Applied Behavior Analysis (ABA) is a technique used to teach children with autisme a variety of skills. In ABA, children with autisme often do not receive reinforcers because they have difficulty performing their targeted behaviors, which consequently leads to challenging behaviors. Objectives of this study are to increase spontaneous request and decrease challenging behavior among children with autisme by introducing a secondary reinforcer during therapy based on ABA model. Secondary reinforcer has lower reinforcing value than the primary reinforcer. When the children tried but were unable to produce their targeted behavior, they were given the secondary reinforcer. The children were divided into two groups, five children in the intervention group and four children in the control group, and they were taught specific target requesting behavior (TRB) to request for a preferred item. Three children in the intervention group recorded an increase in spontaneous request and a reduction in challenging behaviors. Only two children from the control group recorded an increase in spontaneous request and a decrease in challenging behaviors. However, only children from the intervention group were able to maintain their performance during the generalization sessions. The results suggest that children respond differently to specific prompts and interventions. Future studies should focus on how prompts affect children’s performance and also on reinforcer selection. Bigger scale studies are still needed to further determine the effectiveness of a secondary reinforcer in assisting the learning of requesting skill and in reducing challenging behaviors among children with autisme during therapy based on ABA model.

Toxic epidermal necrolysis (TEN) is a severe mucocutaneous disease characterized by extensive epidermal detachment with drugs as the most probable cause. We describe a unique case of TEN where systemic lupus erythematosus (SLE) was found to be the precipitating underlying disease. Our patient was managed in ICU, however succumbed one month after her diagnosis due to overwhelming sepsis and multiorgan failure.

Objective: To delineate and differentiate between late subacute hemorrhage and intracranial lipomas in clinically available conventional and advanced MR sequences. Methods: Two cases of late subacute hemorrhage and two cases of intracranial lipoma were reviewed with CT scans and 3.0T scanner MRI. The sequences evaluated in MRI were T1-weighted (T1W) fast spin echo (FSE), T2-weighted (T2W) FSE, gradient echo T2*-weighted (GRE T2*W) images, diffusion weighted (DWI), apparent diffusion coefficient (ADC) and multivoxel spectroscopy. Results: Late subacute hemorrhage and intracranial lipoma have similar imaging features on T1W, T2W FSE with blooming artefact at the margins on GRE T2*W. However on GRE T2*W sequence, the central area of lipoma demonstrates low signal; while hemorrhage demonstrates high signal. In DWI, late subacute hemorrhage shows hyperintensity; while in lipoma there is loss of signal. Conclusion: Awareness of the potential pitfalls in standard sequence are important, as these entities appear to have similar T1W/ T2W characteristic with blooming artefact on T2*W. Knowing the distinctive central signal intensity pattern on GRE T2W* and DWI is therefore essential to differentiate between these lesions as there are differences to their clinical management.
Magnetic Resonance Imaging

Introduction: Little is known about the treatment outcomes of children with cleft lip and/or palate (CLP) receiving surgical care for primary lip and palate closure in Malaysia. Objectives: This study examined the speech and hearing status of Malay-speaking children with CLP residing in Kuala Lumpur. Methods: Parents whose children were between the age of 5 and 7 years were recruited via the Cleft Lip and Palate Association of Malaysia (CLAPAM) registry. Parents completed a survey and the children completed a speech and hearing assessment at the Audiology and Speech Sciences Clinic, Universiti Kebangsaan Malaysia. Outcomes: Speech measures include nasality rating, nasalance scores, articulation errors and speech intelligibility rating, while hearing measures include hearing thresholds and tympanometry results for each child. Results: Out of 118 registered members who fulfilled the inclusion criteria, 21 agreed to participate in the study. The overall speech and hearing status of children in this sample were poor. Only four (19%) participants had normal speech intelligibility rating and normal hearing bilaterally. In terms of overall cleft management, only four (19%) participants were seen by a cleft team while seven (33%) had never had their hearing tested prior to this study. Conclusion: Participants in this sample had poor outcomes in speech and hearing and received uncoordinated and fragmented cleft care. This finding calls for further large scale research and collaborative efforts into improving and providing centralised, multidisciplinary care for children born with CLP.

The paper describes the validation of the Malay Preschool Language Assessment Tool (MPLAT), a standardized normed referenced language assessment tool for Malay preschoolers within the ages of 4;0-6;11 and whose native language is Malay. The MPLAT (A Razak et al. 2010) is an assessment tool which is designed to assess the areas of receptive language, expressive language and early literacy skills. The MPLAT contains six subtests i.e. picture vocabulary, grammatical understanding, sentence repetition, referential meaning, relational meaning and early literacy skills. This paper is divided into 2 studies. Study 1 tested the psychometric properties and normative data of the diagnostic version of MPLAT on 300 participants recruited from preschools in the rural area of Gua Musang and the urban area of Kota Bahru located in the East Coast state of Kelantan. The construct validity is high with a strong correlation (r = 0.942) between test scores and age, validating the developmental nature of the test. There was also moderate to strong positive correlation between each subtest and the test total, as well as between subtests. It also has high test-retest reliability (r = 0.998 (p < 0.01) and inter-rater reliability (rho = 1.000). The second study looked at the psychometrics properties of the MPLAT short version (screening) compared to the full version diagnostic. The short version of MPLAT is about a quarter of the full (diagnostic) version. About 108 subjects in the urban area of the the Klang Valley, consisting of Kuala Lumpur and Selangor, were administered both versions of the MPLAT. The Pearson correlation revealed a strong positive correlation between the total scores and age (r = 0.718, p<.01), and strong positive correlation for the test-retest reliability (r = 0.881, n=12) for the short MPLAT version. For the full version, the Spearman correlation revealed a strong positive correlation between total scores and age (r = 0.791, p<.01) and a very strong positive Pearson correlation for test-retest reliability (r = 0.943). Cronbach's Alpha values demonstrated the internal consistency of the full version (0.972) and short version (0.929). In summary, both versions of the MPLAT were found to be valid tools to screen and diagnose language problems among Malay preschool children in Malaysia. MPLAT also has the potential to be a useful research tool to delineate language development of the preschool Malay children.
Malay Preschool Language Assessment Tool (MPLAT) ; screening tool ; diagnostic tool ; language assessment ; Malay preschool children ; test development ; test validation

There are 50-100 million dengue infections each year, but dengue encephalitis is relatively uncommon. The aetiology of neuronal injury is proposed to be due to direct viral neurotropism or host immune response-mediated inflammation causing neuronal damage. We report a case of severe dengue encephalitis, presenting during the acute viraemic phase of the disease. This was associated with inflammation and haemorrhage of the internal medullary lamina of both thalami which, to our knowledge, has not yet been reported in other infections of the central nervous system.
Dengue

Background and Objective: There is a great challenge to establish a level 4 epilepsy care offeringcomplete evaluation for epilepsy surgery including invasive monitoring in a resource-limited country.This study aimed to report the setup of a level 4 comprehensive epilepsy program in Malaysia and theoutcome of epilepsy surgery over the past 4 years. Methods: This is a retrospective study analyzingcases with intractable epilepsy in a comprehensive epilepsy program in University Malaya MedicalCenter (UMMC), Kuala Lumpur, from January 2012 to August 2016. Results: A total of 92 caseshad comprehensive epilepsy evaluation from January 2012 till August 2016. The mean age was 35.57years old (range 15-59) and 54 (58.7%) were male. There were 17 cases having epilepsy surgeryafter stage-1 evaluation. Eleven cases had mesial temporal sclerosis and 81% achieved Engel classI surgical outcome. Six cases had lesionectomy and 60% had Engel class I outcome. A total of 16surgeries were performed after stage-2 evaluation, including invasive EEG monitoring in 9 cases.Among those with surgery performed more than 12 months from the time of data collection, 5/10(50%) achieved Engel I outcome, whereas 2 (20%) had worthwhile improvement (Engel class III)with 75% and 90% seizure reduction.Conclusion: Level 4 epilepsy care has an important role and is possible with joint multidisciplinaryeffort in a middle-income country like Malaysia despite resource limitation.

Purpose::Malnutrition is a common problem among hospitalized patients, especially among traumatic brain injury (TBI) patients. It is developed from hypermetabolism and the condition may worsen under the circumstance of underfeeding or incompatible dietary management. However, the data of nutrient intake especially calorie and protein among TBI patients were scarce. Hence, this study aimed to determine the calorie and protein intake among acute and sub-acute TBI patients receiving medical nutrition therapy in hospital Sultanah Nur Zahirah, Terengganu.Methods::This observational study involved 50 patients recruited from the neurosurgical ward. Method of 24 h dietary recall was utilized and combined with self-administered food diaries for 2-8 days. Food consumptions including calorie intake and protein intake were analyzed using Nutritionist PRO? (Woodinville, USA) and manual calculation based on the Malaysian food composition database (2015).Results::Patients consisted of 56% males and 44% females with the median age of 28.0 (IQR = 22.8-36.5) years, of which 92% were diagnosed as mild TBI and the remaining (8%) as moderate TBI. The Glasgow coma scale (GCS) was adopted to classify TBI severity with the score 13-15 being mild and 9-12 being moderate. The median length of hospital stay was 2 (IQR = 2.0-3.3) days. Calorie and protein intake improved significantly from day 1 to discharge day. However, the intake during discharge day was still considered as suboptimal, i.e. 75% of calorie requirement, whilst the median protein intake was only 61.3% relative to protein requirement. Moreover, the average percentages of calorie and protein intakes throughout hospitalization were remarkably lower, i.e. 52.2% and 41.0%, respectively.Conclusion::Although the calorie and protein intakes had increased from baseline, hospitalized TBI patients were still at a risk to develop malnutrition as the average intakes were considerably low as compared to their requirements. Optimum nutrient intakes especially calorie and protein are crucial to ensure optimum recovery process as well as to minimize risks of infection and complications.

Background & Objectives: The National Institute of Health Stroke Scale (NIHSS) provides a valid and quick assessment of stroke severity in hyperacute stroke management. Stroke patients who are eligible for reperfusion therapy require prompt assessment. There is no validated Bahasa Malaysia (BM) version of the NIHSS that allows easier assessment by BM-speaking health professionals. This study aimed to translate and validate a BM version of the NIHSS. Methods: The English NIHSS was translated to BM, then back translated to ensure linguistic accuracy. We also adapted the language assessment of the NIHSS to be more culturally appropriate. Training and certification videos were downloaded from the NIH website and dubbed into BM. We determined intra-class correlation and unweighted kappa as the best measure of reliability. Median scores were used in the analysis for language items. Results: One hundred and one raters participated in the test-retest reliability study. Agreement between the original NIHSS and our translated version of the BM-NIHSS was good (ICC = 0.738, 95% CI: 0.611 to 0.823). Fair to moderate agreement was found on item-by-item analysis (unweighted κ=0.20-0.50) despite high observed agreement. Fifty patients participated in the language assessment arm. Scores were better in BM for reading, naming objects and repetition (Mdn = 100, p < 0.001). There was no difference in the median scores for the description component. Conclusions: The BM-NIHSS is a valid translation of the NIHSS, and may be used in clinical practice by BM-speaking healthcare professionals.

Speech and language skills are among the crucial components in determining cochlear implant habilitation outcomes. The purpose of this study was to investigate speech and language skills of Malay cochlear implant children using a developmental scale questionnaire and to identify the demographic factors that contribute to their performance. This study involved 26 children recruited from the National Cochlear Implant Program under the Malaysian Ministry of Health with chronological ages between 33 to 99 months (mean=72, SD=18.9), implant ages between 18 to 71 months (mean=40, SD=13.5) and hearing ages between 13 to 48 months (mean=30, SD=10.5). The instrument used was The Integrated Scale of Development-Malay version 2 (ISD-Mv2). The questionnaires were given to the parents or caregivers followed with by a phone call interview later. Results from the study showed that only 9 subjects (35%) were able score on the ISD-Mv2 equally or higher than their hearing age. From the six components in the ISD-Mv2, cognitive was scored the highest with 96.79% meanwhile expressive language was the lowest with 76.21%. Pearson correlation test revealed strong positive correlation between audition-receptive language (r=0.554, p<0.05) and cognitive–social communication/ pragmatic (r= 0.625, p<0.05). Speech and language performance of children with demographic factors did not show significant differences. The findings suggests that majority of the Malay cochlear implant children demonstrated delayed speech and language performance as compared to normal hearing children.