Nevin Manimala

Med J Malaysia. 2024 Mar;79(2):141-145.

ABSTRACT

INTRODUCTION: The rise in the cases of chronic kidney disease (CKD) with the increasing prevalence of non-communicable diseases such as type 2 diabetes mellitus and hypertension is a major public health concern in Malaysia. This results in the many cases of chronic kidney disease being managed in primary healthcare clinics. This study examines the pre- and post-clinical outcomes of scheduled nephrologist visits on CKD patients in a primary health care clinic in Ipoh, Perak.

MATERIALS AND METHODS: This is a retrospective crosssectional study reviewing the medical records of patients seen by visiting nephrologists from January 2019 to December 2021 in Greentown Health Clinic. The study population are patients with CKD stage 3b, 4 and 5 who are followed up in Greentown Health Clinic. Universal sampling was done, a total of 87 patients reviewed at least once by the visiting nephrologist and with retrievable medical records were included in the study. Those whose medical records were irretrievable were excluded. Blood pressure, urine protein, fasting blood sugar (FBS), glycated haemoglobin (HbA1c), serum creatinine, eGFR and fasting lipid profile (FLP) pre- and post-visits were collected by reviewing patient medical records and laboratory results. The results were then analysed and compared using SPSS version 26.

RESULTS: The median age of patients in this study was 66 years of age, the majority were male patients (54%) and Malay ethnicity (62.1%). Absence of urine microalbuminuria pre and post referral remain the same (n = 11). During prenephrologist visits, a higher percentage of patients exhibited moderate (30-300 mg/g) and severe (>300 mg/g) increase in urine albuminuria (15.7% and 7.2%, respectively) compared to the post-referral period. In patients with significant urine protein pre-referral, patient group with urine protein 3+ showed the highest increment of 30.1% (n = 22), in comparison to 19.3% (n = 16) observed during prereferral. Statistically significant clinical outcomes between pre- and post-referral to the nephrologist include reduction of systolic blood pressure [141±15 mmHg versus 135 ±12 mmHg, p = 0.001] and diastolic blood pressure [median = 80 mmHg (IQR: 10) versus median=71 mmHg (IQR: 17), p < 0.001]. Similarly, total cholesterol [median = 4.4 mmol/L (IQR: 1.4) versus median = 4.0 mmol/L (IQR: 1.5, p = 0.001] and LDL [median = 2.5 mmol/L (IQR: 1.2) versus median = 2.2 mmol/L (IQR: 1.2), p < 0.001)] exhibited statistically significant differences between pre- and post-referral. However, HDL remained unchanged and other outcome variables showed no significant differences.

CONCLUSION: Incorporating nephrologist visits in primary care seems to have positive impact towards patient clinical outcomes. Results shown in this study can aid other primary care clinics in the decision to initiate nephrologist services in the primary care setting as a multidisciplinary approach to managing CKD patients.

PMID:38553917

Med J Malaysia. 2024 Mar;79(2):133-140.

ABSTRACT

INTRODUCTION: Endoscopic sphincterotomy (EST) plus endoscopic papillary large balloon dilatation (EPLBD) has been reported as a valid alternative to EST alone in removing common bile duct (CBD) stone. The aim of this study is to compare efficacy, and safety of these two groups of patients in removing CBD stone in Hospital Universiti Sains Malaysia (HUSM).

MATERIALS AND METHODS: This is a prospective single centre randomised single blinded comparative study conducted in HUSM. The primary endpoints for this study are the overall complete stone clearance rate and complication rate, while the secondary outcome for this study are duration of procedure and rate of usage of adjunct methods. Objective data analysis is conducted using independent sample t-test and chi-squared test.

RESULTS: A total of 66 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis which is CBD stone. 34 patients were allocated to EST plus EPLBD arm (n=34), and 32 patients were in EST alone arm (n=32) using randomisation method. For intention to treat, patients from EST alone arm that unable to achieve complete stone clearance will be switched to EST plus EPLBD arm. The overall complete stone removal rate for both groups were comparable (EST plus EPLDB: 100% versus EST alone: 93.8%; p= 0.139). The two patients from EST alone group (6.2%) that unable to achieve complete stone clearance were converted to EST plus EPLBD group for intention to treat and able to achieve complete stone clearance by EST plus EPLBD. For procedural time, both arms are comparable as well (EST plus EPLDB: 15.8 minutes vs EST alone: 15.5 minutes; p= 0.860). Complications such as pancreatitis occurred in one patient in EST plus EPLBD arm (EST plus EPLDB: 2.9 % vs EST alone: 0 %; p= 0.328), and bleeding occurred in one patient in EST alone arm (EST plus EPLDB: 0 % vs EST alone: 3.1 %; p= 0.299) , but it is not statistically significant. No perforation or cholangitis complication occurred in both groups. No adjunct usage was observed in both groups.

CONCLUSION: In this study with limited sample size, both EST plus EPLBD and EST alone are effective and has comparable procedural time in removing CBD stone. Even though both methods are equally effective, EPLBD plus EST is an alternative solution if complete stone clearance is unable to achieve via EST alone.

PMID:38553916

Med J Malaysia. 2024 Mar;79(2):124-127.

ABSTRACT

INTRODUCTION: Vaccination is an effective way to overcome the spread of Coronavirus Disease 19 (COVID-19). However, it can give rise to adverse event following immunisation (AEFI). AEFI is an important aspect that is assessed in vaccine safety standards. It is assumed that different vaccine platforms can give rise to different degrees of AEFI severity, but so far there have been no studies that discuss the differences in the degree of AEFI on each type of COVID- 19 vaccine platform.

AIM: Evaluate the differences in the degree of AEFI on each type of COVID-19 vaccine platform.

MATERIALS AND METHODS: The research used a quantitative analytical observational design with a cross sectional approach. Data collection from participants was carried out by filling out questionnaires. The collected data was tabulated and statistical analysis was carried out.

RESULTS: A total of 217 respondents who received three doses of vaccine participated in the study. Of the 651 vaccine doses studied, the results showed that there were significant differences in the degree of AEFI between the three types of vaccine platforms. The degree of AEFI was significantly different (p < 0.05) between each type of vaccine platform, with the degree of AEFI starting from the lowest, namely inactivated vaccine, then viral vector vaccine and the highest was nucleic acid vaccine.

CONCLUSION: The degree of AEFI differs significantly between each COVID-19 vaccine platform. The degree of AEFI, from the mildest to the most severe, was inactivated vaccine, viral vector vaccine and nucleic acid vaccine. No serious AEFI was reported.

PMID:38553914

J Fish Biol. 2024 Mar 30. doi: 10.1111/jfb.15741. Online ahead of print.

ABSTRACT

Mathematical and statistical models underlie many of the world’s most important fisheries management decisions. Since the 19th century, difficulty calibrating and fitting such models has been used to justify the selection of simple, stationary, single-species models to aid tactical fisheries management decisions. Whereas these justifications are reasonable, it is imperative that we quantify the value of different levels of model complexity for supporting fisheries management, especially given a changing climate, where old methodologies may no longer perform as well as in the past. Here we argue that cost-benefit analysis is an ideal lens to assess the value of model complexity in fisheries management. While some studies have reported the benefits of model complexity in fisheries, modeling costs are rarely considered. In the absence of cost data in the literature, we report, as a starting point, relative costs of single-species stock assessment and marine ecosystem models from two Australian organizations. We found that costs varied by two orders of magnitude, and that ecosystem model costs increased with model complexity. Using these costs, we walk through a hypothetical example of cost-benefit analysis. The demonstration is intended to catalyze the reporting of modeling costs and benefits.

PMID:38553910 | DOI:10.1111/jfb.15741

ANZ J Surg. 2024 Mar 30. doi: 10.1111/ans.18995. Online ahead of print.

ABSTRACT

BACKGROUND: We investigated the role of perioperative intraoral glossopharyngeal nerve block to minimize postoperative pain in patients undergoing tonsillectomy through a meta-analysis of the relevant literature.

METHODS: We retrieved eight studies from PubMed, Scopus, Embase, Web of Science, and Cochrane databases up to August 2023. We compared perioperative glossopharyngeal nerve block with a control group, in order to examine postoperative pain, analgesic use, and other postoperative morbidities.

RESULTS: Postoperative pain was significantly reduced at 1-4 h (SMD -1.26, 95% CI [-2.35; -0.17], I² = 94.7%, P = 0.02) and 5-8 hours (SMD -1.40, 95% CI [-2.47; -0.34], I² = 96.1%, p = 0.01) in the treatment groups compared to the control group. However, glossopharyngeal nerve block showed no efficacy in reducing pain or use of analgesic drugs after 12 h compared to the control group. The incidences of postoperative bleeding (OR 0.95, 95% CI [0.35; 2.52], I² = 0.0%), local agent toxicity (OR 4.14, 95% CI [0.44; 38.63], I² = 0.0%), nasal problems (OR 1.25, 95% CI [0.60; 2.61], I² = 0.0%), postoperative nausea and vomiting (OR 1.35, 95% CI [0.78; 2.33], I² = 0.0%), swallowing difficulty (OR 1.61, 95% CI [0.76; 3.42], I² = 56.0%), and voice change (OR 3.11, 95% CI [0.31; 30.80], I² = 0.0%) were not significantly different between the treatment and control groups. The treatment group showed higher prevalence of respiratory problems and dry mouth compared to control without statistical significance, but a significant increase in throat discomfort (p = 0.02).

CONCLUSION: Intraoral glossopharyngeal nerve block for tonsillectomy did not significantly impact postoperative pain management and was associated with some adverse effects with increases in respiratory problems, dry mouth, and throat discomfort compared to controls.

PMID:38553908 | DOI:10.1111/ans.18995

ANZ J Surg. 2024 Mar 30. doi: 10.1111/ans.18987. Online ahead of print.

ABSTRACT

Evaluation is a vital part of any learning activity and is essential to optimize and improve educational programmes. It should be considered and prioritized prior to the implementation of any learning activity. However, comprehensive programme evaluation is rarely conducted, and there are numerous barriers to high-quality evaluation. This review provides a framework for conducting outcome evaluation of simulation-based education programmes in low and middle-income countries (LMICs). The basis of evaluation, including core ideas of theory, purpose and structure are outlined, followed by an examination of the levels and healthcare applications of the Kirkpatrick model of evaluation. Then, methods of conducting evaluation of simulation-based education in LMICs are discussed through the lens of a successful surgical simulation programme in Myanmar, a lower-middle-income country. The programme involved the evaluation of 11 courses over 4 years in Myanmar and demonstrated evaluation at the highest level of the Kirkpatrick model. Reviewing this programme provides a bridge between evaluation theory and practical implementation. A range of evaluation methods are outlined, including surveys, interviews, and clinical outcome measurement. The importance of a mixed-methods approach, enabling triangulation of quantitative and qualitative analysis, is highlighted, as are methods of analysing data, including statistical and thematic analysis. Finally, issues and challenges of conducting evaluation are considered, as well as strategies to overcome these barriers. Ultimately, this review informs readers about evaluation theory and methods, grounded in a practical application, to enable other educators in low-resource settings to evaluate their own activities.

PMID:38553885 | DOI:10.1111/ans.18987

J Magn Reson Imaging. 2024 Mar 29. doi: 10.1002/jmri.29259. Online ahead of print.

ABSTRACT

BACKGROUND: Extracellular volume (ECV) correlates with the degree of liver fibrosis.

PURPOSE: To analyze the performance of liver MRI-based ECV evaluations with different blood pool measurements at different time points.

STUDY TYPE: Prospective.

SAMPLE: 73 consecutive patients (n = 31 females, mean age 56 years) with histopathology-proven liver fibrosis.

FIELD STRENGTH/SEQUENCE: 3T acquisition within 90 days of biopsy, including shortened modified look-locker inversion recovery T1 mapping.

ASSESSMENT: Polygonal regions of interest were manually drawn in the liver, aorta, vena cava, and in the main, left and right portal vein on four slices before and after Gd-DOTA administration at 5/10/15 minutes. ECV was calculated 1) on one single slice on portal bifurcation level, and 2) averaged over all four slices.

STATISTICAL TESTS: Parameters were compared between patients with fibrosis grades F0-2 and F3-F4 with the Mann-Whitney U and fishers exact test. ROC analysis was used to assess the performance of the parameters to predict F3-4 fibrosis. A P-value <0.05 was considered statistically significant.

RESULTS: ECV was significantly higher in F3-4 fibrosis (35.4% [33.1%-37.6%], 36.1% [34.2%-37.5%], and 37.0% [34.8%-39.2%] at 5/10/15 minutes) than in patients with F0-2 fibrosis (33.3% [30.8%-34.8%], 33.7% [31.6%-34.7%] and 34.9% [32.2%-36.0%]; AUC = 0.72-0.75). Blood pool T1 relaxation times in the aorta and vena cava were longer on the upper vs. lower slices at 5 minutes, but not at 10/15 minutes. AUC values were similar when measured on a single slice (AUC = 0.69-0.72) or based on blood pool measurements in the cava or portal vein (AUC = 0.63-0.67 and AUC = 0.65-0.70).

DATA CONCLUSION: Liver ECV is significantly higher in F3-4 fibrosis compared to F0-2 fibrosis with blood pool measurements performed in the aorta, inferior vena cava, and portal vein at 5, 10, and 15 minutes. However, a smaller variability was observed for blood pool measurements between slices at 15 minutes.

LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 3.

PMID:38553860 | DOI:10.1002/jmri.29259

Chron Respir Dis. 2024 Jan-Dec;21:14799731241238435. doi: 10.1177/14799731241238435.

ABSTRACT

OBJECTIVES: This study aimed to determine the feasibility of a group-based pilot programme of low-to-moderate physical activity training, education and social activities, by investigating acceptability, practicality, implementation and efficacy testing. We offer suggestions on programme adaptions for future study.

METHODS: People with a range of chronic respiratory diseases were invited to participate in a pilot 12 week group activity programme. Activities included outdoor walking, tai-chi, education and a range of social activities. Acceptability was determined by participant experiences determined during interviews. Practicality was determined by programme and outcome measure completion, cost and adverse events. Implementation was determined according to whether the programme ran as planned. Efficacy was determined by statistical analyses of outcomes including hand grip strength, timed up and go test, COPD Helplessness Index, COPD Assessment Test, and measures of physical activity via accelerometry.

RESULTS: Thematic analysis indicated that the “BreatheHappy” programme was acceptable. Seven of nine participants completed eight out of 10 sessions and the majority completed all outcome measures. “BreatheHappy” was therefore considered practical. The programme was not implemented as planned, with only 10 sessions running rather than the 12 intended. There was a significant increase in daily step counts (MD: 1284 95% CI: 240-2329 p: 0.024 effect size: 0.988), stepping time (MD: 16 min 95% CI: 5-27 min p: 0.011 effect size: 1.36) and daily minutes completing light physical activity (MD: 23 95% CI: 6-38 p: 0.006 effect size: 1.6). However, time spent sitting for ≥30 min but ≤60 min significantly increased (MD: 26 95% CI: 0.2-52 min p: 0.049 effect size: 0.931), showing signs of efficacy and changing physical activity behaviour patterns.

DISCUSSION: A 10-week programme of low-moderate physical activity training, education and social activities shows signs of feasibility for future research. Suggested adaptions for future study include using physical activity measures such as daily step count or light physical activity for a primary outcome, and mental health and social health related outcome measures relatable to participant’s beneficial experiences of the programme. Recruitment in future studies will try and reach both those less socially active and possibly those who have completed pulmonary rehabilitation (PR). Venues should be close to efficient transport links whilst different frequencies and durations of programme delivery should be trialled. Adequate funding should be provided for both staff running the programme and blinded research staff for outcome measurement.

PMID:38553857 | DOI:10.1177/14799731241238435

J Cachexia Sarcopenia Muscle. 2024 Mar 29. doi: 10.1002/jcsm.13461. Online ahead of print.

ABSTRACT

BACKGROUND: Telomere attrition may share common biological mechanisms with bone and muscle loss with aging. Here, we investigated the association between these hallmarks of aging using data from UK Biobank, a large observational study.

METHODS: Leukocyte telomere length (LTL as T/S ratio) was measured using a multiplex qPCR assay at baseline (2006-2010). Bone mineral density (whole body and regional; via dual-energy X-ray absorptiometry), trabecular bone score (via lumbar-spine dual-energy X-ray absorptiometry images), fat-free muscle volume (thighs; via magnetic resonance imaging), and muscle fat infiltration (thighs; via magnetic resonance imaging) were measured during the imaging visit (2014-2018). Regression models were used to model LTL against a muscle or bone outcome, unadjusted and adjusted for covariates.

RESULTS: A total of 16 356 adults (mean age: 62.8 ± 7.5 years, 50.5% women) were included. In the fully adjusted model, thigh fat-free muscle volume was associated with LTL in the overall sample (adjusted standardized β (aβ) = 0.017, 95% CI 0.009 to 0.026, P < 0.001, per SD increase in LTL), with stronger associations in men (aβ = 0.022, 95% CI 0.010 to 0.034, P < 0.001) than in women (aβ = 0.013, 95% CI 0.000 to 0.025, P = 0.041) (sex-LTL P = 0.028). The adjusted odds ratio (aOR) for low thigh fat-free muscle volume (body mass index-adjusted, sex-specific bottom 20%) was 0.93 per SD increase in LTL (95% CI 0.89 to 0.96, P < 0.001) in the overall sample, with stronger associations in men (aOR = 0.92, 95% CI 0.87 to 0.99, P = 0.008) than women (aOR = 0.93, 95% CI 0.88 to 0.98, P = 0.009), although the sex difference was not statistically significant in this model (sex-LTL P = 0.37). LTL was not associated with bone mineral density, trabecular bone score, or muscle fat infiltration in the overall or subgroup analyses (P > 0.05).

CONCLUSIONS: LTL was consistently associated with thigh fat-free muscle volume in men and women. Future research should investigate moderating effects of lifestyle factors (e.g., physical activity, nutrition, or chronic diseases) in the association between LTL and muscle volume.

PMID:38553835 | DOI:10.1002/jcsm.13461

J Neurosurg. 2024 Mar 29:1-9. doi: 10.3171/2024.1.JNS232450. Online ahead of print.

ABSTRACT

OBJECTIVE: Psammomatous meningiomas (PMs) are a rare histological subtype of meningioma but are rather frequent in spinal meningiomas. The authors aimed to analyze the incidence, clinical features, molecular alterations, long-term outcomes, and prognostic factors of PMs.

METHODS: In total, 151 patients with PMs were included in this study. Clinical characteristics, molecular alterations, and progression-free survival (PFS) were analyzed in PMs. Clinical characteristics were compared between PMs and other WHO grade 1 meningiomas. Targeted sequencing of meningioma-relevant genes was performed to determine the molecular alterations in PMs.

RESULTS: PMs accounted for 1.34% of all meningiomas. Clinically, spinal location (p < 0.001) and female predominance (p < 0.001) were statistically significant in PMs when compared with the other grade 1 subtypes. Radiologically, calcification was frequently found in PMs (88.24%). Genetically, NF2 was the most frequently mutated gene in PMs (59.7%), followed by TRAF7 and AKT1. Ten patients experienced recurrence during the long-term follow-up. Multivariate analysis demonstrated that age (p = 0.009), extent of resection (p < 0.001), Ki-67 index (p = 0.007), and NF2 status (p < 0.001) were independent prognostic factors in the cohort of PMs. Interestingly, NF2 mutation was detected in all (48/48) spinal PMs (SPMs) but in only 38.46% (35/91) of cranial PMs (CPMs), revealing a significant difference (p < 0.001). The mean Ki-67 index (p = 0.044) and proportion of PMs with PR-positive expression (p = 0.048) were significantly higher in SPMs than in CPMs. The frequent NF2 mutations are associated with spinal location predominance and worse PFS in PMs.

CONCLUSIONS: Female sex and spinal location predominance were statistically significant in PMs. NF2 mutation was an independent predictor for worse PFS of PMs. Of note, NF2 mutation was detected in all SPMs but in only 38.46% of CPMs, revealing a significant difference.

PMID:38552238 | DOI:10.3171/2024.1.JNS232450