Plenary Lectures and Symposia

Malays J Med Sci. 2004 Jul;11(2):70.

Photodynamic Therapy in the Management of Cancer

Abstract

Optical technologies using laser spectroscopy and imaging offer the ability to non-invasively diagnose and monitor early cancers in-vivo. For many precancers and early cancers the current standard of care relies on histopathological assessment of directed biopsies in order to obtain a final diagnosis. With optical technologies, optical biopsy based diagnosis can be achieved in real time, using automated techniques, insitu. Fluorescence imaging and spectroscopy is an emerging optical technology that offers particular promise for the diagnosis of disease, in part because of a large number of endogenous biological fluorophores. Some of the more common tissue fluorophores include the aromatic amino acids (trytophan, tyrosine and phenylalanine), the cofactor reduced nicotinamide adenine dinucleotide (NADH), flavins, porphyrins, collagen and elastin. Autofluorescence and drug induced fluorescence imaging and spectroscopy offer a means of assessing both the structural and the biochemical progression of the disease, hence, interest in its use to detect precancers has been increasing. Clinical studies at the NCC have achieved promising results in the bladder, oral cavity and cervix using exogenous porphyrin and perylene quinonoid based fluorescent markers.

It is conceivable in the near future that highly sensitive endoscopic and non-endoscopic tumour detection methods can be successfully complemented by online staging and grading, thus finally fully justifying the term ‘optical biopsy’.

In vivo confocal endomicroscopy is a non-invasive method in digital imaging of hollow organs that enables visible detection of abnormal cells on the surface and sub-surface of any hollow organ. The development of a such a method for both macroscopic and microscopic assessment was posible with a recent invention of the Optiscan fibre confocal endomicroscope by the FDA in 2002. Real time image acquisition and digistisation of optical biopsies allows for further image processing to enable derivation of menaingful real time information of the inspected site

This technique would be immensely useful in the determination of tumour margins and tumour staging during surgery. Fibre-optic fluorescence endoscopic confocal imaging technology could potentially be applied to a number of oragns systems to detect eraly disease or predisposing conditond causing premaliganat changes

Photodynamic Therapy (PDT) has been defined as the combined effect of light and a photosensitising drug to produce biological damage of therapeutic value, under conditions where either the light or the drug alone have little effect. Most PDT drugs are closely related to naturally occurring compounds and therefore have very low toxicity Whilst the concept itself is not new, developments in laser and fibreoptic technology have permitted the drug and light to be brought together within tissue in such a way as to be clinically useful. This has also been facilitated by the fact that several other ‘second generation’ compounds now in clinical trials, concentrate in certain hyperproliferative tissues relative to the surrounding healthy tissue, thus giving a favourable therapeutic ratio.

Benefits of PDT include the relative lack of trauma and pain for patients. Even where normal tissue damage does occur around the target tissue, a remarkably effective natural healing process when compared with apparently equivalent injury produced by other modalities. PDT also offers the possibility of repeat treatment, without apparent limitation. Compared to conventional chemotherapy, surgery or radiotherapy, the side-effects of PDT are minimal and largely consist of a period of skin photosensitivity, as the excess drug is excreted from the body over a period of hours to days. However, even this drawback will become unimportant as the next generation photosensitisers gain regulatory approval for widespread clinical use, since several of these exhibit much shorter optimal tissue accumulation times and excretion times. Indeed, more rapid treatment offers the possibility of PDT becoming an outpatient modality, at least for some indications.

In the past decade several thousand cancer patients have received PDT worldwide although the majority have not been part of a prospective clinical trials. It has been extremely difficult to compare results because different photosensitizers, light sources and treatment parameters have been used. Furthermore, comparison of these reports with standard cancer modalities is limited by the paucity of either long-term follow –up data or histological confirmation of complete response. The coming year will undoubtedly see a substantial expansion in the range of indications for this novel for of therapy for both oncological and non-oncological conditions.

Malays J Med Sci. 2004 Jul;11(2):70–71.

Imaging of Emerging Respiratory Infections

GC Ooi ¹

Abstract

The recent outbreaks of severe acute respiratory syndrome (SARS) and avian H5N1 influenza virus in East Asia has brought home the futility of frontiers and borders. East Asia has found to its cost that infectious diseases, particularly those affecting the respiratory system, do not respect boundaries. Droplet or airborne infections rapidly disseminate amongst a fluid population, assisted by rapid and seamless modern day transportation systems. As infective respiratory diseases normally culminate in an abnormal chest radiograph, imaging therefore provides one of the earliest documentation of a lower respiratory tract infection. The recent SARS outbreak has emphasized the importance of early diagnosis allowing prompt isolation of infected persons, hereby precluding spread of infection to others. Failure to effectively isolate possibly infectious person(s) resulted in the massive SARS outbreaks that occurred in Hong Kong and Beijing. Without a rapid diagnostic test, imaging is often relied upon for diagnostic purposes. This lecture will discuss the clinical utility of imaging infectious respiratory disease outbreaks such as SARS and avian H5N1 influenza, imaging modalities used, and the provision of imaging services with strict adherence to infection control and isolation measures for the containment of infection and minimization of cross infection to personnel and other patients. Main imaging modalities that can be offered as diagnostic services should include dedicated portable radiography units, digitized radiography, and computed tomography (CT) scanning service including mobile CT units.

Malays J Med Sci. 2004 Jul;11(2):71.

Acute Coronary Syndrome: Is the Light Getting Brighter at the End of the Tunnel?

Rosli Md Ali ¹

Abstract

Acute coronary syndrome (ACS) is defined as one of two conditions: unstable angina (US) or non-ST elevation myocardial infarction (NSTEMI). The latter indicates some amount of myocardial necrosis as evidenced by a raised in serum cardiac biomarkers unlike US which dose not show a rise. The pathology behind ACS is similar to ST elevation myocardial infarction (STEMI) which occurs as a result of plaque rupture and fissure. In response to both these conditions, platelet aggregation and fibrin formation occurs. In STEMI there is a predominant of fibrin over the initial lesion and occludes the vessel lumen totally. In ACS the predominant thrombus is a white thrombus which is rich in platelet and only partially occludes the lumen.

The aim of treatment in STEMI is therefore to revascularize or open the vessel promptly to reduce the amount of myocardium that will become necrose either by thrombolytic therapy or primary angioplasty. In ACS the aim is to reduce the risk of developing into STEMI. Thus therapy is directed at preventing the sub-occlusive lesion from turning to a total occlusion.

There is a higher rate of mortality following an ACS which is almost similar as in STEMI especially within the first 2 weeks to 1 month following its occurrence. We need to quickly diagnose and aggressively treat these patients to improve their prognosis.

One of the important issues is to stratify patients with ACS into high, intermediate or low risk groups. High risk patients require more aggressive form of treatment. These can be easily differentiated from the pattern of angina in the history, ST depression in the ECG of more than 0.5 mm and the presence of a raised serum cardiac biomarkers e.g. CKMB, Troponin I or T or myoglobin.

Well proven therapies in ACS treatment are with the use of aspirin, an anti-platelet agent and heparin, an anticoagulant. Clopidogrel and Gp IIb/IIIa receptor inhibitor have been shown to be superior to routine medical therapy. Both are also beneficial when used in patients undergoing urgent percutaneous revascularization though they pose a slight but significantly higher risk of bleeding if patients are sent for bypass grafting surgery early. They need to be stopped over an appropriate duration of time before the surgery.

Low molecular weight heparin (LMWH) is superior to unfractionated heparin with a lower risk of heparin-induced thrombocytopenia and a lower incidence of myocardial infarction and death. Newer agents like fondaparinux are currently being evaluated in ACS. Fondaparinux is a synthetic pentasacharide which is a non-porcine base derivative and will be better accepted in Malaysia if proven to be as beneficial as LMWH.

There has also been a “flip-flop” in managing ACS to either conservative medical therapy or aggressively trying to revascularize these patients especially with percutaneous coronary intervention (PCI). Over the last 2-3 years the swing has been back to urgent revascularization especially with concomitant medical therapy which is able to optimize the passivation of the artery by blocking the expansion of the thrombus. The agents were listed above. The outcome following PCI is better than the existing conservative medical therapy. Benefit were seen in patients who were brought in early to the catheterization lab.

Other important aspects are as important in the treatment of ACS. Other pharmaceutical therapy are like beta-blockers and ACE-inhibitors to prevent further risk of coronary events. Statins have also been noted to stabilize the arteries and reduce subsequent risk benefits which is seen as early as 1 month following the incidence of ACS. It would appear now that lower is better with a study showing that an LDL-C of 1.6 is better than 2.5 mmol/L (what is now within the current recommended limits of <2.6 mmol/L). Other traditional risk factors for coronary heart disease need to be evaluated and intervened e.g. diabetes mellitus, a smoking history, hypertension, etc.

It is hoped that with all these measures made available today, the prognosis of an individual presenting with an ACS will be better improved.

Malays J Med Sci. 2004 Jul;11(2):72.

Traffic Lights – Directing the Flow Medical Traffic

Deborah C Saltman ¹

Abstract

This paper describes the application of the traffic light system of clinical-decision making and prioritisation in medical practice. Two examples will be explored – one clinical and one administrative. The first case study will focus on managing patients with multiple co-morbidities. The second case study will concentrate on appointment scheduling.

The co-morbidity case study describes the situation when more than one medical problem or symptom is present in a patient at the one time. An example would be a patient attending a consultation suffering from hypertension, diabetes, obesity and osteoarthritis. In such a consultation a doctor has to rely on the doctor’s internal traffic lights to decide what is serious and urgent (red), serious but not urgent (yellow) and stable (green).

This information can be incorporated into current medical software packages to prompt clinicians to check on the status of all co-morbidities and co-medication. In the example of our patient with the four co-morbidities mentioned, when a satisfactory blood pressure reading is recorded (green light) in the notes, a pop-up screen could remind the doctor to monitor aspects of obesity and if subsequently a non-steroidal anti-inflammatory agent is prescribed at the same time, a pop-up screen will advise about potential drug interactions (yellow light) as well as requesting traffic light settings for diet and exercise (red light).

Traffic lights are instructions delivered on roads. In health care, they can be used to assist in the effective management of services.

Malays J Med Sci. 2004 Jul;11(2):72.

Light and Your Skin – Friend and Foe

Suraiya H Hussein ¹

Abstract

Light of various wavelengths, occurring naturally from the sun or from artificial light sources, have a great impact on an individual’s skin. They are both beneficial and at the same time can be deleterious. On the beneficial side ultraviolet rays UVA and UVB have long been used for the treatment of such varied conditions as psoriasis, vitiligo, cutaneous T-cell lymphoma, atopic eczema, scleroderma and many others. Wavelengths in the range of visible to infra red light are used as lasers in the treatment of pigmentary, vascular and proliferative disorders on the skin, not to mention their role in hair removal and resurfacing of wrinkled and damaged skin.

On the downside, light is also a well known culprit in disorders such as cutaneous malignancies, particularly malignant melanomas, BCC and SCC. It is responsible for photoaging and all the unwanted cosmetic sequalae, which both men and women these days desperately try to undo. Furthermore, many unfortunate individuals with photosensitive disorders such as SLE, Dermatomyositis, xeroderma pigmentosa have to avoid sunlight to be able to lead a normal life.

The message is to use light sensibly so that we can reap its benefits and avoid its deleterious effects.

Malays J Med Sci. 2004 Jul;11(2):72.

Controversies in Phototherapy for Neonatal Jaundice

Hans Van Rostenberghe ¹

Abstract

Since many decades neonatal jaundice has been treated successfully with phototherapy. It was started when a nurse noticed that the jaundice of the babies who were near the window had a more rapid resolution of their jaundice than the ones more inside. Since then the mechanism of action has been elucidated as photo-isomerisation of the lipid soluble unconjugated bilirubin in the skin to water soluble photo-isomers. These isomers are excreted via another pathway in the liver than the slow glucuronisation process that is the main pathway for excretion of bilirubin.

Phototherapy has been used worldwide. It has been considered as a harmless way to treat neonatal jaundice which has lead to some overuse. It has however its own side effects (e.g. retinal damage, increased bowel motility, fluid losses,) and it should at all times be considered as any other therapy with its proper indications and dosage.

A significant controversy exists around the feasibility of home phototherapy. Benefits include the ease of administration and the continued care for the child in the close to ideal home environment. Disadvantages include the lack of close medical supervision during phototherapy. Neonatal jaundice requiring phototherapy may be a sign of an underlying disease process that is evolving and that easily can be missed in the home setting. That is why many physicians feel that proper monitoring and management of the jaundiced neonate requiring phototherapy is still best done in the hospital. Furthermore in the hospital the problems of compliance (keeping the baby really under the light) may be less.

Recent studies have focused on the quality and intensity of the light given. Green, blue and white light seem to be equally effective. Light of higher intensity (double phototherapy) is more effective than a light of lower intensity (single phototherapy). Another relatively new development is the fiber-optic phototherapy. This form of therapy provides advantages in terms of ease of nursing care but is less effective than conventional phototherapy. However a combination of fiber-optic and conventional phototherapy is more effective than conventional phototherapy alone.

In conclusion, phototherapy is an effective way of treating neonatal jaundice. Newer ways of giving phototherapy seem often appealing. However, after carefully weighing advantages versus disadvantages, conventional hospital based phototherapy has still its own value.

Malays J Med Sci. 2004 Jul;11(2):73.

Cytogenetics – The Basis of Understanding Cancer

Zubaidah Zakaria ¹

Abstract

Cancer cytogenetics is one of the fastest growing areas in human genetics. The success in cancer cytogenetics came 35 years ago when Nowell and Hungerford (1960) detected a small karyotypic marker, the Philadelphia (Ph’) chromosome, in patients with chronic myeloid leukaemia. This acquired chromosomal abnormality, which is a perfect example of somatic mutation in a haemopoeitic stem cell disorder, was the direct cause of the neoplastic state.

A single blinded randomized controlled study of 140 patients, who were given general anaesthesia for elective surgery. 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 and endotracheal intubation was performed after the anaesthetic induction and muscular paralysis. Noninvasive 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. Postoperatively, patients were assessed for hoarseness of voice, sore throat and dysphagia.

Result

There was no significant difference in the haemodynamic parameters between the two techniques. The number of intubation attempts was similar but the intubation time was longer in LWI group (25.7 ± 14.8 vs. 20.0 ± 8.4). The incidence of hoarseness of voice was lower in LWI group (0.1 % vs. 7.6 %), p < 0.05. There was no difference in other pharyngolaryngeal morbidity between the two groups.

Conclusion

Trachlight intubation produced similar haemodynamic changes and less laryngeal trauma as compared to the direct laryngoscopic technique.

Malays J Med Sci. 2004 Jul;11(2):76.

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

M R A Hadi ¹, H Shamsul Kamaruljan ¹, K Junaidi ¹, A Saedah ¹, A J Nizar ¹, G Ghazaime ¹, N M Nik Abdullah ¹

Abstract

Introduction

Morphine has been commonly accepted as opioid analgesia of choice in patient controlled analgesia (PCA) technique. Tramadol is a newer analgesic with lower side effects but its role in PCA has never been established.

Objectives

To evaluate the effectiveness of intravenous PCA tramadol in comparison with PCA morphine in term of analgesic properties, sedation and the incidence of side effects.

Methodology

A randomized, double-blinded study on 160 ASA I and II patients who were divided into two groups. Following surgery, the PCA morphine group (n=80) received a loading dose of 0.1 mg.kg⁻¹ of intravenous morphine followed by 1 mg (1 mg.ml⁻¹) of PCA infusion as required. The PCA tramadol group (n=80) received a loading dose of 2.5 mg.kg⁻¹ of intravenous tramadol followed by 10 mg (10 mg.ml⁻¹) of PCA infusion as required. The lockout intervals were 10 minutes and none of the patients received baseline infusion. Patients were monitored for pain score (Modified pain score), sedation levels (Ramsay sedation score), respiratory rate, nausea, vomiting, pruritus, blood pressure and pulse rate at 30 minutes, 4 hours, 24 hours and 48 hours post operation.

Results

There were no significant different in the mean pain score and mean sedation level between the two groups at 30 minutes, 4 hours, 24 hours and 48 hours post operation (p > 0.05). There were also no difference between the two groups in the incidence of nausea, vomiting and pruritus.

Conclusion

PCA tramadol is comparable and may be used as an alternative to PCA morphine for postoperative pain management.

Malays J Med Sci. 2004 Jul;11(2):76–77.

Comparison of Epidural Ropivacaine 0.2 % with Fentanyl 2 μg.ml⁻¹ Versus Intramuscular Pethidine on the Progress of Labour

M S Abu Bakar ¹, A J Nizar ¹, B Baharuddin ¹, H Roslina ¹, J Kamarudin ¹, H Shamsulkamalrujan ¹, N M Nik Abdullah ¹

Abstract

Objective

To determine the effect of epidural analgesia 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 ropivacaine 0.2 % with fentanyl 2 μg.ml⁻¹ 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.

Results

Epidural analgesia significantly provides good analgesia after 15 minutes (Mean Visual Analogue Score 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 in the epidural group. There were 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 caesarean 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 μg.ml⁻¹ provides better labour analgesia than intramuscular pethidine despite prolongation of labour and increased instrumentation. It was not associated with increased incidence of caesarean delivery when compared with intramuscular pethidine analgesia.

Malays J Med Sci. 2004 Jul;11(2):77.

The Onset Time of Rocuronium: Effect of Low Dose Ephedrine

S Ananda ¹, N M Nik Abdullah ¹, A Muhammad Zihni ¹, O Mahamarowi ¹, P Gnandev ¹, J Kamarudin ¹

Abstract

Introduction

The onset time of rocuronium is partly determined by the speed in which these drugs reach the neuromuscular junction, a factor that appears to be proportional to the cardiac output and muscle blood flow (Simhi and Brandon et al., 1998). Ephedrine is an indirect acting synthetic noncatecholamine that stimulate alpha- and beta-adrenergic receptors and it may promote increase blood flow to the neuro-muscular junction and therefore may fasten the onset of rocuronium.

Objectives

To evaluate the effect of low dose ephedrine administration on the onset time of rocuronium.

Methodology:

A double-blinded prospective study on 44 ASA I and II patients (22 per group), aged between 18 – 60 years who underwent elective surgical procedures. Patients were randomly assigned to receive either i.v ephedrine 50 μg.kg⁻¹ (group 1, n=22) or i.v normal saline (group 2, n=22). Neuromuscular function was assessed by stimulation of the ulnar nerve with train of four monitoring with supramaximal square wave impulse of 0.2 seconds duration administered 2Hz every 10 sec. The onset of rocuronium was defined as the time in seconds from the end of injection of i.v rocuronium to the disappearance of all four twitches of the train of four in the nerve stimulator.

Result:

The onset time of rocuronium in the ephedrine group was significantly faster (70 + 17.5) than the onset time for saline group (99 + 18.3).

Conclusion:

Administration of low dose intravenous ephedrine (50 μg.kg⁻¹) prior to rocuronium helps to fasten the onset time of rocuronium.

Malays J Med Sci. 2004 Jul;11(2):77–78.

Comparison of Intubating Conditions and Haemodynamic Changes Following Induction with Sevoflurane Versus Intravenous Propofol and Suxamethonium

M Nazri ¹, A Saedah ¹, M Azhar ¹, H Shamsul Kamalrujan ¹, G Ghazaime ¹, J Nizar ¹, N M Nik Abdullah ¹

Abstract

Objectives

To compare the intubating conditions and haemodynamic changes in adults following 2 methods of anaesthetic induction, using inhaled sevoflurane 8 % -nitrous oxide-oxygen or intravenous propofol with suxamethonium.

Methodology

A randomized double-blinded prospective study was conducted involving 120 ASA 1 or II similarly premedicated adult patients who were allocated into 2 equally numbered groups. All patients were preoxygenated for 3 minutes and given intravenous fentanyl 1.5 m.kg⁻¹, Group 1 (n=60) received a mixture of inhaled sevoflurane 8 % with 4 litres/ min Nitrous Oxide and 4 litres/ min oxygen for 4 minutes and Group 2 (n=60) received intravenous propofol 2 mg.kg⁻¹ followed by intravenous suxamethonium 1.5 mg.kg⁻¹. Intubating conditions were assessed according to easiness of laryngoscopy, position of vocal cords, jaw relaxation, coughing and limb movement. Baseline blood pressure, heart rate and mean arterial pressure were recorded and measured every minute after induction until 10 minutes post-intubation. Adverse events during induction and immediately post-operative were also recorded.

Results

There were significant differences in the overall intubating conditions (p < 0.05) and haemodynamic changes (p < 0.05) between the two groups. The reduction in mean arterial pressure in Group 1 (sevoflurane) was less than 25% of baseline. 23.3% had breathholding 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

Induction with intravenous propofol/ suxamethonium provides better condition for tracheal intubation and haemodynamic stability than sevoflurane/ Nitrous Oxide technique.

Malays J Med Sci. 2004 Jul;11(2):78.

The Effects of Sedative Oral Premedication on Oxygen Saturation in Patients Undergoing Spinal Anaesthesia

N S Swaran Singh ¹, N M Nik Abdullah ¹, K S Ng ¹, P Gnandev ¹, A Saedah ¹, A Mohd Nikman ¹, J Kamarudin ¹

Abstract

Introduction

Oral sedative premedication is routinely given to majority of patients undergoing anaesthesia. The patients undergoing spinal anaesthesia are monitored with standard ASA monitoring which include pulse oximetry to monitor the oxygen saturation. Oxygen is routinely supplemented to patients undergoing spinal anaesthesia irrelevant of being orally premedicated or not.

The use of protective glasses in working area need to be emphasized to prevent severe eye injury. Education and self-awareness regarding safety measures and the need for safe environment must be stressed not only in the industrial premises but also at home.

Malays J Med Sci. 2004 Jul;11(2):82–83.

Effects of Radiotherapy on Hearing Threshold in Nasopharyngeal Carcinoma Patients.

Shahid Hassan ¹, Hashimah Binti Ismail ¹

Abstract

Introduction

During the course of radiotherapy as the management of head and neck tumors, the temporal bone often falls within the treatment field and both the inner and middle ear may receive the full tumor radiation dose.

Nasopharyngal Carcinoma (NPC) is not very uncommon particularly in Chinese patients in Malaysia. In patients with nasopharyngeal carcinoma (NPC), deafness sometimes occurs following radiotherapy. It is usually conductive but may be sensorineural. Many published studies on effects of radiation on ears have shown conflicting results.

Objective

To study the effects of radiotherapy on hearing threshold of NPC patients.

Subjects and Method

A prospective study to know the effect of radiotherapy on hearing in NPC patients was carried out on 30 patients who attended ENT and combined oncology clinic HUSM during 1999 to 2001. These patients had pure tone audiogram performed before receiving radiotherapy. Tympanometry was used to confirm middle ear effusion. Radiotherapy was delivered via linear accelerator in 2Gy fractions for four and a half weeks to a total dose of 60–70 Gy. Pure tone audiogram was repeated at least six months after completing treatment.

Results

Twenty-two males and three females completed the study. Before the initiation of radiotherapy, otitis media with effusion was observed in 13 ears of which one resolved spontaneously following radiotherapy. On the other hand, 4 ears with no prior middle ear effusion developed it after radiation. This study also showed a significant increase in mean hearing threshold at both low and high frequencies (p<0.05) after radiotherapy. At low frequencies, the increment in mean hearing threshold was observed more at 0.5kHz (p<0.00) and at 8.0kHz for high frequency (p<0.002). Nine ears with middle ear effusion underwent grommet insertion and none developed otorrhoea after radiation treatment.

Conclusion

We establish that radiation which is the mainstay of treatment in NPC patients could result in sensorineural hearing loss and middle ear effusion.

Malays J Med Sci. 2004 Jul;11(2):83–84.

A Histo-Chemical Study of the Cementodentinal Junction (CDJ) in Rat Molar Teeth

Md Nurul Islam ¹

Abstract

Background

It is generally believed that firm cemento-dentinal attachment is maintained by the intermingling of dentinal and cemental fibrils and by mineral reinforcement in human and rat teeth. Previous studies, using scanning electron microscopy have established that fibril intermingling is found only in some regions of the cemento-dentinal junction. Prolong maceration with NaOH breaks down the junction in spite of the fiber intermingling. The purpose of this study was to observe CDJ histochemically and provide information about mineral content of the attachment.

Method

Decalcified blocks were made from male Wistar rat maxilla. Serial 5μm sections were cut mesio-distally and stained with H/E and silver impregnation. For proteoglycan demonstration, PAS and toluidine blue (pH 6.0) were employed. Some sections were used for digestion test using 1% testicular hyaluronidase.

Results

In both acellular and cellular cementum, the cemento-dentinal junction was a layer about 1μm thick. It was intensely stained with hematoxylin, not impregnated with silver, and found PAS and toluidine blue positive. After treatment with testicular hyaluronidase, CDJ lost its affinity for toluidine blue.

Conclusion

This study suggests that cemento-dentinal junction is full of mineral content and is a fiber-poor structure. The mineral content is proteoglycan in nature. It also suggests that the mechanism of attachment between dentin and cementum is mainly by proteoglycan adhesion and not by collagen fiber intermingling.

Malays J Med Sci. 2004 Jul;11(2):83–84.

General Toxicity and Analgesic Properties of Sea Cucumber Extracts

Zury Azreen Bin Azizul Rahman ¹, Farid Bin Che Ghazali ¹, Syed Mohsin Sahil Jamalullail ¹

Abstract

Introduction

Sea cucumber known as gamat in the Malay language or haisom in Hokkien or becher-de-mer, is a remedy derived from a marine animal closely related to starfish and sea urchins. It is also called brunok, bat or bala in various South East Asian Languages. The extracts from sea cucumber have been used as a therapeutic remedy by the Malays and are well known in most local ethnic communities especially in South East Asia. It is claimed to reduce pain in ailments of inflammatory origin or stiffness in arthritis sufferers.

Aims and purpose of the study

The purpose of this study was to highlight the presence of toxicity of selected sea cucumber extracts, namely the Holothurian spp and Stichopus spp on Swiss albino mice.

Materials and methods

Fresh sample of both type of the sea cucumber species were harvested at the Perhentian Island off the coast of Terengganu, Malaysia. Samples were preserved in seawater prior to laboratory processing and subsequent experimentation. Organic and non-organic solvents were used to extract samples from body fluids and tissues of the sea cucumber. Their body fluids were collected during the process of dissecting. Whereas for its tissue, samples were initially dried in a hot air oven then ground into powder and subsequently extracted by organic or non-organic solvents. The resultant materials were then filtered, saturated and finally freeze-dried. From the freeze-dry process, 8 samples of body fluids and body tissues extracts of Holothuriidae and Stichopodidae were produced. Dosage of extracts was calculated based on the amount of powder obtained, volume of solvent used and body weight of the experimental mice. 10mg/kg of extract were then administered to the mice intraperitoneally. CNS effects were observed including behavioral changes and analgesic properties were observed using the tail flick and hot plate test methods. The behavioral study was undertaken over a 4 hours observation period.

Results

Results obtained revealed that CNS disturbances were observed in mice of both the sea cucumber extracts. The observed effects included changes in attitude, restlessness, sedation, tremor, paralysis, pilo-erection, passitivity and jerky movements. Extracts of sea cucumber showed some sedative effect. Stichopodidae body fluid showed the most severe sedative effect. Holothuriidae body fluids have a positive analgesic effect. All the samples showed negative analgesic results when tested using the hot plate test.

Conclusion

The study revealed that extracts of sea cucumber may have some sedative effect while only one extract, that is the body fluid of Holothuriidae showed analgesic properties.

Malays J Med Sci. 2004 Jul;11(2):84.

A Light Microscopic Study of Chromatolysis and Location of Chromatolysed Neuron Somata in the Spinal Cord after an Injury of the Phrenic Nerve in Dog

Muzammil Ullah ^*, Marina Yu Kapitonova ^**, BS Rathna ^**

Abstract

Introduction

Chromatolysis has been induced experimentally by cutting the nerve in a surgical operation by many workers to locate the motor neuron somata of many cranial and spinal nerves (including phrenic nerve) in many mammalian species.

Objective

To study the light microscopic structure of chromatolysed neuron somata stained with thionine and to localize them after an injury of the phrenic nerve in dog.

Methodology

Eight dogs representing both sexes were used in the study. Under general anaesthesia (Nembutal sodium at a dose of 30 mg per Kg. weight intravenously), the right phrenic nerve was exposed in the neck, cut and a part of it removed to prevent re-union. The left side acted as control. The animals were sacrificed 28 to 35 days after operation, circulation flushed with normal saline and perfused with 10 % formal saline at a pressure of 125 mm Hg. The 4^th, 5^th, 6^th, 7^th and 8^th cervical segments of the spinal cord were removed by dorsal approach, separated from each other and embedded in paraffin. Their serial frontal sections were cut at 50 micrometers and stained with thionine for Nissl granules. The sections were examined microscopically to identify the chromatolysed neuron somata. From the tracings of the frontal sections, a map of the longitudinal extent of the chromatolysed neuron somata and their relations with the cell columns of the ventral grey horn were reconstructed at the middle of fifth cervical (C-5), middle of sixth cervical (C-6) and at the cranial part of the seventh cervical (C-7) segments of the spinal cord.

Results

Conclusion

The majority of patients with invasive breast carcinoma in HPP were Chinese and presented at a locally advanced stage with lymph node metastasis. Tumour nuclear pleomorphism correlated with lymph node metastasis.

Malays J Med Sci. 2004 Jul;11(2):86.

Induction of FOS-Like Immunoreactivity (FLI) and its Modulation by Acute Swim Stress in the Rat Formalin Test.

Asma Hayati Ahmad ¹, Azhar Ahmad ², Zalina Ismail ³, Myo Than ⁴

Abstract

Introduction

Induction of fos-like immunoreactivity (FLI) in the spinal cord due to pain has been well studied. However, few have looked into the effects of stress-induced analgesia on FLI in the spinal cord. We used acute swim stress to see its effects on FLI in the spinal cord and its modulation of pain induced by the rat formalin test.

Objectives

To see the effects of acute swim stress on fos-like immunoreactivity (FLI) in the rat formalin test.

Methodology

Adult male Sprague-Dawley rats were assigned to 2 groups, i.e stressed and non-stressed (n=8 for both groups). Rats in the stressed group were subjected to acute swim stress for 3 minutes. After 10 minutes, rats from both groups were injected with 0.5ml of 1% formalin over the right hind paw and the formalin test score was recorded for 60 minutes. Two hours after formalin injection, five rats from each group were sacrificed with an overdose of sodium pentobarbitone i.p., perfused with PBS followed by 4% paraformaldehyde in PB 0.1M, and the spinal cord dissected at the L4-L5 segments. 30 m sections were cut using cryostat and immunohistochemistry for FLI was performed using free-floating method. Sections were then mounted on slides, viewed using an image analyzer and the fos-like immunoreactive neurons were counted.

Results

Results were analyzed using repeated measures ANOVA for formalin test and one-way ANOVA for fos-like immunoreactivity (FLI). For formalin test, acute swim stress produced significant analgesia (p<0.01). The non-stressed rats displayed induction of FLI over the ipsilateral (injected) side of the spinal cord only (p<0.001) while the stressed rats had FLI induced bilaterally (p<0.01). However, for the stressed rats, FLI induction on the ipsilateral side was significantly lower than the FLI induced on the ipsilateral side of the non-stressed rats (p<0.01).

Conclusion

Acute swim stress caused induction of FLI in the spinal cord but in the presence of pain, acute swim stress caused reduction of FLI induction. This phenomenon is believed to be due to the endogenous modulation of pain in the spinal cord.

Malays J Med Sci. 2004 Jul;11(2):86–87.

Levels of Endothelin-1 and Nitric Oxide in Fetoplacental Tissues from Women with Preeclampsia

Wan Malihah Wan Ali ¹, Harbindar Jeet Singh ¹

Abstract

Objective

The aim of the study was to ascertain if there was any difference in the levels of Endothelin-1 (ET-1) and Nitric Oxide (NO) between feto-placental tissues from normotensive pregnant women (NTPW) and women with pre-eclampsia (PE).

Introduction

The pathogenesis for pre-eclampsia remains incompletely understood but overwhelming evidence points to the presence of a placental abnormality contributing to placental insufficiency in pre-eclampsia. An imbalance of vasomotor factors in the placenta of women with PE is hypothesised.

Methodology

Supernatants of homogenates from fresh, vaginally delivered amnion, chorion, and placenta from 12 normotensive and 12 pre-eclamptic women were measured for ET-1 and NO. ET-1 levels were measured using RIA whereas NO were measured using the Griess reaction technique.

Results

There was no significant difference in the ET-1 levels in the amnion between the two groups. However, mean ET-1 levels in the chorion and placental cotyledon were significantly higher in placentae from women with PE when compared to its levels in similar tissues from NTPW (p<0.05). There was no significant difference in the levels of NO or in the activity of NOS between the amnion, chorion and placental cotyledon from NTPW or PE or between corresponding tissues from both the groups. There was also no significant correlation between the levels of ET-1 and NO in the placental cotyledon in either of the groups.

Conclusion

Our observations appear to suggest that ET-1 is significantly elevated in the chorion and placental tissues from women with pre-eclampsia when compared to similar tissues from normotensive women. The absence of any significant difference in NO between tissues from both the groups, suggest a preponderance of vasoconstrictor activity in the intra-placental milieu of women with PE. This may, to an extent, be responsible for the hypothesised placental insufficiency in PE.

Malays J Med Sci. 2004 Jul;11(2):87.

Melatonin Light and Affective Disorders

V Srinivasan ¹

Abstract

Affective disorders involves disruption of intrinsic biological rhythms, like sleep-wake cycle, body temperature rhythms, hormonal rhythms, rest-activity cycle etc. Some of these are phase advanced both in endogenous depression as well as in bipolar affective disorders where in patients exhibit both manic and depressive phases during the course of their illness. Melatonin, the chief hormone secreted form the pineal gland has been shown to be of major importance for establishing the correct phase position of various bodily rhythms, the disturbance of which only causes INTERNAL DESYNCHORINIZATION, the major reason for the occurrence of bipolar affective disorders. Some of the bodily rhythms are phase advanced in both endogenous depression as well as in Bipolar affective disorders. In contrast to this, bodily rhythms are phase delayed in seasonal affective disorders (SAD) or winter depression. Melatonin being a CHRONOBIOTIC has been used successfully to set right the disturbed biological rhythms in patients suffering from affective disorders and is being used as a therapeutic tool for treating these disorders. In addition to this, bright light also is being used successfully to treat endogenous depressives, bipolar patients and patients suffering from winter depression. Since light acts mainly by altering both rhythm and amplitude of melatonin secretion, and is able to set right the disturbed bodily rhythms, an interaction between light and melatonin is very important not only in understanding the pathogenesis of affective disorders but also in employing LIGHT as a useful therapeutic tool in treating affective disorders. Recent aspects on this line of research will be discussed.

Malays J Med Sci. 2004 Jul;11(2):87.

Dimensional Accuracy of Anatomical Replicas Produced by Rapid Prototyping Technology Using Stereolithography Apparatus

Rani Samsudin ¹, Gopal Nair ¹, Lin Naing ¹, Ab Hakim Basir ¹, Nizam Abdullah ¹

Abstract

Aim

The purpose of this study was to determine the dimensional accuracy of the anatomical replicas produced by Rapid prototyping technology using stereolithography apparatus.

Methods

Computer tomography images were captured from four dry normal adult human skulls. The resultant 2-D images were stored in Digital Imaging and Communications in Medicine (DICOM) format. The segmentation of the images was done by using MIMICS software. The slice files were then exported to a stereolithography apparatus (SLA) to produce the replica of each skull. Eight linear measurements were repeatedly made between identified landmarks on each of the original skull and its replica model using an electronic digital caliper. Each of the linear measurements was repeated 5 times and the average was taken to determine the absolute difference and percent difference between the original skull and its replica model.

Results

The overall absolute difference between the four human adult skulls and its replica models was 0.23 mm with a standard deviation of 1.37 mm. The percent difference was 0.08% with a standard deviation of 1.25%.

Conclusion

The degree of error established by this system seems reasonable in clinical applications when these models are used in the field of dental surgery for surgical treatment planning.

Keywords: Rapid prototyping, Stereolithography apparatus, 3-D medical model

Malays J Med Sci. 2004 Jul;11(2):88.

Evaluation of the Nutrient Intake and Feeding Pattern in Cleft Lip and Palate Children

VK Gopinath ¹, Wan Abdul Manam Wan Muda ², CS Kavitha ²

Abstract

Objectives

Cleft lip and palate (CLP) infants present with a number of problems. Among them feeding difficulties are relatively higher. These infants are undernourished and have compromised growth compared with their normal counterparts. The Objectives of this study were to assess the nutrient intake and feeding methods of children with CLP and that of normal children.

Methods

A total of 221 children from birth to six years belonging to both sexes with CLP (60 children) and normal (161 children) were selected. The CLP and normal children were divided into three subgroups according to age. They are subgroup I: birth to 2 years, subgroup II: 2 to 4 years and sub group III: 4 to 6 years. The practice of feeding the infants (breast, bottle, spoon) in subgroup I was assessed by using standard piloted questionnaires. The nutrient intake was evaluated in subgroup II and III using a 24-hour diet recall method.

Results

showed mothers of the normal babies had a significantly more positive attitude (p < .01) towards breast-feeding. When compared to normal children the nutrient intake of CLP children was not significantly different.

Conclusion

It can be concluded that parents with CLP children were more interested in their child’s nutrition, because of the medically compromising condition of the child. Only 40% of the mothers with CLP infants were successful in breast-feeding their infants in contrary to the 90% of the mothers with normal infants.

Malays J Med Sci. 2004 Jul;11(2):88.

Cleft Palate in Children and Adolescent: A Study of Arch Expansion

N Abu Rub ¹, A Burhanuddin ¹, A R Samsudin ¹, A Nizam ²

Abstract

Background

The use of palatal expansion appliances has been claimed to produce a continuous force, which is capable of expanding the maxilla of cleft palate patients who have deficient maxilla. The aim of this study was to evaluate and compare the palatal changes using different arch expansion appliances in patients with cleft palate with or without cleft lip that were treated at the Combined Cleft lip & palate Clinic in Kelantan, and also to correlate these changes at various age of application of these appliances.

Materials and Methods

This is a retrospective record review study involving forty-nine oral cleft patients who underwent palatal expansion at combined clinic in Kelantan. 12 patients had used Pre-Surgical Orthopedic Plate (PSOP), 11 patients used Upper Removable Appliance (URA), 11 patients used Quad-helix (QH), 3 patients used Rapid Maxillary Expansion (RME), and 12 patients used Upper Fixed Appliance (UFA). Pre and post treatment study models were analyzed for changes in inter-tuberosities width, inter-canines width, palatal length and palatal depth using fowler-sliding caliper. Data were analyzed using SPSS 11.0

Results

Results revealed that all expansion appliances were capable of expanding the maxilla. Age did not influence the total amount of expansion in all the appliances except in RME group; the inter-tuberosity width increased as age increased. However, palatal depth in UFA group decreased as age increased.

There was no significant difference in palatal changes between URA, QH and UFA expansion appliances, except the inter-tuberosity width.

Conclusion

In conclusion, all commonly used appliances were suitable for arch expansion in all ages. RME tended to produce more lateral expansion in adolescent and UFA tended to produce more shallow palate in children.

Malays J Med Sci. 2004 Jul;11(2):89.

A Pilot Study of Risk Factors in Cleft Lip/Palate Patients

A R Ismail ¹, NM Ismail ¹, L Naing ¹

Abstract

Introduction

The risks of non-syndromic cleft lip with or without cleft palate and isolated cleft palate (CLP) are influenced by variations at several loci of the gene and these loci interact with environmental factors to determine disease risk.

Objective

The aim of the study is to establish the relationship between environmental risk factors and incidence of cleft lip and palate.

Methodology

This is a case controlled study of non-syndromic CLP patients attending combined clinic in Kota Bharu and patients attending outpatient clinic in HUSM. Information was obtained using questionnaires. The information in the questionnaire includes paternal & maternal smoking habit, amount of tobacco used, genetic consideration. Environmental factors such as area of residence, birth dates, maternal problems, use of complementary medicine and diseases during pregnancy are explored. Details of socio-economic status are also obtained. 201 CLP patients and 212 controls were interviewed. Univariate and multiple logistic regression analysis were used to analyze the data.

Results

It was found that demographically there were variations to risks of non-syndromic CLP. People from Tanah Merah and Tumpat had a 8.74-fold increased risk compared to people from Kota Bharu. There was an association between passive smokers and CLP (OR) = 2.45 (95% CI: 1.52, 3.94). Maternal and paternal history of cleft, occupation of father and position of child in the family increased the risk of CLP (p=0.009).

Conclusion

The study suggested that there were some geographical variations in the risk of CLP. Maternal exposure to cigarette smoke (passive smokers) showed increased risk of CLP. The seventh child and above had increased risk of CLP.

Methods

A descriptive study was carried out on 77 early pregnant women by their interview in a structured questionnaire in the gynae out-patient department (GOPD), Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh. Data were analyzed by using the INRUD prescribing indicators. The following parameters were studied – the average number of drugs per encounter, the percentage of antibiotics prescribed per encounter and the percentage of teratogenic drugs per encounter.

Results

The maximum number of drugs prescribed per encounter was 4. Poly pharmacy was practiced in 3.89 percent of prescriptions. Among all the prescriptions, the maximum 73 prescriptions had vitamin and minimum 1 prescription had analgesic. The rest 53 prescriptions had iron, 20 prescriptions had calcium, 18 prescriptions had folic acid, 8 prescriptions had stemetil, 7 prescriptions had antibiotic and 2 prescriptions had teratogenic drugs. Statistical analysis shows that 9% early pregnant women took antibiotics and 2.5% early pregnant women took teratogenic drugs.

Conclusions

Antibiotics and Teratogenic drugs are not indicated in 1^st trimester of pregnancy though these were used in teaching hospital. So it was highly errational. The most urgent need is the improvement of the rational prescribing in early pregnancy.

Malays J Med Sci. 2004 Jul;11(2):93–94.

The Vanishing Twins Phenomenon

Hakim G Bilal ¹, Awang Nila ¹, N H Nik Hussein ¹, Adibah ¹, Rosilawati ¹

Abstract

The case of a 30 year old Malay lady Gravida 3 para 2 at 6 weeks + 5 days of gestation is described. She presented with a three day history of minimal per vaginal bleeding but with no abdominal pain or having passed products of gestation. Examination showed an eight week size uterus with the cervix long and closed and no adnexal abnormality.

The diagnosis first appeared to be a threatened miscarriage then a missed abortion and then an ectopic pregnancy. It was not a straightforward case!

US showed three gestation sacs, but only one had a viable fetal echo.

This study indicates that FEC chemotherapy regimens suppress the immune system in general. However, they appear to still conserving cell-mediated immunity response needed for fighting against cancer cells.

Malays J Med Sci. 2004 Jul;11(2):95.

Analysis of Exon 21 of the MDR1 Gene in the Acute Lymphoblastic Leukemia (ALL) and Chronic Myeloid Leukemia (CML) Patients Using Denaturing High Performance Liquid Chromatography (DHPLC)

Y Badrul Hisham ¹, H Rosline ², WM Wan Maziah ³, B Abdul Aziz ¹, B Nor Sa’adah ⁴, MY Narazah ¹

Abstract

Introduction

Genetic polymorphisms of the MDR1 gene have been reported where they affect the expression and function of the P-gp efflux pump. DHPLC has been recently described as a feasible method for screening DNA samples for SNPs and mutations. The principle of this machine is that fully an automated system used for the detection of heteroduplexes in PCR products by ion-pair reverse phase HPLC under partially denaturing conditions.

Objective

The objective of this study was to detect SNPs and mutations in exon 21 of MDR1 gene in patients with acute lymphoblastic leukemia (ALL) and chronic myeloid leukemia (CML) from Hospital Universiti Sains Malaysia (HUSM).

Methodology

Whole blood samples were collected from 14 patients diagnosed as ALL and 6 patients diagnosed as CML based on the FAB classification from HUSM. Genomic DNA was extracted using QIAamp blood minikit (QIAGEN). Exon 21 was amplified using primers as described previously and the amplified products were electrophoresed on 1.7% agarose gel. Prior to dHPLC analysis, the amplicons for each exon were prepared by performing the reannealing method using the thermocycler and dHPLC was performed in various temperatures to obtain the optimum temperature. The profiles of dHPLC analysis of these samples were compared with wild type samples as normal controls.

Results

Based on portion elution profiles, 6 (42.86%) ALL and 4 (66.67%) CML samples showed mutation peaks while the rest showed the normal peaks when compared with the wild type.

Conclusion

Thus SNPs and mutations in MDR1 gene has been successfully screened using the dHPLC technique in leukemia patients in HUSM where this information is useful for patients’ stratification of treatment. Further analysis to confirm the mutations using automated sequencing is ongoing.

Malays J Med Sci. 2004 Jul;11(2):95.

Serological Study of Toxoplasmosis Using Enzyme-Linked Immunosorbent Assay

K Al-Jashamy ¹, M Zeehaida ¹, Nik Zairi ¹

Abstract

Background

Toxoplasma gondii is an opportunist protozoan parasite that may induce a disseminated and lethal disease in immunosuppressed patients. Toxoplasma serologic tests are used most commonly for diagnosis, but may be insensitive in patients lacking normal responses. A retrospective study was conducted to review the toxoplasma cases seen in HUSM / laboratory of parasitology.

Methods

During the period from January 2001 to March 2004, all the cases were recorded. Blood samples were examined by enzyme-linked immunosorbent assay using IgG and IgM.

Results

A total of 206 blood samples were collected from the patients who were suspected to have toxoplasmosis. The rate of positive tests for toxoplasmosis was 2.5% (1 out of 40 cases) in 2001, 6.9% (4 out of 58 cases) in 2002 and 16.0% (8 out of 49 cases) in 2003. It was 49.0% (29 out of 59 cases) in the period of 1^st January to 31 ^st of March 2004. The overall positivity for toxoplamosis was 20.0%. No significant differences by age or sex were observed.

Conclusion

The studied individuals had a high prevalence of Toxoplasma gondii infection

Introduction

Abstract

Background

Systemic lupus erythematosus (SLE) is a disease of abnormal immune regulation, characterized by the production of autoantibodies. 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.

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.

Methodology

HLA typing of fifty-five SLE patients from Malay ethnic who fulfilled the American Rheumatism Association (ARA) were analysed, and compared with the control group consisting of 55 healthy unrelated subject with comparable age, sex and ethnic. HLA typing of class II antigen were carried out using MicroSSP Class II generic (DRB/ DQB) from One Lambda Inc.

Results

We found a strong significant association of HLA-DR15 and HLA-DR17 with SLE compared to healthy control group (p corr = 0.002, adjusted OR = 5.513; p corr = 0.04, adjusted OR = 7.87, respectively). There was a weak decrease of HLA-DR4 which was not significant after corrections for multiple comparisons made.

Conclusion

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

Malays J Med Sci. 2004 Jul;11(2):98–99.

An Outbreak of Pantoea Spp. In a Neonatal Intensive Care Unit (NICU) Secondary to Contaminated Total Parenteral Nutrition (TPN).

H Habsah ^*, M Zeehaida ^*, AR Rosliza ^*, H Van Rostenberghe ^**, R Noraida ^**, WI Wan Pauzi ^**, Fatimah I ^**, NY Nik Sharimah ^**, H Maimunah ^*,^**

Osteoporosis is a systemic skeletal disease characterized by low bone mass, fragility and a consequent increase in fracture risk. Currently the recommended method to measure bone mineral density (BMD) is Dual Energy X-Ray Absorstometry (DEXA). However to be more precise in the diagnosis of osteoporosis and fracture risk prediction, other risk factors and biomechanics of the bone should be taken into consideration.

Aims

To obtain bone mineral density reference data for local Malay female population.
To determine the correlation of geometric properties and BMD.

Introduction

Hyperlipidaemia and insulin resistance has a complex relationship. Most of the previous studies were looking at insulin resistance in hyperlipidaemic subjects who were also obese. So influence of obesity and hyperlipidaemia acted simultaneously in the genesis of insulin resistance.

Objective

The present study was designed to determine insulin sensitivity and secretory status of non-obese normoglycemic subjects, and to find out the relationship between hyperlipidemia and insulin sensitivity in a non-obese population.

Methodology

A cross sectional study on 74 non-obese (BMI<25, waist circumference male<102cm, female <88cm.) and non-diabetic subjects age between 30–60 years was carried out. The subjects underwent OGTT, LFT and RFT to exclude type 2 diabetes, IGT, IFG, renal and liver diseases. Fasting plasma glucose, fasting insulin and lipid profile were done. Insulin sensitivity and secretory status was calculated using homeostasis model assessment (HOMA) software (HOMA%S, HOMA%B and HOMA-IR). The subjects were devided into two group according to their lipid status and their insulin sensitivity was compared by MannWhitney test.

Results

The hyperlipidemic subjects showed substantially lower insulin sensitivity and higher insulin resistance in comparison to normolipidemic subjects. The median of HOMA%S of hyperlipidemic and normolipidemic subjects were 50(83) and 232(227) (p<.0001) for male and 71(86) and 241(221)(p<.0001) for female respectively. Insulin secretory status of hyperlipidemic subjects indicate that the B cells of these subjects have to secrete more insulin to overcome lowered insulin sensitivity, the median of HOMA%B were 179(144) and 98(32) for male and 179(102) and 87(34) for female.

Conclusion

Insulin sensitivity of otherwise healthy non-obese hyperlipidemic subjects is lower than normolipidemic subjects.
The B cells of hyperlipidemic subjects have to work more to compensate lowered insulin sensitivity.
Hyperlipidemia can be considered as a risk factor for development of insulin resistance syndrome in future and should be treated.

Malays J Med Sci. 2004 Jul;11(2):104–105.

Three-Dimensional Ultrasound

Saffuwan bin Haji Mohamed Johar ¹, Wan Ahmad Kamil Wan Abdullah ²

Abstract

Background

This project report was done to investigate feasibility and potential application of three-dimensional (3-D) ultrasonography in Hospital Universiti Sains Malaysia (HUSM), Kubang Kerian, Kelantan. First attempt was tested on tissue-equivalent ultrasound phantom to review several 3-D ultrasound enhancements which was not offered by two-dimensional (2-D) ultrasonography. They are 3-D orthogonal slices, arbitrary slicing as well as high resolution reconstruction, volume rendering images and image manipulation interactively.

Method

3-D images were generated by a Siemens Sonoline Elegra Ultrasound Imaging System located at the Radiology Department, HUSM. Transducers used are the linear array transducer (VF13-5) which operates at frequency of 9.0 MHz and sector array transducer (3.5C40H) at frequency of 3.5 MHz. Images were acquired with free-hand technique by linear and rocked methods.

Results

Using this imaging system, 2-D and 3-D phantom structures from various perspectives and orientations were reviewed simultaneously in a four-quadrant display. New 2-D section from anyplane slices may be obtained from the single 3-D volume for visualization.

Conclusion

The results suggest that 3-D ultrasonography developed by the respective ultrasound imaging system has the potential to complement 2-D ultrasonography.

Malays J Med Sci. 2004 Jul;11(2):104–105.

Evaluation of Toshiba Gamma Camera GCA-901A/HG Performance by Using Unconventional Material Filters With TC-99M in Planar Imaging

Sayed Inayatullah Shah ^*, Ahmad Zakaria ^*, Ismaliza ^*, Siti Nazipah ^*

Abstract

Introduction

Data for diagnostically reliable images can only be obtained with gamma camera when the performance parameters, such as, uniformity, sensitivity and spatial resolution are tested and are within the limits of acceptability. These parameters are affected by the scattered radiation emanating from the object/organ to be scanned.

Objectives

To investigate the effects of unconventional material filters (Cu 0.125 mm, Al 0.2 and 0.3 mm thick sheet) on the performance parameters via attenuating some fraction of scattered radiation prior to detection.

Methods

Flood field phantom, petri dish and line source by using Tc-99m radionuclide is scanned for uniformity, sensitivity and spatial resolution measurements, respectively. Either LEGP or LEHR collimators are applied. Data are collected within a symmetrical standard energy window (126 – 154 keV centered at 140 keV) without and with unconventional material filters by mounting on the outer surface of collimator.

Results

Results obtained without material filters are compared with those obtained with unconventional material filters. Integral uniformity is improved when material filter is applied with the LEHR collimator. The sensitivity is decreased, as expected, with both collimators when material filters are mounted. Improvement in FWHM values for 0 – 4 cm source-collimator distance with unconventional filters is noted with both the collimators.

Conclusion

Unconventional material filters may be applied for scanning objects/organs and may provide improved quality images.

Malays J Med Sci. 2004 Jul;11(2):105.

Micronutrients Correlated to Cancer

CS Kavitha Menon ¹, BV Muralikrishna ²

Abstract

Method

Children with obstructive symptoms of tonsillar hypertrophy underwent laser tonsillotomy. The tonsils were dissected using laser from anterior pillar to posterior pillar. The tonsils bed were left untouched. Intraoperative and postoperative conditions were noted.

Result

Intraoperatively, blood loss was negligible. Postoperatively, all of the patients were able to swallow with minimal discomfort and discharged the following day after observation.

Conclusion

Laser tonsillotomy is an alternative procedure in children having obstructive tonsillar hypertrophy.

Objective

To compare the conjunctival surface morphology that develops with the use of topical timolol maleate 0.5% and topical latanoprost 0.005%.

Method

Newly diagnosed glaucoma patients are randomly divided into 2 groups by closed envelope method:

Group 1: treated with topical timolol maleate 0.5%
Group 2: treated with topical latanoprost 0.005%

First conjunctival impression cytology was taken before the treatment was started. Second conjunctival impression cytology was taken after 3 months of treatment. The conjunctival impression cytology of the both groups was compared.

Results

In both the timolol group and latanoprost group, there was no change of the conjunctiva epithelial cell morphology after three months of anti-glaucoma drugs treatment.
Within three months of therapy, both these drugs cause significant reduction of goblet cells and mucous granules.
There was no significant difference in the density of goblet cells and mucous granules in both groups of patients after 3 months of treatment.

Conclusion

Both topical timolol maleate 0.5% and topical latanoprost 0.005% cause significant reduction of conjunctival goblet cells and mucous granules however there was no significant difference of conjunctiva surface morphology between the two groups after treatment.

Malays J Med Sci. 2004 Jul;11(2):107–108.

Experience of Inverted Papillomas in Kelantan

Shamim Ahmed Khan ^*, Shahid Hassan ^*, Mohammad Hamza ^*, Din Sohaimi Ramiza ^*, S Zulkifli ^**

Abstract

Objective

The study looked into the demographic presentation, morbidity due to local invasion, surgical management, outcome and recurrence of inverted papillomas in Kelantan.

Introduction

Inverted papillomas are slow growing, most commonly benign neoplasms of the sinunasal tract. However their three characteristic features, a tendency to recur, a destructive capability for the surrounding structures and an association with malignancy make them distinct from other benign neoplasm of this region.

Methodology

19 operated patients for inverted papilloma were followed through hospital records. Besides demographic data the morbidity of the disease at the time of presentation was noted. The types and extent of surgical procedures were critically evaluated for their morbidity and control of signs and symptoms.

Results

A total of 14 cases were managed through classical medial maxillectomies through lateral rhinotomy approach, in another 4 cases endoscopic medial maxillectomies while in one case intranasal excision was done. Late presentation, refusal for surgery and infrequent follow up of the patients, has been established hallmark of Kelantan. This has ultimately influenced the selection of operative procedure performed.

Conclusion

En block removal of medial wall of maxilla along with partial removal of ethmoids through a lateral rhinotomy approach is a comfortable and satisfactory procedure in the management of inverted papilloma.

Malays J Med Sci. 2004 Jul;11(2):108.

Central Corneal Thickness and Intraocular Pressure Among Malay Undergraduates of Health Campus, Universiti Sains Malaysia.

H Mohd Aziz ¹, AT Liza Sharmini ¹, Mohtar I ¹

Abstract

Method

Primary pterygium patients were randomized into 2 groups by closed enveloped method:

Group A: pterygium excision with air-dried amniotic membrane graft
Group B: pterygium excision with bare sclera technique. Post-operative pterygium recurrence were compared within 7 months follow-up.

Result

In amniotic membrane group, the pterygium recurrence rate was 19.2%. The recurrence rate in bare sclera was significantly higher, 60.7% (p=0.02). However fibrous tissue (grade 3 appearance) was seen more in amniotic membrane group at 7 months of follow-up (31.1%) compare to bare sclera group (13.3%)
The significant difference for recurrence between these 2 groups can be seen as early as 5 months of follow-up. 3) There was no significant difference between recurrence and age or sex

Conclusions

The relatively low recurrence rate for post pterygium excision allows one to use air-dried amniotic membrane graft as an alternative for pterygium surgery. However longer follow-up might revealed higher recurrence rate in this technique as well?

Malays J Med Sci. 2004 Jul;11(2):110.

Long Term Visual Outcome in Diabetic Retinopathy After Laser Photocoagulation Therapy

Rajesh K Khanna ¹, Puneet Agarwal ¹

Abstract

Introduction

Diabetic retinopathy is one of the commonest causes of visual loss in adults of working age in Malaysia. Sight threatening conditions such as maculopathy and proliferative diabetic retinopathy are more amenable to laser treatment if diagnosed at an early stage. Although, unawareness and the lack of skilled personnel remain the major problems in early detection and treatment.

Objective

To analyse the long-term visual outcome in patients with diabetic retinopathy after laser photocoagulation.

Methodology

The records of diabetic retinopathy patients were analysed for demographic data, type and duration of diabetes, diabetic control, associated risk factors, indication for laser therapy, pre- and post-laser best-corrected visual acuity and causes for visual impairment.

Results

After analysing the hospital records of 48 patients who underwent laser photocoagulation therapy for maculopathy and proliferative diabetic retinopathy, a slight female preponderance (52%) was observed with majority of Malays (91.7%) and type-2 diabetes (88%). Nearly half of them presented with retinopathy at the time of presentation with 2 or more risk factors and belonged to the age group between 45-60 years. Fair to good control of diabetes (<10.0% HBA1c or RBS <11.0 m mol/l) was seen in only 11 patients (23%).

The major risk factors were found to be duration of diabetes for more than 10 years (66.7%), hypertension (62.5%), nephropathy (29%), peripheral neuropathy (25%), and hyperlipidemia (25%). Macular oedema (62.5%) was the most important cause of visual impairment followed by vitreous haemorrhage (27%) and tractional retinal detachment (8%).

Long-term visual acuity (post-laser) with minimum of one-year follow-up improved in 7 patients (14.5%), remained stable in 19 patients (39.5%) and worsened in 19 patients (39.5%). Various factors attributing to worsening of vision were found to be uncontrolled diabetes, presence of multiple risk factors, severe exudative maculopathy, vitreous haemorrhage and tractional retinal detachment.

Inspite of laser therapy, legal blindness (<3/60) was seen in 7 patients bilaterally (14.5%) and 14 patients unilaterally (29%) whereas visual impairment (6/60 – 6/ 18) in 6 patients bilaterally (12.5%) and 27 patients unilaterally (56%).

Conclusion

Sight threatening conditions of diabetic retinopathy if treated early by laser therapy, can delay or halt the progression of retinopathy with stabilisation of vision. Although, control of diabetes remains the most important factor in preventing visual impairment along with other complications.

Malays J Med Sci. 2004 Jul;11(2):110–111.

A Study of Rehabilitation Outcome Among Children With Hearing Loss in the Husm ORL-Audiology Clinic

Farohah Mat Zain ^*, Din Suhaimi Sidek ^**, Nor Azlinawani Hussin ^*, Rohaida Ismail ^*, Abdul Wahab Muhammad ^*, Al-Hafiz Ibrahim ^*, Wan Zaharah Abd Wahid ^**, Norazizah Kadil ^**, Rozazipah Ahmad ^**

Abstract

Introduction

Hearing loss is the most common defect in the neonatal period occurring about 1–6 per 1,000 population. Early detection and rehabilitation is of utmost importance as the development of speech and language is biologically time-locked. After the age of 2 years the chance of getting a normal speech and language even using the best hearing devices is slim.

Objective

To document the effect of hearing loss to communication ability among children
To determine factors affecting early rehabilitation
The role of parents and the level of knowledge towards rehabilitation.

Methodology

Children with hearing impairment attending the Audiology and Speech clinic of ORL were divided into early (less than 2 years old) and late (more than 2 years old) rehabilitation. Twenty children were selected, 10 from each group. Home visits were performed and parents were interviewed, questionnaires used and video documentation for speech were taken. The health personnel involved were also interviewed i.e the audiologists, speech pathologists and ENTs.

Results

Children with early detection and rehabilitation do far better in terms of speech and language as compared to the those detected late. However, severity of hearing loss, motivation, implementation of auditory and speech stimulation at home are important success factors.

Discussion

We hope with the implementation of universal hearing screening in HUSM children will be detected and habilitated early. These children, though hearing impaired, benefit from their hearing aids or cochlear implant to be able to speak and hopefully enter into the mainstream education.

Malays J Med Sci. 2004 Jul;11(2):111.

Malaysia Towards Electronic Medical Record

Haslina Mohd ¹, Sharifah Mastura Syed Mohamad ¹

Abstract

Conclusion

Effective strategies should continue to be developed to eliminate obstacles and create conducive working environment for the female surgeons, so that they would be able to combine productive careers with rewarding family lives.

Malays J Med Sci. 2004 Jul;11(2):115.

Medical Education in Bangladesh: Issues and Approaches

Md Ruhul Amin ¹, MdAnwarul Azim Majumder ², Mohammed Nazrul Islam ³, SM Idris Ali ⁴

Abstract

Background

In recent years, educational institutions around the world have been increasingly confronted with the challenge of making their curricula relevant to the needs of the time. Medical education in Bangladesh has also experienced many changes and challenges. The government has taken initiatives to bring reform in medical education through various government-led educational projects and programmes. As a result, an “educational environment for change” has been established in the arena of medical education.

Methods

For this study, relevant publications and documents were consulted and analyzed.

Results

The changes and challenges which medical education in Bangladesh has experienced include growing realization among stakeholders to review the educational programmes, availability of a large “critical mass” of trained teachers in medical education, resources, procedures and guidelines developed by former educational projects, and commitment to improve the medical education in the current government health care programmes.

Conclusion

Quality health care of a country depends on the availability of the well-trained and competent health personnel. Medical education plays an important role to produce such health personnel using need-based “input-process-output” curriculum strategies. Stakeholders should take the note of the various shortcomings of the medical education and draw need-based strategies to improve quality of medical education.

Malays J Med Sci. 2004 Jul;11(2):116.

Students’ Perceptions of ‘Technology-Based’ Lecture Handouts

Mohammed Nazrul Islam ¹, Md Anwarul Azim Majumder ², Rogayah Ja’afar ², Sayeeda Rahman ³

Abstract

Background

Lecture handouts are widely used instructional tools. Handouts supplement rather than substitute students’ regular reading. It is now a common practice to supply PowerPoint handouts and publish lecture handouts on the web for students’ access.

Methods

A questionnaire survey was conducted among the first year medical students (n=142) of School of Medical Sciences (SMS), Universiti Sains Malaysia (USM) in order to determine their perceptions and expectations with regards to lecture handouts provided to them.

Results

A majority of the students reported that they read the lecture handouts as a reference and found them useful as a guide for future learning. However, more than half (68%) of the students have shown their dissatisfaction with overall presentation format of the handouts which is mainly technology-related i.e. PowerPoint and photocopying.

Discussion

This study indicated that students’ expectations and experiences were positive towards the use of handouts. They used handouts as a means of supplementing rather than substituting their learning. Much care is needed when educators supply computer-based handouts, as this study shows some limitations when students use them. Medical schools should consider publishing web-based handouts with online and other facilities to make it interesting and effective.

Malays J Med Sci. 2004 Jul;11(2):116.

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

MN Mohd Nazhari ^*, AK Rusli N dan Abu Hassan Shaari

Abstract

Introduction

Lead exposure poses 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. 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.

Objective

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 wakefulness, forgetfulness, stress, confusion, irritability, headache, vertigo, palpitation, excessive sweating and numbness noted more when there 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 (p=0.01). Mean environmental lead level inside the car spray and painting chambers was 8.07 μg/mL and slightly lower than environmental lead level around services and repairing areas which was 8.58 μg/mL.

Neurobehavioural symptoms, neurobehavioural performances and environmental lead levels were not significantly different 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.

Conclusion

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.

Malays J Med Sci. 2004 Jul;11(2):117.

Adolescents’ Self-Report on the Quality of Friendships and the Relationship With Self-Esteem.

Mohd Jamil Yaacob ¹, Naliza Zulkifli ¹, Mark Newman ¹, Nick Goddard ²

Abstract

Objective

A cross-cultural study was conducted in United Kingdom (UK) and Malaysia to look at the patterns of friendship and self-esteem among adolescents aged 13–16 with respect to age, gender, race and length of friendship.

Methodology

All Year 10 (St Dunstan’s College students in UK) and Form 2 (King George V Secondary School in Malaysia) were included. A total of 198 pupils from both schools were recruited but only 168 were chosen for final statistical analyses using SPSS and EQS computer programme. The 46-item Friendship Qualities Scale and 11-item Rosenberg Self-esteem scale were translated into the Malay language and were subjected to validity and reliability studies using confirmatory and exploratory factor analyses. Cross-cultural comparison was made using non-parametric tests based on compatibility scales between the two cultures.

Result

Friendship varied between St Dunstan’s and King George V but not self-esteem. Girls had higher friendship qualities but lower self-esteem in St Dunstan’s but on the other hand, boys had higher friendship qualities but lower self-esteem in King George V. Race differed with self-esteem in St Dunstan’s but it differed with friendship in King George V. Length of friendship did not differ with friendship and self-esteem in both places.

Conclusion

Contemporary discovery in cross-cultural psychology indicates that there are different paths of development in the West as compared to the East. In UK, the path is one of individual maturation that result in higher self-esteem scores as compared to friendship qualities. In Malaysia, the path is one of symbiotic group maturation, as shown in higher friendship qualities scores as compared to self-esteem.

PERMALINK

Plenary Lectures and Symposia

Photodynamic Therapy in the Management of Cancer

Malini Carolene Olivo

Abstract

Imaging of Emerging Respiratory Infections

GC Ooi

Abstract

Acute Coronary Syndrome: Is the Light Getting Brighter at the End of the Tunnel?

Rosli Md Ali

Abstract

Traffic Lights – Directing the Flow Medical Traffic

Deborah C Saltman

Abstract

Light and Your Skin – Friend and Foe

Suraiya H Hussein

Abstract

Controversies in Phototherapy for Neonatal Jaundice

Hans Van Rostenberghe

Abstract

Cytogenetics – The Basis of Understanding Cancer

Zubaidah Zakaria

Abstract

Comparison of the Use of the Laryngeal Tube (LT) and Laryngeal Mask Airway (LMA) Under Anaesthesia During Spontaneous Ventilation

M Noor Zairul

N M Nik Abdullah

A H Azmi

M Z Rhendra Hardy

G Ghazaime

O Mahamarowi

J Kamarudin

Abstract

Objective

Methodology

Results

Conclusions

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

W A Rohaidah

O Mahamarowi

G Norhafidzah

J Kamarudin

M Z Rhendra Hardy

N M Nik Abdullah

Abstract

Objectives

Methodology

Results

Conclusions

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

T Norizan

P Gnandev

G K Sobha

J Kamarudin

M Z Rhendra Hardy

O Mahamarowi

N M Nik Abdullah

Abstract

Introduction

Objective

Methodology

Result

Conclusion

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

M R A Hadi

H Shamsul Kamaruljan

K Junaidi

A Saedah

A J Nizar

G Ghazaime

N M Nik Abdullah

Abstract

Introduction

Objectives

Methodology

Results

Conclusion

Comparison of Epidural Ropivacaine 0.2 % with Fentanyl 2 μg.ml−1 Versus Intramuscular Pethidine on the Progress of Labour

M S Abu Bakar

A J Nizar

B Baharuddin

Comparison of Epidural Ropivacaine 0.2 % with Fentanyl 2 μg.ml⁻¹ Versus Intramuscular Pethidine on the Progress of Labour