Zaitun Zakaria

Bio: Zaitun Zakaria is an academic researcher from Universiti Sains Malaysia. The author has contributed to research in topics: Health care & Consciousness. The author has an hindex of 2, co-authored 12 publications receiving 11 citations.

Cerebral venous sinus thrombosis 2 weeks after the first dose of mRNA SARS-CoV-2 vaccine.

Abstract: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease 2019 (COVID-19) is a highly transmissible virus and has become pandemic. Part of the prevention of disease spread by the Malaysian government is by getting COVID-19 vaccine. Using the mRNA technology, the Pfizer/BioNTech vaccine is one of the vaccines been approved by the Drug Control Authority in Malaysia. Herein, we report an immediate complication of cerebral VST after the first dose of the Pfizer/BioNTech vaccine.

The Neurological Exam of a Comatose Patient: An Essential Practical Guide.

Abstract: A thorough examination of a comatose patient is essential given the spectrum of clinical diagnoses. The most immediate threat to patients is airway, breathing and circulation. All attending physician should employ a structured and focused approach in dealing with a comatose patient. It is important to recognise the urgent steps needed at the time to prevent further deterioration, followed by the final diagnosis of patient's neurologic status. Here we provide the essential practical guide to the neurological exam of a comatose patient that would assist to determine the aetiology, location and nature of the neurological lesion.

COVID-19 Pandemic and Its Impact on Neurosurgery Practice in Malaysia: Academic Insights, Clinical Experience and Protocols from March till August 2020

Abstract: The newly discovered coronavirus disease 2019 (COVID-19) is an infectious disease introduced to humans for the first time. Following the pandemic of COVID-19, there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. With pooling and outsourcing of more health care workers to emergency rooms, public health care services and medical services, further in-hospital resources are prioritised to those in need. It is imperative to balance the requirements of caring for COVID-19 patients with imminent risk of delay to others who need care. As Malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. Various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in Malaysia. The crisis has certainly put a strain on the effective delivery of services and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in Malaysia. The following details are various measures put in place as the new operational protocols for neurosurgical services in Malaysia.

Quantum and Electromagnetic Fields in Our Universe and Brain: A New Perspective to Comprehend Brain Function.

Abstract: The concept of wholeness or oneness refers to not only humans, but also all of creation. Similarly, consciousness may not wholly exist inside the human brain. One consciousness could permeate the whole universe as limitless energy; thus, human consciousness can be regarded as limited or partial in character. According to the limited consciousness concept, humans perceive projected waves or wave-vortices as a waveless item. Therefore, human limited consciousness collapses the wave function or energy of particles; accordingly, we are only able to perceive them as particles. With this "limited concept", the wave-vortex or wave movement comes into review, which also seems to have a limited concept, i.e., the limited projected wave concept. Notably, this wave-vortex seems to embrace photonic light, as well as electricity and anything in between them, which gives a sense of dimension to our brain. These elements of limited projected wave-vortex and limitless energy (consciousness) may coexist inside our brain as electric (directional pilot wave) and quantum (diffused oneness of waves) brainwaves, respectively, with both of them giving rise to one brain field. Abnormality in either the electrical or the quantum field or their fusion may lead to abnormal brain function.

Intraoperative Cerebrospinal Fluid Sample from First Ventriculoperitoneal Shunt Operation: Is it Indicated?

Abstract: Dear Editor, We read with interest two articles on neurosurgical infections in Hospital Kuala Lumpur in the Malaysian Journal of Medical Sciences published in 2010 with the title “The Risk Factors of External Ventricular Drainage-Related Infection at Hospital Kuala Lumpur: An Observational Study” by Omar and Mohd Haspani (1) as well as another article in the January 2011 issue of the same journal titled “A randomised control trial on the use of topical methicillin in reducing post-operative ventriculoperitoneal shunt infection” written by Theophilus and Adnan. Therefore, we would like to add further comments on a brief study of ventriculoperitoneal (VP) infections done in a tertiary university hospital during the same period (2). Cerebrospinal fluid (CSF) sample is routinely performed in neurosurgical patients, generally to confirm any evidence of intracranial central nervous system (CNS) infection and for follow- up on patients who already on treatment. Commonly performed tests on CSF fluid analysis include protein and glucose levels, cell counts and differential, microscopic examination and culture (3). In the institution where this study was done, intraoperative CSF sampling is a routine procedure following ISO 9001 standards. We reviewed retrospectively all the first VP shunt procedure performed by multiple surgeons from April 2005 until July 2011 in Hospital Universiti Sains Malaysia of whom 101 patients were included in the study. The study subjects had no history of previous neither intracranial operation nor CNS infection, and they were all followed- up within a one-year period. The male-to-female ratios of the patients were 47:54 and 56 of them were less than 16 year-old (55.6%). Right sided VP shunt was the preferred site (86, 85%). Congenital hydrocephalus became the most common indication for the procedure (48, 47.5%). From 101 CSF samples included in the study, there was significant difference between the age at insertion of first VP shunt and indications for the procedure (P = 0.009). 90.1% (91) had white cells count (WCC) less than 6 (not significant), 3.0% (3) had a significant sample, and 6.9% (7) had no sample taken (P < 0.001). When analysing the second CSF samples, eighteen samples were collected; 12.9% (13) had negative samples, and 5% (5) became significant. 82% (83) did not have a repeat CSF samples. Comparing these two samples, they were also statistically significant (P < 0.001). Three patients who had significant results from the first sample, two of them did not have to repeat CSF samples. From 91 patients who had negative first CSF sample, 81% (74) did not have repeat sample, 13.2% (12) who had repeat sample came back negative and only 5.5% (5) came back significant. These CSF sampling indications were based on clinical evidence of surgical site infection (9, 53%); fever (7, 47%); seizure (4, 23.5%); sepsis (3, 17.6%) and one patient had a query of shunt malfunctioning from a post-operative CT finding. Five samples came back significant; all of them were commenced with antibiotics and 4 of them required shunt revisions. Futhermore, we noticed in these samples were positive for microorganisms on CSF culture and sensitivity. Six of them were gram-positive cocci (Staphylococcus sp.) and one was gram-negative bacilli (Chryseobacterium meningosepticum). Three of them had a normal WCC. All were treated with antibiotics and 6 of them had revision of shunts. Intracranial CNS infection is defined as a positive CSF culture on the day that the sample was obtained (4). The term contamination was used when a patient had only one positive CSF culture for a common skin pathogen, the results of the consecutive samples were negative, and no treatment had been started (5). All of our patients who had intraoperative CSF samples taken had no organism seen on culture. Only three of them showed positive CSF sample, but no treatment had been started. Therefore, assumed this might have to be due to sampling contamination. Normal CSF WCC contains between 0–4/μL (6) and up to 5/mm3 in adults (3) and 20/mm3 in newborns (7). Tulipan and Cleves (8) used the value of CSF WCC greater than 40/mm3 as the significant finding and correlated with shunt infection. This was quite high in comparison to our value (> 6/ mm3 was significant). If we used the same value as in the above study, only two significant results were noted on each CSF sample. This might have led to misdiagnosis and delayed in patient’s management and treatment. There are no established published criteria for intraoperative CSF sample taken from patients who underwent first VP shunt, especially when there was no history of previous intracranial CNS infection. A further prospective study should be done to further evaluate the criteria for intraoperative CSF sampling as the diagnosis of any infection can only be established by either a positive culture or when clinical signs are found and therapy is started and increased WCC, elevated protein and/or decreased glucose in CSF are found, as defined by the Centers for Disease Control and Prevention (9). Future study protocols must take heed that ventricular CSF may show lower WCC than lumbar CSF, and the WCC can be different with various microorganisms.

Spectrum of neurological complications following COVID-19 vaccination.

Abstract: COVID-19 vaccines have brought us a ray of hope to effectively fight against deadly pandemic of COVID-19 and hope to save lives. Many vaccines have been granted emergency use authorizations by many countries. Post-authorization, a wide spectrum of neurological complications is continuously being reported following COVID-19 vaccination. Neurological adverse events following vaccination are generally mild and transient, like fever and chills, headache, fatigue, myalgia and arthralgia, or local injection site effects like swelling, redness, or pain. The most devastating neurological post-vaccination complication is cerebral venous sinus thrombosis. Cerebral venous sinus is frequently reported in females of childbearing age, generally following adenovector-based vaccination. Another major neurological complication of concern is Bell's palsy that was reported dominantly following mRNA vaccine administration. Acute transverse myelitis, acute disseminated encephalomyelitis, and acute demyelinating polyneuropathy are other unexpected neurological adverse events that occur as result of phenomenon of molecular mimicry. Reactivation of herpes zoster in many persons, following administration of mRNA vaccines, has been also recorded. Considering the enormity of recent COVID-19-vaccinated population, the number of serious neurological events is miniscule. Large collaborative prospective studies are needed to prove or disprove causal association between vaccine and neurological adverse events occurring vaccination.

The lived experiences of a COVID-19 immunization programme: vaccine hesitancy and vaccine refusal

Abstract: The COVID-19 pandemic has resulted in a global health emergency and lock-down measures to curb the uncontrolled transmission chain. Vaccination is an effective measure against COVID-19 infections. In Malaysia amidst the national immunisation programme (NIP) which started in February 2021, there were rising concerns regarding the prevalence of vaccine hesitancy and refusal, and therefore, vaccine uptake among Malaysians. Although there are many quantitative studies on COVID-19 vaccination, the subjective experience of individuals was understudied. This study aims to explore the lived experiences of Malaysians regarding vaccine hesitancy and refusal, and facilitating factors that could enhance vaccine acceptance and uptake.This qualitative study employed the hermeneutic phenomenological study design. Purposive sampling strategies were used to recruit Malaysians that had direct experiences with friends, family members and their community who were hesitating or refusing to accept the COVID-19 vaccines. A semi-structured interview guide was developed based on the expert knowledge of the investigators and existing literature on the topic. A series of focus group interviews (FGIs) was conducted online facilitated by a multidisciplinary team of experts. The group interviews were transcribed verbatim and analysed.Fifty-nine participants took part in seven FGIs. We found that "incongruence" was the overall thematic meaning that connected all the 3 main themes. These themes comprise firstly, the incongruence between the aims and implementation of the National Immunization Program which highlighted the gap between realities and needs on the ground. Secondly, the incongruence between Trust and Mistrust revealed a trust deficit in the government, COVID-19 news, and younger people's preference to follow the examples of local vaccination "heroes". Thirdly, the incongruence in communication showed the populace's mixed views regarding official media and local social media.This study provided rich details on the complex picture of the COVID-19 immunization program in Malaysia and its impact on vaccine hesitancy and refusal. The inter-related and incongruent factors explained the operational difficulty and complexity of the NIP and the design of an effective health communication campaign. Identified gaps such as logistical implementation and communication strategies should be noted by policymakers in implementing mitigation plans.

Stroke Associated with COVID-19 Vaccines

Abstract: ObjectivesDevelopment of safe and effective vaccines against coronavirus disease 2019 (COVID-19) remains the cornerstone of controlling this pandemic. However, there are increasing reports of various types of stroke including ischemic stroke, and hemorrhagic stroke, as well as cerebral venous sinus thrombosis (CVST) after COVID-19 vaccination. This paper aims to review reports of stroke associated with COVID-19 vaccines and provide a coherent clinical picture of this condition.Materials and methodsA literature review was performed with a focus on data from recent studies.ResultsMost of such patients are women under 60 years of age and who had received ChAdOx1 nCoV-19 vaccine. Most studies reported CVST with or without secondary ischemic or hemorrhagic stroke, and some with Vaccine-induced Thrombotic Thrombocytopenia (VITT). The most common clinical symptom of CVST seen after COVID-19 vaccination was headache. The clinical course of CVST after COVID-19 vaccination may be more severe than CVST not associated with COVID vaccination. Management of CVST following COVID-19 vaccination is challenging and may differ from the standard treatment of CVST. Low molecular weight heparin is commonly used in the treatment of CVST; however, it may worsen outcomes in CVST associated with VITT. Furthermore, administration of intravenous immunoglobulin and high-dose glucocorticoids have been recommended with various success rates.ConclusionThese contradictory observations are a source of confusion in clinical decision-making and warrant further study and development of clinical guidelines. Clinicians should be aware of clinical presentation, diagnosis, and management of stroke associated with COVID-19 vaccination.