Medical Journal of Malaysia最新文献

Introduction: The practice of Do-Not-Attempt-Resuscitation (DNAR) aims to respect patient autonomy and acknowledge medical futility. Despite its global acceptance, there is limited research on DNAR in many Asian countries, including Malaysia. This study addressed this gap by exploring DNAR decision-making processes in a Malaysian tertiary hospital.

Materials and methods: A mixed-method retrospective study was conducted in the emergency and trauma department (ETD) of Sarawak General Hospital, Malaysia, from February to July 2023. Data were collected from 115 DNAR cases using a surveillance form to document the patient demographics, types of DNAR orders, initiating physicians, reasons for DNAR, surrogate decision-makers, specific types of procedures withheld or withdrawn and outcomes. Thematic analysis was used for qualitative data, while inferential statistical analysis was applied to quantitative data.

Results: The mean age of patients was 71.32 years, with a male predominance (63.5%). The primary reasons for DNAR included "critical illness with poor prognosis" (33.9%), "advanced age with frailty and poor prognosis" (20.9%) and "massive haemorrhagic or ischemic stroke" (16.5%). Most DNAR decisions involved withholding resuscitation (90.4%) and were initiated mainly by internal medicine (52.2%) and emergency medicine teams (34.8%). Surrogate decisionmakers were predominantly adult children (63.5%). Only one case had an advance directive. Majority of patients (80.9%) were admitted to wards, while 16.5% died in the emergency department. The median age of patients was significantly older when adult children (78 years) and spouses (76 years) were the surrogates, compared to when they were not involved (64.5 years and 62.5 years, respectively; p < 0.001 and p = 0.003, respectively). Conversely, the median age was significantly younger when parents (41.5 years) and siblings (64 years) were the surrogates, compared to when they were not involved (75 years and 74 years, respectively; p < 0.001 for both).

Conclusion: Advanced directives are rarely applied in Malaysia. DNAR decisions are typically made by surrogates when patients are critically ill, which is a common trend in many Asian cultures where discussing death is taboo. Cultural norms often lead families to withhold terminal diagnoses from patients, posing challenges for end-of-life care. The most frequent surrogates were adult children, who face dilemmas balancing aggressive treatment and their parents' wishes. The study underscores the need for better communication and decision-making support in emergency departments.

Introduction: Connective tissue diseases (CTDs) are autoimmune diseases with multiorgan involvement. CTDs present with a heterogeneous clinical manifestation, especially in the cutaneous system. This study aimed to describe the common cutaneous manifestations of CTDs, to determine the association with antinuclear antibody (ANA) and other associated antibodies, and to assess the impact of CTDs on patient's quality of life (QOL).

Material and methods: This was a cross-sectional study conducted among patients 18 years and above, with a confirmed diagnosis of systemic lupus erythematosus (SLE), systemic sclerosis, dermatomyositis, mixed connective tissue disease (MCTD) or overlap syndrome, who attended the rheumatology clinic at Hospital Sultan Ismail Johor Bahru between March 2023 to June 2023. The assessment instrument used was the Dermatology Quality Life Index (DLQI).

Results: Among 79 patients recruited, the majority were females with a mean age of 39 ± 14.5 years. Malay was the predominant ethnic group. SLE was the most common CTD (64 patients, 81%), followed by systemic sclerosis (six patients, 7.6%), overlap syndrome (four patients, 5.1%), dermatomyositis (four patients, 5.1%) and MCTD (one patient, 1.3%). All patients had cutaneous involvement with photodermatitis being the commonest cutaneous manifestation (65 patients, 82.3%). ANA and anti-double stranded DNA (dsDNA) positivity were significantly associated with SLE while anti-scl70 and anti-centromere antibodies (ACA) were strongly associated with systemic sclerosis (p < 0.05). The presence of anti-dsDNA and antiscl70 were significantly associated with renal involvement and interstitial lung disease (ILD) respectively (p < 0.05). CTD had a moderate effect on patient's QOL.

Conclusion: Photosensitivity was the commonest cutaneous manifestation among CTD patients. ANA was positive in the majority of SLE patients. The presence of anti-dsDNA was significantly associated with lupus nephritis, while anti-scl70 and ACA were strongly associated with systemic sclerosis and ILD. CTD had a moderate effect on patient's QOL.

Introduction: The pathogenesis of nasopharyngeal carcinoma (NPC) is intricate, influenced by a combination of factors including host genetics, viral infection and environmental elements, resulting in genetic and epigenetic modifications. Despite a positive prognosis for early-stage patients, most NPC cases are diagnosed at an advanced stage, highlighting the pressing need for enhanced accessibility to early diagnosis and treatment. The underlying molecular pathways driving NPC progression remain elusive. This study focuses on the use of bioinformatics techniques and databases in carrying out research to gain insights into gene relevance and potential applications in NPC.

Materials and methods: Searches encompassed articles published in English from January 2017 to June 2024, utilising keywords such as 'nasopharyngeal carcinoma,' 'bioinformatics,' 'gene expression' and 'gene microarrays' across PubMed, MEDLINE and Scopus databases. The Gene Expression Omnibus (GEO) database was utilised to access NPC messenger RNA (mRNA) expression profiling studies.

Results: Most studies utilised the GEO database to identify differentially expressed genes (DEGs) between normal and NPC tissues, followed by functional analysis using gene ontology (GO) and Kyoto Encyclopaedia of Genes and Genomes (KEGG) pathways. Protein protein interaction (PPI) networks of DEGs were commonly constructed using STRING and visualised with Cytoscape software. The integration of GO and KEGG pathway analysis alongside PPI network construction provides valuable insights into the dysregulated pathways and molecular mechanisms underlying NPC pathogenesis. Microarray analysis, particularly datasets such as GSE12452, GSE64634 and GSE34573, has enabled the identification of DEGs associated with NPC. PPI network analysis identifies hub genes, such as DNALI1, DNAI2 and RSPH9, implicated in NPC pathogenesis. Validation of gene expression patterns through platforms like GEPIA and Oncomine validates the clinical relevance of identified biomarkers. Furthermore, studies employing RNA sequencing and bioinformatics approaches uncover novel genes involved in NPC radio resistance and prognosis, paving the way for personalised therapeutic strategies.

Conclusion: Integration of bioinformatics analysis provides insights into the complexity of tumour biology and potential molecular pathways, enabling the development of enhanced strategies for early detection, outcome prediction, recurrence detection and therapeutic approaches for NPC.

Introduction: Allergic contact dermatitis (ACD) involving the face and neck region (FNR) is not uncommon. We aimed to determine the sensitisation pattern among patients with dermatitis involving FNR who underwent skin patch tests between 2016 and 2022.

Materials and methods: This is a 7-year retrospective review on contact sensitisation patterns in patients with dermatitis over the FNR who underwent skin patch tests between 2016 and 2022 in the Department of Dermatology Hospital Kuala Lumpur.

Results: There were 291 patients (female-to-male ratio of 7.8:1; mean age of 34.1 ± 14.0 years) with dermatitis at the FNR who underwent patch tests. The majority (n = 116,39.9%) were aged between 20 and 29 years. About 8% were below 19 years of age. Nearly 50% had dermatitis over the perioral region, 8.6% at the periorbital area and 50.6% at the other parts of the face and neck region. The clinical diagnoses included contact dermatitis (n = 145, 49.8%), cheilitis (n = 81, 27.8%), endogenous eczema (n = 28, 9.6%) and others. All were tested with European baseline series, with 91.4% and 77.0% tested with extended series, and own products, respectively. About 70.1% were sensitised to at least one allergen. The most common sensitizing allergen was nickel sulfate (34.0%), followed by cobalt chloride (11.7%), fragrance mix (10.7%), methylchloroisothiazolinone/ methylisothiazolinone (8.9%), and formaldehyde (8.9%). Clinical relevance was documented in 58.8% of them.

Conclusion: Contact sensitisation was detected in about 70% of patients with dermatitis at the FNR who were patchtested. Nickel, cobalt chloride and fragrance mix were the most common sensitising allergens in these patients.

Introduction: Traditional risk stratification systems based on the clinicopathological criteria have limitations and may not accurately predict outcomes for all patients. The neurologic, oncologic, mechanical, and systemic (NOMS) framework aims to optimise treatment outcomes and improve patient care. Here, we aimed to provide a comprehensive overview of the NOMS framework within the context of spinal metastasis.

Materials and methods: The study rigorously followed the guidelines set by PRISMA. We conducted an extensive search and be as transparent as possible across wellregarded databases such as PubMed and Euro PMC. The primary outcome measure focused on examining the feasibility of implementing the NOMS framework for patients with spinal metastasis in real-world clinical settings, and this measure was predefined and justified.

Results: This systematic review included three studies involving 300 participants with spinal metastases at the cervicothoracic junction. The studies examined surgical interventions like decompression, fusion and corpectomy within the NOMS framework. Across the studies, the NOMS approach is consistently associated with adverse outcomes, including complication rates, surgical revisions, hardware complications, deformities, tumour recurrence and variable survival rates. It is also linked to hospital stays, ICU durations and specific discharge statuses. Another study focused on spinal metastasis patients undergoing endoscopic surgery, highlighting the NOMS framework's connection to recurrence rates, performance metrics, neurological status, pain management, functional recovery and quality of life. In addition, other studies explored navigated instrumentation, with a primary focus on screw placement accuracy. All three studies demonstrated methodological rigor by reporting adequate allocation concealment.

Conclusion: NOMS framework consistently associates with adverse spinal metastasis surgery outcomes.

Presentation is a communication method to convey information within a specific time, involving judgment, decision-making and critical thinking. Incorporation of teaching- learning-assessment of presentation skills is essential in medical curriculum because medical education involves presentations such as case reports, seminar, and conferences. The presentation skills equip 'the future doctors' to be at par with the ever-advancing world of technology, artificial intelligence and globalisation. The presentations should involve effective constructive feedback to enhance the effectiveness of presentation skills in medical curriculum.

Introduction: The iron supplementation program for pregnant women is the main program for tackling anemia in various countries, especially in developing countries in which daily diets may lack sufficient iron intake. In Indonesia, it is recommended that expectant mothers ingest 90 iron tablets during their pregnancy; however, the World Health Organization reports that 37% of pregnant women in the country continue to experience anemia. Iron deficiency anemia consistently emerges as the primary etiology for diagnosing anemia; however, it is important to recognize that anemia can stem from various factors beyond just lack of iron. In addition to iron deficiency, chronic illnesses and infections significantly contribute to the prevalence of anemia worldwide. Consequently, this literature review endeavors to uncover the underlying factors responsible for normocytic anemia among pregnant women, focusing on developing countries.

Materials and methods: Eight search engines, specifically Proquest, EbscoHost, Scopus, Cochrane Library, Science Direct, Wiley Online Library, PubMed, Google Scholar, and Garuda, were utilized to identify primary articles. Three independent reviewers assessed abstracts and full articles based on specific inclusion and exclusion criteria. The data collected encompassed information regarding the population under study, research methods employed, and primary findings pertinent to the review's objectives. Fifteen studies, published between 2014 and 2023, that met the eligibility criteria outlined in the PRISMA-ScR.

Results: Among the 15 studies on normocytic anemia in pregnant women, malaria and HIV were the highest causes of normocytic anemia, followed by worm/intestinal parasite infections, chronic diseases, and bleeding.. In pregnant women, anemia of chronic disease and infection often coexists with iron deficiency anemia, both show decrease serum iron levels. Hence, other investigations need to be carried out to diagnose with certainty the cause of anemia in pregnant women.

Conclusion: Anemia is not a standalone disease but rather a symptom of various underlying diseases. Therefore, diagnosing anemia requires identifying the basic disease that causes anemia, rather than simply labeling it as anemia.

Introduction: Postoperative nausea and vomiting (PONV) is a common side effect of all types of surgeries, especially so in bariatric surgery. Dexmedetomidine (DX) is an α2-agonist that may be useful as an adjunct prophylactic medication for PONV. This meta-analysis aims to evaluate the efficacy of DX in reducing the incidence and severity of PONV in laparoscopic bariatric surgeries.

Materials and methods: Databases were searched for articles with the determined MESH terms and keywords before February 2022. Identified articles were screened and 13 randomised clinical trials (RCTs) were included in this meta-analysis based on the inclusion criteria. Data were extracted from the articles and statistical analysis was performed using Review Manager.

Results: Administration of DX significantly reduced the incidence of PONV and Numerical Rating Scale (NRS) scores for PONV. The outcome was probably due to the intrinsic sympatholytic effect of the medication, reduction of postoperative pain and total postoperative opioid usage. DX showed better efficacy as PONV prophylaxis if the duration of surgery was < 120 minutes. Delivery of DX as a continuous infusion without a loading dose before infusion was found to be effective in reducing PONV compared to infusion after a loading dose.

Conclusion: Administration of DX can reduce the incidence of PONV in patients undergoing laparoscopic bariatric surgery. However, further studies are required to investigate the optimal dose of DX as an antiemetic, considering its side effects to increase the applicability of our results in future guidelines for laparoscopic bariatric surgery.

Introduction: Eating disorders are becoming a cause of concern amongst athletes in recent times. The objective of this study was to determine the prevalence of eating disorders amongst physically disabled athletes in Malaysia. Athletes were sampled and screened for eating disorders utilising the Eating Disorder Examination-Questionnaire 6.0 (EDE-Q-for females) and the Eating Disorder Assessment in Males (EDAM-for males).

Materials and methods: Athletes were approached individually, and they responded via an online questionnaire. A total of 271 athletes responded (sample needed 269) from the total of 700 athletes (38.7%).

Results: From the total, 14.4% (n = 39, 95% CI = 10.56-19.28) of the athletes had eating disorders (14.4% of the male athletes and 14.5% of female athletes). The final model of a binary logistic regression was conducted and found that the higher the body weight (AOR: 1.02, 95% CI: 1.00-1.04, p = 0.03), the higher the income (AOR: 0.992, 95% CI: 0.990- 0.994, p = 0.02), the more athlete suffered from coaches intimidating behaviours(AOR: 1.17, 95% CI: 1.03-1.33, p = 0.02), a perception of having stress (AOR: 7.61, 95% CI: 1.69-34.39, p = 0.01) and having stress (AOR: 3.70, 95% CI: 1.02-9.68, p = 0.04) were common factors seen in athletes with eating disorders.

Conclusion: About two in every 10 disabled athletes suffered from eating disorders.