Sickle cell disease (SCD) in pregnancy is uncommon in Malaysia. We present a case of sickle cell disease in pregnancy with maternal and fetal complications. The patient presented with acute pain crisis and hemolysis in the third trimester. Despite thromboprophylaxis, she developed deep vein thrombosis. The pregnancy was further complicated by severe pre-eclampsia and intrauterine growth restriction which require preterm caesarean section. The baby was admitted to Neonatal Intensive Care Unit due to prematurity and low birth weight. Multidisciplinary
approach in managing pregnant patient with SCD is essential in achieving good obstetrics outcome.
Keywords: anemia, sickle cell disease, pregnancy outcomes
The incidence of envenoming from king cobra, Ophiophagus hannah in human is relatively rare. Its venom acts on the postsynaptic region of the neuromuscular junction causing descending flaccid paralysis. Locked-in syndrome is a clinical state of inability to provide motor response in a conscious patient. Many reported cases of locked-in syndrome following neurotoxic snake-bite mimics brain death. We report a case of a middle aged man who presented with progressive neurological deficit following a king cobra bite over his right arm. He had local and systemic neurotoxic envenoming. His condition deteriorated, and was intubated and ventilated in the emergency department. He received a total of 33 vials of the Ophiophagus hannah monospecific antivenom and subsequently recovered well with no neurological deficit. Retrospectively, he was able to recall the events and while he was lying paralysed and intubated under minimal sedation in the intensive care unit. He described it as a terrifying and painful experience. This case highlights the rare presentation of locked-in syndrome following a systemic envenoming from a king cobra bite. It is important to differentiate neurotoxic snake envenoming lock-in syndrome from brain dead. Patients are unable to respond to physical pain and require adequate analgesia. A patient suffering this highly distressing experience may require psychological support.
Keywords: emergency, envenoming, neurotoxicity, snakebite
The Morel-Lavallee lesion is a rare soft tissue injury that occurs due to traumatic shearing force on skin surface causing separation of skin and subcutaneous tissue resulting in hematoma. This case report depicts a 22-year-old gentleman who was involved in a motor vehicle accident. He complained of pain and swelling over lower back. He was treated for soft tissue injury and admitted for pain control. One day post-trauma, he complained of increased swelling over the back. His hemoglobin dropped from 12.2g/dL to 10.7g/dL. Diagnosis of Morel-Lavallae lesion was made. Initially no surgical intervention was planned. However, in view of worsening of swelling, bedside aspiration was performed and subsequently a pigtail catheter was inserted to drain the hematoma. In total, 2.05 litre of liquefied hematoma was drained. Thus, Morel-Lavallee lesion is an uncommon soft tissue injury that can cause significant bleeding following trauma.
Keywords: degloving injuries, hematoma, trauma
Bisep brachii (BB) adalah salah satu otot yang mempunyai pelbagai variasi.
Terkini, kebanyakan maklumat adalah berkenaan variasi asal otot, namun terdapat
beberapa kes yang melaporkan variasi dalam sisipan BB. Dibentangkan di sini
kes BB otot yang mempunyai kedua-dua varian asal dan sisipan dalam otot yang
sama. Varian asal BB adalah panjang dan besar di kepala ketiga (10.2 cm lebar
dan 4.9 cm tebal) yang timbul dari pertengahan badan humerus. Lebih signifikan
lagi, bahagian tengah kepala meliputi dan menyembunyikan bahagian bawah
saraf median dan arteri brachial sebagai gerbang yang berterusan medially untuk
disisipkan ke epicondyle medial humerus. Dalam laporan ini, kami membincangkan
mekanisma yang mungkin untuk pemampatan neurovaskular oleh kepala ketiga
otot BB yang tidak normal dan perubahan BB dari asal dan sisipan. Memahami
perubahan ini adalah sangat penting dalam prosedur pembedahan di sekeliling
sendi siku dan lengan atas dan ia juga memberi ruang untuk diagnosis pembezaan
sindrom perangkap saraf
Kateter Vena Cenral boleh tercabut dengan senang daripada tubuh badan.
Artikel ini membincang tiga teknik terperinci yang berinovasi untuk mengelakkan
berlakunya insiden kateter tercabut. Penempatan leher kateter kira-kira 1cm dari
tempat kateter keluar pada bahagian kulit dengan jahitan tambahan di bahagian
leher kateter membantu mencegah insiden kateter tercabut.
Miscarriage is one of the most common complications in pregnancy. There is emerging evidence that psychological impact following miscarriage is not unusual. Understanding the magnitude of psychological morbidity is important in the management of miscarriage. The main objective of this study was to compare the mean Hospital Anxiety and Depression Scale (HADS) score between women with miscarriage and women with successful pregnancy and to determine the sociodemographic factor and clinical characteristic that are associated with anxiety and depression. A descriptive case control study was conducted in a teaching hospital, over a period of 12-months (from October 2014 till September 2015). A total of 65 women were recruited with 32 women as the study group (miscarriage) and another 33 women as the control group (women with successful pregnancy). Mean HADS-anxiety score was higher in the study group compared to control group although it was not statistically significant (6.53 ± 3.427 vs 5.73 ± 2.875, p=0.309). Mean HADS-depression score was higher in the control group (4.34 ± 2.695 vs 4.45 ± 3.073, p=0.878). Women with maternal age more than 35 years and history of previous miscarriage had a higher tendency of anxiety and depression with higher mean HADS score. There was no association between other sociodemographic data and clinical characteristic with risk of anxiety and depression. As conclusion, there was no significant difference in women with miscarriage as compared to those with successful pregnancies, although older women with history of miscarriage had a preponderance to both disorders.
Keywords: anxiety, depression, miscarriage, morbidity, psychological
Hyperbaric oxygen therapy (HBOT) was established to increase oxygenation and antimicrobial effect that potentially improve the healing of chronic ulcer. Present study aim to assess the effects of HBOT in chronic diabetic foot ulcer (DFU). A total of sixty patients classified according to Wagner 1, 2 or 3 chronic diabetic foot ulcers, were recruited and subsequently divided randomly into two groups; HBOT and control group. All patients underwent the standard treatment for DFU, but for the HBOT group, underwent 20 HBOT sessions, each lasted 80 – 90 mins at 2.5 atmospheres absolute (ATA). White cell count (WCC) and C-reactive protein (CRP) levels were taken during inclusion, at second and fourth week of treatment. Wound sizes were documented at each follow up until six months follow up. SF-36 at one-month post hyperbaric oxygen therapy was used to measure the health-related quality of life. Reduction of WCC and CRP in HBOT group were significant throughout the treatment (p=0.046 and p=0.039, respectively). A total of 26 patients (86.7%) from the HBOT group achieved complete ulcer healing at six months’ follow-up, while 18 patients (60%) in the control group’s ulcer healed completely. Patients treated with HBOT had significantly better mental and physical health constituent of quality of life. It must be emphasised that HBOT is an adjunctive therapy to the standard management of chronic DFU in accelerating wound healing for a better quality of life.
Keywords: oxygenation, quality of life, wound healing
Selulitis orbital merupakan jangkitan tisu di sekitar mata di dalam ruangan orbit yang
termasuk saraf mata. Ia boleh menyebabkan komplikasi yang membawa kematian
sekiranya merebak melalui saraf mata dan ke otak. Penyebab utama jangkitan
adalah termasuk perebakan jangkitan sinusitis dari ruangan paranasal atau melalui
selulitis preseptal. Kes ini menggambarkan jangkitan di luar kebiasaan mengenai
jangkitan orbital selulitis yang berlaku akibat luka torehan pada konjunktiva mata
yang disebabkan oleh kemalangan. Rawatan antibiotik sistemik yang agresif
mengurangkan risiko komplikasi penglihatan. Kesemua luka pada atau sekelililng
mata haruslah dirawat dengan sebaiknya bagi mengelakkan berlakunya komplikasi
yang membahayakan.
Amplikasi isoterma berpengantara gelung (LAMP) merupakan teknik amplifikasi gen
yang menghasilkan produk akhir iaitu mendapan keruh magnesium pirofosfat yang
boleh dianalisis dengan hanya menggunakan mata kasar. Penggunaan pewarna
interkalat yang sesuai adalah penting kerana ia boleh meningkatkan sensitiviti dan
mengurangkan keputusan positif palsu dan negatif palsu untuk pengesanan. Kajian
ini bertujuan untuk membandingkan prestasi tiga pewarna interkalat yang berbeza;
SYBR Green I, SYBR Safe dan pewarna berasaskan calcein di dalam asai LAMP
HPV-16 melalui visualisasi oleh mata kasar, elektroforesis gel dan mesin masanyata
turbidimeter. Reaksi LAMP dilakukan menggunakan amplifikasi kit Loopamp
DNA berisipadu sebanyak 25 μl. Campuran reaksi dieram pada suhu 60�C selama
60 minit dan ditamatkan menggunakan suhu 80�C selama 5 minit dalam mesin
masa-nyata turbidimeter. Untuk pengesanan menggunakan mata kasar, SYBR
Green I dan SYBR Safe telah dicairkan dalam 1:10 DMSO dan telah ditambah ke
dalam tiub yang mengandungi campuran reaksi selepas proses amplifikasi berlaku
manakala calcein ditambah sebelum proses amplifikasi. Sensitiviti asai telah disiasat
menggunakan pencairan DNA HPV-16 yang berkepekatan bermula dari 101
salinan/
μl to 108
salinan/μl. Ketiga-tiga pewarna mempamerkan keputusan yang sama
dari segi sensitiviti dengan had pengesanan adalah 103
salinan/μl. Penambahan
calcein di dalam asai menunjukkan masa pengesanan bertambah selama 10 minit
dengan menggunakan mesin nyata-masa turbidimeter. Prestasi ketiga-tiga pewarna
interkalat untuk pengesanan mata kasar adalah setanding dan boleh digunakan
untuk aplikasi pemeriksaan titik akhir dalam asai HPV-16, manakala dengan mesin nyata-masa turb
Model tiga dimensi (3D) menyerupai ciri-ciri persekitaran tisu asli, justeru
morfologi dan isyarat-isyarat sel daripada kultur 3D selalunya lebih menyerupai
fisiologi asal berbanding sel kultur dua dimensi (2D). Diketahui juga, rembesan
sel mempunyai kesan parakrin kepada pertumbuhan sel-sel lain. Dalam kajian
ini, pengkulturan fibroblast hidung menggunakan system kultur sel 3D telah
dioptimumkan dan kesan bahan rembesan (BR) daripada kultur 3D terhadap kadar
pertumbuhan dan perlindungan sel telah dikaji. Fibroblas hidung dipencilkan
daripada turbinate hidung manusia. Mikrosfera yang sesuai telah dipilih melalui
pengkulturan fibroblast pemindahan ke-3 pada pelbagai jenis mikro sferapolisterin
PolyGEM™. Kemudian, sel-sel telah dikulturkan pada mikrosfera yang terpilih
menggunakan system kultur 3D dan media terkondisi (MT) telah dikumpulkan.
Media terkondisi tiga dimensi (MT3D) telah ditambah kepada fibroblast untuk
mengkaji kadar perlekatan sel, kadar proliferasi, dan perlindungan sel terhadap
kesitotoksikan Centella asiatica. Asai protein asid bicinchonic dijalankan untuk
mengetahui kuantiti protein di dalam BR. Elektroforesis gel poliakrilamida-Sodium
Dodesil Sulfat (SDS-PAGE) telah dilakukan untuk memperoleh profil awal protein
dan membandingkan profil MT3D dengan protein media terkondisi dua dimensi
(MT2D). Kajian ini menunujukkan MT3D tidak menggalakkan perlekatan dan
proliferasi sel secara signifikan. BR didapati memberikan perlindungan sel yang
signifikan pada fibroblast hidung terhadap kesitotoksikan Centella asiatica. MT3D
mempunyai kepekatan protein yang lebih tinggi berbanding MT2D. SDS-PAGE
menunjukkan MT3D mempunyai 3 jalur ekslusif manakala MT2D mempunyai 4 jalur eksklusif. Kajian masa depan harus dijalankan keatas penggunaan BR
fibroblast hidung untuk perlindungan sel terhadap agen-agen yang memudaratkan
di alam sekitar dan produk herba yang sitotoksik.
Adult influenza and pneumococcal vaccinations are grossly underutilized although there is clear benefit in reducing mortality and morbidity among those at risk. The aim of the study was to assess primary care physician’s knowledge on adult influenza and pneumococcal vaccinations, their beliefs and barriers to vaccination. A cross-sectional study using self-administered questionnaires was conducted at eight primary care centres in Kuching, Sarawak. A total of 108 primary care physicians participated in this study. Median age of participants was 29 years (IQR 4.0). The median knowledge score for influenza vaccine was 9 (IQR 3) and for pneumococcal vaccine was 8 (IQR 4). Female participants scored higher compared to their male counterparts for influenza and pneumococcal vaccines (P = 0.005 & 0.007). The highest percentage of correct responses for influenza vaccination was for side effects (75.3%) while the lowest was for contraindications (9.3%). The highest percentage of correct responses for pneumococcal vaccination was for side effects (69.1%) while the lowest was for advocated target groups (6.2%). Most participants believed that pneumococcal and influenza vaccines were safe (92.8 & 99%) and beneficial for patients (89.7 & 93.8%). Cost of influenza and pneumococcal vaccines (94.8% & 96.9%) and their availability (86.6% & 89.7%) were the main barriers to prescribing them. Primary care physicians in the public sector have moderate knowledge of both adult vaccinations. Areas of knowledge paucity and barriers need to be addressed to ensure a more comprehensive health care delivery to the aging Malaysian population.
Keywords: adult, belief, influenza vaccines, knowledge, pneumococcal vaccines
Acanthamoeba spp. merupakan ameba hidup bebas yang biasa ditemui
di persekitaran. Ia merupakan agen penyebab keratitis Acanthamoeba (AK)
dan ensefalitis ameba bergranuloma (GAE). Ameba ini juga mampu menjadi
perumah kepada pelbagai bakteria termasuklah yang bersifat patogenik seperti
Mycobacterium, Legionella dan Staphylococcus aureus rintang metisilin (MRSA).
Berdasarkan maklumat ini, satu kajian dijalankan untuk mengesan kehadiran tiga
bakteria endosimbion berkepentingan perubatan di dalam Acanthamoeba spp. yang
telah dipencilkan dari bolong penghawa dingin yang terdapat di wad and dewan
bedah di Pusat Perubatan Universiti Kebangsaan Malaysia. Kehadiran bakteria
endosimbion ini disaring menggunakan pasangan primer khusus bagi setiap genus
menggunakan reaksi rantai polimerase (PCR) konvensional dan disahkan dengan
analisis penjujukan. Dua puluh sembilan (80.56%) pencilan Acanthamoeba spp.
didapati mengandungi bakteria endosimbion patogenik yang disasarkan dengan
sekurang-kurangnya satu genus bakteria bagi setiap pencilan. Mycobacterium
(82.76 %) adalah bakteria yang paling banyak dikesan, diikuti dengan Legionella sp.
(65.52 %) dan Pseudomonas spp. (62.07 %). Tiada bakteria MRSA dikesan daripada
mana-mana pencilan dalam kajian ini. Dua endosimbion Mycobacterium yang
dikenalpasti telah dikelompokkan ke dalam strain Mycobacterium tuberculosis.
Kami membuat kesimpulan bahawa, kebanyakan Acanthamoeba berpotensi untuk
menjadi perumah bagi pelbagai bakteria patogenik, namun implikasi interaksi ini
terhadap patogenisiti kedua-dua organisma masih kurang jelas dan memerlukan
penyelidikan yang lebih lanjut.
Epidermal naevus is a congenital cutaneous hamartoma with a benign course. We highlight a rare case of epidermal naevus with concurrent basal cell carcinoma. A 79-year-old male had a skin biopsy at our centre for an enlarging skin nodule within a linear papular lesion measuring 2 x 4 cm at the left side of his neck, which was later diagnosed as basal cell carcinoma arising from an epidermal naevus. PIK3CA mutation is attributed to basal cell carcinoma which suggests the basal cell carcinoma component is independent of the epidermal naevus component. Clinicians and pathologists must be aware of possible malignant changes that might arise in an epidermal naevus.
Keywords: basal cell carcinoma, BCC, epidermal naevus
Intussusception is a common cause of gastrointestinal emergency in the paediatric population and it is usually diagnosed through Barium enema radiography or ultrasound. The skill of using an ultrasound by a minimally trained medical officer in diagnosing this cases in the Emergency Department are very helpful and expedite the management. We present the case of a 7-month-old girl who presented to Emergency Department (ED) with the chief complaint of passing blood in stool. Clinically she was dehydrated, irritable and in compensated shock. There was generalised tenderness per abdomen but it was soft and not distended. There was no palpable mass and bowel sound normal. Immmediate fluid resuscitated commenced. Bedside abdominal ultrasound performed by ED medical officer showed a 1.8 cm x 2.5 cm mass of alternating hypo-echoic and hyper-echoic rings at the right lower quadrant, consistent with the ‘target’ sign of intussusception. Supine plain abdominal X-ray did not reveal any abnormality. The ultrasound finding of intussusception was later confirmed by the radiologist. She underwent immediate hydrostatic reduction and was discharged well.
Keywords: diagnosis, Emergency Department, intussusception, paediatric, ultrasound
Mild hyperkalaemia does not typically cause cardiac symptoms. However, for an elderly patient on atrio-ventricular (AV) nodal blocker, even mild hyperkalaemia may result in disastrous outcome. We report a case of persistent bradyarrythmia caused by iatrogenic hyperkalaemia in a patient who had concomitant use of AV nodal medication. An 81-year-old lady with multiple comorbidities and a long list of medications presented with symptomatic bradyarrhythmia. She, in fact, had two AV nodal blockers in her prescription, a beta-blocker and amiodarone. Her potassium level was found to be mildly elevated due to acute renal failure. She remained bradycardic despite initial treatment and was subsequently dependant on intravenous isoproterenol until her renal function improved. This case highlights the different threshold for manifestation of hyperkalaemic symptoms in a growing group of patients: elderly patients with multiple comorbidities and polypharmacy.
Keywords: bradyarrythmia, bradycardia, elderly, hyperkalaemia, polypharmacy
Septic arthritis of the hip in children represents a serious disorder with unfavourable long-term sequelae. In neonates, a poor hip outcome is expected especially if the treatment was delayed. Late sequelae can lead to structural joint damage and instability, causing deformity and dislocations which ultimately may result in limb length discrepancy, early degenerative changes and limited range of motion. Surgery at the appropriate time can improve the hip condition and functional outcome. Previous classifications of post septic hip sequelae are useful guides for treatment, but did not discuss one particular group of patient. This group-septic hip dislocation with a preserved femoral head, has recently been described as a distinct entity. This report highlights an 11-year follow-up of a 2-year-old child who had a successful outcome following open reduction and varus derotation
osteotomy for a septic hip dislocation with a preserved femoral head.
Keywords: septic arthritis, hip dislocation, child, infection
Plasmasitoma ekstramedulari adalah komplikasi myeloma berbilang yang sangat
jarang berlaku. Kami melaporkan kes seorang wanita berumur 56 tahun yang
menghidap myeloma berbilang yang telah mengalami bengkak pada mata kiri. Ia
menyebabkan bola mata beliau tersembul, luka pada kornea dan juga kemerosotan
penglihatan. Biopsi tisu menunjukkan perebakan plasma sel neoplastik yang positif
kepada CD138 dan rantai ringan Kappa yang menepati ciri-ciri plasmasitoma.
Setelah melalui rawatan radio-kemoterapi, pembengkakan mata susut dengan
ketara sekali namun kemerosotan penglihatan beliau tidak berubah.
Kejuruteraan tisu merupakan satu bidang perubatan baru yang membolehkan tisu
manusia dibentuk secara in vitro sebelum pemindahan tisu dilakukan. Sel stem
mesenkima daripada sum sum tulang (BMSCs) adalah sumber sel yang sesuai
dalam kejuruteraan tisu tulang rawan, ekoran kebolehannya untuk membentuk
rawan hialin. Kajian ini telah dijalankan untuk mengkaji potensi BMSCs untuk
membentuk sel rawan secara in vitro dan in vivo. BMSCs dipencilkan daripada
kambing dan dibahagikan kepada dua kumpulan; iaitu kumpulan kajian dan
kumpulan kawalan. Sel di dalam kumpulan kawalan disemai di dalam medium
yang mengandungi 10% serum anak lembu (FBS). Manakala, sel di dalam kumpulan
kajian telah dikultur di dalam medium yang diperkaya dengan 1% FBS, 1% ITS, 5
ng/mL TGF-ß3, 50 ng/mL IGF-1, 40 ng/mL L-proline, 100 nM dexamethasone dan
50 μg / fosfat. Analisis pembentukan sel rawan telah dijalankan secara in vivo pada
model mencit gondol atimus. Sel didapati beragregasi di dalam kumpulan kajian
dan menunjukkan permulaannya kondrogenesis telah berlaku dalam pengkulturan
sel. Kerangka fibrin yang telah disemai bersama sel yang telah atau tidak diaruh
disediakan dan ditanamkan di dalam lapisan subkutaneus mencik gondol atimus
selama 5 minggu. Eksplan tersebut kemudiannya dikeluarkan daripada lokasi
penempelan untuk pemeriksaan histologi. Berdasarkan pewarnaan Safranin O dan
pengekspresan GAG, eksplan daripada kumpulan kajian didapati menghasilkan
matriks rawan pada kadar yang tinggi berbanding eksplan di dalam kumpulan
kawalan. Hasil kajian ini menunjukkan keberkesanan medium rendah serum yang mengandungi TGF-ß3 merangsang pembezaan sel stem mesenkima daripada
sum-sum tulang untuk menjadi sel rawa
Basal cell carcinoma (BCC) of the scrotum is uncommon and its pathogenesis is not well understood. The clinical behaviour of scrotal BCC is thought to be more aggressive and has a higher metastatic potential than BCC of other regions. The mainstay of treatment for localized scrotal BCC is wide local excision, while metastatic disease may need systemic chemotherapy for palliative control. A rare clinical scenario of scrotal BCC presenting concurrently with another metastatic cancer has never been reported. The present case illustrates the diagnostic challenge and management dilemma due to simultaneous presentation of scrotal BCC and metastatic squamous cell carcinoma (SCC). A 70-year-old man complained of a non-healing scrotal ulcer while he was being investigated for metastatic squamous cell carcinoma (SCC) of the external auditory meatus. The scrotal lesion was initially thought to be metastatic SCC. It was later confirmed to be BCC with biopsy and histopathological examination. He underwent surgical resection of the scrotal BCC for local control followed by palliative chemotherapy with cisplatin and radiotherapy for lymph node metastases. He remained well and did not have any local recurrence following 6 months after palliative treatment. Surgery coupled with palliative chemoradiation can offer good quality of life for patients with scrotal BCC and concurrent metastatic SCC.
Keywords: basal cell carcinoma, squamous cell carcinoma, scrotum
Bisecting-angle-technique is a method used to improve patient comfort during periapical radiography. This technique is usually performed without X-ray beam aiming device and has been commonly associated with dental radiographic error. The use of external marker as a beam aiming device in bisecting-angle-technique is potentially effective to reduce the number of errors occurring during periapical radiography. In this study, 240 periapical radiographs were taken by undergraduate dental students. Periapical radiographs were taken using traditional method of bisecting-angle-technique (BAT), bisecting-angle-technique with the use of external marker (BAT-M) and the standard method in periapical radiography; paralleling technique (PT). All radiographic images were evaluated and errors were classified and tabled according to the type and number of errors. Chi-square test was used to compare the total number of radiographic errors made using these three techniques. One of the most common errors with BAT was cone cut error (13.8%). This error had been markedly reduced to 1.3% and 2.5% by implementation of BAT-M and PT, respectively. The total number of errors was also found to be significantly lesser for BAT-M compared to BAT, p< 0.05.
Keywords: errors, dental, radiography