Publications by authors named "Arman Zaharil Mat Saad"

31 Publications

Lower eyelid fornix deepening: A new indication for the facial artery myomucosal flap.

Arch Plast Surg 2021 Jan 20;48(1):80-83. Epub 2021 Jan 20.

Department of Ophthalmology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Malaysia.

Eye socket contracture is a well-known late complication of enucleation surgery, and the additional insult of radiotherapy at an early age causes even further fibrosis and scarring of the socket. Management of the contracted socket is challenging, and several methods have been proposed. We report a case of eye socket contracture after enucleation and radiotherapy in which multiple reconstructive procedures failed. The recurrent contracture caused difficulty in housing and retaining the eye prosthesis. We reconstructed the lower eyelid with a facial artery myomucosal flap and nasolabial flap, and the upper eyelid with a Fricke flap following reconstruction of the orbital rims (supraorbital and infraorbital rims with a calvarial bone graft, and further augmentation of the infraorbital rim with a rib bone graft). Cosmesis post-reconstruction was acceptable and the prosthesis was retained very well.
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http://dx.doi.org/10.5999/aps.2020.00206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861970PMC
January 2021

A harmless evil: Giant fungating benign breast mass in an adolescent mimicking malignancy - Case report.

Int J Surg Case Rep 2021 Mar 28;80:105202. Epub 2020 Nov 28.

Reconstructive Sciences Unit, University of Sciences Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia; Plastic, Reconstructive and Aesthetic Unit, Department of Surgery, University Malaysia Sabah, Sabah, Malaysia. Electronic address:

Introduction: Juvenile giant fibroadenoma is a rare type of fibroadenoma characterized by rapid growth of a breast tumor in an adolescent. Benign in nature, they rarely present as fungating and ulcerating tumors. Benign tumors masquerading as malignancies are surgical conundrums. No co nsensus exists yet on the management of these cases. We aim to discuss the dilemma in managing a bleeding, fungating giant fibroadenoma in an adolescent female and highlight risks of alternative therapies.

Presentation Of Case: A 19-year-old lady presented with a bleeding, fungating breast mass worsened with topical herbal concoction. Examination revealed a 10 × 15 cm fungating breast mass that obliterated her nipple- areolar complex (NAC). Computed Tomography (CT) scan reported a huge heterogeneously enhancing mass 10.6 × 14.5 × 15.1 cm with loss of normal fat plane with the overlying skin but a clear fat plane with the pectoralis muscle posteriorly.

Discussion: Giant breast masses that fungate and ulcerate usually indicate a sinister pathology. Traditional remedies have been reported to exacerbate growth. In cases where most of the breast parenchyma and NAC has been destroyed, it is no longer possible to proceed with breast conserving techniques. Breast reconstruction is crucial in adolescents and should be tailored to the patient's existing breast size as well as body habitus.

Conclusion: In juvenile giant fibroadenomas where breast parenchyma and NAC has been destroyed, breast reconstruction is the goal. The lack of consensus in both diagnosis and management further compounds the difficulty in dealing with this sensitive population. Awareness needs to be raised regarding negative effects related to traditional medicine.
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http://dx.doi.org/10.1016/j.ijscr.2020.10.096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982453PMC
March 2021

Blue rubber bleb nevus syndrome in a Malay girl: A case report and literature review.

Int J Surg Case Rep 2020 1;72:202-206. Epub 2020 Jun 1.

Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia. Electronic address:

Introduction: Blue Rubber Bleb Nevus Syndrome (BRBNS) also known as Bean's Syndrome is an atypical type of vascular malformation. To date, around 200 cases have been reported world-wide. In view of its low incidence rate, clinicians might misdiagnose and under treat. The key features of this syndrome are characterized by multiple cutaneous, soft tissue and gastrointestinal tract venous malformations.

Presentation Of Case: We report the first case of Blue Rubber Bleb Nevus Syndrome in Malaysia, a 23 years old Malay girl who suffers from multiple cutaneous venous malformation and gastrointestinal bleeding episodes.

Discussion: The typical morbidity for this syndrome is symptomatic anemia due to secondary iron deficiency due to the gastrointestinal venous malformation bleeding. In managing the gastrointestinal bleeding, it mainly depends on the severity of gastrointestinal bleeding, some may resolve spontaneously, while the others may be needing blood transfusion, and some may require GIT resections. As for cutaneous lesions, normally it is innocuous depending on the region and size. Large or problematic cutaneous venous malformation might benefit from sclerotherapy or excision.

Conclusion: Multidisciplinary approach is crucial in managing BRBNS case due to its complexity and the spectrum of multiple organ involvement to ensure the best outcome to the patient.
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http://dx.doi.org/10.1016/j.ijscr.2020.05.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298517PMC
June 2020

The Practice of First Aid for Burn Injuries Among the Population of East Coast of Peninsular Malaysia for 2012-2016.

J Burn Care Res 2020 Jul;41(4):905-907

Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia.

Burns are a devastating public health problem that result in 10 million disability-adjusted life-years lost in low- and middle-income countries. Adequate first aid for burn injuries reduces morbidity and mortality. The rate of proper first aid practices in other countries is 12% to 22%.1,2 A 5-year retrospective audit was performed on the database of the Burn Unit in Hospital Universiti Sains Malaysia for 2012-2016; this involved 485 patients from the east coast of Malaysia. The mean age of the patients is 17.3 years old. The audit on first aid practices for burn injury showed poor practice. Out of 485 burned patients, 261 patients (53.8%) claimed that they practiced first aid. However, only 24 out of 485 patients (5%) practiced the correct first aid technique where they run their burn wound under cool water for more than 20 minutes. Two hundred and twenty-two patients had not received any first aid. Two patients did not respond to the question on the first aid usage after burn injury. The mean age of patients who practiced first aid was 15.6 years old. Out of the 261 patients who practiced first aid, 167 (64%) run their wound under tap water for different durations. Others practiced traditional remedies such as the application of "Minyak Gamat" (6.5%), soy sauce (5.5%), other ointments (3.6%), milk (1.8%), and eggs (0.7%), as well as honey, butter, and cooking oil (0.4% each). First aid practices for burn injuries in the population of east coast Malaysia are still inadequate. The knowledge and awareness of school children and the general Malaysian population must be enhanced.
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http://dx.doi.org/10.1093/jbcr/iraa025DOI Listing
July 2020

An unusual cause of subacute airway obstruction in a hemodialysis patient with brachio-cephalic arteriovenous fistula: A rare presentation of central venous occlusion.

Hemodial Int 2020 04 5;24(2):E33-E36. Epub 2020 Mar 5.

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

A young lady with an arteriovenous (AV) fistula on hemodialysis was referred for surgical management following a failed endovascular approach to relieve central venous occlusion. She had an obstructed left brachiocephalic vein with a history of numerous central vein catheter placements. Alternative routes for new arteriovenous fistula creation had been exhausted due to previous contralateral upper limb fistula rupture and ligation. To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with AV fistula have been reported. The importance of identifying the possible emergency red flags in hemodialysis patients with central venous occlusion is important to prevent unwanted consequences.
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http://dx.doi.org/10.1111/hdi.12832DOI Listing
April 2020

Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate.

Arch Plast Surg 2019 Nov 15;46(6):518-524. Epub 2019 Nov 15.

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Background: Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early.

Results: in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft.

Methods: A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty.

Results: In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes.

Conclusions: Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.
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http://dx.doi.org/10.5999/aps.2019.00227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882701PMC
November 2019

A 20-year experience of immediate mandibular reconstruction using free fibula osteocutaneous flaps following ameloblastoma resection: Radical resection, outcomes, and recurrence.

Arch Plast Surg 2019 Sep 15;46(5):426-432. Epub 2019 Sep 15.

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Background: The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma.

Methods: This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved.

Results: Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years.

Conclusions: Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.
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http://dx.doi.org/10.5999/aps.2018.01487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759441PMC
September 2019

Successful ankle replantation in two cases with different presentations.

Arch Plast Surg 2020 Mar 30;47(2):182-186. Epub 2019 Aug 30.

Hospital Universiti Sains Malaysia, Health Campus Universiti Sains Malaysia, Kota Bharu, Malaysia.

We report our experience of treating two patients with ankle amputation with different presentations. The first case was a clean-cut sharp amputation. The second case was an avulsion injury following a motor vehicle accident in a patient who arrived 8 hours after the injury. Replantation was successful in both cases. In avulsion injuries, a secondary operation for wound coverage is required at a later stage. With good strategy and a support team, encouraging limb survival outcomes are possible post-replantation.
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http://dx.doi.org/10.5999/aps.2018.00514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7093274PMC
March 2020

Collapsed wall: destructive and reconstructive surgery of anterior abdominal wall tumour in a young girl.

J Surg Case Rep 2019 Feb 8;2019(2):rjy345. Epub 2019 Feb 8.

Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Natural history of abdominal wall soft tissue sarcoma is still poorly understood due to its rarity. In unpublished data of our institution, only seven cases of abdominal wall soft sarcoma with ICD-10 coding of 49.4 were found for past 10 years. We illustrate a case of juvenile fibrosarcoma of anterior abdominal wall. This is a case of young girl with anterior abdominal wall tumour, underwent wide local excision with immediate reconstruction. There are few options of surgical treatment for this case, but which is the best. It is always a challenge in managing young patient with giant abdominal wall defect in view of long term effect namely weakened abdominal wall, pregnancy related issue and risk of herniation and surgical site recurrence as well.
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http://dx.doi.org/10.1093/jscr/rjy345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368141PMC
February 2019

Skin Microcirculatory Changes in Relation to Arteriovenous Fistula Maturation.

Indian J Nephrol 2018 Nov-Dec;28(6):421-426

Department of Orthopaedic, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Maturation of arteriovenous fistula (AVF) involves complex vascular remodeling. In this study, we evaluated the changes of skin microvascular perfusion over the extremity with AVF maturation using the laser Doppler fluximetry (LDF). A total of 45 patients with chronic kidney disease, Stages IV-V, were included; they had undergone AVF creation from July 2014 to June 2016 at our institute. The measurement of skin microvascular perfusion was accomplished proximal and distal to the fistula anastomosis site: pre- and post-operative day 1, week 2, week 6, and week 12. Thirty-two patients with mean age of 55.6 had achieved AVF maturation. There were 40.6% radial-based and 59.4% brachial-based AVF. There was a 32.8% reduction of mean skin perfusion distal to the fistula by day 1 compared to the baseline perfusion; however, perfusion increased 47% by week 2 compared to day 1 and no dramatic change was subsequently noted. There was an increase of mean skin perfusion, proximal to fistula anastomosis, over 12 weeks with 35.8% at day 1 from the baseline. However, the changes of the mean skin perfusion were not statistically significant. There was no significant relation of skin perfusion changes with the type of fistula, diabetes mellitus, hypertension, and hyperlipidemia. LDF successfully detected the subclinical change of skin microvascular perfusion in relation to AVF creation. Reduction of skin perfusion distal to the fistula suggests that in patients with existing perfusion inadequacy of extremities, they may experience ischemic symptoms as early as day 1 postoperation, and require close monitoring for distal limb ischemic-related complications.
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http://dx.doi.org/10.4103/ijn.IJN_402_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309389PMC
January 2019

A prospective study evaluating wound healing with sea cucumber gel compared with hydrogel in treatment of skin graft donor sites.

Complement Ther Med 2018 Dec 4;41:261-266. Epub 2018 Oct 4.

Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia; Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia.

Background: Gamat (sea-cucumber) is a natural occurring fauna which is popularly used as traditional medication in Southeast Asian countries. There have been many animal studies done on its' biochemical properties and its' effects in vivo. The effect of gamat on human cutaneous wounds was studied using a split-skin graft donor site wound.

Methods: This was a comparative case-control study done on patients in Hospital Universiti Sains Malaysia (Hospital USM), requiring split-thickness skin grafting, whereby, the skin graft donor site was divided to almost equal halves, and applied with both gamat-based gel on one side, with Duoderm hydrogel on the other side. The epithelialization of the wounds was observed and compared on days 10, 14 and 21. Pain score, and pruritus score were also observed. Repeated measure analysis of variance (ANOVA) test and Paired t-test was used to test statistical significance accordingly.

Results: No significant differences were seen in rates of epithelialization of wounds on days 10, 14 and 21 (p > 0.01). No significant difference was also seen in the pain score and pruritus score (p > 0.01).

Conclusions: A gamat-based gel is comparable to conventional hydrogels in treatment of split-skin graft donor site. No adverse effects were observed in either group.
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http://dx.doi.org/10.1016/j.ctim.2018.10.006DOI Listing
December 2018

Microcalcification in the arterial wall and its relationship to the ultrasound criteria of maturation of the arteriovenous fistula.

J Vasc Access 2019 Jan 1;20(1):46-51. Epub 2018 Oct 1.

1 Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia.

Introduction:: A functioning and reliable arteriovenous fistula is a lifeline for individuals suffering from chronic kidney disease. The success and failure to arteriovenous fistula maturation have been frequently related to patient and surgeon factors.

Method:: In total, 138 participants with stage IV and V chronic kidney disease were included in this prospective observational study. Preoperative vascular mapping using ultrasound was performed to evaluate the condition and size of the vessels to fulfil the inclusion criteria. Intraoperatively, the vessel size was measured prior to anastomosis under magnified view. A specimen from the arterial wall of 5 mm in diameter was obtained from the arterotomy for histopathology assessment. Arteriovenous maturation was assessed at 6 weeks with the guidance of the ultrasound criteria of rule of sixes.

Results:: From the total of 138 participants, 110 participants (79.7%) had matured arteriovenous fistula in 6 weeks. The mean size of the artery measured intraoperatively was 3.82 ± 1.33 mm and the vein was 4.05 ± 1.20 mm. Microcalcification in the arterial media which was hypothesised to be the cause of the arteriovenous fistula failure was insignificant, with a p value of 0.115. Despite having atherosclerosis in the artery, 83.3% of the arteriovenous fistula matured.

Conclusion:: Microcalcification and atherosclerosis are frequently seen in the arteries of chronic kidney disease patients, but they do not explain arteriovenous fistula non-maturation.
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http://dx.doi.org/10.1177/1129729818775359DOI Listing
January 2019

Outcome of the Modified Meek Technique in the Management of Major Pediatric Burns.

Ann Plast Surg 2018 09;81(3):295-301

Introduction: The modified Meek micrografting technique has been used in the treatment of severely burned patients and a number of articles have examined the use of the modified Meek technique in adults and in mixed-age groups. However, there is a paucity of research pertaining to the outcome in the pediatric age group. The aim of this study is to present our favorable outcome in pediatric major burns using the modified Meek technique.

Methods: A retrospective review of burn cases in Hospital Universiti Sains Malaysia from 2010 to 2015 was conducted. Cases of major burns among pediatric patients grafted using the Meek technique were examined.

Results: Twelve patients were grafted using the Meek technique. Ten (91.7%) patients were male, whereas 2 (8.3%) were female. The average age of patients was 6 years (range, 2-11 years). The average total body surface area was 35.4% (range, 15%-75%). Most burn mechanisms were due to flame injury (66.7%) as compared with scalds injury (16.7%) and chemical injury (16.7%). There was no mortality. All patients were completely grafted with a good donor site scar. The average graft take rate was 82.3%, although 8 cases had positive tissue cultures from the Meek-grafted areas. The average follow-up duration was 3.6 years (range, 1.1-6.7 years). Only 1 case developed contracture over minor joint.

Conclusions: The Meek technique is useful when there is a paucity of donor site in the pediatric group. The graft take is good, contracture formation is low, and this technique is cost-effective.
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http://dx.doi.org/10.1097/SAP.0000000000001565DOI Listing
September 2018

Mechanism Action of Platelets and Crucial Blood Coagulation Pathways in Hemostasis.

Int J Hematol Oncol Stem Cell Res 2017 Oct;11(4):319-327

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.

Blood is considered to be precious because it is the basic necessity for health; our body needs a steady provision of oxygen, supplied via blood, to reach billions of tissues and cells. Hematopoiesis is the process that generates blood cells of all lineages. However, platelets are the smallest blood component produced from the very large bone marrow cells called megakaryocytes and they play a fundamental role in thrombosis and hemostasis. Platelets contribute their hemostatic capacity via adhesion, activation and aggregation, which are triggered upon tissue injury, and these actions stimulate the coagulation factors and other mediators to achieve hemostasis. In addition, these coordinated series of events are the vital biological processes for wound healing phases. The aim of this review is to summarize and highlight the important pathways involved in achieving hemostasis that are ruled by platelets. In addition, this review also describes the mechanism action of platelets, including adhesion, activation, aggregation, and coagulation, as well as the factors that aid in hemostasis and wound healing.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5767294PMC
October 2017

Autogenous forearm loop arteriovenous fistula creation.

J Vasc Access 2018 Mar 19;19(2):191-194. Epub 2018 Feb 19.

Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian - Malaysia.

Introduction: Arteriovenous fistula is a lifeline for end-stage kidney disease patients on dialysis. The quality of the vein and artery to be used plays a crucial role in attaining a functioning, reliable and long-lasting arteriovenous fistula. The aim of the study is to present an alternative for haemodialysis access to preserve the upper arm vasculature for future use - the forearm loop arteriovenous fistula.

Methods: From October 2015 to September 2016, 202 patients with chronic kidney disease (CKD), stages 4 and 5, underwent arteriovenous fistula creation at the Universiti Sains Malaysia Hospital, Malaysia. Nine patients, with severe atherosclerosis of the distal artery, but with satisfactory veins, underwent forearm loop arteriovenous fistula creation. Maturation of the fistula was based on the classification by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI).

Results: All nine patients who underwent forearm loop arteriovenous fistula have had diabetes mellitus for more than 10 years. Only one fistula failed to mature within 6 weeks. Two arteriovenous fistulas thrombosed at 3 and 5 months, respectively, after the commencement of haemodialysis. However, the other six matured fistulas are still functioning well after a year of regular usage.

Conclusions: Distal forearm arteries in diabetics may be severely atherosclerotic. Forearm loop arteriovenous fistula can be considered as the primary access for cases decided as inconvenient for fistula creation due to severe occlusive atherosclerotic disease of the forearm arteries; in order to preserve upper arm veins for future access procedures.
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http://dx.doi.org/10.5301/jva.5000801DOI Listing
March 2018

Pyogenic granuloma-like lesion in children: Should we wait?

Indian J Plast Surg 2017 Jan-Apr;50(1):104-106

Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia.

Malignant melanoma is a potentially lethal cutaneous malignancy. Melanoma in paediatrics is rare as compared to adult melanoma. The clinicopathological characteristics of paediatric melanoma are different from adult melanoma, and the presence of melanoma mimics which occurs frequently in children (Spitz naevi) resulted in diagnosis uncertainty. We reported a 9-year-old girl who presented with a slow-growing, pyogenic granuloma-like lesion which was diagnosed with melanoma. It is important to have a high index of suspicion in paediatric skin lesion that would usually be deemed benign. Early tissue biopsy in a suspicious lesion prevents delayed diagnosis and treatment.
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http://dx.doi.org/10.4103/ijps.IJPS_25_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469218PMC
June 2017

Report on von Willebrand Disease in Malaysia.

Open Access Maced J Med Sci 2016 Mar 29;4(1):112-7. Epub 2016 Feb 29.

Hemophilia Clinic, National Blood Centre (Pusat Darah Negara), Jalan Tun Razak, 50400, Wilayah Persekutuan, Kuala Lumpur, Malaysia.

Background: Von Willebrand disease (vWD) is an inherited hemostatic disorder that affects the hemostasis pathway. The worldwide prevalence of vWD is estimated to be 1% of the general population but only 0.002% in Malaysia.

Aim: Our present paper has been written to disclose the statistical counts on the number of vWD cases reported from 2011 to 2013.

Material And Methods: This article is based on sociodemographic data, diagnoses and laboratory findings of vWD in Malaysia. A total of 92 patients were reported to have vWD in Malaysia from 2011 to 2013.

Results: Sociodemographic-analysis revealed that 60% were females, 63% were of the Malay ethnicity, 41.3% were in the 19-44 year old age group and 15.2% were from Sabah, with the East region having the highest registered number of vWD cases. In Malaysia, most patients are predominately affected by vWD type 1 (77.2%). Factor 8, von Willebrand factor: Antigen and vWF: Collagen-Binding was the strongest determinants in the laboratory profiles of vWD.

Conclusion: This report has been done with great interest to provide an immense contribution from Malaysia, by revealing the statistical counts on vWD from 2011-2013.
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http://dx.doi.org/10.3889/oamjms.2016.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884229PMC
March 2016

Chitosan: A Promising Marine Polysaccharide for Biomedical Research.

Pharmacogn Rev 2016 Jan-Jun;10(19):39-42

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Biomaterials created 50 years ago are still receiving considerable attention for their potential to support development in the biomedical field. Diverse naturally obtained polysaccharides supply a broad range of resources applicable in the biomedical field. Lately, chitosan, a marine polysaccharide derived from chitins-which are extracted from the shells of arthropods such as crab, shrimp, and lobster-is becoming the most wanted biopolymer for use toward therapeutic interventions. This is a general short review of chitosan, highlighting the history, properties, chemical structure, processing method, and factors influencing the usage of chitosan derivatives in the biomedical field.
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http://dx.doi.org/10.4103/0973-7847.176545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791986PMC
April 2016

Endothelium dependent hyperpolarization-type relaxation compensates for attenuated nitric oxide-mediated responses in subcutaneous arteries of diabetic patients.

Nitric Oxide 2016 Feb 6;53:35-44. Epub 2016 Jan 6.

Pharmacology Vascular Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kota Bharu, Malaysia. Electronic address:

Diabetes impairs endothelium-dependent relaxations. The present study evaluated the contribution of different endothelium-dependent relaxing mechanisms to the regulation of vascular tone in subcutaneous blood vessels of humans with Type 2 diabetes mellitus. Subcutaneous arteries were isolated from tissues of healthy controls and diabetics. Vascular function was determined using wire myography. Expressions of proteins were measured by Western blotting and immunostaining. Endothelium-dependent relaxations to acetylcholine were impaired in arteries from diabetics compared to controls (P = 0.009). Acetylcholine-induced nitric oxide (NO)-mediated relaxations [in the presence of an inhibitor of cyclooxygenases (COX; indomethacin) and small and intermediate conductance calcium-activated potassium channel blockers (UCL1684 and TRAM 34, respectively)] were attenuated in arteries from diabetics compared to controls (P < 0.001). However, endothelium-dependent hyperpolarization (EDH)-type relaxations [in the presence of indomethacin and the NO synthase blocker, l-NAME] were augmented in arteries from diabetics compared to controls (P = 0.003). Endothelium-independent relaxations to sodium nitroprusside (NO donor) and salbutamol (β-adrenoceptor agonist) were preserved, but those to prostacyclin were attenuated in diabetics compared to controls (P = 0.017). In arteries of diabetics, protein expressions of endothelial NO synthase, prostacyclin synthase and prostacyclin receptors were decreased, but those of COX-2 were increased. These findings suggest that in human diabetes, the impairment of endothelium-dependent relaxations is caused by a diminished NO bioavailability; however, EDH appears to compensate, at least in part, for this dysfunction.
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http://dx.doi.org/10.1016/j.niox.2015.12.007DOI Listing
February 2016

Chitosan scaffold enhances growth factor release in wound healing in von Willebrand disease.

Int J Clin Exp Med 2015 15;8(9):15611-20. Epub 2015 Sep 15.

Industrial Biotechnology Research Centre, SIRIM Berhad No. 1 Persiaran Dato' Menteri, Section 2, P. O. Box 7035, Shah Alam 40700, Selangor, Malaysia.

Chitosan-derived biomaterials have been reported to adhere when in contact with blood by encouraging platelets to adhere, activate and aggregate at the sites of vascular injury, thus enhanced wound healing capacity. This study investigated platelet morphology changes and the expression level of transforming growth factor-β1 (TGF-β1) and platelet-derived growth factor-AB (PDGF-AB) in the adherence of two different types of chitosans in von Willebrand disease (vWD): N,O-carboxymethylchitosan (NO-CMC) and oligo-chitosan (O-C). Fourteen vWD voluntary subjects were recruited, and they provided written informed consent. Scanning electron microscopy and enzyme-linked immunosorbent assay test procedures were employed to achieve the objective of the study. The results suggest that the O-C group showed dramatic changes in the platelet's behaviors. Platelets extended filopodia and generated lamellipodia, leading to the formation of grape-like shaped aggregation. The platelet aggregation occurred depending on the severity of vWD. O-C was bound to platelets on approximately 90% of the surface membrane in vWD type 1; there was 70% and 50% coverage in vWD type II and III, respectively. The O-C chitosan group showed an elevated expression level of TGF-β1 and PDGF-AB. This finding suggests that O-C stimulates these mediators from the activated platelets to the early stage of restoring the damaged cells and tissues. This study demonstrated that the greater expression level of O-C assists in mediating the cytokine complex networks of TGF-β1 and PDGF-AB and induces platelet activities towards wound healing in vWD. With a better understanding of chitosan's mechanisms of action, researchers are able to accurately develop novel therapies to prevent hemorrhage.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4658944PMC
December 2015

Long-term outcome of free fibula osteocutaneous flap and massive allograft in the reconstruction of long bone defect.

J Plast Reconstr Aesthet Surg 2015 Dec 19;68(12):1755-62. Epub 2015 Aug 19.

Orthopedics Oncology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia.

Reconstruction of massive bone defects in bone tumors with allografts has been shown to have significant complications including infection, delayed or nonunion of allograft, and allograft fracture. Resection compounded with soft tissue defects requires skin coverage. A composite osteocutaneous free fibula offers an optimal solution where the allografts can be augmented mechanically and achieve biological incorporation. Following resection, the cutaneous component of the free osteocutaneous fibula flaps covers the massive soft tissue defect. In this retrospective study, the long-term outcome of 12 patients, who underwent single-stage limb reconstruction with massive allograft and free fibula osteocutaneous flaps instead of free fibula osteal flaps only, was evaluated. This study included 12 consecutive patients who had primary bone tumors and had follow-up for a minimum of 24 months. The mean age at the time of surgery was 19.8 years. A total of eight patients had primary malignant bone tumors (five osteosarcomas, two chondrosarcomas and one synovial sarcoma), and four patients had benign bone tumors (two giant-cell tumors, one aneurysmal bone cyst, and one neurofibromatosis). The mean follow-up for the 12 patients was 63 months (range 24-124 months). Out of the 10 patients, nine underwent lower-limb reconstruction and ambulated with partial weight bearing and full weight bearing at an average of 4.2 months and 8.2 months, respectively. In conclusion, augmentation of a massive allograft with free fibula osteocutaneous flap is an excellent alternative for reducing the long-term complication of massive allograft and concurrently addresses the soft tissue coverage.
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http://dx.doi.org/10.1016/j.bjps.2015.08.013DOI Listing
December 2015

Effect of the Novel Biodegradable N, O-Carboxymethylchitosan and Oligo-Chitosan on the Platelet Thrombogenicity Cascade in von Willebrand Disease.

Thromb Res 2015 Sep 30;136(3):625-33. Epub 2015 Jul 30.

Industrial Biotechnology Research Centre, SIRIM Berhad, No. 1 Persiaran Dato' Menteri, Section 2, P.O. Box 7035, 40700 Shah Alam, Selangor, Malaysia. Electronic address:

Introduction: Von Willebrand disease (vWD) is the second least common hemostatic disorder in Malaysia, and it has a low prevalence. This study examined the underlying platelet thrombogenicity cascades in the presence of different formulations of chitosan-derivatives in vWD patients. This paper aimed to determine the significant influence of chitosan biomaterial in stimulating the platelet thrombogenicity cascades that involve the von Willebrand factor, Factor 8, Thromboxane A2, P2Y12 and Glycoprotein IIb/IIIa in vWD.

Materials And Methods: Variable chitosan formulations of N,O-Carboxymethylchitosan (NO-CMC) and Oligo-Chitosan (O-C) were tested. Fourteen vWD subjects voluntarily participated in this study after signing informed consent forms. The patient's demographic profiles, family history, type of vWD, clinical symptoms and laboratory profiles were recorded and analyzed. Enzyme-linked immunosorbent assay, flow cytometry and Western blot tests were used to determine the level of the chitosan-adhered-platelet-mechanisms.

Results: The study revealed that most patients were predominantly affected by vWD type I. The O-C group of chitosan's scaffold pores is sufficient to allow for nutrients and cells. The O-C-stimulated-mediators are capable of initiating the platelet actions and were detected to expedite the blood coagulation processes. The oligo-group of chitosans was capable of amplifying and triggering more platelet activator's pathways via the studied mediators. The present findings suggest that the ability of each type of chitosan to coagulate blood varies depending on its chemical composition.

Conclusion: The oligo group of chitosans is potentially capable of triggering platelet thrombogenicity cascades by activating platelets in vWD patients to form a platelet plug for hemostasis process.
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http://dx.doi.org/10.1016/j.thromres.2015.07.027DOI Listing
September 2015

Successful pregnancy "during" pedicled transverse rectus abdominis musculocutaneous flap for breast reconstruction with normal vaginal delivery.

Indian J Plast Surg 2015 Jan-Apr;48(1):81-4

Reconstructive Sciences Unit, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

A transverse rectus abdominis myocutaneous (TRAM) flap is a popular choice for breast reconstruction. Pregnancies in women following a TRAM flap present concerns regarding both safety and the integrity of the abdominal wall. We report a case of a patient who was pregnant during immediate breast reconstruction with pedicled TRAM flap and had a successful spontaneous vaginal delivery. We also conducted a literature review using PubMed on pregnancy post TRAM flap, type of reconstruction, timing of pregnancy after TRAM flap, complication, and mode of delivery, which are summarised in this report. We concluded that patients may have safe pregnancies and normal deliveries following TRAM flap breast reconstruction regardless of the time frame of pregnancy after the procedure. Therefore, TRAM flaps can continue to be a reconstruction option, even in women of childbearing age.
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http://dx.doi.org/10.4103/0970-0358.155276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413497PMC
May 2015

Prognostic factors and survival rate of osteosarcoma: A single-institution study.

Asia Pac J Clin Oncol 2017 Apr 13;13(2):e104-e110. Epub 2015 Apr 13.

Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Aim: Osteosarcoma is a highly malignant primary bone tumor. The study aim to evaluate the prognostic factors influencing the survival rate in our center.

Methods: This was a retrospective cohort study of all patients treated between January 2005 and December 2010.

Results: We included 163 patients with an age range of 6-59 years (median = 19). The median follow-up was 47 months (range 36-84). The overall survival in patients who completed chemotherapy and surgery (n = 117) was 72% at 2 years and 44% at 5 years. Histologically, 99 (85%) had osteoblastic, 6 (5%) had chondroblastic and 3 (2.5%) had telangiectatic osteosarcoma. Limb salvage surgery was performed in 80 (49%) and 41 (25%) underwent amputation. However, 46 patients (28%) underwent no surgical intervention and incomplete chemotherapy. In total, 38/79 patients had a good chemotherapy response. There was a significantly better survival rate for limb salvage versus amputation. Independent prognostic factors for survival are compliance to treatment and presence of lung metastasis.

Conclusion: The overall survival of osteosarcoma patients was influenced by the presence of pulmonary metastases and compliance to treatment. Histological subtype, different chemotherapy regimens and histological necrosis after chemotherapy did not significantly influence survival. The patients who did not complete treatment had significantly poorer survival.
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http://dx.doi.org/10.1111/ajco.12346DOI Listing
April 2017

Glycoprotein IIb/IIIa and P2Y12 induction by oligochitosan accelerates platelet aggregation.

Biomed Res Int 2014 28;2014:653149. Epub 2014 Aug 28.

Industrial Biotechnology Research Centre, SIRIM Berhad, No. 1 Persiaran Dato' Menteri, Section 2, P.O. Box 7035, 40700 Shah Alam, Selangor, Malaysia.

Platelet membrane receptor glycoprotein IIb/IIIa (gpiibiiia) is a receptor detected on platelets. Adenosine diphosphate (ADP) activates gpiibiiia and P2Y12, causing platelet aggregation and thrombus stabilization during blood loss. Chitosan biomaterials were found to promote surface induced hemostasis and were capable of activating blood coagulation cascades by enhancing platelet aggregation. Our current findings show that the activation of the gpiibiiia complex and the major ADP receptor P2Y12 is required for platelet aggregation to reach hemostasis following the adherence of various concentrations of chitosan biomaterials [7% N,O-carboxymethylchitosan (NO-CMC) with 0.45 mL collagen, 8% NO-CMC, oligochitosan (O-C), and oligochitosan 53 (O-C 53)]. We studied gpiibiiia and P2Y12 through flow cytometric analysis and western blotting techniques. The highest expression of gpiibiiia was observed with Lyostypt (74.3 ± 7.82%), followed by O-C (65.5 ± 7.17%). Lyostypt and O-C resulted in gpiibiiia expression increases of 29.2% and 13.9%, respectively, compared with blood alone. Western blot analysis revealed that only O-C 53 upregulated the expression of P2Y12 (1.12 ± 0.03-fold) compared with blood alone. Our findings suggest that the regulation of gpiibiiia and P2Y12 levels could be clinically useful to activate platelets to reach hemostasis. Further, we show that the novel oligochitosan is able to induce the increased expression of gpiibiiia and P2Y12, thus accelerating platelet aggregation in vitro.
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http://dx.doi.org/10.1155/2014/653149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163351PMC
June 2015

Free saphenous venous flap and its modifications: Turbo- and supercharged.

Indian J Plast Surg 2014 Jan;47(1):147-9

Department of Reconstructive Science, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.

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http://dx.doi.org/10.4103/0970-0358.129658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075207PMC
January 2014

Reduced expression of prostacyclin synthase and nitric oxide synthase in subcutaneous arteries of type 2 diabetic patients.

Tohoku J Exp Med 2013 11;231(3):217-22

Pharmacology Vascular Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Health Campus.

Diabetic endothelial dysfunction is characterized by impaired endothelium-dependent relaxation. In this study, we measured the expression of endothelial nitric oxide synthase (eNOS), cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), prostacyclin synthase (PGIS), and prostacyclin receptor (IP) in subcutaneous arteries of type-2 diabetic and non-diabetic patients. Subcutaneous arteries were dissected from tissues from seven diabetics (4 males and 3 females) and seven non-diabetics (5 males and 2 females) aged between 18 to 65 years, who underwent lower limb surgical procedures. Diabetics had higher fasting blood glucose compared to non-diabetics, but there were no differences in blood pressure, body mass index and age. Patients were excluded if they had uncontrolled hypertension, previous myocardial infarction, coronary heart disease, renal or hepatic failure and tumor. The relative expression levels of eNOS, COX-1, COX-2, PGIS and IP receptor were determined by Western blotting analysis, normalized with the β-actin level. Increased expression of COX-2 was observed in subcutaneous arteries of diabetics compared to non-diabetics, whereas the expression levels of eNOS and PGIS were significantly lower in diabetics. There were no significant differences in expression levels of COX-1 and IP receptor between the two groups. Immunohistochemical study of subcutaneous arteries showed that the intensities of eNOS and PGIS staining were lower in diabetics, with higher COX-2 staining. In conclusion, type-2 diabetes is associated with higher COX-2 expression, but lower eNOS and PGIS expression in subcutaneous arteries. These alterations may lead to impaired endothelium-dependent vasodilatation, and thus these proteins may be potential targets for protection against the microvascular complications of diabetes.
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http://dx.doi.org/10.1620/tjem.231.217DOI Listing
November 2013

Wound bed preparation for chronic diabetic foot ulcers.

ISRN Endocrinol 2013 13;2013:608313. Epub 2013 Feb 13.

Department of Reconstructive Sciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.

The escalating incidence of diabetic mellitus has given rise to the increasing problems of chronic diabetic ulcers that confront the practice of medicine. Peripheral vascular disease, neuropathy, and infection contribute to the multifactorial pathogenesis of diabetic ulcers. Approaches to the management of diabetic ulcers should start with an assessment and optimization of the patient's general conditions, followed by considerations of the local and regional factors. This paper aims to address the management strategies for wound bed preparation in chronic diabetic foot ulcers and also emphasizes the importance of preventive measures and future directions. The "TIME" framework in wound bed preparation encompasses tissue management, inflammation and infection control, moisture balance, and epithelial (edge) advancement. Tissue management aims to remove the necrotic tissue burden via various methods of debridement. Infection and inflammation control restores bacterial balance with the reduction of bacterial biofilms. Achieving a moist wound healing environment without excessive wound moisture or dryness will result in moisture balance. Epithelial advancement is promoted via removing the physical and biochemical barriers for migration of epithelium from wound edges. These systematic and holistic approaches will potentiate the healing abilities of the chronic diabetic ulcers, including those that are recalcitrant.
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http://dx.doi.org/10.1155/2013/608313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586512PMC
March 2013

In vitro capacity of different grades of chitosan derivatives to induce platelet adhesion and aggregation.

Int J Biol Macromol 2013 Jan 11;52:244-9. Epub 2012 Oct 11.

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.

Chitosan-derived hemostatic agents with various formulations may have distinct potential in hemostasis. This study assessed the ability of different grades and forms of chitosan derivatives as hemostatic agents to enhance platelet adhesion and aggregation in vitro. The chitosan derivatives utilized were 2% NO-CMC, 7% NO-CMC (with 0.45 mL collagen), 8% NO-CMC, O-C 52, 5% O-CMC-47, NO-CMC-35, and O-C 53. Samples of chitosan derivatives weighing 5mg were incubated at 37°C with 50 μL of phosphate buffer saline (PBS) (pH 7.4) for 60 min. The morphological features of the platelets upon adherence to the chitosan were viewed using scanning electron microscope (SEM), and the platelet count was analyzed with an Automated Hematology Analyzer. For platelet aggregation, we added an adenosine diphosphate (ADP) agonist to induce the chitosan-adhered platelets. O-C 52 bound with platelets exhibited platelet aggregates and clumps on the surface of the membrane layer with approximately 70-80% coverage. A statistically significant correlation (p<0.01) for the platelet count was identified between the baseline value and the values at 10 min and 20 min. The results indicate that O-C 53 and O-C 52 were able to promote clotting have the potential to induce the release of platelets engaged in the process of hemostasis.
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http://dx.doi.org/10.1016/j.ijbiomac.2012.10.001DOI Listing
January 2013

The use of glycerol-preserved skin allograft in conjunction with reconstructive and flap surgery: seven years of experience.

J Reconstr Microsurg 2011 Feb 25;27(2):103-8. Epub 2010 Oct 25.

Reconstructive Sciences Department, Hospital Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia.

Major reconstructive surgery may be extensive and prolonged, and it may cause edema and compromise the flap pedicle if closed under tension. Glycerol-preserved skin allograft (GPA) can provide a means for tension-free closure and temporary cover of the wound. Seven years of analysis on GPA used in conjunction with major reconstruction was undertaken to highlight its indications, results, and outcomes. Forty-seven patients were included, aged between 9 and 73 years. Majority of patients had reconstruction following tumor resection and trauma. The main indication for use of GPA was temporary, loose cover of the wound in 44% of cases; flap pedicle protection in 31% of cases; donor site wound cover in 10%; flap monitoring in one case; and management of flap-related complications in 6% of cases. Free flap reconstruction was performed in 72% of cases. In conclusion, GPA is a useful adjunct in reconstructive surgery. It can be used temporarily to allow tension-free wound closure, as well as to protect the flap pedicle until edema subsides and the pedicle becomes stable. This latter approach allows secondary wound closure and good esthetic outcome.
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http://dx.doi.org/10.1055/s-0030-1268208DOI Listing
February 2011