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Background: Several studies in various populations have been conducted to determine candidate genes that could contribute to age-related macular degeneration (AMD) pathogenesis. Objective: The present study was undertaken to determine the association of high temperature requirement A-1 (HTRA1), vascular endothelial growth factor (VEGF) and very-low-density receptor (VLDR) genes with wet AMD subjects in Malaysia. Methods: A total of 125 subjects with wet AMD and 120 subjects without AMD from the Malaysian population were selected for this study. Genomic DNA was extracted and copy number variations (CNVs) were determined using quantitative real-time Polymerase Chain Reaction (qPCR) and comparison between the two groups was done. The demographic characteristics were also recorded. Statistical analysis was carried out using software where a level of P < 0.05 was considered to be statistically significant. Result: Statistically significant associations of the VEGF gene were observed in mean copy differences between case and control subjects (P < 0.05). The consistency of both unadjusted and age-adjusted data at Copy Number CN gain (CN = 3 and CN = 4) suggested that VEGF could increase the risk of wet AMD disease (P < 0.05). None of CNVs of HTRA1 and VLDR genes showed associations with the wet AMD disease based on comparisons of the frequencies of mean (P > 0.05). Conclusion: Observations of an association between CNVs of VEGF gene and wet AMD have revealed that the CNVs of VEGF gene appears to be a possible contributor to wet AMD subjects in Malaysia. [ABSTRACT FROM AUTHOR]

Background: Delayed-onset of headache seems a specific feature of cerebrovascular events after COVID-19 vaccines. Methods: All consecutive events reported to the United States Vaccine Adverse Reporting System following COVID-19 vaccines (1 January to 24 June 2021), were assessed. The timing of headache onset post-vaccination in subjects with and without concomitant cerebrovascular events, including cerebral venous thrombosis, ischemic stroke, and intracranial haemorrhage was analysed. The diagnostic accuracy in predicting concurrent cerebrovascular events of the guideline- proposed threshold of three-days from vaccination to headache onset was evaluated. Results: There were 314,610 events following 306,907,697 COVID-19 vaccine doses, including 41,700 headaches, and 178/41,700 (0.4%) cerebrovascular events. The median time between the vaccination and the headache onset was shorter in isolated headache (1 day vs. 4 (in cerebral venous thrombosis), 3 (in ischemic stroke), or 10 (in intracranial hemorrhage) days, all P < 0.001). Delayed onset of headache had an area under the curve of 0.83 (95% CI: 0.75–0.97) for cerebral venous thrombosis, 0.70 (95% CI: 0.63–76) for ischemic stroke and 0.76 (95% CI: 0.67–84) for intracranial hemorrhage, and >99% negative predictive value. Conclusion: Headache following COVID-19 vaccination occurs within 1 day and is rarely associated with cerebrovascular events. Delayed onset of headache 3 days post-vaccination was an accurate diagnostic biomarker for the occurrence of a concomitant cerebrovascular events. [ABSTRACT FROM AUTHOR]

Intravenous (IV) thrombolysis is a safe and effective treatment for acute ischemic stroke. The therapeutic benefit is not extended to more than 4.5 hours in many patients due to the protocol’s time window restriction. Here, we reported two acute stroke cases with a moderate National Institutes of Health Stroke Scale (NIHSS) and onset greater than 4.5 hours that were successfully thrombolysed with intravenous recombinant tissue plasminogen activator (tPA) - low-dose Tenecteplase (TNK). The decision to thrombolysed both patients were based on Magnetic Resonance Imaging (MRI) Diffusion-weighted imaging (DWI)-Fluid Attenuation Inversion Recovery (FLAIR) mismatch – tissue basis rather than a time window, and this resulted in a good neurological recovery with a significant improvement in functional Modified Rankin Score (MRS) to zero at 90 days post stroke regardless of the stroke aetiology. In summary, Intravenous thrombolysis in acute ischemic stroke outside the therapeutic window but with significant penumbra based on MRI DWI-FLAIR tissue mismatch resulted in a remarkable neurological recovery after 90 days. [ABSTRACT FROM AUTHOR]

Mycoplasma pneumonia is an atypical bacterium that causes mild respiratory tract infections, especially in the upper respiratory system. Mycoplasma pneumoniae infection is infrequently associated with various CNS manifestations such as encephalitis, meningoencephalitis, myelitis, Guillain-Barre syndrome and acute disseminated encephalomyelitis (ADEM). Here we report a rare case of mycoplasma encephalitis in an adult who presented with a first episode of seizure following fever and neck stiffness for one week. Mycoplasma pneumoniae antibody titer was markedly elevated at >1:320 and MRI brain revealed encephalitic changes with a lesion in the splenium. Interestingly, there was no associated respiratory infection and his stay in the hospital was also complicated by SIADH. The patient improved after treatment with a macrolide antibiotic. [ABSTRACT FROM AUTHOR]

Introduction: Nonvalvular atrial fibrillation is a common cause of cardioembolic stroke which accounts around 50% of all cardioembolic emboli. Oral anticoagulants remain the main choice of stroke prevention in patients with atrial fibrillation. Our study is aimed to determine the safety (absence or presence of bleeding events) and efficacy (absence or presence of ischemic stroke occurrence) of dabigatran versus warfarin for stroke prevention in patients with nonvalvular atrial fibrillation. Methods: A retrospective audit study was conducted based on past data obtained from Electronic Hospital Information System (EHIS) records in Serdang Hospital. Our sample was 150 patients with nonvalvular atrial fibrillation who were at risk of getting stroke and being prescribed with oral anticoagulants either warfarin or dabigatran from the year 2013 until 2019. Results: Our study showed that there was lesser occurrence of ischemic stroke in patients from dabigatran group (1.3%) as compared to those in warfarin group (2.7%). There were also almost 2 times lesser bleeding events in dabigatran group (6.7%) as compared to those in warfarin group (14.7%). The median of CHA2DS2-VASc Score in warfarin sampled patients (median=3+/-1) was lower than dabig- atran sampled patients (median=4+/-1). Conclusion: Both warfarin and dabigatran are effective in preventing stroke for patients with nonvalvular atrial fibrillation. However, dabigatran is associated with lesser bleeding events with lower incidence of major bleeds compared to warfarin. [ABSTRACT FROM AUTHOR]

Background: Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community.Methods: This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms.Results: Out of 4096 respondents, 82.9-92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%CI 1.01-1.92), being Malay (OR 1.74, 95% CI 1.27-2.40), being non-smokers (OR = 2.491, 95% CI: 1.64-3.78), hypertensives (OR: 1.57, 95% CI: 1.02-2.42)and diabetics (OR: 2.54, 95% CI:1.38-4.69) are determinants of right actions to be taken during stroke. Meanwhile, respondents aged 45 years old and older (OR = 1.68, 95% CI: 1.39-2.03), being Malay (OR = 1.49, 95% CI: 1.24-1.79), hypertensive (OR = 1.32, 95% CI: 1.04-1.66) and those who had a previous history of stroke (OR = 2.25, 95% CI: 1.01-5.00) are determinants of good recognition of stroke symptoms.Conclusions: The overall knowledge of stroke in our study population was good. Older age, being Malay, non-smokers, hypertensives and diabetics are determinants of right actions to be taken during stroke. Meanwhile, older age, being Malay, hypertensive and those who had a previous history of stroke are determinants of good recognition of stroke symptoms. [ABSTRACT FROM AUTHOR]

Background: Gestational diabetes mellitus (GDM) is a of the major public health issues in Asia. The present study aimed to determine the prevalence of, and risk factors for GDM in Asia via a systematic review and meta-analysis.Methods: We systematically searched PubMed, Ovid, Scopus and ScienceDirect for observational studies in Asia from inception to August 2017. We selected cross sectional studies reporting the prevalence and risk factors for GDM. A random effects model was used to estimate the pooled prevalence of GDM and odds ratio (OR) with 95% confidence interval (CI).Results: Eighty-four studies with STROBE score ≥ 14 were included in our analysis. The pooled prevalence of GDM in Asia was 11.5% (95% CI 10.9-12.1). There was considerable heterogeneity (I2 > 95%) in the prevalence of GDM in Asia, which is likely due to differences in diagnostic criteria, screening methods and study setting. Meta-analysis demonstrated that the risk factors of GDM include history of previous GDM (OR 8.42, 95% CI 5.35-13.23); macrosomia (OR 4.41, 95% CI 3.09-6.31); and congenital anomalies (OR 4.25, 95% CI 1.52-11.88). Other risk factors include a BMI ≥25 kg/m2 (OR 3.27, 95% CI 2.81-3.80); pregnancy-induced hypertension (OR 3.20, 95% CI 2.19-4.68); family history of diabetes (OR 2.77, 2.22-3.47); history of stillbirth (OR 2.39, 95% CI 1.68-3.40); polycystic ovary syndrome (OR 2.33, 95% CI1.72-3.17); history of abortion (OR 2.25, 95% CI 1.54-3.29); age ≥ 25 (OR 2.17, 95% CI 1.96-2.41); multiparity ≥2 (OR 1.37, 95% CI 1.24-1.52); and history of preterm delivery (OR 1.93, 95% CI 1.21-3.07).Conclusion: We found a high prevalence of GDM among the Asian population. Asian women with common risk factors especially among those with history of previous GDM, congenital anomalies or macrosomia should receive additional attention from physician as high-risk cases for GDM in pregnancy.Trial Registration: PROSPERO (2017: CRD42017070104 ). [ABSTRACT FROM AUTHOR]

Peripheral neuropathy is a common cause for neurological consultation, especially among those with diabetes mellitus. However, research on peripheral neuropathy among the general population is lacking in Malaysia. This study aimed to determine the prevalence and factors associated with peripheral neuropathy in a setting of retail pharmacies. This cross-sectional study of 1283 participants was conducted at retail pharmacies in Selangor. Peripheral neuropathy was defined as the final score in the mild to severe category in the severity rating scale using a biothesiometer. SPSS version 26 was used to perform the analysis. Multiple logistic regressions were used to determine the factors associated with peripheral neuropathy. The prevalence of peripheral neuropathy based on the biothesiometer was 26.5%. According to multiple logistic regression, the predictors of peripheral neuropathy were those who have diabetes (AOR = 3.901), aged more than 50 years (AOR = 3.376), have secondary education or below (AOR = 2.330), are male (AOR = 1.816), and have underlying hypertension (AOR = 1.662). Peripheral neuropathy is a reasonably prevalent condition, affecting a quarter of the general population, and often goes undiagnosed. It is crucial for healthcare providers to proactively screen for peripheral neuropathy, particularly in high-risk populations, to prevent potential complications., Competing Interests: Authors are required to disclose financial or non-financial interests that are directly or indirectly related to the work submitted for publication., (Copyright: © 2024 Ching et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in atrial fibrillation. At the Asia Pacific Advancing Patient care with EdoXaban 2023 meeting, experts shared insights on gastrointestinal bleeding with NOACs for stroke prevention in atrial fibrillation in Asian clinical practice, where NOACs have gained widespread acceptance due to their favourable profiles. Gastrointestinal bleeding risk varies amongst NOACs, emphasizing the importance of diligent patient assessment, dosage selection and vigilant monitoring. Edoxaban emerged as a viable option with a low gastrointestinal bleeding risk profile in Asian compared with non-Asian patients, supporting its continued clinical utilization for appropriate patients., Competing Interests: Disclosure and potential conflicts of interest: RM is an employee of A. Menarini Asia Pacific Holdings Pte Ltd. All other authors declare no conflict of interest. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2024/07/dic.2024-5-5-COI.pdf, (Copyright © 2024 Diaz AB, Chow J, Hoo FK, Keong GLC, Venketasubramanian N, Rey N, Rogelio G, Mehta R.)

Patients with peripheral neuropathy could have damaged peripheral nerves, which leads to sensory and motor dysfunction. Diabetes, infections, and trauma are the major causes of peripheral neuropathy. Vibratory perception threshold (VPT) tools are commonly used to detect peripheral neuropathy. This study aims to determine the assessment of peripheral neuropathy through the different diagnostic tools in the community in Malaysia. A total number of 1283 participants were recruited from the seven retail pharmacies located in Selangor, Malaysia. The peripheral neuropathy test was conducted based on VPT tools on both feet using the digital biothesiometer. Following that, Neurological Symptom Score (NSS) and Neurological Disability Score (NDS) were taken from the participants to assess the neurological symptoms. Participants had an average age of 40.6 ± 12.9 years and were mostly of Chinese ethnicity (54.1%). The findings show that increasing age was associated with more severe peripheral neuropathy across the various assessment tools, but gender differences were found with the biothesiometer test and ethnicity has severity in the biothesiometer and disability scores. The sensitivity and specificity of the biothesiometer test were 0.63 and 0.84, respectively. The combined tool NSS and NDS had high specificity and a high positive predictive value, suggesting that it could be a reliable indicator of peripheral neuropathy when both scores are elevated. The findings show that the biothesiometer test, NSS, and NDS are considered screening VPT tools for diagnosing peripheral neuropathy. However, further evaluation and diagnostic testing are necessary in cases of a positive test result., Competing Interests: The authors declared that there are no conflicts of interest., (© 2024 Mooi, Lee, Yusof Khan, Devaraj, Cheong, Hoo et al., Licensee HBKU Press.)

Background: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe autoimmune encephalitis due to immune production of anti-NMDAR antibodies against the NR1 subunit of the NMDA receptor which is present throughout the central nervous system. This condition had been reported to be prevalent in patients with certain medical conditions; however so far, there have been limited systematic reviews and meta-analyses on the prevalence and factors associated., Objective: This study was to determine the prevalence and factors associated with anti-NMDAR encephalitis among affected patients., Material and Methods: The protocol of this study has been registered (2019: CRD42019142002) with the International Prospective Register of Systematic Reviews (PROSPERO). The primary outcome was the incidence or prevalence of anti-NMDAR encephalitis and secondary outcomes were factors associated with anti-NMDAR encephalitis., Results: There were 11 studies and a total of 873 million patients taken from high-risk populations across 11 countries that were included in the primary analysis. The overall pooled prevalence of anti-NMDAR encephalitis among patients with medical conditions was 7.0% (95% CI = 4.4, 9.6). Those with first episode of psychosis or schizophrenia were at a higher risk of developing anti-NMDAR encephalitis with an odds ratio of 5.976 (95% CI = 1.122, 31.825)., Conclusion: We found that almost one-tenth of patients with medical conditions had anti-NMDAR encephalitis; particularly those with first episode of psychosis or schizophrenia were among the high-risk medical conditions., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Background: Pre-existing neurological diseases have been identified as risk factors for severe COVID-19 infection and death. There is a lack of comprehensive literature review assessing the relationship between pre-existing neurological conditions and COVID-19 outcomes. Identification of high risk groups is critical for optimal treatment and care., Methods: A literature review was conducted for systematic reviews, meta-analyses, and scoping reviews published between January 1, 2020 and January 1, 2023. Literature assessing individuals with pre-existing neurological diseases and COVID-19 infection was included. Information regarding infection severity was extracted, and potential limitations were identified., Results: Thirty-nine articles met inclusion criteria, with data assessing >3 million patients from 51 countries. 26/51 (50.9%) of countries analyzed were classified as high income, while the remaining represented middle-low income countries (25/51; 49.0%). A majority of evidence focused on the impact of cerebrovascular disease (17/39; 43.5%) and dementia (5/39; 12.8%) on COVID-19 severity and mortality. 92.3% of the articles (36/39) suggested a significant association between neurological conditions and increased risk of severe COVID-19 and mortality. Cerebrovascular disease, dementia, Parkinson's disease, and epilepsy were associated with increased COVID severity and mortality., Conclusion: Pre-existing neurological diseases including cerebrovascular disease, Alzheimer's disease and other dementias, epilepsy, and Parkinson's disease are significant risk factors for severity of COVID-19 infection and mortality in the acute infectious period. Given that 61.5% (24/39) of the current evidence only includes data from 2020, further updated literature is crucial to identify the relationship between chronic neurological conditions and clinical characteristics of COVID-19 variants., (Copyright © 2023. Published by Elsevier B.V.)

Purpose: Vitamin D deficiency and insufficiency is common among populations globally, and in Asia and Malaysia. The purpose of this Position Paper is to propose recommendations for both clinicians and non-clinicians to promote vitamin D sufficiency in Malaysian adults. Formation of a national multisector, multidisciplinary alliance is also proposed to progress initiatives relating to safe sun exposure, adequate vitamin D intake through food fortification, and vitamin D supplementation for high-risk groups., Methods: Literature reviews were undertaken to inform summaries of the following: vitamin D status globally and in Asian and Malaysian populations, vitamin D status among individuals with common medical conditions, and current recommendations to achieve vitamin D sufficiency through sun exposure, food intake and supplementation. Recommendations were based on the findings of the literature reviews, recent European guidance on vitamin D supplementation, the 2018 road map for action on vitamin D in low- and middle-income countries, and research recommendations proposed by the Malaysian Ministry of Health in 2017., Results: Recommendations on assessment of vitamin D in the adult Malaysian population include using serum or plasma 25-hydroxyvitamin D concentration as a biomarker, widespread participation by Malaysian laboratories in the Vitamin D Standardization Program, adoption of the US Endocrine Society definitions of vitamin D deficiency and insufficiency, and development of a comprehensive nationwide vitamin D status study. Specific high-risk groups are identified for vitamin D assessment and recommendations relating to loading doses and ongoing management are also made., Conclusion: This Position Paper provides individual clinicians and national stakeholder organisations with clear recommendations to achieve vitamin D sufficiency in the adult population of Malaysia., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Edoxaban, a once-daily, direct-acting oral anticoagulant, is approved to prevent stroke or systemic embolism in non-valvular atrial fibrillation (NVAF) and treat venous thromboembolism. The clinical benefit of edoxaban for stroke prevention in Asian patients with NVAF has been demonstrated in clinical and real-world studies. We share early clinical experiences with once-daily edoxaban and discuss its evidence-based use in patients with NVAF in Southeast Asia through several cases of patients at high risk, including frail patients, elderly patients with multiple comorbidities and patients with increased bleeding risk. These cases demonstrate the effectiveness and safety of once-daily edoxaban in patients with NVAF in Southeast Asia., Competing Interests: Disclosure and potential conflicts of interest: ABD has received honoraria from Menarini Philippines for advisory board participation and from Pfizer as a speaker. KWK has received honoraria from Menarini, Boehringer and Bayer. WST has received honoraria for advisory board participation in Singapore for dabigatran, rivaroxaban, apixaban and edoxaban from Menarini, Boehringer Ingelheim, Bayer and Pfizer. CCW is a Steering Committee member of the Global ETNA-AF program and has received speaker honoraria from Bayer, Boehringer Ingelheim and Daiichi-Sankyo. NV, FKH, GL and JC have no conflicts of interest to disclose. RM is an employee of A. Menarini Asia-Pacific Pte. Ltd. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2023/08/dic.2023-3-3-COI.pdf, (Copyright © 2023 Diaz AB, Chow J, Hoo FK, Koh KW, Lee GCK, Teo WS, Venketasubramanian N, Wang C-C, Mehta R.)

Background and Aims: The corononavirus 2019 (COVID-19) pandemic resulted in modifications in the workflow and redistribution of human resources, causing challenges in setting up of an acute stroke service. We would like to share our preliminary outcome amid this pandemic, to determine if the implementation of COVID-19 standard operating procedures (SOPs) affected the delivery of our hyperacute stroke service., Methods: We retrospectively analyzed one-year data from our stroke registry that began with the establishment of our hyperacute stroke service at Universiti Putra Malaysia Teaching Hospital from April 2020 until May 2021., Results: Setting up acute stroke services during the pandemic with constrained manpower and implementation of COVID-19 SOPs, was challenging. There was a significant dip of stroke admission from April to June 2020 due to the Movement Control Order (MCO) implemented by the government to curb the spread of COVID-19. However, the numbers of stroke admission steadily rose approaching 2021, after the implementation of recovery MCO. We managed to treat 75 patients with hyperacute stroke interventions i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT) or both. Despite implementing COVID-19 SOPs and using magnetic resonance imaging (MRI) as our first line acute stroke imaging modality, clinical outcomes in our cohort were encouraging; almost 40% of patients who underwent hyperacute stroke treatment had early neurological recovery (ENR), and only 33% of patients had early neurological stability (ENS). In addition, we were able to maintain our door-to-imaging (DTI) and door-to-needle (DTN) time in line with international recommendations., Conclusions: Our data reflects that COVID-19 SOPs did not deter successful delivery of hyperacute stroke services in our center. However, bigger and multi center studies are required to support our findings., (© 2023. The Author(s).)

Dyslipidaemia is highly prevalent in the Malaysian population and is one of the main risk factors for atherosclerotic cardiovascular disease (ASCVD). Low-density lipoprotein cholesterol (LDL-C) is recognised as the primary target of lipid-lowering therapy to reduce the disease burden of ASCVD. Framingham General CV Risk Score has been validated in the Malaysian population for CV risk assessment. The Clinical Practice Guidelines (CPG) on the management of dyslipidaemia were last updated in 2017. Since its publication, several newer randomised clinical trials have been conducted with their results published in research articles and compared in meta-analysis. This underscores a need to update the previous guidelines to ensure good quality care and treatment for the patients. This review summarises the benefits of achieving LDL-C levels lower than the currently recommended target of < 1.8mmol/L without any safety concerns. In most high and very high-risk individuals, statins are the first line of therapy for dyslipidaemia management. However, certain high-risk individuals are not able to achieve the LDL-C goal as recommended in the guideline even with high-intensity statin therapy. In such individuals, lower LDL-C levels can be achieved by combining the statins with non-statin agents such as ezetimibe and PCSK9 inhibitors. Emerging non-statin lipid-lowering therapies and challenges in dyslipidaemia management are discussed in this article. The review also summarises the recent updates on local and international guidelines for dyslipidaemia management., Competing Interests: Conflict of Interest The authors have participated in Novartis initiated advisory board meeting for the discussion of dyslipidaemia management landscape in Malaysia and have received advisory board member honoraria., (© Penerbit Universiti Sains Malaysia, 2023.)

Objective: To evaluate the efficacy of high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex as a migraine prevention by conducting a systematic review and meta-analysis., Background: The efficacy of high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex as preventive migraine treatment remains debatable., Methods: PubMed, Scopus, CINAHL, CENTRAL, and BioMed Central databases were searched from their inception until December 2020. Randomised trials comparing high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex with sham for migraine prevention were included. The risk of bias was assessed using the Cochrane guidelines. Headache days, pain intensity, acute medication intake, and disability were extracted as study outcomes and the mean difference with a random-effects model was used to determine the effect size., Results: Meta-analysis revealed that high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex significantly reduced acute medication intake (Mean Difference = 9.78, p = 0.02, 95%CI: 1.60, 17.96, p = 0.02) and functional disability (Mean Difference = 8.00, p < 0.05, 95%CI: 4.21, 11.79). However, no differences were found in headache days and pain intensity reduction, although there was a slight trend favouring high-frequency repetitive transcranial magnetic stimulation., Conclusion: High-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex may be effective in reducing acute medication intake and disability. However, more studies are needed to strengthen this preliminary evidence.

Abstract: Recent advances in technology, particularly in the field of magnetic resonance imaging, have brought forth new sequences, including vessel wall imaging (VWI). Traditionally, the workup for intracranial vascular pathology has always turned to luminal imaging using computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Since its introduction, VWI has enabled researchers and practicing clinicians to better understand disease processes and manage patients to the best standard of care possible. Spontaneous recanalization in acute ischemic stroke (AIS) is a known but understudied phenomenon. Available literature has looked at this phenomenon and postulated the occurrence based on conventional cross-sectional imaging and angiography; however, objective evidence pointing to the occurrence of this phenomenon is scarce. We would like to share our experience using VWI in a patient who was clinically suspected to have a middle cerebral artery syndrome at onset, with resolution of the symptoms 3 hours after initial presentation. VWI showed vessel wall enhancement at the suspected vessel involved, with evidence of acute infarcts at the vascular territory supplied. A presumptive diagnosis of AIS with spontaneous recanalization was made. Our experience could potentially aid in the understanding of spontaneous recanalization in patients with AIS, particularly in the postulation of the pathophysiology., Competing Interests: The authors declare no conflicts of interest., (Copyright © Wolters Kluwer Health, Inc. All rights reserved.)

Background: Malaysians are disillusioned with the increased number of COVID-19 infection cases and the prolonged lockdown period. As a result of COVID-19 mitigation measurements, Malaysians are experiencing emotional and psychological consequences such as anxiety. Thus, there is an urgent need to have an instrument that could serve as a tool to assess the psychological impact of COVID-19 among Malaysians rapidly., Methods: This study aimed to adapt and validate the Malay version of the COVID-19 Anxiety Scale (M-CAS) among Malaysian adults. The back-to-back translation was done to produce a M-CAS. Following face validation, M-CAS was self-administered to 225 participants from Malaysia via an online survey. The participants also completed the Generalised Anxiety Disorder 7-item Scale (GAD-7), World Health Organization Quality of Life Scale, Abbreviated Version (WHOQOL-BREF) and the Fear of COVID-19 Scale (FCV-19S). Data analysis was conducted using Statistical Package for the Social Sciences and Analysis of a Moment Structures. The psychometric properties of the M-CAS were examined via Cronbach alpha and confirmatory factor analysis. M-CAS scores were compared with the other tools to provide external validity., Results: The statistical analysis revealed that the M-CAS demonstrated adequate internal consistency (Cronbach's alpha = 0.890) and presented with a unidimensional factor structure. M-CAS scores were strongly correlated with GAD-7 ( r = 0.511, P < 0.001) and FCV-19S ( r = 0.652, P < 0.001). Lack of correlation between M-CAS and WHOQOL-BREF showed that M-CAS scores did not reflect perceived quality of life., Conclusion: The M-CAS is a valid and reliable tool in the Malay language that can be self-administered among Malaysians to assess anxiety levels induced by COVID-19. The M-CAS has only 7 items and utilised little time in real-life clinical practice., Competing Interests: Conflict of Interest None., (© Penerbit Universiti Sains Malaysia, 2022.)

Background: Despite rapid advances in acute ischaemic stroke (AIS) management, many healthcare professionals (HCPs) might not be aware of the latest recommended management of AIS patients. Therefore, we aimed to determine the level and factors associated with AIS management knowledge among Malaysian HCPs., Methods: This cross-sectional online questionnaire study was conducted nationwide among 627 HCPs in Malaysia using the Acute Stroke Management Questionnaire (ASMaQ). Multiple logistic regression was used to predict the relationship between the independent variables (age, gender, years of service, profession, work setting, work sector, seeing stroke patients in daily practice, and working with specialists) and the outcome variable (good vs poor knowledge)., Results: Approximately 76% (95% CI [73-79%]) of HCPs had good overall knowledge of stroke. The highest proportion of HCPs with good knowledge was noted for General Stroke Knowledge (GSK) [88.5% (95% CI [86-91%])], followed by Advanced Stroke Management (ASM) [61.2% (95% CI [57-65%])] and Hyperacute Stroke Management (HSM) [58.1% (95% CI [54-62%])]. The odds of having poor knowledge of stroke were significantly higher among non-doctor HCPs [adjusted OR = 3.46 (95% CI [1.49-8.03]), P = 0.004]; among those not seeing stroke patients in daily practice [adjusted OR = 2.67 (95% CI [1.73-4.10]), P < 0.001]; and among those working without specialists [adjusted OR = 2.41 (95% CI [1.38-4.18]), P = 0.002]., Conclusions: Stroke education should be prioritised for HCPs with limited experience and guidance. All HCPs need to be up-to-date on the latest AIS management and be able to make a prompt referral to an appropriate facility. Therefore, more stroke patients will benefit from advanced stroke care., Competing Interests: The authors declare that they have no competing interests., (© 2022 Albart et al.)

Introduction: This study aimed to determine the prevalence and factors associated with female sexual dysfunction in an outpatient clinic in Malaysia., Methods: The study was conducted among female patients aged 50 years and older who attended the outpatient clinic of a public hospital in Malaysia. A self-administered questionnaire was used that was based on the Malay version of the Female Sexual Function Index questionnaire. The predictors of female sexual dysfunction were identified using multivariate logistic regression analysis., Results: A total of 263 females were recruited in this study, with a mean age of 60.6 ± 6.7 years. The distribution of the respondents' ethnicities was mostly Malay (42.2%), followed by Chinese (41.8%) and Indian (16.0%). The prevalence of female sexual dysfunction among participants was 68.8%. The prevalence of the subscales of female sexual dysfunction was as follows: desire (85.2%), satisfaction (74.9%), arousal (71.1%), lubrication (66.9%), pain (61.2%), and orgasm (60.8%). According to multivariate logistic regression, patients of Indian ethnicity had an increased risk of female sexual dysfunction (0R=16.60, 95% CI=2.54-108.63), and a higher frequency of sexual intercourse was correlated with a lower risk of female sexual dysfunction (0R=0.13, 95% CI=0.08-0.24)., Conclusion: Seven-tenths of the middle-aged female patients attending the outpatient clinic suffered from female sexual dysfunction. Indian ethnicity and having a lower frequency of sexual intercourse were predictors of female sexual dysfunction. Future intervention studies are needed to address this problem., (© Academy of Family Physicians of Malaysia.)

Background and Objectives: One year after the onset of the coronavirus disease 2019 (COVID-19) pandemic, we aimed to summarize the frequency of neurologic manifestations reported in patients with COVID-19 and to investigate the association of these manifestations with disease severity and mortality., Methods: We searched PubMed, Medline, Cochrane library, ClinicalTrials.gov, and EMBASE for studies from December 31, 2019, to December 15, 2020, enrolling consecutive patients with COVID-19 presenting with neurologic manifestations. Risk of bias was examined with the Joanna Briggs Institute scale. A random-effects meta-analysis was performed, and pooled prevalence and 95% confidence intervals (CIs) were calculated for neurologic manifestations. Odds ratio (ORs) and 95% CIs were calculated to determine the association of neurologic manifestations with disease severity and mortality. Presence of heterogeneity was assessed with I 2 , meta-regression, and subgroup analyses. Statistical analyses were conducted in R version 3.6.2., Results: Of 2,455 citations, 350 studies were included in this review, providing data on 145,721 patients with COVID-19, 89% of whom were hospitalized. Forty-one neurologic manifestations (24 symptoms and 17 diagnoses) were identified. Pooled prevalence of the most common neurologic symptoms included fatigue (32%), myalgia (20%), taste impairment (21%), smell impairment (19%), and headache (13%). A low risk of bias was observed in 85% of studies; studies with higher risk of bias yielded higher prevalence estimates. Stroke was the most common neurologic diagnosis (pooled prevalence 2%). In patients with COVID-19 ≥60 years of age, the pooled prevalence of acute confusion/delirium was 34%, and the presence of any neurologic manifestations in this age group was associated with mortality (OR 1.80, 95% CI 1.11-2.91)., Discussion: Up to one-third of patients with COVID-19 analyzed in this review experienced at least 1 neurologic manifestation. One in 50 patients experienced stroke. In those >60 years of age, more than one-third had acute confusion/delirium; the presence of neurologic manifestations in this group was associated with nearly a doubling of mortality. Results must be interpreted with the limitations of observational studies and associated bias in mind., Systematic Review Registration: PROSPERO CRD42020181867., (© 2021 American Academy of Neurology.)

Background: Transverse myelitis (TM) is a relatively uncommon condition, and vaccine-associated myelitis is even rarer. Concern regarding neurological complications following vaccination escalated following the report of TM during the safety and efficacy trials of the COVID-19 vaccine., Case Presentation: We report the first case of Longitudinal Extensive Transverse Myelitis (LETM) in Malaysia following administration of the chimpanzee adenovirus-vectored (ChAdOx1 nCoV-19) vaccine. A 25-year-old female presented with bilateral lower limb weakness and inability to walk with a sensory level up to T8 with absent visual symptoms. Urgent gadolinium-enhanced magnetic resonance imaging (MRI) of the spine showed long segment TM over the thoracic region. Cerebrospinal fluid autoantibodies for anti-aquaporin-4 and anti-myelin-oligodendrocyte were negative. A diagnosis of LETM following vaccination was made, and the patient was started on a high dose of intravenous methylprednisolone. The patient eventually made a recovery following treatment., Conclusion: LETM is a rare but serious adverse reaction following vaccination. Previously reported cases showed an onset of symptoms between 10 to 14 days post-vaccination, suggesting a delayed immunogenic reaction. However, the incidence of myelitis in COVID-19 is much more common, far greater than the risk associated with vaccination., (© 2021. The Author(s).)

Objectives: Non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) is a common problem associated with obesity and type 2 diabetes mellitus (T2DM). There have been anecdotal reports of the efficacy of sodium-glucose cotransporter 2 inhibitors (SGLT2Is) in improving liver function parameters in those with concomitant T2DM and NAFLD/NASH. We sought to systematically evaluate the evidence of SGLT2Is in improving liver function parameters in T2DM patients with NAFLD, considering the risks of random error based on trial sequential analysis (TSA). We also performed a meta-analysis based on a random-effects model., Methods: A systematic literature search was performed using the Medline, Cochrane, and Embase databases from inception to 20 October 2018. Primary outcome for meta-analyses was the changes in hepatic enzyme levels (alanine transaminase, aspartate transaminase, and gamma-glutamyl transpeptidase). We also performed a meta-analysis on changes in insulin resistance, glycemic, and lipid parameters using SGLT2Is as a secondary objective., Results: Eight eligible randomized controlled studies were eligible for analysis. Meta-analysis showed the efficacy of two SLT2Is, dapagliflozin, and canagliflozin in reducing these enzymes level. TSA showed that canagliflozin significantly reduced the gamma-glutamyl transpeptidase level by weighted mean difference (-5.474, 95% confidence interval (CI): -6.289??-4.659) compared to others comparators, and the evidence is conclusive. Dapagliflozin also had a statistically significant reduction in glycated hemoglobin, which is a parameter of glycemic control and homeostatic model assessment for insulin sensitivity (HOMA-IR), which is a parameter of insulin sensitivity by a weight mean difference, -0.732 (95% CI: -1.087??-0.378) and -0.804 (95% CI: -1.336??0.272), respectively., Conclusions: This study indicated that canagliflozin effectively improves liver function parameters among patients with diabetes, while dapagliflozin is more effective in improving glycemic indices and insulin sensitivity., (The OMJ is Published Bimonthly and Copyrighted 2021 by the OMSB.)

Background: The benefits of qigong for systolic and diastolic blood pressure (BP) reduction have been noted in previously published systematic reviews; however, the data on its effectiveness has been at best scarce. We aimed to update the evidence of qigong on blood pressure reduction after taking into consideration the risks of random error and reliability of data in the cumulative meta-analysis using trial sequential analysis (TSA)., Methods: Included trials were assessed using Cochrane risk of bias instrument. We performed meta-analysis with random-effects model and random errors were evaluated with TSA. We performed the search for the eligible randomized controlled trial (RCT) through Medline, Cinahl, Cochrane Central Register of Controlled Trials and also PubMed., Results: A total of 370 subjects sourced from seven eligible RCTs were entered into the analysis. The pooled results demonstrated the significant reduction with the use of qigong of the systolic blood pressure [weighted mean difference (WMD), - 10.66 mmHg (95% confidence interval (CI) = - 17.69,-3.62, p < 0.001] and diastolic BP [WMD, - 6.76 mmHg, 95% CI = - 12.22, - 1.30, p < 0.001] as compared to the control group., Conclusions: Significant reductions in BP is seen with the use of qigong as compared with the control group, suggesting that qigong may be used as a complementary therapy in the somewhat complicated management of hypertension.

Background: This is a phase II randomised, double-blind, sham-controlled trial to evaluate the effectiveness and tolerability of repetitive transcranial magnetic stimulation for preventive treatment of episodic migraine amongst migraine subjects., Methods: Subjects age 18 to 60 years will undergo a baseline evaluation to establish the diagnosis of migraine based on the International Classification of Headache Disorder 3rd Edition (ICHD-3). Those who fulfil the ICHD-3 criteria for episodic migraine and compliant to the headache diary during a month run-in period will be enrolled. A total of 76 subjects will be randomised to receive either transcranial magnetic stimulation or sham stimulation for 5 sessions within 2 weeks duration. Follow-up sessions will be conducted monthly for three consecutive months. Prior to treatment, subjects will be required to fill up questionnaires and undergo few procedures such as electroencephalography, transcranial Doppler ultrasound and biochemical analysis for serum serotonin, serum calcitonin gene-related peptide and serum beta-endorphin. These procedures will be repeated at month 3 after receiving the last treatment. The primary outcome measure of this study is the difference in mean monthly migraine days at baseline and at months 1, 2 and 3 after treatment sessions., Discussion: Following evidence from previous studies showing restoration of dorsolateral prefrontal cortex (DLPFC) activation to almost normal level, the rTMS intervention will target left DLPFC in this study. An intermediate duration of treatment sessions is selected for this study. It is set to five treatment sessions given within 2 weeks duration., Trial Registration: ClinicalTrials.gov NCT03556722 . Registered on 14 June 2018.

Purpose: This study aimed to identify factors associated with poor-to-moderate quality of life (QOL) among women with gestational diabetes mellitus (GDM) in two tertiary hospitals in Malaysia., Methods: A cross-sectional study was conducted among 526 pregnant women with GDM in two tertiary hospitals in Malaysia. Diabetes-related QOL was assessed using the Asian Diabetes Quality of Life Scale (AsianDQoL). Socio-demographic characteristics, glucose monitoring treatments for GDM, past obstetric history, concurrent medical problems and a family history of diseases were captured from patient records. A multiple logistic regression was used for analysis., Results: A total of 526 respondents with GDM entered the analysis. The median age of the respondents was 32 (interquartile range = 7) while 82.3% were Malay women. More than half of the respondents (69.5%) received an oral hypoglycaemic agent (OHA), and/or diet modification in controlling their GDM. The study reported that 23.2% of the respondents had poor-to-moderate QOL. Those with a family history of depression and/or anxiety (adjusted Odds ratio [AOR] 6.934, 95% confidence interval [CI] 2.280-21.081), and a family history of GDM (AOR 1.814, 95% CI 1.185-2.778) were at higher odds of suffering from poor-to-moderate QOL compared to those without a family history. Similarly, those who received insulin, with or without OHA, and/or are on diet modification (AOR 1.955, 95% CI 1.243-3.074) were at higher odds of suffering from poor-to-moderate QOL compared to those receiving OHA and/or diet modification., Conclusion: Nearly one-quarter of Malaysian women with GDM have poor-to-moderate QOL. GDM women with a family history of depression and/or anxiety, family history of GDM, and those who received insulin, with or without OHA, and/or are on diet modification were associated with poor-to-moderate QOL., Trial Registration: NMRR-17-2264-37814.

Background: This study was initiated to examine the psychometric components of the Diabetes Empowerment Scale (DES) by translating and validating the scale into the Malay language (DES-M) which is the main language spoken in Malaysia. This study can determine the level of empowerment among diabetic patients towards diabetes management. In addition, the reliability and validity of the DES-M was also demonstrated., Methods: A total of 151 patients with type 2 diabetes mellitus were recruited (between June 2016 and October 2016) to complete sets of questionnaires, which were DES-M, the Malay versions of the Diabetes Quality of Life (DQOL) for Adults and Summary of Diabetes Self Care Activities Questionnaire (SDSCA). Confirmatory and Exploratory factor analysis (CFA and EFA) were carried out to determine the factor structures of the DES-M., Results: There were 100 males and 51 females with ages ranging from 19 to 81 years old (55 ± 13) included in this study. The instrument displayed good internal consistency (Cronbach's α =0.920) and the respective coefficients ranged from 0.65-0.84. Discriminant validity showed adequate correlations ranged from 0.257-0.744. Concurrent validity with SDSCA (Pearson's correlation = 0.313, p = 0.012). Predictive validity with DQOL (B = 0.27, p = 0.016). CFA indicated that four factor model of the DES-M has good fit to the data., Conclusion: This study indicates that the DES-M has a good internal consistency and validity. Therefore, it is a valid and reliable instrument for assessing empowerment score among patients with diabetes in Malaysia., Trial Registration: NMRR-16-805-30503 (IIR).

Objective: Prevalence of depression, anxiety and stress symptoms in gestational diabetes mellitus ranges from 10.2% to 39.9% based on previous studies in Malaysia. Presence of depression, anxiety or stress in pregnancy may increase the risk of neonatal morbidity and mortality. The aim of this study was to determine the prevalence of neonatal outcomes and its association among mothers with gestational diabetes mellitus with and without the presence of depression, anxiety and stress symptoms in Malaysia., Design: This was a cross-sectional study., Setting: Tertiary hospitals in Malaysia., Participants: Mothers with gestational diabetes mellitus (n = 418) who deliver their neonates at two major tertiary hospitals in Malaysia., Measurements: Neonatal outcomes, such as low birth weight, preterm birth, macrosomia, metabolic and electrolyte disorders, neonatal respiratory distress and congenital anomalies were determined., Findings: Prevalence of low birth weight in neonates born to mothers with gestational diabetes mellitus was 14.6%, followed by metabolic and electrolyte disorders 10.5%, preterm birth 9.1%, macrosomia 4.8%, neonatal respiratory distress 5.8% and congenital anomalies (2.4%). Among the adverse neonatal outcomes, neonatal respiratory distress was significantly associated with the presence of depression symptoms in mothers with gestational diabetes mellitus using univariate analysis (p = 0.010). After controlling for confounding factors, predictors for neonatal respiratory distress at delivery were the presence of depression symptoms in mothers with gestational diabetes mellitus (Adjusted OR = 3.87, 95% CI = 1.32-11.35), living without a husband (Adjusted OR = 9.74, 95% CI = 2.04-46.51), preterm delivery (Adjusted OR = 7.20, 95% CI = 2.23-23.30), caesarean section (Adjusted OR = 3.33, 95% CI = 1.09-10.15), being nulliparous and primiparous (Adjusted OR = 3.62, 95% CI = 1.17-11.17) and having family history of diabetes (Adjusted OR = 3.20, 95% CI = 1.11-9.21)., Key Conclusions: The findings of this study demonstrate the positive association of neonatal respiratory distress with the presence of depression symptoms in mothers with gestational diabetes mellitus., Implications for Practice: It is therefore important to identify depression symptoms after a diagnosis of gestational diabetes mellitus in pregnant mothers is made to enable early referral and interventions., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Research on antenatal depressive, anxiety and stress symptoms among women with gestational diabetes mellitus (GDM) is lacking in Malaysia. This study aimed to determine the prevalence and factors associated with antenatal depressive, anxiety and stress symptoms among Malaysian women with GDM., Methods: This was a descriptive, cross-sectional study of 526 women with GDM. Depressive, anxiety and stress symptoms are defined as the final score in mild to extremely severe risk in the severity rating scale. Data analysis was performed using SPSS v.21, while multiple logistic regression was used to identify predictors of depressive, anxiety and stress symptoms., Results: Prevalence of anxiety symptoms was highest (39.9%), followed by depressive symptoms (12.5%) and stress symptoms (10.6%) among women with GDM. According to multiple logistic regression analyses, younger age (OR = 0.955, 95% CI = 0.919-0.993), comorbidity with asthma (OR = 2.436, 95% CI = 1.219-4.870) and a family history of depression and anxiety (OR = 4.782, 95% CI = 1.281-17.853) had significant associations with antenatal anxiety symptoms. Being non-Muslim (OR = 2.937, 95% CI = 1.434-6.018) and having a family history of depression and anxiety (OR = 4.706, 95% CI = 1.362-16.254) had significant associations with antenatal depressive symptoms. Furthermore, being non-Muslim (OR = 2.451, 95% CI = 1.273-4.718) had a significant association with antenatal stress symptoms., Conclusions: Within a population of women with GDM in Malaysia, those at higher risk of having depressive, anxiety and stress symptoms can be identified from several baseline clinical characteristics. Clinicians should be more alert so that the high-risk patients can be referred earlier for further intervention.

Onchocerciasis and lymphatic filariasis (LF) are human filarial diseases belonging to the group of neglected tropical diseases, leading to permanent and long-term disability in infected individuals in the endemic countries such as Africa and India. Microfilaricidal drugs such as ivermectin and albendazole have been used as the standard therapy in filariasis, although their efficacy in eliminating the diseases is not fully established. Anti-Wolbachia therapy employs antibiotics and is a promising approach showing potent macrofilaricidal activity and also prevents embryogenesis. This has translated to clinical benefits resulting in successful eradication of microfilarial burden, thus averting the risk of adverse events from target species as well as those due to co-infection with loiasis. Doxycycline shows potential as an anti-Wolbachia treatment, leading to the death of adult parasitic worms. It is readily available, cheap and safe to use in adult non-pregnant patients. Besides doxycycline, several other potential antibiotics are also being investigated for the treatment of LF and onchocerciasis. This review aims to discuss and summarise recent developments in the use of anti-Wolbachia drugs to treat onchocerciasis and LF., Competing Interests: None

Background: The association of HTRA1 rs11200638 and ARMS2 rs10490924 gene polymorphisms with response to intravitreal ranibizumab therapy among neovascular AMD (nAMD) subjects in Malaysia was determined in this study, followed by the expression of HTRA1 and ARMS2 genes., Results: Both single nucleotide polymorphisms (SNPs) recorded a significant association between nAMD and controls with HTRA1 rs11200638 at P = 0.018 (OR = 1.52, 95% CI = 1.07-215) and ARMS2 rs10490924 at P < 0.001 (OR = 2.44, 95% CI = 1.75-3.42). An association was also observed in response to ranibizumab for both SNPs in a logistic regression analysis (P < 0.001). The mRNA levels in the HTRA1 variant between responder and non-responder groups were significantly different for the homozygous non-risk GG genotype (P = 0.032)., Conclusions: The HTRA1 rs11200638 and ARMS2 rs10490924 gene polymorphisms are associated with nAMD among Malaysians. Both gene polymorphisms were also correlated with response to intravitreal ranibizumab therapy based on visual and anatomical outcomes especially the HTRA1 rs11200638 variant.

Aim: To describe the prevalence and changes in treatment patterns of ranibizumab and photodynamic therapy (PDT) among retinal disease patients who attended the Ophthalmology Clinic in the tertiary care Hospital Selayang from 2010 to 2014., Methods: Study subjects were recruited retrospectively using the Electronic Medical Record (EMR) database software in Hospital Selayang. Demographic data, medical history, diagnostic procedure, treatments and diagnosis of patients were recorded., Results: The five-year analysis included 821 patients with a mean age of 65.9±11.73y. Overall, there were a higher number of males (63.1%) and a higher number of Chinese (47.4%) patients. Among the 821 patients, 62.9% received ranibizumab injection followed by 19.2% PDT therapy and 17.9% had ranibizumab combined with PDT therapy. Age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) were the most common retinal eye diseases reported, recording prevalence of 25.0% and 45.6%, respectively. The trend in ranibizumab treatment was reported to increase while PDT showed a decrease in trend from year 2010 to 2014. In terms of treatment, following multiple logistic regression, AMD was associated with the subjects being more likely to have received ranibizumab monotherapy ( P <0.001) while PCV was associated with more likely to have received PDT ( P <0.001) and PDT combined with ranibizumab therapy ( P <0.001)., Conclusion: The tertiary care setting in Malaysia is consistent with management of patients from other countries whereby ranibizumab is the most common treatment given to patients with AMD, while PCV patients most commonly receive PDT and ranibizumab combined with PDT therapy.

Dengue is the most common arboviral disease affecting many countries worldwide. An RNA virus from the flaviviridae family, dengue has four antigenically distinct serotypes (DEN-1-DEN-4). Neurological involvement in dengue can be classified into dengue encephalopathy immune-mediated syndromes, encephalitis, neuromuscular or dengue muscle dysfunction and neuro-ophthalmic involvement. Acute disseminated encephalomyelitis (ADEM) is an immune mediated acute demyelinating disorder of the central nervous system following recent infection or vaccination. This monophasic illness is characterised by multifocal white matter involvement. Many dengue studies and case reports have linked ADEM with dengue virus infection but the association is still not clear. Therefore, this article is to review and discuss concerning ADEM in dengue as an immune-medicated neurological complication; and the management strategy required based on recent literature., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background and Objective: Acute coronary syndrome (ACS) is one of the leading cause of morbidity and mortality worldwide. It is relatively uncommon in young adults as compared to the older population. Our objective was to assess the prevalence, demographic distribution, and risk factors for acute coronary syndrome (ACS) in patients less than 45 years of age admitted to a Malaysian tertiary care centre., Methods: This is a cross-sectional, retrospective, and single centre study with random sampling of the patients admitted for ACS to hospital from January 2005 to December 2013. Data were collected and analyzed. Patients less than 45 years of age were compared with patients more than 45 years of age., Result: A total of 628 patients were included in the study and with the prevalence of young ACS was 6.1% and mean age of 39±6 years. All the young ACS patients were diagnosed with unstable angina and non-ST elevation myocardial infarction (NSTEMI). Tobacco smoking and family history of coronary artery disease (CAD) were more frequent in young ACS. 59.5% of the young ACS patients were smokers, while 37.8% and 51.4% of them were found to suffer from diabetes mellitus and hypertension respectively. Tobacco smoking, diabetes mellitus, and hypertension had shown significant association with the onset of young ACS (p ≤ 0.05)., Conclusion: Three leading risk factors (tobacco smoking, diabetes mellitus, and hypertension) had been shown to be significantly associated with the onset of young ACS. Thus, it is important to identify this cohort and implement aggressive measures in tackling the risk factors in order to prevent or halt the development of coronary artery disease., Competing Interests: Declaration of interest: The authors declare that they have no competing interests.

Backgrounds & Objective: Antimicrobial resistance is an alarming public health threat that requires urgent global solution. Implementation of antimicrobial stewardship program (ASP) is an essential practice element for healthcare institutions in gate-keeping judicious antimicrobial use. This study highlighted the development, first year experience, and result of the implementation of ASP utilizing persuasive and restrictive approaches in a Malaysian district hospital., Methods: An observational study was conducted between January 2015 to December 2015 on implementation of ASP among hospitalized inpatients age 12 years old and above., Results: Recommendations were provided for 60% of cases (110 patients) with the average acceptance rate of 83.33%. Majority of the interventions were to stop the antimicrobial therapy (30.3%), and the most common audited antimicrobials was Piperacillin/Tazobactam (25.5%), followed by Meropenem (11.82%), Amoxicillin/Clavulanate and Vancomycin (8.18%) respectively. The concordance rate towards authorization policy was increased in 2015 (71.59% of cases) as compared before the implementation of ASP in 2014 (60.6% of cases). Restrictive enforcement under ASP had been shown to improve significantly adherence rate towards antimicrobials authorization policy (p-value: 0.004)., Conclusion: ASP was successfully implemented in a district hospital. Future studies on its clinical outcomes are important to evaluate its effectiveness as well as focus on the improvement to the pre-existing strategies and measures.

Post stroke hyperglycaemia (PSH) is prevalent in acute ischaemic stroke (AIS) patients and it has been associated with a dismal outcome of death and disability. Insulin has been proven to attenuate glucose effectively in stroke patients, thus many trials over the years had studied the efficacy of intensive treatment aiming at normalization of blood sugar level in order to improve the bleak outcomes of PSH. However, tight glycaemic control failed to be translated into clinical benefits and the outcomes are no different from the conventional approach, despite the costly healthcare expenditure invested. On the contrary, it brings more significant harm than the intended benefit, as 1 in every 9 treated patients had symptomatic hypoglycaemia. Thus, the benefits of tight glucose control, if any, are overshadowed by this potential risk of hypoglycaemia causing permanent neurological injury. Therefore, international practice guidelines recommend for less aggressive treatment to maintain blood glucose level within an appropriate range in AIS patients. However, there are limited details for stroke-specific glycaemic management and this made management of PSH particularly difficult. This review is to discuss and provide suggestions concerning glycaemic control in acute ischaemic stroke; the direction of its future prospective clinical trials and the treatment strategy required based on recent literature.

Generally, clinical presentations of Graves' disease range from asymptomatic disease to overt symptomatic hyperthyroidism with heat intolerance, tremor, palpitation, weight loss, and increased appetite. However, atypical presentation of Graves' disease with hematological system involvement, notably pancytopenia, is distinctly uncommon. Hereby, we present and discuss a series of three untreated cases of Graves' disease clinically presented with pancytopenia and the hematological abnormalities that responded well to anti-thyroid treatment. With resolution of the thyrotoxic state, the hematological parameters improved simultaneously. Thus, it is crucial that anti-thyroid treatment be considered in patients with Graves' disease and pancytopenia after a thorough hematological evaluation.