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Fulltext A survey of anisakid larvae in marine fish in Penang, Malaysia

Leong TS

Southeast Asian J. Trop. Med. Public Health, 1980 Dec;11(4):493-5.
PMID: 7221690

A total of 104 marine fish belonging to 12 species in 6 families were examined for anisakid larvae. All except one fish species were infected with one or more types of anisakid larvae. Three types of anisakid larvae were recovered, the most abundant being Anisakis type 1 (9 out of 11 fish species) followed by Contracaecum type B (6 out of 11) and Terranova type B (1 out of 11). Latianus malabaricus has the highest mean intensity of both Anisakis type 1 and Contracaecum type B. The public health hazard of anisakine nematodes is briefly discussed.
Antiphospholipid syndrome in Sarawak: real world experience in a developing country

Teh CL, Leong TS

Clin Rheumatol, 2015 Jan;34(1):175-8.
PMID: 24831689 DOI: 10.1007/s10067-014-2671-6

We performed a cross-sectional study of all antiphospholipid syndrome (APS) patients during an 8-year period (2006-2013) to describe the clinical features, serology profiles, treatment regimes, and outcomes in our center. There were a total of 59 patients in our study with the female to male ratio of 9:1. They have a mean age of 41.6 ± 12.1 years and a mean duration of illness of 38.4 ± 68.5 months. The majority of patients presented with vascular thrombosis (69.5 %) with equal arterial and venous involvements. Twenty-six patients (44.1 %) presented with obstetric complications with recurrent abortions (32.2 %) as the main manifestation. Most patients were on daily warfarin doses of 2-6 mg (91.0 %) with target INR of 2-3. There was neither recurrent thrombosis nor bleeding complications documented. There were 80 % live births following treatment in our patients.
Fulltext Successful Non-surgical Treatment of an Acute Calculous Cholecystitis in a Myeloma Patient with Covid-19: Case Report

Tang ASO, Leong TS, Chew LP, Chua HH

SN Compr Clin Med, 2021;3(2):666-669.
PMID: 33554049 DOI: 10.1007/s42399-021-00785-8

COVID-19 has a wide spectrum of clinical phenotypes. While fever and cough are the most common symptoms, abdominal pain is rarely reported. We report the first case of COVID-19 pneumonia in an elderly patient with multiple myeloma (MM), complicated by acute calculous cholecystitis (ACC). A 73-year-old gentleman with underlying IgG kappa MM, presented with fever, cough and dyspnoea. His nasopharyngeal swab was positive for SARS-CoV-2. Piperacillin/tazobactam and oral hydroxychloroquine were started in addition to granulocyte colony-stimulating factor (GCSF) support due to neutropenia. Patient deteriorated on day 5, requiring high flow oxygen support. Dexamethasone, low molecular weight heparin prophylaxis and one dose of intravenous immunoglobulin were given. Despite negative swab on day 10, he developed ACC on day 17. With antibiotics and supportive care, patient showed full recovery without any surgical intervention. It remains elusive whether the gallbladder might be vulnerable to COVID-19, necessitating further validation via prospective studies.
A family of three with haemoglobin Cheverly: low oxygen saturation in stable patients

Chow LC, Puah SH, Tiong XT, Aloysious NS, Leong TS, Chew LP

J R Coll Physicians Edinb, 2021 Sep;51(3):253-256.
PMID: 34528613 DOI: 10.4997/JRCPE.2021.309

Haemoglobin (Hb) Cheverly is a rare, low oxygen affinity haemoglobinopathy. It is a result of point mutation at the 45 codon of the beta globin genes that leads to substitution of phenylalanine by serine. It is characterised by spuriously low peripheral oxygen saturation with normal arterial oxygen saturation. We describe a family of three with Hb Cheverly in Sarawak General Hospital, Malaysia. It was discovered through incidental finding during hospital admission for unrelated complaints. Laboratory testing revealed abnormal haemoglobin detected at the C window of the high performance liquid chromatography. Subsequent DNA analysis detected replacement of thymidine by cytosine at the beta globin genes. Hb Cheverly may or may not have clinical significance as most of the patients live a normal life; however, it is crucial for us to make early diagnosis to prevent unnecessary extensive investigations for hypoxaemia detected via pulse oximetry, especially in the midst of COVID-19 pandemic.
Thrombotic thrombocytopenic purpura-like syndrome associated with arcanobacterium pyogenes endocarditis in a post-transplant patient: A case report

Andy Tang SO, Leong TS, Ruixin T, Chua HH, Chew LP

Med J Malaysia, 2018 10;73(5):344-346.
PMID: 30350823 MyJurnal

Systemic Arcanobacterium pyogenes is a rare bacterial infection in humans.1The diagnosis of thrombotic thrombocytopenic purpura (TTP)-like syndrome and infective endocarditis (IE) is often elusive. We report a case of TTP-like syndrome associated with A. pyogenes endocarditis in a post-allogenic transplant patient.
Fulltext Correction to: Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera: a Case Report

Chow LC, Chew LP, Leong TS, Mohamad Tazuddin EE, Chua HH

SN Compr Clin Med, 2020;2(11):2508.
PMID: 33134841 DOI: 10.1007/s42399-020-00604-6

[This corrects the article DOI: 10.1007/s42399-020-00537-0.].
Fulltext Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera. A Case Report

Chow LC, Chew LP, Leong TS, Mohamad Tazuddin EE, Chua HH

SN Compr Clin Med, 2020;2(11):2406-2410.
PMID: 33043250 DOI: 10.1007/s42399-020-00537-0

Coronavirus disease (COVID-19) has a wide spectrum of clinical manifestations. In this case report, we describe our first case of COVID-19 pneumonia that was complicated by cerebral venous thrombosis and bleeding in a patient with polycythemia vera. Madam A, a 72-year-old lady with polycythemia vera, ischemic stroke, hemorrhoids, diabetes mellitus, hypertension, and dyslipidemia was admitted to the hospital for COVID-19 pneumonia. She was treated with hydroxychloroquine and lopinavir/ritonavir as per hospital protocol. She continued taking hydroxyurea and aspirin for her treatment of polycythemia vera. Subsequently, she developed rectal bleeding when her platelet count was 1247 × 103/μl, even though she was not on an anticoagulant. Her aspirin was withheld. One week later, she was readmitted to the hospital for cerebral venous thrombosis and her D-dimer was 2.02 μg/ml. She was commenced on a therapeutic dose of low molecular weight heparin. Following that, her D-dimer level showed a decreasing trend and normalized upon her discharge. Patients with polycythemia vera are prone to develop thrombotic and bleeding complications. Management of this group of patients has become more complex with COVID-19 infection. It is crucial for us to decide when to start an anticoagulant especially when there is a history of recent bleeding. We need to balance the risks of further bleeding versus potentially fatal thrombotic events. Studies have shown that D-dimer can be used as a clinical marker to predict thrombotic events in COVID-19 infection. Patients with COVID-19 infection and polycythemia vera will benefit from both pharmacological thromboprophylaxis and close monitoring for bleeding.
Fulltext Cost of Treatment for Myelofibrosis Patients in Ministry of Health Hospitals in Sarawak, Malaysia

Tang ASO, Leong TS, Ong JHL, Goh A, Chew LP

Asian Pac J Cancer Prev, 2023 Mar 01;24(3):733-736.
PMID: 36974524 DOI: 10.31557/APJCP.2023.24.3.733

OBJECTIVE: Primary myelofibrosis is a rare type of myeloproliferative neoplasm with an annual incidence rate of 0.47 per 100,000. A retrospective, observational study was conducted to determine the disease evolution and costs of treatment for myelofibrosis (MF) patients managed in 4 Ministry of Health (MOH) hospitals in Sarawak, Malaysia.
METHODS: The estimation of treatment cost was a planned analysis of the Real World Evidence (RWE) study which included retrospective chart review of adult MF patients treated in Sarawak General, Sibu, Bintulu and Miri Hospitals. The study was approved by Sarawak General Hospital HRRC and MREC. The current study was conducted to estimate the cost of out-patient visits, hospitalisation, transfusion and medication from the perspective of MOH. Out-patient visits and hospitalisation costs were calculated using current unit costs for full fee-paying charges of MOH hospitals. Transfusion costs were estimated for packed cell and platelet transfusions. Medication costs were calculated using drug prices from IQVIA database for MOH hospital sub-sector in 2021. Unit costs were standardised to index year of 2021.
RESULT: Data from 63 patients was available for analysis. Mean annual health resource utilisation (HRU) was 6.13 clinic visits, 9.47 days of hospitalisation and 1.61 transfusions per patient per year. Mean HRU cost was RM23,320 (USD5,217) per patient per year, comprised of RM19,122 (USD4,278) in drug costs, RM3,030 (USD678) for hospitalisation, RM799 (USD178) for transfusions and RM368 (USD82) for outpatient cost.
CONCLUSION: The present analysis suggests that medication and hospitalisation were the main drivers of costs for MF treatment in Sarawak MOH hospitals. This study provides the first RWE estimate of the cost of MF in Malaysia and may provide insight into unmet clinical needs and a guide for further health economic research into the treatment of MF.
Fulltext Acquired C1-inhibitor deficiency in chronic lymphocytic leukaemia: a case report

Tang ASO, Wong QY, Yeo ST, Lee JTH, Leong TS, Chew LP

Hong Kong Med J, 2022 Oct;28(5):403-405.
PMID: 38232966 DOI: 10.12809/hkmj219478
Bone health among older persons in medical clinic: A clinical audit

Teh CL, Chuah SL, Lee HK, Wan SA, Leong TS, Tan FHS, et al.

Med J Malaysia, 2020 03;75(2):191-193.
PMID: 32281610

Osteoporosis is commonly underdiagnosed and undertreated. We performed a clinical audit to assess the risk factors and clinical care for osteoporosis among older persons who attended medical clinic during a 4-week period in August 2013. There was a total of 128 patients with a mean age of 73.1±5.8 years, and 20.3%. had a history of fall. Fracture Risk Assessment Tool (FRAX) scores assessment showed 14.2% and 68.8% had a 10-year risk of major osteoporotic and hip fractures respectively. Only 6.3% underwent Dual-energy X-ray absorptiometry (DXA) and 73.4% did not receive any preventive treatment for osteoporosis. Older persons attending medical clinic at high risk of osteoporosis fractures did not receive appropriate screening and treatment. There is a need to improve the suboptimal care for bone health among older persons.
Fulltext Impact of timely BCR-ABL1 monitoring before allogeneic stem cell transplantation among patients with BCR-ABL1-positive B-acute lymphoblastic leukemia

Chong SL, Asnawi AWA, Leong TS, Tan JT, Law KB, Hon SL, et al.

Blood Res, 2021 Sep 30;56(3):175-183.
PMID: 34462403 DOI: 10.5045/br.2021.2021045

Background: With the emergence of tyrosine kinase inhibitors and the incorporation of stringent measurable residual disease (MRD) monitoring, risk stratification for BCR-ABL1-positive acute lymphoblastic leukemia (ALL) patients has changed significantly. However, whether this monitoring can replace conventional risk factors in determining whether patients need allogeneic stem cell transplantation is still unclear. This study aimed to determine the impact of BCR-ABL1 monitoring on the outcome of patients with BCR-ABL1-positive ALL after allogeneic stem cell transplantation.
Methods: We retrospectively analyzed the survival outcome of patients with BCR-ABL1-positive ALL based on the quantification of BCR-ABL1 at 3 timepoints: the end of induction (timepoint 1), post-consolidation week 16 (timepoint 2), and the end of treatment for patients who were either transplant-eligible or non-transplant eligible (timepoint 3).
Results: From 2006 to 2018, a total of 96 patients newly diagnosed with BCR-ABL1-positive ALL were treated with chemotherapy and tyrosine kinase inhibitors. Thirty-eight (41.3%) patients achieved complete remission, and 33 patients underwent allogeneic stem cell transplantation. Our data showed that pre-transplant MRD monitoring by real-time quantitative polymerase chain reaction had the highest correlation with survival in patients with BCR-ABL1-positive ALL, especially for those who underwent allogeneic stem cell transplantation.
Conclusion: Patients without MRD pre-transplantation had superior survival compared with those who had MRD, and they had excellent long-term outcomes after allogeneic stem cell transplantation.
Fulltext The Sarawak Myelofibrosis (SaMy) experience: Demographics and outcome of myelofibrosis patients in Sarawak, Malaysia

Tang ASO, Leong TS, Wong QY, Tan XY, Ko CT, Ngew KY, et al.

SAGE Open Med, 2023;11:20503121231194433.
PMID: 37705719 DOI: 10.1177/20503121231194433

Introduction: Myelofibrosis is a rare disease. There is currently no published data reporting the demographics and outcome of myelofibrosis patients in Malaysia. We aimed to study the demographics, clinical characteristics, and outcome of our patients in Sarawak. Materials and methods: This non-interventional, retrospective, and multi-center study was conducted on secondary data of medical records collected at four Sarawak Public Hospitals. All adult myelofibrosis patients diagnosed between January 2001 and December 2021 were included. Results: A total of 63 patients (male 31) with myelofibrosis were included-47 (74.6%) primary and 16 (25.4%) secondary myelofibrosis. Eleven had antecedent polycythaemia vera, whereas five transformed from essential thrombocythaemia. The combined annual incidence rate was 0.182 per 100,000 population. The period prevalence per 100,000 population over the entire study duration was 2.502. The median age was 59.0 years (33.0-93.0). Majority had high-risk (34/63(54.0%)) and intermediate-2 risk disease (19/63(30.2%)). JAK2V617F mutation was identified in 52 patients (82.5%), followed by CALR mutation in 6 (9.5%) and negative for both mutations in 5 (7.9%). Hydroxyurea was used as first-line therapy in 41/63 (65.1%), followed by interferon (8/63(12.7%)) and ruxolitinib (4/63(6.3%)). Out of 46 patients who received second-line therapy, 18 (39.1%) were switched to ruxolitinib and 9 (19.6%) to interferon. The median age of survival for overall patients was 6.8 years. The use of ruxolitinib in myelofibrosis patients showed a better overall 5-year survival compared to the no ruxolitinib arm, despite no statistical significance (p = 0.34). Patients who had good performance status had lower hazard of death than patients who had poor performance status (high-risk (95% confidence intervals): 0.06(0.013-0.239), p
Fulltext Secondary hemophagocytic lymphohistiocytosis: an unusual complication in disseminated Mycobacterium tuberculosis

Ing SK, Lee GWC, Leong TS, Lee YH, Lau GYL, Yusof NN, et al.

Clin Med (Lond), 2023 Jul;23(4):414-416.
PMID: 37524430 DOI: 10.7861/clinmed.2023-0171

Tuberculosis-associated hemophagocytic lymphohistiocytosis (TB-HLH) is a rare and life-threatening complication of tuberculosis infection. Early recognition and treatment of TB-HLH is crucial for improving outcomes. Treatment typically involves a combination of antituberculosis therapy and immunosuppressive therapy to control the immune system's overreaction. In this report, we present the case of a 53-year-old ambulance driver who was diagnosed with TB-HLH. His CT scan revealed splenic abscesses, hepatomegaly and bilateral lung consolidation. He subsequently developed multiorgan failure, including acute respiratory distress syndrome (ARDS), transaminitis and bone marrow dysfunction. The clinical course and simultaneous increase in serum ferritin raised the suspicion of HLH. His Hscore was 254, indicating a high probability of hemophagocytic syndrome. TB diagnosis was confirmed by positive endotracheal TB GeneXpert and bone marrow aspiration (BMA) which detected acid-fast bacilli organisms. The patient was promptly started on anti-TB, dexamethasone and IVIG. The patient responded well to treatment and made a full recovery without any lasting complications. This case highlights the importance of promptly recognising HLH and identifying the underlying cause. In critically ill patients, it is crucial not to delay HLH-specific treatment while working up for differential diagnosis.