METHODOLOGY: A follow-up in prospective cohort surveillance was conducted on patients admitted to an adult medical-surgical ICU of a university hospital and two governmental hospitals in Malaysia from October 2003 to December 2006. VAP was detected using CDC criteria which included clinical manifestation and confirmed endotracheal secretion culture results.
RESULTS: In total, 215 patients (2,306 patient-days) were enrolled into the study. The incidence of ICU-acquired device-related NI was 29.3 % (n = 63). The device-related VAP infection rate was 27.0 % (n = 58), with a mechanical ventilator utilization rate of 88.7%. The death rate due to all ICU-acquired NI including sepsis was 6.5%. The most common causative pathogen was Klebsiella pneumoniae (n = 27). Multivariate analysis using Cox regression showed that the risk factors identified were aspiration pneumonia (HR = 4.09; 95% CI = 1.24, 13.51; P = 0.021), cancer (HR = 2.51; 95% CI = 1.27, 4.97; P = 0.008), leucocytosis (HR=3.43; 95% CI= 1.60, 7.37; P=0.002) and duration of mechanical ventilation (HR=1.04; 95% CI = 1.00, 1.08; P = 0.030). Age, gender and race were not identified as risk factors in the multivariable analysis performed.
CONCLUSION: The incidence of VAP was comparable to that found in the National Nosocomial Infection Surveillance (NNIS) System report of June 1998. The incidence of VAP was considered high for the three hospitals studied.
OBJECTIVES: To review the evidence on the application of the new VAE surveillance definition in paediatric population and examine the potential challenges in clinical practice.
REVIEW METHODS: A systematic approach was used to locate and synthesise the relevant paediatric literature. Studies were appraised according to epidemiological appraisal instrument (EAI) and the grades of evidence in the National Health Medical Research Council (NHMRC) guidelines.
RESULTS: Seven studies met the inclusion criteria. Quality of study methods was above 50% on the EAI. The overall grade of evidence was assessed as C (satisfactory). The incidence of VAE in children ranged from 1.1 to 20.9 per 1000 ventilator days as a result of variations in surveillance criteria across included studies. There is little agreement between the new VAE and PNU/VAP surveillance definition in the identification of VAP. Challenges in the application of VAE surveillance were related to; the difference in modes of ventilation used in children versus adults, inconclusive criteria tailored to paediatric samples and a lack of data that support for automatic data extraction applied in paediatric studies.
CONCLUSION: This review demonstrated promising evidence using the new VAE surveillance definition to define the VAE in children, but the level of the evidence is low. Before the possibility of real implementation in clinical settings, challenges related to VAE paediatric specific criteria' and the value of automated data collection need to be considered.
AIMS: This study was undertaken to establish the prevalence of VVR among whole blood donors in Hospital Pulau Pinang and to investigate factors that lead to its occurrence.
SETTINGS AND DESIGN: A cross-sectional study was conducted involving 27,890 whole blood donations in 2016.
SUBJECTS AND METHODS: For each donation, donor's demographic and blood donation-related information was extracted from the blood bank database.
STATISTICAL ANALYSIS USED: Qualitative data including age group, sex, race, frequency, and location of donation were analyzed using Chi-square tests, while blood pressure was analyzed using t-test.
RESULTS: Overall, 425 cases of VVRs were reported, resulting in a VVR rate of 1.5% (one event in every 65 donations). We found a statistically significant association (P < 0.05) between the occurrence of VVRs with the young age group, female gender, Indian race, first-time donor, lower predonation blood pressure, and donation performed in a mobile donation campaign. The most common vasovagal symptoms are lightheadedness (88%), followed by nausea (5.4%), muscle twitching (3.5%), vomiting (1.4%), loss of consciousness <30 s (1.4%), and paresthesia (0.2%).
CONCLUSIONS: The prevalence of VVRs among whole blood donors in Hospital Pulau Pinang appeared to be low. Our study reaffirms that blood donation is a relatively safe process, and the incidence of VVR can be further reduced by ensuring strict screening procedure before blood donation.
STUDY DESIGN: Systematic review.
SETTING & POPULATION: Adults requiring maintenance hemodialysis.
SELECTION CRITERIA: All randomized controlled trials and trial protocols reporting vascular access outcomes identified from ClinicalTrials.gov, Embase, MEDLINE, and the Cochrane Kidney and Transplant Specialized Register from January 2011 to June 2016.
INTERVENTIONS: Any hemodialysis-related intervention.
OUTCOMES: The frequency and characteristics of vascular access outcome measures were analyzed and classified.
RESULTS: From 168 relevant trials, 1,426 access-related outcome measures were extracted and classified into 23 different outcomes. The 3 most common outcomes were function (136 [81%] trials), infection (63 [38%]), and maturation (31 [18%]). Function was measured in 489 different ways, but most frequently reported as "mean access blood flow (mL/min)" (37 [27%] trials) and "number of thromboses" (30 [22%]). Infection was assessed in 136 different ways, with "number of access-related infections" being the most common measure. Maturation was assessed in 44 different ways at 15 different time points and most commonly characterized by vein diameter and blood flow. Patient-reported outcomes, including pain (19 [11%]) and quality of life (5 [3%]), were reported infrequently. Only a minority of trials used previously standardized outcome definitions.
LIMITATIONS: Restricted sampling frame for feasibility and focus on contemporary trials.
CONCLUSIONS: The reporting of access outcomes in hemodialysis trials is very heterogeneous, with limited patient-reported outcomes and infrequent use of standardized outcome measures. Efforts to standardize outcome reporting for vascular access are critical to optimizing the comparability, reliability, and value of trial evidence to improve outcomes for patients requiring hemodialysis.
METHODS: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.
FINDINGS: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.
INTERPRETATION: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.
FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).
SETTINGS: A validation study among people living with HIV(PLHIV) aged ≥18 years among the cohorts in the Asia-Pacific region.
METHODS: PLHIV with baseline eGFR>60 mL/min/1.73m were included for validation of the D:A:D CKD full version and the short version without cardiovascular risk factors. Those with <3 eGFR measurements from baseline or previous exposure to potentially nephrotoxic antiretrovirals were excluded. Kaplan-Meier methods were used to estimate the probability of CKD development. Area Under the Receiver Operating Characteristics (AUROC) was also used to validate the risk score.
RESULTS: We included 5,701 participants in full model(median 8.1 [IQR 4.8-10.9] years follow-up) and 9,791 in short model validation(median 4.9 [IQR 2.5-7.3] years follow-up). The crude incidence rate of CKD was 8.1 (95%CI 7.3-8.9) per 1,000 person-years(PYS) in the full model cohort and 10.5 (95%CI 9.6-11.4) per 1,000 PYS in the short model cohort. The progression rates for CKD at 10 years in the full model cohort were 2.7%, 8.9% and 26.1% for low-, medium- and high-risk groups, and 3.5%, 11.7% and 32.4% in the short model cohort. The AUROC for the full and short risk score was 0.81 (95%CI 0.79-0.83) and 0.83 (95%CI 0.81-0.85), respectively.
CONCLUSION: The D:A:D CKD full- and short-risk score performed well in predicting CKD events among Asian PLHIV. These risk prediction models may be useful to assist clinicians in identifying individuals at high risk of developing CKD.
OBJECTIVES: The objectives of this study was to determine whether patients with primary prevention (PP) indications with specific risk factors (1.5PP: syncope, nonsustained ventricular tachycardia, premature ventricular contractions >10/h, and low ventricular ejection fraction <25%) are at a similar risk of life-threatening arrhythmias as patients with secondary prevention (SP) indications and to evaluate all-cause mortality rates in 1.5PP patients with and without devices.
METHODS: A total of 3889 patients were included in the analysis to evaluate ventricular tachycardia or fibrillation therapy and mortality rates. Patients were stratified as SP (n = 1193) and patients with PP indications. The PP cohort was divided into 1.5PP patients (n = 1913) and those without any 1.5PP criteria (n = 783). The decision to undergo ICD implantation was left to the patient and/or physician. The Cox proportional hazards model was used to compute hazard ratios.
RESULTS: Patients had predominantly nonischemic cardiomyopathy. The rate of ventricular tachycardia or fibrillation in 1.5PP patients was not equivalent (within 30%) to that in patients with SP indications (hazard ratio 0.47; 95% confidence interval 0.38-0.57) but was higher than that in PP patients without any 1.5PP criteria (hazard ratio 0.67; 95% confidence interval 0.46-0.97) (P = .03). There was a 49% relative risk reduction in all-cause mortality in ICD implanted 1.5PP patients. In addition, the number needed to treat to save 1 life over 3 years was 10.0 in the 1.5PP cohort vs 40.0 in PP patients without any 1.5PP criteria.
CONCLUSION: These data corroborate the mortality benefit of ICD therapy and support extension to a selected PP population from underrepresented geographies.
METHODS: Qualitative study using six focus groups and 14 semi-structured interviews with doctors responsible for dengue management at a large tertiary hospital in Malaysia.
RESULTS: Dengue was recognised as difficult to diagnose and manage. Wide awareness and use of both WHO and Ministry of Health guidelines was reported, but several limitations noted in their coverage of particular patient groups. However, the phrase 'guidelines' also referred to local algorithms for fluid management, which were less clinically evidence-based. Where Medical Officers were well trained in the appropriate use of evidence-based guidelines, barriers to use included: the potential for 'following the algorithm' to undermine junior clinicians' claims to clinical expertise; inability to recognise the pattern of clinical progress; and lack of clinical experience. Other reported barriers to improved case management were resource constraints, poor referral practices, and insufficient awareness of the need for timely help seeking.
CONCLUSIONS: Awareness of clinical practice guidelines is a necessary, but not sufficient, condition for optimal dengue management. In high prevalence settings, all clinical staff would benefit from regular dengue management training which should include diagnosis, practice in monitoring disease progression and the use of clinical practice guidelines in a range of clinical contexts.
OBJECTIVE: This study aimed to document the process of designing and developing a mobile app for community education on colorectal cancer and assess the usability of the prototype.
METHODS: The nominal group technique (NGT) was used for the content development of the mobile app. NGT involving community educationists and clinicians combined with community representatives as the target users identified relevant health information and communication strategies including features for a user-friendly mobile app. The prototype was developed using framework Ionic 1, based on the Apache Cordova and Angular JS (Google). It was published in the Google Play store. In total, 50 mobile phone users aged 50 years and above and who had never been diagnosed with any type of cancer were invited to download and use the app. They were asked to assess the usability of the app using the validated Malay version of System Usability Scale Questionnaire for the Assessment of Mobile Apps questionnaire. The One-sample t test was used to assess the usability score with a cut-off value of 68 for the usable mobile app.
RESULTS: The Colorectal Cancer Awareness Application (ColorApp) was successfully developed in the local Malay language. The NGT discussion had suggested 6 main menus in the ColorApp prototype, which are Introduction, Sign and Symptoms, Risk Factors, Preventive Measures, Colorectal Cancer Screening Program, and immunochemical fecal occult blood test kit. A total of 2 additional artificial intelligence properties menus were added to allow user-ColorApp interaction: Analyze Your Status and ColorApp Calculator. The prototype has been published in the Google Play store. The mean usability score was 72 (SD 11.52), which indicates that ColorApp is a usable mobile app, and it can be used as a tool for community education on colorectal cancer.
CONCLUSIONS: ColorApp mobile app can be used as a user-friendly tool for community education on colorectal cancer.
METHODS: We retrospectively reviewed infants with ARM who received surgery and were followed at the Sabah Women and Children's Hospital, Malaysia, from 1986 to 2010.
RESULTS: One hundred and twenty-two children with anorectal malformations were studied, after excluding 24 children with incomplete data. Three factors were significant as predictors of the presence of a urological anomaly: high ARM lesion (OR 3.12, 95%CI 1.1-8.9), the presence of genital abnormality (OR 2.95, 95%CI 1.10-7.91) and cloacal anomaly in girls (OR 8.27, 95% CI 1.91-35.6). The most common anomalies were vesicoureteric reflux, single kidney and neurogenic bladder. Chronic kidney disease (CKD) was noted in 5.7%, in children who had recurrent urinary tract infections, neurogenic bladder or complex renal tract pathology; end-stage renal failure was seen in only 0.8% of children with ARM.
CONCLUSION: Urological anomalies were seen in 23% of patients, but the overall incidence of CKD and end-stage renal disease is low. Early identification of infants with ARM at risk of renal failure may be important for renal survival.
METHODS: Incident HD patients without permanent vascular access encountered from January to December 2014 were included in this study. Patients were divided into 2 groups: Group 1 were encountered within 6 months prior to introduction of in-patient IPD bridging therapy in substitution of noncuffed catheter (NCC) insertion while awaiting maturation of permanent vascular access. Group 2 were encountered within 6 months after the introduction of this policy. The number of NCC and peritoneal dialysiscatheter insertion, along with catheter-related infections were evaluated during this period.
RESULTS: Approximately 450 patients were distributed in each group. We achieved 45% reduction in internal jugular catheter insertion from 322 to 180 catheters after policy change. This led to a significant drop in catheter-related blood stream infection (53%, P <0.001). On the other hand, 30% more peritoneal dialysiscatheter were inserted to accommodate our IPD bridging therapy.
CONCLUSIONS: The introduction of IPD as bridging therapy while awaiting maturation of permanent vascular access significantly reduced the utilization of NCC in incident HD patients and catherter-related blodstream infection. With this, it is our hope that it will contribute to the preservation of central vein patency.
METHODS: This is a secondary data review of all diagnosed and reported malaria confirmed cases notified to the Ministry of Health, Malaysia between January 2013 and December 2017.
RESULTS: From 2013 to 2017, a total of 16,500 malaria cases were notified in Malaysia. The cases were mainly contributed from Sabah (7150; 43.3%) and Sarawak (5684; 34.4%). Majority of the patients were male (13,552; 82.1%). The most common age group in Peninsular Malaysia was 20 to 29 years (1286; 35.1%), while Sabah and Sarawak reported highest number of malaria cases in age group of 30 to 39 years (2776; 21.6%). The top two races with malaria in Sabah and Sarawak were Bumiputera Sabah (5613; 43.7%) and Bumiputera Sarawak (4512; 35.1%), whereas other ethnic group (1232; 33.6%) and Malays (1025; 28.0%) were the two most common races in Peninsular Malaysia. Plasmodium knowlesi was the commonest species in Sabah and Sarawak (9902; 77.1%), while there were more Plasmodium vivax cases (1548; 42.2%) in Peninsular Malaysia. The overall average incidence rate, mortality rate and case fatality rates for malaria from 2013 to 2017 in Malaysia were 0.106/1000, 0.030/100,000 and 0.27%, respectively. Sarawak reported the highest average incidence rate of 0.420/1000 population followed by Sabah (0.383/1000). Other states in Peninsular Malaysia reported below the national average incidence rate with less than 0.100/1000.
CONCLUSIONS: There were different trends and characteristics of notified malaria cases in Peninsular Malaysia and Sabah and Sarawak. They provide useful information to modify current prevention and control measures so that they are customised to the peculiarities of disease patterns in the two regions in order to successfully achieve the pre-elimination of human-only species in the near future.