obstuesday | fetal gastrochisis

Many weeks ago, a major storm of uncertainty was brewing wildly within the department over the mode of delivery for an unfortunate baby with gastroschisis at gestation 36weeks, borderline prematurity.

Decision was made after discussion between the head of department with the paediatric surgeon. Much anxiety came from the referral center which failed to read the vital line in the nicely paragraphed conclusion after the detail scan which clearly stated ‘no contraindication for vaginal delivery’, and misinformed about the prior knowledge by the paediatric surgical team. In summary, it was a breakdown of communication due to misinformation.

With the termination of the pregnancy by which I meant delivery, much anxiety was terminated as well.

It struck me as a trainee how little I knew about fetal gastroschisis. Therefore, I looked it up.

What is gastroschisis?
- Inherited congenital abdominal wall defect
- Intestines and sometimes other organs develop outside fetal abdomen through opening in abdominal wall

Gastroschisis also known as?
- Paraomphalocele, Laparoschisis, Abdominoschisis

How to differentiate gastroschisis from omphalocele?
- Omphalocele involved the cords, and organs enveloped by visceral peritoneum

Embryological maldevelopment of gastroschisis?
- Failure of fusion of lateral body folds from ventral to midline
- At fourth week of development
- Bowel herniates through rectus muscle, lying in the right of umbilicus

What is the prevalence of gastroschisis?
- 1 in 10,000
- Male more than female

What is the sonographic features of gastroschisis?
- bowel outside of abdomen

What is the risk factors of gastroschisis?
- young maternal age
- low parity
- maternal smoking, drug abuse
- maternal urinary tract infection, sexually transmitted disease

What is the genetic inheritance of gastroschisis?
- usually autosomal recessive
- can be also sporadic mutation and autosomal dominant

What is the ideal mode of delivery for fetal gastroschisis?
- no difference in neonatal outcome between vaginal and abdominal delivery
- abdominal delivery only by obstetric indication
- may opt for abdominal delivery in the event of lack of resources

What is the ideal timing of delivery?
- no consensus, but ideally at term or with evidence of lung maturity through amniotic sampling

What is the prognosis of gastroschisis?
- 90% survival

What factors badly affect the prognosis of gastroschisis?
- prematurity
- presence of other congenital anomaly
- in utero infection

What is the most common accompanying congenital anomaly?
- atresia of intestine with obstruction
- other malformations are rare

What is the expected neonatal management for baby postdelivery?

At birth, the exposed intestines will be carefully wrapped to prevent heat loss and dehydration and the newborn baby will be transferred immediately to the Children’s Hospital. One option is to bring the baby to the operating room soon after birth and attempt to return all the intestines inside the abdomen. This is called a one-stage or primary repair. In some cases, this is not possible since the abdominal cavity is “too small” relative to the amount of intestines that need to be placed inside. In these cases, we construct a “silo” that we sew to the abdominal wall. The excess bowel is left in the silo and each day a little bit is pushed inside until the silo can be removed. This is called a staged repair. More recently, another option is the placement of a “spring-loaded silo” that can be placed at the bedside without general anesthesia. The definitive closure in the operating room takes place a few days later.

religious obligation

‎"People usually consider walking on water or in thin air a miracle. But I think the real miracle is not to walk either on water or in thin air, but to walk on earth. Every day we are engaged in a miracle which we don't even recognize: a blue sky, white clouds, green leaves, the black, curious eyes of a child -- our own two eyes. All is a miracle."
— Thich Nhat Hanh

For a slight moment, anger and frustration came to me like a spark in the spark plug when the key went the right way. The engine did not get started or heated up, but still it's among the possibilities, closer to probable than possible.

I could not really comprehend the religiously-strayed people (if I can still regards them as human) of the world going into violence and coercion and called it a religious struggle. The only struggle that they are actually doing is struggling in comprehending their own religion.

Gautama Buddha once had a short discourse on the superpowers (No, He is not talking about neither US nor China).

He reached the riverbank.
Someone shouted at him - not in a rude way.
"Hey, Lord Buddha, people hah say you so powerful, I also powerful, you want to see what I can do" (contemporarized, translated)
"Well, what can you do?"
"I can cross the river without getting wet."
"Seriously?!"

And without further explaination, the man flew off the ground and stepped on the water.
He did not sank, but continue to stride above the water till the other side.

And he came back to Buddha the same awesome kungfu way, that some of you might have watch those move in most Hong Kong movies.

"Buddha, you see that?"
"Yes, how many years you've trained?"
"20years."
"Let me show you how can I cross the river without getting wet"
"Awesome. This I must see."

Pheeewwwittt..
Lord Buddha stepped into a boat.
"Hi, boatman, how much to take me across the river?"
"Oh, usually I charge few pennies, but for Lord Buddha, it's my pleasure"

Lord Buddha turned back to the Kungfu Guy.
"As you can see, you had wasted 20years to attain what can be done with few pennies."

Now, the final word about superpowers and miracle is actually to disassociate with them, but instead seek practicality in life.

Asking God/Higher beings/Devas for a lottery strike or wrong bank transaction which ended with few billions surplus in your account is what I called as association with miracle.

Throwing your money for kid's education or food into donation to temple and donation to lottery and hoping for a miracle is not practical.

When your house is on fire, you should go and get a bucket of water to put off the flame,

And not rush to a temple to pray that the fire will cease by itself.

If you do, there can only be one sole outcome -

• you'll lose your house (never play with fire)
  
• have to stay in the temple (which is not a bad thing considering one has much to learn about practicality in Buddhism)

Nuff said.

P.S. My effort in explaining is as futile as trying to explain 'Barr Chin' to my fellow Malaysians, because they are off the older generation or in one word - elders.

etc sunday | smile responsibly

Basically (don't you just hate people who start a sentence with this word) when I welcomed my daughter into this home, it was a much relief for my wife.

Simply because my daughter, Genevieve does not create a feeding nightmare like my elder son do. Trust me when I say nightmare, it is not just your run-off-the-mill normal kid's fussy-eating nightmare. My son can go without a feed even at the tender age of 2-3months. He didn't cry for food for 5hours plus. He pushed the away anything in the mouth with his tongue. We had to forcefeed him when he had his regular meetings with the Sandman.

If it was a repeat episode with my daughter, my wife would have shorten our future fertility plan. Luckily, it wasn't.

But now, my dearest (yes, i preferred to acknowledge my wife this-a-way) bugged me for another reason to be worry of. Yep, there's so much things to worry about. Perhaps one never ever will know that until one had a successful conception and delivery. And no, this is no bragging at all. Trust me.

Dearest: how ar?

Me: How what? (in a nice way)

D: how to answer when nurse in clinic ask whether she can 'balas senyuman' (smile responsively)?

M: If she can't, say she can't lor. (And that's the Penang's 'lor'. Soft and sweet 'lor')

D: Already near 2months, still not smile, she OK or not?

M: Still bit early lor. (Yep, the same kind of 'lor')

D: Don't want to see a doctor?

M: And you know what the doctor will tell you?

D: What?

M: Your daughter lack sense of humor.

D: (smile) haha..

M: Or if the doctor can do bit suturing, probably stitch up the angle of mouth.

D: Aiyaaa... (Yes, the Penang 'Aiya', worry with minute amount of panic)

M: Don't worry, dear. Maybe we can show her more comedy show.

D: (smile)

Basically (again), my daughter can grimace very well, response to sound and follow objects with eyes.

For a girl, I don't think attaining smiling responsively is that important.

More important for her to learn how to smile responsibly.

Doesn't all parents agree with this?

friday flair | Mosque OR Superman's HQ?

Fortress of Solitude?

The proposed Islamic centre, two blocks from the site of the World Trade Centre attacks, has created widespread controversy in the United States.

The designs suggest it will have four floors taken up by a sports, fitness and swimming centre.

There will also be a child care centre, a restaurant, culinary school, art studios, exhibition space and auditorium.

The prayer space for Muslims will be on two levels in the basement, and the 12th floor will have a 9/11 memorial and sanctuary open to people of all faiths.

porcinophobia?

PUTRAJAYA: The Islamic Develop­ment Department (Jakim) will use a locally-produced pig DNA detector to determine if products are free from pig elements.

Its director-general Datuk Wan Mohamad Sheikh Abdul Aziz said the detector was created by researchers from Universiti Putra Malaysia and could identify pig DNA even if trace amounts are as minute as 0.001 nanograms.

Wan Mohamad added that as the pig DNA detector was mobile. It could be used by Jakim’s enforcement officers during checks and raids.

That's a very short and sweet news from The Star.

Probably a welcomed invention, since it will help the religiously-pious Muslims to keep eyes wide open for non-halal stuffs.

Perhaps, they can invent something later to detect whether the cash that they're receiving from the Penang's State government were from 'non-halal' sources.

However, some inventions shouldn't be taken into consideration at face value. Everything comes with a certain value of false positive and false negative. I wonder what are the values for those 'falses'.

Secondly, I'm no scientist but DNA are just fragments of deoxyribonucleic acids and in some sequences, it will make a pig, in another sequence it will procreate human. But they at times will go into fragments in midst of procreating. And those fragments will have great similarities across few species.

And some DNA can even go into combination. For instance, from H1N1, certain parts pig DNA, certain parts avian DNA and some parts human DNA.

Thirdly, the worries about Muslims rejecting certain drugs or blood transfusions for life-saving procedures should really be thrown out of the window.

Islam in its own uniqueness, do not lead Muslims to doom.

Firman Allah Taala bermaksud:

Dan Dia tidak menjadikan kamu menanggung sesuatu keberatan dan susah payah di dalam perkara agama.

(Surah al-Hajj: Ayat 78).

Firman Allah Taala bermaksud:

Allah tidak memberatkan seserang melainkan apa yang terdaya olehnya.

(Surah al-Baqarah: Ayat 286).

Firman Allah Taala bermaksud:

Tetapi barangsiapa yang dalam keadaan terpaksa (memakannya) sedang ia tidak menginginkannya dan tidak (pula) melampaui batas, maka tidak ada dosa baginya. Sesungguhnya Allah Maha Pengampun lagi Maha Penyayang.

(Surah al-Baqarah: Ayat 173).

In Islam, there's darurat.

For a treatment to be of 'darurat', 3 criteria must be fulfilled:

1. There's a danger without this treatment
2. There are no halal substitutes for it.
3. Confirmation from a Muslim doctor with good i’tikad (trusted in practice and spiritually)

I used to give advise to patients requiring porcine-based medication for their heart disease without fulfillment of the 3rd criteria. No wonder, my advice, no matter how lengthy and easy to understand, was rejected always, until a fellow Muslim colleague came along and further convinced the patients.

Similarly, in Buddhism, there are precepts and the 5th precepts stated in the simplest way as 'Do not take intoxicants' or

But are medications classified as intoxicants?

By strict translation, the Fifth Precept of Buddhism, translated from the Pali Canon, is "I undertake the training rule to abstain from fermented and distilled intoxicants which are the basis for heedlessness."

Violating the precept requires an intoxicant, an intention to take an intoxicant, the activity of ingesting the intoxicant, and the actual ingestion of the intoxicant. Taking medication containing alcohol, opiates or other intoxicants for genuine medical reasons does not count, nor does eating food flavored with a small amount of liquor. Otherwise, Theravada Buddhism considers the Fifth Precept to be a clear prohibition of drinking.