Medical Journal of Malaysia最新文献

Introduction: Custodial-HTK (Histidine-Tryptophan- Ketoglutarate) solution and blood cardioplegia are both established methods for myocardial protection during cardiac surgery. However, their utility in patients undergoing complex cardiac surgery is not extensively study. This study compares clinical outcomes between patients receiving Custodial-HTK and blood cardioplegia in one of the tertiary Malaysian cardiac center.

Materials and methods: We retrospectively analyzed data from 79 patients who underwent elective, on-pump, crossclamp cardiac surgeries at Faculty of Medicine, Universiti Teknologi MARA (UiTM) from August 2022 to July 2023. Patients undergoing emergency procedures, off-pump, or incomplete records were excluded. Patients receiving Custodial-HTK were typically those with impaired LVEF or requiring complex surgeries.

Results: Custodial-HTK was used in 12% of cases. These patients had slightly higher mean age (61.9 ± 7.6 vs. 59.9 ± 8.8 years) and higher mean EuroSCORE II, although the latter was not statistically significant (p = 0.115). Comorbidities including diabetes, hypertension, stroke, and renal disease were comparable between groups. The Custodial group showed significantly lower mean LVEF (43.7 ± 14.7%) and greater use of pre-induction intra-aortic balloon pump (IABP) (20%). Complex procedures were more frequent (50%), with longer mean cardiopulmonary bypass (181.7 ± 65.1 minutes) and cross-clamp durations (131.3 ± 50.4 minutes). Despite these differences, postoperative complication rates, ICU stay, total hospital stay, and 30-day mortality did not differ significantly between groups.

Conclusion: Although patients receiving Custodial-HTK had higher surgical complexity and poorer baseline cardiac function, postoperative outcomes were within acceptable clinical range to the blood cardioplegia group. These findings support the use of Custodial-HTK as a safe and effective alternative in high-risk cardiac surgery patients.

Introduction: In Malaysia, the rising number of medical graduates has led to a shift from permanent to contract employment in the healthcare system since 2016. This study investigates the impact of employment status on mental health outcomes, job satisfaction, and career perceptions among junior doctors in Malaysia.

Materials and methods: This nationwide study compared 1,966 contract and 698 permanent junior doctors in Malaysia using validated instruments (Maslach Burnout Inventory, DASS-21, WHOQOL-BREF) and career perception measures.

Results: Contract doctors showed higher depression (adjusted mean 8.72 [95% CI: 8.18-9.26] vs 6.88 [95% CI: 6.25- 7.51], p<0.001), anxiety (adjusted mean 6.41 [95% CI: 5.96- 6.86] vs. 4.89 [95% CI: 4.36-5.41], p<0.001), stress (adjusted mean 8.74 [95% CI: 8.24-9.23] vs 7.86 [95% CI, 7.28-8.44], p<0.001), emotional exhaustion (adjusted mean 32.14 [95% CI: 30.86-33.42] vs 27.18 [95% CI: 25.68-28.68], p<0.001), and depersonalization (14.10 [95% CI: 13.41-14.80] vs 11.94 [95% CI: 11.13-12.76], p<0.001). Their quality of life was lower in physical (adjusted mean 10.48 [95% CI: 10.30-10.67] vs 11.09 [95% CI: 10.87-11.31], p<0.001), psychological (adjusted mean 11.50 [95% CI: 11.29-11.70] vs 11.86 [95% CI: 11.63- 12.10], p<0.001), and environmental domains (adjusted mean 12.42 [95% CI: 12.18-12.65] vs 13.11 [95% CI 12.83-13.38], p<0.001). Contract doctors reported significantly lower satisfaction across multiple domains. Despite similar aspirations to succeed in medicine (OR 0.8 [95% CI: 0.6-1.1], p=0.117), contract doctors reported lower career security (OR 0.04 [95% CI: 0.03-0.05], p<0.001), reduced confidence in specialty training access (OR 0.3 [95% CI: 0.2-0.3], p<0.001), and higher intentions to change careers (OR 5.9 [95% CI: 4.7- 7.5], p<0.001) or emigrate (OR 1.9 [95% CI: 1.5-2.3], p<0.001).

Conclusion: Contract employment is associated with poorer mental health, reduced job satisfaction, and diminished career confidence despite similar professional aspirations. These findings suggest current employment practices may threaten healthcare workforce sustainability and highlight the need for policy reforms.

Introduction: The prevalence of oncogenic driver mutations in early-stage resectable non-small-cell lung cancer (rNSCLC) in Malaysia remains unknown. This information may guide treatment decisions, especially tyrosine kinase inhibitor (TKI) use. We characterised the genomic landscape of early-stage NSCLC in a surgical cohort and explored its impact on TKI administration, particularly osimertinib.

Materials and methods: 146 patients who underwent curative resection for early-stage rNSCLC were included in this study. Real-time polymerase chain reaction (PCR) and nextgeneration sequencing (NGS) were used to identify genetic alterations in tumour samples. Associations between EGFR status and clinico-pathological characteristics were analysed using uni- and multivariate logistic regression.

Results: A majority of patients were female non-smokers of Chinese ethnicity with an incidental adenocarcinoma. EGFR mutations were detected in 62.3% (n=91) of patients, with 93.4% harbouring single-locus mutations, primarily in exons 19 and 21. Co-mutations occurred in 11% (n=10) of EGFRmutant cases, most frequently involving TP53, and less commonly CTNNB1, HER2/ErbB2, and PTEN. Six (6.6%) patients had multi-loci EGFR mutations. Female sex and higher tumour histological grade were independent predictors for EGFR mutations, while former/never smokers showed higher odds on univariate analysis. Among patients tested for PD-L1 (78.8%), 46.6% had negative expression (tumour proportion score <1%), with no correlation to EGFR status.

Conclusion: This is the first genomic molecular profiling study to report exclusively on early-stage NSCLC in Malaysia. The high prevalence of EGFR mutations observed, predominantly involved sensitizing mutations at exons 19 and 21, and was associated with the female sex, a non- smoking status, higher tumour grade, but not PD-L1 expression. Early reflex genomic testing is vital to guide biomarker-driven peri-operative treatment strategies for rNSCLC.

No abstract available.

Introduction: Referrals from Primary Health Facilities (PHF) to hospitals occur due to clinical needs for speciality care in managing the presenting illness, social factors such as poor compliance or lack of family support, and are requested by patients. The journey for any patients transferred from PHF to hospitals has three major components, which are (a) the PHF intervention and activation of ambulances; (b) the Prehospital Care Services (EMS) deployment, care of the patient and transportation to the hospital; and (c) the process of review or admission at the destination hospital. We detail the journey, processing time, and outcomes of patients referred from PHFs via EMS to a tertiary referral hospital in Selangor, Malaysia.

Materials and methods: This is a retrospective study analysing data from 980 referred patients from PHFs transported by Klang Valley Ambulance Service (KVAS) to Hospital Sungai Buloh between 1st January 2023 and 30th June 2023. Data collected includes PHF classification, KVAS activation details, patient demographics, Emergency Department length of stay (EDLOS), and the patient's outcome in the ED. Patient's outcome in ED is categorised as (a) admitted; (b) discharged; or (c) discharged against medical advice (DAMA).

Results: Out of the 980 referred patients, 83.3% were triaged as Priority 1 by PHFs. The majority were males (56.8%), with a mean age of 28 years. The median waiting time for ambulance arrival was 54-58 minutes. The percentage of referred patients who were admitted to the ward was 65.8%. The median EDLOS was 540 minutes (9 hours), with discharged patients having a shorter median EDLOS of 321 minutes (approximately 5 hours). The median total patient waiting time from PHF to final disposition was 605 minutes (10 hours) for admitted patients and 382 minutes (6 hours) for discharged patients.

Conclusion: A significant proportion of referred patients experienced prolonged EDLOS, whereas only 22.4% of referred patients were discharged within eight hours. Average EDLOS of 12 hours suggests the need for a "Fast- Track Referral System" to improve efficiency and reduce unnecessary gatekeeping processes.

Introduction: Stroke is a leading cause of death and disability worldwide. Prompt treatment with recombinant tissue plasminogen activator (rt-PA) and endovascular therapy improves outcomes in acute ischemic stroke. Although Emergency Medical Services (EMS) facilitate timely treatment. This study compared rt-PA administration rates and clinical outcomes between patients who arrived via EMS and those who did not in Mueang District, Chachoengsao Province.

Materials and methods: A retrospective descriptive study was conducted from January 2021 to January 2024, including patients presenting within 4.5 hours of onset, without inter-hospital transfer, and completing 90-day follow-up. Data included transport mode, treatment times, and outcomes.

Results: Of 103 patients, 28 (27.2%) arrived by EMS and 75 (72.8%) by non-EMS. Lipid-lowering agent use was less frequent in the EMS group (17.9% vs. 46.7%, p = 0.008). Onset-to-hospital, door-to-needle, and onset-to-needle times showed no significant differences, and rt-PA administration rates were comparable. In univariable analysis, EMS patients had a higher median NIHSS score than non-EMS patients (median difference = 6.00, 95% CI: 0.99-11.01, p = 0.019), but this was not significant in multivariable analysis (median difference = 0.45, 95% CI: -1.99 - 2.84, p = 0.706). rt-PA was administered in 53.6% of EMS patients and 38.7% of non- EMS patients (p = 0.174). Mechanical thrombectomy was performed more often in EMS patients (42.9% vs. 22.7%, p = 0.043). Discharge NIHSS and 90-day mRS did not differ significantly.

Conclusion: EMS use was associated with greater thrombectomy referral but not with higher rt-PA administration rates or improved outcomes.

Introduction: Open-window thoracostomy offers a chance of treatment for cases of empyema thoracis not amenable for closed drainage or decortication. We review herein a collection of 12 cases based on our five years' experience in Kuala Lumpur Hospital, Malaysia performing this procedure.

Materials and methods: Medical records of open-window thoracostomy cases performed from March 2018 till February 2023 were reviewed retrospectively. Data extracted included demographic information, indication for surgery, surgical approach, perioperative parameters, complications, and 18-months outcome. The primary end point for this study is sepsis resolution. Secondary endpoints are length of stay and spontaneous closure.

Results: 12 patients with mean age of 50.6 years underwent open-window thoracostomy. Five cases of empyema thoracis caused by bronchopleural fistula, five cases of destroyed lung and two recurrent empyema thoracis following unsuccessful decortication. All patients were extubated post-operatively except for two who required postoperative ventilatory support for two days. The primary end point was reached in all cases except one. Three complications were encountered in which blood loss exceeded 750mls.

Conclusions: Open-window thoracostomy may be performed safely in cases of empyema thoracis not amenable for closed drainage or decortication. Preoperative planning, preparation and counselling are vital to ensure good outcome and to manage patient's expectation.

Introduction: Schizophrenia is a complex mental disorder involving genetic, environmental, and neurodevelopmental factors. Despite significant progress in identifying several genetic contributors to schizophrenia, the role of apolipoprotein in lipid metabolism, neurodevelopment, and neuroprotection remains underexplored. This systematic review aims to synthesise existing genetic studies on apolipoproteins associated with schizophrenia to clarify their potential role in the disorder's pathogenesis.

Materials and methods: A comprehensive literature review was conducted using the PubMed and Scopus databases, involving studies published from 2004 to 2023, and limited to English. Keywords included "schizophrenia," "apolipoprotein," "genetic," and "genetics." Non-research publications such as books, reviews, editorials, letters to editors, short communications, book series, chapters, and conference proceedings were excluded from this review. Only peer-reviewed journal articles were selected to ensure the reliability and credibility of the systematic review.

Results: A total of 41 articles were included in the review, with four key themes identified. The themes addressed specific aspects of apolipoproteins in schizophrenia, including their role in schizophrenia susceptibility, lipid metabolism, and cognitive functions within the disorder. This review presents a novel synthesis of these studies, focusing on the underexplored roles of apolipoprotein genes, including APOE, APOL, APOD, APOA, APOC, APOER2, and APOBEC, in schizophrenia.

Conclusion: This systematic review provides a comprehensive understanding of the genetics of apolipoprotein in schizophrenia, particularly in relation to lipid metabolism. The findings suggest future research directions to enhance the understanding of schizophrenia pathogenesis and highlight the importance of targeted research to identify specific genetic biomarkers for therapeutic interventions.

Introduction: Seizures are a common and clinically significant complication of infective encephalitis, often associated with greater disease severity and poorer neurological outcomes. Identifying reliable clinical and diagnostic predictors of seizures is critical to improve early risk stratification and guide targeted management. However, regional data on the seizure prevalence and associated factors in encephalitis remain limited. This study aims to determine the prevalence, clinical characteristics, and risk factors associated with seizure occurrence in patients with infective encephalitis admitted to a tertiary care centre in Malaysia.

Materials and methods: We conducted a retrospective observational study involving 173 patients diagnosed with infective encephalitis and admitted to a tertiary referral hospital. Data on demographics, clinical presentation, Glasgow Coma Scale (GCS) scores, electroencephalography (EEG), neuroimaging, and cerebrospinal fluid (CSF) parameters were extracted from medical records. Seizure occurrence and characteristics were analysed. Statistical analyses included univariate and multivariate logistic regression to identify independent predictors of seizures. Missing data for selected variables were imputed using median substitution based on the distribution of available data.

Results: Seizures were reported in 55.5% of patients (n=96), with generalised seizures being more common than focal. EEG abnormality emerged as the most significant independent risk factor for seizure occurrence (aOR 5.22, 95% CI 2.22-12.26, p <0.001). Altered behaviour (aOR 0.22, 95% CI 0.11-0.45, p < 0.001) and elevated CSF protein (OR 0.44, 95% CI 0.20-0.95, p = 0.036) were significantly associated with lower odds of seizures. Functional outcomes at discharge (assessed by Glasgow Outcome Scale), showed that higher seizure burden, particularly status epilepticus (p<0.001) and increased seizure frequency (p=0.008) was significantly associated with poorer recovery at discharge.

Conclusion: This study confirms the substantial clinical burden of seizures in infective encephalitis and highlights the need to prioritise systemic risk stratification in routine care. EEG abnormality is the strongest independent predictor of seizure risk and should be incorporated into early diagnostic evaluation for risk stratification. Early EEG monitoring, timely antiseizure management, and structured neurological assessment are critical to mitigate secondary brain injury and optimise outcomes.