Table of Contents
Synovial Tuberculosis Masquerading As Monoarticular Inflammatory Arthritis
Kishan Rao Subramaniam, Nor Hamizan Noor Hadi
We report a case of a young girl presented with history of swelling over right knee for a period of 3 years which clinical, laboratory investigations and initial radiographic features were suggestive of auto-immune arthritis. Subsequently an open biopsy was done, although cultures were negative for MTB or NTM, histopathological examination (HPE) reported a chronic granulomatous inflammation which was highly suggestive of Tuberculosis (TB). She received anti-tuberculosis treatment for a total of one year and noted marked improvement which was evidently shown clinically and radiograhically. Musculoskeletal TB is known to be a great mimicker of other pathology. A high index of suspicion is needed especially in a TB-prone area.
A Survey On Prevalence Of Orthorexia Nervosa And Its Risk Factors Among The Undergraduate Medical Students In Private Medical College, Malaysia.
Jacqueline Law Tze Hui, Danny Foo bin Amar Foo, Maslina binti Baktiar, Adi Aslam bin Abu Bakar, and Kreeshan a/l Murugan Suresh
Orthorexia nervosa (ON) is a new eating behaviour disorder which is characterized by pathological obsession of biological pure food, free from artificial substances such as pesticides and herbicides.  The prevalence of ON is higher among the health professions and also medical students.
To find the prevalence of ON (dependent variable) and its risk factors (independent variable) such as age, anxiety level, gender, BMI, ethnicity, vegetarian or non-vegetarian among the undergraduate medical students in private medical college, Malaysia.
This cross-sectional study was carried out from June to July 2019 among 202 medical students in Melaka Manipal Medical College, Muar, Johor, Malaysia. The research is carried out by distributing a questionnaire that consists of 3 sections, which are social-demographic details, Beck Anxiety Inventory (BAI) questionnaires and validated ORTO-15 questionnaires. Chi-Square test and multiple logistic regression were used to analyse the data and P<0.05 was accepted as statistically significant.
Out of 202 students participated in the study, 66.83% of the students are suffering ON. However, there is no significant association between age (p-value 0.073), gender (p-value 0.143), diet (p-value 0.538), ethnicity (p-value for malay, indian and others are 0.991. 0.314 and 0.057 respectively), BMI (p-value for underweight <18.5, overweight >25.0 are 0.441 and 0.526 respectively) and anxiety level (p-value for mild, moderate and severe are 0.621, 0.150 and 0.699 respectively) and ON.
Most of the medical student in the college are suffering from ON. There are no significant association between ON and the risk factors such as age, gender, ethnicity, diet, BMI and anxiety level.
Are Undergraduate Medical Students Aware of Patient’s Rights?
Tan Wee Kiong, Vanndhana Naharajan Sakarai, Nanduni Dissanayake, Matthew Edwin Ravendaran and, Darshana Ghandi Bal
Patient’s rights was established around the world as a way to uphold the safety and quality of treatment offered by the healthcare system. Due to the advancements in technology and the rising costs of treatment, the community are more aware of their rights as patients and medical staffs ought to have the same level of awareness to avoid any future medicolegal issues.
To assess the knowledge that undergraduate medical students have onf patients’ rights, a 25 component questionnaire was administered and the students were asked to respond to the questionnaire on a three-point Likert scale- Agree, Disagree and Don’t know; depending on the personal extent to which they agreed on the concerned patient right. Each correct answer was given a score of 1 and 0 for every incorrect response including the option, ‘Don’t Know’. The score was converted into percentage. If the knowledge percentage was ≥75, then the level of knowledge was categorized as adequate, and inadequate if it was <75.
Our study showed that students who were aware of patient rights’ were significantly more likely to have adequate knowledge, when compared to the students who were not aware of patient rights’ (95% CI for OR 1.09 to 3.39; P-value 0.024).
More initiative to integrate the basis of patient rights’ into the curriculum should be done as a step into the betterment of the knowledge on patient rights’ among medical staffs. Since our study only includes medical students in one private college, we would like to recommend future researchers to include general physicians, nurses and patients in their study so as to improve the standards of the health care profession.
Analysis Of Responses To Questionnaire Administered During 'Advanced Care Planning And End Of Life Care Workshop' At Hospital Raja Permaisuri Bainun, Ipoh.
Yeat C L, Kasinathan N, Chan SJ, Tan LG, Vighneshvaran R and Leong SL
A questionnaire was administered during the 'Advanced Care Planning And End Of Life Care Workshop' conducted in the Auditorium of the Ambulatory Care Centre of Hospital Raja Permaisuri Bainun on 20th January 2017 to all participants comprising Specialists, Medical Officers and House Officers to assess their knowledge, attitude and practice of Advance Care Planning during patient consultations. This report is an analysis of the responses to the questionnaire administered. The objectives of this study were in general to assess and analyze the knowledge, attitude and practice of medical practitioners on Advance Care Planning in clinical practice in Hospital Raja Permaisuri Bainun, Ipoh and specifically to determine analytically the level of awareness on Palliative Care and knowledge, attitude and practice of medical practitioners on Advance Care Planning in clinical practice in Hospital Raja Permaisuri Bainun, Ipoh. The questionnaire designed was administered to all medical practitioners who attended the workshop and was analyzed on SPSS without the personal identifiers. The 70 respondents who filled out the questionnaires comprised of doctors subdivided into 3 categories namely House Officers (38.8%) Medical Officers (36.3%) and Specialists (12.5%). Amongst the respondents, 34.3% of the respondents were males and the remaining 65.7%) were females. The minimum age of the respondents was 24 and the maximum age was 52. The mean age was 30.03 years with a standard deviation of 5.228 years. From the analysis by age, majority of the respondents were aged between 26-30 years (48.6%) followed by 31-35 years (34.3%). Only 1.4% of the respondents were aged above 50 years and 4.3% of the respondents were aged 25 years and below. Majority of the respondents were Muslims (33.3%), followed by Buddhists (30.4%) and Hindus (20.3%). Majority of the respondents had less than 5 years of work experience (66.7%) within their present designation. 18 respondents (26.1%) had 10-15 years of work experience and 7.2% had more than 5 years of work experience. there was statistically significant difference when categorical age was cross tabulated with the 9th and 11th questions with p= 0.004 and p=0.003 respectively. The 9th question was pertaining to if a patient has a right to discuss treatment options and refuse treatment even if his disease could advance and the 11th question was concerning awareness of Advanced Care Planning (ACP). There was a secondary statistically significant correlation between the Questions 1a and 1b on if the respondent has ever received teaching on managing EOL patients and the place where this teaching was obtained with p= 0.005. There was statistically significant correlation between position / designation at work and Question 6 on whether the respondent was comfortable with discussions on patient's deterioration and resuscitation status with p = 0.004. There was also a secondary statistically significant correlation between the cross tabulation of designation with Question 2a on Experience with taking care of EOL patients and 2b on number of EOL patients seen per month with p= 0.001. There was otherwise no other statistically significant difference in comparisons made between majority of the 11 questions in comparison to position / designation at work. There was also statistically significant difference established in the correlation between years of experience and awareness of Advanced Care Planning with p = 0.000. However, there was otherwise no other statistically significant difference in comparisons made between majority of the 11 questions in comparison to position / designation at work. In conclusion, the analysis of this questionnaire has successfully established the level of knowledge, attitude and practice of Advanced Care Planning and End Of Life Care amongst doctors who attended the workshop.
Efficacy And Tolerability Of Antidepressants In Palliative Care Patients With Anxiety And Depression – A Systematic Review
Depression and anxiety, amongst other clinical symptoms, are commonly faced by palliative patients approaching end of life due to terminal life limiting illness. The aim of this study was to systematically review Randomized Controlled Trials on ‘Efficacy and Tolerability of Antidepressants in Palliative Patients with Anxiety and Depression’ based on set criterion (scores on Hospital Anxiety and Depression Scale - Depression and Anxiety Subscales; HAD-D and HAD-A or other validated scales. A research protocol was first prepared and the PICOS selection process of trials for systematic review employed. A rigorous search was then carried out on Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE (Excerpta Medical Database) and other databases and search engines employing standard search parameters. A total of 7106 study titles were obtained in January 2017. These study titles were then vetted, and 6234 remained after duplicates removed. Only 26 were selected and full articles were obtained electronically by late February 2017. The measurement tools used to assess and monitor clinical improvement during the studies include among others, the Hamilton Rating Scale for Depression (HRSD), Montgomery-Asberg Depression Rating Scale (MADRS), Clinical Global Impression (CGI), Zung Self-Rating Depression Scale (ZSRDS) and the Beck Depression Inventory (BDI). The full text copies of all potentially relevant papers that fulfilled the stage 1 inclusion criteria were obtained and screened for inclusion and exclusion criteria. Subsequently selected studies were screened for methodological quality. All relevant data from these studies were then extracted. The data was then synthesized, findings discussed and conclusions drawn, then a formal dissertation report written out. Analysis across all the included trials shows that the heterogeneity was 52 % with all trials analysed simultaneously. But when a subgroup comprising the 7 trials using SSRIs versus Placebo was analysed, heterogeneity reduced to 0%. It can be concluded that in most of the 15 included trials, the Odds Ratio (OR) was more than 1 and the corresponding Absolute Risk Reduction (ARR) was positive and likely represented that the relative risk reduction (or response to the drug) was higher than in the placebo group. The NNT values showed that the response to the interventional drug was satisfactory in most of these trials and this better response was attributable to efficacy of the drug, placebo effect and also due to chance but unlikely due to chance alone. The overall effect of 4.64 too suggests that the null hypothesis could be rejected. A total of 4 studies showed a negative ARR value for their investigational drug versus placebo; and thereby also yielding a Number Needed to Harm (NNH) value which could be explained by low efficacy and / or poor tolerability of the investigational antidepressant. Evidence from this systematic review is in keeping with findings of previous reported systematic reviews on a similar theme. However, it is difficult to make a recommendation in favour of any one antidepressant over another in this subgroup of patients based on efficacy alone. However, it can be concluded that SSRIs such Sertraline and NASSA group drugs were less likely to cause severe side effects compared to tricyclic antidepressants and should be recommended as first line antidepressants in palliative patients if used judiciously.
An Introspection At Trending Of Patient Admissions to the Palliative Ward of a Regional Referral Hospital in Malaysia in 2014, 2015 and 2017
Yeat CL, Kasinathan N, Tan LG, Chan SJ and Shafie KK
The Palliative Ward of HRPB has a rapid turnover of patients. The objectives were to analyze the reasons for admission, treatment rendered, duration of admission and outcome of patients at the Palliative Ward, HRPB Ipoh for January to June 2017, compared to the same period in 2014 and 2015. This was a retrospective audit, with purposeful sampling of all admissions for the period of January to June 2017. The data was keyed into an SPSS database from the electronic patient information system (SPP). Relevant personal identifiers were omitted. Data collected was then analyzed between cancer and non-cancer patients and comparisons made to data collected for the same period in 2014 and 2015. A total of 821 admissions were included, 277 for the period of January to June 2017, with comparisons made to 246 and 298 admissions respectively for the same period in 2015 and 2014. A notable rise in the percentage of non-cancer patients in 2017 (24.55%) versus 8.72% in 2014 and 9.76% in 2015 which comprised Chronic Renal Failure (20.69%), Chronic Liver Failure (18.10%) and End Of Life Care (24.14%) was seen. However, patients with cancer predominated with Respiratory Malignancies (21.42%) followed by Gastrointestinal Malignancies (13.19%) and Breast Malignancies (12.06%). The presenting features include Pain (26.31%), Dyspnea (21.56%) and Fever (10.23%). Of interest, pain was more prevalent amongst cancer (32.48%) versus non-cancer patients (5.43%) but Dyspnea showed almost equal prevalence (20.42% versus 32.61%). The mainstay of pharmacological treatment was Opioid Therapy for 61.38% and Antibiotics (12.81%). Most patients were admitted for 5 days or less (54.68%), discharged home (53.11%) or passed away at the Palliative Ward (34.47%). The reasons for admissions to the palliative ward have been examined and no significant difference in the clinical presentation and treatment rendered between cancer and non-cancer palliative patients have been elucidated.
Initial Experience and Outcome of Extracorporeal Shockwave Lithotripsy (ESWL) by Dornier Gemini EMSE 220-F XXP-HP in Hospital Sultanah Aminah, Johor Bahru Malaysia
William Ong Lay Keat, Shamsuddin Omar
BACKGROUND & OBJECTIVES:
Extracorporeal Shockwave lithotripsy (ESWL) was developed in early 1980’s and proven to have excellent safety profile while achieving acceptable stone clearance. This study aims to assess the efficacy and safety of ESWL with Dornier Meditech lithotripter (Dornier Gemini EMSE 220F XXP-HP) in managing the patients with urolithiasis.
A total of 224 patients have undergone outpatient ESWL for renal and ureteral calculi from November 2016 till June 2018 in Hospital Sultanah Aminah Johor Bahru. The patients’ demographic data, stone characteristics & locations, energy and total number of shockwaves were investigated along the stone-free rate and periprocedural complications.
We analysed 217 patients who have underwent ESWL, excluding 7 defaulted follow-up patients. 169 (77.8%) had renal stones and 48 (22.1%) had ureteric stones. The mean age of the patients was 52.55 ±12.29 years with male: female= 1.46:1. The mean ± SD stone size was 1.39 ±0.55 cm. Treatment success (defined as complete clearance of ureteric stones, stone-free or clinically insignificant residual fragments of <0.4 cm for renal stones) was 59.7% for renal stones and 58.3% for ureteric stones. 79 patients required additional sessions to archive stone clearance. Complications occurred in 11.1% patients with majority of them (n=8) suffered from loin or suprapubic pain. Using simple Logistic Regression analysis, the only pre-treatment factor found to have significant effect on stone-free rate was the stone size (p<0.001).
Extracorporeal shockwave lithotripsy using Dornier Gemini EMSE 220F XXP-HP is a safe, non- invasive and relatively effective modality for treating the renal and ureteric calculi.
Management Challenges In Monophasic Synovial Sarcoma Of Distal Femur With Lung Metastasis: To Amputate Or Limb-Salvage Surgery
Rubenandran R, Asyraf M, Suryasmi D, Chye PC, Rampal S, Raghuraman SF
Synovial sarcoma is one of the commonest malignant soft tissue sarcomas with poor prognosis, especially when detected in late stages. It has a wide spectrum of biologic behavior, a high degree of local invasiveness and capability to spread trans compartment. There appears to be a lack in the reporting of these tumours locally as the challenges of diagnosis and management are often demanded at advance stages. We present a case of synovial sarcoma in an adolescent who presented very late with a huge lesion over right thigh with metastasis to the lung. This report highlights the diagnostic challenges which directly affect the type of surgical intervention and physical outcomes of patient.