Role of pre-operative ureteral stent on outcomes of retrograde intra-renal surgery (RIRS): systematic review and meta-analysis of 3831 patients and comparison of Asian and non-Asian cohorts.

PURPOSE: To evaluate the outcomes of pre-stented (PS) versus non-pre-stented (NPS) patients who have undergone retrograde intrarenal surgery (RIRS) for renal calculi with subgroup analysis of Asian and non-Asian cohorts. METHODS: Protocol is registered in PROSPERO, CRD42021261123. Eligible studies identified from four electronic databases. Meta-analysis was done to enumerate the outcomes of RIRS in between PS and NPS. Secondary sub-analysis was done to look for differences in outcomes in Asian and non-Asian cohorts. RESULTS: Fourteen studies involving 3831 patients (4 prospective, 10 retrospective studies) were included. PS patients experienced higher success rates of ureteral access sheath (UAS) insertion than NPS (RR 1.09, 95% CI 1.05-1.13, p < 0.00001). PS patients had lower risk of ureteral injuries from UAS placement (RR 0.69, 95% CI 0.50-0.96, p = 0.03). No significant differences in intra- and postoperative complications between two groups were found. Stone-free rate (SFR) outcomes for residual fragment (RF) cut-off of < 1 mm and < 4 mm favoured the PS patients (RR 1.10, 95% CI 1.04-1.17, p = 0.002 for < 4 mm, RR1.10, 95% CI 1.02-1.19, p = 0.02 for < 1 mm). In the subgroup analysis, PS Asian patients had similar SFR as NPS patients for SFR(< 4 mm) but non-Asian population showed better outcomes in the PS patients for SFR(< 4 mm) (RR 1.31, 95% CI 1.13-1.52, p = 0.0005). CONCLUSIONS: This meta-analysis suggests that pre-stenting results in a higher success for UAS placement, minimising intraoperative ureteric injury, with higher overall SFR for any RF cut-off in PS cohorts. In non-Asian cohort, significant differences occurred at SFR < 4 mm but not for SFR < 1 mm. No difference was seen in our Asian cohort for any SFR cut-off in both PS and NPS patients.

The effectiveness of an emotion-focused educational programme in reducing diabetes distress in adults with Type 2 diabetes mellitus (VEMOFIT): a cluster randomized controlled trial.

AIMS: To evaluate the effectiveness of a brief, value-based emotion-focused educational programme (VEMOFIT) in Malay adults with Type 2 diabetes mellitus compared with a programme of active listening to participants' emotional experiences, social support and their opinion on the health clinic diabetes care services (attention control). METHODS: Malay adults with severe diabetes distress [Diabetes Distress Scale (DDS-17) mean score ≥ 3] were included. VEMOFIT consisted of four biweekly group sessions, a booster session after 3 months and a follow-up 6 months post intervention. The attention control programme consisted of three sessions over the same period. Outcomes included diabetes distress, depressive symptoms, self-efficacy and disease control. Required total sample size was 165. RESULTS: Participants (n = 124) were randomized to either VEMOFIT (n = 53) or the attention control programme (n = 71). Participants had a mean (sd) age of 55.7 (9.7) years, median diabetes duration of 7.0 (8.0) years and mean HbA1c level of 82 mmol/mol (9.7%). The mean DDS-17 level decreased significantly in both the VEMOFIT and the attention control programmes (3.4 to 2.9 vs. 3.1 to 2.7, respectively). The adjusted between-group DDS-17 difference was not significant [-0.01, 95% confidence interval (CI) -0.38, 0.35]. The proportion of individuals with severe diabetes distress decreased in both groups, from 89% to 47% vs. 69% to 39% (odds ratio 0.88; 95% CI 0.26, 2.90). Other outcomes did not differ between groups. CONCLUSIONS: Both interventions decreased diabetes distress significantly. The theory-based VEMOFIT programme was not superior to the attention control programme. The latter approach is a simpler way to decrease severe diabetes distress (Trial registration: NCT02730078; NMRR-15-1144-24803).

The reliability and validity of the Malay version 17-item Diabetes Distress Scale.

INTRODUCTION: Diabetes-related distress (DRD) refers to patient's concerns about diabetes mellitus, its management, need of support, emotional burden and access to healthcare. The aim of this study was to translate and examine the psychometric properties of the Malay version of the 17-item Diabetes Distress Scale (MDDS-17) in adult patients with type 2 diabetes mellitus (T2D). METHODS: A standard procedure was used to translate the English 17-items Diabetes Distress Scale into Malay language. We used exploratory factor analysis (EFA) with principal axis factoring and promax rotation to investigate the factor structure. We explored reliability by internal consistency and 1-month test-retest reliability. Construct validity was examined using the World Health Organization quality of life-brief questionnaire, Morisky Medication Adherence Scale, Patient Health Questionnaire and disease-related clinical variables. RESULTS: A total of 262 patients were included in the analysis with a response rate of 96.7%. A total of 66 patients completed the test-retest after 1 month. EFA supported a three-factor model resulting from the combination of the regimen distress (RD) and interpersonal distress (IPD) subscales; and with a swapping of an item between emotional burden (EB; item 7) and RD (item 3) subscales. Cronbach's α for MDDS-17 was 0.94, the combined RD and IPD subscale was 0.925, the EB subscale was 0.855 and the physician-related distress was 0.823. The test- retest reliability's correlation coefficient was r = 0.29 (n = 66; p = 0.009). There was a significant association between the mean MDDS-17 item score categories (<3 vs ≥3) and HbA1c categories (<7.0% vs ≥7.0%), and medication adherence (medium and high vs ≥low). The instrument discriminated between those having diabetes-related complication, low quality of life, poor medication adherence and depression. CONCLUSION: The MDDS-17 has satisfactory psychometric properties. It can be used to map diabetes-related emotional distress for diagnostic or clinical use.

Social support and glycemic control in adult patients with type 2 diabetes mellitus.

INTRODUCTION: The purpose of this study is to examine the prevalence of social support and its association with glycemic control in patients with type 2 diabetes mellitus (T2D) in an urban primary care center within an academic institution. Social support is important in the management of chronic diseases. However, its association with glycemic control has been controversial. METHODS: This was part of a study examining religiosity in T2D patients. Nonsmoking patients with T2D for at least 3 years and aged 30 years and above were recruited. Social support was measured using The Social Support Survey-Medical Outcomes Study (SS), a self-administered questionnaire; the scores range from 19 to 95, and a high score indicates better social support. Glycemic control was measured using the 3 most recent glycosylated hemoglobin (HbA1c) levels within the past 3 years. RESULTS: A total of 175 participants completed the SS survey (response rate 79.0%). The mean age was 62.7 (standard deviation [SD] = 10.8) years, and the mean duration of diabetes was 11.74 (SD = 6.7) years. The mean HbA1c level was 8.15 (SD = 1.44). The mean SS score was 68.1. The prevalence of high and low social support were 29.7% and 24.0 %, respectively. A significant correlation was found between SS score and number of social supporters (n = 167). No significant correlation was found between the self-reported number of social supporters or the SS score and the mean HbA1c level. CONCLUSIONS: Social support was not associated with glycemic control in adult patients with T2D in this primary care setting.

"Personal mission statement": An analysis of medical students' and general practitioners' reflections on personal beliefs, values and goals in life.

BACKGROUND: Personal mission in life can determine the motivation, happiness, career advancement and fulfilment in life of the medical students (MSs) along with improvement in professional/clinical performance of the family physicians. This study explored the personal beliefs, values and goals in the lives of MSs and general practitioners (GPs). METHODS: Fourth-year MSs at the Universiti Putra Malaysia and GPs who participated in a 2-hour session on 'Ethics in Family Medicine' in 2012 were invited. All the participants submitted the post-session written reflections about their personal missions in life. The written reflections were analysed using thematic analysis. RESULTS: A total of 87 MSs and 31 GPs submitted their written reflections. The authors identified 17 categories from the reflections contained by four themes-good vs. smart doctor, professional improvement vs. self-improvement, self-fulfilment and expressed motivation. The most common categories were "to be a good doctor" (97/330) and "professional improvement" (65/330). Many MSs had expressed motivation and wanted to be a smart doctor as compared to the GPs, whereas a larger number of GPs wished to have a fulfilled life and be a good doctor through professional improvement. CONCLUSION: The difference between the two student groups might indicate different levels of maturity and life experiences. Medical teachers should engage students more effectively in orientating them towards the essential values needed in medical practice.

Assessing HIV/AIDS Knowledge and Stigmatizing Attitudes among Medical Students in Universiti Putra Malaysia.

OBJECTIVE: Medical students are future doctors who are trained to treat all kind of diseases including people living with HIV/AIDS (PLWHA) without prejudice. This study was to determine the factors associated with knowledge on HIV/AIDS and stigma towards PLWHA among medical students. METHODS: This was a cross sectional study with stratified random sampling conducted in a public university, Malaysia. The participants were preclinical-year (year 1 and year 2) and clinical-year (year 3 and year 4) medical students. Simple randomisation was carried out after stratification of medical students into preclinical and clinical-year. The selfadministered questionnaires were consisted of sociodemographic data, items assessing HIV/AIDS knowledge and items assessing stigmatisation attitudes towards PLWHA. RESULTS: We had 100% response rate of 340 participants. Pre-clinical and clinical year medical students each contributed 170 (50%). Majority was female (64.1%). About two-thirds (60.6%) was Malay, followed by Chinese (31.2%) and Indian (7.1%). Pre-clinical students were significantly more stigmatizing in subscale of "attitudes towards imposed measures" (t=3.917, p<0.001), even with adjustment for previous encounter and ethnicity (B= 1.2, 95% CI 0.48 to 1.83, p=0.001). On the other hand, clinical students were found to be significantly less comfortable in handling HIV/AIDS cases (t=0.039, p=0.039), even after controlled for previous encounter and ethnicity (B=0.6, 95% CI 0.29 to 0.98, p< 0.001). CONCLUSION: Clinical encounter with PLWHA was associated with higher knowledge in HIV/AIDS. Medical students in preclinical years were having stigmatizing attitude towards imposed measures compared to the clinical years who had more stigmatizing attitude in being less comfortable with PLWHA.

Comparing the disease profiles of adult patients with type 2 diabetes mellitus attending four public health care facilities in Malaysia.

AIM: We examined disease profiles of patients with type 2 diabetes mellitus (T2D) at four different public health facilities in Malaysia to determine which site would be the most suitable for early and intensive diabetes care against diabetes-related complications. METHODS: This study analysed 57,780 T2D patients in the Adult Diabetes Control and Management registry database in the year 2009. The four public health facilities were hospital with specialists (HS), hospital without specialists (HNS), health clinics with family medicine specialists (CS) and health clinic without doctors (CND). Descriptive analyses were used to examine age, duration of diseases, intervals from the onset of diabetes to co-morbidities (hypertension and dyslipidaemia) and complication of T2D patients at the four public health facilities. RESULTS: Patients were significantly older in HS. Patients with T2D at HS had significantly longer duration of diabetes, hypertension and dyslipidaemia. Health clinics, both the CS and the CND, were seeing T2D patients with shorter duration of macrovascular and microvascular complications. CONCLUSION: Public health clinics in this country managed T2D patients who were younger and at the early stage of diabetes, hypertension, dyslipidaemia and complications. Thus, primary care physicians are best positioned to provide early and intensive diabetes care for this group of T2D patients to prevent the development of diabetes-related complications.

Type 2 Diabetes Mellitus Patient Profiles, Diseases Control and Complications at Four Public Health Facilities- A Cross-sectional Study based on the Adult Diabetes Control and Management (ADCM) Registry 2009.

INTRODUCTION: Diabetes care at different healthcare facilities varied from significantly better at one setting to no difference amongst them. We examined type 2 diabetes patient profiles, disease control and complication rates at four public health facilities in Malaysia. MATERIALS AND METHODS: This study analyzed data from diabetes registry database, the Adult Diabetes Control and Management (ADCM). The four public health facilities were hospital with specialist (HS), hospital without specialist (HNS), health clinics with family physicians (CS) and health clinic without doctor (CND). Independent risk factors were identified using multivariate regression analyses. RESULTS: The means age and duration of diabetes in years were significantly older and longer in HS (ANOVA, p< 0.0001). There were significantly more patients on insulin (31.2%), anti-hypertensives (80.1%), statins (68.1%) and antiplatelets (51.2%) in HS. Patients at HS had significantly lower means BMI, HbA1c, LDL-C and higher mean HDL-C. A significant larger proportion of type 2 diabetes patients at HS had diabetes-related complications (2-5 times). Compared to the HS, the CS was more likely to achieve HbA1c ≤ 6.5% (adjusted OR 1.2) and BP target < 130/80 mmHg (adjusted OR 1.4), the HNS was 3.4 times more likely not achieving LDL-C target < 2.6 mmol/L. CONCLUSION: Public hospitals with specialists in Malaysia were treating older male Chinese type 2 diabetes patients with more complications, and prescribed more medications. Patients attending these hospitals achieved better LDL-C target but poorer in attaining BP and lower HbA1c targets as compared to public health clinics with doctors and family physicians.

A One Month Review of the Types of Medical Emergencies and their Treatment Outcomes at Two Urban Public Health Clinics.

INTRODUCTION: Our study was to examine prevalence and treatment outcomes of medical emergencies at two urban public health clinics in the Petaling district, Selangor, Malaysia. METHODS: A prospective universal sampling was employed to recruit all emergencies over one month period (12 April to 11 May 2011). A structured case record form was used to capture demographic data, whether the index case was selfpresenting or decided by health care workers as a medical emergency, presenting complaints, diagnoses, concurrent chronic diseases and their treatment outcomes at the clinic level. Emergency presentations and diagnoses were classified according to the International Classification of Primary Care, revised second edition (ICPC-2-R). RESULTS: A total of 125 medical emergencies with 276 presenting complaints were recorded. The mean age was 30.7 years old (SD 19.9). The prevalence of medical emergency was 0.56% (125/22,320). Chief complaints were mainly from ICPC-2-R chapter R (respiratory system) and chapter A (general and unspecified), 40.0% and 28.0% respectively. The most common diagnosis was acute exacerbation of bronchial asthma (34.6%). Forty percent were referred to hospitals. After adjusting for age and gender, patients who presented with painful emergency (OR 4.9 95% CI 2.0 to 11.7), cardiovascular emergency (OR 63.4 95% CI 12.9 to 310.4) and non-respiratory emergency were predictors of hospital referral (OR 4.6 95% CI 1.1 to 19.1). CONCLUSION: There was about one medical emergency for every 200 patients presenting to these urban public polyclinics which were mainly acute asthma. More than half were discharged well and given a follow-up.

Ethnic differences in glycaemic control and complications: the adult diabetes control and management (ADCM), Malaysia.

INTRODUCTION: Ethnicity is an important factor in diabetes care. The understanding of its effect in this country may help to improve diabetes care, glycaemic control and diabetic complication rates. This study was to determine the diabetes control profile in relation to complication rates between the three main ethnics group in Malaysia. METHODS: This nested cross-sectional study was part of the Audit of Diabetes Control and Management (ADCM), an ongoing cohort patient registry focused on diabetes control and management in the primary care setting in Malaysia. This registry registers all diabetes patients aged 18 years old and above. Demographic data, diabetes duration, treatment modalities, as well as various risk factors and diabetes complications are reported. Data was handled by statisticians using STATA version 9. RESULTS: A total of 20330 patients from 54 health centers were registered at the time of this report. The majority were type 2 diabetics (99.1%) of whom 56.6% were female. The mean age was 57.9 years (SD 11.58). Malay accounted for 56.3%, Chinese 19.5% and Indian 22.5%. There were 30.3% who attained HbA1c < 7%. Among three main races more Chinese had HbA1c < 6.5% (Chi-square: X2 = 71.64, p < 0.001), but did not show less complications of nephropathy (Indian suffered significantly more nephropathy, Chi-square: X2 = 168.76, p < 0.001), ischaemic heart disease (Chi-square: X2 = 5.67, p = 0.532) and stroke (Chi-square: X2 =15.38, p = 0.078). CONCLUSION: This study has again emphasized the existence of ethnic differences in glycaemic control and complication profiles. The Chinese diabetics suffer as many diabetes-related complications despite better glycaemic control. Further studies will need to look into other socio-genetic factors in order to provide a more personalized effective diabetes care.

Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen: long-term followup.

PURPOSE: Hemorrhagic cystitis is a recognized possible side effect of therapeutic radiation administered for a variety of pelvic malignancies. Patients may experience pain, bleeding and clot retention. Various palliative treatments, including instillation of alum, silver nitrate and formalin, may be unsuccessful in alleviating patient symptoms. Hyperbaric oxygen therapy is often used to treat poorly healing wounds. We assess the long-term efficacy of hyperbaric oxygen therapy in treating the manifestations of radiation induced injury to the bladder. MATERIALS AND METHODS: A total of 11 patients with radiation induced hemorrhagic cystitis, confirmed by cystoscopy and biopsy, were treated with hyperbaric oxygen therapy. Symptoms included intractable hematuria in all 11 patients, and some also had other voiding symptoms, including persistent suprapubic pain and urinary urgency. In all patients most other types of management had failed and there was no evidence of active infection or recurrent malignancy. Patients received 100% oxygen in a hyperbaric chamber at 2.0 atmospheres for 90 minutes 5 days a week. Average number of treatments was 40 and median followup was 5.1 years. RESULTS: Of these 11 patients 3 (27%) experienced complete and durable resolution of symptoms, 3 had persistent symptoms despite hyperbaric treatments and required supravesical urinary diversion, and 5 initially responded to hyperbaric oxygen therapy but experienced long-term recurrent symptoms necessitating urinary diversion as definitive therapy. CONCLUSIONS: Hyperbaric oxygen offers a noninvasive therapeutic alternative in the management of radiation cystitis. It appears to produce good short-term benefits but it often does not produce definitive long-term cure of the disease process.

Dose-related potent brain stimulation by the neuropeptide endothelin-1 after intraventricular administration in conscious rats.

Injection of the neuropeptide, endothelin-1 (ET, range of 3-9 pmol), into a lateral ventricle (ICV) of rats produced barrel rolling and other convulsions including ataxia, forelimb and facial clonus, nystagmus, and tonic extension of the tail and hindlimbs. Using the quantitative autoradiographic [14C]deoxyglucose method, we resolved the focal hypermetabolic correlates of the convulsive activity in numerous brain regions. The present study tested whether the effects of ET were dose dependent by assessing 13 behavioral, 9 physiological, and brain metabolic responses in six individual structures of rats treated separately with ICV ET in doses between 1.5 and 18 pmol. Barrel-rolling convulsions, having a threshold for onset at 3 pmol, displayed increased incidence and severity, and a shorter latency to onset, with the higher ET doses. Within 10-20 min, ET evoked dose-dependent increases in mean arterial pressure and plasma glucose levels, and a significant reduction in arterial PCO2. Among brain structures, the periventricular caudate nucleus near the injection site had an elevated rate of glucose metabolism (+60%) at a 3 pmol threshold. The substantia nigra pars reticulata, medial terminal nucleus of the accessory optic tract, rostral lamella of the inferior olivary nucleus, cerebellar paramedian lobule, and cerebellar copula pyramis, all of which have moderate to dense populations of ET-1 receptors and are related by anatomical connections, displayed significant metabolic stimulation by 9 pmol ET (+47 to +122%). The behavioral, physiological, and focal hypermetabolic effects of the central ET appear to be time coordinated, interrelated, and dose dependent. Identification of the threshold dose for central actions of ET at 3 pmol ICV reveals this peptide as the most potent neuroactive substance yet described in vivo.

Magnetic resonance imaging of knee ligaments.

Magnetic resonance imaging is a noninvasive and nonionizing imaging modality that has made a significant contribution to our understanding of musculoskeletal injury. With technological advances, sequences have become more accurate and valuable in providing information for the clinician. This information often can guide diagnosis and treatment. The decision to use MRI technology over other modalities is based on cost, availability, information required, and observer interpretation. The risk exists, however, for abuse of this expensive technology at a time when health-care dollars are becoming more scarce. It should never be used as a substitute for sound clinical judgment in the form of careful history taking and thorough physical examination. Also, it should be used when a patient management or intervention will be altered based on the information obtained. The future management of knee ligament injury undoubtedly will be shaped by MRI and its related technologies.

NMDA-mediated metabolic activation of the cerebellar cortex in behaving rats by the neuropeptide endothelin-1.

Generalized barrel-rolling convulsions and focal hypermetabolic responses in the cerebellar cortex of conscious rats to lateral ventricular injection of the neuropeptide, endothelin-1 (ET; 9 pmol), were diminished or eliminated by i.c.v. pretreatment with the glutamatergic NMDA receptor antagonist, MK-801 (44 nmol). Using the quantitative autoradiographic [14C]deoxyglucose technique, we assessed rates of glucose metabolism in individual structures anatomically connecting forebrain nuclei within a polysynaptic network linked to the cerebellar cortex. Cerebellar cortical afferent sources from specific subnuclei of the inferior olivary complex, cuneate nucleus, and medial vestibular nucleus, all of which were hypermetabolic following injection of ET alone, were also inhibited by MK-801. The findings indicate that a convulsive i.c.v. dose of ET elicits an NMDA-related stimulatory effect, whose origin is probably at the periventricular caudate nucleus, that activates rates of glucose metabolism in several afferent sources and subregions of the cerebellar cortex involved in the regulation of equilibrium, posture, and the visuovestibular system.

Calcium-mediated metabolic stimulation of neuroendocrine structures by intraventricular endothelin-1 in conscious rats.

We examined the hypothesis that the vascular- and brain-derived peptide, endothelin-1 (ET), would affect cerebral neuroendocrine structures when administered via the peripheral circulation or via a lateral cerebral ventricle (i.c.v.). ET was infused intravenously (14 nmol/min) or injected i.c.v. (9 pmol) in conscious rats in which local cerebral glucose metabolism was assessed by the quantitative autoradiographic [14C]deoxyglucose technique. Whereas intravenously infused ET was previously demonstrated to selectively stimulate metabolic activity in the pituitary intermediate and anterior lobes of conscious rats, it was without effect in 20 individual structures or subnuclei involved in neuroendocrine functions, including several circumventricular organs. Intraventricular ET, however, caused hypermetabolic responses in 9 neuroendocrine structures, including the pineal gland, subfornical organ, median eminence, the hypothalamic paraventricular and supraoptic nuclei, and other hypothalamic and preoptic structures. The metabolic stimulation resulting from central ET was abolished or attenuated regionally by i.c.v. pretreatment with the calcium L-channel inhibitor, nimodipine. The findings indicate that i.c.v. ET elicits a calcium-mediated hypermetabolic effect on several neuroendocrine structures in the forebrain involved in the regulation of fluid homeostasis, the cardiovascular system, and body temperature.

Potent metabolic stimulation of septal gray and cerebral white matter in vivo by intraventricular endothelin and nitric oxide.

Endothelin-1 (ET) and sodium nitroprusside (SNP, which liberates nitric oxide, NO) were given alone or together into a lateral cerebral ventricle (icv) of anesthetized rats to assess their potential interaction on cerebral rates of glucose metabolism (autoradiographic [14C]deoxyglucose technique). ET (9 pmol) produced hypermetabolic effects ipsilaterally in the septal nuclei and periventricular white matter. NO lesioned the septum, which displayed neuronal damage and diminished metabolic activity, and evoked potent increases in glucose metabolism bilaterally in commissural and projection white matter tracts. Together, ET and NO had synergistic hypermetabolic effects in the hippocampal fimbria, but were antagonistic on the metabolic rate of the lateral septal nucleus and choroid plexus. The results reveal an extraordinary sensitivity in the metabolic rate of septal gray matter to ET and of white matter fibers to NO in vivo. Icv administration offers a useful approach for examination of the metabolic and toxicological properties of the novel neurotransmitter substances ET and NO on septal neurons, myelinated fibers, and choroidal epithelia.