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.

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.

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.

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 (rs = -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.

Antioxidant Enzymes in Tears Among Malay Age-related Macular Degeneration Patients

@#Introduction: Age-related macular degeneration (ARMD) is an ocular degenerative disorder that associated with impairment of central vision. Oxidative stress plays an important role in the pathogenesis of ARMD. The aim of this study was to determine the level of antioxidant enzymes (catalase and glutathione peroxidase) in tears among Malay ARMD patients. Methods: A cross sectional study was conducted between September 2015 and November 2017 among Malay ARMD patients. Schirmer paper was used to collect the tear samples. The level of catalase and glutathione peroxidase level in tears was evaluated using commercially available oxidative stress marker kits. Results: A total of 136 Malay ARMD patients were recruited into the study with 68 controls. Mean tear catalase and glutathione peroxidase levels were significantly lower in ARMD patients (1348.97 SD 109.11 µM and 453.87 SD 41.96 U/L respectively) as compared to the control group (1453.38 SD 38.87 µM and 502.28 SD 34.29 U/L respectively) (P<0.001 and P<0.001 respectively). Late ARMD has lower mean of catalase level in tears as compared to early ARMD (P=0.044). Based on subtypes of neovascular late ARMD, neovascular ARMD has lower mean catalase level in tears compared to idiopathic polypoidal choroidal vasculopathy (IPCV) (P=0.031). Conclusion: This study showed that antioxidant enzyme might play an important factor in the pathogenesis of ARMD.

Ultrasound findings of plasma leakage as imaging adjunct in clinical management of dengue fever without warning signs

@#ed as outpatients. Ultrasonographyevidence of plasma leakage either pleural effusion,thickened gallbladder wall, ascites or pericardial effusionwere compared with clinical findings and laboratoryparameters for plasma leakage. Results: Of the 83 dengue patients, eventually 72.3% haddengue fever with warning signs and 6.0% had severedengue fever. There were 38 patients who had subclinicalplasma leakage at initial presentation, 84.2% and 7.9% ofthem then progressed to dengue fever with warning signsand severe dengue respectively. There was a minimalagreement between serial bedside ultrasound andhaematocrit level in the detection of plasma leakage(observed kappa 0.135). Conclusions: Serial bedside ultrasound is an adjunctprocedure to physical examination and may detect plasmaleakage earlier compared to haemoconcentration. The earlyusage of serial ultrasound is of paramount importance indetecting dengue patients who are at risk of progressing tosevere dengue.

Evaluation of vascular endothelial growth factor levels in tears and serum among diabetic patients.

OBJECTIVE: Detection of vascular endothelial growth factor (VEGF) levels in ocular tissue may perhaps provide insight into the role of VEGF in the pathogenesis and progression of diabetic retinopathy (DR). The aim of this study was to evaluate the levels of VEGF in tears and serum amongst type 2 diabetes mellitus (DM) patients. METHODS: A comparative cross-sectional study was conducted between August 2016 and May 2018 involving type 2 DM patients with no DR, non-proliferative DR (NPDR), and proliferative DR (PDR). Tear samples were collected using no.41 Whatman filter paper (Schirmer strips) and 5 mL blood samples were drawn by venous puncture. VEGF levels in tears and serum were measured by enzyme-linked immunosorbent assay. RESULTS: A total of 88 type 2 DM patients (no DR: 30 patients, NPDR: 28 patients, PDR: 30 patients) were included in the study. Mean tear VEGF levels were significantly higher in the NPDR and PDR groups (114.4 SD 52.5 pg/mL and 150.8 SD 49.7 pg/mL, respectively) compared to the no DR group (40.4 SD 26.5 pg/mL, p < 0.001). There was no significant difference in the mean serum VEGF levels between the three groups. There was a fair correlation between serum and tear VEGF levels (p = 0.015, r = 0.263). CONCLUSION: VEGF levels in tears were significantly higher amongst diabetic patients with DR compared to those without DR and were significantly associated with the severity of DR. There was a fair correlation between serum and tear VEGF levels. Detection of VEGF in tears is a good non-invasive predictor test for the severity of DR. A large cohort study is needed for further evaluation.

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.

Median Survival Time of Endometrial Cancer Patients with Lymphovascular Invasion at the Hospital Universiti Sains Malaysia

Background: Endometrial cancer is the most common gynaecologic malignancy among females worldwide. The purpose of this study was to determine the median survival time of endometrial cancer patients at the Hospital Universiti Sains Malaysia (USM). Methods: A list of 121 endometrial cancer cases registered at Hospital USM between 2000 until 2011 was retrospectively reviewed. The survival time of the endometrial cancer patients was estimated by Kaplan-Meier survival analysis. Log-rank tests were performed to compare the survival of the patients based on socio-demographics and clinical presentation. Results: Only 108 patients, 87.0%, were included who were of Malay ethnicity. Previous history included menopause in 67.6% of patients and diabetes mellitus in 39.8% of patients; additionally, 63.4% of patients were nulliparous. Tumour staging was as follows: 24.5% stage I, 10.8% stage II, 26.5% stage III and 38.2% stage IV. The overall median survival time of the endometrial cancer patients was 70.20 months (95% confidence interval (CI): 51.79, 88.61). The significant factors were age, the presence of lymphovascular invasion and treatment received. Conclusion: The overall survival of endometrial cancer was low. A prospective study needs to be carried out to discover more effective and accurate tests for the early detection of endometrial cancer.

Reporting Statistical Results in Medical Journals

Statistical editors of the Malaysian Journal of Medical Sciences (MJMS) must go through many submitted manuscripts, focusing on the statistical aspect of the manuscripts. However, the editors notice myriad styles of reporting the statistical results, which are not standardised among the authors. This could be due to the lack of clear written instructions on reporting statistics in the guidelines for authors. The aim of this editorial is to briefly outline reporting methods for several important and common statistical results. It will also address a number of common mistakes made by the authors. The editorial will serve as a guideline for authors aiming to publish in the MJMS as well as in other medical journals.