Sarawak General Hospital

Intravenous ketamine is increasingly used for refractory and super-refractory status epilepticus (RSE/SRSE), yet its efficacy and optimal use remain uncertain. We therefore aimed to synthesize the available evidence to quantify the effectiveness of ketamine in achieving seizure cessation and to explore differences in treatment characteristics between patients who respond and those who do not. We conducted a systematic review and meta-analysis to estimate the pooled seizure cessation rate associated with intravenous ketamine. Secondary analyses compared ketamine initiation timing, dosing, and infusion duration between patients who achieved seizure cessation (responders) and those who did not (nonresponders). Fourteen studies comprising 388 adult patients (249 responders, 139 nonresponders) were included. The pooled seizure cessation rate with ketamine was 64% (95% CI 49%-76%) with moderate heterogeneity (I 2 = 54.1%). Sensitivity analysis showed no single study substantially influenced results, supporting robustness. Responders received ketamine earlier (3.2 ± 2.6 days) than non-responders (4.3 ± 2.6 days), mean difference of -0.90 days (95% CI: -1.31 to -0.49; p < 0.0001). The mean maintenance dose was 2.5 ± 1.4 mg/kg/hr (responders: 2.5 ± 1.3; nonresponders: 2.6 ± 1.4), with no significant difference between groups (mean difference -0.14 mg/kg/hr; 95% CI -0.45 to 0.18; p = 0.39). Infusion duration averaged 5.0 ± 4.2 days in both groups, with no significant difference (mean difference -0.07 days; 95% CI -1.02 to 0.88; p = 0.88). Ketamine discontinuation due to adverse events was rare (0.7%, 3/55 patients). Intravenous ketamine demonstrates consistent effectiveness and safety as an adjunctive therapy in RSE/SRSE. However, the timing of initiation cannot be reliably linked to improved clinical outcomes given current methodological limitations and heterogeneity across studies. Future prospective research using standardized definitions and rigorous temporal data collection is needed to clarify whether the timing of ketamine initiation independently influences therapeutic success and to define its optimal integration within established status epilepticus (SE) treatment algorithms. The systematic review was registered (June 7, 2024) with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024549523).

Minimal residual disease (MRD) detection using liquid biopsy is an emerging tool for risk stratification and monitoring for recurrence in resected early stage NSCLC. There is increasing need for clear guidance on its optimal clinical implementation. The Asian Thoracic Oncology Research Group (ATORG) convened a multidisciplinary panel of 27 experts to develop a consensus statement on the clinical application of circulating tumor DNA-based MRD testing in early stage resected NSCLC, using a structured Delphi methodology. Statements were organized into the following broad thematic domains: assay validity and standardization; harmonization in research and trials; clinical application; challenges in implementation; consensus recommendations; infrastructure for regional MRD adoption; and roadmap for pragmatic trials. A total of 23 position statements were developed, of which all except one achieved strong consensus. The consensus highlighted the need to define minimum analytical performance thresholds for MRD assays, improve standardization of reporting metrics, and clear guidelines for pre-analytical handling. Harmonization of blood sampling time points and terminology across clinical trials is also essential to confirm the prognostic value of MRD assays. Although current MRD assays demonstrate high specificity and positive predictive value, variable sensitivity precludes routine use for adjuvant therapy de-escalation outside clinical trials. Broader access, sustainable funding, ongoing consensus building, and collaborative real-world data generation are also critical to support clinical implementation and adoption. Future clinical trials must account for the distinct biology and changing standards of care associated with different driver genes. These consensus recommendations provide a pragmatic framework to guide the responsible integration of MRD testing into clinical research and practice.

Flexible cystoscopy is well tolerated by women. Reprocessing of cystoscopes requires sterilization or, at least, high-level disinfection (HLD). This study aims to assess the incidence of bacteriuria after flexible cystoscopy using ortho-phthalaldehyde HLD. This is a prospective study. Seventy-eight women undergoing diagnostic outpatient flexible cystoscopy were included. Exclusion criteria were microbiologically confirmed or acute urinary tract infection, significant urethral stricture, and bleeding disorders. Cystoscopes were reprocessed using ortho-phthalaldehyde. Pre-cystoscopic urine cultures were obtained via catheterization 3-5days prior. Post-cystoscopic urine cultures were obtained immediately after the procedure. No antibiotics prophylaxis. One woman (1.3%) developed post-cystoscopy bacteriuria. The overall mean age was 58.7 ± 11.2years; the mean BMI was 23.4 ± 3.3kg/m2. In the non-bacteriuric cohort, the mean age was 58.87 ± 11.3years, 40 (51.9%) were in the older age group (> 60years), 60 (77.9%) were postmenopausal, 69 (89.6%) were non-diabetic, 20 (26%) had a prior hysterectomy, 13 (16.9%) had previous pelvic reconstructive surgery, 10 (13%) had undergone anti-stress urinary incontinence surgery, and no woman had current pelvic organ prolapse. The most common indication for flexible cystoscopy was hematuria (n = 45, 58.4%). Seventy-three (94.8%) women had unremarkable cystoscopic findings. The single bacteriuric woman was 53years old, postmenopausal, non-diabetic, with a BMI of 22.3kg/m2, and an intact uterus; cystoscopy was performed for interstitial cystitis. The incidence of bacteriuria following flexible cystoscopy was 1.3%. Ortho-phthalaldehyde is effective for HLD in flexible cystoscopy, provided robust rinsing, drying, and exposure-tracking protocols are maintained.

Direct oral anticoagulants (DOACs) are preferred for atrial fibrillation (AF) due to their efficacy and safety, though response variabilities raises concerns about fixed-dose regimens. This study investigates the association between ABCB1 and CES1 genetic polymorphisms with Dabigatran trough drug levels (DL), clotting time (CT), and clinical outcomes in a multiethnic Malaysian cohort. A total of 180 AF patients in Dabigatran were sequenced across the entire length of ABCB1 and CES1 genes using the Illumina MiSeq platform. Trough Dabigatran levels and clotting time were measured by LC-MS/MS and viscoelastic assay (Clotpro®), respectively. Patients were followed up for one year to assess major adverse cardiovascular and cerebrovascular events (MACCE). The mean dabigatran level was 34.7 ± 45.4 ng/ml (CV: 130%), and clotting time was 374.6 ± 207.9 s (CV: 55.5%). Trough levels were significantly correlated with clotting time (r = 0.663, p < 0.001). Multiple non-coding variants in ABCB1 and CES1 showed nominal associations (unadjusted p < 0.05) with drug level (35 SNPs) and/or clotting time (32 SNPs), although none remained statistically significant after false discovery rate correction. A total of 17 SNPs overlapped, and were associated with both. Overall, these findings suggest that non-coding regulatory variation may contribute to inter-individual variability in dabigatran pharmacokinetics and pharmacodynamics, but the results are exploratory and require replication in larger cohorts. This study highlights the importance of population-specific pharmacogenomic research for future investigations on personalized anticoagulation strategies.

Femoral neck fractures in older adults often require extensive recovery, making family caregivers essential in providing daily assistance and emotional support. This study examined the quality of life and burden among 176 informal caregivers in Malaysian public hospitals using the SF-36 and Caregiver Burden Inventory. Findings showed moderate physical (PCS = 48.84) and mental (MCS = 51.81) quality of life, alongside moderate caregiver burden (CBI = 46.39). Caregivers nonetheless reported notable strain across multiple domains. These results highlight the need for improved support systems, including psychosocial resources, respite care, and stronger rehabilitation services to enhance caregiver well-being and patient recovery.

In Malaysia, the rising number of medical graduates has led to a shift from permanent to contract employment in the healthcare system since 2016. This study investigates the impact of employment status on mental health outcomes, job satisfaction, and career perceptions among junior doctors in Malaysia. This nationwide study compared 1,966 contract and 698 permanent junior doctors in Malaysia using validated instruments (Maslach Burnout Inventory, DASS-21, WHOQOL-BREF) and career perception measures. Contract doctors showed higher depression (adjusted mean 8.72 [95% CI: 8.18-9.26] vs 6.88 [95% CI: 6.25- 7.51], p<0.001), anxiety (adjusted mean 6.41 [95% CI: 5.96- 6.86] vs. 4.89 [95% CI: 4.36-5.41], p<0.001), stress (adjusted mean 8.74 [95% CI: 8.24-9.23] vs 7.86 [95% CI, 7.28-8.44], p<0.001), emotional exhaustion (adjusted mean 32.14 [95% CI: 30.86-33.42] vs 27.18 [95% CI: 25.68-28.68], p<0.001), and depersonalization (14.10 [95% CI: 13.41-14.80] vs 11.94 [95% CI: 11.13-12.76], p<0.001). Their quality of life was lower in physical (adjusted mean 10.48 [95% CI: 10.30-10.67] vs 11.09 [95% CI: 10.87-11.31], p<0.001), psychological (adjusted mean 11.50 [95% CI: 11.29-11.70] vs 11.86 [95% CI: 11.63- 12.10], p<0.001), and environmental domains (adjusted mean 12.42 [95% CI: 12.18-12.65] vs 13.11 [95% CI 12.83-13.38], p<0.001). Contract doctors reported significantly lower satisfaction across multiple domains. Despite similar aspirations to succeed in medicine (OR 0.8 [95% CI: 0.6-1.1], p=0.117), contract doctors reported lower career security (OR 0.04 [95% CI: 0.03-0.05], p<0.001), reduced confidence in specialty training access (OR 0.3 [95% CI: 0.2-0.3], p<0.001), and higher intentions to change careers (OR 5.9 [95% CI: 4.7- 7.5], p<0.001) or emigrate (OR 1.9 [95% CI: 1.5-2.3], p<0.001). Contract employment is associated with poorer mental health, reduced job satisfaction, and diminished career confidence despite similar professional aspirations. These findings suggest current employment practices may threaten healthcare workforce sustainability and highlight the need for policy reforms.

An iatrogenic bronchopleural fistula from chest tube injury caused an air leak in empyema thoracis. Bronchoscopic placement of an endobronchial Watanabe spigot sealed the leak, offering a minimally invasive alternative when surgery was not feasible. https://bit.ly/3XOAFfS.

ABSTRACTEvidence for the use of prophylactic anti‐seizure medication (ASM) in traumatic brain injury (TBI) in reducing the occurrence of early post‐traumatic seizure (EPTS) remains equivocal. This study aimed to analyze the prevalence of EPTS in children with TBI, compare clinical characteristics of those with and without EPTS, and explore the association between prophylactic ASM and EPTS. We performed an observational study among 28 pediatric intensive care units in 15 countries from January 2014 to October 2022. The rate of EPTS was compared between individuals prescribed prophylactic ASM and those who were not. Logistic regression was used to examine the association between ASM and EPTS. Among 697 children with TBI, 161 (23.1%) developed EPTS and 280 (40.2%) received prophylactic ASM treatment. Use of prophylactic ASM was associated with a lower likelihood of developing EPTS (27/280 (9.6%) vs. 134/417 (32.1%), p < 0.001). The most frequently used prophylactic ASMs were phenytoin, levetiracetam, and phenobarbital. Age ≤ 4 years and GCS ≤ 8 were associated with increased odds of developing EPTS (aOR 2.29, 95% CI 1.54–3.40, p < 0.001 and aOR 1.80, 95% CI 1.18–2.74, p = 0.01). Our data provide evidence supporting the potential protective role of prophylactic ASM against EPTS.