Clinical pathways have been implemented in many healthcare systems with mix results in improving the quality of care and controlling the cost. CP is a methodology used for mutual decision making and organization of care for a well-defined group of patients within a well-defined period. In developing the CPs for a medical centre, several meetings had been carried out involving expert teams which consist of physicians, nurses, pharmacists and physiotherapists. The steps used to develop the pathway were divided into 5 phases. Phase 1: the introduction and team development, Phase II: determining the cases and information gathering, Phase III: establishing the draft of CP, Phase IV: is implementing and monitoring the effectiveness of CP while Phase V: evaluating, improving and redesigning of the CP. Four CPs had been developed: Total Knee Replacement (TKR), ST Elevation Myocardial Infarction (AMI), Chronic Obstructive Airways Diseases (COAD) and elective Lower Segment Caesarean Section (LSCS). The implementation of these CPs had supported the evidence-based medicine, improved the multidisciplinary communication, teamwork and care planning. However, the rotation of posts had resulted in lack of document ownership, lack of direction and guidance from senior clinical staff, and problem of providing CPs prior to admission. The development and implementation of CPs in the medical centre improved the intra and inter departmental communication, improved patient outcomes, promote patient safety and increased patient satisfaction. However, accountability and understanding of the CPs must be given more attention.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Rituximab (RTX) is a monoclonal anti-CD20 antibody used to treat non-Hodgkin's lymphoma. RTX-organising pneumonia (RTX-OP) is a rare complication following treatment with RTX. We report a 49-year-old woman, with CD5-negative B-cell lymphoproliferative disorder who developed high-grade fever, dyspnoea and dry cough 3 days after the first dose of RTX. She responded poorly to antibiotics and antifungal therapy. High-resolution CT (HRCT) of the chest revealed bilateral patchy ground-glass opacities with arcade-like signs suggestive of OP. She was pulsed with intravenous methylprednisolone and RTX was discontinued. She was able to be weaned off the non-invasive ventilation (NIV) support and was discharged with maintenance prednisolone 1 mg/kg and tapered over 6 weeks. A repeated HRCT of the chest at 6 weeks showed a total resolution of OP. This highlights the early occurrence at day 3 of RTX-OP following the first dose of RTX and the complete resolution with steroid therapy.
Pleural infection is an important clinical problem with significant morbidity. In poorly draining complex pleural effusions, the current management favours a less invasive image-guided placement of smaller bore catheters and adjunctive intrapleural fibrinolysis therapy (IPFT). We describe our experience of using IPFT in three patients with different bleeding risks with complex pleural effusions. The first was a 30-year-old with transfusion-dependent β-thalassemia with haemoglobin of 7.8 g/dL; second was an 87-year-old on dabigatran with haemoglobin of 10 g/dL; and the third was an 80-year-old with diffuse large B-cell lymphoma with haemoglobin of 8.6 g/dL. All three patients received three doses of alteplase and deoxyribonuclease (DNase) without any adverse effects of bleeding and had resolution of the effusion. This case series is an addition to the current literature on the safety of IPFT and we highlight the use of IPFT in patients with low baseline haemoglobin and on anticoagulation therapy.
Acute COVID-19 usually lasts 4 weeks from the onset of symptoms. We report two cases of COVID-19-associated organising pneumonia (OP) occurring beyond 4 weeks from the acute onset of symptoms. Both tested positive for SARS reverse transcription-PCR 2 months before presentation with a resolution of respiratory symptoms. The first case presented with residual fatigue and worsening exertional dyspnoea. Chest CT revealed an OP pattern. The second case presented with worsening cough and new-onset pleuritic chest pain with persistent radiological consolidation. A transbronchial lung biopsy confirmed OP. Both patients responded well to 12 weeks of steroid therapy. This case illustrates the rare presentation of OP as a late sequela of COVID-19 and the good response to steroid therapy.
Malignant pleural effusion with persistent air leak (PAL) is a rare manifestation of lung malignancy. We present a woman in her 50s with postpleuroscopy PAL. Pleural biopsy confirmed adenocarcinoma with detection of epidermal growth factor receptor mutation in exon 19. An indwelling pleural catheter (IPC) was inserted and connected to an Atrium Express Mini ambulatory drain. This procedure reduced the length of hospital stay. Autopleurodesis with resolution of PAL occurred at week 3 of IPC insertion.
The use of Cannabis sativa, also known as marijuana, is believed to have dated back to thousands of years B.C. More than 200 decades later, it remains a popular recreational psychoactive substance that can be smoked through a water pipe. We report a case of marijuana smoking via a "bong" device, which has resulted in severe Pseudomonas aeruginosa necrotizing pneumonia treated with conservative medical therapy. This case highlights the importance of recognizing that life-threatening pneumonia can potentially be linked to marijuana and "bong" usage. Complicated cases should be considered for early surgical intervention.
Tracheobronchial stenosis is a known complication of endobronchial tuberculosis. Despite antituberculous and steroid therapy, the development of bronchial stenosis is usually irreversible and requires airway patency to be restored by either bronchoscopic or surgical interventions. We report the use of balloon dilatation and topical mitomycin-C to successful restore airway patency.
BACKGROUND: Exacerbations, a leading cause of hospitalization in patients with chronic obstructive pulmonary disease (COPD), affect the quality of life and prognosis. Treatment recommendations as provided in the evidence-based guidelines are not consistently followed, partly due to absence of simplified task-oriented approach to care. In this study, we describe the development and implementation of a clinical pathway (CP) and evaluate its effectiveness in the management of COPD exacerbation.
METHODS: We developed a CP and evaluated its effectiveness in a non-randomized prospective study with historical controls on patients admitted for exacerbation of COPD to Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Consecutive patients who were admitted between June 2009 and December 2010 were prospectively recruited into the CP group. Non-CP historical controls were obtained from case records of patients admitted between January 2008 and January 2009. Clinical outcomes were evaluated by comparing the length of stay (LOS), complication rates, readmissions, and mortality rates.
RESULTS: Ninety-five patients were recruited in the CP group and 98 patients were included in the non-CP historical group. Both groups were comparable with no significant differences in age, sex and severity of COPD (p = 0.641). For clinical outcome measures, patients in the CP group had shorter length of stay than the non-CP group (median (IQR): 5 (4-7) days versus 7 (7-9) days, p
BACKGROUND: Dental laboratory technicians are at risk of developing occupational respiratory diseases due to exposure to various potentially toxic substances in their working environment. Since 1939, few cases of silicosis among dental technician have been reported.
CASE PRESENTATION: We illustrate a 38 year-old female, who worked in a dental laboratory for 20 years, initially treated as pulmonary tuberculosis and chronic necrotising aspergillosis without much improvement. Computed tomography guided lung biopsy and bronchoscopic transbronchial lung biopsy were performed. Lung tissue biopsies showed presence of refractile dental materials within the areas of histiocyte proliferation. The diagnosis of dental technician pneumoconiosis was obtained and our patient underwent pulmonary rehabilitation.
CONCLUSIONS: This case highlights the importance of obtaining a detailed occupational history in tuberculosis endemic area, as pulmonary tuberculosis is a great mimicker of other respiratory diseases.
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.
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.
Upper gastrointestinal bleeding as a result of gastrointestinal metastases from lung cancer is extremely rare. We report two cases of patients with duodenal metastases from lung adenocarcinoma presented with recurrent melena. Histopathological examination and immunohistochemical staining of the duodenal biopsies supported the diagnosis of metastatic lung adenocarcinoma.
Pleural anthracosis is rare and, in most cases, is diagnosed incidentally or at autopsy. We report a 67-year-old man with pleural anthracosis. He was initially referred for possible tuberculous pleural effusion and had recurrent admissions for symptomatic pleural effusion, which increased with each subsequent episode. A thoracoscopic examination demonstrated diffuse hyperpigmentation in both parietal and visceral pleura. Parietal pleural biopsy indicated granuloma with foreign body giant cell. A contrast-enhanced computed tomography (CECT) thorax showed focal plaques in parietal pleura with calcifications in the ipsilateral lung. Investigations for tuberculosis, fungal, and malignancy proved to be negative. With these results, a diagnosis of pleural anthracosis was made. This case highlights the unusual presentation of pleural anthracosis with pleural effusion.
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.
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.
Tobacco and nicotine derivatives uses are multiple in nature. These include conventional cigarettes (CCs), heated tobacco products (HTPs), and electronic cigarettes (ECs). This study aims to determine the practices, nicotine dependency profile, association with exhaled carbon monoxide (eCO) level, and pulmonary function (PF) among adult product users and non-smokers. This cross-sectional study involved smokers, nicotine users, and non-smokers from two public health facilities in Kuala Lumpur from December 2021 to April 2022. Data on socio-demography, smoking profile, nicotine dependency level, anthropometry, eCO monitor, and spirometer measurements were recorded. Out of 657 respondents, 52.1% were non-smokers, 48.3% were CC only smokers, poly-users (PUs) (27.3%), EC-only users (20.9%), and HTP-only users (3.5%). EC use was prevalent among the younger aged, tertiary educated, and females; HTP use was prevalent among those of an older age and CC users was common among lower educated males. The highest median eCO (in ppm) seen were as follows: in CC users only (13.00), PUs (7.00), EC users (2.00), HTP users (2.00), and the least was observed among non-smokers (1.00), which is significantly different across the groups (p <0.001). Comparison of practice between the different product users showed significant differences in age of product initiation (p <0.001, youngest in CC users in PUs), duration of product use (p <0.001, longest in exclusive CC users), cost per month (p <0.001, highest in exclusive HTP users) and attempt to quit product (p <0.001, CC use in PUs had the highest attempt to quit), while there is no significant difference in Fagerström score across the groups. Among EC users, 68.2% successfully switched from smoking CCs to ECs. The findings suggest that EC and HTP users are exhaling less CO. The use of these products in a targeted approach may manage nicotine addiction. Switching practice was higher among current EC users (from using CCs), hence emphasizing the need of switching encouragement and total nicotine abstinence later on. Lower eCO levels in the PU group, (as compared to CC-only users) and high quit attempt rate among in CC use in PUs may indicate attempt of PUs in reducing CC use through alternative modalities such as ECs and HTPs.
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.