The Osseous Pathology of Purpura Fulminans in a TwoYear-Old Child: A Case Report

@#Purpura fulminans (PF) is a severe clinical manifestation of Neisseria meningitides infection that is associated with high mortality rates in children. Survivors are frequently left with debilitating musculoskeletal sequelae. There is a paucity of reports on the musculoskeletal pathology of purpura fulminans. We report on a 2-year-old boy with purpura fulminans due to meningococcemia. The child developed distal gangrene in both the upper and lower limbs. Amputations were done for both lower limbs. Histological examination of the amputated specimens showed an inflammatory process and features of osteonecrosis. The latest follow-up at the age of 6 years showed a right knee valgus due to asymmetrical growth arrest of the proximal tibia. PF and its complications are challenging to treat and may require a multidisciplinary approach to improve patient’s functional ability.

Risk Perception and Emergency Preparedness Against Flood Affected Participants From the Primary Health Care Centre, Malaysia: A Comparison Between Genders

@#Introduction: Flooding has become a major natural disaster in Malaysia in recent decades. There may be a gender difference in many aspects related to flood response and practice. This study aimed to examine the gender gap in knowledge, attitudes, and practice of flood preparedness in Malaysia. Method: This cross-sectional study was conducted among patients attending the primary care clinic at Universiti Sains Malaysia health campus, Kelantan. A validated questionnaire was used for data collection. Results: 328 subjects were recruited, 56.1% of them were females. The female respondents were younger than the males (36 vs. 41 years old). However, females have better knowledge, and practice on flood preparedness compared to male respondents. Among those, women were more aware of the local emergency plan than males (p=0.01). More female respondents kept their vaccination and personal medical records in a waterproof container or sealed plastic bag during past and future flood preparations (3-5 day supply of non-perishable food) than male respondents (p<0.05). In addition, with the practice of keeping a one-week supply of medication, and having their medical records in a waterproof container along with a first-aid kit (p=0.001). For future flood preparation, more women would filter the cloudy water through clean clothes for boiling (p=0.035). The determinants of good preparedness for future floods for female were older-age (p=0.001), blue-collar (p=0.043); whereas male were lower household income (p=0.014), being blue collar (0.014) and white collar (0.039) compared with student/retiree based on multivariate logistic regression. Conclusion: Our study reported that the determinants of good preparedness for future floods were older-age, blue-collar and having a lower-household income.

Tissue Window versus Time Window? A Review of Patients Receiving Extended Hours Thrombolysis Guided By DWI-FLAIR Mismatch : Case Series

@#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.

Acute Mycoplasma Pneumoniae Encephalitis in an Adult

@#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.

Associations of eating behaviours, fast food purchasing and availability with BMI-for-age z-score among adolescents in Labuan, Malaysia

@#Introduction: A cross-sectional study was conducted to determine the associations of socio-demographic factors, eating behaviours, fast food purchasing by parents for family meals, and availability of neighbourhood fast-food outlets with BMI-for-age z-score (BAZ) among adolescents. Methods: Through multi-stage stratified cluster sampling method, a total of 420 adolescents from five selected public secondary schools participated in the current study. Data on socio-demographic factors, eating behaviours, and parent’s purchases of fast food were obtained through selfadministered questionnaires. The availability of fast-food outlets was assessed using Geographic Information System (GIS). Body weight and height of the adolescents were measured. Results: The prevalence of overweight, obesity, thinness and severe thinness among adolescents in the present study were 17.6%, 15.5%, 3.1% and 0.7%, respectively. The current findings showed that a higher monthly household income (rs =0.12, p=0.02) and less purchases of fast food by parents for family meals (rs =-0.11, p=0.03) were significantly associated with higher BAZ of the adolescents. However, there were no significant associations between eating outside of home, eating at fast-food restaurants, buying delivery fast food, and availability of neighbourhood fast-food outlets with BAZ. Multiple linear regression showed that less purchases of fast food by parents for family meals significantly contributed towards higher BAZ (β=−0.25, p=0.02). Conclusion: A higher household income and less fast food purchasing by parents were associated with higher BAZ. Fast food purchasing of adolescents were not associated with BAZ. Therefore, an appropriate obesity intervention programme should focus on adolescents and their parents from middle- and high-income households in Labuan.

A life-threatening condition—ruptured ectopic pregnancy with negative urine pregnancy test: A case report

@#Ectopic pregnancy is an extra-uterine pregnancy and is a potentially life-threatening condition that can lead to death from intra-peritoneal hemorrhage. This case reports a rare occurrence of ruptured tubal pregnancy in which the patient presented early with abdominal pain and a negative urine pregnancy test but subsequently presented again with evidence of intra-peritoneal hemorrhage. A negative urine pregnancy test is often used to rule out pregnancy, but it is not 100% sensitive. Complete assessment is critical in this important diagnosis in order to plan for the appropriate emergency management.

A Prevalence Study of Pharyngitis and Its Associated Factors Among Adults With a Sore Throat in Three Primary Clinics in Selangor, Malaysia

@#Introduction: Since pharyngitis in adults is one of the most common infectious diseases seen in general practitioner consultations in Malaysia, data on pharyngitis among adults concerning to its prevalence, socio-demographic, risk factors and clinical manifestations is very much lacking. This study aims to determine the prevalence of pharyngitis among adults in Sepang, Selangor, Malaysia from 2016 to 2017 and its associated demographic and risk factors. Methods: We conducted a cross-sectional study on 215 adult patients with a sore throat as the main symptom and who did not receive any antibiotic treatment within two weeks at three Malaysian primary care clinics. The researchers assessed the participants’ clinical manifestations and collected throat swabs for culture to determine the presence of group A streptococcus (GAS). Data on demographic characteristics, clinical manifestation and throat swab culture results were analyzed using chi-square test and multivariate logistic regression. Results: Pharyngitis was diagnosed in 130/215 (65%) adults with a sore throat. Only six isolates (2.8%) were identified as GAS. The overall mean age ± S.D was 36.43 ± 15.7. The majority of the participants were in the age group of 18-28 years. There were 42.3% males and 57.7% females; most participants were Malay 62.8%, followed by 30.2% Indian, 5.1% Chinese, and 1.9% other ethnicities. The most common symptom among the participants was cough 196 (91.2%), followed by rhinorrhea 161 (74.8%), tonsillar swelling or exudates 68 (31.6%), inflamed or reddish of pharynx 62 (28.8%), swollen anterior cervical lymph nodes 50 (23.3%), and fever ≥37.5°C 28 (13.0%). Conclusion: Besides, there was no significant association between pharyngitis and the demographic variables; the current findings emphasized that inflamed or reddish pharynx, tonsillar swelling or exudates were among the factors associated with pharyngitis.

Coronavirus Disease-2019: Knowledge and Practices Behaviour of Healthcare Workers at a University Teaching Hospital in Malaysia

@#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.

Efforts on Reducing Dietary Salt Intake and its Associated Factors Among Medical Students in Universiti Putra Malaysia

@#Introduction: Increased dietary salt intake can cause retention of fluid and subsequently an increase in blood pressure. Excessive salt consumption is one of the main causes of hypertension. This study aims to determine efforts done by medical students to reduce dietary salt intake and its associated factors in Universiti Putra Malaysia (UPM). Methods: This is a cross-sectional study. A self-administered questionnaire looking into efforts to reduce dietary salt intake adapted from the WHO STEPS questionnaire was used. There were six efforts altogether which were; limiting consumption of processed food; looking into sodium contents on food labels; purchasing low salt or sodium alternatives; avoid eating out; using spices when cooking; and doing things specifically to control salt consumption. Other factors in this questionnaire are on socio-demographic, practice of salt consumption, awareness, perception, attitude of dietary salt intake. Results: A total of 362 respondents participated. The majority had good awareness on salt intake (98.1%). A larger proportion of females significantly made the effort to buy low salt alternatives (p=0.003) and avoided eating out (p=0.048). On salt consumption practice, there were a bigger proportion of those that rarely ate processed food, that avoided eating out (p=0.08), bought low salt/sodium alternatives (p<0.001), looked at the sodium contents on labels (p=0.027) and limited the consumption of processed food (p<0.001). Conclusion: There are significant associations between the female gender and practice of eating processed food with efforts to decrease salt intake. More studies are recommended to look into assisting efforts to reduce salt consumption.

Angular Deformities of the Knee in Children Treated with Guided Growth

@#Introduction: The guided growth technique is an alternative to corrective osteotomy for treating angular deformities of the extremities. It has the advantage of being minimally invasive and is effective in a growing child. This study reports on the outcome of guided growth technique using a plate in correcting knee angular deformities. Materials and methods: We conducted a retrospective study of children with angular deformity of the knee treated by the guided growth technique from January 2010 to December 2015 in a tertiary centre. The guided growth technique was done using either the flexible titanium plate (8-plate) or the 2- hole reconstruction plate. Correction of deformity was assessed on radiographs by evaluating the mechanical axis deviation and tibiofemoral angle. The implants were removed once deformity correction was achieved. Results: A total of 17 patients (27 knees) were evaluated. Twenty-two knees (81.5%) achieved complete correction of the deformity. The median age was 4.0 (interquartile range 3.0-6.0) years and the median Body Mass Index (BMI) was 26.0 (25.0-28.0). There were 7 unilateral and 10 bilateral deformities with different pathologies (14 tibia vara, 3 genu valgus). The median rate of correction was 0.71° per month. One patient (1 knee) had screw pull-out and two patients (4 knees) had broken screws in the proximal tibia. Three patients (5 knees) failed to achieve complete correction and were subsequently treated with corrective osteotomies. Out of five patients (8 knees) who were followed-up for at least 12 months after removal of hardware, two had rebound deformities. No permanent growth retardation occurred in our patients. Conclusion: Our outcome for guided growth to correct knee angular deformity was similar to other studies. Guided growth is safe to perform in children below 12 years old and has good outcome in idiopathic genu valgus and Langeskiold II for tibia vara. Patients should be observed for recurrence until skeletal maturity following implant removal.

The role of social media in primary care

@#Online activities have become the norm. From searching for new information to conducting business meetings, social media’s role in daily life continues to grow in prominence. It is estimated that the majority of the population uses social media, and users include doctors and other healthcare professionals. It is critical for primary care doctors to note how social media can substantially influence one’s healthcare behaviour and decision making. Because primary care doctors are usually the first line of contact for patients, they are the most easily accessible and most instrumental in using social media to steer the public toward proper information on healthcare.

Anxiety Reaction in Children During Cast Removal using Oscillating Saw versus Cast Shear - A Randomised, Prospective Trial

@#Introduction: To compare the anxiety levels demonstrated by children during cast removal procedure between oscillating saw vs cast shear methods. Material and methods: A randomised prospective study of 102 children (mean age 8.3 ± 3.5 years) with fractures involving upper or lower limbs. Children undergoing removal of cast were divided into 2 groups; either by an oscillating saw or a cast cutting shear. The level of anxiety was assessed by recording the heart rate with a portable fingertip pulse oximeter before, during and after removal of the cast. Objective assessment was performed by documenting the fear level on Children’s Fear Scale (CFS). Results: There was a significant increase in the heart rate of children during cast removal while using the oscillating saw compared to cast shear (p<0.05). The noise level produced by the saw exceeded 80 dB (mean 103.3 dB). The fear level was significantly lower in the cast shear group (p<0.05). Conclusion: The noise produced by the oscillating saw was associated with an increased anxiety level in children undergoing cast removal. Cast shear is a simple and inexpensive instrument that can be used for cast removal in overly anxious children.

Appraisal of wellness-lifestyle status among Malaysian undergraduate students: A cross-sectional and gender-based wellness survey

Wellness is a continuous and intentional attempt to remain healthy and attain a maximum potential for well-being.A high level of wellness is vital to produce a well-balanced and competent graduate. This study aims at evaluatingthe wellness status of Malaysian undergraduate students. A total of 250 undergraduate students drawn from variousfaculties in one of the public universities in Malaysia participated in this study from 2019 to 2020. The wellnesslifestyle inventory that evaluates an initial rating of a person’s present attempt to remain healthy was used as a tool forassessing the wellness status of the students. Analysis for the rating scores in their awareness revealed that the studentshave an excellent to moderate awareness on key wellness elements consisting of avoiding chemical dependency,personal safety, emotional well-being, environmental health and protection, stress management, personal hygiene,and disease prevention, while poor scores were recorded in nutrition and health-related fitness. With reference togender, it was observed that female students were significantly more informed in the four major areas of wellnesselements, specifically health-related fitness, personal hygiene and health, disease prevention, and environmental healthprotection, while male students were better at avoiding chemical dependency (p < 0.05). The findings of this studyprovide significant information on the wellness-lifestyle status of the students and its practices that could assist thestakeholders to be informed about the students’ overall wellness, in order to be able to design appropriate activitiesand programs to cater to their needs.

Boarding School: A Simple Approach To Reduce Soil Transmitted Helminth Infections In Orang Asli Children Of Sungai Siput, Perak, 2017

@#Soil transmitted helminth (STH) infection is a major public health concern among the indigenous children of Malaysia. Precarious living conditions at home including unavailability of water, drinking of contaminated water, poor sanitation and livestock presence, are known risk factors for the infection. In order to provide better living conditions, these children are enrolled in boarding schools. This study was conducted to determine whether boarding schools is a solution in reducing soil transmitted helminth infection among Orang Asli children in Sg Siput, Perak, Malaysia. An analytical cross-sectional study was conducted among 204 schoolchildren aged 7-17 years from three boarding schools in Sungai Siput, Perak from January to March 2017. Stool samples were collected and examined using direct smear and Kato-Katz technique. Information on sociodemographic and environmental conditions were collected using a modified Demographic Health Survey (DHS) questionnaire. Data analysis was done using IBM SPSS Statistics Processor 20.0.Out of a total of 204 children, only 48% (n= 97) were infected with at least one type of STH species which showed a reduced prevalence as compared to previous studies conducted among home dwelling schoolchildren with overall prevalence of 78-97%. Majority of the children had monoparasitism (31%; n=63) with moderate intensity by T trichuira (n=51, 25%). Univariate analysis shows that unavailability of water at home has a statistically significant association with STH infection among boarding school children (OR=0.73; 95% CI= 0.56-0.95 p=0.021). Multivariate analysis proves children who had unavailability of water at home has 2.1 times more likelihood of getting an STH infection (OR= 2.08; 95%CI= 1.07-4.07; p= 0.032).This study demonstrates a reduced STH prevalence among Orang Asli boarding school children as better living condition there limits the spread of STH infection among them.

A Reliability Study of the Malay Version of the Malaysian Ministry of Health’s Adolescent Client Satisfaction Questionnaire among Adolescents Attending Health Clinics in Northeastern Malaysia / 가정의학회지

Background@#The need for client feedback in assessing healthcare services is widely recognized. However, little is known about the satisfaction of adolescent clients utilizing healthcare services in Malaysia. To the best of our knowledge, there is no validated instrument to measure the satisfaction of adolescent clients attending health clinics in Malaysia. This cross-sectional study aimed to determine the reliability of the Malay version of the Malaysian Ministry of Health’s Adolescent Client Satisfaction Questionnaire among adolescents attending health clinics in northeastern Malaysia. @*Methods@#A cross-sectional study was conducted in January 2019 among adolescents aged 10–19 years attending four designated health clinics in the northeastern state of Peninsular Malaysia. The test for Cronbach’s α was performed to determine the internal consistency reliability. @*Results@#There were a total of 85 adolescent clients involved in this study. The mean age of respondents was 15.6 years. The majority of respondents were female, Malay, students, and had attained a secondary level of education. The mean total satisfaction score was 78.35. The internal consistency reliability according to the Cronbach’s α of the domain was 0.854, which is considered highly reliable. The corrected item-total correlation for the domain was acceptable as it was ≥0.4. @*Conclusion@#The Malay version of the Malaysian Ministry of Health’s Adolescent Client Satisfaction Questionnaire has excellent internal consistency reliability. Therefore, it may be recommended as a tool to measure the satisfaction level among adolescents attending health clinics in Malaysia.

Decoding death by unknown causes using postmortem image-guided virtopsy: A review of recent literature and the Malaysian experience

@#Introduction: Autopsy is one of the most important approaches to identify clearly the exact cause of death, whether it was due to natural causes, sudden death, or traumatic. Various studies have been done in different countries regarding ways to improve the diagnosis during autopsy. The imaging approach is one of the methods that has been used to complement autopsy findings and to enhance the diagnosis for achieving the most accurate post-mortem diagnosis. The aim of this study is to identify the role of imaging modalities that complement routine autopsy and correlate the findings of diagnostic imaging that can help improve the accuracy of diagnosing the cause of death. Methods: We sourced articles from Scopus, Ovid and PubMed databases for journal publications related to post-mortem diagnostic imaging. We highlight the most relevant full articles in English that explain the type of modality that was utilised and the added value it provided for diagnosing the cause of death. Results: Minimally invasive autopsies assisted by imaging modalities added a great benefit to forensic medicine, and supported conventional autopsy. In particular the role of post mortem computed tomography (PMCT), post mortem computed tomography angiography (PMMR) and positron emission tomography computed tomography (PMCTA) that have incremental benefits in diagnosing traumatic death, fractures, tissue injuries, as well as the assessment of body height or weight for corpse identification. Conclusion: PMCT and PMMR, with particular emphasis on PMCTA, can provide higher accuracy than the other modalities. They can be regarded as indispensable methods that should be applied to the routine autopsy protocol, thus improving the findings and accuracy of diagnosing the cause of death.

A survey on smartphone dependence and psychological effects among undergraduate students in a Malaysian University

@#Objective: Problematic smartphone use (PSU) is the development of pathological dependence at the expense of performing activities of daily living, thus having negative health and psychological impact on the users. Previous PSU studies focused on medical students and little is known regarding its effect on students undergoing other courses. The objective of this study is to identify the pattern of smartphone usage and determine the psychological factors affecting PSU among undergraduate students in Malaysia and compare the pattern among students from different fields of study. Method: A prospective cross-sectional study was conducted using the validated Smartphone Addiction Scale–Malay version (SAS-M) questionnaire. One-way ANOVA was used to determine the correlation between the PSU among the students categorised by their ethnicity, hand dominance and by their field of study. MLR analysis was applied to predict PSU based on socio-demographic data, usage patterns, psychological factors and fields of study. Results: A total of 1060 students completed the questionnaire. Most students had some degree of problematic usage of the smartphone. Students used smartphones predominantly to access SNAs, namely Instagram. Longer duration on the smartphone per day, younger age at first using a smartphone and underlying depression carried higher risk of developing PSU, whereas the field of study (science vs. humanities based) did not contribute to an increased risk of developing PSU. Conclusion: Findings from this study can help better inform university administrators about at- risk groups of undergraduate students who may benefit from targeted intervention designed to reduce their addictive behaviour patterns

Effects of Social support and Self-efficacy of Glucose Control Among Malaysian Type 2 Diabetes Mellitus Patients in Primary Care

@#Diabetic control depends partially on self-management. Diabetes self-care is reported to be a strong predictor of glycemic control in Type 2 Diabetes Mellitus (T2DM) patients. Factors contributing to better self-care include self-efficacy and social support. We aim to determine effects of these factors on glucose control in T2DM patients in a primary care clinic. Methods: This study utilised data from a bigger study looking into factors affecting social support and self-efficacy and their correlation in T2DM patients. This study was done among 329 T2DM patients attending a primary care clinic in Selangor, Malaysia between November 2013- January 2014. Systematic random sampling was used. Instruments used were the MOS Social Support Survey and the Diabetic Management Self Efficacy Scale (DMSES). Patients’ socio-demographic data and glucose monitoring records were obtained. The association between social support and self-efficacy with blood glucose control was determined using logistic regression. Results: The mean age of the respondents is 54.6 (+11.2), mostly female (55.3%) and Malay ethnicity (63.5%). Being older and retired were predictors for good glucose control (OR=1.05,p=0.01 and OR=2.2,p=0.023) respectively. There is also significant correlations between number of close friends/relatives with social support and self-efficacy (r=0.162,p=0.030 and r=0.190,p=0.01) respectively. The correlation of social support and self-efficacy with HbA1c levels are r= -0.044(p=0.426) and r= -0.08(p= 0.744) respectively. Conclusion: There were no correlations between social support and self-efficacy with the level of HbA1c among patients with T2DM in this study. We found older aged and retired patients to have better HbA1c levels.

The objective assessment of the effects on cognition functioning among military personnel exposed to hypobaric-hypoxia: A pilot fMRI study

@#Objective: To identify regions of the brain affected during cognitive working memory during tasks to assess attention, planning and decision making among military aviation personnel who have chronic intermittent exposure to high altitude environment. Method: A case-control study was conducted in the Universiti Putra Malaysia among eight military personnel, four of whom had chronic intermittent exposure to high altitude training. They were divided into two groups, chronic intermittent exposure group (CE) (n=4) and a control group (n=4). They underwent a task-based functional magnetic resonance imaging (fMRI) that utilised spatial working memory task to objectively evaluate the neural activation in response to the Tower of London paradigm. Each correct answer was given a score of one and the maximum achievable score was 100%. Results: A consecutive dichotomised group of CE (4/8) and control (4/8) of age-matched military aviation personnel with a mean age of 37.23±5.52 years; showed significant activation in the right middle frontal gyrus (MFG). This in turn was positively correlated with response accuracy. A significant difference in the response accuracy was noted among both the groups at p<0.05. Conclusion: At the minimum results of power analysis of this preliminary fMRI study, our group of aviation personnel who had chronic intermittent exposure to hypobaric hypoxic environment, did not have any significant decrease in cognitive function namely attention, decision-making and problem solving compared to controls during a working memory task