Distinguishing features of COVID-19 and non-COVID-19 febrile seizures in hospitalised children.

INTRODUCTION: Febrile seizures in children can be associated with various underlying conditions, including COVID-19. Differentiating COVID-19 and non-COVID-19 related febrile seizures is crucial for tailored patient management and for implementing appropriate infection control measures to prevent nosocomial transmission. This study aimed to describe the clinical features of children hospitalised for COVID-19 and non-COVID-19 febrile seizures and to identify factors that differentiate between the two groups. MATERIALS AND METHODS: This retrospective cross-sectional study involved children aged 6 months to 6 years who were hospitalised for febrile seizures in Hospital Tuanku Ja'afar Seremban (HTJS) from January 2021 to June 2022. Descriptive statistics were used to summarise the differences in demographics and clinical presentations. Logistic regression analyses were performed to identify factors associated with COVID-19 and non-COVID-19 febrile seizures. RESULTS: Of the 345 patients (median age 22 months, IQR 15- 32; 59.7% were males) included in the study, 130 (37.7%) tested positive for COVID-19, while 215 (62.3%) tested negative. There were no significant differences between both groups based on age, comorbidities, history of febrile seizures, seizure types, temperature on arrival, cough and rhinorrhoea. Multivariate analysis revealed that a family history of febrile seizures and leucocytosis were associated with increased odds of non-COVID-19 febrile seizures. In contrast, lymphopenia was associated with decreased odds. CONCLUSION: The clinical presentation of COVID-19 and non- COVID-19 febrile seizures are remarkably similar, highlighting the importance of including COVID-19 screening in febrile seizures workup. Full blood count readings may be potentially useful for differentiating between these conditions.

The outcome of 12-week corticosteroid therapy in COVID-19-related diffuse interstitial lung abnormalities.

INTRODUCTION: The efficacy of long-course corticosteroid therapy in treating COVID-19-related diffuse interstitial lung abnormalities (DILA) needs to be better understood. We aimed to investigate the benefits of 12-week corticosteroid treatment in COVID-19-related DILA by evaluating computed tomography (CT) lung severity scores. MATERIALS AND METHODS: This retrospective, single-centre observational study included patients aged 18 years or older admitted with moderate to severe COVID-19 pneumonia who received 12 weeks of oral prednisolone between January 2021 and December 2021. We recorded clinical parameters, baseline CT scores and post-treatment, modified Medical Research Council (mMRC) dyspnoea scale and pulmonary function tests. RESULTS: A total of 330 patients were analysed. The mean (standard deviation, SD) age was 54.6 (14.2) years, and 43% were females. Three-point nine per cent (3.9%) require noninvasive ventilation (NIV), while 14.6% require mechanical ventilation (MV). On follow-up at 12 weeks, the CT patterns showed improvement in ground-glass opacities, perilobular density and consolidation. There was an improvement in the mean (SD) CT score before and after prednisolone therapy, with values of 17.3 (5.3) and 8.6 (5.5), respectively (p<0.001). The median mMRC was 1 (IQR 0-1), and 98.8% had a radiological response. The common side effects of prednisolone therapy were weight gain (13.9%), hyperglycaemia (1.8%) and cushingoid habitus (0.6%). CONCLUSION: A 12-week treatment with prednisolone showed significant improvement in CT scores with minimal residual dyspnoea and was relatively safe. Longer duration of steroids may be beneficial in moderate to severe COVID-19- related DILA.

Predictive risk factors for pneumothorax following fluoroscopic-guided transbronchial lung biopsy.

INTRODUCTION: Fluoroscopic-guided transbronchial lung biopsy (FG-TBLB) is routinely performed via bronchoscopy to diagnose focal peripheral lesions and diffuse lung disease. Identifying the risk factors of FG-TBLB-related pneumothorax can assist the operator in taking pre-emptive measures to prepare for this potential complication. MATERIALS AND METHODS: We retrospectively analysed data from 157 patients who underwent FG-TBLB, with the primary outcome being procedure-related pneumothorax. We assessed several risk factors for pneumothorax following FG-TBLB: patient characteristics, location of biopsy, number of biopsies and computed tomography pattern. Univariate and multivariate logistic regression analyses were performed. RESULTS: One-hundred fifty-seven patients were included [mean (SD) age 57.9 (16.2) years; 60.5% male]. The most common location for FG-TBLB was the right upper lobe (n=45, 28.7%). The mean (SD) number of biopsy samples was 6.7 (2.1). Radiographic evidence of pneumothorax was reported in 12 (7.6%) patients, with 11 of those requiring intercostal chest tube intervention (mean air leak time: 5.7 days and 1 had persistent air leak requiring autologous blood patch pleurodesis. None experienced pneumothorax recurrence. Female gender and upper lobe location of the biopsy were identified as predisposing factors for pneumothorax. In the multivariable analysis, upper lobe biopsies were associated with a higher risk of pneumothorax (OR 0.120; 95% CI 0.015-0.963; p = 0.046). CONCLUSION: The overall rate of pneumothorax is low. We recognise the increased risk of pneumothorax associated with upper lobe biopsy. These findings suggest that clinicians should exercise caution when performing FGTBLB in this region and consider alternative biopsy locations whenever feasible. We suggest adequate planning and preparation should be implemented to minimise the risk of pneumothorax following FG-TBLB.

A case series of pulmonary alveolar proteinosis: Response differently to whole lung lavage.

Pulmonary alveolar proteinosis (PAP) is a rare disease and its prognosis can be improved by whole lung lavage (WLL). Herein, we present three cases with idiopathic PAP treated successfully with either single or double WLL in the same setting. All three of them presented with exertional dyspnoea with radiographic findings of pulmonary infiltrates. They showed a marked clinical and physiologic improvement post WLL. Two of them were in remission. These three cases were diagnosed using different lung biopsy modalities, including video-assisted thoracoscopic lung biopsy, computed tomography-guided percutaneous transthoracic tru-cut needle lung biopsy, and transbronchial forceps lung biopsy (TBLB), respectively. The current cases have shown that TBLB may provide adequate diagnostic yield, and the invasive surgical lung biopsy may not be necessary to achieve a definitive diagnosis.

Clots in tuberculosis.

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.

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.

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.

Effects of long-term inhaled corticosteroid treatment on fragility fractures in older women: the Manitoba BMD registry study.

The effects of inhaled corticosteroids (ICS) on fracture risk in older women with chronic respiratory diseases are not well established. Our results indicate long-term ICS use in this population does not increase the risk of major osteoporotic fracture. This finding further elucidates the long-term safety of ICS in older women. INTRODUCTION: Inhaled corticosteroids (ICS) are frequently used in older women with chronic respiratory diseases. There is insufficient evidence regarding the association between long-term ICS use and the risk of fragility fractures in this population. METHODS: We used linked Manitoba health administrative databases and the provincial bone mineral density (BMD) registry (1996-2013) to identify women ≥ 40 years of age with asthma and/or chronic obstructive pulmonary disease (COPD) within 3 years preceding the baseline BMD test. We followed them until the first major osteoporotic fracture or end of study, whichever came first. ICS use, stratified by exposure tertiles, was measured within the 12-month period following the baseline BMD test (by total days and quantity, primary outcome), and over the entire follow-up period (by medication possession ratio (MPR) and average annual dose, secondary outcome). The hazard ratio of fracture with ICS use was estimated using a Cox proportional hazards model, controlling for baseline determinants of fracture. RESULTS: Of 6880 older women with asthma (38%) or COPD (62%), 810 (12%) experienced a major osteoporotic fracture over a mean follow-up of 7.7 years (SD = 3.9). ICS use at any tertile was not associated with an increased risk of fracture (dispensed days, p = 0.90; dispensed quantity, p = 0.67). Similarly, ICS use at any tertile during the entire follow-up period was not associated with an increased risk of fracture (MPR, p = 0.62; average annual dose, p = 0.58). CONCLUSION: Our findings do not support an increased risk of major osteoporotic fracture in older women with chronic respiratory diseases due to long-term ICS use.

Patient-reported outcomes after surgery or radiotherapy for localised prostate cancer: a retrospective study.

INTRODUCTION: To compare the intermediate-term outcomes and patient-reported outcomes of robot-assisted laparoscopic prostatectomy (RALP) and radical external beam radiotherapy (RT) in Chinese patients with localised prostate cancer. METHODS: This was a retrospective study of patients with localised prostate cancer diagnosed between 2010 and 2011 and treated with either RALP or RT. Baseline patient and disease characteristics, post-treatment complications, and latest disease status were retrospectively collected from hospital records. For assessment of patient-reported outcomes, the Chinese version of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire was completed by the patients. RESULTS: Ninety three patients aged 58 to 84 years were recruited. Thirty patients were treated by RALP (32.3%), whereas 63 received RT (67.7%). The RALP group had significantly lower baseline prostate-specific antigen levels than the RT group (P<0.001). More patients who underwent RALP reported urinary incontinence (70.0% vs 3.2%, P<0.001), whereas more patients who underwent RT reported other voiding symptoms (87.3% vs 50.0%, P<0.001) and perirectal bleeding (36.5% vs 0%, P<0.001) during follow-up. Of the 85 patients who were still alive at the time of the study, 52 (61.2%) returned completed questionnaires. Patients who underwent RALP had poorer median (interquartile range) EPIC urinary summary scores than patients who underwent RT [81.5 (18.3) vs 88.9 (17.9), P=0.016]. Urinary function [75.9 (20.4) vs 93.6 (16.2), P<0.001] and incontinence [60.5 (31.8) vs 91.8 (14.5), P<0.001] were also significantly worse in the RALP group. The bowel and sexual domain scores were similar between the two groups. CONCLUSIONS: We found that RALP and RT were associated with different patterns of complications and patient-reported outcomes. Urinary incontinence was much more prevalent in the patients treated surgically. This may significantly affect patients' quality of life.

High intensity non-invasive positive pressure ventilation for refractory decompensated acute hypercapnic respiratory failure in advanced chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a debilitating progressive lung disease characterised by irreversible airflow obstruction. In addition to an increase in morbidity and mortality, exacerbation also results in frequent hospital visits, which place a burden on healthcare systems. Non-invasive positive pressure ventilation (NPPV) with conventional inspiratory pressures is the standard ventilatory support for patients in exacerbation. At present, the use of higher inspiratory pressures through high intensity noninvasive positive pressure ventilation (Hi-NPPV) during an exacerbation remains unknown. We describe a novel application of Hi-NPPV in a patient with acute exacerbation who was refractory to conventional NPPV.

Intra-pleural Instillation of Autologous Blood - Fine-tuning Techniques for Better Success Rate: Two Case Reports.

In the past, many case series have reported the effectiveness of autologous blood patch pleurodesis (ABPP) in recurrent secondary spontaneous pneumothorax (SSP), particularly in those who were unfit for surgery. We describe two cases of persistent air leak in pneumoconiosis and pulmonary fibrosis with bronchiectasis, whereby the techniques employed had improved the success rate of ABPP. The determining factors that lead to the success of ABPP were determined by the volume of autologous blood instilled, Trendelenburg position post instillation, and early chest physiotherapy with mobilisation by application of pneumostat.

Evaluation of a bilingual questionnaire-based assessment on hearing in children with speech delay.

INTRODUCTION: To correlate the score obtained using a bilingual (Malay and English) 14 points questionnaire in the detection of hearing loss at the University of Malaya, Medical Centre (UMMC), Kuala Lumpur, Malaysia over a 9 month period. METHODS: This is a prospective instrument correlation study done on 93 children aged 1-4 years of age with speech and language delay for at least 3 months. Hearing status was confirmed using otoacoustic emissions, pure tone audiometry and brainstem evoked response (BSER). Hearing status was then compared to the 14-point questionnaire final scores and is statistically correlated. RESULTS: There were 26 patients, 15 males (58%) and 11(42%) females who were diagnosed to have hearing loss. The average age of presentation was 2.49 and conductive hearing loss accounted for about 74% of cases of hearing loss. The mean questionnaire score obtained through our patients was 3.83±1.987. Discriminant analysis suggests that a questionnaire score of above 4 was indicative that the child was suffering from hearing loss. CONCLUSION: Our study suggests that the low-cost bilingual (Malay and English) questionnaire can be used to detect hearing loss in the Malaysian population and could potentially be useful in rural health centres to help detect hearing loss and to determine the urgency of referral to a tertiary health centre.

Angiosarcoma - a rare fatal cause of recurrent pericardial effusions.

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.

COVID-19 detected from targeted contact tracing, attempting to see the pattern in random happenings: early lessons in Malaysia.

The world feels strange as we face what is for most of us our first ever pandemic. The number of newly diagnosed cases rises daily in many parts of the world, and we are faced with the reality that there are still many things to learn about this new disease. We share here our experience of treating our first 199 COVID-19 patients in the Hospital Canselor Tuanku Muhriz, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM).

Knowledge and attitude of nurses towards diabetic foot care in a secondary health care centre in Malaysia.

INTRODUCTION: Nurses play a vital role in the care and prevention of ulcers in patients with diabetic foot. Patient education, prevention of ulcers and rehabilitation are some of the vital aspects that nurses provide on a daily basis. Thus, good knowledge and attitude of nurses towards diabetic foot ulcers and its care will ensure better patient care. OBJECTIVES: The aim is to study the level of knowledge and attitude of nurses towards diabetic foot ulcers and its care in Hospital Segamat, Malaysia. METHODS: A validated questionnaire was used between February 2019 to May 2019 covering area such as demography, predisposing factors of ulcer formation, characteristics of ulcers, complications of ulcers, and attitude towards diabetic foot care. RESULTS: A total of 101 nurses took part and 57% of the participants scored poorly in the knowledge section of the questionnaire. In all 72% had scored poorly when asked regarding complications of diabetic foot ulcers; 49.5% of the nurses had positive attitude towards diabetic foot care; and 79.3% thought that care for diabetic foot ulcer is timeconsuming. Majority of them think that their colleagues are the main source of information. All demographic variables were deemed to be confounders with the knowledge and attitude of nurses towards diabetic foot ulcers and its care. CONCLUSIONS: Nurses in this centre had poor knowledge towards diabetic foot ulcers and its care. None of the variable studied were correlated with the level know knowledge. Good or poor knowledge of nurses does not correspond equally to good or poor attitude towards diabetic foot ulcers care. More frequent formal training of diabetic foot care would be needed to ensure better knowledge.

A descriptive study of the psychological experience of health care workers in close contact with a person with COVID-19.

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.

Diabetic foot infection and surgical treatment in a secondary health care centre in Malaysia.

INTRODUCTION: Diabetic foot infection is often associated with high morbidity, disability and poor quality of life. This study focuses on the demography, the number of repetitive surgery and length of stay in hospital of patients with diabetic foot infection. METHOD: This is a retrospective observational study. Patients who were admitted to the Orthopaedic ward of Hospital Segamat (HS), Johor, Malaysia from January 2016 to December 2018 and required surgical intervention were included in the study. Data was collected from the computer system of HS and medical notes of patients. RESULTS: 35.6% of the total orthopaedic emergency surgeries performed were for patients with diabetic foot infection, 25% of the surgical procedures performed were major amputations of lower limb and 40% of the patients with diabetic foot infection required more than one surgical operation. DISCUSSION: The demographics of the patients is consistent with the demographics of Malaysia where majority of them are Malays followed by Chinese, Indians and others. Despite being only 10% of total admission to the department, this group of patients contributed to 35.6% of the total emergency surgeries performed. The amputation rate in the centre is comparable to the other local studies. The average length of stay in hospital was found to be shorter compared to overseas due to different rehabilitation protocols.

Lung computed tomography patterns of a cluster of asymptomatic young males with COVID-19 admitted to a teaching hospital in Kuala Lumpur.

BACKGROUND AND OBJECTIVE: Coronavirus Disease 2019 (COVID- 19) was first reported in Malaysia in March 2020. We describe here the clinical characteristics and computed tomography (CT) patterns in asymptomatic young patients who had laboratory-confirmed COVID-19. METHODS: This is a retrospective observational study where 25 male in-patients with laboratory-confirmed COVID-19 in Hospital Canselor Tuanku Muhriz. Demographics, clinical data and CT images of these patients were reviewed by 2 senior radiologists. RESULTS: In total there were 25 patients (all males; mean age [±SD], 21.64±2.40 years; range, 18-27 years). Patients with abnormal chest CT showed a relatively low normal absolute lymphocytes count (median: 2.2 x 109/L) and absolute monocyte count (median: 0.5 x 109/L). Lactate dehydrogenase was elevated in 5 (20%) of the patients. The procalcitonin level was normal while elevated levels of alanine aminotransferase, total bilirubin, platelet and C-reactive protein were common. Baseline chest CT showed abnormalities in 6 patients. The distribution of the lesions were; upper lobe 3 (12%) lower lobe 3 (12%) with peripheral distribution 4 (16%). Of the 25 patients included, 4 (16%) had ground glass opacification (GGO), 1 (4%) had a small peripheral subpleural nodule, and 1 (4%) had a dense solitary granuloma. Four patients had typical CT features of COVID-19. CONCLUSION: We found that the CT imaging showed peripheral GGO in our patients. They remained clinically stable with no deterioration of their respiratory symptoms suggesting stability in lung involvement. We postulate that rapid changes in CT imaging may not be present in young, asymptomatic, non-smoking COVID-19 patients. Thus the use of CT thoraxfor early diagnosis may be reserved for patients in the older agegroups, and not in younger patients.

Associations of clinical and dosimetric parameters with late rectal toxicities after radical intensity-modulated radiation therapy for prostate cancer: a single-centre retrospective study.

INTRODUCTION: This study assessed the incidence of late rectal toxicities and evaluated potential predictive factors for late proctitis in patients treated with prostate-specific intensity-modulated radiotherapy in Hong Kong. METHODS: This retrospective longitudinal observational study included patients with localised prostate cancer who were treated with intensity-modulated radiation therapy in an oncology unit in Hong Kong between January 2007 and December 2011, and who had >1 year of follow-up. Clinical, pharmacological, and radiation parameters were recorded. Toxicities were measured by Common Terminology Criteria for Adverse Events version 4. RESULTS: In total, 232 patients were included in this analysis. The mean follow-up time was 7.3 ± 2.1 years and 46.5% of the patients had late rectal toxicities. Late proctitis occurred in 30.5% of patients; 25% of the patients with late proctitis exhibited grade ≥2 toxicity. Median onset times for late proctitis and rectal bleeding were 15 and 18.4 months, respectively. Multivariable regression showed increased odds for the occurrence of late proctitis in patients with older age (odds ratio [OR]=1.11, 95% confidence interval [CI]=1.04-1.19, P=0.003), higher V70 (OR=1.08, 95% CI=1.01-1.15, P=0.027), and presence of acute rectal toxicities (OR=4.47, 95% CI=2.37-8.43, P<0.001). Antiplatelet use was not significantly associated with the occurrence of late proctitis (OR=1.98, 95% CI=0.95-4.14, P=0.07). CONCLUSIONS: The incidence of late rectal toxicities was considerable among patients in this study. Clinicians should consider the possibility of late proctitis for patients with older age, acute rectal toxicities, and higher V70. High doses to rectal volumes should be limited because of the significant association with V70.

Ways to overcome non-draining indwelling pleural catheter in malignant pleural effusion.

The indwelling pleural catheter (IPC) is a 16-Fr-multifenestrated catheter. It has become an accepted practice in the management of malignant pleural effusion, especially in patients with non-expandable lung. However, IPC blockage or not draining is common. A 53-year-old female with malignant pleural effusion presented to us with blocked IPC and symptomatic pleural loculation one month after IPC insertion. After failing saline flushing and low-pressure wall suction, intrapleural alteplase was instituted through the IPC with a favourable outcome, and she continued to drain daily thereafter. The present case highlights the safety of intrapleural alteplase via IPC in the non-expandable lung.

Kounis syndrome following solenopsis (fire ant) bite.

Anaphylaxis is rarely associated with the vasospastic acute coronary syndrome with or without the presence of underlying coronary artery disease. We report here a case of Kounis syndrome in a man with no known cardiovascular risk developed acute ST-elevation myocardial infarction complicated with complete heart block following Solenopsis (fire ant) bite.