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.

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.

Aorto-left atrial fistula post-percutaneous device ASD closure.

Use of percutaneous devices for closure of atrial septal defects (ASD) continues to increase owing to relative safety and ease of implementation compared with traditional surgical repair. Complications such as perforation and displacement requiring surgical intervention have been reported. We describe a case of perforation with intracardiac fistula formation, with an underlying mechanism likely to be similar to the few cases previously described, occurring during medium term follow up after ASD device closure. Appropriate case selection can reduce the incidence of this complication with caution taken in ASD cases with deficient aortic and superior rims.

Outcome of Living Donor Transplant Kidneys With Multiple Arteries.

BACKGROUND: Living donor transplantation (LDT) using kidneys with multiple arteries (MA) has previously been reported to be associated with increased complications and poorer outcomes in recipients. The objective of this study was to investigate outcomes of LDT with MA at the National University Hospital of Singapore, an institution with modest kidney transplant volumes. METHODS: From 2007 to 2014, a total of 109 consecutive living donor kidney transplantations were performed. Of the nephrectomies, 91% were left sided. A total of 19 cases involved MA, of which 7 with small polar vessels (<2 mm) were ligated and 12 were revascularized. Baseline characteristics and outcomes were comparable between donor-recipient pairs with MA and single artery (SA). Both groups had equivalent induction and maintenance immunosuppressive regimens. RESULTS: Mean warm ischemia time (minutes) was similar for kidneys with MA and SA (4.3 ± 3.2 vs 3.9 ± 3.2, P = .38). Operative time (minutes) in the recipients was also equivalent (P > .05) for MA and SA (158 ± 39.2 and 145 ± 57.2, respectively). The MA kidney recipients had a lower estimated glomerular filtration rate (eGFR) on postoperative day 5 compared to SA (56.6 ± 24.2 vs 74.1 ± 35.9 mL/min/1.73 m(2), P = .058). However, eGFR at 1 year was the similar for both groups (64.9 ± 16.2 vs 66.4 ± 18.1 mL/min/1.73 m(2), respectively, P = .76). Delayed graft function rates were 5.6% and 6.6% for MA and SA, respectively (P = .9). There were no surgical complications for LDT recipients within the MA group. Patient and graft survival was 100% in the MA group compared with 98% in the SA group (P > .05). CONCLUSIONS: With current surgical techniques, LDT with MA can achieve equally good functional outcomes at 1 year as SA kidneys, with minimal surgical complications.

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.

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.

PIP: Blood hemoglobin and serum ferritin levels were measured at the initial visit and 12 months after sterilization and IUD insertion. Ferritin levels were unaltered in Progestasert users after 12 months but hemoglobin values increased though not significantly. Ferritin levels fell in Multiload Cu250 users and in sterilized women; hemoglobin levels were also observed to fall but were significant only in the latter group. Iron deficiency anemia was prevalent at initial contact and there appeared to be an increased risk subsequently in Multiload Cu250 users and in those who were sterilized. Screening and monitoring for anemia is indicated. From the viewpoint of iron status, the Progestasert is preferable to the Multiload Cu250 but it has 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 anemia develops after sterilization.

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.

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.

PIP: 2-9 months following insertion of the Multiload Cu250 (ML Cu250; n=54) and Alza T (n=30) IUDs, mean menstrual blood loss (MBL) was 46.3 ml and 32.7 ml, respectively (p0.005). Significantly more of the Alza T users had losses below 40 ml and they also perceived their menses to be lighter. Based on a hemgloboin level of 12 gm/dL, the upper normal limit of MBL was about 40 ml. These findings are consistent with earlier observations that during the 1st year, ferritin levels fall in ML Cu250 users whereas they remain unchangeed in Alza T users.

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.

PIP: Insertion of copper-bearing IUDs has been associated with a 50% increase in menstrual blood loss (MBL), which is a potential cause of anemia in women, particularly those from developing countries. This study is an attempt to evaluate this risk. 3 copper IUDs (Copper-7, T-220C and Multiload 250) were randomly assigned to 84 healthy Malaysian women (mean age, 27.9; average parity, 2.4). 28 patients had Cu-7, 32 Multiload 250 and 24, T-220C. Blood samples were collected for measurement of hemoglobin (Hb), serum iron (S/Fe), unbound iron-binding capacity (UIBC), and transferrin saturation (T/S). There was no significant drop in mean Hb up to the 12-month visit (p 0.3). The S/Fe progressively declined, with significant levels being reached at 12 months (p 0.01). The T/S exhibited a significant drop as early as 6 months following insertion (p 0.05). There were no signficant differences in mean Hb, S/Fe, and T/S levels between the 6th- and 12th-month visits (p 0.5). A significant risk of anemia following copper IUD insertion is noted, particularly with long-term usage. Though further trials are necessary, the progestogen-releasing IUDs may provide the most feasible solution to the risk of anemia in the Malaysian context.

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.

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.

Early experience with the copper 7, copper T220C and multiload 250 intrauterine devices.

PIP: A preliminary study was conducted to assess the progress made in the IUD project being carried out at 3 university centers in Kuala Lumpur, Singapore and Medan. The three IUDs studied were the Copper 7 (Cu-7), the Copper T220C, and the Multiload 250 (MLCu250). Due to the fact that the number of acceptors was relatively small, only the first six months of use were analyzed. The study group consisted of 574 parous women who chose the IUD as the sole method of contraception. Insertions were made in the interval period, either 4 weeks following an abortion or 8 weeks after a delivery. Allocation of the device was made on a random basis and all patients had been followed up for at least 6 months or had been terminated from study by August 31, 1977. The age range of acceptors was 19-35 years. The mean parity was 2.6. Of the 572 insertions made, 70 or 12.2% were terminated in the first 6 months of use. The overall continuation rate at 6 months was 87.7/l00 users for a total of 3253 woman-months of use. The removal rate for pain/bleeding was comparable among the three IUDs. The mean of 3.1/l00 users is low in contrast to the rate of 9.9 for the Lippes Loop. The primary differences between the devices was in their rates for expulsion and accidental, but the data is too small at this time for any tests of significance to be meaningful. If present trends continue, the TCU 220C may prove to be the most effective device.^ieng

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.