Misdiagnosis of community-acquired pneumonia in patients admitted to respiratory wards, Penang General Hospital.

INTRODUCTION: Pneumonia continues to be as one of the top causes of hospitalisations and deaths in Malaysia despite the advancement in prevention and treatment of pneumonia. One of the possible explanations is the frequent misdiagnosis of pneumonia which had been reported elsewhere but such data is not available locally. OBJECTIVES: This is an audit project aiming to evaluate the proportion of misdiagnosis among hospitalised communityacquired pneumonia (CAP) patients in the Respiratory wards of Penang General Hospital based on their initial presentation data, and their associated outcomes. METHODS: We reviewed the medical notes and initial chest radiographs of 188 CAP patients who were admitted to respiratory wards. Misdiagnosis was defined as cases which lack suggestive clinical features and/or chest radiograph changes. In-hospital mortality and length of stay (LOS) were the outcomes of interest. RESULTS: The study found that 38.8% (n=73) of the hospitalised CAP patients were misdiagnosed. The most common alternative diagnosis was upper respiratory tract infection (32.8%, n=24). There was no statistical difference between misdiagnosis and CAP patients in the demographic and clinical variables collected. In terms of outcomes, misdiagnosed patients were discharged earlier (mean LOS= 3.5±3.28 days vs. 7.7±15.29 days, p=0.03) but the in-hospital mortality difference was not statistically significant (p=0.07). CONCLUSIONS: One third of our CAP admissions were misdiagnosed. Although initial misdiagnosis of CAP in our study did not show any increase in mortality or morbidity, a proper diagnosis of CAP will be helpful in preventing inappropriate prescription of antibiotics and unnecessary admission.

Mass Spectrometry-Based Analysis for the Discovery and Validation of Potential Colorectal Cancer Stool Biomarkers.

Colorectal cancer (CRC) is the third leading cause of cancer mortality for both men and women, and the second leading cause of cancer death for men and women combined. If detected early, before metastasis has occurred, survival following surgical resection of the tumor is >90%. Early detection is therefore critical for effective disease surveillance. Unfortunately, current biomarker assays lack the necessary sensitivity and specificity for reliable early disease detection. Development of new robust, non- or minimally invasive specific and sensitive biomarkers or panels with improved compliance and performance is therefore urgently required. The use of fecal samples offers several advantages over other clinical biospecimens (e.g., plasma or serum) as a source of CRC biomarkers, including: collection is noninvasive, the test can be performed at home, one is not sample limited, and the stool effectively samples the entire length of the inner bowel wall contents (including tumor) as it passes down the gastrointestinal tract. Recent advances in mass spectrometry now facilitate both the targeted discovery and validation of potential CRC biomarkers. We describe, herein, detailed protocols that can be used to mine deeply into the fecal proteome to reveal candidate proteins, identify proteotypic/unitypic peptides (i.e., peptides found in only a single known human protein that serve to identify that protein) suitable for sensitive and specific quantitative multiplexed analysis, and undertake high-throughput analysis of clinical samples. Finally, we discuss future directions that may further position this technology to support the current switch in translation research toward personalized medicine.

A Review of Coronary Artery Disease Research in Malaysia.

Coronary artery disease is the major cause of mortality and morbidity in Malaysia and worldwide. This paper reviews all research and publications on coronary artery disease in Malaysia published between 2000-2015. 508 papers were identified of which 146 papers were selected and reviewed on the basis of their relevance. The epidemiology, etiology, risk factors, prevention, assessment, treatment, and outcomes of coronary artery disease in the country are reviewed and summarized. The clinical relevance of the studies done in the country are discussed along with recommendations for future research.

CT and MRI of primary and metastatic fibrolamellar carcinoma: a case series of 37 patients.

OBJECTIVE: Fibrolamellar carcinoma (FLC) is a rare disease, with limited radiographic reported information. We assessed the imaging patterns of primary and metastatic FLC. METHODS: CT and MR examinations of patients with FLC were retrospectively reviewed. Imaging features were assessed for primary and recurrent liver tumours, including dimension, enhancement characteristics, and presence or absence of central scars. Locations of nodal and extranodal metastases were also recorded. RESULTS: Of 37 patients (18 males and 19 females; average age, 23.5 years) with FLC, 24 had imaging of their primary tumour; 13 had metastases at presentation and 7 developed metastases on follow-up. The remaining 13 patients had follow-up imaging of metastatic disease. Primary FLC had a mean diameter >11 cm, with central scars in ten (46%) patients. Most tumours enhanced heterogeneously (96%) and showed arterial enhancement (81%). On MRI, 62% of FLCs were hypointense on T1 weighted imaging and 54% were hyperintense on T2 weighted imaging. 13 patients (54%) had nodal metastases at presentation, mostly in the upper abdomen (92%) and commonly in the chest (38%). Extrahepatic metastases were most frequently pulmonary or peritoneal. Predominantly small and homogeneous intrahepatic recurrences were detected on follow-up in 15 patients. CONCLUSION: FLC often presents as a large hepatic tumour with nodal and distant metastases. Thoracic adenopathy and lung metastases were frequently found in our series, suggesting the need for pre-operative and follow-up chest imaging. ADVANCES IN KNOWLEDGE: Thoracic nodal and lung metastases are common in FLC; therefore, dedicated chest imaging should be part of the evaluation of a patient with FLC.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper.

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

The role of social media for patients and consumer health. Contribution of the IMIA Consumer Health Informatics Working Group.

OBJECTIVES: : To provide an overview on social media for consumers and patients in areas of health behaviours and outcomes. METHODS: A directed review of recent literature. RESULTS: : We discuss the limitations and challenges of social media, ranging from social network sites (SNSs), computer games, mobile applications, to online videos. An overview of current users of social media (Generation Y), and potential users (such as low socioeconomic status and the chronically ill populations) is also presented. Future directions in social media research are also discussed. CONCLUSIONS: : We encourage the health informatics community to consider the socioeconomic class, age, culture, and literacy level of their populations, and select an appropriate medium and platform when designing social networked interventions for health. Little is known about the impact of second-hand experiences faciliated by social media, nor the quality and safety of social networks on health. Methodologies and theories from human computer interaction, human factors engineering and psychology may help guide the challenges in designing and evaluating social networked interventions for health. Further, by analysing how people search and navigate social media for health purposes, infodemiology and infoveillance are promising areas of research that should provide valuable insights on present and emergening health behaviours on a population scale.

Septooptic dysplasia.

The term septooptic dysplasia was coined in 1956 by de Morsier, who pointed out the association of optic nerve hypoplasia and absence of the septum pellucidum. Patients with this condition may present with clinical features of hypopituitarism, decreased visual acuity and neurodevelopmental disabilities that lead to this diagnosis. The case that is presented here is unusual in that this patient was initially diagnosed as having low tension glaucoma during a routine screening examination and was treated for glaucoma for over a year before he was discovered to have septooptic dysplasia, also known as de Morsier's syndrome.

Visual disturbances with clomiphene.

Clomiphene is a widely prescribed drug for the treatment of infertility. Visual symptoms that occur as a side effect of this drug are uncommon. Some doctors may neglect to mention this side effect when prescribing clomiphene. Thus these visual disturbances can be very alarming to the patient and may also pose a hazard if the patient is doing activities such as driving or operating machinery. The patient should be told to stop taking clomiphene and ophthalmologic evaluation should be performed. Although visual disturbances generally cease on stopping clomiphene, some women may experience persistent visual disturbances.

Ocular fishhook injuries.

Ocular fishhook injuries are rare, yet potentially vision threatening as complications such as corneal scarring, retinal detachment and endophthalmitis may result. The surgical management of these cases is challenging due to the construction of barbed fishhooks.

The visible embryo project: embedded program objects for knowledge access, creation and management through the World Wide Web.

We have designed a prototype knowledge management online environment for the biomedical sciences which integrates access to online representations of the scientific literature, bibliographic databases, high-performance visualization technologies, large-scale scientific databases, and tools for authoring new-generation scientific publications. This system will provide widespread access to its resources by using the World Wide Web for its underlying architecture. This system expands upon our Weblet Interactive Remote Visualization (IRV) server technology to produce a set of dedicated Internet "visualization servers" which provide interactive control of real-time visualizations from the Visible Embryo Project database from within Web pages viewed with our WebRouser software package. This system will be used to develop a set of prototype applications for both online education of medical students in developmental anatomy and for an interactive patient education system for expectant parents. We recognize that knowledge represented by these national resource databases is not static, therefore it is essential to include tools for both the creation of new "compound documents" which incorporate embedded objects, as well as for managing the peer-review of scholarly publications, in order to ensure the integrity of new knowledge as it is added to these databases in the future. We have therefore begun to design integrated tools for our system which facilitate both the creation of and the validation of new generations of scientific knowledge.