A clinical audit on the diagnosis and management of infective endocarditis in a tertiary heart centre in Malaysia.

INTRODUCTION: Infective endocarditis (IE) has a high mortality rate in developing countries including Malaysia. This clinical audit aims to identify the shortcomings in the diagnosis and management of IE patients in a local tertiary centre to implement changes for improvement. MATERIALS AND METHODS: This retrospective audit had two cycles - the first includes all IE patients in Sarawak Heart Centre, Malaysia from January 2020 to December 2022 with different parameters (blood culture, echocardiogram, the appropriateness of antibiotics and surgery) assessed against Malaysian Clinical Practice Guideline (CPG); and reaudit from July 2023 to December 2023. Interventions before re-audit include presentation at different hospital levels and continuing medical education. RESULTS: Fifty patients were recruited (37 in the first cycle, 13 in the second cycle). The median age was 48.5 years with male predominance. Valve prosthesis (12.0%) and rheumatic heart disease (10.0%) were the commonest predisposing factors. Native mitral (44.0%) and aortic valves (28.0%) were most commonly involved. Twenty-eight (56.0%) patients were culture-positive. In the first cycle, most parameters (culture technique 0.0%, vegetation measured 54.1%, empirical 5.4%, culture-guided 29.7% antibiotics therapy, indicated surgery 0.0%) did not achieve the expected standard except timeliness of echocardiograms and blood culture incubation period. After initial interventions, all parameters showed statistically significant improvement (culture technique p<0.001, echocardiography p<0.001, empirical p<0.001, culture-guided p=0.021, surgery p<0.001) during the re-audit. CONCLUSION: Compliance with clinical practice guidelines (CPG) on IE management was suboptimal during the first audit but improved after interventions. Hence, regular continuing medical education (CME) is essential, and a written hospital protocol may be useful. Regular audits alongside multidisciplinary teamwork are crucial efforts.

Factors associated with in-hospital mortality among infective endocarditis patients.

INTRODUCTION: Despite recent advancements in the diagnosis and management of infective endocarditis (IE), it is associated with substantial morbidity and mortality. Our study objective is to determine the factors associated with in-hospital mortality in IE patients among the local population. MATERIALS AND METHODS: All IE patients who were diagnosed with definite or possible IE and were treated at Sarawak Heart Centre from 1st January 2020 to 31st December 2022 were recruited. We examined the demographic features of the subjects and the factors that contributed to in-hospital mortality. Multivariate logistic regression was used to analyse the associated factors and in-hospital mortality. RESULTS: Our study population comprised a total of 37 patients with a mean age of 46.4 years and male predominance. The in-hospital mortality rate of IE in this study was 44.4%. Haemodynamic instability and anaemia were found to be strong predictors of IE survival outcome, with an odds ratio of 51.5 and 35.7 respectively. Patients with vascular phenomenon and heart failure were at 10.5- and 6.0-times higher odds of dying, however, these two associations were found to be not statistically significant. CONCLUSION: The in-hospital mortality due to IE in our study was among the highest in developing countries. Factors of hypotension and optimal response to individual hemodynamic parameters may confer lower mortality. While anaemia is demonstrable as a risk factor for inpatient mortality, a target has yet to be reasonably established.

A pre-admission triaging tool to predict severe COVID-19 cases: ABCD score.

INTRODUCTION: Isolation of SARS-CoV-2-infected individuals is an important COVID-19 pandemic control measure. While most cases have uncomplicated infection, a small proportion of them has developed life-threatening disease. We set up a retrospective study to determine preadmission triaging tool to predict the development of severe COVID-19. MATERIALS AND METHODS: A retrospective study was conducted from 1 October 2020 to 31 January 2021 with enrolment of all SARS-CoV-2 PCR-confirmed persons aged ≥13 years. The disease severity was assessed on admission and daily throughout the hospitalisation. Test-positive individuals were considered as having "severe COVID-19" if they had ≥1 of the following: room air oxygen saturation 30 breaths/minute, signs of severe respiratory distress, or received mechanical ventilation and/or vasopressor therapy. Uni- and multi-variate analyses using SPSS Statistics Ver. 26 were performed. RESULTS: We showed that age ≥ 60 years, BMI ≥ 30.0, presentation on days 7-12 of illness, and ≥1 comorbidity were associated with development of severe COVID-19. A scoring system based on the four variables is a useful COVID-19 risk assessment tool. A total score ≥2 had a sensitivity of 60.9%, specificity of 88.2%, positive predictive value of 37.8% and negative predictive value of 95.0%. CONCLUSION: Development of preadmission triaging tool can help health care providers (HCPs) decide on the placement of test-positive individuals to appropriate isolation facilities according to the risk of developing severe COVID-19.

Case series: Fulminant community-acquired Acinetobacter pneumonia.

Acinetobacter infection, especially the drug-resistant strain, is a common cause of nosocomial infection. However, community-acquired Acinetobacter infection is uncommon. We reported three cases of community-acquired Acinetobacter pneumonia. All three cases had histories of regular home-brewed alcohol consumption presented with severe acute respiratory symptoms requiring ventilatory support and had low total white cell count. They succumbed to the illness within 2 to 10 days of admission. They had positive blood or endotracheal aspirate cultures of sensitive-strain Acinetobacter sp. which was only sensitive to high dose sulbactam. Early recognition and correct antibiotic can help reduce mortality.

Thrombotic thrombocytopenic purpura-like syndrome associated with arcanobacterium pyogenes endocarditis in a post-transplant patient: A case report.

Systemic Arcanobacterium pyogenes is a rare bacterial infection in humans.1The diagnosis of thrombotic thrombocytopenic purpura (TTP)-like syndrome and infective endocarditis (IE) is often elusive. We report a case of TTP-like syndrome associated with A. pyogenes endocarditis in a post-allogenic transplant patient.

Subcutaneous mycosis presenting as a non- healing left calf ulcer in an immunocompromised patient.

This is a case report of subcutaneous mycosis presenting as a non-healing left calf ulcer in an immunocompromised patient. Traumatic inoculation of the causative agent is the most likely route of infection. The diagnosis requires a detailed history and high clinical suspicion, confirmed by histopathological examination. The management requires a multidisciplinary team approach involving surgeon, pathologist, physician sub-specialised in infectious disease, wound care nursing team as well as social support services. The literature review recommended that the treatment of choice for such infection is surgical debridement in addition to optimal antifungal therapy.

Epidemiology of Culture-positive Infection in Adult Patients with Haematological Malignancies in Sarawak.

No abstract available.

A fatal case of chikungunya virus infection with liver involvement.

Recovery from chikungunya is previously considered universal and mortality due to the virus is rare and unusual. Findings from recent chikungunya outbreaks occurred in Reunion Island and India have since challenged the conventional view on the benign nature of the illness. Malaysia has experienced at least of 4 outbreaks of chikungunya since 1998. In the present on-going large outbreak due to chikungunya virus of Central/East African genotype, a previous healthy sixty six years gentleman without co-morbidity was noted to have severe systemic infection by the virus and involvement of his liver. He subsequently passed away due to cardiovascular collapse after 5 days of illness.

Outbreak of chikungunya in Johor Bahru, Malaysia: clinical and laboratory features of hospitalized patients.

In 2008, an outbreak of chikungunya infection occurred in Johor. We performed a retrospective review of all laboratory confirmed adult chikungunya cases admitted to Hospital Sultanah Aminah, Johor Bahru from April to August 2008, looking into clinical and laboratory features. A total of 18 laboratory confirmed cases of chikungunya were identified with patients presenting with fever, joint pain, rash and vomiting. Haemorrhagic signs were not seen. Lymphopenia, neutropenia, thrombocytopenia, raised liver enzymes and deranged coagulation profile were the prominent laboratory findings. We hope this study can help guide physician making a diagnosis of chikungunya against other arborviruses infection.

Upregulation of tyrosine kinase TKT by the Epstein-Barr virus transactivator Zta.

The Zta protein is a key transactivator involved in initiating the Epstein-Barr virus (EBV) lytic cascade. In addition to transactivating many viral genes, Zta has the capacity to influence host cellular signals by binding to promoter regions or by interacting with several important cellular factors. Based on the observation that tyrosine kinases play central roles in determining the fate of cells, a kinase display assay was used to investigate whether cells expressing Zta have an altered pattern of kinase expression. The assay revealed that TRK-related tyrosine kinase (TKT) is expressed at significant levels in Zta transfectants but not in control cells. Additional evidence was obtained from Northern and Western blotting. Importantly, the upregulation of phosphorylated TKT and TKT downstream effector matrix metalloproteinase 1 in Zta transfectants hinted that TKT might initiate a signaling cascade in Zta-expressing cells. In addition, deletion analysis of the Zta protein revealed that the transactivation and dimerization domains were both essential for the upregulation of TKT transcription. Moreover, correlation of expression levels of Zta and TKT transcripts in nasopharyngeal carcinoma biopsy specimens was clearly demonstrated by quantitative PCR (Q-PCR), which provides the first evidence for an effect of Zta on cellular gene expression in vivo. These findings offer insight into the virus-cell interactions and may help us elucidate the role of EBV in tumorigenesis.