Predictors of in-hospital mortality by logistic regression analysis among melioidosis patients in Northern Malaysia:A retrospective study

Objective:To identify the predictors of mortality among in-hospital melioidosis patients.Methods:A total of 453 patients in Hospital Sultanah Bahiyah,Kedah,and Hospital Tuanku Fauziah,Perlis with culture-confirmed melioidosis were retrospectively included in the study.Advanced multiple logistic regression was used to obtain the final model of predictors of mortality from melioidosis.The analysis was performed using STATA/SE 14.0.Results:A total of 50.11%(227/453)of the patients died at the hospital,and a majority(86.75%,393/453)of cases were bacteremic.The logistic regression estimated that the bacteremic type of melioidosis,low platelet count,abnormal white blood cell counts,and increased urea value were predictors of mortality.The results showed that bacteremic melioidosis increased the risk of death by 4.39 times(OR 4.39,95%CI 1.83-10.55,P=0.001)compared to non-bacteremic melioidosis.Based on laboratory test,the adjusted ORs from the final model showed that all three blood investigations were included as the associated factors of mortality for the disease[high white blood cell(>10×10^(9)/L):OR 2.43,95%CI1.41-4.17,P<0.001;low white blood cell(<4×10^(9)/L):OR 3.82,95%CI 1.09-13.34,P=0.036;low platelet(<100×10^(9)/L):OR 4.19,95%CI 1.89-9.30,P<0.001;high urea(>7800μmol/L):OR 5.53,95%CI 2.50-12.30,P<0.001;and low level of urea(<2500μmol/L):OR 3.52,95%CI 1.71-7.23,P=0.001].Conclusions:Routine blood investigations during a hospital admission can early identify predictors of mortality in melioidosis patients.

Migrating fish bone piercing the common carotid artery,thyroid gland and causing deep neck abscess

Foreign body(FB) ingestion is very common in Malaysian population.The most commonly ingested FB is fish bone.Common presenting symptoms include FB sensation,odynophagia and or sharp pricking pain during swallowing.A careful history and physical examination is very important.Despite negative laryngoscopy and rigid esophagoscopy,persistent symptoms warrants further radiographic imaging studies.The FB can migrate extraluminally and involve other important adjacent structures of the neck and along the digestive tract.We report 3 cases of extraluminal migration of fish bone and their complications,which were successfully managed.One case with vascular complication which involve common carotid artery and the other two cases with neck abscess formation involving thyroid gland,retropharyngeal and parapharyngeal abscess.

Randomized controlled trial of Letrozole versus Clomiphene citrate for induction of ovulation in polycystic ovarian syndrome (PCOS): A Malaysian experience

Background: The purpose of this study was to compare the effectiveness of Letrozole versus Clomiphene citrate for ovulation induction in polycystic ovarian syndrome (PCOS) with infertility. Methods: This was a prospective randomized trial involving 150 women with PCOS attending the Infertility Clinic at three hospitals in Malaysia. During the initial visit, anthropometric measurements and baseline investigations were performed. Patients were randomized to 5.0 mg Letrozole daily (75 patients) or 100 mg Clomiphene citrate daily (75 patients) from the fifth until the ninth day of menstruation. Serial transvaginal scans were performed to see the dominant follicles, endometrial thickness and number of follicles. Transvaginal scans were performed serially to look for evidence of ovulation. Results: The subjects were homogenously distributed. The difference between Letrozole and Clomiphene citrate for ovulation rate was 59 (78.7%) versus 40 (53.3%). Patients taking Letrozole exhibited a mean endometrial thickness (ET) at mid cycle of menses (Day 11-D14) of9.2 mm(SD ± 2.3) versus8.4 mm(SD ± 2.2) for patients taking Clomiphene citrate, and these differences were statistically significant

Traumatic optic neuropathy secondary to acupuncture treatment for glaucoma: A case report

Internal organ injuries have been recognized as a major complication of acupuncture. Reported ocular adverse events include traumatic cataract, oculomotor nerve injury, endophthalmitis and retinal puncture. We report a case of traumatic optic neuropathy and self-sealed globe perforation following acupuncture. A Chinese gentleman with primary open angle glaucoma presented with sudden loss of vision in the right eye after acupuncture therapy. The vision dropped to 2/60 from 6/6 premorbid. Relative afferent pupillary defect was present. Fundus examination showed hemorrhage from the optic disc into the vitreous. It is likely that the optic nerve injury occurred when the acupuncture needle was advanced deep into locations near the optic nerve. Main acupoints used in acupuncture treatment of glaucoma include Tongziliao GB-1, Jingming BL-1 and Chengqi ST-1. It is crucial to have a good understanding of ocular anatomy to avoid potentially blinding complications.

Comparison of Cox proportional hazards model,Cox proportional hazards with time-varying coefficients model,and lognormal accelerated failure time model:Application in time to event analysis of melioidosis patients

Objective:To compare the prognostic factors of mortality among melioidosis patients between lognormal accelerated failure time(AFT),Cox proportional hazards(PH),and Cox PH with time-varying coefficient(TVC)models.Methods:A retrospective study was conducted from 2014 to 2019 among 453 patients who were admitted to Hospital Sultanah Bahiyah,Kedah and Hospital Tuanku Fauziah,Perlis in Northern Malaysia due to confirmed-cultured melioidosis.The prognostic factors of mortality from melioidosis were obtained from AFT survival analysis,and Cox’s models and the findings were compared by using the goodness of fit methods.The analyses were done by using Stata SE version 14.0.Results:A total of 242 patients(53.4%)survived.In this study,the median survival time of melioidosis patients was 30.0 days(95%CI 0.0-60.9).Six significant prognostic factors were identified in the Cox PH model and Cox PH-TVC model.In AFT survival analysis,a total of seven significant prognostic factors were identified.The results were found to be only a slight difference between the identified prognostic factors among the models.AFT survival showed better results compared to Cox's models,with the lowest Akaike information criteria and best fitted Cox-snell residuals.Conclusions:AFT survival analysis provides more reliable results and can be used as an alternative statistical analysis for determining the prognostic factors of mortality in melioidosis patients in certain situations.

Endogenous endophthalmitis secondary to melioidosis in paediatric patients: Case series and review article

Endogenous endophthalmitis is a devastating infection of the eye which can lead to permanent blindness. We report two rare cases of paediatric endogenous endophthalmitis secondary to melioidosis with contrasting visual outcomes. Both patients presented with acute painful visual loss with poor vision on presentation after exposure to open water sources (swimming at two separate locations with waterfalls). Both were diagnosed to have melioidosis endogenous endophthalmitis based on the ocular features clinically and via positive melioidosis serology. They otherwise did not exhibit any symptoms and signs suggestive of systemic melioidosis infection. Even though the two children demonstrated severe ocular involvement, ocular culture from vitreous and aqueous sampling taken from one of the patients did not yield any positive results. No ocular sampling was taken from the other patient. After standard antimicrobial treatment, the first patient responded well with good visual recovery without requiring any surgical intervention for the endophthalmitis. In contrast, our second patient ended up with poor visual outcome despite undergoing multiple intravitreal antibiotic injections and early pars plana vitrectomy. This is because he developed extensive retinal detachment due to the aggressive ocular infection. The diagnosis of endogenous endophthalmitis due to ocular melioidosis remains challenging and requires a high index of suspicion in areas endemic for the causative organism. Early empirical antibiotic treatment should be initiated in suspicious cases, even though the treatment outcomes may vary greatly.

Validation model of fibrosis-8 index score to predict significant fibrosis among patients with nonalcoholic fatty liver disease

BACKGROUND Identifying hepatic fibrosis is crucial for nonalcoholic fatty liver disease(NAFLD)management.The fibrosis-8(FIB-8)score,recently developed by incorporating four additional variables into the fibrosis-4(FIB-4)score,showed better performance in predicting significant fibrosis in NAFLD.AIM To validate the FIB-8 score in a biopsy-proven NAFLD cohort and compare the diagnostic performance of the FIB-8 and FIB-4 scores and NAFLD fibrosis score(NFS)for predicting significant fibrosis.METHODS We collected the data of biopsy-proven NAFLD patients from three Asian centers in three countries.All the patients with available variables for the FIB-4 score(age,platelet count,and aspartate and alanine aminotransferase levels)and FIB-8 score(the FIB-4 variables plus 4 additional parameters:The body mass index(BMI),albumin to globulin ratio,gamma-glutamyl transferase level,and presence of diabetes mellitus)were included.The fibrosis stage was scored using nonalcoholic steatohepatitis CRN criteria,and significant fibrosis was defined as at least fibrosis stage 2.RESULTS A total of 511 patients with biopsy-proven NAFLD and complete data were included for validation.Of these 511 patients,271(53.0%)were female,with a median age of 51(interquartile range:41,58)years.The median BMI was 29(26.3,32.6)kg/m2,and 268(52.4%)had diabetes.Among the 511 NAFLD patients,157(30.7%)had significant fibrosis(≥F2).The areas under the receiver operating characteristic curves of the FIB-8 and FIB-4 scores and NFS for predicting significant fibrosis were 0.774,0.743,and 0.680,respectively.The FIB-8 score demonstrated significantly better performance for predicting significant fibrosis than the NFS(P=0.001)and was also clinically superior to FIB-4,although statistical significance was not reached(P=0.073).The low cutoff point of the FIB-8 score for predicting significant fibrosis of 0.88 showed 92.36%sensitivity,and the high cutoff point of the FIB-8 score for predicting significant fibrosis of 1.77 showed 67.51%specificity.CONCLUSION We demonstrated that the FIB-8 score had significantly better performance for predicting significant fibrosis in NAFLD patients than the NFS,as well as clinically superior performance vs the FIB-4 score in an Asian population.A novel simple fibrosis score comprising commonly accessible basic laboratories may be beneficial to use for an initial assessment in primary care units,excluding patients with significant liver fibrosis and aiding in patient selection for further hepatologist referral.

Unusual cause of hemorrhagic pleural effusion:A case report

BACKGROUND Infected aortic aneurysms are uncommon and difficult to treat.We present a case of infected aortic aneurysm with recurrent nontyphoidal Salmonella bacteremia.CASE SUMMARY A 68-year-old gentleman presented with non-specific symptoms and was found to have nontyphoidal Salmonella bacteremia and was treated with intravenous ceftriaxone.However his condition did not improve,and he developed a multiloculated right pleural effusion.Thoracocentesis was done to drain hemorrhagic pleural fluid.Chest computed tomography demonstrated descending thoracic aorta saccular aneurysm with periaortic hematoma likely due to recent bleed and extending to the right pleural cavity.He was referred to cardiothoracic surgery team and was planned for medical therapy in view of hemodynamic stability and no evidence of active leakage.He completed intravenous antibiotic for 5 wk and refused surgical intervention.Unfortunately,he was admitted twice for recurrent nontyphoidal Salmonella bacteremia.Finally,he agreed for surgical intervention and underwent endovascular aortic repair 3 mo later.Postoperatively,his condition remained stable with no recurrence of infection.CONCLUSION Our case highlights the importance of high index of suspicion of infected aortic aneurysm in patients with Salmonella bacteremia with high-risk factors such as atherosclerosis.

Perceptions of Malaysian medical students from different academic years on primary care:a qualitative research

Objective To explore the perception of medical students from a private medical college in Perak,Malaysia,on primary care practice and induce the factors influencing their perception and willingness to consider primary care as a career pathway.Design Qualitative study using focus group discussions.Participants’responses were audio recorded,transcribed,grouped under various domains and listed out and analysed.Setting A private medical college in Perak state,Malaysia.Participants Forty-six medical students from years 2 to 5 were included.Eight focus groups were formed with two focus groups from each academic year(six students each in seven groups and four students in one group).Students were informed through their respective student leader of each year and received a participant information sheet and an informed consent form which were completed and returned if they decided to participate in the focus group discussions.results The participants had different levels of understanding of primary care depending on their level of exposure to primary care.Senior students with more exposure had a better understanding about primary care and its services.Attractive factors towards choosing primary care as a career included short working hours with a more balanced family and social life,being able to treat patients as a whole with continuity of care and closer relationship with patients.Unattractive factors included routine,unchallenging and boring practice,poor salary,work overload and administrative work in government clinics,being less recognised by other specialties;and the poor perception by other doctors that those pursuing primary care were not‘brilliant enough’for more‘sophisticated disciplines like surgery or paediatrics’.Conclusion This study showed that the medical students’level of exposure to primary care played a crucial role in determining their understanding of primary care practice and their choice of career in primary care.Issues to be addressed include remuneration,workload and the prejudice against primary care as a career pathway.Suggestions included introducing early exposure to fun and challenging primary care postings in the medical curriculum and producing well trained,skilled and enthusiastic role models.