Master of Science in Medical Statistics Programme at Universiti Sains Malaysia: 20 Years Ongoing

Health and medical research are important parts of the curriculum of medical and health programmes in universities and play an important role in the functioning of organisations related to health care. There is a shortage of well-trained health and medical research statisticians. This article describes the courses and structure of the Master of Science in Medical Statistics programme at Universiti Sains Malaysia (USM), as well as the graduates' achievements. It is a 2-year programme that prepares qualified and competent graduates in statistical methods and data analysis for research in health and medical sciences. The Biostatistics and Research Methodology Unit, School of Medical Sciences, USM has been running the programme since 2003. It is currently the only medical statistics programme available in Malaysia. There have been 97 graduates since 2005, with an employment rate of 96.7% and a successful subsequent doctorate rate of 21.1%. Most of the students returned to their previous employments, mainly with the Ministry of Health of Malaysia and several others became lecturers, statisticians or research officers. The employability of graduates from this programme is very high and their professional future is bright. We hope our graduates will impart their knowledge and skills to the nation.

Supradiaphragmatic central venous catheter malposition detection using the parasternal long-axis echocardiographic view and dextrose 50% contrast solution: A pilot study

Background

Contrast-enhanced ultrasonography (CEUS) using saline was studied to detect supradiaphragmatic central venous catheter malposition. Commonly used echocardiographic views are apical 4-chamber (A4c) and subcostal views. However, this standard method is not feasible in certain situations. We explored the feasibility of the right ventricle inflow parasternal long axis (RVI-PLAX) echocardiographic view and dextrose 50% (D50%) contrast solution for detecting supradiaphragmatic central venous catheter malposition.

Method

This pilot study screened 60 patients who underwent ultrasound-guided supradiaphragmatic central venous catheter insertion. We compared the investigators' guidewire's J-tip detection, D50% rapid atrial swirl sign (RASS) findings on the RVI-PLAX view and the central venous catheter tip on chest radiograph. We also compared the mean capillary blood sugar level before and after the 5 ml D50% flush.

Results

No guidewire J-tips were detected from the RVI-PLAX view. The first and second investigators' diagnosis of central venous catheter malposition detected on RVI-PLAX CEUS achieved an almost perfect agreement (κ = 1.0 (95% confidence interval (CI): 0.90 to 1.0), p < .0001). The RVI-PLAX CEUS was not able to detect two central venous catheter malpositions (one atrial malposition and one left brachiocephalic vein venous catheter malposition). The capillary blood sugar was significantly elevated (8.96 mmol/L vs. 9.75 mmol/L) after D50% flush (p < 0.005) with no complications reported within 30 minutes after the D50% flush.

Conclusion

RVI-PLAX view should not be used for guidewire detection. CEUS using D50% and RVI-PLAX view are potentially useful tools in detecting central venous catheter malposition. Further studies comparing them with conventional methods are needed.

Prophetic Medicine for Treatment of Radiotherapy-Induced Mucositis

Objective: Mucositis is a debilitating complication of radiotherapy treatment in nasopharyngeal carcinoma (NPC). Mucositis can lead to malnutrition due to poor oral intake, and the cancer treatment protocol might be postponed due to this condition. Until now, there is no specific treatment to prevent radiotherapy-induced mucositis in NPC patients. The usage of propolis mouthwash is believed to be one of the important remedies to reduce the severity of mucositis in the future. We sought to evaluate the effectiveness of propolis mouthwash in preventing radiotherapy-induced mucositis in NPC patients.Methods: This is a double arm, prospective, randomized control trial (RCT) with intervention involving 17 patients diagnosed with NPC attending ORL-HNS clinic in Institut Perubatan & Pergigian Termaju (IPPT) Bertam. 10 patients were given propolis mouthwash and another 7 patients were given normal saline mouthwash as a placebo. The effectiveness of propolis mouthwash was assessed by repeated measures ANOVA.Result: All 17 NPC patients were randomly divided into propolis group (intervention) and normal saline group (placebo). 10 patients were given propolis mouthwash and another 7 patients were given normal saline mouthwash. Comparison of adjusted mean and 95% confidence interval of mucositis grading score between propolis mouthwash and normal saline showed at the second week was 0.10(- 0.13, 0.33) vs 1.14(0.31, 1.98), fourth week: 0.50(0.12, 0.88) vs 2.00(1.47, 2.53), and sixth week: 1.20(0.90, 1.50) vs 2.86(2.51, 3.21), respectively. Repeated measures ANOVA showed P<0.001, indicating a significant improvement of mucositis grading between propolis and normal saline group.Conclusion: Propolis mouthwash is proved to be effective in reducing the severity of radiotherapyinduced mucositis in NPC patients and it is safe to be used. Therefore, its use is recommended as an adjunct treatment during the treatment protocol of NPC.International Journal of Human and Health Sciences Supplementary Issue: 2022 Page: S41

Endocan-microvascular Density in Primary Ovarian Carcinoma

BACKGROUND

Epithelial ovarian cancer is among the leading causes of death in women and is driven by angiogenesis. Microvascular density (MVD) can be used to evaluate angiogenesis in carcinomas and thus it can be used as a potential biomarker for ovarian cancer. This study is aimed to establish the association between endocan-MVD with clinicopathological factors in primary epithelial ovarian cancer.

METHODS

The clinicopathological characteristics were acquired from the medical records filed between January 2008 and December 2018 of 89 epithelial ovarian cancer cases in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Sectioned samples were analyzed for endocan through immunohistochemistry followed by the quantification of MVD. The association between clinicopathological characteristics and endocan-MVD was analyzed using the Pearson chi-square test and Fischer's exact test.

RESULTS

All cases of epithelial ovarian carcinomas were positive for endocan. The mean ± standard deviation value of endocan-MVD level was 21.6±14.60 microvessels per 200x field. A total of 53 (59.6%) cases had low and 36 (40.04%) had high endocan-MVD values. High endocan-MVD level had a significant association with the older age group (p-value = 0.009), smaller tumor size (p-value<0.001), type II tumor (p-value<0.001), high-grade tumor (p-value<0.001), advanced FIGO stage (p-value=0.002), and presence of tumor recurrence (p-value=0.017). No significant association was found between endocan-MVD and the other clinicopathological characteristics such as race, pre-operative serum CA-125 level, presence of diabetes mellitus, endometriosis, lymph node involvement, distant metastasis, and family history of malignancy.

CONCLUSION

Endocan-MVD showed a significant association with age, tumor size, tumor type, tumor grade, FIGO stage, and recurrence in primary epithelial ovarian cancer. Thus, endocan-MVD could be implemented as a reliable marker to predict prognosis in epithelial ovarian cancer in the future.

Survival and Prognostic Factors of HIV-positive Patients after Antiretroviral Therapy Initiation at a Malaysian Referral Hospital

Background

Antiretroviral therapy (ART) has transformed the management of human immunodeficiency virus (HIV) infection and significantly improved survival rates, but there is lack of such survival data from Malaysia.

Objective

The objective was to determine the survival rates and prognostic factors of survival in HIV-infected adults treated with ART in Malaysia.

Materials and Methods

This retrospective cohort study considered all HIV-positive adult patients registered in Sungai Buloh Hospital, a major referral center in Malaysia, between January 1, 2007 and December 31, 2016. Then, patients were selected through a systematic sampling method. Demographic, clinical, and treatment data were extracted from electronic medical records. Person-years at risk and incidence of mortality rate per 100 person-years were calculated. The Kaplan-Meier survival curve and log-rank test were used to compare the overall survival rates. Cox proportional hazards regression was applied to determine the prognostic factors for survival.

Results

A total of 339 patients were included. The estimated overall survival rates were 93.8%, 90.4%, 84.9%, and 72.8% at 1, 3, 5, and 10 years, respectively, from ART initiation. The results of multiple Cox proportional hazard regression indicated that anemic patients were at a 3.76 times higher risk of mortality (95% confidence interval [CI]: 1.97-7.18; P < 0.001). The hazard risk was 2.09 times higher for HIV patients co-infected with tuberculosis (95% CI: 1.10, 3.96; P = 0.024).

Conclusion

The overall survival rates among HIV-infected adults in this study are higher than that from low-income countries but lower than that from high-income countries. Low baseline hemoglobin levels of <11 g/dL and tuberculosis co-infection were strong prognostic factors for survival.

Foetal and maternal outcomes in hyperuricaemia pre-eclampsia patients in Hospital Universiti Sains Malaysia

Preeclampsia patients have frequently been found to experience hyperuricaemia and this may result in poor outcomes compared to those with normal uric acid levels. This study aimed to determine the relationship of hyperuricaemia in pre-eclampsia patients with foetal and maternal outcomes. This prospective cohort study involved 79 patients in a tertiary centre from year 2016 to 2018. Blood samples were taken antenatally and at the 6th week, post-delivery for renal function including serum uric acid level. Our findings indicate that there was a higher incidence of poor maternal and foetal outcomes in the hyperuricaemia group than the normal uric acid group. Serum uric acid has been shown to be a significant predictor for low birth weight and premature delivery in preeclampsia patients. It was also found that there was a significant negative correlation between uric acid level and antenatal creatinine clearance (r_s = -0.338, p = .002). The assessment of the serum uric acid level seems to be important to ensure better outcomes in patients with preeclampsia.Impact statementWhat is already known on this subject? Preeclampsia is a serious pregnancy-related complication and remains as one of the most important cause of maternal and foetal morbidity and mortality, affecting 2-8% in all pregnancy. Many studies have established the association between hyperuricaemia and preeclampsia. Besides, numerous studies have found that hyperuricaemia contributed to adverse maternal and foetal outcomes.What the results of this study add? There was a significant increase in adverse foetal and maternal outcomes in the hyperuricaemia group compared to the normal uric acid group. This study revealed that serum uric acid remains a significant predictor for low birth weight and premature delivery in preeclampsia patients.What the implications are of these findings for clinical practice and/or further research? Hyperuricaemia does not merely become an indicator for the severity of disease in preeclampsia patients but also indicates adverse foetal outcomes. Large population-based studies are required to establish the absolute maternal and foetal outcomes in patients with hyperuricaemia. Besides, further studies are recommended on long-term implication of hyperuricaemia which is not limited to only during antenatal period.

Effect of physical activity on severity of primary angle closure glaucoma

Objective:

To determine the association between physical activity and severity of primary angle closure glaucoma in Malay patients.

Methods:

A cross-sectional study was conducted involving 150 primary angle closure glaucoma patients between April 2014 and August 2016. Using the International Physical Activity Questionnaire, the physical activity status was assessed and divided into three categories: mild, moderate and heavy physical activity. The duration of physical activity and corresponding minimum energy requirements were calculated. Ocular examination was performed including Humphrey visual field 24-2 analysis assessment. Based on two consecutive reliable Humphrey visual fields, the severity of glaucoma was scored according to modified Advanced Glaucoma Intervention Study and classified as mild (0–5), moderate (6–11) and severe (12–20). Association between physical activity and Advanced Glaucoma Intervention Study score was determined with multiple linear regression analysis.

Results:

A total of 150 Malay patients with primary angle closure glaucoma were included (50 patients with mild, 50 with moderate and 50 with severe glaucoma). Physical activity showed inverse association with the severity of primary angle closure glaucoma. After calculating adjustments for age, sex, duration of glaucoma, body mass index, systemic co-morbidities, family history of glaucoma, myopia and educational status [adjusted b –3.41, 95% confidence interval (–5.23, –1.59), p < 0.001], there was also an inverse relationship with Advanced Glaucoma Intervention Study score. Every increase in physical activity level reduces the Advanced Glaucoma Intervention Study score by 3.4 point.

Conclusion:

Physical activity is the potential modifiable risk factor in reducing the severity of glaucoma among primary angle closure glaucoma patients. However, there is possibility of the severity of glaucoma restricted the physical activity of primary angle closure glaucoma patients.

Evaluation of Optic Nerve Head Parameters, Retinal Nerve Fiber Layer Thickness, and Ocular Perfusion Pressure in Migraine Patients

Background

Neurovascular changes occur during the migraine is believed to cause alteration in cerebral and retinal circulation that possible result in damage to the brain and even retina or optic nerve. Retinal nerve fiber layer (RNFL) thickness measurement can be used as an index to assess ganglion cell and retinal nerve fiber damages. The aim of this study was to evaluate the optic nerve head (ONH) parameters, RNFL thickness, and ocular perfusion pressure (OPP) in migraine patients.

Methods

This was a cross-sectional study, conducted in Hospital Universiti Sains Malaysia, Kelantan from July 2016 to November 2018, involving patients with a confirmed diagnosis of migraine and controls. Ninety-four eyes of 47 migraine patients and 94 eyes of 47 healthy subjects were included in this study. Blood pressure and intraocular pressure were measured and OPP was calculated. ONH parameters and RNFL thickness were measured using optical coherence tomography (OCT) after pupillary dilatation. Statistical analysis was done using Statistical Package for the Social Science (SPSS Inc Version 24).

Results

With respect to all means values of ONH parameters, there was no statistically significant difference between migraine patients and controls. For RNFL, there were significant reductions in average and superior RNFL thickness on both eyes with adjustment of age and gender (P-value: right eye (RE) average = 0.027; RE superior = 0.034; left eye (LE) average = 0.037; LE superior = 0.031). In view of OPP, there was no significant difference between migraine patients and controls (P-value = 0.172). Weak correlations were found between the ONH parameters and RNFL thickness with OPP, respectively, in migraine patients.

Conclusion

This study showed no difference in ONH parameters between migraine patients and healthy subjects. There was significant thinning in average and superior RNFL for migraine patients. No difference found in OPP between both groups. ONH parameters and RNFL thickness had a weak correlation with OPP in migraine patients.