The most common extra-articular manifestation of rheumatoid arthritis (RA) is interstitial lung disease (ILD). RA related ILD (RA-ILD) is associated with significant morbidity and mortality. The main objective of this study was to determine the correlation between the rheumatoid factor (RF) serotypes and the severity of RA-ILD based on computed tomography (CT) findings. We recruited a total of 100 RA patients who were tested for IgA RF, IgG RF and IgM RF and had high resolution CT chest performed. Seventy-two patients had ILD changes on HRCT of the chest and were included in this study. We found that the the CT scores for ground glass showed significant positive correlation with disease duration and IgA RF levels whereas the fibrosis scores had significant relationship with multiple clinical covariates i.e age, disease duration, IgA RF levels, IgG RF levels and anti-CCP levels. On multivariate analysis, only IgA levels remained significantly (p
Androgen ablation therapy using gonadotropin-releasing hormone agonists is reported to be associated with metabolic abnormalities. Annatto tocotrienol (AnTT) is reported to reduce the expression of genes related to adipogenesis but the mechanism remains elusive. This study sought to determine the effects of annatto tocotrienol on body composition (lean and fat mass), serum adiponectin, leptin, and glucose levels in male rats treated with buserelin, a testosterone ablation agent. Three-month-old male Sprague Dawley rats (n=32) were randomly divided into four groups. The normal control (n=8) was given corn oil orally daily and normal saline subcutaneously daily. The remaining groups were injected with buserelin subcutaneously (75μg/kg/day). The buserelin group (n=8) was given corn oil orally, while the treatment groups were supplemented orally with AnTT at 60 or 100 mg/ kg (n = 8/group). After treatment of 12 weeks, rats were euthanized. Dual-energy x-ray absorptiometry was performed to determine the lean and fat mass of the rats. Blood was collected for the evaluation of adiponectin, leptin and glucose levels. After 12 weeks, the lean mass, fat mass, adiponectin and leptin levels for all groups increased significantly compared to their respective baseline levels irrespective of their treatment (P
Bystander rate of cardiopulmonary resuscitation (CPR) is still low worldwide because of inadequate skills and knowledge. Training the public on CPR is one of the methods to increase the bystander CPR rate. This study aimed to compare the efficacy in acquiring and retaining CPR skills and knowledge among secondary school students in Klang Valley trained by school teachers and medical students. We recruited five school teachers and five medical students as trainers. They were trained in several sessions by American Heart Association (AHA)-certified instructors using the video-assisted CPR training module. The recipients were 44 secondary school students divided between the teacher’s group and the medical student’s group. We compared knowledge and psychomotor skills between these two groups prior, immediately after and at three months after CPR training. Students in the teacher’s group showed a higher increase in knowledge comparable to the medical student’s group (median score difference 3 vs 2, p>0.05) and in psychomotor skill (median score difference 5 vs. 7, p
Hypertension has been recognised as an important public health issue, affecting paediatric population. This study aimed to determine the prevalence of hypertension and its relationship with obesity among different ethnic, gender primary school children in Kuching division, Sarawak. It was a cross-sectional study using multistage sampling. Data was collected using anthropometric equipment and digital blood pressure monitor. Data was analysed using SPSS version 20. A total of 1314 respondents participated. 36.9% of the respondents were overweight and obese, 31% were overfat and obese, 29% had abnormal waist circumference and 32.8% had abnormal waist-height ratio (WHtR). About 22.1% of the respondents were found to be in pre-hypertension and hypertension stage. There were significant differences in overweight and obese, overfat and obese, WHtR between males and females. Indigenous Sarawak reported to have the highest number of hypertensive at risk, overweight and obese, overfat and obese, abnormal waist circumference and WHtR. Those respondents who were hypertensive were found to be overweight and obese, overfat and obese, with abnormal waist circumference and WHtR. Screening of potential risk factors at a young age would help to reduce the incidents of chronic disease in the adulthood. Blood pressure measurement should be included in the routine physical examination, to identify high risk children for further investigation.
Research on the medical benefit of stingless bee honey (kelulut honey) is rather new although it has been used as traditional food and additive for ages. The primary objective of our study was to evaluate the antioxidant properties of kelulut honey and its effect on lymphoblastoid cell line. We analysed the antioxidant properties of kelulut honey by ferric reducing antioxidant potential assay, total phenolic and flavonoid contents using UV spectrophotometry. The total phenolic content, total flavonoid content and ferric reducing antioxidant potential of Malaysian kelulut honey produced by Trigona spp. were found to be 844.45 mg RE/kg honey, 78.29 mg RE/kg honey and 1132.66 mM FE/kg honey, respectively. Our findings showed a strong correlation between total phenolics and flavanoids contents with its antioxidant potential at R2 = 0.920 and R2 = 0.951, respectively. The effect of honey on cell viability of lymphoblastoid cell line (LCL) was also investigated. The cells were cultured in RPMI-1640 medium supplemented with 0 - 500 μg/mL of kelulut honey for 24 hours. Cell viability was quantitated using 3-(4,5-dimethylthiazol- 2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, MTS assay showed that honey supplementation boosted the viability of LCL up to 164.64% (p< 0.01). The significant increase in cell viability might be modulated by the antioxidant properties of kelulut honey.
Palm oil tocotrienol-rich fraction (TRF) containing majorly of αα, β, γ and δ-tocotrienols and some αα-tocopherols, was reported to have anti-ageing effects in both human and non-human model organisms, but still remains unexplored in the yeast model. It was reported to have the ability to extend the lifespan of several organisms. Chronological lifespan is one of the means to measure ageing in yeasts. The effect of TRF on the viability of three strains of Saccharomyces cerevisiae (wild-type, CTT1ΔΔand GPx2Δ) was studied. Phenotypic growth analysis of all strains was carried out for 15 hours by measuring the absorbance at OD600nm and cell counting. The optimum dose of TRF was optimised by determining the number of colony-forming unit by the wild-type strain at the end of a 24-hour treatment with TRF (ranging from 0μg/ml to 300μg/ml). TRF at 300 μg/mL showed the best result, and selected as a working dose. Treatment of cells with 300 μg/mL of TRF improved the viability of the wild-type strain in the initial stationary phase, but not on the knockout strains. These finding suggests that TRF has a potential in prolonging the chronological lifespan of S. cerevisiae, and perhaps other organisms as well.
The endothelial nitric oxide synthase (eNOS) rs1799983 polymorphism is known to increase the risk towards stroke, but data is under-reported in Malaysian population. Therefore, this study sought to investigate this association in a Malaysian population and in a comprehensive meta-analysis. Genotyping of the eNOS rs1799983 polymorphism was performed for 241 Malaysians using a hydrolysis probe. Odd ratio with 95% confidence interval was calculated. Meta-analysis was conducted using the Comprehensive Meta-Analysis software ver. 2.2.064. A p-value less than 0.05 was considered statistically significant. Overall, our results showed that the presence of eNOS rs1799983-T allele increases the risk towards stroke, particularly in males, fast-food goers and Malaysian Chinese. The meta-analysis showed that the rs1799983 polymorphism is significantly associated with an increase ischemic stroke risk in the recessive and allelic models. After stratified with population, these associations remain significant in the Asian population but not in the Caucasian population. In summary, this study establishes a significant relationship between the eNOS rs1799983 polymorphism with gender, lifestyle and ethnicity differences towards stroke risk in the Malaysian population. In addition, our meta-analysis suggests that the eNOS rs1799983 polymorphism is associated with an increase risk of ischemic stroke.
Overweight and obesity have become a global concern and estimated with more than 1.9 billion adults worldwide were overweight and more than 650 million were obese in 2016. Nurses in Malaysia were no exception to overweight and obesity. This research was conducted with the aim to identify the prevalence of overweight among nurses on shift duty in a teaching hospital and to understand the relationship between abnormal eating behavior and body mass index. A total of 280 respondents participated in this research and Dutch Eating Behavior Questionnaire was used. Body Mass Index (BMI) score was categorized according to Clinical Practice Guidelines 2004. Results showed that 68.5% of the nurses were either overweight (37.1%) or obese (31.4%). The nurses’ BMI does not showed any association with socio-demographic data except age (r=0.156). As age increases, the nurses’ BMI also increase. This research also showed that there was no association between emotional and external eating behavior to BMI. However, there was a statistically significant differences in BMI for restraint eating (F=6.056, p=0.003). In conclusion, restraint eating behavior was the most practiced form of eating behavior in an attempt to achieve the ideal body weight but unfortunately lead to overweight among the nurses. Overweight or obese nurses will have a negative impression to the society and even reduce their confidence towards nurses’ health education. Overweight or obesity also ruined the nurses’ working performance and quality of care for patients. This issue requires immediate action and interventions to promote healthy lifestyles and eating habits among nurses should be conducted in the hospital.
Door to needle (DTN) time for thrombolysis in the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre (ED, UKMMC) is an indicator that can reduce mortality and morbidity of patients with ST Elevation Myocardial Infarction (STEMI). This study was conducted to determine factors that influence DTN time for acute ST Elevation Myocardial Infarction (STEMI) and whether it has achieved the recommended time of 30 minutes. A cross-sectional study was conducted among patients diagnosed with acute STEMI and thrombolysed in ED, UKMMC from June 2016 until March 2017. A data collection sheet was used to collect patient’s demographic data and clinical data which included time of arrival to ED, time of initial electrocardiogram (ECG), time of drug preparation and time of thrombolytic delivery to the patient. A total of 98 patients were included in this study. Majority of patients (77.6%) were thrombolysed more than 30 minutes following ED arrival. Mean DTN in ED, UKKMC was 59.28 + 36.01 minutes. The mean door to ECG time was 7.19 + 8.08 minutes and the mean drug preparation time was 9.86 + 7.51 minutes. Out of 76 (77.6%) patients that were thrombolysed after 30 minutes of ED arrival, 59.2% (n=45) were due to multiple disciplinary referral. Other factors were delay in performing initial ECG 19.8% (n=15), incorrect initial ECG interpretation 9.2% (n=7) and unavoidable need for prior resuscitation 9.2% (n=7). As a conclusion this study showed that there was an unacceptable delay in hospital thrombolysis for acute STEMI.
The use of simulation as a teaching methodology in medical institutions has been in Malaysia for over two decades. This study aimed to evaluate the current scenarios of simulation impact and utilization in Malaysian academic healthcare institutions (AHIs). We conducted a population-based survey on all AHIs in Malaysia including public and private. We performed an online survey followed by a face-to-face interview evaluating the number of institutions that used simulation, duration of experience, purpose, funding, users’ category and healthcare domain, research activities, dedicated-trained staff and the challenges faced. Out of 75 healthcare institutions approached, 38 agreed to participate in this study. Twenty-two (57.9%) were public hospitals while 16 (42.1%) were private institutions. Thirty-five (92.1%) out of 38 institutions used simulation as a teaching method. The majority (15, 42.9%) had less than five years’ experience, and about a third (11, 31.4%) used simulation for teaching, training and performance assessment. Nurses (30, 26.1%) were the main users followed by physicians and paramedic (19, 16.5% each respectively). In-hospital and procedural group were the top two domains of utilizers. Almost three quarters (25, 71.4%) have dedicated support staff to manage the centre. Funding was mainly from internal institutional support mechanisms. Seven different categories of challenges were identified, the biggest being financial support. In summary, even though healthcare simulation has been in Malaysia for the past two decades but the most substantial impact happened over the last five years. Utilization was mainly for teaching, training, and performance assessment with minimal use in research.
Infective endocarditis (IE) is a potentially life-threatening disease which carries high risk of morbidity and mortality. The variability of clinical presentation of infective IE remains a diagnostic challenge for the Emergency Physicians. The clinical manifestation may present as an acute, rapidly progressive infection with the absence of classical immunological vascular phenomenon or as subacute or chronic disease with vague constitutional symptoms that may mislead initial assessment and mimic other conditions. Symptoms may also manifest as a result of systemic embolization which can be catastrophic and life-threatening especially if it ends up in the cerebral circulation. IE complicated by cerebral mycotic aneurysm (CMA) is the worst neurological sequalae and can be misdiagnosed as a primary intracranial infection such as meningoencephalitis. Here, we report a case of neurological emergency secondary to systemic embolization of IE with a devastating diagnosis of CMA. History of prolonged fever associated with headache and focal neurological deficit led to the initial diagnosis of meningoencephalitis due to a low clinical suspicion of the disease in the Emergency Department. In emergency setting, a combination of high degree of clinical suspicion together with thorough history, physical examination and diagnostic imaging are crucial in order to guide and establish the diagnosis of this potentially devastating disease. Early recognition and initiation of aggressive treatment is crucial to provide better prognosis and higher survival rate for patients with CMA.
Local anaesthesia systemic toxicity (LAST) is an uncommon and a potentially life-threatening event that develops after peripheral nerve block. The cause may be multifactorial and may include the choice of drug, technique of block and individual patient risk factors. We report a case of a 55-year-old female who developed slurring of speech and quadriplegia after receiving a mixture of lignocaine and hydrocortisone through an intra-articular injection to the right shoulder. Neurological examination revealed hypotonia and absence of power (0/5) in all limbs. These toxic events may have resulted from an accidental intra-arterial or dural cuff injection of local anaesthesia or absorption from surrounding tissues. This case report demonstrated that an intra-articular injection in the shoulder may cause LAST and may be under-recognized as it can mimic stroke.
Proximal femur fracture in paediatric patients are very rare and can easily be missed especially when the history of trauma is so trivial, and associated with pathological fracture. We report a case of 6-year-old girl with a history of left knee pain following a fall from a height of 2 feet. She was treated as a soft tissue injury of the left knee as the left knee radiograph was normal. She was reassessed at day 3 of injury with worsening symptoms. Radiograph of the pelvis and left knee revealed a comminuted intertrochanteric fracture of left femur with an underlying bone cyst. We would like to highlight this case report to avoid missing a proximal femur fracture where a trivial trauma resulted In the presentation of a non-specific knee pain. Femur fracture in peadiatric age group can result in the significant complication of growth such as osteoporosis.
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.
Individuals with disabilities have different needs and concerns at different stages of life. The arrival of puberty brings about new challenges especially for females with issues related to menstrual care involving both the patient and their caregivers. This case report is about a 13-year-old girl with Down syndrome who was cared for by her widowed father since the age of six. She was suffering from severe mental disability. Her father was concerned, because she was unable to maintain personal hygiene during menses such as changing sanitary napkins and managing stains, hence requested for menstrual manipulation. Options for menstrual manipulation for individuals with disabilities include both medical and surgical interventions. Hormonal therapy options include oral contraceptive pills, depo-provera, progestin implants and progesterone release intra-uterine contraceptive devices. Surgical options such as hysterectomy or endometrial ablation may be considered as a last resort as it is more invasive and irreversible, involving ethical and legal implications. Selection of the suitable therapy involves shared decision making between health care provider and caregiver taking into consideration the patient’s best interest. This case report also highlights the role of family physicians in managing and coordinating care on delicate issues related to menstrual care for people with disabilities. This case report may serve as a guide to physicians and families with special needs children, while approaching issues on menstrual care.
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.
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.
In trauma, a systematic approach has been developed to assist physician and surgeon in identifying immediate life-threatening injuries so that prompt intervention can save lives and reduce mortality. This approach also called for a head-to-toe examination so that other injuries are not missed out. Sacral fracture, although rare, but could have serious complications. The present case discusses about a trauma patient who presented with complain of genitalia pain with normal genitalia examination. Sacral fracture was not suspected and was only detected when a pelvic radiograph was ordered as part of the trauma survey. Fortunately, the patient had no complications resulting from the injury itself. The aim of the present case is to discuss the importance of investigating beyond patient’s complaint, as in this case the patient only complained of genitalia pain which ended up as a sacral fracture.
Major depressive disorder is an important psychiatric illness that can be a life-threatening condition when it presents with suicidality. This case report describes an adolescent who presented with major depressive disorder but with an underlying undiagnosed attention deficit hyperactive disorder (ADHD). The 17-year-old male adolescent presented with psychosomatic complaint of non-resolving left sided chest pain. He also had major depressive symptoms and suicidal ideation. His ADHD was being missed. This case highlights the difficulty of diagnosing ADHD during adolescence as the presentation may not be as typical as during early-childhood years.
Aneurysm and pseudoaneurysm of the dorsalis pedis artery remains to be rare vascular entities with a reported incidence of 0.5% of peripheral arterial aneurysms. Only, few cases were reported. The formation of pseudoaneurysm is commonly associated with fracture, laceration wound or iatrogenic arterial injury. An arterial injury that coincides with pseudoaneurysm can initially be missed due to lack of clinical findings. Prompt recognition remains paramount to reduce morbidity and mortality. Here, we present a rare complication of a commonly performed orthopaedic procedure in a young male who presented with painful swelling over left foot after he was involved in an industrial injury. He presented again with a pulsating mass over his left foot after 2 months post fixation surgery of a Lisfranc injury. He was treated conservatively with compression bandage and able to regain to his normal activity after the treatment initiated.