The first case of COVID-19 was reported in Malaysia on the 25 January 2020. By the 20 January 2021, the cumulative numbers reported confirmed cases of COVID-19 had reached 169,379 including 630 deaths. Malaysia has been hit by three waves of COVID-19. This article reports on the three waves, the current situation and some of the possible factors associated. It outlines the need to reassess the overall situation, re-strategize the approach in order to contain the spread. The first COVID-19 wave lasted from 25 January to 16 February 2020, the second wave occurred between the 27 February 2020 and the 30 June 2020. The current third wave began on 8th September 2020.The sudden surge of cases in the third wave was mainly due to the two largest contributors, namely the Benteng Lahad Datu cluster in Sabah state and Kedah's Tembok cluster. The current situation is critical. The daily confirmed cases of COVID-19 continue to soar. The challengers faced by healthcare workers and other front liners is tremendous. Non-communicable diseases such as cardiovascular diseases, diabetes and cancer are the leading cause of death in Malaysia. A paradigm shift in the approach is required to ensure the sustainability of the normal healthcare services provided by the government especially for the lower income groups. There is also a need to expedite the tabling of Tobacco Control Bill in coming parliament session which is long overdue. H.E. the King of Malaysia has called on all Malaysians to put aside political, racial and religious differences and show the spirit of loyalty, humanitarianism and steadfastness in fighting the COVID-19 pandemic.

The Malaysian Medical Association (MMA) is the body that represents registered medical practitioners in Malaysia. In 1994, it introduced a national Continuing Medical Education (CME) system on a voluntary basis for all doctors in the country. As a longstanding member of the MMA Continuing Professional Development (CPD) Committee, I wish to record some reflections on the MMA CPD System and document the history and the pioneering work of MMA in the area of CPD.

Acute ischaemic stroke (AIS) is a devastating disease and one of the leading causes of disabilities worldwide. From 2010 to 2014, the incidence of stroke in Malaysia had increased from 65 to 187 per 100,000 population.1 Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset has been shown to be an effective treatment for AIS. Patients who receive thrombolysis are 30 percent more likely to achieve excellent functional outcome (modified Rankin scale of 0 to 1) at 3 months compared to placebo.2 Unfortunately, the delivery of stroke thrombolysis service in Malaysia is often limited by the availability of neurologists. To date, the ratio of neurologists capable of performing thrombolysis serving in public hospitals to the Malaysian population is 1:1.4 million.3 To counteract this disparity and to cope with the increasing stroke burden in Malaysia, there has been an advocacy for greater involvement of non-neurologists, i.e., general and emergency physicians in performing of stroke thrombolysis.4 Emerging data based on short term outcomes appear to support this notion. Based on a 2015 single center study on 49 AIS patients in Australia, A. Lee et al., reported that there was no significant difference in door to needle time, rates of symptomatic intracranial bleeding (SICH), and mortality between patients thrombolysed by neurologists versus stroke physicians.5 In 2016, a larger multicentre study in Thailand reported that patients thrombolysed in hospitals without neurologists had lower National Institute of Health Stroke Scale (NIHSS) scores at discharge and lower inpatient mortality rate compared to patients treated in neurologist hospitals.6 Based on these short term outcomes, both studies suggest that nonneurologists are able to thrombolyse AIS patients safely and effectively. Data comparing long term functional outcomes in thrombolysis prescribed by neurologists and nonneurologists are still very limited. The primary objective of this study was to evaluate and compare the 3-month functional outcomes of thrombolytic therapy between hospitals with and without on-site neurologists. The secondary objective was to assess the doorto-needle time and complication rates of thrombolysis service in both hospitals

Spontaneous subarachnoid haemorrhage (SAH) is a significant cause of stroke and may lead to severe neurological deficit or death. It is also associated with high morbidity and mortality for patients despite optimal medical and surgical treatment. Based on the World Health Organization the annual incidence of spontaneous SAH varies in different regions of the world between 2.0-22.5 per 100,000 populations with Finland and Japan having the highest incidence and South and Central America with lowest incidence.1

Introduction: COVID-19 is a highly transmissible respiratory virus that has affected millions of people worldwide in the span of months. The burden of disease among healthcare workers (HCW) has not been well studied despite reports of infectivity and transmission around the world. Two HCW in Hospital Teluk Intan (HTI) contracted COVID-19 while attending a social event. They were in close proximity with colleagues upon returning to work, resulting in the spread of infection among other HCW in HTI.

Introduction: The aim of this study was to determine the spontaneous pregnancy rate and safety of our surgical technique of performing laparoscopy cystectomy for endometrioma

Objective: The aim of this study was to compare the postoperative refractive outcome after cataract surgery between a hospital-based and an outreach-based cataract service centre. Methods: This study was conducted at the Hospital Selayang (HS), Selangor, Malaysia, a tertiary referral centre and an outreach-based cataract service centre (Pusat Pembedahan Katarak MAIWP, PPKM). Data was sourced from the Cataract Surgery Registry (CSR) in the National Eye Database (NED). Results: A total of 2318 surgeries were analysed. PPKM achieved postoperative refraction outcome within ±1.0D in 94.3% of cases compared with 88.4% in Selayang Hospital. Mean absolute prediction error was also better in PPKM (0.39±0.27D vs. 0.33±0.24D, p<0.001). Multivariate analysis showed that the tertiary hospital, persons of Chinese ethnicity, history of uveitis, previous history of ocular surgery and intraoperative complications as significant independent predictive factors for poor refractive outcomes. Conclusion: The outreach-based cataract service centre, which incorporates streamlined process designs and workflows, achieved superior refractive outcomes within ±1 dioptre after cataract surgery compared to a tertiary hospital.

Non-transfused β-thalassaemia patients develop complications related to unsuppressed ineffective erythropoiesis (IE). Serum markers of IE would be useful for risk stratification and monitoring treatment. We studied βthalassaemia trait (β-TT) and non-transfusion-dependent βthalassaemia (β-NTDT) patients. Serum erythropoietin (EPO) and soluble transferrin receptor (sTfR) were correlated against markers of clinical severity (haemoglobin, LDH, retics, bilirubin, spleen size) and iron overload (ferritin, hepcidin, and MRI-T2* in NTDT patients). Eleven β-NTDT and nine β-TT subjects were studied. βNTDT patients had significantly higher markers of haemolysis and iron overload. In β-NTDT, liver iron ranged from mild to severe, but no cardiac loading was seen. EPO and sTfR were higher in patients with β-NTDT than β-TT, and correlated significantly with each other (ρ=0.630, p=0.003). Both markers were negatively correlated with haemoglobin (sTfR ρ=-0.540, p=0.014; EPO ρ=-0.807, p<0.001, and positively correlated with spleen size (sTfR ρ=0.783, p<0.001; EPO ρ=0.654, p=0.002) and markers of iron overload. There was a strong correlation between ferritin and hepcidin (ρ=0.720, p<0.001), and a relatively lower increment of hepcidin for the degree of iron overload in βNTDT compared to β-TT. EPO and sTfR appear to be reliable markers of erythropoiesis in non-transfused β-thalassaemia and correlate well with markers of disease severity. Their role in managing patients, predicting complications, and monitoring response to treatments aimed at reducing IE should be explored.

Introduction/Objective: The management of potential treatment-related complications and bleeding events in haemophilia is challenging in developing countries. Providing optimal care among these patients improve their quality of life (QOL) and life expectancy. This study explores the demographic characteristics and treatment outcome in a major haemophilia treatment centre in Malaysia. Materials and Methods: A total of 260 patients were recruited in this retrospective cross-sectional analysis. Clinical data, including treatment regimens and outcome, were collected and analysed. Results: A total of 211 patients were diagnosed with haemophilia A (HA) (severe disease, 72.5%) and 49 patients had haemophilia B (HB) (severe disease, 65.3%). The median age was 31 (IQR;2-84) years. Majority of the patients had at least one episode of musculoskeletal bleeding since diagnosis. The mean annual bleeding event (ABE) was 4.91 (SD±6.07) in 2018. Target joints were identified in 80.4% of the patients. Chronic arthropathy and synovitis collectively accounted for more than half of the musculoskeletal complications. 30.1% of the patients had contracted hepatitis C with less than half received treatment. Thirty-one patients (16.8%) with severe haemophilia developed inhibitor and 12 patients successfully underwent immune tolerance induction. More than three-quarters of the severe haemophilia patients were treated with factor concentrate prophylaxis. The mean prophylaxis dose for HA and HB were 41.3 (SD±19.1) and 48.6 (SD±21.5) IU/kg/week, respectively. In patients with severe disease, prophylaxis significantly reduced the ABE (5.45,9.03;p=0.005). Conclusion: The importance of utilising a low to moderate dose regimen as prophylaxis in haemophilic patients is highlighted in our study. Future studies should include QOL assessment will further improve the management in haemophilia.

Introduction: Sarawak has a population that is geographically and characteristically widely varied. This study aimed to determine the demographic profile of patients in Sarawak, Malaysia. Materials and Methods – A cross-sectional study was conducted in 2019 at four major haemophilia treatment centres in Kuching, Sibu, Bintulu and Miri Hospitals, Sarawak. Demographic and clinical data were collected with consents from patients. Results and Discussion: Ninety-six haemophilia patients were identified - 79(82.3%) haemophilia A(HA) and 17(17.7%) haemophilia B(HB). Severe haemophilia patients were noted in 45.6% (36/79) of HA and 64.7% (11/17) of HB. In all 44.3% of the HA and 52.9% of the HB population had no identifiable family history of haemophilia. Two-thirds of the patients with severe HA were on prophylaxis [24/36 (66.7%)] and only onethird [4/11 (36.4%)] in severe HB. Inhibitors developed in 9/79 (11.4%) of the HA population [3/79 (3.8%) high responders]. The median inhibitor titre was not significantly different between the different treatment groups – on demand versus prophylaxis (1.0BU versus 2.0BU; z statistic -1.043, p-value 0.297, Mann-Whitney test). None of the patients developed inhibitory alloantibodies to factor IX. Four HA patients (5.1%) underwent immune tolerance induction where one case had a successful outcome. Three severe HA patients received emicizumab prophylaxis and showed remarkable reduction in bleeding events with no thromboembolic events being reported. One female moderate HA patient received PEGylated recombinant anti-haemophilic factor. Eleven patients underwent radiosynovectomy. One mild HB patient succumbed to traumatic intracranial bleeding. Our data reported a prevalence (per 100,000 males) of 5.40 cases for all severities of HA, 2.46 cases for severe HA; 1.16 cases for all severities of HB, and 0.75 cases for severe HB. The overall incidence of HA and HB was 1 in 11,500 and 1 in 46,000, respectively. Conclusion: This study outlines the Sarawakian haemophilia landscape and offers objective standards for forward planning. Shared responsibilities among all parties are of utmost importance to improve the care of our haemophilia population.