A Comparison between Continuous Indirect Calorimetry and Single Weight-Based Formula in Estimating Resting Energy Expenditure in Nutritional Therapy: A Prospective Randomized Controlled Study in Critically Ill Patients

Optimal nutritional therapy is important to improve outcome in critically ill population in an intensive care unit (ICU). Although indirect calorimetry (IC) is currently a gold standard for resting energy expenditure (REE) measurement, yet it is still not routinely used in the ICU. A total of 146 mechanically ventilated patients were randomised to receive enteral nutrition (EN) with energy targeted based on continuous indirect calorimetry (IC) measurements (IC group, n=73) or according to 25 kcal/kg/day (SWB group, n=73). Patient characteristics were equally distributed and the IC group showed lower mean measured REE (1668.1 + 231.7 vs 1512.0 + 177.1 kcal, p<0.001). Results also showed a significant deficiency in the daily (-148.8 + 105.1 vs. -4.99 + 44.0 kcal, p<0.001) and total cumulative energy balances (-1165.3 + 958.1 vs. 46.5 + 369.5 kcal, p<0.001) in the SWB group as compared to the IC group. From the Kaplan-Meier survival analysis, we found that ICU mortality was significantly lower in the IC group with better survival probability compared to the SWB group (log-rank test, p = 0.03). However, both groups showed comparable results in terms of ICU length of stay, duration of mechanical ventilation and incidence of feeding intolerance. In conclusion, this study showed that tightly supervised nutritional therapy based on continuous IC measurement provides significantly less mean daily and cumulative energy deficits as well as significantly reduced ICU mortality rate.

Neuroleptic Malignant Syndrome in an Elderly Patient with Bipolar Disorder

Neuroleptic malignant syndrome (NMS) is a well-known and potentially fatal complication of antipsychotic use. The elderly population, with multiple risk factors, are more vulnerable to this condition. We described a case of an 80-yearold man with bipolar disorder, previously on oral extended-release sodium valproate, aripiprazole and long-acting injectable paliperidone, who developed NMS. He presented with generalised muscle rigidity, fever, fluctuating blood pressure and elevated creatinine kinase during his hospitalisation for a manic episode. Contributing factors included old age, underlying vascular Parkinsonism, electrolyte imbalance, intercurrent lung infection with acute exacerbation of chronic obstructive pulmonary disease, hyperactive delirium, and repeated administration of parenteral typical antipsychotic. Antipsychotics were withheld promptly, and the patient was treated with dantrolene, bromocriptine and amantadine. His symptoms resolved after a week. He subsequently remained well with oral extended-release sodium valproate alone. Relevant clinical points are discussed. Clinical vigilance, close interdisciplinary cooperation, and prompt interventions are keys to successful to management of NMS in elderly patients.

Knowledge Levels of Medical Faculty Students and Residents about Ionizing Radiation

This study aimed to evaluate the knowledge levels of medical school students and residents about ionising radiation. The study is designed as descriptive research, and it was conducted with 369 medical school students and residents. A survey form was used in the research. A Chi-square test was used to compare categorical variables. In the study, 369 people were reached within the scope of the research. A total of 60.7% of the research participants were clinical medicine students (4th, 5th, 6th grade) and 39.3% were residents. A total of 42.0% of the participants of the study were male, 58.0% were women. It was found that 17.9% of the clinical medical students and 18.6% of the residents had sufficient knowledge of ionising radiation (p=0.002). A total of 87.0% of the participants in the study answered correctly that magnetic resonance imaging (MRI) does not contain radiation and 93.5% answered correctly that ultrasonography (USG) does not contain radiation. 74.8% of the participants stated that having knowledge about ionising radiation would contribute to “protecting sensitive groups from ionising radiation” in medical practice. This ratio is 77.2% in clinical medicine students and 71.0% in residents. The study found that knowledge levels of medical faculty students and residents about ionising radiation were insufficient. Medical students and residents are recommended to be trained on radiation and the radiological requests of residents to be evaluated.

Correlation of Corneal Thickness Measurements Between Tono-pachymeter and Scheimpflug- Placido Topography

Central corneal thickness (CCT) measurements are important for diagnosis, treatment, and surgery planning in ophthalmology. The purpose of this study was to see whether CCT measurements taken with Tono-pachymeter and Scheimpflug- Placido Topography had any significant differences. Tono-pachymeter and topography CCT measurements were taken (n=400). Inter-measurement agreement between them was determined using Bland-Altman Plot analysis. Age groups were also formed as group 1 (aged 18-50 years, 94 males, 106 females) and group 2 (age >51 years, 100 males, 100 females). Mean CCTs measured by Tonopachymeter and topography were 563.77 +±26.43 and 560.88 + 26.341 microns. Bland-Altman Plot analysis showed in total, 13 were above the upper limit and 5 were under the minimum limit of agreement with regression analysis showing no significant relationships (p=0.213). Group 1 had 7 above and 2 below from the limits of agreement. Group two had 9 above and 2 below from the limits of agreement. Both groups showed insignificant differences between devices (p=0.07 and p=0.86). Tono-pachymeter and Scheimpflug-Placido Topography give reliable CCT results within each other. However, since the limit of agreement ranges can still affect one-to-one patient evaluations, we recommend clinics that use these devices to not interchange measurements in practice.

The Effectiveness of Non-clozapine Antipsychotics Combined with Electroconvulsive Therapy versus Clozapine Combined with Electroconvulsive Therapy for Treatment-resistant Schizophrenia

The study aimed to compare the effectiveness and safety of other atypical antipsychotics (non-clozapine) plus electroconvulsive therapy (ECT) (NC+ECT) versus clozapine plus ECT (C+ECT) for treating treatment-resistant schizophrenia (TRS). Data of 32 patients with TRS who was receiving ECT were analysed. We compared clinical characteristics, response to treatment [defined as an improvement of 40% in the Brief Psychotic Rating Scale (BPRS) psychotic symptom subscale from pretreatment scores], change of Mini-mental Status Exam (MMSE) scores, and other adverse effects between the NC+ECT group (N= 16) and C+ECT group (N =16). We found that the overall response rate was 65.6% (75.8% for the NC+ECT group and 56.3% for the C+ECT group, p=0.26). The overall BPRS score in both groups decreased significantly. The mean difference in total BPRS psychotic subscale score between pre-ECT and after last ECT was 10.4 + 5.8 (p<0.001) for the NC+ECT group and 6.6 + 7.3 (p = 0.002) for the C+ECT group. When comparing the NC+ECT group to the C+ECT group, the mean difference in total BPRS psychotic subscale score was not significant. (p = 0.104). The mean difference in MMSE score between pre-ECT and after the last ECT was -1.1 + 5.1 (p =0.45) for the NC+ECT group and 0.2 + 4.3 (p=0.855) for the C+ECT group. The change of MMSE score in the NC+ECT group was not significant different compare to the C+ECT group (p = 0.461). We concluded the combination of antipsychotics and ECT is an effective and safe treatment option for patients with TRS. Other NC+ECT groups’ efficacy may be comparable to that of clozapine plus ECT.

Utilising Virtual Reality in Pain Management: A Systematic Review

Virtual reality (VR) offers patient with a drug free supplement, an alternative or complementary therapy to traditional pain management. VR technology allowing its use in a wide variety of settings in the medicine world. So, we would like to evaluate the current existing evidence supporting VR in pain management. We conducted a systematic review of interventional and observational studies that examined VR applications in pain management between 2010 and 2019. We used Scopus databases, PubMed, Web of Science, Ovid MEDLINE and EBSCOhost to identify the studies using keywords “patient”, “virtual reality”, “medicine” and “pain management”. Data was obtained by two investigators and agreement was reached with the involvement of a third and fourth investigator. Narrative synthesis for all research was done. A total of 451 citations were identified, among which 12 studies met the criteria for inclusion. Studies involve various countries with participant age ranging from 6 to 75 years old. Studies were small, employed different design, instrument and measure for outcome. Studies addressed experimental, acute and chronic pain with four categories of condition which are burn injury, orthopedic diseases and chronic headache. VR was effective during the procedure in experimental and acute pain management. Majority of studies involving VR in painful physical rehabilitation therapy found VR reduced chronic pain and some provide evidence of lasting analgesia effect of VR after therapy. The usage of VR in chronic pain in term of psychological and cognitive behavioral therapy (CBT) showed improvement of positive mood, emotional and motivation that could lead to improvement of quality of life. VR also useful to elicit findings during painful cervical kinematics assessment in chronic neck pain. VR is a promising technology to be applied in managing chronic and acute pain. Some research showed that VR usage is able to provide lasting effect of analgesia even after VR session. However, there is a need for long term, larger sample sizes and well controlled studies to show clinical and cost-effectiveness for this technology to be used in clinical settings.

Comparison of Intravenous Lignocaine and Esmolol in Attenuating Hemodynamic Response and Cough Reflex during Extubation in Hypertensive Patients under General Anaesthesia

Tracheal extubation carries higher complication rates compared to intubation during general anaesthesia (GA). Thus, various drugs are used to attenuate hemodynamic responses and cough reflex during extubation. We investigated if intravenous (IV) lignocaine and esmolol, given prior extubation, was able to achieve that in hypertensive patients under GA. In this prospective, double-blinded, randomised controlled study, 68 hypertensive patients on treatment undergoing GA were analysed. Group L received IV lignocaine 1 mg/kg while Group E received IV esmolol 1.5 mg/kg, 2 minutes before extubation. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded at the following interval: before study drug administration (T-0), prior extubation (T-1), 1 minute (T-2), 3 minutes (T-3), 5 minutes (T-4) and 10 minutes (T-5) post-extubation. Group L showed significantly increase in HR at T-2 while SBP and MAP increased significantly from T-1 until T-5. Group E showed a significant reduction in HR at T-1 up to T-5 and significantly lower HR at T-1 and T-2 compared to Group L. Group E showed stable SBP, DBP and MAP at all intervals. In conclusion, IV esmolol at 1.5 mg/kg was able to attenuate the hemodynamic response more pronounced when compared to IV lignocaine at 1 mg/kg from extubation stress in patients with hypertension on treatment. Both lignocaine and esmolol were equally effective in suppressing cough reflex during extubation.

Haemophagocytic Lymphohistiocytosis (HLH) in Adult with Dengue Infection

Haemophagocytic lymphohistiocytosis (HLH) or haemophagocytic syndrome is a rare but life-threatening syndrome of excessive immune activation with nonspecific clinical presentation. HLH is one of the complications in dengue infection. A 69-year-old lady was treated for severe dengue with multi-organ dysfunction with superimposed pneumonia, requiring mechanical ventilation. However, persistent cytopenia despite blood transfusion without evidence of haemorrhage raised the suspicion of HLH. Further blood investigations revealed hypertriglyceridaemia, hypofibrinogenaemia and hyperferritinaemia. Bone marrow aspiration showed haemophagocytosis. Patient fulfilled the diagnostic criteria for HLH by HLH-2004 trial. Her HScore is 281, with the probability of having HLH is 99.9%. Patient’s condition improved after administration of intravenous immunoglobulin (IVIG) and intravenous dexamethasone in tapering doses. Early specific treatment of HLH with IVIG and/or corticosteroid is important but diagnosis is usually delayed due to nonspecific clinical findings and laboratory results. High index of suspicion with the aid of diagnostic criteria by HLH-2004 trial and HScore is helpful to recognise this syndrome.

The Translation and Validation of The Smartphone Use Questionnaire (SUQ) Into The Malay Language

Interruptions caused by frequent smartphone use steals attention away from daily activities, bringing serious implications onto an individual’s health, safety and education. Smartphone Use Questionnaire (SUQ) is a 20-item questionnaire developed to assess the pattern of smartphone use and its effect on attention. This study was done to translate and validate the Malay-language version of the SUQ and to measure the psychometric properties of the Malay-version SUQ to justify its use in Malaysia. A forward and back-translation was done by four individuals, who were three physicians and one linguist. Content and face validity was done involving three experts who were a linguist, psychiatrist and epidemiologist. Psychometric testing was conducted on a sample of 195 individuals proficient in the Malay language. A construct validity test was performed using factor analysis and the internal reliability was tested by calculating for the Cronbach’s Alpha. The age range of the sample was 13-59 years, most of which were female and of the Malay race. Using principal component analysis with direct oblimin rotation, the factor analysis extracted two components similar to the original study: General Use and Absent-Minded Use. However, question number 20 was grouped into General Use component, whereas in the original study it was under the Absent- Minded Use component. The Cronbach’s Alpha for the obtained components was 0.884 and 0.927, respectively. This study found that the Malay-version SUQ was a valid and reliable instrument for use in Malaysia in assessing inattention associated with smartphone use.

Psychotropic Polypharmacy among Elderly Patients with Mental Illness in a Malaysian University Hospital: A 10-Year Review of Hospital Databases

Psychotropic polypharmacy among elderly patients is problematic due to their multiple comorbidities. This study investigated psychotropic polypharmacy among elderly patients discharged from a Malaysian university hospital and its associated factors. Discharges of patients aged 65 years or above from the psychiatric wards from 2010 to 2019 were reviewed. Sociodemographic data, length of stay (LOS), psychiatric and other diagnoses, and psychotropic prescription upon discharge were extracted from electronic databases. Multiple logistic regression was conducted with age, gender, race, marital status, main psychiatric diagnosis, LOS, and the number of medical comorbidities as independent variables, and polypharmacy (>2 psychotropics) as the dependent variable. There were 354 discharges in this period. The mean age was 72.4 years (SD=5.9 years); 63.0% were female and 39.8% were Malays. Most were married (84.2%). The commonest category of psychiatric diagnosis was mood disorders (54.5%). A total of 76.8% of the discharges involved one or more medical comorbidities. The median number of psychotropics was two, with 38.1% prescribed three or more psychotropics. In the multiple regression model, female gender, Malay race, and being married were significantly associated with psychotropic polypharmacy. Sociocultural factors may contribute to psychotropic polypharmacy among elderly patients. Such factors require further investigations to elucidate their roles.