Trends of Stroke Incidence and 28-Day All-Cause Mortality after a Stroke in Malaysia: A Linkage of National Data Sources.

Background: Data on nationwide trends for stroke metrics are crucial to understand the extent of the disease burden to a country's health system. Yet, this information remains scarce in low- and middle-income countries. Objectives: This study investigated trends of stroke incidence and 28-day all-cause mortality after a stroke from 2008 to 2016 in Malaysia, through linkage across national data sources. Methods: Hospital admissions with a principal diagnosis of stroke or transient ischemic attack were included. Cases with first stroke were identified through linkage of hospital admission registers where age and sex-standardized trends of stroke incidence and its subtypes were calculated. By linking hospital registers to the National Death Register, the 28-day all-cause mortality rates after a stroke were estimated. Mann-Kendall's test was used for trend evaluation. Results: From 243,765 records, the trend of stroke incidence showed an increase of 4.9% in men and a drop of 3.8% among women. Incidences were higher in men, at 99.1 per 100,000 population in 2008 and 103.9 per 100,000 in 2016 than women (80.3 per 100,000 in 2008 and 77.2 per 100,000 in 2016). There was a substantial increase in stroke incidence among those below 65 years old, with the largest increase of 53.3% in men aged between 35-39 years and 50.4% in women of similar age group. The trend for 28-day all-cause mortality showed a decline for men at -13.1% and women, -10.6%. Women had higher mortality from stroke (22.0% in 2008 and 19.7% in 2016) than men (19.4% in 2008 to 17.2% in 2016). Conclusion: This first empirical study on stroke trends in Malaysia revealed a worrying increase in stroke incidence among the younger population. Despite a declining trend, mortality rates remained moderately high especially in women. Comprehensive strategies to strengthen the prevention and management of stroke care are warranted.

A survey on patients' disease perception and the impact of the COVID-19 pandemic on persons living with amyotrophic lateral sclerosis in Malaysia.

Aim: To investigate the patients' perception of their disease, its management and the impact of the COVID-19 pandemic on persons living with amyotrophic lateral sclerosis (ALS) in Malaysia. Patients & methods: An online survey comprising 42 questions was conducted on ALS patients during the peak of the COVID-19 pandemic. Results: Responses were received from 37/60 (62%) participants with ALS directly or through their caregivers. During the COVID-19 pandemic, two-thirds of patients were negatively impacted by the sudden disruption to their hospital appointments, rehabilitation sessions and reduced social interactions. Conclusion: This study provided insight into patients' perception of their care and management of ALS in Malaysia which will facilitate in implementing changes that can improve care to persons living with this devastating illness.

Foot ulcers and their association with diabetic Charcot foot complications.

BACKGROUND AND OBJECTIVES: Diabetic Charcot foot (DCF) can cause gross structural deformities of the foot and ankle. The main objective of this study was to identify complications of DCF and its associated factors. METHOD: This is a retrospective cohort study. Data on medical background, previous DCF treatment and complications were obtained. Multiple logistic regression analysis was performed to measure factors related to various complications of DCF. RESULTS: Ninety-eight patient records were retrieved. Of the 83 patients who were still alive, 75.9% (n = 63) had recurrent ulcers, 53.0% (n = 44) had undergone foot surgery and 45.8% (n = 38) had undergone amputation. Patients with a history of recurrent ulcers have the highest predilection to amputation (odds ratio: 8.5; 95% confidence interval: 1.8, 39.1). DISCUSSION: In terms of DCF complications, foot ulcers are an independent predictor of recurrent foot ulcers, foot surgery and amputation. Regular foot assessment of patients with DCF to prevent ulcers is strongly recommended.

Early AbobotulinumtoxinA (Dysport®) in Post-Stroke Adult Upper Limb Spasticity: ONTIME Pilot Study.

The ONTIME study investigated whether early post-stroke abobotulinumtoxinA injection delays appearance or progression of upper limb spasticity (ULS) symptoms. ONTIME (NCT02321436) was a 28-week, exploratory, double-blind, randomized, placebo-controlled study of abobotulinumtoxinA 500U in patients with ULS (Modified Ashworth Scale [MAS] score ≥ 2) 2⁻12 weeks post-stroke. Patients were either symptomatic or asymptomatic (only increased MAS) at baseline. Primary efficacy outcome measure: time between injection and visit at which re-injection criteria were met (MAS ≥ 2 and ≥1, sign of symptomatic spasticity: pain, involuntary movements, impaired active or passive function). Forty-two patients were randomized (abobotulinumtoxinA 500U: n = 28; placebo: n = 14) with median 5.86 weeks since stroke. Median time to reach re-injection criteria was significantly longer for abobotulinumtoxinA (156 days) than placebo (32 days; log-rank: p = 0.0176; Wilcoxon: p = 0.0480). Eleven (39.3%) patients receiving abobotulinumtoxinA did not require re-injection for ≥28 weeks versus two (14.3%) in placebo group. In this exploratory study, early abobotulinumtoxinA treatment significantly delayed time to reach re-injection criteria compared with placebo in patients with post-stroke ULS. These findings suggest an optimal time for post-stroke spasticity management and help determine the design and sample sizes for larger confirmatory studies.

Cortical Modulation After Two Different Repetitive Transcranial Magnetic Stimulation Protocols in Similar Ischemic Stroke Patients.

BACKGROUND: Stroke is one of the leading causes of mortality and morbidity in Malaysia. Repetitive transcranial magnetic stimulation (rTMS) is one of the new non-invasive modality to enhance the motor recovery in stroke patients. OBJECTIVES: This pilot study compared the motor evoked potential (MEP) changes using different settings of rTMS in the post-ischemic stroke patient. The goal of the study is to identify effect sizes for a further trial and evaluate safety aspects. METHODS: Eight post-stroke patients with upper limb hemiparesis for at least six months duration were studied in a tertiary hospital in Northeast Malaysia. Quasi experimental design was applied and the participants were randomised into two groups using software generated random numbers. One of the two settings: i) inhibitory setting, or ii) facilitatory setting have been applied randomly during the first meeting. The motor evoked potential (MEP) were recorded before and after application of the rTMS setting. A week later, a similar procedure will be repeated but using different setting than the first intervention. Each patient will serve as their own control. Repeated measures ANOVA test was applied to determine the effect sizes for both intervention through the options of partial eta-squared (η2 p). RESULT: The study observed large effect sizes (η2 p > 0.14) for both rTMS settings in the lesion and non-lesion sides. For safety aspects, no minor or major side effects associated with the rTMS was reported by the participants. CONCLUSIONS: The partial eta square of MEP value for both rTMS settings (fascilitatory and inhibitory) in both lesion and non-lesion sides represents large effect sizes. We recommend further trial to increase number of sample in order to study the effectiveness of both settings in ischemic stroke patient. Our preliminary data showed both settings may improve the MEP of the upper extremity in the ischemic stroke patient. No significant improvement noted when comparing both settings.

Implementation of Clinical Quality Management for Rehabilitation in Malaysia.

In February 2017, the World Health Organization (WHO) launched its historic "Rehabilitation 2030: A Call for Action". Scaling up rehabilitation in health systems requires concerted action across all 6 components of WHO's Health Systems Framework. For rehabilitation, information about functioning is essential, as it is required for effective rehabilitation at all levels of the health system. What is missing is a countrywide demonstration project involving the implementation of a clinical quality management system for the continuous improvement of rehabilitation, both at the level of clinical care for individual patients and at the level of rehabilitation service provision. Consequently, the Department of Rehabilitation Medicine at the University of Malaya and University Malaya Medical Centre, together with the Cheras Rehabilitation Hospital of the Ministry of Health, and the Social Security Organisation (SOCSO) Rehabilitation Centre in Malacca, Malaysia, initiated a project to develop a Malaysian-wide clinical quality management system for rehabilitation (CQM-R Malaysia). The objective of this paper is to describe CQM-R Malaysia. First, a conceptual description of a CQM-R based on the International Classification of Functioning, Disability and Health (ICF) is set out. The methods, results and conclusions of a situation analysis conducted in January 2017 are then reported. Finally, the building blocks and implementation action plan developed for CQM-R Malaysia are presented.

Risk factors of diabetic foot Charcot arthropathy: a case-control study at a Malaysian tertiary care centre.

INTRODUCTION: This study aimed to determine the risk factors of diabetic Charcot arthropathy of the foot among diabetic patients with and without foot problems. METHODS: This was a case-control study involving diabetic patients attending the Diabetic Foot Care and Wound Management Clinic at University Malaya Medical Centre, Kuala Lumpur, Malaysia, from June 2010 to June 2011. Data on sociodemographic profiles, foot factors and diabetes characteristics was collected and analysed. RESULTS: A total of 48 diabetic patients with Charcot arthropathy of the foot were identified. Data from these 48 patients was compared with those of 52 diabetic patients without foot problems. Up to 83.3% of patients with diabetic Charcot arthropathy presented with unilateral Charcot foot, most commonly located at the midfoot (45.8%). Patients with a history of foot problems, including foot ulcer, amputation, surgery or a combination of problems, had the highest (26-time) likelihood of developing Charcot arthropathy (odds ratio 26.4; 95% confidence interval 6.4-109.6). Other significant risk factors included age below 60 years, more than ten years' duration of diabetes mellitus and the presence of nephropathy. CONCLUSION: A history of prior diabetic foot problems is the greatest risk factor for developing diabetic Charcot arthropathy, compared with other risk factors such as diabetes characteristics and sociodemographic profiles. Preventive management of diabetic foot problems in the primary care setting and multidisciplinary care are of paramount importance, especially among chronic diabetic patients.

Neurophysiological and behavioral effects of tDCS combined with constraint-induced movement therapy in poststroke patients.

BACKGROUND: Recovery of motor function after stroke may depend on a balance of activity in the neural network involving the affected and the unaffected motor cortices. OBJECTIVE: To assess whether transcranial direct current stimulation (tDCS) can increase the training-induced recovery of motor functions. METHODS: In an exploratory study, 14 patients with chronic stroke and mean Fugl-Meyer Upper Extremity Motor Assessment of 29 (range = 8-50) entered a double-blind sham-controlled study, aimed to investigate neurophysiological and behavioral effects of bihemispheric tDCS (cathodal stimulation of the unaffected motor cortex and anodal stimulation of the affected motor cortex), combined with constraint-induced movement therapy (CIMT). RESULTS: Patients in both groups demonstrated gains on primary outcome measures, that is, Jebsen Taylor Hand Function Test, Handgrip Strength, Motor Activity Log Scale, and Fugl-Meyer Motor Score. Gains were larger in the active tDCS group. Neurophysiological measurements showed a reduction in transcallosal inhibition from the intact to the affected hemisphere and increased corticospinal excitability in the affected hemisphere only in the active tDCS/CIMT group. Such neurophysiological changes correlated with the magnitude of the behavioral gains. Both groups showed a reduction in corticospinal excitability of the unaffected hemisphere. CONCLUSIONS: CIMT alone appears effective in modulating local excitability but not in removing the imbalance in transcallosal inhibition. Bihemispheric tDCS may achieve this goal and foster greater functional recovery.

Validation of the comprehensive ICF core sets for diabetes mellitus:a Malaysian perspective.

INTRODUCTION: Diabetes mellitus (DM) is a chronic disease that is prevalent in many countries. The prevalence of DM is on the rise, and its complications pose a heavy burden on the healthcare systems and on the patients' quality of life worldwide. MATERIALS AND METHODS: This is a multicentre, cross-sectional study involving 5 Health Clinics conducted by Family Medicine Specialists in Malaysia. Convenience sampling of 100 respondents with DM were selected. The International Classifi cation of Functioning, Disability and Health (ICF) based measures were collected using the Comprehensive Core Set for DM. SF-36 and self-administered forms and comorbidity questionnaire (SCQ) were also used. RESULTS: Ninety-seven percent had Type 2 DM and 3% had Type 1 DM. The mean period of having DM was 6 years. Body functions related to physical health including exercise tolerance (b455), general physical endurance (b4550), aerobic capacity (b4551) and fatiguability (b4552) were the most affected. For body structures, the structure of pancreas (s550) was the most affected. In the ICF component of activities and participation, limitation in sports (d9201) was the highest most affected followed by driving (d475), intimate relationships (d770), handling stress and other psychological demands (d240) and moving around (d455). Only 7% (e355 and e450) in the environmental category were documented as being a relevant factor by more than 90% of the patients. CONCLUSION: The content validity of the comprehensive ICF Core set DM for Malaysian population were identified and the results show that physical and mental functioning were impaired in contrast to what the respondents perceived as leading healthy lifestyles.