Intrauterine infection has emerged to be the main and frequent cause of premature delivery and foetal demise. Microorganisms gain entry into the amniotic cavity via ascending route, haematogenous dissemination, retrograde seeding from peritoneal cavity and accidental introduction during invasive procedures. This is a case of foetal loss in utero from a twin pregnancy due to intrauterine sepsis diagnosed through placenta examination. Both maternal and foetal evidences of inflammatory response were demonstrated in the placenta on histology. Microscopically, there were acute chorioamnionitis and villitis as well as abundant gram positive cocci in the foetal blood within placental villous capillaries. The presence of intravascular bacterial organism provides evidence for a conclusive diagnosis of intrauterine sepsis, particularly where the placenta or foetal blood microbiological cultures results are not available or equivocal. More attention should therefore be given when sampling, as pathological evidences of underlying foetal compromise or death could be provided by well-represented placental tissue samples.
Dandy-Walker syndrome is a rare congenital malformation of the brain that involves the cerebellum and the fourth ventricle. It is characterised by a classical triad of hydrocephalus, cystic dilatation of the fourth ventricle and complete or partial agenesis of the vermis. Majority of cases are diagnosed during neonatal or early infantile period. In this case report, a seven-year-old boy complained of recurrent headaches for the past one year. Physical examination was unremarkable. Examination of the fundus on the same day revealed bilateral papilloedema. His subsequent computed tomography scan of the brain done at a major district hospital demonstrated features in keeping with Dandy-Walker malformation. Our case highlighted the importance of embarking on a detailed and thorough approach when dealing with a child with chronic headache, especially in rural settings where advanced medical equipment is not readily available.
Xylazine is an alpha-2agonist often used as a sedative, analgesic and muscle relaxant agent
in animals. Xylazine was not accepted by Food and Drug Administration (FDA) for human use
due to hazardous side effect such as hypotension, bradycardia, respiratory depression and coma.
This is a rare case report of a 64-year-old farmer who accidentally injected himself with Xylazine
which was supposed to be given to a fractious cow. He developed altered conscious level, hypotension, bradycardia and respiratory failure requiring mechanical ventilation. Fortunately, he
recovered and was discharged home after three days. This occurred due to improper handling of
Xylazine without standard operating procedures. Xylazine is regulated for animal use only. Therefore, effects of Xylazine toxicity in human must be emphasized for awareness on proper handling as well as for right management of its poisoning incident in future.
Obscure gastrointestinal bleeding is a surgical enigma of disastrous proportions. Patient’s haemodynamic status often dictates the path of management ranging from endoscopy, embolization and/or surgery. Minority of the cases has failed to identify the exact source of bleeding during endoscopic and imaging techniques. Emergency surgery is warranted in hypovolaemic shock which has failed to respond to fluid and blood resuscitation. We present a 72-year-old male with an obscure upper gastrointestinal bleeding due to ruptured cystic artery pseudoaneurysm and illustrate the rarity of the presentation with successful management.
Purple urine bag syndrome (PUBS) is a rare presentation of urinary tract infections (UTIs). It is commonly seen in constipated patients. There is a deep purple discoloration of contents of urine bag due to presence of indigo and indirubin pigments which are metabolites of tryptophan. We would like to describe an interesting case of purple urine bag syndrome of 88-year-old woman who presented with catheter-related urinary tract infection. She had low-grade fever and suprapubic discomfort for three days duration. She had increased white cell count and C-reactive peptide (CRP). Urinalysis showed protein 2+, nitrite and leucocyte esterase positive. Urine culture grew Escherichia coli and Klebsiella pneumoniae. She was treated with oral cefuroxime and recovered. This case report may be the first case of PUBS reported in this region.
Reconstruction of hand injury is the challenge for the surgeon especially in rural settings. This case report is about a 10-year-old boy, who sustained large degloving wound of dorsum of right hand with extensor tendon injury following a road traffic accident. We performed a staged abdominal flap with tensor fascia lata graft for tendon reconstruction as microsurgery facilities was not available. Post-operatively he was subjected to physiotherapy and he has a functional right hand. This case report aimed to highlight abdominal flap as reconstructive option as compared to skin grafting which is reproducible with limited resources. Besides that, overall exposure to all surgical options is of paramount importance in the training of trainees to equip them with skills to serve in rural setting.
Medication errors (MEs) are preventable mistakes that occur when there is a failure in the treatment process of any disease that can cause potential harm to patients. Having an effect on patients, health outcomes and costs incurred, it does burden our economically-developing country. Database systems have been created worldwide for the reporting of MEs, but varying countries practise different classifications of MEs hence it poses a challenge to categorize them. This makes it next to impossible to fully curb this continual problem. There are a number of classifications of MEs, based on mistakes and errors based on skills, based on the mistakes itself, based on symptoms and based on the stages of drug delivery system. This review summarizes the pre-existing classifications of MEs.
Rowing exercise is one of the cardiorespiratory exercises that induce higher aerobic capacity. Cardiorespiratory parameters, cardiac output (CO), stroke volume (SV), and heart rate (HR) are indicators to measure one’s cardiorespiratory fitness. The aim was to study the effects of 12-week rowing training on resting cardiac output (RCO), resting stroke volume (RSV), and resting heart rate (RHR) of stroke survivors. Ten stroke survivors (6 males; 4 females), mean age of 43.6 ± 16.15 years, were subjected to a 12-week rowing training (Concept II Rowing Ergometer, Model C, USA). An individualised programme was prescribed based on %HRR for each of stroke individual. Rowing training was conducted twice per week (12 HIIT; 12 MR). Paired t-test and repeated measures ANOVA (RPM ANOVA) were used for statistical analyses using IBM® SPSS® Statistics 20 software. RPM ANOVA analysis showed no significant effect on RCO [F (5, 45) = 1.066, p = 0.392, RSV [F (2.188, 19.693) = 0.677, p = 0.532)], and RHR [F (5, 45) = 0.856, p = 0.518]. Paired t-test showed no significant difference between pre- and posttest despite the improved values of Mean ± Standard Deviation (RCO: 8129.50 ± 3916.31 to 8494.18 ± 6248.86 mL/min; RSV: 99.27 ± 33.98 to 121.84 ± 66.24 mL; RHR: 78.02 ± 17.39 to 77.17 ± 11.98 bpm) for all respective parameters. Twelve weeks rowing training did not improve resting cardiorespiratory parameters of stroke survivors statistically. Future studies are suggested to include gender difference and medication effect variables.
Pain management with analgaesics employs a multidisciplinary approach of clinicians towards patients. Nevertheless, preventing drug abuse and misuse in pain management is also an important goal. Understanding patients’ behaviour in the usage of painkillers may facilitate more effective communication and to educate them on the appropriate choice of painkillers. This study aimed to assess patients’ knowledge, attitude and practice towards painkillers. This was a questionnaire-based cross-sectional study conducted from February to May 2016 among patients in Tawau Hospital. Respondents were selected via convenience sampling and interviewed based on a questionnaire to assess their knowledge, attitude and practice towards painkillers. A total of 193 questionnaires with complete responses were analysed. Most of the respondents
(60.1%) obtained their painkillers from public facilities. Generally, they were very satisfied with the painkillers that they had used (36.7%). However, most of them (75.0%) did not know the name of the ingredient of the painkillers that they had taken before. They were also not aware of the side effects (73.1%) and allergic reactions (64.8%) caused by painkillers. Most of the respondents (58.5%) had not been informed regarding the side effects of the painkillers by healthcare professionals. Only 25.0% of the respondents had been asked regarding their past medical history, past medication history and allergic history by healthcare professionals before a painkiller was recommended to them. This study highlights the need of continuous efforts by healthcare professionals to inform patients of the proper use and risks associated with painkillers to improve the quality use of painkillers.
Calcineurin inhibitors, cyclosporine and tacrolimus are increasingly becoming part of the standard immunosuppresant therapies for renaltransplanted patients in Malaysia. In this study, the clinical safety and efficacy of cyclosporine and tacrolimus in a Malaysian renal-transplanted population is compared. A fourteen-year retrospective review on all renal-transplanted patients (from September 1991 to September 2015) or patients being followed up at University Malaya Medical Centre (UMMC) on cyclosporine or tacrolimus regime was conducted. We collected the clinical and laboratory parameters at 3-month, 6-month, 7-month, 8-month, 9-month, 10-month, 11-month, 12- months, 2-year and 3-year following from transplantation for each drug. The mean cyclosporine and tacrolimus trough levels were within the recommended therapeutic ranges (189.16 ± 69.10 ng/ml and 7.84 ± 2.18 mg/day respectively). The mean low-density lipoprotein (LDL) was significantly higher at eleven months for tacrolimus compared to cyclosporine. Similarly, the mean total bilirubin level was significantly higher with cyclosporine as compared to tacrolimus between 3 – 9 months post transplantation but did not show any significant difference (p = 0.49). The overall monthly means of serum uric acid levels in patients were also similar, 380 ± 87 mg/dL (cyclosporine) and 390.96 ± 95.97 mg/dL (tacrolimus) (p = 0.49). The Kaplan-Meier survival rate is significantly longer (p = 0.03) with cyclosporine-based treatment as compared to tacrolimus. Overall, cyclosporine and tacrolimus did not show any significant difference in terms of safety and efficacy parameters among Malaysian renal-transplanted patients indicating that they may be used interchangeably.
Breast cancer is the number one malignancy in women worldwide. It tends to metastasize distantly via lymphatic and haematogenous route. Skeletal metastases are frequent with more than three quarter of cases in all malignant bone tumours. Breast cancer can infiltrate the axial bone especially spine, but rarely affect the temporomandibular joint. In view of its rarity and the significance of early detection, the diagnosis is always challenging and shall be considered in the differential diagnosis. We endeavour to highlight this unfortunate 37-year-old premenopausal lady who had just undergone left mastectomy and axillary dissection but was complicated with left temporomandibular joint metastasis.
Malaysia has high prevalence of general and central obesity which can be signified by measurements of BMI and waist circumference respectively. Both parameters are established risk factors and predictors for non-communicable diseases including diabetes and hypertension. A health screening programme was conducted in a rural district of Sabah, Malaysia where a total of 42 participants were examined for weight, height, BMI, waist circumference, systolic and diastolic blood pressure, pulse rate and capillary blood glucose. Mean age of the participants was 52.4 ± 14.9 years old. General obesity based on BMI was 42.9% while central obesity based on waist circumference was 26.2%. Proportion for hypertension and hyperglycaemia were equal at 33.3%. BMI was strongly correlated to waist circumference (r = 0.873, p < 0.001). Moreover, both BMI and waist circumference were independently correlated with systolic blood pressure (r = 0.418, p = 0.006 and r = 0.383, p = 0.012 respectively). Finally, systolic blood pressure was directly correlated with weight of the participants (r = 0.350, p = 0.023). These findings were found to be closely similar and comparable to currently available epidemiological data.
The huge population of persuadable, active, healthy and young students is the potential as blood donors to meet safe blood donation. This study focused on the existing level of knowledge regarding voluntary blood donation among medical (Faculty of Medicine and Health Science) and nonmedical students with science background (Faculty of Engineering) at the Universiti Malaysia Sabah. Four hundred and fifty-five students consisting of medical (231) and nonmedical (224) were selected through stratified random sampling to participate in the study. Data was collected using validated structured questionnaire. Statistical analysis was performed by structural equation modelling using SPSS AMOS Graphics version 22 and SPSS version16. The results showed a significant (pp
Escherichia coli sequence type 131 (ST131) carries multiple drug resistance (MDR) genes as well as virulence genes. Drug resistant characteristics give a management problem to health care personnel. Four MDR Escherichia coli ST131 H30-Rx subclones were identified among 80 Uropathogenic E. coli (UPEC) isolates by using 4 allelic-specific Polymerase Chain Reactions (PCR) in two hospitals of Kota Kinabalu, Sabah, Malaysia. There is emergence of multidrug resistant E. coli in Kota Kinabalu.
Both metformin and gliclazide have been used extensively in the management of type II diabetes mellitus. Metformin and gliclazide overdose can lead to severe hypoglycaemia refractory to intravenous (IV) dextrose rescue therapy. A 21-year-old man complained of vomiting and felt dizzy after four hours of taking 70 tablets of Metformin 500 mg and 40 tablets of Gliclazide 80 mg. He had major depressive disorder and wanted to commit suicide. He was given IV Dextrose 50% 50 cc immediately. Octreotide had been used successfully to reverse the refractory hypoglycaemia caused by gliclazide overdose. Unfortunately, he developed severe lactic acidosis with acute kidney injury. Dialysis had been done by continuous venovenous haemodiafiltrationa and intravenous sodium bicarbonate 8.4% infusion was given. However, the patient succumbed due to the severe lactic acidosis and kidney failure despite of urgent dialysis. Octreotide infusion helps in preventing refractory hypoglycaemia secondary to sulfonylurea overdose by inhibit calcium-mediated insulin release. Metformin overdose causes severe lactic acidosis due to conversion of glucose to lactate. Sodium bicarbonate therapy in metformin induced lactic acidosis is also controversial. Though sulfonylurea and metformin are the most commonly-prescribed anti-hypoglycaemic agents, thus during prescribing everyone has to be careful about the overdoses and side effects of these drugs.
Colonic lipomatosis is relatively a rare tumour of mesenchymal origin, composed of welldifferentiated adipocytes interlaced by fibrous tissues. A 59-year-old lady presented with right iliac fossa pain with positive rebound tenderness, Rovsing’s and obturator signs. Investigation revealed marked leucocytosis suggestive of an acute appendicitis. Diagnostic laparoscopy revealed an inflamed appendix with concomitant caecal mass suspecting of a malignancy. Laparoscopic right hemicolectomy was proceeded following oncologic resection. However, final histopathologic examination was consistent with caecal colonic lipomatosis with concomitant acute appendicitis. Hereby, dual pathologies can be elicited in an acute abdomen.
Fat embolism syndrome is manifested by the fat globule presence in the pulmonary and systemic circulation. A 34-year-old man was involved in a motor vehicle accident with a fracture of the left femur and avulsion fracture of the left posterior cruciate ligaments. He developed signs and symptoms that suggested an early diagnosis of fat embolism syndrome. Intravenous methylprednisolone administration was administered as part of the treatment. The role of methylprednisolone in a patient with fat embolism syndrome is controversial due to unproven effectiveness. In this case, fat embolism syndrome after a femur fracture was treated successfully with methylprednisolone.
Oxidative stress is an imbalance in redox coupling
in the body. Lack of antioxidants to scavenge the
reactive oxygen species produces adverse effects
on health. The causes for an imbalance in redox
coupling are multi-factorial. Though, reactive
oxygen species are beneficial in the body, excessive
generation and lack of proper scavenging may
pose a threat. Both internal and external factors
may elevate the level. Environmental pollution is
a major contributor. Man-made chemicals such as
pesticides, heavy metals, and carbon combustion
products are blamed. Chronic exposures lead to
disease processes through oxidative stress. They
mediate pro-inflammatory cytokines and produce
free radicals. Pro-oxidant to antioxidant mismatch
leads to the adverse effects. Nrf2 activates a number
of genes that encode the antioxidants. Glutamate
cysteine ligase is activated in response to Nrf2
and it is a key enzyme for GSH production. Nrf2
functionality protects the cells from environmental
pollutants. Nrf2 mediates the antioxidant response
due to chemical insults, translocated in the cell
nucleus. Oxidative stress is known to induce a
number of diseases such as genetic abnormalities,
carcinogenesis, cardiovascular and respiratory
diseases, neuro-degeneration - Parkinson’s and
Alzheimer’s diseases. Pesticides are the major
pollutants. Studies confirm oxidative stress and
environmental pollution need to be addressed for
public welfare.
Emergence of multidrug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) is one of the reasons why tuberculosis (TB) continues to cause great mortality and morbidity in less-developed countries. The development of rapid diagnostic methods targeting genetic mutations associated with resistance to the anti-tuberculous drugs is essential to fight this deadly pathogen. Isoniazid (INH) has been included in the multidrug regimens for the treatment of drug-susceptible TB for the decades. In the worldwide setting, isoniazid resistance was highly prevalent and was observed in one of every seven TB cases. Since katG315 mutation is highly prevalent, the common mutation in the enzyme essential for the activation of the INH concerned with the mechanism of drug resistance and associated with high level resistance to INH, katG315 mutation was necessary to be identified by molecular method as a molecular determinant of INH resistant Mycobacterium tuberculosis. The prevalence of katG315 mutation in various countries was discussed in this report and a new molecular method for the detection of the mutation was proposed.
Primary pleural melanoma is a very rare condition
and highly aggressive tumour. A patient presented
with productive cough, haemoptysis, pluritic chest
pain and breathlessness. On investigation, she was
diagnosed as left-sided lung mass with pleural
effusion. Pleural biopsy confirmed malignant
melanoma of pleura and she was subsequently
referred to the oncology team for palliative
chemotherapy. In conclusion, primary pleural
melanoma remains a rare disease with no proven
effective treatment regime available.