We present two cases of diamniotic, dichorionic twin pregnancies in which after the loss of the first foetus in the setting of clinical chorioamnionitis, both pregnancies were successfully managed by delayed-interval delivery. A fourstage protocol including aspects of management in this specific setting is proposed. We consider the importance of a selection process when managing conservatively, measures to promote latency and decisions regarding delivery of the foetuses. Whilst we report successful case studies of conservative management with delayed-interval delivery, we support a cautious approach and understand that in the setting of clinical chorioamnionitis of the remaining foetus, delivery is necessary.

Large intracranial tumour may present only with psychiatric symptoms without any neurological deficits. Delay in surgical treatment may significantly affect the quality of life in these patients. We report a case of a young engineering student who was diagnosed as treatment-resistant depression without initial neuroimaging study. Further neuroimaging studies revealed he has a large falcine meningioma. His psychiatric symptoms resolved following surgical resection of the tumour. We emphasized the importance of initial neuroimaging study in young patients presenting with psychiatric symptoms.

Burkitt lymphoma is a rare entity especially in this part of the world. We had an 11-year-old patient presented with swelling of the mandible for a short one-month duration. He was planned for excision biopsy. However developed severe abdominal pain while in the hospital and was diagnosed as intussusception after ultrasound was done. We proceeded with right hemicolectomy and excision of buccal mass. Early recognition and close monitoring of insidious jaw lesions is recommended even in young adults not within the modal age category of endemic Burkitt.

Testicular adrenal rest tumours (TART) are aberrant adrenal tissue within the testes (1). Although benign, they can lead to obstruction of the seminiferous tubules and infertility in patients with congenital adrenal hyperplasia (CAH). We report six boys who developed TART, a complication of CAH. Diagnosis was confirmed by ultrasound and testicular vein sampling of elevated 17-hydroxyprogesterone (17-OHP) levels. Glucocorticoids dosages were increased 1½-2 folds to suppress size of the aberrant adrenal tissues. Despite reductions in 17-OHP, the lesions remained unchanged. Three patients had testis-sparing surgery to excise the TART and to preserve normal testicular tissues.

This is a case report of single-stage total thoracic aortic repair by the frozen elephant trunk technique for a 75-yearold female with a complex aortic pathology of mega-aorta extending from the ascending aorta to the descending aorta. We used a Thora flex™ Hybrid device, a frozen elephant trunk device with four branched grafts and the distal stent graft. The distal stent graft was inserted into the downstream descending aorta via an aortic arch and positioned 15 cm beyond the left subclavian artery after total arch replacement had been performed using a four-branch graft. The postoperative course was unremarkable with no complications. A post procedural computed tomography scan demonstrated complete exclusion of the descending thoracic aneurysm without endoleak. Therefore, fixing the whole mega-aorta in a single stage using the frozen elephant trunk was effective and safe.

Thymoma is a rare mediastinal tumour that can be accompanied by different paraneoplastic syndromes. Here we report a case of Type A thymoma associated with relapsing minimal change disease (MCD). This case highlights: (1) The need to balance rapid prednisolone weaning against risk for relapse in an elderly patient at risk for steroid-induced complications. (2) The addition of calcineurin inhibitor in relapsed thymoma-related MCD, to achieve steroid sparing effects. Resection of the offending tumour and prompt immunosuppressive therapy are critical in getting best renal and overall outcomes in this rare entity

Acute massive haemothorax is a life-threatening situation, which is often associated with a preceding trauma. However, spontaneous haemothorax is a rare occurrence, especially in pregnancy. Spontaneous haemothorax in the immediate post-partum period secondary to a ruptured intercostal AVM is extremely rare more so in the background of an undiagnosed neurofibromatosis. This is a report of a young lady presenting with pleuritis and breathlessness after the delivery of her 1st child. Her management is discussed.

Objective: Elderly with diabetes has been found to have a higher chance of depression. Therefore, the aim of this study is to determine the prevalence of depression and its associated factors among elderly with Type 2 Diabetes Mellitus in Kedah. Methods: A cross-sectional study was conducted at the Klinik Kesihatan Bandar, Sungai Petani, Kedah. The inclusion criteria were patients aged ≥60 years with Type 2 Diabetes Mellitus. Those with cognitive impairment, presence of organic brain syndrome, presence of severe mental disorder and patients who are either deaf or mute were excluded. The Malay version of Geriatric Depression Scale (M-GDS-14) was used to assess the depressive symptoms. The data was analysed using descriptive statistic and multiple logistic regression. Results: A total of 511 patients participated in the study. The mean age of the respondents is 64.5 (Standard Deviation 7.0) years old. There were slightly more males (53.8%). Majority were Malay (63.0%), married (76.9%) and has a household income of less than RM1000 (67.5%). The prevalence of depression was 32.1%. The number of elderly people living with their children (Adjusted Odds Ratio, aOR0.20, 95%CI: 0.07, 0.55), elderly living with spouse, children, in law and grandchildren (aOR2.95, 95%CI: 1.18, 7.37), diabetic complication (aOR4.68, 95%CI: 2.63, 8.35) and HbA1c (aOR1.23, 95%CI: 1.09, 1.39) are significantly associated with depression. Conclusion: The level of depression was found to be high. Factors contributing to the significantly high level of depression are found to be associated with living arrangements, diabetic complication and HbA1c were significantly associated with depression.

Introduction: Organ donation rate in Malaysia is amongst the lowest in the World. Healthcare professionals (HCPs) working in critical care areas play an important role in the deceased organ donation (DOD) process. This study seeks to identify the demographics of HCPs working in the critical care areas and their knowledge and attitudes toward the DOD process. Method: A cross-sectional survey on the demographics, knowledge and attitudes of the doctors and nurses working in critical care areas was undertaken by the random sampling method, using a validated, structured questionnaire. HCP’s knowledge and attitudes towards brain death (BD), DOD, organ transplantation (OT), and possession of organ donor card were compared against their demographics. Results: Four hundred and twelve (72.9%) out of the total 565 HCPs in critical care areas responded of whom 163 (39.6%) were doctors and 249 (60.4%) were nurses. After adjusting for other factors, department of work and profession were highly correlated with the overall knowledge score (p<0.001 and p=0.003 respectively) and knowledge about BD (p<0.001 and p=0.013 respectively). HCPs from the neurosurgical intensive care unit (p<0.001) and doctors (p<0.001) had higher mean knowledge scores compared to their counterparts. Profession was most significantly correlated with having a positive attitude towards BD (p<0.001) and OT (p<0.001). Conclusion: Department, profession and ethnicity were the demographic characteristics that correlated with knowledge and attitudes of HCPs on organ donation. Efforts to improve DOD rates in Malaysia should include targeted interventions to address the knowledge and attitudes of HCPs working in critical care areas.

Introduction: This study evaluates factors that influence door to operation theatre (OT) time in a tertiary referral centre following activation of trauma team. Specific factors observed in this study were association of the injury severity score (ISS), activation of trauma team and the number of referred specialty to door to operation theatre time. Methods: Retrospective chart review that evaluates all trauma patients which required immediate operative intervention from January 2011 to December 2015. Trauma patients were selected from the resuscitation log book and data were collected by chart review of selected patients. Results: Only 5 out of 279 patients (1.8%) achieved optimal door to OT time. (<60 minutes) Mean door to OT time was 299.27 minutes (95% CI: 280.52, 318.52). Trauma team activation has shown significant improvement in door to OT time (p=0.047). Time of multiple team referrals (p=0.023) and time of operative decision (p<0.001) both had significant impact on door to OT time. Other factors included were demographics, ISS score, Glasgow Coma Scale (GCS), mechanism of injury and systolic blood pressure on arrival all which showed no significance.