Ketoacidosis can Be alcohol in origin: A case report.

Background: Alcoholic ketoacidosis (AKA) is a common reversible biochemical pathology arising from hyperketonaemia in patients with a history of chronic alcohol consumption. It is typically fatal when there is a delay in early recognition and management. A further complicating factor is that this condition is frequently confused with diabetic ketoacidosis (DKA). Case presentation: This report presents the case study of an elderly Chinese man with a 40-year history of alcohol consumption. The patient presented with acute shortness of breath, generalised abdominal pain, and vomiting. Blood gas analysis indicated severe high anion gap metabolic acidosis (HAGMA) with elevated serum ketones and modest hyperglycaemia which was initially treated as diabetic ketoacidosis (DKA). A diagnosis of AKA was later made after obtaining a thorough history of his binge drinking. The patient subsequently responded well to thiamine and aggressive fluid resuscitation. This case highlights the importance of a well-documented patient history and in-depth knowledge of ketoacidosis. Discussion: AKA must be suspected in patients with a history of chronic alcohol consumption and dependence. The symptoms are non-specific such as abdominal pain, nausea, vomiting and diarrhoea. The latter two result in malnutrition and starvation subsequently leading to hyperketonaemia, hypovolaemia and HAGMA. AKA should be clearly differentiated from DKA to prevent mismanagement. The mainstay of management of AKA is thiamine, fluid resuscitation and good sugar control to prevent Wernicke's encephalopathy. Conclusion: A precise patient's medical history is crucial to prevent misdiagnosis. A non-diabetic patient with a history of chronic alcohol consumption who presents with severe HAGMA, hyperketonaemia and dysglycaemia should raise a clinical suspicion of AKA. Thiamine and judicious fluid resuscitation as well as electrolytes and malnutrition correction should be promptly initiated in patients with AKA. Good family, social support and rehabilitation programs are crucial to help patients with alcohol abuse.

A rare occurrence of a metastatic urothelial carcinoma to the thoracic vertebra: A case report.

BACKGROUND: Urothelial carcinoma (UC) is a common urinary tract malignancy that predominantly affect the urinary bladder with a low recurrence rate after surgical removal. It usually metastasizes to the lungs, regional lymph nodes, and liver. However, it rarely spread to the thoracic spine and bones, especially in the Asian populations. CASE PRESENTATION: A 50-years-old Asian man, with a one-year history of surgically resected UC, presented to us with a complaint of worsening upper back pain for three months. Magnetic resonance imaging (MRI) showed a destructed second thoracic (T2) vertebra with lytic lesion. A thoracic vertebrectomy was performed and histopathological examination (HPE) showed high-grade infiltrating metastatic malignant UC. Postoperatively, he was well and did not have any back pain. He was followed up under combined spine and oncology clinic regularly and was planned for chemoradiotherapy. DISCUSSION: UC commonly metastasizes to the lungs, liver, and lymph nodes. In young Asians, thoracic spinal metastases are rare. Urgent palliative spinal surgery is indicated to prevent further deterioration of function. Intraoperative usage of targeted controlled infusion (TCI) of remifentanil and propofol as maintenance of anaesthesia are gold standard in assisting spine surgeons who are guided by neuromuscular monitoring. CONCLUSION: Spinal metastasis to the thoracic vertebra is rare among young Asian men. Patients presented with acute neurological deficits and back pain are indicated for spinal surgery. Multidisciplinary approach is needed for management of patients with spinal metastasis. Targeted controlled infusion (TCI) of remifentanil and propofol are gold standard for maintenance of anaesthesia for spine surgeries which are guided by somatosensory, and motor evoked potential monitoring.

Case report: Challenges, treatment, prognosis and outcome of a patient with partially treated seminomatous testicular carcinoma.

BACKGROUND: Testicular carcinoma is a rare malignancy in men. It is ranked the 18th most common male cancer in Malaysia with seminoma representing 40% of the primary testicular neoplasms. Early detection of the tumour and the immediate initiation of treatment and disease management provide high possibilities of positive outcomes for patients. CASE PRESENTATION: A 36-year-old male was initially diagnosed with a left cryptorchidism and metastatic testicular seminoma. However, due to socioeconomic circumstances and the Coronavirus-19 (COVID-19) pandemic, he defaulted on his chemoradiotherapy follow-up treatments. He returned to us four years later with a progressively enlarging testicular mass with normal tumour marker values and subsequently underwent a successful radical left orchidectomy. Histopathological examination revealed features of regressed germ cell tumour (GCT). He successfully underwent chemoradiotherapy treatment and surveillance follow-ups did not show tumor recurrences. DISCUSSION: Seminoma is the commonest type of testicular carcinoma with good prognosis among young patients. In huge masses, as seen in our patient, early chemoradiotherapy with the intention to reduce tumor bulk and invasiveness after which will be followed by radical orchidectomy. Residual mass post chemotherapy for patients with seminomas should be properly assessed for viability of tumor cells within it. CONCLUSION: Undescended testis and cryptorchidism present key risk factors for developing testicular carcinomas which are uncommon among men. Early detection, surgery and chemoradiotherapy on seminomas would usually lead to positive outcomes. The remarkable chemosensitivity of a seminomatous type tumour towards a platinum-based regiment in combination with radical resection entails good prognosis and effective local disease control.

Case report: A giant hemorrhagic adrenocortical carcinoma causing cardiorespiratory embarrassment.

BACKGROUND: Adrenocortical carcinoma (ACC) is a rare aggressive tumor that can be hormone or non-hormone secreting. It is usually associated with fatal outcomes due to its physiological hormonal interaction. We report a successful anaesthetic and surgical management for a patient who presented to us with a huge hemorrhagic ACC which was complicated with acute respiratory failure. CASE PRESENTATION: A 56-year-old lady presented to us with progressive abdominal distension and right hypochondriac pain for two months. She was anemic with elevated liver enzymes. Urgent computed tomography (CT) of the abdomen and pelvis showed a huge right supra renal mass. She subsequently developed respiratory failure due to splinting of diaphragm, of which successfully underwent an emergency exploratory laparotomy. Subsequent endocrine and histopathological work up showed an adrenocortical carcinoma (ACC). DISCUSSION: Suprarenal masses usually originate from the adrenal glands. They should be investigated to rule out phaeochromocytoma, which originate from the inner adrenal medulla or outer cortex to form ACC. The latter usually occur in women and of poor prognosis. Huge ACC may cause acute respiratory failure by way of splinting of diaphragm. Both anaesthetic and surgical teams should be well trained in handling patients who undergo adrenal surgeries. CONCLUSION: A giant hemorrhagic functional ACC is extremely uncommon with very poor prognosis. Such conditions should be investigated to rule out phaeochromocytoma. Its potential neuro-hormonal interactions and anatomical correlations can cause fatal perioperative cardio-respiratory embarrassment. The anaesthetic and surgical teams should be capable in managing the hemodynamic instabilities that may present during surgical manipulation and resection of a large ACC.

Anaesthetic challenges in a morbidly obese man for cardiac myxoma resection: A case report.

BACKGROUND: Cardiac myxoma is a rare neoplasm with female preponderance. It is the commonest benign cardiac neoplasm. We report a case entailing the perioperative anaesthetic challenges in managing a young morbidly obese man with a huge left atrial myxoma, who presented to us with acute symptoms of heart failure. CASE PRESENTATION: A young morbidly obese man with a body mass index (BMI) of 43.3 kg/m2 presented to us with acute symptoms of heart failure. An urgent transthoracic echocardiogram showed a huge pedunculated mass which arise from the left atrium, which occasionally completely occludes the mitral valve during each diastole. He underwent a resection of cardiac myxoma, which was complicated with intraoperative hypotension. Fortunately, it was successfully managed by placing the patient in Trendelenburg position for optimum blood pressure control. DISCUSSION: Tumours of the heart are very rare. Common histopathological findings are myxomas, followed by uncommon types of rhabdomyosarcomas and angiosarcomas. Pedunculated cardiac tumours can cause partial to complete obstructions which may lead to devastating conditions. Anaesthesia for morbidly obese patients with pedunculated cardiac myxoma are extremely challenging. Cardiac anaesthetists should be vigilant in managing these patients as they posed many life-threatening complications. CONCLUSION: Cardiac myxoma are uncommon benign tumor of the heart with higher preponderances on the left atrium. Pedunculated mass can cause obstruction by limiting left ventricular filling, mimicking severe mitral stenosis. Positioning the patient Trendelenburg can transiently reduce intracardiac obstruction, improve cardiac output and venous return to the heart. Optimum patient positioning and management will lead to excellent outcomes.

Obstetric challenges during COVID-19 pandemic: A narrative review.

The severe acute respiratory coronavirus 2 (COVID-19) pandemic impacts the health of women at reproductive age in different ways, starting from pregnancy planning to post-delivery. This narrative review summarises the challenges to obstetric practice posed by the severe acute respiratory coronavirus 2 (COVID-19) pandemic. In this paper, we highlight the impacts of COVID-19 to obstetric practice globally and the efforts taken to address these challenges. Further study is critical to investigate the effects of COVID-19 on pregnancy, the outcome of COVID-19 positive pregnant women, and the safety of vaccination during pregnancy and breastfeeding.

Anaesthetic challenges in a child with perforated appendicitis and COVID-19 Co-Infection: A case report.

BACKGROUND: The deadly coronavirus disease 2019 (COVID-19) wreaked havoc globally in early 2020 and caused lives to a standstill. Healthcare workers (HCW) handling patients infected with COVID-19 wore protective equipment to defend themselves from cross infection and curbing further spread. Nevertheless, these do hamper their dexterity, especially during surgical procedures. CASE PRESENTATION: A child presented to our centre needing an emergency open appendicectomy during the coronavirus disease 2019 (COVID-19) pandemic in June 2021. Prior to the surgery, her initial test for COVID-19 was negative but subsequently became positive on the second test. Fortunately, all HCW during the care for the patient, donned full personal protective equipment (PPE), and avoided cross-infection. DISCUSSION: HCW handling patients with COVID-19 should wear adequate PPE to. However, these pose detrimental effects to their dexterity during routine care of such patients. Good teamwork and communication among HCW and parents are important during the safe management of a young child with COVID-19. CONCLUSION: HCW should have low index of suspicion of COVID-19 in children with upper respiratory tract infection. Prompt and pro-active measures should be rapidly taken to prevent exposure and co-infection. Wearing multi layers of PPE do negatively affect the mood and agility of HCW handling young children with COVID-19. Thus, they should practice good team work, receive regular simulation and scenario-based training to be better prepared for pressurised situations.

Case report: A rare occurrence of a huge mediastinal mass from disseminated prostate carcinoma.

BACKGROUND: Prostatic carcinoma is the commonest malignancy among men. It usually metastasizes to the spine and regional lymph nodes. However, it is extremely rare for it to metastasize to the mediastinum. CASE PRESENTATION: An elderly man presented to us with progressive onset of bilateral lower limb weakness which was associated with thoracic radiculopathy and urinary incontinence. An urgent magnetic resonance imaging (MRI) of the spine showed severe cord compression with enlarged prostate and superior mediastinal mass. A computed tomography (CT) guided biopsy of the mediastinal mass was suggestive of prostatic malignancy. An emergency posterior instrumentation and fusion (PSIF) in prone position was successfully done. Histopathological examination of the spine showed malignant glandular tissues, suggestive of prostate. DISCUSSION: A huge mediastinal mass can compromise the cardiorespiratory system and is very challenging for the anaesthetist to safely secure the airway for surgical procedures. Androgen deprivation therapy (ADT) for patients with metastatic prostatic carcinoma can be achieved either by medical castration or with bilateral orchidectomy. CONCLUSION: It is extremely uncommon for a prostatic carcinoma to metastasize to the mediastinum. Patients with a huge mediastinal mass possess risks of cardiorespiratory collapse perioperatively. Chemoradiotherapy and androgen deprivation therapy (ADT) can be utilized for metastatic prostatic carcinoma with good outcomes.

Knowledge, Attitude And Practice Towards Sexual And Reproductive Health Including Comprehensive Sexuality Education Among First Year Students Of University Malaysia Sabah (Ums), Malaysia

@#This study aims to assess knowledge, attitude and behavior in sexual and reproductive health (SRH) including comprehensive sexuality education (CSE) among 439 first year students; 213 sciences and 226 arts students from 5 Faculties of University Malaysia Sabah (2016-2017). Exposure of Malaysian students to sexual education is limited to science subjects which are only being taught at upper elementary and secondary high school levels. Arts students are less exposed to sexual education across Malaysia as it is delivered in Basic Science subject only. It was a university-based, cross-sectional, descriptive study. Pretested self- administered questionnaire was anonymously completed by all participants and was conducted from November 2016 to January 2017. Students’ demographic characteristics from Science and Arts streams were same except females, Sabah ethnics and Malays were more in Arts. Awareness of HIV/AIDS, Condom, Wet dream, COC pills and abortion services were more in Science students and statistically significant. 34.3 % and 81.2% of Science students agreed that CSE should be introduced in primary and secondary school but not statistically significant. 22 out of 439 students were sexually active. Science students had more knowledge about SRH and favourable attitude towards sexuality education but less favourable behaviour of watching and reading pornographic materials. It was concluded that there were gaps in knowledge, attitude and behaviour of SRH and need to remedy these by giving appropriate CSE classes to first-year university students in an elective module according to their culture and religious beliefs in accord with International Technical Guidance on Sexuality Education (ITGSE).

Life-Threatening Dyskalaemia after Barbiturate Coma Therapy: The Strategy of Management

Barbiturate coma therapy (BCT) is a treatment option that is used for refractory intracranial hypertension after all other options have been exhausted. Although BCT is a brain protection treatment, it also has several side effects such as hypotension, hepatic dysfunction, renal dysfunction, respiratory complications and electrolyte imbalances. One less concerning but potentially life-threatening complication of BCT is dyskalaemia. This complication could present as severe refractory hypokalaemia during the therapy with subsequent rebound hyperkalaemia after cessation of the therapy. Judicious potassium replacement during severe refractory hypokalaemia and gradual cessation of the therapy to prevent rebound hyperkalaemia are recommended strategies to deal with this complication, based on previous case series and reports. In this case report, we show that these strategies were applicable in improving severe hypokalaemia and preventing sudden, life-threatening rebound hyperkalaemia. However, even with use of these strategies, BCT patients could still present with mild, asymptomatic hyperkalaemia.