Decompression illness associated with underwater logging: 6 case reports from Kenyir Lake, Malaysia

The formation of Kenyir Lake as part of a hydroelectric project in the 1980s caused much forest area to be submerged. From 1991, underwater divers were employed to log these sunken trees at depths of up to 100 meters. At least 6 mishaps involving underwater logging personnel were recorded from March 1994 to August 1996. We retrospectively reviewed 5 cases who were managed in Hospital Kuala Terengganu. The patients presented with marked cardiorespiratory and neurological disturbances. One diver died in the Hospital while another died at the recompression chamber. Three divers were treated with recompression and improved. Average delay before the start of recompression was 14 hours. Underwater logging has definite dangers and steps must be taken to ensure that both the divers and the equipment are appropriate for the task. Availability of a nearby recompression facility would greatly enhance the management of diving accidents, not only for commercial divers but also for recreational divers who frequent the islands nearby.     

Decompression illness secondary to occupational diving: recommended management based current legistation and practice in Malaysia

Occupational divers are exposed to hazards which contribute to the risk of developing decompression illnesses (DCI). DCI consists of Type I decompression sickness (DCS), Type II DCS and arterial gas embolism (AGE), developed from formation of bubbles in the tissues or circulation as a result of inadequate elimination of inert gas (nitrogen) after a dive. In Malaysia, DCI is one of the significant contributions to mortality and permanent residual morbidity in diving accidents. This is a case of a diver who suffered from Type II DCS with neurological complications due to an occupational diving activity. This article mentions the clinical management of the case and makes several recommendations based on current legislations and practise implemented in Malaysia in order to educate medical and health practitioners on the current management of DCI from the occupational perspective. By following these recommendations, hopefully diving accidents mainly DCI and its sequalae among occupational divers can be minimized and prevented, while divers who become injured receive the proper compensation for their disabilities.     

Scuba diving medical examinations in practice: a postal survey

OBJECTIVE: To assess variability of opinion regarding fitness to dive among doctors currently doing diving medical examinations. DESIGN: Anonymous, reply-paid postal survey containing 15 clinical scenarios for which respondents were asked to declare the prospective scuba diver fit, unfit, fit after investigation or to offer specialist referral. PARTICIPANTS: All 81 doctors in Queensland, identified as members of the South Pacific Underwater Medical Society, who had completed approved training in underwater medicine, and who were doing diving medical examinations in June 1998. MAIN OUTCOME MEASURES: Variability in responses, and agreement with our interpretation of the action recommended by Australian Standard (AS) 4005.1-1992, the medical standard for fitness to scuba dive for recreational divers. RESULTS: 52 of the 81 questionnaires were returned (64% response rate). There was a wide variety of opinion about fitness to dive for all 15 hypothetical cases, with 70% consensus about unfitness in only four cases (one of which should have been referred according to AS guidelines) and fitness in only two cases (both of which should have been referred according to AS guidelines). No case was considered either fit or unfit by all respondents. Only 17.6% of responses recommended specialist referral, although the AS guidelines suggest that 10 of the 15 cases should be referred. One doctor failed 13 of the 15 potential divers outright and another passed seven outright and failed only four. For each case that the AS guidelines firmly indicate as unfit to dive, at least one respondent passed the hypothetical prospective diver as fit. CONCLUSIONS: There is no consensus among doctors who perform diving medical examinations as to what constitutes fitness to dive; current guidelines need to be improved.     

军队医院野战医疗所在非战争军事行动时医疗救护的展开实践

目的探讨军队医院野战医疗所在非战争军事行动时医疗救护的展开效果,提高突发事件的救治能力。方法野战医疗所的10、15、50和120人的编组构成与展开流程的实践回顾。结果本组2314例伤病员中,存活2213例（96%）,死亡101例（4%）;伤后1h以内死亡23例（23%）,24h以内死亡59例（58%）;死于创伤合并症者99例（98%）,中暑死亡者2例（2%）。结论军队医院野战医疗所在非战争行动时医疗救护的实践,提高了突发事件救护的快速反应能力、整体配合能力和救护水平,丰富了军队医院野战医疗所的救护经验。     

Pre-employment medical examination of Indonesian domestic helpers in a private clinic in Johor Bahru--an eight year review

On review of 3117 patients' records (all were female Indonesian foreign workers over the span of eight years (1997 to 2004 in a private clinic in Johor Bahru, 223 cases (7.2%) were found to have various medical problems. These 3117 foreigners were to be employed as domestic helpers in Malaysia. They were examined upon arrival in Johor Bahru even though our government did not require this pre-requisite (before 1st August 2005) as they were examined and certified fit in their country of origin before embarking to Malaysia. The proportion of female Indonesian foreign workers who were afflicted with category 1 conditions was 55.6% (which rendered them unfit for employment) and category 2 conditions was 44.4%. The medical problem detected most frequently was hypertension. Sixty-one (80.3%) out of 76 workers had stage 2 hypertension (JNC 7 report). Pulmonary tuberculosis ranked second in this review and is a category 1 condition. This paper supports the recent move by the Malaysian Ministry of Health to implement mandatory medical examinations for all foreign workers arriving in Malaysia within one month of arrival regardless of whether or not they are certified fit in their countries of origin.     

扩血管与加压治疗对神经系统减压病疗效的临床分析

目的:探讨减压病的发病机理及治疗方案.方法:将60例神经系统减压病的患者随机分为2组:A组28例接受氟桂利嗪和加压治疗,B组32例只接受加压治疗.另收集未进行加压治疗的神经系统减压病患者36例作为比较,其中病初使用扩血管药物的20例为C组,未使用扩血管药物的16例为D组.采用欧洲卒中量表(ESS),Barthel指数(BI)评价神经功能恢复状况.结果:扩血管治疗组ESS分数迅速增加,组间(A组与B组,C组与D组)差异有统计学意义.结论:血管痉挛可能是减压病的重要病因之一,因而扩血管治疗对神经系统减压病有效.     

An investigation of corneal integrity in recreational divers

OBJECTIVE: To compare the corneal integrity of recreational divers and non-divers. METHODS: The cross-sectional study was conducted at the St. Erik s Eye Hospital, Stockholm, Sweden, between September 2003 and February 2004. Questionnaires were randomly distributed to determine the potential diving and non-diving participants. After filling the questionnaires and giving informed consent, corneal endothelial photographs were obtained from the right eyes of the study participants (age range, 20-42 years). Aided and unaided visual acuities were obtained using the Snellen acuity chart. RESULTS: One of the divers reported temporary blurred vision immediately after a diving session, which resolved 2 days later. The average median corneal endothelial cell size for the recreational divers was 14.3 microm2 larger than that of the non-divers (p=0.43), and the mean endothelial cell density was 95.7 cells/mm2 less than the non-divers (p=0.51). CONCLUSION: There are no significant adverse permanent effect of diving on vision amongst the recreational divers. There is an indication of polymegethism and pleomorphism among the divers, however, no significant difference in the corneal morphology of the recreational divers and the non-divers. However, a further investigation with a larger sample size is needed to confirm this.     

水下加压治疗的现状

潜水实践中,如果潜水员罹患潜水相关疾病,但现场既无加压舱也没有条件后送至有效救治机构进行治疗时,在设备条件和技术条件允许的情况下可进行水下加压治疗.但是,并不是所有潜水相关疾病都需要进行水下加压治疗,也不是所有的情况下都适合进行水下加压治疗.同时,水下加压治疗存在着一定的风险.潜水作业现场,患病潜水员选择水下加压治疗时需综合考虑多方面因素后做出选择.本文对选择水下加压治疗的条件及水下加压治疗存在的风险、治疗方案和实施要求进行简要总结.     

Epidemiology of Open Tibia fractures presenting to a tertiary referral centre in Southern Malawi: a retrospective study

BackgroundRoad traffic accidents in Malawi have increased in recent years resulting in a high incidence of trauma seen in the hospitals as well as a high prevalence of musculoskeletal impairment in the community. Open fractures are a common consequence of road traffic accidents and the tibia is the most common long bone open fracture.ObjectiveEpidemiology of open tibia fractures at the largest tertiary level hospital in Malawi and incidence of infections of open fractures managed at the institution.MethodologyThis was a retrospective study of consecutive open tibia fracture patients seen and admitted to Queen Elizabeth Central Hospital''s (QECH) orthopedic department from 1st January 2019 to 31st December 2019. Patients with life-threatening head, chest, or abdominal injuries were excluded as management takes priority over any limb-threatening injury.ResultsThere were 72 open tibia fractures screened, and 60 of these met our entry criteria; 6 patients did not, while 6 patient files were missing. The median age of patients was 36 years, IQR (27–44.75) with Males making up 82%(n=49) of open fractures. Most of the open tibia fractures were caused by road traffic accidents 63%(n=38), followed by assaults 18%(n=11), falls 17%(n=10), and industrial accidents 2%(n=1). 26.7% (n=16) of open tibia fractures developed an infection. We found that patients'' average length of stay was 16. 9(IQR 9.5–31.25) days. Most of the injuries (68.3%, n=41) were moderate to high energy injuries being Gustilo et al. grade II and III open tibia fractures.ConclusionThis study identified that open tibia fractures were common in our hospital and that were often high energy injuries requiring an extended hospital stay to manage. The infection rate noted was higher than that reported on average in lower- and middle-income countries. There is a need to do more robust prospective studies in the area to gather more information.     

Preoperative physiotherapy and short-term functional outcomes of primary total knee arthroplasty

INTRODUCTION

Physiotherapy is an important part of rehabilitation following arthroplasty, but the impact of preoperative physiotherapy on functional outcomes is still being studied. This randomised controlled trial evaluated the effect of preoperative physiotherapy on the short-term functional outcomes of primary total knee arthroplasty (TKA).

METHODS

50 patients with primary knee osteoarthritis who underwent unilateral primary TKA were randomised into two groups: the physiotherapy group (n = 24), whose patients performed physical exercises for six weeks immediately prior to surgery, and the nonphysiotherapy group (n = 26). All patients went through a similar physiotherapy regime in the postoperative rehabilitation period. Functional outcome assessment using the algofunctional Knee Injury and Osteoarthritis Outcome Score (KOOS) scale and range of motion (ROM) evaluation was performed preoperatively, and postoperatively at six weeks and three months.

RESULTS

Both groups showed a significant difference in all algofunctional KOOS subscales (p < 0.001). The mean score difference at six weeks and three months was not significant in the sports and recreational activities subscale for both groups (p > 0.05). Significant differences were observed in the time-versus-treatment analysis between groups for the symptoms (p = 0.003) and activities of daily living (p = 0.025) subscales. No significant difference in ROM was found when comparing preoperative measurements and those at three months following surgery, as well as in time-versus-treatment analysis (p = 0.928).

CONCLUSION

Six-week preoperative physiotherapy showed no significant impact on short-term functional outcomes (KOOS subscales) and ROM of the knee following primary TKA.     

Pulmonary overinflation syndrome in an underwater logger

Pulmonary overinflation syndrome (POIS) is a group of barotrauma-related diseases caused by the expansion of gas trapped in the lung, or over-pressurization of the lung with subsequent over-expansion and rupture of the alveolar air sacs. This group of disorders includes arterial gas embolism, tension pneumothorax, mediastinal emphysema, subcutaneous emphysema and rarely pneumopericardium. In the case of diving activities, POIS is rarely reported and is frequently related to unsafe diving techniques. We report a classical case of POIS in an underwater logger while cutting trees for logs in Tasik Kenyir, Terengganu. The patient, a 24-year-old worker, made a rapid free ascent to the surface after his breathing equipment malfunctioned while he was working underwater. He suffered from bilateral tension pneumothoraces, arterial gas embolism giving rise to multiple cerebral and cerebellar infarcts, mediastinal and subcutaneous emphysema as well as pneumopericardium. He was treated in a recompression chamber with hyperbaric oxygen therapy and discharged with residual weakness in his right leg.     

Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group

CONTEXT: Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields. OBJECTIVE: To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI. DESIGN AND SETTING: Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center. PATIENTS: One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging. INTERVENTIONS: Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53). MAIN OUTCOME MEASURES: Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group. RESULTS: At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval ?CI?, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=. 43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=. 05). CONCLUSIONS: In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions. JAMA. 2000;283:3075-3081     

溴隐停治疗中枢性高热临床观察

目的:观察溴隐停治疗中枢性高热的效果。方法:将脑血管意外、重度颅脑损伤、脑肿瘤术后等中枢神经疾病引起的中枢性高热患者55例,随机分成二组,即对照组和治疗组,二组均采用物理降温配合治疗。其中,对照组27例,同时给予解热镇痛剂对乙酰氨基酚;治疗组28例同时给予溴隐停。每日3次口服,疗程5~7d。结果:治疗组的显效率25%,总有效率85.7%;对照组显效率7.4%,总有效率53.5%,治疗组显效率和总有效率均高于对照组。结论:溴隐停治疗中枢性高热疗效显著。     

HCV及其与HBV重叠感染患者血清HCVRNA检测的临床意义

目的探讨HCV及其与HBV重叠感染患者血清HCV RNA检测的临床意义。方法收集我院HCV感染及其与HBV重叠患者血清标本共179例,分为慢性丙型肝炎组（n=101）、肝硬化组（n=45）和肝癌组（n=33）。采用ELISA法检测血清抗HCV,用荧光定量PCR检测HCV RNA;对重叠感染HCV和HBV的31例患者同时检测HBVDNA。结果 179例患者抗HCV的总阳性率为97.8%,高于HCV RNA的阳性率（69.8%）（P〈0.01）。肝硬化组和肝癌组HCV RNA的阳性率分别为82.2%和84.8%,高于慢性丙型肝炎组阳性率64.4%（P〈0.05）。HCV与HBV重叠感染组的HCV RNA的阳性率为48.4%,低于单纯HCV感染组的HCV RNA阳性率（71.6%）（P〈0.05）。HCV与HBV重叠感染患者的HBV DNA阳性率为35.5%,也显著低于单纯HBV感染患者阳性率（76.7%）（P〈0.01）。HCVRNA阳性组ALT异常率（60.8%）高于HCV RNA阴性组（35.2%）（P〈0.05）。结论对HCV感染相关的不同疾病患者联合检测抗HCV、HCV RNA和ALT,对于HCV和HBV重叠感染者同时检测HBV DNA,有利于疾病的明确诊断、病情观察及预后判断。     

MAGNETIC RESONANCE IMAGING CHARACTERISTICS AND SURGICAL RESULTS OF ADRENOCORTICOTROPIN-SECRETING PITUITARY ADENOMAS

Objective To evaluate magnetic resonance imaging （MRI） characteristics and surgical results of adrenocorticotropin （ACTH） -secreting pituitary adenomas. Methods MRI characteristics and relationship between MRI positive rate and surgical results of 266 patients with pathologically confn＇med Cushing＇s disease were analyzed retrospectively. All patients underwent thin-section sagittal and coronal scans of the pituitary gland before and after administration of gadolinium-diethylene triamine pentaacetic acid （Gd-DTPA） on a 1. 5 Tesla MR/scanner, and dynamic enhanced MR/was performed in 39 patients. All patients underwent transsphenoidal adenomectomy. Endocrinological examinations and assessments were performed. Results Preoperative MR/revealed normal results in 41 （ 15.4% ） cases, microadenoma in 179 （67. 3% ）, macroadenoma in 42 （ 15.8% ）, and huge adenoma in 4 （ 1.5% ）. Pituitary apoplexy was found in 13 （4.9%） cases. Positive rate of ACTH-secreting adenomas was 84.6% （225/266） on MR/scans, and that of small microadenomas was 87.2% （34/39） on dynamic enhanced MRI scans. Preoperative endocrinological tests of 199 cases supported the diagnosis of typical Cushing＇s disease, while the other 67 cases had atypical endocrinological results. The endocrinological cure rate, remission rate, and inefficacy rate were 85.7%, 7.9%, and 6. 4%, respectively. There was no difference in the initial endocrinological cure rate between the patients with positive and normal MRI results （90% vs. 87. 8%, P =0. 904）. Conclusions Enhanced coronal pituitary MR/ is helpful for preoperative localization of ACTH-secreting pituitary microadenoma. Dynamic enhanced MR/may improve detection rate of microadenoma. There is no marked difference in the surgical results for patients with preoperative MR/results indicating presence or absence of microadenoma.     

Paediatric palliative care at home: a single centre’s experience

INTRODUCTION

There is increased awareness of paediatric palliative care in Malaysia, but no local published data on home care services. We aimed to describe the paediatric experience at Hospis Malaysia, a community-based palliative care provider in Malaysia.

METHODS

We conducted a retrospective case note review of patients aged up to 21 years who were referred to Hospis Malaysia from 2009 to 2013.

RESULTS

A total of 137 patients (92 male, 45 female) with a median age of 140 (3–250) months were included in this study. The majority (71.5%) had malignancies. At referral, 62 patients were still in hospital and 17 died prior to discharge. A total of 108 patients received home visits. At the first home visit, 89.8% of patients had at least one physical symptom. Pain was the most common (52.5%) symptom. Patients had various supportive devices: 39 were on feeding tubes, ten had tracheostomies, five were on bilevel positive airway pressure and ten had urinary catheters. 66 families discussed the preferred location of care at end-of-life. Among those who died, 78.9% died at home, as they preferred (p < 0.001). Regression analysis showed no statistically significant association between a home death and age, diagnosis and number of home visits. Bereavement follow-up occurred for 93.3% of families.

CONCLUSION

Community care referrals tend to occur late, with 25.5% of patients dying within two weeks of referral. At referral, patients often had untreated physical symptoms. The majority of families preferred and had a home death.     

选择性血浆置换联合拉米夫定治疗慢性重型乙型肝炎的临床研究

目的：探讨选择性血浆置换（PPE）联合拉米夫定（3TC）抗病毒治疗慢性重型乙型肝炎的临床疗效。方法：将69例慢性重型乙型肝炎患者随机分为治疗组34例,对照组35例。治疗组用PPE联合3TC治疗,加内科治疗;对照组仅予以内科治疗。两组治疗前后比较临床治愈好转率。并观察主要肝功能、凝血功能及HBVDNA定量检测的变化。结果：治疗结束后,治疗组总有效率为85．3％,疗效优于对照组的28．6％。且治疗组TBiL、ALB、ALT、CHE、PTA、HBVDNA等实验室指标的定量检测均较对照组有明显改善（P〈0．05）;同时治疗组治疗前后其肝功能、凝血功能与HBVDNA定量检测也有显著改善（P〈0．01）。结论：PPE联合3TC治疗慢性重型乙型肝炎有较好疗效。     

The effectiveness of self-directed learning (SDL) for teaching physiology to first-year medical students

Background

Self-directed learning (SDL) has become popular in medical curricula and has been advocated as an effective learning strategy for medical students to develop competence in knowledge acquisition.

Aims

The primary aim was to find out if there was any benefit of supplementing self-directed learning activity with a traditional lecture on two different topics in physiology for first-year medical students.

Method

Two batches of first-year Bachelor of Medicine and Bachelor of Surgery (MBBS) (Batch A and Batch B) comprising 125 students each, received an SDL session on Morphological classification of anaemia. The students belonging to Batch A received a one-hour lecture on the same topic three days prior to the SDL session. The students were given a 10 multiple choice questions (MCQ) test for a maximum of 10 marks immediately following the SDL session. The next topic, Conducting system of the heart, disorders and conduction blocks was taught to both batches in traditional lecture format. This was followed by an SDL session on the same topic for Batch A only. The students were evaluated with a MCQ test for a maximum of 10 marks.

Results

The mean test scores on the first topic were 4.38±2.06 (n=119) and 4.17±1.71 (n=118) for Batch A and Batch B, respectively. The mean test scores on the second topic were 5.4± 1.54 (n=112) and 5.15±1.37 (n=107) for Batch A and Batch B, respectively. There was no significant difference between the groups.

Conclusion

For first-year medical students, SDL is an effective teaching strategy for learning physiology. However, no additional benefit is gained by supplementing SDL with a lecture to facilitate learning physiology.     

PBL教学法在医学生心理健康教育中的应用

目的 了解医学生心理健康的现状,比较以问题为基础的教学法(problem-based learning,PBL)与传统教学方法改善医学生心理健康的效果,为制定大学生心理健康教育的有效教学策略提供依据。 方法 采取方便整群抽样方式,采用SCL-90量表对某医学院在校学生进行问卷调查,获取有效样本357名,采用随机数表法分成对照组(178名)和实验组(179名),进行为期16周的教学实验,采用独立样本t检验和χ2检验进行组间比较。 结果 医学生SCL-90量表平均总得分为129.44分,阳性检出率为15.97%,各因子均分介于1.21~1.81分之间,且均低于全国常模水平。实验后,对照组总分下降4.93分,阳性检出率下降2.99%,各因子均得分下降介于0.04~0.09分之间,其中躯体化、人际关系敏感、焦虑和敌对因子变化差异具有统计学意义(P<0.05),实验组总分下降6.31分,阳性检出率下降7.51%,差异具有统计学意义(P<0.05),各因子均得分下降介于0.06~0.11分之间,且除抑郁因子外,其余各因子差异具有统计学意义(P<0.05)。 结论 与全国大学生常模比较医学生心理健康相对较好,心理健康教育中,采用传统教学法和PBL教学法均能降低医学生心理症状自评得分,但PBL教学法改善效果更好。      

不同信息框架对军校医学专业大学生决策行为影响的研究

目的探讨医疗风险决策信息框架对军校医学专业大学生决策行为的影响。方法采用肺癌治疗决策问卷,采用随机抽样的方式,抽取293名大学生,将其随机分成三组:正面框架组,负面框架组和平衡框架组。结果正面框架组被试保守和冒险方案选择百分比分别为63.4%和36.6%;负面框架组为24.6%和75.4%,差异具有显著性(χ2=30.550,P=0.000)。确认被试风险偏好基线水平的平衡框架中选择保守和冒险的比例相近(49.5%,50.5%)。与基线水平比较发现,仅在负面框架与基线水平之间差异具有显著性。此外,男女性别之间无显著性差异。结论军校医学专业大学生在肺癌治疗风险决策情境中的基线水平接近中性,负面信息刺激导致冒险偏好。