Gastro-peritoneal fistula is a rare but serious complication of laparoscopic sleeve gastrectomy with significant morbidity and mortality. We present the case of a 42-year-old man who underwent laparoscopic sleeve gastrectomy for morbid obesity and presented later with a history of chronic epigastric pain and severe reflux. Upper gastrointestinal series showed the presence of a communicating fistula between the stomach and the left hemi-diaphragm and peri-splenic area.
Right iliac fossa pain can often be misdiagnosed as something sinister or benevolent despite assistance with state of the art imaging techniques. This is particularly more challenging in the female gender whereby the error of managing a right iliac fossa pain may approach forty percent. A 66-year-old lady, ten years post-menopause, presented with a week history of progressively worsening right iliac fossa pain. Malignancy was suspected with a palpable abdominal mass. Computed tomography was suggestive of an abscess collection, but a needle aspirate produced brown faecal material suggestive of a diverticulitis. An exploratory appendisectomy revealed a non malignant appendicular abscess. In conclusion, when clinical and imaging assessments are inconclusive, an exploratory laparotomy for a surgical excision is warranted primarily if malignancy is suspected.
The presence of thrombus within the inferior vena cava (IVC) is often a sign of advance hepatocellular carcinoma (HCC). Various treatment methods have been described with variable and inconclusive results. Now, the advancement of endovascular approach offers new possibility as a potential treatment modality. We discuss the removal of tumour thrombus with catheter directed mechanical thrombectomy. IVC tumour secondary HCC was removed by AngioJet® rheolytic system (Possis Medical, Minneapolis, MN, USA) with good result. Further work should be encouraged to explore the prospect of this technique with other treatment modalities.
This case report highlights Charles Bonnet Syndrome as a precursor to the development of major neurocognitive disorder due to Alzheimer’s disease in the elderly with visual impairment and the possible differential diagnoses that could be considered. We report a case of an elderly lady with no known previous medical illness, who presented for the first time to the psychiatric clinic with complex visual hallucinations consisting of well-formed images of people and inanimate objects of long standing duration of 18 months. About a year later, there was emergence of cognitive impairment which progressed gradually accompanied by other psychotic symptoms such as auditory hallucinations and persecutory delusions. There were no affective or obsessional symptoms. She had poor insight towards her illness. Ophthalmological examination revealed significant reduction in bilateral visual acuity. Otherwise, physical examination was unremarkable. She received inpatient treatment with Rivastigmine patch 4.6 mg/24 hours and Zydis 10 mg noctre. Her cognitive impairment and psychotic symptoms gradually improved over a period of 2 weeks upon commencing treatment and on subsequent follow-ups at outpatient clinic. She had also gained some insight into her illness. Charles Bonnet syndrome could be a possible precipitating factor and precursor to the development of major neurocognitive disorder due to Alzheimer’s disease in the elderly with visual impairment which is often overlooked or misdiagnosed and hence under reported.
Study site: Psychiatric clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
This case report stresses the role of depression in the manifestation of a homicide-attempted suicide. We report the case of a man who allegedly murdered his partner and then attempted suicide. Previously, he had several failures and rejections in relationships in addition to work-related stress. He was diagnosed with major depressive disorder and treated with antidepressant. The scarcity of homicide-attempted suicide as exemplified in this case could give an insight to the Psychiatrist for better understading and possible prevention.
Low Grade Papillary Nasopharyngeal Adenocarcinoma (LGPAC) is a very rare tumour of mucosal origin compared to a higher incidence of well differentiated keratinized/non-keratinized nasopharyngeal carcinoma. It is an epithelial tumour with glandular differentiation. Its papillary figure seen histologically, is also seen in metastatic papillary thyroid carcinoma. This has caused a significant challenge to the Pathologist to differentiate primary papillary nasopharyngeal adenocarcinoma and metastatic tumour. Thyroid Transcription Factor-1 (TTF-1) is also expressed in subsets of papillary nasopharyngeal adenocarcinoma, which is valuable as a diagnostic tool. LGPAC is a benign-like malignant neoplasm. An early diagnosis with a complete tumour removal via conventional excision or endoscopic approach has offered a good prognosis with low risk of recurrence.
MeSH terms: Adenocarcinoma; Carcinoma; Nasopharyngeal Neoplasms; Neoplasm Recurrence, Local; Nuclear Proteins; Prognosis; Thyroid Neoplasms; Transcription Factors; Incidence; Early Detection of Cancer
Fetomaternal haemorrhage (FMH) may occur following a sensitizing event, during pregnancy or at delivery. In cases of rhesus (Rh) incompatibility between mother and the fetus, it can thus subject to the haemolytic disease of the newborn. The Kleihauer test for quantification of FMH lacks standardization and results are less accurate. Furthermore, it cannot differentiate the foetal cell from the adult HbF. Flowcytometry analysis using monoclonal antibodies, is a new technique for the quantification of FMH and it allows larger number of cells to be analysed. It is also able to differentiate the foetal cell from maternal HbF, and thus is more sensitive and accurate. The objective of our study was to determine the FMH using the flowcytometric analysis of anti-HbF antibody and to correlate the FMH using flow cytometry and the standard Kleihauer test. Ninety eight peripheral blood samples from pregnant women at more than 20 weeks of pregnancy and post delivery were analyzed by both methods. The percentage of the foetal cells were recorded and the FMH were calculated. We found a fair correlation between the two methods with the correlation coefficient r = 0.633 (p
The popularity of ultrasound for acute diagnosis of fractures in the Emergency Department (ED) has increased over the recent years. This present study aimed to determine the sensitivity and specificity of ultrasound use for detection of fractures in a different environment, which is at the triage area of the ED. We compared the results of bedside ultrasound in detecting non-critical fractures to the current gold standard of X-rays in the triage area. The design was a single centered crosssectional study. From August 2014 till November 2014, a total of 46 patients were recruited, creating 75 image pairs. Following consent, a bedside ultrasound was performed and subsequently compared with X-ray reporting regarding the presence or absence of fractures. SPSS analysis was used to determine the sensitivity and specificity of ultrasound in diagnosing fracture as compared to X-rays. Ultrasound had a sensitivity of 72% (95% CI, 50.6% - 87.9%) and a specificity of 80% (95%CI: 66.3 - 90%) when compared to X-rays in fracture diagnosis. The kappa analyses showed moderate inter observer agreement (0.5) between ultrasound and X-rays in diagnosing fractures. This study suggests that the use of ultrasound as a triage tool yet has unacceptable sensitivity and needs further evaluation and consideration.
MeSH terms: Cross-Sectional Studies; Emergency Service, Hospital; Humans; Sensitivity and Specificity; Triage; X-Rays; Observer Variation; High-Energy Shock Waves; Fractures, Bone
Stroke is frequently associated with long-term disability. Stroke leads to high risk of physical and neuropsychological consequences. Residual disabilities among post-stroke survivors can lead them to depression. This study aimed to determine the relationship between clinical characteristics and the levels of depression among post-stroke survivors at a teaching hospital in Kuala Lumpur. This cross-sectional study recruited 195 post-stroke survivors who attended follow-up Rehabilitation Clinic of a teaching hospital over a study period of 4 months. Information collected included socio-demographic, clinical characteristics (post stroke duration, stroke types and stroke severities) and level of depression. Beck’s Depression Inventory (BDI) was used to assess the level of depression. The mean age of participants was 61 years (SD=13.86, range: 22-87 years), with 118 male and 81 female survivors having a median duration of post-stroke of 12 months (range: 1-79 months). This study showed post stroke survivors 116 (59.5%) with depression. A Chi-square test for level of stroke severity was significantly associated with depression, χ2 (2,n=195) = 28.724, p
Crab meat is a valuable source of proteins and functional lipids and it is widely consumed worldwide. However, the prevalence of crab allergy has increased over the past few years. In order to understand crab allergy better, it is necessary to identify crab allergens. The aim of the present study was to compare the IgE-binding proteins of raw and cooked extracts of mud crab (Scylla serrata). Raw and cooked extracts of the mud crab were prepared. Protein profiles and IgE reactivity patterns were identified by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) followed by immunoblotting using sera from 21 skin prick test (SPT) positive patients. In SDS-PAGE, 20 protein bands (12 to 250 kDa) were observed in the raw extract while the cooked extract demonstrated fewer bands. Protein bands between 40 to 250 kDa were sensitive to heat denaturation and no longer observed in the cooked extract. In immunoblotting experiments, raw and cooked extracts demonstrated 11 and 4 IgE-binding proteins, respectively, with molecular weights of between 23 and 250 kDa. A heat-resistant 36 kDa protein, corresponding to crab tropomyosin was identified as the major allergen of both extracts. In addition, a 41 kDa heat-sensitive protein believed to be arginine kinase was shown to be a major allergen of the raw extract. Other minor allergens were also observed at various molecular weights.
Cardiac concussion is a sudden, direct blunt trauma cause to the chest which led to death. However, there are patients who did not completely fulfil this definition. We report two cases which did not fit into the definition domain. Two male patients presented to Emergency Department with moderate anterior chest pain after motor vehicle crash showed transient anterior ST segment elevation at chest lead V2 and V3 with raised creatine kinase and normal troponin T. The electrocardiogram changes fully resolved after 24 hours. Both patients were discharged uneventfully after 24 hours monitoring in Emergency Department short-stay ward. Conventional definition of cardiac concussion (commotion cordis) and cardiac contusion may be unsuitable to describe these cases. Therefore, we propose the diagnosis of focal
cardiac concussion. We also highlighted the ability of Emergency Department to manage these patients in short-stay ward.
Keywords: commotio cordis, chest pain, nonpenetrating, electrocardiography
Pain is an unpleasant sensation that can cause physical and psychological problems for the patient. Despite the pharmacological intervention for reducing pain, it remains as an issue after surgery. Music therapy as non-pharmacological intervention can effect post-operative pain and patients’ requirement of analgesics. The purpose of this study was to determine effect of music therapy on pain after elective total knee replacement (TKR) surgery. This study compared analgesics consumption by patients post-operatively for five days. A Quasi-experimental design with convenience sample of patient with a mean of 64.35 (49-76) who underwent TKR in UKM Medical Centre from May to December 2012 was used. Forty patients were randomly assigned in one of the two groups using a sealed-envelope technique. The experimental group listened to music for five days post-operatively and were on analgesics and control group were treated with pharmacological intervention only. Pain was measured by McGill Pain Questionnaire-Short Form (MPQ-SF) for patient on bed rest on day one, day three and day five post-operatively. Statistical (Mann- Whitney) findings between groups showed the experimental group significantly had less pain on day one and day five rather than the control group at 0.05 level using Pain Rating Intensity (PRI), Visual Analogue Scale (VAS) and Present Pain Intensity (PPI). Statistical (Friedman) tests within group showed that the patient had significantly decreased pain over time at level 0.05 using PRI, VAS and PPI. Statistical (Mann- Whitney) tests revealed that there was no significant difference when using analgesics between the two groups in five days post-operatively at milligram but comparing median showed experimental group used less analgesic than control group. Music therapy is simple, available, save and cheap effective intervention for pain management post-operatively. Pain management is one of the key roles of nursing and nurses can use music therapy as a simple intervention to reduce pain.
Patient’s belief towards pain management may affect pain management outcomes and quality of life. The main aim of the present study was to determine the impact of a pre-operative pain education package towards pain belief among patients undergoing orthopaedic surgery in a tertiary hospital. A one-group pre-test post-test design study was conducted on orthopaedic surgery patients. Thirty respondents were recruited and pre-operative pain education was administered individually before surgery. Pre-operative and post-operative pain belief, management scores and side effects were measured using the Barrier Questionnaire (BQ-13). The results reported significant differences between pre-test scores (Mean = 41.87, Standard Deviation = 11.467) and post-test scores (Mean=34.80, Standard Deviation=13.026) of pain belief (t = 2.84, p = 0.004). There were also significant differences between pre-test scores (Mean = 37.10, Standard Deviation = 10.610) and post-test scores (Mean=30.80, Standard Deviation = 11.424) of pain management (t = 3.856, p = 0.0005). Respondent’s gender (t = -2.403, p = 0.023) and ethnicity (F = 5.038, p=0.014) reported significant differences with p value < 0.05, respectively. However, there were no significant differences between educational level, ethnicity, prior surgical history with pain belief (p> 0.05). There was positive impact of the pain education package towards pain belief and painmanagement among respondents who underwent orthopaedics surgery in a tertiary hospital. Reinforcement of pain educational program is pivotal in order to achieve optimal post-operative pain management.
Keywords: pain, education, orthopaedics, patient, surgery
Kebelakangan ini, tanda-tanda kemurungan dalam kalangan remaja semakin meningkat. Kajian ini dijalankan untuk menentukan prevalens kemurungan dan faktor-faktor ramalan. Satu kajian keratan rentas telah dijalankan 191 remaja yang terpilih secara rawak dan terdiri daripada pelajar tingkatan empat dari lima buah sekolah menengah di negeri Selangor, Malaysia. Satu soal selidik yang terdiri daripada enam bahagian (A) demografi, (B) tahap kemurungan, (C) hubungan keluarga, (D) tahap sokongan rakan sebaya, (E) harga diri, dan (F) pencapaian akademik telah diedarkan. Prevalen kemurungan adalah 50.3%. Analisis regresi logistik mendapati, remaja yang mempunyai masalah dengan rakan-rakan adalah lebih cenderung untuk mengalami kemurungan berbanding dengan mereka yang tidak mempunyai masalah dengan rakan-rakan mereka (aOR 2.84, 95% CI 1.50, 5.36). Kajian selanjutnya perlu meneliti faktor-faktor lain seperti tekanan daripada guru-guru untuk mengukuhkan pemahaman kita mengenai kemurungan di kalangan remaja. Diharapkan hasil kajian ini berguna kepada pelbagai pihak yang mengambil berat tentang masalah ini.
MeSH terms: Glycosaminoglycans; Malaysia; HIV Integrase; Drug Resistance, Viral
Globally, stroke is the commonest cause of long-term disability. The residual disabilities among post stroke patients affect their daily living activities. The aim of rehabilitation therapy is to help stroke survivors to gain back their functional ability. The present study aimed to determine the relationship between post stroke duration with functionality status of post-stroke survivals at a teaching hospital in Kuala Lumpur. A cross-sectional study involved one hundred nine five post stroke patients who attended the Rehabilitation Clinic over a 4-month period. The data on post stroke duration was reveale from patient’s cleckship. Their functional status was assessed with Modified Barthel Index (MBI). Results showed the mean age of participants was 61 years (SD=13.86, range:22-87 years), with 118 males and 81 females having a median duration of 12 months post-stroke (range: 1-79 months). The prevalence 123 (63.1%) of stroke survivors are found to be dependent in their daily living activity. A Chi-square test for independence indicated there was significant relationship between post-stroke duration with levels of functioning, χ2 (2 , n=195) = 6.455, p<0.05,phi = 0.182. Patients in post-stroke duration of 13-24 months were independent (52.1) than ≤ 12 months and ≥ 24 months.
Keywords: functional status, post-stroke disability, mbi, activities of daily living, rehabilition therapy
Study site: rehabilitation clinic , Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Radiation retinopathy (RR) is a known complication after radiotherapy for Nasopharyngeal Carcinoma (NPC). This study aims to relate the relationship of RR and radiation dose in patients with NPC through assessment with clinical
funduscopy and fundus fluorescein angiogram (FFA). A cross sectional study was conducted on patients with NPC who had completed radiotherapy treatment in the Oncology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Eighty two eyes of 42 patients were examined and the prevalence of RR was found to be 35.4%. The severity of RR is strongly associated with the dose of radiation to the retina (Spearman correlation value=0.48; p<0.001). The common features of RR assessed by FFA were telangiectatic vessels (26.2%) and capillary non-perfusion (14.3%). Retinal neovasularization occurred in 10.7% of eyes. The level of visual deterioration correlated with the severity of RR with 26% of eyes experiencing a visual acuity of 6/18 or worse. More than one third of patients developed RR, with radiation maculopathy being the commonest cause for significant visual loss. FFA is a useful tool in detecting early signs of radiation retinopathy and maculopathy.
Keywords: nasopharyngeal carcinoma, fluorescein fundus angiography, retinopathy, radiotherapy
Study site: Oncology Clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Objektif kajian ialah untuk menentukan kesan program latihan papan Wobble ke atas daya keseimbangan para atlet yang mengalami ketakstabilan fungsi pergelangan kaki (FAI). Sebanyak 30 subjek (n=30) yang mengalami FAI direkrut berdasarkan kriteria rangkuman dan eksklusi. Kesemua subjek dinilai daya keseimbangan menggunakan ujian dirian anggota tunggal (single limb stance) dan ujian jangkauan fungsi dan didedahkan kepada program latihan papan Wobble sebanyak lima sesi seminggu selama empat minggu. Ujian t berpasangan digunakan untuk membandingkan min data pra dan post-ujian dan aras signifikan ditetapkan pada nilai 0.05. Pada ujian dirian anggota tunggal, para atlet mendapat min skor postlatihan yang tinggi [26.4] berbanding pra-latihan. Perbezaan disahkan dengan nilai ‘t’ yang diperolehi [16.00]. Bagi ujian jangkauan fungsi, para atlet memperolehi min skor post-latihan yang tinggi [15.88] berbanding pra-latihan [1.26]. Perbezaan disahkan dengan nilai ‘t’ yang diperolehi [12.54]. Ini menunjukkan bahawa latihan papan Wobble meningkatkan keseimbangan dinamik dan statik para atlet yang mengalami FAI. Secara kesimpulannya, latihan papan Wobble mungkin efektif dalam meningkatkan keseimbangan para atlet yang mengalami FAI.
Estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) immunohistochemistry are important markers in the management of patient with breast carcinoma. In this study, we determine the concordance rate of ER, PR and HER2 immunohistochemistry markers between core needle biopsy (CNB) and excisional biopsy (EB) of breast carcinoma in patients of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from January 2002 until December 2012. A total of 93 female patients with CNB and subsequent EB were included in this retrospective descriptive study. Immunohistochemistry is used to determine ER, PR and HER2. ER and PR was graded using Allred score (0 to 8) while HER2 was scored from 0 to 3+. The markers between these two biopsies were compared to determine the concordance rate. In ER and PR, 93 samples were compared. ER was concordant in 80 cases (86.0%) and 13 cases (14.0%) was discordant. PR was concordant in 82 cases (88.2%) and discordant in 11 cases (11.8%). In HER2, 87 samples were compared and 62 cases (71.3%) were concordant while 25 cases (28.7%) were discordant. Concordance between CNB and EB was high for ER and PR. However, concordance rate for HER2 immunohistochemistry was less consistent. Overall, immunohistochemical analyses of CNB reflect the tumour marker status of the excised specimen.
Keywords: breast carcinoma, core needle biopsy, estrogen receptor, progesterone receptor, HER2
Acne can affect personal appearance and impair quality of life. A cross sectional study, over a period of 12 months was conducted among medical students at Universiti Kebangsaan Malaysia to evaluate the disability, self management and help-seeking behaviour of medical students for acne. A total of 361 students were selected using stratified cluster random sampling. Acne was graded using the Comprehensive Acne Severity Score (CASS) while acne disability was assessed using the Cardiff Acne Disability Index (CADI). Acne self management and helpseeking behaviour was assessed using the acne management questionnaire. Mean CADI score was 3.35 + 2.39, with mostly mild (83.8%, n=206) and moderate (14.6%, n=36) levels of impairment. Female students and those from the nonMalay ethnic group demonstrated higher disability (3.76 + 2.24, p=0.006 and 3.79 + 2.59, p=0.018, respectively). Although the majority of students (87.4%, n=215) knew that acne can be treated, they preferred to discuss their acne problems with friends (54.1%, n=133) rather than consulting a physician (9.3%, n=23). Most of them also practiced non-evidence based measures for their acne. The results of the present study shows that young adults tend to have mild grades of acne severity and disability. However, efforts are needed to enhance their knowledge on evidence based management of acne and modify their help seeking behavior. This would help reduce complications such as permanent scars and improve quality of life, as acne is a treatable dermatological disorder.
Keywords: acne vulgaris, medical, disability, quality of life, students, severity, self care
Insertion/deletion (I/D) polymorphisms found in the angiotensin converting enzyme (ACE) gene have been associated with hypertension, diabetes and renal disease. The present study sought to determine the association of I/D polymorphisms of the ACE gene with end-stage renal disease (ESRD) patients in Malaysia.