Management of severe dengue remains a clinical challenge. This retrospective study evaluated clinical features and laboratory biomarkers associated with severe dengue at Hospital Sultanah Aminah Johor Bahru from 1 January 2022 to 31 March 2023. Records of 99 patients, categorized into ICU (51) and non-ICU (48) groups, were identified and analyzed using SPSS version 28.0. Sociodemographic details, clinical features and laboratory biomarkers were collected. Patients aged 50 and older, those with obesity, and those with pre-existing comorbidities were significantly more likely to be admitted to the ICU. The four most common warning signs in both cohorts were lethargy/restlessness/confusion, abdominal pain, persistent vomiting, and diarrhea. Fever, or history of fever, and thrombocytopenia were the two most common severe dengue criteria present in both cohorts. ICU patients exhibited more signs of plasma leakage and abnormal laboratory findings, including normal white cell count, hypoalbuminemia, hyperbilirubinemia, and elevated creatine kinase. In contrast, leukopenia and normal albumin, bilirubin, and creatine kinase levels were more common in non-ICU patients. Hyponatremia and raised lactate dehydrogenase were seen in both groups. This study highlighted key differences and similarities in clinical features and laboratory biomarkers between ICU and non-ICU patients, emphasizing the need for further research to develop a comprehensive risk assessment tool for predicting severe dengue that resulted in ICU admission.

Background: During the coronavirus disease 2019 (COVID-19) pandemic, physical in-person classes in Newcastle University Medicine Malaysia (NUMed) were replaced with e-learning. Teaching in NUMed was being delivered online during COVID-19 pandemic for the last one and a half academic years (18 March 2020 – June 2021) due to the strict lockdowns and physical distancing measures in place, limited in-person sessions on campus, and disrupted hospital attachments. There was concern over the effectiveness and satisfaction with e-learning amongst our students, and how this affects their overall academic performance. Our study aims to explore students’ e-learning experiences and its perceived benefits and challenges during the pandemic. Methods: 285 students participated in this cross-sectional study using a convenience sampling method. Participants completed a self-administered online questionnaire via an email invitation between July 12th and August 12th, 2021 which comprised of sociodemographic characteristics and experiences with e-learning. The data was analysed using descriptive statistics and Spearman’s correlation tests were used to identify correlation between students’ e-learning experiences, the effects of e-learning, and academic performance. Results: Most students used laptops (n=275, 96.5%) for e-learning and owned at least two electronic devices (n=245, 86%). Over half of our students (n=148, 51.9%) reported their theoretical knowledge remains unchanged, while about three-quarters (n=213, 74.7%) perceived practical skills to have worsened. Students preferred paper-based exams (n=170, 59.6%) and objectively formatted online exams (n=193, 67.7%). Since transitioning to e-learning, the majority of students (n=207, 72.6%) reported difficulties studying online and were unsatisfied with their academic performance (n=166, 58.2%). Students preferred e-learning due to the lower risk of contracting COVID-19 (n=256, 89.8%), the convenience of online classes (n=244, 85.6%) and flexible schedules (n=219, 76.8%). However, the lack of patient contact (n=236, 82.8%), lecturer and peer interactions (n=234, 82.1%), and unreliable internet (n=201, 70.5%) made e-learning challenging. Students’ experiences were generally affected by multiple factors encompassing personal, lecturer, and environmental aspects. Conclusion: E-learning during the COVID-19 pandemic has negatively impacted students’ academic performance, particularly practical skills and performance satisfaction. Therefore, the university should look towards addressing e-learning constraints and providing adequate support to improve students’ educational experiences in the ongoing pandemic.

Background The frequent disruption to the delivery of education and the switch to online learning amidst the COVID-19 pandemic affected students’ mental health. The objectives of the study were to explore the levels of anxiety, depression, somatic symptoms, and stress among students during the COVID-19 pandemic and their associations with sociodemographic status, clinical teaching, and concerns about COVID-19. Methods A cross-sectional study was conducted using convenience sampling via an online self-administered questionnaire-based survey with 285 participants. The survey included questionnaires on sociodemographics, anxiety, depression, somatic symptoms, and stress levels using a validated questionnaire. Data was analyzed using Spearman’s correlation test and ordinal logistic regression to identify correlations between psychological well-being and the effectiveness of e-learning. Results More than half of the students reported anxiety (57.2%), depression (58.6%), somatic symptoms (54.4%) and moderate to high stress (79.7%) during the pandemic. Students who stated that online role players were not helpful had increased anxiety levels (rho=-0.18, P =0.005). However, somatic symptoms were reduced among students who found campus role players helpful (rho=0.16, P =0.012). More than half the participants (55.8%) felt that they were supported by the university during the COVID-19 pandemic, although most students (91.6%) sought clear information and prompt updates from the university. We found that students with psychological distress experiencing anxiety (OR=2.47, 95% confidence interval, CI=1.49-4.08), depression (OR=3.22, 95% CI=1.94-5.34), somatic symptoms (OR=2.94, 95% CI=1.76-4.91, P <0.001), and stress (OR=3.08, 95% CI=1.76-5.41) would value more mental health support from the university. Conclusions The university should consider increasing campus role-play sessions and providing prompt updates and mental health resources to help students cope better psychologically during the pandemic.

Objetivo: Nuestro objetivo es explorar las experiencias vividas de los actores públicos desde los aspectos de los beneficios, las barreras y los facilitadores del juego de roles en una escuela de medicina en Malasia.

© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/ by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Oxford Medical Case Reports, 2022, 4, 142–143

Rhodococcus equi is a Gram-positive coccobacillus bacterium commonly found on dry surface soil of farming and livestock properties. This organism is a rare cause of subacute, necrotizing infection, and mostly causes cavitary pneumonia and lung abscess, especially in immunocompromised hosts with advanced human immunodeficiency virus (HIV) infection.

© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/ by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Oxford Medical Case Reports, 2022, 7, 251–252

Infective endocarditis can result in potentially fatal complications such as heart failure, systemic embolization, mycotic aneurysm and neurological complications. Staphylococci and streptococci are the most common causative agents of infective endocarditis, with Streptococcus gordonii being a rare cause. We present a case of infective endocarditis in a young patient who presented with an acute abdomen 2 months after being diagnosed with cerebrovascular accident. An abdominal computed tomography revealed superior mesenteric artery thrombosis, and infarct in the right kidney and spleen as a result of systemic septic embolism. Echocardiography showed numerous vegetations at the aortic and mitral valves. Infective endocarditis was diagnosed based on echocardiographic findings and positive blood cultures for S. gordonii. He was treated with intravenous benzylpenicillin and was also referred for surgical intervention.

Enterococcus hirae infection accounts for about 1% of all enterococcal infections. This number is likely to be underestimated because of inadequate identification. Human infection due to E. hirae is rarely reported. We present the case of a young woman with diabetes mellitus who developed symptoms of pyelonephritis and diabetic ketoacidosis. Renal computed tomography scan revealed the presence of subcapsular perinephric collection and renal abscesses. Her blood culture yielded E. hirae. Our patient was successfully treated with antimicrobials based on the susceptibility result. To our knowledge, this is the first reported case of perinephric collection and renal abscesses associated with E. hirae bacteremia.

Background Adherence to preventative measures designed to mitigate transmission of COVID-19 depends on individual’s understanding and perception of COVID-19. The objective of this study was to assess the knowledge, perceptions, behavioural adaptation and psychological well-being related to COVID-19 among students attending Newcastle University Medicine Malaysia. Methods A cross-sectional study was conducted using convenience sampling of students. The self-administered online questionnaire was sent via email in Google forms format between 18 April and 30 April 2020. The questionnaire focused on sociodemographic, perception, attitude and behavioural responses, knowledge and sources of information and anxiety level. Results 326 university students with mean age of 21.8 (S.D 2.3) participated in this study. More females (n =236) took part in the study than males (n= 90). Most students (80%) believed that they knew how to protect themselves. More than two-thirds (68%) of students strongly agreed that COVID-19 was a serious public health issue. Most students (>90%) practised the recommended measures, except for avoid touching of eyes, nose and mouth with unwashed hands (82%). Wearing a facemask was positively associated with behavioural uptake in university students. Conclusions This study showed a good attitude, behavioural responses, knowledge level and emotional responses among NUMed students towards COVID-19.

Background Newcastle University Medicine (NUMed) Malaysia adheres to the UK Medical Schools protocol on screening for blood borne viruses including hepatitis B (HBV), Hepatitis C and HIV as health requirements for new entry medical students’ admissions and continuing medical practice. This study specifically aims to assess the outcome of HBV vaccination and the subsequent seroconversion status along with other required vaccinations. Methods This 4-year cross-sectional study included 345 new entry Malaysian medical students to NUMed from 2015 to 2018 excluding 80 students with missing data. Demographic data, HBV vaccination status, and HBV surface antibody (anti-HBs) titers were obtained from participants’ health screening reports and recorded in a pre-designed data template. Seroconversion status (anti-HBs titer >10 IU/L) measured using an enzyme-linked immunoassay, was determined and seroconversion rates were calculated. None of the participants received a booster anytime prior to testing. Both demographic and vaccination data were matched to investigate seroconversion rate in relation to ethnicity and gender. Chi-square test was used for analysis using Prism with statistical significance defined as P < 0.05. Results Out of 345, only 223 (64.6%) vaccinated individuals showed seroconversion, while 117 (33.9%) did not seroconvert. Among participants, 121 (35.1%) were male and 224 (64.9%) were female. The majority of the participants were of Chinese ethnicity (62.0%), followed by Malay (19.7%) and Indian ethnicity (18.3%). None of the 345 new entry medical students were tested positive for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), indicating an overall HBV prevalence of 0%. A total of 287 participants (83.2%) were vaccinated against varicella-zoster virus, while 58 (16.8%) were not vaccinated. Vaccination coverage of other vaccines, such as measles, rubella, MenQ and yellow fever were 257 (74.5%), 237 (68.7%), 154 (44.6%) and 20 (5.8%) respectively. There is no significant difference in the seroconversion rate of HBV vaccine between male participants (62.0%) and female participants (64.3%, P = 0.298). However, there is a statistically significant difference in the HBV seroconversion rate between the 3 ethnicity groups, with students of Malay ethnicity showing the lowest seroconversion rate of 47.1%, followed by those of Indian (68.3%) and Chinese ethnicity (69.6%) (P = 0.002). Conclusions This is the first study demonstrating a low HBV vaccine seroconversion rate (64.6%) among young new entry medical students at NUMed (median age: 19) following standard recommended 3-dose vaccination. Students of Malay ethnicity showed a significant non-conversion rate of 51.5% (p=0.002) as compared to the students of Chinese (29.4%) and Indian (28.6%) origin. Previous studies showed seroconversion rates of over 90% and further studies should be considered to investigate why this young population of Malaysian students did not mount protective antibody titer.

FIGURE 1: Multiple plaques and nodules with raised edges and central crust seen over the face. A 25-year-old man with newly diagnosed human immunodeficiency virus (HIV) infection (CD4 count = 53 cells/mm3) presented with a one-month history of generalized cutaneous lesions starting at the trunk and spreading to the face and limbs. The patient experienced intermittent fever, fatigue, and weight loss, but no cough, breathlessness, abdominal pain, or diarrhea. Physical examination revealed multiple plaques and nodular lesions with raised edges and a central crust (Figure 1). Abdominal ultrasonography showed splenomegaly (spleen length=15.9 cm). Skin biopsy revealed abundant fungal spores highlighted by positive periodic acid-Schiff (PAS) and Grocott's methenamine silver (GMS) stains (Figure 2). His blood culture revealed growth of Talaromyces marneffei, and hyphae were visualized on Gram stain. The skin lesions improved following treatment with intravenous amphotericin B for two weeks, followed by oral itraconazole as consolidation and maintenance therapy. Antiretroviral therapy and antifungal therapy were initiated.

Hemophagocytic lymphohistiocytosis is a rare but severe complication of dengue infection which carries a high mortality. This report highlights the importance of early recognition of this condition as prompt appropriate treatment improves outcomes.

ObjectivesThe aim of the study was to describe a UK‐wide process to assess adherence to guidelines for the routine investigation and monitoring of HIV‐positive adults aged ≥ 50 years and provide clinical services with individual feedback to support improvement in quality of care.MethodsThe British HIV Association (BHIVA) invited HIV clinical care sites to provide retrospective data from case notes of up to 40 adults aged ≥ 50 years with HIV‐1 infection attending the clinic for care during 2017 and/or 2018, using a structured dynamic online questionnaire.ResultsA total of 4959 questionnaires from 141 clinical services were returned. Regarding the key targets specified in the BHIVA monitoring guidelines, 97% of patients on antiretroviral therapy (ART) had had their viral load measured in the last 9 months, or 15 months if on a protease inhibitor, and 94% had had all medications recorded in the last 15 months. Only 67% of patients on ART without cardiovascular disease (CVD) had had a 10‐year CVD risk calculated in the last 3 years. It was reported that 80% and 92% had had their smoking status documented in the last 2 years and blood pressure checked in the last 15 months, respectively. HIV services had communicated with the general practitioners of 90% of consenting individuals, but consulted electronic primary care records for only 10%.ConclusionsNationally, targets were met for viral load and blood pressure monitoring but not for CVD risk assessment, smoking status documentation and recording of comedication. There was variable performance in relation to other outcomes; adherence and laboratory measurements were carried out more regularly than lifestyle and wellbeing assessments.

Pulmonary arteriovenous malformation is a vascular anomaly that predisposes to complications of paradoxical embolization including stroke and brain abscess. Here, we present a case of brain abscess associated with pulmonary arteriovenous malformation.

BackgroundIt is cost-effective to perform an HIV test in people with specific indicator conditions (IC) with an undiagnosed HIV prevalence of at least 0.1%. Our aim was to determine the HIV prevalence for 14 different conditions across 20 European countries.MethodsIndividuals aged 18-65 years presenting for care with one of 14 ICs between January 2012 and June 2014 were included and routinely offered an HIV test. Logistic regression assessed factors associated with testing HIV positive. Patients presenting with infectious mononucleosis-like syndrome (IMS) were recruited up until September 2015.ResultsOf 10,877 patients presenting with an IC and included in the analysis, 303 tested positive (2.8%; 95% CI 2.5-3.1%). People presenting with an IC in Southern and Eastern Europe were more likely to test HIV positive as were people presenting with IMS, lymphadenopathy and leukocytopenia/ thrombocytopenia. One third of people diagnosed with HIV after presenting with IMS reported a negative HIV test in the preceding 12 months. Of patients newly diagnosed with HIV where data was available, 92.6% were promptly linked to care; of these 10.4% were reported lost to follow up or dead 12 months after diagnosis.ConclusionThe study showed that 10 conditions had HIV prevalences > 0.1%. These 10 ICs should be adopted into HIV testing and IC specialty guidelines. As IMS presentation can mimic acute HIV sero-conversion and has the highest positivity rate, this IC in particular affords opportunities for earlier diagnosis and public health benefit.

Melioidosis is a potentially fatal infection caused by Burkholderia pseudomallei, a bacterium endemic to certain tropical and subtropical world regions. It most frequently enters the body through small abrasions on the feet or lower limbs when individuals walk barefoot, or in open footwear, through contaminated wet or muddy environments. We report on three female cases successfully treated for melioidosis within the Newcastle upon Tyne NHS Hospitals over a 12-month period; a 52-year-old with a mediastinal abscess, a 38-year-old with an intra-cerebral abscess, and a 69-year-old with pneumonia and bacteraemia. Two patients were diabetic, the latter with established microvascular complications, but the third patient had no immunosuppressive risk factor identified. All had recently travelled to Thailand, although one remained solely within the confines of her holiday resort and another did not leave the city of Pattaya. Clinicians must remain vigilant to the potential for imported cases of melioidosis into the UK in travellers returning from endemic areas, such as Southeast Asia.

Background Tenofovir alafenamide is associated with less renal and bone toxicity than tenofovir disoproxil fumarate and might improve the long-term safety of antiretroviral therapy. We aimed to investigate the effect on bone mineral density of switching from a regimen containing tenofovir disoproxil fumarate to one containing tenofovir alafenamide in participants aged 60 years and older. Methods We did a prospective, open-label, multicentre, randomised trial in 36 European centres. Participants were virologically suppressed (HIV-1 RNA <50 copies per mL), aged 60 years or older, on a tenofovir disoproxil fumarate-containing regimen and were randomly assigned (2:1) via an interactive web-response system to open-label elvitegravir (150 mg), cobicistat (150 mg), emtricitabine (200 mg), and tenofovir alafenamide (10 mg) daily or continued therapy containing tenofovir disoproxil fumarate (300 mg). Participants were stratified by spine and hip bone mineral density categories. Primary endpoints were change from baseline to week 48 in spine and hip bone mineral density with a null hypothesis of zero between-group difference tested at a significance level of 0.05. This study was registered with ClinicalTrials.gov, NCT02616783. Findings Between Dec 22, 2015, and March 21, 2018, 167 participants were randomly assigned to elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (n=111 [66%]) or tenofovir disoproxil fumarate (n=56 [34%]). One participant in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group did not receive treatment and was excluded from all analyses. At week 48, the mean percentage change in spine bone mineral density was 2.24% (SD 3.27) in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group and -0.10% (3.39) in the tenofovir disoproxil fumarate group (between-group difference 2.43% [95% CI 1.34-3.52]; p<0.0001), and mean percentage change in hip bone mineral density was 1.33% (2.20) in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group and -0.73% (3.21) in the tenofovir disoproxil fumarate group (difference 2.04% [1.17-2.90]; p<0.0001). The most common adverse events were nasopharyngitis (12 [11%]), back pain (nine [8%]), and diarrhoea (eight [7%]) in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group; and bronchitis (six [11%9, vitamin D deficiency (four 17%1), and arthralgia (four [7%]) in the tenofovir disoproxil fumarate group. 22 (20%) participants in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group and one (2%) participant in the tenofovir disoproxil fumarate group had an adverse event that was considered to be related to treatment. No treatment-related serious adverse events were observed. The proportions of adverse events leading to premature treatment discontinuation were similar between groups (four [4%] in the elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide group; and one (2%) in the tenofovir disoproxil fumarate group). Interpretation The significantly improved bone mineral density, overall safety, and efficacy data show the feasibility of switching from a regimen containing tenofovir disoproxil fumarate to elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in virologically suppressed people living with HIV aged 60 years or older. Copyright (C) 2019 Elsevier Ltd. All rights reserved.