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Fulltext Prevalence and risk factors of prehypertension in university students in Sabah, Borneo Island of East Malaysia

Qaiser S, Daud MNM, Ibrahim MY, Gan SH, Rahman MS, Sani MHM, et al.

Medicine (Baltimore), 2020 May 22;99(21):e20287.
PMID: 32481309 DOI: 10.1097/MD.0000000000020287

Unhealthy lifestyle contributes mainly to an increased prevalence of non-communicable diseases including hypertension and cardiovascular diseases tend to increase in Malaysia. These diseases lead to an increased risk of end organ damage and cardiovascular complications. In this study, the prevalence of prehypertension and its associated risk factors among a cohort of university students in Sabah was determined.This is a prospective, cross-sectional study conducted among 365 undergraduate students irrespective of faculties at Universiti Malaysia Sabah (UMS). Standardized and validated World Health Organization (WHO) STEPS questionnaires were used to collect sociodemographic data. Additionally, clinical and anthropometric data were measured and recorded by a trained staff, followed by descriptive and logistic regression analyses.A total of 365 UMS undergraduate students aged 18 years and above participated in the study. The prevalence of prehypertension among university students was high (31%) (95% CI [29.1%, 34.3%]). Well-known risk factors for hypertension including family history of hypertension, reduced sleep duration, reduced physical activity, smoking, being overweight or obese were significantly associated with the risk of developing prehypertension (P
Fulltext Prevalence and risk factors of hypertension in myanmar: a systematic review and meta-analysis

Naing C, Aung K

Medicine (Baltimore), 2014 Nov;93(21):e100.
PMID: 25380081 DOI: 10.1097/MD.0000000000000100

Hypertension (HPT) is the most common condition seen in primary care that can lead to health consequences and death if not detected early and treated appropriately.This study aimed to synthesize the prevalence, awareness, and control of HPT, and investigate the risk factors for HPT in Myanmar.We performed a meta-analysis of observational studies. Relevant studies were searched in electronic databases. The methodological quality of the included studies was assessed in 3 domains: selection bias, measurement bias, and bias related to data analysis. The overall prevalence and proportions was calculated using random-effect model of DerSimonian-Laird method. To identify the risk factors for HPT in Myanmar, we entered the ratio measures of the (adjusted) effect as a log odds ratio (OR) and the standard error of the log OR using generic inverse-variance weighting method. For stability of results, we performed leave-one-study-out sensitivity analysis by omitting individual studies one at a time from the meta-analysis.Seven studies (n = 20,901) were included in this analysis. Overall prevalence of HPT in Myanmar was 22% (95% confidence interval (CI): 14%-31.7%, I: 99.6%), stratified as 21.5% (95% CI: 14.1%-29.9%, I: 98.7%) in men and 22.7% (95% CI: 10.8%-34.6%, I: 99.5%) in women. Overall, prevalence of HPT increased with an advancing age of the participants. The proportions of awareness and controlled HPT were 55% (95% CI: 43%-67%, I: 97.7%) and 11% (95% CI: 6%-15%, I: 93.8%), respectively. A weak but significant association was observed between HPT and alcohol drinking (summary OR: 1.38, 95% CI: 1.14%-1.65, I: 0%) and smoking (summary OR: 1.32, 95% CI: 1.0%-1.74, I: 50%). In sensitivity analysis, when a study that made confirmation of HPT by the former World Health Organization criteria was dropped, the prevalence increased to 26% (95% CI: 20.8%-32.1%, I: 98.1%).HPT was considerably prevalent in Myanmar, while the levels of awareness and controlled HPT were low. Health promotion strategy tailored to the education on modifiable risk factors and establishment of blood pressure screening in primary health care context would be of immense value. Upcoming well-powered studies, using the standardized research design and covering more regions of the country are recommended.
Fulltext Predictors of delayed sputum smear conversion among pulmonary tuberculosis patients in Kota Kinabalu, Malaysia: A retrospective cohort study

Mokti K, Md Isa Z, Sharip J, Abu Bakar SN, Atil A, Hayati F, et al.

Medicine (Baltimore), 2021 Aug 06;100(31):e26841.
PMID: 34397855 DOI: 10.1097/MD.0000000000026841

Smear-positive pulmonary tuberculosis (SPPTB) is the major contributor to the spread of tuberculosis (TB) infection, and it creates high morbidity and mortality worldwide. The objective of this study was to determine the predictors of delayed sputum smear conversion at the end of the intensive phase of TB treatment in Kota Kinabalu, Malaysia.This retrospective study was conducted utilising data of SPPTB patients treated in 5 TB treatment centres located in Kota Kinabalu, Malaysia from 2013 to 2018. Pulmonary TB (PTB) patients included in the study were those who had at least completed the intensive phase of anti-TB treatment with sputum smear results at the end of the 2nd month of treatment. The factors associated with delayed sputum smear conversion were analyzed using multiple logistic regression analysis. Predictors of sputum smear conversion at the end of intensive phase were evaluated.A total of 2641 patients from the 2013 to 2018 periods were included in this study. One hundred eighty nine (7.2%) patients were identified as having delayed sputum smear conversion at the end of the intensive phase treatment. Factors of moderate (advanced odd ratio [aOR]: 1.7) and advanced (aOR: 2.7) chest X-ray findings at diagnosis, age range of >60 (aOR: 2.1), year of enrolment 2016 (aOR: 2.8), 2017 (aOR: 3.9), and 2018 (aOR: 2.8), smokers (aOR: 1.5), no directly observed treatment short-course (DOTS) supervisor (aOR: 6.9), non-Malaysian citizens (aOR: 1.5), and suburban home locations (aOR: 1.6) were associated with delayed sputum smear conversion at the end of the intensive phase of the treatment.To improve sputum smear conversion success rate, the early detection of PTB cases has to be fine-tuned so as to reduce late or severe case presentation during diagnosis. Efforts must also be in place to encourage PTB patients to quit smoking. The percentage of patients assigned with DOTS supervisors should be increased while at the same time ensuring that vulnerable groups such as those residing in suburban localities, the elderly and migrant TB patients are provided with proper follow-up treatment and management.
Fulltext Paradoxical Manifestation is Common in HIV-negative Tuberculous Meningitis

Tai ML, Nor HM, Kadir KA, Viswanathan S, Rahmat K, Zain NR, et al.

Medicine (Baltimore), 2016 Jan;95(1):e1997.
PMID: 26735523 DOI: 10.1097/MD.0000000000001997

Paradoxical manifestation is worsening of pre-existing tuberculous lesion or appearance of new lesions in patients whose condition initially improved with antituberculous treatment. Our hypothesis was that paradoxical manifestation in non-HIV tuberculous meningitis (TBM) patients was underestimated and this could contribute to patients' prognosis. This was the first systemic study of paradoxical manifestation in HIV-negative TBM patients. Between 2009 and 2014, TBM patients were studied prospectively in 2 hospitals. Clinical features, cerebrospinal fluid, and radiological findings were monitored. Paradoxical manifestation was divided into definite (4 weeks or more) and probable (between 14 and 27 d) after commencement of antituberculous treatment. Forty-one non-HIV TBM patients were recruited. Definite paradoxical manifestation occurred in 23/41 (56%) of the patients. Time to onset of paradoxical manifestation was between 28 days and 9 months, and majority was between 28 and 50 days. Neuroimaging manifestation in the brain (22/41 patients, 54%) and clinical manifestation (22/41 patients, 54%) were most commonly seen, followed by cerebrospinal fluid manifestation (7/41 patients, 17%). Neuroimaging changes most commonly seen were worsening of leptomeningeal enhancement, new infarcts, new tuberculomas, and enlargement of tuberculoma. Initial Computed Tomography Angiography/magnetic resonance angiography brain showed vasculitis in 14 patients, with 2 (12.5%) showing paradoxical vasculitis during follow-up. Recurrence of the paradoxical manifestation was seen in 7/23 (30%) of the patients. More than half (14/23, 61%) of the patients improved, 6 (26%) patients died, and 3 (13%) patients had persistent neurological deficit. Paradoxical manifestation was very common in non-HIV TBM patients. Neuroimaging paradoxical manifestation of 2-4 weeks may not be paradoxical manifestation but could be delayed treatment response.
Fulltext Outcomes of guideline-based medical therapy in patients with acute heart failure and reduced left ventricular ejection fraction: Observations from the Gulf acute heart failure registry (Gulf CARE)

Jan RK, Alsheikh-Ali A, Mulla AA, Sulaiman K, Panduranga P, Al-Mahmeed W, et al.

Medicine (Baltimore), 2022 Jun 10;101(23):e29452.
PMID: 35687781 DOI: 10.1097/MD.0000000000029452

This study aimed to report on the use, predictors and outcomes of guideline-based medical therapy (GBMT) in patients with acute heart failure (HF) with reduced ejection fraction of <40% (HFrEF), from seven countries in the Arabian Gulf.Patients with acute HFrEF (N = 2680), aged 18 years or older, and hospitalized February-November 2012 were recruited and data were collected post discharge at 3 months (n = 2477) and 1 year (n = 2418). The use and doses of GBMT were evaluated as per European, American and Canadian HF guidelines. Analyses were performed using multivariate logistic regression. This study was registered at clinicaltrials.gov (NCT01467973).The majority of patients were on dual (39%) and triple (39%) GBMT modalities, 14% received one GBMT medication, while 7.2% were not on any GBMT medications. On admission, 80% of patients were on renin-angiotensin system (RAS) blockers, 75% on b-blockers and 56% on mineralocorticoid receptor antagonists (MRAs), with a small proportion of these patients were taking target doses (RAS blockers 13%, b-blockers 7.3%, MRAs 14%). Patients taking triple GBMT were younger (P
Fulltext Outcomes and modifiable resuscitative characteristics amongst pan-Asian out-of-hospital cardiac arrest occurring at night

Ho AFW, Hao Y, Pek PP, Shahidah N, Yap S, Ng YY, et al.

Medicine (Baltimore), 2019 Mar;98(10):e14611.
PMID: 30855446 DOI: 10.1097/MD.0000000000014611

Studies are divided on the effect of day-night temporal differences on clinical outcomes in out-of-hospital cardiac arrest (OHCA). This study aimed to elucidate any differences in OHCA survival between day and night occurrence, and the factors associated with differences in survival.This was a prospective, observational study of OHCA cases across multinational Pan-Asian sites. Cases were divided according to time call received by dispatch centers into day (0700H-1900H) and night (1900H-0659H). Primary outcome was 30-day survival. Secondary outcomes were prehospital and hospital modifiable resuscitative characteristics.About 22,501 out of 55,881 cases occurred at night. Night cases were less likely to be witnessed (40.2% vs. 43.1%, P
Fulltext Observational study of financial and non-financial conflicts of interest among the Japanese government advisory board members concerning coronavirus disease 2019

Mamada H, Murayama A, Ozaki A, Hashimoto T, Saito H, Sawano T, et al.

Medicine (Baltimore), 2023 Jan 27;102(4):e32776.
PMID: 36705373 DOI: 10.1097/MD.0000000000032776

This cross-sectional analysis aimed to assess the extent of conflicts of interest among the Japanese government coronavirus disease 2019 (COVID-19) advisory board members and elucidate the accuracy of conflicts of interest (COI) disclosure and management strategies. Using the payment data from all 79 pharmaceutical companies in Japan between 2017 and 2019 and direct research grants from the Japanese government between 2019 and 2020, we evaluated the extent of financial and non-financial COI among all 20 Japanese government COVID-19 advisory board members. The Ethic Committee of the Medical Governance Research Institute approved this study. Japanese government COVID-19 advisory board members were predominantly male (75.0%) and physicians (50.0%). Between 2019 and 2020, 2 members (10.0%) received a total of $819,244 in government research funding. Another 5 members (25.0%) received $532,127 in payments, including $276,722 in personal fees, from 31 pharmaceutical companies between 2017 and 2019. The average value of the pharmaceutical payments was $9155 (standard deviation: $12,975). Furthermore, neither the Ministry of Health, Labor, and Welfare nor the Japanese Cabinet Secretariat disclosed financial or non-financial COI with industry. Additionally, the government had no policies for managing COI among advisory board members. This study found that the Japanese government COVID-19 advisory board had financial and non-financial COI with pharmaceutical companies and the government. Furthermore, personal communication received as part of this research indicated that there were no rigorous COI management strategies for the COVID-19 advisory board members. Any government must ensure the independence of scientific advisory boards by implementing more rigorous and transparent management strategies that require the declaration and public disclosure of all COI.
Fulltext Novel clinical risk scoring model for predicting mortality in patients with necrotizing fasciitis: The MNF scoring system

Khamnuan P, Chuayunan N, Duangjai A, Saokaew S, Chaomuang N, Phisalprapa P

Medicine (Baltimore), 2021 Dec 23;100(51):e28219.
PMID: 34941083 DOI: 10.1097/MD.0000000000028219

Necrotizing fasciitis (NF) is a life-threatening soft tissue infection that rapidly progresses and requires urgent surgery and medical therapy. If treatment is delayed, the likelihood of an unfavorable outcome, including death, is significantly increased. The goal of this study was to develop and validate a novel scoring model for predicting mortality in patients with NF. The proposed system is hereafter referred to as the Mortality in Necrotizing Fasciitis (MNF) scoring system. A total of 1503 patients with NF were recruited from 3 provincial hospitals in Thailand during January 2009 to December 2012. Patients were randomly allocated into either the derivation cohort (n = 1192) or the validation cohort (n = 311). Clinical risk factors used to develop the MNF scoring system were determined by logistic regression. Regression coefficients were transformed into item scores, the sum of which reflected the total MNF score. The following 6 clinical predictors were included: female gender; age > 60 years; white blood cell (WBC) ≤5000/mm3; WBC ≥ 35,000/mm3; creatinine ≥ 1.6 mg/dL, and pulse rate > 130/min. Area under the receiver operating characteristic curve (AuROC) analysis showed the MNF scoring system to have moderate power for predicting mortality in patients with NF (AuROC: 76.18%) with good calibration (Hosmer-Lemeshow χ2: 1.01; P = .798). The positive likelihood ratios of mortality in patients with low-risk scores (≤2.5) and high-risk scores (≥7) were 11.30 (95% confidence interval [CI]: 6.16-20.71) and 14.71 (95%CI: 7.39-29.28), sequentially. When used to the validation cohort, the MNF scoring system presented good performance with an AuROC of 74.25%. The proposed MNF scoring system, which includes 6 commonly available and easy-to-use parameters, was shown to be an effective tool for predicting mortality in patients with NF. This validated instrument will help clinicians identify at-risk patients so that early investigations and interventions can be performed that will reduce the mortality rate among patients with NF.
Fulltext Neurological infection and complications of SARS-CoV-2: A review

Singh S, Meher N, Mohammed A, Razab MKAA, Bhaskar LVKS, Nawi NM

Medicine (Baltimore), 2023 Feb 03;102(5):e30284.
PMID: 36749239 DOI: 10.1097/MD.0000000000030284

The primary target of severe acute respiratory syndrome coronavirus 2 is the respiratory system including the nose and lungs, however, it can also damage the kidneys, cardiovascular system and gastrointestinal system. Many recent reports suggested that severe acute respiratory syndrome coronavirus 2 infections can also affect the central nervous system as well as peripheral nervous system that lead to the several neurological complications. The virus can break the blood brain barrier and enters the brain via haematological route or directly by the angiotensin-converting enzyme 2 receptors present on endothelial cells of many cerebral tissues. The neurological complications are manifested by headache, dizziness, encephalopathy, encephalitis, cerebrovascular disease, anosmia, hypogeusia, muscle damage, etc. This review article described the possible routes and mechanism of nervous system infection and the range of neurological complications of COVID-19 that may help the medical practitioners and researchers to improve the clinical treatment and reduce the mortality rate among patients with viral diseases.
Fulltext Muscle oxygenation during hybrid arm and functional electrical stimulation-evoked leg cycling after spinal cord injury

Hasnan N, Mohamad Saadon NS, Hamzaid NA, Teoh MX, Ahmadi S, Davis GM

Medicine (Baltimore), 2018 Oct;97(43):e12922.
PMID: 30412097 DOI: 10.1097/MD.0000000000012922

This study compared muscle oxygenation (StO2) during arm cranking (ACE), functional electrical stimulation-evoked leg cycling (FES-LCE), and hybrid (ACE+FES-LCE) exercise in spinal cord injury individuals. Eight subjects with C7-T12 lesions performed exercises at 3 submaximal intensities. StO2 was measured during rest and exercise at 40%, 60%, and 80% of subjects' oxygen uptake (VO2) peak using near-infrared spectroscopy. StO2 of ACE showed a decrease whereas in ACE+FES-LCE, the arm muscles demonstrated increasing StO2 from rest in all of VO2) peak respectively. StO2 of FES-LCE displayed a decrease at 40% VO2 peak and steady increase for 60% and 80%, whereas ACE+FES-LCE revealed a steady increase from rest at all VO2 peak. ACE+FES-LCE elicited greater StO2 in both limbs which suggested that during this exercise, upper- and lower-limb muscles have higher blood flow and improved oxygenation compared to ACE or FES-LCE performed alone.
Fulltext Multilevel analysis of hemodialysis-associated infection among end-stage renal disease patients: results of a retrospective cohort study utilizing the insurance claim data of Fukuoka Prefecture, Japan

Jamal A, Babazono A, Li Y, Yoshida S, Fujita T

Medicine (Baltimore), 2020 May;99(18):e19871.
PMID: 32358355 DOI: 10.1097/MD.0000000000019871

The presence of comorbid conditions along with heterogeneity in terms of healthcare practices and service delivery could have a significant impact on the patient's outcomes. With a strong interest in social epidemiology to examine the impact of health services and variations on health outcomes, the current study was conducted to analyse the incidence of hemodialysis-associated infection (HAI) as well as its associated factors, and to quantify the extent to which the contextual effects of the care facility and regional variations influence the risk of HAI.A total of 6111 patients with end-stage renal disease who received hemodialysis treatment between 1 October 2015 and 31 March 2016 were identified from the insurance claim database as a population-based, close-cohort retrospective study. Patients were followed for one year from April 1, 2016 to March 31, 2017. A total of 200 HAI cases were observed during the follow-up and 12 patients died within 90 days of the onset of HAI. Increased risks for HAI were associated with moderate (HR 1.73, 95% confidence interval [CI] 1.00-2.98) and severe (HR 1.87, 95% CI 1.11-3.14) comorbid conditions as well as malignancy (HR 1.36, 95% CI 1.00-1.85). Increased risk was also seen among patients who received hemodialysis treatment from clinics (HR 2.49, 95% CI 1.1-5.33). However, these statistics were no longer significant when variations at the level of care facilities were statistically controlled. In univariate analyses, no statistically significant association was observed between 90-day mortality and baseline patients, and the characteristics of the care facility.The results of the multivariate, multilevel analyses indicated that HAI variations were only significant at the care facility level (σ 2.07, 95% CI 1.3-3.2) and were largely explained by the heterogeneity between care facilities. The results of this study highlight the need to look beyond the influence of patient-level characteristics when developing policies that aim at improving the quality of hemodialysis healthcare and service delivery in Japan.
Fulltext Low intensity extracorporeal shockwave therapy for chronic pelvic pain syndrome patients with erectile dysfunction

Daneshwar D, Nordin A

Medicine (Baltimore), 2022 Jan 14;101(2):e28546.
PMID: 35029213 DOI: 10.1097/MD.0000000000028546

INTRODUCTION: In this study, the efficacy of low intensity shock wave therapy (LSWT) in improving symptoms of chronic pelvic pain syndrome (CPPS) and erectile dysfunction (ED) was investigated.
METHODS: Men diagnosed with CPPS and ED (n = 50) were prescribed with LSWT. The LSWT was administered in 10 sessions over the course of 5 weeks at 3,000 pulses with .25 mJ/mm2 energy flow and 5 Hz frequency. Outcome parameters were measured before and after LSWT.
RESULTS: Clinical symptoms related to CPPS and ED were measured using four validated questionnaires namely National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function (IIEF), the International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM). The effect of LSWT on each of the three domains of NIH-CPSI, namely Pain, Symptoms, and Quality of Life (QoL) were also analyzed. Uroflowmetry was measured to assess LSWT effect on urine voiding. The mean baseline CPPS symptoms on NIH-CPSI domains of pain, symptoms and QoL were 9.92 ± 5.72 (mean ± SD), 5.14 ± 14.5, and 8.02 ± 3.17, respectively. LSWT resulted in significant reduction of CPPS symptoms on all NIH-CPSI domains (Pain = .9 ± 1.37; Symptoms = .74 ± 1.03; QoL = 1.16 ± 1.78). The baseline means of CPPS symptoms on IIEF, IPSS, and SHIM were 45.42 ± 16.24, 24.68 ± 9.28, and 14.28 ± 6.02, respectively. LSWT significant improved CPPS symptoms on IIEF (49.48 ± 28.30) and IPSS (9.04 ± 7.01) but not on SHIM (16.02 ± 9.85). No statistically significant differences were observed with all uroflowmetry parameters.
CONCLUSION: The current study demonstrated for the first time the safety and efficacy of LSWT administered in 10 sessions over 5 weeks in improving symptoms of CPPS and ED without causing any significant adverse effect to the patient.
Fulltext Knowledge of and willingness to perform Hands-Only cardiopulmonary resuscitation among college students in Malaysia

Karuthan SR, Firdaus PJFB, Angampun ADG, Chai XJ, Sagan CD, Ramachandran M, et al.

Medicine (Baltimore), 2019 Dec;98(51):e18466.
PMID: 31861024 DOI: 10.1097/MD.0000000000018466

Worldwide, millions of people die of sudden cardiac arrest every year. This is partly due to limited and sometimes ineffective bystander cardiopulmonary resuscitation (CPR). The need for mouth-to-mouth contact, fear of causing harm, litigation, and the complexity of delivering CPR are the main deterrents. In view of this, the basic life support algorithm has been simplified and lay rescuers are encouraged to perform Hands-Only CPR.The objective of this study is to assess knowledge on and willingness to perform Hands-Only CPR among Malaysian college students and to determine the relationship between the two.In an online self-administered survey, college students responded to a questionnaire on demographics, exposure to CPR, knowledge on Hands-Only CPR, and their willingness to perform Hands-Only CPR in 5 different scenarios (family members or relatives, strangers, trauma victims, children, and elderly people).Data for 393 participants were analyzed. For knowledge, the mean score was 8.6 ± 3.2 and the median score was 9. In the sample, 27% of the respondents did not attend any CPR training before, citing that they were unsure where to attend the course. The knowledge score among those who attended CPR training (M = 3.6, S = 2.9) was significantly higher compared to those who did not (M = 6.7, S = 3.0). Out of the 393 participants, 67.7%, 55%, 37.4%, 45%, and 49.1% were willing to perform Hands-Only CPR on family members or relatives, strangers, trauma victims, children, and elderly people, respectively. There were significant associations (P
Fulltext Is pre-operative axillary ultrasound alone sufficient to determine need for axillary dissection in early breast cancer patients?

Jamaris S, Jamaluddin J, Islam T, See MH, Fadzli F, Rahmat K, et al.

Medicine (Baltimore), 2021 May 14;100(19):e25412.
PMID: 34106588 DOI: 10.1097/MD.0000000000025412

ABSTRACT: Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN.383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement.The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126).There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.
Fulltext Invasive pyogenic infection and infective endocarditis due to Streptococcus anginosus: A case report

Cheng CW, Feng CM, Chua CS

Medicine (Baltimore), 2019 Nov;98(48):e18156.
PMID: 31770258 DOI: 10.1097/MD.0000000000018156

RATIONALE: Streptococcus anginosus mostly colonizes the digestive and genitourinary system, including the oropharyngeal region. It commonly causes invasive pyogenic infection, but less likely causes infective endocarditis (IE).
PATIENT CONCERNS: An 18-year-old woman who had an underlying mitral valve prolapse without mitral regurgitation presented to our hospital with low-grade fever, left leg weakness, and left abdominal pain. She was diagnosed with brain infarction and microabscess as well as IE. The patient totally recovered after the 6-week course of intravenous antibiotics.
DIAGNOSIS: Brain magnetic resonance imaging revealed brain infarction and microabscess. Abdominal computed tomography revealed splenic and left renal infarction. Three sets of blood culture were positive for S anginosus. Transthoracic echocardiogram identified mitral valve prolapse with moderate eccentric mitral valve regurgitation, and a 0.3 × 0.6-cm vegetation was found on the left mitral valve. All of these results meet the modified Duke criteria.
INTERVENTIONS: The abdominal pain and left leg weakness were improving after 2 weeks of intravenous antibiotics treatment. No neurological sequelae were noted after completing the 6-week course of medical treatment.
OUTCOMES: The patient was successfully treated and discharged after completing the 6-week intravenous antibiotics treatment.
LESSONS: IE should be considered in young patients with native valve disease who have prolonged fever. Though S anginosus commonly causes invasive pyogenic infection, patients with native valve disease should be checked for IE.
Fulltext Intravenous immunoglobulin in the therapeutic armamentarium of systemic lupus erythematosus: a systematic review and meta-analysis

Sakthiswary R, D'Cruz D

Medicine (Baltimore), 2014 Oct;93(16):e86.
PMID: 25310743 DOI: 10.1097/MD.0000000000000086

Prepared from the plasma of thousands of blood donors, therapeutic intravenous immunoglobulin (IVIg) mostly consists of human polyspecific immunoglobulin G (IgG). The use of IVIg in systemic lupus erythematosus (SLE) is still considered experimental without any clear indications. The purpose of this systematic review is, therefore, to evaluate the available evidence to determine the therapeutic role of IVIg in SLE. A comprehensive, computerised search was performed in the MEDLINE (Pubmed), Scopus, EMBASE, and Cochrane controlled trials. The study eligibility criteria were randomized controlled trials, and prospective and retrospective observational studies that examined the efficacy of IVIg in adult patients with SLE who were considered the participants.IVIg therapy was the mode of intervention in these patients. Data abstracted included the study design, study population, changes in the disease activity scores (Systemic Lupus Erythematosus Disease Activity Index, Systemic Lupus Activity Measure, and Lupus Activity Index-Pregnancy), steroid dose, complement levels, autoantibodies, and renal function. Thereafter, data analysis established statistical procedures for meta-analysis. Thirteen studies (including 3 controlled and 10 observational) were eligible for inclusion. There was significant reduction in the SLE disease activity scores with IVIg therapy with a standard mean difference of 0.584 (P = 0.002, 95% confidence interval [CI] 0.221-0.947). In terms of rise in complement levels, the response rate was 30.9% (P = 0.001, 95 CI 22.1-41.3). The effects of IVIg on other clinical outcome measures including anti-double-stranded DNA, antinuclear antibody, average steroid dose, and renal function could not be determined because of the limited numbers of trials. The limitations of this review were lack of well-designed controlled trials with adequate sample size on the use of IVIg in SLE. In conclusion, the use of IVIg is associated with significant reduction in SLE disease activity and improvement in complement levels.
Fulltext Initiation of the pharmacist-delivered antidiabetic medication therapy management services in a tertiary care hospital in Nepal

Sapkota B, Bokati P, Dangal S, Aryal P, Shrestha S

Medicine (Baltimore), 2022 Apr 22;101(16):e29192.
PMID: 35482989 DOI: 10.1097/MD.0000000000029192

The medication therapy management (MTM) pharmacists follow the philosophy of pharmaceutical care to address individualistic medication therapy requirements in their practice settings.The present study aimed to introduce the pharmacist-delivered MTM services among type 2 diabetes mellitus patients at a tertiary care hospital in Nepal.Cross-sectional study was conducted at Patan Hospital, Lalitpur, Nepal, among 200 patients with type 2 diabetes mellitus from July to December 2019. The intervention included maintenance of medication profile for individual patients, and then MTM service was proposed based on 5 core elements of MTM services proposed by the American Pharmacists Association. Both antidiabetic and non-antidiabetic medicines were coded as per the anatomic, therapeutic, and chemical classification and defined daily dose assignment 2020 for documentation. The Charlson Comorbidity Index was used to index comorbidities. The drug interaction profile was checked with the Medscape Drug Interaction Checker.Both fasting and postprandial blood sugar levels were significantly associated with age (P-values
Fulltext Inherited IL-12p40 deficiency: genetic, immunologic, and clinical features of 49 patients from 30 kindreds

Prando C, Samarina A, Bustamante J, Boisson-Dupuis S, Cobat A, Picard C, et al.

Medicine (Baltimore), 2013 Mar;92(2):109-122.
PMID: 23429356 DOI: 10.1097/MD.0b013e31828a01f9

Autosomal recessive interleukin (IL)-12 p40 (IL-12p40) deficiency is a rare genetic etiology of mendelian susceptibility to mycobacterial disease (MSMD). We report the genetic, immunologic, and clinical features of 49 patients from 30 kindreds originating from 5 countries (India, Iran, Pakistan, Saudi Arabia, and Tunisia). There are only 9 different mutant alleles of the IL12B gene: 2 small insertions, 3 small deletions, 2 splice site mutations, and 1 large deletion, each causing a frameshift and leading to a premature stop codon, and 1 nonsense mutation. Four of these 9 variants are recurrent, affecting 25 of the 30 reported kindreds, due to founder effects in specific countries. All patients are homozygous and display complete IL-12p40 deficiency. As a result, the patients lack detectable IL-12p70 and IL-12p40 and have low levels of interferon gamma (IFN-γ). The clinical features are characterized by childhood onset of bacille Calmette-Guérin (attenuated Mycobacterium bovis strain) (BCG) and Salmonella infections, with recurrences of salmonellosis (36.4%) more common than recurrences of mycobacterial disease (25%). BCG vaccination led to BCG disease in 40 of the 41 patients vaccinated (97.5%). Multiple mycobacterial infections were rare, observed in only 3 patients, whereas the association of salmonellosis and mycobacteriosis was observed in 9 patients. A few other infections were diagnosed, including chronic mucocutaneous candidiasis (n = 3), nocardiosis (n = 2), and klebsiellosis (n = 1). IL-12p40 deficiency has a high but incomplete clinical penetrance, with 33.3% of genetically affected relatives of index cases showing no symptoms. However, the prognosis is poor, with mortality rates of up to 28.6%. Overall, the clinical phenotype of IL-12p40 deficiency closely resembles that of interleukin 12 receptor β1 (IL-12Rβ1) deficiency. In conclusion, IL-12p40 deficiency is more common than initially thought and should be considered worldwide in patients with MSMD and other intramacrophagic infectious diseases, salmonellosis in particular.
Fulltext Inflammatory bowel disease and associated cardiovascular disease outcomes: A systematic review

Jaiswal V, Batra N, Dagar M, Butey S, Huang H, Chia JE, et al.

Medicine (Baltimore), 2023 Feb 10;102(6):e32775.
PMID: 36820570 DOI: 10.1097/MD.0000000000032775

BACKGROUND: There is limited and conflicting data available regarding the cardiovascular disease outcomes associated with inflammatory bowel disease (IBD).
OBJECTIVE: We aim to perform a systematic review to evaluate the cardiovascular outcomes and mortality associated with IBD patients.
METHODS: A systematic literature search has been performed on PubMed, Embase, Cochrane, and Scopus from inception till May 2022 without any language restrictions.
RESULTS: A total of 2,029,941 patients were included in the analysis from 16 studies. The mean age of the patients was 45.6 years. More females were found compared with males (57% vs 43%). The most common risk factors for cardiovascular disease (CVD) included smoking (24.19%) and alcohol (4.60%). The most common comorbidities includes hypertension (30%), diabetes mellitus (14.41%), dyslipidemia (18.42%), previous CVD (22%), and renal disease (10%). Among outcomes, all-cause mortality among IBD patients was 1.66%; ulcerative colitis (UC): 15.92%; and Crohn disease (CD): 0.30%. Myocardial Infarction (MI) among IBD patients were 1.47%, UC: 30.96%; and CD: 34.14%. CVD events among IBD patients were 1.95%. Heart failure events among IBD patients were 5.49%, stroke events among IBD patients were 0.95%, UC: 2.63%, and CD: 2.41%, respectively.
CONCLUSION: IBD patients are at higher risk for adverse cardiovascular outcomes, especially in women. Although there remains a lack of concrete treatment algorithms and assessment parameters that better characterize IBD risk factors, nutritional modifications and physical activity should be at the forefront of CVD prevention in IBD.
Fulltext Improving the position of resuscitation team leader with simulation (IMPORTS); a pilot cross-sectional randomized intervention study

Saiboon IM, Apoo FN, Jamal SM, Bakar AA, Yatim FM, Jaafar JM, et al.

Medicine (Baltimore), 2019 Dec;98(49):e18201.
PMID: 31804343 DOI: 10.1097/MD.0000000000018201

BACKGROUND: Leadership and teamwork are important contributory factors in determining cardiac resuscitation performance and clinical outcome. We aimed to determine whether fixed positioning of the resuscitation team leader (RTL) relative to the patient influences leadership qualities during cardiac resuscitation using simulation.
METHODS: A cross-sectional randomized intervention study over 12 months' duration was conducted in university hospital simulation lab. ACLS-certified medical doctors were assigned to run 2 standardized simulated resuscitation code as RTL from a head-end position (HEP) and leg-end position (LEP). They were evaluated on leadership qualities including situational attentiveness (SA), errors detection (ED), and decision making (DM) using a standardized validated resuscitation-code-checklist (RCC). Performance was assessed live by 2 independent raters and was simultaneously recorded. RTL self-perceived performance was compared to measured performance.
RESULTS: Thirty-four participants completed the study. Mean marks for SA were 3.74 (SD ± 0.96) at HEP and 3.54 (SD ± 0.92) at LEP, P = .48. Mean marks for ED were 2.43 (SD ± 1.24) at HEP and 2.21 (SD ± 1.14) at LEP, P = .40. Mean marks for DM were 4.53 (SD ± 0.98) at HEP and 4.47 (SD ± 0.73) at LEP, P = .70. The mean total marks were 10.69 (SD ± 1.82) versus 10.22 (SD ± 1.93) at HEP and LEP respectively, P = .29 which shows no significance difference in all parameters. Twenty-four participants (71%) preferred LEP for the following reasons, better visualization (75% of participants); more room for movement (12.5% of participants); and better communication (12.5% of participants). RTL's perceived performance did not correlate with actual performance CONCLUSION:: The physical position either HEP or LEP appears to have no influence on performance of RTL in simulated cardiac resuscitation. RTL should be aware of the advantages and limitations of each position.

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