Phlebectasia is the abnormal saccular fusiform dilatation (without tortuosity) of a vein, which may affect any vein. Its etiology remains unknown and it is seen usually in the pediatric age group as a unilateral lower neck swelling, mostly on the right side. The other differential diagnoses of the neck swellings which increase in size during a Valsalva manoeuver are tumors or cysts of the upper mediastinum, external laryngeal diverticulum or laryngoceles. Our case report has highlighted the importance of understanding the nature of this lesion by using non-invasive radiological diagnostic modalities (USG), in order to avoid invasive investigations which can lead to catastrophic results. Case report. We describe a case of five year old boy with history of inguinal hernia repair a year ago presented with intermittent right sided neck swelling since he was two years old. His examination at rest was normal. However, with the Valsalva manoeuver a soft, painless, compressible swelling which appeared in the right lower neck was seen, which was not attached to the deep structures. Flexible nasopharyngolaryngoscope revealed normal laryngeal finding. Initial ultrasound finding revealed normal looking cervical lymph nodes bilaterally with no suspicious cystic lesion or collection. Patient then arranged for MRI neck where there are multiple bilateral subcentimeter cervical lymph nodes. However, repeated ultrasound neck while performing Valsalva manoeuver by patient showed sonographic features in keeping with bilateral internal jugular veins phlebectasia. Patient then was referred to pediatric surgeon for further management. A clinical diagnosis can be achieved by having a strong suspicion about this intermittent neck mass. It should be evaluated with non-invasive radiological modalities to avoid the possible catastrophic results which result from invasive techniques.
Ensuring quality in healthcare calls for a coordinated, systematic, congruous, and sustained approach. Nevertheless, it demands defining what the quality of healthcare means in the local context. Presently, the Malaysian healthcare system utilizes various definitions of quality of healthcare across the different initiatives and levels of healthcare, which can lead to fragmented or ineffective quality improvement. The study aims to describe the process undertaken in developing an explicit definition of the quality of healthcare tailored to the Malaysian context, which is currently lacking. A pluralistic method was used to explore the different perspectives. Three distinct approaches were used to understand how quality is defined among the different stakeholder groups: (i) interactive policy-makers engagement sessions, (ii) a review of local quality-related documents, and (iii) an online survey engaging the public. The domains depicting quality of healthcare that emerged through these three approaches were mapped against a framework and synthesized to form the local definition of quality. A national quality-related technical working group convened on several sessions to achieve consensus and finalize the definition of quality of healthcare. Quality healthcare in Malaysia is defined as providing high-quality healthcare that is safe, timely, effective, equitable, efficient, people-centred, and accessible [STEEEPA] which is innovative and responsive to the needs of the people, and is delivered as a team, in a caring and professional manner in order to improve health outcomes and client experience. The consensus-driven local definition of healthcare quality will guide policies and ensure standardization in measuring quality, thereby steering efforts to improve the quality of healthcare services delivered in Malaysia.