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MED J MALAYSIA VOL 48 NO 1 MARCH 1993
EDITORIAL
CHOLERA - STILL A MAJOR HEALTH PROBLEM
V K E Lim, FRCPath, Department of Medical Microbiology & Immunology, Faculty
of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz,
50300 Kuala Lumpur
The recent outbreaks of cholera in several states of Malaysia serve as atimely reminder that cholera is still a major public health problem inMalaysia. According to the Minister of Health, in 1991 alone there were 504cases of cholera with 5 deaths. Malaysia is not alone in facing this oldadversary. Cholera is endemic in many countries in Asia and Africa. In arecent survey of diarrhoea in Bangladesh, cholera was the most commonenteropathogen detected, accounting for 39% of all enteric pathogens. Even inthe United States, approximately 1 case a week is being reported, althoughthe majority of cases were acquired during international travel. In lateJanuary 1991, cholera made its first appearance in South America in the 20thcentury. The epidemic started in Peru but spread rapidly throughout most ofLatin America. By March 1992, there were already 450,000 cases with over4,000 deaths.
The causative agent of cholera, Vibrio cholerae, was first described in 1854.
There are at least 83 serogroups based on the O antigen but only Vibriocholerae O1 has been implicated in cholera epidemics. It has now beenestablished that river estuaries with brackish water of salinities between 5-25 parts per thousand are the natural aquatic habitats of V. cholerae.
Temperature also plays an important role in its survival, as the organism israrely encountered when temperatures fall below 10°C or exceed 30°C. Theorganism may also occur in the environment in a quiescent state, which,though viable, is undetectable by the usual culture methods. Global warmingmay affect water ecology to an extent as to enhance the spread of Vibriocholerae to areas previously unaffected.
There have been 7 pandemics of cholera to-date. The first 6 were due to theclassical strain of Vibrio cholerae O1 and all originated from the Indiansub-continent. The seventh started in the early sixties in Sulawesi,Indonesia, and was due to the biotype el tor. The seventh pandemic sweptthrough much of Asia in the sixties and Africa in the seventies. The LatinAmerican strain is also of the biotype el tor and appears to be related tothe seventh pandemic strain. Although cholera is classically described as awater-borne infection, many different foods have also been identified asvehicles for transmission. These include raw and cooked shellfish, otherseafood, millet gruel, peanut sauce, fruit and vegetables.
Although the usual presentation of cholera is severe watery diarrhoea withdehydration and shock, other less usual clinical presentations likecholangitis and bacteremia have been reported. Replacement of fluids andelectrolytes is the mainstay of treatment and oral rehydration therapy isprobably the most important therapy available in preventing death. Citrate-based oral rehydration solutions have been found superior to bicarbonate-based solutions. Antibiotics lessen the severity and shorten the duration ofdiarrhoea. Tetracycline remains the antibiotic of choice. A single dosedoxycycline treatment has been found to be as effective as multi-dosetetracycline. However, tetracycline resistance has been reported from many countries including Malaysia. Alternative microbial treatments includefurazolidone, erythromycin and norfloxacin.
The detection of Vibrio cholerae in clinical specimens involves culture invarious enrichment and selective media. More recently, the polymerase chainreaction has been used to detect cholera toxin from cultured strains or fromstool specimens as well as in the environment. The use of the polymerasechain reaction in detecting non-culturable but viable Vibrio cholerae inwater samples is a significant advance and can facilitate the epidemiologicalcontrol of the disease in endemic areas. The older killed cholera vaccineswhich are given parenterally do not give adequate protection. There are neworal vaccines undergoing trials and the results appear to be promising.
Cholera affects more than just the health of the people. The disease alsocarries with it economic implications with regards to the tourist industryand the export of food items. It has been said that the existence of cholerais testimony to the inability to provide a consistently decent standard ofliving to the people. To control or eliminate cholera, human sewage must notbe allowed to contaminate potable water sources. This would mean provision ofpiped, treated water and proper sewage disposal facilities to all theinhabitants of the country. This is simple in theory but difficult inpractice. Nevertheless, it is hoped that as Malaysia moves towards 2020 anddeveloped country status, cholera will no longer be a major health problem.
ORIGINAL ARTICLES
Acute Appendicitis - The University Hospital Experience
H Y Lee, MBBS*, P Jayalakshmi, MRCPath**, S H Syed Noori, FRCS*, *Departments
of Surgery and **Pathology, University Hospital, Kuala Lumpur
Summary
A 1 year review of 529 cases of acute appendicitis, treated at the University
Hospital in 1990, was performed. Perforation rate was 23.7% and delay in
diagnosis was found to be significant. Patients above 50 years of age were
particularly at risk. Diagnostic error was 19.3% and it was a problem not
only in young women but also in children. Temperature and rectal examinations
were not found to be helpful in the diagnosis in contrast to leukocytosis.
Waiting time for operation was long (median 7 hours), be it for a perforated
or a non-perforated appendicitis.
Key Words : Acute Appendicitis, Diagnostic Error, Perforation
A Review of Acute Appendicitis seen in the Taiping District Hospital from July to
December 1990
M W Chua*, Y Fazidah*, M Y Khalijah*, Z A Sofiah*, B Hashami**, K G Lim***,
*Medical Students, Universiti Kebangsaan Malaysia, **Department of Community
Health, Universiti Kebangsaan Malaysia, ***Taiping District Hospital
Summary
In a retrospective study, 455 people were found to have been admitted to the
Surgical Unit of the Taiping District Hospital, suspected of acute
appendicitis in the study period from 1 July to 31 December 1990. However,
only 147 (32.2%) were clinically confirmed to have appendicitis and underwent
appendicectomy. Out of these, 120 (81.6%) cases were subjected to detailedanalysis.
The study showed that the commonest age group affected was the 10 to 20 yearold. Males were slightly more often affected but there seemed to be an equaldistribution among the major races. The diagnostic accuracy, that is theoperated cases that were actually acute appendicitis, was 92.5%. Theperforation rate was 31.5%. Fifty-five percent of patients developed somepost-operative complications, of which the commonest was fever.
Key
Words
:
Acute
Appendicitis,
Appendicectomy,
Retrospective
Study,
Demographic Data, Diagnostic Accuracy, Perforation Rate, Post-Operative
Complication
Gas-Containing Liver Abscesses : Assessment by Ultrasound (US) and Computed
Tomography (CT)
S A Samad, FRCR, M A Zulfiqar, MMed (Radiology), A Maimunah, MMed
(Radiology), Department of Radiology, Faculty of Medicine, Universiti
Kebangsaan Malaysia, Kuala Lumpur
Summary
Single gas-containing pyogenic liver abscesses in 11 patients were studied by
ultrasound and computed tomography (CT). On ultrasound, all abscesses were
predominantly echogenic compared to the normal liver parenchyma. The gas
collections
associated with acoustic shadowing and ring-down artifacts. Ten abscesses(90%) had ill-defined margins on ultrasound, causing under-estimation oftheir sizes in these patients. All abscesses were shown to be multi-loculatedand had clearly defined borders on CT, not appreciated or mistaken formultiplicity of abscesses on ultrasound. Ultrasound may be inadequate in theevaluation echotexture in addition to ring-down artifacts, acoustic shadows and poorly-defined margins; leading to under-estimation of abscess size, difficulty inidentifying loculations and erroneous interpretation of multiplicity ofabscess cavities.
Key Words : Ultrasound, Gas-Containing Liver Abscess, Computed Tomography
Hydatidiform Mole and Post-Evacuation Regression Patterns of Serum Beta Human
Chorionic Gonadotrophin
K Kamariah, BSc*, N Satgunasingam, PhD*, N M I Nasri, MRCOG**, K Y Ng,
MRCOG***, *Division of Radiochemistry, Institute for Medical Research, Kuala
Lumpur, **Department of Obstetrics and Gynaecology, Faculty of Medicine,
Universiti Kebangsaan Malaysia, ***Department of Obstetrics and Gynaecology,
General Hospital, Kuala Lumpur (presently at Tengku Ampuan Rahimah General
Hospital, Klang)
Summary
Eighty-nine patients who had hydatidiform moles evacuated at the General
Hospital, Kuala Lumpur, were followed with serum ßhCG determinations from
October 1998 to June 1991. A regression curve for serum ßhCG, as measured by
RIA, was derived from the results of 47 of the patients who demonstrated
spontaneous regression of serum ßhCG titres. All 47 patients had normal serum
titres at 135 days after evacuation. The mean time taken to reach normallevel was 82.6 days, while the range was 39 to 135 days (5 to 19 weeks).
Key Words : Hydatidiform Mole, hCG, ßhCG, Regression
Detection of Gene Deletions by PCR Analysis in a Malaysian Patient with Duchenne
Muscular Dystrophy
M K Lee, MRCP*, V Manonmani, MRCP**, K Arahata, MD***, *Division of
Neurology, Department of Medicine, Faculty of Medicine, University of Malaya,
**Department of Paediatrics, Faculty of Medicine, University of Malaya,
***National Institute of Neuroscience, Kodaira, Tokyo, Japan
Summary
Duchenne muscular dystrophy (DMD), the commonest X-linked disorder, is a
progressive, eventually fatal disease. With the advent of molecular genetics,
the
characterised. Molecular diagnosis of DMD, identification of carriers andantenatal diagnosis is now possible. We describe here the use, in a Malaysianboy with DMD, of a recent innovation, multiplex polymerase chain reaction(PCR), to obtain molecular diagnosis by detection of dystrophin genedeletions.
Key Words : Multiplex PCR, Gene Deletion, Duchenne Muscular Dystrophy,
Dystrophin
Profile of Extracranial Cerebrovascular Disease in Kelantan : A Study by Continuous
Wave Doppler Ultrasonography
R C Pratap, MD, M Mafauzy, MRCP, Department of Medicine, University Hospital,
Kubang Kerian, Kelantan
Summary
The present study outlines the clinical profile and patterns of extracranial
vascular abnormalities detected by continuous wave doppler ultrasonography
(CWDU) in 100 patients with cerebrovascular insufficiency states. Males
outnumbered females (65:35); completed stroke (CS) was a more common mode of
presentation than transient ischaemic attacks (TIA); carotid strokes were
more common than vertebro-basilar ones; and hypertension was the most common
predisposing factor. The CWDU evaluation revealed extracranial vascular
disease in 73% of patients. Vascular occlusions were more common in patients
with TIA. Overall, 33% of the patients had evidence of proximal obstruction
of the cerebral vessels below the neck. The clinical prediction of vascular
territory (carotid or vertebro-basilar) matched with the findings on CDWU,
but evidence of subclinical multiple-vessel involvement could be detected in
48% of the patients.
Key Words : Cerebrovascular Disease, Doppler Ultrasound
Response of Ovary in Young Women Experiencing Laparoscopy under General
Anaesthesia
W P Chow, A Loganath, K L Peh, P C T Chew, R Gunasegaran, S S Ratnam,
University Department of Obstetrics & Gynaecology, National University
Hospital and Institute of Science & Forensic Medicine, Singapore
Summary
This
immunoreactive oestradiol-17ß (E2), progesterone (P) and testosterone (T)occur in women at follicular (n = 18, age 25 to 39 years) and luteal (n = 17,25 to 39 years) phases of the normal menstrual cycles, experiencinglaparoscopy after intravenous sedation with general anaesthesia. The pre- andintra-operative follicular phase plasma steroid hormone concentrations were153.5 ± 84.3 vs 297.4 ± 220.8 pg/ml for E2, 2.0 ± 3.2 vs 3.3 ± 3.8 ng/ml for Pand 746.6 ± 415.9 vs 1325.8 ± 535.1 pg/ml for T, respectively. Thecorresponding luteal phase steroid levels were 259.7 ± 120.2 vs 382.7 ± 188.7pg/ml, 7.0 ± 4.8 vs 9.9 ± 6.1 ng/ml and 819.4 ± 355.7 vs 1703.5 ± 1058.1pg/ml. Using the Wilcoxon rank sum test, intra-operative hormone levels withthe exception of P in the luteal phase were found to be significantlyelevated (p < 0.05). The results suggest that laparoscopy under generalanaesthesia evokes increased secretion of ovarian hormones, possibly via theactivation of hypothalamo-pituitary-ovarian axis.
Key Words : Laparoscopy, General Anaesthesia, Endocrine Changes, Elevated
Oestradiol-17ß, Progesterone and Testosterone Levels, Hypothalamo-Pituitary-
Ovarian Activation
The Prevalence of Endemic Goitre in Kelantan, Malaysia
M Mafauzy, MRCP, W B Wan Mohamad, MD, M Y Yasmin Anum, PhD*, M Musalmah,
PhD*, B E Mustafa, MBBS, FRCP, Division of Endocrinology & Metabolism,
Department of Medicine, School of Medical Sciences, Universiti Sains
Malaysia, Kubang Kerian, Kelantan, *Department of Chemical Pathology, School
of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan
Summary
A large-scale study was undertaken in the Sate of Kelantan, to determine the
prevalence of goitre. A total of 2,450 subjects above the age of 15 years
were selected from 31 localities in the state and examination for goitre was
done using the technique of Perez. The state was divided into 3 areas -
coastal area (area 1), inland area (area 2) and the area in between the coast
and the inland area (area 3). The overall prevalence of goitre was 36.8% and
the prevalence in areas 1, 2 and 3 were 23.0%, 35.9% and 44.9% respectively
and ranged from 6.9% in a locality in area 1 to 59.7% in a locality in area
3. In all areas, the prevalence was higher in females than in males. The
prevalence of grades I, II and III goitres were 21.5%, 1.0% and 0.5%
respectively in area 1, 33.6%, 1.5% and 0.7% respectively in area 2 and
41.7%, 2.2% and 1.0% respectively in area 3. Amongst age groups, goitre
prevalence was highest in the 36 to 45 years age group in area 1 (33.9%), in
the 15 to 25 years age group in area 2 (39.6%) and in the 26 to 35 years
group in area 3 (54.3%). In all the areas, goitre prevalence was lowest in
the above 56 years age group. We concluded that the prevalence of goitre was
high in Kelantan and there were regional differences in the prevalence rate
within the state.
Key Words : Endemic Goitre, Goitre Prevalence
Comparison of the Efficacy of Single and Multiple Regimens of Carbimazole in the
Treatment of Thyrotoxicosis
M Mafauzy, MRCP*, W B Wan Mohamad, MRCP*, M K Zahary, MMed**, B E Mustafa,
FRCP*, *Division of Endocrinology & Metabolism, Department of Medicine,
School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian,
Kelantan, **Department of Radiology, Hospital Universiti Sains Malaysia,
Kubang Kerian, Kelantan
Summary
Carbimazole, in 3 divided daily doses, is commonly prescribed for the
treatment of thyrotoxicosis. However, based on its long intra-thyroid half-
life, the drug may be effective when used as a single or twice daily dose.
This study was undertaken to determine the effect of once, twice or thrice
daily
Seventy previously untreated thyrotoxic patients were randomly allocated toreceive carbimazole 30 mg once (group 1), 15 mg twice (group 2) and 10 mgthrice (group 3) daily. All patients were also prescribed propranalol 20 mgthrice daily for the first 4 weeks. Blood was taken for total T3, T4, TSH,blood counts and liver enzyme determinations at the beginning and at 6 weeksof treatment. Only 48 (68.6%) patients were included in the analysis, as therest defaulted follow-up (20.0%) or blood samples were not available atreview (11.4%). Of the 48 patients, 17 were in group 1, 16 in group 2 and 15in group 3.
Following 6 weeks of treatment, there was no significant difference in themean serum levels of total T3 and T4 between the 3 groups. However, there wasa significant decrease in the mean serum level total T3 and T4 as compared tothe start of the treatment.
Four patients (23.5%) in group 1, 4 patients (25%) in group 2 and 3 patients(20%) in group 3 were still thyrotoxic at 6 weeks of treatment, whilst 10patients (58.8%) in group 1, 6 patients (37.5%) in group 2 and 3 (20%) ingroup 3 were biochemically hypothyroid. There was no significant differencein total white cell count, serum alanine aminotransferase (ALT) and aspastatetransaminase (AST) values between the 3 groups.
In conclusion, carbimazole given in once or twice daily doses was aseffective as when given in thrice daily doses in the treatment ofthyrotoxicosis, with no adverse effect on white cell count and liver enzymes.
Key Words : Carbimazole, Thyrotoxicosis
Ukuran Antropometri Kanak-Kanak Melayu Keluarga Mewah di Taman Tun Dr Ismail,
Kuala Lumpur
A Osman*, A Suhardi*, B A K Khalid**, *Jabatan Kesihatan Masyarakat, Fakulti
Perubatan, Universiti Kebangsaan Malaysia, Kuala Lumpur, **Jabatan Perubatan,
Fakulti Perubatan, Universiti Kebangsaan Malaysia, Kuala Lumpur
Summary
This study was done to determine the anthropometric measurement patterns of
Malay children from wealthy families in Malaysia and to make a comparison
with NCHS reference population. A population of 900 children aged between 3-
12 years old from Taman Tun Dr Ismail, Kuala Lumpur (TDI), was examined but
only 871 of them were eligible for the study. Weight, height, mid-armcircumference and skin fold thickness were measured. The increment pattern ofanthropometric measurements of TDI children was quite similar to NCHS exceptfor having a lower median weight for age and height for age. There wasprepubescent increase in skin fold thickness in both sexes, followed by amidpubescent decrease and a late pubescent increase. The study indicated thatMalay children from a wealthy background have growth rates comparable tochildren in the West, hence NCHS percentile charts are suitable as areference for comparing the nutritional status of Malay children in Malaysia.
Key Words : Growth Rates, Malay Children

Source: http://www.mma.org.my/Portals/0/MED%20J%20MALAYSIA%20VOL%2048%20NO%201%20MARCH%201993.pdf