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-yearold 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

Congenital Adrenal Hyperplasia: Diagnostic Pitfalls in Prolonged Neonatal Jaundice

Congenital Adrenal Hyperplasia (CAH) is a genetic disorder that leads to cortisol deficiency. However, prolonged neonatal jaundice is a rare presentation of CAH. The pathophysiology of hyperbilirubinemia in CAH is still ill-defined. Plausible causes are related to the synthesis of bile, maturity of the liver and adrenal function. This case reported a neonate who presented with severe prolonged jaundice that lasted for more than a month. A short Synacthen test confirmed diagnosis of CAH. He was started on steroid replacement. He had regular follow-up under paediatric endocrinologist and primary care physician for long-term monitoring and overall health care. This case demonstrates the importance of recognizing the clinical and biochemical features of CAH for early detection and referral. Long-term follow-up and monitoring is necessary due to the risk of complications and side effects of medications. This is the first case of CAH presented with persistent hyperbilirubinemia to be reported from Malaysia. The case describes the difficult workup that has been encountered in the patient’s care and management

Relationship of Self Efficacy in Medication Understanding with Quality of Life among Elderly with Type 2 Diabetes Mellitus on Polypharmacy in Malaysia

Self-efficacy (SE) has been shown to be positively correlated with quality of life (QOL) among patients with type 2 diabetes mellitus (T2DM). Medication understanding (MU) on the other hand, leads to good adherence that indirectly improves QOL. Measuring self-efficacy in medication understanding is useful to ascertain patient’s confidence in medication adherence. However, there is a lack of studies on the relationship between self-efficacy in medication understanding with QOL. This study aimed to determine the relationship between self-efficacy in medication understanding and QOL, and the factors associated with QOL in elderly with T2DM on polypharmacy. A cross-sectional study was conducted on these populations at primary care specialist clinic. Malay version of MU in SE questionnaire (MUSE) was used. Higher scores showed a better understanding. A revised Version Diabetic Quality of Life-13 (RVDQOL-13) questionnaire was used with lower scores indicating higher QOL. A total of 321 patients participated, with the majority being male (58.3%), Malay (84.7%), a predominant age group of 60–69 (75.7%) with mean age (±SD) of 66.7 (±0.286) years old. The median (IQR) of MUSE was high—30 (4)—while the RVDQOL-13 was low—19 (8)—which demonstrated high QOL. Inverse correlation was found between MUSE and QOL (r −0.14, p < 0.01). Multiple linear regression analysis demonstrated that MUSE score (β −0.282; 95% CI: (−5.438, −2.581); p < 0.001), low-income group (β −0.144; 95% CI: (−3.118, −0.534); p = 0.006) and duration of medications ≥240 days (β −0.282; 95% CI: (−5.438, −2.581); p < 0.001) were associated with better QOL, while medications ≥10 (β 0.109; 95% CI: 0.214, 4.462; p = 0.031) and those with pills and insulin (β 0.193; 95% CI: 1.206, 3.747; p < 0.001) were associated with poor QOL. In conclusion, higher MUSE is associated with better QOL. Findings suggest emphasizing self-efficacy in medication understanding in the management of elderly with T2DM on polypharmacy to improve QOL

Congenital Adrenal Hyperplasia: Diagnostic Pitfalls in Prolonged Neonatal Jaundice

Congenital Adrenal Hyperplasia (CAH) is a genetic disorder that leads to cortisol deficiency. However, prolonged neonatal jaundice is a rare presentation of CAH. The pathophysiology of hyperbilirubinemia in CAH is still ill-defined. Plausible causes are related to the synthesis of bile, maturity of the liver and adrenal function. This case reported a neonate who presented with severe prolonged jaundice that lasted for more than a month. A short Synacthen test confirmed diagnosis of CAH. He was started on steroid replacement. He had regular follow-up under paediatric endocrinologist and primary care physician for long-term monitoring and overall health care. This case demonstrates the importance of recognizing the clinical and biochemical features of CAH for early detection and referral. Long-term follow-up and monitoring is necessary due to the risk of complications and side effects of medications. This is the first case of CAH presented with persistent hyperbilirubinemia to be reported from Malaysia. The case describes the difficult workup that has been encountered in the patient’s care and management

Management of pulmonary tuberculosis in health clinics in the Gombak district: How are we doing so far?

This audit report assessed the structure, processes and outcome of the pulmonary tuberculosis (PTB) management in adults conducted at eight government health clinics within the high TB burden Gombak district. All newly diagnosed PTB patients from November 2012 to November 2013 were identified from the tuberculosis registry. Patients less than 18 years old, were transferred out or extrapulmonary tuberculosis was excluded from the study. The assessment criteria for PTB were defined according to the latest Malaysian TB clinical practice guidelines (TB CPG) 2012. A total of 117 patients were included in this report and data were extracted and analysed using SPSS version 20.0. The mean age of patients was 40.4 ± 14.4 SD. Majority was men (63.2%). Out of 117 patients, 82.1% were Malaysian citizens and 17.9% were foreigners. Malays were the majority (65%) followed by 7.7% Chinese, 10.3% Indian and 17.1% others. The most common clinical feature was cough (88.0%) followed by loss of weight (58.1%), loss of appetite (57.3%), fever (56.4%), night sweat (30.8%) and haemoptysis (32.5%). Acid-fast bacilli (AFB) smear was positive in 94% of cases. Chest X-ray and human immunodeficiency virus (HIV) screening results were available for 89.1 and 82.1% cases respectively. The results for the sputum culture were available in 27.4% of patients and 54.7% were documented as done but pending results. The clinics have a successful directly observed therapy (DOT) program with 94.0% patients documented under DOT. Out of 53 patients on maintenance phase, 47.2% were identified as cured. Cure rate for those completed treatment was 100%. The defaulter rate was 17.1%. This audit demonstrated the attempt made by the clinics to adhere to the recommended guidelines. However, improvements are to be made in the documentation of medical records, tracing of investigation results and reduction of the number of defaulters

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

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