Pernicious anaemia is an autoimmune disorder where vitamin B12 deficiency is caused by autoantibodies that interfere with vitamin B12 absorption by targeting intrinsic factor or parietal cells or both. It is commonly associated with anaemia, rarely pancytopenia. Here we reported two cases of pancytopenia due to undiagnosed pernicious anaemia. First case was a 26-year-old man presented with lethargy and reduced effort tolerance, associated with postural giddiness and palpitation. Clinically, he was pale with no other findings. On blood investigations, the patient was diagnosed pancytopenia secondary to pernicious anaemia. He was treated with daily subcutaneous injection of vitamin B12 cyanocobalamin 1 mg for one week followed by weekly injection for a month and subsequently with lifelong monthly subcutaneous injection. After receiving 2 weeks of B12 replacement, his full blood count had normalized and his symptoms resolved. Second case was a 65-year-old man presented with yellowish discolouration of the eyes with lethargy. On examination, he was pale with jaundice. On blood investigations, the patient was diagnosed pancytopenia secondary to pernicious anaemia. He was started with intramuscular injection of 1000 mcg vitamin B12 replacement daily for one week followed by monthly for 6 months. After one week of B12 replacement, his full blood count had normalized. He was started on lifelong 3 monthly injections of vitamin B12 replacement and he remained symptom free. Patients with pernicious anaemia often present with general signs and symptoms which occur insidiously. It is important that early diagnosis is made to avoid harmful complications such as neuropsychiatric disorders.
Hypophosphataemia occurs in an abnormally low serum phosphate level. Three main mechanisms are postulated: decreased intestinal absorption, increased renal excretion, and extracellular shifts to intracellular compartments. It is potentially a fatal disease if not intervene. The management is merely treating the underlying disorder, giving phosphate supplement and requiring close biochemical monitoring. The incidence of symptomatic isolated hypophosphataemia is extremely rare. In this case report, a 33-year-old man presented with three days history of dysphagia, inability to complete sentences and generalized muscle weakness. He developed blurred vision especially upon exposure to bright light. He had a history of single parathyroidectomy for parathyroid adenoma 2 years ago. Physical examinations were unremarkable. Laboratory investigations were normal except for phosphate level of 0.30 mmol/L. Intravenous KH2PO4 with a dosage of 10 mmol was administered in slow bolus in 3 hours. His symptoms resolved slowly after correction. Although isolated hypophosphataemia is rare but need to recognize the symptoms and signs of hypophosphataemia and treat accordingly.
Non-cirrhotic portal hypertension (NCPH) is clinically defined as the presence of portal hypertension in the background of non cirrhotic liver. It is diagnosed by the findings in ultrasound of the hepatobiliary system and also oesophagogastroduodenoscopy (OGDS) that consistent with that of a portal hypertension, but otherwise has a relatively normal liver function and echotexture. The treatment mainly focuses on primary and secondary prophylaxis of variceal bleeding both pharmacologically like non-selective beta-blockers and octreotide, and non-pharmacologically like endoscopic band ligation of varices and sclerotherapy. In advance cases, sometimes surgery such as Porto systemic shunt or splenectomy may be required especially in patients with uncontrolled variceal bleeding or with symptomatic hypersplenism. Here we report a case of a young man who presented with upper gastro-intestinal bleeding, which was initially thought from a bleeding ulcer but was found to be secondary to oesophageal and gastro-oesophageal varices. Apart from having mild ascites, he has no other features of portal hypertension. His liver biochemistry and echotexture were also normal. Unfortunately, the patient was lost to follow up while he was still in the early stage of investigating the condition. The purpose of this case report is to share an uncommon occurrence of NCPH in East Malaysia, where liver cirrhosis predominates the aetiology of portal hypertension. Also, to the best of our knowledge, there is a very limited reporting of a similar case in this region.
This article will cover some of the most recent advances in the diagnosis of the world’s most common cancer in women, namely, breast cancer as we enter the era of precision medicine. The authors will discuss the differences between East and West pertaining to the incidence and mortality rates, the types of breast cancer and the revised staging criteria of breast cancer according to the American Joint Committee on Cancer (AJCC) Staging Manual, 8th edition. In addition, the advances of newer imaging modalities are presented and compared with traditional ultrasonography and mammography
Skeletal metastasis is a frequent complication of cancer resulting in significant morbidity as well as mortality. We highlight a case of a 73-year old gentleman with metastatic squamous cell carcinoma of the sternum. He denied dysphagia, shortness of breath, goitre, and presence of chronic non-healing ulcer. He was anaemic and carcinoembryonic antigen (CEA) was 18.7. Chest radiograph on lateral view showed a suspicious cortical irregularity. Computed tomography (CT) scan of thorax revealed an aggressive sternal lesion with soft tissue component. Ultrasound guided biopsy was performed and the biopsy was consistent with metastatic squamous cell carcinoma. Squamous cell carcinoma has a predilection to metastasize via haematogenous spread, but direct extension of tumour into the bone is not frequently seen. Finding the primary cause is utmost importance either via imaging modalities or invasive procedures. Isolated secondary lesion is extremely rare but unfortunate among defaulters. We discuss its diagnostic work-up and treatment options conserved to manage this condition.
The number of active smokers in Malaysia is increasing despite the availability of stop smoking clinics and smoking cessation medications. Other than smokers’ level of motivation to quit smoking, competency of the healthcare professionals involved in providing smoking cessation intervention using evidence based guidelines needs to be considered. Hence, knowledge, attitude and practice (KAP) of the healthcare providers in relation to existing clinical practice guidelines on smoking cessation should be assessed. In this review, we look at the factors contributing to the KAP of medical personnel on the guidelines and also the previously available assessment tool, mainly in the form of a validated questionnaire, for the purpose of applying it to the context of the Malaysian healthcare providers.
Anaphylactic reaction towards antibiotics is common during anaesthesia. It may present as bronchospasm, hypotension, desaturation, or urticarial. However it is uncommon for anaphylaxis reaction to present only as supraventricular tachycardia (SVT). This is a rare interesting case report on a 23-year-old healthy man whose anaesthetic categorization is American Society of Anaesthesiologist (ASA) 1, developed supraventricular tachycardia (SVT) towards intravenous cefuroxime, peri operatively. His condition resolved with carotid sinus massage. No pharmacological interventions were used. His skin prick intradermal tests showed allergies towards cefuroxime, cefazoline and cefoperazone. The patient subsequently underwent.
Strongyloides stercoralis is an intestinal nematode which is endemic in tropical and subtropical countries. The global prevalence of Strongyloides is unknown. Strongyloidiasis is found more frequently in the socioeconomically disadvantaged, in institutionalized populations, and in rural areas. The spectrum of disease varies. It may cause asymptomatic infection, mild eosinophilia or hyperinfection syndrome in the most severe form. Here we reported a case of Strongyloides hyperinfection syndrome in an immunosuppressed patient. This patient is a 54-year-old man with myasthenia gravis on long term azathioprine and prednisolone. He presented with fever associated with diarrhoea and was in septic shock. His blood culture was positive forKlebsiella pneumoniae.Strongyloides stercoralis larvae were detected in his sputum and stool sample. He was diagnosed to have Strongyloides hyperinfection and was treated with subcutaneous ivermectin. He recovered well. Our case demonstrated the association of Strongyloideshyperinfection with superimposed gram-negative sepsis as a consequence of prolonged immunosuppression. A high index of suspicion is needed in approaching patient with risk factors of hyperinfection syndrome.
Fracture is common after trauma. Proximal humeral fracture can occur in the elderly after fall and in youngsters after motor vehicle accidents (MVA) and sport injuries. A 37-year-old man was admitted with a fracture of his left proximal humerus following an MVA. He sustained a 3-part fracture and treated surgically using a PHILOS plate. There are few options in managing proximal humerus fracture ranging from conservative to surgical intervention based on its severity. We reminiscent the usage of PHILOS plate as a mode of treatment of such fracture.
The normal pericardium is a fibroelastic sac containing a thin layer of fluid that surrounds the heart. Cardiac tamponade, which may be acute or subacute, is characterized by the accumulation of pericardial fluid under pressure. Tuberculous pericarditis is a complication of tuberculosis which is often diagnose late due to the difficulty in establishing this diagnosis. We present a case of pericardial tuberculosis diagnosed in a 20-year-old young retroviral disease patient who presented with signs of cardiac tamponade. His clinical condition improved post-pericardial tapping and he was discharged with anti tuberculosis medications. This case highlight the importance of having a high level of suspicion as this condition is easily curable.
As general population of obese patients in Malaysia rapidly increases, more obese patients are requiring anaesthesia for various operative procedures. Obesity is associated with anatomical and physiological differences and co-morbidities that influence on the choices of anaesthesia care. A surgical case with general anaesthesia is used as a basis of discussion. A 37-year-old female, history of untreated hypertension and gastrooesophageal reflux disease (GORD), BMI of 41 admitted for laparoscopic cholecystectomy for symptomatic cholelithiasis under general anaesthesia. She presented with pain at the upper right abdomen and associated with bloated abdomen, nausea and vomiting after intake of meals. General anaesthesia and right ultrasound-guided transversus abdominis plane (TAP) block for abdominal wall blocks via subcostal approach was performed. Operation was removal gallstones in the common bile duct via laparoscopic approach. Post-operation patient was extubated successfully. She was prescribed paracetamol 1g 4 hourly and started on fentanyl patient-controlled analgesia (PCA) for next 2 days. In this case report, there is the description of the application of TAP block which when used in obese abdominal surgical procedure, can provide excellent postoperative pain relief, early mobilization and recovery.
Critical aortic stenosis (AS) is very severe narrowing at aortic valve in newborns, causing left ventricular outflow tract obstruction (LVOTO). It is lethal if not treated soon after birth.
Introduction: Vision is an important requirement for learning and plays a critical role in the development of a child during the first three years of life. Little is known regarding the extent of visual impairment amongst preschool children in Sabah.
Objective: To determine visual status among preschool children in Kota Kinabalu and to determine prevalence of refractive error among children who were referred by the programme.
Methodology: A retrospective cohort study of clinical records was conducted at Department of Ophthalmology, Hospital Queen Elizabeth, Kota Kinabalu, Sabah from May to September 2017. Criteria for failed vision were VA 6/12 (0.3 LogMar) or worse. All records of referred children were selected for prevalence of refractive error. Data collected include basic demographic data, visual acuity and refractive error. Myopia was defined as spherical equivalent (SE) ≥−1.00 DS, hyperopia SE ≥+3.00 DS and astigmatism ≥−1.50 DC.
Results: A total of 192 children age 4 to 6 years old were screened, comprised of 102 (53.1%) male and 90 (46.9%) female (mean age: 5.81 ± 0.41 years). Of the 192 students, 39 (20.3%) of them failed vision screening. Among the 39 children, only 17 children came for further eye assessment. Twelve (70.6%) of them had a binocular visual impairment (VI) while 5 (29.4%) children had monocular VI. Six years old children were found to have VI more compared to other age groups (n= 14, 82.4%) and majority of this age group having binocular VI (n=10, 83.3%). Mean SE was −0.60 ± 0.94. Astigmatism is the commonest type of refractive error found with a prevalence of 41.4% followed by myopia, 27.6%.
Conclusion: This study was the first attempt to investigate the visual status among preschool in Kota Kinabalu. As most children were found with astigmatism, early detection of significant refractive error could help to minimize the effect of VI.
Introduction: Critically-ill patients are commonly fed with EN via open system (OS) or closed system (CS). Several studies showed that patients on CS had received greater volume of EN compared to OS.
Objective: As there was no study conducted in Malaysia, hence this study is conducted to compare the energy and protein adequacy of both systems.
Methodology: This cohort prospective study was conducted in GICU (OS) and NICU/NHDW (CS) in Hospital Kuala Lumpur. Patients aged ≥18 years and fed by feeding pump in OS were included. Patients who were moribund or not given EN were excluded. Patients’ demographic data and disease severity score were collected on day 1 in ICU and followed for 5 days until decease or discharge. Adequacy was determined by percentage of energy/protein received from requirements.
Results: Fifty-five patients were included (25 OS and 30 CS) with mean aged 45.41±17.46 years old, 78.2% male and 65.5% Malay. The mean SAPS II, SOFA score and ICU LOS were 46.47±10.65, 8.60±3.64 and 9.24±7.91 days respectively. The ICU mortality was 20%. EN was started about 2.56±2.89 days after ICU admission and the mean adequacy of energy was 74.56±32.23%, while protein adequacy was and 69.15±35.78%. Compared with the CS, OS were significantly older than CS (51 years old vs 42.5 years old; p=0.035) and had a higher SOFA score (10 vs 7.5; p= 0.014). No difference in ICU LOS and mortality between group were found. Energy (45.64% vs 96.71%; p<0.001) and protein adequacy (38.78% vs 94.12%; p<0.001) were significantly higher in the CS than the OS.
Conclusion: CS as compared with OS may improve nutritional adequacy as CS delivered more 108% energy and 141% protein than OS. The difference in adequacy might be attributed to these factors; feeding method used in the system, patients’ characteristics and condition rather than the feeding system itself.
Keywords: enteral nutrition, critically-ill patients, open system, closed system, adequacy
Occupation-related fatigue and sleep loss are common among shift workers in the emergency department (ED), who deliver round-the-clock critical care service to patients. These factors affect their performance and impose an unnecessary hazard to patients, while also endangering themselves.
Cerebral aneurysm is an exceedingly rare aetiology of neonatal Subarachnoid Haemorrhage (SAH). Detailed history and pattern recognition of the SAH is crucial in suspecting aneurysm.
Men who have sex with men (MSM) is one of the key populations affected by HIV epidemic with infection rates exceeding five percentages. Due to a strict and prohibitive socio-cultural and legal environment, male-to-male sexual practices are often misunderstood and highly stigmatised, thus creating barriers for MSM to access HIV prevention, treatment, care and support services.
The success of cataract surgery is accessed by the improvement in visual acuity and accuracy of the post-operation refractive outcome against the pre-operation refractive target. Hence, the benchmark of 85% of patients achieving a final spherical equivalent within 1D of the desired target is used to monitor the refractive outcome. Meanwhile, the unaided visual acuity threshold of 6/12 after cataract operation is chosen as a yardstick because it allows patients to perform instrumental activities of daily living (IADL) independently without relying on spectacles.
In Malaysia, there is an increase in both demand and prescribing of supplements. Such trend raises the likelihood of adverse events and treatment costs. Numerous prescribing policies have been suggested for better utilization of resources. However, the adherence and improvement from such policies are yet to be fully characterized.
Sabah is a high tuberculosis (TB) burden area with incidence rate of 120 – 138 per 100,000 population. Until now, TB is still unable to control due to high loss to follow up rates. Loss to follow up TB treatment can cause to increase notification rate, prolonged infection, recurrent TB infections, increase multiple drug-resistance, and increase morbidity and mortality rates. To know the factors that contribute towards loss to follow up will better understand the epidemiology of treatment outcome and guide for appropriate strategies planning to improve the situation. Previous study by Liew et al. indicated that, incidence rate for loss to follow up in 2012 in Malaysia was 10.5%.