End of life care is framework to allow for a peaceful, comfortable and dignified death while considering the patients’ personal and religious values, bioethics and knowledge of the disease process. A well planned end of life pathway should allow for the flexibility to shift from an active (or aggressive) treatment approach to one of comfort and care when initial interventions have failed. The need for this pathway is most apparent in the intensive care setting. Implementation of a pathway will face various challenges due to religious and cultural beliefs, education of healthcare providers to carry out difficult discussions and larger socioeconomic implications. Clear medico-legal framework will be required to support this pathway. In conclusion, an end of life pathway tailored to our local needs is the way forward in allowing for dignified death of terminally ill patients; this will require the active participation of medical societies, religious leaders, healthcare providers, patients and their care givers.

Sternal metastasis from differentiated thyroid carcinoma (DTC) is rare and presents a conundrum for surgeons. We present a lady diagnosed with follicular thyroid carcinoma and sternal metastasis who underwent thyroidectomy, sternectomy and sternoplasty with titanium mesh and acrylic plate. She developed a surgical site infection, of which multiple conservative approaches were attempted. She eventually required removal of the implant. Closure of sternal defect was completed with bilateral pectoralis major advancement flaps. This article highlights a series of complications faced during the course of treatment and how they were managed in a tertiary healthcare centre.
Adenocarcinoma, Follicular

and taste loss were early subclinical symptoms of COVID-19patients. The objective of this review was to identify theincidence of smell and taste dysfunction in COVID-19,determine the onset of their symptoms and the risk factorsof anosmia, hyposmia, ageusia or dysgeusia for COVID-19infection.Methods: We searched the PubMed and Google Scholar on15th May 2020, with search terms including SARS-COV-2,coronavirus, COVID-19, hyposmia, anosmia, ageusia anddysgeusia. The articles included were cross sectionalstudies, observational studies and retrospective orprospective audits, letters to editor and shortcommunications that included a study of a cohort ofpatients. Case reports, case-series and interventionalstudies were excluded. Discussion: A total of 16 studies were selected. Incidence ofsmell and taste dysfunction was higher in Europe (34 to86%), North America (19 to 71%) and the Middle East (36 to98%) when compared to the Asian cohorts (11 to 15%) inCOVID-19 positive patients. Incidence of smell and tastedysfunction in COVID-19 negative patients was low incomparison (12 to 27%). Total incidence of smell and tastedysfunction from COVID-19 positive and negative patientsfrom seven studies was 20% and 10% respectively.Symptoms may appear just before, concomitantly, orimmediately after the onset of the usual symptoms. Occurspredominantly in females. When occurring immediately afterthe onset of the usual symptoms, the median time of onsetwas 3.3 to 4.4 days. Symptoms persist for a period of sevento 14 days. Patients with smell and taste dysfunction werereported to have a six to ten-fold odds of having COVID-19.Conclusion: Smell and taste dysfunction has a highincidence in Europe, North America, and the Middle East.The incidence was lower in the Asia region. It is a strong riskfactor for COVID-19. It may be the only symptom and shouldbe added to the list of symptoms when screening for COVID-19.KEYW

A 68-year-old female presented with a 1-month history of lower back pain with right-sided radiculopathy and numbness. She was diagnosed with lumbar spondylosis and treated conservatively with analgesia and physiotherapy. Imaging showed multiple susuk, a metal alloy, in the lower back region and other regions of the body. The patient had undergone traditional medicine consultation 10 years earlier when the susuk was inserted in the lower back as talisman. The practice of the insertion of susuk is popular in rural East Malaysia and Indonesia. These foreign bodies act as possible causes of chronic inflammation and granuloma formation. In addition, the localised heighten peril upon imaging. This report suggests that the insertion of multiple susuk as talisman carries risk to safety of patients when imaging, and this practice complicates the management of musculoskeletal disorders