The Brain-Gut Clinic in Hospital Universiti Sains Malaysia: Pioneering New Service to Advance Neuro-Gastroenterology and Motility in Malaysia

Neurogastroenterology and motility is a new but advanced subspecialty within gasteroenterology that cater to difficult, persistent and refractory gut-brain symptoms. Hospital USM has the country's first and new state-of-the art motility lab that was recently launched on the 25 May 2023, and is covered in nationwide media. Another first is the Brain-Gut Clinic, established on the 16 November 2022. The clinic is a new concept that builds on unique multiple disciplines in relation to the gut-brain axis. It is hoped that there will be more awareness on the existence of neurogastroenterology and motility among doctors and community, and that more research can be forthcoming to reduce the disease burden.

Bite envenomation by Latrodectus geometricus (Araneae: Theridiidae) spiders in Malaysia

We report two confirmed human bite cases by Lactrodectus geometricus , also known as the brown widow spider. These are the first reported bite envenomation incidents by L. geometricus in Malaysia. The incidents occurred in Tawau, Sabah and Paka, Terengganu. Both men were bitten on their ear while putting on motorcycle helmets. The spiders appeared to have nested in the helmets. The dead specimens were collected and sent to the Invertebrate and Vertebrate Neurobiology Laboratory, Department of Parasitology, Universiti Malaya for identification. The species identity was confirmed by DNA barcoding.

A case of cough induced rib fracture with subcutaneous emphysema and pneumothorax

Coughing is an important reflex mechanism which enhances the clearance of secretions and particulates from the airways, however repetitive muscle strain due to prolonged coughing may cause the uncommon complication of stress fracture of the ribs. The following is an unusual case of cough induced multiple rib fractures associated with subcutaneous emphysema and pneumothorax which was missed in the emergency setting. Delayed diagnosis and treatment would have been avoided if this uncommon condition was considered as a possibility.

Innovative findings about ferrous oxalate dihydrate crystallization in simulated dihydrate phosphoric acid product

The basic fundamentals of ferrous oxalate dihydrate (FeC₂O₄.2H₂O) crystallization including supersaturation, nucleation and crystal growth in simulated dihydrate phosphoric acid product with and without cetyl pyridinium chloride (CPC) additive were studied. Oxalic acid and ferrous sulfate heptahydrate crystals were mixed with dilute phosphoric acid (28% P₂O₅) at 60 °C and the turbidity of the reaction mixture was measured at different time intervals. Induction time of ferrous oxalate dihydrate crystals was calculated at different supersaturation ratios ranging from 2.5 to 6.7. With increasing the supersaturation ratio, the induction time decreased. The nucleation rates are 46.4 × 10²⁸ nuclei cm^-3 s^-1 and 50.2 × 10²⁸ nuclei cm^-3 s^-1 at supersaturation ratio 6.7 with and without CPC addition, respectively. The surface energy increases with CPC addition compared to the baseline. In addition, the formed crystals are modified from cubic shape to rod-like shape with increasing CPC dose.

Non-front-fanged colubroid ("colubrid") snakebites: three cases of local envenoming by the mangrove or ringed cat-eyed snake (Boiga dendrophila; Colubridae, Colubrinae), the Western beaked snake (Rhamphiophis oxyrhynchus; Lamprophiidae, Psammophinae) and the rain forest cat-eyed snake (Leptodeira frenata; Dipsadidae)

CONTEXT

Non-front-fanged colubroid snakes (NFFC; formerly and artificially taxonomically assembled as "colubrids") comprise the majority of extant ophidian species. Although the medical risks of bites by a handful of species have been documented, the majority of these snakes have oral products (Duvernoy's secretions, or venoms) with unknown biomedical properties/unverified functions and their potential for causing harm in humans is unknown.

CASE DETAILS

Described are three cases of local envenoming from NFFC bites inflicted respectively by the mangrove or ringed cat-eyed snake (Boiga dendrophila, Colubridae), the Western beaked snake (Rhamphiophis oxyrhynchus, Lamprophiidae) and the rain forest cat-eyed snake (Leptodeira frenata, Dipsadidae). The effects ranged from mild pain, edema and erythema to severe pain, progressive edema, and blistering with slowly resolving arthralgia; there were no systemic effects.

DISCUSSION

Although these three taxa occasionally inflict bites with mild to moderate local effects, there is no current evidence of systemic involvement. Two of these cases were reported to one of the authors for medical evaluation, and although verified, thus constitute reliably reported cases, but low-quality evidence. Type-1 local hypersensitivity may contribute to some cases, but most local effects observed or reported in these three cases were consistent with the effects of venom/oral product components.

Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation and analgesia in the emergency department

The study compared the effectiveness of ketamine and midazolam/fentanyl as procedural sedation and analgesia agents for reduction of fractures and dislocated joints. Forty-one adult patients were enrolled by convenience sampling. They were randomized to receive ketamine or midazolam/fentanyl. Depth of sedation, pain score, procedural outcome and memory of the procedure were documented. The ketamine group had deeper sedation, but there was no statistical difference in other variables between the two groups. Three patients in the midazolam/fentanyl group had oxygen desaturation. More adverse effects were associated with ketamine. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation.

Audit of pain management in the emergency department

Pain management in Malaysian Emergency Departments has not been studied well. Convenience sampling was used to recruit 402 patients who presented with acute pain over a 2-week period. The 11-point Numerical Rating Scale was used to quantify pain. Pain relieving medications were prescribed to 178 patients (44.3%) in the Emergency Department. These patients had a median pain score of 7 on arrival. Nonsteroidal anti inflammatory drugs were the most commonly prescribed class of analgesic. Pain was found to be inadequately treated.

Effect of immunosuppression of the virulence of Giardia lamblia cysts

This study was done to evaluate the pathological effects of Giardia lamblia cysts obtained from immunosuppressed host on the small intestine and liver of immunocompetent hosts. Thirty mice, subdivided into two groups, were infected with G. lamblia cysts in a dose of 5000 cysts/mouse. The first group (10 mice) was inoculated with Giardia cysts obtained from immunocompetent patients and the second group (20 mice) was inoculated with Giardia cysts obtained from already immunosuppressed mice (injected with cyclophosphamide). Stool examination revealed that mice in both groups passed cysts on day 6 +/- 1 after infection. The pathological changes of small intestine in both groups were more or less similar. The changes were in the form of shortening and widening of the villi with cellular inflammatory infiltrate in the lamina propria. The liver of both groups showed no pathological changes. It can be concluded that, although immunosuppression affects the immune system and the defensive mechanism of the host, yet it has no effects on the virulence of the excreted Giardia lamblia cysts.

Isolation and Characterization of a Mo 6+ -Reducing Bacterium

A Mo 6+ -reducing bacterium (strain 48), which grew on medium supplemented with 200 mM Mo 6+ , was isolated from stream water obtained from Chengkau, Malaysia. The chemical properties of strain 48 conform to the characteristics of Enterobacter cloacae . Under anaerobic conditions in the glucose-yeast extract medium containing phosphate ion (2.9 mM) and Mo 6+ (10 mM), the bacterium reduced Mo 6+ to form molybdenum blue. Approximately 27% of Mo 6+ added to the medium was reduced after 28 h of cultivation. The reduction of Mo 6+ with glucose as an electron donor was strongly inhibited by iodoacetic acid, sodium fluoride, and sodium cyanide, suggesting an involvement of the glycolytic pathway and electron transport in Mo 6+ reduction. NADH and N,N,N′,N′ -tetramethyl- p -phenylenediamine served as electron donors for Mo 6+ reduction. When NADH was used as an electron donor, at first cytochrome b in the cell extract was reduced, and then molybdenum blue was formed. Sodium cyanide strongly inhibited Mo 6+ reduction by NADH (5 mM) but not the reduction of cytochrome b in the cell extract, suggesting that the reduced component of the electron transport system after cytochrome b serves as an electron donor for Mo 6+ reduction. Both ferric and stannous ions strongly enhanced the activity of Mo 6+ reduction by NADH.