitudinally by means of serial measurements of blood haemoglobin concentration (Hb), serum iron (S/Fe) and transferrin saturation (T/S). The initial Hb was under 12 gm% in 33.7% of patients. The mean Hb showed no significant change up to 12 months while S/Fe fell significantly at the end of this time; the T/S was significantly reduced as early as 6 months post-insertion. There is a significant risk of anaemia following copper-IUD insertion, particularly with long-term usage. Progestogen-releasing IUDs may offer the most feasible solution to this problem in our local context since oral medication with iron or drugs to reduce menstrual blood loss is not practicable.

Complete atrioventricular block due to giant cell myocarditis

A rare instance of complete atrioventricular block due to giant cell myocarditis with histopathological correlation is documented. The haemodynamic changes and echocardiographic findings are described.

Scanning suprasternal echocardiography

Scanning suprasternal echocardiography was performed in 280 patients with a variety of cardiac anomalies. By using the special suprasternal transducer on the suprasternal notch, the aortic arch, right pulmonary artery, and left atrium were recorded superoinferiorly. From this reference position various scanning techniques were made to record the main pulmonary artery, pulmonary valve, ascending aorta, aortic valve, and distal aortic arch, wherever possible. These scans made it possible to assess (a) the integrity and size of right pulmonary artery and main pulmonary artery in pulmonary atresia, stenosis of origin of right pulmonary artery, pulmonary artery banding, kinked Waterston anastomosis, and aneurysm of pulmonary artery; (b) relative positions of aortic valve and pulmonary valve in malposition complexes; (c) the position and size of the aortic arch in tetralogy of Fallot and aortic coarctation. Measurements of the left atrium made by suprasternal echocardiography were consistently larger than those made by praecordial echocardiography. Changes in relative sizes of aortic arch, right pulmonary artery, main pulmonary artery, and left atrium were also documented in the various cardiac anomalies. The atrial baffle after Mustard repair for d-transposition of the great arteries and the atrial membrane in cor triatriatum were also demonstrated. The introduction of scanning techniques has thus widened the scope of suprasternal echocardiography.

Copper 7 devices devoid of copper: implications for duration of useful life

Two copper 7 intrauterine devices were found to be devoid of copper on removal after 55 and 63 months of use respectively. The implications of this observation are discussed in relation to data regarding the useful lifespan of such contraceptive devices.

The management of congenital tricuspid incompetence

2 examples of severe tricuspid incompetence presenting in the newborn period are described. Both recovered with medical treatment alone, with subsequent decrease in tricuspid incompetence. Postnatal course is attributed to normal decrease in pulmonary vascular resistance. Some infants may be at considerable risk until this decrease occurs.

Massive pulmonary arteriovenous fistula in the newborn

Although pulmonary arteriovenous fistula as a cause of cyanosis is well recognized, most of the reported cases occur in older children and adults, and its importance as a correctable lesion in the newborn is often overlooked. The details of two babies who presented with cyanosis in the first few days of life are presented to emphasize that this eminently treatable lesion may need to be managed as an emergency.

Mycotic aneurysm of the pulmonary artery. A report of 2 cases

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