ISSN 1560 5876 Print

ISSN 2079 3146 Online

Online version of the journal is available at www.bimjonline.com

Volume 7, Supplement 2, 20 November 2011 (23 Zulhijjah 1432H)

Brunei International

Medical Journal Official Publication of

the Ministry of Health,

Brunei Darussalam

MEDICAL SYMPOSIUM

‘Advancement in Medicine: Past, Present

and Future’

20th November 2011

CT showing signet ring

cell lymphoma of the ileum

Endoscopic image of

oesophageal lipoma Brown tumour of the

bone

Brunei international Medical Journal (BIMJ) is now indexed with Google Scholar, Western Pacific

Region Index Medicus (WPRIM), Directory of Open Access Journal (DOAJ), Index Copernicus, Open-J-Gate and SCOPUS.

King of fruits, Durian

Brunei International Medical Journal (BIMJ)

Official Publication of the Ministry of Health, Brunei Darussalam

EDITORIAL BOARD

Editor-in-Chief Vui Heng CHONG

Sub-Editors William Chee Fui CHONG

Ketan PANDE

Editorial Board Members Nazar LUQMAN

Muhd Syafiq ABDULLAH

Alice Moi Ling YONG

Ahmad Yazid ABDUL WAHAB

Pandare SUGATHAN

Jackson Chee Seng TAN

Dipo OLABUMUYI

Pemasiri Upali TELISINGHE

Roselina YAAKUB

Pengiran Khairol Asmee PENGIRAN SABTU

Ranjan RAMASAMY

Dayangku Siti Nur Ashikin PENGIRAN TENGAH

INTERNATIONAL EDITORIAL BOARD MEMBERS

Lawrence HO Khek Yu (Singapore) Surinderpal S BIRRING (United Kingdom)

Emily Felicia Jan Ee SHEN (Singapore) Leslie GOH (United Kingdom)

John YAP (United Kingdom) Chuen Neng LEE (Singapore)

Christopher HAYWARD (Australia) Jimmy SO (Singapore)

Jose F LAPENA (Philippines) Simon Peter FROSTICK (United Kingdom)

Advisor

Wilfred PEH (Singapore)

Past Editors

Nagamuttu RAVINDRANATHAN

Kenneth Yuh Yen KOK

Proof reader

John WOLSTENHOLME (CfBT Brunei Darussalam)

ISSN 1560-5876 Print

ISSN 2079-3146 Online

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Table of Contents

Free papers

Demographics and clinical characteristics of patients attending tertiary

care Diabetes Centre in Brunei Darussalam

Guan Choon CHAN, Caroline TAN, Haslinda HASSAN, Alice Moi Ling YONG

Endocrine Unit, Department of Medicine, RIPAS Hospital

A study of pulmonary involvement based on radiological findings

amongst culture proven cases of melioidosis

Luke MATHEW, Manoj PETHE, Panduru KISHORE, Sara SILIANG

Division of Respiratory Medicine, Department of Medicine, RIPAS Hospital

Helicobacter pylori testing using Pronto-dry and histology and impact of

acid suppression therapy

Saima Javed PARACHA, Vui Heng CHONG, Anand JALIHAL

Division of Gastroenterology and Hepatology, Department of Medicine,

RIPAS Hospital

Clinical study of patients with Brugada Electrocardiograms and Brugada syn-

drome in Brunei Darussalam

Bee Ngo LAU, Nazzar LUQMAN,

Division of Cardiology, Department of Medicine, RIPAS Hospital

A study of the observation ward in the Accident and Emergency

department of RIPAS Hospital, Brunei Darussalam

Sunil Kumar SHETTY,

Department of Accident and Emergency, RIPAS Hospital

The role of statin in blood pressure control in hypertensive and resistant

hypertensive patients

Siew Chee WONG, Mas Rina Wati BADUL HAMID, Chee Fui CHONG

Pengiran Anak Puteri Rasidah Sa’adatul Bolikah Institute of Health Science, Universiti

Brunei Darussalam

v

v

v-vi

vi

vi-vii

vii

Brunei Int Med J. 2011; 7 (Supp 2): iii

Table of Contents

Posters

Clinical characteristics and outcomes of obesity management in patients

attending Obesity clinic

Guan Choon CHAN, Caroline TAN, Haslinda HASSAN, Alice Moi Ling YONG

Endocrine Unit, Department of Medicine, RIPAS Hospital

Retrospective analysis of yield of diagnostic bronchoscopy for a period of one

year in the Division of Respiratory Medicine of RIPAS Hospital

Panduru V KISHORE, Osama ABOUZEID, Manoj PETHE, Yahya HASAN,

Khalizah JAMIL, Luke MATHEW,

Division of Respiratory Medicine, Department of Medicine, RIPAS Hospital

Audit of anti-epileptic medication usage in women of child bearing age

Rosimah SIDEK, Siti Nur’Ashikin PENGIRAN TENGAH

Rehabilitation Unit, Department of Medicine, RIPAS Hospital

Case series of Motor Neurone Disease patients at RIPAS hospital: to

investigate nursing role

Mariani MUSTAPA, Siti Nur’Ashikin PENGIRAN TENGAH

Rehabilitation Unit, Department of Medicine, RIPAS Hospital

Signet ring cell lymphoma of the small bowel

Norwani BASIR, Ian C BICKLE, Pemasari Upali TELISINGHE, Vui Heng CHONG, Department of Medicine, RIPAS Hospital

Oesophageal tuberculosis: rare but not to be forgotten

Natalie MOMIN, Vui Heng CHONG,

Department of Medicine, RIPAS Hospital

Durian allergy: an unfortunate encounter

Natalia MOMIN, Alice Moi Ling YONG,

Endocrinology Unit, Department of Medicine, RIPAS Hospital

A rare case of dysphagia secondary to a large oesophageal lipoma

Kai Shing KOH, Vui Heng CHONG, Samuel Kai San YAPP, Chee Fui CHONG

Department of Medicine, RIPAS Hospital

Parathyroid cancer presenting with Brown tumours mimicking bone

metastases

Mercy GEORGE, Alice Moi Ling YONG,

Endocrinology Unit, Department of Medicine, RIPAS Hospital

viii

viii

viii-ix

xi

xi

ix-x

x

x

x

Brunei Int Med J. 2011; 7 (Supp 2): iv

Free Papers Brunei Int Med J. 2011; 7 (Supp 2): v

F1: Demographics and clinical character-

istics of patients attending tertiary care

Diabetes Centre in Brunei Darussalam

Guan Choon CHAN, Caroline TAN, Haslinda HAS-

SAN, Alice Moi Ling YONG, Endocrine Unit, Depart-

ment of Internal Medicine, RIPAS Hospital, Bandar

Seri Begawan, Brunei Darussalam

Introduction: Patients who attended tertiary re-

ferral centre are usually those with Type 1 diabetes

mellitus (T1DM) or complicated Type 2 diabetes

mellitus (T2DM). The aim of this study is to de-

scribe the demographics and clinical characteristics

of patients attending tertiary care diabetes centre

in Brunei Darussalam.

Materials and Methods: Medical case-notes of all

patients who attended the Diabetes Centre, RIPAS

Hospital in the month of August 2009 were re-

viewed. Data collected included age, sex, ethnicity,

type of diabetes, diabetes duration, types of ther-

apy, co-morbidities and complications.

Results: 286 patients were studied; 156 (55%)

female and 130 (45%) male with mean age 51.9 ±

12.9 years (range 18-89). Patients were 89% Ma-

lay, 8% Chinese, 1% Indian and 2% of other eth-

nicity. 279 (97.5%) has T2DM, 6 (2.1%) with T1DM

(defined as presenting with ketosis and low C-

peptide level) and one patient was described as

LADA (Latent Autoimmune Diabetes of Adulthood).

The proportion of patients with diabetes diagnosed

within 10 years, 10-20 year and >20 years were

54%, 36% and 10% respectively. The mean age of

diagnosis was 41.3 ± 11.8 years (range 12-73).

59% were on oral hypoglycaemic agents (OHA)

only, 32% on a combination of OHA and insulin,

7% insulin only and 2% on diet control only. Com-

plications were present in 58%; 48% nephropathy,

22% retinopathy, 7% peripheral neuropathy whilst

5% has ischaemic heart disease and 2% has

stroke/transient ischaemic attack.

Conclusions: Although the majority of patients

have T2DM, 39% were on insulin treatment either

as add on to OHA or insulin alone. 58% have either

micro- or macro-vascular complications. These may

reflect the fact that these patients probably have

longer duration of diabetes and are attending a

tertiary diabetes clinic.

Luke MATHEW, Manoj PETHE, Panduru KISHORE,

Sara SILIANG, Division of Respiratory Medicine,

Department of Medicine, RIPAS Hospital, Brunei

Darussalam

Introduction: Melioidosis is endemic in Southeast

Asia and Northern Australia. Infection usually fol-

lows percutaneous inoculation or inhalation of

causative bacterium Burkholderia pseudomallei,

which is present in soil & water surface in endemic

region. There is a great clinical diversity, from lo-

calised skin ulcer or abscess to fulminant septic

shock with multiple organ involvement. Though the

organism can infect any organ, the lung is the most

commonly affected organ.

Materials and Methods: A retrospective review of

71 culture proven cases of melioidosis treated over

a five year period (2005-2010) in the Raja Isteri

Pengiran Anak Saleha (RIPAS) Hospital, Bandar

Seri Begawan, Brunei Darussalam was carried out.

Radiological imaging were retrieved and reviewed

in detail.

Results: Overall 48 (67.6%) patients had pulmo-

nary involvement based on positive radiological

findings. A majority of the patients who had multi-

ple zone involvement, bilateral diffuse nodular and

alveolar opacities and consolidation on chest radio-

graph were associated with septicaemia. There was

no predilection for any specific zone involvement.

Diabetes mellitus was the most common factor

(83.3%). The spleen was the other most commonly

affected organ (n=19, 39.58%) followed by the

liver (n=11, 22.91%).

Conclusion: Acute septicaemic melioidosis must be

suspected in endemic areas for the patients with

diabetes mellitus and other immunocompromised

illness presenting with bilateral diffuse nodular/

alveolar opacities or consolidation, as early appro-

priate treatment leads to significant reduction in

mortality.

Free papers presented in the Medical Symposium ‘Advancement in Medicine:

Past, Present and Future’ 20th November 2011, The Empire Hotel and Country

Club, Brunei Darussalam

F3: Helicobacter pylori testing using

Pronto-dry and histology and impact of

acid suppression therapy

Saima Javed PARACHA, Vui Heng CHONG, Anand

JALIHAL, Division of Gastroenterology and Hepa-

tology, Department of Medicine, RIPAS Hospital,

Brunei Darussalam

Introduction: Helicobacter pylori (H. pylori) is a

strongly associated with peptic ulcer diseases and

F2: A study of pulmonary involvement

based on radiological findings amongst

culture proven cases of melioidosis

Free Papers Brunei Int Med J. 2011; 7 (Supp 2): vi

gastric malignancies such as adenocarcinoma and

mucosa associated lymphoid tissue (MALT) lym-

phoma. H. pylori infection can be detected by sev-

eral tests such as rapid urease test (Pronto-dry),

histology, stool antigen and urea breathe test.

Rapid urease test has been shown to be affected by

use of acid suppressions. We assess the impact of

acid suppression on the testing of H. pylori with

Pronto-dry and histology.

Materials and Methods: Patients undergoing en-

doscopy in the Endoscopy unit, RIPAS Hospital and

had testing for H. pylori over a six months period

were recruited. Only patients who had both Pronto-

dry and histology (n=233, mean age 45.0 ± 16.1

years, male; 57.5%) testing were included in the

study. Positivity for H. pylori was taken when either

or both tests were positive.

Results: The overall positivity rate (either or both

positive) for H. pylori was 38.2%; Pronto-dry

(24%, n=56) and histology (33.0%, n=77). The

concordant rate was 80.9% (both +ve; 18.9%,

both -ve 61.8%) and disconcordant rate was

19.4% (Histology +ve/Pronto-dry -ve in 14.2% and

histology –ve/Pronto-dry +ve in 5.2%). Use of acid

suppressions (either proton pump inhibitor [PPI] or

histamine 2 receptor antagonist [H2RA]) resulted

in false negative rate of 34.1% and 15.9% respec-

tively for Pronto-dry and histology. The false nega-

tive rates were higher for PPI (52% for Pronto-dry

and 24% for histology) compared to H2RA (10.5%

for pronto-dry and 5.3% for histology).

Conclusion: Our study showed that both the

Pronto-dry and histology are associated with false

negative. Proton pump inhibitor is associated with

more false negative results compared with H2RA,

more with Pronto-dry than histology.

gada ECGs were included. The clinical and follow-up

data of these patients were obtained through re-

view of medical records and telephone interviews.

Asymptomatic patients with intermittent Brugada

type I ECG and Brugada type II or III ECG under-

went provocative testing with oral flecainide, a

class 1c anti-arrhythmic. Symptomatic patients

with aborted sudden death (SCD) or syncope at

time of diagnosis and underwent electrophysiologi-

cal testing (EPS).

Results: 24 patients (19 men, mean age 42.2 ±

11.1 years, range: 29 to 59) were identified with a

male predominance (19 males, 79%) and 17

(70.8%) were Malay, three Ibans (12.5%), two

Dusuns (8.3%) and one (4.2%) Chinese and Fili-

pino. Respectively. Two patients (8.3%) had a fam-

ily history of SCD. Seven patients (29.2%) had

spontaneous Brugada type I ECG which included six

patients who initially had Brugada types II and III.

Six had EPS and four were found to have inducible

ventricular fibrillation/ventricular tachycardia (VF/

VT).: syncope and palpitations (n=2), palpitations

(n=1) and survivor of cardiac arrest (n=1). All had

implantable cardioverter defibrillator (ICD) im-

plants. The remaining two with non-inducible EPS

were asymptomatic. Overall, 17 patients (70.8%)

had Brugada type II or III ECGs. Sixteen under-

went provocative test and six had positive test. Two

of these patients had EPS and were non-inducible

for VF/VT. The patients with Brugada syndrome

(16.7%, 2 men) had a mean age of 33.5 ±10.8

years compared to the 20 patients with Brugada

ECGs (83.3%, 17 men) with a mean age of 44 ±

10.5 years. There was no death. One patient re-

ceived an appropriate shock for VF from her ICD,

while another received inappropriate shocks due to

supraventricular tachycardia.

Conclusion: Brugada ECGs and Brugada syndrome

are present in the Bruneian population and are

seen in the different racial and ethnic groups. Pa-

tients with Brugada ECGs and Brugada syndrome

are probably under-recognised and underestimated.

Patients at high risk for SCD should receive ICD

implants.

FP4: Clinical study of patients with Brugada

electrocardiograms and Brugada syndrome in

Brunei Darussalam

Bee Ngo LAU, Nazzar LUQMAN, Division of Cardi-

ology, Department of Medicine, RIPAS Hospital,

Brunei Darussalam

Introduction: Patients with Brugada syndrome

have structurally normal hearts and are susceptible

to ventricular tachyarrhythmia and sudden cardiac

death. The aim of the study was to analyse the

clinical profile of Bruneian patients having Brugada

electrocardiogram (ECG) and Brugada syndrome.

Materials and Methods: Patients attending the

Cardiology Unit, RIPAS hospital between March

2006 and February 2011, and found having Bru-

FP5: A study of the observation ward in

the Accident and Emergency Department

of RIPAS Hospital, Brunei Darussalam

Sunil Kumar SHETTY, Department of Accident and

Emergency, RIPAS Hospital, Brunei Darussalam

Introduction: Day ward is an essential aspect of

the Accident and Emergency Department (AED),

Free Papers Brunei Int Med J. 2011; 7 (Supp 2): vii

and the hospital as a whole. The Day ward serves

as an area where patients can be observed and

reviewed after a few hours, before deciding on

whether patients need to be admitted or can be

discharged.

Materials and Methods: A retrospective study on

4,459 patients who were admitted to the day ward

of the AED, RIPAS Hospital from 1 January to 30

June 2007 was carried out. The triage sheets were

analysed. Data on the time from triage to the time

of admission/discharge, the presenting symptoms,

and reasons for admissions to the various wards

were extracted.

Results: Close to 60,000 patients visited the AED

during the 6 months period. There were more male

patients than the female patients; however female

patients were more likely to be admitted to the day

ward for observation. Of the 4,459 patients who

were admitted to the day ward, only 179 patients

(4.01%) were admitted to the hospital wards, more

female than the male patients. The most common

symptoms were giddiness and body weakness.

They were mainly admitted to the medical wards

mainly for deranged laboratory investigations. The

average duration spent in the day ward was 5-6

hours.

Conclusion: Day ward is very essential to the AED

and hospital. Many patients present to AED with a

wide spectrum of symptoms, but only a small frac-

tion of the require admission, most of them dis-

charged after a brief period of observation.

mia are two of the main contributory risk factors to

the emerging epidemic of chronic diseases. Hence,

the aim of this study is to investigate the role of

statins in blood pressure control among hyperten-

sive patients.

Materials and Methods: Hypertensive patients

were recruited from the Hypertension OPD in RI-

PAS, and the medications prescribed were noted

down. Relevant information was also taken from

the corresponding medical records. Participants

were then divided into two groups based on the

number of anti-hypertensive drugs that they were

taking, namely hypertensive (n≤3) and resistant

(n>3) hypertensive group.

Results: Overall, 85 participants were recruited.

There was a significantly higher proportion of pa-

tients in the resistant hypertensive group who did

not achieved the targeted guidelines according to

the National Cholesterol Education Program Adult

Treatment Panel, NCEP ATP III compared to the

simple hypertensive group (p=0.009). For the hy-

pertensive group of patients who were on statins,

there was a significant reduction in the diastolic

(p=0.005) and systolic (p=0.022) blood pressure in

patients who have their cholesterol level under

controlled. As for those who did not have their

blood cholesterol under control, there was a signifi-

cant reduction only in the systolic blood pressure

(p=0.021). The proportion of patients with uncon-

trolled blood pressure was significantly higher in

the resistant hypertensive group as compare to the

hypertensive group (p<0.005). Diabetes and hy-

percholesteraemia were also found to be independ-

ent cardiovascular risk factors for resistant hyper-

tension (p=0.010 and p=0.030 respectively).

Conclusion: Statins may have a beneficial effect

on blood pressure reduction independent of lipid

lowering effect. However, this beneficial effect is

not seen in those with resistant hypertension. Pa–

tients with diabetes and hypercholesteraemia were

more likely to develop resistant hypertension. The

issue of the high prevalence of uncontrolled blood

pressure and uncontrolled cholesterol should also

be reviewed by the health care providers.

F6: The role of statin in blood pres-

sure control in hypertensive and re-

sistant hypertensive patients

Siew Chee WONG 1, Mas Rina Wati ABDUL HAMID 1, Chee Fui CHONG 2, 1 PAPRSB Institute of Health

Sciences, Universiti Brunei Darussalam, Jalan

Tungku Link, Gadong, Brunei Darussalam and 2

Department of General Surgery, RIPAS Hospital,

Bandar Seri Begawan, Brunei Darussalam

Introduction: Hypertension and hypercholesterae-

Posters Brunei Int Med J. 2011; 7 (Supp 2): viii

P1: Clinical characteristics and outcome

of patients attending tertiary Obesity

Clinic in Brunei Darussalam

Ernie MOHIDI ¹, Zakaria KAMIS ², Alice Moi Ling

YONG ³, Obesity Clinic, RIPAS Hospital, Bandar

Seri Begawan, Brunei Darussalam.

Introduction: A tertiary level Obesity Clinic at RI-

PAS Hospital was started in 2006 with the aim to

manage patients with obesity to lose weight and

regain their health. The multidisciplinary team fo-

cuses on life-long healthy lifestyle management.

Individuals with body mass index (BMI) ≥30kg/m²,

aged ≥18 year, with or without co-morbidities were

referred.

Materials and Methods: Data was collected from

patients who joined the clinic from Sept 2006 till

April 2010 and completed at least 6 months of fol-

low-up. Data collected include source of referral,

age, sex, BMI, co-morbidities, retention rate and

body weight at baseline, three and six month of the

programme.

Results: Of 460 patients who were referred, only

265 (57.6%) patients joined the clinic program.

58% were referred from within RIPAS Hospital,

29% from government out-patient clinics, 1% from

private general practitioners and unknown in 12%.

Mean age of patients was 35.9 years (18-68), base-

line mean weight 116.8kg (71.7-200.8) with a

mean BMI 44.9 kg/m2 (30.5-76.4). Majority were

females (61.1%) with an average age of 35.9 years

and weight of 116.8kg. Retention rate was 66.8%

at three months and 48.7% at six months of follow

up. Co-morbidities seen were 55.7% hypertension,

51% hyperlipidaemia, 23.4% diabetes mellitus,

7.8% cardiovascular disease and 6.8% gout. Al-

though most patients lost weight across all age

groups, the highest number of patients with weight

loss of >5% total body weight (TBW) was seen in

the 31-40 age group at three months. More than

10% TBW lost after six months was again seen

most in the 31-40 age group followed by the 18-30,

the 51-60 and the 41-50 age groups respectively.

Conclusion: Like other obesity services worldwide,

majority of our patients are female. The highest

number of patients with 5% and 10% TBW loss are

seen in the 31-40 years age group.

Panduru V KISHORE, Osama ABOUZEID, Manoj

PETHE, Yahya HASAN, Khalizah JAMIL, Luke

MATHEW, Division of Respiratory Medicine, Depart-

ment of Medicine, RIPAS Hospital, Brunei Darussa-

lam

Introduction: Fiberoptic bronchoscopy (FB) is a

useful procedure in the diagnosis and management

of pulmonary diseases. Its widespread availability

and ease of procedure has encouraged its use in

pulmonology units as a routine procedure. The di-

agnostic yield of FB is high, although it depends on

the indication and the technique used.

Materials and Methods: All consecutive FB were

retrospectively reviewed using bronchoscopy re-

ports and patients’ chart over one year (from Jan

2010 to December 2010) in RIPAS hospital.

Results: A total of 86 patients underwent FB proce-

dure. 51 (59.3%) were females. 69% were Brunei

nationals. A total of 85 bronchoscopy lavage (BAL),

eight brushing and four bronchial biopsy (BB) were

performed. Indications of bronchoscopy were sus-

pected tuberculosis, suspected malignancy, lung

abscess and suspected tracheo-oesophageal fistula.

The overall diagnostic yield was 75 (88.23%). Tu-

berculosis was suspected in 73 patients (84.8%),

followed by malignancy in 11 patients (12.79%).

Cytology of BAL was positive for AFB in 16 cases,

three positive for malignancy. Overall, FB was diag-

nostic of pulmonary tuberculosis in 23 patients

(27%).

Conclusion: Our study showed a diagnostic yield of

(75/85) 88.2% which higher than what has been

reported in other studies from Europe and Middle

East which was 57% and 58% respectively. How-

ever, our findings are in agreements with reports

from neighbouring countries where infection is the

most common indication for bronchoscopy. The

diagnostic yield of the bronchoscopy is high with

good selection of the patients and has a major role

for the yield of diagnosis in suspected cases with no

definite diagnosis.

P2: Retrospective analysis of yield of di-

agnostic bronchoscopy for a period of

one year in the division of Respiratory

Medicine of RIPAS Hospital

P3: Audit of anti-epiletic medication

usage in women of child-bearing age

Rosimah SIDEK, Siti Nur’Ashikin PENGIRAN

TENGAH, Rehabilitation Unit, Department of

Medicine, RIPAS Hospital, Brunei Darussalam

Introduction: Women of child-bearing age should

be given monotherapy with less teratogenicity risk.

Monotherapy with Lamotrigine has been shown to

be relatively safe for this group. Sodium Valproate

Posters Brunei Int Med J. 2011; 7 (Supp 2): ix

either as monotherapy or polytherapy should be

avoided as studies have shown higher teratogenic

risk compared to other anti-epileptic drugs (AEDs).

This study aimed to audit AED usage in patients

attending the outpatient clinic in the Rehabilitation

Unit, RIPAS Hospital, Brunei Darussalam.

Materials and Methods: Data were collected from

reviewing casenotes of patients attending from 1st

January until 30th June, 2011 as part of a larger

audit of AED usage across all Neurology Clinics at

RIPAS Hospital. We also reviewed the literature

regarding teratogenicity risk of AEDs.

Results: There were 18 female patients of child-

bearing age with a diagnosis of epilepsy who

attended during this time. Twelve patients were on

monotherapy: Carbamazepine six (33%),

Lamotrigine five (28%), Phenytoin one (5.5%). Six

patients were on polytherapy: Sodium Valproate

and Lamotrigine one (5.5%), Carbamazipine and

Phenytoin one (5.5%), Sodium Valproate and

Phenytoin one (5.5%) and Carbamazepine and

Sodium Valproate three (16.6%). Of 18 patients,

onepatient had allergic reaction Lamotrigine and

onepatient had allergic reaction to Phenytoin,

Carbamazepine and Phenobarbital. Reasons for AED

change or choices are because of adverse drug

reaction, cost and poor seizure control.

Conclusion: In our clinic we had achieved

monotherapy in 67% of our patients. However risk

of uncontrolled epilepsy outweighs the teratogenic

risk, hence 33% of our patients still require

polytherapy including with Sodium Valproate

(28%). Further efforts are required to optimise AED

usage which includes patient counselling.

patients with MND seen at RIPAS hospital over one

year and also to suggest a future role for nurses in

its care.

Materials and Methods: We reviewed notes of

prevalent cases of MND seen at RIPAS Hospital

from 1st July 2010 to 30th June 2011 and also

reviewed literature on MND. In all patients the

diagnosis was confirmed by a Consultant

Neurologist.

Results: There were five patients with MND during

the study period (three male, two female). Age

range was 39–67 years (mean 52). Two presented

with limb weakness, three presented with bulbar

palsy. Four progressed to having both limb

weakness and bulbar palsy. Time from diagnosis to

the end of the study period or death ranged from

four to 43 months. Average duration of illness was

17 months. Two died of respiratory failure during

the study period.

Conclusion: Symptoms were wide-ranging

similarly to published literature. In two cases, time

from diagnosis to death was short. The nurses' role

as the key worker within a multidisciplinary team

includes dealing with communication problems,

respiratory dysfunction, feeding and nutrition and

legal and ethical issues.

P4: Case series of Motor Neurone Disease

patients at RIPAS Hospital- to investigate

nursing role

Mariani MUSTAPA, Siti Nur’Ashikin PENGIRAN

TENGAH

Rehabilitation Unit, Department of Medicine, RIPAS

Hospital, Brunei Darussalam

Introduction: Motor Neurone Disease (MND) is an

idiopathic and rare, progressive neurological disease

resulting in death of brain upper motor neurones

(UMN), brainstem bulbar motor neurones and spinal

cord lower motor neurones (LMN). Spastic

paralysis, flaccid muscle weakness, wasting, and

fasciculations are features of the disease.

Worldwide incidence is estimated to be 1-2/100,000

people with prevalence of seven in 100,000. This

study aimed to describe a prevalent case series of

P5: Signet ring cell lymphoma of the

small bowel

Norwani BASIR 1, Ian C BICKLE 2, Pemasari Upali

TELISINGHE 3, Vui Heng CHONG 1, 1 Department of Medicine, 2 Department of Radiol-

ogy, 3 Department of Pathology, RIPAS Hospital,

Brunei Darussalam

Signet ring cell lymphoma (SRCL) is a rare variant

of non-Hodgkin’s lymphoma that is characterised by

clear cytoplasm with displaced nuclei to the periph-

ery giving a signet ring appearance. SRCL have

been reported in other organs but have not been

previously reported in the small bowel. We report

the rare case of a 78-year-old woman who pre-

sented with short history of fever, loss of appetite,

nausea, vomiting, mild weight loss with abdominal

discomfort and was later diagnosed to have SRCL of

the ileum.

P6: Oesophageal tuberculosis: rare but

not to be forgotten

Natalie MOMIN, Vui Heng CHONG, Department of

Medicine, RIPAS Hospital, Brunei Darussalam

Tuberculosis remains an important cause of morb-

Posters Brunei Int Med J. 2011; 7 (Supp 2): x

P9: Parathyroid cancer presenting with

brown tumours mimicking bone

metastasis

Mercy GEORGE, Alice Moi Ling YONG, Endocrinol-

ogy Unit, Department of Medicine, RIPAS Hospital,

Brunei Darussalam

Bone metastasis is the most common diagnosis

considered for lytic lesions in the bone. Parathyroid

cancer presenting as overt bone disease with dif-

fuse lytic lesions secondary to untreated hyperpara-

thyroidism (HPT) is a rare entity nowadays. We

report a 50 years old woman with parathyroid can-

cer who presented with diffuse bone lesions and

vertebral collapse with hypocalcaemia mimicking

bone metastasis. Her bone biopsy excluded malig-

nant metastasis to the bone and further investiga-

tions confirmed primary hyperparathyroidism

(PHPT). Ultrasound showed a 3.3 x 1.7cm left supe-

rior parathyroid adenoma. The patient underwent

transpedicular fixation of the spine, followed by

parathyroid excision. The post-operative histopa-

thology showed parathyroid cancer. A high index of

suspicion for HPT in these patients are important to

avoid unnecessary investigations and search for

primary malignancy, which will also make early

treatment and surgery possible for these patients.

idity and mortality especially in the under-develop

and developing nations. Manifestations can be non-

specific and mimic many other conditions including

malignancies. Oesophageal involvement is surpris-

ingly rare despite the prevalent of pulmonary tuber-

culosis and the close proximity of these two struc-

tures. We report two cases of oesophageal tubercu-

losis, a 73-year-old man as part of upper gastroin-

testinal involvement and a 45-year-old man with

isolated oesophageal involvement. Both cases were

initially suspected of underlying malignancies and

responded to anti-tuberculous treatment.

P7: Durian allergy: an unfortunate

encounter

Natalie MOMIN, Alice Moi Ling YONG, Endocrinol-

ogy Unit, Department of Medicine, RIPAS Hospital,

Brunei Darussalam

We report a case of a tourist to Brunei experiencing

anaphylactic symptoms following durian consump-

tion. A 53-year old female tourist to Brunei had her

first taste of a spoonful of Monthong durian four

hours after arriving in Brunei. Thirty minutes after

ingestion, she felt unwell with difficulty breathing,

giddiness and a widespread rash. During the epi-

sode, she was noted have hypotension (BP 77/49

mmHg) and tachycardia, but with no stridorous

breathing nor cyanosis. She was treated with intra-

venous chlorpheniramine, hydrocortisone 200mg

and intravenous fluid. Fortunately she had an un-

eventful recovery without serious sequelae.

P8: A rare case of dysphagia secondary

to a large oesophageal lipoma

Kai SHing KOH 1, Vui Heng CHONG 1, Samuel Kai

San YAPP 2, Chee Fui CHONG 2, 1 Department of

Medicine, 2 Department of Surgery, RIPAS Hospital,

Brunei Darussalam

Dysphagia is considered a warning symptom that

requires exclusion of significant pathology such as

oesophageal cancer especially in the elderly patient.

Benign neoplasms of the oesophagus are rare. We

report a case of a 69-year-old lady who presented

with a five years history of intermittent dysphagia

that had progressed over the previous one month.

This was associated with globus sensation, weight

loss, intermittent episodes of stridor and aspiration

pneumonia. Investigations revealed a large oeso-

phageal lipoma in the proximal oesophagus extend-

ing down to the lower oesophagus. This was suc-

cessfully resected via a left cervical approach. She

had remained well two years after the surgery.

Please look out for

Annual Medical Symposium

September/October 2012

AND

the 6th Annual Brunei

Surgical Scientific Session in conjunction

with the 9th Surgical Forum

November 2012

Abstract submissions from colleagues from the

other departments and hospitals are

welcome

Free papers or poster presentations will be

published in the Supplements of

Brunei International Medical Journal

Announcements

Medical Writing Workshop- ‘Original Research: Planning, data collection,

analyses, writing to publication’

February 2012 (Sunday), organised by the Clinical Research Unit, Ministry of Health,

RIPAS Hospital, Brunei Darussalam.

Venue and date to be announced.

3rd National Medical Writing Skills Workshop

May 2012, organised by the Clinical Research Unit, Ministry of Health,

RIPAS Hospital, Brunei Darussalam.

Date and Venue: To be announced.

Medical Symposium

September/October 2012 (Sunday), organised by Department of Medicine,

RIPAS Hospital, Brunei Darussalam.

Date and Venue: To be announced.

The organising committee invites our local researchers to contribute to the free papers section. Any topics

that are medically related in the forms of case reports, case series and original articles are welcome. A few

these submissions will selected for free papers presentations and the remainder will be presented as poster

presentations.

Free papers and posters presentations will be published as Supplement of BIMJ.

6th Annual Brunei Surgical Scientific Session in conjunction with the

9th Surgical Forum

November 2012 (Sunday), organised by Department of Surgery, RIPAS Hospital, Brunei

Darussalam.

Date and Venue: To be announced.

The organising committee invites our local researchers to contribute to the free papers section. Any topics

that are surgically related in the forms of case reports, case series and original articles are welcome. A few

these submissions will selected for free papers presentations and the remainder will be presented as poster

presentations.

Free papers and posters presentations will be published as Supplement of BIMJ.

3rd National Evidence Based Medicine and Nursing Workshop

Organised by Ministry of Health, Brunei Darussalam.

Venue and date: To be announced (November 2012, three days workshop).

Updates and details of programs, Continuous Medical Education (CME) or conferences are available from the

CRU/journal website (www.bimjonline.com).

NOTES: For organisers who wish to advertise their meetings (National CME meetings, conferences or

workshops), please contact the CRU, Ministry of Health located at RIPAS hospital either via email or through

telephone. Please visit the journal website for more details.