CASE PRESENTATION: A 33-year-old Malay man with underlying acquired immunodeficiency syndrome receiving highly active antiretroviral therapy was referred to the Opthalmology Department with complaints of blurry vision for the past 2 months. He had tested positive for and been diagnosed with COVID-19 1 month previously. Clinical examination of the fundus revealed extensive perivascular sheathing of both the artery and vein suggestive of FBA in the right eye. Laboratory testing of nasal swabs for COVID-19 polymerase chain reaction (PCR) and serum CMV antibody were positive. The patient was then admitted to the COVID-19 ward and treated with intravenous ganciclovir.
CONCLUSION: Clinicians should be aware of and take the necessary standard precautions for possible coexistence of COVID-19 in an immunocompromised patient presenting with blurred vision, eye redness, dry eye and foreign body sensation despite the absence of clinical features suggestive of COVID-19. Whether FBA is one of the ocular signs of co-infection of COVID-19 and CMV remains unknown. Further studies are needed to provide more information on ocular signs presented in patients with concurrent COVID-19 and CMV infections.
METHODS: A systematic review and meta-analysis was performed in accordance with the PRISMA statement. MEDLINE, EMBASE and Cochrane Library were searched for completed manuscripts until May 2019 on TIA/ischaemic stroke patients, ≥ 18 years, treated with commonly-prescribed antiplatelet therapy, who had platelet function/reactivity testing and prospective follow-up data on recurrent stroke/TIA, myocardial infarction, vascular death or other cerebrovascular outcomes. Data were pooled using random-effects meta-analysis. Primary outcome was the composite risk of recurrent stroke/TIA, myocardial infarction or vascular death. Secondary outcomes were recurrent stroke/TIA, severe stroke (NIHSS > 16) or disability/impairment (modified Rankin scale ≥ 3) during follow-up.
RESULTS: Antiplatelet-HTPR prevalence was 3-65% with aspirin, 8-56% with clopidogrel and 1.8-35% with aspirin-clopidogrel therapy. Twenty studies (4989 patients) were included in our meta-analysis. There was a higher risk of the composite primary outcome (OR 2.93, 95% CI 1.90-4.51) and recurrent ischaemic stroke/TIA (OR 2.43, 95% CI 1.51-3.91) in patients with vs. those without 'antiplatelet-HTPR' on any antiplatelet regimen. These risks were also more than twofold higher in patients with vs. those without 'aspirin-HTPR' and 'dual antiplatelet-HTPR', respectively. Clopidogrel-HTPR status did not significantly predict outcomes, but the number of eligible studies was small. The risk of severe stroke was higher in those with vs. without antiplatelet-HTPR (OR 2.65, 95% CI 1.00-7.01).
DISCUSSION: Antiplatelet-HTPR may predict risks of recurrent vascular events/outcomes in CVD patients. Given the heterogeneity between studies, further prospective, multi-centre studies are warranted.
METHODS: A qualitative study using a case-study approach was conducted between January 2019 and November 2019 in the districts of Gombak and Klang, where the relevant key informants were located. Nineteen interviews were conducted among elite healthcare personnel from different divisions: management, vector, laboratory, inspectorate, health promotion and entomology. Semi-structured interviews were conducted. The sample size was determined through saturation point criteria. Purposive sampling techniques were used to recruit the participants. The interviews were audio recorded, and the transcribed text was analysed with deductive thematic analysis.
RESULTS: Data analysis led to the development of 5 themes and 13 categories. The major principles of governance were embodied in a milieu of predicament, linked to constraints but also opportunities. The constraints resulted from inherent determinants of dengue outbreaks, the serviceability of governing policies and the macro-economics of budget allocation. The opportunities to sustain governance at the local operating level stem from a prevalent supportive internal management system, collaborative efforts among corresponding external government agencies and willingness to innovate and embrace novel technology.
CONCLUSION: Elites are influential, often well-informed personnel tasked with making decisions that can reverberate across an organisation, impacting future plans and strategic policies. Political arrangements at higher levels will reflect in advance the tone of how governance in dengue prevention and control is operationalised by entities and individuals at lower levels of the health system. The prevailing centralised structure in the Malaysian health system will continue to entrench the position of the elite and intertwine it with governance and its predicaments.
MATERIALS AND METHODS: Dental students (n = 122) in their clinical years, year 3 (n = 37), year 4 (n = 44), and year 5 (n = 41) received training (two-hour introductory lecture on ICDAS, followed by a 90 min e-learning video, and practice sessions using extracted teeth and photographs) from a calibrated expert. After training, the students examined a prevalidated set of extracted teeth and assigned scores in two sessions. The intra- and inter-examiner agreement between students was analyzed using weighted kappa statistics and a focus group discussion was conducted for qualitative feedback.
RESULTS: The range of kappa values for intra-examiner agreement among the year 3, 4, and 5 students for ICDAS caries code (0.611-0.879, 0.633-0.848, and 0.645-1.000) and restoration code (0.615-0.942, 0.612-0.923, 0.653-1.000), respectively. The range of kappa values for inter-examiner agreement for year 3, 4, and 5 students with a trained expert for ICDAS caries code (0.526-0.713, 0.467-0.810, and 0.525-0.842) and restoration code (0.531-0.816, 0.682-0.842, and 0.645-0.928), respectively.
CONCLUSION: The ICDAS system is a promising tool for caries detection and its implementation in the curriculum was perceived by dental students as an effective method. In general, there was moderate to substantial agreement for ICDAS caries and restoration code between students of different academic year groups and with a trained ICDAS expert.
CLINICAL SIGNIFICANCE: ICDAS is a simple, logical, and evidence-based system for the detection and classification of caries. Introducing ICDAS to dental students enables them to detect caries in a reliable and reproducible manner irrespective of their past clinical experience and also significantly improves their caries detection skills.