Endogenous endophthalmitis is a devastating intraocular infection. Finding the primary infection and directed treatment is life-saving. We describe a 47-year-old man, with uncontrolled diabetes mellitus, who presented with two weeks history of progressive reduced vision and redness of the left eye (LE). He was generally unwell since a month, previously. Examination showed relative afferent pupillary defect (RAPD) in the affected eye and visual acuity was hand movement. There was moderate anterior chamber and vitreous reaction. Fundus examination showed a huge dome-shaped choroidal mass covering the entire macula. Diagnosis of severe endogenous endophthalmitis was made, with isolation of Enterobacter sp. from his blood culture. Meanwhile, he also had elevated inflammatory markers with presence of leucocytosis, neutrophilia and elevated erythrocyte sedimentation rate (ESR) as well as C-reactive protein (CRP). Vitreous tap and aqueous tap had no growth, He improved with combination of intravitreal and systemic antibiotic, as shown by the resolved fever and reduced inflammatory markers but progressive inflammation occluded the fundus details and the LE vision eventually became no projection of light despite treatment. Subsequently, he developed rubeotic glaucoma and was treated conservatively because the LE was painless with poor vision. The repeated blood culture and urine was normal. In conclusion, endogenous endophthalmitis with eventual panophthalmitis is difficult to treat and has very poor visual prognosis. Our case highlights the challenges faced in the management of vision-threatening endophthalmitis and panophthalmitis in this patient.
Post-infectious bronchiolitis obliterans is a rare disease that may occur following a microbiological insult towards the lower respiratory tract causing a severe form of chronic obstructive airway disease. Subpleural lung cyst may occur in 20-36% of Down syndrome. We report a case of a 30-month-old Down syndrome child who had interesting radiological concurrent findings of bronchiolitis obliterans with subpleural cysts on High Resolution Computed Tomography (HRCT) thorax. This patient was born premature and had early onset pneumonia during the neonatal period. Subsequently, he had three episodes of pneumonias at 18, 19 and 26 months. He presented with recurrent symptoms of cough, wheeze, rapid breathing and had features of persistent airway obstruction characterized by chest hyperinflation, persistent tachypnoea with crepitations and rhonchi despite on regular bronchodilators. The only positive culture was Influenza B from his nasopharyneal aspirate culture. To our knowledge, this is the first reported case with both radiological entities in a child with Down syndrome.
Posterior Polymorphous Dystrophy (PPD) is a rare, innocuous and asymptomatic condition in which corneal endothelial cells display characteristics similar to epithelium. It is often bilateral and frequently asymmetric. We report a case of a 10-year-old girl with a family history of glaucoma who presented with right eye blurring of vision since few years. She had frequent spectacle-prescription changing due to unimproved visual acuity. Cycloplegic refraction revealed high astigmatism and moderate amblyopia over the right eye. Her best corrected vision was 6/9 for the right and left eyes. Slit-lamp examination showed a vesicular-like lesion at the periphery of corneal endothelial layers in both eyes. Endothelial cell density was much reduced on the right eye compared to the left, with more severe astigmatism. Other ocular examinations were unremarkable. Patient was instructed to patch her better left eye periodically. Although patients with Posterior Polymorphous Dystrophy (PPD) present at the age of adulthood, the age at diagnosis is highly variable. It is rare and inherited through an autosomal dominant pattern. PPD may rarely lead to astigmatism, by which was present in the patient due to the features of non-keratoconic and keratoconic cornea on the right and left eye, respectively. Endothelial cell counts were reduced more on the right eye compared to the left, which later may worsen her visual acuity thus indicating corneal transplant in the future. Patient also had a strong family history of glaucoma. Hence, screening of associated disease of corneal endothelial dystrophy in the family may be necessary.
Many anatomical variations exist in and around the carpal tunnel. However, symptomatic anomalies causing carpal tunnel syndrome is rare. Additionally, carpal tunnel surgery is considered a simple operation commonly done by junior surgeons who are usually unaware of variations resulting in unfavorable surgical outcomes. We highlight a case of lumbrical muscle variation causing carpal tunnel syndrome. A 73-year-old male presented with numbness and pain of both hands associated with abnormal fullness over both wrists and distal forearms. Initially the right hand was numb and subsequently a year later, the left hand became numb. Physical examination was positive for Durkan, Phalen and Tinel signs at the carpal tunnel. Magnetic Resonance Imaging (MRI) showed abnormal muscle tissues in the carpal tunnel. During the carpal tunnel release and exploratory surgery, we noted an abnormally proximal origin of the lumbrical muscles in the forearm rather than the typical palmar origin. He also had lumbrical muscle hypertrophy in the left side. These two factors resulted in overcrowding within the carpal tunnel. Post-operatively the patient recovered well with pain relief and gradual improvement of his numbness. Variations in the anatomy of the lumbrical muscles is not uncommon and may result in carpal tunnel syndrome. Hence, carpal tunnel release surgeries may not be as straight forward as expected and surgeons should be aware of this possibility.
Traditional and Complimentary Medicines (TCMs) can potentially cause Adverse Cutaneous Drug Reactions (ACDRs). The aim of this study was to describe the characteristics of ACDRs due to TCMs and compare with those due to conventional medicine. This was a retrospective study with 134 cases being diagnosed with ACDR at the Dermatology Clinic of a tertiary hospital in Kuala Lumpur. Most (82.1%) ACDRs were caused by conventional drugs, while 17.9% were due to TCMs. Majority (70-75%) of the ACDRs were of mild to moderate severity. The most common ACDR to TCM was Exfoliative Dermatitis (ED) and Acute Generalized Exanthematous Pustulosis (AGEP) (both 16.7%) while maculopapular rash was the most common reaction for conventional medications (25.5%). The onset of adverse reaction to TCM was about 4 weeks (60.2%) while reactions due to conventional medication was earlier (1 to 6 days, 65.4%; p
Bacteraemia is a common and one of the serious complications in haematopoietic stem cell transplantation (HSCT). To date, there are no published data on antibiotic resistance and clinical outcome among HSCT recipients in Malaysia. The aim of the present study was to analyse the prevalence, antibiotic resistance and clinical outcome of bacteraemia in HSCT recipients, within 100 days following transplantation. We retrospectively analysed the prevalence, antibiotic resistance pattern and mortality rate of early bacteraemia among HSCT recipients in a single centre over a 5-year period (2013-2017). Thirty patients of 85 HSCT recipients developed bacteraemia with 40 positive cultures resulting in prevalence of 47% (40/85). Gram negative bacteria (GNB) accounted for 60.5% of total isolates. Enterobacteriaceae and Coagulase negative Staphylococcus (CoNS) were the commonest pathogens isolated. GNB showed a high resistance rate to ciprofloxacin. Only 30% of recipients responded to first line empirical antibiotics for febrile neutropenia (FN). The mortality rate was 13.3% (4/30), of which 50% was attributed to multi-drug resistance (MDR) Acinetobacter and 25% to extended spectrum beta-lactamase (ESBL) Enterobacteriaceae. Bacteraemia is a frequent and life-threatening early complication among HSCT recipients with MDR GNB being the commonest cause of mortality. The high rate of resistance to ciprofloxacin and failure of the first line empirical antibiotics to treat FN calls for a thorough evaluation of the current antibiotic prophylaxis and empirical treatment protocols. These findings have important clinical implications regarding the use and selection of both prophylactic and empiric antibiotic regimens to treat FN.
Point-of-care testing (POCT) of cardiac troponin device is aimed for improvement in turn round time (TAT) and assist in acute management care of acute coronary syndrome (ACS). The present study was conducted to assess the analytical performance and correlation of HUBI-QUANPro troponin I with an existing laboratory instrument of high-sensitivity troponin I, Abbott Architect. The factors that were studied, included precision study by using manufacturer quality control (QC) material (2 levels) and correlation study of sample differences (whole blood, plasma and serum) and methodology (immunochromatographic assay and chemiluminescent immunoassay). A total of 30 QC was used for precision study and 42 sample serum and EDTA for the correlation study. An acceptable total imprecision of 10.9% and 6.7% were seen at level of 0.91 ng/mL and 2.66 ng/mL, respectively. Regression analysis of sample differences (plasma vs whole blood) in HUBI-QUANPro showed slope of 0.935, r=0.991 (p=
Heart failure is a physically debilitating and psychologically distressing chronic condition. Although depressive disorder is a strong predictor of short-term deterioration of heart failure symptoms and mortality, only few studies have focused on habit and daily routines. The present study aimed to investigate the relationship between depression and anxiety and heart failure patients’ self-care behaviour. Interviews were completed with 161 patients at hospital outpatient clinics in Belfast and Dublin. Depression and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS). Self-care behaviour was assessed using the European Heart Failure Self-Care Behaviour Scale (EHFSCBS). ‘Probable’ clinical depression was indicated in 18%, and ‘probable’ caseness of anxiety disorder in 16% of patients. Self-care behaviour adherence varied considerably across behaviours and was higher for taking medication as prescribed (93.1%), and taking it easy if breathless (75.1%) and lower for daily self-weighing (13.6%), regular exercise (33.6%) and limiting fluid intake (38.5%). No significant relationship was found between overall reported self-care adherence and anxiety or depression. However, significant association with depression were found for five of the 12 self-care items, and also with anxiety for two of these. Our results demonstrated that mental well-being in patients with heart failure plays a significant role in the patients’ ability to adhere to self-care regimens.
Among diabetic patients, fasting is associated with increased risk of ketoacidosis, hypoglycaemia and dehydration. Previous randomised controlled trials and prospective studies have shown that intensive pre-Ramadan education on fasting is able to help patients fast successfully during Ramadan. At the same time, observational studies show that many diabetic patients are still able to fast successfully throughout Ramadan despite deficiencies in knowledge about fasting practices. We conducted a retrospective recall study in Klinik Kesihatan Jalan Perak, Penang to determine the factors associated with successful fasting. Patients were selected using convenience sampling. Successful fasting was defined as a patient fasted as intended, and not having to break-fast due to hypo/ hyperglycaemia symptoms or hospitalization due to diabetic complications. Multiple logistic regression was used to determine independent factors associated with successful fasting. 113 patients were enrolled. 70.9% (n=80) of patients were able to fast successfully. Knowing the name of their diabetic medications were significantly associated with successful fasting (AOR=8.56, 95%CI: 2.04;35.8, p=0.003). Knowledge and fasting practices were not associated with successful fasting. We may identify patients who might not fast successfully by evaluating their understanding of their diabetic medications. They can then be targeted for further pre-Ramadan counselling. Nonetheless, an intensive pre-Ramadan counselling is still optimal if resources are available.
Pharmacology teaching during preclinical years is important for medical students to make rational choices in choosing suitable treatment for patients in future. Therefore, the present study determined the adequacy and effectiveness of pharmacology teaching in the undergraduate medical program at the Universiti Kebangsaan Malaysia Medical Center (UKMMC). Suggestions for improvement of the curriculum were also identified. An online questionnaire on the perceptions of pharmacology teaching methodology was distributed to a total of 459 medical students in 4th and 5th year at UKMMC. The questionnaire covered demographics, perceptions about pharmacology teaching, the ideal teaching learning methodology for learning pharmacology, pharmacology topics which are useful for future clinical practice, the pharmacology topic which was most interesting and recommendations for improvement. The response rate was 46.4% and majority of the participants were females (65.7%). Most of the students agreed that interactive learning was more helpful than didactic lectures (88.0%). Seventy percent of the students reported that pharmacology lectures in the preclinical years were helpful during the clinical years. Percentage of students who agreed that pharmacology teaching in their preclinical was adequate for their clinical practice was 47.0%. There was no association between demographic variables (gender, race, year of study and medical family background) and interest in pharmacology (p>0.05). In conclusion, the pharmacology teaching during preclinical years was perceived to be effective and useful for students’ clinical practice. More pharmacology teaching sessions in clinical years was suggested which may improve adequacy of pharmacology teaching.
This prospective crossover study compared the incidence of posterior vessel wall puncture between two approaches during ultrasound-guided simulated central venous cannulation by anaesthesiology trainees. Each phantom model, simulating a central vein and artery, was cannulated by 37 anaesthesiology trainees under ultrasound-guidance using the in-plane approach (IPA) and out-of-plane approach (OPA). Total procedural time and the time taken from starting image scanning until commencing puncture, was recorded. The number of attempts required to achieve successful venous cannulation was noted. Finally, the models were examined for posterior venous wall and arterial puncture. Total procedural time was shorter with the OPA (26.5 vs 50.3 seconds, p=0.001). The time taken from starting image scanning until commencing puncture was shorter for the OPA (2.2 vs 12.3 seconds, p
Chronic myeloid leukemia (CML) patients who have BCR-ABL T315I mutation, usually present in the advance phase of the disease with overall survival (OS) shorter than those without the mutation. This study aimed to determine the prevalence of T315I mutation amongst imatinib mesylate (IM) resistant CML patients and to compare the OS between T315I-mutated and non-T315I-mutated patients. Sixty consecutive CML patients who were treated with IM for at least 18 months and their treatment responses, were recorded. The mutation analysis was done using allele-specific oligonucleotide reverse transcriptase-polymerase chain reaction (RT-PCR) assay followed by direct sequencing technique. Forty-two patients (70%) were found to have IM-resistance. Five out of 42 patients had detectable T315I mutation. Median OS of IM-resistant T315I-mutated patients was 96 months (95% CI:54-138) compared to 84 months (95% CI:48-120) in non T315I-mutated patients, although this was found to be statistically insignificant (p = 0.43). The present study showed a higher prevalence of T315I mutation as compared to a few local studies. Median OS of T315I-mutated patients were observed to be longer than non-T315-mutated patients. Further studies encompassing larger cohort of patients are required to confirm this finding.
Cardiopulmonary capacity should be evaluated accurately to determine exercise intolerance and training intensity of stroke survivors before an exercise rehabilitation programme is prescribed. However, no cardiopulmonary exercise test (CPET) is suitable because of the stroke victims’ physical impairment. The aim of this study was to develop and validate a new rowing-ramp protocol as a CPET for stroke survivors. Eleven stroke patients (6 male; 5 female; age, 45 + 16.01 years, performed two incremental exercise tests on a Concept II rowing ergometer to determine the peak oxygen consumption (VO2 peak). Test-retest reliability for VO2 peak, measured 1-week apart, resulted in an intra-class correlation of 0.97 and 0.95, respectively. A linear regression equation was developed to predict the VO2 peak from final stage stroke power. Validity and reliability of the prediction equation were established. The regression equation for predicted VO2 peak was VO2 peak=11.429±+ 0.232 (Final Stage Stroke Power) + 12.63 (F=25.326, p
Charcot arthropathy is a devastating degenerative condition which affects one or more joints that is marked by joint instability, hypermobility resulted from peripheral nerve damage. This was a retrospective study performed on patients who were diagnosed with Charcot arthropathy and those underwent surgery for hindfoot arthrodesis at Universiti Kebangsaan Malaysia Medical Centre from January 2011 until June 2016. The objective of the study was to review the feasibility of an algorithm in managing Charcot arthropathy and to assess functional, clinical and radiographic outcomes of Charcot arthropathy joints treated with hindfoot arthrodesis, at least 6 months follow-up using standardized and internationally accepted scoring systems, which were the American Orthopaedic Foot and Ankle Surgery (AOFAS) score and SF36. A total of 16 patients were included in this study of which 4 (25%) were males and 12 (75%) were females. The mean age was 58.1 (20-71) years. There was equal distribution for side of fusion. We achieved union in 13 out of our 16 (81%) cases followed up. Out of the 3 patients with non-union, 2 were attributed to deep infections. The AOFAS scores for hindfoot and midfoot showed significant improvement post operatively with p-value
Most spider species in Malaysia are considered harmless and spider bites are rarely reported. This is partly due to the mild effects from the bite and victims do not seek medical treatment in the hospital. To date, there are few well-documented cases of medically significant bites from indigenous spider species in Malaysia. Here, we report the presentation, clinical management and outcome of two patients following a bite by the yet to be described ‘Black & Gold’ Huntsman spider from the genus Thelcticopis in Malaysia. The first case involved a 42-year-old man who was bitten on the tip of the distal phalanx of his right middle finger and presented with severe pain and local swelling. He was treated symptomatically and was discharged well. The second case involved a 57-year-old woman, who was bitten on the proximal phalanx of her right little finger and presented with severe throbbing pain and progressive swelling. She was treated symptomatically and was discharged after 24 hours observation in the medical ward. However, she noted moderate neck and generalized joints pains especially affecting the hips and knees, one day prior to discharge. She was treated with oral analgesia and symptoms resolved within two days.
Acute retinal necrosis (ARN) is a rare, blinding disease that typically affects adults. However, in this case report, we highlight the diagnosis, management and outcome of herpes simplex acute retinal necrosis in a 13-year-old healthy girl, who presented with painful right eye, redness and blurring of vision for one week. Examination of the right eye showed features of granulomatous panuveitis. Optic disc was swollen and retina appeared pale. There were multiple patches of retinitis and haemorrhages at mid-periphery of the fundus with inferior serous detachment observed. Rapidly progressive inflammation in just four days along with secondary cataract that obscured fundus view, imposed greater challenge to the diagnosis and management. Intravenous acyclovir 300mg, 3 times a day was initiated promptly while vitreous fluid was sent for polymerase chain reaction, which identified Herpes Simplex Virus-1. Inflammation improved, but she developed vitreous haemorrhage secondary to proliferative retinopathy, which required panretinal photocoagulation. ARN is therefore, principally a clinical diagnosis and high index of suspicion is crucial particularly, in children for prompt diagnosis and treatment. Complications should also be addressed timely to improve the chances of preserving vision.
Orbital cellulitis is an infection of the orbital soft tissue that could possibly lead to serious complications if treatment is delayed. It is important to differentiate this condition from a less life-threatening condition like preseptal cellulitis as orbital cellulitis would require a more aggressive treatment than the former condition. The present case discusses about a patient who was diagnosed with orbital cellulitis and developed complications from the disease. The delayed administration of the appropriate antibiotic subsequently led to the patient’s death. The delay was because of the reason that the patient belonged to the immunocompromised group who harbour different causative organism than the normal population.
Data on knowledge, attitude and ST Elevation Myocardial Infarction (STEMI) electrocardiography (ECG) detection among pre-hospital paramedics in Malaysia is still scarce. It is imperative to gain this information as a pre-requisite in initiating pre-hospital thrombolysis. This was a descriptive study conducted from May 2016 until November 2017 on paramedics from Universiti Kebangsaan Malaysia Medical Center (UKMMC) and Kuala Lumpur Hospital (HKL). It was to assess knowledge on pre-hospital thrombolytic therapy and ECG detection of STEMI. One hundred and six questionnaires were answered and analyzed. More than 60% of the candidates were unable to detect STEMI ECG changes and lacked of confidence in handling and administering thrombolytic treatment at the level of pre-hospital phase. Only 20.8% candidates managed to detect more than 8/10 of the correct ECG pattern in STEMI. Less than 40% of the candidates achieved more than 80% marks in answering questions regarding STEMI and treatment. It is concluded that the overall performance and knowledge of paramedic regarding pre-hospital thrombolytic therapy is generally poor. Further training need to be done prior to implementing pre-hospital STEMI thrombolytic therapy in Malaysia.
Solitary fibrous tumour (SFT) is a fibrotic neoplasm, also previously designated as hemangiopericytoma. STAT6 is a protein for signal tranducers and activators of transcription (STAT) family which is involved in immune function and early cell growth. Oncogenic alteration of STAT6 plays an important role for specific driver for tumour genesis of solitary fibrous tumour via NAB2-STAT6 fusion gene. The aim of the study was to compare and evaluate STAT6 expression between SFT and other soft tissue histological mimics. We evaluated a total of 30 cases material formalin fixed paraffin embedded tissue block previously diagnosed SFT cases (n=14) and soft tissue tumours mimic cases (n=16) over period of 15 years. Fourteen SFT cases (100%) showed nuclear expression of STAT6, which was diffuse and intense. All other tumour types were negative for STAT6, except for one case of dedifferentiated liposarcoma, one gastrointestinal stromal tumour and one spindle cell lipoma, which showed weak non-specific cytoplasmic staining. Nuclear STAT6 expression is useful and reliable as adjunctive marker for solitary fibrous tumour when the diagnosis is inconclusive by conventional methods.
Gelatin has been frequently used in tissue engineering scaffold due to its favorable biological properties in wound healing enhancement. Genipin, a natural compound derived from Gardenia plants, was shown to be effective in improving physicochemical characteristics of the gelatin scaffold. This systematic review reported the utility of genipin as a crosslinker in gelatin scaffold fabrication. Two electronic databases, namely Scopus and MEDLINE via Ebcoshost were searched for publication between January 1999 and December 2018, using the keywords ‘gelatin’ and ‘genipin’. Articles published in English, reporting the utility of genipin in the fabrication of gelatin sponge were included. The keywords search yielded 830 articles, in which 14 articles were selected and examined in this review. The result of the search provided input in terms of the optimum concentration, crosslinking temperature, and fabrication method of genipin to be used. From the literature, it was found that 0.5% is the optimum genipin concentration and 25˚C is the optimum crosslinking temperature. The result also revealed a gap in the knowledge regarding genipin crosslinker and justifies the need to create awareness of the utility of genipin as a gelatin scaffold crosslinker. The current review provides an extensive overview on the current knowledge on genipin crosslinking and be a guide to an optimal fabrication of the genipin-crosslinked gelatin scaffold.