Public Health Observational Research - Hospital Sibu
Transcription
Public Health Observational Research - Hospital Sibu
Sarawak Health Journal Towards Better Clinical Outcomes Volume 3 2016 Datu Dr Zulkifli Jantan (Sarawak State Health Director) Medical care has always been an important component to improve the quality of health care services in our country and has been improved beyond recognition over the past decades. An important contribution for this improvement is clinical research. Clinical research includes many different types and complexity of research ranging from basic research, patient-oriented research, translational research and outcome research. Implementation of clinical research findings help to move health care towards more widespread use of evidence-based medicine, with the ultimate goal for achieving better patient diagnosis, treatment and rehabilitation. For example, the development of effective drugs has revolutionised the treatment of heart attacks and hypertension and enabled many people with chronic illnesses such as schizophrenia and type I diabetes mellitus to stay at home with medication without the need to be admitted to hospital. Malignancies such as acute leukaemia have now become treatable, and people can now live with many types of cancers instead of dying from them. Advanced imaging technologies such as CT (Computed Tomography) scan and MRI (Magnetic Resonance Imaging) have provided more accurate diagnosis resulting in correct and focussed treatments. For example, a patient who is now diagnosed with ischaemic stroke through CT scan after ruling out haemorrhagic stroke is able to receive treatment with streptolysis within the golden hour period, whereby the neurological deficit might be reversible resulting in better prognosis. Sarawak has been active in research and has contributed to new scientific knowledge that has global implications. A number of our medical research and case studies have been published in international journals. The initial discovery of Plasmodium knowlesi in Kapit, Sarawak has enormous implications on malaria control and treatment especially for tropical countries of South East Asia leading to reduced mortality. The study of the effects of Japanese encephalitis vaccination and controlling of climate variability in Sarawak by Dr Daniel Impoinvil, Dr Ooi Mong How (Paediatrician of Sarawak General Hospital) et al has shown the true extent of reduction in the incidence of Japanese Encephalitis transmission by taking into account climate inter-annual variability. The discovery of enterovirus 71 as an important cause of Hand, Foot and Mouth Disease (HFMD) outbreak and mortality in Sarawak has enormous implications in the management of HFMD outbreaks and clinical cases. With rapidly increasing healthcare demands, driven by population growth rate and increasing lifetime expectancy, more and more clinical research are needed to achieve the ultimate goal of better patient diagnosis, treatment and rehabilitation. There are 30 Ministry of Health (MOH) hospitals with clinical research centres in Malaysia which include three hospitals in Sarawak, namely Sibu Hospital, Sarawak General Hospital and Miri Hospital. For the State Research Day 2015, we had more than 100 participations from the whole Sarawak. They consisted of different categories of staff ranging from clinical and public health specialists, medical officers, nurses and allied health staff. As the Sarawak State Health Director and advisor for Sarawak State Health Research Day 2015, I would like to express a warm thank you to all who have been involved in the State Research Day preparation, and to congratulate all the participants for their impressive research and presentations. I hope that some of the research findings can be applied in medical practice in future and contribute to bring better health and quality of life of patients in Sarawak as well as the rest of the world. 1 Sarawak Health Journal Volume 3 2016 The New Clinical Research Centre at Sarawak General Hospital – A Review and Update Dr Alan Fong Yean Yip The new Clinical Research Centre at Sarawak General Hospital (CRC SGH) is slated to open this year. The concept of a purpose-built CRC, located within a public-access tertiary referral centre, originated in 2005, when there was an increase in clinical trials, both industry-sponsored (ISR) and investigator-initiated (IIR), at SGH. With an increasing number of clinicians developing interest in clinical research, and steady success since early 2000, the Ministry of Health added SGH to its Network of Clinical Research Centres (NCRC) in 2003. Prof Dr Sim Kui Hian, as the first Head of CRC SGH, oversaw the birth and early growth of CRC SGH. He also initiated plans to construct a purpose-built CRC at SGH - a facility that was able to undertake early and late phase clinical trials. Such a facility would not only address the limitations associated with the heavy clinical responsibilities of a tertiary care centre, but also augment research output directly at the site, and also for its collaborative partner institutions. In addition to critical knowledge generation, it was envisioned that this centre would also accelerate the growth of the entire clinical research ecosystem – locally and nationally. The new CRC SGH was constructed at the site adjacent to the critical care block, operating theatres and the clinical Block D of SGH. The foundation stone was laid by the then Director General of Health, Tan Sri Dato’ Seri Dr Hj Mohamed Ismail bin Merican, on 27 September 2007. Foundation works commenced on 15th January 2011. Following a steady construction schedule, this new CRC SGH block aims to be completed this year. The new CRC SGH is located over three levels in the new block – Level 4 – clinical areas, Level 5 – administrative areas, Level 6 – archiving areas. The clinical areas have a 10-bedded intensive monitored ward and five clinic consultation rooms. In addition, it will house a fully equipped bioanalytical laboratory and a human physiology laboratory - the former containing advanced instruments for drug level measurements, and the latter instruments to assess heart, lung and brain functions. There are monitored bioarchiving facilities and an internal electronic data capture system. These instruments are to optimise safety and efficiency of clinical trial execution, especially for early phase studies. In-house staff training was done in earnest since conception of CRC SGH and the centre now has 45 staff. In conjunction with efforts in partnership with the NCRC and Clinical Research Malaysia, the new CRC SGH aims to be a leading clinical research facility of the Ministry of Health Malaysia, in this region. 2 Sarawak Health Journal Volume 3 2016 Hospital Observational Research Hospital Observational Research 3 Sarawak Health Journal Volume 3 2016 Procedure Duration Estimation & Accuracy: A New Key Performance Index? Chan WK1, Kuan PX2, Teo SC1 & Norzalina E1 1 Anaesthesiology and Intensive Care Unit, Sarawak General Hospital, Malaysia; 2Clinical Research Centre, Sarawak General Hospital, Malaysia Corresponding Author: Chan Weng Ken ([email protected]) Introduction: Malaysia reported a total health expenditure of 4.5% Gross Domestic Product in 2012, of which RM 14,331 million (63.8%) goes into services of curative care in public sector (MNHAU, 2014). Typical operating theatre (OT) consumes at least 10% of the hospital budget ( Macaulay et al, 1966). As a measure to improve productivity and harmony of the workflow, National Health Service in United Kingdom has introduced ‘The Productive Operating Theatre’ in September 2008. Since its implementation, it had resulted in significant savings, an average of £7 million per hospital (NHS, 2013). In our recent OT audit done in December 2014, there were an average of 1.6 elective patients cancelled daily, eight to 24 emergency cases brought forward daily, and 35 elective operating theatres overshot more than 60 minutes. These numbers translated into cancellation of elective cases, longer waiting time for emergency cases due to overshot elective OT’s which resulted in rising bed occupancy rate, patients’ dissatisfaction and medical complications from prolonged hospital stay and delayed operation. These escalated the cost in treating patients. There is a need to utilize OT efficiently especially in regards to time management to avoid wastage. Hence, we look into clinicians’ ability to estimate the duration of their procedure as better accuracy will results in better planning, therefore more efficacious resource management. Main Objectives: i) To assess the accuracy of anaesthetists and surgeons in estimating time taken to complete a procedure. ii) To determine the relationship between American Society of Anaesthesiologists (ASA) classification, mode of anaesthesia and surgical discipline with duration to complete a procedure. Methods: Retrospective analysis on estimated time vs actual duration taken to complete a procedure for all elective cases done in Sarawak General Hospital Main OT in February 2015. Prior to operation, both surgeons and anaesthetists were asked to estimate the procedure’s duration, which were subsequently compared with the actual time taken. All data were entered and analysed in Statistical Package for Social Science version 20 using paired sample T-test, Analysis of Variance and KruskalWallis. Results and Discussion: Actual time for induction, skin to skin and reversal showed statistically significant overestimation reflecting the predicting inaccuracies of the participants in procedural time (p<0.001). A possible explanation would be that participants tend to overestimate during this audit period. Anaesthetists were more often accurate in estimating induction and reversal time as compared with surgeons in estimating preparation and skin-to-skin time. There is no significant relationship between ASA classes during induction (p=0.770) likely due to efficient utilization of manpower when inducing patients who were ASA>2. Longer induction time for total intravenous anaesthesia cases (50 mins) could be explained by the preponderance of Neurosurgery and Spine cases. Plexus block and subarachnoid block resulted in significantly shorter reversal time, 33.3% and 46.7% respectively the time needed for general anaesthesia / intermittent positive pressure ventilation (GA/IPPV). 4 Sarawak Health Journal Volume 3 2016 Conclusion: We propose that multi-disciplinary pre-operative discussion among anaesthetists and surgeons should be held in order to improve the use of resources and patient management. We also advocate regional anaesthesia to improve turn-around-time. Key Words: Procedure duration estimation; operating theatre management References: 1. Malaysia National Health Accounts Unit (MNHAU). Malaysia National Health Accounts: Health Expenditure Report 1997-2012. MOH 2014. Retrieved from: http://www.moh.gov.my/ english.php/pages/view/56 on 18 April 2015. 2. Macaulay HMC & Davies RL. Hospital planning and administration. WHO 1966. Retrieved from: http://apps.who.int/iris/handle/10665/41781 on 18 April 2015. 3. National Health Service. Evaluation of the productive operating theatre programme 2013. Retrieved from: http://www.optimitymatrix.com/wp-content/uploads/2013/09/Evaluation-ofThe-Productive-Operating-Theatre-programme-FINAL.pdf on 18 April 2015. Table 1: Accuracy of estimation according to surgical discipline Discipline Induction Preparation Skin to skin Reversal General Surgery Accurate Accurate Often misestimate Accurate Plastic & combined Accurate Accurate Often misestimate Accurate Paediatric Surgery Accurate Often misestimate Accurate Misestimate Neurosurgery Accurate Often misestimate Often misestimate Accurate Orthopaedic Accurate Accurate Often misestimate Accurate Ear, Nose & Throat Accurate Accurate Accurate Accurate Misestimate Accurate Accurate Often misestimate Obstetrics & Gynaecology Accurate Accurate Misestimate Accurate Dental Accurate Accurate Accurate Accurate Misestimate Accurate Often misestimate Accurate Accurate Often misestimate Often misestimate Accurate Eye Urosurgery Spine 5 Sarawak Health Journal Volume 3 2016 Effectiveness of the Introduction of Modified RE-LY Warfarin Dosing Algorithm in International Normalized Ratio Clinic of Kapit Hospital on Anticoagulation Control Chin WV1, Siong JYK2 & Theng MI2 1 Medical Department, Kapit Hospital, Sarawak, Malaysia 2 Pharmacy Department, Kapit Hospital, Sarawak, Malaysia Corresponding Author: Chin Wei Ven ([email protected]) Background: Despite emergence of novel oral anticoagulants (NOAC), warfarin remains a widely used anticoagulant in view of its easy reversibility of action. Time within Therapeutic Range (TTR), a measurement used to determine the proportion of time for which the INR is below, within or above the therapeutic range, can be quantified using Rosendaal linear interpolation method. The major bleeding and mortality rates are significantly higher among TTR<60% compared to TTR>75%. Thus, modified RE-LY algorithm had been implemented in Kapit Hospital’s INR clinic since January 2015 with these cases review study conducted to assess the effectiveness of the modified RE-LY algorithm in term of TTR improvement. Methods: INR values from June 2014 to June 2015 for all INR clinics’ patients, excluding those fulfilling exclusion criteria, were studied. TTR for each patient was calculated and the distribution of TTR for pre-and post-algorithm over six months was analysed. The mean of the TTR for prealgorithm and post-algorithm was compared using paired T-test. Results: Thirty-eight patients (21 males and 17 females) were included in the study. Fifty-three per cent (n=20) of them were less than 65 years old and 18 of them were over 60 years old. A majority (52.6%) of them did not have formal education, while the remainder had primary education (15.8%), secondary education (28.9%) and only one (2.6%) had tertiary education. The reasons for them being on warfarin were atrial fibrillation (68.4%), thromboembolism (18.4%), and mechanical valve replacement (13.2%). The study’s sample size of 38 patients with mean TTR post-algorithm phase showed significant improvement from 57 to 69 (p=0.011). The percentage of patients with TTR>65% increases in the post-algorithm phase from 37% to 58%. Besides, the study showed there is no significant association between the TTR value and socio demographic data collected, such as gender, age, education level, availability of caretaker and years on warfarin. Discussion: In this study, the mean TTR in post algorithm showed significant increment from 57% to 69% with a p value of 0.011. This indicates implementation of modified RE-LY algorithm had significantly improved the TTR among the INR clinic’s patients. However, this study analysis showed that there is no significant association between the TTR with the socio-demographic background among the patients. These findings are inconsistent with studies conducted by others. The discrepancy of findings with other studies could be due to the small sample size of 38 patients, short duration of study which is only six months and imbalance of socio demographic data distribution. Conclusion: With implementation of modified RE-LY algorithm, TTR showed significant improvement, thus it should be implemented widely in the INR clinics to ensure optimization of TTR level. Key Words: International Normalized Ratio (INR); Time within therapeutic range (TTR); warfarin; anticoagulation; dosing algorithm NMRR ID: 15-513-25315 6 Sarawak Health Journal Volume 3 2016 Case Record Review on the Effectiveness of Modified Paediatric Early Warning Sign Score in Shortening the Duration Required for Clinical Intervention in Kapit Hospital Gan LWˡ, Hii KC1 & Mavis B1 1 Paediatric Department, Kapit Hospital, Sarawak, Malaysia Corresponding Author: Gan Lee Wan ([email protected]) Introduction: Hospitalised children are at risk of clinical deterioration and some may even develop cardio-respiratory failure. The survival rate for these children is poor. Many children have a prolonged physiological deterioration before cardiac arrest. Hence the development of Paediatric Early Warning Signs (PEWS) score by the National Health Service, United Kingdom in 2006 to ensure timely identification and prompt medical intervention during this ‘pre-arrest’ phase (www.institute.nhs.uk/safer_care/paediatric_safer_care/pews_charts.html). Kapit Hospital adapted and modified original PEWS score for use in paediatric ward in July 2012. Objective: To evaluate the effectiveness of modified PEWS score in shortening the duration of intervention from the onset of clinical deterioration and reducing the invasive intervention. Methods: Case notes for patients admitted to Paediatric Intensive Care Unit (PICU) or High Dependency Unit and those requiring transfer to Sibu Hospital in years 2010 to 2014 were reviewed. Transferred cases not attributable to clinical deterioration and patient with incomplete data were excluded from the study. Vital signs for patient in pre-implementation phase (Jan 2010-June 2012) were re-charted into the modified PEWS chart. The time frame between the highest PEWS score to clinical intervention was compared between pre- and post-implementation phase using MannWhitney test. Association between the modified PEWS score implementation and requirement of invasive intervention was analysed using Chi-square test. Results and Discussion: A total of 67 patients have been included in this study, 29 from preimplementation and 38 post-implementation. Time frame of intervention pre-PEWS implementation was 42.64 min. There was significant reduction of the time frame required for clinical intervention after PEWS implementation (27.41 min, Z statistics, -3.172, p=0.002). There was also a reduction of requirement of invasive intervention from six cases to one case after PEWS implementation with statistically significant association between the PEWS implementation and the requirement of invasive intervention (p<0.05). This finding is consistent with a study conducted by Tucker et al in 2008, which suggests that the PEWS tool provides highly reliable and valid clinical scoring data. High PEWS are predictive of patients who will require transfer to PICU. Conclusion: Implementation of PEWS enables earlier prompt medical intervention with earlier detection of clinical deterioration, thus reducing the requirement of invasive intervention. Thus it should be implemented widely throughout the paediatric health care system. Key Words: Paediatric early warning signs score (PEWS); Paediatric intensive care unit (PICU) References: 1. Haines C, Perrott M& Weir P. Promoting care for acutely ill children: Development and evaluation of a pediatric early warning tool. Intensive Crti Care Nurs 2006; 22(2): 73-81. 2. Tucker KM, Brewer TL, Baker RB, et al. Prospective evaluation of a pediatric inpatient early warning scoring system. J Spec Pediatr Nurs 2009 Apr;14(2):79-85. 3. Duncan H, Hutchison J & Parshuram CS. The Pediatric Early Warning Score: A severity of illness score to predict urgent medical need in hospitalised children. J Crit Care 2006; 21(3): 271-9. NMRR ID: 15-1009-25887 7 Sarawak Health Journal Physiotherapy in Critically Ill Patients in Sarawak General Hospital Volume 3 2016 Kuan PX1, Chan WK2 & Fong AYY3 1 Clinical Research Centre, Sarawak General Hospital, Malaysia 2 Anaesthesiology and Intensive Care Unit, Sarawak General Hospital, Malaysia 3 Clinical Research Centre and Cardiology Department, Sarawak General Hospital, Malaysia Corresponding Author: Kuan Pei Xuan ([email protected]) Introduction: Physiotherapy plays major role in improving short and long term clinical outcomes in mechanically ventilated patients in the Intensive Care Unit (ICU) setting. It has been shown to be beneficial for patients with retained secretions, atelectasis and preventing prolonged ventilation. Main Objectives: 1. To explore the demographic of patients referred for physiotherapy in ICU 2. To determine the relationship between physiotherapy with ventilator dependency and duration of ICU stay Methods: Single centre, cross-sectional review of consecutive patients admitted to ICU in October 2014. Data were collected from clinical documentation. Data was entered and analysed in SPSS version 16.0. Results: A total of 105 patients were admitted to ICU over a four-week period in October 2014. The median duration of ventilation was one day. More than half of the patients (52.4%) were intubated intra-operatively; then admitted post-operatively, mainly for close monitoring and weaning of mechanical ventilation. Overall, the median length of ICU stay was two days with interquartile range of 1.5 days. Only 15 (14.3%) patients were referred for physiotherapy, consisting of 6 (40.0%) male and 9 (60.0%) female patients. Fourteen (93.3%) in this group were ventilated in ICU with 3 (20.0%) having background lung pathology. The median day-to-initiation of physiotherapy after ventilation was 2 (25th and 75th centiles: 1, 5). Physiotherapy had significant trend towards shorter duration of ventilation (p=0.017), and while this is consistent with the study by Malkoc et al (2009), it did not significantly affect duration of ICU stay (p=0.085). Discussion and Conclusion: Approximately one-seventh of patients admitted to ICU were referred for physiotherapy. These were typically females with no lung pathology. We found that early initiation of physiotherapy was able to reduce the duration of ventilator support but not the duration of ICU stay. Our results are inconsistent with the published data; therefore further research over longer term is warranted. Key Words: ICU; mechanical ventilation; physiotherapy References: 1. Ambrosino N, Janah N & Vagheggini G. Physiotherapy in critically ill patients. Rev Port Pneumol 2011; 17(6): 283-8. 2. Malkoc M, Karadibak D & Yıldırım YC. The effect of physiotherapy on ventilator dependency and the length of stay in an intensive care unit. Int J Rehabil Res 2009; 32(1): 85-8. 3. Stiller K. Physiotherapy in intensive care. Chest 2000; 118: 1801-13. NMRR ID: 14-1189-22983 8 Sarawak Health Journal Volume 3 2016 Exploration of Analgesic Prescribing Pattern in an Outpatient Setting of a District Hospital in Sarawak Kwong CI1, Phan HS1, Pang MSH1, Wong DSH1 & Chai SK1 1 Department of Pharmacy, Bau Hospital, Sarawak, Malaysia Corresponding Author: Kwong Chea Ing ([email protected]) Introduction: Analgesics are among the most commonly prescribed drugs in hospitals. Rampant use of analgesics often results in aggravated side effects and drug interactions. Our study was conducted to explore the prescribing pattern of analgesic use in a district hospital in Sarawak. Methods: A descriptive cross-sectional study was conducted in the Outpatient Department, Bau Hospital over a period of seven days with a total sample size of 500 prescriptions containing analgesics. Relevant information on types of analgesics, indications, concomitant medications, and past medical conditions were obtained from the prescriptions, home-based card and through patients’ interview. A standardized surveillance form was designed to facilitate data collection. The study results were analysed using descriptive statistics. Results and Discussion: Five hundred (56.4%) of the total 887 prescriptions screened contained analgesics, which included paracetamol (87.2%), non-steroidal anti-inflammatory drugs (NSAIDS) (12.0%) and tramadol (0.8%). The study findings are consistent with previous research done by AlHomrany et al in a similar setting.1 There were 66.8% of the analgesics prescribed were indicated for pain and fever. However, 20.4% were given without any specific indications while another 12.8% were prescribed on patients’ demand. Ninety-nine (57.6%) of 172 patients with chronic illness follow up received at least three prescriptions with analgesics in their past six visits. Of 60 patients on NSAIDS, 38.3% (n=23) had co-existing medical conditions that required extra precautions in using NSAIDs, namely asthma (10.0%), gastritis (25.0%) and cardiovascular disorder (2.0%). Concerning NSAIDs use associated with increased risk of gastro intestinal bleed, most of the NSAIDs (81.7%) prescriptions in this study were co-prescribed with gastro-protectants. This finding was relatively high compared to Sulaiman et al, in which only 10.8% of them were given gastro-protectants.2 Five per cent were on a combination of NSAIDs, diuretic and angiotensin-converting enzyme inhibitors which may significantly impair the renal function. It is an adverse effect known as “triple whammy” as identified by Loboz et al.3 Conclusion: Our study showed the widespread of analgesic prescribing in district hospital, Sarawak. Rational use of analgesics should be emphasized taking into consideration justifiable indication, coexisting conditions and drug interactions. Key Words: Analgesics; prescribing pattern; NSAIDs use; indication References: 1. Al-Homrany MA & Irshaid YM. Pharmacoepidemiological study of prescription pattern of analgesics, antipyretics, and nonsteroidal anti-inflammatory drugs at a tertiary health care center. Saudi Med J 2007; 28(3): 369-74. 2. Sulaiman W, Ong PS & Rosli I. Patient’s knowledge and perception towards the use of nonsteroidal anti-inflammatory drugs in rheumatology clinic northern Malaysia. Oman Med J 2012; 27(6): 505-8. 3. Loboz KK & Shenfield GM. Drug combinations and impaired renal function – the “triple whammy.” Br J Clin Pharmacol 2005; 59(2): 239-43. NMRR ID: 14-514-20439 9 Sarawak Health Journal Volume 3 2016 Retrospective Review of Prevention of Mother-To-Child Transmission HIV Programme in Sarawak General Hospital Lim HH1, Chai CY1, Niponi S1, Francis C1& Chua HH1 1 Infectious Disease Unit, Sarawak General Hospital, Malaysia Corresponding Author: Lim Han Hua ([email protected]) Introduction: Improvement of HIV patients care in Malaysia has resulted in a declining trend of HIV-related mortality in recent years. One of the core HIV prevention programmes that were introduced is the prevention of maternal-to-child transmission (PMTCT). Objective: To study the timing and regime of antiretroviral therapy (ART) used, mean CD4 count during pregnancy and outcome of HIV-positive mothers that underwent PMTCT programme at Sarawak General Hospital (SGH) from 2004 to 2014. Methods: Data of all HIV-positive pregnant women who underwent PMTCT programme at SGH from 2004 to 2014 were reviewed retrospectively. Results: Among the 45 HIV-positive pregnant women reviewed, a total of four patients did not receive ART because they presented during labour and were excluded. In the remaining 41 patients, 2 patients were already on ART before pregnancy while the other patients were diagnosed HIV during ante-natal screening. Patients who were initiated on ART antenatally or were already on ART, successfully delivered newborns who were free of HIV infection. The only newborn detected HIV positive, was delivered by a mother, who did not receive ART antenatally due to non-adherence to follow-up. The demographic characteristics of the patients started on ART are as shown in Table 1. Discussion: The measures in PMTCT programme include routine antenatal HIV screening, providing antenatal combination antiretroviral therapy for HIV-positive mothers, prophylaxis for HIV-exposed infants, ensuring safe mode of delivery and avoidance of breast-feeding. By implementing all the measures above, the risk of transmission can be reduced to less than 1%.¹ In this review, most (95%) received zidovudine-based regime as part of the combined ART. The remaining 2 (5%) patients were on tenofovir-based regime and it has been shown to be non-inferior in PMTCT.² Of those in the first group, 15 (37%) patients were also on efavirenz combination therapy. There were no cases of foetal abnormality reported in our study indicating that efavirenz was safe.3 Although the recommendation is to initiate combined anti-retroviral therapy as early as 14 weeks of gestation, it is never too late as seen in 38% of our patients who received ART in the third trimester but yet had successful intervention. Conclusion: The antenatal HIV screening should be pursued vigorously as the 100% PMTCT success rate in this hospital means the vertical HIV transmission can be effectively stopped. PMTCT is effective even if initiated in third trimester of pregnancy. However, 25% (one out of four) of the patient picked up during labour delivered a child who was infected with HIV. Key Words: HIV; prevention; mother-to-child 10 Sarawak Health Journal Volume 3 2016 Antibiotic Sensitivity and Spectrum of Bacterial Isolated in Kanowit Hospital: A Retrospective Study Loo SC1 1 Pharmacy Unit, Kanowit Hospital, Sarawak, Malaysia Corresponding Author: Loo Shing Chyi ([email protected]) Aim: To identify the common bacteria isolated in Kanowit Hospital laboratory and to determine the antibiotic sensitivity patterns of the commonly isolated bacteria. Objectives: Identify the common bacteria that are isolated according to specific culture and sensitivity Explore the antibiotic sensitivity of the common isolated bacteria in Kanowit region Introduction: One of the most serious public health issues around the globe nowadays is antimicrobial resistance. Although the concerns may be different by region or country, it is clear that Asian countries are the epicentres of resistance as we could observe that the prevalence of antibiotic resistance of major pathogens is increasing in these locations. However, the public health infrastructure to combat this problem is very poor1. This prompted us to have a proper monitoring system on antibiotic sensitivity trends and usage from for our own setting. Antibiotic usage in terms of Defined Daily Dose (DDD) per 100 admissions has shown that our hospital is the highest, while DDD for 1000 days patient stay in hospital is the third highest among all district hospitals without specialist in Sarawak. The commonly used antibiotics parenterally are ampicillin-sulbactam, ceftriaxone, cefoperazone, and ciprofloxacin, whereas the most commonly used oral antibiotics are ampicillin, penicillin VK, cloxacillin, erythromycin, and amoxicillin. These indicators alerted us of the need to monitor our antibiotic usage in Kanowit Hospital. One of the ways to reduce antibiotic usage is to explore the local microbial culture and sensitivity patterns. Methods: All positive bacteria growth culture and sensitivity samples from in-patients and outpatients isolated from June 2013 to June 2014 were included for this retrospective study. Result and Discussion: The antimicrobial resistance patterns of the various bacteria described refer to the clinical isolates encountered in our hospital laboratory. This study does not differentiate between the antimicrobial resistance patterns of bacteria in community-acquired and hospitalacquired infections; neither does it cover only the clinically significant isolates. The resistance rates described here are only based on in vitro tests. A total of 435 specimens with bacterial growth were recorded in this study. Among these, we found 360 incidents of resistances toward antibiotics. The highest percentage frequencies of resistance were Ampicillin [143 (39.72%) resistance], Augmentin [49 (13.61%) resistance], and Co-trimaxazole [48 (13.33%) resistance]. This might due to high usage of these antibiotics in a peripheral hospital setting. Conclusion: The most common bacteria isolated from sputum, urine, stool, swab, and pus culture and sensitivity are Klebsellia sp., Escherichia coli, Escherichia coli, Staphylococcus aureus and Escherichia coli respectively. These correspond to the National Antibiotic Guidelines 2014. A similar study is recommended for all hospitals as the bacterial culture and sensitivity patterns in district hospitals may be different from that in tertiary hospitals. 12 Sarawak Health Journal Volume 3 2016 Table 1: Summarized total number of bacterial resistance to specific antibiotic (top10) Antibiotic Total number of Resistance Total number of bacteria resistant to specific antibiotic Percentage of resistant of bacteria to specific antibiotic Ampicillin 360 143 39.72% Augmentin 360 49 13.61% Co-trimaxazole 360 48 13.33% Cefuroxime 360 23 6.39% Gentamicin 360 16 4.44% Amoxicillin 360 14 3.89% Ciprofloxacin 360 12 3.33% Vancomycin 360 10 2.78% Penicillin G 360 10 2.78% Ceftriaxone 360 7 1.94% Key Words: Antibiotic sensitivity; spectrum of bacterial isolated Reference: 1. Kang CI & Song JH. Antimicrobial resistance in Asia: Current epidemiology and clinical implications. Infect Chemother 2013; 45(1): 22-31. NMRR ID: 15-77-24375 13 Sarawak Health Journal Volume 3 2016 Assess the Effectiveness of Interventions on Knowledge of Nurses towards High Alert Medications in Kanowit Hospital Loo SC1 1 Pharmacy Unit, Kanowit Hospital, Sarawak, Malaysia Corresponding Author: Loo Shing Chyi ([email protected]) Aim: To improve the level of awareness and knowledge of staff nurse toward High Alert Medications (HAM)Objectives: 1) to assess awareness and knowledge level of Staff Nurse in Kanowit Hospital toward HAM; 2) to explore the factors affecting the knowledge and awareness level (pre-intervention scores) of Staff Nurse regarding HAM; 3) To explore the effectiveness of an educational intervention on Kanowit Hospital Staff Nurse knowledge and awareness regarding HAM. Introduction: Studies have shown that the administration stage accounts for most medications errors and the factors associated with the errors are lack of knowledge and awareness.1,2,3 When there are involvement of dose calculations, rates of infusion of HAM and setting up of infusion pumps, nurses tend to get confused easily. We would like to explore the nurses’ knowledge and awareness level, and implement interventions that help to increase the knowledge and awareness. Methods: Our study will be a comparative cross-sectional study. All respondents will be given a preinterventional test as a baseline. Interventions (HAM logo, educational talk, HAM dilution and HAM list pocket guide) will be implemented, and a post-intervention test will be given to the same respondents. Our target is to have all nurses involved. However the minimal sample size is at least 30 participants for paired T-test to be valid. Result and Discussion: A total of 32 respondents were included in this study. Based on the results of multiple linear regression, we found that respondents with post-basic qualifications or further training in midwifery or haemodialysis in our study scored 6.6 marks higher then respondents without post-basic training. This may be due to their attitude in learning and knowledge. [Adj. b value was 6.6; p=0.04]. Pre-intervention mean score was 69.13 (SD 7.94); post-intervention mean score was 78.53 (SD 8.00). This show significant improvement by 9.40 (95% CI: 6.27, 12.54, t-statistics 6.13, df 31, p < 0.001) marks after intervention. Conclusion: Nurses who have further training were the only factors affecting the pre-interventional score. Interventions carried out in this study showed significant effects in increasing the knowledge and awareness among staff nurses towards HAM. Key Words: High Alert Medications (HAMs); nurses; knowledge References: 1. Lu MC, Yu S, Chen IJ, et.al. Nurses’ knowledge of high-alert medications: A randomized controlled trial. Nurse Educ Today 2013; 33: 24-30. 2. Bergqvist M, Karlsson EA, Björkstén KS, et.al. Medication errors by nurses in Sweden classification and contributing factors. Open assess scientific report 2012; 1(11): 527. 3. Phillips J, Beam S, Brinker A, et.al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58(19): 1835-41. NMRR ID: 14-844-20978 14 Sarawak Health Journal Pyogenic Liver Abscess Review in Sarawak General Hospital 2013 - 2015 Volume 3 2016 Mohd Firdaus AK1, Khairunnissa CG1, Nurazim S1, Siam F1 & Nik Azim NA1 1 Department of General Surgery, Sarawak General Hospital, Malaysia Corresponding Author: Mohd Firdaus A Karim ([email protected]) Objective: To review demographics and clinicopathological presentations of patients with pyogenic liver abscess (PLA) treated in Sarawak General Hospital. Background: PLA is a potentially fatal disease. Understanding of its clinocopathological profile in a local population allows for a more effective diagnosis and treatment. We present a case series of PLA treated in Sarawak General Hospital between 2013 and 2015. Methods: A retrospective review was performed for all patients who presented to Sarawak General Hospital with a diagnosis of PLA. Results: Eighty-six patients were admitted with the diagnosis of PLA. Fifty-nine (68%) were male and 27 were female (32%). The average age of patient presented was 52-year-old with the youngest being a 15-year-old boy and the eldest an 86-year-old lady. The most common presenting symptoms were fever and right hypochondrial pain. The right lobe of the liver was involved in 65% of the cases and 72% of the liver abscesses were solitary. Most patients (65%) had a combination of percutaneous drainage and antibiotics; 29 had antibiotics alone and one required open drainage as clinical examination showed peritonitis. Pus culture grew predominantly gram-negative organisms in 49 (57%) patients with Klebsiella pneumoniae being the most common organism isolated. In contrast, no organism was isolated in 29 (34%) patients. Two patients’ blood cultures were positive for Burkholderia pseudomallei. There was no in-house mortality seen in this review. Conclusion: PLA is associated with high mortality and morbidity; the development of sophisticated imaging system allows early diagnosis and prompt management that result in better outcome.1 It is a disease that occurs most commonly in the sixth to seventh decade of life2, as reflected in our study, with the average age of 65 years old. Most PLA are treated with antibiotics and catheter drainage. Drainage of the abscess helps relieve symptoms and guides the type of antimicrobial management. Gram-Negative organisms, with Klebsiella pneumonia being the most common, are the main organism isolated from the blood and abscess fluid which support the findings of previous study.3 Key Word: Pyogenic liver abscess References: 1. Ruiz-Hernández JJ, León-Mazorra M, Conde-Martel A, et al. Pyogenic liver abscesses: mortality-related factors. Eur J Gastroenterol Hepatol 2007; 19: 853-8. 2. Lee KT, Wong SR & Sheen PC. Pyogenic liver abscess: an audit of 10 years’ experience and analysis of risk factors. Dig Surg 2001; 18: 459-66. 3. Rahimian J, Wilson T & Oram V. Pyogenic liver abscess: Recent trends in etiology and mortality. Clin Infect Dis 2004; 39(11): 1654-9. 15 Sarawak Health Journal Burn Cases in Intensive Care Unit, Sarawak General Hospital Volume 3 2016 Mohd Tarmimi M1, Farah R1, Jamaidah J1, Mustaffa Kamil ZA1 & Norzalina E1 1 Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Malaysia Corresponding Author: Mohd Tarmimi bin Mustapha ([email protected]) Introduction: Burn patients represent a minor fraction of hospital admissions with significant amount of morbidity and mortality. The objective of this study is to review the clinical data and outcome of burn cases admitted to the Intensive Care Unit (ICU), Sarawak General Hospital (SGH). Methods: This retrospective study was conducted in a 15-bedded multidisciplinary ICU at a 765bedded tertiary medical centre, SGH. All admitted burn patients from 1st April 2013 to 30th March 2015 were included. Data on basic demographics, admission diagnosis, intervention done, length of stay (LOS) and causes of death were collected. Results: A total of 52 burn patients requiring ICU support were analysed. Median age was 33 [27, 49] years, predominantly (n=36, 69.2%) males. Mean total burn surface area (TBSA) was 31.9% (21, 44); 63.5% of patients sustained more than 20% TBSA burn. The commonest cause of burn was flame burn (n=44, 84.6%) predominating in the 20 to 39 years age group; 23 (44.2%) patients had inhalational injury, requiring ventilation. Twelve out of 52 burn patients underwent emergency operation (escharectomy / tangential excision). Six (11.5%) patients underwent tracheostomy for anticipated prolonged ventilation. The median duration of ventilation was two [1, 6] days. The median length of stay in ICU stay was six [3, 9] days. The mortality rate for burn was 26.9 % (n=14), with multiorgan failure as the main cause of mortality (n=6, 42.9%). There was no correlation between age (p=0.300), TBSA (p=0.113) and LOS (p=0.086) with mortality rate as reported in other literature.2 Discussion: Male foreigners between the ages 20 to 39 were identified as the main contributors for burn cases admitted to ICU SGH. This may be related to the numerous fire incidents that happened in plantations and coal mines throughout Sarawak. Our mortality rate is significantly higher compared to other studies done locally and abroad, which quotes figures from 6.5% to 12%.1,2,3,4 For a state with a total population 2.4 million people and a total area of 126 million km2, we only have one burn facility located at SGH to cater for the entire state needs. Conclusion: Multiorgan failure remains the main cause for mortality in burn patient. Therefore the burn critical care has to be focused on acute management and prevention of complications. Key Words: Burn; Intensive Care Unit (ICU); Sarawak General Hospital (SGH) References: 1. Chan KY, Hairol O, Imtiaz H, et al. A review of burns patients admitted to the Burns Unit of Hospital Universiti Kebangsaan Malaysia. Med J Malaysia 2002; 57(4): 418-25. 2. Duci SB, Arifi HM, Selmani ME, et al. A retrospective study of 69 patients admitted at the intensive care unit University Clinical Center of Kosovo during the period 2008 – 2012. Indian J Burns 2014; 22: 88-92. 3. Ho WS, Ying SY & Burd A. Outcome analysis of 286 severely burned patients: Retrospective study. Hong Kong Med J 2002; 8: 235-9. 4. Shankar G, Naik VA & Powar R. Epidemiological study of burn injuries admitted in two hospitals of north Karnataka. Indian J Community Med 2010; 35: 509-12. 16 Sarawak Health Journal Volume 3 2016 A Review of Complicated Appendicitis and Modified Alvarado Score as a Diagnostic Tool in Kapit Hospital Year 2014 Sun CCY1, Wong WK2, Hii KC2 & Toh TH3 1 Surgical Department, Kapit Hospital, Sarawak, Malaysia 2 Paediatric Department, Kapit Hospital, Sarawak, Malaysia 3 Paediatric Department and Head of Clinical Research Centre, Sibu Hospital, Sarawak, Malaysia Corresponding Author: Carine Sun Chung Yine ([email protected]) Introduction: Acute appendicitis is the most common cause of an acute abdomen. Early detection and intervention is the key to preventing complicated appendicitis, which has a four to five folds increase in mortality rate compared to the uncomplicated one. The Alvarado Score is a diagnostic tool that predicts the likelihood of appendicitis; however one of its criteria “shift of white blood cell count to the left” is not always available during emergency or after-hours in rural hospitals. Thus a modified Alvarado Scoring System (MASS) with omission of such criteria was adopted in our hospital. Objectives: 1. To identify the common forms of complicated appendicitis and the incidence of negative appendicectomy rate. 2. To evaluate the reliability of MASS in predicting the likelihood of appendicitis. Methods: We performed a case record review of all patients with suspected appendicitis who received treatment in Kapit Hospital in the year 2014. Data reviewed included the demographics, operative findings and the histopathological examination results of the appendicectomy specimen. The data was then analysed with SPSS v.20.0. Results and Discussion: A total of 79 patients were included, with majority male (55%) and in age group of 11 to 20 years old. Both younger and older age groups presented with complicated appendicitis, most likely due to difficulty in early diagnosis. Sixty-one patients were clinically suspected to have appendicitis of whom 59 underwent operation while two were treated conservatively. The overall incidence of complicated appendicitis was 34%, the common forms being perforation (25.0%), appendicular mass (3.6%), and necrosis (3.6%). Negative appendicectomy rate was 8.5% overall, but drastically higher in female (14.8%) than male (3.0%) highlighting the diagnostic difficulties in females presenting with right iliac fossa pain with additional diagnostic modalities warranted. We suggest a MASS score cut off point of ≥ 6 in our setting as it has a positive predictive value that is similar to the cut off of 7 i.e. 74%, but with a higher negative predictive value of 41%. Those with low scores should be re-assessed with other modalities such as ultrasound to prevent misdiagnosis. Patients with complicated forms of appendicitis were found to have MASS score of > 7 (OR 3.935, 95% CI: 1.260, 12.607). Conclusion: MASS > 6 can help to predict the likelihood of appendicitis; however a score of < 6 does not exclude appendicitis. Those with MASS score of > 7 are more likely to have complications. Key Words: Complicated appendicitis; Modified Alvarado Score; Kapit Hospital; complication rate. NMRR ID: 15-327-25124 17 Sarawak Health Journal Volume 3 2016 Red Cell Alloimmunisation among Multiple Transfused Patients at Sarawak General Hospital Tay SP1, Ho ZH1, Kong PI1, Ng JCH1, Liew ML1, Ong GB2, Chew LP3 & Gudum HR1 1 Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak (UNIMAS), Malaysia 2 Department of Paediatrics, Sarawak General Hospital, Malaysia 3 Department of Medicine, Sarawak General Hospital, Malaysia Corresponding Author: Tay Siow Phing ([email protected]) Introduction: Alloimmunisation, the immune response that occurs when an incompatible isoantigen encounters an immuno-competent host, can occur against red blood cell (RBC), platelet and human leucocyte antigens. The formation of alloantibodies by recipients against transfused RBC is one of the complications of blood transfusion. Despite blood transfusion being a life-saving procedure, RBC alloimmunisation can cause severe and life-threatening consequences. The risk of RBC alloimmunisation depends on the frequency of transfusions, antigen immunogenicity and the recipient’s immune response. The alloantibodies in recipients must be systematically identified before each transfusion to ensure safe and compatible transfusion. In Peninsular Malaysia, the prevalence of RBC alloantibodies ranged from 0.58% to 3.4%.1,2 However, there is a paucity of published data on the incidence of RBC alloimmunisation among the multiple transfused patients in Sarawak. Objectives: This study aimed to determine the frequency of RBC alloimmunisation among multiple transfused patients; to determine the association of development of alloantibodies as well as the haematological parameters with age of first transfusion, frequency and duration of transfusion. Methods: This was a cross-sectional study involving 60 multiple transfused patients from Sarawak General Hospital (SGH) with 33 males (55%) and 27 females (45%). The patients comprised thalassaemia (66.7%), leukaemia (19.9%), myelodysplastic syndromes (6.7%) and other haematological diseases (6.7%). The blood samples were analysed for full blood count (Haematology Analyzer Sysmex XS-800i), and the presence of RBC alloantibodies was detected using 3-cell and 11-cell gel card panels (Diamed, Switzerland). Results: In this study, there was no RBC alloantibodies detected in all the studied patients. Thus, the association of development of alloantibodies with other studied variable cannot be established in this study. However, significant correlations were demonstrated between the transfusion frequency with thrombocytosis (r=0.56; p=0.002) and basophilia (r=0.62; p<0.001). Transfusion duration also associated significantly with thrombocytosis (r=0.67; p<0.001) and basophilia (r=0.61; p=0.001). Discussion: Although the comparatively smaller sample size (n=60) could be the reason for this extremely low frequency (0%), our finding was comparable to the larger scale of studies by University Malaya (3.4%, n=143,501)1 and Universiti Kebangsaan Malaysia (0.58%, n=24,263)2 medical centres, which also showed very low prevalence of RBC alloimmunisation. The absence of alloantibodies in SGH patients was probably due to the homogeneity of our donors’ pool and recipients’ RBC antigens. It could also be attributed to the routine use of leucodepleted blood for chronically transfused patients at SGH, which had proven to be effective in preventing alloimmunisation in multiple transfusions.3 In addition, one-third of our patients were haemato-oncological patients who had undergone postchemotherapy and immuno-compromised. This might have contributed to the low frequency of alloimmunisation in this study. In this study, increased transfusion frequency and duration were associated significantly with thrombocytosis and basophilia, indicating that long-term multiple transfusions had triggered the patients’ immune reactivity. 18 Sarawak Health Journal Volume 3 2016 Conclusions: The risk of developing RBC alloantibodies among multiple transfused patients at SGH was very low. The comprehensive pre-transfusion testing in SGH had successfully eliminated the risk of alloimmunisation among these patients. Future studies can be extended to other district hospitals to determine the actual prevalence of RBC alloimmunisation in Sarawak. Key Words: Red cell alloimmunisation; multiple transfusions References: 1. Nadarajan VS, Laing AA, Saad SM, et al. Prevalence and specificity of red-blood-cell antibodies in a multi-ethnic South and East Asian patient population and influence of using novel UT+Mur+ kodecytes on its detection. Vox Sang 2012; 102(1): 65-71. 2. Yousuf R, Abdul Aziz S, Yusof N, et al. Incidence of red cell alloantibody among the transfusion recipients of Universiti Kebangsaan Malaysia Medical Centre. Indian J Hematol Blood Transfus 2013; 29(2): 65-70. 3. Singer ST, Wu V, Mignacca R, et al. Alloimmunization and erythrocyte autoimmunization in transfusion-dependent thalassemia patients of predominantly Asian descent. Blood 2000; 96: 3369-73. NMRR ID: 10-988-13863 19 Sarawak Health Journal Volume 3 2016 A Review of Clinician-Investigators at Sarawak General Hospital Undertaking Clinical Research – Industry or Investigator Initiated Studies? Tiong XT1 & Fong AYY2 1 Clinical Research Centre, Sarawak General Hospital, Malaysia 2 Clinical Research Centre and Cardiology Department, Sarawak General Hospital, Malaysia Corresponding Author: Tiong Xun Ting ([email protected]) Introduction: Sarawak General Hospital (SGH) is the main public tertiary referral hospital for the state of Sarawak. SGH has been a site of clinical research for over three decades, undertaking both industry and investigator-initiated studies. SGH has been recognized as a site for world class clinical research, and with a steady increase in the number of practising specialists, there is a need to profile clinician-investigators who have, are, and likely to, undertake clinical research. It is intended that SGH contributes significantly towards the knowledge economy in the biomedical field, particularly through clinical research activities and strong collaborative efforts with its partner sites. Objective: The aim of this research was to identify the type and total number of research done by clinicians. Methods: This study was carried out over a month period. It is a cross-sectional data collection through National Medical Research Register (NMRR) registry. NMRR registry data on investigators was cross-checked with a list of clinicians available in SGH. Data was entered in Microsoft excel. Descriptive data analyses were carried out. Results: Data collected through NMRR from year 2007 to October 2014 for research carried out in SGH and Heart Centre, SGH were gathered. A total of 851 researchers were registered after duplicate entries were removed. Total number of investigators (primary investigators, PI and Co-investigators, Co-I) registered in NMRR database was 2295. Out of 851 researches, 702 researches obtained an NMRR ID while 149 researches were without an NMRR ID. Based on NMRR registry (n=702), 225 were interventional studies (with mostly clinical trials–223); 358 were observational trials (with patient registry - 171, clinical epidemiology - 164); while others studies are 119. Table 1: Funding of researches done in SGH Source of funding For all With NMRR ID Without NMRR ID Department operational fund 7 5 2 Government (non-MOH) grant 6 5 1 Industry sponsored 185 178 7 MOH-NIH grant 49 41 8 Others 12 12 0 Self-funding 568 446 122 University research grant 24 15 9 Total 851 702 149 Discussion: Incomplete NMRR registration is present. As SGH is a tertiary hospital equipped with specialist and a big pool of patients, observational type of studies is more common compared to interventional studies. Proper classification of studies in the NMRR registry is needed. 20 Sarawak Health Journal Volume 3 2016 Conclusion: SGH conducted a fair amount of researches based on NMRR registry. The main field of research conducted was clinical trial, followed by patient registry and clinical epidemiology. Observational type of research is slightly more common. Most research done in SGH is self-funded (63.6%), followed by industry-sponsored (26.3%), research with grant applications (7%). Acknowledgement: This work was supported and approved by Clinical Research Centre Network, National Institutes of Health and Ministry of Health Malaysia. We would like to thank Logos Biomed Systems Sdn. Bhd. for sponsoring this study and NMRR secretariats for the data source and management of the NMRR website. The authors declare no conflict of interest with the Sponsor in this scientific study. Key Words: Research; Sarawak General Hospital; NMRR NMRR ID: 14-1190-22973 21 Sarawak Health Journal Volume 3 2016 Incidence, Risk Factors and Clinical Epidemiology of Melioidosis in Miri Hospital, Sarawak, Malaysia Vimal V1, Ling HW1, Cho WM1 & Norhuzaimah J1 1 Department of Anaesthesiology and Intensive Care, Miri Hospital, Sarawak, Malaysia Corresponding Author: Vimal Varma ([email protected]) Background: Melioidosis is a fatal community-acquired infection caused by the gram-negative bacteria Burkholderia pseudomallei. The overall mortality of melioidosis approaches 100% if untreated, but can be reduced to 37-54% with optimal management. Methods: This retrospective study describes the incidence, risk factors, clinical epidemiology of the disease by analysing 15 culture-confirmed cases of melioidosis treated in Miri Hospital from Jan 2014 to June 2015. Results: Patients’ ages ranged from 19 to 78 years old (mean = 49.07). Male patients accounted for 60% of the cases. The overall mortality rate was 53.3%, of whom 62.5% died after 14 days of admission. Respiratory involvement (33.3%) accounted for the majority of the clinical presentations followed by fever without definite source of infection (26.7%) and musculoskeletal involvement (20%). Respiratory involvement carries the highest mortality rate of 80%. Patients with underlying diabetes mellitus, hypertension and renal impairment on admission were found to have high mortality rates. As for antimicrobial therapy, most patients received ceftazidime (60%), followed by meropenem (20%) and imipenem (20%). Based on in-vitro sensitivity testing, antibiotic sensitivity of clinical isolates was 100%, 90% and 60% to imipenem, ceftazidime and meropenem respectively. Discussion: The overall mortality rate of culture-positive cases in our study is 53.3%, comparable to a study done in Pahang (54%).1 Diabetes mellitus has been reported as the most common underlying disease in melioidosis with an incidence up to 60%2 which is consistent with this study with 53.3% of the patients having underlying diabetes. Hypertension is not a known risk factor for melioidosis, however surprisingly in this study, patients with underlying hypertension has 100% mortality rate; therefore further studies are necessary to investigate this association. White et al demonstrated that ceftazidime could reduce overall mortality by 50%.3 According to the antibiogram, ceftazidime still carries 90% sensitivity. For carbapenem group, the sensitivity of meropenem and imipenem towards Burkholderia pseudomallei were 60% and 100%, respectively. All the patients who received carbapenem group died despite the antibiotic having high sensitivity towards the pathogen. This finding may be biased as carbapenem groups were most likely prescribed to severely ill patients, hence accounting for the higher mortality rate. A further study with a bigger sample size is imperative to establish a significant relations between the parameters analysed towards the outcome of this disease. Conclusion: Melioidosis is an emerging complex socio-ecological health problem in this part of the region. The wide range of clinical presentations and fatal outcomes of melioidosis require high index of suspicion for prompt early diagnosis and aggressive treatment to reduce the overall mortality. From the results of this study, we suggest that, in an endemic area such as our region, melioidosis should always be included as a working diagnosis in cases presenting with community-acquired infection. 22 Volume 3 2016 Sarawak Health Journal Table 1: Frequency and mortality rate according to risk factors, initial laboratory results and antibiotics used Percentage % (n) Mortality % (n) Diabetes Mellitus 53.3 (8) 75 (6) Hypertension 33.3 (5) 100 (5) Kidney Disease 20 (3) 66.7 (2) Liver Disease 13.3 (2) 0 40 (6) 66.7 (4) Abnormal Platelet Count 46.7 (7) 42.9 (3) Abnormal White Cell Count 66.7 (10) 60 (6) Abnormal Capillary Blood Sugar 46.7 (7) 57.1 (4) High Urea 33.3 (5) 100 (5) High Creatinine 73.3 (11) 72.7 (8) High Bilirubin 20 (3) 100 (3) Low Albumin 60 (9) 55.6 (5) Ceftazidime 60 (9) 55.6 (5) Trimethoprim / Sulfamethoxazole 26.7 (4) 50 (2) Meropenem 20 (3) 100 (3) Imipenem 20 (3) 100 (3) Ceftriaxone 46.7 (7) 71.4 (5) Doxycycline 26.7 (4) 50 (2) Piperacillin / Tazobactam 20 (3) 66.7 (2) Amoxicillin / Clavulanic Acid 13.3 (2) 100 (2) Cloxacillin 13.3 (2) 0 Metronidazole 20 (3) 33.3 (1) Co-morbid Initial Laboratory Results Low Haemoglobin Antibiotics Key Words: Melioidosis; risk factors; Miri References: 1. How SH, Ng KH, Jamalludin AR, et al. Melioidosis in Pahang. Malaysia Med J 2005; 60(5). 2. Cheng AC & Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clinical Microbiol Rev 2005; 18: 383-416. 3. White NJ. Melioidosis. Lancet 2003; 361: 1715-22. NMRR ID: 15-795-26243 23 Sarawak Health Journal Volume 3 2016 Demographic and Clinical Features of Leptospirosis in Paediatric and Adolescent Population in Kapit Hospital Wong WK1, Tan PW1, Sun CCY1 & Hii KC1 1 Paediatric Department, Kapit Hospital, Sarawak, Malaysia Corresponding Author: Wong Wai Kit ([email protected]) Introduction: Leptospirosis is a zoonotic disease prevalent mainly in developing countries. It is caused by infection with spirochetes of genus Leptospira, and is re-emerging with a worldwide distribution. Acute febrile illness remains one of the most common presentations of leptospirosis in Kapit Hospital. In our setting, a child with acute febrile illness and leptospirosis serology positive are often treated clinically for leptospirosis pending microscopic agglutination test (MAT) results. Objective: To study the clinical and laboratory presentations of leptospirosis MAT-positive subjects among paediatric and adolescent population in Kapit Hospital. Methods: Case records of admissions between September 2013 and February 2015 to Kapit Hospital were reviewed. All hospitalized patients less than 19 years old with positive result of Leptospirosis Serology and without evidence of other infections were included in this study. More detailed analyses were done for MAT-positive leptospirosis patients. MAT-positive leptospirosis patients are defined as those with titres of 1:400 or higher. Results and Discussions: Forty-four cases tested positive for leptospirosis serology, but only 33 cases were included, as the remainder had other sources of infection. Among 33 cases with leptospirosis serology positive, only 18 came back with leptospirosis MAT-positive during follow up. Male-to-female ratio is about 10:1. History of swimming in the river prior to illness was found in 12 (66%) patients, while 5 (28%) had a history of jungle trekking. One 4-year-old child died. The common symptoms manifested were fever, 17 (94%); vomiting, 9 (50%); diarrhoea, 7 (38%) and headache, 6 (33%). Cough, 5 (27%) was the only respiratory symptom observed. We had 6 (33%) subjects who were noted to have conjunctival suffusion, which is pathognomonic of leptospirosis, with a significant p value of 0.017 compared to leptospirosis MAT-negative group. Other signs observed included abdominal pain and hepatomegaly. Leptospirosis is characterized by a broad spectrum of clinical manifestations varying from unapparent infection to fulminant fatal disease. Children, in particular often bear the brunt of these tropical diseases, and pose the greatest diagnostic challenges to clinicians. Most of our patients presented with non-specific symptoms. Serology rapid test is still the most practical diagnostic method of Leptospirosis, with MAT being the “gold standard” but often requiring a long waiting-period. There was no positive culture for Leptospirae in our study, thus it was of limited diagnostic value. Conclusion: A high index of suspicion for leptospirosis should be maintained at all times in a child with positive leptospirosis serology, presenting with fever, vomiting, diarrhoea, headache and conjunctival suffusion especially in our setting. The increase in awareness of paediatric leptospirosis will help guide the appropriate use of healthcare resources in often resource-limited settings. 24 Sarawak Health Journal Table 1: Laboratory findings of lepto MAT positive Volume 3 2016 Key Words: Paediatric leptospirosis; adolescent leptospirosis; Kapit Hospital; lepto MAT; leptospirosis serology References: 1. Libraty DH, Myint KS, Murray CK, et al. A comparative study of leptospirosis and dengue in Thai children. PLoS Negl Trop Dis 2007; 26:111. 2. Tullu MS & Karande S. Leptospirosis in children: A review for family physicians. Indian J Med Sci 2009; 63(8): 368-78. NMRR ID: 15-994-26301 25 Sarawak Health Journal Volume 3 2016 Prevalence of Antibiotic Resistance in Burkholderia Pseudomallei Cases Presented to Miri General Hospital Yong KY1, Tang ASO1, Teh YC1, Fam TL1 & Chua HH2 1 Department of Medical, Miri Hospital, Malaysia 2 Department of Medical, Sarawak General Hospital, Malaysia Corresponding Author: Yong Kar Ying ([email protected]) Background: Melioidosis is caused by the gram-negative bacilli, called Burkholderia pseudomallei. It is an endemic infection in Southeast Asia.1 There is a wide spectrum of disease manifestation and associated with high mortality rate.2 Antibiotic resistance has been emerging and it poses significant challenges in our practices. We conducted a cross-sectional study to determine the prevalence and resistance rate of Burkholderia pseudomallei in Miri Hospital from January 2011 to May 2015. Methods: Patients’ demographic data, types of culture specimens and resistance rate to common antibiotics as well as all cases with positive cultures identified from the bacteriology laboratory were reviewed. Cultures sensitivity on antibiotics was determined by using disc diffusion method. Results and Discussion: In this study, 58 cases known to have positive cultures for Burkholderia pseudomallei were identified. Most of the samples identified were from blood cultures. Majority of the patients were males and less than 40 years old. There was no resistance to ceftazidime; but, the rate of resistance to imipenem, meropenem, trimethoprim-sulfamethoxazole (TMP-SMX) and amoxycillin / clavulanate (AMC) were varied. Resistance rate to meropenem (25% to 85.7%) was higher compare to imipenem (0% to 14.3%). TMP-SMX, was commonly used as oral medication for melioidosis eradication treatment with a mean resistance rate of 38.1%. The resistance rate for AMC ranged from 25% to 68.2%. Table 1: Percentage of resistance rate of Burkholderia pseudomallei (from 2011 till June 2015) Type of Antibiotic Ceftazidime Meropenem Imipenem Trimethoprim / Sulfamethoxazole Amoxycillin / Clavulanate 2011 (%) 2012 (%) 2013 (%) 2014 (%) 2015 (%) 0 0 0 0 0 0 25.0 45.5 85.7 28.1 0 0 0 14.3 0 16.7 0 36.4 100 37.5 50.0 25.0 68.2 16.7 53.1 Conclusion: Burkholderia pseudomallei remains sensitive to ceftazidime despite its usage as a firstline antibiotic for melioidosis treatment over the years. The true resistance rate to imipenem, meropenem, AMC and TMP-SMX should be determined by using e-Test technique for better accuracy of antibiotic of choice.3 Key Words: Burkholderia pseudomallei; meliodosis; antibiotic resistance References: 1. Cheng AC & Currie BJ. Melioidosis: Epidemiology, pathophysiology, and management. Clin Microbiol Rev 2005; 18(2): 383-416. 2. How SH & Ng KH. Meliodosis in Pahang, Malaysia. Med J Malaysia 2015; 60(5): 606-13. 3. Tan AL & Tan ML. Melioidosis: Antibiogram of cases in Singapore 1987-2007. Trans R Soc Trop Med Hyg 2008; 102(S1): 101-2. NMRR ID: 15-925-26358 26 Sarawak Health Journal Volume 3 2016 Public Health Observational Research Public Health Observational Research 27 Sarawak Health Journal Volume 3 2016 Iodine Nutritional Status amongst School Children after Five Years of Universal Salt Iodisation in Sarawak Jeffery S1, Jambai E1, Kiyu A1 & Zulkifli J 1 1 Sarawak State Health Department, Kuching, Sarawak, Malaysia Corresponding Author: Jeffery Stephen ([email protected]) Introduction: Iodine deficiency is a public health problem worldwide. Globally, the WHO estimates 31% or two billion people are iodine-deficient. Iodine deficiency has many consequences such as goitre, cretinism, intellectual impairments, growth retardation, neonatal hypothyroidism neurological disorders and impairment in physical development; pregnant mothers and children are especially susceptible. Sarawak is endemic for iodine deficiency disorders (IDD). Many intervention programmes have been implemented to eliminate the IDD including the establishment of saltiodisation plants, water iodisation system for longhouse communities, free distribution of iodised table salt to local communities with priority to antenatal mothers, implementation of legislation requiring the iodization of fine table salt in certain highly-goitrous areas as well as universal salt iodisation (USI) programme. Objective: To determine the iodine status amongst school-aged children in Sarawak after five years of USI programme. Methods: We analysed the Sarawak State IDD Survey (2014) Database and the findings were compared with the National IDD Survey results which were done in 2008. Urinary iodine concentration (UIC) was used as the impact indicator. AWHO/ICCIDD/UNICEF criterion was used to classify iodine status into different degrees of public health significance as well as for monitoring of IDD elimination progress. Results and Discussion: The median UIC in 2014 was 114.9 µg/L – that was a significant increase from 102.1 µg/L in 2008 (p<0.001). The median UIC in rural areas significantly improved from 91.9 µg/L (mild iodine deficiency) in 2008 to 113.6 µg/L (optimal) in 2014 (p<0.001). The median UIC in urban areas increased significantly from 109.3 µg/L (optimal) in 2008 to 120.8 µg/L (optimal) in 2014 (p<0.001). Overall, the percentages of children who were iodine-deficient (median UIC less than 100 µg/L) were lower in 2014 (41.2%) compared to 2008 (49.3%). The Bumiputera’s median UIC also improved from 95.0 µg/L in 2008 to 123.0 µg/L in 2014 (p<0.00). Conclusion: There was significant reduction in the proportion of school-aged children who were iodine-insufficient in 2014 compared to 2008. Median UIC for rural areas improved significantly from 91.9 µg/L (iodine insufficient) in 2008 to 113.6 µg/L (not iodine-deficient) in 2014. Significant improvement in iodine status was observed amongst Bumiputera children. Monitoring and evaluation of the availability of adequately iodised salt and household iodised salt consumption should be strengthened. Health education on the benefits of adequate iodine intake should be carried out continuously to the public. After 5 years of USI implementation in Sarawak, the iodine status of the school aged children in 2014 has improved compared to 2008. Key Words: Iodine deficiency; universal salt iodisation; school-aged children; Sarawak NMRR ID: 15-956-26509 28 Sarawak Health Journal Volume 3 2016 Pendekatan Program Community Feeding Dalam Memulihkan Kanak-Kanak Kekurangan Zat Makanan Di Long Urun, Belaga Lai SF1, Nicholas AG2 & Hasrina H3 1 Klinik Kesihatan Kapit, Sarawak, Malaysia 2 Klinik Kesihatan Belaga, Sarawak, Malaysia 3 Pejabat Kesihatan Bahagian Kapit, Sarawak, Malaysia Pengarang Koresponden: Lai Sher Fang ([email protected]) Pengenalan: Perkhidmatan kesihatan kerajaan telah diperluaskan ke kawasan Long Urun pada tahun 2012 dan dididapati peratus kanak-kanak kekurangan zat makanan (KZM) bawah 5 tahun di Daerah Belaga meningkat daripada 13.1% (2011) kepada 15.9% (2012). Keadaan ini merunsingkan kerana tren telah menunjukkan penurunan purata 2.1% sejak 2009. Dengan itu, Program Community Feeding (PCF) telah diperkenalkan di Long Urun mulai Disember 2013 untuk memperkasakan Program Pemulihan Kanak-kanak KZM (PPKZM). Objektif: Kajian ini bertujuan untuk menilai keberkesanan pelaksanaan PCF dalam meningkatkan status pemakanan kanak-kanak KZM berbanding dengan PPKZM sahaja. Kaedah: Senarai nama kanak-kanak KZM bawah tujuh tahun daripada komuniti Penan yang berdaftar dalam PPKZM serta kombinasi PCF dan PPKZM, yang berada dalam program sekurangkurangnya 12 bulan telah diperolehi daripada Laporan Bulanan KPIKZM101 sejak 2012. Kes-kes yang mempunyai masalah perubatan (contoh: congenital heart disease) serta gagal ditimbang berat badan lebih daripada dua bulan berturut-turut telah dikecualikan daripada kajian ini. Purata kenaikan berat badan (g) antara kes-kes yang berdaftar bawah PPKZM (n=26) serta kombinasi PCF dan PPKZM (n=18) telah dianalisa dengan merujuk kepada berat badan semasa bermula bantuan dan berat badan pada bulan ke-12 berada dalam program. Peratus kes yang menunjukkan kenaikan status makanan antara kes yang berdaftar bawah kedua-dua program telah dianalisa dengan merujuk kepada z-score berat-untuk-umur semasa bermula bantuan dan z-score berat-untuk-umur pada bulan ke-12 berada dalam program. Peratus kes yang meningkat berat badan juga dianalisa dengan merujuk kepada data berat badan setiap bulan selama 12 bulan berada dalam program. Keputusan: Kombinasi PPKZM dan PCF berjaya meningkatkan berat badan kes dengan 355.6 g lagi lebih daripada PPKZM. Selain itu, kombinasi program PCF dan PPKZM juga menunjukkan 10.2% lebih berkesan dalam meningkatkan status pemakanan kes ke satu kategori yang lebih baik berbanding dengan PPKZM sahaja. Peratus kes yang meningkat berat badan dari kombinasi PCF dan PPKZM adalah lebih tinggi (72.2%) berbanding dengan PPKZM sahaja (7.7%). Kesimpulan: Kombinasi PPKZM dan PCF merupakan pendekatan yang lebih berkesan dalam meningkatkan status pemakanan kanak-kanak KZM. Ia mungkin disebabkan oleh penjagaan yang lebih rapi serta pemberian bantuan makanan yang lebih kerap. Namun, ini memerlukan kajian yang lebih lanjut untuk mengkaji faktor penyumbang keberkesanan program. Dengan itu, kombinasi PPKZM dan PCF diharap dapat diperluaskan ke lokaliti lain di bahagian Kapit yang mempunyai kes KZM yang ramai pada masa akan datang. Kata Kunci: Program Community Feeding; kanak-kanak kekurangan zat makanan; Long Urun Rujukan: 1. Garis Panduan Program Community Feeding. Bahagian Pemakanan, KKM 2014; 1. 2. Garis Panduan Program Pemulihan Kanak-kanak Kekurangan Zat Makanan. Bahagian Pemakanan, Kementerian Kesihatan Malaysia 2014; 6-7. 29 Sarawak Health Journal Volume 3 2016 Dengue Fever Outbreak in the Long House: What is the Responsibility of Divisional Health Office? Shafizah AS1, Tze SN1, Phua AL1 & Azlee A1 1 Divisonal Health Office Bintulu, Sarawak, Malaysia Corresponding Author: Shafizah Ahmad Shafei ([email protected]) Introduction: Cumulatively, Sarawak has registered 871 dengue cases this year which is an increase (162.3%) compared to 539 cases only last year. Meanwhile, Bintulu Division recorded 42 dengue cases cumulatively up to epid week 14/2015 compared to 28 cases within the same period last year, which is a 50% increase in the number of cases. Bintulu Divisional Health Officer (DHO) has declared a dengue fever outbreak in Rumah Suhaili, 25th Mile Bintulu-Miri road on 12 April 2015 upon receiving a second notification from the same locality on 11 April 2015. The first case was recorded on 8th April 2015. Objective: To identify the epidemiology of the outbreak, the source of infection and the appropriate action for prevention and control Methods: The case was investigated within 24 hours of notification using the investigation form for dengue fever case PBV (DF / DDB / JE / CHIKU) Amendment 301 4/13. Validation is done through serological test case. Epidemic control measures that have been implemented include thermal fogging, destruction of breeding grounds (PTP) and active case detection. The effectiveness of control activities especially fogging was evaluated through 48 hours ovitrap survey. Results: The outbreak of dengue fever was caused by the Aedes albopictus mosquito as shown from the entomological survey. Both confirmed cases of dengue fever have positive serological test (Case 1: positive for NS1 antigen, Case 2: positive for NS1 antigen, IgM and IgG). Ovitrap index examined after the control activities were carried out was 0%. Discussion: The main cause of the incident was caused by the absence of clean water supply that encouraged residents to use 45-gallon (205-litre) drums as water containers. The absence of a proper waste disposal system also has resulted in the outbreak in that area. Control measures have been done together with the local authorities and residents and were reflected well with the decrease of amount of potential containers and the reduction of Aedes Index, Breteau Index and Container Index. Commitment from the Local Authorities in providing better waste disposal system has contributed to the effectiveness of the control activities. Conclusion: The outbreak of dengue fever that occurred in the longhouse was due to the absence of a clean water supply and an improper waste disposal. Control measures have been carried out in accordance with the guidelines and standards set by the Ministry of Health (MOH). 30 Sarawak Health Journal Volume 3 2016 Table 1: Summary of activities carried out to assess Aedes breeding activity levels Date 09.04.2015 12.04.2015 Total houses visited Total 19.04.2015 30 30 30 90 Total houses inspected 30 30 30 90 Outside 30 30 30 90 Inside 25 25 25 75 Aed. Aeg 0 0 0 0 Aed. Alb. 2 0 0 2 Locked 2 2 2 6 Vacant 3 3 3 9 No. of houses +ve 2 2 2 2 Aedes Index* (%) 6.7 0 0 2.2 Inside 20 27 10 57 Outside 51 28 16 95 Total 71 55 26 152 Inside 0 0 0 0 Outside 2 0 0 2 Total 2 0 0 2 Breteau Index**% 6.7 0 0 2.2 Container Index*** 2.8 0 0 1.3 Inspected Number of houses Positive for Aedes Number of containers inspected Number of containers positive * Aedes IndexAedes Index (AI) or House (premises) Index (HI): Percentage of houses or premises positive for Aedes larvae ** Breteau index (BI): number of positive containers per 100 houses inspected. *** Container index (CI): percentage of water-holding containers infested with larvae or pupae. Key Words: Dengue fever; treated water References: 1. Heymann DL. Control of Communicable Diseases Manual. American Public Health Association 2008. 2. Jabatan Kesihatan Negeri Sarawak. Buletin Mingguan Epidemiologi Denggi Minggu Unit Penyakit Bawaan Vektor. Epid 14/2015. 3. Kementerian Kesihatan Malaysia. Garis Panduan Halatuju Baharu Kawalan Denggi. Kementerian 2014. 4. Kementerian Kesihatan Malaysia. Surat Pekeliling Ketua Pengarah Kesihatan Malaysia Bil. 29/2010. Tindakan Susulan Keputusan Mesyuarat Jawatankuasa Peringkat Kebangsaan Mengenai Denggi dan Mesyuarat Jemaah Menteri: Pengaktifan Jawatankuasa Wabak Denggi Peringkat Daerah. Kementerian 2010. 5. World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. New Edition. The Organization 2009. 31 Sarawak Health Journal Food Poisoning Outbreak at the Ocean: A Case Report Volume 3 2016 Shafizah AS1, Connie AA1, Nurdiana S1 & Azlee A1 1 Divisional Health Office Bintulu, Sarawak, Malaysia Corresponding Author: Shafizah Ahmad Shafei ([email protected]) Introduction: A food poisoning outbreak among offshore workers occurred on an accommodation vessel in South China Sea near Bintulu shore. The Communicable Disease Control (CDC) Unit of Bintulu Divisional Health Office received a notification of food poisoning outbreak on 22nd August 2014 involving offshore workers from JC Company who stayed in an accommodation vessel in the South China Sea of Bintulu shore. JC Company was one of the many companies responsible for building oil rigs for a multinational company based in Kuala Lumpur. All of the construction workers from all these different companies resided in an accommodation vessel that was attached to the oil rig platform. Altogether, there were 284 persons on board the accommodation vessel. Objective: To determine the epidemiology of the outbreak and its control measures. Methods: Cases sent onshore were investigated using the standard form FWBD/UMU/BG/007. The remaining workers who experienced the symptoms were investigated with the help of the Safety and Health Officer of the affected company using a questionnaire developed based on the standard form with additional questions on types of meals eaten by the workers. The food that caused the outbreak was identified by determining the food attack rate which was calculated based on the list of menu given. Investigation by Hazard Analysis Critical Control Point was also conducted. Results: Thirty-five workers reported of having gastrointestinal symptoms. Almost all cases had diarrhoea, while 94.2% experienced abdominal pain and 68.5% had fever. Only 60% had nausea and 48.5% had vomiting and headache. The incubation period ranged from 15 to 53 hours. Fried chicken with dried tofu scored the highest food attack rate of 10.3% and was identified as the culprit, and followed by chicken curry and fried noodles at 8.5% and 7.4%, respectively. Refer to Figure 1 for the epidemic curve of food poisoning among workers (page 60). Discussion: The food poisoning outbreak involving 35 workers aged between 18 to 54 years old occurred at the accommodation vessel. The affected workers experienced mainly lower gastrointestinal (GI) symptoms with overall attack rate of 12.3%. The aetiological agent responsible for the outbreak was most likely Salmonella spp. based on the incubation period, signs and symptoms of cases and food taken at that moment. The incubation period correlated with the incubation period of Salmonella spp. as well as the suspected menu that was based on chicken. The limitation for case investigation was mainly due to tight security since it involved heavy industry related to the oil industry in the sea. Lesson Learnt: Food poisoning can occur anywhere. Heavy industries must practise food safety and hygiene. This can be done in their routine safety practice especially those who work offshore. Innovative and alternative methods of investigation need to be implemented when normal procedures cannot be applied. Coordination with related agencies needs to be optimized to ensure timeliness of control measures. Key Words: Food poisoning; Salmonella spp. Reference: 1. Kementerian Kesihatan Malaysia. Garis Panduan Pengurusan Wabak Keracunan Malaysia di Malaysia. Putrajaya. Kementerian Kesihatan Malaysia 2006. 32 Sarawak Health Journal Case Reports and Case Series Reports and Case Series 33 Volume 3 2016 Sarawak Health Journal Volume 3 2016 Inferior Epigastric Artery Injury – A Complication of Femoral Line Insertion despite Under Ultrasound Guidance Chan WK1, Ng PN1 & Norzalina E1 1 Anaesthesiology and Intensive Care Unit, Sarawak General Hospital, Malaysia Corresponding Author: Chan Weng Ken ([email protected]) Introduction: Accidental arterial puncture is a complication of central venous catheter (CVC) insertion with reported incidence ranging from 4.2% to 9.3%.1. The National Institute for Health and Care Excellence (NICE) 2002 guideline advocates ultrasound-guided CVC placement to reduce this complication.2 We present a case of inferior epigastric artery (IEA) injury sustained during CVC insertion into the femoral vein despite being under ultrasound guidance. Case Presentation: A 62-year-old gentleman with underlying diabetes mellitus, chronic kidney disease and other comorbidities including a recent stroke presented with acute parapharyngeal abscess requiring Intensive Care Unit (ICU) admission. He was planned for incision and drainage. Preoperative blood investigations showed leucocytosis and uraemia (34.2 mmol/L). Right femoral CVC was inserted under ultrasound guidance uneventfully. On the left however, two attempts were needed using 7 Fr CVCs. Post insertion, he underwent haemodialysis for four hours uneventfully before being sent to the operating theatre. Vital signs remained stable with no obvious haematoma at the CVCs site. Post-operatively, upon arrival at ICU, it was noted that he developed significant bilateral scrotal haematoma extending up to lower abdominal wall with haemodynamic instability requiring fluid resuscitation and high vasopressor support. His haemoglobin level had dropped more than 4 g/dL and patient developed lactic acidosis. Urgent femoral angiogram showed left IEA leakage, which was embolised by the interventional radiologist. He required massive blood transfusions. Subsequently, his condition improved. A repeated angiogram two days later showed no more haemorrhage. However, patient continued to be managed in ICU as he had acute respiratory distress syndrome, delayed wound healing and hospital-acquired infection. Unfortunately, patient succumbed to aspiration pneumonia three months later. Discussion: IEA injuries occur more commonly among the patients with coagulopathy, and embolisation is an effective measure for haemorrhage control.3 Despite ultrasound guidance, iatrogenic complication can still occur. In order to reduce the risk, it is crucial to visualise the tip of the needle at all times. This skill is operator-dependent and requires some training and is best learnt through a simulation model which is sold commercially and should be made available to all training centres. Some authors have advocated static or dynamic ultrasound techniques but this minor difference in ultrasound guiding techniques which often involves both the so-called static and dynamic methods is negligible.4 Conclusion: Arterial injury is a known complication of central venous access. Ultrasound guidance may reduce inadvertent arterial puncture and potential life threatening haemorrhage. However, clinicians need to learn this technique correctly. Key Words: Dynamic ultrasound; central venous access complications; inferior epigastric artery 34 Sarawak Health Journal Volume 3 2016 Diffuse Large B-Cell Lymphoma of the Terminal Ileum Mimicking Appendicular Mass in a Young Adult Devanraj S1, Suriaraj K1, Premjeet S1 & Soon KC2 1 Miri Hospital, Sarawak, Malaysia 2 Sarawak General Hospital, Sarawak, Malaysia Corresponding Author: Devanraj A/L Selvam ([email protected]) Introduction: Lymphomas of the gastrointestinal (GI) tract are the most common primary extranodal lymphomas, of which 15-20% of these manifests as primary intestinal lymphoma.1 The presentations for GI lymphomas are usually non-specific and clinically indistinguishable from other benign and malignant GI conditions. Case Report: We report a 20-year-old lady with primary lymphoma of the terminal ileum who presented initially to our centre with one day history of pain and a mass at the right iliac fossa. The blood results were of no significance but the computed tomography (CT) scan of the abdomen was suggestive of an appendicular mass (Figure 1). From the outset, a conservative regime was planned for her with antibiotics, fluids and rest, and a subsequent follow-up in the surgical clinic. However after four weeks, her pain recurred and she then underwent an emergency surgery during which it was noted that there was a small bowel mass at the terminal ileum along with multiple mesenteric lymphadenopathies. A right hemicolectomy (Figure 2) was performed and she was discharged well. Histo-pathological examination of the terminal ileum revealed it to be of the Diffuse Large B-Cell type of lymphoma with the involvement of only one out of the 23 mesenteric lymph nodes. A staging CT thorax, abdomen and pelvis showed evidence of para-aortic and mesenteric lymphadenopathy without affecting the supra-diaphragmatic lymph nodes. Chemotherapy was commenced for her shortly after that. Discussion: Extranodal lymphomas are lymphomas that arise from tissues other than lymph nodes. Lymphoma constitutes 15-20% of all small intestine neoplasms with the most common site of involvement being the ileum (60-65%).2 Ileo-caecal lymphoma commonly presents with abdominal pain, altered bowel habits and weight loss, along with the finding of an abdominal mass. Nevertheless, primary intestinal lymphoma is usually only diagnosed after exploratory laparotomy such as in our patient. Treatment of primary intestinal lymphoma differs according to the extent of the disease. Surgical resection should always be attempted for localized disease.1 This, combined with systemic chemotherapy, appear superior to any other treatment combination in localized disease. On the other hand, in disseminated cases, chemotherapy alone or in combination with surgery was the treatment modality associated with the highest complete remission and five-year survival. Diffuse large B-cell lymphoma (DLCL) of the intestine is usually treated with aggressive poly-chemotherapy, which is usually combined with a monoclonal antibody such as Rituximab.3 The major prognostic factors for survival are the size of the primary tumour, the likelihood of radical surgical resection, its degree of extension to adjacent structures, the amount of residual disease after surgery, stage and histological subtype.4 Conclusion: Albeit lymphoma at the ileo-caecal junction is relatively uncommon, it should always be considered as a pertinent differential of a right iliac fossa mass in a young adult, especially when conservative management fails. Key Words: Lymphoma; terminal ileum; appendicular mass 36 Sarawak Health Journal Volume 3 2016 Figure 1: Heterogeneous mass seen at the right iliac fossa which was initially suggestive of an appendicular mass Figure 2: Gross specimen of the right hemicolectomy with multiple mesenteric lymphadenopathies References: 1. Zinzani PL, Magagnoli M, Pagliani G, et al. Primary intestinal lymphoma: Clinical and therapeutic features of 32 patients. Haematologica 1997; 82(3): 305-8. 2. Schottenfeld D, Beebe-Dimmer JL & Vigneau FD. The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol 2009; 19: 58-69. 3. Ghimire P, Wu GY & Zhu L. Primary gastrointestinal lymphoma. World J Gastroenterol 2011; 17(6): 697-707. 4. Weingrad DN, Decosse JJ, Sherlock P, et al. Primary gastrointestinal lymphoma: A 30-year review. Cancer 1982; 49: 1258-65. NMRR ID: 15-802-26254 37 Sarawak Health Journal Volume 3 2016 Silantek Burn Disaster 2014: Critical Care Experience and Lesson Learned Farah R1, Yusopian Y1, Natasha N1, Fakhzan M1& Norzalina E1 1 Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Malaysia Corresponding Author: Natasha Mohd Noh ([email protected]) Introduction: Burn disaster is uncommon and management after a casualty is important. On 22nd November 2014, a coal mine exploded in Silantek Pantu, Sri Aman, Sarawak. Case Presentation: The Intensive Care Unit (ICU) in Sarawak General Hospital (SGH) is 15-bedded and it was converted to 20-bedded during the incident. Thirty patients were brought to SGH. Fifteen of them who were admitted to ICU were foreigners from North Korea, Myanmar, Indonesia, and China. Their ages were between 21 to 44 years old. Most had full-thickness burns and more than 40% Total Body Surface Area (TBSA). The Burn Unit ventilated four patients, while the general ward ventilated ten patients. Of those in the ICU, two had inhalational injury, one with intracranial bleed, and two with fractures. Other hospitals in Sarawak (including private medical centres) with ICU facilities were identified. During the first 24 hours, six patients were transferred to two private hospitals in Kuching for ventilator support, and they were transferred back to SGH at day-five postincident. A total of eight patients were transferred to Sabah and West Malaysia for facilities up to 72 hours post-incident. Patients ventilated in general wards were later transferred to ICU. Four operating rooms were dedicated for burn cases for the first week. Mortality rate in ICU was 40% (n=6). Discussion: The purpose of this report is to review our recent experience and lessons learned with burn disaster with respect to the planning and management from the anaesthesiology and intensive care perspectives. As the incident occurred over the weekend, staff were called back to work and most had to stay overnight in the hospital. The critical shortages of ventilators and ICU beds became our main problem. Those patients transferred away were the ones intubated with minor injuries. Planning, communication, and documentation are the most important element in managing a casualty. There must be a disaster plan in place in the hospital with a proper framework. Communication must be established by defining the role of the leader and others for an effective disaster response. Triage is essential as burn victims need immediate medical care and to prevent overload at a burn centre especially in the ICU. Personnel shortages and organization of work through formation of teams is required. Supplies and equipment such as medications, ventilators and transport monitors are potentially scarce when critical care capacity is expanded; hence the list should be updated. The timely transfer of patients to other identified hospitals or regions in the country is crucial and this may include aeromedical evacuation.5 Acute hours of life-saving resuscitation and surgery include 24 hours post-disaster whereby patients may need surgery. Conclusion: The challenges faced were manpower and limitation of ICU resources to accommodate mechanically-ventilated patients in ICU, Burn Unit and general ward. Transfer decision is a priority to ensure optimum care of the critically-ill patients. Effective planning and communication is needed to ensure that the sudden onset of a crisis situation at an unexpected time does not overwhelm hospital manpower and resources. Key Words: Disaster management; Silantek; burn 38 Sarawak Health Journal Endocrine Disorder Masquerading as Blood Malignancy: A Case Report Volume 3 2016 Lee WH1, Leong TS1 & Chew LP1 1 Haematology Unit, Medical Department, Sarawak General Hospital, Malaysia Corresponding Author: Lee Wan Hui ([email protected]) Introduction: Hypercalcemia is a commonly encountered medical problem in our practice, which can be attributed to a myriad of aetiologies. We present a case that was evaluated for hypercalcaemia, anaemia and multiple lytic lesions with a strong suspicion of blood malignancy which eventually turned out to be an endocrine disorder. Case Presentation: A 68-year-old lady presented to us with generalized body weakness, nausea, headache, confusion, and abdominal pain. Blood investigation showed normochromic normocytic anaemia and hypercalcemia. Skeletal survey revealed multiple lytic lesions. Multiple myeloma was suspected. However, bone marrow aspiration revealed a dry tap and trephine biopsy did not show plasma cells. Hence, we encountered a diagnostic dilemma and we were hesitant to start treatment for multiple myeloma, considering the high cost and potential life-threatening side effects of the treatment. Fortunately, the intact parathyroid hormone level came back on time and noted to be markedly raised. The diagnosis of primary hyperparathyroidism was considered and the case was referred to an endocrinologist. Outcome / Follow-up: Ultrasound of the neck revealed a right retrothyroid lesion. Sestamibi scan was suggestive of hyperfunctioning parathyroid tissue. Subsequently the patient underwent parathyroidectomy where a right parathyroid adenoma of 2 cm x 1.5 cm was resected. A follow-up four weeks later revealed a stable calcium level with haemoglobin of 11 (without any blood transfusion). As expected, serum and urine protein electrophoresis were negative for paraprotein, not suggestive of any blood malignancy. Discussion: Hyperparathyroidism may be a precipitating factor important to the development of anaemia which might progress into myelofibrosis. However, there had been only a few reported cases on anaemia and myelofibrosis secondary to primary hyperparathyroidism. It is suggested that parathyroid hormone (PTH) interferes with normal erythropoiesis by down- regulating the erythropoietin (EPO) receptors on erythroid progenitor cells in the bone marrow; hence anaemia ensues. This effect is observed with very high concentrations of PTH. Hypercalcaemia and anaemia are expected to resolve once the source of high PTH is removed. This is clearly illustrated in our case scenario. Conclusion: In the presence of anaemia, hypercalcaemia and radiographic evidence of multiple lytic lesions, primary hyperparathyroidism should always be kept in differential diagnosis and should be looked into after other causes such as (blood) malignancy has been excluded. A high index of suspicion will lead to an early diagnosis and appropriate treatment. Key Words: Hypercalcaemia; anaemia; multiple myeloma; primary hyperparathyroidism 39 Sarawak Health Journal Cutting the Queue: Young Myocardial Infarction Volume 3 2016 Kang WJ1 & Ng SG1 1 Emergency and Trauma Department, Sarikei Hospital, Sarawak, Malaysia Corresponding Author: Kang Wen Ji ([email protected]) Introduction: How young is actually young? Standard teaching imparts that myocardial infarction (MI) occurs mainly in patients older than 45 years. But in reality, 3% of MI occurs in patients between 15 and 34 years old, which is rarely highlighted.1 This group of patients has a wide range of aetiologies, which poses a management challenge. Here, we share a case of a young MI. Case Presentation: A 24-year-old gentleman, smoker with no co-morbid presented with typical chest pain. He had no family history of heart disease and denied any recreational drug abuse. On examination, vital signs were stable. His lungs were clear and heart sounds were normal. Electrocardiogram (ECG) showed ST elevation in the anteroseptal leads. Bedside echocardiogram revealed anteroseptal wall hypokinaesia and troponin T level was raised. Blood sugar and lipid profiles were normal. He was immediately thrombolysed with intravenous streptokinase and ECG post-thrombolysis showed good resolution. This patient subsequently stopped taking his medications. He landed in a heart centre with severe chest pain and developed ventricular fibrillation. He was resuscitated and primary percutaneous coronary intervention (PCI) was done, showing occlusion of the proximal segment of left anterior descending (LAD) and was stented successfully. Echocardiogram was done: ejection fraction of 25-35% with regional wall motion abnormalities over the anteroseptal. Discussion: When a young patient presents with chest pain and ECG shows ST elevations, we should consider the different aetiologies and risk factors of coronary artery disease (CAD) in young adults before rushing for thrombolysis. In general, the aetiologies of young MI can be divided into two categories: (a) atheromatous CAD and (b) non-atheromatous CAD.4 (a) Atheromatous CAD The atheromatous process was linked to the conventional risk factors as in older adults, which are cigarette smoking, lipid abnormalities, insulin resistance, hypertension, obesity and positive family history of premature CAD.1,2,3,4 In our patient, the risk factors were cigarette smoking. The relative risk for CAD was 3 times higher in smokers1. Repeated exposure to cigarettes results in damaged endothelial cells, leading to injury of the vascular intima. (b) Non-atheromatous CAD Recreational drug use (e.g. cocaine) was found to be associated with MI by causing coronary vasospasm and the effects can present up to 76 hours.4 Hypercoagulable states e.g. antiphospholipid syndrome, nephrotic syndrome are associated with recurrent vessels thrombosis. Congenital coronary artery anomalies and coronary embolisation of septic vegetation are other rare causes of MI in young adults. Although rare, all the above causes must be considered in every young patient presenting with MI while chasing time. Primary PCI was done and showed occlusion of LAD. Young patients are more likely to have single vessel disease as compared to their older counterparts1 and the LAD was the most susceptible site of atherosclerotic occlusion in younger patients with MI2. Lessons Learnt: 1. The causes of a young patient presenting with MI should be weighed and evaluated due to the wide range of aetiologies. 2. Young MI is rare but possible. If the diagnosis is definite, do not hesitate to thrombolyse them. Remember, time is myocardium. 40 Key Words: Young myocardial infarction Sarawak Health Journal Volume 3 2016 References: 1. Klein LW & Nathan S. Coronary artery disease in young adults. J Am Coll Cardiol 2003; 41(4): 529-31. 2. McGill HC Jr, McMahan CA, Tracy RE, et al. Relation of a postmortem renal index of hypertension to atherosclerosis and coronary artery size in young men and women. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler Thromb Vasc Biol. 1998; 18: 1108-18. 3. Kannel W, McGee D & Castelli W. Latest perspectives on cigarette smoking and cardiovascular disease. The Framingham Study. J Card Rehabil 1984; 4: 267-77. 4. Egred M, Viswanathan G & Davis GK. Myocardial infarction in young patients. Postgrad Med 2005; 81: 741-5. 41 Sarawak Health Journal An Early Experience of Treating Paediatric Neck of Femur Fracture Volume 3 2016 Kesavan R1, Hafiz D1, Norzatulsyima N1 & Isymth AR1 1 Miri Hospital, Sarawak, Malaysia Corresponding Author: Kesavan Ramachandran ([email protected]) Introduction: Femoral neck fractures are rare in children and usually occur in high energy trauma settings. These fractures pose a challenge for orthopaedic surgeons, because of its potential complications and the high degree of expertise needed in its management. Case Report: We report a 5-year-old girl who presented with a closed left femoral neck fracture. The mechanism of injury in our case was that of a high-impact trauma from motor vehicle accident. Upon arrival at hospital, the left lower limb was externally rotated with no obvious deformity seen. Attempted manoeuvre around the hips was painful. The frontal pelvic radiograph (Figure 1) showed a left cervico–trochanteric (Type III) femoral neck fracture. She was operated within 24 hours. Closed reduction was attempted on the left side under an image intensifier and the fracture was fixed with two partial treaded cannulated 7.0 mm screws. Post-operatively, the patient was on spica immobilization for six weeks. The follow up review showed that the fracture had healed with no sign of femoral head avascular necrosis (Figure 2). The range of movements of both hip joints was full and painless with no limb length discrepancy noted. Discussion: Femoral neck fractures in children are nearly always the result of high energy trauma because the femoral neck of children is relatively denser and harder compared to adult femoral neck.2 Occasionally, they can occur due to underlying metabolic disorders.1 The mechanism of injury in our case was due to direct high impact force. Other mechanisms of injury that have been described include indirect abduction and external rotation which cause the femoral neck to hinge against the acetabular rim.3 Avascular necrosis (AVN) is the most dreaded complication following these fractures, reported to be 18% to 30%.4 There is a higher incidence of AVN up to 41% when hip decompression is not done, compared with 8% in those treated with early hip decompression. In our case, AVN has not been observed up to 6 months post injury. The main factors influencing AVN rates are the initial fracture displacement, the degree of initial insult, and the timing of surgical fixation together with hip decompression. Operative fixation should be carried out preferably within 48 hours of fracture. Conclusion: It is important not to miss this femoral neck fractures in children involved in high impact trauma as early correct management involving surgical intervention can lead to good outcome. Key Words: Paediatric; neck of femur; fracture 42 Sarawak Health Journal Volume 3 2016 Figure 1: Anteroposterior radiograph of pelvis showing left neck of femur fracture Figure 2: Radiograph showing left neck of femur fracture healed with implant in-situ References: 1. Saied A& Jalili A. Bilateral femoral neck fractures in a child. Eur J Orthop Surg Traumatol 2009; 19: 349-51. 2. Quinlan WR, Brady PG & Regan BF. Fracture of the neck of the femur in childhood. Injury 1980; 11(3): 242-7. 3. Upadhyay A, Maini L, Batra S, et al. Simultaneous bilateral femoral neck fractures in children - mechanism of injury. Injury 2004; 35: 1073-5. NMRR ID: 15-966-26537 43 Sarawak Health Journal A Rare Disease Encounter: Hitting Hard May Not Be the Answer Volume 3 2016 Leong TS1, Lee WH1 & Chew LP1 1 Haematology Unit, Medical Department, Sarawak General Hospital, Malaysia Corresponding Author: Chew Lee Ping ([email protected]) Introduction: Cutaneous T-cell lymphoma is the most common type of skin lymphoma but the case we are presenting is an uncommon presentation of a rare form of T-cell skin lymphoma. We hope to present a new “treatment” to this rare skin lymphoma, with minimal side effects and better quality of life. Case Presentation: A 20-year-old female, presented with pyrexia of unknown origin for one month. She had microcytic hypochromic anaemia and lymphopenia. Her LDH of 2343 mmol/L was unusually high. However, all septic work up and autoimmune screening were negative. Bone marrow examination did not show any obvious abnormality. However, she started noticing a right breast lump that grew rapidly. CT scan showed a large cystic mass occupying the right breast. Biopsy revealed subcutaneous panniculitis-like T-cell lymphoma (SPTCL), a rare form of blood malignancy. Treatment / Outcome: She was started on chemotherapy CHOP, which was escalated to DAEPOCH as new satellite lesions were growing around the breast lump. Despite that, she started developing red plaque-like tender lesions at both her lower limbs. Treated as a refractory disease, she was given Bendamustine + Ara C high dose (BAC). Histopathologic examination (HPE) of the skin showed perivascular pleomorphic skin infiltrate but inconclusive of panniculitis T- cell lymphoma. Her conditions continued to deteriorate with pancytopenia, fever and peripheral neuropathy. The only consolation was the breast lump healed totally, leaving a small scar. Out of desperation, based on anecdotal evidence, she was started on a combination of milder oral chemotherapeutic drug, namely prednisolone, cyclosporine and methotrexate. To our surprise, her condition improved. Her fever settled, cytopenia resolved and the skin plaque eventually disappeared. She was able to resume back her activities of daily living subsequently. Conclusion: Subcutaneous panniculitis-like T-cell lymphoma (SPTCL), is a subtype of Peripheral T-cell lymphoma (PTCL)1, which usually presents with subcutaneous nodules at trunk and extremities.2 Involvement of lymph nodes and dissemination to other organs are rare.3 Our patient presented with extracutaneous manifestation of SPTCL i.e. B symptoms, breast tumour, cytopenias, pleural effusion, lymphadenopathy, hepatitis and later bilateral peripheral neuropathy. Multiorgan involvement may mask the diagnosis of this cutaneous lymphoma, making diagnosis difficult. Currently, no standard treatment has been established for SPTCL due to its low incidence and lack of clinical trials. From the various trials published, combination chemotherapy e.g. CHOP-like therapy is not successful in treating this disease, with five years median survival of 80%.4 High-dose chemotherapy followed by auto/allogenic stem cell transplant has been suggested as an option in patients with refractory or recurrent SPTCL.5 This case illustrates a real-world experience where intensive chemotherapy may not always be the answer, especially for a rare disease that many people are not familiar with. Perhaps a more gentle and individualized therapy should be adopted to manage this rare form of lymphoma. Key Words: T-cell lymphoma; treatment; skin lesion 44 Sarawak Health Journal Volume 3 2016 References: 1. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. 2008; 2945. 2. Gonzalez CL, Medeiros LJ, Braziel RM, et al. T-cell lymphoma involving subcutaneous tissue. Am J Surg. Pathol 1991; 15: 17-27. 3. Willemze R, Jaffe ES, Burg G, et al. EORTC classification for Primary cutaneous lymphoma. Blood 2005; 111: 838-45. 4. Go RS & Wester SM. Immunophenotypic and molecular features, clinical outcomes, treatments, and prognostic factors associated with subcutaneous panniculitis-like T-cell lymphoma: a systematic analysis of 156 patients reported in the literature. Cancer 2004; 101(6): 1404-13. 5. Alaibac M, Berti E, Pigozzi B, et al. High-dose chemotherapy with autologous blood stem cell transplantation for aggressive subcutaneous panniculitis-like T-cell lymphoma. J Am Acad Dermatol 2005; 52: 121-3. 45 Sarawak Health Journal Does Low Platelet Count Equate to Immune Thrombocytopenic Purpura? Volume 3 2016 Leong TS1, Lee WH1 & Chew LP1 1 Haematology Unit, Medical Department, Sarawak General Hospital, Malaysia Corresponding Author: Leong Tze Shin ([email protected]) Introduction: Thrombocytopenia is commonly treated as immune thrombocytopenic purpura (ITP), especially when longstanding. We report the case of a family with a rare inheritable form of platelet disorder. They were initially treated for ITP. Case Presentations: Case One: Ms A was a 26-year-old female, diagnosed as “ITP” at the age of five years. She was noncompliant to steroids. During her first pregnancy, she went into labour with platelet of less than 10,000, needing platelet transfusion and delivered a healthy baby boy. Estimated blood loss was 200 ml. Case Two: Mr B was a 23-year-old male, also diagnosed with ITP when he was 3 years old. He was treated for dengue fever, when he had fever and platelet count of 3 x 103/dl. However at day 14 of illness, platelet count remained 9k. He was treated as ITP but did not respond to steroid. Outcome/Follow-up: Peripheral blood film showed presence of giant platelets with Dohle inclusion bodies in the neutrophils. Based on further history from Mr B’s mother, we identified probably the first documented pedigree of May Hegglin Anomaly in Kuching after examining the relatives’ blood films. Ms A and Mr B are actually first-degree cousins. Related family members’ bloods were sent to Australia for genetic mutation testing for May-Hegglin anomaly. Figure 1: Pedigree of May-Hegglin Anomaly 46 Sarawak Health Journal Volume 3 2016 Discussion: May-Hegglin anomaly is a type of autosomal dominant genetic disorder characterized by large platelet, thrombocytopenia and variable degree of bleeding tendencies. It involves mutations in the MYH9 gene encoding for the non-muscle myosin heavy chain IIA of platelet. May-Hegglin anomaly is a rare disorder that has been under-recognised and misdiagnosed as ITP and leads to inappropriate treatment such as corticosteroids (with numerous side effects) and splenectomy. Conclusion: These cases illustrate the potential clinical pitfalls in our approaches in managing thrombocytopenia. Family history taking and peripheral blood film will lead to the correct diagnosis. Key Words: Thrombocytopenia; low platelet; Dohle inclusion body; May-Hegglin anomaly 47 Sarawak Health Journal Clinical Suspicion of Pulmonary Leptospirosis — Treat or Die! Volume 3 2016 Norhayani Y1, Ng SG1, Ngoi YS1, Hnin NC1 & Mohd Zaim AZ1 1 Emergency & Trauma Department, Sarikei Hospital, Sarawak, Malaysia Corresponding Author: Norhayani bt Yahya ([email protected]) Introduction: Pulmonary leptospirosis is recognised increasingly as a major and lethal complication of leptospirosis. Mortality remains significant, mostly related to delays in diagnosis due to inadequate clinical suspicion even in endemic regions. The incidence of pulmonary involvement in leptospirosis has been reported to be increasing affecting up to 70% of the patients. Case presentation: A 14 year-old-boy presented to the Emergency Department with two days history of shortness of breath and fever; no leptospirosis risk factors. Upon arrival, he was conscious, tachypneoic with respiratory rate of 60 bpm, febrile, tachycardic and oxygen saturation under highflow oxygen was 92%. There was generalized crepitation of the lungs. His arterial blood gases showed type I respiratory failure, non-invasive ventilation was applied but after 30 minutes, he started to cough out blood and was unable to maintain oxygen saturation; he was intubated subsequently. Chest X-ray showed diffuse nodular infiltration with periphery involvement. Blood investigations revealed white cell count 19,000/L, platelet 349 x 103/dl, creatinine kinase 216 U/L, urea 12.5 mmol/L, creatinine 130 mol/L with normal liver function test. Our initial diagnosis was pulmonary leptospirosis and he was started with intravenous Rocephine and methylprednisolone. He required high ventilator setting to maintain adequate oxygen saturation. After discussion with anaesthesia team, he was started on lung recruitment strategy with prone position and successfully extubated after three days. Discussion: This is a young, healthy patient with a short history of febrile illness with pulmonary manifestation requiring high-flow oxygen and deteriorated rapidly requiring intubation within 1 hour of presentation. The spectrum of pulmonary manifestation of leptospirosis is wide and ranging from mild respiratory symptoms to the presence of ARDS. Dry cough, dyspnea and hemoptysis are the most common pulmonary symptoms that usually appear between day 3 and 6 of disease and may lead to death in less than 72 hours.1 The only risk factor in this patient was cigarette smoking. Garcia et al. actually found that cigarette smoking was a risk factor for the development of respiratory involvement in Leptospirosis.2 Shenoy et al. demonstrated that corticosteroid reduces mortality and change its outcome significantly. Stat dose of methylprednisolone given within the first 12 hours of onset of respiratory involvement is life-saving in severe pulmonary leptospirosis.3 However, this is a small scale study, larger randomised control study is needed. Lesson Learnt: Leptospirosis is endemic in Sarawak. Due to its geographical setting, high index of suspicion towards leptospirosis, particularly pulmonary leptospirosis, is required in patient with fever and no obvious sources of infection with or without risk factors. Evolution of pulmonary leptospirosis may be rapid and fatal, thus prompt initiation of treatment is crucial. Key Words: Pulmonary; leptospirosis References: 1. Dolhnikoff M, Mauad T, Bethlem EP, et al. Leptospiral pneumonias. Curr Opin Pulm Med. 2007; 13: 230-5. 2. Martinez Garcia MA, de Diego Damia A, Menendez Villanueva R, et al. Pulmonary involvement in leptospirosis. Eur J Clin Microbiol Infect Dis 2000; 19(6): 471-4. 3. Shenoy VV, Nagar VS, Chowdhury AA, et al. Pulmonary leptospirosis: An excellent response to bolus methylprednisolone. Postgrad Med J. 2006; 82: 602-6. 48 Sarawak Health Journal Volume 3 2016 Unusual Presentation of Intussusception in Henoch-Schonlein Purpura - A Case Report Nursheila Izrin AZ1, Premjeet S1 & Suraj PB1 1 Department of General Surgery, Miri Hospital, Sarawak, Malaysia Corresponding Author: Nursheila Izrin Abu Zaki ([email protected]) Introduction: Henoch-Schonlein Purpura (HSP) is a self-limited, systemic, nongranulomatous, autoimmune complex, small vessel vasculitis, with multiorgan involvement. It is the commonest cutaneous vasculitis in children compromising up to 90% of cases, with gastrointestinal symptoms occurring in about two-thirds of patients.2 Intussusception is a rare complication and is the most common surgical indication of HSP and occurs in 0.7 to 13.6% of patients.3 Case presentation: A 3-year-old Iban girl presented with a three-day history of fever and palpable skin rash over her extremities. During admission she developed vomiting and intermittent colicky abdominal pain and distension, localised to the right iliac fossa. Abdominal ultrasound showed thickening of the terminal ileum with dilated small bowels. There was no sonographic evidence of intussusception. Suspicion of appendicitis dictated her treatment. She had open appendicectomy after no improvement from antibiotics. Intraoperatively, appendix was normal with dilated small bowels secondary to an ileo-ileal intussusception 5 cm from the ileocecal junction. After manual reduction, 10 cm of gangrenous small bowel was resected with primary anastomosis performed. Discussion: Gastrointestinal symptoms in HSP include abdominal pain that worsens after meals, similar to bowel ischemia, resulting from inflammation, oedema or haemorrhage in the intestinal wall.2,3 It is uncommon in adults and those less than three years of age, and may occur at any stage of the illness.4 The sites of intussusception with HSP are most commonly ileo-ileal (51%), followed by ileo-colic (39%).1,3 Bowel wall oedema or submucosal bleeding is typically identified as the lead point in intussusception with HSP. Ultrasonography is the imaging of choice to assess patients of HSP presenting with abdominal pain for complications such as intussusception, with sensitivity of 98-100% and specificity of 88%.5 Contrast or air enema reduction is ineffective in majority of intussusceptions with HSP because they are confined to the small bowel.1,3 Surgical intervention is required in non-reducible intussusception by air or contrast enema, or with no spontaneous reduction of ileoileal type for over 24 hours or in the case of intestinal perforation.3 Conclusion: In patients of HSP with gastrointestinal symptoms, abdominal ultrasound is recommended for early diagnosis of intussusception and to exclude bowel perforation. A negative ultrasound finding does not rule out intussusception and patients need to be monitored closely. Key Words: Intussusception; Henoch-Schonlein; paediatrics; purpura; case References: 1. Choong CK, Kimble RM, Pease P, et al. Colo-colic intussusception in Henoch-Schonlein purpura. Pediatr Surg Int 1998; 14: 173-4. 2. Glasier CM, Siegel MJ, McAlister WH, et al. Henoch-Schonleiun syndrome in children: gastrointestinal manifestation. AJR Am J Roentgenol 1981; 136: 1081-5. 3. Ebert EC. Gastrointestinal manifestations of Henoch-Schonlein purpura. Dig Dis Sci 2008; 53: 2011-9. 4. Martinez-Frontanilla LA, Haase GM, Ernster JA, et al. Surgical complications in HenochSchonlein purpura. J Pediatr Surg 1984; 19: 434-6. 5. Hu SC, Feeney MS, McNicholas M, et al. Ultrasonography to diagnose and exclude intussusception in Henoch-Schonlein purpura. Arch Dis Child 1991; 66: 1065-7. NMRR ID: 15-816-26307 49 Sarawak Health Journal Case Report: Leiomyoma of the Anterior Abdominal Wall Volume 3 2016 Ong ECW1 & Siow SL1 1 Department of General Surgery, Sarawak General Hospital, Malaysia Corresponding Author: Ernest Ong Cun Wong ([email protected]) Case Report: A 72-year-old Bidayuh gentleman presented with lower abdominal pain for one year, associated with constipation, loss of weight and appetite for the past two months. On examination, there was a palpable mass at the left iliac fossa which was firm, tender and mobile, measuring about 5 cm x 5 cm. There was no palpable cervical or axillary lymph node. Tumor markers and initial investigations for tuberculosis (sputum for acid-fast bacilli, Mantoux test, erythrocyte sedimentation rate and chest radiograph) were negative. Colonoscopy revealed an extraluminal compression of the sigmoid colon. Computed tomography (CT) scan of the abdomen and pelvis (Figure 1) revealed a calcified mesenteric mass measuring 37 mm x 47 mm x 45 mm at the left iliac fossa region. Figure 1: Preoperative computed tomography images of the abdomen and pelvis Diagnostic laparoscopy revealed a tumour arising from the anterior abdominal wall (Figure 2). The tumour was laparoscopically excised, and the patient was discharged well on the second postoperative day, and remained well 6 months later. Histology revealed a tumour with proliferating smooth muscle cells arranged in interlacing bundles, showing mild pleomorphism and hyperchromatic nuclei. Some of the cells showed mild pleomorphism and hyperchromatic nuclei. The smooth muscle cells were positive for smooth muscle actin, and negative for CD117 and CD34. 50 Sarawak Health Journal Volume 3 2016 Figure 2: Intraoperative picture of bivalve tumour Discussion: The exact aetiology for the development of a leiomyoma in an area which primarily consist of skeletal muscle tissue is unknown. Possibilities in this patient include secondary leiomyomatous metaplasia or smooth muscle tumour arising from blood vessels.1,2,3 In the assessment of a peritoneal tumour, it is sometimes difficult to differentiate between mesenteric, omental and peritoneal tumours on CT and ultrasound (US). MRI is sometimes used in conjunction with CT to characterize a mesenteric mass.4 Surgical excision is considered to be the first choice of the treatment for leiomyoma and long‑term follow‑up of minimum one-year duration is recommended for surveillance of any tumour recurrence. Conclusion: Leiomyoma of the anterior abdominal wall is a rare condition that may pose diagnostic difficulties, especially in the presence of clinical features of malignancy. A diagnostic laparoscopy is advocated for the management of any suspicious intraabdominal mass. Key Words: Leiomyoma; anterior abdominal wall; laparoscopic surgery References: 1. MS S, Manna V & RL. Leiomyomas of the spleen. Internet J Pathology 2010; 12(1). 2. Wu Q, Liu C, Luo X, et al. Neurology India ISSN 2013; 61(6): 686-7. 3. Harnanan D, Hariharan S et al. Acta Obstetricia et Gynecologica Scandinavica 2012; 91(10): 1233-6. 4. Park JY, Kim KW, Kwon HJ, et al. Peritoneal mesotheliomas: clinicopathologic features, CT findings and differential diagnosis. AJR Am J Roentgenol 2008; 191(3): 814-25. 51 Sarawak Health Journal A Rare Case of Spontaneous Renal Artery Rupture Premjeet S1, Devanraj S1, Nursheila Izrin AZ1, Suraj PB1 1 Department of General Surgery, Miri Hospital, Sarawak, Malaysia Volume 3 2016 Corresponding Author: Premjeet Singh ([email protected]) Introduction: Traumatic artery rupture, accidental injury of arteries during manipulation intraoperatively, and even rupture of fairly common aneurysms like abdominal aorta or berry aneurysms are commonly encountered during clinical practice. However, spontaneous rupture of an artery is rare and only few cases have been reported. We are presenting a rare case of spontaneous renal artery rupture presenting with acute abdomen and peritonitis and would like to highlight the importance of prompt investigations and intervention. A battery of investigations were ordered including a CT (Computerized Tomography) scan, and subsequently immediate intervention (exploratory laparotomy and vessel repair) was carried out, saving the life of this patient. Case Report: This previously well 40-year-old gentleman presented to us with acute abdomen and clinical examination revealed peritonitis. Erect chest X-ray showed no free air and a CT scan (Figure 1) was subsequently ordered which showed haemoperitoneum, and active bleeding seen around the greater curvature, lesser sac and mesentery. Patient was acidotic, however, and was sent for surgery after resuscitation. Intra-operative findings revealed 5 L of blood with active bleeding noted from left renal artery. The vessel was repaired with prolene and haemostasis was secured. Patient’s condition improved and was discharged on post-operative day 6. We planned for a post-operative CT Angiogram and further workup like connective tissue disease screening but patient defaulted follow up. Discussion: The spontaneous rupture of a renal artery is indeed rare. Only one case has been reported by Lincoln, back in January 1918 where a 64-year-old previously-well gentleman, presented with peritonitis and hypovolemic shock. Intraoperatively, a hematoma was found at the retroperitoneal space around the right kidney. When evacuated, there was profuse bleeding from the renal artery which was ligated one inch away for the renal pelvis after which patient recovered well.1 However, many cases have been reported of ruptured renal artery aneurysms and pseudo-aneurysms which have an overall incidence range between 0.01% and 1%.2 For instance, a case report published in January 2015 in Korea of a giant renal artery pseudo-aneurysm (9.4 cm in diameter) with severe left flank pain and a syncopal attack in a 32-year-old with uncontrolled hypertension3. A case of a previously healthy 46-year-old man presenting with flank pain and gross haematuria which later was diagnosed as having a ruptured renal artery aneurysm in 2010 was reported in America.4 Spontaneous renal artery rupture has also been reported in patients with underlying connective tissue diseases. A 12year-old with Ehlers Danlos Syndrome Type IV, presented with peritonitis and was found intraoperatively to have a ruptured right renal artery with the wall of the vessel being friable and weak.5 Conclusion: Rare and unexpected causes of acute abdomen such as a ruptured artery should always be kept in mind in clinical practice and prompt investigation and intervention should be carried out for a successful outcome. Clinical suspicion of a ruptured artery together with an early CT scan is mandatory on the survival of this patient with this rare condition. It may be possible to reduce the incidence of renal artery rupture through imaging and autoimmune screening if clinically indicated. Keywords: Renal; artery; rupture; rare; haemoperitoneum 52 Sarawak Health Journal Volume 3 2016 Figure 1: CT abdomen pelvis Figure 2: CT abdomen pelvis References: 1. Lincoln WA. Spontaneous rupture of the renal artery. J Am Med Assoc 1918; 70(2): 80-2. 2. Giannopoulos A, Manousakas T, Alexopoulou E, et al. Delayed life-threatening haematuria from a renal pseudoaneurysm caused by blunt renal trauma treated with selective embolization. Urol Int 2004; 72: 352-54. 3. Kim MS, Lee YB, Lee JH, et al. Spontaneous rupture of a renal artery pseudoaneurysm in a previously hypertensive patient. Clin Hypertens 2015, 21:4. 4. Wason SEL & Schwaab T. Spontaneous Rupture of a Renal Artery Aneurysm Presenting as Gross Hematuria 2015. Rev Urol 2010 Fall; 12(4): e193-e196. 5. Øyen O, Clausen OP, Brekke IB, et al. Spontaneous rupture of the renal artery in a patient with Ehlers-Danlos syndrome type IV. Eur J Vasc Endovasc Surg 1997; 13(5): 509-12. NMRR ID: 15-797-26245 53 Sarawak Health Journal A Rare Case of Pure Miller Fisher Syndrome: A Case Report Volume 3 2016 See WYN1,2 & Yew YH2 Department of Ophthalmology, University Malaya, Kuala Lumpur, Malaysia 2 Department of Ophthalmology, Sarawak General Hospital, Malaysia 1 Corresponding Author: Wendy See Yen Nee ([email protected]) Introduction: Miller Fisher syndrome (MFS) is a rare, acquired nerve disease that is considered to be a variant of Guillain-Barre syndrome (GBS)3 with estimated annual incidence of 1 in 1,000,0001. It is named after Dr. C. Miller Fisher in 1956 as a limited variant of ascending paralysis.4 Case Report: A 55 year old housewife presented to t he E ye Department with sudden onset of double vision with no preceding trauma. Initial examination revealed binocular diplopia in all gazes with ophthalmoplegia in left eye on upward and horizontal gazes, which was not consistent with any cranial nerve palsies. Otherwise, all other ocular examinations were normal with visual acuity of 6/9 in both eyes. She presented again the next day with progressive worsening of ophthalmoplegia (Picture 1) involving both eyes. She also had bilateral knee weakness, fingertips numbness and areflexia in all limbs. There was no ptosis, fatigability or dyspnoea. Later, she developed total ophthalmoplegia in both eyes and ataxic gait after admission. Computed tomography of the brain and orbit were normal. She underwent lumbar punctures twice, which were normal. A nerve conduction study was performed and it showed evidence of underlying diffuse mild sensorymotor demyelination. She was diagnosed with Miller-Fisher syndrome and started only on T. Neurobion. During subsequent follow-up, her diplopia, ophthalmoplegia a n d a l l n e u r o l o g i c a l d e f i c i t s spontaneously resolved within six weeks (Picture 2). Picture 1: Limited eye movements in both eyes, inconsistent with cranial nerve palsies 54 Sarawak Health Journal Volume 3 2016 Picture 2: Complete resolution of ophthalmoplegia in both eyes 1,4 Discussion: Pure MFS characterised by a triad of ataxia, arreflexia and ophthalmoplegia, as described in our case, is uncommon. Acute onset of external ophthalmoplegia is a cardinal feature of MFS. Ophthalmologists may be the first physician to encounter such patients due to double vision or rapid drop of vision. MFS symptoms can be a signal of GBS development, with breathing difficulties. Thus most patients are admitted for observation. Generally, a pure MFS affects nerve group of the head first, resulting in loss of extraocular muscles control and coordination, whereas the other forms of GBS typically begins in the legs. Fortunately, most MFS is usually self-limiting with spontaneous recovery within two to four months from onset of symptoms.4 High- dose immunoglobulins or plasma exchanges are reserved for severe cases. Recurrence occurs in less than 3% of cases.3 Conclusion: Kozminski stated that clinicians need to be aware of symptoms and clinical findings consistent with MFS so a s n o t to misdiagnose them with GBS, myasthenia gravis or those of ischemic events such as stroke and transient ischemic attack, especially in patients older than 40 years of age.2 Keywords: Miller Fisher Syndrome; ophthalmoplegia; binocular diplopia; areflexia References: 1. Aranyi Z, Kovacs T, Sipos I, et al. Miller Fisher syndrome: Brief overview and update with a focus on electrophysiological findings. Eur J Neurol. 2012; 19(1): 15-20. 2. Kozminski MP. Miller Fisher of Gullain Barre syndrome: A case report. J Am Osteopath Assoc 2008; 108 (2). 3. National Institute of Neurologic Disorder and Stroke: Miller Fisher syndrome Information Page (2015). Available from: http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher .htm 4. Matthew Hansen. Miller Fisher Syndrome. Gullain Barre Syndrome and Chronic Inflammatory Demyelinating Polyneuropathy Foundation International (2012). Available from: https://www.gbs-cidp.org/wp-content/uploads/2012/01/MillerFisherSyndrome.pdf 55 Sarawak Health Journal Volume 3 2016 Cryptogenic Invasive Klebsiella Pneumoniae Liver Abscess Syndrome – A Case Report Yogessvaran K1, Seak CK1, Anna Fitriana AR1, Siam F1& Nik Azim NA1 1 Sarawak General Hospital, Malaysia Corresponding Author: Yogessvaran Krishnan ([email protected]) Introduction: Klebsiella pneumoniae (KPN) is a pathogen with worldwide distribution. Cryptogenic invasive Klebsiella pneumoniae liver abscess (CIKPLA) Syndrome is an emerging distinct clinical syndrome in Southeast Asia characterized by bacteraemia, liver abscess and metastatic infections. Case report: We report a case of a 44-year-old man with underlying diabetes mellitus who presented with fever and right upper quadrant pain for one week. Blood investigations were normal except for deranged liver enzymes. Ultrasound and Computed Tomography (CT) Abdomen showed solitary liver abscess (measuring 7.6 cm x 7.8 cm) which was drained percutaneously at right lobe, segment VII/ VIII. He was put on a 6-week course of antibiotics and discharged well. However, three weeks later, he presented again with left calf swelling and new onset of fever. Lower limb sonography showed left gastrocnemius myositis with abscess formation. Open drainage was done and complete destruction of left gastrocnemius-soleus complex noted intraoperatively. During the same admission, patient developed left eye endopthalmitis and a large anterior chest wall abscess with deep extension to the neck and intrathoracic cavity. Intravitreal antibiotics were administered and drainage of chest wall abscess done. All specimens sent for culture grew mono-microbial KPN with an identical antibiogram. Discussion: CIKPLA syndrome is a rare entity characterized with KPN-associated mono-microbial solitary liver lesion and metastatic septic seeding. It is most commonly reported in Taiwan with emerging number of cases being reported in South East Asia. KPN serotypes isolated in Taiwanese patients are invasive strains that demonstrate hypervirulence which may explain the prevalence of this condition in Taiwan. There is a 20-fold increased risk of metastatic septic spread in patients with underlying diabetes mellitus. Common metastatic septic seeding includes endophthalmitis, CNSrelated infections such as meningitis and abscesses manifesting in other organs. Recent reports showed that catastrophic disability due to ocular or neurological complications from CIKPLA could lead to poor long-term prognosis. Mainstay of therapy is percutaneous drainage of abscess with systemic antibiotics which has good vitreous and cerebrospinal fluid penetration. Figure 1: Chest wall abscess 56 Sarawak Health Journal Volume 3 2016 Figure 2: Liver abscess Conclusion: CIKPLA syndrome is a rare insidious syndrome that needs to be considered especially in diabetic patients with solitary liver abscess because if treated inadequately, this condition can be associated with ocular and CNS complications. Key Words: Cryptogenic invasive Klebsiella pneumoniae liver abscess syndrome (CIKPLA); Klebsiella pneumonia (KPN); metastatic liver abscess References: 1. Braiteh F& Golden MP. Cryptogenic invasive Klebsiella pneumoniae liver abscess syndrome. Int Journal of Infect Dis 2007; 11: 16-22. 2. Yu VL, Hansen DS, Ko WC, et al. Virulence characteristics of Klebsiella and clinical manifestations of K. pneumonia bloodstream infections. Emerg Infect Dis 2007; 13: 986-93. 3. Anstey JR, Fazio TN, Gordon DL, et al. Community-acquired Klebsiella pneumoniae liver abscesses - an “emerging disease” in Australia. Med J Aust 2010; 193: 543-5. 4. Ko WC, Paterson DL, Sagnimeni AJ, et al. Community-acquired Klebsiella pneumoniae bacteremia: global differences in clinical patterns. Emerg Infect Dis 2002; 8: 160-6. 57 Case Report: Lesson from the Serpent’s Kiss Sarawak Health Journal Volume 3 2016 Zyneelia H1, Kandasamy V1& Chan HC1 1 Department of Emergency and Trauma, Sarawak General Hospital, Malaysia Corresponding Author: Zyneelia Husain ([email protected]) Introduction: Snake bite is a well-known occupational hazard amongst farmers, plantation workers, herdsmen and other outdoor workers. Worldwide, it is estimated that more than 5 million persons per year are bitten by snakes, out of which approximately 100,000 develop severe sequelae.1,2 In Malaysia, there are 400 to 650 snakebites per 100,000 populations per year which carries a mortality rate of 0.04% per year.2,3 Hence, identification of the species of the offending snake is important for optimal clinical management. However, in most instances, precise identification of the offending snake is not possible and this may result in suboptimal treatment delivered by the inexperienced healthcare providers. We describe two cases of unidentified snake bites that were presented to rural healthcare facilities in Sarawak in which both patients developed complications arising from local and systemic envenomation. Case 1: A 32-year-old farmer was bitten on his right shin and subsequently sustained severe pain and swelling over the bitten part. First aid supportive treatment was given when he attended the rural clinic. He started to develop episodes of vomiting and hence was transferred to the nearest hospital. Unfortunately, the patient, en route to the hospital, developed cardiorespiratory arrest. Return of spontaneous circulation was achieved after five minutes of cardiopulmonary resuscitation and successful endotracheal intubation. The only available vial of antivenom was given and the patient was subsequently transferred to the tertiary care centre for the completion of antivenom course and continuation of multidisciplinary care. He underwent multiple wound debridement for his infected bite wound which eventually led to limb amputation. He was discharged from hospital in a vegetative state and on a tracheostomy. Figure 1: Enlargement of necrotic patch with presence of bullae over the mid-shin and the foot at day 3 58 Sarawak Health Journal Volume 3 2016 Figure 2: Wound debridement at day 6 Case 2: A 43-year-old security guard was bitten on his left ankle and sustained severe pain and swelling over the bitten part. En route to the clinic, he developed difficulty in breathing, vomiting and bilateral lower leg weakness. Upon arrival to the clinic, he complained of generalised body weakness accompanied with slurred speech. First aid supportive treatment was given and the patient was promptly transferred to the hospital. The patient was later intubated for airway protection in view of shallow laboured breathing. The available six vials of antivenom were administered. After one hour of antivenom administration, he showed good neurological recovery and was subsequently extubated .The swelling of the bitten part had gradually reduced in size during his admission in the hospital. No surgical intervention was needed. He was discharged well to home. Conclusion: Two case reports as illustrated above show that adequate and timely administration of antivenom is vital in preventing the development of serious sequelae of snakebite injury. The awareness about clinical manifestations of snake bite helps the healthcare providers to determine the appropriate treatment modalities and antivenom administration. In addition, continuous training programmes should be provided to healthcare providers at all levels in order to enhance the knowledge and confidence in managing snake envenomation. Key Words: Snake bite; envenomation; neurotoxicity; antivenom; tropical disease References: 1. Swaroop S & Grab B. Snakebite mortality in the world. Bulletin of the World Health Organization 1954; 10(1): 35-76. 2. Chippaux JP. Snake-bites: appraisal of the global situation. Bulletin of the World Health Organization 1998; 76(5): 515-24. 3. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The Global Burden of Snakebite: A literature analysis and modelling based on regional estimates of envenoming and deaths. Winkel K, ed. PLoS Medicine 2008; 5(11). 59 Figure 1: Epidemic curve of food poisoning among workers (for abstract by Shafizah et al on page 32) Sarawak Health Journal 60 Volume 3 2016 Key Note Address Towards Better Clinical Outcomes Datu Dr Zulkifli Jantan 1 The New Clinical Research Centre at Sarawak General Hospital – A Review and Update Dr Alan Fong Yean Yip 2 Hospital Observational Research Procedure Duration Estimation & Accuracy: A New Key Performance Index? 4-5 Chan WK, Kuan PX, Teo SC & Norzalina E Effectiveness of the Introduction of Modified RE-LY Warfarin Dosing Algorithm in International Normalized Ratio Clinic of Kapit Hospital on Anticoagulation Control 6 Chin WV, Siong JYK & Theng MI Case Record Review on the Effectiveness of Modified Paediatric Early Warning Sign Score in Shortening the Duration Required for Clinical Intervention in Kapit Hospital 7 Gan LW, Hii KC & Mavis B Physiotherapy in Critically Ill Patients in Sarawak General Hospital 8 Kuan PX, Chan WK & Fong AYY Exploration of Analgesic Prescribing Pattern in an Outpatient Setting of a District Hospital in Sarawak 9 Kwong CI, Phan HS, Pang MSH, Wong DSH & Chai SK Retrospective Review of Prevention of Mother-To-Child Transmission HIV Programme in Sarawak General Hospital 10-11 Lim HH, Chai CY, Niponi S, Francis C & Chua HH Antibiotic Sensitivity and Spectrum of Bacterial Isolated in Kanowit Hospital: A Retrospective Study 12-13 Loo SC Assess the Effectiveness of Interventions on Knowledge of Nurses towards High Alert Medications in Kanowit Hospital 14 Loo SC Pyogenic Liver Abscess Review in Sarawak General Hospital 2013 - 2015 15 Mohd Firdaus AK, Khairunissa CG, Nurazim S, Siam F & Nik Azim NA Burn Cases in Intensive Care Unit Sarawak General Hospital 16 Mohd Tarmimi M, Farah R, Jamaidah J, Mustaffa Kamil ZA & Norzalina E A Review of Complicated Appendicitis and Modified Alvarado Score as a Diagnostic Tool in Kapit Hospital Year 2014 Sun CCY, Wong WK, Hii KC & Toh TH ii 17 Red Cell Alloimmunisation among Multiple Transfused Patients at Sarawak General Hospital 18-19 Tay SP, Ho ZH, Kong PI, Ng JCH, Liew ML, Ong GB, Chew LP & Gudum HR A Review of Clinician-Investigators at Sarawak General Hospital Undertaking Clinical Research – Industry or Investigator Initiated Studies? 20-21 Tiong XT & Fong AYY Incidence, Risk Factors and Clinical Epidemiology of Melioidosis in Miri Hospital, Sarawak, Malaysia 22-23 Vimal V, Ling HW, Cho WM & Norhuzaimah J Demographic and Clinical Features of Leptospirosis in Paediatric and Adolescent Population in Kapit Hospital 24-25 Wong WK, Tan PW, Sun CCY & Hii KC Prevalence of Antibiotic Resistance In Burkholderia Pseudomallei Cases Presented to Miri General Hospital 26 Yong KY, Tang ASO, Teh YC, Fam TL & Chua HH Public Health Observational Research Iodine Nutritional Status amongst School Children after FiveYears of Universal Salt Iodisation in Sarawak 28 Jeffrey S, Jambai E, Kiyu A & Zulkifli J Pendekatan Program Community Feeding Dalam Memulihkan Kanak-Kanak Kekurangan Zat Makanan Di Long Urun, Belaga 29 Lai SF, George NA & Hasrina H Dengue Fever Outbreak in the Long House: What is the Responsibility of Divisional Health Office? 30-31 Shafizah AS, Tze SN, Phua AL & Azlee A Food Poisoning Outbreak at the Ocean: A Case Report 32 Shafizah AS, Connie AA, Nurdiana S & Azlee A Case Report and Case Series Inferior Epigastric Artery Injury – A Complication of Femoral Line Insertion Despite under Ultrasound Guidance 34-35 Chan WK, Ng PN & Norzalina E Diffuse Large B-Cell Lymphoma of the Terminal Ileum Mimicking Appendicular Mass in a Young Adult 36-37 Devanraj S, Suriaraj K, Premjeet S & Soon KC Silantek Burn Disaster 2014: Critical Care Experience and Lesson Learned Farah R, Yusopian Y, Natasha N, Fakhzan M & Norzalina E iii 38 Endocrine Disorder Masquerading as Blood Malignancy: A Case Report 39 Lee WH, Leong TS & Chew LP Cutting the Queue: Young Myocardial Infarction 40-41 Kang WJ & Ng SG An Early Experience of Treating Paediatric Neck of Femur Fracture 42-43 Kesavan R, Hafiz D, Norzatulsyima N & Isymth AR A Rare Disease Encounter: Hitting Hard May Not Be the Answer 44-45 Leong TS, Lee WH & Chew LP Does Low Platelet Count Equate to Immune Thrombocytopenic Purpura? 46-47 Leong TS, Lee WH & Chew LP Clinical Suspicion of Pulmonary Leptospirosis - Treat or Die! 48 Norhayani Y, Ng SG, Ngoi YS, Hnin NC & Mohd Zaim AZ Unusual Presentation of Intussusception in Henoch-Schonlein Purpura - A Case Report 49 Nursheila Izrin AZ, Premjeet S & Suraj PB Case Report: Leiomyoma of the Anterior Abdominal Wall 50-51 Ong ECW & Siow SL A Rare Case of Spontaneous Renal Artery Rupture 52-53 Premjeet S, Devanraj S, Nursheila Izrin AZ & Suraj PB A Rare Case of Pure Miller Fisher Syndrome: A Case Report 54-55 See WYN & Yew YH Cryptogenic Invasive Klebsiella Pneumoniae Liver Abscess Syndrome – A Case Report 56-57 Yogessvaran K, Seak CK, Anna Fitriana AR, Siam F & Nik Azim NA Case Report: Lesson from the Serpent’s Kiss 58-59 Zyneelia H, Kandasamy V & Chan HC Food Poisoning Outbreak at the Ocean: A Case Report (Figure 1: Epidemic curve of food poisoning among workers) Shafizah AS, Connie AA, Nurdiana S & Azlee A iv 60