On the 18th of March 2020, the Malaysia government declared a movement control order (MCO) due to the unprecedented COVID-19 pandemic. Although the majority of patients presented with respiratory-related symptoms, COVID-19 patients may present atypically with neurological manifestations and may even have an increased risk of stroke. The Malaysia Stroke Council is concerned regarding the level of care given to stroke patients during this pandemic. During the recent National Stroke Workflow Steering Committee meeting, a guide was made based on the currently available evidences to assist Malaysian physicians providing acute stroke care in the hospital setting in order to provide the best stroke care while maintaining their own safety. The guide comprises of prehospital stroke awareness, hyperacute stroke care, stroke care unit and intensive care unit admission, post-stroke rehabilitation and secondary prevention practice. We urge continuous initiative to provide the best stroke care possible and ensure adequate safety for both patients and the stroke care team.

Introduction: Chronic and post-prandial hyperglycemia are independent risk factors for diabetic complications. Glycemic patterns among hemodialysis end-stage-renal-disease (ESRD) differ as glucose metabolism changes with declining kidney function with more pronounced glycemic fluctuations. The objectives of this study are to determine glycemic patterns on hemodialysis days, the magnitude of post-hemodialysis rebound hyperglycemia (PHH) and their associated factors. Methodology: 148 patients on hemodialysis were analysed, 91 patients had end-stage-diabetic-renal disease (DM-ESRD), and 57 patients had end-stage-non-diabetic renal disease (NDM-ESRD). Glycemic patterns and PHH data were obtained from 11-point and 7-point self-monitoring blood glucose (SMBG) profiles on hemodialysis and non-hemodialysis days. PHH and its associated factors were analysed with logistic regression. Results: Mean blood glucose on hemodialysis days was 9.33 [SD 2.7] mmol/L in DM-ESRD patients compared to 6.07 [SD 0.85] mmol/L in those with NDM-ESRD (p<0.001). PHH occurred in 70% of patients and was more pronounced in DM-ESRD compared to NDM-ESRD patients (72.5% vs 27.5%; OR 4.5). Asymptomatic hypoglycemia was observed in 18% of patients. DM-ESRD, older age, previous IHD, obesity, high HbA1c, elevated highly-sensitive CRP and low albumin were associated with PHH. Conclusion DM-ESRD patients experienced significant PHH in our cohort. Other associated factors include older age, previous IHD, obesity, high HbA1c, elevated hs-CRP and low albumin.
Renal Dialysis ; Diabetes Complications ; Hyperglycemia ; Risk Factors ; Asian

Hypersexuality is rare in children. Our case describes a 14-year-old girl who presented with a history suggestive of hypersexuality. She was repeatedly raped and exposed to video pornography at a very young age. Consequently, she became addicted to pleasure during sexual intercourse and actively involved in multiple unprotected sexual intercourses. Management, in this case, was challenging, where early intervention with contraceptive methods and cognitive behavioural therapy were unsuccessful. Subsequently, alternative treatment with Islamic psycho-spiritual therapy combined with conventional therapy resulted in an improvement in her sexual pre-occupation. This case highlights the importance of recognition of hypersexuality, especially among children with a history of sexual abuse as management proofs to be challenging, and requires a multimodal approach to prevent a potentially devastating outcome.

Puncture injury from sea-urchin stings may lead to a local and systemic inflammatory reaction. We are reporting a case of longitudinal extensive transverse myelitis (LETM), which occurred ten days post-sea-urchin stings, where the patient presented with bilateral lower limb weakness. MRI showed multilevel segment spinal cord T2-weighted hyperintensity. Prompt intravenous methylprednisolone was administered, and the patient had a full recovery. To date, there is no case report of LETM associated with sea-urchin stings. Possible mechanism due to delayed immunological hypersensitivity to sea-urchin venom. This case demonstrates the potential serious neurological sequelae that may be associated with post-sea-urchin sting and the importance of prompt recognition and management in aiding recovery.

Mycoplasma pneumonia is an atypical bacterium that causes mild respiratory tract infections, especially in the upper respiratory system. Mycoplasma pneumoniae infection is infrequently associated with various CNS manifestations such as encephalitis, meningoencephalitis, myelitis, Guillain-Barre syndrome and acute disseminated encephalomyelitis (ADEM). Here we report a rare case of mycoplasma encephalitis in an adult who presented with a first episode of seizure following fever and neck stiffness for one week. Mycoplasma pneumoniae antibody titer was markedly elevated at >1:320 and MRI brain revealed encephalitic changes with a lesion in the splenium. Interestingly, there was no associated respiratory infection and his stay in the hospital was also complicated by SIADH. The patient improved after treatment with a macrolide antibiotic.

Introduction: Intravenous thrombolysis (IVT) is the gold standard for the treatment of patients with acute ischemic stroke (AIS) presenting within four and a half hours of onset. However, development of new thrombolytic agents and advanced imaging has led to extended time for thrombolysis based on advanced imaging. Here we describe four patients who presented in the extended hours; that benefitted from thrombolysis. Case series: We advocate magnetic resonance imaging (MRI) for AIS, that includes diffusion weighted imaging (DWI), apparent diffusion coefficient (ADC), fluid attenuated inversion recovery (FLAIR), susceptibility weighted imaging (SWI), and magnetic resonance angiography (MRA). We included four patients who were more than 18 years old, with National Institute of Health Stroke Scale (NIHSS) of six or more, presenting between four and a half to nine hours after stroke onset with no contraindications for intravenous thrombolysis. The imaging criteria used to determine eligibility for IVT is evidence of DWI-FLAIR mismatch on MRI. If FLAIR detects no signal change in the area of stroke on DWI, it is then termed DWIFLAIR mismatch, or FLAIR-negative – indicating high probability that the brain tissue is still viable, and that patients are good candidates for IVT. Conclusion: For patients with AIS who present within nine hours, DWI-FLAIR mismatch serves as an excellent surrogate marker of salvageable brain tissue, allowing a greater proportion of patients benefiting from this life-saving therapy. Our experience also shows that with careful patient selection, treatment with IVT can safely be given without an increased risk of bleeding or mortality.

Stroke care service in Malaysia is suboptimal despite the fact that it is one of the commonest cause of death. This is due to several limitations, including lack of resources and funding for the stroke care establishment and the management itself. Alternatively, other regions have come up with numerous ways to combat the difficulties in order to provide better stroke care services. We have identified the overwhelming benefits of creating stroke care units, thrombolysis services, and endovascular thrombectomy. For this reason, we designed a Regional Emergency Stroke Quick Response Network (RESQ) based on the needs of the current situation in Malaysia. With a standardised RESQ training, we hope to achieve close-knitted cooperation in between the emergency medical services, emergency department team and the RESQ, which subsequently will create an ideal improvised stroke care units.

Introduction: This study aims to determine the prognostic factors and survival outcomes of patients that underwent this surgery. Method: A retrospective review of 43 patients who underwent exenteration for periocular malignancies over a 14-year period was carried out. Patient demographics, tumour histology, treatment details, surgical margins’ status and post-operative survival were recorded. The survival outcome examined was the overall survival (OS) rate. Cox regression and Kaplan-Meier analysis were used to evaluate post-exenteration survival. Results: In total, 20 females and 23 males with a median age of 62 ± 17.3 years were identified. The most common indication for exenteration was basal cell carcinoma (20.9%), followed by squamous cell carcinoma (18.6%), adenocystic carcinoma (14%), malignant melanoma (14%) and sebaceous gland carcinoma (11.6%). The independent predictors for worse OS on multivariate analysis were Chinese ethnicity (adjusted hazard ratio [aHR] 4.95, p =0.017), sebaceous gland carcinoma (aHR 57.61 p=0.006), adenocystic carcinoma (aHR 45.87, p=0.008), clear surgical margins (aHR 5.41, p=0.025), receiving only chemotherapy (aHR 169.13, p=0.004), and receiving both adjuvant chemotherapy and radiotherapy (aHR 41.51, p=0.010). Conclusion: We recommend targeted public health initiatives for Chinese patients due to their increased mortality risk from peri-ocular malignancies. In addition, we advise comprehensive adjuvant therapy for all patients regardless of whether a clear surgical margin is achieved. Basal cell carcinoma and adenocystic carcinoma may also benefit from genetic research. We advocate more training for ophthalmologists to identify periocular malignancies earlier for better treatment options and increased chances of survival.

Introduction: Coronavirus disease-2019 (COVID-19) was declared a global pandemic in March 2020, with 15 million people have been infected worldwide, and this number is increasing. Our study sought to assess the knowledge and practice of healthcare workers (HCWs) in a teaching hospital in Malaysia. Methods: This cross-sectional study was undertaken using online Google form links among HCWs. Knowledge and practice were assessed using a validated questionnaire. The analysis was performed with SPSS version 26. Factors associated with poor knowledge were analysed using multivariate analysis. Results: A total of 193 HCW responded to our online survey. Majority of our HCWs were female (74.1%) with a mean age of 32.5 years. We found 53 (27.5%) and 134 (69.4%) of our HCWs had good knowledge and good practice on COVID-19, respectively. Knowledge gap was identified in the symptomatology, investigation methods and management. Based on multiple logistic regression, determinants of poor knowledge scores were those work as medical attendants (aOR = 3.626; 95% CI = 1.489, 8.834) and nurses (aOR = 4.107; 95% CI = 1.175, 14.358). Conclusion: Around one-third and 70% of our HCWs have good knowledge and practice of COVID-19 infection respectively. Continuous, specifically targeted and updated medical education, need to be carried out to improve the knowledge and practice among our HCWs in order to keep abreast of the fast-moving pace of COVID-19 knowledge development.