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.

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.
Diabetes Mellitus, Type 1 ; Diabetic Ketoacidosis

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.

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.

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.

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.

Kidney transplantation is the treatment of choice for the majority of patients with Kidney Failure in an ideal world and is preferred over dialysis on the basis of evidence that demonstrate improvement in health-related quality of life and prolongation of life expectancy. However, shortage of suitable organs remains a limiting factor for program expansion. In Brunei Darussalam, despite having conducted over 16 cases of successful living related donor-recipient kidney transplantation over a period of 8 years, the program is still considered at its infancy state. This review article discusses the evolution of our program and the problems associated with setting up such a nationwide kidney transplantation program and elaborate our plans to increase the scope of services in the future, towards ‘Wawasan 2035’.

Introduction: Lung cancer has been the leading cause of cancer deaths in Brunei Darussalam for the past five years. This study is the first to supply data for the 5-year survival of patients diagnosed with non-small cell lung cancer (NSCLC) in Brunei Darussalam. Materials and Methods: From 2002 to 2009, 302 patients diagnosed with NSCLC were identified from the National Cancer Registry of Brunei Darussalam. Demographic and clinical data were retrospectively retrieved from the clinical notes. All deaths and dates of death were obtained and crosschecked with the National Birth and Death Registry at the Immigration Department. Data were analysed using SPSS statistical software and 5-year Kaplan -Meier survival curves were derived and analysed using Log Rank test. Predictors of 5-year survival were analysed using Cox regression analysis. Results: Mean age of the 302 patients was 64.9 ± 12.8 (27.4–90.6 years) with male to female ratio of 194:108. Racial distribution consisted of 84.4% (n=255) Malay, 12.5% (n=38) Chinese and 3.1% of other racial origin (indigenous and foreign nation- als). Histological types of NSCLC consisted of 67.9% (n=205) adenocarcinoma, 16.2% (n=49) squa- mous cell carcinoma, 6.3% (n=19) large cell carcinoma, 5.3% (n=16) bronchioalveolar carcinoma and 4.3% of other origin. Only 13.9% of patients underwent surgical resection. At completion of follow-up, only 47 (15.5%) patients were still alive. There were 255 deaths. Overall 5-year survival for the whole group was 3.6% with a median survival time of 6.5 ± 0.9 months (95% CI: 4.7-8.4 months) but ac- cording to stage of disease was 60.9% for Stage IA, 29.9% for Stage IB, 10.0% for Stage IIB, 7% for Stage IIIB and 3% for Stage IV. Significant prognostic factors were younger age at diagnosis, surgical resection, tumour types and tumour stages. Conclusion Overall 5-year survival of patients diagnosed with NSCLC in Brunei Darussalam is still generally poor but comparable to previously reported data. Significant prognostic factors were younger age at diagnosis, surgical resection, tumour types and tu- mour stages.

Introduction:: Psychosocial stress including work-related stress has been shown to cause endothelial dysfunction and plays a role in the aetiology and pathogenesis of a wide range of cardiovascular diseases. Junior doctors are exposed to high levels of daily work-related stress and more so when they are on-call. This study aimed to investigate the adverse effects of stress of being on-call for 24-hours on endothelial function in junior doctors in a busy tertiary referral hospital. Materials and Methods:: A prospective single arm study of junior doctors working in a busy tertiary referral hospital was conduct- ed. Junior doctors aged between 25 years and 50 years were recruited to have their brachial artery flow mediated vasodilatation (BAFMD) assessed on the morning, before and after being on-call for 24-hours. Blood supply to the forearm was occluded for 5 minutes and the brachial artery diameter was measured at 1, 2, 3 and 5 minutes post cuff deflation, using a duplex Doppler ultrasound. A within-participant (paired) analysis was performed to compare diameter changes at all time intervals. Results:: BAFMD in junior doctors after a 24-hour on-call was significantly attenuated when compared to pre-call BAFMD. This trend was significant at 2 minutes (p=0.03) and 3 minutes (p=0.003) hyperaemic response after cuff release. Analysis on variables such as duration of sleep (<5hrs), gender, racial origin of junior doctors were all significant factors for attenuation of BAFMD after a period of 24 hours on-call. Conclusion: The effect of stress of a 24-hour on-call has significant adverse effects on BAFMD in junior doctors working in a busy tertiary referral hospital. This adverse effect is significantly more prominent in junior doctors who had less than 5 hours of sleep of male gender, of Malay racial origin and of single marital status.