1. A retrospective study was conducted to explore the importance of CYP2C9 genotyping for the initiation and maintenance therapy of warfarin in clinical practice. A total of 191 patients on warfarin therapy in a local hospital were recruited after written informed consent. Their medical records were reviewed and no intervention of warfarin dose was performed. 2. A total of 5 ml of blood were taken from each subject for DNA extraction and identification of 1, 2, 3 and 4 CYP2C9 alleles, using a nested-allele-specific-multiplex-polymerase chain reaction (PCR). Half the patients were Malays and the remaining were Chinese. 3. Two genotypes were detected; 93.2% had CYP2C9 1/1 and 6.8% were CYP2C9 1/3. Warfarin doses were higher in patients with CYP2C91/1. Patients with the 1/3 genotype experienced a higher rate of serious and life-threatening bleeding; 15.4 versus 6.2 per 100 patients per 6 months. 4. The observation clearly highlights the inadequacy of the current dosing regimens and the need to move toward a more individualized approach to warfarin therapy. Prospective clinical studies are now being conducted to assess dosing algorithms that incorporate the contribution of the genotype to allow the individualization of warfarin dose.
From August 2006 to July 2007 a prospective study of out-of-pocket costs incurred by care-givers of children hospitalized for rotavirus gastroenteritis was conducted in a hospital in Malaysia. Data on caretaker out-of-pocket costs were collected from 260 children hospitalized with diarrhoea. A stool sample was collected from 198 of these children of which 46 (23%) were positive for rotavirus by latex agglutination assay. The mean (median; interquartile range) out-of-pocket cost incurred by the care-givers was US$194 (US$169; US$47-738), constituting 26% of average monthly income of the households surveyed. Major components of the cost were hospital expenses (45%) and productivity loss (37%). These findings will allow further assessment of the cost-effectiveness of any future rotavirus immunization program in Malaysia.
This study explored the extent to which Malaysian and Thai smokers believe "light" and menthol cigarettes are less harmful than "regular" cigarettes and the correlates of these beliefs.
To examine the impact of tobacco advertising policy on adult smokers' awareness of tobacco promotion in two developing countries--Malaysia and Thailand.
OBJECTIVES: To determine treatment outcomes and associated predictors of all patients registered in 2012 with the Malaysian National Tuberculosis (TB) Surveillance Registry.
METHODS: Sociodemographic and clinical data were analysed. Unfavourable outcomes included treatment failure, transferred out and lost to follow-up, treatment defaulters, those not evaluated and all-cause mortality.
RESULTS: In total, 21 582 patients were registered. The mean age was 42.36 ± 17.77 years, and 14.2% were non-Malaysians. The majority were new cases (93.6%). One fifth (21.5%) had unfavourable outcomes; of these, 46% died, 49% transferred out or defaulted and 1% failed treatment. Predictors of unfavourable outcomes were older age, male sex, foreign citizenship, lower education, no bacille Calmette-Guérin (BCG) vaccination scar, treatment in tertiary settings, smoking, previous anti-tuberculosis treatment, human immunodeficiency virus infection, not receiving directly observed treatment, advanced chest radiography findings, multidrug-resistant TB (MDR-TB) and extra-pulmonary TB. For all-cause mortality, predictors were similar except for rural dwelling and nationality (higher mortality among locals). Absence of BCG scar, previous treatment for TB and MDR-TB were not found to be predictors of all-cause mortality. Indigenous populations in East Malaysia had lower rates of unfavourable treatment outcomes.
CONCLUSIONS: One fifth of TB patients had unfavourable outcomes. Intervention strategies should target those at increased risk of unfavourable outcomes and all-cause mortality.
A retrospective review of patients with focal non-typhoidal Salmonella (NTS) infection was performed to determine its features and outcome. All patients with focal NTS infection admitted to the University of Malaya Medical Center, Malaysia, from 1993 to 2002 were studied. More than half (58%) of the 35 cases (54% male, median age 39 years, range 1.5 months to 79 years) were immunocompromized or had chronic medical conditions. One-third of the patients (34%) had superficial infections (lymphadenitis or subcutaneous tissue infection) and all recovered with antimicrobial therapy alone. Deep infections (66%) noted were: meningitis (9%), osteomyelitis or arthritis (26%), abscesses of the gastrointestinal tract or adjacent organs (20%), and others (11%). Deep infections were more likely to occur in the extremes of age (<6 months or >60 years, p< 0.04), associated with adverse outcomes with an overall mortality rate of 9%, or required major surgery (15%).
The Virology Division in the Institute for Medical Research, Kuala Lumpur, Malaysia performs potency tests on oral polio vaccines and live attenuated measles vaccines. Since these potency tests were introduced in 1981 a total of 752 tests have been performed on vaccine samples from peripheral immunization centers. Of 165 representative vaccine samples sent for potency evaluation after a cold chain breakdown 154 (87%) passed minimum potency requirements recommended for immunization of infants. In the absence of potency evaluation, those vaccines exposed to temperatures higher than the recommended storage range would be discarded, perhaps resulting in unnecessary wastage and economic loss. Results of the vaccine potency evaluation has enabled health authorities to indirectly monitor cold chain efficiency and ensure the high quality of viral vaccines used in our childhood immunization program.
In 1990 the Institute for Medical Research carried out a serosurvey in the state of Kelantan to study the age stratified immune prevalence rates for measles and poliomyelitis. Our findings indicate that 981 out of 1,097 (89%) of the population screened had measles antibodies and more than 90% (366 out of 400) had antibodies to all three serotypes of poliovirus. The susceptible group for measles was infants below one year of age, of whom 53.3% (8/15) did not have measles antibody. Of 400 subjects, 125 (31.3%) who were either incompletely vaccinated or had not been vaccinated against poliomyelitis, had polio neutralizing antibodies to all three poliovirus serotypes, suggesting herd immunity in the population. No high risk age group could be identified for poliomyelitis.
We aimed to determine the outcome of nutritional intervention in children with moderate to severe malnutrition following persistent diarrhoea (PD), referred to a tertiary referral unit in Malaysia. Thirty-one (44%) of the 71 children (median age 19 months) with PD had moderate to severe malnutrition on admission. Fifty-three (75%) required dietary modification and 15 (21%) needed parenteral nutrition (PN, median duration 96 days). Of the 70 patients in whom remission of diarrhoea could be ascertained, 64 (91%) achieved remission. Three required home PN. At three months after discharge, there was a significant improvement in the mean weight-for-height z-score as compared to the original score at initial presentation (from -1.83 +/- -1.77 to -0.80 +/- -1.17; p < 0.001), although 12 (22%) of the 55 patients in whom nutritional status could be ascertained still had moderate to severe malnutrition. In conclusion, moderate to severe malnutrition was a common complication following PD resulting from diverse causes. With appropriate therapy, remission can be achieved in majority of patients, although a small number of patients needed home PN because of persistence of diarrhoea.
Mortality from acute diarrhoea in developed countries is low, but the morbidity and financial cost remains significant. A one-year prospective, descriptive, non-interventional, hospital-based study of acute gastroenteritis (AGE) was conducted in the year 2002 in the paediatric unit of University of Malaya Medical Centre, Kuala Lumpur, an urban hospital in Malaysia, to determine its morbidity and management. During the study period, 393 children with AGE were admitted, utilizing 0.50% of total patient-bed-day of the hospital. The median duration of symptoms before admission was two days. Seventy-seven percent of patients had consulted family physicians before admission. Antidiarrhoeal drugs (57%) and anti-emetics (48%) were commonly prescribed, but oral rehydrating solution (36%) was rarely advised. Upon admission, severe vomiting (24%) and severe diarrhea (24%) were not common, while 17% had moderate or severe dehydration. Rotavirus (22%) was the commonest pathogen identified. Electrolyte derangement, secondary septicaemia and chronic diarrhoea were all rare. Eighty-nine percent of patients received intravenous fluid therapy whilst in the hospital. No death was noted. The morbidity and mortality of children with AGE requiring hospital care in this study was low. However, preadmission management and fluid therapy after admission was not ideal. Efforts to encourage better adherence to established management protocol of AGE among family physicians and hospital clinicians should be instituted.
The profile of admissions staying less than 24 hours admitted to the paediatric wards of University Malaya Medical Center, Kuala Lumpur, over a period of six weeks was reviewed to ascertain the need of a short-stay ward. Ninety-three (22%) of the 428 admissions admitted during the study period were discharged within 24 hours, 56 (60%) were discharged within 12 hours. Major categories of admissions were: elective investigative procedures (43%), and emergency admissions (44%). Reasons for emergency admissions: infections 42%, minor trauma/cerebral concussion 25% and febrile/afebrile seizures 11%. Only 20% required percutaneous oximetry monitoring and 2% required observations more frequently than 2 hourly. There may be a case for a short stay ward in a big paediatric unit in Malaysia.
The risk factors and modes of death following acute diarrhoeal illness in children admitted to University Hospital, Kuala Lumpur between 1982 and 1997 were studied retrospectively. Among 4,689 cases of acute gastroenteritis admitted, ten deaths were noted. The case mortality rate was 2.1/1000 admissions. All deaths were infants below one year, with eight females and two males. Acute renal failure and acute pulmonary oedema were common preceding events. Female sex, infants less than twelve months, the presence of hyper or hyponatraemia and moderate to severe dehydration on admission were risk factors for deaths.
A retrospective review of all stool samples obtained from children aged < 16 years with diarrhoea from University of Malaya Medical Centre (UMMC), Kuala Lumpur, from 1978 to 1997 was undertaken to ascertain the pattern of bacterial pathogens causing diarrhoea in children in an urban area in Malaysia. Of 26444 stool samples processed, 2989 (11%) were positive. The five most common bacterial pathogens isolated were non-typhoidal Salmonella (57%), enteropathogenic E. coli (EPEC) (14%), Shigella spp. (11%), Campylobacter spp. (5%) and Aeromonas spp. (4%). There was a significant reduction in the average percentage of positive isolation during the last 5 years of the study period as compared to the first 5 years (15.0% vs. 7.2%; r = -0.92, p = 0.0001). EPEC and Shigella spp. were less commonly isolated in the last five years compared with the first five years of the study (6% vs 21% p < 0.001 for E. coli; 7% vs 22%, p < 0.001 for Shigella spp.). This information is important for public health education in reducing the incidence of childhood diarrhoea further, and in the selection of appropriate antimicrobials in the management of extra-intestinal complications of childhood diarrhoea.
Two hundred and ninety five children admitted with acute gastroenteritis from January 1, 1996 to December 31, 1996 to the Paediatric unit, University of Malaya Medical Centre, Kuala Lumpur, were reviewed. Eighty-nine percent of children received treatment before admission. Information regarding the type of treatment received were available in 152 (52%) cases. Eighty percent of them were prescribed medications, 40% were prescribed glucose-electrolyte mixtures, and 13% were advised a change of formula. Only 18 children (12%) were advised to take glucose-electrolyte mixtures alone. The four most common prescribed drugs were: antibiotics (43%), antipyretics (39%), antidiarrhoeal agents (30%), and antiemetics (24%). The use of antibiotics, antiemetics and antidiarrhoeal drugs for children with acute gastroenteritis among primary care doctors appears to be common. The use of glucose-electrolyte mixtures was uncommon.
From October 1996 to March 1997, 31 children with febrile convulsions were admitted to the University Hospital, Kuala Lumpur. Human Herpesvirus 6 (HHV 6) was virologically and/or serologically confirmed to be the cause of the febrile episode in 5 of these children (16.1%). Age, sex and other associated clinical features (diarrhoea, cough, running nose and type of seizure) were not useful in differentiating cases of febrile convulsion due to HHV 6 from those of other aetiology. However, uvulo-palatoglossal junctional ulcers were noted in children in whom the cause of the seizure could be attributed to HHV 6 but not in the remaining cases in the study group. HHV 6 DNA was detected in peripheral blood mononuclear cells from all patients with febrile convulsions attributed to HHV6, and in patients shown serologically to have already been exposed to the virus by nested polymerase chain reaction amplification. Only genotype HHV 6B was detected from patients with seizure due to HHV 6 but both genotype 6A and 6B were detected in the remaining cases studied.
Improvements in the overall treatment of patients with aggressive, large tumours involving the bone have made it possible to preserve and salvage limbs instead of amputating them. Each patient is unique in his clinical presentation and social circumstance. The different reconstructive options available allow us to choose the most appropriate method suited to the particular patient and with minimal delay, even when resources are limited. The patient and the relatives actively participate in the choice. The early experience of the different techniques for reconstructing these bone defects at our hospital are presented in this paper.
There is an increasing trend for Shigella isolates worldwide to be resistant to commonly prescribed antibiotics. The species distribution and antibiotic resistance of Shigella species isolated from children in Kuala Lumpur, Malaysia from 1978 to 1997 was reviewed. Three hundred and eighty six isolates were positive for Shigella species, representing 1.4% (95% CI: 1.3%-1.6%) of the 26320 total stool specimens and 13% (95% CI: 11.8%-14.2%) of 2986 isolates positive for bacterial pathogens. Shigella flexneri, constituting 74% of all isolates in the first five years of the study, decreased by 40% during the last five years (95% CI of decrease: 22.1%-57.9%), p-value < 0.0001) to 34%. There was a significant reduction (chi2 for linear trend = 77.6, p-value < 0.001) in the number of Shigella isolates as a percentage of total stool isolates obtained. 58% of the 241 isolates tested for antibiotic sensitivity were resistant to at least one antibiotic, and 42% wEre multi-resistant to three or more antibiotics. Shigella species was not a common pathogen among children admitted with diarrhoea in Kuala Lumpur, and was more likely to be resistant to commonly prescribed antibiotics.
A six-week-old male infant was admitted for investigation of cholestasis and pale stools. He became lethargic and apnoeic with prolonged seizures after a percutaneous liver biopsy. Subsequent investigations showed conjugated hyperbilirubinaemia, elevated liver enzymes, and hypoglycaemia. The radinuclide hepatobiliary scintigraphy was non-excretory. After an operative cholangiogram, the infant developed Addisonian-like crisis with bradycardia, hypotension, respiratory distress, metabolic acidosis, hypoglycaemia, hyponatraemia, and hyperkalaemia. Blood investigations confirmed congenital hypopituitarism. Hormone replacement therapy with L-thyroxine and cortisone acetate resulted in dissolution of jaundice and the reduction of the liver size.