A Case Report of a Rare ER+, PR- Pure Metaplastic Breast Squamous Cell Carcinoma with HER2 Overexpression.

BACKGROUND Breast squamous cell carcinoma (SCC) is a subtype of metaplastic breast carcinoma (MBC), which is a rare malignancy and accounts for 0.1% of all invasive breast carcinomas. Guidelines on definitive management and treatment of breast SCC are not well established, given its rarity and diverse immunohistochemistry (IHC) profile, and lack of clinical data. Most cases of breast SCC are triple-negative breast cancer - negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). This case report outlines the clinicopathological profile of a pure breast SCC case with a rare IHC profile; HER2 and ER positive. CASE REPORT A 41-year-old woman presented with a right breast mass that had been growing for 2 months. Biopsy confirmed breast SCC, a rare malignancy with IHC profile as follows: HER2 overexpression, ER positive, and PR negative. She underwent neoadjuvant chemotherapy for 3 months followed by right mastectomy with axillary clearance, adjuvant radiotherapy, and oral tamoxifen therapy. Unfortunately, she did not receive anti-HER2 therapy. She developed early locoregional recurrence at 2 months postoperatively, which was treated with excision of the right chest wall and transverse rectus abdominis musculocutaneous (TRAM) flap. She developed liver and lung metastasis and succumbed to her disease at 15 months post-diagnosis. CONCLUSIONS Breast SCC is a rare and aggressive tumor with heterogeneous clinicopathological features. Available guidelines do not outline the definitive treatment for breast SCC, given its rarity and heterogenous IHC profile, leading to a general lack of clinical data. Hence, due to the challenges in managing this rare condition, treatment modalities need to be individualized.

The Elusive Primary: Metastatic Adenocarcinoma of the Breast Presenting Solely as a Hard Sternal Mass.

BACKGROUND Carcinoma of unknown primary (CUP) is a diverse category of malignancies diagnosed in patients who have metastatic disease but without an identifiable primary tumor at initial presentation. CASE REPORT We report a case of CUP which was later diagnosed to be metastatic adenocarcinoma of the breast in a 62-year-old woman. The patient initially presented to a primary care clinic with an incidental finding of a small hard mass in the middle of the sternum, with no other clinical findings in the breast or axillary lymph nodes. Chest X-ray, ultrasound, and CT scan of the sternum suggested a benign sternal lesion, and a mammogram was normal. Due to the persistence of the mass, a biopsy was performed. The histopathological findings revealed a metastatic adenocarcinoma, most likely from breast origin, with positive estrogen receptor (ER) and mammaglobin on immunohistochemistry studies. The patient subsequently underwent PET scan, repeat mammogram, and MRI of the breast. Following high uptake in the rectum on PET, a colonoscopy was performed, revealing a suspicious rectal mass. The mass was surgically excised, and the final histopathological examination concluded the mass was a second primary adenocarcinoma of the rectum. Genetic analyses for BRCA1 and BRCA2 were negative. CONCLUSIONS This is a rare case of an isolated bone-like lesion on the sternum due to metastatic adenocarcinoma of the breast in a patient with no prior history of breast cancer and lacking any clinical or radiological evidence of breast or axillary lymph node lesions on presentation. The patient was also subsequently diagnosed with 2 primary carcinomas. Thorough clinical examination, extensive radiological investigations, laboratory investigations, histopathological examination, and a multidisciplinary approach are essential in managing CUP.

A Case of Linear Scleroderma in a Young Child: A Diagnosis Easily Missed in Primary Care.

BACKGROUND This case illustrates the challenges in diagnosing linear scleroderma (LS) in a child who presented to a primary care setting. Diagnosis of LS is easily missed due to the lack of prominent symptoms, subtle visible skin changes, and under-recognition of this condition. CASE REPORT A 7-year-old boy presented with a linear, painless, non-itchy rash at the center of his forehead, which has been present for 6 months. The rash extends vertically from the hairline to the bridge of the nose. The color gradually evolved from reddish to purplish-grey and shiny within 3 months. He had underlying eczema, allergic rhinitis, and allergic conjunctivitis since birth. His condition remained unrecognized despite consultations with various medical specialties, including family medicine specialist, ophthalmologist, otorhinolaryngologist, and a general pediatrician. Six months after the onset of his lesion, he was subsequently referred to a pediatric dermatologist and pediatric rheumatologist, who made the diagnosis of LS. Laboratory investigations for autoimmune disease showed that negative antinuclear antibodies (ANA) and inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), were normal. Skin biopsy provided a tissue confirmation of the diagnosis. MRI of the lesion showed no extension into the underlying muscle or bone erosions. The patient was initially treated with intravenous (IV) methylprednisolone for 3 days, followed by oral methotrexate weekly and prednisolone. The lesion improved after 1 month of treatment, and after 15 months it was less pigmented and less noticeable. CONCLUSIONS LS is the commonest form of localized scleroderma in children. LS on the forehead can erode into the underlying tissues and is sometimes associated with extensive hemifacial atrophy. Treatment should be instituted early to prevent late irreversible fibrotic sequelae. This report aims to highlight the importance of early diagnosis and treatment of an uncommon but potentially disfiguring condition.

New insights of minimum requirement on legumes (Fabaceae sp.) daily intake in Malaysia.

BACKGROUND: Despite their low energy density and high nutrient content, legumes may be under-recognised as a beneficial food for the prevention and management of obesity and related diseases, such as cardiovascular disease (CVD). This study aims to analyse the moderation effect of legume intake on the relationship between BMI and the prevalence of CVD among the Malaysian adult population. METHODS: This study addressed communities of urban and rural Malaysia, including adults aged between 35 and 70 years old at the baseline recruitment. A series of standardised questionnaires were used to assess legume intake, history of comorbidities and socio-demographic information. Resting blood pressure measurements and physical examinations were performed to collect blood pressure and anthropometric data. Bivariate analysis was completed to determine the association between legume intake, socio-demographic characteristics and CVD prevalence. Moderation analysis was used to quantify the moderation effect of minimum daily legume intake on the relationship between BMI and CVD prevalence. RESULTS: This study found that those who consume less than 3 servings of legumes per day benefit from protective effects against CVD risk (POR = 0.56, 95% CI = 0.37 - 0.85). Moderation analysis of a minimum of three servings/day for the relationship between BMI and CVD prevalence showed significant effects. The group that benefited the most from this effect was those with a BMI in the range of 26 to 34 kg/m2. CONCLUSIONS: This study provides new insights into the recommendation for legume intake according to the relationship between BMI and the prevalence of CVD in Malaysian adults. This study recommends that those with a BMI of 26 to 34 kg/m2 should consume at least 3 servings of legumes per day to reduce the risk of CVD. Further prospective research is warranted to affirm these findings throughout the Malaysian population.

Physical Activity in Malaysia: Are We Doing Enough? Findings from the REDISCOVER Study.

Physical activity (PA) in the form of structured or unstructured exercise is beneficial for health. This paper aims to study PA levels across four domains according to the International Physical Activity Questionnaire (IPAQ) and its associated factors. A total of 7479 Malaysian adult participants between 18 to 90 years old from the REDISCOVER study who completed the IPAQ were analyzed. PA was calculated as MET-min per week and were categorized according to insufficiently active, sufficiently active and very active. Multinomial regression was used to determine the association between sociodemographic, clinical factors and the level of PA. The mean age of the participants was 51.68 (±9.5 SD). The total reported physical activity in median (IQR) was 1584.0 (0-5637.3) MET-min per week. The highest total for PA was in the domestic domain which is 490 (0-2400) MET-min per week. Factors associated with sufficiently active or very active PA include Malay ethnicity, no formal education, elementary occupation, current smokers and high HDL. Whereas low income, male and normal BMI are less likely to participate in sufficiently active or very active PA. Intervention to encourage higher PA levels in all domains is important to achieve recommended PA targets.

The Agony of the Mystical Practice of Susuk: A Case Report.

BACKGROUND Charm needle, otherwise known as susuk, is a needle-shaped pin inserted subcutaneously into various body parts. It is most commonly inserted by shamans in the orofacial region to grant magical powers to the wearer, such as health, wealth, beauty, and other benefits. These talismans are prevalent among women in South-East Asia countries. CASE REPORT A 75-year-old woman presented with recurrent musculoskeletal symptoms over multiple sites, but physical assessment only revealed mild tenderness over the right hip joint. A plain pelvic radiograph showed incidental findings of susuk around the genital regions, with older skull and pelvic radiograph displaying similar findings. The patient had a susuk insertion more than 20 years ago for marriage stability and beauty. After this incidental discovery, the patient had repeated visits to the clinic to request more imaging to determine whether the susuk were still present after the shaman's attempted mystical removal. She also developed persistent preoccupation, worry, and guilt related to the susuk presence and was referred to psychiatry for further assessment. She was diagnosed with generalized anxiety disorder. She was then started on psychotherapy and pharmacological treatment, with simultaneous spiritual therapy. CONCLUSIONS This case report describes the link between susuk implantation and psychological illness. Even though there are no reports that specifically correlate susuk with generalized anxiety disorder, it has been established that guilt and shame have a strong relationship with anxiety.

Does Less Pain Predict Better Quality of Life among Malaysian Patients with Mild-Moderate Knee Osteoarthritis?

This study aims to identify the relationship between knee functional status and Health-Related QoL (HRQoL) in mild to moderate knee osteoarthritis (OA) patients and to ascertain which subdomain of knee functional status best predicts good HRQoL. A cross-sectional study was conducted in an orthopaedic clinic of a tertiary hospital in Malaysia. Patients aged 40-75 years old with mild-moderate primary knee OA were recruited. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and SF-36 questionnaires were used to measure knee functional status and HRQoL, respectively. Subdomains of KOOS include "function in daily living", "function in recreational activities", "pain", "symptom", and "knee-specific quality of life". Subdomains for SF-36 are Physical Component Summary (PCS) and Mental Component Summary (MCS). Overall, 290 patients fulfilled the inclusion criteria of the study, with a mean age of 66.8 years old (±7.06). Majority were female (57.6%) and Malay (79.7%). The relationships between all KOOS and HRQoL subdomains were significant. "Pain" contributed most towards better physical HRQoL ((PCS) Adj. B (95% CI); 0.063 (0.044, 0.169)), while "function in daily living" contributed most towards better mental HRQoL ((MCS) Adj. B (95% CI); 0.624 (0.478, 0.769)). Thus, better HRQoL was related to better pain control and improved "function in daily living" in these patients.

Validation study of the Parent Attitudes About Childhood Vaccines (PACV) questionnaire: the Malay version.

Vaccine hesitant parents are linked with re-emergence of vaccine preventable diseases, but evidence is scarce locally. The Parent Attitudes about Childhood Vaccines (PACV) questionnaire was validated and used in the USA to identify vaccine hesitant parents. This study aimed to adapt and translate the 15-item PACV questionnaire from English into the Malay language, and to examine its validity and reliability. The sample population was parents of children aged 0-24 months, recruited at an urban government health clinic between November 2016-June 2017. During content validation, two items from the "Behavior" subdomain were identified as items with formative scale and excluded from exploratory factor analysis (EFA) but retained as part of demography. A total of 151 parents completed the questionnaire with response rate of 93.3%. Test-retest reliability was tested in 25 respondents four weeks later and the intra-class correlation was between 0.53 and 1.00. EFA of the 13 items showed possibility of two to four factor domains, but three domains were most conceptually equivalent. Two of the domains were similar to the original and one factor was identified de novo. One item was deleted due to poor factor loading of < 0.3. Therefore, the validated final PACV-Malay consisted of 12 items framed within three-factor domains. The PACV-Malay was reliable with total Cronbach alpha of 0.77. In conclusion, the PACV-Malay is a valid and reliable tool which can be used to identify vaccine hesitant parents in Malaysia. Confirmatory factor analysis and predictive validity are recommended for future studies.

Relationship between coping styles and lipid profile among public university staff.

BACKGROUND: The scarcity of data about coping styles with a biochemical marker namely lipid profile, potentially associated with cardiovascular risk factors is most striking among professionals working in public university. Hence, this research aimed to investigate the relationship between coping styles and lipid profile comprising total cholesterol (TC), triglyceride (TG), HDL-cholesterol (high density lipoprotein-cholesterol) and LDL-cholesterol (Low density lipoprotein-cholesterol) among this group of professionals. METHODS: A cross sectional survey was conducted among staff from a tertiary education centre. Subjects were contacted to ascertain their medical history. A total of 320 subjects were interviewed and 195 subjects were eligible and subsequently recruited on a suitable date for taking blood and administration of the questionnaires. The subjects completed questionnaires pertaining to demographic details and coping styles. Pearson's correlation coefficient was used to measure the strength of association between lipid profile and coping styles. RESULTS: Majority of the subjects were non-academic staff (60.0%), female (67.2%), Malay (91.8%), married (52.3%) and educated until Diploma level (34.9%). Academic staff scored significantly higher mean scores in task-oriented coping styles (Mean = 64.12). Non-academic staff scored significantly higher mean scores in emotion (Mean = 48.05) and avoidance-oriented coping styles (Mean = 57.61). Malay subjects had significantly higher mean scores in emotion (Mean = 47.14) and avoidance-oriented coping styles (Mean = 55.23). Non-malay subjects (Mean = 66.00) attained significantly higher mean scores in task-oriented coping styles. Single/divorced/widowed individuals scored significantly higher mean scores in emotion (Mean = 48.13) and avoidance-oriented coping styles (Mean = 56.86). There was a significant negative correlation between TC (r = -0.162) and LDL (r = -0.168) with avoidance-oriented coping styles (p = 0.023, p = 0.019 respectively). CONCLUSION: Avoidance-oriented coping style was more likely to engender favourable lipid profile. Hence, assessment of coping styles would certainly assist health care practitioners in predicting subjects who would be at a greater risk of developing cardiovascular diseases.

A nationwide survey of public healthcare providers' impressions of family medicine specialists in Malaysia: a qualitative analysis of written comments.

OBJECTIVE: To examine impressions of public healthcare providers/professionals (PHCPs) who are working closely with family medicine specialists (FMSs) at public health clinics. DESIGN: Cross-sectional study. SETTING: This study is part of a larger national study on the perception of Malaysian public healthcare professionals on FMSs (PERMFAMS). PARTICIPANTS: PHCPs from three categories of health facility: hospitals, health clinics and health offices. MAIN OUTCOME MEASURES: Qualitative analyses of written comments of respondents' general impression of FMSs. RESULTS: The participants' response rate was 58.0% (780/1345), with almost equal proportions from each public healthcare facility. A total of 23 categories for each of the 648 impression comments were identified. The six emerging themes were: (1) importance of FMSs; (2) roles of FMSs; (3) clinical performance of FMSs; (4) attributes of FMSs; (5) FMS practice challenges; (6) misconception of FMS roles. Overall, FMS practice was perceived to be safe and able to provide effective treatments in a challenging medical discipline that was in line with the current standards of medical care and ethical and professional values. The areas of concern were in clinical performance expressed by PHCPs from some hospitals and the lack of personal attributes and professionalism among FMSs mentioned by PHCPs from health clinics and offices. CONCLUSIONS: FMSs were perceived to be capable of providing effective treatment and were considered to be important primary care physicians. There were a few negative impressions in some areas of FMS practice, which demanded attention by the FMSs themselves and the relevant authorities in order to improve efficiency and safeguard the fraternity's reputation.

Low serum high density lipoprotein cholesterol concentration is an independent predictor for enhanced inflammation and endothelial activation.

BACKGROUND: Inflammation, endothelial activation and oxidative stress have been established as key events in the initiation and progression of atherosclerosis. High-density lipoprotein cholesterol (HDL-c) is protective against atherosclerosis and coronary heart disease, but its association with inflammation, endothelial activation and oxidative stress is not well established. OBJECTIVES: (1) To compare the concentrations of biomarkers of inflammation, endothelial activation and oxidative stress in subjects with low HDL-c compared to normal HDL-c; (2) To examine the association and correlation between HDL-c and these biomarkers and (3) To determine whether HDL-c is an independent predictor of these biomarkers. METHODS: 422 subjects (mean age±SD = 43.2±11.9 years) of whom 207 had low HDL-c concentrations (HDL-c <1.0 mmol/L and <1.3 mmol/L for males and females respectively) and 215 normal controls (HDL-c ≥1.0 and ≥1.3 mmol/L for males and females respectively) were recruited in this study. The groups were matched for age, gender, ethnicity, smoking status, diabetes mellitus and hypertension. Fasting blood samples were collected for analysis of biomarkers of inflammation [high-sensitivity C-reactive protein (hsCRP) and Interleukin-6 (IL-6)], endothelial activation [soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1), soluble Intercellular Adhesion Molecule-1 (sICAM-1) and E-selectin)] and oxidative stress [F2-Isoprostanes, oxidized Low Density Lipoprotein (ox-LDL) and Malondialdehyde (MDA)]. RESULTS: Subjects with low HDL-c had greater concentrations of inflammation, endothelial activation and oxidative stress biomarkers compared to controls. There were negative correlations between HDL-c concentration and biomarkers of inflammation (IL-6, p = 0.02), endothelial activation (sVCAM-1 and E-selectin, p = 0.029 and 0.002, respectively), and oxidative stress (MDA and F2-isoprostane, p = 0.036 and <0.0001, respectively). Multiple linear regression analysis showed HDL-c as an independent predictor of IL-6 (p = 0.02) and sVCAM-1 (p<0.03) after correcting for various confounding factors. CONCLUSION: Low serum HDL-c concentration is strongly correlated with enhanced status of inflammation, endothelial activation and oxidative stress. It is also an independent predictor for enhanced inflammation and endothelial activation, which are pivotal in the pathogenesis of atherosclerosis and atherosclerosis-related complications.

A nationwide survey on the expectation of public healthcare providers on family medicine specialists in Malaysia-a qualitative analysis of 623 written comments.

OBJECTIVE: To examine the expectation of public healthcare providers/professionals (PHCPs) who are working closely with family medicine specialists (FMSs) at public health clinics. DESIGN: Cross-sectional study. SETTING: This study is part of a larger national study on the perception of the Malaysian public healthcare professionals on FMSs. PARTICIPANTS: PHCPs from three categories of health facilities, namely hospitals, health clinics and health offices. MAIN OUTCOME MEASURES: Qualitative analysis of written comments of respondents' expectation of FMSs. RESULTS: The participants' response rate was 58% (780/1345) with an almost equal proportion from each public healthcare facility. We identified 21 subthemes for the 623 expectation comments. The six emerging themes are (1) need for more FMSs, (2) clinical roles and functions of FMSs, (3) administrative roles of FMSs, (4) contribution to community and public health, (5) attributes improvement and (6) research and audits. FMSs were expected to give attention to clinical duty. Delivering this responsibility with competence included having the latest medical knowledge in their own and others' medical disciplines, practising evidence-based medicine in prehospital and posthospital care, better supervision of staff and doctors under their care, fostering effective teamwork, communicating more often with hospital specialists and making appropriate referral. Expectations ranged from definite and strong for more FMSs at the health clinics to low expectation for FMSs' involvement in research; to mal-expectation on FMSs' involvement in community and public health programmes. CONCLUSIONS: There were some remarkable differences in expectations on FMSs from the three different PHCPs. These ranged from being clinically competent and administratively available for patients and staff at the health clinics, to mal-expectations on FMSs to engage in public health affairs. Relevant parties, including FMSs themselves, could take appropriate self-improvement initiatives to enhance public practice of family medicine and patient care. TRIAL REGISTRATION NUMBER NMRR ID: 08-12-1167.