Impact of vaccination on COVID-19 severity during the second wave in Brunei Darussalam, 2021

@#Objective: Coronavirus disease (COVID-19) vaccinations have been shown to prevent infection with efficacies ranging from 50% to 95%. This study assesses the impact of vaccination on the clinical severity of COVID-19 during the second wave in Brunei Darussalam in 2021, which was due to the Delta variant. Methods: Patients included in this study were randomly selected from those who were admitted with COVID-19 to the National Isolation Centre between 7 August and 6 October 2021. Cases were categorized as asymptomatic, mild (symptomatic without pneumonia), moderate (pneumonia), severe (needing supplemental oxygen therapy) or critical (needing mechanical ventilation) but for statistical analysis purposes were dichotomized into asymptomatic/mild or moderate/severe/critical cases. Univariate and multivariable analyses were conducted to identify risk factors associated with moderate/severe/critical disease. Propensity score-matched analysis was also performed to evaluate the impact of vaccination on disease severity. Results: The study cohort of 788 cases (mean age: 42.1 + 14.6 years; 400 males) comprised 471 (59.8%) asymptomatic/mild and 317 (40.2%) moderate/severe/critical cases. Multivariable logistic regression analysis showed older age group (>45 years), diabetes mellitus, overweight/obesity and vaccination status to be associated with increased severity of disease. In propensity score-matched analysis, the relative risk of developing moderate/severe/critical COVID-19 for fully vaccinated (two doses) and partially vaccinated (one dose) cases was 0.33 (95% confidence interval [CI]: 0.16–0.69) and 0.62 (95% CI: 0.46–0.82), respectively, compared with a control group of non-vaccinated cases. The corresponding relative risk reduction (RRR) values were 66.5% and 38.4%, respectively. Vaccination was also protective against moderate/severe/critical disease in a subgroup of overweight/obese patients (RRR: 37.2%, P = 0.007). Discussion: Among those who contracted COVID-19, older age, having diabetes, being overweight/obese and being unvaccinated were significant risk factors for moderate/severe/critical disease. Vaccination, even partial, was protective against moderate/severe/critical disease.

Post-COVID-19 health-care utilization: one year after the 2020 first wave in Brunei Darussalam

@#Objective: Patients who recover from coronavirus disease (COVID-19) infection are at risk of long-term health disorders and may require prolonged health care. This retrospective observational study assesses the number of health-care visits before and after COVID-19 infection in Brunei Darussalam. Methods: COVID-19 cases from the first wave with 12 months of follow-up were included. Health-care utilization was defined as health-care visits for consultations or investigations. Post-COVID condition was defined using the World Health Organization definition. Results: There were 132 cases; 59.1% were male and the mean age was 37.1 years. The mean number of health-care visits 12 months after recovery from COVID-19 (123 cases, 93.2%; mean 5.0 ± 5.2) was significantly higher than the prior 12 months (87 cases, 65.9%, P<0.001; mean 3.2 ± 5.7, P<0.001). There was no significant difference when scheduled COVID-19 visits were excluded (3.6 ± 4.9, P = 0.149). All 22 cases with moderate to critical disease recovered without additional health-care visits apart from planned post-COVID-19 visits. Six patients had symptoms of post-COVID condition, but none met the criteria for diagnosis or had alternative diagnoses. Discussion: There were significantly more health-care visits following recovery from COVID-19. However, this was due to scheduled post-COVID-19 visits as per the national management protocol. This protocol was amended prior to the second wave to omit post-COVID-19 follow-up, except for complicated cases or cases with no documented radiological resolution of COVID-19 pneumonia. This will reduce unnecessary health-care visits and conserve precious resources that were stretched to the limit during the pandemic.

COVID-19 and Mycobacterium coinfection in Brunei Darussalam: case series

@#Coronavirus disease (COVID-19) and tuberculosis (TB) coinfection is expected to become more common in countries where TB is endemic, and coinfection has been reported to be associated with less favourable outcomes. Knowing about the manifestations and outcomes of coinfection is important as COVID-19 becomes endemic. During the second wave of the COVID-19 pandemic in Brunei Darussalam, we encountered seven patients with COVID-19 and Mycobacterium coinfection. Cases of coinfection included three patients with newly diagnosed pulmonary Mycobacterium infection (two cases of pulmonary TB [PTB] and one case of Mycobacterium fortuitum infection) and four patients who were already being treated for TB (three cases of PTB and one case of TB lymphadenitis). Among the new cases, one had previously tested negative for PTB during a pre-employment medical fitness evaluation and had defaulted from follow up and evaluation. One case died: a 42-year-old man with diabetes mellitus, chronic kidney disease and hypertension who had severe COVID-19 and needed urgent dialysis and supplemental oxygen. All other patients recovered from COVID-19 and completed their TB treatment.

Characteristics of children with newly diagnosed type 1 diabetes mellitus in Brunei Darussalam / Journal of the ASEAN Federation of Endocrine Societies

Objective@#This study aims to characterize the presentation, biochemical status of children with T1DM at diagnosis, the type of subcutaneous insulin regimens initiated, and to determine the incidence of T1DM in Bruneian children aged 18 years and younger.@*Methodology@#A retrospective electronic and paper medical chart review was performed on patients aged 18 years and younger diagnosed with T1DM from 2013 to 2018 in Brunei Darussalam.@*Results@#A total of 31 children with a mean age of 10.2 ± 3.6 years old were diagnosed with T1DM, of which 66.7% presented with diabetic ketoacidosis (DKA), a majority in severe DKA with an intercurrent illness (p=0.021). The mean HbA1c was 13.6 ± 2.7% with a mean serum glucose of 37.0±14.9 mmol/L at diagnosis. In the majority of the children (67.7%), multiple daily injections of subcutaneous insulin were initiated. The incidence of T1DM in children aged 18 years and younger was 4.9 per 100,000 for the year 2018.@*Conclusions@#The majority of the patients in this study presented with severe DKA with an intercurrent illness. This highlights the importance of childhood T1DM awareness among the public and healthcare providers. The incidence of childhood T1DM in Brunei Darussalam is similar to other countries in the Asian region, being relatively low, compared to the rest of the world.

Clinical and demographic characteristics of COVID-19 cases in Brunei Darussalam: comparison between the first and second waves, 2020 and 2021

Abstract@#Differences in clinical manifestations between strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported. This retrospective descriptive study compares the clinical and demographic characteristics of all confirmed coronavirus disease (COVID-19) cases admitted to the National Isolation Centre (NIC) in the first wave and at the beginning of the second wave of the pandemic in Brunei Darussalam.@*Methods@#All COVID-19 cases admitted to the NIC between 9 March and 6 May 2020 (first wave) and 7–17 August 2021 (second wave) were included. Data were obtained from NIC databases and case characteristics compared using Student’s t-tests and chi-squared tests, as appropriate.@*Results@#Cases from the first wave were significantly older than those from the second wave (mean 37.2 vs 29.7 years, P<0.001), and a higher proportion reported comorbidities (30.5% vs 20.3%, P=0.019). Cases from the second wave were more likely to be symptomatic at admission (77.7% vs 63.1%, P<0.001), with a higher proportion reporting cough, anosmia, sore throat and ageusia/dysgeusia; however, myalgia and nausea/vomiting were more common among symptomatic first wave cases (all P<0.05). There was no difference in the mean number of reported symptoms (2.6 vs 2.4, P=0.890).@*Discussion@#Our study showed clear differences in the profile of COVID-19 cases in Brunei Darussalam between the first and second waves, reflecting a shift in the predominating SARS-CoV-2 strain. Awareness of changes in COVID-19 disease manifestation can help guide adjustments to management policies such as duration of isolation, testing strategies, and criteria for admission and treatment.

COVID-19 symptom duration: associations with age, severity and vaccination status in Brunei Darussalam, 2021

@#Objective: This retrospective, cross-sectional, observational study assessed the duration of coronavirus disease 2019 (COVID-19) symptoms during the second wave in Brunei Darussalam. Methods: Data from COVID-19 cases admitted to the National Isolation Centre during 7–30 August 2021 were included in the study. Symptom onset and daily symptom assessments were entered into a database during hospitalization and disease was categorized by severity. The time between symptom onset and hospital admission, the duration of symptoms and length of hospitalization were assessed separately by age group, disease severity and vaccination status using one-way analysis of variance with Bonferroni post hoc corrections. Results: Data from 548 cases were included in the study: 55.7% (305) of cases were male, and cases had a mean age of 33.7 years. Overall, 81.3% (446) reported symptoms at admission (mean number of symptoms and standard deviation: 2.8 ± 1.6), with cough (59.1%; 324), fever (38.9%; 213) and sore throat (18.4%; 101) being the most common. Being older, having more severe disease and being unvaccinated were significantly associated with the time between symptom onset and hospital admission, symptom duration and length of hospitalization. Discussion: Knowing which factors predict the duration of COVID-19 symptoms can help in planning management strategies, such as the duration of isolation, predict the length of hospitalization and treatment, and provide more accurate counselling to patients regarding their illness.

Right atrial myxoma: An unusual cause of clinical right heart failure

Myxomas are the most common type of primary cardiac tumour with 86% occurring in the left atrium. Right atrial myxomas is far less common. Patients usually present with progressive dyspnoea, fever, weight loss, right-sided heart failure, or pulmonary embolisation. We report the case of a 55-year-old man who presented with progressive dyspnoea and signs of right heart failure secondary to a large right atrial myxoma, which was diagnosed with a bedside transthoracic echocardiogram. This was successfully removed surgically.

A Rare Case of Dysphagia Secondary to a Large Oesophageal Lipoma

Dysphagia is considered a warning symptom that requires exclusion of significant pathology such as oesophageal cancer, especially in elderly patients. Benign neoplasms of the oesophagus are rare. We report the case of a 69-year-old lady who presented with a five years history of infrequent intermittent dysphagia that had rapidly progressed over one month. This was associated with globus sensation, weight loss, intermittent episodes of stridor and aspiration pneumonia. Investigations revealed a large oesophageal lipoma in the proximal oesophagus extending down to the lower oesophagus. This was successfully resected via a left cervical approach. She remained well two years after the surgery.

Anabolic steroids induced acute myocardial infarction

Androgenic anabolic steroids are commonly abused by athletes and body-builders to help develope lean body mass and muscular strength to enhance their performance. However, at doses which are much higher than recommended therapeutic dosage, abuse of these drugs is commonly associated with cardiovascular side-effects that can lead to acute myocardial infarction and sudden death. We report here three cases of acute myocardial infarction in local young bodybuilders who were using Stanazolol, an androgenic anabolic steroid, and discuss the pathophysiological mechanisms behind the observed cardiovascular side effects.

Evaluation of the RIPASA Score: a new appendicitis scoring system for the diagnosis of acute appendicitis

Introduction: We recently developed a scoring system for diagnosis of acute appendicitis. This study prospectively evaluates the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score for the diagnosis of acute appendicitis in patients presenting to the Accident & Emergency department or the Surgical wards with right iliac fossa pain. Materials and Methods: From November 2008 to April 2009, consecutive patients presenting to the Accident & Emergency department or the surgical wards with right iliac fossa pain were recruited for the study. The RIPASA score was applied but the decision for radiological investigations or emergency appendicectomy was made based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived. Ethical approval for the study was obtained from the Medical & Health Review Ethics Committee. Results: Within six months, 144 consecutive patients with a mean age of 29.5 ± 13.3 yrs were recruited to the study. Ninety-eight patients underwent emergency appendicectomy of which 79 were confirmed histologically for acute appendicitis. The observed negative appendicectomy rate was 19.4%. The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. The predicted negative appendicectomy rate was 13.5%, which is a 5.9% reduction from the observed rate of 19.4% (p=0.3). Conclusion: The RIPASA score is a more suitable appendicitis scoring system developed for our local settings with a population that is reflective of our region in South-east Asia and has high sensitivity, specificity and diagnostic accuracy.

Brunei International Medical Journal: Achieving standards with indexing and open access journal status

It has only been six month since the relaunch of the face lifted Brunei International Medical Journal (BIMJ) together with free open online access platform at www.bimjonline.com, BIMJ has made great strides in its aim of achieving high standards. We would like to share some of these achievements with our contributors and readers.

Routine chest drainage after patent ductus arteriosis ligation is not necessary

Introduction Chest drain insertion after surgical patent ductus arteriosus (PDA) ligation creates significant morbidity in terms of pain, pleural space infection, reduced mobility as well as prolonged hospital stay. We investigated the safety and efficacy of performing drainless thoracotomy closure following PDA ligation in a paediatric population. Materials and Methods Retrospective analysis of data collected from 13 paediatric patients undergoing PDA ligation at RIPAS hospital by a single surgeon over a period of five years (2001 to 2006) was performed. All continuous data were presented as mean ± standard deviation. Results PDA ligation was performed via a left thoracotomy in 13 paediatric patients with a mean age of 2.24 ± 2.03 years (ten females and three males). Mean duration of the procedures was 67 ± 12 minutes. There was minimal blood loss and no transfusions were required. Postoperatively, ten patients required only oral paracetamol for pain relief. Two patients required additional non steroidal anti-inflammatory drugs (NSAIDs). One patient had one dose of pethidine immediately post-operatively. Post-operative chest radiographs confirmed full expansion of the left lung except in one patient who had a small apical pneumothorax. Two other patients developed mild surgical emphysema despite full expansion of the left lung. All three complications resolved spontaneously after a day. Median post-operative stay was two days. There were no cases of left recurrent nerve injury and no mortality. Conclusion Routine chest drainage is not necessary following uncomplicated surgical PDA ligation and patients recovered more quickly and were discharged earlier.

Use of Heartstring aortic seal device with selective epiaortic scanning in OPCAB

Introduction: Excessive manipulation of the aorta in conventional on-pump coronary artery bypass (ONCAB) is associated with postoperative neurological complications. We assessed the results of a protocol of 'minimal-aortic manipulation' in off-pump-CABG (OPCAB) using Guidant Heartstring aortic-seal with selective epiaortic scanning. Materials and Methods: A protocol of 'minimal-aortic manipulation OPCAB' using Heartstring aortic-seals was introduced in patients undergoing OPCAB from January 2005. Data were prospectively collected for one year. Intra-operative epiaortic scanning was selectively used. Mean graft flow and pulsatility index (PI) were routinely measured. Results: Sixty-nine Heartstring aortic-seals were used in 31 patients (23 Male; 8 Female). Mean age and left ventricular ejection fraction (LVEF) were 62.5 ± 10.8 years and 57.8 ± 14.2% respectively. Five patients had intra-operative epiaortic scanning performed. Left internal thoracic artery (LITA) to left anterior descending (LAD) artery was achieved in 100% with mean LITA graft flow and PI of 32.09 ± 19.48 ml/min and 3.26 ± 1.74 respectively. Mean flow and PI in radial artery graft (RAG) and saphenous venous graft (SVG) were 20.47 ± 5.37 ml/min; 1.97 ± 0.31 and 22.84 ± 16.88 ml/min; 3.93 ± 2.83 respectively. There were no postoperative neurological complications or death. Conclusions: Routine use of Heartstring aortic-seals with selective epiaortic scanning in a protocol driven 'minimal-aortic manipulation OPCAB' is safe. The avoidance of partial aorta cross-clamping may translate to a reduction in post-operative neurological complications.

Ruptured right atrial appendage secondary to blunt chest trauma

Rupture of one or more cardiac chambers following domestic blunt chest trauma is rare. A positive outcome depends on high level of suspicion and early surgical intervention. We report here an interesting case of a ruptured right atrial appendage in a four year old boy following a blunt crushing injury to the chest and abdomen by a heavy porcelain sink which was successfully repaired. Therefore, accurate diagnosis is very important for appropriate management.