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Angiosarcoma - a rare fatal cause of recurrent pericardial effusions

Ng BH, Tan YS, Pavitratha P, A Hing C, Zainul NH, Lim CH

Med J Malaysia, 2020 11;75(6):759-761.
PMID: 33219196

A 40-year-old man presented to the Hospital Sultanah Bahiyah, Alor Setar, Kedah, with constitutional and respiratory symptoms. Physical examination and echocardiogram demonstrated massive pericardial effusion. Patient required multiple attempts of pericardiocentesis due to recurrent pericardial effusion. Initial workup including pericardial fluids examination and computed tomography imaging did not reveal any apparent cause. Magnetic resonance imaging showed a suspicious mass infiltrating into the right atrium. Autoimmune screening was negative. Patient was subsequently treated as having tuberculous pericarditis. However, his disease progressed rapidly and he eventually passed away due to right atrial rupture. Postmortem revealed a ruptured right atrial tumour leading to massive haemothorax. Histopathological examination confirmed the diagnosis of primary pericardial angiosarcoma.
Fulltext Resolution of refractory chylothorax with a combination of talc pleurodesis and CPAP

Ng BH, Nik Abeed NN, Abdul Hamid MF, Soo CI, Low HJ, Ban AY

Respirol Case Rep, 2020 Oct;8(7):e00624.
PMID: 32685169 DOI: 10.1002/rcr2.624

Chylothorax is an uncommon cause of pleural effusion. Recurrent chylous effusions are often resistant to conservative treatment and many need surgical intervention. We report a 69-year-old woman with refractory idiopathic chylothorax resistant to medium-chain triglyceride diet and intermittent thoracentesis. Lymphangiography and lymphoscintigraphy failed to identify the site of leakage. We initiated continuous positive airway pressure (CPAP) 12 h before and 48 hours after talc pleurodesis. Chest drain was removed at day 3 and she was discharged at day 5. To our knowledge, this is the first case of successful resolution of idiopathic refractory chylothorax with CPAP ventilation used in tandem with talc pleurodesis.
Fulltext Indwelling pleural catheter and successful autopleurodesis of refractory inflammatory lupus effusion

Ng BH, Nik Abeed NN, Abdul Hamid MF, Soo CI, Low HJ, Ban AY

Respirol Case Rep, 2020 Oct;8(7):e00621.
PMID: 32685166 DOI: 10.1002/rcr2.621

Indwelling pleural catheter (IPC) is a useful tool for refractory malignant pleural effusions (MPEs). It allows palliation by intermittent symptomatic relief of the effusion and improves quality of life. Its use in benign pleural effusions comes mainly from retrospective studies, case series, and case reports. Lupus effusion is common, causes minimal symptoms, and usually responds to either steroid therapy or immunosuppressants. Refractory lupus effusion is less common and treatment may require invasive surgical pleurectomy. We describe a 52-year-old woman whose first presentation of systemic lupus erythematosus (SLE) was a pleural effusion refractory to steroids and immunosuppressants. She successfully achieved spontaneous pleurodesis with intermittent IPC drainage at three months.
Understanding of Coronavirus Disease 2019 (COVID-19) and the practice of preventive measures among doctors and nurses in a university teaching hospital- A cross-sectional study

Ng BH, Low HJ, Nik Nuratiqah NA, Faisal AH, Soo CI, Periyasamy P, et al.

Med J Malaysia, 2021 07;76(4):454-460.
PMID: 34305104

INTRODUCTION: Knowledge and adequate practice of preventive measures among health care workers (HCWs) are important to reduce the risk of COVID-19 transmission.
METHODS: A cross-sectional study was conducted among doctors and nurses in the medical department in Pusat Perubatan Universiti Kebangsaan Malaysia between November 18, 2020 and December 18, 2020 during the third wave of COVID-19 epidemic in Malaysia. We studied the knowledge and practice of preventive measures of COVID-19 among doctors and nurses in the COVID-19 or sudden acute respiratory infection (SARI) wards and general medical wards. Data was collected using a validated self-designed google form online-questionnaire.
RESULTS: A total of 407 subjects completed the study and 80.8% were females; 55.8% were aged between 30-39 years; 46.4% were medical doctors. The main source of COVID-19 knowledge was the Ministry of Health Malaysia (MOH) website (35.1%). Majority (97%) had sufficient knowledge and 82% practiced proper preventive measures. Doctors had a higher mean knowledge score compared to nurses (p < 0.001). HCWs working in COVID-19 or SARI wards scored higher in knowledge questions compared to those in the general medical wards (p = 0.020). Nurses practiced better preventive measures (p < 0.001). Good knowledge could not be predicted based on professions (OR: 0.222, 95% CI: 0.048 - 1.028, p = 0.054). Majority were unable to recall the proper steps of donning (85.8%) and doffing (98.5%).
CONCLUSIONS: Although majority had good knowledge and practiced proper preventive measures, there was a poor recall in donning and doffing steps regardless of place of practice. The MOH website is a useful platform for tailored continuous medical education and regular updates on COVID-19. Regular training and retraining on donning and doffing of PPE is needed to bridge this gap.
Fulltext Aerosolized SARS-CoV-2 transmission risk: Surgical or N95 masks?

Periyasamy P, Ng BH, Ali UK, Rashid ZZ, Kori N

Infect Control Hosp Epidemiol, 2021 09;42(9):1150-1152.
PMID: 32928321 DOI: 10.1017/ice.2020.465
A new experience of auditory brainstem implantation in Malaysia

Tang IP, Kevin Ng BH, Prepageran N, Donald Ngian SL, Albert Sii HW

Med J Malaysia, 2018 10;73(5):347-348.
PMID: 30350824 MyJurnal

Auditory brainstem implantation (ABI) is the only solution to restore hearing when cochlear nerves are disrupted together with the pathologies where bilateral cochleae do not provide a suitable location for cochlear implantation. We reported first two successful auditory brainstem implantation cases in patients with neurofibromatosis Type II (NF2) with bilateral acoustic neuroma causing bilateral profound sensorineural hearing loss in Malaysia. A good candidate selection, dedicated surgeons and rehabilitation team as well as strong family support are the crucial factors in achieving the best possible surgical, audiological and speech outcomes.
Bioavailability and pharmacokinetic studies of eurycomanone from Eurycoma longifolia

Low BS, Ng BH, Choy WP, Yuen KH, Chan KL

Planta Med, 2005 Sep;71(9):803-7.
PMID: 16206032

A validated HPLC analysis of eurycomanone (1), a bioactive quassinoid, in rat plasma following oral and intravenous administration of Eurycoma longifolia Jack extract was developed for pharmacokinetic and bioavailability studies. Relatively high plasma eurycomanone concentrations were detected after an intravenous injection of 10 mg/kg extract F2 containing 1.96 mg/kg of the quassinoid. However, it declined rapidly to zero after 8 h. Its mean elimination rate constant (k(e)), biological half-life (t(1/2)), volume of distribution (V(d)) and clearance (CL) were 0.88 +/- 0.19 h (-1), 1.00 +/- 0.26 h, 0.68 +/- 0.30 L/kg and 0.39 +/- 0.08 L/h/kg, respectively. Following oral administration of eurycomanone, its Cmax and Tmax values were detected as 0.33 +/- 0.03 microg/mL and 4.40 +/- 0.98 h, respectively. The plasma concentration of the quassinoid after oral administration was much lower than after intravenous application in spite of the oral dose being 5 times higher. The results indicate that eurycomanone is poorly bioavailable when given orally. A comparison of the AUC (0-->infinity) obtained orally to that obtained after an intravenous administration (normalized for dose differences) revealed that the absolute bioavailability of the compound was low with 10.5 %. Furthermore, the compound appeared to be well distributed in the extravascular fluids because of its relatively high V(d) value. The poor oral bioavailability was not attributed to instability problems because eurycomanone has been shown to be stable under different pH conditions. Thus, its poor oral bioavailability may be due to poor membrane permeability in view of its low P value and/or high first-pass metabolism.
Clots in tuberculosis

Ng BH, Andrea YLB, Nuratiqah NA, Faisal AH, Low HJ

Med J Malaysia, 2021 Nov;76(6):953-955.
PMID: 34806695

Tuberculosis (TB) is a common communicable disease. Active TB infection may be complicated by both venous and arterial thrombosis which are often under-recognised. We report two patients with incidental TB associated thrombosis involving different venous systems. Both responded to anticoagulant and anti-tuberculous therapy (ATT). Patients with tuberculosis are at risk of VTE and careful monitoring for venous thromboembolism (VTE) is needed during ATT. Our case illustrates the importance of having a high index of suspicion for silent VTE as it may complicate active TB infection.
Fulltext Successful drainage of complex haemoserous malignant pleural effusion with a single modified low-dose intrapleural alteplase and dornase alfa

Ng BH, Mohd Aminudin NH, Nasaruddin MZ, Abdul Rahaman JA

BMJ Case Rep, 2021 Feb 05;14(2).
PMID: 33547099 DOI: 10.1136/bcr-2020-239702

Patients with symptomatic complex malignant pleural effusion (MPE) are frequently unfit for decortication and have a poorer prognosis. Septations can develop in MPE, which may lead to failure of complete drainage and pleural infection. Intrapleural fibrinolytic therapy (IPFT) is an alternative treatment. The use of IPFT in patients with anaemia and high risk for intrapleural bleeding is not well established. We report a successful drainage of complex haemoserous MPE with a single modified low-dose of intrapleural 5 mg of alteplase and 5 mg of dornase alfa in a patient with pre-existing anaemia with no significant risk of intrapleural bleeding.
Fulltext Successful treatment of a complex malignant pleural effusion with 1 mg alteplase instilled through a non-draining indwelling pleural catheter

Nik Abeed NN, Faisal M, Ng BH, Ban Yu-Lin A

BMJ Case Rep, 2021 Feb 19;14(2).
PMID: 33608330 DOI: 10.1136/bcr-2020-236116

Indwelling pleural catheter (IPC) is the treatment of choice in managing symptomatic recurrent malignant pleural effusion (MPE). Loculated effusions following insertion may occur due to infection, catheter malfunction or the inflammatory nature of MPE. Loculations may lead to ineffective drainage and make the IPC non-functional. We report a 56-year-old man with symptomatic loculated malignant pleural effusion with an IPC, successfully drained with a single dose of 1 mg recombinant tissue plasminogen activator alteplase. This is the lowest dose currently applied in our centre for efficient drainage and improvement of dyspnoea.
Combined intrapleural alteplase and DNase therapy in complicated pleural infection arising from postsurgery oesophageal leak

Ng BH, Nik Abeed NN, Ban AY, Abdul Hamid MF

BMJ Case Rep, 2023 Aug 17;16(8).
PMID: 37591627 DOI: 10.1136/bcr-2022-249927

Managing a complicated pleural infection related to postsurgery can pose a clinical challenge, especially when initial interventions such as intercostal chest drain and antibiotics prove ineffective. We describe a man in his mid-60s who developed a recurrence of exudative pleural effusion caused by an oesophageal leak following laparoscopic total gastrectomy with Roux-y oesophagojejunostomy for gastric adenocarcinoma. Surgical repairs and oesophageal stenting were performed to address the oesophageal leak. Despite attempts at intercostal chest tube drainage, ultrasonography-guided targeted drainage of the locule and antibiotics, he did not show any improvement. He was unfit for surgical decortication. Due to the risk of bleeding, we chose a modified dose of intrapleural alteplase 5 mg and DNase 5 mg at 12-hour intervals for a total of three doses. This led to the complete resolution of the effusion. This case highlights that intrapleural tPA/DNase can be an adjunctive therapy in postsurgery-related complicated pleural effusion.
Recurrent bilateral idiopathic chylothorax: a therapeutic challenge

Ng BH, Ban AY, Nik Abeed NN, Abdul Hamid MF

BMJ Case Rep, 2023 Dec 16;16(12).
PMID: 38103910 DOI: 10.1136/bcr-2023-258049

Chylothorax is a rare condition caused by pleural effusion resulting from thoracic duct injury. Recurrent chylothorax is often resistant to conservative treatment and presents a clinical conundrum in its management. Here, we report a compelling case of recurrent chylothorax that persisted despite the administration of total parenteral nutrition, octreotide and thoracic duct embolisation. The patient eventually required thoracic duct ligation and talc pleurodesis, which resulted in the resolution of the effusion. Our case is an illustrative example of the effective multidisciplinary management of recurrent bilateral idiopathic chylothorax.
Fulltext Silicone pneumonitis after gluteal filler: a case report and literature review

Ng BH, Mat WRW, Abeed NNN, Hamid MFA, Yu-Lin AB, Soo CI

Respirol Case Rep, 2020 Apr;8(3):e00538.
PMID: 32076554 DOI: 10.1002/rcr2.538

Liquid silicone (polydimethylsiloxane) is an inert material that is commonly used for cosmetic purpose. Silicone embolization syndrome (SES) can rapidly progress to pneumonitis as a consequence of the injection of nonmedical-grade liquid silicone. We describe a case of severe silicone pneumonitis complicated with acute respiratory distress syndrome and bilateral pneumothorax secondary to silicone gluteal augmentation. In this case report, we aim to discuss our experience and approach in managing an uncommon case of SES.
Fulltext What happens when we treat the "Typhoid Mary" of COVID-19

Ng BH, Nik Abeed NN, Abdul Hamid MF, Soo CI, Low HJ, Ban YA

Respirol Case Rep, 2020 Aug;8(6):e00604.
PMID: 32607242 DOI: 10.1002/rcr2.604

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was declared a pandemic on 11 March 2020. We have since seen its fast spread worldwide. A likely contributing factor was the lack of symptoms of some of the carriers, making them unaware of their risk of spreading to other more vulnerable individuals. The other important finding has been the reported cases of infectivity despite lack of symptoms. We describe the SARS-CoV-2 pneumonia patterns in asymptomatic individuals. The common computed tomography (CT) thorax patterns found are peripheral ground-glass opacification (GGO) with upper or lower lobe predominance. We believe screening for 2019-novel coronavirus (COVID-19) in high-risk individuals may help identify the patients needing longer follow-up.
Fulltext Re-establishing indwelling pleural catheter patency with alteplase after failure of streptokinase

Faisal M, Nurhanis S, Nik Abeed NN, Ng BH, Ban AY

Respirol Case Rep, 2020 Oct;8(7):e00639.
PMID: 32774860 DOI: 10.1002/rcr2.639

Indwelling pleural catheter (IPC) has revolutionized the management of malignant pleural effusion (MPE). IPC is relatively safe, although complications can occur. We report a 53-year-old woman with stage IVA lung adenocarcinoma and recurrent MPE. Two months post insertion, the IPC was blocked with residual effusion and presence of new loculations. Attempts to restore patency with six doses of intrapleural (IP) streptokinase failed. She was referred to our centre for further management. We used a single dose of 2.5 mg IP alteplase which was successful in establishing patency of the IPC and draining the effusion. This case highlights the safety and efficacy of IP alteplase via IPC following a failed instillation of streptokinase.
Fulltext Tocotrienols for normalisation of hepatic echogenic response in nonalcoholic fatty liver: a randomised placebo-controlled clinical trial

Magosso E, Ansari MA, Gopalan Y, Shuaib IL, Wong JW, Khan NA, et al.

Nutr J, 2013;12(1):166.
PMID: 24373555 DOI: 10.1186/1475-2891-12-166

Nonalcoholic fatty liver disease (NAFLD) is one of the commonest liver disorders. Obesity, insulin resistance, lipid peroxidation and oxidative stress have been identified amongst the possible hits leading to the onset and progression of this disease. Nutritional evaluation of NAFLD patients showed a lower-than-recommended intake of vitamin E. Vitamin E is a family of 8 isoforms, 4 tocopherols and 4 tocotrienols. Alpha-tocopherol has been widely investigated in liver diseases, whereas no previous clinical trial has investigated tocotrienols for NAFLD. Aim of the study was to determine the effects of mixed tocotrienols, in normalising the hepatic echogenic response in hypercholesterolaemic patients with ultrasound-proven NAFLD.
Fulltext A descriptive study of the psychological experience of health care workers in close contact with a person with COVID-19

Ng BH, Nuratiqah NA, Faisal AH, Soo CI, Low HJ, Najma K, et al.

Med J Malaysia, 2020 09;75(5):485-489.
PMID: 32918414

BACKGROUND: COVID-19 has the potential to affect the mental health of health care workers (HCWs). It is known that HCWs who serve as front-liners during the COVID-19 pandemic experience stress and have the fear of contracting the infection. Little is known of how being a positive contact affects HCWs.

OBJECTIVE: We examined the experience of HCWs who were quarantined following a close unprotected contact with a COVID-19 positive colleague and explore the psychological impact especially as the timing of the quarantine coincided with the Eid (annual Muslim festival) celebration in Malaysia.

METHODS: This was a cross-sectional on-line questionnaire study, involving HCWs exposed to a COVID-19 positive colleague in Universiti Kebangsaan Malaysia Medical Centre, a teaching hospital. Data on demographics, levels of depression, anxiety and stress using a validated depression, anxiety, and stress scale (DASS-21) questionnaire, aspects of quarantine, wearing of masks, hand hygiene practice and swab experience were collected.

RESULTS: Twenty-two HCWs participated. Eighteen (81.8%) were between 30-39 years and 17 (77.3%) were women. Majority 19 (86.3%) were Malays. There were twelve (54.5%) medical officers, 5 (22.7%) specialists and 5(22.7%) allied health staff. Eighteen out of 22 (81.8%) felt they were able to do home quarantine adequately. All tested negative with a mean (Standard Deviation) hour of contact of 2.56±2.38 hours. Eighteen reported their biggest concern was infecting their families.

CONCLUSION: HCWs undergoing contact swabbing and quarantine are vulnerable to depression, anxiety and stress. The ability of the HCW to adequately home quarantine should not be taken for granted. Psychological support should be offered to HCWs who are positive contacts.
Satisfaction and tolerability using virtual reality (VR) as adjunctive treatment during flexible bronchoscopy: a randomized control trial

Sooriyaghandan IV, Mohamad Jailaini MF, Nik Abeed NN, Ng BH, Yu-Lin AB, Shah SA, et al.

BMC Pulm Med, 2023 Jan 10;23(1):10.
PMID: 36627598 DOI: 10.1186/s12890-023-02304-y

BACKGROUND: Patient comfort during invasive and therapeutic procedures is important. The use of virtual reality (VR) devices during flexible bronchoscopy (FB) as a method of distraction to increase patient tolerability and improve satisfaction has not been investigated. We aim to assess the satisfaction and tolerability of participants undergoing FB with or without VR.
METHODS: This was a single-center, open-label study on patients undergoing bronchoscopy, randomized into the control and interventional (VR) groups. The control group received standard care during FB. The interventional group was given a VR device during FB showing nature videos with soothing instrumental music. Pain, breathlessness, and cough were evaluated using a 10 cm visual analogue scale administered before and after FB. Anxiety was assessed using the State-Trait Anxiety Inventory. Satisfaction questionnaire (5-point Likert scale) was given to participants post FB.
RESULTS: Eighty participants enrolled, 40 in each arm. Median (IQR) satisfaction score in the VR group was 5.0 (3.0-5.0), and in the control group was 4.0 (3.0-5.0); (p
Fulltext The benefit of indwelling pleural catheter with ambulatory pneumothorax device and autologous blood patch pleurodesis in lymphangioleiomyomatosis with persistent air leak

Ng BH, Low HJ, Nik Abeed NN, Jailaini MFM, Abdul Hamid MF, Ban Yu-Lin A

Respirol Case Rep, 2023 May;11(5):e01143.
PMID: 37065172 DOI: 10.1002/rcr2.1143

We report a 35-year-old woman who presented with dyspnoea and chest pain for 1 week. High-resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video-assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter (Rocket® IPC™; Rocket Medical plc; WASHINGTON) was inserted and the patient was discharged after 1 day with an atrium pneumostat (Pneumostat™; Atrium Medical Corporation, Hudson, NH, USA) chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL.
The prevalence and predictors of poor sleep quality and excessive daytime sleepiness in epilepsy: A single tertiary centre experience in Malaysia

Chong CS, Tan JK, Ng BH, Lin ABY, Khoo CS, Rajah R, et al.

J Clin Neurosci, 2023 Dec;118:132-142.
PMID: 37935067 DOI: 10.1016/j.jocn.2023.10.012

BACKGROUND AND OBJECTIVE: People with epilepsy frequently encounter sleep disruptions that can stem from a variety of complex factors. Epilepsy-related sleep disturbance can lead to reduced quality of life and excessive daytime hypersomnolence. Identification of sleep disturbances may help in the overall management of epilepsy patients. This study was conducted to determine the prevalence and predictors of poor sleep quality and daytime sleepiness in epilepsy.
METHODS: A cross-sectional study on 284 epilepsy patients was performed in a local tertiary centre. The demographic and clinical epilepsy data were collected. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaires were utilised to determine the quality of life and daytime hypersomnolence of epilepsy patients, respectively.
RESULTS: Poor sleep quality was reported in 78 (27.5%) patients while daytime hypersomnolence was present in 17 (6%) patients. The predictors of poor sleep quality include structural causes (OR = 2.749; 95% CI: 1.436, 5.264, p = 0.002), generalised seizures (OR = 1.959, 95% CI: 1.04, 3.689, p = 0.037), and antiseizure medications such as Carbamazepine (OR = 2.34; 95% CI: 1.095, 5.001, p = 0.028) and Topiramate (OR 2.487; 95% CI: 1.028, 6.014, p = 0.043). Females are 3.797 times more likely score higher in ESS assessment (OR 3.797; 95% CI: 1.064, 13.555 p = 0.04).
DISCUSSION: Sleep disturbances frequently coexist with epilepsy. Patients should be actively evaluated using the PSQI and ESS questionnaires. It is imperative to identify the key factors that lead to reduced sleep quality and heightened daytime sleepiness in patients with epilepsy, as this is essential to properly manage their condition.

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