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Fulltext Insertion of Hickman catheters by the percutaneous technique

Teh A, Leong KW

Med J Malaysia, 1995 Dec;50(4):353-8.
PMID: 8668056

Hickman catheters have previously been conventionally placed by surgical dissection. This usually performed by experienced surgeons and is carried out under general anaesthesia. We report our preliminary experience in Hickman catheter placement by percutaneous technique in twenty patients. We outline the implantation methods and complications encountered by this technique. The procedure is relatively simple provided the operator is skilled in central venous cannulation. The chief advantages are that the procedure can be done under local anaesthesia and results in less trauma compared with surgical dissection. Such an alternative in catheter insertion would promote wider usage of Hickman catheters in cancer patients.
Fulltext Corticosteroid-responsive prolonged thrombocytopenia following dengue haemorrhagic fever

Leong KW, Srinivas P

Med J Malaysia, 1993 Sep;48(3):369-72.
PMID: 8183156

A case of prolonged thrombocytopenia following dengue haemorrhagic fever in a 15 year old boy is reported. The mechanism was presumed to be immunological and he responded dramatically to oral prednisolone.
Fulltext Tretinoin in pregnancy complicated with acute promyelocytic leukaemia

Leong KW, Teh A, Bosco JJ

Med J Malaysia, 2000 Jun;55(2):277-9.
PMID: 19839162

Acute promyelocytic leukemia (APL) in pregnancy poses serious danger to both the mother and fetus. Cytotoxic chemotherapy may cause teratogenicity to the fetus. APL is unique because it is usually associated with a coagulopathy that markedly increases the risk for the mother and fetus. A 21 year old lady with APL in her third trimester of pregnancy was treated with oral tretinoin. Tretinoin reversed the coagulopathy and normalised her blood counts without causing cytotoxic damage associated with cancer chemotherapy. Fetal distress occurred at 37 weeks of gestation and an emergency caesarean section was performed without complications and no blood transfusion support was needed as her coagulopathy and thrombocytopenia had resolved. A remission was achieved with only tretinoin induction. She subsequently had consolidation and maintenance chemotherapy. The mother and baby remain well at 4 years from completion of chemotherapy. A total of 10 pregnancies associated with APL have been reported in the current literature. Premature delivery and a fetal arrhythmia were the only complications. Although retinoin is considered teratogenic, its use so far in second and third trimester has been safe.
Successful pregnancy following aplastic anaemia

Leong KW, Teh A, Bosco JJ, Lim J

Postgrad Med J, 1995 Oct;71(840):625-7.
PMID: 8545293

Pregnancy following idiopathic aplastic anaemia is rare and is difficult to manage because of life-threatening episodes of bleeding and infections. Only a handful of cases has been reported in the literature. The pregnancies were unsuccessful in the majority. The present report describes a patient with moderately severe idiopathic aplastic anaemia who was managed with intensive haematological support leading to delivery of a healthy infant by caesarean section. Despite platelet transfusion refractoriness as a result of transfusions prior to pregnancy, adequate platelet transfusions prevented excessive bleeding. The literature is reviewed and management with platelet transfusions is discussed.
Acute myelomonocytic leukaemia complicated by an acute aortic thrombosis

Leong KW, Bosco JJ, Shaik IB

Postgrad Med J, 1995 Feb;71(832):112-3.
PMID: 7724422

Acute aortic thrombosis is a rare condition, occurring mainly as a result of trauma or atherosclerosis and occasionally secondary to hypercoagulable states. We report a patient with relapsed acute myeloid leukaemia who developed an unusual complication, acute aortic thrombosis.
Advantage of induction therapy with all trans retinoic acid in acute promyelocytic leukaemia in a country with limited transfusion resources: a Malaysian experience

Leong KW, Bosco JJ, Teh A

Eur J Haematol, 1994 Oct;53(4):237-41.
PMID: 7957809

Induction of remission of acute promyelocytic leukaemia (APL) needs intensive blood support (16) to prevent bleeding attributed to disseminated intravascular coagulation. Between 1989 and 1991, at the University Hospital in Kuala Lumpur, Malaysia, the remission rate of APL was only 27% with conventional chemotherapy as a result of inadequate transfusion resources. The use of all trans retinoic acid in induction therapy followed by consolidation and maintenance chemotherapy has improved the situation dramatically. Twelve patients entered the study. Ten patients achieved remission (83%), indicating how ATRA had significantly improved the results (p = 0.003). Blood component transfusions were also significantly reduced (p = 0.003). Two ethnic Chinese patients developed pulmonary leucostasis. Published Chinese (2, 6) and Japanese (11) studies have not reported this serious adverse effect. We can now state that leucostasis is not a phenomenon limited to the Western population. ATRA has proved to be extremely beneficial for patients at this centre. Early analysis also suggests that consolidation and maintenance chemotherapy has prolonged remission duration. ATRA should be made available for the treatment of APL in all countries where there are inadequate transfusion services.
Radiation-induced pericardial disease: a case report

Doi SA, Azman W, Leong KW, Bosco J

Ann Acad Med Singap, 1995 May;24(3):459-61.
PMID: 7574433

A typical case of chronic pericardial effusion resulting in cardiac tamponade is presented. A pericardiocentesis was done for diagnosis and drainage, followed by a pleuro-pericardial window as definitive therapy. The minimal cumulative dose expected to produce pericardial disease is about 4000 rads, and the disease usually manifests within 12 months of such radiation exposure, as in this patient. It is concluded that for symptomatic pericardial effusions, available evidence justifies a subtotal pericardiectomy, a window procedure being reserved to tide over ill patients as in this patient. No strong evidence exists for the efficacy of steroid therapy; such therapy is reserved for asymptomatic mild effusions, which may also resolve spontaneously.
Fulltext Anti-lymphocyte globulin therapy in aplastic anaemia--a university hospital experience

Leong KW, Teh A, Bosco JJ, Jayaranee S, Sadat U

Med J Malaysia, 1995 Jun;50(2):158-61.
PMID: 7565186

Antilymphocyte globulin (ALG) was given every other day for 5 doses with platelet transfusions immediately following ALG administration in 6 patients with aplastic anaemia. Four patients responded and 3 durable remissions were achieved. One patient relapsed and further treatment with anti-thymocyte globulin and cyclosporin also failed. One patient died of Flavobacterium septicaemia 6 days after completion of ALG. Our data suggests that using an alternate day regimen, a response rate similar to a daily regimen can be obtained.
Fulltext Acquired haemophilia--a therapeutic challenge

Teh A, Leong KW, Bosco JJ, Koong PL, Jayaranee S

Med J Malaysia, 1995 Jun;50(2):166-70.
PMID: 7565188

Acquired haemophilia is a rare clinical condition arising from the spontaneous development of inhibitors to factor VIII. We describe two cases encountered in the University Hospital over the past five years. We also review the literature and discuss the therapeutic difficulties faced in dealing with patients with high levels of inhibitors. In one of these patients we also describe, for the first time in this region, a novel method in managing the acute bleeding episode in acquired haemophilia using recombinant factor VIIa.
Fulltext Adult allogeneic bone marrow transplantation: initial experience in the University Hospital, Kuala Lumpur

Teh A, Bosco JJ, Leong KW, Saw MH, Menaka N, Devashanti P

Med J Malaysia, 1997 Mar;52(1):26-32.
PMID: 10968050

Prior to 1993, bone marrow transplantation for adult patients was not available in Malaysia. Adult allogeneic bone marrow transplantation commenced in Malaysia when the first transplant was conducted at the University Hospital, Kuala Lumpur on 2 November 1993. Up till July 1995, 10 adult bone marrow transplants had been conducted at the University Hospital. Five patients had acute myeloid leukaemia in first remission, 4 had chronic myeloid leukaemia and 1 had acute lymphoblastic leukaemia in first partial remission. The age range of patients at the time of transplant is 16-40 years (mean 25.5 years). All patients engrafted successfully and the survival for the first 100 days post-transplant is 90%. One patient demonstrated haematological relapse post-transplant but achieved remission with donor buffy-coat infusion. The mean drug cost incurred was RM28,269 for the first 100 days. Locally available adult allogeneic bone marrow transplantation is safe, affordable and has comparable results with reputable overseas transplant centres.
Anesthetic considerations in scoliosis patient with dopa-responsive dystonia or Segawa's syndrome

Hasan MS, Leong KW, Chan CY, Kwan MK

J Orthop Surg (Hong Kong), 2017 01;25(1):2309499016684743.
PMID: 28166704 DOI: 10.1177/2309499016684743

Segawa's syndrome or dopa-responsive dystonia is a rare hereditary disorder characterized by progressive dystonia of childhood onset, diurnal fluctuation of symptoms and complete or near complete alleviation of symptoms with administration of low-dose oral levodopa. From our literature search in PubMed, we found only three related publications: two on anesthesia for cesarean section and one on anesthesia for electroconvulsive therapy. We report our experience in providing anesthesia for corrective scoliosis surgery in two biological sisters with Segawa's syndrome. A review of the literature is also included.
Fulltext Candida Chorioamnionitis in Mothers with Gestational Diabetes Mellitus: A Report of Two Cases

Shazniza Shaaya E, Halim SAA, Leong KW, Ku KBP, Lim PS, Tan GC, et al.

Int J Environ Res Public Health, 2021 07 13;18(14).
PMID: 34299901 DOI: 10.3390/ijerph18147450

Background:Candida chorioamnionitis is rarely encountered, even though vulvovaginal candidiasis incidence is about 15%. Interestingly, it has characteristic gross and histological findings on the umbilical cord that are not to be missed. Case Report: We report two cases of Candida chorioamnionitis with presence of multiple yellowish and red spots of the surface of the umbilical cord. Microscopically, these consist of microabscesses with evidence of fungal yeasts and pseudohyphae. The yeasts and pseudohyphae were highlighted by periodic acid- Schiff and Grocott methenamine silver histochemical stains. Both cases were associated with a history of gestational diabetes mellitus. Discussion: Peripheral funisitis is a characteristic feature of Candida chorioamnionitis. It is associated with high risk of adverse perinatal and neonatal outcomes, such as preterm delivery, stillbirth and neonatal death. We recommend careful examination of the umbilical cord of mothers with gestational diabetes mellitus.
Fulltext The use of text messaging to improve attendance in primary care: a randomized controlled trial

Leong KC, Chen WS, Leong KW, Mastura I, Mimi O, Sheikh MA, et al.

Fam Pract, 2006 Dec;23(6):699-705.
PMID: 16916871

BACKGROUND: Non-attendance is common in primary care and previous studies have reported that reminders were useful in reducing broken appointments.
OBJECTIVE: To determine the effectiveness of a text messaging reminder in improving attendance in primary care.
DESIGN:
Multicentre three-arm randomized controlled trial.
SETTING: Seven primary care clinics in Malaysia. Participants. Patients (or their caregivers) who required follow-up at the clinics between 48 hours and 3 months from the recruitment date. Interventions. Two intervention arms consisted of text messaging and mobile phone reminders 24-48 hours prior to scheduled appointments. Control group did not receive any intervention. Outcome measures. Attendance rates and costs of interventions.
RESULTS: A total of 993 participants were eligible for analysis. Attendance rates of control, text messaging and mobile phone reminder groups were 48.1, 59.0 and 59.6%, respectively. The attendance rate of the text messaging reminder group was significantly higher compared with that of the control group (odds ratio 1.59, 95% confidence interval 1.17 to 2.17, P = 0.005). There was no statistically significant difference in attendance rates between text messaging and mobile phone reminder groups. The cost of text messaging reminder (RM 0.45 per attendance) was lower than mobile phone reminder (RM 0.82 per attendance).
CONCLUSIONS: Text messaging reminder system was effective in improving attendance rate in primary care. It was more cost-effective compared with the mobile phone reminder.
Fulltext Closing the global cancer divide--performance of breast cancer care services in a middle income developing country

Lim GC, Aina EN, Cheah SK, Ismail F, Ho GF, Tho LM, et al.

BMC Cancer, 2014;14:212.
PMID: 24650245 DOI: 10.1186/1471-2407-14-212

BACKGROUND: Cancer is the leading cause of deaths in the world. A widening disparity in cancer burden has emerged between high income and low-middle income countries. Closing this cancer divide is an ethical imperative but there is a dearth of data on cancer services from developing countries.
METHODS: This was a multi-center, retrospective observational cohort study which enrolled women with breast cancer (BC) attending 8 participating cancer centers in Malaysia in 2011. All patients were followed up for 12 months from diagnosis to determine their access to therapies. We assess care performance using measures developed by Quality Oncology Practice Initiative, American Society of Clinical Oncology/National Comprehensive Cancer Network, American College of Surgeons' National Accreditation Program for Breast Centers as well as our local guideline.
RESULTS: Seven hundred and fifty seven patients were included in the study; they represent about 20% of incident BC in Malaysia. Performance results were mixed. Late presentation was 40%. Access to diagnostic and breast surgery services were timely; the interval from presentation to tissue diagnosis was short (median = 9 days), and all who needed surgery could receive it with only a short wait (median = 11 days). Performance of radiation, chemo and hormonal therapy services showed that about 75 to 80% of patients could access these treatments timely, and those who could not were because they sought alternative treatment or they refused treatment. Access to Trastuzumab was limited to only 19% of eligible patients.
CONCLUSIONS: These performance results are probably acceptable for a middle income country though far below the 95% or higher adherence rates routinely reported by centres in developed countries. High cost trastuzumab was inaccessible to this population without public funding support.
Fulltext Real-world experience of first-line afatinib in patients with EGFR-mutant advanced NSCLC: a multicenter observational study

Ho GF, Chai CS, Alip A, Wahid MIA, Abdullah MM, Foo YC, et al.

BMC Cancer, 2019 Sep 09;19(1):896.
PMID: 31500587 DOI: 10.1186/s12885-019-6107-1

BACKGROUND: This study aimed to evaluate the efficacy, side-effects and resistance mechanisms of first-line afatinib in a real-world setting.
METHODS: This is a multicenter observational study of first-line afatinib in Malaysian patients with epidermal growth factor receptor (EGFR)-mutant advanced non-small cell lung cancer (NSCLC). Patients' demographic, clinical and treatment data, as well as resistance mechanisms to afatinib were retrospectively captured. The statistical methods included Chi-squared test and independent t-test for variables, Kaplan-Meier curve and log-rank test for survival, and Cox regression model for multivariate analysis.
RESULTS: Eighty-five patients on first-line afatinib from 1st October 2014 to 30th April 2018 were eligible for the study. EGFR mutations detected in tumors included exon 19 deletion in 80.0%, exon 21 L858R point mutation in 12.9%, and rare or complex EGFR mutations in 7.1% of patients. Among these patients, 18.8% had Eastern Cooperative Oncology Group performance status of 2-4, 29.4% had symptomatic brain metastases and 17.6% had abnormal organ function. Afatinib 40 mg or 30 mg once daily were the most common starting and maintenance doses. Only one-tenth of patients experienced severe side-effects with none having grade 4 toxicities. The objective response rate was 76.5% while the disease control rate was 95.3%. At the time of analysis, 56 (65.9%) patients had progression of disease (PD) with a median progression-free survival (mPFS) of 14.2 months (95% CI, 11.85-16.55 months). Only 12.5% of the progressed patients developed new symptomatic brain metastases. The overall survival (OS) data was not mature. Thirty-three (38.8%) patients had died with a median OS of 28.9 months (95% CI, 19.82-37.99 months). The median follow-up period for the survivors was 20.0 months (95% CI, 17.49-22.51 months). Of patients with PD while on afatinib, 55.3% were investigated for resistance mechanisms with exon 20 T790 M mutation detected in 42.0% of them.
CONCLUSIONS: Afatinib is an effective first-line treatment for patients with EGFR-mutant advanced NSCLC with a good response rate and long survival, even in patients with unfavorable clinical characteristics. The side-effects of afatinib were manageable and T790 M mutation was the most common resistance mechanism causing treatment failure.
The epidemiology and clinical characteristics of myeloproliferative neoplasms in Malaysia

Yap YY, Law KB, Sathar J, Lau NS, Goh AS, Chew TK, et al.

Exp Hematol Oncol, 2018;7:31.
PMID: 30564475 DOI: 10.1186/s40164-018-0124-7

Background: The evolution of molecular studies in myeloproliferative neoplasms (MPN) has enlightened us the understanding of this complex disease consisting of polycythaemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). The epidemiology is well described in the western world but not in Asian countries like Malaysia.
Materials and methods: This retrospective national registry of MPN was conducted from year 2009 to 2015 in Malaysia.
Results: A total of 1010 patients were registered over a period of 5 years. The mean age was 54 years with male predominance. The ethnic distribution revealed that Chinese had a relatively high weighted incidence proportion (43.2%), followed by Indian (23.8%), Malay (15.8%) and other ethnic groups (17.2%). The types of MPN reported were 40.4% of ET (n = 408), 38.1% of PV (n = 385), 9.2% of PMF (n = 93), 3.1% of hypereosinophilic syndrome (HES) (n = 31) and 7.9% of unclassifiable MPN (MPN-U) (n = 80). Splenomegaly was only palpable clinically in 32.2% of patients. The positive JAK2 V617F mutation was present in 644 patients with 46.6% in PV, 36.0% in ET, 9.0% in PMF, and 7.4% in MPN-U, and had significantly lower haemoglobin (p
Oncologist-led BRCA counselling improves access to cancer genetic testing in middle-income Asian country, with no significant impact on psychosocial outcomes

Yoon SY, Wong SW, Lim J, Ahmad S, Mariapun S, Padmanabhan H, et al.

J Med Genet, 2022 Mar;59(3):220-229.
PMID: 33526602 DOI: 10.1136/jmedgenet-2020-107416

BACKGROUND: Identifying patients with BRCA mutations is clinically important to inform on the potential response to treatment and for risk management of patients and their relatives. However, traditional referral routes may not meet clinical needs, and therefore, mainstreaming cancer genetics has been shown to be effective in some high-income and high health-literacy settings. To date, no study has reported on the feasibility of mainstreaming in low-income and middle-income settings, where the service considerations and health literacy could detrimentally affect the feasibility of mainstreaming.
METHODS: The Mainstreaming Genetic Counselling for Ovarian Cancer Patients (MaGiC) study is a prospective, two-arm observational study comparing oncologist-led and genetics-led counselling. This study included 790 multiethnic patients with ovarian cancer from 23 sites in Malaysia. We compared the impact of different method of delivery of genetic counselling on the uptake of genetic testing and assessed the feasibility, knowledge and satisfaction of patients with ovarian cancer.
RESULTS: Oncologists were satisfied with the mainstreaming experience, with 95% indicating a desire to incorporate testing into their clinical practice. The uptake of genetic testing was similar in the mainstreaming and genetics arm (80% and 79%, respectively). Patient satisfaction was high, whereas decision conflict and psychological impact were low in both arms of the study. Notably, decisional conflict, although lower than threshold, was higher for the mainstreaming group compared with the genetics arm. Overall, 13.5% of patients had a pathogenic variant in BRCA1 or BRCA2, and there was no difference between psychosocial measures for carriers in both arms.
CONCLUSION: The MaGiC study demonstrates that mainstreaming cancer genetics is feasible in low-resource and middle-resource Asian setting and increased coverage for genetic testing.

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