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Resistant hypertension during antituberculosis treatment: how is rifampicin implicated?

Lee SL, Lim WJ, Chai ST

Med J Malaysia, 2020 09;75(5):591-593.
PMID: 32918434

A 67-year-old mental institute resident was treated for smear-positive pulmonary tuberculosis. His background history included chronic essential hypertension which was well-controlled with amlodipine 10mg daily. However, his blood pressure became suboptimal one week into antitubercular treatment, necessitating escalation of antihypertensive therapy up to six medications. Following completion of antitubercular treatment, his blood pressure improved markedly. The number of antihypertensives was able to be reduced to only two after a month. We postulate that rifampicin has attenuated the therapeutic effect of amlodipine via potent induction of hepatic CYP3A4 but the failure to control the blood pressure even with medications unrelated to cytochrome P450 pathways raises the spectre of an additional interaction.
Fulltext COVID-19 Mandatory self-quarantine wearable device for authority monitoring with edge AI reporting & flagging system

Lim WJ, Abdul Ghani NM

Health Technol (Berl), 2022;12(1):215-226.
PMID: 35036282 DOI: 10.1007/s12553-021-00631-w

A mandatory self-quarantine is necessary for those who return from overseas or any red zone areas. It is important that the self-quarantine is conducted without the non-adherence issue occurring and causes the self-quarantine individual to be the carrier of the COVID-19 in the community. To navigate and resolve this issue, most countries have implemented a series of COVID-19 monitoring and tracing systems. However, there are some restrictions and limitation which can lead to intentional non-adherence. The quarantined individuals can still travel within the community by removing the wristband or simply providing an incorrect contact status in the tracing application. In this paper, a novel configuration for mandatory self-quarantine system is proposed. It will enable interaction between the wearable and contact tracing technologies to ensure that the authorities have total control of the system. The hardware of the proposed system in the wearable device is low in cost, lightweight and safe to use for the next user after the quarantine is completed. The software (software and database) that linked between the quarantine user and normal user utilizes edge artificial intelligence (AI) for reporting and flagging mechanisms.
Fulltext Verapamil-Induced Hypotension in End-Stage Renal Disease: The Role of Calcium Gluconate

Kaisbain N, Lim WJ, Kaisbain V

Cureus, 2023 Jan;15(1):e33341.
PMID: 36741660 DOI: 10.7759/cureus.33341

Verapamil is a useful drug in supraventricular tachycardias, atrial flutters, and fibrillations. However, its usage is accompanied by an undesirable side effect of hypotension. This limits its usage in patients where even the slightest reduction of blood pressure for a brief period may prove detrimental, e.g., in patients with critical coronary artery disease. Intravenous calcium given as pretreatment to verapamil prevented verapamil-induced hypotension. Its usage after hypotension restored the blood pressure to its baseline level. All these occur without the loss of the antiarrhythmic effect of verapamil. Furthermore, the pharmacokinetics of verapamil is unaltered in patients with chronic kidney disease. Thus, no dosage adjustment is required in this population. Here we describe a case of verapamil-induced hypotension in a patient with end-stage renal failure, which was reverted with intravenous calcium administration without altering the atrioventricular blockade effect of verapamil.
Fulltext Atrial septal defect with Crochetage sign presenting with pulmonary artery thrombosis

Kaisbain N, Lim WJ, Kim HS

BMJ Case Rep, 2021 Jul 27;14(7).
PMID: 34315750 DOI: 10.1136/bcr-2021-244180

Atrial septal defect (ASD) is the most common congenital heart disease observed in adult. Several ECG findings are considered sensitive for the diagnosis of ASD. We describe a 50 years old man who displayed Crochetage sign, incomplete right bundle branch block (IRBBB) and right ventricular strain pattern on ECG. Crochetage sign is highly specific for ASD and it correlates with shunt severity. The diagnostic specificity for ASD increases if the R waves have both Crochetage patterns and IRBBB. It is important not to confuse Crochetage signs with IRBBB abnormalities on ECG. Our patient was ultimately diagnosed with a large ASD measuring 3 cm with bidirectional shunt and concomitant pulmonary thrombosis. This illustrates that high suspicion of the ASD with the use of good-old ECG signs remains relevant in this modern era. This also reminds us that patients with Eisenmenger syndrome are at higher risk for pulmonary thrombosis.
A Rare Combination: Dengue Fever Complicated With Guillain-Barre Syndrome

Lim CS, Kaisbain N, Lim WJ

Cureus, 2023 Jun;15(6):e40957.
PMID: 37503499 DOI: 10.7759/cureus.40957

Guillain-Barre syndrome (GBS) is an uncommon neurological complication of dengue viral infection. It is more commonly reported with Campylobacter jejuni, Epstein-Barr virus, and Cytomegalovirus infection. We report an uncommon case of a 49-year-old man with dengue fever, who developed bilateral lower limb weakness and areflexia on day two of dengue illness. He was diagnosed with GBS as a sequel of dengue infection with the nerve conduction study showing evidence of demyelinating neuropathy. He recovered gradually without immunotherapy and was discharged after a week of hospitalization.
ECG lead misplacement in the frontal and horizontal plane mimicking A myocardial infarction

Kaisbain N, Khoo KKL, Lim WJ

Am J Emerg Med, 2023 Dec;74:196.e1-196.e4.
PMID: 37863804 DOI: 10.1016/j.ajem.2023.10.009

BACKGROUND/AIMS: Electrocardiogram (ECG) is an inexpensive, fundamental screening tool used in daily clinical practice. It is essential in the diagnosis of life-threatening conditions, such as acute myocardial infarctions, ventricular arrhythmias etc. However, ECG lead misplacement is a common technical error, which may translate into wrong interpretations, unnecessary investigations, and improper treatments.
METHODS/RESULTS: We report a case of a multiple ECG lead misplacement made across two different planes of the heart, resulting in a bizarre series of ECG, mimicking an acute high lateral myocardial infarction. Multiple ECGs were done as there were abrupt changes compared to previous ECGS. Patient was pain free and administration of potentially harmful procedures and treatments were prevented.
CONCLUSION: Our case demonstrated the importance of high clinical suspicion in diagnosing ECG lead misplacement. It is the responsibility of both the healthcare workers who are performing and interpreting the ECG to be alert of a possible lead malposition, to prevent untoward consequences to the patient.
Fulltext A 1, 4-benzoquinone derivative isolated from Ardisia crispa (Thunb.) A. DC. root suppresses angiogenesis via its angiogenic signaling cascades

Lim WJ, Chan PF, Hamid RA

Saudi Pharm J, 2024 Jan;32(1):101891.
PMID: 38111673 DOI: 10.1016/j.jsps.2023.101891

The root hexane extract of Ardisia crispa (ACRH), which belongs to the Primulaceae family, has been reported to possess anti-inflammatory, chemopreventive, anti-arthritic, and antiangiogenic activities. In this study, we isolated a p-benzoquinone derivative, 2-methoxy-6-undecyl-1,4-benzoquinone (AC2), from ACRH and investigated its potential antiangiogenic activity in human umbilical vein endothelial cells (HUVECs) and zebrafish embryo models. Prior to this study, AC2 was characterized using 1H NMR spectroscopy and MS. AC2 significantly suppressed HUVEC proliferation in a time-independent manner, with an IC50 value of 1.35 ± 0.05, 1.15 ± 0.02, and 1.00 ± 0.01 µg/mL at 24, 48, and 72 h, respectively. AC2 also induced apoptosis in HUVECs and significantly suppressed their migration, invasion, and tube formation in a concentration-dependent manner. Additionally, AC2 significantly attenuated most of the analyzed protein markers, including pro-MMP-2, VEGF-C, VEGF-D, angiopoietin-2, endothelin-1, fibroblast growth factor (FGF)-1, FGF-2, follistatin, heparin-binding epidermal growth factor-like growth factor (HB-EGF), and hepatocyte growth factor (HGF) at all tested concentrations. Furthermore, AC2 significantly inhibited zebrafish embryo intersegmental vessels (ISVs), confirming its antiangiogenic role. In conclusion, AC2 exhibits a potential anti-angiogenic effect by suppressing several proangiogenic and growth factors. Further studies are needed to investigate their effects on other excessive angiogenic diseases.
Natural fixatives alternative to formalin in histopathology: A systematic review

Yee AWM, Oo PS, Aye SN, Lim WJ, Chee VCX, Krishnappa P

Med J Malaysia, 2023 Jan;78(1):98-108.
PMID: 36715199

INTRODUCTION: Since constant long-term exposure to formaldehyde endangers the health of laboratory personnel, sugar-based natural products have become interesting alternative fixatives to formaldehyde because of their preservative and antibacterial properties. However, there are controversial findings on the fixative effects of natural fixatives. This study systematically reviews the evidence comparing natural fixatives' types, dilutions, fixative properties and staining quality in normal tissues and histopathological specimens.
MATERIALS AND METHODS: A comprehensive search was performed for studies comparing the natural fixatives- and formaldehyde-fixed tissues using databases from inception to January 2022: PubMed, Ovid Medline and Google Scholar. Two independent reviewers did data extraction. The data were pooled for the type of natural fixatives, their concentrations and fixative qualities compared to formaldehyde.
RESULTS: Fifteen studies were included in this systematic review. Nine studies used one natural fixative with different dilutions, while six used several natural fixatives to compare their fixative properties with formaldehyde. The most used natural fixative was honey (n = 12) followed by jaggery (n = 8), sugar (n = 3) and others (n = 1). Honey showed the most promising results in fixation and staining, which are compatible with formalin. Jaggery and sugar also showed the possibility of replacing formaldehyde in tissue fixation and staining in smaller tissue samples.
CONCLUSION: Natural fixatives showed promising results in tissue fixation. However, optimising the concentrations and conditions of natural fixatives is difficult because of the different chemical constituents and production steps. More comprehensive studies are necessary for application.
Gambir, "Gambir Sarawak" and toad venom

Lim WJ, Yap AT, Mangudi M, Hu CY, Yeo CY, Eyo ZW, et al.

Drug Test Anal, 2017 Mar;9(3):491-499.
PMID: 27367276 DOI: 10.1002/dta.2034