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The Malaysian Journal of Medical Sciences : MJMS logoLink to The Malaysian Journal of Medical Sciences : MJMS
. 2005 Jan;12(1):71–95.

Abstracts of Theses Approved for the M.Sc., M.Med. and PhD. Degrees at the School of Medical Sciences, University Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia.

PMCID: PMC3349417
Malays J Med Sci. 2005 Jan;12(1):71.

(1) Identification of Uridine Diphosphate Glucuronosyl Transferase 1A1(UGT1A1) Gene Mutations in Babies With Early Onset of Neonatal Jaundice

Norlelawati bt A Talib 1,2

Abstract

Background :

Neonatal jaundice is common in South-East Asian and it is a potential cause of permanent brain damage. In most of the cases, no obvious aetiology is identified. Recently, mutations in the bilirubin uridine diphosphate glucuronosyl transferaselAl(UGTlAl) gene attributed to neonatal jaundice and hyperbilirubinemia syndromes have been reported in many populations. The underlying molecular defects are heterogeneous and may be attributed to any part of the five exons of the UGT1 gene.

Objective :

There were two main objectives in this study. The first objective of this study was to apply molecular techniques for the investigation of the UGT1A1 mutation in three babies [Bl, B2, B3] who presented with early onset of jaundice. Identifiable causes of pathological jaundice have been excluded earlier. An inherited phenomenon of this mutation will be demonstrated by doing family study and molecular analysis.

The second objective of the study was to develop a screening test for G71R mutation and to investigate the relationship of this mutation with neonatal hyperbilirubinemia.

Methodology :

For this purpose, sixty-eight Malay neonates were recruited. The subjects were divided into two groups:- hyperbilirubinemia and non-hyperbilirubinemia. Blood samples were taken and were screened for G71R mutation using denatured high performance liquid chromatography (DHPLC).

Results :

Nucleotides sequenced study of the three babies identified two different novel mutations within the studied gene in two Malay babies [Bl, B2]. One mutation was transversion G Æ C at nucleotide 1477 in exon 5 corresponding to G493R in Bl. Another mutation was transition AÆ G at nucleotide 964 in exon 2 corresponding to I322V in B2. A specific mutation i.e transition GÆA at nucleotide 211 in exon 1 corresponding to G71R was identified in B3, a Chinese. Previous studies have identified this specific mutation in Chinese, Korean and Japanese populations.

Population study for G71R mutation had revealed that it is present in four out of thirty-two hyperbilirubinemia neonates and one out of thirty-six non hyperbilirubinemia neonates with allele frequency of 0.03%. However, the association between the presence of this mutation and neonatal hyperbilirubinemia was insignificant (p> 0.05).

Conclusion :

Two novel intraexonic mutations were detected in two Malay babies [Bl, B2] and a specific G71R mutation was identified in a Chinese baby [B3}. These results suggest that mutations in UGT1A1 gene may play a role in the pathogenesis of early onset neonatal jaundice in Malay babies. Population study results showed that G71R mutation was found in Malay population; however its contribution to neonatal hyperbilirubinemia is equivocal due to limited samples sized and thus warrants further study in near future.

Dr. Narazah Mohd. Yusoff : (Supervisor)

Dr. Rosline Hassan : (Co-Supervisor)

Assoc. Prof. Dr. Amin Hans Van Rostenberghe : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):71–72.

(2) The Association of HLA Class II Antigens With Anticardiolipin Antibody Expression in Malays With Systemic Lupus Erythematosus

Nurul Khaiza bt Yahya 1,2

Abstract

Background :

Systemic lupus erythematosus (SLE) is a disease of abnormal immune regulation, characterized by the production of autoantibodies and the accumulation of immune complexes which eventually lead to inflammation in multiple organs and cause a wide range of clinical manifestations. Autoantibody production depends on the interaction of helper T lymphocytes with HLA Class II molecules on antigen presenting cells; therefore, the class II genes have a role in susceptibility through alteration of T cell recognition. The aetiology is still remain unknown, however genetic predisposition, sex hormones and environmental factors might play a role in the pathogenesis of SLE.

Objective :

This study was designed to evaluate the frequency of HLA-DR and -DQ alleles in ethnic Malays with SLE in order to determine the role of these genes in disease susceptibility. We also study the frequency of anticardiolipin antibody present in SLE and evaluate its association with HLA antigens. Finally we tried to correlate of these two parameters with clinical manifestations.

Methodology :

This cross sectional study was conducted in the Medical clinic and Immunology laboratory, Hospital Universiti Sains Malaysia from November 2002 until August 2003. Fifty-five Malay SLE patients who fulfilled the American Rheumatism Association (ARA) were analysed. HLA typing and anticardiolipin antibody screening were compared with the control group consisting of 55 healthy unrelated subjects with comparable age and sex from the same ethnic group. HLA typing of class II antigen were carried out using MicroSSP Class II generic (DRB/DQB) from One Lambda Inc.; while anticardiolipin antibody screening was performed using RELISA Cardiolipin Antibody Screening Test by Immunoconcepts.

Results :

We found a strong association of HLA-DR15 and HLADR17 with SLE compared to healthy subjects (p corr = 0.002, adjusted OR = 5.513 ;p con = 0.04, adjusted OR = 7.87, respectively). Anticardiolipin antibodies was significantly positive in SLE patients compared to healthy subjects with p corr < 0.001(adjusted OR = 15.541) however no significant association with HLA Class II antigens was found. There was a significant positive association of DR15 with arthritis, whereas anticardiolipin antibody has no correlation with clinical manifestations.

Conclusion :

Our data suggests the role of the HLA Class II genes in conferring SLE susceptibility and in clinical expression.

Assoc. Prof. Dr. Mustaffa Musa : (Supervisor)

Dr. Nadeem Afzal : (Co-Supervisor)

Assoc. Prof. Dr. Kamaliah Daud : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):72.

(3) Effects of Sedative Oral Premedication on Oxygen Saturation in Patients Undergoing Spinal Anaesthesia

Swaran Singh A/L Norpa Singh 1

Abstract

Backgroud :

This has been a prospective study carried out over a period of ten months at Hospital University Sains Malaysia, Kubang Kerian, Kelantan. Oxygen is routinely supplemented to all patients in the operation theatre undergoing spinal anaesthesia for lower limb or lower abdominal surgery.

Objectives :

This study was undertaken to evaluate the effect of sedative oral premedication on oxygen saturation of patients undergoing spinal anaesthesia and if they require oxygen supplement as a routine. This study also evaluated if oxygen supplement is required as a routine in patients undergoing Spinal anaesthesia when they were not given premedication.

Methodology :

All the patients belonged to the American Society of Anaesthesia (ASA) 1 and 2 and in the age group of 18 – 45. Total of 140 patients were included in this study. Premedicated patients group A;n=70. were from the elective operative list seen one day prior to their operation and premedicated with tablet midazolam at night and one hour prior to surgery. Un premedicated patients group B;n=70. were from the emergency operative list who had not received any sedation for the last 4 hours.

Results :

Of the seventy patients in the orally premedicated group, 7% of the patients had oxygen desaturation of less than 92 % and had to be given supplemental oxygen of 4 liters per minute by a venturi mask. Desaturation occurred at 15 to 30 minutes after spinal anaesthesia and improved soon after oxygen supplement. Haemodynamic parameters were stable in both the groups and easily managed with no complications.

Conclusions :

We conclude that sedative oral premedication Tablet Midazolam 7.5 mg did not cause desaturation in patients undergoing spinal anaesthesia and oxygen supplement was not routinely required in patient undergoing spinal anaesthesia.

Assoc. Prof. N. Abdullah N. Mohamad : (Supervisor)

Dr. Rhendra Hardy Mohd Zain : (Co-Supervisor)

Dr. Saedah Ali : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):72.

(4) A Comparative Study Between Invasive Bronchoscopy (By Using Bronchoalveolar Lavage Technique) and Non-Invasive Deep Endotracheal Aspiration in Diagnosing Ventilator - Associated Pneumonia

Wan Rohaidah Wan Ahmad 1,2

Abstract

Background :

Approximately 10–50 % of mechanically ventilated patients will develop ventilator -associated pneumonia at a rate of 1–3% per day. It is one the main causes of acquired infection in ICU which contribute to increase length of ventilation, ICU stay,- morbidity and mortality, hence increase the cost of caring for the critically ill patients. Optimal management is crucial for confirmation of diagnosis and identification of pathogen.

Objectives :

The aim of this study is to determine the efficiency of endotracheal aspiration and bronchoscopic bronchoalveolar lavage in diagnosing VAP. The safety of both techniques will also be assessed.

Methodology :

A prospective clinical study of 100 patients with clinical diagnosis of VAP by a new, progressive infiltration on CXR, fever, leucocytosis, purulent sputum and Pao2/Fio2 less than 240 were randomly assigned into one of two groups. Group 1 (n = 50) underwent endotracheal aspiration and group 2 (n = 50) underwent bronchoscopic bronchoalveolar lavage. All specimen were sent to microbiology laboratory immediately. All microorganisms isolated were identified by standard laboratory methods. Threshold of 105–106 Colony Forming Unit/ml for endotracheal aspiration and 104 Colony Forming Unit/ml without antibiotic, 103 Colony Forming Unit/ml with antibiotic for bronchoalveolar lavage were taken for diagnosis of ventilator-associated pneumonia. Complications and qualitative bacteriologic culture were also recorded.

Results :

There were no significant demographic differences between the two groups in term of sex, race, age, height and weight. Ventilator-associated pneumonia was detected in 36 (72.0 %) patients by using deep endotracheal aspiration technique as compared to 34 (68.0 %) patients by using the bronchoalveolar lavage technique with p=0.828. 22 (22.0 %) had Acinetobacter baumanii isolated from the culture, 18 (18.0 %) cases of Klebsiella Pneumonia and Pseudomonas aeruginosa were isolated respectively.

Other microorganisms for example Methicillin-Resistant Staphylococcus aureus (MKSA) and E. Coli were isolated in 11 (11.0 %). 31 (31.0 %) failed to grow any culture. Only 1 (2.0 %) out of 50 patients in the bronchoalveolar lavage group developed hypoxaemia i.e SaO2 less than 90 %. No other complications occurred in that group. No complication was noted in the endotracheal aspirate group (p =1.0). All patients were on antibiotic at the time of sampling. After receiving the result of colony count and culture and sensitivity, antibiotics were changed according to the sensitivity in 87 (87.0 %) patients of both groups. Antibiotics were not changed in 13 (13.0%) patients. Mortality occurred in 18 (36.0%) patients in endotracheal aspirate group and 25 (50.0%) patients in bronchoalveolar lavage group.

Conclusions :

Our study showed that the quantitative culture of endotracheal aspirate were comparable to those using invasive bronchoscopic bronchoalveolar lavage technique in patients already receiving antibiotics. Quantitative endotracheal aspiration is a valuable way to be a pathogenic diagnostic test for VAP with fewer complications, simple and inexpensive. It is worth to recommend quantitative endotracheal aspiration in clinical practice. Invasive quantitative bronchoalveolar lavage technique can be considered as a reference standard in confirming or ruling out infection.

Assoc. Prof. N. Abdullah N. Mohamad : (Supervisor)

Dr. Mahamarowi Omar : (Co-Supervisor)

Dr. Asai Abd. Rahman : (Co-Supervisor)

Dr. Ali Salleh : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):72–73.

(5) Intubating Conditions and Haemodynamic Changes Following Induction With Sevoflurane Versus Intravenous Propofol and Succinylcholine for Tracheal Intubation in Adults

Nazri bin Mohamed 1,2

Abstract

Objectives and methodology :

A randomized double blinded prospective study was conducted involving a total of 120 ASA I or II similarly premedicated adult patients who were allocated into 2 equally numbered groups. After preoxygenation for 3 minutes and given intravenous fentanyl (1.5 micrograms/kg). Group S (n=60) received a mixture of inhaled sevoflurane 8% with 4 litre/min nitrous oxide and 4 litre/mm oxygen for 4 minutes and Group P (n=60) received intravenous propofol (2mg/kg) followed by suxamethonium (1.5 mg/kg). Intubating conditions were assessed according to easiness of laryngoscopy, vocal cord position, jaw relaxation, coughing and limb movement. Baseline blood pressure, heart rate and mean arterial pressure were recorded and continued every minute after induction until 10 minutes post intubation.

Results :

Adverse events during induction and immediately postoperative were also recorded. Comparing born methods of induction, intubating conditions were more acceptable with propofol induction compared to sevoflurane (96.7% acceptable and 3.3% unacceptable intubating conditions in Group P versus 85.0% acceptable and 15.0% unacceptable intubating conditions in Group S, p< 0.05) and also less haemodynamic changes during induction in Group P compared to Group S (p<0.05) but intubations were successful with the first attempt in all patients without any incidence of trauma or bronchospasm. The reduction in mean arterial pressure in Group S was less than 25% of baseline seen mainly at 3 and 4 minutes of induction. 23.3% had breatholding during induction with sevoflurane and 28.3% had pain on propofol injection. Incidence of sorethroat, headache, nausea, vomiting, confusion and agitation were not significant (p> 0.05).

Conclusion :

We conclude that induction with intravenous propofol an suxamerhonium provides better condition for tracheal intubation and haemodynamic stability but intubation following induction with sevolurance is a useful alternative without major complications.

Assoc. Prof. N. Abdullah N. Mohamad : (Supervisor)

Dr. Shaiful Azman Zakaria : (Co-Supervisor)

Dr. Saedah Ali : (Co-Supervisor)

Dr. Shamsul Kamalrujan Hassan : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):73.

(6) Comparison of Propofol and Etomidate With Rocuronium for Rapid Sequence Induction of Anaesthesia.

Zurhayati bt Awang 1,2

Abstract

Background :

The choice of hypnotics and opioids for rapid sequence induction is influenced by the choice of the muscle relaxant. Suxamethonium has been the 'gold standard' neuromuscular relaxant for rapid sequence induction but rocuronium has been proposed as a suitable alternative due to its rapid onset and less undesirable side effects. Propofol has been proven as the induction agent of choice for rapid trachea! intubation in haemodynamically stable patients. We were interested to see ifintubating conditions and cardiovascular changes under rapid sequence conditions were acceptable if anaestesia was induced with etomidate and rocuronium, rather than with propofol and rocuronium.

Objectives :

The objectives of this double-blinded, randomized study were to compare the intubation conditions and cardiovascular effects by two different induction agents (etomidate and propofol) using rocuronium as the muscle relaxant in modified rapid sequence induction. The adverse events related to the drugs used were also noted.

Methods :

140 patients, ASA physical status I or II, were randomized to two groups. They will received fentanyl (1.5 μg/kg) followed by etomidate (0.3 mg/kg) or propofol (2.5 mg/kg) and subsequently rocuronium (0.6 mg/kg) in both groups. Baseline and post induction blood pressure and heart rate were noted. The end of injection of muscle relaxant was designed as time zero and another blood pressure and heart rate reading were taken. Tracheal intubation was commenced 60 s after injection of rocuronium. Intubation conditions were graded on a scale of I to IV by a single intubator. Patients were also monitored for excitatory events, nausea and vomiting. Haemodynamic measurement were repeated every 1 minute until 5 minutes post induction.

Results :

Intubation conditions at 60 seconds were acceptable in 48.6 % of patients in etomidate group and 82.9% of patients in propofol group. The intubation conditions following etomidate induction were significantly worse than propofol group (p < 0.05). Etomidate produced less changes in systolic and diastolic blood pressure as compared to propofol induction. In comparison, there were statistically significant differences in the percentage of excitatory events (higher in etomidate group) between the groups. No differences in the incidence of nausea and vomiting between the two groups.

Conclusion :

The intubation results reported in this study showed that propofol provides more acceptable intubation conditions at 60 seconds compared to etomidate when rocuronium 2X ED95 were used. However, etomidate produced less systolic and diastolic blood pressure changes in comparison with propofol induction. Excitatory events were significantly higher in etomidate group.

Dr. Saedah Ali : (Supervisor)

Assoc. Prof. N. Abdullah N. Mohamad : (Co-Supervisor)

Assoc. Prof. Dr. Kamaruddin Jaalam : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):73–74.

(7) A Comparison of Haemodynamic Changes after Endotracheal Intubation Using the Lightwand Device (Trachlight) and the Larynggoscope

Tuan Norizan bt Tuan Mahmud 1,2

Abstract

Background :

This is a single blinded randomized controlled study of 140 patients, who had undergone elective surgery under general anaesthesia in Hospital Universiti Sains Malaysia from November 2002 to August 2003. A comparison was made in terms of haemodynamic changes after tracheal intubation, intraoperative and postoperative complications related to tracheal intubation, intubation time and number of attempts in intubation between lightwand technique and direct laryngoscopic groups.

Methodology :

Subjects were randomly assigned to either LSI (endotracheal intubation by direct laryngoscope) or LWI group (endotracheal intubation by trachlight). A standardized anaesthetic technique was used. Endotracheal intubation was performed after the induction of anaesthesia with intravenous fentanyl, propofol and muscle relaxant with vecuronium. Non-invasive systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were recorded preinduction, preintubation, immediately after intubation and every minute for the first five minutes after intubation. Half an hour postoperatively, recovery nurse at the recovery room assessed for any hoarseness of voice, sore throat and dysphagia.

Results :

This study demonstrated that, there was no significant difference in haemodynamic changes between the two techniques. The number of intubation attempts was similar between the groups, but intubation time was longer in LWI group (25.7 ± 14.8 vs. 20.0 ± 8.4), p = 0.003. The incidence of hoarseness of voice was lower in LWI group (0.1 % vs. 7.6 %), P=0.04. there was no difference in other pharyngolaryngeal morbidity among groups.

Conclusion :

As a conclusion, the effect of trachlight intubation on haemodynamic changes was similar to those of direct laryngoscopic technique.

Dr. Gnandev Phutane : (Supervisor)

Assoc. Prof. N. Abdullah N. Mohamad : (Co-Supervisor)

Dr. Ghazaimie Ghazali : (Supervisor)

Malays J Med Sci. 2005 Jan;12(1):74.

(8) Effect of Epidural Ropivacaine with Fentanyl 2 μgml−1 versus Intramuscular Pethidine Analgesia on the Progress of Labour

Abu Bakar bin Mohd Supa’at 1,2

Abstract

Objective :

Our purpose was to determine the effect of epidural analgesia as compared to intramuscular pethidine on the progress of labour in the perspective of duration of labour and modes of delivery.

Methodology :

One hundred and ninety two (192) uncomplicated full term gravida 2–5 women with tested pelvis in spontaneous labour were randomized to receive either epidural or intramuscular pethidine analgesia. Epidural catheter was inserted at first request of pain relief during active phase of labour at cervical dilatation of 3 to 5 cm. Ropivacaine 0.2% with fentanyl 2 ug/ml were used as local anesthetic of choice as it provides good pain relief and less motor block.

Results :

There are no significant findings in demographic data. Epidural significantly provides good analgesia after 15 minutes (Mean Visual Analogue Score-VAS at 15 minutes was 11.3 mm vs. 68.6 mm, P = 0.001) and at full dilatation (25.1 mm vs. 94.4 mm, P = 0.001). 86% of patients experienced no motor block (Bromage 0) in epidural group. From this study we found that there are significant associations between epidural administration and prolongation of first stage (506.6 min vs 392.1 min. P = 0.001) and second stage (24.0 min. vs. 10.1 min. P = 0.001) of labour. Instrumental delivery but not the cesarean section rates were increased. (11.7% vs. 2.1%, P = 0.008), (11.7% vs. 7.1%, P ‘=• 0.186) respectively. No difference in neonatal outcome as shown by Apgar score at 1 and 5 minutes. Patient satisfaction was statistically significant whereby 84% of patient opted for epidural analgesia for next delivery.

Conclusions :

Epidural ropivacaine 0.2% with fentanyl 2 u.g/ml provides better labour analgesia than intramuscular pethidine despite prolongation of labour and increased instrumentation. It was not associated with increased numbers of cesarean delivery when compared with intramuscular pethidine analgesia.

Assoc. Prof. Dr. N. Abdullah N. Mohamad : (Supervisor)

Assoc. Prof. Dr. Kamaruddin Jaalam : (Co-Supervisor)

Dr. Nizar Abd. Jalili : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):74.

(9) Comparison of Conjunctival Impression Cytology Between Glaucoma Paatients Treated With Topical Timolot Maleate 0.5% and Topical Latanoprost 0.005%

Tan Soo Hoi 1,2

Abstract

Introduction :

All topical medications are known to cause conjunctival reactions, and topical anti-glaucoma drugs are also no exception. Long term drug induced toxicity to the conjunctiva is postulated to cause filtering bleb scarring and subsequent filtration surgery failure. Chronic application of topical timolol maleate 0.5% and topical latanoprost 0.005% had been shown to alter the morphology of the conjunctival ocular surface.

Objective :

To compare conjunctival surface morphological changes with the use of the topical timolol maleate 0.5% and topical latanoprost 0.005%.

Methodology :

Newly diagnosed glaucoma patients who met the selection criteria were randomly divided into two groups. One group treated with topical timolol maleate 0.5%, another group treated with topical latanoprost 0.005%. Before the treatment was started, the first conjunctival impression cytology was taken as base line. After three months of treatment, the second conjunctival impression cytology was obtained. The changes that occurred between the first and second conjunctival impression cytology in the individual group were analyzed. Conjunctival surface changes that occurred with the use of topical timolol maleate 0.5% were also compared with the conjunctiva surface changes that occurred with the use of topical latanoprost 0.005%.

Results :

Thirty-nine newly diagnosed glaucoma patients were included in this study. Twenty patients were in the Timolol group and nineteen patients in the Latanoprost group. In both groups of patients, there was no change of the conjunctival epithelial cell morphology after three months of anti-glaucoma therapy. However, there was statistically significant reduction of the goblet cell and mucous granule density in both groups of patients after three months of the topical anti-glaucoma therapy (P-value <0.001). By using the independent T-test, there was no significant difference of the goblet cell and mucous granule density between the Timolol group and the Latanoprost group after three months of treatment.

Conclusion :

This study gives evidence that topical timolol maleate 0.5% and topical latanoprost 0.005% cause morphological changes of the conjunctival surface after short term (three months) therapy.

Dr. Wan Hazabbah b. Wan Hitam : (Supervisor)

Malays J Med Sci. 2005 Jan;12(1):74–75.

(10) A Study on the Use of a Trauma Scoring System in the Assessment of Trauma Patients Introduction

Mohd Idzwan bin Zakaria 1,2

Abstract

Introduction :

Injury is an ever-increasing problem in Malaysia as in other developing countries. In Malaysia, it is the fifth leading cause of death in hospital (7.93%) and third leading cause of admission to government hospitals (9.25%) [Ministry of Health Annual Report, 2000]. Trauma registry serves as a powerful tool for the quality improvement program. Trauma severity scoring is one of the tools in trauma registry. Revised Trauma Score(RTS) is one of the physiological trauma score. This study incorporates RTS in HUSM trauma cases and hence provides comparison with other trauma centers. This study also hopefully will introduce HUSM to a standard trauma score in future.

Objectives :

The objectives of this study are:

  1. To determine whether is there a relationship between RTS and mortality in HUSM

  2. To determine the difference between the probability of survival in HUSM compared to expected probability of survival in US based on RTS

  3. To determine the association between age, gender, pre hospital transport, mechanism of injury, presence of high risk mechanism of injury and coexistence of pre-morbid condition with mortality in HUSM

  4. To study the socio-demographic patterns of trauma patients seen in HUSM

  5. To compare the outcome of trauma patients with high risk mechanism of injury or co-existence of pre-morbid condition in HUSM and mortality of trauma patients with high risk mechanism of injury or co-existence of pre-morbid conditions according to weighted RTS of the sample study

Methodology :

462 trauma patients arriving at the emergency department HUSM fulfilling the inclusion and exclusion criteria were chosen during a study period of 6 months. The patients were triaged and proformas were filled. Demographic data were collected and the RTS were calculated. The data were compiled and analyzed using various descriptive studies from the Statistics Program for Social Studies (SPSS) version 11.5. The association between age, gender, pre hospital transport, mechanism of injury, presence of high risk mechanism of injury and co existence of pre morbid condition with mortality in HUSM were analyzed using logistic regression analysis. RTS and probability of survival in HUSM was analyzed using Pearson's Correlation and Receiver Operating Characteristic curve. The probability of survival in HUSM and the probability of survival in US based from Champion et al was analyzed using one-sample t-test. The association between probability of survival in HUSM and probability of survival according to weighted RTS of the sample study with the high risk mechanism of injury and co-existence of pre-morbid condition were tabulated.

Results :

From this study, it was found that:

  1. Trauma patients with high risk mechanism of injury has 2.56 fold increased mortality risk with a p-value of 0 (0.05) using the logistic regression analysis. Trauma patients with pre morbid condition have 0.825 fold increased mortality risk with a p-value 0.011(0.05). Age, gender, pre hospital transport and mechanism of injury didn't show any association with mortality in this study.

  2. There is a strong correlation between weighted RTS and probability of survival with Pearson's correlation coefficient of 0.927 and two-tailed p-value of 0.00. The area under the ROC curve, which is how well the weighted RTS able to predict death is 0.991 with an asymptomatic significance of 0 (0.05). This shows that weighted RTS is able to predict death in 99.1% of the cases.

  3. From the one-sample t-test, with a mean difference of 0.3644, t statistic of 2.56, degree of freedom of 8 and p value 0.034, we can say that there is a significant difference between the probability of survival in HUSM and probability of survival in USA with a 95% confidence interval (0.04, 0.69) hence a significant lower probability of survival compared to the US with the same RTS.

  4. This study shows that there is a similarity between the outcome in high risk mechanism of injury in HUSM and the predicted mortality based on RTS with high risk mechanism of injury (outcome in HUSM: 17%, mortality based on RTS: 19%). Outcome from low risk injury shows a difference of 1.5% lower mortality compared to the predicted mortality based on RTS (outcome in HUSM: 17%; predicted mortality: 3%). Co-existence of premorbid condition shows similar outcome when compared with probability of survival according to RTS. Both were 17.9% mortality. In trauma patients with no pre-morbid factors, the outcome in HUSM was 8.7% and the expected mortality based on RTS was 10.6%.

Conclusions :

Based on the results of this study, the following have been proposed:

  1. There is a strong inverse relationship between RTS and mortality of trauma cases in HUSM and hence RTS is applicable in HUSM as a form of trauma score in quality assessment.

  2. This study shows that there is a significantly lower probability of survival in HUSM than in US with the same RTS.

  3. High risk mechanism of injury and pre morbid conditions increases the mortality risk. Age, gender, pre hospital transport and mechanism of injury did not show a significant increase in mortality risk.

  4. There is a strong similarity between outcomes of trauma patients in HUSM with high risk mechanism of injury or co-existence of pre-morbid condition and mortality predicted by weighted RTS in these patients.

Dr. Wan Aasim Haji Wan Adnan (Supervisor)

Dr. N. Hishamuddin N. Ab. Rahman : (Co-Supervisor)

Assoc. Prof. Dr. Kamaruddin Jaalam : (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):75–76.

(11) Exposure to Second-Hand Smoke and the Risk of Non-Syndromic Cleft Among Malay Children in Kelantan: A Molecular and Epidemiological Association

Ayu Abdullah 1,2

Abstract

Introduction :

The prevalence of cleft lip and palate in human ranges from 1 in 500 to 1000 live births worldwide. Non-syndromic clefts are a complex trait with both genetic and environmental etiology. Transforming Growth Factor Alpha (TGFa) is a modifier gene which is susceptible to environmental factors, leading to development of sporadic non-syndromic clefts.

Objectives :

The aims of the study were to identify risk factors of families with cleft and to assess the association between maternal exposure to second-hand smoke during pregnancy and TGFa gene polymorphism in cleft children genotype. The study was divided into two parts: Part I: Unmatched case-control study was carried out among Malays in Kelantan. Case and control subjects were defined as mothers of cleft children and mothers of normal children respectively. The cleft children were recruited from the Combined Cleft Clinic at Kota Bharu Dental Clinic. Normal children were selected at Orthodontic Clinic, Kota Bharu.

Methodology :

A total of 184 cases and controls with age range from 17 to 50 years were interviewed using the standard craniofacial registration form. Part II: Retrospective cohort study was carried out among cleft children with and without maternal exposure to cigarette smoke during pregnancy. A total of 33 subjects were identified for exposed (16 Males: 17 Females) and 32 were identified as non-exposed (20 Males: 12 Females) with age range from 3 months to 10 years. DNA was extracted from blood samples and amplified with PCR. Then RFLP technique was used with enzyme Hinfl and Ncol for K region; and Taq enzyme for Taq-1 region. Multiple Logistic Regression modeling was used to estimate adjusted odds ratio of factors associated with non-syndromic oral cleft.

Results :

Significant factors include history of miscarriage (OR: 3.40; 95% CI: 1.05, 11.08) p=0.042; duration of exposure to secondhand smoke for 15–30 minutes (OR: 2.41; 95% CI:1.42, 4.09) p<0.001; duration of exposure > 30 minutes (OR: 5.16; 95% CI:2.87, 9.28) p<0.001 and occupation of the mother (OR: 2.26; 95% CI: 1.40, 3.64) p<0.001. Chi-square(X2) test detected a significant difference at allele 4 at K region between exposed and non-exposed subjects (RR: 2.94, 95% CI:1.07, 8.06) but not at Taq-1 region.

Conclusion :

This study showed that maternal exposure to secondhand smoke during pregnancy was a significant risk factor for getting a cleft child and also significantly associated with polymorphism of oral cleft patients.

Dr. Noorliza Mastura Bt. Ismail (Supervisor)

Prof. Mohd. Nizam Isa (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):76.

(12) Effect of Deworming on Cognitive Performance of Rural Primary Schoolchildren in Bachok, Kelantan

Anees Abdul Hamid 1,2

Abstract

Introduction :

Previous studies have found that helminthiasis to be very common among school-aged children. This may be due to their outdoor activities, poor personal hygiene and poverty. Helminthiasis is also related to poor school performance. In this study, we are going to determine the effect of deworming on cognitive performance of rural primary school children in Kelantan.

Method :

This study was a community trial involving 600 schoolchildren in Bachok from 6 primary schools (aged between 9 and 11 years) was undertaken. The sampling frame involved all 17 rural primary schools in Bachok, Kelantan. Based on the sample size calculations, manpower and limitation of time, six schools were randomly selected with 728 schoolchildren. One-stage cluster sampling was used to choose the schools whereby all Standard 3 and Standard 4 children in the selected schools were recruited. At baseline, questionnaires on socioeconomic and health data related with helminthiasis were given, stool analysis and also cognitive performance tests was done. The cognitive tests administered to each child were the arithmetic test, coding test, digit span forward and backward tests. These three tests were taken from the Wechsler Intelligence Scale for Children. The other test given was the Raven’s colored progressive matrices test. The schools were then randomly assigned into treatment and control group. Each child in the treatment group received 400mg albendazole while children in the control group were not given anthelmintic until the end of the study. After 6 months all of the cognitive tests were repeated.

Results :

A total of 728 children from 6 schools were invited to join this study. However, 600 children (82.4%) were enrolled, and 572 children (95.3%) completed the study after 6 months. There were 331 (55.2%) children aged 9–10 years and 269 (44.8%) children aged 10–11 years. There were 290 (48.3%) girls and 310 (51.7%) boys. The overall prevalence of total helminthiasis was 74.2% (n=445). Prevalence of Trichuris trichiuria, Ascaris lumbricoides and hookworms were 67.2% (95% CI: 63.4%, 70.9%), 49.7% (95%CI: 45.6%, 53.7%) and 1.2% (95%CI: 0.3%, 2.0%) respectively. On baseline examination, children with helminthiasis scored significantly lower than those uninfected in arithmetic test, coding test and Raven’s colored progressive matrices test. However, in the digit span forward test and digit span backward test, even though the scores were lower in the infected children compared to those not infected, the differences was not statistically significant. Male children are 1.57 times more associated with helminthiasis compared to female students and children who having number of children in the house- 5 and more were 2.54 times more associated with helminthiasis compared to those having number of children less than 5. Following deworming with albendazole, at 6 months, multivariate analysis using repeated measures ANOVA showed significant difference in the coding test (Fi,57 = 5.41, P=^02) and the Raven’s colored progressive matrices test (Fi,57 = 9.39, p=0.02) between the treated and control group. However, the digit span backward test, the arithmetic test and digit span forward test were not significantly different in the 2 groups. After adjusting for infection status and family income, almost similar result were noted whereby, children in the treatment group had significantly higher scores for the coding (Fi,56 = 5.33, p=0.02) and Raven’s colored progressive matrices tests (Fi,56 = 10.10, p=0.00) compared to the control group. However, for 3 other tests, arithmetic, digit span forward and digit span backward there were no significant different.

Conclusion :

Children who have helminthiasis have generally poorer cognitive performance. Gender and number of children in the family were significantly associated with helminthiasis. There were improvements in certain cognitive tests 6 months after children were given anthelmintic. Mass deworming with single doses of oral albendazole should be given to rural schoolchildren as it may improve some aspects of their cognitive performance.

Assoc. Prof. Dr. Zulkifli Ahmad (Supervisor)

Dr. Azni Alias (Co-supervisor)

Dr. Mohamed Hashim Mohd Hassan (Co-supervisor)

Assoc. Prof. Dr. N. Kumaraswamy (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):76–77.

(13) The Epidemiology of Physical Disability Among Elderly in Kota Bharu, Kelantan

Latifah bt Dahlan 1,2

Abstract

Introduction :

Globally, the decline in fertility and mortality as well as improvement in life expectancy were said to be responsible for the aging population. In Malaysia, the elderly population was 1.2 million or 5.9% of the 20 million total population in the country in 1995. This number was projected to increase to 11.3% by the year 2020. Elderly population are prone to get chronic medical illnesses as well as physical disability. This is a cross-sectional study to determine the prevalence of physical disability and its associated factors among the elderly, aged 60 years and above.

Methodology :

A total of 270 participants were taken randomly from 3 health clinics in the Kota Bharu operational areas by using multistage sampling. Interviewer assisted - questionnaire were administered and the subjects were asked to go to clinics or community center on the appointed date for physical examination and blood taking for fasting blood sugar and total cholesterol. Physical disability was measured by activities of daily living (ADLs) and instrumental’s activities of daily living (lADLs). ADLs is comprised of bathing, dressing, going to toilet, transferring from bed or chair, continence, and feeding. Whereas IADLs encompass the following domestic function : using the telephone, using transportation, shopping, cooking, house-keeping, taking medication and budgeting. The lADLs methods offer indicators of “ applied “ problem that extend the disability theme of ADLs scales to include some elements of handicap concept. Physical disability was defined as the inability to accomplish one or more ADLs or IADLs. Separate multiple logistic regression was used to determine the associated factors for both physical disabilities.

Results :

The prevalence of physical disabilities in ADLs and lADLs were 10.7% (95% CI:7.0%, 14.0%) and 34.8% (95% CL-29.0%, 41.0%) respectively. Significant risk factors of ADLs were age (OR=2.67, 95%CI:1.11, 6.64), hearing impairment (OR- 2.54, 95%CI: 1.03,6.23), diastolic blood pressure (OR= 3.80, 95%CI:1.25, 11.58), and total cholesterol (OR= 1.55, 95%CI: 1.07, 2.20).Whereas for IADL the associated factors were age (OR=2.39, 95%CI: 1.19,4.83), income (OR= 0.22, 95%C1.−0.08, 0.62),diastolic blood pressure (OR=2.02, 95%CI: 1.04,3.94), marital status (OR=2.38, 95%CI:1.23,4.61) and obesity (OR=4.68,95%CI:1.54, 14.18). There was a strong significant association between ADLs and lADLs (OR=9.01, 95%CI:3.40, 23.89). The prevalence of physical disability for ADLs and lADLs was similar with others studies. These findings also suggested that certain sociodemographic characteristics (i.e age, income & marital status), lifestyle behavior (obesity) and medical illnesses (hearing impairment, total blood cholesterol and high diastolic blood pressure) were significant risk factors of physical disability in elderly.

Conclusion :

Physical disability in ADLs was strongly associated with physical disability in lADLs. The majority of associated factors of physical disability that were identified by this study can be modified either by treatment, life-style change or special device. Public health efforts to reduce prevalence of all these factors in both sexes should continue.

Assoc.Prof. Dr. Dr. Aziz Al-Safi Ismail (Supervisor)

Dr. Hamzah Ag. Mat (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):77.

(14) Effect of School Supplementary Feeding Programme on Improving Nutritional Status of Primary School Childen in Rural Areas of Tumpat and Bachok District

Che Asiah Taib 1,2

Abstract

Introduction :

Undernutrition is a serious global problem especially among developing countries. Undernutrition is still common among poor rural children in Malaysia. The School Supplementary Feeding Programme (SSFP) is one of the intervention strategies implemented to improve the nutritional status of children in Malaysia.

Objectives :

The objectives of the study were to determine the prevalence of malnutrition, associated factors of underweight, stunting and wasting and to evaluate the effect of School Supplementary Feeding Programme on improving nutritional status among primary one children in rural areas of Tumpat and Bachok districts.

Methodology :

The study had 2 phases. Phase 1 was a cross-sectional study and the Phase 2 was a cohort study. The study was done among primary one children in rural areas of Tumpat and Bachok districts from February 2002 to March 2003. Nine hundred and thirty seven children from 18 primary schools were’ selected. Questionnaires eliciting socio-economic and demographic informations were answered by the parents. The weight and height of the children were measured three times; before starting SSFP, after 6 months and after 12 months of SSFP. The WAZ, HAZ and WHZ were calculated using Epi-Nut Anthropometry software (Epi Info version 6). The prevalence of malnutrition were calculated based on cutoff point of z-score < −2 SD as Undemutrition and > +2 SD as ovemutrition. The school administration chose eligible children to participate in the SSFP.

Results :

Five hundred and forty one children were enrolled in SSFP and 396 were in non-SSFP group. The prevalence of underweight, stunting and wasting at baseline were 25.2%, 21.1% and 6.2% respectively. Only 1.1% of children were overweight. In multiple logistic regression analysis the significant risk factors of underweight were being male children (OR=1.4, P<0 05) Tumpat district (OR=1.5, p<0.05) and monthly family income of RM 0–250 fOR=2.2, p<0.05) and RM 251–500 (OR=2.3, p<0.05). Being a male children (OR=1.6, p<0.05) was the only significant factor for stunting and working mother (OR=2.1, n<0.05) was the only significant factor of wasting. Repeated measures ANOVA showed there was significant different of increment of WHZ (p = 0.007) between SSFP and non SSFP group with regard to time and adjusted for gender, district, family income group and baseline nutritional status. However, no significant different of WAZ (p=0.126) and HAZ (p=0.266) with regard to time and group was found. In conclusion, there is still a high prevalence of undemutrition among children in rural areas of Tumpat and Bachok. The condition was associated with low socio-economic and demographic status of the population.

Conclusion :

The SSFP had significantly improved the nutritional status of children with wasting. Also, the increment of WAZ, HAZ and WHZ was better among undernourished children compared to normal children.

Assoc. Prof. Dr. Zulkifli Ahmad (Supervisor)

Dr. Mohamed Hashim Mohd Hassan (Co-supervisor)

Keywords: deworming, cognitive performance, rural, primary school children, Bachok

Malays J Med Sci. 2005 Jan;12(1):77–78.

(15) The Study of Outcome and Survivl of Patients With Chronic Myeloid Leukaemia in Hospital Universiti Sains Malaysia and Hospital Kota Bharu –A Retrospective Analysis

Mat Zuki Bin Mat Jaeb 1,2

Abstract

Introduction :

The Study of Outcome and Survival of Patients with Chronic Myeloid Leukaemia in Hospital Universiti Sains Malaysia and Hospital Kota Bharu - A retrospective analysis. There have been several studies looking at the prognostic factors of survival in Chronic Myeloid Leukaemia (CML).

Objectives :

We undertook a retrospective study on all eligible CML patients treated with hydroxyurea or busulphan in Hospital Universiti Sains Malaysia (HUSM) and Hospital Kota Bharu (HKB) diagnosed from 1st January 1986 to 31st august 2001, to determine the factors which influence the outcomes and survival.

Methodology :

A total of 72 patients were eligible for analysis, with the assumption of Philadelphia chromosome were present in all of them.

Results :

In our study the median age of diagnosis was 41 years old, range from 14 to 77 years old with male to female ratio of 1.4 to 1. Almost all (99%) had symptoms at presentation with 100% of patients had splenomegaly and 87% had hepatomegaly. About 66% of patients were in high-risk category with Sokal score of more than 1.2. In this study, 56 patients died and remaining 16 patients still alive at the end of the study. Overall median survival was 58 months. Univariate analysis of prognostic factors for survival has revealed, bleeding symptom, liver and spleen sizes, haemoglobin level, total white count and percentage of basophil and percentage of blast in peripheral blood, Sokal score at presentation and the outcomes were the factors that significantly influenced survival (p <0.05). Multivariate analysis with Cox regression test only showed bleeding symptom, percentage of basophil, total white count and all the outcomes after treatment, significantly influenced survival. From total of 72 patients, 40 (56%) of them achieved complete haematological response (CHR). Out of 40 patients, 23 patients (57%) achieved CHR after 6 months of treatment. Mean time that was taken to achieve CHR was 8.5 months. Spleen size, haemoglobin level percentage of blast and Sokal score significantly influenced the achievement of CHR (p < 0.05). The analysis of factors, which influenced the time to achieve remission showed only the presence of abdominal symptoms and percentage of basophil in peripheral blood were statistically significant. A total of 36 patients (90%) who had achieved CHR, remained in remission (CHR) more than 12 months with mean duration of 12.3 months. In the analysis of factors which influenced duration of CHR; only the time that was taken to achieve CHR and liver size were statistically significant.

Conclusion :

In summary, our study has confirmed several factors which were proven to influence survival in previous studies. Though in this study we were unable to show Sokal score as a prognostic factor of survival in multivariate analysis, we believed that this could be explained by the fact that majority of patients (66%) were in high-risk category and our sample size was small.

Prof. Dr. Aziz Baba (Supervisor)

Dr. Abu Dzarr Abdullah (Co-Supervisor)

Dr. Tengku Norbani (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):78.

(16) Pattern of Typhoid Fever Among Adult Patients in HUSM and the Outcome of Treatment Comparing Ceftriaxone Versus Chloramphenicol

Wan Hasnul Halimi bin WanHassan 1,2

Abstract

Introduction :

Typhoid fever is a well documented infectious disease worldwide cause by Salmonellatyphi. It remains an endemic health problem in Malaysia throughout the years and the state of Kelantan had been reported to have the highest annual incidence. Unfortunately, this far, there is no published report on the pattern of typhoid fever among adult in Kelantan. We have taken the opportunity to look into the pattern of typhoid fever among adult and study the outcome of treatment using ceftriaxone and chloramphenicol.

Methods :

This was a retrospective study. Records of all patients admitted to Hospital Universiti Sains Malaysia from January 1996 to March 2003 recorded to have typhoid were analysed. Only those who were confirmed to have typhoid fever were studied.

Results :

A total of 279 patients with confirmed typhoid were reviewed and analysed. The incidence rate was 10.6 cases per 1000 admissions. The cases appeared to be sporadic through out the month without any seasonal predilection. Demographic data reveals majority were Malays (97.5%), almost the same male to female ratio (1.3: 1) and from Kota Bharu district (72.4%). Most were students (50.9%) with median age of 20. All patients had fever, mostly with chills and rigors. Gastrointestinal symptoms predominate. Relative bradycardia (40.5%), hepatomegaly (46.2%) and splenomegaly (19.7%) were among the predominating clinical signs. More than 90% of cases had uncomplicated typhoid with no mortality. Majority had normal full blood count results with only 15% anaemia, 14% leucopaenia and 34.1% thrombocytopaenia. Biochemical profile shows 56.6°/ had hyponatraemia and 39.8% hypokalaemia. We observed that blood C&S was highly specific but had a low yield (61.6%). Widal test provided even lower yield f43 6%). EIA dot blot test provided a promising result with high pick up rate (87.5%) and sensitivity (80%). We have found that fever resolved significantly faster in patients treated with ceftriaxone compared to chloramphenicol (3.9 days versus 4.8 days, P0.05). The mean duration of therapy with chloramphenicol were significantly longer than ceftriaxone (13.6 versus 5.2 days, P<0.05). Patient treated with chloramphenicol also required longer hospital stay (13.3 days versus 8 days, P0.05).

Conclusion :

Typhoid fever in adult showed similar pattern compared to previous study in terms of the incidence and clinical features. Treatment of typhoid with ceftriaxone is better than treatment with chloramphenicol in terms of shorter fever clearance time, duration of treatment and hospital stay. Patient treated with ceftriaxone can be discharge early compare to patients treated with chloramphenicol.

Assoc. Prof. Dr. Zainal Darus (Supervisor)

Dr. Tengku Norbanee (Co-Supervisor)

Assoc. Prof. Dr. Nazmi Mohd Noori (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):78.

(17) Methicillin-Resistant Staphylococcus Aureus in HUSM : A Study on the Prevalence, Risk Factors and the Cost of Treatment of MRSA Bacteraemia

Sarimah Abdullah 1,2

Abstract

Introduction :

Methicillin-resistant Staphylococcus aureus (MRSA), one of the major concerns of nosocomial infections, is particularly alarming because due to its association with multiple resistance to other antibiotics. The prevalence of MRSA infections varies from 5% to more than 50%, depending on the characteristics and size of the hospitals. In Malaysia, the prevalence of MRSA has increased from 23% in 1991 to 33% in the year 2000.

Objectives :

The aim of this study is to determine the prevalence, risk factors and treatment costs of MRSA bacteraemia in Hospital Universiti Sains Malaysia (HUSM).

Methodology :

A one-year cross sectional study, from the 1st July 2002 to 30th June 2003 was conducted in HUSM. Respondents included 264 patients with MRSA isolates, 99 patients with S. aureus bacteraemia and 32 patients on vancomycin.

Results :

The majority of patients were Malays. The mean rate of MRSA isolates was 9.6 (range: 5.9 to 13.7) per 1000 admissions. The prevalence of MRSA was 40.4% (95% CI; 31.0–50.0). The mean (SD) duration of hospitalisation before isolation of MRSA was 14.16 (4.68) days as compared to 3.88(1.11) days of methicillin-sensitive Staphylococcus aureus (MSSA). The odds for patients to develop MRSA bacteraemia were 7 times and 9.7 times higher if they were on ventilation and had taken antibiotics, respectively. Adult patients seemed to be protected from developing MRSA bacteraemia compared to paediatric patients. The mean (SD) total cost for the 32 patients on intravenous vancomycin was RM871.87 (643.15) and the median (Inter-Quartile Range (IQR)) was RM695.39 (RM751.94). The mean (SD) laboratory cost was RM63.37 (RM15.31). The median (IQR) day costs and drug costs were RM381.70 (763.40) and RM266.39 (323.63) respectively. The mean (SD) and median (IQR) days that attributed to MRSA bacteraemia were 3.13 (3.25) and 2.0 (4.0) days. The median (IQR) length of hospitalization stay was 31.00 (31.50). The presence of four significant risk factors and prolonged duration of hospitalization in MRSA bacteraemia will give impact to patients as well as hospital.

Conclusion :

The current requirement for prolonged parenteral antibiotic therapy, particularly intravenous vancomycin for MRSA bacteraemia, remains a major constraint in reducing the length of acute hospitalization and costs of patient care. The high treatment costs indicate that the economic burden associated with MRSA is substantial and these costs are likely to increase if the rate of MRSA continues to rise further.

Assoc. Prof. Dr. Mohamed Rusli Abdullah (Supervisor)

Assoc. Prof. Dr. Mohd. Radzi Johari (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):78–79.

(18) Quality of Life Among Patients on Regular Haemodialysis: Comparing Diabetic Versus Non-Diabetic Groups

Amir bin Ramli @ Shaari 1,2

Abstract

Introduction :

Generally, end stage renal failure patients have lower quality of life compared to healthy individual. Among ESRD group, diabetic patients on regular haemodialysis have lower quality of life (QOL) compared to non-diabetic patients. The main objective of this study is to prove that the lower quality of life seen among diabetic patients on regular haemodialysis was due to inadequate amount of dialysis therapy given to them.

Method :

This was a cross sectional study done from January to June 2003 in all haemodialysis patients in Renal Care private haemodialysis centre and Hospital Universiti Sains Malaysia who fulfilled our selection criteria. They were interviewed using a set of WHOQOL-BREF questionnaire (Malay version) contains twenty six QOL questions; with two questions concerning the general health and satisfaction of QOL, while the remaining twenty four items made up physical, psychological, social and environment components. In addition, their blood parameters such as renal function, haemoglobin, haematocrit, serum albumin and serum parathyroid hormone were analysed. At the same time, the adequacy of amount of dialysis was measured by urea kinetic modelling (Kt/V).

Result :

This study demonstrated that end stage renal failure patients have significant lower mean scores in physical, psychological and environmental components of QOL compared to the healthy population despite no significant difference in gender, ethnic composition, marital status and social class in both groups. However, the mean age of healthy population was younger compared to end stage renal failure (p=0.05). At the same time, this study established that among ESRD patients on regular dialysis, the diabetic group has significant lower physical’s mean scores (11.4±: 2.5 Vs. 13.2 ± 2.4) and significant lower psychological mean score (11.9 ± 2.6 Vs. 13.5 ± 2.8) compared to non-diabetic even with no significant difference in age, gender, ethnic composition, marital status, social class, haemoglobin, haematocrit, nutrition, and parathyroid hormone. Even though diabetic patients have significant lower mean score in physical and psychological components of QOL, they were given the similar amount of dialysis treatment compared to non-diabetes (1.2 ± 0.2 Vs. 1.3 ± 0.3) with p = NS.

Conclusion :

Despite similar amount of dialysis treatment, diabetic patients with ESRD on regular haemodialysis still have lower physical and psychological components of QOL compared to non-diabetic patients. This may suggest that the reason why diabetic patients have lower QOL is not due to inadequate dialysis treatment but perhaps they require higher amount of dialysis prescription for better QOL. Future interventional study is required to prove this hypothesis.

Assoc. Prof. Zainal Darus (Supervisor)

Assoc.Prof. Dr. Hasanah Che Ismail (Co. supervisor)

Malays J Med Sci. 2005 Jan;12(1):79.

(19) Randomised Placebo Control Trial on the Effect of Different Doses of Ramipril on Arterial Stiffness in Patient at High Risk O Cardiovascular Events

Suhairi Ibrahim 1,2

Abstract

Introduction :

ACE inhibitors have proven benefits in a broad range of patients at high risk for cardiovascular events. Despite the abundant evidences for its cardio-protective and vasculo-protective effects, it is still underutilized and is used sub-optimally. This is because physicians are worried of the risk for adverse events if a higher dosage of ACE inhibitors is used. However, the maximum benefit of ACE inhibitors may not be seen if the dose is underutilized. The main objective of this study is to compare the effects of different doses of ACE inhibitors on arterial stifness and microalbuminuria, the proven surrogate markers for cardiovascular disease.

Methods :

A randomised double blind placebo control trial was designed. There were 4.0 patients randomised into four groups; placebo, 2.5mg, 5mg and l0mg ramipril. Patients were followed up for 3 months. The primary end point was to look at the effects of different doses ACE inhibitors on arterial stiffness. Arterial stiffness was assessed by augmentation index and pulse wave velocity (PWV) using automated SphygmoCor® machine. Besides arterial stiffness, the study was also looked at the effects of ACE inhibitors on microalbuminuria. Urine micro albumin was measured by using dipstick test. Other measurement obtained were blood pressure, height, weight, full blood count, renal and liver function test, fasting blood sugar, HbAlc, total cholesterol and triglyceride.

Result :

There were no significant differences in baseline characteristics between groups except total cholesterol was higher in the placebo treated group. Towards the end of the study, there was a clear trend of reduction in augmentation index and pulse wave velocity (PWV) with l0mg ramipril but not with other doses (placebo, 2.5mg and 5.0mg ramipril). However, the reduction was statistically not significant. For microalbuminuria, there was a higher proportion in placebo treated group to develop positive microalbuminuria compared to ramipril treated groups at final visit. There were six patients (15%) who developed adverse events throughout study period and no significant difference between placebo, 2.5mg, 5.0mg and 10.0mg treated groups.

Conclusion :

Work from this dissertation shows that arterial stiffness in patients with high cardiovascular risk can be lowered using l0mg ramipril, but not at the dose of 2.5 or 5.0mg. There was no significant different in adverse events when comparing l0mg ramipril with lower doses and even placebo. Ramipril also reduced the progression of microalbuminuria compared to placebo. This result indirectly showed that l0mg ramipril should be used in patients with high risk for cardiovascular disease to get the optimum benefit. These findings are in line with results from clinical trials which looked at clinical outcomes.

Prof. Dr. Abdul Rashid Abdul Rahman (Supervisor)

Dr. Thann Winn (Co-Supervisor)

Dr. Amir Hakim Hj. Basri (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):79–80.

(20) Seroprevalemce and Demographic Data of Hepatitis C in Tiply Transfused Thalassaemia Patients in HUSM

Hasaruddin Ridzal Hanafi 1,2

Abstract

Introduction :

The population of multiply transfused thalassemic patients was at higher risk for HCV infection due to its blood-to-blood route of transmission.

Objectives :

The main objective of this study was to determine the seroprevalence of anti HCV antibody in multiply transfused thalassaemia children.

Methodology :

A retrospective study was done in paediatric hematology-oncology ward in Hospital Universiti Sains Malaysia, a tertiary unit hospital on the northern-eastern side of peninsula Malaysia in the state of Kelantan. Subjects included all thalassaemia patients who required blood transfusion equal or more than twice per year who are under follow-up in HUSM. Anti-HCV status was determined using HCV EIA 3.0. Data were analyzed using SPSS version 11.0 and statistical methods used were Chi Square, Fischer exact test, independent t-test, Mann-Whitney test and multiple logistic regression.

Result :

A total of 39 patients were included in the study. All subjects come from Kelantan and Besut district in Terengganu. The mean age of patients was 11.4 years, ranging from 2 to 19 years old. There were 34 Malays, 4 Chinese and 1 Siamese patients. The seroprevalence of anti-HCV positive was 35.9%. The seroprevalence of anti-HCV antibody positive was found to be associated with the timing of blood transfusion before donor screening was started (OR = 10.7, p = 0.007). However, it was not associated with age of the patient (p = 0.45), gender (p =0.1), race (p = 0.06), frequency of blood transfusion (p = 0.08), splenectomy status (p = 0.97) and type of thalassaemia (p = 0.12). There was no significant difference in ALT levels between anti-HCV positive and negative patient (p = 0.25).

Conclusion :

This is a preliminary data on seroprevalence of anti- HCV positivity in thalassaemia patients in HUSM Kubang Kerian. The results showed about 36% of our multiply transfused thalassaemia patients had positive anti-HCV and it is associated with donor screening program.

Dr. Ariffin Nasir (Supervisor)

Dr. Noorizan Haji Abdul Majid (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):80.

(21) Nocturnal Enuresis (NE) in Healthy 8-Year-Old School Children from East Coast of Malaysia: Prevalence and Parental Perception.

Md Nazim Abu 1,2

Abstract

Introduction :

Enuresis is a common problem among young children. It has puzzled families and professionals for centuries. Prevalence figures are therefore needed to estimate the scope of the problem. The identification of associated risk factors in our society would assist further intervention and management strategies. Parental behavior regarding perception of the disease and methods of treatment were also examined in this study.

Objectives :

Our main objective was to determine the prevalence of enuresis in healthy 8-year old school children in our community. This study also evaluated the associated risk factors and the effects of family characteristics on enuretic children. Finally, to identify parental perception of nocturnal enuresis and the common methods of enuresis management.

Methodology :

A community based, cross-sectional study was conducted from October to November 2001. A total of 1339 set of questionnaires were distributed to parents of all standard two, school children attending eight primary schools in the district of Kota Bharu. The ICD-10 definition of enuresis was used.

Results :

The overall response rate was 83.3%. Nocturnal enuresis was reported in 121 out of 1075 children (11.3%), primary nocturnal enuresis in 95 children (8.8%) and secondary nocturnal enuresis in 26 children (2.4%). Fifty-five (45.5%) of these children had two or more wet nights per week. There were 55.4% (67) boys and 44.6% (54) girls with enuresis. 52% of those with primary enuresis had a positive family history. Using multivariate logistic regression analysis, independent risk factors for nocturnal enuresis were Malay ethnicity compared to non-Malay ethnicity (OR 1.8, 95% Cl 1.1–2.9%) and loss of loved ones (OR 2.3, 95% Cl 1.2–4.2%). A protective factor was achieving high score in examination results (OR 0.99, 95% Cl 0.981–0.999%). The majority of parents with enuretic children 61.8% (63/102) were not aware that enuresis is abnormal and majority (61.8%) of these children received punishment. 90.7% (88/97) of the parents treated the children themselves, 19.6% (19/97) sought modern medicine and 27.8% (27/97) practiced traditional method. Parental belief regarding the causes of enuresis and frequent methods of treatment corresponded well with other studies.

Conclusion :

The prevalence of nocturnal enuresis in healthy 8- year old school children was comparable to that found in western studies but the parental understanding and its effect on the child was still poor. Malay ethnicity and loss of loved ones were significant risk factors and a high score in examination was a protective factor. The psychosocial impact on the child and the family needs to be addressed, and the public should be made aware of options for treatment, and their availability, for this common problem.

Assoc. Prof Dr. Nik Zainal Abidin Nik Ismail (Supervisor)

Assoc. Prof Dr. Amin Hans Van Rostenberghe Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):80–81.

(22) Kawasaki Disease : A 15-Year Review of Clinical Spectrum and Outcome at Hospital Universiti Sains Malaysia, Kelantan

Nik Rosenorleyaney bt Nik Ibrahim 1,2

Abstract

Introduction :

Kawasaki disease(KD) is not an uncommon disease in Malaysia. It is a febrile systemic vasculitic illness also known as Infantile Acute Febrile Mucocutaneous Lymph Node Syndrome (MCLS). Kawasaki disease was first reported in Japan in 1967 and later has been reported all over the world. It is more common among Asian populations, especially the Japanese. The diagnosis of Kawasaki disease is important because of the associated acquired cardiac lesion that leads to high morbidity and mortality especially in untreated children and young adults.

Methods :

This study is a 15-year retrospective study (1987–2001) of paediatric patients at a tertiary health centre Hospital Universiti Sains Malaysia, situated in the northeast of Penisular Malaysia. All patients records who had been diagnosed to have Kawasaki disease based on ‘ICD 10’ from the ‘INFORMIX’ and ‘Lifeline 2000’ Hospital Universiti Sains Malaysia filing systems were reviewed. Subjects were selected only if they fulfilled the criteria for Diagnostic guidelines of Kawasaki disease, the 5th Revised Edition, February 2002 for either classic or atypical Kawasaki disease since no specific etiology or diagnostic test is available. All the data regarding clinical presentations, laboratory data, echocardiography and imaging studies, complications, underlying cardiac abnormality, as well as management in Kawasaki disease patients were recorded.

Results :

From 35 records analyzed, only 28 patients were found to have Kawasaki disease based on diagnostic criteria of Kawasaki disease. Patients’ ages range from 3 to 120 months with the median age of 24 months (mean age of 36 months) with 82% of cases being less than 5 years. Malay was the commonest ethnic group (82%) with a male to female ratio of 1.2:1. Of all Kawasaki disease patients, 2(7.1%) patients were diagnosed as atypical KD and 1(3.6%) patient was diagnosed as recurrent Kawasaki disease. Almost all patient 27(96.4%) presented with a fever duration of 5 days or more. Common presenting clinical features were development of a body rash in 25(89.3%) patients, extremities changes either swollen or desquamation in 23(82.0%) patients, cervical lymphadenopathy in 22(78.6%) patients, mucosal changes in 22(78.6%) patients and conjunctivitis in 18(64.3%) patients. For associated symptoms in KD, only 4(14.3%) patients had central nervous systems manifestation, 3(10.8%) patients presented with acute abdomen for which 2(7.1%) patients underwent laparotomy, and 4(14.3%) patients had diarrhoea, otitis extema, pneumonia and upper respiratory tract infection. Most patients had evidence of an acute phase response with elevation of erythrocyte sedimentation rate, Creactive protein and neutrophils. Thrombocytosis occured towards the end of the second week of illness. Only 2(8%) patients were found to have hydrops gall bladder by ultrasonography. Twenty five (89.3%) patients had echocardiography done and of these 7(28%) patients had abnormal coronary artery dilatation in which 1(4%) patient had a giant aneurysm of the coronary artery. In this study, a total of 12(42.8%) patients received intravenous immunoglobulin in which 10(35.7%) patients received high single dose of immunoglobulin and 2(7.1%) patients received low dose of immunoglobulin. High dose of aspirin was administered in 18(64.4%) patients followed by 21(75%) patients who received low dose of aspirin. Only 1(3.6%) patient received methylprednisolone for prolonged fever of more than 2 weeks with unresolved giant aneurysm. All patients who were diagnosed as Kawasaki disease survived with no long term complications or disabilities.

Conclusion :

Even though the number of cases of Kawasaki disease patients in this study were small, the disease still accounts for significant morbidity in the paediatric population. The cardiac complications were still high in which 7(28%) patients were affected. Lack of awareness, late recognition and the delayed initiation of treatment in this disease increase the number of complications. Therefore the diagnosis of Kawasaki disease should be considered in any child, regardless of the age, who presents with persistent fever, some signs of mucocutaneous inflammation and laboratory values associated with severe systemic inflammation such as elevation in ESR, CRP and thrombocytosis.

Assoc. Prof. Dr. Sharifah Ainon bt. Ismail Mokhtar (Supervisor)

Dr. Fuziah Md. Zain (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):81.

(23) Validation of Malay Version Short-Form Geriatric Depression Scale and Study of Prevalence of Major Depression Scale Study of Prevalence of Major Depression and its Associated Psychosocial Factors Among Elderly Inpatients at University Sains Malaysia Hospital.

The Ewe Eow 1,2

Abstract

Introduction :

Depression is prevalent among the elderly physically ill inpatients and has important clinical implications, but often under recognized and under treated. There is no previous Malaysian data on the prevalence of major depression among the elderly inpatients.

Objectives :

This study aimed to validate the Malay version of the short form Geriatric-Depression Scale (GDS) in order to determine the prevalence of major depression and its associated psychosocial risk factors among the elderly inpatients hospitalized for general medical condition.

Methods :

The study consisted of 2 stages. First, the validation of the Malay version-GDS; followed by a cross sectional prevalence study, participated by 271 elderly inpatients. Data were collected using a self-administered questionnaire, the validated Malay version-GDS and WHOQOL-BREF. Major depression was defined as score above the optimum cut-off point on Malay version-GDS determined at the validation study.

Results :

The validation study showed the item-9 from Malay version-GDS-15 had no minatory value in differentiating cases and non-cases and poorly correlated with the total corrected item score. By omitting the item-9, the newly formed scale, M-GDS-14, has satisfactory reliability and validity as a screening scale for depression among physically ill elderly inpatients. At the cut off point of 7/8, the M-GDS-14 had 100% sensitivity and 92.0% specificity in detecting major depression. The overall prevalence for major depression was 37.3%, 25.9% for male and 45.8% for female. Under multivariable analysis, the female to male odds ratio for major depression was 2.2 (p = 0.03). Those depended on working as the primary source of personal income, were at significant higher risk than pension group for major depression (OR = 7.8). The self-rating of relatively having enough money to meet needs, satisfactory personal relationship, adequate accessibility to information needed and opportunity for leisure activities were all significant protective factors against major depression.

Conclusion :

The prevalence yielded in this study was relatively high. Clinician should be aware of this highly comorbid condition along with patients’ physical illness. Good social resources play important role in preventing major depression in the elderly inpatients.

Assoc. Prof. Dr. Hasanah Che Ismail (Supervisor)

Dr. Mohd Ayub Haji Sadiq (Co-Supervisor)

Dr. Syed Hatim Noor (Co-Supervisor)

Keywords: Geriatric Depression Scale, prevalence, major depression, elderly, inpatient, physical illness

Malays J Med Sci. 2005 Jan;12(1):81–82.

(24) A Study on Validation of Brief Patient Health Questionnaire (PHQ-9) Among Adult Attending Family Medicine Clinic at Hospital Univeriti Sains Malaysia

Nor Azah bt Mohamad Nawi 1,2

Abstract

Objective :

Validation of Malay version of the Brief Patient Health Questionnaire among adult attending Family Medicine Clinic, Universiti Sains Malaysia Hospital to determine the suitability of this questionnaire before it can be used for Malaysian population, consequently to use it for screening of depression among adult attending primary health care services.

Material and Method :

Initially, the back to back translations of Brief Patient Health Questionnaire (PHQ-9) were done and a Malay version was produced. Then, a validation study was conducted involving 265 adult patients attending Family Medicine Clinic, Hospital Universiti Sains Malaysia. All of 265 patients were asked to complete the Malay version of PHQ-9. All of patients with positive scores (141 patients with score more than 5) and few of patients with negative scores (39 patients with score 4 and less) were then interviewed by using the Composite International Diagnostic Interview (CIDI). They were also assessed with Hamilton Depression Rating Scale (HDRS) and Hospital Anxiety and Depression Scale (HADS). The validity of PHQ-9 was tested against this clinical diagnosis and the concurrent validity against HDRS and the Malay version of HADS was also evaluated.

Results :

The best cut-off score of the Malay version of PHQ-9 was 5 with the sensitivity of 69.0% and specificity of 60.5%. The best cutoff score for severe depression was 10 with sensitivity of 60.9%, specificity of 80.7% and positive predictive value of 38.6%. The PHQ-9 was significantly correlated with HDRS (r =0.68, p < 0.001) and HADS (r =0.69, p < 0.001)

Conclusion :

The Malay version of PHQ-9 is a valid and reliable screening tool for detection of depression in primary care. However the sensitivity and specificity of this tool is quite low and this is may be related to the different understanding and cultural variation of depression between Kelantan population and Western population.

Dr. Shaiful Bahari Ismail (Supervisor)

Dr. Juwita Shaaban (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):82.

(25) A Cross Sectional Study on Oral Anomalies and Speech Abnormality Among Operated Non-Syndromic Cleft Lip and Palate Children in Kelantan

Nor Normastura bt Abd Rahman 1

Abstract

Objectives :

To determine the prevalence of various types of dental anomalies as well as facial profile and speech abnormality and its association with Non-syndromic CLP children compared to non-cleft children. The dental arch dimension were also determined and compared between the two groups.

Methodology :

A comparative cross sectional study was conducted from July 2002 to January 2003. Case group comprised of 98 operated Non-syndromic CLP children-unilateral (UCLP) and bilateral (BCLP) who attended the Combined Clinic while the comparison group comprised of 109 non-cleft children who attended the outpatient clinic at the Kota Bharu Dental Clinic. Their ages were between 3 to 12 years old. Socio-demographic data were obtained and examination for oral anomalies in terms of dental (morphology, number and alignment) and facial profile as well as speech assessment was done. Data were entered and analyzed in SPSS version 11.0.

Results :

The prevalence of anomalies in morphology of teeth in CLP was 24.5% (95% CL15.82, 33.16) and non-cleft was 10.1% (95% Cl: 4.35, 15.84), number of teeth in CLP was 44.9% (95%: Cl 34.87, 54.92) and non-cleft was 7.3% (95% Cl: 2.37, 12.31), mal-alignment in CLP was 79.6% (95% Cl:71.47, 87.71) and non-cleft was 27.5% (95% Cl: 19.00, 36.04), facial profile in CLP was 26.5% (95% CM 7.63, 35.43) and non-cleft was 9.1 % (95% Cl: 3.67, 14.68) and speech abnormality in CLP was 61.2% (95% Cl: 51.41, 71.04) and non-cleft was 0.9% (95% Cl: −0.09, 2.74). The results also showed significant association between CLP and anomalies in morphology (OR= 3.80, 95% Cl: 1.68, 8.61), number (OR= 15.26, 95% Cl: 6.18, 37.65), mal-alignment (OR = 23.67, 95% Cl: 9.93, 56.40), abnormality in facial profile (OR =5.10, 95% Cl: 2.17, 12.00) and speech (OR= 174.45, 95% Cl: 23.04, 1320.67); (p < 0.05). The dental arch dimension also showed significant difference between CLP and non-cleft group; maxillary arch dimension (Mean difference = −0.24 cm, 95% Cl: −0.38, −0.11) and mandibular arch dimension (Mean difference= 0.17 cm, 95% Cl: 0.06, 0.29); (p<0.05).

Conclusion :

There were a high prevalence and risk of having dental anomalies, facial profile and speech abnormalities in CLP children compared to non-cleft children. The dental arch dimension was also significantly different between CLP and non-cleft group. Therefore CLP children required a multidisciplinary management leading to long duration of treatment and involving high cost. A reasonable protocol for management should be developed to improve the standard of care for benefit of these groups of patients.

Dr. Nizam Abdullah (Supervisor)

Dr. Mohd. Ayub Sadiq @ Lin Naing (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):82.

(26) A Study of Needle-Stick Injuries and Associated Factors Among Staff Nurses in Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan.

Anita Suriani bt Abdul Shukor 1,2

Abstract

Introduction :

Needle-stick injury is the commonest injury reported among health care workers and nurses are being identified as having the highest risk of needle-stick injuries by several studies.

Objective :

To determine the prevalence of needle-stick injury among nurses and associated factors contributing toward needle-stick injuries.

Methodology :

A cross-sectional study was done in January 2003 to December 2003. Two pilot studies were done to validate the questionnaire. Out of 386, 355 nurses responded giving a response rate of 92%. Data was collected through self-administered questionnaire in nurses randomly selected based on a name list provided by the Matron. A walk-through survey was subsequently done to assess the workplace’s safety and risk profile. All 42 workplaces were assessed using Ministry of Health’s format. For the questionnaire, factor analysis extracted three common factors for knowledge and 2 common factors for attitude. Cronbach alpha values from 0.49 to 0.67 in the reliability analysis showed that the questionnaires were reliable and valid.

Results :

Results show that the prevalence of needle-stick injury among staff nurses was 37% (95% CI 32% − 42%). In this study, there was no significance difference of mean score of KAP noted between injured nurses and non-injured nurses. Simple logistic regression showed that the presence of Hepatitis B immunization (crude OR 2.49, 95% CI 0.88–7.02), working in high-risk area (crude OR 0.58, 95%CI 0.351–0.96) and total practice score (crude OR 0.95, 95% CI 0.89 – 0.99) were significantly associated with needle-stick injuries. However, multiple logistic regression analysis showed that Hepatitis B immunization (adjusted OR 2.82, 95% CI 1.03–7.76) was significantly associated with needle-stick injuries among staff nurses. A walkthrough survey revealed that 95.2% of work places were good in term of health and safety and only 4.8% were fair. Some of the pitfalls noted and can be improved.

Conclusion :

We conclude that Hepatitis B immunization status was significantly associated with needle-stick injuries among staff nurses in HUSM.

Prof. Rusli Nordin (Supervisor)

Dr. Mohd. Ayub Sadiq @ Lin Naing (Co-Supervisor)

Keywords: needle-stick injuries, staff nurses, sharp container, blood-borne disease, universal precaution, HUSM

Malays J Med Sci. 2005 Jan;12(1):82–83.

(27) A Pilot Study: Prevalence of Negative Plain CT and Positive Perfusion CT Scan in Cases of Acute Stroke

Khoiri bin Man 1,2

Abstract

Introduction :

Computed Tomography (CT) scan is the usual imaging modality used to diagnose acute stroke in most major hospitals. Previously, the purpose of plain CT scan in acute stroke was to exclude intracerebral haemorrhage. The introduction of recombinant of tissue Plasminogen Activator (rtPA) as a mode of treatment in acute stroke has changed the role of CT scan. Stroke patient who received treatment with rtPA can develop intracerebral haemorrhage. Therefore, correct selection of patient who is suitable for thrombolysis is important. CT perfusion study is a new method to diagnose infarction in cases of normal plain CT scan. It also identifies the area of ischemia and size of infarction.

Objectives :

The aim of this study is to determine the number of cerebral infarction cases in Hospital USM where there is normal plain CT scan and abnormal Perfusion CT.

Material and Methods :

Forty two consecutive plain and perfusion CT examinations of brain in patients 12 years and above perform from August 2002 to August 2003 were evaluated qualitatively. Plain CT scan was performed in patients presented with acute stroke symptoms followed by Perfusion CT. A registrar and radiologist reviewed both CT scans at different sitting. The qualitative parameters were normal and abnormal plain and Perfusion CT. The area of penumbra was determined from CT Perfusion.

Result :

Twelve out of 42 cases were found to have normal plain CT scan. Nine out of these 12 patients were positive for infarction in Perfusion CT scan. Two out of 12 cases turned out to be transient ischemic attack and one case, CT perfusion was normal even though patient showed signs and symptoms of acute stroke. The prevalence of negative plain CT scan and positive perfusion CT for acute stroke in Hospital USM from August 2002 to August 2003 was 21.3%.

Conclusion :

CT perfusion is a useful imaging tool for determining ischemia and infarction in cases where the plain CT scan is normal. It is available 24 hours and suitable in emergency situation unlike Magnetic Resonance Imaging (MRI). The results obtained from CT perfusion scanning used to determine mode of treatment suitable for acute stroke patients.

Dr. Mohaideen Abdul Kareem (Supervisor)

Dr. Wan Asim Wan Omar (Co-Supervisor)

Dr. Atul Prasad (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):83.

(28) The Determination of Bone Mineral Density of Local Malay Female and its’ Correlation With Geometric Properties in the Evaluation of Skeletal Status

Lee Cheng Wai 1,2

Abstract

Introduction :

Currently the recommended method to measure bone mineral density (BMD) is Dual Energy X-Ray Absorptiometry (DEXA) which is costly and not widely available. BMD is the ratio of bone mineral content to bone area and does not represent the real bone density. Therefore by incorporating geometric properties, a lower cost tool to measure BMD and screening for osteoporosis can be achieved.

Objectives :

  1. To obtain bone mineral density of normal Malay women.

  2. To determine the correlation of geometric properties and BMD.

Methods and materials :

A total of 137 Malay female volunteers who had given a written informed consent underwent DEXA of the spine, dual femur and total body. There were six age group from third to eight decade. This was followed by radiograph of the non-dominant hand which was later used for digital x-ray radiogrammetry (DXR) and geometric properties (GP) calculation. Local Malay female reference curves derived from BMD of vertebral, dual femur and total body plotted against age. Correlation of BMD and geometric properties which consist of inner diameter(ID), outer diameter (OD), cortical thickness(CT), metacarpal index (MCI), cortical area (CA), polar moment of inertia (J) and section polar moment (Z) were analysed. Multiple linear regression were performed to determine variables in prediction of vertebral BMD(VTBMD), dual femur BMD (DFBMD) and total body BMD (TBBMD). Rationship between BMD measured by DXR (DXRBMD) with VTBMD, DFBMD and TBBMD were also performed.

Results :

Graphs of VTBMD, DFBMD and TBBMD versus age group was obtained from the mean and standard deviation. The highest BMD of vertebral, dual femur and I total body were from the 40–49, 30–39 and 50–59 age group respectively. The local BMD corresponding to −2.0SD from the peak adult value for vertebral and total body were 9% and 0.7% respectively lower compared to the Caucasian reference data (U.S/Europe) whereas the value for dual femur was 5% higher than the Caucasian. In the statistical analysis of BMD and GP, fair correlation were found between CT and MCI of second, third and fourth metacarpal with BMD particularly of dual femur and total body. The correlation between dual femur and CT was r = 0.299–0.372 and MCI was r = 0.280–0.310. The correlation between total body and CT was r = 0.269–0.448 and MCI was r = 0.264–0.320. Cortical area (CA) of second metacarpal has greater correlation with BMD compared to third and fourth metacarpal. No correlation between section polar moment (Z) and polar moment of inertia (J). Good to excellent correlation between BMD measured by DXR with ID, OD, CT, MCI and CA of second (r = −0.404, 0.175, 0.675, 0.526, 0.500) third (r = −0.453, 0.253, 0.753, 0.598, 0.551 and fourth (r- −0.402, 0.189, 0.618, 0.516, 0.473) metacarpal. In multiple linear regression analysis, two models age- CA2 and age-CT2 in addition to weight improved the prediction power of VTBMD. Age and CT2-age in addition to weight also improved the prediction power of DFBMD. In the prediction of TBBMD, the significant variables were derived from models weight-CA2-J2-age- Z2 and weight-CT2-age. When correlation of GP and BMD were based on age group, the 20–29 age group has greater association than the rest of the age group. There were also fair correlation of BMD measured by DXR with BMD of vertebral (r = 0.369, dual femur (r = 0.455) and total body (r = 0.443).

Conclusion :

A local Malay female BMD reference database has been established and there were differences in VTBMD, DFBMD and TBBMD value compared to Caucasian BMD. The combination of GP and BMD in the assessment of fracture risk are possible. DXR may become a lower cost tool for follow up cases as well as for screening of osteoporosis in view of fair correlation between DXRBMD with VTBMD, DFBMD and TBBMD. Excellent correlation between non-dominant hand BMD measured by DXR and GP obtained from same hand radiograph, indicates correlation of GP and BMD is also site specific.

Dr. Haji Abdul Kareem (Supervisor)

Assoc. Prof. Dr. Hj. Ibrahim Lutfi Shuaib (Co-Supervisor)

Dr. Mohd. Ezane Aziz (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):83–84.

(29) Carotid Intima-Media Thickness as an Independent Predictor of Coronary Artery Disease - A Study in Hospital Universiti Sains Malaysia (HUSM)

Wan Mohd Razin bin Wan Hassan 1,2

Abstract

Introduction :

A cross sectional study to measure the common carotid artery intima-media thickness (IMT) was conducted on patients who had undergone coronary angiogram in Hospital Universiti Sains Malaysia since it was started in October 2002.

Objective :

The aim of this study is to determine the association between carotid IMT with the severity of the coronary angiographic result. This study also aims to look for the association between the coronary artery disease (CAD) risk factors with IMT.

Methodology :

Common carotid IMT was measured by ultrasound in 274 subjects of mean age 55.8 ± 9.6 (standard deviation) years (range, 30 to 84 years) whether as outpatient or in-patient- i.e. before or after the procedure.

Results :

Mean carotid IMT was 0.818 ± 0.235 (SD) mm (range, 0.374 to 2.060 mm). Coronary angiograms were analyzed for disease severity by using vessel score (number of vessels with ≥ 70% stenosis), or stenosis score (Gensini score). It was found that mean carotid IMT had fair and significant positive correlation with CAD severity, r = 0.279 for vessel score, and r = 0.396 for Gensini score (p < 0.001). Increasing age, male sex, history of smoker, total-cholesterol, and duration of diabetes were all associated with a significantly (p < 0.05) higher value of IMT. However, only male sex, presence of diabetes, and IMT value were considered as predictors for severity of coronary artery disease, suggesting differential effects of these traditional risk factors on the coronary and common carotid arteries.

Conclusion :

Measurement of common carotid artery IMT was also found to become clinically useful as a screening test for coronary artery disease. It was quite sensitive, and specific. Using receiver operating characteristic (ROC) curve to predict the absence of coronary artery disease, 3 IMT value were tested as the cut-off point. At the value of 0.70 mm, it has a sensitivity of 77.5%, and its specificity is 84.2%, whereas at the value of 0.75 mm, sensitivity reduced to 66.9% whiles its specificity unchanged. Although the specificity was quite high (86.8%) if IMT at 0.80 mm is taken, its sensitivity was very low (53.4%). As a conclusion, carotid IMT is fairly and significantly correlated with the severity of CAD. It also can be considered as an independent predictor for coronary artery disease. This method also may be used as a screening test for coronary artery disease in current clinical practice.

Prof. Madya Dr. Zurkurnai Yusof (Supervisor)

Dr. Tee Meng Hun (Co-Supervisor)

Dr. Mohd Sapawi Mohamed (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):84.

(30) The Prognostic Value of Initial and Follow-Up Computerized Tomography (CT) of Brain in Adult Patients With Moderate and Severe Head Injury Following Motor Vehicle Accident

Azman bin Kifle 1,2

Abstract

Introduction :

Head injury is still the most common problem throughout the world. In Malaysia, the most common cause of head injury is due to motor vehicle accident. The impact of the head injury is so great because the younger generation is the highest populations involved. The outcome may ranges from good recovery and disability to death. In view of the important of the outcome, the author felt that it is important to assess the clinical as well as the CT scan of brain of those patients in order to predict the outcome. Currently, it is believed that the permanent outcome of the patient can be predicted from a follow-up CT scan of brain as early as six weeks.

Objective :

The aim of this study is to predict the outcome of the adult patients with moderate and severe head injury in motor vehicle accident by using clinical parameters (age, Glasgow Coma Scale), initial CT scan of brain parameter (intracranial haemorrhage, volume and site of intracranial haemorrhage, midline shift and hydrocephalus) and follow-up CT scan of brain parameter (residual intracranial bleed, post-traumatic hydrocephalus, midline shift and gliosis).

Methodology :

The patient is assessed clinically on admission for GCS. Those categorised into moderate and severe head injury with initial and follow-up CT scan of brain 6 weeks later will be selected for the study. The parameters were analyzed statistically using univariate analysis, chi square test and logistic regression. The p value of < 0.05 is taken as significant level.

Results :

A total of 31 patients were selected, 67.7% are male and 32.3% are female. The GCS of the patients were statistically significant as outcome predictors. Other significant predictors analyzed from the study are midline shift and volume of subdural haemorrhage in the initial CT scan and post-traumatic hydrocephalus and gliosis in the follow-up CT scan.

Conclusion :

The study showed that the above-mentioned parameters are significant predictors of outcome. The author also have suggested a new outcome predictors by using the parameters from follow-up CT scan i.e. presence of gliosis, site of gliosis and post-traumatic hydrocephalus.

Assoc. Prof. Dr. Nurul Azman Alias (Supervisor)

Dr. Abdul Kareem (Supervisor)

Prof. Dr. Jafri Malin Datuk Abdullah (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):84–85.

(31) High Resolution Ultrasonography of the Wrist Among Typist in USM

Nazihah Mohamad 1,2

Abstract

Introduction :

Atrial fibrillation is the most common cardiac rhythm abnormality encountered in clinical practice and it is strongly associated with higher incidence of stroke. Atrial fibrillation in the presence or absence of rheumatic valvular disease is associated with an increased risk of stroke. The incidence of stroke is higher in the presence of additional risk factors such as increasing age, rheumatic heart disease, poor left ventricular function, previous myocardial infarction, hypertension and diabetes mellitus and a past history of a thromboembolic event. Data from numerous clinical trials in both primary and secondary prevention of thromboembolism in patients with atrial fibrillation have proven the beneficial effect of antithrombotic agents, particularly warfarin in reducing incidence of stroke. Previous studies done documented that utilization of warfarin in patients with atrial fibrillation varies from 12% in 1989 to 38% in 1993 and did not significantly increase thereafter. Other studies had reported that between 1998 and 2000 the clinical utilization of anticoagulants was still at a low rate.

Objectives :

This audit aimed to look at local clinical practice in relation to the percentage of patients with atrial fibrillation who were prescribed anticoagulants.

Methodology :

The subject consists of 372 patients from three referral centres which were Hospital Universiti Sains Malaysia, Institute Jantung Negara and Hospital Universiti Kebangsaan Malaysia between January 2001 and December 2002.

Results :

The results showed that 210 patients (56%) of the total patients were given warfarin and only 92 patients (43.8%) of all warfarinized patients had their INR level within therapeutic range, it varies between 41.1% and 51.1% among centers involved. Among those 162 patients that were not on warfarin, 33 patients (20.4%) did not have any specific reasons mentioned in the case notes. Most of these patients not on warfarin were aged between 60 – 90 years old. Thirty five cases (16.7%) on warfarin developed major bleeding and 32 cases (15.3%) developed minor bleeding complications over 2 years. These figures are higher than that reported in clinical trials (major complications range from 1.5% – 2.8% and minor complications 1.5% – 16% per year).

Conclusions :

There were significant differences among these three centers in the frequencies of patients given warfarin. This might represent differences in clinical practice of those centers. In conclusion, this study found that the utilization of warfarin in patients with atrial fibrillation in these 3 referral centers were still not optimum. The therapeutic INR achieved can also be improved. As a whole, complications rate were comparable to reports from previous study. A strategic plan is needed to optimize utilization of warfarin in order to reduce complications among atrial fibrillation patients.

Assoc. Prof. Dr. Ibrahim Lutfi Shuaib (Supervisor)

Dr. Mohd. Ezane Aziz (Co-supervisor)

Dr. Mahayidin Haji Muhamad (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):85.

(32) Neurobehavioural Performances in Car Spray Painters and Mechanics Exposed to Environmental Lead in Kota Bharu, Kelantan

Mohd Nazhari bin Hj Mohd Nawi 1,2

Abstract

Introduction :

Lead exposure posed a major public health hazard and is recognized as the most prevalent and preventable health issue in many industrialized countries. Lead-based paint poisoning, a well recognized entity among young children in poor, urban neighbourhoods, is not confined exclusively to such areas. Worldwide, about 830,000 people died every year through illness linked to exhaust fumes and industrial smog that engulfed many cities of the Third World. In Latin America alone, me figure stands at 115,000. In the remaining parts of Asia, Africa and Eastern Europe, the fumes are loaded with heavy metal such as lead. Most accurate estimates of health risks due to lead can be obtained from reliable history of blood lead measurements. Level of lead in air will consequently lead to contamination of soil, water and food and subsequently increase exposure to future generation. Previous study have shown that chronic exposure to inorganic lead among spray painters, mechanics and battery workers caused neurobehavioural effect in the workers.

Objectives :

To investigate the neurobehavioural performances of car spray painters and mechanics exposed to environmental lead in the workplace.

Methodology :

This is a cross-sectional comparative study of 44 car spray painters exposed to lead chromate in car paint and 44 car mechanics working in car spray painting and service premises in Kota Bharu, Kelantan. Assessment of exposure and outcome were based on symptoms of possible neurotoxic obtained via WHO standard questionnaire form; signs of neurotoxic obtained via WHO standard examination form; blood lead levels checked as exposure consistent for biological monitoring; neurobehavioural performance tested using WHO NCTB; and environmental lead level.

Results :

Symptoms of lethargy, sleepiness, sudden wakefiilness, forgetfulness, stress, confusion, irritability, headache, vertigo, palpitation, excessive sweating and numbness noted more when mere was high level of blood lead and recognized among car spray painters and car mechanics. Mean blood lead level among car spray painters was 10.19 μg/dl and significantly higher as compared to car mechanics was 7.39 μg/dl. Mean environmental lead level inside the car spray and painting chambers was 8.07 μg/m3 and slightly lower than environmental lead level around services and repairing areas which was 8.58 μg/m3.

Discussions :

There was a significant difference in mean blood lead levels between car spray painters as compared to mechanics (p==0.01). However, neurobehavioural symptoms, neurobehavioural performances and environmental lead levels were not significant between car spray painters and mechanics. Also noted mean blood lead levels of car spray painters and car mechanics were higher as compared to other group of occupation in Malaysia. Although environmental lead levels around car servicing and maintaining areas were slightly higher than inside car spraying chamber, it actually not showing the true exposure and what actually needed was the personal air sampling.

Conclusions :

Car spray painters had significantly higher in blood lead level as compared to car mechanics. However, neurobehavioural symptoms, neurobehavioural performances and environmental lead levels were not significant between car spray painters and mechanics.

Prof. Dr. Rusli Nordin (Supervisor)

Dr. Abu Hassan Shaari Abdul Kadir (Co-supervisor)

Malays J Med Sci. 2005 Jan;12(1):85.

(33) Anticoagulation in Atrial Fibrilation: An Audit of its Utilization in Three Referral Centres

Siti Khairani bt Zainal Abidin 1,2

Abstract

Introduction :

Diabetic nephropathy is one of the most feared complications of diabetes mellitus as it is associated with high prevalence of morbidity and mortality. Microalbuminuria is a known predictor of clinical nephropathy. Several risk factors have been shown to be associated with the presence of microalbuminuria in diabetic patients. It is important to recognize these risk factors to enable early detection of microalbuminuria and prevent or delay the development of nephropathy. This study aimed to determine the prevalence of microalbuminuria and associated factors in Type 2 diabetic patients in Hospital Universiti Sains Malaysia (HUSM), Kelantan.

Method :

A cross sectional study was conducted at Family Health Clinic, HUSM from July 2001 to February 2002. A total of 322 Type 2 diabetic patients with negative proteinuria on dipstick examination were studied for the presence of microalbuminuria on random morning urine specimens. Physical examination was performed and blood investigations for fasting plasma sugar, HbAlc, fasting lipid profile, serum creatinine, uric acid and C-peptide were done. Microalbuminuria was defined as urine albumin concentration of equal or more than 30mg/ml.

Results :

The prevalence of microalbuminuria was 32.9%. In univariate analysis, the significant variables associated with microalbuminuria were duration of diabetes, diastolic blood pressure, fasting plasma sugar and HbAlc (p<0.05). However, in multiple logistic regression analysis, the only significant associated factors were duration of diabetes (OR=1.43, 95%CI=1.30,1.57), fasting plasma sugar (OR=1.11, 95%CI=1.04,1.18), mean diastolic blood pressure (OR=2.46, 95%CI=1.24,4.88), HDL cholesterol level (OR=0.43, 95%CI=0.20,0.93) and being an ex-smoker (OR=1.96, 95%CI=1.02, 3.78), p<0.05.

Conclusions :

There is a high prevalence of microalbuminuria in patients with Type 2 diabetes in HUSM, Kelantan. The associated factors were duration of diabetes, poor diabetic control, high diastolic blood pressure, low HDL cholesterol level and being an ex-smoker. Therefore, it is very important to screen for microalbuminuria in patients with Type 2 diabetes especially in those with the associated factors.

Prof. Dr. Rashid Abdul Rahman (Supervisor)

Prof. Dato’ Dr. Mustafa Embong (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):86.

(34) A Study of Ipsilateral Femur and Tibia Overgrowth in Children Treated With Dynamic Compression Plate in Closed Unilateral Femoral Shaft Fractures.

Joehaimey bin Johari 1,2

Abstract

Objectives :

A prospective study of ipsilateral femoral and tibial overgrowth in closed unilateral femoral shaft fracture in children treated with dynamic compression plate was carried out in General Hospital Kota Bharu and University Sains Malaysia Hospital. The overgrowth was defined as acceleration of growth of the injured femur or ipsilateral tibia in comparison to normal uninjured limb until the growth rate is equal. The excess of the limb length of the injured femur or ipsilateral tibia will be taken as the length of overgrowth after the period of growth was equal on both side of the limbs.

Methodology :

All cases of closed simple unilateral femoral shaft fractures from January 1997 to December 2001 in children aged from 6 to 14 years old were included in the study. Finally, twenty two out of thirty patients meet the criteria of this study. The overgrowth phenomenon of the injured femur and ipsilateral tibia were assessed using Computer Tomographic Scanogram (C.T.Scanogram) after 18 months post injury. C.T. Scanogram was chosen as method of limb length measurement because of its accuracy and less radiation exposure to the children. Duration of bone growth acceleration of the injured femur until the rate is equal to the opposite femur was determined. The relationship of the overgrowth to age, sex, handedness, site and type of fracture also were studied.

Results :

All children in this group experienced femoral overgrowth of the plated site ranging from 0.10 cm to 2.00 cm with a mean overgrowth of 1.18 cm. The study showed that the overgrowth phenomenon stop at or after 18 months post injury. Age was the only factor that has been identified to have correlation with the femoral overgrowth. The femoral overgrowth will become 0.078 cm less with each subsequent year as the child get older. The younger the patient injured the femur the more overgrowth the patient will have. Sex, handedness, site and type of fractures do not contribute to the overgrowth of the femur. Only 13 out of 22 patients had ipsilateral tibial overgrowth with a mean overgrowth of 0.060cm which is not statistically significant after analyzed by Paired t Test and Wilcoxon Signed Rank Test.

Conclusions :

The overgrowth of the femur and ipsilateral tibia did not cause any clinically significant limb length inequality as the overgrowth was less than 2.0 cm. All the children or their parents did not aware of the limb length discrepancy. To our knowledge this is the first study done to determine overgrowth phenomenon in closed simple unilateral femoral shaft fractures treated with dynamic compression plate using C.T Scanogram method. The results showed that plating does not cause severe limb length inequality and overgrowth stop after 18 months post injury.

Dr. Mohd. Iskandar Mohd Amin (Supervisor)

Dr. Anwar Hau Abdullah (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):86.

(35) Effect of Honey on Healing of Diabetic Foot Ulcers: A Comparative Study Between Honey and Povidone Dressing

Mohd Shukrimi Awang 1,2

Abstract

Introduction :

Diabetes Mellitus is one of the most important and common disorder affecting about 100 million people worldwide and 4% of Malaysian population. One of it long term complications are diabetic foot ulcers. Diabetic foot ulcers are still among the major reasons of admission to the hospitals in diabetic patients. Diabetic neuropathy and angiopathy are the most important aetiologic factors, together with other contributory factors, such as altered foot pressures, limited joint mobility, glycemic control, ethnic group and so on.

Objectives :

This is control clinical trial study to look the efficacy of honey as a dressing material in diabetic foot ulcer Wagner’s stage 2, as compared to povidone, which is commonly used in this institution.

Methodology :

This study was done from January 2002 till Jun 2003 in HUSM. It involved thirty patients. Both sexes are equally involved in study. The age of the patient is range from 31 to 65 years, with mean of 52.1 years. In both group, at the end of the study, the wound become sterile in about 50% of the cases. In povidone group, 46.7% of the wound is sterile and in honey group 53.3%. The duration taken for wound healing after dressing with povidone is 15.4 days and in honey group is 14.4 days. However, honey has better effect in term of reducing pain when changing the dressing due the moist environment created by honey over the wound avoiding sticking to the gauze, reduce the oedema faster and also suppress the bad odour of the wound faster than povidone. There are also no local or systemic complications in both groups. The overall cost of the dressing using honey is cheaper than povidone.

Conclusions :

The study has concluded that the honey dressing has a comparable result as compared to commonly used dressing, povidone, for treatment of diabetic foot ulcer in term of sterility of the wound and the duration taken for wound healing.

Dr. Abdul Halim Yusof (Supervisor)

Dr. Abul Razak Sulaiman (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):86–87.

(36) Effects of Pulsed Infrared Radiation on Fracture Healing A Study in Rabbits

Mohamed Azril Mohamed Amin 1,2

Abstract

Introduction :

Biophysical stimulation provides a non invasive alternatives in enhancement of fracture healing. Effect of Infrared radiation on bone healing was never evaluated before.

Objectives :

This is a pilot study, descriptive in nature carried out in Medical School University Sains Malaysia Kubang Kerian Kelantan.

Methodology :

The population sample consist of 16 adult male rabbits. Each was subjected to a surgically induced tranverse osteotomy on the right tibia. The fracture is then reduced with an intermedullary K-wire and the leg immobilized with Plaster of Paris. They are then devided into 2 groups eqully. One group is exposed to infrared radiation for 1 hour a day while the other group serves as a control. 4 from each group were sacrificed at 3 and 6 weeks. The operated tibia is harvested. Radiology and histology assessment were then carried out.

Conclusion :

Both the group showed fracture union at 3 weeks but a much higher hard callus volume were noted in the infrared group. At 6 weeks the hard callus volume are almost equal in both the groups. In conclusion, Infrared Radiation does enhanced fracture healing in rabbits.

Dr. Abdul Halim Yusof (Supervisor)

Dr. Mohd. Iskandar Mohd. Amin (Supervisor)

Malays J Med Sci. 2005 Jan;12(1):87.

(37) A Study of the Flexor Tendon Repair of the Hand Using Six-Strand Technique With Early Passive and Controlled Active Mobilization

Mohammad bin Paiman 1,2

Abstract

Introduction :

Repair of the ruptured flexor tendon in the hand particularly in zone I and II was known to have poor outcome. Tendon adhesion is a well-known complication that contributes to the poor outcome. Adhesion was associated with delaying in passive or active rehabilitation program. However, shifting from delay to early passive and active rehabilitation program was associated with high incidence of ruptured of the repaired tendon especially in 2-strand Kessler method of tendon repair (currently is widely used technique of tendon repair in almost all hospitals in Malaysia). The dilemma is early motion improves result but requires greater strength. Six -strand method give immediate strength of 62 N whereas 2-strand give immediate strength of only 24 N. Therefore this study determines the clinical outcome of 6-trand technique of tendon repair with early motion rehabilitation program.

Objectives :

To measure the performance of selected cut flexor tendon of the fingers that undergone ‘Six-strand technique of flexor tendon repair’ in zone I and II with ‘12-week early passive and controlled active post rehabilitation program’ and to observe the effectiveness of this technique in producing the end result.

Methods :

A prospective well-controlled clinical study was conducted to observe the performance of flexor tendon repair using six-strand technique with early passive and controlled active mobilization for 12 weeks. Each finger will be assessed using Strickland method of assessment after 12 weeks of rehabilitation program.

Result :

Seventeen well-controlled digits, which were cut at zone I and II, were repaired by this technique within six months of period. Total active movement of the digital performance using Strickland’s method of assessment showed 52.9% of the digits had performance of more than 90%, 17.6% of the digits had performance between 80–90%, 11.8% of the digits performed between 70–79%, 5.9% of the digits performed 50–59%, 5.9% of the digits performed 30–39% and 5.9% of the digits was ruptured. International Federation for Hand Surgeon System Classification of Outcome graded this technique of repair produced excellent and good result in 88% of the studied samples.

Conclusion :

The technique is reliable to be used as a standard technique for flexor tendon repair in zone I and II of the hand.

Dr. Mohd. Iskandar Mohd. Amin (Supervisor)

Prof. Dr. Zulmi Wan (Co-Supervisor)

Assoc. Prof. Dr. Ahmad Sukari (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):87.

(38) Primary Plating in Delayed Surgical Treatment of Type II Open Tibia Fracture

Shamsul Kahar bin Kamarul Ghani 1,2

Abstract

Objectives :

A prospective study to analyse the result of primary plating of type II open tibia fracture with delayed surgical treatment was done from November 2001 to November 2002 in Hospital Kota Bharu.

Result :

There were initially 35 patients with type II open tibia fracture with delayed surgical management, but only 19 of them were primarily plated and included in the study. Most of the delayed in the initial surgical debridement was due to a long waiting list for emergency operation with a mean time of 29 hours. The overall infection rate was 21.1% with 10.5% of deep infection which was noted to be comparable to other study. Type II open fracture involving the distal third of the tibia was noted to have a higher risk of infection as compared to the proximal third and midshaft of the tibia. There was no significant correlation noted between the pre and postdebridement open wound culture with the incidence of post plating wound infection. The overall union rate in this study was 19.6 weeks which is comparable to the average time to union of type II open tibial fracture. There were three patients with non-union. Two of them finally unite after treated with reamed intramedullary nail. One patient ended up with chronic infected non-union. Sixteen patients have a good lower limb function in terms of full range of motion of both ankle and knee joint and painless full weight bearing at union.

Prof. Dr. Zulmi Wan (Supervisor)

Mr. Mohammad Anwar Hau Abdullah (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):87–88.

(39) Outcome Study of Closed Supracondylar Fracture of Femur Treated With a Retrograde Supracondylar Nailing

John Ooi Tzen Chuong 1,2

Abstract

Introduction :

Supracondylar fractures of the femur occur in two groups of patients. For the young age group it is almost always due to a road traffic accident. In the elderly, the usual cause is a minor fall at home. The standard treatment for this type of fractures is open reduction and fixation with a lateral plate device e.g. an angle blade plate or a dynamic condylar screw. However the use of such implants is associated with complications such as bleeding, a lot of periosteal stripping, nonunion and infection. A relatively new implant, the retrograde supracondylar nail, is an alternative device that can be used for treatment of supracondylar fracture of the femur. This devices can be inserted percutaneously without the need for periosteal stripping, therefore reduces the risk of bleeding, nonunion and infection.

Objectives :

This study is a retrospective analysis of supracondylar fracture of the femur treated with the supracondylar nail. The clinical outcome and complications of this procedure were evaluated.

Methodology :

During the period from January 1998 to December 2002, a total of 47 patients were treated with the retrograde supracondylar nail at Hospital Alor Setar. 27 patients fulfilled the inclusion criteria and were analyzed. The mean age was 27 years old. Twenty five patients sustained the fracture after a motor vehicle accident and 2 after a fall. The clinical outcome was evaluated using the Sander’s Knee Score.

Conclusion :

This study concludes that the retrograde supracondylar nail is an acceptable alternative treatment for supracondylar fracture of femur. This method of treatment leads to a high union rate without the need for bone grafting. The average time to union was 3.9 months. Functional scores were satisfactory in high proportions of patient (70%). Best results were seen in the young and the extra-articular type of fractures. However there are a number of specific complications related with the use of this device.

Dr. Abd. Halim Yusuf (Supervisor)

Prof. Dr. Zulmi Wan (Co-Supervisor)

Assoc. Prof. Dr. A. S. Devnani (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):88.

(40) The Definitive Treatment of Hirshsprung’s Disease With a Modified Duhamel Procedure

Mark Jeevan Erudayam 1,2

Abstract

Introduction :

Hirschsprung’s disease or congenital megacolon is the most common cause of neonatal intestinal obstruction. Harald Hirschsprung first described the disease as a separate clinical entity in 1886. Currently three surgical procedures are commonly used in the management of Hirschsprung’s disease, namely, the Swenson Procedure, the Duhamel Procedure and the Soave Procedure. The standard management consists of a staged procedure, in which a diverting colostomy is created for purposes of bowel decompression prior to the definitive surgical correction at a later stage. However, in recent years, a primary approach to the surgical repair at an earlier age, without the need for a diverting colostomy, has been adopted with results of this method being comparable to the staged repair.

Objectives :

The main objective of this study was to evaluate the outcome of patients treated with the modified Duhamel procedure. From current literature, the Duhamel and Soave procedures are more commonly performed for the correction of Hirschsprung’s disease. The concept of the modified Duhamel procedure adopted in this study differed from the original Duhamel procedure in three crucial areas, namely, the level of the anal incision through which the ganglionic bowel is pulled and anastomosed to the posterior wall, the use of the gastro-intestinal stapler for the side-to-side colo-rectal anastomosis and lastly the utilization of a proximal end-to-side colo-rectal anastomosis to obliterate a blind rectal pouch. The study was to further evaluate also, the use of rectal irrigations for bowel decompression as a safe alternative to a leveling colostomy (that is, a colostomy sited at the level of the normally innervated and normally functioning bowel) and to study the outcome of infants less than 4 months of age treated with this operation as a primary pull-through procedure.

Methodology :

During a study period of 4 and a half years, from January 1998 to June 2002, a total of 84 cases were diagnosed to have Hirschsprung’s disease and had undergone surgical repair with the modified Duhamel procedure in Hospital Alor Setar. Data of these patients were recorded and studied retrospectively.

Results :

Of the 84 patients, there were 66 males and 18 females, a ratio of 4:1. The majority of patients presented within the first week of life (51.2%). The main presenting clinical features were abdominal distension, bilious vomiting and delayed passage of meconium. The majority of patients were diagnosed in the neonatal age group (68%). The most common length of disease involvement was short segment aganglionosis (65.5%). The use of rectal irrigations as a method of bowel decompression prior to a primary surgical repair was attempted in 66 patients, of which 55 patients (83.3%) had successful bowel decompression (although only 54 patients actually had a primary repair done since one patient had to be later converted to a staged procedure intra-operatively). The most common cause of failure of rectal irrigation was due to total colonic aganglionosis, where none of the patients could be maintained on rectal irrigations. Regarding the definitive surgical repair, 54 cases (64.3%) had a primary repair and 30 patients (35.7%) had a staged repair. In the immediate and early post-operative period, a good outcome was seen in 85.71% of patients overall, the most common complication seen was wound infection in 4 patients (4.76%). The most significant morbidity was seen in one patient who had developed an anastomotic leak in the primary repair group, hi the group of patients undergoing a primary repair aged less than 4 months, a good outcome was seen in 94.9% of patients, with the most significant morbidity being a reoperation in one infant with prolonged ileus. In the follow-up period, ranging from 3 months to 4 and a half years, overall 69% of the patients did not have any significant problems or complications. The most distressing problems were enterocolitis seen in 15 patients and recurrence of Hirschsprung’s like symptoms seen in 12 patients. Only one case, an infant with total colonic aganglionosis had to undergo a redo-Duhamel procedure. In comparison, infants less than 4 months undergoing a primary repair, 79.5% of patients had a good outcome, with the two most common problems being also enterocolitis and recurrence of Hirschsprung’s like symptoms. There were no mortalities in this study. No significant differences statistically, were seen when comparing patients undergoing a definitive repair before or after the age of 4 months (p>0.05) except in case of enterocolitis, which was significantly higher in those, operated on after the age of 4 months (p=0.036). No significant differences in outcome were again seen in patients undergoing a primary repair as compared to a staged repair (p>0.05). Extent of aganglionosis had an influence on the outcome, where in the group of patients with long segment disease or total colonic aganglionosis had a significantly higher incidence of complications as compared to ultra-short or short segment disease involvement (p<0.05).

Conclusion :

Rectal irrigations can be safely used as an alternative to a stoma for bowel decompression prior to a primary surgical repair in all levels of aganglionic bowel involvement except for total colonic aganglionosis. The outcome of patients undergoing the modified Duhamel procedure as a definitive procedure for the treatment of Hirschsprung’s disease, in this study, is comparable to the results of other types of surgical repair. And, lastly an operative procedure in infants less than 4 months of age as a primary procedure is feasible and can be recommended as a standard method of treatment for Hirschsprung’s disease.

Mr. Mohan Nallusamy (Supervisor)

Dr. Zainal Mahamud (Co-Supervisor)

Dr. Ahmad Zahari (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):88–89.

(41) A Comparative Study of Corneal Thickness and Endothelial Cells Changes in Type 2 Diabetic and Non-Diabetic Patients Following Cataract Surgery

Rosli bin Mohd Kassim 1,2

Abstract

Introduction :

Corneal endothelium acts as a cellular barrier. Loss or damage of endothelial cells 1 eads to a compromise in its function. This consequently results in increased corneal hydration and corneal thickness. Our aim is to observe the effect of extracapsular cataract extraction surgery on endothelial cells morphometry and central corneal thickness changes in type 2 diabetes patients.

Objectives :

To compare the corneal endothelial cell morphometry and corneal thickness between type 2 diabetic and non-diabetic patients and subsequently to observe the changes following cataract surgery.

Methodology :

An observational prospective comparative study was conducted. 25 type 2 diabetic and 20 non-diabetic patients with cataract were recruited preoperatively. They were electively scheduled for extracapsular cataract surgery with intraocular lens implant. The measurements of central endothelial cells density, coefficient of variation of cell size and percentage of cell hexagonality were taken preoperatively and, at one month and three months after cataract surgery. Central corneal thickness measurement was taken preoperatively, at one month and three month after cataract surgery. The corneal endothelial cells image and central corneal thickness was obtained with Topcon SP-2000P specular microscope. During analysis, the source of image was blinded and retraced method of image analysis was performed with IMAGEnet cell analytic function.

Results :

There was no significant difference (p=0.970) in mean endothelial cell density in type 2 diabetic patients (2474 ± 332 cells/mm2) compared to non-diabetic patients (2478 ±337 cells/mm2). However there was significantly increased corneal thickness in diabetic patients (537 ± 36 um) compared to non-diabetic patients (513 ± 30 μm; p = 0.022). There was no significant difference in cell hexagonality and coefficient of variation between type 2 diabetic and non-diabetic patients preoperatively. After surgery endothelial cell density was reduced and a decreased in cell hexagonality in both groups. Coefficient of variation of cell size decreases following surgery in type 2 diabetics, however in non-diabetic patients, it was increased. Both groups demonstrate significant difference in corneal thickness before and after surgery. Surgically induced endothelial cell losses was not significantly different (p= 0.664) between type 2 diabetic (291 cells/mm2) and nondiabetic patients (259 cells/mm2) at three months.

Conclusion :

Endothelial cells morphometry was not damage in type 2 diabetic patients, however central corneal thickness was increased. After cataract extraction with intraocular lens implant, damage to the endothelial cells morphometry in type 2 diabetes mellitus was not significantly different from non-diabetic patients. However, the damage to the endothelial cell did not resulted into an increase in the central corneal thickness after cataract surgery. Three month after cataract surgery, endothelial cell loss in type 2 diabetic was no different from non-diabetic patients.

Dr. Wan Hazabah Wan Hitam (Supervisor)

Dr. Zunaina Embong (Co-Supervisor)

Dr. Liza Sharmini Ahmad Tajudin (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):89.

(42) A Study on Central Corneal Thickness and Morphology in Myopic Malay Undergraduates of Health Campus, Universiti Sains Malaysia.

Mohd Aziz bin Husni 1,2

Abstract

Objective :

To evaluate the central corneal thickness and morphology in myopic Malay undergraduates of Health Campus, Universiti Sains Malaysia.

Methodology :

A cross sectional observational study was done on 130 subjects (65 were myopes and another 65 were emmetropes). Patient selection was done according to the inclusion and exclusion criteria. Central corneal thickness, corneal curvature, spherical equivalent, endothelial density, morphology (coefficient of variation and hexagonality) were measured in all subjects. All measurements were performed between 3 to 5 pm. Spherical equivalent and cornea curvature was measured with Humphrey Automated Refractor/Keratometer 599 (Humphrey System, USA). Cornea thickness and endothelial morphology were measured with non-contact Topcon SP2000P specular microscope (Topcon Corp, Japan). Comparisons were made between myopes and emmetropes. The correlation between each parameter and degree of myopia (spherical equivalent) was tested. Any parameters that showed a significant correlation were further tested with linear regression analysis.

Results :

Myopes had a significantly thinner central cornea (p = 0.003), lower endothelial cell density (p =0.017) and steeper cornea curvature (p =0.017) compared to emmetrope. There was no difference in endothelial hexagonality and coefficient of variation between emmetropes and myopes. We also noted a positive correlation between degree of myopia (measured in spherical equivalent) and central corneal thickness (r =0.262 [95% CI 0.372–4.878], p =0.023). There was progressive thinning of the central cornea as the degree of myopia increased.

Conclusion :

Myopes have significant corneal changes compared to emmetropes. This includes thinner central cornea, lower endothelial density and steeper cornea curvature. Higher degree of myopia is associated with thinner central cornea. All these factors need to be considered in managing myopia.

Dr. Mohtar Ibrahim (Supervisor)

Dr. Liza Sharmimi Ahmad Tajuddin (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):89.

(43) Detection of Herpes Simplex Infection in Viral Conjunctivitis Using Polymerase Chain Reaction – A Pilot Study

Azma Azalina bt Ahmad Alwi 1,2

Abstract

Objective :

To detect the viral conjunctivitis in Hospital Universiti Sains Malaysia caused by herpes simplex virus using a polymerase chain reaction method.

Method :

A total number of 70 patients with viral conjunctivitis were seen in the ophthalmology clinic, HUSM during one year period. The presenting clinical features were identified and conjunctival scrapping using sterile conjunctival swab was taken from superior and inferior fornices of the affected eye for PCR analysis. The PCR was performed with primers obtained from a commercially available primer kit for HSV. The presence of this amplified target sequence was determined by agarose gel. A positive result reflected the prevalence of viral conjunctivitis caused by HSV. Descriptive analysis was performed using SPSS system.

Results :

The prevalence of viral conjunctivitis in HUSM caused by herpes simplex infection, using PCR method, was found to be 17.1 % (95 % CI = 8.1, 26.0). Majority of HSV conjunctivitis patients presented with moderate follicular conjunctivitis with frequent corneal involvement, commonly subepithelial punctuate keratitis. It was also observed that a larger portion of HSV conjunctivitis patients presented with unilateral involvement.

Conclusion :

This study showed the prevalence of viral conjunctivitis caused by herpes simplex infection, in HUSM was higher than other reported studies. The most important cause for high prevalence is the PCR method used which is a highly sensitive and specific diagnostic test. Some of the clinical features of HSV conjunctivitis was similar to adenoviral conjunctivitis caused by Group D subgenera. The only possible differentiating feature was the unilaterality which may help to discriminate HSV conjunctivitis from adenoviral conjunctivitis.

Dr. Elias Hussein (Supervisor)

Dr. V. Gopalakrishnan (Co-Supervisor)

Dr. M. Ravichandran (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):89–90.

(44) The Effects of Low Dose Ephedrine on the Onset Time of Rocuronium

S Ananda 1,2

Abstract

Introduction :

Anaesthetist have employed a multitude of muscle relaxants for the establishment of neuromuscular blockade, so that smooth endotracheal intubation can be performed. The ideal neuromuscular blockers are drugs that is able to establish neuromuscular blockade in the shortest duration of time with the minimum side effects. The fast and reliable succinylcholine is the gold standard against which all other muscle relaxants are compared but side effects preclude its use in all patients. This has led to a longstanding interest in decreasing the onset time of nondepolarising neuromuscular blocking drugs resulting in faster drugs and new techniques of administration such as the use of priming dose before administration of intubation dose, increments in the dose and combination of drugs. The time of loss of consciousness to tracheal intubation is a period during which patient is at risk of developing hypoxia and pulmonary aspiration. The length of this period is determined by the establishment of neuromuscular blockade and so it is desirable to use a muscle relaxant with the shortest duration of time. The onset is partly determined by the speed with which these drugs reach the neuromuscular junction, a factor that appears to be proportional to cardiac output and muscle blood flow. Ephedrine increases these variables and hence is used in this study.

Methodology :

A total of 44 American Society of Anesthesiology (ASA) 1 and 2 patients scheduled for elective low to moderate risk surgical procedures were randomly selected and grouped into 2 population samples. With each of the assigned group receiving either intravenous ephedrine 50 microgram/kg or intravenous normal saline. A standardized anaesthetic technique was used for both groups of patients. Vital signs were monitored and charted before induction which served as a baseline to the haemodynamic changes. Induction of anesthesia was performed by using sodium thiopentone 2.5% titrated to loss of eye lash reflex. The study drug of each allocated population sample was administered accordingly anesthesia was maintained with 100% oxygen and 1.5% isoflurane while pharmacological paralysis was maintained with 0.6mg/kg of rocuronium. The onset time of both groups was determined by stimulating the ulnar nerve using surface electrodes giving supramaximal square wave impulse of 0.2 sec duration administered 2Hz every l0sec by using a battery operated stimulator with train of four monitoring. The onset time of rocuronium was defined as the time from the end of injection of i.v. rocuronium to the disappearance of all 4 twitches in train of four. Data collection consist of pulse rate, systolic, diastolic, mean blood pressure and onset time of rocuronium in seconds.

Results :

Findings of this study when comparing the 2 groups show that the group in which i.v. ephedrine is used has an onset time of 20% less than the placebo group. Thus the result of this study pointed to the fact that low dose i.v. ephedrine can decrease the onset time of non-depolarising muscle relaxant i.v. rocuronium by 20% have minimal effect on the haemodynamic changes.

Assoc. Prof. Dr. Nik Abdullah bin Nik Mohamad (Supervisor)

Dr. Shamsul Kamalrujan bin Hassan (Co-Supervisor)

Dr. Saedah binti Ali (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):90.

(45) Comparison of the Use of the Laryngeal tube (VBM) and Laryngeal Mask Airway Under Anaesthesia During Spontaneous Ventilation

Noor Zairul Muhamad 1,2

Abstract

Objectives :

The purpose of this study is to assess whether the newly developed laryngeal tube (VBM) is a fast, reliable and easy device for airway management. We compared the use of the laryngeal tube (VBM) with the laryngeal mask airway in spontaneously ventilating adult patient undergoing general anesthesia and measured the easiness of insertion, incidence of airway trauma and sore throat and also the haemodynamic responses to insertion of these devices.

Methodology :

A randomized single blinded prospective study was conducted involving a total of 121 premedicated, ASA I or II patients, aged 18 to 65 years and were divided into 2 groups either laryngeal tube (VBM) or laryngeal mask airway group as for airway management during elective surgery. After a standardized induction of anaesthesia with fentanyl 1.5 μg.kg−1 and propofol 2 mg.kg−1, a size 3 or 4 laryngeal tube (VBM) or laryngeal mask airway was inserted and the patients breathed spontaneously throughout the surgery with no muscle relaxants given. Anaesthesia was maintained with nitrous oxide, oxygen and isoflurane. The airway device was removed at the end of surgery with the patients fully awake. The speed and ease of insertion and the number of attempts needed to successfully secure the airway were recorded. The incidence of airway trauma, sore throat and haemodynamic changes such as systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate at different time intervals were recorded. Episodes of airway manipulations intraoperatively and end-tidal CO2 at various time intervals were also recorded.

Results :

We found that there was no statistically significant difference in time required for successful insertion and number of attempts for both groups. We were able to achieve a clear airway in 75.4% patients in LT group at the first attempt. There were no difference in incidence of airway trauma and sore throat between laryngeal tube and laryngeal mask airway. Both groups had no statistical differences in haemodynamic parameters during spontaneous ventilation under anaesthesia. Although, the incidence of airway manipulations and end - tidal CO2 were higher with laryngeal tube (VBM) compared to the laryngeal mask airway but it is not likely to be clinically relevant in this study.

Conclusion :

We conclude that during spontaneous ventilation, the laryngeal tube (VBM) is a suitable alternative to the laryngeal mask airway.

Assoc.Prof. Dr. Nik Abdullah bin Nik Mohamad (Supervisor)

Dr. Mahamarowi Omar (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):90–91.

(46) A Comparative Study of Intravenous Patient-Controlled Analgesia Morphine and Tramadol in Patients Undergoing Major Operation

Rozilah @Abdul Hadi Mohamed 1,2

Abstract

Introduction :

The success of major surgery depends partly on providing effective post-operative pain relief, which can be achieved by morphine administration via PCA system. Tramadol is a weak opioid analgesic, which act mainly on μ-opioid receptor. The purpose of this study was to evaluate the effectiveness of intravenous patient-controlled analgesia (PCA) Tramadol in comparison with PCA Morphine in term of analgesic properties, sedation and other side effects such as nausea, vomiting and pruritus.

Methods :

A randomized, double-blinded study was conducted on 160 selected ASA I and II patients who were divided into two groups by a closed envelope technique. Following surgery, the PCA morphine (M) group (n=80) received a loading dose of 0.1 mg/kg of intravenous morphine followed by 1 mg (1 mg/ml) of PCA infusion as required. The PCA tramadol (T) group (n=80) received a loading dose of 2.5 mg/kg of intravenous tramadol followed by 10 mg (10 mg/ml) of PCA infusion as required. The lockout intervals for both groups were 10 minutes. None of the patients received baseline infusion. In the recovery room, patients were given oxygen via facemask and monitored for pain score according to Modified Pain Score, sedation score according to Ramsay Sedation Score, respiratory rate, nausea, vomiting, pruritus, blood pressure and pulse rate. Patients were evaluated at the end of 30 minutes in recovery room. After 4 hours, 24 hours and 48 hours post operation, patients were again evaluated in the ward.

Results :

This study showed no difference in the demographic data between the two groups (p>0.05). The mean pain score in tramadol group at 30 minutes, 4 hours, 24 hours and 48 hours post operation were 1.32 ± 0.79, 1.04 ± 0.79, 0.35 ± 0.48 and 0.09 ± 0.33 respectively. Whereas, the mean pain score in morphine group at 30 minutes, 4 hours, 24 hours and 48 hours post operation were 1.35 ± 0.99, 1.14 ± 0.81, 0.40 ± 0.54 and 0.10 ± 0.34 respectively. There were no significant differences in the mean pain score between the two groups at each duration of assessment (p>0.05). The mean sedation score in tramadol group at 30 minutes, 4 hours, 24 hours and 48 hours post operation were 0.90 ± 0.74, 0.56 ± 0.59, 0.08 ± 0.27 and 0.02 ± 0.16 respectively. Whereas, the mean sedation score in morphine group at 30 minutes, 4 hours, 24 hours and 48 hours post operation were 0.84 ± 0.70, 0.46 ± 0.64, 0.08 ± 0.27 and 0.01 ±0.11 respectively. There were no significant differences in the mean sedation score between the two groups at each duration of assessment (p>0.05). There were also no significant differences between the two groups in the incidence of nausea, vomiting and pruritus.

Conclusion :

This study indicates that PCA tramadol is suitable to be used as an alternative to PCA morphine in controlling pain following major surgery. The incidence of sedation, nausea and pruritus were similar in the two groups.

Dr. Shamsul Kamarujan Hassan (Supervisor)

Assoc.Prof. Dr. Nik Abdullah bin Nik Mohamad (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):91.

(47) A Study of the Morbidity Associated With Salivary Glands Hyposecretion Among Post-Irradiated Head and Neck Cancer Patients at HUSM

Khairudin Abdullah 1,2

Abstract

Introduction :

Head and neck cancer is increasingly common in developing countries including Malaysia. The main treatment modalities are mainly radiotherapy besides surgical resection, laser excision and chemotherapy. It is known from literatures that radiotherapy caused significant effects to these patients both acute and long-term complications. One of the important morbidity faced by these patients is dryness of mouth (xerostomia). Xerostomia results from salivary glands hypofunction secondary to radiation causing marked reduction in salivary output. Long-term complications of xerostomia lead to variety of morbid oral sequelae.

Objectives :

To study the oral morbidity as a result of salivary glands hyposecretion after radiotherapy among patients with head and neck cancer at HUSM.

Methodology :

A cross-sectional study was carried out in Otorhinolaryngology clinic, Department of Otorhinolaryngology, Science University of Malaysia (USM) from July 2002 to September 2003. A total of 30 patients with head and neck cancer and had received radiotherapy treatment were studied. Questionnaires were used to assess xerostomia and xerostomia-related morbidity of the study subjects. Oral cavity was examined to determine the dental status and evidence of xerostomia. The unstimulated and stimulated whole salivary flow rates were carried out and compared to 30 normal subjects. The study subjects were also investigated for radiological evidence of dental caries involving the roots and alveolar bone resorption.

Results :

Majority of the patients suffered from xerostomia of various severity as well as xerostomia-related morbidity. The most predominant oral presentations in these patients were radiation dental caries, followed by periodontal diseases, dry lips and mouth ulcers. Both salivary flow rate parameters of the patients were significantly reduced compared to the normal subjects. Unstimulated whole salivary flow rate was a good predictor of xerostomia and its related morbidity. Total dose of radiotherapy is the only radiotherapy parameters found to have significant correlation with the studied parameters i.e. xerostomia-related morbidity. Orthopantomogram (OPT) findings done on the patients showed significant evidence of radiation dental caries and alveolar bone resorption.

Conclusions :

Salivary gland hyposecretion was found to be a common problem in post-radiotherapy patients for head and neck cancer. Salivary glands hypofunction or hyposecretion results in significant reduction of the whole salivary output often caused dryness of mouth (xerostomia), its morbid oral sequelae and impairment of normal oral functions.

Prof. Dr. Rani Samsudin (Supervisor)

Dr. Nizam Abdullah (Co-Supervisor)

Dr. Baharudin Abdullah (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):91–92.

(48) Ultrasound Guidance Versus the Landmark Technique for the Placement of Internal Jugular Venous Catheter in the Hospital Universiti Sains Malaysia.

Rushdi Abdullah 1,2

Abstract

Objective :

To determine if the ultrasound-guided internal jugular venous cannulation in the Emergency Department and Intensive Care Unit is safer and faster than the traditional landmark technique.

Methods :

We carried out a prospective study involving 150 patients that required central venous access via the internal jugular vein in the Emergency Department and Intensive Care Unit, Hospital Universiti Sains Malaysia, Kubang Kerian. These patients that were then randomized into 2 groups; those presented on even days had their internal jugular vein cannulated under direct ultrasound guidance, while those presented on odd days had their vein cannulated using the traditional landmark technique. The access time, the number of attempts made until successful cannulation and the number of acute complications were then recorded. Results from each technique were recorded and then compared with independent t-test analysis. A p value of below 0.05 was taken to be significant.

Results :

There were significant improvements in the 3 parameters measured in the ultrasound guidance technique as compared to the landmark technique. The access time was shorter (p<0.05), the number of cannulation attempts were less (p<0.05) and the number of acute complications were reduced (p<0.05).

Conclusion :

The rate of complications from the blind landmark technique is still low and no serious fatalities were recorded in the study, hence its use by the experienced operator in the acute medical setting is still acceptable. In conclusion, the study has shown that both ultrasound-guided and the landmark techniques are safe procedures in the emergency settings, the former being shown to be superior to the latter, as it reduces the access time, cannulation attempts and number of complications.

Assoc. Prof. Dr. Kamarudin Jaalam (Supervisor)

Dr. Maharomwi Omar (Supervisor)

Dr. Wan Aasim Wan Adnan (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):92.

(49) Ruling out Myocardial Infarction in the Emergency Department in Patients Presenting With Chest Pain and Initial Normal or Non Diagnostic Electrocardiogram Using a 6 Hour Protocol

Faizal Salikin 1,2

Abstract

Introduction :

The rapid and correct diagnosis of patients with chest pain to rule out myocardial infarction is an extremely important aspect in emergency care. However, acute myocardial infarctions are missed in up to 6% of patients presenting to the Emergency Department and are discharged home inappropriately. This study aims to rule out myocardial infarction in the emergency department within a 6 hour period using an investigative protocol driven approach for chest pain patients with normal or non diagnostic electrocardiograms.

Methodology :

A diagnostic prospective cohort study was conducted on 182 patients presenting to the Emergency Department with chest pain but with nondiagnostic electrocardiogram changes for myocardial infarction. The protocol involved observation in the Emergency Department for 6 hours for serial measurements of Creatinine Kinase, serial electrocardiogram monitoring and evolving clinical symptoms. Elevated Creatinine Kinase levels prompted further testing with Troponin T to detect myocardial infarction. The patient was then admitted to the medical ward for further management. Performance of the diagnostic 6 hour myocardial infarction rule out protocol in the Emergency Department using serial electrocardiogram, serum Creatinine Kinase measurements and/or Troponin T level is compared with the gold standard consisting of the final hospital discharge diagnosis according to World Health Organization criteria of diagnosing myocardial infarction.

Results :

Outcome of the gold standard test was available for 162 patients. The diagnostic test for the protocol obtained 22 positive results and 140 negative results. There were 7 false positive results and one false negative result.

Sensitivity was 93.8%, specificity was 95.2%, the negative predictive value was 99.3% and the positive predictive value was 68.2%.

Conclusions :

The six hour diagnostic protocol to rule out myocardial infarction is both clinically accurate and efficacious in patients presenting to the Emergency Department with low to moderate risk of myocardial infarction.

Dr. Mahamarowi Omar (Supervisor)

Datuk Dr. Haji Abu Hassan Asaari Abdullah (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):92.

(50) A Comparative Prospective Study Between Two Oxytocin Regimens in Augmentation of Labour

Roszaman Ramli 1,2

Abstract

Objective :

To compare the cost-effectiveness between the new and the old oxytocin regimes in the augmentation of labour and to evaluate the influence on the maternal and fetal outcome.

Methodology :

213 pregnant women in labour at term with obstetric indication for labour augmentation. The women were randomly assigned to receive new oxytocin regime of 5U in 500 cc of Dextrosaline at titration of 5 dpm with increments of 5 dpm to a maximum of 60 dpm, or an old oxytocin regime of 1/2/4 U with titration of 20/40/60 dpm for primipara and half the dosage for multipara.

Result :

There was no significant influence on the maternal and neonatal morbidity and mortality (p = 0.07). There was no significant difference in the duration of labour (p = 0 45) and augmentation (p = 0.9) between the two regimes studied. There seemed to be higher incidence of caesarean section in the old oxytocin group (p = 0.001). Moderate achievement in the reduction of cost per annum was noted (RM 962.34). The new oxytocin regime was found to be more easy and convenient to prepare by the labour room staff and avoid unnecessary and frequent change in oxytocin solution.

Conclusion :

The results showed that the new oxytocin regime was more cost effective and more convenient for the labour room staff to prepare without apparent increase in the maternal and fetal morbidity and mortality.

Dr. Ghazali Ismail (Supervisor)

Assoc. Prof. Dr. Mohd Shukri Othman (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):92–93.

(51) A Cross Sectional Study of Nasal Polyposis Among Asthmatic Population Attending Asthma Clinic, Hospital Universiti Sains Malaysia and Hospital Kota Bharu, Kelantan

Rosdi Ramli 1,2

Abstract

Introduction :

Nasal polyps have been a medically recognized condition since the time of the ancient Egyptians. It is the most common chronic disease affecting the mucous membranes of the nasal cavity and the paranasal sinuses. The relationship of sinonasal diseases with bronchial asthma have been known to be associated since the 19th century. Causal relationships, tike similarity of the inflammatory cellular infiltrates have been proposed but not proven. This study aims to get the prevalence of nasal polyposis among the asthmatic population and to look for the association of nasal polyp formation in relation to a few parameters in asthmatic population.

Objectives :

To study the prevalence of nasal polyposis among the asthmatic population at Hospital Universiti Sains Malaysia (HUSM) and Hospital Kota Bharu (HKB), Kelantan and the association of nasal polyps with age, gender, duration and severity of bronchial asthma in established asthmatic patients.

Methodology :

A cross-sectional study was carried out in the Chest Clinic HUSM and HKB from October 2002 till August 2003. One hundred and thirty (130) asthmatic patients without other lungs pathology were included in the study. After filling all the patient’s particulars, selected patients were examined by using a 0 degree Karl Storz nasoendoscope and findings were recorded. In case where difficulties found during nasoendoscopy procedure like narrow nostrils or intolerability to pain, then the nose was packed with cocaine or lignocaine with adrenaline or lignocaine alone prior to procedure.

Results :

From a total of one hundred and thirty (130) asthmatic patients, the prevalence of nasal polyps noted to be 28.5% which was nearer to the reference data, 32.0%. The occurrence of nasal polyp was not associated with sex, races and severity of bronchial asthma. Nasal polyps formation noted to be significantly related to the age of the patients. Asthmatic patients above 40 years of age were prone to develop nasal polyps twice more than compared to the patients below 40 years of age (p=0,053).

Conclusions :

Since the prevalence of nasal polyps among asthmatic patients were high (28.5%) with having a strong association with increasing age of the patients, it is recommended that all the asthmatic cases should be examined by Otorhinolaryngologist for regular endoscopic examinations at least once in a year. To get a clear picture on the association of these two parameters, a further study using a large sample size should be conducted in future.

Dr. Shamim Ahmed Khan (Supervisor)

Assoc. Prof. Dr. Kamarudin Jaalam (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):93.

(52) In-Vitro Evaluation of the Growth Enhancing or Cytotoxic Effect of Sticophus Species (GAMAT) on Established Human Fibroblasts Cell Line Cultures

Philip Rajan 1,2

Abstract

Objectives :

The objective of this study was to evaluate the effect of Gamat, the local term for sea-cucumber extract, of the species Sticophus sp1, on an established human fibroblast cell line culture whether it is cytotoxic or growth promoting.

Methodology :

Preliminary Tests : The Gamat extract was diluted with the growth media (DMEM+ FBS). The test substances (one ml) were added to fibroblast culture wells (one ml) to obtain Gamat concentrations of 5 mg/ml, 10 mg/ml, 20 mg/ml and 100 mg/ml. A neutral red assay was performed at Day-2, Day-4 and Day-6 from the day the test substances were introduced. The cell density was measured with a spectrophotometer at 540 nm. Tests were done in triplicates and repeated. Osmolarity Testing and Chemical Analysis :Based on the results of the preliminary tests, osmolarity testing and chemical analysis of the Gamat extract was undertaken. Final Cell Culture Tests : In the final tests the effective concentrations tested were 5 mg/ml each for Gamat and NaCI. Comparisons were made against growth media (DMEM) and supplemented growth media (DMEM+FBS). All the test solutions were approximately iso-osmolar. The tests were carried out in a similar fashion to the preliminary tests. Antimicrobial Testing : The Gamat extract and NaCI were tested for antimicrobial activity against Staphylococcus aureus. Escherichia coli and Pseudomonas aeruginosa was undertaken. Concentrations of 10 mg/ml, 50 mg/ml, 100 mg/ml and 200 mg/ml were used.

Results :

Preliminary Tests : From concentrations of 10 mg/ml and above the Gamat extract diluted in growth media was cytotoxic to fibroblasts. At 5 mg/ml the results were equivocal. Osmolarity Testing and Chemical Analysis : Osmolarity testing revealed that dilution of the Gamat extract with the growth media resulted in a hyperosmolar solution. The chemical analysis showed a high composition of sodium chloride in the Gamat extract. Final Cell Culture Tests : Gamat concentrations of 5 mg/ml were neither cytotxic nor growth enhancing No difference in cell growth was noted between Gamat and NaCI. Significant growth proliferation was noted in FBS supplemented cell wells. Antimicrobial Testing : At all concentrations tested Gamat exhibited antimicrobial activity against S.aureus, E.coli and P.aeruginosa. NaCI showed no antimicrobial activity against S.aureus and E.coli at all concentrations tested. However from concentrations of 50 mg/ml onwards NaCI demonstrated anti-pseudomonal activity.

Conclusion :

Gamat concentrations of 5 mg/ml was neither cytotoxic nor growth enhancing.

The Gamat extract contains substances with antimicrobial activity against S.aureus, E.coli and P.aeruginosa.

Assoc. Prof. Dr. Din Suhaimi Sidek (Supervisor)

Dr. Rosdan Salim (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):93–94.

(53) A Study on Common Sexually Transmitted Disease Infection in Infertile Female Attended to Infertility Clinic HUSM, Kota Bharu, Kelantan.

Nik Ahmad Zuky bin Nik Lah 1,2

Abstract

Introduction :

Sexually transmitted disease (STDs), once called venereal disease, are among the most common infectious diseases in the world. In Western countries, there has been a dramatic increase in the reported incidence of sexually transmitted diseases (STD) during the past 25 years. It is tragic irony that despite medical efforts against sexually transmitted diseases and the existence, since the 1940s, of powerful treatments for them, these diseases persist; even thrive in the twenty first century. This trend was augmented by earlier sexual maturity in girls and earlier age of onset of sexual activity in both sexes. Other sociological changes which contribute to the increased incidence of STD include urbanization, increased mobility among the young, and the greater ease of world-wide travel. Sexual tourism is increasingly common. This last factor has also promoted the importation of unusual tropical STDs and antibiotic-resistant infections. Traditionally, five diseases have been classified as sexually transmitted diseases which are syphilis, gonorrhoea, lyphogranuloma venereum, chancroid, and granuloma inguinale. Lyphogranuloma venereum is one of disease caused by Chlamydia thrachomatis. To date more than 20 distinct sexually transmitted or transmissible pathogens were identified which may have different clinical manifestations. However in this study we are only concentrate on three common sexually transmitted diseases which are chlamydial infection, gonorrhoea and syphilis. Chlamydial infection and gonorrhoea are well known to cause pelvic inflammatory disease (PID) and their sequelae; infertility, chronic pelvic pain and ectopic pregnancy, whereas syphilis affect the outcome of the baby before and after the pregnancy. Another important issue is that, the genital chlamydial infection is increasing in trend worldwide.

Objectives :

To determine the local prevalence of common organism in Sexually Transmitted Diseases (STDs) infections (Chlamydia trachomatis, gonorrhoea and syphilis) in infertile females attended to Infertility Clinic Hospital Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan. And to determine the clearance rate of Chlamydia trachomatis and gonorrhoea infection after a course of azithromycin 1 gram single dosage.

Methodology :

This is a prospective study involving 150 infertile females under follow up at infertility clinic Department of Obstetrics and Gynaecology, Hospital Universiti Sains Malaysia between 1st of March 2002 till 28th of February 2003. Endocervical samples were obtained to detect Chlamydia trachomatis by direct immunofluorescence, Neisseria gonorrhoea by Gram smear and culture & sensitivity. Blood samples were also obtained for Venereal Disease Research Laboratory (VDRL) testing and for Ig M antibody toward chlamydia. For VDRL testing positive patient another blood sample for Treponema pallidum haemagglutination assay (TPHA) will be taken. In a patient with a positive Chlamydia trachomatis or gonorrhoea or both infections, she and her partner will be treated with a single dose of azithromycin 1 gram orally. After 2 weeks of azithromycin, the respective investigation(s) will be repeated to determine the clearance of such infection(s). In a natient who was positive for syphilis she will be treated with intramuscular Benzanthine Penicillin 2.4 Megaunit 3 doses. A repeated TPHA testing will be carried out after a month of completed treatment.

Results :

Chlamydia trachomatis infection was present in 6 (4.0%) patients. There was no incidence of gonorrhoea or syphilis infection in the studied population. All repeated investigations after azithromycin for Chlamydia trachomatis infection showed a negative testing. The clearance rate of gonorrhoea or syphilis is unable to determine as there is no incidence of such infections in the studied group.

Conclusion :

The prevalence of sexually transmitted diseases (Chlamydia trachomatis, gonorrhoea and syphilis) infection in infertile female is low in our studied group. The clearance rate of Chlamydia trachomatis infection by azithromycin is good. There is statistically significant correlation between the incidences of tubal factor causing infertility with Chlamydia trachomatis infection among them. The prevalence is not a true representation of Malaysian populations as it is a hospital-based study. A larger scale study involving a few centers is needed in order to obtain a better representation of Malaysian populations.

Dr. Nik Hazlina Nik Husain (Supervisor)

Assoc. Prof. Dr. Mohd. Radzi Johari (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):94.

(54) Does the Ultrasonographic Findings and Surgeon’s Interpretation During Evacuation for the First Trimester Pregnancy Failure Predict the Histological Findings? – A Prospective Cross Sectional Study at HUSM

Enie Akhtar bt Nawawi 1,2

Abstract

Introduction :

The practice of sending all tissues obtained during surgical evacuation varies from one hospital to the other and there is no local data available regarding the issue.

Objectives :

To assess the validity/ accuracy of the ultrasound findings and surgeon’s observation during surgical evacuation for the first trimester silent or incomplete miscarriage or uncertain of both in predicting the histological findings of presence of POC as confirmation of the diagnosis.

Methodology :

A prospective cross sectional study was conducted from November 2002 to June 2003, there were 200 patients diagnosed as either silent or incomplete miscarriage or suspicious of both at or less than thirteen week gestation. These were subjected to surgical evacuation (D&C). All tissues obtained were sent for HPE and results were analyzed. They were given follow-up appointment in three months time or earlier upon discharge and note if any complication arises.

Results :

One hundred sixty three patients had histological evidence of product of conception in the tissue obtained from evacuation of the uterus. Thirty five had evidence of deciduas and two patients had features of partial hydatidiform mole. The sensitivity and specificity of ultrasound was 98 % and 2.7 %, and for surgeons’ interpretation was 99.4 % and 2.7 % respectively. The Positive Predictive Value and Negative Predictive Value for ultrasound was 81.6 % and 25 %, and for surgeons’ interpretation was 82.3 % and 50 % respectively. On follow-up, no cases of ectopic pregnancy in those with decidua on histology, and were uneventful in the other.

Conclusions :

Due to the limited number of true negative cases that caused low specificity for both ultrasound and surgeons’ findings, it is recommended that case-control study is conducted in future. All tissues obtained from first trimester silent/incomplete miscarriage or uncertain of both must be sent for histopathological diagnosis because though there only 2 cases of PHM, they were not predicted either by ultrasound or by the surgeons.

Assoc. Prof. Dr. Md. Shukri Othman (Supervisor)

Dr. Wan Abu Bakar Wan Yusuf (Co-Supervisor)

Assoc. Prof. Dr. Manoharan Madhavan (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):94.

(55) An Evaluative Study of Distraction Test and Teoae in Detection of Hearing Impairment in Early Childhood.

Azah Yusof 1,2

Abstract

Objective :

The objectives for the study were to determine the validity of distraction test and transient evoked ototacoustic emission (TEOAE) in detection of hearing impairment in early childhood.

Methodology :

This was a cross sectional study done in the children in the age group of 6 months to 24 months referred for hearing assessment to the audiology clinic in Hospital Universiti Sains Malaysia between Nov 2001 to August 2002 and February 2003 to June 2003. All these children underwent all the 3 tests in a defined order-distraction test, TEOAE and then auditory brainstem response (ABR). ABR was considered as gold standard against which the validity of distraction test and TEOAE were determined.

Results :

A total of 127 ears (65 patients) were included in this study based on the inclusion criteria. It was found that 35 (27.6%) ears had hearing impairment of more than or equal to 30 dBnHL. Out of these 35 ears, 34 (97%) belonged to the high risk group. The sensitivity and specificity for distraction test were 88.6% and 93.5% respectively. The predictive values for positive and negative tests for distraction test were 83.8% and 95.6% respectively. The sensitivity and specificity of TEOAE were 91.4% and 88% respectively. The positive and negative predictive values for TEOAE were 74.4% and 96.4% respectively. The overall accuracy was 92.1% and 88.9% for distraction test and TEOAE respectively.

Conclusion :

Both distraction test and TEOAE were found to have good performance. There was a slight drop in the sensitivity of distraction as it missed out few ears with mild hearing loss of less than 40dB. The specificity and negative predictive value (NPV) of TEOAE was reduced because of high incidence of middle ear effusion in the study age group which gave rise to false positive results. One patient with auditory neuropathy who passed the TEOAE was picked up by distraction test and ABR. It appears that a combination of hearing tests is important for complete hearing assessment and no single test in isolation is efficient.

Dr. Ishak Abdul Samad (Supervisor)

Dr. Hakim Ghaib Bilal (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):94–95.

(56) Early Oral Feeding After Caesarean Section

Asha Gupta 1,2

Abstract

Objective :

To determine whether patients can tolerate immediate postoperative oral feeding after uncomplicated caesarean section without substantial adverse effects on the gastrointestinal function.

Methods :

A prospective study was conducted whereby patients who had undergone caesarean section were randomized to one of two groups, the “early feeding” group or the “traditional feeding” group. Patient’s information and outcome data were collected by the medical officer in-charge using a standard questionnaire. Outcomes assessed include presence of postoperative nausea, vomiting and ileus, postoperative fever and day of patient’s dischargec 2 test and Fisher exact test were used to compare the two groups.

Results :

A total of 152 patients were recruited in the study; 71 in the “early feeding” group and 81 in the “traditional feeding” group. There was no significant difference between the two groups in term of demographic profile and caesarean section profile. Fourteen of the 71 patients in the “early feeding” group did not ate within the specified first 6 hours. There was no significance difference in the presence of postoperative nausea, vomiting and ileus between the two groups.

Conclusion :

Early feeding after uncomplicated caesarean section was not associated with an increase in gastrointestinal symptoms and was tolerated by most patients.

Assoc. Prof. Dr. Din Suhaimi Sidek (Supervisor)

Dr. Mohd. Khairi bin Md Daud (Co-Supervisor)

Malays J Med Sci. 2005 Jan;12(1):95.

(57) A Comparison Between the Use of Succinylcholine and Rocuronium for Rapid Sequence Intubation in the Emergency Department, Kuala Lumpur Hospital.

Mohd Lotfi Bin Hamzah 1,2

Abstract

Introduction :

Patients who require tracheal intubation in the emergency department (ED) often require a rapid sequence intubation (RSI) technique to facilitate intubation and to protect against aspiration of gastric contents. Traditionally, succinylcholine has been the neuromuscular blocking drug of choice in rapid sequence intubations because of its rapid onset of action. However, it can be associated with many side-effects such as an increase in intra-cranial pressure, an increase intrao-cular pressure, muscle pains, bradycardia, and increased plasma concentration of serum potassium. Amongst the currently available nondepolarising neuromuscular blocking drugs, rocuronium has the most rapid onset of action and is comparable with those of succinylcholine i.e.; within 60–90 seconds. Studies had been done to compare the use of succinylcholine and rocuronium but, most of the studies were done in anaesthesia settings. In emergency settings, very few studies had been done but mainly as observational studies. In Malaysia, so far no study has been done on the comparison in the use between the two drugs in the emergency department.

Objective :

To determine whether the intubation conditions created by rocuronium are as good as to those of succinylcholine during rapid sequence induction during each intubation.

Methodology :

272 patients were involved in this study, undertaken in Kuala Lumpur Hospital (HKL), a main Malaysian referral centre for government hospitals, performed using data collection form completed at the time of intubation. The study design was ‘Prospective Randomized Open-End Study (PROVE) with the study period from 1st February 2003 to 30th July 2003. Patients who required intubations were randomly allocated into 2 groups using systematic randomization. The 1st group, Group I, n=136 were given succinylcholine 1.0 mg/kg and the other group, Group II, n=136 were given rocuronium 1.0 mg/kg. Both groups of patients were induced with fentanyl 1–2 mcg/kg and thiopentone 2–4mg/kg. Laryngoscopy and tracheal intubations were carried out by an assessor after the neuromuscular agent was administered. The intubations conditions were graded on a three point scale as excellent, good and poor. Data were compiled and analyzed using ‘Statistical Package for the Social Sciences’ (SPSS)®, version 11.5.

Result :

Intubation conditions in RSI using succinylcholine were 78% excellent, 20% good and 2% poor. Intubation conditions in RSI using rocuronium were 65% excellent, 32 % was good and 3% poor. There was no significant difference with regard to the intubating conditions between the two groups (p=0.071). There was also no significant difference in their complications (p>0.05).

Conclusion :

Rocuronium was found to be comparable to succinylcholine in terms of grading of intubation condition and could used as an alternative in patients undergoing RSI in the Emergency Department.

Assoc. Prof. Dr. Nik Abdullah Nik Mohamed (Supervisor)

Dr. Wan Aasim Wan Adnan (Co-Supervisor)

Articles from The Malaysian Journal of Medical Sciences : MJMS are provided here courtesy of School of Medical Sciences, Universiti Sains Malaysia

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