Aim: Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging soci... more Aim: Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging society. The present study examined the clinical characteristics and outcomes of AF-related cardioembolic stroke in patients aged ≥80 years. Methods: Between September 2011 and April 2014, consecutive patients with ischemic stroke and AF were retrospectively extracted from the multicenter database. Clinical characteristics were compared between patients aged ≥80 years and <80 years. Multivariate cox proportional hazard models were used to estimate hazard ratios and 95% confidential intervals on 90-day mortality for age of ≥80 years. Results: A total of 253 patients aged ≥80 years (87 men, 86.4 ± 5.0 years) and 196 patients aged <80 years (134 men, 70.4 ± 7.1 years) were included. Patients aged ≥80 years were more frequently female, and more likely to have higher premorbid modified Rankin Scale score (mRS), lower body mass index, previous history of stroke, prior antiplatelet therapy, congestive heart failure, and persistent AF. Patients aged ≥80 years had higher initial National Institutes of Health Stroke Scale score and were more likely to have occlusion of the cervicocephalic arteries, but less likely to receive thrombolysis. Patients aged ≥80 years had a higher mRS and mortality after 3 months. Age of ≥80 years was a significant predictor of 90-day mortality after adjustment for sex (hazard ratio 2.20, 95% confidential interval 1.25-4.09), but was no longer significant after further adjustment for other clinical characteristics and stroke severity. Conclusions: In AF-related cardioembolic stroke, patients aged ≥80 years had different clinical characteristics and poorer outcome compared with patients aged <80 years. Geriatr Gerontol Int 2016; ••: ••-••.
Objective: This study aimed to assess effectiveness and safety outcomes of antiplatelet therapy f... more Objective: This study aimed to assess effectiveness and safety outcomes of antiplatelet therapy for secondary prevention among patients with ischaemic stroke or transient ischaemic attack (TIA) in Malaysia. Method: Patients with a first ischaemic stroke/TIA between 2014 and 2017 were identified from stroke registry and data was linked with other data sources for information on antiplatelet exposure and outcome events. Exposure was defined as antiplatelet therapy at discharge from the index stroke hospitalisation and categorised into single antiplatelet therapy (SAPT) and dual antiplatelet therapy (DAPT) groups. Primary outcome was composite events of stroke, myocardial infarction, and all-cause death at up to one year after the index stroke in an intention-to-treat analysis. Results: Of 4434 patients included in the analysis, 6.7% were treated with DAPT and 93.3% were in SAPT group. During the 1-year follow-up, composite events occurred in 5.7% of patients in DAPT group and in 12.3%...
• to assess effectiveness and safety outcomes of antiplatelet therapy for secondary prevention am... more • to assess effectiveness and safety outcomes of antiplatelet therapy for secondary prevention among patients with ischaemic stroke or transient ischaemic attack (TIA) in Malaysia.
Factors related to the prescription of secondary preventive drugs among ischemic stroke patients ... more Factors related to the prescription of secondary preventive drugs among ischemic stroke patients by types of drugs (multivariable analysis). This table is similar to Fig. 3aâ d but the estimates are provided in a table format. (DOCX 21 kb)
Operationalization and proportion of missingness for determinants. This table shows definitions f... more Operationalization and proportion of missingness for determinants. This table shows definitions for each variable included in the regression analysis, the types of variables and its proportion of missingness in the dataset. (DOCX 19 kb)
There are established correlation between risk factors and the recurrence of ischemic stroke (IS)... more There are established correlation between risk factors and the recurrence of ischemic stroke (IS), however does the hazard of recurrent IS change although without the influence of established risk factors? This study aimed to quantify the hazard of recurrent IS at different time points after the index IS. This was a population cohort study extracted data of 7697 patients with a history of first IS attack registered with National Neurology Registry of Malaysia. A repeated time to recurrent IS model was developed using NONMEM version 7.5. Three baseline hazard models were fitted into the data. The best model was selected using maximum likelihood estimation, clinical plausibility and visual predictive checks. Three hundred and thirty-three (4.32%) patients developed at least one recurrent IS within the maximum 7.37 years follow-up. In the absence of significant risk factors, the hazard of recurrent IS was predicted to be 0.71 within the first month after the index IS and reduced to 0.0...
A shortage of computed tomographic (CT) machines in low and middle income countries often results... more A shortage of computed tomographic (CT) machines in low and middle income countries often results in delayed CT imaging for patients suspected of a stroke. Yet, time constraint is one of the most important aspects for patients with an ischemic stroke to benefit from thrombolytic therapy. We set out to assess whether application of the Siriraj Stroke Score is able to assist physicians in prioritizing patients with a high probability of having an ischemic stroke for urgent CT imaging. From the Malaysian National Neurology Registry, we selected patients aged 18 years and over with clinical features suggesting of a stroke, who arrived in the hospital 4.5 hours or less from ictus. The prioritization of receiving CT imaging was left to the discretion of the treating physician. We applied the Siriraj Stroke Score to all patients, refitted the score and defined a cut-off value to best distinguish an ischemic stroke from a hemorrhagic stroke. Of the 2176 patients included, 73% had an ischemi...
Objective: Gender as an independent predictor in stroke has been well documented. However, data o... more Objective: Gender as an independent predictor in stroke has been well documented. However, data on gender differences among first-ever ischemic stroke in developing country are limited. We aim to describe gender effects on clinical characteristics, thrombolysis treatment received, and outcomes of patients with first-ever ischemic stroke. Methods: Data were extracted from the prospective multiethnic stroke registry, National Neurology Registry (NNEUR). Descriptive analysis and logistic regression were performed. Results: A total of 4762 first-ever ischemic stroke patients admitted to 13 government hospitals from July 2009 to June 2015 were available for this study. Slightly over half were male (55.1%), and they were 1.7 years younger than female (mean age, 63.6 versus 61.9 years, p < 0.001). Genderage-adjusted incidence was observed to be higher in females (66.7 per 100,000) compared to males (57.4 per 100,000). First-ever ischemic stroke incidence increased by 24.3 and 11.2% among female and male annually. Female experienced significantly poorer functional outcome and greater 30-day in-hospital mortality compared to male. In subgroup analysis, only 31 (0.65%) patients were treated with thrombolysis. Discussion: First-ever ischemic stroke incidence increased by 24.3 and 11.2% among female and male annually. There were distinct symptoms at hospital presentation between genders. All our patients discharged home regardless of genders. In summary, Malaysian female first-ever ischemic stroke was older, present with severe stroke, greater number of risk factors and poorer functional outcome and 30-day in-hospital mortality compared to male.
Journal of Stroke and Cerebrovascular Diseases, 2015
Background: Stroke remains a major health burden worldwide. The incidence and prevalence rates of... more Background: Stroke remains a major health burden worldwide. The incidence and prevalence rates of stroke are decreasing in developed countries, an opposite trend is taking place in the Asia Pacific, where an increasing number of patients are being diagnosed with acute stroke. The results of the present study on acute stroke in multi-ethnic Malaysia will significantly contribute to the global stroke epidemiological data. We aimed to present epidemiological data of stroke including incidence and prevalence rates as well as associated risk factors from a prospective nationwide hospital-based registry from 2010 to 2014. Methods: Patients diagnosed with stroke upon admission at the hospital were prospectively enrolled into the registry from January 1, 2010, to December 31, 2014. Descriptive analyses were performed. Results: A total of 7668 patients were available for analysis. On average, patients were aged 62.7 years (standard deviation of 12.5). Ischemic stroke accounts for 79.4% of the cohort with a slightly higher proportion of male patients (55%). Ischemic stroke incidence is estimated to increase annually by 29.5% and hemorrhagic stroke by 18.7%. Hypertension is a major risk factor for both ischemic and hemorrhagic strokes regardless of stroke event with an excess of 8.4% hypertensive female compare to male patients (P ≤ .001). Majority of patients with ischemic and hemorrhagic strokes experienced mild and moderate stroke with 11.7% and 21.1%, respectively, documented as severe (P ≤ .001). Conclusions: The incidence and prevalence of stroke in Malaysia increased dramatically in the 5-year study period. Therefore, implementation of risk factor control strategies is important to prevent further increase of stroke burden in the country.
Background: Internuclear ophthalmoplegia (INO) frequently appears in multiple sclerosis, but is r... more Background: Internuclear ophthalmoplegia (INO) frequently appears in multiple sclerosis, but is rare as an isolated sign in stroke. Objective: To present clinical and imaging data of 3 cases of ischemic stroke with uni-or bilateral INO. Patients and methods: Two patients with unilateral and another one with bilateral INO were investigated by a 3 Tesla Philips Achieva scanner. Results: A 66-year-old female and a 62-year-old male were admitted with acute right sided and an 80-year-old male with bilateral INO. Diffusion weighted MRI scans (DWI) confirmed restricted water diffusion in the medial longitudinal fascicle (MLF) in all cases. Unilateral INO was associated with unilateral MLF lesion whereas in the patient with bilateral signs the MLF was also affected on both sides. Hypertension was present in all three patients. Two patients had hyperlipidemia, one had diabetes, and one was a heavy smoker. The patient with bilateral INO had malignant melanoma which could also have caused prothrombotic state. Antiplatelets (aspirin or clopidogrel) were administered in all patients. The clinical signs were resolved in the patient with bilateral INO after two months. Patients with unilateral INO also improved during the first month after their stroke and their follow-up is ongoing. Conclusion: INO due to a small infarct affecting the MLF may cause uni-or bilateral signs. As Fisher proved, signs can be bilateral if the terminal branch of a paramedian artery divides and these vessels supply the MLF on both sides. Such small arteries are not visible however even for a 3 Tesla MRI.
IntroductionInformal caregivers play a crucial role in supporting the activities of daily living,... more IntroductionInformal caregivers play a crucial role in supporting the activities of daily living, rehabilitation, and the road to recovery for stroke survivors. However, these informal caregivers are often reported as experiencing neglect and lack of recognition despite their primary contribution to stroke recovery. This study investigated the experiences of the caregivers of stroke survivors and access to stroke care in Malaysia.MethodThis qualitative study with a phenomenological approach utilized in-depth interviews, including ten primary caregivers, one formal caregiver, and stroke healthcare providers as the participants. The interviews were done until the data saturation was achieved, and the data was analyzed using thematic analysis.ResultThree primary themes and 14 subthemes were identified from the interviews. The role of primary caregivers of stroke survivors had tremendous physical, mental and social impact on the caregivers. Caregivers had two primary needs. The need for...
Background and Purpose: Factors associated with ischemic stroke (IS) recurrence and the contribut... more Background and Purpose: Factors associated with ischemic stroke (IS) recurrence and the contribution of pharmacological treatment as secondary preventions among nondiabetics especially in the non-elderly population are unclear and not widely investigated. This was a population-based study that aimed to identify recurrent IS predictors and to determine the possible impact of secondary preventive medications on the IS recurrence in non-elderly adults with or without diabetes. Methods: Data of 3386 patients <60 years old who had a history of index IS were extracted from the Malaysian National Neurology Registry (NNEUR) from 2009 to 2016. Recurrent IS was defined as any IS event recorded after the index IS in the NNEUR database. Multivariate logistic regression analysis was performed by using SPSS version 22. Results: Ischemic heart disease (IHD) was the significant predictor of IS recurrence in nonelderly adults both with or without diabetes (adjusted odds ratio (AOR) of 3.210; 95%CI: 1.909-5.398 and 2.989; 95%CI: 1.515-5.894) respectively). Receiving antiplatelet as secondary stroke prevention (AOR: 0.194; 95%CI: 0.046-0.817) and continuation of antidiabetic medication after the index IS event (AOR: 0.510; 95%CI: 0.298-0.872) reduced the odds of IS recurrence only in non-elderly diabetic adults. Among non-elderly adults without diabetes, hyperlipidemia and every increased in 1 mmHg of systolic blood pressure significantly increased the odds of IS recurrence following the indexing event (AOR: 1.796;
Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are ... more Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored. Objective: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Methods: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR)-a prospective cohort study and followed-up for six months. Patients' baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal. Results: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05). Conclusions: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was suboptimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.
Background Diabetes and dyslipidemia are significantly associated with stroke recurrence, yet the... more Background Diabetes and dyslipidemia are significantly associated with stroke recurrence, yet the evidence for this relationship is conflicting. Consequently, the parameters in the glucose and lipid profiles may inform us regarding their relationship with stroke recurrence, thus enhancing the physicians’ clinical decision-making. Aim This study sought to investigate whether glucose and lipid profiles could prognosticate stroke recurrence in Malaysia. Methods We conducted a retrospective hospital-based study where we analyzed the first-ever stroke cases regarding about which the Malaysia National Stroke Registry was informed between 2009 and 2017, that fulfilled this study’s criteria, and that were followed for stroke recurrence. Using the Cox proportional hazard regression analysis, we estimated the adjusted hazard ratios (HRs), which reflected the prognostic effect of the primary variables (i.e., glucose and lipid profiles on the first-stroke admission) on stroke recurrence. Result...
Pharmaceutical industry is one of the main contributors of public health. In a pharmaceutical ind... more Pharmaceutical industry is one of the main contributors of public health. In a pharmaceutical industry, Data integrity is one of the most important aspect that relates to drug quality, safety, efficacy and purity. Recently, many industries have been given warning letters due to the violation of data integrity and strict action had been taken by international and local regulatory authorities. Data integrity should be a part of pharmaceutical policy. It claims that product has been manufactured after meeting the predetermined specification and quality attributes and showed compliance of testing methods according to the guidelines given in official books. The FDA, USA considers integrity of data, from initial step where it is generated, and extending throughout its life cycle, to be a critical component which ensures that only high quality and safe drugs are manufactured. Hence, it is essential to record each and every detail of drug manufacturing and testing which should comply with cGMP practices. In future, the completeness, consistency, and accuracy of the data will decide the fate of the pharmaceutical companies.
Background and Purpose. Diabetes mellitus has been reported as a strong independent risk factor f... more Background and Purpose. Diabetes mellitus has been reported as a strong independent risk factor for stroke recurrence. Data on the modifiable factors contributing to the recurrence of stroke in type 2 diabetic Malaysian population with a history of stroke stratified by genders are lacking, and this supports the importance of this study. Method. The data of 4622 patients with T2DM who had a history of stroke was obtained from the Malaysian National Stroke Registry. Univariate analysis was performed to differentiate between genders with and without stroke recurrence in terms of demographics, first stroke attack presentations, and other clinical characteristics. The significant factors determined from the univariate analysis were further investigated using logistic regression. Results. Ischemic heart diseases were found significantly associated with the stroke recurrence in males (OR=1.738; 95% CI: 1.071-2.818) as well as female (OR=5.859; 95% CI: 2.469-13.752) diabetic patients. The d...
Aim: Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging soci... more Aim: Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging society. The present study examined the clinical characteristics and outcomes of AF-related cardioembolic stroke in patients aged ≥80 years. Methods: Between September 2011 and April 2014, consecutive patients with ischemic stroke and AF were retrospectively extracted from the multicenter database. Clinical characteristics were compared between patients aged ≥80 years and <80 years. Multivariate cox proportional hazard models were used to estimate hazard ratios and 95% confidential intervals on 90-day mortality for age of ≥80 years. Results: A total of 253 patients aged ≥80 years (87 men, 86.4 ± 5.0 years) and 196 patients aged <80 years (134 men, 70.4 ± 7.1 years) were included. Patients aged ≥80 years were more frequently female, and more likely to have higher premorbid modified Rankin Scale score (mRS), lower body mass index, previous history of stroke, prior antiplatelet therapy, congestive heart failure, and persistent AF. Patients aged ≥80 years had higher initial National Institutes of Health Stroke Scale score and were more likely to have occlusion of the cervicocephalic arteries, but less likely to receive thrombolysis. Patients aged ≥80 years had a higher mRS and mortality after 3 months. Age of ≥80 years was a significant predictor of 90-day mortality after adjustment for sex (hazard ratio 2.20, 95% confidential interval 1.25-4.09), but was no longer significant after further adjustment for other clinical characteristics and stroke severity. Conclusions: In AF-related cardioembolic stroke, patients aged ≥80 years had different clinical characteristics and poorer outcome compared with patients aged <80 years. Geriatr Gerontol Int 2016; ••: ••-••.
Objective: This study aimed to assess effectiveness and safety outcomes of antiplatelet therapy f... more Objective: This study aimed to assess effectiveness and safety outcomes of antiplatelet therapy for secondary prevention among patients with ischaemic stroke or transient ischaemic attack (TIA) in Malaysia. Method: Patients with a first ischaemic stroke/TIA between 2014 and 2017 were identified from stroke registry and data was linked with other data sources for information on antiplatelet exposure and outcome events. Exposure was defined as antiplatelet therapy at discharge from the index stroke hospitalisation and categorised into single antiplatelet therapy (SAPT) and dual antiplatelet therapy (DAPT) groups. Primary outcome was composite events of stroke, myocardial infarction, and all-cause death at up to one year after the index stroke in an intention-to-treat analysis. Results: Of 4434 patients included in the analysis, 6.7% were treated with DAPT and 93.3% were in SAPT group. During the 1-year follow-up, composite events occurred in 5.7% of patients in DAPT group and in 12.3%...
• to assess effectiveness and safety outcomes of antiplatelet therapy for secondary prevention am... more • to assess effectiveness and safety outcomes of antiplatelet therapy for secondary prevention among patients with ischaemic stroke or transient ischaemic attack (TIA) in Malaysia.
Factors related to the prescription of secondary preventive drugs among ischemic stroke patients ... more Factors related to the prescription of secondary preventive drugs among ischemic stroke patients by types of drugs (multivariable analysis). This table is similar to Fig. 3aâ d but the estimates are provided in a table format. (DOCX 21 kb)
Operationalization and proportion of missingness for determinants. This table shows definitions f... more Operationalization and proportion of missingness for determinants. This table shows definitions for each variable included in the regression analysis, the types of variables and its proportion of missingness in the dataset. (DOCX 19 kb)
There are established correlation between risk factors and the recurrence of ischemic stroke (IS)... more There are established correlation between risk factors and the recurrence of ischemic stroke (IS), however does the hazard of recurrent IS change although without the influence of established risk factors? This study aimed to quantify the hazard of recurrent IS at different time points after the index IS. This was a population cohort study extracted data of 7697 patients with a history of first IS attack registered with National Neurology Registry of Malaysia. A repeated time to recurrent IS model was developed using NONMEM version 7.5. Three baseline hazard models were fitted into the data. The best model was selected using maximum likelihood estimation, clinical plausibility and visual predictive checks. Three hundred and thirty-three (4.32%) patients developed at least one recurrent IS within the maximum 7.37 years follow-up. In the absence of significant risk factors, the hazard of recurrent IS was predicted to be 0.71 within the first month after the index IS and reduced to 0.0...
A shortage of computed tomographic (CT) machines in low and middle income countries often results... more A shortage of computed tomographic (CT) machines in low and middle income countries often results in delayed CT imaging for patients suspected of a stroke. Yet, time constraint is one of the most important aspects for patients with an ischemic stroke to benefit from thrombolytic therapy. We set out to assess whether application of the Siriraj Stroke Score is able to assist physicians in prioritizing patients with a high probability of having an ischemic stroke for urgent CT imaging. From the Malaysian National Neurology Registry, we selected patients aged 18 years and over with clinical features suggesting of a stroke, who arrived in the hospital 4.5 hours or less from ictus. The prioritization of receiving CT imaging was left to the discretion of the treating physician. We applied the Siriraj Stroke Score to all patients, refitted the score and defined a cut-off value to best distinguish an ischemic stroke from a hemorrhagic stroke. Of the 2176 patients included, 73% had an ischemi...
Objective: Gender as an independent predictor in stroke has been well documented. However, data o... more Objective: Gender as an independent predictor in stroke has been well documented. However, data on gender differences among first-ever ischemic stroke in developing country are limited. We aim to describe gender effects on clinical characteristics, thrombolysis treatment received, and outcomes of patients with first-ever ischemic stroke. Methods: Data were extracted from the prospective multiethnic stroke registry, National Neurology Registry (NNEUR). Descriptive analysis and logistic regression were performed. Results: A total of 4762 first-ever ischemic stroke patients admitted to 13 government hospitals from July 2009 to June 2015 were available for this study. Slightly over half were male (55.1%), and they were 1.7 years younger than female (mean age, 63.6 versus 61.9 years, p < 0.001). Genderage-adjusted incidence was observed to be higher in females (66.7 per 100,000) compared to males (57.4 per 100,000). First-ever ischemic stroke incidence increased by 24.3 and 11.2% among female and male annually. Female experienced significantly poorer functional outcome and greater 30-day in-hospital mortality compared to male. In subgroup analysis, only 31 (0.65%) patients were treated with thrombolysis. Discussion: First-ever ischemic stroke incidence increased by 24.3 and 11.2% among female and male annually. There were distinct symptoms at hospital presentation between genders. All our patients discharged home regardless of genders. In summary, Malaysian female first-ever ischemic stroke was older, present with severe stroke, greater number of risk factors and poorer functional outcome and 30-day in-hospital mortality compared to male.
Journal of Stroke and Cerebrovascular Diseases, 2015
Background: Stroke remains a major health burden worldwide. The incidence and prevalence rates of... more Background: Stroke remains a major health burden worldwide. The incidence and prevalence rates of stroke are decreasing in developed countries, an opposite trend is taking place in the Asia Pacific, where an increasing number of patients are being diagnosed with acute stroke. The results of the present study on acute stroke in multi-ethnic Malaysia will significantly contribute to the global stroke epidemiological data. We aimed to present epidemiological data of stroke including incidence and prevalence rates as well as associated risk factors from a prospective nationwide hospital-based registry from 2010 to 2014. Methods: Patients diagnosed with stroke upon admission at the hospital were prospectively enrolled into the registry from January 1, 2010, to December 31, 2014. Descriptive analyses were performed. Results: A total of 7668 patients were available for analysis. On average, patients were aged 62.7 years (standard deviation of 12.5). Ischemic stroke accounts for 79.4% of the cohort with a slightly higher proportion of male patients (55%). Ischemic stroke incidence is estimated to increase annually by 29.5% and hemorrhagic stroke by 18.7%. Hypertension is a major risk factor for both ischemic and hemorrhagic strokes regardless of stroke event with an excess of 8.4% hypertensive female compare to male patients (P ≤ .001). Majority of patients with ischemic and hemorrhagic strokes experienced mild and moderate stroke with 11.7% and 21.1%, respectively, documented as severe (P ≤ .001). Conclusions: The incidence and prevalence of stroke in Malaysia increased dramatically in the 5-year study period. Therefore, implementation of risk factor control strategies is important to prevent further increase of stroke burden in the country.
Background: Internuclear ophthalmoplegia (INO) frequently appears in multiple sclerosis, but is r... more Background: Internuclear ophthalmoplegia (INO) frequently appears in multiple sclerosis, but is rare as an isolated sign in stroke. Objective: To present clinical and imaging data of 3 cases of ischemic stroke with uni-or bilateral INO. Patients and methods: Two patients with unilateral and another one with bilateral INO were investigated by a 3 Tesla Philips Achieva scanner. Results: A 66-year-old female and a 62-year-old male were admitted with acute right sided and an 80-year-old male with bilateral INO. Diffusion weighted MRI scans (DWI) confirmed restricted water diffusion in the medial longitudinal fascicle (MLF) in all cases. Unilateral INO was associated with unilateral MLF lesion whereas in the patient with bilateral signs the MLF was also affected on both sides. Hypertension was present in all three patients. Two patients had hyperlipidemia, one had diabetes, and one was a heavy smoker. The patient with bilateral INO had malignant melanoma which could also have caused prothrombotic state. Antiplatelets (aspirin or clopidogrel) were administered in all patients. The clinical signs were resolved in the patient with bilateral INO after two months. Patients with unilateral INO also improved during the first month after their stroke and their follow-up is ongoing. Conclusion: INO due to a small infarct affecting the MLF may cause uni-or bilateral signs. As Fisher proved, signs can be bilateral if the terminal branch of a paramedian artery divides and these vessels supply the MLF on both sides. Such small arteries are not visible however even for a 3 Tesla MRI.
IntroductionInformal caregivers play a crucial role in supporting the activities of daily living,... more IntroductionInformal caregivers play a crucial role in supporting the activities of daily living, rehabilitation, and the road to recovery for stroke survivors. However, these informal caregivers are often reported as experiencing neglect and lack of recognition despite their primary contribution to stroke recovery. This study investigated the experiences of the caregivers of stroke survivors and access to stroke care in Malaysia.MethodThis qualitative study with a phenomenological approach utilized in-depth interviews, including ten primary caregivers, one formal caregiver, and stroke healthcare providers as the participants. The interviews were done until the data saturation was achieved, and the data was analyzed using thematic analysis.ResultThree primary themes and 14 subthemes were identified from the interviews. The role of primary caregivers of stroke survivors had tremendous physical, mental and social impact on the caregivers. Caregivers had two primary needs. The need for...
Background and Purpose: Factors associated with ischemic stroke (IS) recurrence and the contribut... more Background and Purpose: Factors associated with ischemic stroke (IS) recurrence and the contribution of pharmacological treatment as secondary preventions among nondiabetics especially in the non-elderly population are unclear and not widely investigated. This was a population-based study that aimed to identify recurrent IS predictors and to determine the possible impact of secondary preventive medications on the IS recurrence in non-elderly adults with or without diabetes. Methods: Data of 3386 patients <60 years old who had a history of index IS were extracted from the Malaysian National Neurology Registry (NNEUR) from 2009 to 2016. Recurrent IS was defined as any IS event recorded after the index IS in the NNEUR database. Multivariate logistic regression analysis was performed by using SPSS version 22. Results: Ischemic heart disease (IHD) was the significant predictor of IS recurrence in nonelderly adults both with or without diabetes (adjusted odds ratio (AOR) of 3.210; 95%CI: 1.909-5.398 and 2.989; 95%CI: 1.515-5.894) respectively). Receiving antiplatelet as secondary stroke prevention (AOR: 0.194; 95%CI: 0.046-0.817) and continuation of antidiabetic medication after the index IS event (AOR: 0.510; 95%CI: 0.298-0.872) reduced the odds of IS recurrence only in non-elderly diabetic adults. Among non-elderly adults without diabetes, hyperlipidemia and every increased in 1 mmHg of systolic blood pressure significantly increased the odds of IS recurrence following the indexing event (AOR: 1.796;
Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are ... more Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored. Objective: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Methods: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR)-a prospective cohort study and followed-up for six months. Patients' baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal. Results: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05). Conclusions: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was suboptimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.
Background Diabetes and dyslipidemia are significantly associated with stroke recurrence, yet the... more Background Diabetes and dyslipidemia are significantly associated with stroke recurrence, yet the evidence for this relationship is conflicting. Consequently, the parameters in the glucose and lipid profiles may inform us regarding their relationship with stroke recurrence, thus enhancing the physicians’ clinical decision-making. Aim This study sought to investigate whether glucose and lipid profiles could prognosticate stroke recurrence in Malaysia. Methods We conducted a retrospective hospital-based study where we analyzed the first-ever stroke cases regarding about which the Malaysia National Stroke Registry was informed between 2009 and 2017, that fulfilled this study’s criteria, and that were followed for stroke recurrence. Using the Cox proportional hazard regression analysis, we estimated the adjusted hazard ratios (HRs), which reflected the prognostic effect of the primary variables (i.e., glucose and lipid profiles on the first-stroke admission) on stroke recurrence. Result...
Pharmaceutical industry is one of the main contributors of public health. In a pharmaceutical ind... more Pharmaceutical industry is one of the main contributors of public health. In a pharmaceutical industry, Data integrity is one of the most important aspect that relates to drug quality, safety, efficacy and purity. Recently, many industries have been given warning letters due to the violation of data integrity and strict action had been taken by international and local regulatory authorities. Data integrity should be a part of pharmaceutical policy. It claims that product has been manufactured after meeting the predetermined specification and quality attributes and showed compliance of testing methods according to the guidelines given in official books. The FDA, USA considers integrity of data, from initial step where it is generated, and extending throughout its life cycle, to be a critical component which ensures that only high quality and safe drugs are manufactured. Hence, it is essential to record each and every detail of drug manufacturing and testing which should comply with cGMP practices. In future, the completeness, consistency, and accuracy of the data will decide the fate of the pharmaceutical companies.
Background and Purpose. Diabetes mellitus has been reported as a strong independent risk factor f... more Background and Purpose. Diabetes mellitus has been reported as a strong independent risk factor for stroke recurrence. Data on the modifiable factors contributing to the recurrence of stroke in type 2 diabetic Malaysian population with a history of stroke stratified by genders are lacking, and this supports the importance of this study. Method. The data of 4622 patients with T2DM who had a history of stroke was obtained from the Malaysian National Stroke Registry. Univariate analysis was performed to differentiate between genders with and without stroke recurrence in terms of demographics, first stroke attack presentations, and other clinical characteristics. The significant factors determined from the univariate analysis were further investigated using logistic regression. Results. Ischemic heart diseases were found significantly associated with the stroke recurrence in males (OR=1.738; 95% CI: 1.071-2.818) as well as female (OR=5.859; 95% CI: 2.469-13.752) diabetic patients. The d...
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