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Fulltext Husbands’ experience with their wives’ breast cancer: a qualitative study

Yusoff, N., Reiko Yap, K.M., Ahmad, A.

Malaysian Journal of Public Health Medicine, 2012;12(1):31-38.
MyJurnal

This study aims to explore the life experience of the husbands of women who survived breast cancer for more than five years following breast removal. Basic interpretative of qualitative methodology was applied in order to construct the phenomenon of breast cancer from the perspective of husbands. This approach allowed researchers to explore in-depth the experience of husbands in facing breast cancer of their wives. Four themes were identified. These are marital
challenges, pattern of life, supportive atmosphere and psychological defenses. Health strategies should direct the family member to the specific pathway in order to facilitate them towards the effective action of healthcare at their level. Evidence from this study is a direction for future research and health planning for better health policy.
Fulltext The Malay Version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30): Reliability and Validity Study

Yusoff, N., Low, W.Y., Yip, C.H.

International Medical Journal Malaysia, 2010;9(2):45-50.
MyJurnal

Introduction: The Malay Version of EORTC-QLQ C30 was validated among Malaysian women who had undergone breast cancer surgery. Materials and Methods: Test-retest evaluation (i.e. three weeks and ten weeks following surgery) was carried out to examine the validity and reliability of the scale. The Cronbach’s alpha value was used to determine the internal consistency, meanwhile, test-retest Intraclass Correlation Coefﬁ cients (ICC) indicates the reliability of the scale. Effect Size Index and Mean Differences interpret the sensitivity of the scale. Discriminant validity was evaluated by comparing two groups i.e. women who had mastectomy and women who had lumpectomy. Results: Internal consistencies are acceptable for Global Health Status (0.91), Functional domains (ranging from 0.50-0.89) and Symptomatology domains (ranging from 0.75-0.99). Intraclass Correlation Coefﬁ cient (ICC) ranged from 0.05 to 0.99 for Global Health Status and Functional domains, and ranged from 0.13 to 1.00 for Symptomatology domains. Sensitivity of the scale was observed in nearly all of the domains. Conclusion: The Malay Version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30) is a suitable tool to measure the quality of life of women with breast cancer.
Fulltext Cosmos caudatus Kunth. extract reduced number of microflora in oyster mushroom (Pleurotus ostreatus)

Yusoff, N. A. H., Sanuan, F. M., Rukayadi, Y.

International Food Research Journal, 2015;22(5):1837-1842.
MyJurnal

Nowadays consumer is more demand on natural foodstuff instead of synthetic product due to their concern on health. The objective of this study is to investigate the effect of C. caudatus extract on the number of microflora in oyster mushroom at different concentration of C. caudatus extract and exposure time using dilution method. The results showed that the number of microorganisms (Log10 CFU/g) in oyster mushroom in term of Total Plate Count (TPC), Bacillus cereus, Escherichia coli and Staphylococcus aureus were 6.13 ± 0.04, 6.15 ± 0.09, 5.97 ± 0.04, and 6.46 ± 0.00, respectively. The effect of C. caudatus extract on microflora in oyster mushroom at concentrations of 0.00%, 0.05%, 0.5%, and 5.0% with exposure time of 0, 5, 10, and 15 min demonstrated that the reduction number of microflora in oyster mushroom was dependent on the concentration of C. caudatus extract and exposure times. The number of TPC (Log10 CFU/g) in oyster mushroom was significantly reduced after treated with C. caudatus extract at concentration of 0.05% for 15 min; 6.13 ± 0.04 reduced to 2.62 ± 0.07. Moreover, B. cereus (Log10 CFU/g) in oyster mushroom was significantly reduced by treatment of C. caudatus extract at concentration of 0.05% for 5 min; 6.15 ± 0.09 reduced to 3.77 ± 0.15. Meanwhile, the number of E. coli (Log10 CFU/g) in oyster mushroom was significantly reduced at concentration of 0.05% for 10 min; 5.97 ± 0.04 reduced to 3.21 ± 0.13. Lastly, the survival number of S. aureus in oyster mushroom was significantly reduced after treated with C. caudatus extract at concentration of 0.05% for 15 min; 6.46 ± 0.00 reduced to 4.83 ± 0.07. In conclusion, C. caudatus extract has potentiality to be developed as natural sanitizer for rinsing raw food materials such as oyster mushroom.
Fulltext Translation and validity of the Malay version of the five-factor nonverbal personality questionnaire (FFNPQ)

Ab Rashid, N.F., Arifin, W.N., Kueh, Y.C., Yusoff, N.

International Medical Journal Malaysia, 2018;17(2):91-98.
MyJurnal

Introduction: The Five-Factor Nonverbal Personality Questionnaire (FF-NPQ) is a non-verbal personality inventory consisting of illustrations of different social situations, designed to measure five broad factors underlying the Big-Five model of personality. This study aimed to prove the validity of the FF-NPQ in Malaysia. Methods: The FF-NPQ instruction and the answer option were translated to the Malay language, which is the main language spoken in Malaysia. A total of 153 university students aged 18–30 years from Universiti Sains Malaysia were involved in this study. Confirmatory factor analysis (CFA), composite reliability and intraclass correlation (ICC) were applied to show evidence of validity by internal structure. Results: CFA indicated that only 26 out of 60 items remained in the final model while maintaining the five personality factors. Each factor had a good composite reliability value of 0.68–0.77. The ICC values from the test-retest analysis ranged from 0.65 to 0.75. Conclusion: Overall, the shortened Malay Version of the FF -NPQ (five-factor, 26 items) exhibited acceptable evidence of validity in Malaysia.
Fulltext A minireview of CYP2C9 and CYP2C19 single nucleotide polymorphisms (SNPs) among Malaysian populations

Rosdi R.A., Yusoff S., Mohd Yusoff N., Ismail R., Tan, C.S., Musa N.

Journal of Biomedical and Clinical Sciences, 2017;2(1):47-52.
MyJurnal

It has been recognized extensively that studies of pharmacogenetics provide massive examples of causal relationship between genotypes and drug effectiveness to account for interindividual phenotypic variations in drug therapy. In most cases, cytochrome P450 (CYP) polymorphisms are one of the major variables that affecting those drug plasma concentration, drug detoxification and drug activation in humans. Thus, understanding of CYP polymorphisms can be crucially valuable in order to allow early and more accurate drug dosage prediction and improve the drug response accordingly. Despite the high level of homologous amino acid sequences, CYP2C9 and CYP2C19 genes are among the most important CYP genes which metabolize a wide range of clinically therapeutic drugs. Several critical reviews have been published relating to the aforementioned genes. However, this minireview aims to systematically merge reported studies on the SNPs frequencies of both genes concentrating only on Malaysian population. It is hoped that, the minireview can be an opener for new opportunities to reevaluate the evidence on the prevalence of CYP2C genes as a potential genetic factor influencing a particular drug efficacy and safety among Malaysian. Such evaluation can be developed to the next level of early prediction of better and specific drug treatment, thereby improving the drug response while helping the government in minimising the drug expenditures.
Fulltext Drivers of green purchasing behaviour: a systematic review and a research agenda

Yusoff N, Alias M, Ismail N

F1000Res, 2023;12:1286.
PMID: 38196406 DOI: 10.12688/f1000research.140765.1

Background: Green purchasing is an important aspect of sustainable consumption, which decreases society's environmental effect. Although numerous research has been conducted to investigate the determinants of green buying behaviour, there has been a lack of effort in comprehensively analysing these findings. The purpose of this study is to examine the available literature on the factors that influence green purchasing behaviour. Methods: The review focused on empirical research published in peer-reviewed English-language publications between 2017 and 2021 in Web of Science and Scopus. The research took place from May to June 2021. Mixed Methods Appraisal Tool (MMAT) is used to assess the risk of bias in systematic literature reviews. Results: 41 articles were included, with significant focus on the retailing sector. Most of these studies were centred in Asian countries, primarily China and India. The Theory of Planned Behaviour was the most prominent, appearing 15 times, followed by the Theory of Reasoned Action (seven times). Analysis identified five main themes and 15 sub-themes related to green purchase behaviour drivers. These themes were categorized by occurrence: People (34 papers), marketing (13), knowledge (12), environment (12), and influence (nine). The dominant driver was people (34 studies), encompassing sub-themes including motivation (three), perception (eight), behavioural (13), and psychographic characteristics (10). Conclusions: This study has given an overview of the present status of green purchasing behaviour, which serves as a foundation for future studies and guidance for policymakers and practitioners. However, it does not include unpublished materials and non-English papers. Secondly, it focuses on articles from two databases within the last five years which doesn't encompass all article types, prompting the need for future exploration. Thirdly, extending the review's time frame could unveil more pronounced GPB patterns. Lastly, although all eligible papers were assessed based on criteria, the chance of overlooking some papers is acknowledged.
Ergonomic evaluation of postural stress in school workshop

Hashim AM, Dawal SZ, Yusoff N

Work, 2012;41 Suppl 1:827-31.
PMID: 22316824 DOI: 10.3233/WOR-2012-0249-827

The objective of this study is to compare the evaluation of postural analysis between a self-report questionnaire and physical assessments methods for students aged 13 to 15 years old in school workshop. 336 students were volunteered as participants to fill in the questionnaire and being observed in the workshop. Total of 104 positions were selected and analyzed while students performing their tasks. Questionnaire data was examined to specify the prevalence of postural stress symptoms. The relationship of postural stress by physical assessment methods (RULA and REBA methods) was defined to identify the risk level of students' working posture. From the results, comparison of four factors categorized from total of 22 questions among ages, the mean values were lower for 13 years old students meaning that they were faced higher posture problems while using the workstation. The obtained results from both physical assessment methods and questionnaire analysis have identified 13 years old students faced higher risk exposure. Analysis results emphasized the fact that self-reports questionnaire method has almost accurate as postural evaluation methods to identify physical risks in workplace. The result also shows that an intervention is needed to overcome the posture problems.
Fulltext The health seeking trajectories of Malaysian women and their husbands in delay cases of breast cancer: a qualitative study

Yusoff N, Taib NA, Ahmad A

Asian Pac J Cancer Prev, 2011;12(10):2563-70.
PMID: 22320956

The aim of this study was to assess why women delay in getting treatment (i.e. surgery) for breast cancer, as well as to explore on what type of issues are involved in such delay cases. Basic interpretative of qualitative methodology was applied to construct the reality of delay phenomena, and its interaction with social worlds. Six themes were identified: new conception of breast cancer treatment, psychological defenses, health support system, symtomatology experience, model and barriers. The delay issue in breast cancer requires attention as a multidimensional problem as this will facilitate more comprehensive and effective intervention to reduce delay.
Fulltext Psychometric properties of the Malay Version of the hospital anxiety and depression scale: a study of husbands of breast cancer patients in Kuala Lumpur, Malaysia

Yusoff N, Low WY, Yip CH

Asian Pac J Cancer Prev, 2011;12(4):915-7.
PMID: 21790225

The main objective of this paper is to examine the psychometric properties of the Malay Version of the Hospital Anxiety and Depression Scale (HADS), tested on 67 husbands of the women who were diagnosed with breast cancer. The eligible husbands were retrieved from the Clinical Oncology Clinic at three hospitals in Kuala Lumpur, Malaysia. Data was collected at three weeks and ten weeks following surgery for breast cancer of their wives. The psychometric properties of the HADS were reported based on Cronbach' alpha, Intraclass Correlation Coefficients (ICC), Effect Size Index (ESI), sensitivity and discriminity of the scale. Internal consistency of the scale is excellent, with Cronbach's alpha of 0.88 for Anxiety subscale and 0.79 for Depression subscale. Test-retest Intraclass Correlation Coefficient (ICC) is 0.35 and 0.42 for Anxiety and Depression Subscale, respectively. Small mean differences were observed at test-retest measurement with ESI of 0.21 for Anxiety and 0.19 for Depression. Non-significant result was revealed for the discriminant validity (mastectomy vs lumpectomy). The Malay Version of the HADS is appropriate to measure the anxiety and depression among the husbands of the women with breast cancer in Malaysia.
Study site: Oncology clinic, University of Malaya Medical Centre (UMMC), Hospital Kuala Lumpur, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Fulltext Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy: a Malaysian study

Yusoff N, Low WY, Yip CH

Med J Malaysia, 2010 Mar;65(1):41-4.
PMID: 21265247 MyJurnal

This paper validates the Brief COPE Scale in Malaysian women with breast cancer. Test-retest evaluation was undertaken at two/three weeks and ten weeks following surgery. Internal consistencies ranged from 0.25 to 1.00. Meanwhile, the Intraclass Correlation Coefficient (ICC) ranged from 0.05 to 1.00. Sensitivity of the scale was indicated by the mean differences as observed in most of the domains with Effect Size Index (ESI) ranged from 0 to 0.53. Significant differences between mastectomy and lumpectomy were observed for Active coping, Planning and Acceptance. Brief COPE Scale showed fairly good reliability and validity.
Aerosol-based delivery of fibroblast cells for treatment of lung diseases

Kardia E, Yusoff NM, Zakaria Z, Yahaya B

J Aerosol Med Pulm Drug Deliv, 2014 Feb;27(1):30-4.
PMID: 23409833 DOI: 10.1089/jamp.2012.1020

Cell-based therapy has great potential to treat patients with lung diseases. The administration of cells into an injured lung is one method of repairing and replacing lost lung tissue. However, different types of delivery have been studied and compared, and none of the techniques resulted in engraftment of a high number of cells into the targeted organ. In this in vitro study, a novel method of cell delivery was introduced to investigate the possibility of delivering aerosolized skin-derived fibroblasts.
Genetic variation in the glucose-6-phosphate dehydrogenase gene in Kelantan Malays with neonatal jaundice

Mohd Yusoff, N., Choo, K.E., Ghazali, S., Ibrahim, I., Mohd Hussin, Z.A., Mohd Yunus, et al.

Malaysian Journal of Paediatrics and Child Health, 2000;12(1):11-15.
MyJurnal

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked red blood cell enzymopathy common in malaria endemic areas. Individuals affected by this disease show a wide variety of clinical signs including neonatal jaundice. In this preliminary report we describe the heterogeneity of G6PD deficient gene in neonatal jaundice in the Malay population in Kelantan. Thirteen G6PD deficient Malay neonates with hyperbilirubinemia were subjected to mutation analysis of the G6PD gene for known candidate mutations. Molecular defects were identified in the 13 patients studied. Though all of these were mis-sense mutations, identified nucleotide changes were heterogeneous. Six patients were found to have a C to T nucleotide change at nucleotide 563 of the G6PD gene (C563T), corresponding to G6PD Mediterranean; three cases had a single nucleotide change at T383C (G6PD Vanua Lava), two cases had G487A (G6PD Mahidol) and two cases had G1376T (G6PD Canton). These findings suggest that there are heterogeneous mutations of the G6PD gene associated with neonatal jaundice in the Malay population in Kelantan.
Fulltext Psychometric properties of the Malay version of the Breast Module (BR23)

Yusoff N, Low WY, Yip CH

Singapore Med J, 2012 Jan;53(1):36-9.
PMID: 22252181

The Breast Module (BR23) is increasingly being used worldwide in breast cancer research. This study evaluates the appropriateness of the translated version (i.e. BR23-Malay version) as a useful tool for the Malaysian population who could understand Malay, and examines the reliability and validity of the BR23-Malay version.
Fulltext Maximum acceptable frequency of lift for combined manual material handling task in Malaysia

Widia M, Md Dawal SZ, Yusoff N

PLoS One, 2019;14(5):e0216918.
PMID: 31141545 DOI: 10.1371/journal.pone.0216918

BACKGROUND: Extensive studies have been carried out over the years to determine the maximum acceptable weight that a worker is capable of lifting in a given situation among Occidental populations across Europe and US. Nonetheless, studies that place emphasis on using lifting frequency as the quantifying task parameter, especially in developing countries such as Malaysia, appear to be in scarcity. Hence, this study determined the maximum acceptable frequency of lift (MAFL) for combined manual material handling (MMH) tasks amongst Malaysian males.
METHOD: Two lifting loads were considered in this study: 1 kg and 5 kg. Each subject adjusted his frequency of lifting using a psychophysical approach. The subjects were instructed to perform combined MMH task as fast as they could over a period of 45 minutes without exhausting themselves or becoming overheated. The physiological response energy expenditure was recorded during the experimental sessions. The ratings of perceived exertion (RPE) for four body parts (forearms, upper arm, lower back and entire body) were recorded after the subjects had completed the instructed task.
RESULTS: The mean frequencies of the MMH task had been 6.8 and 5.5 cycles/minute for lifting load of 1 and 5 kg, respectively, while the mean energy expenditure values were 4.16 and 5.62 kcal/min for 1 and 5 kg load, respectively. These displayed a significant difference in the Maximum Acceptable Frequency of Lift (MAFL) between the two loads, energy expenditure and RPE (p < 0.05) whereby the subjects appeared to work harder physiologically for heavier load.
CONCLUSION: It can be concluded that it is significant to assess physiological response and RPE in determining the maximum acceptable lifting frequency at varied levels of load weight. The findings retrieved in this study can aid in designing tasks that do not exceed the capacity of workers in order to minimise the risk of WRMSDs.
Fulltext The Effect of Sex on the Electropsychological Process of Emotional Arousal Intensity

Yusoff N, Anuar NN, Reza MF

Malays J Med Sci, 2018 May;25(3):103-110.
PMID: 30899191 MyJurnal DOI: 10.21315/mjms2018.25.3.10

Background: Sex is a psychobiological factor that is important in the process of emotion. This study determines the effect of sex on the electropsychological process of various intensities of emotional arousal.
Methods: In the Event-related Potential (ERP) session, electroencephalographic (EEG) data was recorded for 90 participants, 60% of whom were females. The participants responded to 30 universal emotional pictures, randomly chosen from the International Affective Picture System (IAPS), which were classified as invoking high, moderate, and low intensity of emotional arousal.
Results: From the analysis of variance of two-way mixed design, the interaction between sex and emotional intensity was observed in the occipital regions (O2), indexed by the amplitude of P300 and N200 components. Males exhibited higher amplitude of P300 and N200 components (in the occipital region) as responded to high and low emotional arousal stimuli than females.
Conclusion: Sex is a fundamental factor that modulates psychological states in reaction to emotional stimuli.
Role of supraspinal vasopressin neurones in the effects of atrial natriuretic peptide on sympathetic nerve activity

Yusof AP, Yusoff NH, Suhaimi FW, Coote JH

Auton Neurosci, 2009 Jun 15;148(1-2):50-4.
PMID: 19349212 DOI: 10.1016/j.autneu.2009.03.005

The aim of the present study was to determine if paraventricular-spinal vasopressin neurones participate in the sympatho-inhibitory effects of systemically administered atrial natriuretic peptide (ANP) on renal sympathetic nerve activity (RSNA). Experiments were carried out on male Sprague-Dawley rats anesthetized with 1.3 g/kg urethane. Changes in mean arterial pressure (mm Hg), heart rate (beats per minute) and RSNA (%) were measured following intravenous bolus administration of ANP (250 ng, 500 ng and 5 microg). Intrathecal application of selective V 1a receptor antagonist was performed to test for the involvement of supraspinal vasopressin pathways in mediating the effect on sympathetic outflow evoked by intravenous ANP administration. The results obtained demonstrated that both low and high doses of ANP caused renal sympathoinhibition (250 ng; - 7.5 +/- 1%, 500 ng; - 14.2 +/- 1%, 5 microg; - 16.4 +/- 2%), concomitant with vasodilation and bradycardia. After spinal vasopressin receptor blockade, the inhibitory effects of ANP were prevented and there was a small renal sympatho-excitation (250 ng; + 1.7 +/- 0.2%, 500 ng; + 6.1 +/- 0.03%, 5 microg; + 8.0 +/- 0.03%, P < 0.05). Therefore, the renal sympathetic nerve inhibition elicited by circulating ANP is dependent on the efficacy of a well established supraspinal vasopressin pathway. Since supraspinal vasopressin neurones without exception excite renal sympathetic neurones, it is suggested that ANP elicits this effect by activating cardiac vagal afferents that inhibit the spinally projecting vasopressin neurones at their origin in the paraventricular nucleus of the hypothalamus.
The prevalence of enamel opacities in permanent teeth of 11-12 year-old school children in Kuala Lumpur, Malaysia

Yusoff N, Jaafar N, Razak IA, Chew YY, Ismail N, Bulgiba AM

Community Dent Health, 2008 Mar;25(1):55-8.
PMID: 18435236

To determine the prevalence, distribution, severity and treatment need of enamel opacities among 11-12 year-old school children in a fluoridated urban community.
Fulltext 56 nm Wide-Band Tunable Q-Switched Erbium Doped Fiber Laser with Tungsten Ditelluride (WTe2) Saturable Absorber

Ahmad H, Albaqawi HS, Yusoff N, Yi CW

Sci Rep, 2020 Jun 17;10(1):9860.
PMID: 32555280 DOI: 10.1038/s41598-020-66664-9

A wide-band and tunable Q-switched erbium-doped fiber (EDF) laser operating at 1560.5 nm with a tungsten ditelluride (WTe2) saturable absorber (SA) is demonstrated. The semi-metallic nature of WTe2 as well as its small band gap and excellent nonlinear optical properties make it an excellent SA material. The laser cavity uses an 89.5 cm long EDF, pumped by a 980 nm laser diode as the linear gain while the WTe2 based SA generates the pulsed output. The WTe2 based SA has a modulation depth, non-saturable loss and saturation intensity of about 21.4%, 78.6%, and 0.35 kW/cm2 respectively. Stable pulses with a maximum repetition rate of 55.56 kHz, narrowest pulse width of 1.77 µs and highest pulse energy of 18.09 nJ are obtained at the maximum pump power of 244.5 mW. A 56 nm tuning range is obtained in the laser cavity, and the output is observed having a signal to noise ratio (SNR) of 48.5 dB. The demonstrated laser has potential for use in a large number of photonics applications.
Electrocatalytic Reduction of Hydrogen Peroxide and Its Non-Enzymatic Electrochemical Detection Using Silver Nanoparticles Anchored on Reduced Graphene Oxide

Ikhsan NI, Rameshkumar P, Yusoff N, Huang NM

J Nanosci Nanotechnol, 2019 Nov 01;19(11):7054-7063.
PMID: 31039858 DOI: 10.1166/jnn.2019.16630

Silver-reduced graphene oxide (Ag-rGO) nanohybrid was synthesized by applying a slight modification to the Turkevich method using trisodium citrate as a reducing and stabilizing agent to catalyze the non-enzymatic electrochemical detection of hydrogen peroxide (H₂O₂). Spherical silver nanoparticles (AgNPs) with an average particle size of 2.2 nm surfaced on reduced graphene oxide (rGO) sheets. Cyclic voltammograms (CV) obtained from glassy carbon (GC) electrode coated with Ag-rGO nanohybrid (4 mM) exhibited a peak at an overpotential of -0.52 V, with a larger faradaic current for the reduction of H₂O₂. Using the modified electrode for the linear sweep voltammetry (LSV) detection of H₂O₂, the detection limit and sensitivity were determined to be 4.8 μM (S/N ═ 3) and 0.0262 μA μM-1, respectively. The sensor appeared selective and stable towards H₂O₂ in the presence of possible interference, and it also demonstrated good recoveries of H₂O₂ concentration in real water samples.
Internal jugular vein thrombosis in a child

Thong PL, Yusoff NA, Nunis MA, Khairoonnisa MN

Med J Malaysia, 2021 05;76(3):438-440.
PMID: 34031350

Venous thrombosis is a potentially life-threatening condition with varied aetiology. First described in 1912 as a complication of peritonsillar abscess, internal jugular vein (IJV) thrombosis is a rare entity in children with very few cases reported until now. Among the leading causes of this condition are prolonged use of IJV for venous access and central venous catheterisation, acute mastoiditis and Lemierre's syndrome.1 IJV thrombosis can also occur as a complication of head and neck infections, but rarely appears as its first presentation. The clinical manifestations are often vague and ambiguous, thus requiring a high index of suspicion to diagnose IJV thrombosis. We describe here a case of internal jugular vein thrombosis (IJVT) and the management of this rare condition in an otherwise healthy 8- year-old boy. The patient was investigated thoroughly to rule out possible pathological causes of IJV thrombosis and managed holistically with a multidisciplinary team approach. Although the occurrence is rare, it should be recognised as a complication of deep neck infections in order to initiate prompt and accurate therapy.

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