CASE PRESENTATION: A 35 years old man presented with a 5 month history of debilitating painful lower limb and scrotal ulcers. This was associated with polyarthralgia and morning stiffness involving both hands. He also complained of swallowing difficulties. He had unintentional weight loss of 10 kg and fatigue. Physical examination revealed alopecia, multiple cervical lymphadenopathies, bilateral parotid gland enlargement and atrophic glossitis. There was Raynaud's phenomenon noted over both hands and generalised hyper-pigmented fragile skin. Laboratory results disclosed anaemia, leukopenia, hyponatraemia and hypocortisolism. Detailed anaemic workup revealed low serum ferritin and cobalamin level. The autoimmune screen showed positive ANA, anti SmD1, anti SS-A/Ro 52, anti SSA/Ro 60, anti U1-snRNP with low complement levels. Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis and duodenitis. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were all negative. Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum. Based on the clinical findings and positive immunologic studies, he was diagnosed as systemic lupus erythematosus. His general condition improved substantially with commencement of corticosteroids, immunosuppressants and vitamin supplements.
CONCLUSIONS: We report a case of PG as the first manifestation of SLE which was treated successfully with immunosuppressants and vitamin supplements. Our report highlighted the need to consider connective tissue diseases such as SLE in a patient presenting with PG in order for appropriate treatment to be instituted thereby achieving a good outcome.
METHODS: This qualitative exploratory study focused on the health education component derived from a complex enhanced primary health care intervention. Participants were purposively selected from patients who attended regular NCD treatment at 8 primary healthcare facilities in rural and urban areas of Johor and Selangor. Data collection was conducted between April 2017 and April 2018. Individual semi-structured interviews were conducted on 4 to 5 patients at each intervention clinic. Interviews were transcribed verbatim, coded and analyzed using a thematic analysis approach.
RESULTS: A total of 35 patients participated. Through thematic analysis, 2 main themes emerged; Perceived Suitability and Preferred HCPs. Under Perceived Suitability theme, increased waiting time and unsuitable location emerged as sub-themes. Under Preferred HCPs, emerging sub-themes were professional credibility, continuity of care, message fatigue, and interpersonal relationship. There are both positive and adverse acceptances toward health education delivered by HCPs. It should be noted that acceptance level for health information received from doctors are much more positively accepted compared to other HCPs.
CONCLUSION: Patients are willing to engage with health educators when their needs are addressed. Revision of current location, process and policy of health education delivery is needed to capture patients' attention and increase awareness of healthy living with NCDs. HCPs should continuously enhance knowledge and skills, which are essential to improve development and progressively becoming the expert educator in their respective specialized field.
MATERIALS AND METHODS: A descriptive study involved 58 Malays and 15 Chinese women newly diagnosed with breast cancer prior to treatment. Quality of life was measured using the Malay version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast-specific module (QLQ-BR23). Socio-demographic and clinical data were also collected. All the data were analyzed using SPSS version 20.0.
RESULTS: Most of the women were married with at least a secondary education and were in late stages of breast cancer. The Malay women had lower incomes (p=0.046) and more children (p=0.001) when compared to the Chinese women. Generally, both the Malay and Chinese women had good functioning quality-of-life scores [mean score range: 60.3-84.8 (Malays); 65.0-91.1 (Chinese)] and global quality of life [mean score 60.3, SD 22.2 (Malays); mean score 65.0, SD 26.6 (Chinese)]. The Malay women experienced more symptoms such as nausea and vomiting (p=0.002), dyspnoea (p=0.004), constipation (p<0.001) and breast-specific symptoms (p=0.041) when compared to the Chinese.
CONCLUSIONS: Quality of life was satisfactory in both Malays and Chinese women newly diagnosed with breast cancer in Kelantan. However, Malay women had a lower quality of life due to high general as well as breast-specific symptoms. This study finding underlined the importance of measuring quality of life in the newly diagnosed breast cancer patient, as it will provide a broader picture on how a cancer diagnosis impacts multi-ethnic patients. Once health care professionals understand this, they might then be able to determine how to best support and improve the quality of life of these women during the difficult times of their disease and on-going cancer treatments.
PATIENT CONCERNS: A 61-year-old Asian female with underlying type 2 DM presented to our ED with body weakness, dyspnea, nausea, vomiting, and mild abdominal pain for the past 2 days. These symptoms were preceded by poor oral intake for 1 week due to severe toothache. Dapagliflozin was recently added to her antidiabetic drug regimen of metformin and glibenclamide 2 weeks ago.
DIAGNOSES: Arterial blood gases showed a picture of severe metabolic acidosis with an elevated anion gap, while ketones were elevated in blood and positive in urine. Blood glucose was mildly elevated at 180 mg/dL. Serum lactate levels were normal. Our patient was thus diagnosed with eDKA.
INTERVENTION: Our patient was promptly admitted to the intensive care unit and treated for eDKA through intravenous rehydration therapy with insulin infusion.
OUTCOMES: Serial blood gas analyses showed gradual resolution of the patient's ketoacidosis with normalized anion gap and clearance of serum ketones. She was discharged uneventfully on day 4, with permanent cessation of dapagliflozin administration.
LESSONS: Life-threatening eDKA as a complication of dapagliflozin is a challenging and easilymissed diagnosis in the ED. Such an ED presentation is very rare, nevertheless emergency physicians are reminded to consider the diagnosis of eDKA in a patient whose drug regimen includes any SGLT2 inhibitor, especially if the patient presents with nausea, vomiting, abdominal pain, dyspnea, lethargy, and is clinically dehydrated. These patients should then be investigated with ketone studies and blood gas analyses regardless of blood glucose levels for prompt diagnosis and treatment.