University Malaya Medical Centre Research Articles

A-204 Commitment to Sustainability From Laboratory Medicine

Abstract Background According to McGill University, sustainability means “meeting our needs without compromising the ability of future generations to meet their own needs”. Sustainable environmental practices improve water and air quality, reduce landfills, and increase renewable energy sources in the long term. In response to the growing urgency of global sustainability challenges, the healthcare industry is taking a step forward to reduce its environmental impact. University of Malaya Medical Centre (UMMC) is a government-funded teaching hospital and medical institution, which processes about 3.95 million chemistry and 371,000 immunoassay tests per year. This study aims to evaluate the sustainability aspects of Atellica Solution, focusing on water usage, power consumption, carbon dioxide emissions and plastic waste generations. Methods Power and water consumption for the analysers Advia Chemistry 2400 & XPT and Advia Centaur XPT were obtained from Atellica Solution using the year 2022 test volumes and compared with those of Siemens legacy system for the year 2019 test volumes. In addition, the reduction of plastic usage was also assessed for the year 2019 and 2022. Results With innovative Atellica Solution replacing Siemens legacy system, the data showed reduction in water and energy consumption by 36.44% and 47.74% respectively, whereas the annual throughput increased by 13.7%. By using Atellica INTELIQ QC management, fewer aliquot tubes were used and thus plastic waste was reduced by 168 kg. These reductions combined to lower CO2 emissions by about 16 tons. Conclusions Atellica Solution is designed for high throughput and sustainability, reducing water and energy consumption while also significantly reducing CO2 emissions. Furthermore, it enables faster, streamlined quality control management with Atellica INTELIQ QC management system. UMMC is strongly committed to minimizing laboratories’ environmental footprint and provide better access to care eventually contributing to the well-being of patients.

ECG Risk Score Model to Predict SCD in HFrEF: Retrospective Review in a Tertiary Centre

INTRODUCTION: Heart failure with reduced ejection fraction (HFrEF) patients need to be risk stratify as guidelines have shown that patients with left ventricularejection fraction (LVEF) <35% could be prevented from sudden cardiac death (SCD) by insertion of prophylactic implantable cardioverter-defibrillator (ICD). Thus we conducted a retrospective single tertiary centre study to evaluate the used of electrocardiogram (ECG) risk score model in identifying the individuals who at higher risk of SCD. MATERIALS AND METHODS: A total of 356 heart failure with reduced ejection fraction (HFrEF) patients treated at University Malaya Medical Centre between January 2017 and December 2021 were enrolled into this study. The patients’ demographics, types of heart failure, medications, and ECG parameters data were collected. The study outcomes were survivor or death in and the cause of death were subdivided into SCD or non-sudden cardiac death (non-SCD). RESULTS: A total of 156 study patients were survivor whereas another 120 had SCD and 70 had non-SCD. There were six ECG parameters that remained significant in the final model, namely the bundle branch block (BBB), abnormal P waves, QRS duration, QTc duration, TpTe interval and PR interval. The significant ECG parameters were combined into a risk score to enumerate prediction ability towards SCD. From our ECG risk score model, subject with ≥2 ECG abnormalities had more than 3-fold increased risk for SCD (HR 3.739, 95% CI 1.703-8.211, P 0.001) and the risk proportionately increased with increasing ECG abnormalities. CONCLUSION: Our findings suggested that the cumulative ECG risk score model was independently associated with SCD and particularly effective for LVEF <40% where risk stratification model remained scarce. So, we would like to propose for a prospective study to further evaluate our study outcome.

Incidence and risk factors of cognitive impairment in COVID-19 survivors within the first six months and its association with functional outcome

Background & Objective: There is growing evidence of cognitive decline post-COVID-19, even in mild infection. We aim to evaluate the incidence of cognitive impairment, domains affected, its risk factors and the effect on function during the subacute period when rehabilitation is crucial. Methods: In this study, the incidence of impaired cognition was assessed in patients at 3 and 6 months post-COVID-19 infection between August 2021 and July 2022 at University Malaya Medical Center, with Montreal Cognitive Assessment (MoCA). The most common cognitive domains affected were identified with descriptive analysis. Associated sociodemographic and clinical factors were analyzed with simple and multiple logistic regression models. The post-COVID-19 Functional Scale (PCFS) was used to assess functional status. The correlation between cognition (MoCA score) and functional status (PCFS scale) was performed using Spearman correlation test. Results: We recruited 100 patients and found that 44% had impaired cognition at three months and 43% at six months. Patients with secondary education level (p =0.001, OR 13.541), oxygen therapy (p=0.039, OR 7.811), and obesity (p=0.029, OR 4.764) were associated with a higher risk of impaired cognition. The most affected MoCA domains were language, executive function, attention and memory. Lower MoCA score was correlated with higher PCFS grade (lower functional status) (p <0.001, ρ -0.729). Conclusion: Post-COVID-19 cognitive impairments were common up to 6 months of illness and affect function. Clinicians are advised to perform cognitive screening especially in higher risk patients and provide necessary interventions.

The use of prophylactic infusion of calcium gluconate compared to placebo in reducing the rate of early hypocalcaemia after total thyroidectomy: a double-blinded, randomized controlled trial.

Hypocalcaemia as a common complication after total thyroidectomy [23-40% in University Malaya Medical Centre (UMMC)] and could result in prolonged hospital stay. We compared the early hypocalcaemia rate between prophylactic infusion of calcium and placebo among post total thyroidectomy patients and to establish whether prophylactic intravenous infusion of calcium reduces the rate of hypocalcaemia in the first 48 hours after surgery. Patients undergoing elective total thyroidectomy in UMMC between June 2020-May 2022, were recruited and randomized to receive placebo or prophylactic calcium infusion. Both groups of patients received same dosages of post-operative prophylactic vitamin D and oral calcium. Early hypocalcaemia (within 48 hours) rate after surgery was the primary outcome and duration of hospital stay was the secondary outcome. The data collected was analysed using per-protocol analysis. Thirty-four patients were randomized equally (1:1) into both arms. No differences in the early hypocalcaemia rate between the intervention and placebo arms (0% vs. 5.8%, P>0.05). The median serum calcium levels were comparable between the intervention and placebo arms at 6 hours (2.33 vs. 2.37 mmol/L, P=0.59) and 48 hours (2.26 vs. 2.23 mmol/L, P=0.19) post-surgery. However, the median serum calcium level at 24 hours was statistically significantly higher in the intervention arm than the placebo arm (2.31 vs. 2.22 mmol/L, P=0.02). Similar duration of hospital stay between the both groups (2 vs. 2 days, P=0.81). Routine prophylactic calcium infusion with oral calcium and vitamin D does not diminish the rate of early symptomatic hypocalcaemia post total thyroidectomy in a low-risk group. However, its usefulness needs to be further assessed in a large scale randomized controlled trial (RCT) incorporating more bigger population. Registered on ClinicalTrials.gov (NCT04491357).

295 University Malaya Medical Centre experience using VMAT for total body irradiation

295 University Malaya Medical Centre experience using VMAT for total body irradiation

281 Radiotherapy for localised prostate cancer: University Malaya Medical Centre experience

281 Radiotherapy for localised prostate cancer: University Malaya Medical Centre experience

Mindful breathing for cancer pain: efficacy of a single 20-minute session – a randomised controlled study

ObjectivesCancer pain is a prevalent and challenging symptom affecting a significant number of patients globally, with inadequate control remaining a substantial challenge despite advancements in pain management. Non-pharmacological interventions, including...

Sexual activity, vaginal symptoms, maternal perineal hygiene behavior, and constipation on ano-vaginal colonization of group B streptococcus in near term pregnancy

BackgroundMaternal Group B Streptococcus (GBS) colonization is influenced by many factors but results are inconsistent. Consideration of antenatal risk factors may help inform decision making on GBS microbiological culture screening where universal screening is not standard of care. We sought to identify independent predictors of GBS colonization at 34–37 weeks gestation incorporating vaginal symptoms, perineal hygiene measures, sexual activity, and a potential novel factor, constipation.MethodsIn this prospective cross-sectional study, 573 women at 34–37 weeks gestation had an ano-vaginal swab taken and sent for selective culture for GBS. Women were asked about vaginal bleeding, discharge, irritation and candidiasis, antibiotic use during pregnancy, ano-vaginal hygiene practices such as douching and perineal cleansing after toileting, sexual intercourse related activities, and a potential novel factor for GBS carriage, constipation. Maternal basic demographics and obstetric-related characteristics were also collected. Bivariate analyses were performed to identify associates of GBS colonization. All variables with p < 0.05 found on bivariate analysis were then included into a model for multivariable binary logistic regression analysis to identify independent risk factors for GBS colonization.ResultsGBS colonization was found in 235/573 (41.0%) of participants. Twenty six independent variables were considered for bivariate analysis. Eight were found to have p < 0.05. Following adjusted analysis, six independent predictors of GBS colonization were identified: ethnicity, previous neonatal GBS prophylaxis, antenatal vaginal irritation, antibiotic use, recent panty liner use, and frequency of sexual intercourse. Vaginal discharge and perineal cleansing were not associated after adjustment. Recent douching and constipation were not associated on bivariate analysis.ConclusionThe identification of independent predictors of GBS colonization in late pregnancy may inform the woman and care provider in their shared decision making for microbiological screening at 35–38 weeks gestation in locations where universal GBS screening is not standard of care.Ethics oversightThis study was approved by the Medical Ethics Committee of University Malaya Medical Centre (UMMC) on August 9, 2022, reference number 2022328-11120.

Skull Base Osteomyelitis: A 5-Year Review and Prognostic Outcome in a Single Tertiary Institution.

The primary objective of this study is to review the clinical parameters associated with skull base osteomyelitis (SBO), with a secondary aim of studying their association with patient outcomes 1 and 6 months after treatment initiation. This is a single-center restrospective observational study. The study was conducted from January 2018 to December 2022 at the University Malaya Medical Center in Kuala Lumpur. Patients aged over 15 years with a diagnosis of SBO were included in the study. Clinical parameters, investigations, and follow-up records were recorded. The disease outcomes were analyzed at 1 and 6 months after treatment initiation using multivariable analyses. The study identified 31 patients with SBO, the majority of whom were elderly males with comorbidities such as diabetes and hypertension. Otalgia and otorrhea were the most common symptoms, and computed tomographyscans were used for diagnosis. Pseudomonas aeruginosa was the most commonly identified pathogen, and intravenous broad-spectrum antimicrobials were used to treat all patients. Surgical intervention was required for 25% of patients, and underlying ischemic heart disease, anemia, and single nerve palsy were significantly associated with an unfavorable prognosis. Patients with higher body mass indexand elevated C-reactive protein showed poorer outcomes after 1 and 6 months of treatment, respectively. Early recognition, prompt treatment, better control of comorbidities, nutrition, and monitoring can improve SBO outcomes and reduce complications. Therefore, as the prevalence of SBO increases, diagnostic criteria or management guidelines should be established to guide the best clinical practice.

Is There a Relationship Between Damage-Associated Molecular Patterns (DAMPs) And Colorectal Cancer?

Objectives: Interleukin 1 α (IL-1α) and High Mobility Group Box 1 (HMGB1) are damage-associated molecular patterns (DAMPs), which have been associated with cancer progression by promoting proliferation, angiogenesis, invasion, and metastasis. This study aimed to determine the expression of IL-1α and HMGB1 in CRC tumours compared to their normal tissue adjacent to tumour (NAT) in CRC patients and their relationship with clinicopathological features. Methods: Ethics approval was obtained from Medical Research Ethics Committee University of Malaya Medical Centre (UMMC). 40 adult patients who underwent CRC tumour resection were recruited. Important clinical information was noted from the patient’s medical records. DAMPs expression levels in tumour and NAT samples were determined based on the percentage of area stained using immunohistochemistry (IHC). Images were analysed using Image J software and subjected to statistical analysis testing for comparison and correlations. Results: 20 male and 20 female patients were recruited with a mean age of 67.93 ± 1.697 years. Patients presented with stage I, 11, III and IV were 11 (27.5%), 11 (27.5%), 16 (40%) and 2 (5%) respectively. Stage IV subjects were excluded from analysis due to low numbers. IL-1α and HMGB1 were significantly higher in tumour samples when compared to NAT, with IL-1α in tumour 17.29% ± 1.685% and 8.326% ± 0.994% in NAT (p &lt; 0.0001), and HMGB1 expressions being 0.04% ± 2.383% in tumour and 22.95% ± 1.848% in NAT (p = 0.0213). A significant difference and positive correlation were observed in the levels of HMGB1 with disease staging (p = 0.0461, r = 0.344). No significant correlations were found with other clinicopathological features. Conclusion: Higher levels of DAMPS in tumour tissues and higher levels of HMGB1are correlated with more advanced disease staging could serve as potential diagnostic and prognostic markers for CRC. This work was supported by UMSC Care Grant PV017-2020.International Journal of Human and Health Sciences Supplementary Issue 01: 2024 Page: S52

Abnormalities Detection in Apert Syndrome using Hierarchical Clustering Algorithms

Craniosynostosis syndrome is a congenital condition occurring due to the abnormal development of the skull, leading to abnormalities in skull morphology. Apert syndrome is one of common craniosynostosis syndrome in Malaysia and this syndrome can be categorized as the severe craniofacial disorders. The abnormalities of skull morphological in Apert syndrome patient can be identified as outliers which are investigated in this study. This study presents a skull morphological analysis based on a case study involving six paediatric patients diagnosed with Apert syndrome, alongside 22 control patients aged 0 to 12 years, all of whom underwent treatment at the University Malaya Medical Centre (UMMC). The computerized tomography scan (CTSCAN) data is provided by UMMC recorded from year 2012 until 2020 and the data is measured using MIMICS software by taking the measurement of cranial angles. The clustering-based procedures will be applied to identify the abnormalities in skull angle dataset. There are 12 skull angles and these angles are analysed using hierarchical clustering algorithms for identifying the outliers or abnormalities. The objective is to detect the abnormalities and determine the skull angles that associated with Apert syndrome (AS) in Malaysia population using clustering-based procedure. The abnormalities in Apert syndrome datasets are successfully detected by the algorithms and this study found that there are skull angles with specific location of angles are associated with Apert syndrome. This study also found that the location of skull angles for patients age 0-24 months old and &gt;24 months old are different. The findings of this study can assist the surgical team in directing additional focus towards specific regions of the skull during the planning of interventions. This guidance has the potential to optimize surgical outcomes and reduce the risk of potential complications.

Erdosteine in children and adults with bronchiectasis (BETTER trial): study protocol for a multicentre, double-blind, randomised controlled trial

IntroductionBronchiectasis is a worldwide chronic lung disorder where exacerbations are common. It affects people of all ages, but especially Indigenous populations in high-income nations. Despite being a major contributor to...

Prevalence and predictors of post-acute COVID syndrome among infected healthcare workers at University Malaya Medical Centre.

Post Acute COVID Syndrome (PACS), a complex and poorly understood condition characterised by persistent symptoms following the acute phase of COVID-19 infection, has emerged as a significant global health concern. Healthcare workers who had been at the forefront of the pandemic response are at heightened risk of contracting the virus and subsequently developing PACS. Therefore, we aim to determine the prevalence and risk factors for PACS among healthcare workers infected with COVID-19. A cross-sectional study was conducted between October 2022 and August 2023 using an online REDCap electronic data capture tool questionnaire. PACS was defined as new or persistent symptoms lasting more than 28 days after a positive SARS-CoV-2 polymerase chain reaction or rapid test kit antigen test. Multivariable logistic regression was performed to determine predictors associated with PACS. Among 609 infected healthcare workers, they were predominantly female (71.8%), Malays (84.6%), and aged 18-39 years (70.1%). 50.7% of infected healthcare workers experienced PACS. The most common PACS symptoms experienced were fatigue (27.9%), cough (25.1%), decreased physical strength (20.5%), and musculoskeletal pain (19.2%). Those who are more likely to develop PACS were females, underlying asthma, and COVID-19 severity category 3. On the other hand, those who received booster vaccinations were less likely to develop PACS. PACS is prevalent among healthcare workers with COVID-19 at the University Malaya Medical Centre. These findings emphasise the critical need for those with higher risk to receive regular health monitoring and checkups to detect any early signs of PACS. It underscores the need for continuous support and healthcare interventions to mitigate the impacts of PACS and ensure the physical and mental well-being of healthcare workers.

A study of hospitalized COVID-19 patients with AKI in a setting of multiracial developing country

BackgroundThe commonest indication for hospitalization in COVID-19 patients is hypoxemia or severe respiratory symptoms. However, COVID-19 disease may result in extrapulmonary complications including kidney-related pathology. The reported incidence of renal involvement related to COVID infection varies based on geographical location.ObjectiveThis study aimed to assess the incidence rate of AKI in hospitalized COVID-19 patients and identify risk factors and prognostic predictors.MethodIn this retrospective study, we recruited hospitalized COVID-19 patients from January 2021 until June 2021 at the University Malaya Medical Center. The inclusion criteria were hospitalized for ≥ 48 h with confirmed COVID-19 infection and at least 18 years old. Patient demographic and clinical data were collected from electronic medical records. The staging of AKI was based on criteria as per KDIGO guidelines.ResultsOne thousand five hundred twenty-nine COVID patients fulfilled the inclusion criteria with a male-to-female ratio of 759 (49.6%) to 770 (50.3%). The median age was 55 (IQR: 36–66). 500 patients (32.7%) had diabetes, 621 (40.6%) had hypertension, and 5.6% (n = 85) had pre-existing chronic kidney disease (CKD). The incidence rate of AKI was 21.1% (n = 323). The percentage of COVID patients in different AKI stages of 1,2 and 3 were 16.3%, 2.1%, and 2.7%, respectively. Fifteen hospitalized patients (0.98%) required renal replacement therapy. 58.8% (n = 190) of AKI group had complete recovery of kidney function.Demographic factors included age (p < 0.001), diabetes (p < 0.001), hypertension (p < 0.012), CKD (p < 0.001), and vaccination status (p = 0.042) were associated with an increased risk of developing AKI. We found that the AKI cohort had statistically significant lower platelet counts and higher ferritin levels than the non-AKI cohort. AKI is a risk predictor of prolonged hospitalization (p < 0.001) and higher mortality rates (P < 0.001).ConclusionAKI is a common clinical complication among hospitalized COVID-19 patients. The etiology of AKI is multifactorial and may have an adverse impact on patient morbidity and mortality.

Financial Impact on Malaysian Families with Children Admitted with Community Acquired Pneumonia

Introduction: Hospitalisation following community-acquired pneumonia (CAP) among children may cause considerable burden to a family. This study was conducted to determine the financial impact on the parents and risk factors for prolonged hospitalisation. Methods: A prospective, cross-sectional hospital-based study was conducted at the University Malaya Medical Centre (UMMC) among patients aged between 3 months and 12 years old with CAP. Parents were interviewed and medical records were reviewed. Results: A total of 95 patients were enrolled in this study with a median age of 13 months, of whom 52 were boys (54.7%) and 43 were girls (45.3%). The median (IQR) total expenses incurred by the parents was RM546.90 (USD 128.23), which constituted 12.6% of total household income. The median workday loss was 9 (4 – 29) days. Pre-existing chronic illness and underweight were found to be strong predictors of prolonged hospitalisation with odds ratio of 3.97 and 4.5, respectively. Conclusion: CAP resulted in a significant financial burden in terms of loss of productivity and costs incurred by parents.

Comparative retrospective analysis: exploring the quality of life of people with epilepsy in two cohorts

People with epilepsy (PWE) are reported to have a lower quality of life (QOL). QOL among PWE were primarily observed through cross-sectional studies, and there is little information about the progression of QOL among PWE over the years. This study aimed to investigate the changes in QOL among PWE at a tertiary referral centre. A retrospective observational study was conducted among PWE from the Neurology clinic at the University Malaya Medical Centre. Data were extracted from the Quality of Life in Epilepsy Inventory (QOLIE-31) database for 2016, 2017, and 2020. A total of 88 subjects were included in Cohort 1 (2016 vs. 2017) and Cohort 2 (2017 vs. 2020), respectively. There was a significant improvement in mean scores of QOLIE-31 in Cohort 1 (57.7±12.2 vs. 63.2±14.2; p&lt;0.001), in terms of seizure worry, emotional well-being, cognitive functioning, medication effects and social function (p&lt;0.05, respectively). However, significant deterioration was observed in Cohort 2 (67.1±15.6 vs. 63.1±14.9; p=0.008), in terms of seizure worry and cognitive functioning (p&lt;0.05, respectively). Based on the calculated Jacobson Reliable Change Index (RCI) for the QOLIE-31 score, 28.4% from Cohort 2 experienced deterioration of QOL as compared to those from Cohort 1 (8%) (p&lt;0.001), which was most likely attributed to the COVID-19 pandemic. This study provides insights into the change of QOL among PWE in Malaysia over time, encompassing the COVID-19 pandemic period.

Routine vaginal examination to assess labor progress at 8 compared to 4 hours after early amniotomy following Foley balloon ripening in the labor induction of multiparas: a randomized trial

BackgroundVaginal examination to monitor progress in labor is recommended at least every 4 hours but it can cause pain and embarrassment to women. Trial data is limited on the best intensity for vaginal examination. Vaginal examination is not needed for oxytocin dose titration after amniotomy has been performed and oxytocin infusion started. The Foley balloon commonly ripens the cervix without strong contractions; amniotomy and oxytocin infusion is usually required to drive labor. ObjectiveTo evaluate the first vaginal examination at 8 vs 4 hours after amniotomy-oxytocin following Foley ripening in multiparous labor induction. MethodsA randomized controlled trial was conducted from October 2021 to September 2022 in University Malaya Medical Center. Multiparas at term were recruited at admission for labor induction. Participants were randomized to a first routine vaginal examination at 8 or 4 hours after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to initiate contractions. The two primary outcomes were the time from amniotomy to delivery (non-inferiority hypothesis) and maternal satisfaction (superiority hypothesis). Data were analyzed with the Student t-test, Mann-Whitney U test, Chi square test (or Fisher exact test) as suitable for the data. Results204 women were randomized, 102 to each arm. Amniotomy to birth interval was mean±standard deviation 4.97±2.47 vs 5.79±3.17, mean difference -0.82, 97.5% CI (-1.72 to 0.08) hours p=0.041 (Bonferroni correction), which was non-inferior within the pre-specified 2 hour upper margin and maternal satisfaction score with allocated labor care was median[interquartile range] 9[8-9] vs 8[7-9] p=0.814 (11-point 0-10 NRS) for 8 vs 4 hours arms respectively. Oxytocin infusion to birth interval difference was also non-inferior within the 97.5% CI (-1.59 to 0.23) margin of 2 hours. Of the maternal outcomes, amniotomy to first vaginal examination intervals were 3.9±1.8 vs 3.4±1.3hours p=0.026 and number of vaginal examinations was 2[2-3] vs 3[2-3.25] p<0.001 for 8 vs 4 hours arms respectively. For the 8 hours arm, first vaginal examination was less likely to be as scheduled and more likely to be indicated by sensation to bear down (p<0.001) and epidural analgesia rate was lower 13/102 (12.7%) vs 28/102 (27.5%) RR 0.46 95% CI 0.26–0.84 p=0.009. Other outcomes of mode of delivery, indications for cesarean and delivery blood loss were not different. Neonatal outcomes were not different. ConclusionRoutine first vaginal examination at 8 hours compared to 4 hours is non-inferior for the time to birth but does not improve maternal satisfaction.

Robotic Precision vs. Human Dexterity—Benchtop Comparative Study of Free-Hand vs. Robotic-Assisted Puncture in Fluoroscopy-Guided Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard procedure for treating large kidney stones, especially those measuring over 20 mm or staghorn stones. Accurate placement of the tract into the renal collecting system of interest is crucial. Objective: To compare the free-hand puncture technique with robotic-assisted puncture during fluoroscopy-guided PCNL on a phantom kidney model in terms of efficiency and safety. A self-assessment of confidence levels after each puncture was recorded. Study Design: This prospective single-center benchtop study was conducted at the University Malaya Medical Centre (UMMC). Four urological residents participated and performed phantom punctures using both the free-hand bull’s eye technique and the automated needle targeting system with X-ray (ANT-X). Each resident performed a total of 60 punctures on the renal phantom models, with 30 punctures using the free-hand technique and 30 punctures using the ANT-X robotic-assisted system. Results: A total of 240 needle insertions were conducted, with 120 in the ANT-X group and 120 in the free-hand group. The success rate of needle insertions was 100% in both groups. However, the study revealed that the ANT-X group required, on average, an additional 51 s for needle puncture compared to the free-hand group (p &lt; 0.001). In terms of fluoroscopic exposure, the ANT-X group exhibited significantly lower radiation exposure compared to the free-hand group (p &lt; 0.001). Sub-analysis showed that puncture time remained consistent regardless of the technique used, but fluoroscopic screening time decreased with increasing participant experience. The ANT-X group also resulted in significantly lower radiation exposure during initial sessions compared to the free-hand technique. Surgeons’ self-assessment of confidence levels indicated a high level of confidence in needle puncture. Conclusions: Our benchtop study comparing the efficacy and safety between free-hand and ANT-X phantom punctures revealed comparable results. The needle puncture technique facilitated by the ANT-X system showed promising results in terms of reducing fluoroscopic exposure, albeit at the cost of longer operative times. This technology holds promise for novice surgeons who are in the early stages of their learning curve and might be useful for experienced surgeons looking to reduce radiation exposure.

Poor HIV-related Knowledge, Perceived Risks and Attitudes Among Urban-dwelling Malaysian Older Adults: Key Barriers to Zero HIV Transmission by 2030.

Globally and in Malaysia, there are increasing rates of HIV infection among older adults but a corresponding decline in other younger age groups. We aimed to investigate the HIV-related knowledge, perceived risks, attitudes, and risk behaviours among multi-ethnic urban-dwelling older adults in Malaysia. A cross-sectional, questionnaire-based study was conducted among 320 adults aged 50 years and above residing in urban Klang Valley, Malaysia. Participants were recruited via convenience sampling in the community and in the outpatient clinics and pharmacy of University Malaya Medical Centre, Malaysia, from April 2021 to January 2022. The median (IQR) age of participants was 58 (55-64) and 42.5% were males. The median (IQR) knowledge score was 10 (8-12) out of 14. Significant knowledge gaps were noted and ethnic Chinese, higher education levels and better HIV-related attitudes were associated with better scores. The median (IQR) attitude score was 49 (41-55) out of 65. Ethnic Chinese and Indian, knowing people living with HIV (PLHIV), and better HIV-related knowledge were associated with better attitude scores. Many (43.8%) older adults were sexually active however rates of consistent condom use was low (19%) and the majority (89.9%) of participants had low self-perceived risk of HIV. These findings highlight underlying drivers for HIV transmission and delayed treatment among older adults in Malaysia and indicate a need for targeted HIV prevention programs for this population.

ANALYSIS OF HARDWARE REMOVAL IN MAXILLOFACIAL TRAUMA: A RETROSPECTIVE STUDY IN A MILITARY HOSPITAL IN SANA'A, YEMEN

Background and objective: Dental trauma is a significant problem for total dental health in terms of expenses, frequency, and age (young patients). Collaboration between various professionals, including oral surgeons, maxillofacial surgeons, dentists, orthodontists, and periodontists, frequently results in the treatment process. Surgical treatment may entail placing plates for fractures and shattered bones for long or permanent periods, and may require their removal for many reasons. Therefore, this study sought to ascertain the reasons for plate removal in individuals referred to the Department of Oral and Maxillofacial Surgery at Military Hospital in Sana'a, Yemen during a period of 3 years. Method: The study included 57 Yemeni patients who visited the Department of Oral and Maxillofacial Surgery at the Military Hospital in Sana’a during the period 2021-2023. Cases of hardware removal were extracted from the medical records to include sex, age, medical history, accident history, type of fracture, primary complaint, period from the date of the first operation, approach to the operation, tooth in the fracture line, and extracted tooth. Results: Gunshot injuries (40.4%) and explosive injuries (31.6%) were the most common causes of maxillofacial fractures. Mandibular fractures (68.4%) were the most frequent, followed by orbital and zygomatic fractures (12.3% each). The main reason for hardware removal was infections (29.8%), followed by patient preference (22.8%) and visible exposed hardware (15.8%). Mini-plates (68.4%) were the most commonly removed hardware, and the extra-oral approach (56.1%) was the most frequently used for removal. There was a significant association between orbital fractures and the incidence of positive discharge, as well as between reconstructive plates and the incidence of positive discharge. Longer plate usage, exceeding 24 months, increased the probability of positive discharge. Tooth involvement and extraction were minimal. Conclusion: Gunshot and explosive injuries were the main causes of maxillofacial fractures, while infections, patient preferences, visible exposed devices, and pain and discomfort were the main reasons for removal of devices. Mandibular fractures were the most common and orbital fractures carry a higher risk of infection, while small plates have shown lower rates of infection. Prolonged panel use beyond 24 months increased the probability of positive discharge. Peer Review History: Received: 25 October 2023; Revised: 18 November; Accepted: 24 December, Available online: 15 January 2024 Academic Editor: Dr. Gehan Fawzy Abdel Raoof Kandeel, Pharmacognosy Department, National Research Centre, Dokki, 12622, Giza, Egypt, gehankandeel9@yahoo.com Received file: Reviewer's Comments: Average Peer review marks at initial stage: 6.0/10 Average Peer review marks at publication stage: 7.0/10 Reviewers: Dr. George Zhu, Tehran University of Medical Sciences, Tehran, Iran, sansan4240732@163.com Dr. Hasniza Zaman Huri, University of Malaya Medical Centre, Kuala Lumpur, hasnizazh@ummc.edu.my