Intraductal Papillary Mucinous Neoplasm (IPMN) of the pancreas in association with Autosomal Dominant Polycystic Kidney Disease (ADPKD) is extremely rare, even though 10% of ADPKD patients may develop simple pancreatic cyst. The first case report was published by Yasunori Sato from Japan in 2009. Since then less than 10 case reports are available worldwide to describe about this condition. We reported such a rare case of a 67-year-old man with ADPKD who was referred to our centre because of chronic abdominal pain and diagnosed as IPMN based on the serial imaging procedures. Despite of the high risk comorbidities, he successfully underwent pylorus preserving total pancreaticoduodenectomy with splenectomy.

A study on heavy metals accumulation and human health risk assessment in the consumption of two tropical freshwater eel species (A. bengalensis bengalensis) from the Sungai Perak at Kuala Kangsar, Perak and (A. bicolor bicolor) from the Air Hitam irrigation canal, Kampung Kuala Sanglang, Kedah was carried out. Specimens were examined and analyzed for Pb and Cd concentrations using ICP-MS while the total Hg concentration was measured using a direct mercury analyzer (MA-3000). The range for the total concentrations (µg/g wet wt.) in A. bicolor bicolor were 0.01-0.4 (Cd), 0.03-0.77 (Pb) and 0.36-0.94 (Hg) while for A. bengalensis bengalensis, they were 0.76-1.23 (Cd), 0.01-0.10 (Pb) and 0.27-1.5 (Hg). A. bengalensis bengalensis (Sungai Perak) showed a significant strong relationship between Hg/Pb (r = .771, P < 0.05) and A. bicolor bicolor (Air Hitam irrigation canal) with Cd/Pb (r = -.895, P < 0.05) in muscle tissues and the results indicated Hg and Pb were introduced from point and non-point sources, therefore it is of concern. Interspatial comparison with the findings of previous local and international studies showed both species of freshwater eels accumulated Hg to high levels, exceeding the safe limits stipulated in the Malaysian Food Act of 1984, Food Regulations (1985) and USEPA (1997). However, the Target Hazard Quotient (THQ) and Hazard Index (HI) indicated that both freshwater eel spp. from the studied sites are safe to consume as there is no risk posed from consumption based on the health risk assessment results as Pb, Cd and Hg concentrations were under the permissible limits of nutrient intake.

A 24-year-old man presented to the casualty department with a history of left-sided, colicky abdominal pain for one day. It was associated with an inability to pass flatus or motion within the same duration. There was no history of vomiting. On examination, the vital signs were within normal limits, and he was afebrile. His abdomen was soft, but a hard mass was palpable on the left side of his abdomen. There was no peritonitis. The bowel sounds were sluggish.

A motorcyclist was involved in a motor vehicle accident and presented with respiratory distress and neck swelling with surgical emphysema. He sustained gross tracheal injury, severe pneumothoraces and lung contusions. As intubation was successful, the tracheal injury was not addressed immediately in view of the other severe respiratory problems. Evidence of aspiration lead to further investigations which confirmed the diagnosis 22 days post trauma. Thyrotracheal anastomosis was carried out without stenting. A complete cricotracheal separation is a rare event and can be easily overlooked in the emergency department.

Abstract. This study was conducted to investigate the low prevalence of Dirofilaria immitis in dogs in Johor Bahru as reported by veterinary practitioners, using wet blood mount, Knott’s Concentration Test and two heartworm antigen test kits (IDEXX Canine SNAP® 4Dx and RapiGEN®). This study also compared the two test kits used and determined the microfilaria species. Blood were collected from 100 owned dogs and 50 stray dogs in Johor Bahru via cephalic venipuncture. A thick blood smear was done and examined for samples that were positive for microfilaria species identification. The overall prevalence of D. immitis in dogs in Johor Bahru was 1.33% (2/150) and the microfilaria identified was D. immitis. The prevalence of heartworm in owned and stray dogs in this study was 1% and 2% respectively. With only one false negative result from RapiGEN® test kit, comparing the sensitivity between the two test kits could not be achieved. The low prevalence of D. immitis found in this study confirmed anecdotal evidence that prevalence of dirofilariasis is indeed low in Johor Bahru. Additionally, we speculate that dirofilariasis in dogs might be considered as an indicator of vector availability.

The implementation of the Chronic Disease Management Program or PROLANIS has been adopted in Indonesia by National Social Security Implementation on Health Agency (BPJS-K) since 2015. The program focuses on hypertension (HT) and diabetes mellitus (DM). However, since the first time the program was implemented, there was no comprehensive evaluation of it. The aim of this study was to analyze health service quality among HT and DM patients based on five dimensions of quality in 25 community health services (CHSs) in the Sleman district, Yogyakarta, Indonesia. This is a cross-sectional study with a simple random sampling technique that included 230 respondents from 25 CHSs. The instrument was SERVQUAL that consisted of 35 items of a questionnaire. The data were analyzed by a gap analysis, Customer Satisfaction Index (CSI) and Importance Performance Analysis (IPA); meanwhile, a Man–Whitney test was proposed to determine differences in health services quality in the PROLANIS program. Based on the gap analysis, it was found that whole dimensions were below 0-point; the CSI analysis obtained 74.45 for HT and 75.15 for DM; and the IPA analysis found that the distribution of respondents’ answers in the questionnaire were in quadrants 1 and 2. The Man–Whitney analysis was used to get the assurance aspect correlated with health service quality in DM and HT patients (p = 0.001). Health service quality in the PROLANIS program was based on five dimensions of quality was low, unless assurance dimension. The government should improve health services quality in aspects of tangibility, responsiveness, empathy, and reliability to get satisfaction among HT and DM patients in the PROLANIS program.

Background: Occurrence of epileptic seizure in patients with brain tumors is not uncommon. In spite of the huge data from the developed world on epilepsy caused by brain tumor, there is paucity of data emanating from Nigeria, hence, this study. Methods: The cases were recruited from a total of 302 consecutive patients with late onset epilepsy, with fi rst episode of seizure after 25 years of age, from three tertiary centres in northern and southern Nigeria. Information was collected on the demography, seizure characteristics, and additional neurological, cognitive or behavioral symptoms. All the patients had EEG and neuroimaging. Results: Sixty six patients, comprising 48 males (73%) and 18 females (27%) had symptomatic seizure from brain tumor which constituted 21.9 % of patients. Seizure was the only symptom in 27.3% and the fi rst symptom in 36.4% of the patients. Forty fi ve (68.2%) patients had focal seizure. The most common histological type was low grade astrocytoma. Common EEG fi ndings were epileptiform discharges (54.5%) and focal slowing (24.2%). EEG was normal in 10.6% of the patients. Conclusion: Seizure as the initial symptom was common among Nigerian patients with brain tumor presenting as late onset epilepsy. Gliomas were the most common brain tumor. There is need to investigate for tumor in Nigerian patients presenting with late onset epilepsy.

Extracranial aneurysms are a rare presentation accounting for only less than 5% of all peripheral artery aneurysms. The left common carotid artery aneurysm is considered even rarer. We present a case of a 46-year-old gentleman who presented to casualty unit with a neck mass, stridor and acute respiratory distress. Prior to this admission patient was being investigated for Takayasu arteritis (TA). Patient was subsequently intubated due to respiratory compromise. A CT angiography of the thorax was done showed a proximal left common carotid artery aneurysm with contained leakage of aneurysm with severe compression of the trachea. Patient was subsequently transferred to the vascular team in National Heart Institute for further management.
Aneurysm

Tracheostomy can be associated with numerous complications. Here, we present a case of large hypertrophic skin of tracheostoma with tracheal granulation tissue causing malpositioning of tracheostomy tube and airway obstruction, secondary to prolong placement of a cuff tracheostomy tube due to improper tracheostomy care. This case illustrates that awareness and knowledge of proper tracheostomy tube care among medical personnel are very important to avoid any mismanagement that can cause life-threatening complications.
Tracheostomy

Public health clinical rotation in the Faculty of Medicine, Universitas Islam Indonesia, was conducted in Puskesmas (community health center). This study aims to evaluate the public health clinical rotation in Puskesmas, part of the clinical clerkship of the Faculty of Medicine, Universitas Islam Indonesia. Several concerns have been highlighted regarding the implementation of clinical rotations in public health in Puskesmas. A briefing session before placement in the village must be coherent with a guidebook. The placement of students in the village was based on community health issues determined by the Puskesmas supervisor. Priority in the curriculum was given to converting the alertness village (Desa Siaga) into a Program Indonesia Sehat–Pendekatan Keluarga (Healthy Indonesia Program–Family Education) program throughout implementation. Moreover, scheduling after four major clinical programs was difficult, and the writing of reports served as a guide for establishing the correct format. Therefore, the objective of the evaluation was to assess knowledge, skill, and psychomotor, and the burden of assignment in Puskesmas was difficult to accomplish a primary task in the community.