If you or your child ever had these skin problems, the answer may well be a yes! It is estimated that about 20% of children and 10% of adults suffer from a condition called ECZEMA.

What is eczema?
Eczema is the medical term for a skin condition that causes dry, itchy and inflamed rashes on the skin. It is a common condition in young children but it can occur in almost any age group. It is not contagious. The skin barrier helps your skin to retain moisture and protects your body from outside elements. When eczema happens, the skin barrier is weakened. This will allow bacteria, viruses, irritants and allergens to enter the body easily.

What are the Symptoms?
Initially, itchy rashes and skin dryness are first noticed. Depending on the patient’s skin colour, the rash can be red, pink or brownish in colour. Rubbing or scratching worsens the rash so it is often called “the itch that rashes.” The itch is usually worse in the evening triggered by sweating or rough clothing. It tends to involve the face, neck, elbow, elbow folds, knee and at the back of knees. Close family members with similar skin problems make the diagnosis more likely.

Who is prone to eczema?
Almost anyone of any race or gender can have eczema at any age. However, it tends to begin in the first 2 years of life but some may develop it even after puberty or during adulthood. Those with a family background of atopy (i.e eczema, bronchial asthma and allergic rhinitis) are more likely to get it.

What makes eczema worse?
     •   Climate: extremes of temperature, low humidity
     •   Irritants: wool/ rough fabrics, perspiration, detergents
     •   Infections: skin infections or other infections
     •   Environmental allergies: dust mites, pollen
     •   Food allergies: common allergens- eggs, milk, peanuts, shell fish, soy, wheat

(Note: detection of allergen specific Ig E via blood does not necessarily mean that allergy triggers the eczema)

The impact?
Eczema can have a significant impact on a person’s daily life. When scratching results in a wound with itchiness and inflammation, a child may not want to bathe as he will suffer an unpleasant stinging sensation. Sleep will be disturbed leaving the child irritable. In school, they may be stigmatized and other children may be hesitant to interact with the child with eczema. As they grow older, they may become self-conscious of the way their skin looks. Fortunately, early diagnosis and effective treatment can help patients and family members deal with this skin condition.

When to consult a dermatologist?
When sensitive skin care regimes and avoidance of irritants fail to completely clear up the itchy rash, it is time to consult a dermatologist. You or your child may need more potent treatment. Alternatively, it is possible that the rash is not due to eczema.

How do we treat eczema?
Upon diagnosing eczema, the dermatologist will prescribe topical products, such as topical steroids or calcineurin inhibitors as well as oral antihistamines. Other treatment options include phototherapy, wet wrap, systemic medications that target the immune system. Recently, newer oral and injectable monoclonal antibody have been proven effective.

Although eczema cannot be cured, it can be managed. Fortunately, some children’s symptoms lessen or disappear as they grow up. Hence, eczema should be diagnosed and managed early so that your child can thrive!

All photos credit: Dr. Janet Lee Hoong May

Dr. Janet specialises in a variety of skin, scalp, hair and nail disorders for both adults and children i.e. acne, psoriasis, eczema, skin allergy and allergic testing, skin pigmentations, skin cancers, skin infections as well as hair loss. She has vast experience in dermatological procedures such as skin biopsy, electrocautery and excision, intralesional injections, cryotherapy, lasers and chemical peeling.

by Dr. Yeo Geok Ping,
Consultant Nephrologist & Physician

In National Health and Morbidity Survey 2019, the prevalence of Diabetes Mellitus (DM) amongst adults age >18 years old had increased from 11.2% (2011) to 18.3%.(2019). Over time, DM may lead to serious complications like heart attacks, strokes, kidney disease, vision loss, and nerve damage. DM remains the most common cause of End Stage Kidney Disease (ESKD), accounting for 53% of all new ESKD patients in 2021, followed by hypertension (33.9%).

How diabetes cause kidney disease?
Kidneys are two bean-shaped organs, each about the size of a fist located in the middle of your back, just below your ribcage. Each kidney is made up of millions of tiny filters called nephrons. These filters help to remove waste and excess water from the blood into the urine while leaving protein and other substances in blood. Kidneys also help to control blood pressure, produce red blood cells and activate Vitamin D. Over time, high blood sugar from diabetes can damage blood vessels in the kidneys as well as nephrons so they don’t work as well as they should.  Around 20-30% of people with diabetes develop Diabetic Kidney Disease.

How to detect Diabetic Kidney Disease (DKD)?
Diabetic Kidney Disease (DKD) is kidney damage caused by DM. When the kidneys are working normally, they prevent albumin from leaking into the urine. Hence, the earliest sign of DKD is increased excretion of albumin in the urine. The kidney doctor (nephrologist) will perform assessment and screen for kidney damage by doing blood and urine tests.

Screening tests may include:

1.  Urine test to measure excretion of albumin in urine.
2. Blood test to measure level of creatinine. It can estimate how well the kidneys filter blood. High creatinine indicates a low eGFR (estimated Glomerular Filtration Rate), indicating poor kidney function.
3. Ultrasonography of kidneys to assess the size of kidneys. The kidneys are usually normal or increased in size in the initial stages but later may shrink as the disease progresses.

What happens if there is kidney failure?
There are five stages of Chronic Kidney Disease (CKD). It is a silent killer as it may progress insidiously over time without any clinical manifestation. Eventually, DKD may cause the kidneys to shut down, leading to the last stage (stage 5) of CKD, known as End Stage Kidney Disease (ESKD).

Symptoms and signs of kidney failure include:
     •   Nausea and vomiting
     •   Fatigue
     •   Swelling in the face, ankles and feet
     •   Breathlessness
     •   High blood pressure
     •   Confusion
     •   Dry skin and itchiness
     •   Anemia

ESKD occurs when the kidneys can barely function to meet day-to-day requirements. In this final stage, dialysis or kidney transplant is a must in order to survive. Kidney transplant involves the transfer of a healthy kidney from one person into the body of a person who has little or no kidney function. Kidney transplantation is the optimal treatment for improving survival and quality of life for patients with ESKD.

There are two types of dialysis treatments available to remove toxin and extra fluids from the body. Haemodialysis will require a machine that removes blood from the body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to body via vascular access either arteriovenous fistula (AVF) or dialysis catheter. Every Haemodialysis will be individualized but generally it takes an average of 4 hours per session and 3 treatments per week. Peritoneal Dialysis is dialysis using the peritoneal membrane, which is the natural lining of abdomen, via a tenckhoff catheter that is  surgically placed in the abdomen. Continuous Ambulatory Peritoneal Dialysis (CAPD) is carried out manually every day. There are usually 4 exchanges during the day. Automated Peritoneal Dialysis (APD) requires a machine to perform three to five exchanges during the night while sleeping.

How do we treat Diabetic Kidney Disease (DKD)?
There is no medication or therapy that can reverse the kidney damage done. However, with the correct treatment, we can slow down the progression of DKD:
• Lifestyle modification : Stop smoking, regular exercise (At least 150 minutes per week)
• Healthy diet: Low salt and sugar.
• Good sugar control : The treatment will be individualized to prevent development of hypoglycaemia (low blood sugar)
• Good blood pressure control: Recommended goal below 130/80 mmHg, however target should be individualized.
• Avoid over-the-counter pain medication including non-steroidal anti-inflammatory drugs (NSAIDS) or non-FDA approved supplement.
• Compliance to medications and follow up are of paramount importance to retard the disease progression of DKD.

Time is critical in the treatment of kidney disease. The key point here is to have early diagnosis and treatment without delay, in order to minimize loss of kidney tissue from the injury. 

Therefore, it is imperative to consult a nephrologist early, in order for a prompt diagnosis and initiation of treatment.

Sidenote: 
Having foamy urine?
This could be your kidneys ‘leaking’ protein, the earliest sign of kidney disease.

“Time is kidney”
A key point here is to have early diagnosis and treatment as soon as possible without losing time, in order to minimize loss of kidney tissue from the injury.

A brain tumour is a mass of abnormal cells in the brain. Skull, which encloses the brain, is very rigid. Any growth inside such a restricted space can cause problems.

Brain tumours (BT) can be divided into primary and secondary tumours. Primary BT refers to a tumour that originates from the brain tissue and remain inside the brain. This is further divided into non-cancerous (benign) and cancerous (malignant) tumours.

Secondary brain tumours, also known as a metastatic brain tumour, occurs when cancer cells spread to brain from another organ. Metastatic tumours are considered cancer and are malignant. Secondary brain tumours most often occur in people who have a history of cancer. Rarely, a metastatic brain tumour may be the first sign of cancer that began elsewhere in your body. In adults, secondary brain tumours are far more common than are primary brain tumours.

Any cancer can spread to the brain, but common types include:
     •   Breast cancer
     •   Colon cancer
     •   Kidney cancer
     •   Lung cancer
     •   Melanoma

Data from the Malaysian National Cancer Registry Report (MNCRR) for 2012-2016 revealed a total number of 2,097 cases of brain BT among the Malaysians with 1,117 cases among males and 908 cases females, which ranked as 11th and 13th most common cancer among males and females respectively.

There are many symptoms of brain tumour. The early warning signs of a brain tumour can vary depending on the location of the tumour and the functional system (e.g., motor, sensory, language) it affected. Usually, the specific neurological effects of brain cancer may be associated with the brain tumour’s location or with compression of a certain area of the brain. For instance, a brain tumour near the optic nerve may result in visual problems but potential signs can include weakness, the ability to think, concentrate and balance problems. Individuals with brain tumours may also experience seizures and mental confusion.

But symptoms of brain cancer may not always match up to the tumour location—a brain tumour may cause more compression elsewhere, and the symptoms may correspond to the region of compression, not the area of the cancer.

Any considerably large brain tumour may cause several symptoms because of the pressure produced by the mass. Swelling in the brain caused by the brain tumour or surrounding inflammation may also result in specific symptoms.

Common symptoms of brain tumour may Include:
     •   A headache gets worse over time and certain time of the day
     •   Seizures
     •   Difficulty walking
     •   Numbness in part of the body
     •   Nausea and vomiting
     •   Memory loss
     •   Muscle weakness
     •   Blurring of vision, double vision or vision problems
     •   Difficulty in speaking 
     •   Mood and personality changes
     •   Tiredness
     •   Gradual changes in emotional response and intellectual capacity

Some symptoms may be caused by other diseases. The only way to tell for sure is to get tested. Brain cancer may develop overtime, without any obvious signs or with mild symptoms, but it may also suddenly cause severe and fast deterioration.

Imaging tests can help to differentiate if the tumour is a primary brain tumour or secondary cancer that has spread to the brain from elsewhere in the body. Imaging tests show pictures of the inside of the body.

Few factors need to consider when choosing a diagnostic test:
     •   Type of tumour
     •   Signs and symptoms
     •   Age and general health
     •   The results of earlier medical tests

With advancement in imaging techniques can pinpoint brain tumours. Diagnostic tools include computed tomography (CT or CAT scan), Positron Emission Tomography (PET scan) and magnetic resonance imaging (MRI).

CT scan using x-ray to takes images of the inside of the body from different angles. A computer software will reconstruct these pictures into a detailed, 3-dimensional image that shows any abnormalities or tumours. A CT scan can help find blood clot inside the brain and accumulation of fluid in the fluid-filled spaces of the brain, called ventricles. Any bone changes in the skull can also be seen on a CT scan. Sometimes, a contrast medium (dye) is given into patient’s vein (intravenous) before the scan to provide better detail on the image.

Positron emission tomography (PET) or PET-CT scan is used at first to find out more about a tumour while a patient is receiving treatment. It may also be used if the tumour comes back after treatment. A PET scan is usually combined with a CT scan, called a PET-CT scan. A small amount of a radioactive substance is injected into the patient’s body. This substance is taken up by tumour cell as they are actively dividing (growing), they absorb more of the radioactive substance. However, the amount of radiation in the substance is too low to be harmful. A scanner then detects this substance to produce images of the inside of the body.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A special dye called a contrast medium is given into patient’s vein before the scan to create a clearer picture. MRIs create more detailed pictures than CT scans and are the preferred way to diagnose a brain tumour. The MRI may be of the brain, spinal cord, or both, depending on the type of tumour suspected and the likelihood that it will spread in the brain and spinal cord. There are different types of MRI, doctor will helps determine which type of MRI to use.

A functional MRI (fMRI) provides information about the location of specific areas of the brain that are responsible for muscle movement and speech. During the fMRI examination, the patient is asked to perform certain tasks that cause changes in the brain activity and can be seen on the fMRI image. This test is used to help plan surgery in order to avoid damaging the functional parts of the brain while removing the tumour.

Magnetic resonance spectroscopy (MRS) is a test using an MRI that provides information on the chemical composition of the brain. It can help tell the difference between any dead tissue caused by previous radiation treatments and new tumour cells in the brain.

A sample of the tumour’s tissue is the only definitive way a brain tumour can be diagnosed. A sample of tumour tissue for examination under a microscope by a pathologist, a doctor who specialises in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A biopsy can be done as part of surgery to remove the entire tumour. Or surgery may be done as a separate procedure if completely removing the tumour is not possible because of its location or a patient’s health.

Treatment for brain tumours depends on the specific size and type of the mass as well as the patient’s specific tolerance for medications. Treatment options include medications to control seizures, surgery and steroid medications, as well as radiation and chemotherapy. Individuals with tumours that have the potential to grow rapidly may benefit from targeted therapy treatments in which specific parts of the cell are treated to hinder their growth.

Dr. Ch’ng Chee How is a resident Consultant Neurosurgeon with special interests in Brain Tumour and Minimally Invasive Endoscopic Skull Base Surgery.

He has gained vast experience in Brain and Spine Surgery from working at various tertiary neurosurgical centres including Hospital Pulau Pinang, Hospital USM, Hospital Kuala Lumpur, Hospital Sultanah Aminah (Johor) and Hospital Queen Elizabeth (Sabah). In 2018, he was conferred the Excellent Service Award from Hospital Pulau Pinang for exemplary overall performance.

by Dr. Lim Shyang Yee,
General, Upper Gastrointestinal & Bariatric Surgeon

Gastro-esophagus junction is where your food pipe (esophagus) joins the stomach. Cancer which starts from the inner lining of this junction is called gastro-esophagus cancer.

It may be sometimes difficult to tell the difference between stomach, esophagus and gastro-esophagus cancer. In combination esophagus and stomach cancer are the 4th most common cancer. Both cancers in combination are the second most cause of cancer deaths in Malaysia. They can behave differently to cancers of the stomach and esophagus.

In Malaysia, the incidence of esophagus cancer located at the gastro-esophagus junction has increased from 55% to nearly 70% over the last 15 years. Yet 70-80% of patients with this cancer present to specialist very late either stage III or IV of the disease.

Who is at risk?
     •   Chronic Gastroesophagus Reflux Disease (with or without Hiatus Hernia)
     •   Obesity: Higher incidence of hiatus hernia and GERD
     •   Barrett’s Esophagus: Pre-cancerous condition.
     •   Smoking & Excessive Alcohol

How do I know?
Early cancer does not have a specific symptom. Dyspepsia or indigestion is a non-specific symptom. Most patients have difficulty of swallowing by the time they seek consultation.

Upper endoscopy examination under sedation (inserting a flexible camera inside the esophagus and stomach through the mouth) to visualize any growth and take sample for confirmation of the diagnosis.

Once diagnosis is confirmed, radiology imaging like PET-CT scan to determine the stage of the cancer and doctor to discuss treatment option.

Can this cancer be cured?
Stage of cancer determined the curability of the cancer. If pre-cancerous condition like Barrett’s esophagus is detected early on endoscopy, it can be burned with endoscopic radiofrequency ablation (RFA) and prevent progression to cancer.

Early cancer can be treated with endoscopic resection (shaving the inner layer of the gastro-esophagus mucosa/lining).

Advanced stage II and III cancer require pre-operative treatment of chemotherapy before surgical removal of the lower end of esophagus and removal of affected the lymph nodes. If the cancer has spread to significant portion of the stomach, the stomach will require complete removal.

Can I still able to eat after stomach or esophagus resection?
After surgical removal of the disease esophagus and small portion of the stomach, the remaining stomach will be used to restore the continuity of the food passage. After recovering from surgery, food must be properly chewed for smooth swallowing.

For cancer that spreads to the stomach and require total removal of the stomach, the small or large intestine (colon) will be used to restore the continuity of the food passage. After recovering from surgery, patient will still be able to eat and consume smaller portion of food with proper chewing and frequent meals. As absorption of food nutrient occur in the small intestine, most patient can live with their regular food and vitamin B12 supplements.

How is the recovery after surgery?
Surgery to remove the gastro-esophagus cancer is a major complex surgery. Enhanced recovery after surgery (ERAS) pathway is beneficial for patient who undergoes major complex surgery. Before going for a major sport event athletes undergo proper physical training and adequate preparation & nutrition. Likewise this surgery needs pre-habilitation (activity to improve functional capability and enhanced general wellness before surgery) with adequate pre-surgery nutrition supplements, stop smoking and stabilizing the patient’s co-existing medical conditions before embarking on surgery.

Minimal invasive surgery (keyhole or laparoscopic surgery) can be performed with less post-operative pain and early ambulation.

Is gastro-esophagus cancer preventable?
Maintaining a healthy weight, early treatment of GERD and pre-cancerous Barrett’s esophagus can prevent this cancer. Early upper endoscopy is essential for early detection and better survival.