Prescribing Practice of Third Generation Cephalosporins in Medical Wards at Hospital Queen Elizabeth II (HQEII)

Cephalosporins are amongst the most used antibiotics in hospital settings worldwide. The antibiotic report collated by the Pharmacy Department from Hospital Queen Elizabeth II(HQEII) in 2018 reflected high usage of third generation cephalosporins in medical wards, and indeed HQE II was one of the top users nationwide. This study aimed to evaluate the prescribing pattern of third-generation cephalosporins in medical wards as per National Antimicrobial Guidelines (NAG) 2019. A prospective, observational study was conducted in medical wards from June 2019 till January 2020. Patients who were started with third-generation cephalosporins (ceftazidime, ceftriaxone, cefotaxime, cefoperazone/sulbactam)were recruited, where 137 patients were enrolled with 60.6% were males. The mean age of patients was 53+16.8 years old. Antibiotics were initiated as per NAG recommendation. Cultures were taken before antibiotic initiation. Respiratory-related infections (n = 54, 39.4%) were the main indication and, antibiotics were continued as definite therapy in 38 patients (27.7%). The median duration of antibiotic treatment was 5 days (interquartile range = 3). Ceftazidime (n = 85, 62%) was most prescribed followed by ceftriaxone (n = 48, 35%)and cefotaxime (n = 4, 2.9%) respectively. It was worth noting that ceftazidime was primarilyused as empirical therapy for melioidosis (n = 64, 75.3%), particularly in patients with diabetes mellitus (n = 40, 62.5%), chronic kidney disease (n = 27, 42.2%), and/or occupational exposure (n = 4, 6.3%). The mean ceftazidime duration for empirical melioidosis was 3.2+1.6 days. Overall, third-generation cephalosporins were appropriately prescribed in medical wards as per NAG 2019. Further exploration of ceftazidime usage in empirical melioidosis is warranted.

Gallstone Ileus with Resolution of Bile Leak Post-Subtotal Cholecystectomy and Spontaneous Closure of Cholecystoduodenal Fistula: Case Report and Literature Review

Gallstone ileus (GSI) is a mechanical intraluminal bowel obstruction caused by biliary calculi through the biliary-enteric fistula. This is a rare sequela of cholelithiasis occurring in 0.3 – 1.5% of patients with worrying mortality of 11.7 – 20%. This is a case of GSI in a 67-year-old woman who presented with small bowel obstruction secondary to impaction of biliary calculi at terminal ileum with underlying cholecystoduodenal fistula (CDF). Enterolithotomy with stone extraction (ES) was performed, followed by subtotal reconstituting cholecystectomy due to iatrogenic gallbladder perforation. The diagnosis of GSI is ascertained by the presence of the Rigler’s triad on abdominal X-ray, while CDF was demonstrated by post-surgery CT images. Bile leak post-operation was managed conservatively based on the SNAP (Sepsis, Nutrition, Anatomy, Plan) approach, and spontaneous closure of CDF was observed. In a nutshell, GSI should always be kept in mind as a differential diagnosis of mechanical bowel obstruction, especially among elderly female patients. Radiological findings of Rigler’s triad aid clinical diagnosis of GSI. Despite its rare incidence, early diagnosis is crucial as it is readily treatable with surgery. ES alone is the gold standard in the management of GSI.

Evolving Stroke in Tuberculous Meningitis

Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary tuberculosis which carries high mortality with 100% mortality without treatment. A neurological complication of TBM includes hydrocephalus, brain abscess and stroke. In this report, we would like to illustrate a case of stroke in a patient with TBM. In this case, a 37-year old man initially presented with fever for 1 week associated with severe headache and occasional vomiting. Computed tomography (CT) of the brain showed leptomeningeal enhancement and lumbar puncture findings consistent with infective in nature. His MARAIS score was 13 and was treated as tuberculous meningitis with anti-tuberculous therapy. While in the ward, he developed right-sided body weakness with evolving CT brain findings. His condition then stabilized with anti-tuberculous treatment which consists of isoniazid, rifampicin, pyrazinamide and streptomycin. Dexamethasone was also initiated. On follow up, his condition further improves and is functionally independent. In conclusion, tuberculous meningitis is an aggressive disease with high morbidity. Stroke can occur as a result of TBM. Timely initiation of treatment is important in improving the outcome of the patients.

Children Vaccination of COVID-19

The Delta variant is currently the highly contagious predominant variant of the SARSCoV-2 virus worldwide that causes severe illness more than the previous variants in unvaccinated people (CDC, 2021). At a White House briefing, the National Institute of Allergy and Infectious Diseases director, Anthony Fauci, predicted that there would be an increase in the number of child hospitalisation proportionate to the increased number of children getting infected with the Delta variant (Press briefing White House, 2021). In response to this situation, the FDA (U.S. Food and Drug Administration) approved Pfizer-BioNTech and Moderna vaccines for children aged 12 – 17 years. Vaccines in children aged 5 – 11 years are currently under clinical trial (Sick-Samuels & Messina, 2021).

Extracorporeal Reconstruction of the Radial Head

Radial head fractures are common in adults. The radial head acts as an important stabilizer of the radius, especially during the forearm pronation and supination. Surgical treatment of Mason type III fracture of the radial head includes radial head excision, radial head replacement and open reduction and internal fixation. For patients treated with radial head excision, the radius might migrate proximally, causing complications such as chronic pain at the wrist, forearm, and elbow. On the other hand, radial head arthroplasty is associated with a high revision and removal rate. Hence, openreduction and internal fixation are preferred when feasible. This is technically demanding due to the severe displacement of the radial head fragments and limited surgical space. Mr K, a 30-year-old manual worker sustained a closed right radial head fracture Mason type III after an alleged fall. The radial head was displaced anteriorly. Intra-operatively, the radial headpieces were retrieved and were reconstructed extracorporeal and fixed with a miniplate. The patient subsequently recovered with good function. The new technique of extracorporeal reconstruction of the radial head offers a viable option to the surgeon with similar, or even better, outcomes in terms of elbow function.

Knowledge, Attitude and Practice of Public on Breast Cancer Screening: A Systematic Review

Breast cancer is among the commonest cancers that affect women worldwide. Nevertheless, many patients were diagnosed with breast cancer in the terminal stage due to their late presentation to healthcare centres despite the advanced development of screening modalities. Therefore, a systematic review was conducted to summarize the trend of knowledge, attitude, and practice level of breast cancer screening among the public globally. Review identification was performed in database search using PubMed, Scopus and CINAHL. Based on the criteria consisting of full papers in English published from January 2010 to September 2020, 27 articles were eligible for review. The systematic review revealed that the public had inadequate knowledge, negative attitudes, and poor practice on breast cancer screening. Educational programmes should be implemented among communities. Communication skills training must be instilled among healthcare workers to raise knowledge of breast cancer that can influence the attitude and practice of the public on breast cancer screening positively.

The First COVID-19 Mortality in Batu Pahat, Johor: Lesson Learnt

COVID-19 had been declared as a global pandemic on 11 March 2020. This case report is about Severe Acute Respiratory Infection (SARI) due to COVID-19 (Corona Virus-19). A 68-yearold lady with underlying hypertension and congestive cardiac failure presented with fever and productive cough for 5 days duration. One week before her presentation, she had travelled to Kluang, Johor for a wedding gathering which was later found to have contributed to a cluster of COVID-19 cases. Otherwise, she denied any sick or known COVID-19 contact. Respiratory examination revealed left lower zonecrepitations. She was tachypnoeic on a high flow mask 15 L and hypotensive (BP 90/70 mm Hg) on arrival at the hospital. Chest radiograph showed bilateral asymmetrical consolidations. There was a presence of lymphopenia while her dengue serology result was negative. She was treated as SARI secondary to pneumonia with septic shock and required mechanical ventilation due to respiratory failure. Nasopharyngeal swab for SARS CoV-2 (Severe Acute Respiratory Syndrome Corona Virus-2) was taken as positive for COVID-19 on the third day of admission. Apart from supportive andintensive care measures, she was commenced on oral hydroxychloroquine, subcutaneous Interferon Beta and syrup lopinavir/ritonavir per local guidelines during that period. Unfortunately, she developed acute respiratory distress syndrome (ARDS) on day 3 of admission and passed away due to respiratory failure. Clinicians should pay attention to the COVID-19 critical disease profile and mortality risks. By identifying high-risk patients early, medical resources can be administered in an organized way and timely way to improve the efficacy of the healthcare services.

Unparalleled Experiences of Online Medical Education during COVID-19 Pandemic

The novel coronavirus (COVID-19 or Sars-C0v2) pandemic in Malaysia have adversely affected the country in many aspects especially the economy and education sectors. Schools and universities alike are facing challenges in providing quality education to the students especially during the conditional movement control order (CMCO) periods, where many educational institutions have to close for the safety of students and personnel. Many strategies have been recommended to improve the quality of online teaching to enhance student engagement in the teaching learning processes. MOOC or Massive Open Online Courses are one of the alternative teaching strategies to advocate the students to access education remotely. Massive Open Online Courses (MOOCs) can be attended by hundreds of students in their own pace and time, which enable them to study from anywhere, at any time virtually. Thus, MOOCs have risen as an alternative option in addition to other online educational platforms. It is time to take advantage of the uncertain period of COVID-19 into an opportunity to develop the MOOCs as an educational tool for our students. The benefits of MOOCs are self-paced, self-directed, interactive and accessible by unlimited users.

Acne Vulgaris: More Than Skin Deep

Acne vulgaris is one of the recognized skin issues among adolescents, though occasionally it may persist through adulthood. Though being popularly known to the communities, its impact on the patients is often less recognized, minimized or worse neglected. Acne vulgaris can cause an ample amount of psychological stress among the affected individuals which may increase the likelihood of psychiatric comorbidity. Depression is one of the psychiatric burdens associated with acne vulgaris. Therefore, it is considered more than a skin disorder. Instead of perceiving it as normal, it should be recognized as one of the most prevalent skin disorders which need early treatment to prevent exacerbation and also avoid permanent scarring.

Clinical, Biochemical and Radiological Factors Affecting the Prognosis of Neurological Deficit Improvement in Spinal Tuberculosis Patients at Hospitals of Sabah

The incidence of spinal tuberculosis is highest in developing nations. We aimed to analysethe clinical, biochemical, and radiological parameters in spinal tuberculosis patients withsignificant neurological impairment in relation to their functional outcome. This cross-sectional study involved 224 patients who had been presented to three hospitals in Sabah from July 2017 to June 2018, with significant neurological impairment fulfilling the inclusion criteria were enrolled. Diagnosis of spinal tuberculosis was determined by clinical and radiological factors and confirmed with histopathology, micro bacteriology, and immunoassay. Patients with significant neurology received standard treatment protocol according to the middle pathway regime, anti-tuberculosis for the first three weeks, and were subjected to surgery if there was no improvement. Age, duration of symptoms, c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white cell count (WCC), thoracolumbar spine involvement, and presence of soft tissue collection were evaluated. Modified Barthel Index (MBI) was used to assess the functional outcome. After a year, 146 patients (65.1%) had good functional outcomes and 78 patients had no significant improvement. On univariate analysis, there were no significant correlations between functional outcome and age (p>0.45); duration of symptoms (p>0.68); CRP (p>0.76); WCC (p>0.99); and presence of soft tissue collection (p>0.21).. High ESR (p<0.008) and thoracolumbar lesions were associated with poor functional outcomes (p<0.033). Higher ESR values and thoracolumbar lesions were associated with poor prognostic factors functional outcome in spinal tuberculosis patients.