8th Negeri Sembilan Research Day Program Book

List of Case Report 8th Negeri Sembilan Research Day 2023 48 No Title Presenting Author & Department CR09 Application of Electro Acupuncture In the Management Of Complex Regional Pain Syndrome Janusyia Sivananthan Anaesthesiology HTJS CR10 A Heavy Spleen That Wandered: A Case Report Kalaaiwani A/P Silverjah Radiology HTAN CR12 Malignant Phyllodes Tumor of the Breast with Heterologous Angiosarcoma: A Case Report Maya Iradah Binti Abdul Hamid Pathology HTJS CR13 Spectrum of Listeria monocytogenes infection in Systemic Lupus Erythematosus (SLE) Mohanan A/L Ganasen Medical HTAN CR14 White Spots On Skin Is Not To Be Ignored : Case Series Of Hypopigmented Variant Mycoses Fungoides Nasiha Binti Abu Pathology HTJS CR15 Aortocaval fistula of infrarenal abdominal aortic aneurysm: A rare complication Noor Zulaika Binti Rusli Radiology HTAN CR16 Follicular Thyroid Carcinoma Presenting with Frontal Bone Metastases Nor Shela Binti Sayonor Radiology HTAN

List of Case Report 8th Negeri Sembilan Research Day 2023 49 No Title Presenting Author & Department CR17 Case Report: Orbital Cellulitis A Mirror For Aggressive Maxillary Sinus Lymphoma Nur Athirah Adnan Ophthalmology HTAN CR18 Combination of Pharmacological and Vision Therapy in Managing Accommodative Spasm: A Case Report Nurul Akimi Abdullah Ophthalmology HTAN CR19 Ohvira A Rare Cause Of Lower Abdominal Pain Punitha A/P Mohanan Radiology HTAN CR20 Replantation Dilemma,Atypical Avulsed Young Permanent Incisor with Root Fracture:A Case Report Sharlene Devi Pediatric Dental Surgery HTAN CR21 The Rare and Forgotten Complication: Brucella Infective Endocarditis Siow Ee Hong Medical HTJS CR22 Hemopericardium Post Fibrinolysis Leading To Cardiac Tamponade Steven Wong Poh Hock Medical HTJS CR23 A Peculiar Case Of Dabigatran-Related Nephropathy : A Case Report Steven Wong Poh Hock Medical HTAN

List of Case Report 8th Negeri Sembilan Research Day 2023 50 No Title Presenting Author & Department CR24 BAYES SYNDROME: The Missing Puzzle Piece In Stroke Prevention? Steven Wong Poh Hock Medical HTAN CR25 Riding Out A Storm In A Non-Cardiac Centre - A Challenging Conundrum Steven Wong Poh Hock Medical HTAN CR26 Eye Catching Tuberculosis Thamarai A/P Munirathinam Ophthalmology HTJS CR27 Heterozygous Hemoglobin Charlieu Non-Deletional Alpha Thalassemia and Southeast Asian Ovalocytosis in a Newborn: A Rare Mutation Causing Early Onset Severe Hemolytic Anemia Yau Kim Boon Paediatric HTAN

8th Negeri Sembilan Research Day 2023 Case Abstract Report 51 A Case of Anterior Mediastinal Mass with Life Threatening Massive Left Chylothorax Afifah Kamarudin1 , Han Loong Tan1 , Xiang Ying Lee1 , See Guan Toh2 , Raymund Dass1 1 Respiratory Unit, Department Of Internal Medicine, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan 2 Hematology Unit, Department Of Internal Medicine, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan Background: Chylothorax is a rare condition resulting from thoracic duct damage with chyle leakage from lymphatic system into the pleural space. It gives an odourless milky like appearance pleural effusion and is defined as pleural fluid triglyceride level > 110mg/dL. We illustrate a case of B cell Lymphoma presented with life threatening chylothorax responding to dexamethasone, chemotherapy and pleural drainage. Case report: A 25 years old female complained of breathlessness for one month, cough with whitish sputum and intermittent palpitation. Chest x-ray showed massive left pleural effusion with presence of a mediastinal mass. 1500 mls milky white pleural fluid was drained but subsequently she developed respiratory failure requiring mechanical ventilation and triple inotropic support. Pleural fluid analysis demonstrated triglyceride level 310mg/dL, cholesterol 77mg/dL, LDH 1530. Adequate fluid resuscitation, pleural drainage, broad spectrum antibiotic and empirical intravenous dexamethasone eventually stabilize the patient. Biopsy of the mediastinal mass shows B Cell Lymphoma and she was started on IV Cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) chemotherapy regime. Discussion: Chylothorax may be misdiagnosed as empyema due to similar gross appearance. In patients suspicious of chylothorax, pleural fluid triglyceride and cholesterol level aid in the diagnosis. Non-traumatic chylothorax commonly results from thoracic duct obstruction due to malignancy, for which lymphoma is found in 70% of cases. Conclusion: In young patient with a mediastinal mass and chylothorax, there is a need to have a high index of suspicion of lymphoma. The correct treatment given after identifying the cause of chylothorax will improves patient’s prognosis. CR01

8th Negeri Sembilan Research Day 2023 Case Abstract Report 52 Ileo-ileal Intussusception With Concurrent Proximal Ascariasis: A Case Study A Ahmad Faiz1 , AL Nurulhuda1 , AW Zurina1 1 Department of Radiology, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan Background: Intussusception is an occurrence when a bowel segment slides into an adjacent bowel, resulting in bowel obstruction. It is a common cause of acute intestinal obstruction in children. The diagnosis can be made following an ultrasound. Treatment involves reduction of the affected bowel to relieve the obstruction and restore the perfusion. Ascariasis is the infestation by the Ascaris lumbricoides and also a common aetiology of intestinal obstruction. The diagnosis of ascariasis is based on the history of passing out worms through mouth or rectum, and the findings of worms in the ultrasound. Its treatment typically requires an anti-helmintic agent. Case report: Here, we discuss a case of ileo-ileal intussusception with concurrent ascariasis infestation in a 3-year-old kid. She was admitted due to worsening abdominal pain associated with vomiting and diarrhoea. An abdominal ultrasound showed ileo-ileal intussusception. There were few intraluminal tubular echogenicities in the bowel proximal to the affected bowel consistent with worms. The intussusception was reduced on its own and the patient was treated with an anti-helminthic agent.  The patient passed out worms, followed by the resolution of symptoms. Discussion/conclusion : This case was deemed worthy of reporting as it has two pathologies that occur independently. Both conditions can cause worsening intestinal obstruction and, subsequently, can lead to bowel ischaemia. This case report may be of benefit to clinicians, as such cases are rarely reported, and it may help them on appropriate plan of management as no standardised guidelines exist yet for managing these occurrences. CR02

8th Negeri Sembilan Research Day 2023 Case Abstract Report 53 L-Asparaginase Associated Cerebral Venous Thrombosis (CVT) and Intracerebral Haemorrhage In Acute Lymphoblastic Leukemia (ALL) HY Chan1 , EL Gan1 , SG Toh1 1 Haematology Unit, Department of Medicine, Hospital Tuanku Jaafar Seremban Background: Central venous thrombosis (CVT) is a known complication of acute lymphoblastic leukemia (ALL) induction therapy with treatments including L‐asparaginase (L‐ASP). Herein, we report a case of CVT in patient undergoing induction chemotherapy. Case report: A 27-year-old lady diagnosed with CALLA positive precursor B-cell ALL was started on paediatric-inspired ALL protocols. She received subcutaneous low molecular weight heparin during the induction chemotherapy. After receiving 8th dose of L-asparaginase, she complained of left-sided weakness. Motor examination revealed left sided power grade of 3/5. A computerised tomography (CT) of brain showed acute intraparenchymal bleed seen at right parietal region. CT cerebral venography findings favour right superficial cerebral vein and superior sagittal sinus thrombosis. Haemoglobin was 8.2g/dl, leukocytes 4.3 x 109 /L and the platelet count 40 x 109 /L. Her coagulation screen showed an increased prothrombin time and low fibrinogen. She was substituted with cryoprecipitate and fresh frozen plasma. Following that, she received LMWH and was discharged a month later. Discussion: L‐ASP depletes Asparagine, thereby inhibiting protein synthesis in leukemic cells and the synthesis of plasma proteins. These changes have considerable impact as they may induce bleeding and thromboembolic events. The reduced circulating anticoagulant proteins cause impaired inhibition of thrombin. Early diagnosis is essential, such that prompt therapy can be administered to reduce mortality and morbidity. Conclusion: We conclude that the occurrence of sudden onset of neurological symptoms being treated with L‐ASP, mandates ruling out CVT. Early diagnosis demands a low threshold for imaging that enables proper diagnosis and prompt anticoagulation. CR03

8th Negeri Sembilan Research Day 2023 Case Abstract Report 54 Single Step of Fabricating A Closed Hollow Bulb Obturator: A Case Report WW Chan1 , Samsanizah A2 1 Department of Restorative Dentistry, Klinik Pergigian Kuala Pilah, Negeri Sembilan, Malaysia Background: There are numerous methods and techniques have been introduced and advocated for open or closed hollow bulb obturator fabrication. A closed bulb obturator is a feasible treatment option to rehabilitate patient with congenital and acquired maxillary defect. Nevertheless, it poses a few considerations in terms of materials used for hollowing and its pros and cons. This case report described single step of fabricating a closed bulb obturator utilizing hard thermoplastic splint material, self-curing acrylic resin and heat-cured acrylic resin. Case Report: This technique was used to fabricate a closed hollow bulb obturator in a 53-year-old patient with Veau Class II complete cleft hard and soft palate. A C-Silicone index was used as guide to fabricate a bulb template using 2 pieces of hard thermoforming splint materials. Both bulb and lid part of defect were formed separatedly and sealed using self-curing acrylic resin to produce a hollow bulb. After dewaxing and loading the cleft area with heat-cured acrylic resin, the sealed bulb template was adapted in the cleft area and proceeded for packing, curing, deflasking, finishing and polishing. Discussion: This technique helps to control the thickness and reduce weight of obturator. It can reduce the drawbacks of water leakage, bacterial infection and discoloration of obturator as the autopolymerised area is completely covered in heat cured acrylic resin. Ease of fabrication is also a major advantage in term of minimizing laboratory time as it uses a single flask and one time processing method. CR04

8th Negeri Sembilan Research Day 2023 Case Abstract Report 55 A Rare Case of NUT Midline Carcinoma; A Case Report With Diagnostic Challenges Dharshinie D1 , Nurul Azlin I1 1 Department Of Pathology, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan Introduction: NUT midline carcinoma is an extremely rare and aggressive malignancy of the head and neck region. It arises due to a genetic rearrangement of NUT protein in testis (NUTM1) gene of chromosome 15. This poorly differentiated carcinoma accounts for only 1% of total head and neck malignancies with a median survival of less than a year. We report a case of primary NUT carcinoma in a 54 year old Indian lady presenting to Hospital Tuanku Jaafar Seremban. Case: A previously healthy patient presented with bilateral nasal block, epistaxis, facial pain and blurring of vision for 4 months. Lesional biopsy led to the diagnosis of Adenoid cystic carcinoma. Two years post radiotherapy completion, the patient was noted to have a left nasal mass in a surveillance follow up. Repeated CT imaging, tumour debulking and HPE revealed a sphenoid rostrum tumour supporting the recurrence of malignancy. A series of biopsies were commenced thereafter with extensive inconclusive immunohistochemistry (IHC) panels suggestive of high grade invasive carcinoma. Subsequently, this case was referred for expert opinion and IHC for NUT1 protein was done showing strong nuclear positivity in more than 90% of tumour cells, thus confirming the diagnosis of NUT carcinoma. Discussion: A poorly differentiated tumour of the head and neck region with inconclusive IHC panel should raise a suspicion of NUT carcinoma. Conclusion: Immunohistochemistry for NUT 1 protein is crucial for diagnosis, as the poorly differentiated nature of NUT carcinoma makes the morphological diagnosis challenging. CR05

8th Negeri Sembilan Research Day 2023 Case Abstract Report 56 Eagle Syndrome : A Case Report M Fauzan1 , AL Nurulhuda2 , AW Zurina3 1 Department Of Radiology, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan Abstract : Eagle syndrome is a condition characterised by extension of the styloid process or calcification of the stylohyoid ligament. An elongated styloid process is defined as being at least 30 mm long. The incidence is 4-8 cases per 10,000 people. The symptoms vary in severity, ranging from asymptomatic to complex. Due to its low prevalence and complex presentations, this syndrome is frequently discovered by chance during imaging. In some cases, it can be misdiagnosed due to its complexity. Case presentation : We reported a case of a 59-year-old male who allegedly fell into the drain. Post-fall, the patient experienced transient loss of consciousness and central neck pain, associated with midline cervical tenderness on palpation. A computed tomography (CT) scan of the cervical spine revealed undisplaced fractured spinous processes of 2nd to 4th cervical spine and incidental findings of elongated right and left styloid processes measuring 6.7cm and 6.8cm respectively. Discussion : Eagle syndrome can be diagnosed through imaging. It should be suspected in patients presenting with unresolved neck pain. The patients who were diagnosed incidentally on imaging should be made aware of the consequences. Patients who develop troubling symptoms that necessitate further care require a comprehensive approach. CR06

8th Negeri Sembilan Research Day 2023 Case Abstract Report 57 Primary Laryngeal Histoplasmosis YT Ho1 , Suvintheran T2 , TK Ng3 , Wan Mansor WN4, Ahmad A5 1 Department Of Internal Medicine Hospital Tuanku Ja’afar Seremban, Negeri Sembilan Background: Histoplasmosis is a granulomatous disease of worldwide distribution caused by a dimorphic fungus Histoplasma capsulatum. Transmission of infection is through inhalation of the spores present in soil, contaminated by bat or bird droppings. Histoplasmosis of larynx is uncommon and poses diagnostic difficulty because clinically it may be mistaken for malignancy. Case Report: We report an unusual case of laryngeal histoplasmosis in a 67 years old chronic smoker. He presented with 2-month history of odynophagia with significant weight loss. Direct laryngoscope showed irregular mucosa with slough and ulcers confined to the supraglottic larynx. Tissue biopsy confirmed the diagnosis of histoplasmosis via fungal polymerase chain reaction. Histopathological examination showed fungal bodies seen within the tissue and squamous epithelium, highlighted by Periodic acid-Schiff and Grocott’s methenamine silver stain. Treatment with intravenous amphotericin B was given. However, he developed severe upper gastrointestinal bleed due to peptic ulcer disease during the treatment course and required lifelong pantoprazole which contraindicates the use of itraconazole. Discussion: A high index of suspicion is needed to make a diagnosis of histoplasmosis early especially in immunocompetent host. Clinical features are similar to the commonly seen granulomatous infections or laryngeal carcinoma. Diagnosis needs to be established via tissue biopsies and cultures obtained from affected tissues for early antifungal treatment. Itraconazole or amphotericin B is recommended as first-line treatment for histoplasmosis. However, as itraconazole is contraindicated in our case, other newer triazole agents such as voriconazole is used. The clinical efficacy of voriconazole is yet to be evaluated CR07

8th Negeri Sembilan Research Day 2023 Case Abstract Report 58 Orbital Cellulitis Complicated With Cavernous Sinus Thrombosis Post COVID-19 Insyirah MZ1 , Logeswari K¹, Khairul Husnaini MK¹ 1 Department Of Ophthalmology, Hospital Tuanku Ampuan Najihah Kuala Pilah, Negeri Sembilan Objective: To report a case of right orbital cellulitis secondary to pansinusitis complicated with bilateral cavernous sinus thrombosis and superior ophthalmic vein thrombosis. Method: Case report Results: An 11-year-old girl presented with painless right upper eyelid swelling associated with fever, painful neck swelling, dysphagia and reduced oral intake for 2 days. Patient was post COVID-19 infection day 14. On ocular examination, right eye visual acuity was 6/12 while left eye visual acuity was 6/9. RAPD was negative. Extraocular muscle movements were full. Hertel’s exophthalmometer showed 2mm increment over the right eye. Optic nerve function was intact. Externally, noted right upper eyelid swelling with mechanical ptosis. Mild tenderness over superior orbital rim. Anterior segment examination and fundus examination was unremarkable. Systemic examination showed right painful neck swelling. CECT paranasal sinus and orbit showed right orbital cellulitis secondary to pansinusitis with bilateral cavernous sinuses, superior ophthalmic vein, bilateral facial and retromandibular vein thrombosis. There is localized irregular thickening and enhancement of the anteromedial wall of right orbit may present subperiosteal collection or lacrimal duct inflammation. A diagnosis of right orbital cellulitis secondary to pansinusitis complicated with bilateral cavernous sinus thrombosis was made. Patient was transferred to a tertiary centre with infectious disease specialization and was treated with intravenous antibiotics and subcutaneous clexane. Patient responded well and currently is stable. Conclusion: COVID-19 infection may predispose patients to coagulopathies and thrombotic events. A prompt diagnosis, urgent radiological imaging and a multidisciplinary approach and treatment can reduce morbidity and mortality rate. CR08

8th Negeri Sembilan Research Day 2023 Case Abstract Report 59 Application of Electro Acupuncture In the Management Of Complex Regional Pain Syndrome Janusyia S1 , Mohamad Aswad Abu1 1 Department Of Anaesthesia & Intensive Care, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan Background: Complex regional pain syndrome (CPRS) is a chronic and progressive condition that leads to sympathetic nervous system involvement and trophic changes of the affected limb. CPRS is diagnosed based on the IASP criteria which includes continuing disproportionate pain, signs in multiple categories (sensory,vasomotor,edema,trophic) and is a diagnosis of exclusion. Case report: This patient is a 46y/o female with a history of prolapsed intervertebral disc and right frozen shoulder since 2010, was diagnosed with chronic regional pain syndrome (CPRS) in 2018. Despite receiving multimodal analgesia and multidisciplinary approach for pain management, the patient had minimal improvement and continued to experience severe pain that affected her work, daily activities and sleep. Subsequently the patient received electro acupuncture starting 2020, and after just one session, there was significant improvement in her pain and CRPS symptoms including reduction of tenderness, edema, and hyperalgesia over her right arm and improved range of motion over right shoulder. Outcome was measure using numeric rating scale of pain and functional score of daily activities. The patient continued to receive monthly electroacupuncture therapy and reported a sustained improvement in her pain, CPRS symptoms, work and her daily living activities. Discussion: Chronic regional pain syndrome is a challenging condition to treat and manage. Electro acupuncture should be considered as a synergistic treatment option in managing CPRS in addition to multimodal analgesia and multidisciplinary approach. This case report highlights the potential benefit of electro acupuncture in improving pain and CPRS symptoms in patients with refractory chronic pain. CR09

8th Negeri Sembilan Research Day 2023 Case Abstract Report 60 A Heavy Spleen That Wandered: A Case Report S Kalaaiwani1 , AR Siti Khairunnisaak2 , AW Zurina2 1 Department Of Radiology, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan Background: Cyst within a wandering spleen is an uncommon condition which predisposes the patient to a higher incidence of complications. Timely diagnosis with appropriate imaging is therefore crucial in evading serious outcomes. Case Report: A 29-year-old female was referred for asymptomatic splenomegaly. Initial ultrasound (USG) revealed a well-defined splenic collection with echogenic material. Follow-up computed tomography (CT) scan revealed a thin-walled splenic cyst. Serial sonography revealed recurrent splenic cyst with repeated USG guided drainage. The biochemical result of the fluid aspirated remained unremarkable. Due to her ongoing pregnancy, she refused splenectomy and was discharged but returned two years later with abdominal distention and discomfort. USG revealed splenomegaly with a cystic mass in the left paraumbilical region. CT scan revealed a cyst within a wandering spleen in the pelvic region. Patient was counselled for splenectomy and is currently awaiting surgery. Discussion: With an incidence rate of only 0.2% worldwide, wandering spleen is the intraperitoneal migration of the organ from its anatomical position, suspended only by its vascular pedicle. Acquired condition is due to increased laxity of the suspensory ligaments that hold the spleen, mostly associated with pregnancy and splenomegaly. Cystic lesions of the spleen be it parasitic or nonparasitic, are equally uncommon with an incidence rate of 1%. Wandering spleen accompanied by a cyst as described in this case however has hardly ever been estimated in the literature. Due to ambiguity of the presenting symptoms, high suspicion combined with early diagnosis with proper imaging techniques is critical to avoid catastrophic consequences. CR10

8th Negeri Sembilan Research Day 2023 Case Abstract Report 61 Malignant Phyllodes Tumor of the Breast with Heterologous Angiosarcoma: A Case Report. Maya Iradah AH ¹, Nor Akmar T ¹ ¹ Department of Pathology, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan. Introduction: Phyllodes tumor (PT) of the breast, particularly malignant PT with heterologous sarcomatous differentiation is extremely rare tumor. The most common heterologous sarcomatous elements that may arise secondary to malignant PT are fibrosarcoma, liposarcoma and rhabdomyosarcoma. Rarely, chondrosarcoma, osteosarcoma and angiosarcoma can also be encountered. We report a case of malignant phyllodes tumour with angiosarcomatous differentiation with no history of previous surgery or radiation therapy.  Report: A 29-year old female presented with a hard mass in the breast with engorged superficial veins. She had an ultrasound done and revealed a BIRADS-2 lesion with solid and cystic component and increased internal vascularity. The core needle biopsy revealed as fibroadenoma. The patient underwent incisional biopsy, which showed malignant PT with heterologous angiosarcoma. Gross examination in the subsequent mastectomy sample showed the tumour size was 10x7x5cm, a well circumscribed, white fleshy mass with area of hemorrhage and necrosis. Histopathological examination demonstrated a fibroepithelial lesion associated with malignant epithelioid and spindle cells proliferation involving the stromal component. The latter proliferation showed high-grade cytologic atypia with numerous mitoses and areas of extensive necrosis. Vasoformative growth were seen, as well as prominent hemorrhage. This tumor expressed positivity towards CD31 and CD34. Discussion: Phyllodes tumours of breast show variable clinicopathological behaviour ranging from benign to malignant depending on histological features. Malignant change usually occurs within the hyperplastic stromal cells, resulting in sarcomatous lesions. Our current case is the fifth case in the literature of angiosarcoma developing in a PT. Conclusion: ● Breast angiosarcomas are a rare entity, specially arising from phyllodes tumour. CR12

8th Negeri Sembilan Research Day 2023 Case Abstract Report 62 Spectrum of Listeria monocytogenes infection in Systemic Lupus Erythematosus (SLE) G Mohanan, Z Nurdalila, M Fauzan, S Shantene 1 Department of Medical, Hospital Tuanku Ampuan Najihah, Kuala Pilah. Introduction: L. monocytogenes infection is a rare complication in SLE and commonly affect the gut and central nervous system(CNS). Methodology: We report a 46 years old Indonesian lady diagnosed SLE (2013) with musculoskeletal, hematological and renal involvement (Class II Lupus Nephritis), underwent corticosteroid pulse and mycophenolate induction therapy. 1 month later, she presented with fever and diarrhea for 5 days. She was started on broad spectrum antibiotics for infective gastroenteritis with renal impairment. On day 4 of admission, she developed multiple seizures in ward, hence requiring intubation. Lumbar puncture revealed raised cerebrospinal fluid protein, lymphocytes predominant. CECT brain showed communicating hydrocephalus requiring shunt insertion. Blood cultures grew Listeria monocytogenes hence antibiotics were switched to IV Ampicillin. In view of active infection and possible cerebral lupus, she received 5 days of Intravenous Immunoglobulin (IVIG). Unfortunately, she further deteriorated with hematochezia and CTA mesentery revealed acute small bowel bleed with pneumoperitoneum. She was however conservatively managed as unfit for surgery. Patient finally succumbed to nosocomial ESBL E. Coli bacteremia after 3 weeks of ICU stay. Discussion: L. monocytogenes is transmitted through ingestion of contaminated food. The challenge in management for this case, was distinguishing between neurolisteriosis and cerebral lupus with possible gut vasculitis thus requiring judicious steroid use, IVIG and appropriate antibiotics. To conclude L. monocytogenes infection in immunosuppressed SLE patients with neurological and gut manifestation, should always be ruled out. CR13

8th Negeri Sembilan Research Day 2023 Case Abstract Report 63 White Spots On Skin Is Not To Be Ignored : Case Series Of Hypopigmented Variant Mycoses Fungoides Nasiha A1 , Nor Akmar T1 1 Department Of Pathology, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan Introduction: Mycosis fungoides (MF) is a primary cutaneous T-cell lymphoma clinically characterized by the sequential evolution of varying hue patches with scale, plaques and tumours, and pathologically comprised of infiltrates of clonal small to medium sized mature T cells with hyperconvoluted nuclei, which are mostly epidermotropic. Typically these T lympocytes are predominantly CD4 positive.We present a case series of total 3 patients diagnosed with hypopigmented variant MF. Case report : All these patients were male, age third to fourth decade with Fitzpatrik skin type 3 . The latent period between onset and diagnosis was around 6 months to 5 years. All of the patients were asymptomatic with hypopigmented skin changes . Most common sites of distribution of the lesions were the back of the trunk and lower extremities (bathing suit distribution). All of the cases had been clinically mistaken for other skin disease such as fungal infections , Leprosy disease and vitiligo prior to correct diagnosis. Marked epidermotropism and tagging of epidermis by atypical lymphocytes characterizes the condition histopathologically. One of the case showed predominant CD8 positive epidermotropic infiltrates and the other two are predominantly CD4 positive. Discussion: Hypopigmented mycosis fungoides (HMF) is an uncommon variant of mycosis fungoides (MF) and it mimics many other benign hypopigmented skin lesions. It differs from the classic form in its clinical, histopathological, and immunohistochemical aspects. Conclusion : A high index of clinical suspicion, thorough clinical history and a histopathological examination will lead to proper and faster treatment of this rarely seen condition. CR14

8th Negeri Sembilan Research Day 2023 Case Abstract Report 64 Aortocaval Fistula Of Infrarenal Abdominal Aortic Aneurysm: A Rare Complication Noor Zulaika Rusli1 , Siti Khairunnisaak Abdul Rahman2 , Zurina Abdul Wahab3 1 Radiology Department, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan Background: An abdominal aortic aneurysm (AAA) is a localised dilation of the abdominal aortic wall with one of the consequences being aortocaval fistula which is an abnormal communication between the aneurysm and the inferior vena cava (IVC). Case report: This a case of a 60-year-old Malay gentleman with hematemesis, blackish stool, and abdominal pain and a significant drop in haemoglobin count. Transabdominal ultrasonography revealed an infrarenal abdominal aorta aneurysm. CTA of the abdominal aorta revealed a fusiform infrarenal AAA with several tortuous and dilated vessels that appear to emanate from the aneurysm's inferior aspect and communicate with the IVC. The aneurysmal wall appears to have displaced mural calcification with alternating thrombosed wall densities, as well as wall defect. An extended filling defect was also found within the IVC. Impending rupture of infrarenal abdominal aortic aneurysm with confined leak, complicated with aortocaval fistula and IVC thrombosis was stated as the overall features. Discussion: Ruptured abdominal aortic aneurysms are responsible for 3 to 7% of aortocaval fistula with more than 80% occurring spontaneous. Abdominal pain, back discomfort (or both), a pulsatile mass, and an abdominal bruit are the classic trio of clinical symptoms and signs in AAA patients with aortocaval fistula. Contrast CT is diagnostic in the majority of patients with suspected aortocaval communication. The majority patients require immediate surgical therapy, either endovascular or open surgery. CR15

8th Negeri Sembilan Research Day 2023 Case Abstract Report 65 Topic: Follicular Thyroid Carcinoma Presenting with Frontal Bone Metastases S Nor Shela1 , AL Nurulhuda1 , AW Zurina1 1 Department of Radiology, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan Background: Follicular thyroid carcinoma (FTC) is a slow growing tumour with high possibility for lungs and bone metastases. The incidence of skull metastases is otherwise rare, and usually occurred after the diagnosis and treatment of primary tumour (FTC). Case Report: We reported the case of a 71-year-old lady presented with two left frontals swelling that gradually became larger for 3 months. A computed tomography (CT) scan of the brain showed two lytic bone lesions with soft tissue components involving the left frontal bone. They involved the outer table, diploic space as well as the inner table of the left frontal bone. The biopsy showed atypical cells suggestive of metastatic thyroid follicular cells. On further questioning, the patient’s neck has been swollen for years without any increase in volume or compressive symptoms. An ultrasound of the neck showed a large heterogeneous mass occupying the whole right thyroid lobe, which caused tracheal deviation to the left. Thyroid mass histologic study showed follicular neoplasm.  Discussion: Bone metastasis from FTC is often to ribs, vertebra, and sternum. Skull is a rare site for metastasis of FTC. In few reported cases, skull metastasis of FTC is located in the skull base and also in the intraparenchyma, but in our case, it was seen at the frontal bone. CR16

8th Negeri Sembilan Research Day 2023 Case Abstract Report 66 Case Report: Orbital Cellulitis A Mirror For Aggressive Maxillary Sinus Lymphoma Nur Athirah A1 , Sangeetha1 , Jemaima Che Hamzah2 1 Department of Ophthalmology, Hospital Tuanku Ampuan Najihah, 72000 Kuala Pilah, Negeri Sembilan Background: The most prevalent nonepithelial tumours of the nasal cavity and paranasal sinuses are sinonasal lymphomas. They may invade adjacent tissues, such as the orbits, resulting in a variety of presentations and a diagnostic conundrum. Case report: A 62-year-old male patient presented with painful proptosis with visual impairment in the right eye for 14 days. On ocular examination, best-corrected visual acuity was 6/18 in the right eye (RE) and 6/9 in the left eye. There was right non-axial proptosis with hypertropia, swollen and erythematous eyelids, restricted extraocular movement in all gaze and conjunctival congestion with chemosis and tortuous conjunctival vessels. There is no relative afferent pupillary defect but reduced red saturation of left eye. The intraocular pressure was raised and fundus showed choroidal folds and scattered dot blot haemorrhages. The case was diagnosed as right eye orbital cellulitis to rule out cavernous sinus thrombosis and orbital tumour. He was admitted and treated with broad-spectrum intravenous antibiotics and antiglaucoma. Urgent contrast- enhanced computed tomography (CECT) orbit showed features suggestive of malignant right maxillary sinus mass with right orbital extension. ENT consultation with diagnostic nasal endoscopy and biopsy was done. Histopathological reports showed features of lymphoma. Patient was referred to tertiary centre for further management. Unfortunately, patients’ visual acuity of RE deteriorates to non-perception to light within two weeks. Discussion: Orbital malignancies masquerading as orbital cellulitis can pose a diagnostic dilemma. A multidisciplinary approach involving ENT consultation, radiological investigation, and pathological sampling can help achieve a timely diagnosis and appropriate management. CR17

8th Negeri Sembilan Research Day 2023 Case Abstract Report 67 Combination of Pharmacological and Vision Therapy in Managing Accommodative Spasm: A Case Report Nur Hidayah Y¹, Nurul Akimi A2 , 1 Department Of Ophthalmology, Hospital Tuanku Ampuan Najihah Kuala Pilah, Negeri Sembilan Background: Accommodative spasm is one of arising problem nowadays. Most of the cases was associated with the over usage of gadget. It may course severe symptom such as reduced visual acuity and asthenopia. This report present the chronology of assessing this kind of case and the utility of drug therapy and vision therapy in managing accommodation spasm. Objective: To report a case of severe accommodation spasm where the combination of drug therapy and vision therapy revealed successful result. Case report: We presented a case of accommodation spasm which presented with very poor initial visual acuity and symptom of prolong headache. 13 years old girl with initial VA 1/60 on RE and 2/60 on LE with history of excessive smartphone usage. This patient was started with drug therapy using Atropine 1% for one month which brings improvement in visual acuity. Refractive assessment after 1 month of drug therapy showed patient having mild hyperopia with astigmatism. Binocular assessment done after VA improved and revealed accommodative lead of -0.75 RE and -1.00 LE. Besides, amplitude of accommodation also reduced. Then patient prescribed with lens sorting, hart chart and rock card exercise and with patient compliance the accommodative function back to normal with AA of 13D on RE and 15D on LE which compatible with patient’s age. All symptoms also resolved. Discussion/conclusion: In this case, we support the previous study which showed combination of drug therapy and vision therapy provide patient with symptomatic relief and bring back normal accommodation function. CR18

8th Negeri Sembilan Research Day 2023 Case Abstract Report 68 Ohvira A Rare Cause Of Lower Abdominal Pain M.Punitha 1, AR Siti Khairunnisaak1 , AW Zurina1 1 Radiology Department, Hospital Tuanku Ampuan Najihah, Negeri Sembilan Background: Obstructed hemivagina and ipsilateral renal anomaly(OHVIRA) syndrome also known as Herlyn–Werner–Wunderlich(HWW) syndrome, abbreviates a complex urogenital anomaly of the female urogenital tract with variable onset of presentation. We present a case with emphasis on the imaging findings. Case Report: This is a case of a 13 years old girl, single, nulliparous, menarche at 11 years old with normal gynecological history. She presented with abdominal pain for 1 week associated with difficulty to urinate and passing motion. Examination showed suprapubic tenderness. Perineal examination revealed no hematocolpos whilst rectum compressed by mass from vagina anteriorly. Bedside transabdominal ultrasound by primary team showed a small uterus, complex cystic right adnexal mass and absent right kidney. Computed tomography findings of uterine didelphys with unilateral obstructed right hemivagina, right hematometrocolpos and hematosalpinx associated with ipsilateral renal agenesis. Patient was referred to a tertiary centre where she underwent uncomplicated vaginal septotomy. Post operatively, she was well with regular menses and normal ultrasound findings. She was scheduled for 3-6 monthly follow ups to ensure regular menses and serial ultrasounds to look for collections. Discussion: Prevalence of Müllerian tract congenital abnormalities is 2%-3%. Workup for related renal anomalies should be conducted. Ultrasound is low cost and real time imaging. CT scan or MRI would evaluate female reproductive system morphology, level of obstruction, characterise fluid contents, has multiplanar imaging capability, detect associated renal agenesis and diagnose complications1 . It helps for planning different treatment approaches. Early intervention is needed to reduce risk of endometriosis and infertility2. CR19

8th Negeri Sembilan Research Day 2023 Case Abstract Report 69 Replantation Dilemma,Atypical Avulsed Young Permanent Incisor with Root Fracture:A Case Report Sharlene Devi1 , Adelene Agos2 1 Department Paediatric Dental Surgery,Hospital Tuanku Ampuan Najihah,Kuala Pilah Negeri Sembilan Background: Avulsion happens 16% of all dental injuries in young permanent anterior incisors. Ideally, an avulsed tooth with adequate root length formation would be replanted back into the socket. However, root surface fracture on an avulsed tooth imposes a significant clinical challenge.The prognosis is highly dependent on the site of injury. Case Report: A case report of surface root fracture in young permanent maxillary central incisors of a 7 years 4 months old boy and its treatment dilemmas was discussed. He was brought in with an avulsed maxillary central incisor.The tooth was clinically examined and revealed a middle third surface root fracture with exposed pulp.Radiographic examination disclosed a radiopacity indicating the missing root surface fragment on the mesial wall of the socket.The root surface fragment was retrieved.The patient and parents were informed about the chances of replanted tooth survival and the probability of recurrent infections. Patient was reviewed periodically and an interim partial denture was issued to prevent loss of space.The management of this case was tailored according to patient compliance and the long term prognosis that would benefit the child in future. CR20

8th Negeri Sembilan Research Day 2023 Case Abstract Report 70 The Rare and Forgotten Complication: Brucella Infective Endocarditis Siow Ee Hong, MBBS1 , Lallitha Sivalinggam2 , MBBS, Suvintheran Thangavelu, MRCP(UK)1 1 Infectious Disease Unit, Medical Department, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan, Malaysia Background: Infective endocarditis secondary to brucellosis involving native or prosthetic valves is often considered to be an rare entity. Clinicians need to have a higher degree of suspicion as Brucella can present with non-specific signs and symptoms. Timely diagnosis with appropriate management using antibiotics that can prevent valvular damage and restore the valve's structural integrity and prevent mortality. In this case report, we present a case of Brucella Melitensis infective endocarditis treated with antibiotics and the challenges that we faced throughout the treatment period. Case Report: A 76 year old lady who had no known medical illness, presented with a 1 week history of fever, and malaise. She had exposure to cattle. On presentation she was febrile with no other signs or symptoms. She was admitted and treated empirically for urinary tract infection, whereby her blood culture grew: Brucella Melitensis on day 7 of admission. Sensitivity was not done for the culture. Echocardiogram showed a vegetation seen at posterior mitral valve measuring 1.06cm2 and diagnosis of Brucella Melitensis Infective Endocarditis was made. She was initiated on streptomycin, bactrim, rifampicin and docycycline. She however developed renal impairment needing the cessation of streptomycin and initiation of ciprofloxacin.  Discussion: Management of Brucella Infective Endocarditis remains a challenge due to long duration of treatment, combination of antibiotics and complication. Aminoglycosides, rifampicin and doxycycline are the common drugs used for treatment . Renal impairment is a common complication of aminoglycosides. Treatment strategies for patients with renal impairment and brucellosis infective endocarditis will be discussed.  CR21

8th Negeri Sembilan Research Day 2023 Case Abstract Report 71 Hemopericardium Post Fibrinolysis Leading To Cardiac Tamponade S.P.H. Wong1 , S.Kuppan2 , F.Azizan1 1 Department Of Internal Medicine, Hospital Tuanku Ampuan Najihah, Negeri Sembilan 2 Department Of Cardiology, Hospital Serdang Objective: We report a case of a hemopericardium causing cardiac tamponade in a patient who received combination therapy of fibrinolytic, antiplatelet and anticoagulant agents. Case Summary: A 66 year old gentleman presented with typical angina to a district rural hospital. His ECG showed ST segment elevations consistent with anterior STEMI (Killip I). He promptly received aspirin, clopidogrel, and streptokinase infusion. Fibrinolysis was successful and he was nursed in CCU. However on Day 3, he developed cardiogenic shock, cardiorenal syndrome and therefore transferred to the nearest Tertiary Hospital. Repeated ECG showed recurrence of ST elevation. He did not have angina at that time. Urgent echocardiography showed cardiac tamponade with ejection fraction of 35%. Cardiologist was consulted and was decided for pericardiocentesis which revealed hemopericardium. After 250ml was drained, tamponade resolved but however after 5 hours, it recurred and another 750ml was drained and he was transferred to CCU Hospital Serdang for further management. At Serdang, repeated ECHO ruled out myocardial rupture and CT angiography ruled out aortic dissection. Urgent angiogram showed triple vessel disease with culprit lesion at LAD for which POBA was done. Pericardial effusion resolved and Cardiac MRI showed viable RCA territory. He was discharged well. Discussion: When tamponade due to hemopericardium follows fibrinolysis for acute myocardial infarction, the clinical manifestations of tamponade might be easily mistaken for increasing heart failure. Under such circumstances, clinicians should suspect hemopericardium and promptly obtain an echocardiogram as early recognition and intervention is life-saving and yields favourable outcome. CR22

8th Negeri Sembilan Research Day 2023 Case Abstract Report 72 A Peculiar Case Of Dabigatran-Related Nephropathy : A Case Report S.P.H. Wong1 , F.Azizan1 1 Department Of Internal Medicine, Hospital Tuanku Ampuan Najihah, Negeri Sembilan Objective: To illustrate a rare case of Dabigatran-related nephropathy Case Summary: A 73 year old lady presented with nausea, vomiting and reduced oral intake for three days. Physical examination was unremarkable. She had recent hospitalization for pneumonia 2 weeks prior where she was found to have atrial fibrillation; therefore Dabigatran was initiated. She does not have history suggestive of connective tissue disorder. There were no nephrotoxic drug exposure otherwise. Her glomerular filtration rate decreased from a baseline of 52 to 6 mL/min, and she required acute hemodialysis as she was acidotic and uraemic. There were clinical improvement after one session of hemodialysis and renal function gradually improved with hydration and cessation of dabigatran. Autoimmune screen and imaging were unremarkable. Discussion between patient and nephrologist was made and it was decided not to pursue renal biopsy in view of the high risks involved; being elderly with small sized kidneys. We also discussed regarding anticoagulant reinitiation with a different class of anticoagulant, however she opted to wait until her kidney recovers further. She was discharged well after 8 days of hospitalization. Discussion: Dabigatran-related nephropathy can occur without prior renal disease. This widens the differential diagnosis for acute renal failure; especially when anticoagulants are used. Prompt diagnosis and cessation of anticoagulant has the potential to prevent kidney deterioration or dialysis. There is a need for more research on estimating the prevalence, along with stratifying risk factors and outcomes of this condition. CR23

8th Negeri Sembilan Research Day 2023 Case Abstract Report 73 BAYES SYNDROME : The Missing Puzzle Piece In Stroke Prevention? S.P.H. Wong Department Of Internal Medicine, Hospital Tuanku Ampuan Najihah, Negeri Sembilan Objective: Bayes syndrome is a new clinical entity, characterized by association of Interatrial block with increased risk of stroke, dementia and mortality. This case illustrates Bayes syndrome in a patient whom presented with stroke. Case Summary: An 81 year old lady with hypertension and dyslipidemia presented with left hemiparesis, slurred speech and facial asymmetry. ECG upon arrival appears to be just sinus bradycardia, but closer inspection revealed biphasic P wave morphology (±) in inferior leads, consistent with Bayes Syndrome. CT brain revealed right MCA territory infarction. Left atrium was dilated, otherwise ejection fraction and valves were normal. Antiplatelet, Statin, enteral feeding and rehabilitation was commenced. On Day 4 of stroke, ECG was repeated due to irregular pulse during review which showed Atrial fibrillation(AF). She was asymptomatic of palpitation. On the next day, her AF had spontaneously reverted back to sinus rhythm with Bayes pattern. She was discharged well on Day 7 post stroke with a follow up CT brain reassessment on Day 14 post stroke to decide anticoagulant initiation. Discussion: Although clinical trials are still ongoing to study the role of anticoagulation in Bayes syndrome, early identification of this pattern will prompt more extensive cardiac monitoring searching for AF, allowing earlier initiation of oral anticoagulation to prevent future stroke. For instance, the high suspicion of the clinician in this case allows detection of paroxysmal AF which could be missed as the patient was asymptomatic and it reverted back to sinus rhythm the next day. CR24

8th Negeri Sembilan Research Day 2023 Case Abstract Report 74 Riding Out A Storm In A Non-Cardiac Centre - A Challenging Conundrum S.P.H. Wong Department Of Internal Medicine, Hospital Tuanku Ampuan Najihah, Negeri Sembilan Objective: To illustrate a case of Ventricular tachycardia (VT) storm successfully managed with overdrive pacing, which is usually only performed in a Cardiology Centre. Case Summary: A 70 year old man, whom has hypertension, dyslipidemia, prosthetic aortic valve, and ischaemic heart disease presented to a district hospital with typical chest pain. Upon arrival he was hypotensive and cardiac monitor showed VT, which reverted to sinus rhythm after synchronized cardioversion. He was transferred to Serdang Hospital for percutaneous coronary intervention (PCI) which showed 99% ostial lesion at RCA which was stented and transferred back for continuation of care. However on Day 4 post PCI, he developed recurrent VT despite multiple cardioversions, amiodarone and lignocaine. Therefore overdrive pacing was performed under the remote guidance from Cardiologist. After stabilisation, he was transferred to CHDW Hospital Serdang for further management with an overdrive rate of 120 bpm. PCI showed patent RCA stent and single chamber Implantable Cardioverter Defibrillator was implanted. He was discharged well and scheduled for follow up in 1 month. Discussion: VT storm is a complex scenario to treat. The problem lies not in breaking an individual episode of VT; rather it is often that the VT keeps coming back. It is also a vicious cycle where repeated shocks causes myocardial injury leading to increased endogenous catecholamines, which in turn promotes more arrhythmias. A team approach is needed, with coordination between multiple services (eg: critical care, interventional cardiology, electrophysiology) to stabilize the patient. CR25

8th Negeri Sembilan Research Day 2023 Case Abstract Report 75 Eye Catching Tuberculosis Thamarai M1 , Sangeeta Kuganasan1 , Azhany Yaakub2 1 Department of Ophthalmology, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan 2 Universiti Sains Malaysia Introduction: Tuberculosis is an infection caused by Mycobacterium tuberculosis, an obligate aerobic acid fast bacillus. It can affect any organs and results in a broad spectrum of diseases. Ocular involvement represents extra pulmonary manifestation of tuberculosis which is rare, however it is highly recognized for causing devastating outcomes due to pathological damage to various structures including anterior uveal tract, retina and choroid. Case series: We report a retrospective myriad of ocular manifestations of tuberculosis in four of our patients from the Department of Ophthalmology at Hospital Tuanku Ja’afar Seremban from June 2022 to March 2023. Results: Four patients had a history of acute onset of unilateral reduced vision. Case 1 presented with bilateral optic disc hyperemia, choroiditis, vasculitis and multifocal retinal detachment. Case 2 presented with neuroretinitis with macula star. Case 3 presented with unilateral optic disc swelling and choroiditis in the peripapillary region. Case 4 presented with unilateral conjunctival abscess associated with peripheral ulcerative keratitis. A tuberculin skin test was positive in 3 patients and one patient had a positive Interferon Gamma Quantiferon Release Assay test. All the four patients were treated with Akurit 4 and Pyrodoxine. For all cases, systemic immunosuppressants were commenced to treat the associated inflammation. Case 1 and 2 received high doses of intravenous Methylprednisolone for 3 days followed by oral prednisolone while case 3 and 4 were treated with oral Prednisolone. All patients showed good visual outcomes with the antituberculosis treatment. Conclusion: Ocular tuberculosis imposes challenges in diagnosis as it can affect various ocular structures resulting in different manifestations. High clinical suspicion and early commencement of antituberculous treatment are crucial to prevent irreversible visual loss. CR26

8th Negeri Sembilan Research Day 2023 Case Abstract Report 76 Heterozygous Hemoglobin Charlieu Non-Deletional Alpha Thalassemia and Southeast Asian Ovalocytosis in a Newborn: A Rare Mutation Causing Early Onset Severe Hemolytic Anemia Liew CH1 , Yau KB1 1 Paediatric Department, Hospital Tuanku Ampuan Najihah, Kuala Pilah Background: Hemoglobin Charlieu (Hb Charleiu) is an exceptionally rare genetic mutation that leads to non-deletional alpha thalassemia. Presently, only two cases of this mutation have been reported worldwide. Notably, both cases were asymptomatic during early childhood and only developed anemia later in life. The novelty of our case report lies in the unusual presentation of this rare mutation, causing severe hemolytic anemia within the first week of birth. Case Summary: We present a case of a male child with Hb Charleiu and Southeast Asian Ovalocytosis (SAO) diagnosed at 1 year and 2 months of age. The patient experienced severe hemolysis on day 2 of his life and required a blood transfusion due to severe anemia at day 30 and 2 months of age. Peripheral blood film showed hypochromic microcytic red cells with ovalocytosis and stomatocytes, and genetic analysis confirmed a heterozygous state of alpha2 Codon 106 (CTG > CCG) Hb Charleiu mutation. Both parents were non-consanguineous, and while the father carried the same mutation, the mother had SAO without the Hb Charleiu mutation. Discussion: Our case report emphasizes the significance of examining additional hemoglobin abnormalities that may coexist with Hb Charleiu alpha thalassemia as a potential etiology of severe and early-onset neonatal anemia, despite the previous understanding of the asymptomatic nature of heterozygous hemoglobin Charleiu mutation. CR27

Acknowledgement Clinical Research Centre Hospital Tuanku Ja’afar would like to express our deepest gratitude and appreciation to the following individuals and groups towards the 8th Negeri Sembilan Research Day: Ybhg Datuk Dr. Muhammad Radzi Abu Hassan Director General of Health, Ministry of Health Malaysia Ybhg Datuk Dr. Nor Fariza binti Ngah Deputy Director General of Health (Research & Technical Support) Ybhg Datin Dr. Shamini A/P Sivasampu Director of Institute for Clinical Research, NIH Ybhg Dato’ Dr. Harlina binti Abdul Rashid Director of Health of Negeri Sembilan Ybhg Dato’ Dr. Zaleha binti Md Noor Director of Hospital Tuanku Ja’afar Seremban Dr. Akhmal Yusof Chief Executive Officer, Clinical Research Malaysia (CRM) Prof. Dr. Noran Naqiah binti Mohd Hairi Professor of Epidemiology & Public Health, University Malaya Particularly to our honourable judges for oral and poster competitions A heartfelt gratitude to our abstract reviewer Deepest thanks to our sponsor; AstraZeneca Sincere appreciation to: Unit Pendidikan & Promosi Kesihatan JKNNS Clinical Research Centre HTAN Unit Pendidikan & Promosi Kesihatan HTJS Unit Teknologi Maklumat & Komunikasi HTJS Unit Perhubungan Awam HTJS Unit Kualiti HTJS Unit Angkut HTJS Everyone who has contributed towards the success of the 8th Negeri Sembilan Research Day 2023. 8th Negeri Sembilan Research Day 2023 77

Clinical Research Centre (CRC) Hospital Tuanku Ja’afar Seremban Aras 2, Bangunan Klinik Pakar, Hospital Tuanku Ja’afar Seremban, Jalan Rasah, 70300 Seremban, Negeri Sembilan. Telephone : 06-768 4171 / 06-768 5255 Email : [email protected]