Resolution of asthmatic symptoms following successful endoscopic resection of tracheal mucoepidermoid carcinoma

Mucoepidermoid carcinoma (MEC) is a rare tumour of the trachea accounting for up to 0.2% of reported primary lung malignancy. We report a case of a 54-year-old man, ex-smoker, whose presentation mimicked adult onset asthma with cough and wheezing, which did not respond to conventional treatment. He had occasional haemoptysis and weight loss in which CT scan performed for malignancy screening showed a protruding mass in the distal trachea causing endobronchial obstruction. Bronchoscopic intervention was performed to relieve the obstruction that resulted in resolution of asthmatic symptoms. Histological diagnosis confirmed MEC. This case emphasised the importance of a high index of suspicion in an unusual presentation of a common disease and the pivotal role of bronchoscopic intervention in malignant central airway obstruction

Glycemic patterns and factors associated with post-hemodialysis hyperglycemia among end-sStage-renal disease patients undergoing maintenance hemodialysis

Introduction. Chronic and post-prandial hyperglycemia are independent risk factors for diabetic complications. Glycemic patterns among hemodialysis end-stage-renal-disease (ESRD) differ as glucose metabolism changes with declining kidney function with more pronounced glycemic fluctuations. The objectives of this study are to determine glycemic patterns on hemodialysis days, the magnitude of post-hemodialysis rebound hyperglycemia (PHH) and their associated factors. Methodology. 148 patients on hemodialysis were analysed, 91 patients had end-stage-diabetic-renal disease (DM-ESRD), and 57 patients had end-stage-non-diabetic renal disease (NDM-ESRD). Glycemic patterns and PHH data were obtained from 11-point and 7-point self-monitoring blood glucose (SMBG) profiles on hemodialysis and non-hemodialysis days. PHH and its associated factors were analysed with logistic regression. Results. Mean blood glucose on hemodialysis days was 9.33 [SD 2.7] mmol/L in DM-ESRD patients compared to 6.07 [SD 0.85] mmol/L in those with NDM-ESRD (p<0.001). PHH occurred in 70% of patients and was more pronounced in DM-ESRD compared to NDM-ESRD patients (72.5% vs 27.5%; OR 4.5). Asymptomatic hypoglycemia was observed in 18% of patients. DM-ESRD, older age, previous IHD, obesity, high HbA1c, elevated highly-sensitive CRP and low albumin were associated with PHH. Conclusion. DM-ESRD patients experienced significant PHH in our cohort. Other associated factors include older age, previous IHD, obesity, high HbA1c, elevated hs-CRP and low albumin

Hypersexuality in a rape victim child

Hypersexuality is rare in children. Our case describes a 14-year-old girl who presented with a history suggestive of hypersexuality. She was repeatedly raped and exposed to video pornography at a very young age. Consequently, she became addicted to pleasure during sexual intercourse and actively involved in multiple unprotected sexual intercourses. Management, in this case, was challenging, where early intervention with contraceptive methods and cognitive behavioural therapy were unsuccessful. Subsequently, alternative treatment with Islamic psycho-spiritual therapy combined with conventional therapy resulted in an improvement in her sexual pre-occupation. This case highlights the importance of recognition of hypersexuality, especially among children with a history of sexual abuse as management proofs to be challenging, and requires a multimodal approach to prevent a potentially devastating outcome

Glycemic patterns and factors associated with post-hemodialysis hyperglycemia among end-stage renal disease patients undergoing maintenance hemodialysis

Introduction: Chronic and post-prandial hyperglycemia are independent risk factors for diabetic complications. Glycemic patterns among hemodialysis end-stage-renal-disease (ESRD) differ as glucose metabolism changes with declining kidney function with more pronounced glycemic fluctuations. The objectives of this study are to determine glycemic patterns on hemodialysis days, the magnitude of post-hemodialysis rebound hyperglycemia (PHH) and their associated factors. Methodology: 148 patients on hemodialysis were analysed, 91 patients had end-stage-diabetic-renal disease (DM-ESRD), and 57 patients had end-stage-non-diabetic renal disease (NDM-ESRD). Glycemic patterns and PHH data were obtained from 11-point and 7-point self-monitoring blood glucose (SMBG) profiles on hemodialysis and non-hemodialysis days. PHH and its associated factors were analysed with logistic regression. Results: Mean blood glucose on hemodialysis days was 9.33 [SD 2.7] mmol/L in DM-ESRD patients compared to 6.07 [SD 0.85] mmol/L in those with NDM-ESRD (p<0.001). PHH occurred in 70% of patients and was more pronounced in DM-ESRD compared to NDM-ESRD patients (72.5% vs 27.5%; OR 4.5). Asymptomatic hypoglycemia was observed in 18% of patients. DM-ESRD, older age, previous IHD, obesity, high HbA1c, elevated highly-sensitive CRP and low albumin were associated with PHH. Conclusion: DM-ESRD patients experienced significant PHH in our cohort. Other associated factors include older age, previous IHD, obesity, high HbA1c, elevated hs-CRP and low albumin

Giant intracavernous aneurysm presenting with isolated trigeminal neuralgia: a case report

Background: Trigeminal neuralgia (TN) commonly affects individuals aged more than 50 years and is mostly primary owing to trigeminal nerve neurovascular compression. We report a case of secondary TN attributed to a giant intracavernous aneurysm compressing the trigeminal nerve. Case presentation: A 74-year-old female presented with classic TN symptoms, which were initially refractory to medical treatment. Imaging including MRI brain, MR angiography, and cerebral angiogram revealed a giant intracavernous aneurysm measuring 1.7 cm × 2.8 cm, inducing mass effect on the left Meckel's cave. Aneurysm embolization was challenging due to the difficult cannulation of the distal portion of the aneurysm. The patient opted for conservative management with mild improvement of symptoms. Conclusions: Intracavernous aneurysm rarely present with isolated trigeminal neuralgia. This case report emphasizes that the assessment of the intracranial vasculature should be considered as part of the diagnostic imaging work-up for patients presenting with TN

Assessment of obstructive sleep apnea among Malaysians with open-angle glaucoma using the STOP-Bang questionnaire

INTRODUCTION: Glaucoma is the most common cause of irreversible loss of vision worldwide. Numerous studies have confirmed an association between open-angle glaucoma (OAG) and obstructive sleep apnea (OSA) among Caucasian and Chinese populations; however, there has been no published study from South East Asia on this subject.MATERIALS AND METHODS: Therefore, our objectives were to use the STOP-BANG questionnaire (SBQ) to determine the factors (socio-demography, medical comorbidities) associated with the risk of OSA among patients with OAG and the association between glaucoma parameters and OSA. The SBQ was used for classifying patients as OSA low risk (score ≤ 2) to moderate/high risk (score ≥ 3).RESULTS: We found that the mean patient age was 64.2 ± 8.9 years, of which 55.4% (245 subjects) were males. The prevalence of moderate/high risk of OSA among the open angle glaucoma patients was 247 (55.9%), which comprised of mostly males(n=196,44.34%) compared to females (n=51,11.54%). Multiple logistic regression analysis showed that the predictors of moderate/high risk of OSA were males [odds ratio (OR) = 189.7, 95% confidence interval (CI) = 55.21, 651.69], high body mass index (OR = 1.23, 95% CI = 1.14, 1.33), diabetes (OR = 3.1, 95% CI = 1.45, 6.63) and hypertension (OR = 70.73, 95% CI = 22.59,221.50).CONCLUSION: The identification of modifiable risk factors will be beneficial in the prevention of visual loss from glaucoma. The prevalence of moderate to high risk OSA risk was 56.9% among patients with OAG, that supports the vascular theory causing glaucomatous damage.peer-reviewe

Case report: Incomplete penetrance of autosomal dominant myotonia congenita caused by a rare CLCN1 variant c.1667T>A (p.I556N) in a Malaysian family

Myotonia congenita (MC) is a rare neuromuscular disease caused by mutations within the CLCN1 gene encoding skeletal muscle chloride channels. MC is characterized by delayed muscle relaxation during contraction, resulting in muscle stiffness. There is a lack of MC case reports and data on the prevalence among Malaysians. We report a clinical case of a 50-year-old woman presents with muscle stiffness and cramp episodes that started in early childhood. She had difficulty initiating muscle movement and presented with transient muscle weakness after rest, which usually improved after repeated contraction (warm-up phenomenon). She was diagnosed with MC after myotonic discharge on electromyography (EMG). Her brother had similar symptoms; however, no additional family members showed MC symptoms. Serum creatine kinase levels were elevated in both the proband and her brother with 447 U/L and 228 U/L recorded, respectively. Genetic analysis by whole-exome sequencing (WES) revealed a previously reported pathogenic CLCN1 gene variant c.1667T&gt;A (p.I556N). Genetic screening of all family members revealed that the same variant was observed in the children of both the proband and her brother; however, the children did not present with either clinical or electrophysiological MC symptoms. The multiplex ligation-dependent probe amplification (MLPA) analysis conducted identified neither exon deletion nor duplication in CLCN1. In conclusion, this report describes the first case of MC in Malaysia in which incomplete penetrance observed in this family is caused by a known pathogenic CLCN1 variant

Stiff person-like syndrome: an unusual presentation of pituitary macroadenoma with panhypopituitarism

Pituitary adenoma can manifest as pituitary hypofunction, which can cause symptoms of panhypopituitarism. Commonly, symptoms of hormonal deficiencies such as lethargy, weight change, cold intolerance, and sexual dysfunction are reported. Optic chiasmal compression leads to visual field changes and the discovery of the pituitary lesion. However, limb stiffness is a rare presentation of hypopituitarism, especially hypocortisolism. We report a 68-year-old man who presented with progressive lower limb stiffness associated with truncal instability mimicking a stiff person syndrome (SPS). Hypoglycaemia and hyponatraemia prompted the discovery of pituitary macroadenoma with panhypopituitarism. Investigation showed pituitary macroadenoma on magnetic resonance imaging with hypocortisolism, hypothyroidism, and hypogonadotropic hypogonadism. After initiating hydrocortisone replacement, the patient had complete resolution of lower limb stiffness with no permanent neurological sequelae. It is postulated that hypocortisolism and hyponatraemia disrupt the metabolic function of muscle leading to stiffness. As a result, lower limb rigidity, flexion deformities, and pain are more common. Differentiating adrenal insufficiency associated with rigidity and SPS is important as the response to treatment for both conditions differs. Prompt treatment leads to fast resolution and prevents contractures in adrenal insufficiency-associated rigidity. Thus, recognizing limb rigidity as the first presentation of hypopituitarism is important to avoid long-term complications

Repetitive transcranial magnetic stimulation of the primary motor cortex in stroke survivors-more than motor rehabilitation: a mini-review

Stroke is a leading cause of morbidity and mortality among elderly populations worldwide. During the early phase of stroke, restoring blood circulation is of utmost importance to protect neurons from further injury. Once the initial condition is stabilized, various rehabilitation techniques can be applied to help stroke survivors gradually regain their affected functions. Among these techniques, transcranial magnetic stimulation (TMS) has emerged as a novel method to assess and modulate cortical excitability non-invasively and aid stroke survivors in the rehabilitation process. Different cortical regions have been targeted using TMS based on the underlying pathology and distorted function. Despite the lack of a standard operational procedure, repetitive TMS (rTMS) of the primary motor cortex (M1) is considered a promising intervention for post-stroke motor rehabilitation. However, apart from the motor response, mounting evidence suggests that M1 stimulation can be employed to treat other symptoms such as dysphagia, speech impairments, central post-stroke pain, depression, and cognitive dysfunction. In this mini-review, we summarize the therapeutic uses of rTMS stimulation over M1 in stroke survivors and discuss the potential mechanistic rationale behind it

Assessment of factors associated with post-dialysis hyperglycemic spike and glycemic variability in patients undergoing maintenance haemodialysis

Introduction: Chronic hyperglycemia and post-excursion hyperglycemia had been established as independent risk factors for diabetic complications. Recently, the concept of glycemic triumvirate, which encompasses chronic hyperglycemia, hypoglycemia and glycemic variability (GV) being favored as the main pathophysiology in diabetic outcome mainly cardiovascular complications. In Malaysia, cardiovascular disease attributed to one-third of all death in diabetic hemodialysis patients with a 3-fold increase in mortality as compared to non-diabetic patients. Objective: This study is performed to determine magnitude of post-dialysis rebound hyperglycemia, GV and their contributing factors. Methodology: 150 patients on haemodialysis were recruited, 93 patients had end-stage-diabetic-renal disease (DM-ESRD) and 57 patients had end-stage-non-diabetic renal disease (NDM-ESRD). Post-dialysis rebound hyperglycemia and GV indices (standard deviation [SD] and %co-variant [%CoV]) were obtained from 11-point and 7-point self-monitoring blood glucose (SMBG) profiles during hemodialysis day (HD) and non-hemodialysis day (NHD). GV were analysed between HD vs. NHD in DM-ESRD patients as well as those with NDM-ESRD. Results: Mean blood glucose during dialysis-day was 9.33 [SD 2.7, %CoV 30.6%] mmol/L in DM-ESRD compared to 6.07 [SD 0.85, %CoV 21.3%] mmol/L in NDM-ESRD (p =<0.01). Post-dialysis rebound hyperglycaemia occurred in 71% of patients (n=105. This spike was pronounced in DM-ESRD compared to NDM-ESRD (83.5% vs. 53.6%; OR 4.39 [95% CI 2.05 – 9.42]). Significantly higher GV indices were observed in DM-ESRD compared to NDM-ESRD during HD and NHD day especially in group with HbA1c 8-10% (p= <0.01). Furthermore, GV indices tended to be higher on HD compared to NHD (p= <0.01). Asymptomatic hypoglycemia was observed in 18% of patients (n=21), mostly during first-hour of hemodialysis. Higher HbA1c levels and older age were the main factors contributing to higher post-dialysis rebound hyperglycemia and GV and in this study (p<0.05). Correlation between HbA1c and mean blood glucose in this population is moderate with r2 = 0.58. Conclusion: Diabetic patients on haemodialysis are at increased risk of post-dialysis rebound hyperglycemia and fluctuations in blood glucose on hemodialysis-days with high HbA1c level and old age being two significant contributing factors. Since this group of patients are vulnerable to CVD mortality urgent attention is needed to rectify it