IIUM Medical Journal Malaysia (IMJM)
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The Spine Crasher: A Challenging Diagnosis
Get PDFIntroduction: Spinal tuberculosis in children is an established preventable disease in developing countries. Complications are devastating due to its aptitude to cause bone destruction, spinal deformity and paraplegia. Case report: We present an eight-month old girl with isolated gross motor regression and evolving spastic paraplegia. It highlights the challenge we encountered due to delay in garnering the pertinent investigation. She presented to clinic with history of legs weakness and loss of rolling after a period of prolonged febrile illness. Both parents are medical practitioners. Mother had history of SVT during pregnancy in spite on anti-arrhythmic treatments. Her father is a thalassaemia carrier. A thorough examination revealed gross motor delay and upper motor neuron signs. She had raised inflammatory markers, anaemia and thrombocytosis with persistent low-grade temperature. CT brain with contrast showed meningeal enhancement. Full septic work up revealed the CSF result reflecting partially treated meningitis. She was treated with third generation cephalosporin and acyclovir. Mother claimed exposure to TB patients hence Mantoux test was recommended which came positive. Her chest x-ray, sputum culture, CSF culture and NAA studies came non-conclusive for pulmonary tuberculosis. MRI for brain and spine showed features of tuberculous spondylodiscitis of T4-T5 vertebrae with associated subligamentous paravertebral spread and epidural extension causing spinal cord compression and T3-T6 hydro-syringomyelia. After multidisciplinary team discussion, patient started on intensive antituberculosis regimen with good initial response. Discussion: Clinically lower limbs power improved with good antigravity movement. Laboratory and radiological investigations have improved inflammatory markers and dropping trend thrombocytosis, and spinal gibbous stay stationary with improvement in plain radiology. She is under regular follow up awaiting serial MRI. Conclusion: The challenge in diagnosis of extra pulmonary tuberculosis in infants is getting them excluded early. High index of suspicion along with radiological investigation is vital to aid the diagnosis and establishment of treatment to expect a good outcome
The Prevalence of High Risk of Obstructive Sleep Apnea and its Association with Sociodemographic Factors among Adults in Taman Dato' Rashid Salleh, Indera Mahkota, Kuantan
Get PDFIntroduction: Obstructive sleep apnea (OSA) is an insidious sleep breathing disorder, with cardinal manifestations of snoring, witnessed breathing pause during sleep and excessive daytime sleepiness. The aim of the study was to estimate the prevalence of OSA and its associated factors among adult population in Taman Dato’ Rashid Salleh, Kuantan. Materials and method: A cross-sectional study was carried out among 157 participants who lived in Taman Dato’ Rashid Salleh from May 2018 to June 2018. Obstructive sleep apnea was quantified using the self-administered Malaynvalidated Berlin questionnaire which apart from the demographic data included three categories (10 questions) designed to elicit information regarding snoring (category 1), daytime somnolence (category 2) and the presence of obesity and/or hypertension (category 3). The respondents were considered as high risk of OSA if two or more categories were positive. Weight, height and neck circumference were measured by using Secca© weight scales, Secca© stadiometer and non-elastic plastic tape, respectively. Descriptive statistics was used to measure the prevalence, while chi-square test was used to explore the association of OSA and its background variables. Results: Out of 157 respondents, female and Malay were dominant with the 56.7% and 91.0 %, respectively. The mean age of the respondents was 36.7 (12.2) years old. The prevalence of high risk of OSA in was 18.5%. There was no association between gender, age, race, smoking and neck circumference with risk of OSA while Body Mass Index (BMI) and hypertension were significantly related to an increased risk for developing OSA (p-value < 0.001 and p=0.001, respectively). Conclusions: Two in every 10 adults in Taman Dato’ Rashid Salleh, Kuantan were at high risk of OSA. It is recommended that appropriate health promotion should be targeted to this community to instill awareness and increase the level of understanding of the public on OSA
Increasing Neonatal Healthcare Productivity using Clinical Reasoning Coaching Tools
Get PDFIntroduction: Productivity in medical field has inherent value in terms of improving our lives, which can expand our economies. Productivity in medicine has many aspects including improving clinical diagnostic skills, safety, and quality and quantity care. This study will assess whether early exposure to structured clinical reasoning coaching tools would improve their clinical decision making and productivity. Research question: Does clinical reasoning coaching tools Increase neonatal healthcare productivity? Materials and method: Medical practitioners recently joined neonatal units will participate over 2 years in an innovative series of clinical reasoning coaching sessions blended with virtual patients. Practitioners will be exposed to many teaching methods during the neonatal training that includes lectures, bedside teaching sessions and small group discussions beside website continuous contact for learning and chairing skills. Teaching series scope should cover resuscitating sick neonates, handling ventilators either conventional or high frequency, practicing common neonatal procedures, dealing with common neonatal scenarios, infection control policy and, effective communication skills The evaluation sessions will be introduced at the beginning of their training, during the course and at the end of the clerkship to assess their improving productivity, using diagnostic thinking inventory(DTI). Selection of the medical practitioners will be based on either on stratified random sampling or cohort control depending on the funding and logistic. All items will be analysed advanced statistical analysis methods. Results: The coaching tool may yield dramatic impact, allowing the innovators to be more productive. Suggesting widely utilize it for nurses, undergraduate and postgraduate medical Subspecialty. Conclusion: The research hypothesis is assuming that DTI scores and productivity will be higher after the coaching sessions as rated by the candidate’s performance
Prevalence of Pediculosis and Its Predictors among Urban Primary School Children in Kuantan, Pahang
Get PDFIntroduction: Pediculosis capitis among primary school children is always known as the problem of the lower socio-economic class and rural communities. It carries significant consequences to the school children and caregivers. Limited studies have been conducted among the urban populations. Thus, this study aims to investigate the prevalence and predictors of Pediculosis capitis among Urban primary school children in Kuantan. Materials and method: An analytical cross-sectional study using cluster random sampling was carried out in Kuantan, Pahang, Malaysia. A selfadministered validated questionnaire was issued to the participants with purpose to collect socio-demographic data related to age, gender and factors that associated with head lice infestations among primary school children from standard one to six. It was then followed by hair and scalp examination by a well-trained examiners to check the infestation status. The results were analyzed using the chi-squared test and logistic regression analysis. Results: A total of 1347 students from 5 schools were included in this study. Majority of them were males (53.6%), Malays (61.0%), household income between RM1000-RM2999 (32.1%). The overall prevalence was 9.1% (n=122). Multivariate analysis showed that predictors for pediculosis capitis were female gender (OR= 6.02, 95% CI= 2.97-12.21), Indian ethnicity (OR= 5.55 , 95% CI=3.26-9.45), sibling of more than 5 (OR= 2.72 , 95% CI=1.04-7.12) and contact with infested person (OR=2.42, 95% CI=1.58-3.71). Conclusion: The prevalence of Pediculosis capitis among urban primary school children in Kuantan, Pahang is endemic (9.1%) and predictors are female genders, Indian ethnicity, having siblings of more than 5 and contact with infested person. Hence, preventive measures are necessary to reduce the transmission of head lice among school children
Splenic Pseudocyst by Aeromonas Salmonicida in Adolescent an Isolated Occurrence: A Case Report
Get PDFIntroduction: Aeromonas Salmonicida is a rare type of the causative agent for splenic pseudocyst. We are reporting a case of splenic pseudocyst treated with deroofing of the cyst wall. An adolescent presented to us with a history of abdominal pain, fever, and loose stool for 3 days and was investigated. Computed tomography showed huge cystic mass arising from the inferior pole of the spleen. The adolescent underwent laparotomy, drainage of splenic cyst, and deroofing of cyst wall. The culture of Aeromonas Salmonicida was growth in the cyst content. To the best of our knowledge, this is the first case of such nature
Factors Associated with Pediculosis Capitis among Primary School Children in Kuantan, Pahang
Get PDFIntroduction: Pediculosis capitis among primary school children is a worldwide problem which carries significant consequences among the school children and caregivers. Despite causing significant health problem which needs to be intervened, only few studies were conducted in Malaysia and there is no previous study conducted in Pahang. Thus, this study aims to investigate the determinants of prevalence of Pediculosis capitis among primary school children in Kuantan, Pahang, Malaysia. Materials and method: An analytical cross-sectional study using cluster random sampling of primary schools was carried out in Kuantan. Selfadministered validated questionnaire was used followed by hair and scalp examination. Multivariate logistics was done to determine the predictors and to control for confounding effect. Results: The overall median age of the 1,365 respondents was 8.0 years. Majority of them were males (53.41%), Malays (60.29%), household income between RM1000-RM2999 (31.87%) and from urban school location (98.68%). The overall prevalence of Pediculosis capitis was 9.6% (n=131). Multivariate logistic regression analysis showed that female (Odds ratio (OR)=8.571, 95% Confidence interval (CI)=5.024-14.620), Indian (OR = 5.560, 95% CI=3.3849.136), those who had number of siblings more than five (OR = 2.644, 95% CI=1.0446.700), history of contact with infested person (OR=2.445, 95% CI=1.619-3.691) and urban school location (OR=0.030, 95% CI=0.284-0.091) were predictors for Pediculosis capitis. Conclusion: The prevalence of Pediculosis capitis among primary school children in Kuantan, Pahang is endemic(9.6%) and predictors are female, Indian, having siblings of more than 5 and contact with infested person. Hence, preventive measures are necessary to reduce the transmission of head lice among school children
Perioperative Hyperglycemia as a Risk Factor for Early Surgical-Site Infection in Stable Trauma Patients in Orthopedic Unit
Get PDFIntroduction: Perioperative hyperglycemia resulted from known diabetes mellitus, occult diabetes or stressed-induced hyperglycemia. It is associated with increasing risk of surgical-site infection (SSI). This research is to evaluate relationship between perioperative hyperglycemia and early SSI in stable trauma patients with orthopaedic injuries. Materials and method: We conducted an observational cohort study in Hospital Sultanah Nur Zahirah, Kuala Terengganu over 15 months. We included patients 18 years and older with operative orthopaedic injuries and excluded those with steroid use, multisystem injuries, critically ill or unstable and patients with perioperative infection. Demographics, medical comorbidities, body mass index, type of fracture, HbA1c level in diabetic patients and length of hospital stay were recorded. Fingerprick glucose values were obtained twice daily. Hyperglycemic index (HGI), an area under the glucose curve above the normal range divided by the length of stay, were calculated. Perioperative hyperglycemia was defined by HGI greater than 1.76. SSI was defined by gross purulence or positive intraoperative culture at reoperation within 30 days. The categorical data were analysed using chi square test while continuous data were analysed using T-test. Results: Total of 90 patients, 15-diabetic and 75 non-diabetic. 10 diabetic and 1 non-diabetic patients were hyperglycemic (p=0.001). Perioperative hyperglycemia was associated with mean age 54.3 year old, having 1 or more co-morbidity or mean admission glucose 13.1 mmol/L (p=0.001). There were 12 early SSI giving infection rate 13.3%. Early SSI was associated with HGI 1.76 and more (p=0.001), patients with 1 or more co-morbidity (p=0.006), mean admission glucose of 9.63 mmol/L (p=0.001). Conclusion: Our study showed perioperative hyperglycemia in stable trauma patients with orthopaedic injuries were associated with SSI. More patients are needed to find association of other variables and more studies are required in determining the acceptable glucose level and optimal treatment of perioperative hyperglycemia in stable trauma patients
Synchronous Gastrointestinal Stromal Tumor (GIST) of the Rectum And Jejunum: A Rare Case Report
Get PDFIntroduction: GIST are rare tumor and uncommon to occur in rectum where it accounts about 5% of all GIST [1] and rarer to develop simultaneously. Several surgical options are available, large tumours with aggressive features have been commonly treated with abdominoperineal resection.This is the first reported case of synchronous GIST of the rectum and jejunum. Case report: 66 year old man who presented with rectal bleeding and altered bowel habit. Colonoscopy revealed submucosal tumor on anterior wall of the rectum. Computerized Tomography (CT) of abdomen and Magnetic Resonance Imaging (MRI) of pelvis demonstrated a mass of approximately 88 AP x 88 W x 89mm CC in size on the anterior wall of the rectum at a distance of 2.3 cm from the anal verge, without any invasion to the prostate or evidence of metastasis, Histological examination of the biopsy sample via the rectum showed spindle cell neoplasm suggestive of GIST. An abdominoperineal resection was performed with wedge resection of small bowel lesion who discovered intraoperatively as yellow mass measuring 1.5 cm in its diameter involving the serosa. Histopathological examination of the sample confirmed the diagnosis of GIST of both rectal and small bowel specimen with positive CD117 on immunohistochemical assessment. Patient recovered post operatively. Discussion: Incidence of GIST as overall are about 1/100000 per year and commonly found in stomach (60-70%), small intestine (20-25%) but rarely occur in rectum (5%). Because of the low incidence of rectal GISTs, cases of simultaneous development of a GIST in rectum and jejunum are scarce. Simple coincidence could be the reasonable explanation in our case. For rectal GIST, surgical procedures may be considered, including abdomino-perineal resection. Conclusion: Simultaneous GISTs in the rectum and jejunum is extremely rare. Resection is the treatment of choice, suspicious lesions discovered during operation should be biopsied or removed as GIST could appear synchronously
Infected Pseudoaneurysm in a Tertiary Centre: A Retrospective Audit
Get PDFIntroduction: Infected pseudoaneurysms among intravenous drug abusers are a serious clinical condition that carries significant morbidity and mortality. The management of such cases has been controversial on deciding the need of revascularisation following simple ligation and local debridement. In this audit, we present the results of simple ligation and local debridement of our patients with infected pseudoaneurysm. Materials and methods: We conducted a retrospective review from 2013 to 2018 on 15 of our patients who are intravenous drug abusers that underwent simple ligation and local debridement for an infected pseudoaneurysm. Results: All 15 patients underwent simple ligation and local debridement. They were all male patients, and majority of the patients were between group ages of 30-40 years old at 66.7%. The oldest patient was 63 years old. All the patients self-injected the affected site for a minimum duration of 36 months. 73% of the patients had femoral pseudoaneurysm, making it the most common affected site in our audit. The remaining patients had axillary and radial pseudoaneurysm and none of our patients had brachial pseudoaneurysms. Majority of our patients were underlying Hepatitis C at 46.7%, 2 of our patients were HIV positive and only one had Hepatitis B. The remaining 5 patients’ statuses were unknown. In accessing the complications, two patients had re-bleeding after the procedure and were eventually discharged well and were uneventful. One patient required amputation as he developed a gangrenous limb within the same admission after ligation and excision of the infected pseudoaneurysm. There were two deaths due to sepsis with multiorgan failure. 10 patients were discharged well without any complications after surgery. Conclusion: Infected pseudoaneurysms can be safely managed with simple ligation and local debridement without revascularisation as they pose acceptable complication rates
Diabetic Foot Care Practice and its Associated Factors among Type 2 Diabetes Mellitus Patients Attending Primary Health Clinics in Kuantan, Malaysia: A Cross Sectional Study
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INTRODUCTION: One of the most important and debilitating complication of diabetes mellitus is foot problem such as ulcers, infections and amputations. However, these complications are preventable by simple intervention such as regular foot care practice. This study aims to assess the foot care practice and its associated factors among type 2 diabetes mellitus patients attending primary health clinics in Kuantan. MATERIALS AND METHODS: This was a cross-sectional study conducted at four primary health clinics in Kuantan involving 450 study participants who were selected by using universal sampling method. Level of awareness and practice toward diabetic foot care was assessed using validated self-administered questionnaire. Multiple logistic regressions were performed to identify factors associated with poor foot care practice among the respondents. RESULTS: About 59.6% of respondents had poor foot care practice and 50.9% had poor awareness level. Multivariate logistic regression analysis identified that, increasing age (OR 0.97, 95% CI: 0.955-0.993) and good awareness towards foot problem (OR 0.43, 95%CI: 0.289-0.643) were less likely to have poor foot care practice. However, Malay ethnicity (OR 1.81, 95% CI: 1.002-3.271) and obesity (OR 1.9, 95% CI: 1.225-2.976) were associated with poor foot care practice after controlling other variables. CONCLUSION: Majority of the respondents had poor foot care practice and poor awareness. Respondents who are older and have better awareness are less likely to have poor foot care practice. Diabetic patients who are Malays and/or obese are predicted to have poor diabetic foot practice and hence must be prioritized for a sustainable patient education and compliance towards foot care practice at primary care level.