Critical adjustments and trauma surgery trends in adaptation to COVID-19 pandemic in Malaysia

Malaysia has one of the highest total numbers of COVID-19 infections amongst the Southeast Asian nations, which led to the enforcements of the Malaysian “Movement Control Order” to prohibit disease transmission. The overwhelming increasing amount of infections has led to a major strain on major healthcare services. This leads to shortages in hospital beds, ventilators and critical personnel protective equipment. This article focuses on the critical adaptations from a general surgery department in Malaysia which is part of a Malaysian tertiary hospital that treats COVID-19 cases. The core highlights of these strategies enforced during this pandemic are: (1) surgery ward and clinic decongestions; (2) deferment of elective surgeries; (3) restructuring of medical personnel work force; (4) utilization of online applications for tele-communication; (5) operating room (OR) adjustments and patient screening; and (6)continuing medical education and updating practices in context to COVID-19. These adaptations were important for the continuation of emergency surgery services, preventing transmission of COVID-19 amongst healthcare workers and optimization of medical personnel work force in times of a global pandemic. In addition, an early analysis on the impact of COVID-19 pandemic and lockdown measures in Malaysia towards the reduction in total number of elective/emergent/trauma surgeries performed is described in this article.     

Unexpected complication of arteriovenous fistula of the left common carotid to internal jugular vein following central venous catheterization

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of<1%.This is due to the advancements and wide availability of ultrasound to guide its insertion.Formation of arteriovenous fistula after arterial puncture is an unexpected complication.Till date,only five cases(including this case)of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture.The present case is a 26-year-old man sustained traumatic brain injuries,chest injuries and multiple bony fractures.During resuscitative phase,attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery.Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula.The catheter was removed successfully and common carotid artery was repaired.Postoperatively,the patient recovered and clinic visits revealed no neurological deficits.From our literature review,the safest method for removal is via endovascular and open surgical removal.The pull/push technique(direct removal with compression)is not recommended due to the high risk for stroke,bleeding and hematoma formation.     

Genetic polymorphisms of HbE/beta thalassemia related to clinical presentation: implications for clinical diversity

Annals of Hematology - HbE/Beta thalassemia (HbE/β-thalassemia) is one of the common genetic disorders in South East Asia. It is heterogeneous in its clinical presentation and molecular...     

Risk factors for augmentation of the flow of blood to the lungs in pulmonary atresia with intact ventricular septum after radiofrequency valvotomy

Some patients with pulmonary atresia with an intact ventricular septum, mild to moderate right ventricular hypoplasia, and a patent infundibulum remain duct dependent on the flow of blood through the arterial duct despite adequate relief of the obstruction within the right ventricular outflow tract. The objective of our study was to review the risk factors for stenting of the patent arterial duct, or construction of a Blalock-Taussig shunt, in the patients with pulmonary atresia and an intact ventricular septum who remain duct-dependent following radiofrequency valvotomy and dilation of the imperforate pulmonary valve. We reviewed the data from 53 patients seen between November 1995 and December 2001. Of the 47 patients who survived, 6 required stenting of the patent arterial duct, while 4 needed construction of a modified Blalock-Taussig shunt to augment the flow of blood to the lungs at a mean of 7 plus or minus 5.7 days following the initial intervention. The remaining 37 patients required no additional procedures. We compared the findings in these two groups. The mean diameter of the tricuspid valve in the patients requiring early reintervention was 8.5 plus or minus 3.7 millimetres, giving a Z-score of -1.1 plus or minus 1.47, whilst those in the group without early reintervention had values of 10.7 plus or minus 2.2 millimetres, giving a Z-score of -0.58 plus or minus 1.18 (p equal to 0.003). No statistically significant differences were found in right ventricular morphology, McGoon ratio, or residual obstruction across the right ventricular outflow tract after decompression of the right ventricle. The diameter of the tricuspid valve, therefore, appears to be the only factor predicting the need for augmentation of flow of blood to the lungs. As just over one-fifth of our survivors required such augmentation, we hypothesize that stenting of the patent arterial duct may be performed as an integral part of primary transcatheter therapy in patients with pulmonary atresia and intact ventricular septum who have moderate right ventricular hypoplasia and a small tricuspid valve.     

Common bile duct perforation due to tuberculosis: a case report

A young man with HIV presented with biliary peritonitis secondary to spontaneous common bile duct perforation. Investigation revealed that the perforation was due to Mycobacterium tuberculosis. Tuberculosis of the bile duct is uncommon and usually presents with obstructive jaundice due to stricture. Bile duct perforation due to tuberculosis is extremely rare. Its management is discussed.     

Deletion analysis of SMN1 exon 7 alone may be necessary and sufficient for the diagnosis of spinal muscular atrophy

The authors suggest a simplification for the current molecular genetic testing of spinal muscular atrophy (SMA). Deletion analysis of SMN1 exon 7 alone may be necessary and sufficient for the diagnosis of SMA. It is based on sole contribution of survival motor neuron 1 (SMN1) exon 7 to SMA pathogenesis.     

Correlation between free thyroxin levels and left ventricular ejection fraction in Graves' disease (preliminary study)

AIM: to determine the correlation between free thyroid hormone level and left ventricular ejection fraction in newly diagnosed Graves' patients. METHODS: this is a preliminary study with an initial cross-sectional design using free thyroxine level as a parameter of thyroid hormone state and left ventricular ejection fraction (LVEF) as a parameter of left ventricular systolic function. Free thyroxine level was measured in the laboratory and the LVEF was assessed by Simpson's methods of echocardiography study. RESULTS: ten patients (7 men and 3 women; age 18-52 years old) were studied. Their average of fT4 was 5.75 (SD 0.96) ng/dL and their average of LVEF was 70.57 (SD 4.50)%. There was positive correlation coefficient between free thyroxine level and left ventricular ejection fraction (r=0.711, p=0.021) in newly diagnosed Graves' patients. CONCLUSION: in this study strong positive correlation was found between free thyroxine (fT4) and left ventricular ejection fraction (LVEF) in newly diagnosed Graves' patients.