Residual disease in patients with acute leukaemia indicates unfavorable prognosis. The evaluation of remission using flow cytometry allows a better estimation of minimal residual disease (MRD) after induction chemotherapy in childhood acute lymphoblastic leukaemia (ALL) cases. Patients in morphological marrow remission with presence of blast cells of less than 5%, may still have up to 1010 leukaemic cells. However with flow cytometric analysis, lower levels of the residual leukaemic cells (1 in 104 cells) can be detected and it can be used as a tool to predict relapse. This study compared the presenting clinical and haematological features of children with ALL and their residual disease status determined by flow cytometry. Analysis of their MRD status following remission-induction chemotherapy were done at day-28, week-12 and week-20. The cases were also followed up to five years, to determine their survival status. Their residual disease status by flow cytometric immunophenotyping was also compared with their bone marrow findings morphologically. Thirty-eight cases of precursor B-ALL in pediatric patients from UKM Medical Centre (UKMMC) were analyzed. There was no significant correlation between demographic, clinical and haematological features with MRD status at day-28. However, there was a significant correlation between MRD status by flow cytometry and by morphological marrow examination at week-12. Three cases showed persistent MRD findings until week-20 where two of the cases relapsed and died subsequently. Twenty four patients were still alive after five years of follow up.

Juvenile myelomonocytic leukaemia (JMML), previously known as juvenile chronic myeloid leukaemia (JCML) is a rare, myelodysplastic – myeloproliferative disease typically presenting in early childhood. This disorder is diffi cult to distinguish from other myeloproliferative syndrome such as chronic myeloid leukaemia (CML) because of the similarities in their clinical and bone marrow fi ndings. However, because of its unique biological characteristics such as absolute monocytosis with dysplasia, absence of Philadelphia chromosome or BCR-ABL fusion protein, hypergammaglobulinaemia and raised fetal haemoglobin level, this disorder does not satisfy the criteria for inclusion in the CML or chronic myelomonocytic leukaemia (CMML) group, as seen in adult patients. We describe a series of three patients with JMML, who had almost similar clinical and laboratory fi ndings, and discuss the diffi culty in the classifi cation and treatment of the disease.

Lately, increasing workplace violence is a problem that requires serious attention by the management of the healthcare sector. This study was carried out to examine workplace violence experienced by nurses in the Universiti Kebangsaan Malaysia Medical Centre. It aimed to identify the category of nursing staff who formed the highest number of victims, the perpetrators and the common types of workplace violence. This was a descriptive cross-sectional study carried out over a three month period on 55 nurses who had participated voluntarily in this study. The demographic data and data on the violent incident were collected by using a 21-item questionnaire. The reliability and validity with Cronbach’s alpha was 0.872. Information on the most common types of violence, victims and the perpetrators was also collected. The study revealed that workplace violence among the nursing staff was 3.7% with an average of 1.2% being abused per month and one nurse being abused every other day. The study also revealed that the staff nurses were the most common victims and the perpetrators were mainly the patients (40.6%) and the patients’ relatives (37.5%). The most common forms of violence were verbal abuse (31.9%) and verbal threat (23.7%). Physical violence was experienced by 44.4% of the victims. These results suggest that workplace violence is a serious problem which should be addressed in order to create a safe environment for the nurses.

Ventilated patients who require intensive care unit (ICU) treatment may encounter unpleasant experiences. These experiences may include factual incidents and delusional memories of ICU such as dreams, hallucinations and frightening experiences. A cross sectional study using “Intensive Care Experience Questionnaire” consisted of four domains: awareness of surrounding, frightening experiences, recall of experience and satisfaction with nursing care. Forty five participants who fulfilled the inclusion criteria were recruited in this study. This study was conducted in ICU of HUKM from January to March 2006. Results showed that 20 respondents (44%) were aware of their surrounding and 31 respondents (69%) reported frightening experiences. Majority of respondents (43 respondents, 96%) reported satisfaction with the delivery of nursing care. There was positive correlation between awareness of surrounding and their abilities to recall their experiences (p<0.05). Patients’ awareness of surrounding achieved the strongest statistical significance as a contribution to the prediction of their abilities to recall their experiences with beta coefficient value of 0.353 and p<0.05. The finding of this study permits nurses to see the problems of mechanically ventilated patients through reports of unpleasant recollections by the patients themselves. Patients reported frustrations in their attempts to make their needs known. Although they are on sedation, they are aware of all unpleasant events occurring in the ICU

Parenting stress is the stress level experienced within the role of a parent (HoekstraWeebers et al. 1998). The source of stressors is variable and dependent on the phase of disease and chemotherapy (Sawyer et al. 2000). Failure to cope with these stressors may in turn affect the child’s emotional and social adjustment towards the diagnosis of cancer in addition to poor medical treatment adherence behaviour(Sawyer et al. 1993). The objectives of this study are to determine the level of parenting stress, the risk factors contributing to high parenting stress, and the coping mechanisms used to handle the stress. This single centred, cross-sectional study was done amongst 117 parents at the Paediatric Haematology and Oncology Unit, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) over two years duration. Self-administered questionnaires comprising the Parenting Stress Index/Short Form (PSI/SF) and Coping Inventory for Stressful Situation (CISS) were distributed to parents of children who were 12 years old and below. The mean total parenting stress score amongst parents of children diagnosed with acute leukaemia was 91.5±21.1(95%CI). A total of 27.3% of parents experienced a high total parenting stress score(defined as total PSI score ≥ 75th centile, ie ≥ 103). Task-oriented coping mechanism was used by the majority of parents. Emotion-oriented coping mechanism was the only identifiable risk factor for high parenting stress score following multiple logistic regression analysis. A parent who used emotion-oriented coping mechanism was 7.1 times (95% Confidence Interval 1.2 to 41.4) more likely to have a high parenting stress score compared to a parent who used other coping mechanisms. By identifying these at-risk parents, appropriate counselling and psychological support may be offered early to alleviate the stress as well as assist in the coping and adjustment mechanisms of these parents.

We report a case of bone marrow necrosis preceding infantile acute lymphoblastic leukaemia (ALL). Bone marrow necrosis is a rare antemortem event and has been known to be present in many conditions, notably in haematological malignancies like acute lymphoblastic leukaemia. This case was a 6-month-old Chinese boy who was referred to Hospital Universiti Kebangsaan Malaysia for further investigation of pancytopaenia, high-grade fever, bloody diarrhoea and petechial rashes for one week. His first bone marrow aspirate revealed bone marrow necrosis. His clinical condition improved after ten days. However, his full blood picture then revealed the presence of 5% blast cells. His subsequent marrow 2 weeks later revealed acute lymphoblastic leukaemia (FAB-L1) and immunophenotyping showed precursor B acute lymphoblastic leukaemia-null type. He was started on United Kingdom Acute Lymphoblastic leukaemia (UK ALL) Infantile Leukaemia protocol, however, he defaulted treatment after 3 days. Mode of presentation, mechanism of disease and laboratory investigations and outline of treatment will be discussed.
Acute ; Lymphoblast ; Bone Marrow ; Necrosis ; week

Pregnancy is perceived by many pregnant mothers as a period of happiness in anticipation of motherhood. Not all pregnant mothers experience cheerfulness as some may experience a high anxiety and depression level for unknown reasons. The purpose of this study was to determine the level of anxiety and depression among high risk pregnant women and the factors that contribute to their level of anxiety and depression. A descriptive cross-sectional study was conducted on 38 high risk mothers whose stay in hospital exceeded more than three days in the obstetric ward of Hospital Universiti Kebangsaan Malaysia. A self assessment questionaire "Hospital Anxiety Depression Scale"was used to measure the level of anxiety and depression among high risk pregnant women. Of the 38 participants, 16 (42.1%) women experienced a mild level of anxiety and 22 (57.9%) experienced a severe level of anxiety. Seventeen (44.7%) women was classified as having mild depression and 21 (55.3%) severe depression. The factors contributing to the level of anxiety and depression, include those related with "lack of information on disease", "family matters" and "finance". High risk pregnant women in this study experienced a significant level of anxiety and depression during their stay in hospital. It is therefore important for nurses and doctors to be aware and sensitive to the influencing factors that cause anxiety and depression as to enable high risk pregnant mothers to enjoy their pregnancy and childbirth.

Stress has a negative effect on student nurses well-being and can impede learning or motivate them and is conducive to learning. This study examined the perceived stress and factors that influenced daily students’ life among both the Diploma and Bachelor of Nursing students. A total of 241 nursing students were involved in this research project. Findings of this study indicated that junior nursing students (<21 years) of both cohorts perceived significantly more stress than older (≥21 years) nursing students. Second year students of the Diploma group claimed being more stressed than their peers (1st and 3rd years). Personal problems were the main issue of concern among the second year Diploma students. Workload of nursing education and fear of failing the nursing programme were the major stressors among the first year nursing students of the Bachelor cohort as compared to their seniors. A mixture of negatively and positively significant correlations was observed between academic work and clinical scores among the Diploma and Bachelor of Nursing students respectively. Both the Diploma and Bachelor of Nursing students’ stress did not influence their GPA scores. Negatively significant correlation was noted between stress and clinical scores among the Diploma of Nursing students. A negatively significant correlation was found between age and CGPA scores among the Bachelor cohort. Both male and female Diploma and Bachelor nursing students perceived no differences in stress related to their academic work. The findings of this study provide important information for nursing education at the institute examined in this study, and have implications for future research.

Leukaemic stem cells have heterogenous differentiation potential. The immunophenotypes of blast cells are usually consistent throughout the disease course even at relapse. Rarely, blast cells may undergo a ‘lineage switch’ during the course of disease especially during relapse. We would like to highlight such a case in a 10-year old boy who presented with a two weeks history of lethargy, poor appetite, low grade fever, respiratory distress, cardiac failure, generalized oedema and hepatosplenomegaly. Full blood count showed a leucocyte count of 41.5x109/L and platelet count of 37x109/L. The peripheral blood film showed presence of numerous blast cells. Bone marrow aspiration revealed a hypercellular marrow, which consisted of mainly blast cells with high nuclear to cytoplasmic ratio and inconspicuous nucleoli. Immunophenotyping and cytochemistry results were consistent with the diagnosis of T-cell acute lymphoblastic leukaemia. The patient achieved remission after treatment with UK ALL 97 protocol, regime B chemotherapy. However, he relapsed seven months after the initial diagnosis with 26% blast cells in the bone marrow aspirate. The majority was L1 blast cells admixed with some L2 blast cells. Immunophenotyping was consistent with common precursor B acute lymphoblastic leukaemia. The treatment was changed to a more lineage specific chemotherapy. Nonetheless, the patient never achieved remission and was planned for palliative management. This case illustrated a unique and rare case of rapid lineage switch from T-cell acute lymphoblastic leukaemia to common precursor B-cell acute lymphoblastic leukaemia.

Sharps injury among health care workers in HUKM has received serious attention lately due to the possible transmission of diseases like HIV, Hepatits B and Hepatitis C, which can cause serious consequences for the victim. The aim of the study was to gain a deeper understanding of the emotional problems experienced by health care workers who had incurred a sharps injury and the coping strategies adopted by them to overcome the problem. A 28 item semi-structured questionnaire was designed by the supervisors and the researcher as there was no existing questionnaire to be adopted, as no research had been carried out in this area prior to this. The target group consisted of 64 health care workers of different categories working in HUKM. Data was collected over a period of five months from November 2000 to March 2001. The results of the study revealed that the most frequently injured were the staff nurses, nearly 90% of whom were emotionally upset and were worried that they might contract a disease. There was no significant difference in the emotional stress experienced by the different categories of the health care workers, all were equally upset about the injury but each category of staff adopted different methods to overcome the tragedy. Open comments and opinions about prevention and the management of the sharps injury in HUKM as given by the respondents here are taken into account. Several views given by the participants were explored and discussed. Finally, several implications for nursing and recommendations have been presented.