University Malaya Medical Centre Research Articles

Chemotherapy-related cognitive impairment (CRCI) among early-stage breast cancer survivors in Malaysia

ABSTRACT Introduction: Breast cancer survivors frequently develop cognitive impairment following chemotherapy which can significantly hamper their well-being, ability to function independently, and overall quality of life. Evidence of cognitive functioning in breast cancer survivors from lower and middle-income countries remains scarce. We examined the prevalence of cognitive impairment among Malaysian multiethnic early-stage breast cancer survivors one to three years post-chemotherapy. Methods: This cross-sectional study included 160 breast cancer survivors from the University Malaya Medical Center (UMMC). The cognitive assessments used included the Montreal Cognitive Assessment (MoCA-BM), the Rey Auditory and Verbal Learning Test (RAVLT-BM), and the digit span and arithmetic of the Working Memory Index (WMI) of Wechsler Adult Intelligence Scale-IV (WAIS-IV). Data were analyzed using independent sample t-tests and Pearson’s correlation. Results: Our breast cancer survivors demonstrated poor performances in MoCA-BM (31.9%) RAVLT-BM, recall (53.8%), and WMI of WAIS-IV (51.3%) with 30.6% of them performed poorly in all three cognitive tests administered. There were no significant mean group differences in cognitive performances between <24 months after chemotherapy and ≥24 months after chemotherapy. Conclusions: A high proportion of breast cancer survivors exhibited poor performances in the cognitive assessments. Cognitive rehabilitation programmes tailored to the needs of these survivors should be incorporated into cancer care management.

Is pre-operative axillary ultrasound alone sufficient to determine need for axillary dissection in early breast cancer patients?

Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN.383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement.The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value < .05). Cortical thickness of > 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126).There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.

The effect of 5‐min mindfulness of love on suffering and spiritual quality of life of palliative care patients: A randomized controlled study

Suffering is a common experience in palliative care. In our study, we aimed to determine the effect of 5-min mindfulness of love on suffering and the spiritual quality of life of palliative care patients. We conducted a parallel-group, blinded, randomized controlled study at the University of Malaya Medical Centre (UMMC), Malaysia from February 2019 to April 2019. Sixty adult palliative care patients with an overall suffering score of 4/10 or above based on the Suffering Pictogram were recruited and randomly assigned to either the 5-min mindfulness of love group (N=30) or the 5-min supportive listening group (N=30). There were statistically significant improvements in the overall suffering score (mean difference=-2.9, CI=-3.7 to -2.1, t=-7.268, p=0.000) and the total FACIT-Sp-12 score (mean difference=2.9, CI=1.5 to 4.3, t=4.124, p=0.000) in the intervention group compared to the control group. The results provided evidence that 5-min mindfulness of love could affect the actual state of suffering and the spiritual quality of life of palliative care patients.

The Detection of Hypermucoviscous Carbapenem-Resistant Klebsiella pneumoniae from a Tertiary Teaching Hospital in Malaysia and Assessment of Hypermucoviscous as Marker of Hypervirulence.

Background: Hypermucoviscous carbapenem-resistant Klebsiella pneumoniae (hmCRKp) is emerging globally and approaching the worst-case scenario in health care system. Aims: The main objective in this study was to determine the hypermucoviscous characteristics among the carbapenem-resistant K. pneumoniae (CRKp) isolated from a teaching hospital in Malaysia. The association of hypermucoviscous phenotype with the virulence traits and clinical presentations were also investigated. Methods: A retrospective study was conducted in University Malaya Medical Centre (UMMC). The presence of hypermucoviscous K. pneumoniae was identified among a collection of CRKp clinical isolates (first isolate per patient) from 2014 to 2015 using string test. Correlation between clinical and microbial characteristics of the hmCRKp was investigated. Results: A total of nine (7.5%) hmCRKp were detected among 120 CRKp isolates. Majority of the isolates were hospital acquired or health care-associated infections. None of the patients had typical pyogenic liver abscess. All of the hmCRKp isolates harbored carbapenemase genes and were multidrug resistant. K1/K serotype, peg-344, allS, and magA were not identified among hmCRKp isolates, whereas aerobactin siderophore receptor gene (iutA), iroB, rmpA, and rmpA2 were detected. Only three hmCRKp isolates were resistant to serum bactericidal. Conclusions: All the isolates presented inconclusive evidence for the interpretation of hypervirulence. Therefore, more study should be performed in the future to have a better understanding of the virulence mechanisms in correlation with the clinical and microbial determinants.

Implementation of a COVID-19 surveillance programme for healthcare workers in a teaching hospital in an upper-middle-income country.

IntroductionThe reporting of Coronavirus Disease 19 (COVID-19) mortality among healthcare workers highlights their vulnerability in managing the COVID-19 pandemic. Some low- and middle-income countries have highlighted the challenges with COVID-19 testing, such as inadequate capacity, untrained laboratory personnel, and inadequate funding. This article describes the components and implementation of a healthcare worker surveillance programme in a designated COVID-19 teaching hospital in Malaysia. In addition, the distribution and characteristics of healthcare workers placed under surveillance are described.Material and methodsA COVID-19 healthcare worker surveillance programme was implemented in University Malaya Medical Centre. The programme involved four teams: contact tracing, risk assessment, surveillance and outbreak investigation. Daily symptom surveillance was conducted over fourteen days for healthcare workers who were assessed to have low-, moderate- and high-risk of contracting COVID-19. A cross-sectional analysis was conducted for data collected over 24 weeks, from the 6th of March 2020 to the 20th of August 2020.ResultsA total of 1,174 healthcare workers were placed under surveillance. The majority were females (71.6%), aged between 25 and 34 years old (64.7%), were nursing staff (46.9%) and had no comorbidities (88.8%). A total of 70.9% were categorised as low-risk, 25.7% were moderate-risk, and 3.4% were at high risk of contracting COVID-19. One-third (35.2%) were symptomatic, with the sore throat (23.6%), cough (19.8%) and fever (5.0%) being the most commonly reported symptoms. A total of 17 healthcare workers tested positive for COVID-19, with a prevalence of 0.3% among all the healthcare workers. Risk category and presence of symptoms were associated with a positive COVID-19 test (p<0.001). Fever (p<0.001), cough (p = 0.003), shortness of breath (p = 0.015) and sore throat (p = 0.002) were associated with case positivity.ConclusionCOVID-19 symptom surveillance and risk-based assessment have merits to be included in a healthcare worker surveillance programme to safeguard the health of the workforce.

Validation of 3-Minute Nutrition Screening-Paediatric (Paediatric 3-MinNS) for Hospitalized Children

Nutrition screening in pediatric hospitals is not a common practice in many countries. This study validated the 3-Minute Nutrition Screening-Paediatric (Paediatric 3-MinNS) with Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP), anthropometric measures, biochemical parameters, and dietary assessment. This cross-sectional study included 165 patients aged 2 to 12 years admitted as pediatric patients to the University Malaya Medical Centre. The tool identified 26.1% of patients as being at high risk of malnutrition. The findings suggest that Paediatric 3-MinNS offers a valid and reliable screening tool for early recognition of children at risk of malnutrition.

Mortality in adult epilepsy patients in Malaysia: a hospital-based study

Background: The standardized mortality ratio (SMR) of epilepsy in Asia ranges from 2.5 to 5.1. However, there are no such published data in Malaysia to date. Understanding the mortality rate and related factors will allow us to better assess and monitor the health status of PWE, thereby, preventing premature deaths among PWE. Hence, this study aimed to determine the mortality rate of adults with epilepsy (PWE) at the University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia. Method: A total of 2218 PWE were recruited retrospectively into this study. Deceased cases from 2009-2018 were identified from the National Registry Department of Malaysia. Age-, gender-, and ethnic-specific SMR were calculated. Result: There was a total of 163 deaths, of which 111 (68.1%) were male. The overall case-fatality rate (CFR) was 7.3%. Male PWE had higher CFR (9.2%) compared to females (5.1%, p<0.001). The annual death rate of PWE was 867 per 100, 000 persons. The overall all-cause SMR was 1.6 (CI 95% 1.3-1.8). The SMR for younger age groups (15-19 and 20-29 years) were higher (5.4-5.5) compared to other age groups (0.4-2.5). Overall SMR for male PWE (1.8, 95% CI 1.5-2.1) was higher than females (1.2, 95% CI 0.9-1.6). However, the SMR for female PWE in the younger age groups (15-19, 20-29 and 30-39 years) was higher. SMR among the Indian PWE was the highest (1.6, 95% CI 1.2-2.0) compared to the Chinese (1.5, 95% CI 1.2-1.9) and the Malays (1.4, 95% 1.0-1.9). The CFR was higher in those with focal epilepsy (8.5% vs. 2.5-3.7% in genetic and other generalized epilepsies, p=0.003), epilepsy with structural cause (9.5% vs. 5.9% in others, p=0.005) and uncontrolled seizures (7.9% vs. 5.2% in seizure-free group, p<0.001). Conclusion: The mortality rate of PWE in Malaysia is higher than that of the general population but lower compared to other Asian countries. Specifically, the rates are higher in the younger age group, male gender, and Indian ethnicity. Those with focal epilepsy, structural causes and uncontrolled seizures have higher mortality rates.

Cutaneous manifestations of patients with Human Immunodeficiency Virus (HIV) Infection: A retrospective review of a tertiary referral centre with clinicopathological correlation.

The majority of patients with Human Immunodeficiency Virus (HIV) will have cutaneous manifestation during their disease course. We report the spectrum of cutaneous manifestations and clinicopathological concordance in the diagnosis of skin diseases in patients with HIV. A retrospective review of all cutaneous manifestations of HIV-infected patients with skin biopsy-proven histopathological confirmation, treated in the University of Malaya Medical Centre, from 2016 till 2018, was performed. Clinical characteristics and histopathological correlation of these patients were reviewed. A total of 38 cases were included where the median age was 40.5 (interquartile range (IQR) 13.3). The median duration of HIV diagnosis to the development of skin disease was 3years (IQR 7.8). Majority of our patients were male (89.5%, n=34), and the commonest mode of transmission is men who have sex with men (36.8%, n=14). Most patients (92.1%, n=35) had Acquired Immunodeficiency Syndrome when they presented with skin diseases, predominantly non-infectious types (51.4%, n=19). Commonest skin diseases include eczema (n=7) and pruritic papular eruption of HIV (n=6). Papules and plaques were the commonest morphology for both infectious and non-infectious skin diseases. Duration of HIV diagnosis (P=0.018) and non-compliance to Highly Active Antiretroviral Therapy (HAART) (P=0.014) were significantly associated with the development of non-infectious skin diseases. Overall, clinicopathological concordance was 84.2% in our centre. A wide spectrum of cutaneous diseases can occur in HIV patients depending on the degree of immunosuppression. skin biopsy along with appropriate stains, and microbiological cultures are important in helping clinicians clinch the right diagnosis.

Happiness at the end of life: A qualitative study.

Dying is mostly seen as a dreadful event, never a happy experience. Yet, as palliative care physicians, we have seen so many patients who remained happy despite facing death. Hence, we conducted this qualitative study to explore happiness in palliative care patients at the University of Malaya Medical Centre. Twenty terminally ill patients were interviewed with semi-structured questions. The results were thematically analyzed. Eight themes were generated: the meaning of happiness, connections, mindset, pleasure, health, faith, wealth, and work. Our results showed that happiness is possible at the end of life. Happiness can coexist with pain and suffering. Social connections were the most important element of happiness at the end of life. Wealth and work were given the least emphasis. From the descriptions of our patients, we recognized a tendency for the degree of importance to shift from the hedonic happiness to eudaimonic happiness as patients experienced a terminal illness. To increase the happiness of palliative care patients, it is crucial to assess the meaning of happiness for each patient and the degree of importance for each happiness domain to allow targeted interventions.

Impact of alcohol withdrawal training program on knowledge, attitude, and perception among healthcare providers in a hospital setting

ABSTRACT Background Delirium tremens is a life-threatening complication of alcohol withdrawal, which is preventable by prompt recognition and management. This study aimed to evaluate the impact of an alcohol withdrawal training program on knowledge, attitude, and perception among healthcare providers in a hospital setting. Methods This was a quasi-experimental study with a pre and post-test design conducted at the Department of Psychological Medicine, University Malaya Medical Center, Malaysia. A total of 36 participants consisted of postgraduate psychiatry trainees who underwent a 60-min online training program whereby pre- and post-training evaluation was done using a locally validated 21-item knowledge, attitude, perception questionnaire on alcohol withdrawal and the Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) scales. Results There was a significant difference between pre- and post-training scores in knowledge, attitude, and perception domains (p < .05). Furthermore, significant difference in pre- and post-training CIWA-Ar scores (p < .05) were detected. Post-training CIWA-Ar score approached the true value and with minimal variation of scores among the participants. Conclusion The alcohol withdrawal training program was clinically significant with an effect size of 0.75. It can be utilized to train healthcare providers from various departments treating alcohol withdrawal patients to ensure better standardization of care.

Outcomes of Asian Women Treated With Grisotti Flap Reconstruction for Centrally Located Breast Cancers: 5-Years Single Institutional Experience.

Breast conserving surgeries were previously contraindicated for central breast cancers because of poor cosmetic outcomes of central mastectomy without oncoplastic surgery. Grisotti flap is a breast-conserving surgery incorporating oncoplastic surgery technique for centrally located breast cancers. We present our experience and outcome from Breast Surgery Unit, University Malaya Medical Center. A prospective analysis of 15 patients with central retroareolar breast cancer operated from 2012 to 2018 in University Malaya Medical Center. We assessed postoperative complications, margins, locoregional recurrence, and survival outcome. All patients received postoperative radiotherapy. Patients were followed-up 1 week, 1 month, 3 monthly for 1 year and 6 monthly for 5 years. Mean age of patients is 62 years. Mean follow-up is 51 months (15-84 months). All tumors were less than 5 cm (1-2.5 cm). Majority of the patients are stage 1 (6 patients/40%) and stage 2 (8 patients/ 53.3%). 2 patients had surgical site infection resolved with antibiotics. One patient had hematoma. None require reoperation. Tumor margins were clear in all patients. No locoregional recurrence. Overall survival is 100%. All are satisfied with their cosmetic outcomes. Grisotti flap is a volume displacement technique, which provides satisfactory cosmetic outcome for centrally located breast cancer. This evolutionary thinking leads us to changes in existing techniques with the purpose of achieving oncological safety while reaching for better esthetic results. Our 5 years' experience in Asian population showed that this technique is oncologically safe with good cosmetic outcomes and could be used selectively. It provides a good alternative in patients who are otherwise subjected for mastectomy. This relatively simple technique is a worthwhile endeavor and should be offered when feasible.

DRUG-RELATED PROBLEMS ENCOUNTERED BY COMMUNITY-DWELLING OLDER PERSONS IN THE KLANG VALLEY, MALAYSIA: AN EXPLORATORY STUDY

Introduction: The population of Malaysia is ageing rapidly. Due to the relatively greater incidence of noncommunicable diseases among older adults, polypharmacy is highly prevalent in this population. This polypharmacy along with other age-related factors increases the risk of drug-related problems to several folds. Currently, no study in Malaysia or even Asia has determined the type and nature of drug-related problems among non-institutionalised older adults. Therefore, this study aims to highlight common drug-related problems among community-dwelling older persons (≥ 65 years) with polypharmacy. Materials and Methods: A cross-sectional exploratory study was carried out where in-depth home medication reviews were carried out by two pharmacists. Participants were recruited from geriatric and fall clinics of the University of Malaya Medical Centre located in the urban area of the Federal Territory of Malaysia. The total numbers of drug-related problems were classified using the Pharmaceutical Care Network Europe (PCNE) classification V9.0. Recommendations and referral letters were provided based on the pharmaceutical care issues identified. Results: Thirty participants were recruited, among whom 178 drug-related problems were identified with a median value of six [range 1-11] drug-related problems per participant. The majority of problems were related to the effectiveness of prescribed treatment (69.1 %), followed by the possibility of adverse effects (28.7 %). Conclusion: Home medication review identifies numerous medication-related issues and allows for patient education and detailed counselling in an informal and patient-friendly manner. Future studies to determine the longitudinal effect of home medication review on patient outcome, cost implications, and overall healthcare utilization are now indicated.

P68.01 Qualitative Computed Tomographic Features Predict Epidermal Growth Factor Receptor Mutations in Advanced Lung Adenocarcinoma

Introduction: Current guidelines recommend reflex testing for EGFR mutations in patients with advanced lung adenocarcinoma. Although tissue biopsy is considered the “gold standard” for EGFR mutation testing, it may not always be feasible in a small group of patients. Hence, this study aims to determine the computed tomography (CT) features that may predict the presence of common sensitising EGFR mutation in newly diagnosed advanced lung adenocarcinoma patients. Methods: 182 diagnostic contrast enhanced CT-images of newly diagnosed advanced lung adenocarcinoma patients who attended University Malaya Medical Center from 2010 to 2014 were analysed. For EGFR mutation testing, tissue biopsy specimens of all patients were tested for exon 19 deletion and exon 21 L858R point mutation. Results: Of the 182 patients, 158 patients with measurable primary tumour, were included in the analysis. 67 (42.4%) patients had common sensitising EGFR mutations, of which 43 (64.1%) were exon 19 deletion and 24 (35.9%) were exon 21 L858R point mutation. CT features of these patients are stated in Table 1. Common sensitising EGFR mutations were significantly more common in primary tumours with round contour (p ¼ 0.029), homogenous enhancement (p ¼ 0.029) and presence of air-bronchogram (p ¼ 0.029). On the other hand, presence of emphysema (p ¼ 0.005) and intrathoracic lymph nodes enlargement (p ¼ 0.001) were significantly against the presence of common sensitising EGFR mutations. These findings were further supported by the multivariate analysis: round contour [odd ratio (OR): 13.6, 95% confidence interval (CI): 1.40 - 13.2, p ¼ 0.024], homogenous enhancement (OR: 2.5, 95% CI: 1.00 - 6.47, p ¼ 0.049), presence of air bronchogram (OR: 2.7, 95% CI: 1.28 e 5.53, p ¼ 0.009) and intrathoracic lymph nodes enlargement (OR: 0.2, 95% CI: 0.05 - 0.52, p ¼ 0.002). None of the CT features could differentiate exon 19 deletion from exon 21 L858R point mutation. Conclusion: Tumours with round contour, homogenous enhancement and air bronchogram as well as absence of intrathoracic lymph nodes enlargement were independent predictors of the presence of common sensitising EGFR mutations. This information is helpful to clinicians in selecting best empirical treatment for patients who are not eligible for tissue biopsy and in those who need urgent treatment because of rapid clinical deterioration.

Detection and confirmation of dengue pre- and postintroduction of dengue NS1-antigen test at the University Malaya Medical Centre: An observational study.

Early diagnosis of dengue is important to ensure proper management of patients and effective implementation of control measures. The present study was undertaken to determine the outcome of the implementation of dengue NS1-antigen (Ag) rapid diagnostic test (RDT) in the confirmation of dengue at the first patient hospital visit at the University Malaya Medical Centre. A total of 1036 and 1097 sera from the year 2008 and 2015 were used, representing samples from before and after dengue NS1-Ag RDT was implemented as routine diagnostic at the hospital. Results showed that similar dengue confirmation percentage (56%) was made in 2008 and 2015, regardless of the main laboratory diagnostic method used. Confirmation of dengue, however, increased to 68% and 73% when dengue NS1-Ag test or dengue immunoglobulin M-capture enzyme-linked immunosorbent assay was used as the second test for the 2008 and 2015 samples, respectively. Detection of dengue virus (DENV) using multiplex reverse transcription-polymerase chain reaction (RT-PCR) showed that DENV-1 was the highest in circulation in 2008 and that both DENV-1 and DENV-2 were dominant in 2015. In summary, the present study demonstrated that the introduction and use of the dengue NS1-Ag RDT did not change or compromise confirmation of dengue, highlighting the advantage of using the method. With the reducing cost of molecular detection tools, DENV detection using RT-PCR remains a viable option for further confirmation of dengue in hospital settings.

Conduct of neuro-oncology multidisciplinary team meetings and closing the "gaps" in the clinical management of childhood central nervous system tumors in a middle-income country.

Multidisciplinary team meetings (MDTMs) are essential in the clinical management of pediatric central nervous system (CNS) tumors. Evaluations of the impact of MDTMs on childhood CNS tumors and clinicians' perspectives on their effectiveness are scarce. We retrospectively reviewed the clinical data of pediatric patients (aged <18 years) with CNS tumors diagnosed and treated in the Pediatric Hematology-Oncology Division at the University Malaya Medical Center from 2008 to 2019. We also conducted a web-based survey of the core members of the multidisciplinary team to evaluate the impact of the MDTMs. During the pre-MDTM era (2008-2012), 29 CNS tumors were diagnosed and treated, and during the MDTM era (2014-2019), 49 CNS tumors were diagnosed and treated. The interval for histologic diagnosis was significantly shorter during the MDTM era (p=0.04), but the interval from diagnosis to chemotherapy or radiotherapy and the 5-year overall survival of the 78 patients did not improve (62.1% ± 9.0% vs. 68.8% ± 9.1%; p=0.184). However, the 5-year overall survival of patients with medulloblastoma or rare tumors significantly improved in the MDTM era (p=0.01). Key factors that contributed to delayed treatment and poor outcomes were postoperative complications, the facility's lack of infrastructure, poor parental education about early treatment, cultural beliefs in alternative medicine, and infection during chemotherapy. Eighteen clinicians responded to the survey; they felt that the MDTMs were beneficial in decision-making and enhanced the continuity of coordinated care. MDTMs significantly reduced the diagnostic interval and improved the overall outcomes. However, delayed treatment remains a major challenge that requires further attention.

ABO-Incompatible Living-Donor Kidney Transplantation in a Developing Country: A Multicenter Experience in Malaysia

Malaysia has a low deceased-donor donation rate and has not embarked on a paired kidney exchange program; therefore, ABO-incompatible and HLA-incompatible transplantation remain the main contributor to the sustainability of the national kidney transplantation (KT) program. There were 26 cases of ABO-incompatible KTs performed from 2011 to 2018 in 3 major transplant centers, namely, Hospital Kuala Lumpur, University Malaya Medical Centre, and Prince Court Medical Centre. We collected perioperative and follow-up data through June 2019. The desensitization protocol varies and is center specific: the localized Japanese protocol and Swedish protocol with a target anti-A/B isoagglutinin titer of 16 or 32 on the day of transplant. The induction and tacrolimus-based maintenance protocol was nearly identical. The median follow-up time was 62.3 months (interquartile range, 37.0-79.7). Fifteen subjects had the highest predesensitization anti-A/B titer of ≥32 (57.7%). The acute cellular rejection and antibody-mediated rejection incidence were 12.5% (3 cases) and 8.3% (2 cases), respectively. Patient, graft, and death-censored graft survival rates were 96.2%, 92.3%, and 96.0%, respectively, 1 year post-living-donor KT (LDKT) and 96.2%, 87.2%, and 90.7%, respectively, 5 years post-LDKT. Our experience shows that ABO-incompatible LDKT using a suitable desensitization technique could be a safe and feasible choice for LDKT even with varied desensitization regimens for recipients with relatively high baseline isoagglutinin titers.

Robust radiogenomics approach to the identification of EGFR mutations among patients with NSCLC from three different countries using topologically invariant Betti numbers

ObjectivesTo propose a novel robust radiogenomics approach to the identification of epidermal growth factor receptor (EGFR) mutations among patients with non-small cell lung cancer (NSCLC) using Betti numbers (BNs).Materials and methodsContrast enhanced computed tomography (CT) images of 194 multi-racial NSCLC patients (79 EGFR mutants and 115 wildtypes) were collected from three different countries using 5 manufacturers’ scanners with a variety of scanning parameters. Ninety-nine cases obtained from the University of Malaya Medical Centre (UMMC) in Malaysia were used for training and validation procedures. Forty-one cases collected from the Kyushu University Hospital (KUH) in Japan and fifty-four cases obtained from The Cancer Imaging Archive (TCIA) in America were used for a test procedure. Radiomic features were obtained from BN maps, which represent topologically invariant heterogeneous characteristics of lung cancer on CT images, by applying histogram- and texture-based feature computations. A BN-based signature was determined using support vector machine (SVM) models with the best combination of features that maximized a robustness index (RI) which defined a higher total area under receiver operating characteristics curves (AUCs) and lower difference of AUCs between the training and the validation. The SVM model was built using the signature and optimized in a five-fold cross validation. The BN-based model was compared to conventional original image (OI)- and wavelet-decomposition (WD)-based models with respect to the RI between the validation and the test.ResultsThe BN-based model showed a higher RI of 1.51 compared with the models based on the OI (RI: 1.33) and the WD (RI: 1.29).ConclusionThe proposed model showed higher robustness than the conventional models in the identification of EGFR mutations among NSCLC patients. The results suggested the robustness of the BN-based approach against variations in image scanner/scanning parameters.

Malaysian outcome of acute necrotising encephalopathy of childhood

ObjectiveDescribe the outcome of a Malaysian cohort of children with acute necrotising encephalopathy (ANE). MethodRetrospective study of children with ANE seen at University of Malaya Medical Centre from 2014 to 2019. All clinical details including ANE-severity score (ANE-SS), immunomodulation treatment and neurodevelopmental long-term outcome were collected. ResultsThirteen patients had ANE and brainstem death occurred in 5. In 10 patients (77%) viruses were isolated contributing to ANE: 8 influenza virus, 1 acute dengue infection, and 1 acute varicella zoster infection. The ANE-SS ranged 2–7: 9 were high risk and 4 were medium risk. Among the 8 survivors; 1 was lost to follow-up. Follow-up duration was 1–6 years (median 2.2). At follow-up among the 4 high-risk ANE-SS: 2 who were in a vegetative state, 1 remained unchanged and 1 improved to severe disability; the other 2 with severe disability improved to moderate and mild disability respectively. At follow-up all 3 medium-risk ANE-SS improved: 2 with severe disability improved to moderate and mild disability respectively, while 1 in a vegetative state improved to severe disability. Early treatment with immunomodulation did not affect outcome. ConclusionOur ANE series reiterates that ANE is a serious cause of encephalopathy with mortality of 38.5%. All survivors were in a vegetative state or had severe disability at discharge. Most of the survivors made a degree of recovery but good recovery was seen in 2. Follow-up of at least 12 months is recommended for accurate prognostication. Dengue virus infection needs to be considered in dengue endemic areas.

Hematocrit change as a predictor of readmission for decompensated heart failure: a retrospective single centre study.

In patients with acute heart failure (AHF), hemoconcentration has been suggested as a surrogate for volume changes (AHF). However, literatures comparing the outcome of AHF patients that achieved hemoconcentration during hospitalization with those that do not are limited. The aim of this research is to see if achieving hemoconcentration prior to discharge is linked to a lower risk of re-admission in AHF patients. 124 patients hospitalized in the Cardiology Unit, University Malaya Medical Centre (UMMC) for AHF between November 2019 and November 2020 were enrolled. Information on patients' clinical characteristics, laboratory values and in-hospital treatments were collected through electronic medical record. At admission and discharge, the change in hematocrit (HCT) levels was calculated, and patients were stratified based on two quantiles of delta HCT, either discharged with hemoconcentration (ΔHCT >1.5%) or without hemoconcentration (ΔHCT ≤1.5%). The study's outcome was AHF readmission after a 90-day follow-up period. Readmission was significantly associated with ejection fraction (p = 0.032) and HCT change (p = 0.005). Consecutively, logistic regression performed revealed that patients with haemoconcentration were 78.3% less likely to be readmitted than those without haemoconcentration (OR = 0.217, p = 0.003, 95% CI = 0.078-0.605) and Patients with a lower ejection fraction have a threefold greater chance of being readmitted than those with a preserved ejection fraction (OR = 3.316, p = 0.022, 95% CI = 1.188-9.256). In conclusion, among patients hospitalized and discharged for AHF, those that (i) do not achieve haemoconcentration and (ii) patients with a reduced ejection fraction were more likely to be readmitted with acute heart failure. Therefore, optimising patients' haematocrit levels prior to discharge may potentially reduce rehospitalizations among heart failure patients.

Ethnic variability in mortality from ischaemic heart disease/cardiomegaly in Malaysia.

The prevalence of ischaemic heart disease with associated cardiomegaly and other chronic diseases such as diabetes mellitus has increased in Malaysia in recent years. As the contribution to mortality from ischaemic heart disease/cardiomegaly in different ethnic populations is unclear, a three year (January 2013-December 2015) retrospective study of autopsy cases was undertaken at the Department of Forensic Pathology, University Malaya Medical Centre. There were 80 cases with lethal ischaemic heart diseases/cardiomegaly. The age range was 30-69 years (mean 50.19 years) with a male to female ratio of 39:01. The most vulnerable age was 50-59 years accounting for 38.75% of cases. Malays accounted for 15% of cases, Indians for 32.5% and Chinese for 36.25%. Although in 35 cases (43.75%) there was a history suggestive of ischaemic heart disease, the remaining 45 cases (56.25%) were apparently healthy until the terminal collapse. It appears that Indian males in the 50-59 year age range are most at risk for lethal cardiac events in this population, most often with no preceding symptoms or signs. The study demonstrates the value of studying subpopulations for disease risk rather than relying on accrued general population data.