MASH Journal Volume 6 Issue I

March 2021
Association Between Assessment And Missed Pain Treatment Among Patients With Headache Pain Presenting To The Emergency Department
Gurjeet Singh, Ariff Arithra


Pain assessment and management has been widely practiced in emergency departments all over the world. As proper pain management is directly related to improvement in patient satisfaction, health care officers have to be effective in dealing with pain related chief complaints daily. A common chief complaint of patients presenting to the emergency departments all over the world including Malaysia is headache. The aim of this study is to determine the missed pain assessment and management of headache at the Emergency Department (ED) in Hospital Universiti Sains Malaysia and the factors that were influencing them. The factors associated with missed pain assessment and treatment among patients with headache presenting to the emergency department were investigated. A cross sectional retrospective observational study was performed from December 2017 to May 2018 among all patients presenting with headache to the emergency department of Hospital University Sains Malaysia (HUSM). A total of 94 patients were enrolled in this study and 77 patients met the inclusion criteria. There was a statistically significant association (p-value<0.05) between pain reassessment and triage zone (x2 =6.858) and patient’s arrival time (x2 =5.773). A significant association (p-value<0.05) between missed pain treatment and triage zone, and patient’s arrival time was noted. The chi square value (x2) for triage zone and patient arrival were 7.428 and 4.807 respectively. Whereas, there was no significant association between pain treatment and attending physician. Triage zone and arrival time of patients are the factors influencing missed assessment and management of pain among patients with headache presenting to ED. A proper action plan and more intervention studies are warranted in order to overcome the above mentioned issues and optimize pain management for headache.

Bleeding Battle In Soft Tissue Sarcoma Surgery: A Review Of Perioperative Considerations And Management
Eyrique G., Paul AG and Looi C


Bleeding is a common expected complication during surgery, but more so in advanced sarcoma resection surgery owing to the tumour’s angiogenesis. As surgery is potentially curative for primary nonmetastatic extremity soft tissue sarcoma – hence surgery is necessitated. In this case, we have a patient with significant bleeding intraoperatively requiring several methods and techniques to control the hemorrhage. The management of bleeding involves multiple assessment and strategies to ensure appropriate care for the patients. The management is perioperative involving all stages: preoperative risk identification and optimization to intraoperative surgical options and techniques to postoperative care. The objective of this review is to establish a guideline on factors and options that surgeons should to be aware, going into surgery from preoperative to postoperative management when bleeding ensues. Latest updates and recent evidence help ensure improved clinical management for sarcoma patients undergoing surgery.

A Rare Case Of Myelomatous Pleural Effusion
Chelvam Rajesvaran, Noor Laili Mokhtar, Nadira Shahrul Baharin, Leong Tze Shin


Myelomatous pleural effusion is a rare cause of pleural effusion in patients with multiple myeloma, with an incidence rate of 1-2%. The diagnosis is best appreciated on cytological examination. Visualisation of atypical and immature plasma cells in large numbers in the pleural fluid is characteristic, however may be easily missed in smears. We reported a case of a 61 years old gentleman of Malay ethnicity, with underlying refractory multiple myeloma, presented with worsening shortness of breath and found to have a left-sided pleural effusion. Pleural fluid from pleural tapping procedure was submitted for cytological examination. The pleural fluid showed singly scattered atypical plasmacytoid cells in close admixture with mesothelial cells and lymphocytes, which were more apparent on the cell block. Immunohistochemically, the plasmacytoid cells were positive for CD138 while scattered cells consistent with mesothelial cells were positive for calretinin. The patient was diagnosed with a myelomatous pleural effusion. The rarity of this finding and use of cell block to enhance the detection of the cells is highlighted.

Overweight And Obesity Leads To Dental Problems: A Mini Review
Ashraful Kabir


Teeth are a much neglected part of most people. They care for their whole body except teeth. In this regard, they suffer many dental problems, especially in their mixed dentition stages. After checking the teeth of the students of a Cantonment School of Bangladesh with a registered physician and medical assistant, the result showed many teeth-related problems as well as the dental cavity. In addition, their feeding habit and the education of their parents at home were observed. Proper knowledge of health, food habit and exercise should be increased in most families.

Waiting Times For Covid-19 Patients In The Emergency Department During The Pandemic: Experience From A Single Center In Malaysia.
Gurjeet Singh and Mohamed Alwi Bin Hj Abdul Rahman


Patients presenting to the emergency departments who turn out to be COVID-19 positive long length of stay is associated with more exposure to health care staff and other patients. The objective of this study was to use routinely collected daily data of patients to add to the literature on long waiting times of COVID-19 positive patients in the emergency department. An observational study and case series study was performed for a period of time observing patients presenting to the ED who turn out to be COVID-19 positive, time of exposure and waiting time for admission. The results showed that mean time of a COVID-19 patient’s stay in the emergency department is 13.88 hours. These results show that the patients waiting time for the results of COVID-19 test and waiting time for admission to the wards is long and thus poses high risk of exposure to the health care workers in the emergency department and neighboring patients in the ED.

The Effects Of Energy Drinks On Choice Reaction Time Tasks Among Mmmc Medical Students - A Randomized-Controlled Trial.
Muhammad Farid Ali, Nurul Najwa Raffiq Raveendran, Privitha Kumari Perumal, Wong Yee Von, Kuhan Olakanathan1 and Muhamad Arieff Hafizi Jamlus


Consumption of energy drinks is on the rise among all age groups, especially young adults. These drinks contain taurine and caffeine as their main ingredients. Thus, the objective of this study is to investigate the effects of energy drinks on choice reaction time in comparison to mineral water among healthy young adults. A randomized controlled trial was done in a private medical college in Malaysia in October 2016. Participants were divided into 2 intervention groups; energy drink (n=18) and placebo (n=16) and were given the intervention drink (250ml). Their choice reaction time was assessed using Deary-Liewald Reaction Time and cardiology parameters (systolic and diastolic blood pressure and heart rate) were recorded before and after the intervention. After a 7-day washout period, the test was repeated with a crossover of the groups. The change in response and parameters were analyzed using independent T-test. There was a significant decrease in the choice reaction time after consumption of energy drink along with slight increase in blood pressure and heart rate as compared with placebo. Energy drink can improve the choice reaction time with slight changes in systolic and diastolic blood pressure and heart rate as compared to placebo.

Surveillance Of Adverse Events Following Immunization (AEFI) After First Dose Of Covid-19 Vaccination Program: A Short Audit.
Gurjeet Singh, Mohamed Alwi Bin Hj Abdul Rahman, Mohd Alfian Anas bin Mohd Hashim


Adverse Events Following Immunization (AEFI) may occur following vaccinations which may range from mild to severe. A new vaccination program for Covid-19 was started in Malaysia and thus the presentation of persons to the emergency response clinic with AEFI after the first dose of covid-19 vaccination program was studied. The objectives of this study were to use collected daily data of persons presenting to the Emergency Response Clinic with AEFI following the first dose of covid-19 vaccination to know the incidence of AEFI, its presentation and severity. An audit was performed throughout the first dose of Covid-19 vaccination program in a single tertiary center observing patients presenting to the Emergency Response Clinic who turn out to have symptoms post vaccination. The results showed that AEFI incidence was low among those vaccinated and out of these, majority had mild symptoms and only a few had moderate side effects with no one developing severe effects post vaccination. These results show that the vaccine is considered safe because the percentage who had seek treatment was low, and mostly had only mild symptoms. The establishment of an Emergency Response Team will ensure better recognition, monitoring, treatment and referral process for a COVID-19 vaccination program which will identify early and improve the outcomes in patients post vaccination.

Preparing And Mitigating A Fire Drill During The Covid19 Pandemic
Gurjeet Singh, Mohamed Alwi Bin Hj Abdul Rahman, Mohd Alfian Anas bin Mohd Hashim


As the world continues its battle with Covid-19, with some countries going into recoveries and some in resurgence of cases, we should not forget that different types of hazards still are a threat to our hospitals and emergency departments. A well-known hazard to the hospitals in Malaysia is fires and we should be prepared for it even with the ongoing pandemic. To conduct a fire drill in the hospital during the Covid-19 pandemic to ensure awareness of fires as a threat and a type of hazard in the hospitals, and also to modify the evacuation pathways taking into count the presence of Covid positive and Severe acute respiratory illness (SARI) within the hospitals. A fire drill was conducted in the emergency department of a single tertiary center hospital observing Standard Operating Procedure (SOP) as set by the Ministry of Health (MOH). The alertness, activation, evacuation pathways and disposition of the patients and staff were observed. Referees consisting of all levels including support staff, doctors, specialist and invites from the fire unit, administration RADICARE services, security forces, PBSM were present to provide a feedback. The results showed that the alertness of a fire was still present among the staffs amidst the pandemic and new routes of evacuation pathways for COVID-19 and Covid-19 suspected patients were implemented and was an important part of the drill to ensure adequate distancing and prevention of spread of the covid-19 virus. These results show that even though we are in a pandemic, the other forms of disasters with its types and hazards cannot be ignored. An awareness of fire as a hazard must still be present during this time of crisis and new evacuation pathways separating the covid-19 positive and suspected patients is important to prevent its spread during a fire without compromising the care of the patients.

Infantile Otorrhea: Not As Benign As Perceived
Sanjay Woodhull , Sharnya S Arunasalam, Jeyanthi Kulasegarah, Santhi Pillai and Saira Bahnu Mohamed Yousoof


Otorrhea in preschool children is most often infective and benign in nature. Temporal bone tumours presenting with persistent otorrhea often have associated features such as raised intracranial pressure, temporal bone swelling and facial nerve palsy. We describe an infant with temporal bone Ewing sarcoma presenting with isolated chronic otorrhea and review the clinical features of the four commonest paediatric temporal bone tumours over the last 50 years.

Necrotic Bowel In A Male With Takayasu Arteritis: A Case Report
Choon Seong Ng, Sow Lai Kan, Ai Lee Lim and Pavitratha Puspanathan


Takayasu Arteritis is one of the two large vessel vasculitis according to 2012 revised International Chapel Hill Consensus Conference definition of vasculitis. Disseminated Takayasu Arteritis in a male patient presented as intestinal gangrene is very rare and potentially fatal. Here, we have a case of a 40-year-old male of Asian ancestry with disseminated Takayasu Arteritis, came with acute abdomen and acute renal failure. No associated hemoptysis and no prior history of limb claudication. He was hypertensive with absent bowel sounds. Clinically he was hypertensive with raised acute phase reactants. No bruits were present. CT angiography showed total occlusion of abdominal aorta. Histopathogical analysis of resected bowel showed involvement of small vessels as well. Absence of history of ischemic symptoms of upper and lower limb ischemia is unique in this case. Early diagnosis is important for early targeted therapy to avoid further ischemic events and even mortality.

MASH Journal Volume 6 Issue 2

June 2021
Malposition Of Hemodialysis Catheter: Double Superior Vena Cava
Xiong Khee Cheong, Lydia Kamaruzaman, Khairina Adliah Kamal Arifin


Central venous catheter placement is a common procedure for physicians and interventional nephrologists. Left persistent superior vena cava (PLSVC) is an uncommon venous anomaly accounts for 0.3% to 0.5% of individuals in the general population; due to the failure of left anterior cardinal vein to regress during embryonic life. We described a regular hemodialysis patient with PLSVC that discovered incidentally after jugular vein catheterization. Patient was asymptomatic and the catheter was successfully used for hemodialysis. This case highlighted the importance on recognition of anatomical variation of the cervico-thoracic vessels to prevent unnecessary complications.

The Outcome Of A Carbapenem Stewardship Initiative In A Local Tertiary Teaching Hospital
CS Ng, Petrick P, CL Lau, XY Chua3, Farah WT3, Sarah AR3, Nur Jannah A3, L Loong3, B Pau3, SH Kong3, Dexter VD3, Faridah MY3 and S Ponnampalavanar


Carbapenem-resistant isolates have been increasingly reported recently. Carbapenem stewardship is designed to optimize its usage particularly among medical wards with high prevalence of carbapenem prescriptions to combat such emerging resistance. Carbapenem stewardship programmes (CSP) can reduce antibiotic use but clinical outcome of such measures needs further evaluation. We examined this in a prospective manner using feedback mechanism. Our single-center prospective cohort study involved all carbapenem prescriptions across the medical wards (including medical patients admitted to intensive care unit) in a tertiary university hospital setting. The impact of such stewardship was analysed according to the accepted and the rejected groups. The primary endpoint was safety. Safety measure applied in this study was death at Day 30. Secondary endpoints included readmission at day 30, and length of hospitalisation. Over the 19 months’ period, input from 144 carbapenem prescriptions was analysed on the basis of acceptance of our CSP recommendations on the use of carbapenem. Recommendations made were as follows: de-escalation of carbapenem; stopping the carbapenem; use for a short duration of 5-7 days; prolonging up to 2 weeks in the case of carbapenem-sensitive Extended Spectrum Beta-Lactamases bacteremia; dose adjustment; and surgical intervention for removal of septic foci. Acceptance rate was 53%. Those who accepted CSP recommendations had no increase in mortality (p = 0.07), had a shorter length of hospital stay (LOS) by 6 days and had less readmission rates. Carbapenem stewardship program in the medical wards is safe and does not harm the patients with added benefits of reducing the length of hospital stay. However, more time is needed to engage the primary clinical teams by formal clinical presentation and immediate personal feedback by senior Infectious Disease (ID) personnel to increase its acceptance.

Ancient Thought And Doses Of Medicinal Plants: A Review
Ashraful Kabir


Medicinal plants have a remarkable significance on human health. Not only in the world but also the Asian region is commonly famous for using these plants and medicines. Tribal people are not scanty in the world as a whole. From their core of belief, and for the availability of those plants, they use it in their most ailments. So-called herbal plants have no side effects if those collecting, processing, analyzing, and doses are scientific. Ethnobotany is a branch of medical science as its continuation with modern medicines needs to come out with further justification and clarification. In this regard, more scientific studies on medicinal plants should implement in all medical sectors.

Intestinal Pseudo-Obstruction With Ureterohydronephrosis As A Complication Of Lupus.
Choon Seong Ng , Ying Fun Ng, Sow Lai Kan, Ai Lee Lim, Li Chen Fang , Mohd Fadli,


We report the case of a 35-year- old lady followed-up at our Rheumatology unit for a 9-year history of lupus nephritis, who presented with recurrent abdominal pain and diarrhoea for the past nine months. The abdominal radiograph showed dilated small bowel, while computed tomography scan showed diffuse thickening of large and small bowels. Bilateral uretero-hydronephrosis without any evidence of obstructive uropathy was present on imaging. Ileocolic resection was done for presumed intestinal obstruction and the ileocolic biopsy did not reveal any granuloma, malignancy or vasculitis except for non-specific inflammation of cecum. Oesophagoduodenoscopy and colonoscopy were offered in view of persistent unexplained loose stools and abdominal pain. Multiple biopsy specimens of the small and large bowels did not show any remarkable findings. Second relook of the initial hemicolectomy specimen with special actin immunostain on the smooth muscle revealed degenerative changes of the muscularis propria. Intestinal pseudo-obstruction was diagnosed. Smooth muscle dysmotility could be the underlying pathology of this patient presentation. The patient responded well to intravenous immunoglobulin. It is potentially reversible with prompt recognition. Long term prognosis of this rare entity is, however, varying.

Prevalence Of Depression Symptoms Among Acute Coronary Syndrome (ACS) Patients At The National Heart Institute (IJN), Malaysia.
Philip George, Nagappan Sethuraman, and Sharatha Chandran


In Malaysia, ischaemic heart disease has been a leading cause of death since early 1980s. Depression is a major cause of morbidity worldwide. In most countries the number of people who would suffer from depression during their lives falls within an 8–12% range. Depression and cardiovascular disease have been linked since the early 1990s when studies have reported the prevalence of major depression in hospitalized patients with Acute Coronary Syndrome (ACS). A total of 115 ACS patients at National Heart Institute (IJN) were assessed using the Becks Depression Index (BDI-II) to screen for depression. 48.7% ACS patients at IJN had positive BDI II scores (>13). Depression was strongly associated with age, gender, marital status and history of anxiety or depression. There seemed to be no significant association with race, education, employment status and history of myocardial infarction or angina. Depression appears to be common among patients with ACS and services providing intervention for depression will help decrease morbidity and mortality among these patients.

POCUS A Valuable Tool In Early Detection Of Intracardiac Mass.
Hazmi Adly Harun, Ainnur-Ashirah Kamisan, Gurjeet Singh,


A young patient presenting to the Emergency Department with chest pain may pose a diagnostic challenge. A wide range of differential diagnosis from life threatening to common causes needs to be ruled out. Even though rare, cardiac tumors or cardiac myxomas can present as a cause of chest pain in younger patients and it can be picked out with a high index of suspicion, utilization of bedside POCUS in all young patients presenting with chest pain to the emergency department and the management and definitive treatment can be planned out accordingly.