Tabiat merokok adalah perilaku yang tidak sihat malah membahayakan bukan sahaja diri sendiri malahan masyarakat sekeliling. Walaupun terdapat banyak kempen anti-merokok telah diperkenalkan oleh kerajaan, namun keberkesanannya masih di tahap rendah. Oleh itu objektif kajian ini adalah untuk meneroka faktor utama kegagalan kempen anti-merokok di Malaysia, meneroka keberkesanan “Klinik Berhenti Merokok” dan menemui penyelesaian terbaik untuk memastikan kempen yang dijalankan berkesan pada masa akan datang. Ini adalah kajian rentas kualitatif di mana temuduga dijalankan di kalangan lima sukarela responden yang terdiri dari perokok dan bekas perokok di kawasan awam dan tiga klinik berhenti merokok yang terpilih. Data dianalisis dengan menggunakan analisis bertema. Kajian ini mendapati beberapa faktor penyumbang dari perspektif perokok dan pihak berkuasa perlu diberi keutamaan untuk penambahbaikan iaitu kurang kreativiti yang minimum dalam menguruskan promosi anti-merokok, kurang kreatitivi dah terhadap kesihatan, permintaan bahan pencetus semangat di tempat kerja, dan dalam pengurusan tekanan yang lemah. Hasil kajian mengesyorkan bahawa kempen bermula di sekolah rendah dan menengah, improvisasi tanda amaran penyakit, meluaskan kawasan promosi, memberi ganjaran semasa kempen dan perokok perlu mengambil inisiatif melibatkan diri dalam program ini. Kerajaan perlu menumpukan perhatian kepada program pencegahan merokok terlebih dahulu, daripada program intervensi berhenti merokok yang mungkin melibatkan kos kewangan yang tinggi.
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.
Individuals with double aneuploidy of Down-Turner syndrome are very rare and to date, fewer than 50 cases have been reported, worlwide. We report a case of a male infant who presented with dysmorphic features of upslanting eyes, flat nasal bridge, wide spaced nipples and macroglossia. Based on the clinical features, he was diagnosed with Down syndrome. His peripheral blood sample was taken and sent for cytogenetic analysis for confirmation. Chromosome analysis of his lymphocyte cell culture revealed a mosaic pattern of double aneuploidy with monosomy X identified in 31 metaphases and trisomy 21 in 14 metaphases: (45,X[31]/47,XY,+21[14]). Further analysis with fluorescence in situ hybridization (FISH) using Vysis LSI SRY Spectrum Orange/CEP X Spectrum Green Probe and Vysis CEP Y Spectrum Aqua Probe and Vysis LSI 21 Spectrum Orange Probe performed on the cells (nuclei and metaphases) has confirmed the presence of the abnormal two cell lines (81% monosomy X and 19% trisomy 21) in the patient. Ultrasound investigations of his pelvic region showed normal testes and no evidence of uterus, ovary or vagina. To the best of our knowledge, this is the first Down-Turner syndrome reported in Malaysia. In conclusion, this case demonstrates the importance of Giemsa-banded karyotype and FISH analyses as diagnostic tools in identifying the chromosomal abnormality and determining the ratio of the normal:abnormal cells present in the patient. An annotated bibliography of earlier reported cases of Down-Turner with documented karyotyping is also included in this report.
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
Plasma cell myeloma is known to cause expansion of a single clone of munoglobulin (Ig) which results in the secretion of a unique homogeneous monoclonal protein (M component). However, there are cases which reported that it can also cause production of two different clones of these monoclonal proteins. Although it is relatively very rare as the prevalence is only 2% of all plasma cell myeloma cases, the clinical features are said to be similar to monoclonal gammopathy. It is suggested that these biclonal gammopathy results from either one monoclonal cell clone in monoclonal gammopathy or two different monoclonal cell clones. Whichever the mechanism of the disease be, the response to treatment seems to be similar as compared to the monoclonal cases although some reports shows chemoresistant. Here, we report a rare case of plasma cell myeloma with IgG (lambda) and IgA (lambda) type of biclonal gammopathy, the clinical presentation, the haematological and biochemical markers as well as the response to the treatment.
Keywords: biclonal gammopathy, M protein, plasma cell myeloma
Open tracheal injury is rare but can lead to disastrous consequences such as massive bleeding, airway obstruction or failure and aspiration of blood. We present a case of open tracheal injury of a man who tried to attempt suicide using a knife. In this case, the initial management was securing the airway by attempting orotracheal intubation. However, it was unsuccessful when the tube came out from the laceration wound. Intubation was then re-attempted through the distal cut-end of the trachea in the face of airway failure. A quick initial assessment and anticipation of a failed airway should always be the top priority in any emergency physician managing these cases. Direct intubation through the laceration wound might be the only option when all else fail and your patient is crashing.
Keywords: intubation, laceration, trachea
Pregnancy is perceived by many pregnant mothers as a period of happiness in anticipation of motherhood. Not all pregnant mothers experience cheerfulness as some may experience a high anxiety and depression level for unknown reasons. The purpose of this study was to determine the level of anxiety and depression among high risk pregnant women and the factors that contribute to their level of anxiety and depression. A descriptive cross-sectional study was conducted on 38 high risk mothers whose stay in hospital exceeded more than three days in the obstetric ward of Hospital Universiti Kebangsaan Malaysia. A self assessment questionnaire “Hospital Anxiety Depression scale” was used to measure the level of anxiety and depression among high risk pregnant women. Of the 38 participants, 16 (42.1%) women experienced a mild level of anxiety and 22 (57.9%) experienced a severe level of anxiety. Seventeen (44.7%) women was classified as having mild depression and 21 (55.3%) severe depression. The factors contributing to the level of anxiety and depression, include those related with “lack of information on disease”, “family matters” and “finance”. High risk pregnant women in this study experienced a significant level of anxiety and depression during their stay in hospital. It is therefore important for nurses and doctors to be aware and sensitive to the influencing factors that cause anxiety and depression as to enable high risk pregnant mothers to enjoy their pregnancy and childbirth.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Cerebral palsy is a common cause of childhood disability. It has a great impact on parents and caregivers, especially when it reoccurs in the same family. Although familial cerebral palsy is relatively uncommon, cases have been reported among children from consanguineous, non-consanguineous marriages and multiple pregnancies suggesting a possible complex genetic mode of inheritance. Physicians need to be aware of the possibility of familial cerebral palsy for early detection and counseling. We describe a rare case of two male siblings from a non-consanguineous marriage affected by cerebral palsy.
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
Acute mastoid abscess is common in daily practice. In children, it is usually caused by unsuccessful treatment or partially treated acute otitis media (AOM). Some authors had reported that chronic suppurative otitis media (CSOM) can be the source of infection but it is usually associated with the presence of cholesteatoma. A case of an acute mastoid abscess in a 7 year old girl is presented. She had a history of severe otalgia with left post auricular swelling for 3 days. Clinically she was febrile, the left otoscopy showed diffuse post auricular swelling and sagging of the posterior wall of the external canal. She underwent an emergency cortical mastoidectomy for the left mastoid abscess and had an uneventful recovery. In conclusion, this patient was partially treated with antibiotics which increased the risk for ‘masked mastoiditis’, and she later developed a mastoid abscess. Therefore we advocate that all AOM patients should be treated with antibiotics at least for a duration of one week.
Electrocardiographic abnormalities can be associated with acute pancreatitis. However, data regarding the actual causative factor still remains elusive. Many previous cases were reported on non-specific ST and T wave abnormalities concurrent with acute pancreatitis but rarely with an increasing trend of cardiac markers. We describe the case of a 70-year-old female who presented with one such conundrum. Our patient had typical presentation of acute pancreatitis but had dynamic ECG changes with markedly increased cardiac markers. Subsequently after initiation of treatment for acute pancreatitis and observation for the course of several days, the ECG returned to the baseline as pre admission. This substantiates the fact that acute pancreatitis can mimic both biochemical and electrical manifestation of an acute coronary syndrome. Thus, Emergency Physicians should consider acute pancreatitis as a possible diagnosis in patients who present with abnormal electrocardiograms.
A claw hand causes disability as kinematics are affected due to hyperextension at the metacarpophalangeal joints. Zancolli lasso procedure is a simple tenodesis procedure which effectively lessens clawing to allow better grip. We present a 56-year-old lady who had a history of trauma with progressive clawing of her left hand. She has been diagnosed with partially recovered incomplete lower trunk brachial plexus injury. She underwent successful Zancolli lasso procedures for all of her fingers but 8 months later, the patient developed triggering of the index and middle fingers. We experimented by releasing the adhesions in one finger and releasing the whole A1 pulley together with the lasso-ed flexor digitorum superficialis (FDS) in the other finger and the latter worked.We repeated the procedure in the index finger and the triggering resolved. Although both her index and middle fingers now have a flexor digitorum profundus (FDP) only (the FDS having retracted proximally), she did not have a recurrence of her clawing. We attributed the triggering due to increasing A1 pulley volume as well as contractures causing post-release functional positions.
Paediatric hand fractures are common and prompt management is mandatory to achieve a good functional outcome. However many fail to realize that treating a fracture does not only involve bones but the soft tissues, as well. K-wiring itself can be difficult with multiple attempts inadvertently injuring the flexor or extensor tendons and resulting in adhesions. We highlight this possible complication of K-wiring which we believe is under reported due to the perception that K-wiring is a simple procedure. We present a case of a 9-year-old child, who sustained a closed displaced fracture of the base of the proximal phalanx (Salter Harris type 2) of the left index finger. He underwent percutaneous K-wiring but was complicated with severe adhesions of the flexor digitorum profundus (FDP) and flexor digitorum superficialis tendons (FDS). He was unable to flex the proximal and distal interphalangeal joints of the affected finger. We subsequently performed tendon adhesiolysis twice together with A2 pulley reconstruction, to restore movement of the finger. K-wiring of the fingers are not just simple bony procedures but also involve soft tissue components which can be prone to adhesions.
Each human being exhibits their own personality traits and each aspect of stress and coping is essential and related. The relationship between the big five personality traits, coping mechanisms and stress level among final year medical students of Universiti Kebangsaan Malaysia (UKM) was investigated in this study. In this cross-sectional study, 152 final year medical students batch 2017/2018, were randomly selected, excluding those who had chronic diseases, married and repeated final year. The questionnaires used were Big Five Personality Inventory and 12-Item General Health Questionnaire. An open-ended question was used to determine how the respondents cope with their stress. Data was analyzed using SPSS 20.0. Agreeableness was the most common personality trait portrayed among the students, whereas Openness to Experience appeared to be the least. The relationship between the Big Five Personality Traits and coping mechanisms (p=0.016; p
Midazolam is one of the most commonly used drugs for sedation in Emergency Department (ED). This was a retrospective study conducted on 380 patients from December 2012 to May 2014 in ED of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). The objective was to elicit the frequency of side effects and correlation to various factors i.e. socio-demography, co-morbidities, age groups and underlying illnesses. Out of 380 patients, 35 patients experienced side effects (20 patients with midazolam alone, 15 patients with combination of drugs). The average age was 42 years and the average dose of midazolam was 3.5mg. The most common other drug combined was fentanyl. The overall complication rate for midazolam was 5.3%. The most common side effect recorded was excessive somnolence (1.6%). Other side effects included local skin reactions (1.1%), vomiting (0.8%), headache (0.8%) and hypotension (0.5%). There was no significant association between the socio-demographic factors and drugs combination with the side effects of midazolam on patients. It was concluded that midazolam was a safe drug due to absence of any life-threatening side effects. There are possibilities that most side effects recorded could be caused by other comfounding factors e.g. underlying injuries or disease and combination with other drugs.
This report stresses on the occurrence of a rare adverse reaction to clozapine, i.e. allergic cutaneous and visceral angioedema, in a patient with treatment resistant schizophrenia (TRS). We report the case of a schizophrenic patient who was resistant to treatment and developed an allergic reaction involving her skin and gastro-intestinal system upon the commencement of clozapine. She was then treated with a combination pharmacotherapy which left some residual symptoms. The manifestation of allergic reactions to clozapine and its management strategies are discussed in the paper. There is a pressing need to develop a new psychotropic which is on par with clozapine.
Keywords: allergy, angioedema, clozapine, schizophrenia
Rhabdomyosarcoma (RMS) is the most common soft tissue malignancy in children and adolescents. The rarity of its occurrence in infant poses a great difficulty in terms of diagnosis and management. Here, we report an aggressive case of alveolar rhabdomyosarcoma in an infant who presented with neck swelling and neurological complications. The Magnetic Resonance Imaging (MRI) revealed a soft tissue swelling of the neck with intraspinal extension and spinal cord compression, raising the possibility of a neurogenic or malignant nerve sheath tumour. Histopathological examination revealed a primitive, small round cell tumour with no rhabdoid differentiation. The clinical presentation, neurological symptoms, tumor location and the histopathologic features were highly suggestive of neuroblastoma. However, the tumour cells were positive for desmin with focal and weak nuclear positivity for myogenin and MyoD1; immunoexpressions which were in favour of rhabdomyosarcoma. Fluorescent in situ hybridization (FISH) confirmed the presence of a translocation t(2;13)(q35;q14), supporting the diagnosis of alveolar rhabdomyosarcoma. Despite chemotherapy, patient succumbed to death after two months due to septic shock. Rhabdomyosarcoma is highly aggressive mesenchymal neoplasm which may present with diagnostic difficulty. This case highlights the importance of molecular studies in making an accurate diagnosis so that appropriate chemotherapy may be instituted.
Amitraz poisoning is rare and there has been no reported cases in the Malaysian literature. Ingestion of this compound carries many life threatening side effects. We describe a case of Amitraz poisoning in an 18 years old young adult. He developed hypotension, required ventilatory support and a day of intensive care unit stay. He had a quick recovery after he was treated symptomatically and was discharged well after 3 days.
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.
Patient positioning is a vital in ensuring patient comfort, dignity and good access to
the operative site. Accurate positioning helps in minimising the risk of injury to the
patient. An in-house airbag made from recyclable medical supplies can be used
to replace the conventional sandbag for head and neck surgeries. It involves the
use of an empty irrigation bottle, a valve and suction tubing. Its shape and volume
is readily adjustable by altering the volume of inflated air. Moreover, compressible
air moulds the bag to the curvature of the patient’s external surface reducing the
risk of pressure sores in prolonged surgery. Ultimately this serves as an innovative technique which is financially savvy with the use of recyclable items.