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Fulltext Hemicrania Continua With Scintillating Scotoma: A Rare Presentation

Hussein A, Han Shu T, Chong MF, Cheah CF

Cureus, 2020 Sep 27;12(9):e10680.
PMID: 33133846 DOI: 10.7759/cureus.10680

Headache can be a primary or secondary disorder. The characteristics of headache and its associated features, especially the presence of red flag signs, are important in distinguishing secondary from primary causes. Hemicrania continua is a type of primary headache disorder characterized by a continuous unilateral headache with episodes of exacerbations and association with cranial autonomic symptoms, which include several ocular symptoms. The absolute response to indomethacin remains the hallmark of this disease. We would like to report a rare case of hemicrania continua with scintillating scotoma during exacerbations apart from the typical autonomic features of conjunctival injection, ptosis, eyelid edema, and lacrimation.
Silent microaspirations: The forerunner to the diagnosis of bulbar onset myasthenia gravis in a young woman

Tan TL, Tan HJ, Cheah CF, Kumaresh R, Azzahra NA

Med J Malaysia, 2020 05;75(3):295-297.
PMID: 32467548

Recurrent pneumonia warrants a diligent work-up to identify the underlying cause that perpetuates the disease process. Insidious bulbar dysfunction is arguably the most devastating as it would be diagnosed late after significant pulmonary complications due to chronic micro-aspiration. Bulbar disorder should be considered as the potential aetiology of recurrent pulmonary infections in the young population after excluding immunodeficiency disorder and respiratory anatomical anomaly. This report illustrates a rare case of bulbar onset myasthenia gravis which manifested as focal bronchiolectasis due to recurrent undiagnosed aspiration pneumonia three years earlier. Absence of hallmark features of Myasthenia Gravis (MG) such as ptosis, opthalmoplegia and proximal muscle weakness contributed to the diagnostic delay and challenges in this case. The diagnosis was established with the collaboration of multidisciplinary teams. Subsequent correct therapeutic interventions resulted in remarkable recovery in functional status and prevented her from further aspiration in the long run.
Fulltext Plate waste study among hospitalised patients receiving texture-modified diet

Razalli NH, Cheah CF, Mohammad NMA, Abdul Manaf Z

Nutr Res Pract, 2021 Oct;15(5):655-671.
PMID: 34603612 DOI: 10.4162/nrp.2021.15.5.655

BACKGROUND/OBJECTIVES: While plate waste has been widely investigated in hospitals, there have been minimal studies specific to the texture-modified diet (TMD). This study aims to determine the percentage of plate waste among patients prescribed with TMD and its contributory factors.
SUBJECTS/METHODS: This was a single-centre study conducted in the university hospital on three types of TMD (blended diet, mixed porridge, minced diet) during lunch and dinner meals. Weighing method and visual estimation method assisted by digital photograph were adopted in this study. Face to face interview was carried out to investigate on 1) the food/food service quality factors in terms of patients' satisfaction level towards sensorial quality of food and food services provided and 2) the clinical/external factors including appetite, the provision of oral nutrition support, time taking the diet, the need for feeding assistance and the length of hospital stay.
RESULTS: The mean percentage of overall plate waste of 95 patients receiving TMD was high (47.5%). Blended diet was identified as the most wasted diet (65%) followed by minced diet (56%) and mixed porridge (35%). Satisfaction level among patients was moderate. Patients on TMD in general had higher satisfaction level on the aspect of food service as compared to food quality. Substantial association between sensorial qualities of food and plate waste were varied according to individual TMD type. A multiple linear regression showed that only the satisfaction level toward the aspects of appearance and variety of foods were the predictors of TMD plate waste (R2 = 0.254, P < 0.05).
CONCLUSIONS: A significant relationship between the percentage of plate waste and the overall satisfaction level of patients receiving TMD suggests that vigorous strategies are needed to reduce the food waste of TMD which will lead to a better nutritional status and clinical outcomes among the patients.
Fulltext Takotsubo Cardiomyopathy in Traumatic Brain Injury

Cheah CF, Kofler M, Schiefecker AJ, Beer R, Klug G, Pfausler B, et al.

Neurocrit Care, 2017 04;26(2):284-291.
PMID: 28000134 DOI: 10.1007/s12028-016-0334-y

BACKGROUND: Takotsubo cardiomyopathy (TC) is a well-known complication after aneurysmal subarachnoid hemorrhage and has been rarely described in patients with traumatic brain injury (TBI).
METHODS: Case report and review of literature.
RESULTS: Here, we report a 73-year-old woman with mild traumatic brain injury (TBI) presenting in cardiogenic shock. Takotsubo cardiomyopathy (TC) was diagnosed by repeated echocardiography. Cardiovascular support by inotropic agents led to hemodynamic stabilization after initiation of levosimendan. Cardiac function fully recovered within 21 days. We performed an in-depth literature review and identified 16 reported patients with TBI and TC. Clinical course and characteristics are discussed in the context of our patient.
CONCLUSION: Takotsubo cardiomyopathy is under-recognized after TBI and may negatively impact outcome if left untreated.
Fulltext A Rare Ocular Manifestation of Idiopathic Hypertrophic Cranial Pachymeningitis

Lee JEH, Subramaniam S, Cheah CF, Chan KH, Adil H

Cureus, 2021 Dec;13(12):e20633.
PMID: 35106199 DOI: 10.7759/cureus.20633

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare form of thickening of the dura mater. There are limited reports on the ocular manifestation of IHCP and its treatment. Up to our knowledge, there is no report on bilateral superior ophthalmic veins (SOV) dilatation with IHCP and there are only a few reports on anterior scleritis with IHCP. We report a 62-year-old gentleman with underlying hypertension and chronic headache who presented with fever, headache, and unresolving both eyes redness as manifestations of bilateral anterior scleritis, anterior uveitis, secondary glaucoma, and multiple cranial nerve palsies. Magnetic resonance imaging of the brain showed global thickening and enhancement of the pachymeninges with bilateral SOV dilatations. The diagnosis of IHCP was made after ruling out infective and autoimmune causes. The patient was treated with oral prednisolone, oral azathioprine, topical timolol maleate, topical dexamethasone, and topical moxifloxacin. The patient was successfully treated and was stable throughout two years review. In conclusion, unresolved red eyes with headaches can be an early presentation of IHCP. Pathophysiology and treatment of the ocular manifestations and IHCP were discussed.
A previously misdiagnosed cohort of aquaporin 4 antibody-positive neuromyelitis optica spectrum disorder with disease duration of >10 years in multi-ethnic Penang, Malaysia: Clinical features and disease course

Hor JY, Lim TT, Chow HB, Tan K, Cheah CF, Ching YM, et al.

Mult Scler Relat Disord, 2016 Jan;5:89-90.
PMID: 26856950 DOI: 10.1016/j.msard.2015.11.008
Thymoma-associated myasthenia gravis and LGI1-encephalitis, with nephrotic syndrome post-thymectomy

Hor JY, Lim TT, Cheng MC, Chia YK, Wong CK, Lim SM, et al.

J Neuroimmunol, 2018 04 15;317:100-102.
PMID: 29395322 DOI: 10.1016/j.jneuroim.2018.01.011

Thymoma is associated with a wide spectrum of autoimmune paraneoplastic syndromes, though it is uncommon for multiple paraneoplastic syndromes to be present in a single individual. We report a rare case of an elderly gentleman who was found to have thymoma-associated myasthenia gravis and LGI1-encephalitis with myokymia, who presented with nephrotic syndrome (minimal change glomerulopathy) after thymectomy. The latter two paraneoplastic syndromes had manifested when prednisolone was tapered down to low dose. This case serves to remind neurologists that apart from paraneoplastic neurological manifestations, thymoma may also be associated with renal disease. Nephropathy in myasthenia patients with thymoma should be properly evaluated, as it is treatable with immunotherapy, and it may even occur post-thymectomy.
Prevalence of neuromyelitis optica spectrum disorder in the multi-ethnic Penang Island, Malaysia, and a review of worldwide prevalence

Hor JY, Lim TT, Chia YK, Ching YM, Cheah CF, Tan K, et al.

Mult Scler Relat Disord, 2018 Jan;19:20-24.
PMID: 29100047 DOI: 10.1016/j.msard.2017.10.015

BACKGROUND: Neuromyelitis optica spectrum disorder (NMOSD) occurs worldwide in all ethnicities. Recently, population-based studies have shown that NMOSD is more common among non-White populations. There is scarce data about NMOSD prevalence in South East Asian populations.
METHODS: (1) A population-based study was undertaken to estimate NMOSD prevalence in the multi-ethnic Penang Island, Malaysia, comprising Chinese, Malays, and Indians. Medical records of NMOSD patients followed up at the Penang General Hospital (the neurology referral centre in Penang Island) were reviewed. The 2015 diagnostic criteria of the International Panel for NMO Diagnosis were used for case ascertainment. (2) A review of population-based prevalence studies of NMOSD worldwide was carried out. PubMed and conference proceedings were searched for such studies.
RESULTS: Of the 28 NMOSD patients, 14 were residents of Penang Island on prevalence day [13 (93%) Chinese and one (7%) Malay]. All 14 patients were females and aquaporin 4 seropositive. The prevalence of NMOSD in Penang Island was 1.99/100,000 population; according to ethnicities, the prevalence in Chinese was significantly higher than in Malays (3.31/100,000 vs 0.43/100,000, respectively, p = 0.0195).
CONCLUSION: Based on our and other population-based studies, among Asians, East Asian origin populations (Chinese and Japanese) appear to have higher NMOSD prevalence than other Asian ethnic groups. Worldwide, Blacks seem to have the highest NMOSD prevalence. More studies in different geographical regions and ethnic groups will be useful to further inform about potential factors in NMOSD pathogenesis.
Fulltext Biomechanical System Versus Observational Rating Scale for Parkinson's Disease Tremor Assessment

Chan PY, Mohd Ripin Z, Abdul Halim S, Kamarudin MI, Ng KS, Eow GB, et al.

Sci Rep, 2019 05 31;9(1):8117.
PMID: 31148550 DOI: 10.1038/s41598-019-44142-1

There is a lack of evidence that either conventional observational rating scale or biomechanical system is a better tremor assessment tool. This work focuses on comparing a biomechanical system and the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale in terms of test-retest reliability. The Parkinson's disease tremors were quantified by biomechanical system in joint angular displacement and predicted rating, as well as assessed by three raters using observational ratings. Qualitative comparisons of the validity and function are made also. The observational rating captures the overall severity of body parts, whereas the biomechanical system provides motion- and joint-specific tremor severity. The tremor readings of the biomechanical system were previously validated against encoders' readings and doctors' ratings; the observational ratings were validated with previous ratings on assessing the disease and combined motor symptoms rather than on tremor specifically. Analyses show that the predicted rating is significantly more reliable than the average clinical ratings by three raters. The comparison work removes some of the inconsistent impressions of the tools and serves as guideline for selecting a tool that can improve tremor assessment. Nevertheless, further work is required to consider more variabilities that influence the overall judgement.
Intravenous thrombolysis for multi-ethnic Asians with acute ischaemia stroke in Malaysian public primary stroke centres versus acute stroke ready hospitals: Comparison of real-world clinical outcomes

Schee JP, Ang CL, Crystal Teoh SC, Tan HJ, Chew SH, Steven A, et al.

Med J Malaysia, 2023 Sep;78(5):594-601.
PMID: 37775485

INTRODUCTION: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator is beneficial in acute ischaemic stroke (AIS). We aim to compare the realworld clinical outcomes and service efficiency of IVT in Malaysian primary stroke centres (PSCs) versus acute stroke ready hospitals (ASRHs).
MATERIALS AND METHODS: We conducted a multi-centre cohort study involving 5 PSCs and 7 ASRHs in Malaysia. Through review of medical records of AIS patients who received IVT from 01 January 2014 to 30 June 2021, real-world data was extracted for analysis. Univariate and multivariate regression models were employed to evaluate the role of PSCs versus ASRHs in post-IVT outcomes and complications. Statistical significance was set at p<0.05.
RESULTS: A total of 313 multi-ethnic Asians, namely 231 from PSCs and 82 from ASRHs, were included. Both groups were comparable in baseline demographic, clinical, and stroke characteristics. The efficiency of IVT delivery (door-toneedle time), functional outcomes (mRS at 3 months post- IVT), and rates of adverse events (intracranial haemorrhages and mortality) following IVT were comparable between the 2 groups. Notably, 46.8% and 48.8% of patients in PSCs and ASRHs group respectively (p=0.752) achieved favourable functional outcome (mRS≤1 at 3 months post-IVT). Regression analyses demonstrated that post-IVT functional outcomes and adverse events were independent of the role of PSCs or ASRHs.
CONCLUSION: Our study provides real-world evidence which suggests that IVT can be equally safe, effective, and efficiently delivered in ASRHs. This may encourage the establishment of more ASRHs to extend the benefits of IVT to a greater proportion of stroke populations and enhance the regional stroke care.