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External quality assurance in Malaysia

Nawawi H, Lim HH, Zakiah I

Southeast Asian J. Trop. Med. Public Health, 1999;30 Suppl 3:39-45.
PMID: 10926257

An activity supportive of the MOH QA Programme, the National EQAS for clinical chemistry monitors for analytical performance in core routine biochemical testing by the pathology laboratories, with unsatisfactory performance scores serving to alert against deficiencies or problems and the scores in subsequent challenges providing the feedback of effectiveness of remedial actions taken. While unacceptable individual analyte performance score (variance index score, VIS) indicated problems in instruments, reagent and calibrators, or the use of inherently poorer methods, repeated occurrence of unsatisfactory OMRVIS was traceable to generally poor laboratory management of usually inadequately-equipment small laboratories. The outcome has been one of slow but gradual improvement in the overall performance of participating laboratories, with a move towards methods upgrading and standardization to achieve greater concordance of results. Presently, the programme is limited to 61 government and 4 private hospital laboratories in the country for 12 commonly assayed clinical biochemistry analytes. It is hoped that the NEQAS could be extended to the other private laboratories and that of academic institutions. However, this is dependent to a large extent on the manpower and financial support obtainable by the organizing body of the programme in the future. Belk and Sunderman, 1947 demonstrated that laboratories participating in an quality assessment scheme could rapidly and dramatically improve their analytical performance. In some countries, participation has become mandatory, and acceptable performance is a requirement in laboratory accreditation. The need and value of the NEQAP is, therefore, evident. While there may be limitations in the national programme. efforts are being made at improving the programme within the means and resources of the organising body. The goals of the NEQAP are not just to monitor performance but also to educate. On this, matters related to and supportive of these goals have also been pursued. The annual workshop/forum on quality controls had allowed exchange of information between representatives of participating laboratories and the organising body. Recently in the 1997 MOH Quality Improvement evaluation, Quality Control has been evaluated together with the other 17 such activities. The study on knowledge, attitude and practice has provided the necessary feedback and will be used for future planning in making efforts at increasing the effectiveness and benefits of the all QC activities including this NEQAP for clinical chemistry. In addition, there is a need to look into areas such as selection of methods and test systems, and improvement of continuing education, training as well as research in quality improvement as suggested by the Quality Improvement evaluation.
An evaluation of the Beckman glucose analyser 2

Lim HH, Zaini-Rahman M

Med J Malaysia, 1979 Jun;33(4):317-20.
PMID: 522742
Fulltext Asbestosis in Malaysia: report on first two cases

Lim HH, Rampal KG, Joginder S, Abu Bakar CM, Chan KH, Vivek TN

Med J Malaysia, 1999 Sep;54(3):364-7.
PMID: 11045065

The first two cases of asbestosis in Malaysia are reported. Both had considerable occupational exposure to asbestos dust in the past, with a long latency period exceeding 30 years. One case presented with distinctive clinical and radiological features, while the other case was only confirmed by histological diagnosis. The usefulness of modern investigation techniques such as CT scan in the diagnosis of asbestosis is also illustrated.
Fulltext Respiratory conditions in Malaysian asbestos cement workers

Lim HH, Rampal KG, Joginder S, Abu Bakar CM, Chan KH, Vivek TN

Med J Malaysia, 2002 Sep;57(3):340-7.
PMID: 12440274 MyJurnal

A cross-sectional study was conducted to determine the prevalence and type of respiratory conditions including asbestos-related diseases among Malaysian asbestos cement workers. The study population consisted of 1164 workers who had undergone medical surveillance from 1995 to 1997, including full history, physical examination, chest radiography and spirometry. More than half the male workers were smokers or ex-smokers, with smokers having more respiratory symptoms and signs, and reduced FEV1 compared with non smokers. The five most common respiratory conditions diagnosed were bronchial asthma, chronic bronchitis, pulmonary tuberculosis, upper respiratory tract infections and allergic rhinitis. On follow-up, there were also two cases of asbestosis and one case of bronchial carcinoma. The asbestosis cases were probably related to heavy occupational exposure to asbestos fibres in the past, before governmental regulations were gazetted in 1986. Further follow-up is essential for continued monitoring of the health status of asbestos workers.
Blood cadmium levels in Malaysian pregnant women

Lim HH, Ong CN, Domala Z, Phoon WO

Southeast Asian J. Trop. Med. Public Health, 1983 Sep;14(3):394-8.
PMID: 6658508

Blood cadmium levels in Malaysian pregnant women were determined. There was no significant urban-rural difference in mean blood cadmium levels.
Fulltext Dynamic measurement of axial vertebral rotation and rotational flexibility in scoliosis by flouroscopic method

Lim HH, Ong CH

Med J Malaysia, 2001 Jun;56 Suppl C:41-5.
PMID: 11814248

The Pedriolle torsion meter is an established method of vertebral rotation assessment in scoliosis. However, the assessment of scoliosis by this method is static and indirect. The objective of this study is to compare the accuracy of a direct method of assessing scoliosis rotation by fluoroscopy compared to the Pedriolle torsion meter. Secondly, to determine that vertebral body rotation changes with supine posture compared to erect position. Eight volunteers with idiopathic scoliosis were assessed for the apical vertebral rotation with this method and the Pedriolle torsion meter. These patients were also assessed in the supine and erect position with the fluoroscopic method to determine if the apical vertebral rotation would change with posture. The mean Cobb angle of the curves was 62.8 degrees (range 45 degrees to 86 degrees). The mean apical vertebral rotation in a standing position was assessed to be 21.5 degrees by Pedriolle torsion meter and 29 degrees by the fluoroscopic method. This difference was not statistically significant by the student t-test. In most patient, the rotation of vertebrae improved by a varying degree ranging from none to 24 degrees in the supine position. In conclusion, the fluoroscopic method is an alternate mean of measuring vertebrae rotation in idiopathic scoliosis, with comparable accuracy to the Pedriolle torsion meter method. The amount of vertebral rotation changes with posture of the patient.
The Malaysian Clinical Guidance on the management of postmenopausal osteoporosis, 2012: a summary

Yeap SS, Hew FL, Lee JK, Goh EM, Chee W, Mumtaz M, et al.

Int J Rheum Dis, 2013 Feb;16(1):30-40.
PMID: 23441770 DOI: 10.1111/1756-185x.12037

AIM: This Clinical Guidance is aimed to help practitioners assess, diagnose and manage their patients with osteoporosis (OP), using the best available evidence.
METHODS: A literature search using PubMed (MEDLINE) and The Cochrane Library identified all relevant articles on OP and its assessment, diagnosis and treatment, from 2005, to update from the previous edition published in 2006. The studies were assessed and the level of evidence assigned; for each statement, studies with the highest level of evidence were used to frame the recommendation.
RESULTS: This article summarizes the diagnostic and treatment pathways for OP, highlighting the new data that have changed the way we assess and treat OP. Instead of starting treatment based on bone mineral density alone, there has been a move to assessing 10-year fracture risk before treatment, using tools such as the Fracture Risk Assessment Tool (FRAX). There has been a re-evaluation on calcium supplementation and more emphasis on the importance of vitamin D. There has been concern about the potential adverse effects of the long-term usage of bisphosphonates, which we have discussed fully. New drugs that have been licensed since 2006 in Malaysia have been included.
CONCLUSIONS: Adequate intake of calcium (1000 mg from both diet and supplements) and vitamin D (800 IU) daily remain important in the treatment of OP. However, in confirmed OP, pharmacological therapy with anti-resorptives is the mainstay of treatment. Patients need to be regularly assessed while on medication and treatment adjusted as required.
Fulltext Tophaceous gout causing atlanto-axial subluxation mimicking rheumatoid arthritis: a case report

Wazir NN, Moorthy V, Amalourde A, Lim HH

J Orthop Surg (Hong Kong), 2005 Aug;13(2):203-6.
PMID: 16131689 DOI: 10.1177/230949900501300220

This is a case report of an extremely rare condition of atlanto-axial subluxation secondary to gouty arthritis, which mimicked rheumatoid arthritis at presentation. Gouty arthritis involving the spine is a rare condition. We highlight a case of gouty arthritis involving the atlanto-axial joint resulting in joint instability, subluxation, and neurological deficit. A 66-year-old obese woman who had a polyarticular disease for the previous 3 years presented with neck pain and progressive neurology. A 2-stage procedure was performed: posterior decompression and occipitocervical fusion followed by further anterior trans-oral decompression. However, after an initial neurological improvement, she succumbed to aspirational pneumonia and septicaemia. Atlanto-axial subluxation caused by gouty arthritis can present in the same way as rheumatoid arthritis. Therefore, the possibility of this as a differential diagnosis should be kept in mind.
Fulltext Coronal plane and apical vertebral rotation correction of adolescent idiopathic scoliosis with multisegmented hook-rod system--a retrospective review

Kwan MK, Chooi WK, Lim HH

Med J Malaysia, 2004 Dec;59 Suppl F:14-8.
PMID: 15941155

Between April 1998 and December 1999, thirty patients with Idiopathic Scoliosis were operated with Multisegmented Hook-Rod System. These patients were operated at the mean age of 16 years and were followed up for a mean of 22.3 months (range 13-34 months). Seven patients had anterior release to increase the curve flexibility followed by second stage posterior instrumentation on the same day. The average operating time for a posterior instrumentation alone and anterior release combined with posterior instrumentation were 270 minutes and 522 minutes respectively. The average blood loss was 2.2 litres for posterior instrumentation alone and 3.3 litres for single day anterior release and posterior surgery. The mean preoperative Cobb's angle was 70 degrees. The mean immediate postoperative and final follow up Cobb's angles were 38 and 42 degrees, which represented an average coronal plane correction of 46.7% and 40.0% respectively. The mean preoperative apical vertebral rotation was 25 degrees, which improved to 15 degrees after the operation. At final follow up, the mean apical vertebra rotation was 20 degrees, which represented a mean apical vertebral rotation correction of 20%. Complications of the procedure included one transient neurological deficit, one infection, one graft site infection and one case of screw cut out. We were able to obtain satisfactory correction of idiopathic scoliosis with the Multisegmented Hook-Rod System.
Fulltext Delayed decompression of chronic C1C2 subluxation in a pediatric patient with tetraplegia--is recovery possible?

Razif M, Lim HH

Med J Malaysia, 2001 Jun;56 Suppl C:76-9.
PMID: 11814256

A 2 year-old Malay girl was admitted to our institution with a chesty cough and breathlessness but later found to have a chronic C1/C2 subluxation for one and half year with tetraplegia. Her cervical cord was decompressed and occipito-cervical fusion performed. Her neurological status improved significantly post-operatively and is able to care for her personal hygiene. The authors believe that the ability of the cervical cord to recover in the paediatric age group is remarkable that surgical option should be considered even when all seen lost. We believe that this is the first report in the literature to support this potential.
Health problems of agricultural workers in Malaysia

Lim HH

Trop Geogr Med, 1983 Mar;35(1):83-9.
PMID: 6612777

The present paper reviews the health problems of rural agricultural workers in Malaysia. As is common with most developing countries, the agricultural sector forms the pillar of the national economy in Malaysia, the major products being rubber, palm oil, rice and timber. Most of the agricultural workers, who form the largest occupational group in the country, live in the rural areas under poor socioeconomic and environmental conditions. Their general health problems include large families, substandard housing, overcrowding, lack of piped water supply and sanitary excreta disposal, malnutrition and prevalent diseases such as cholera, typhoid, dysentery and parasitic infections. The specific occupational health problems include infectious diseases, agricultural accidents, pesticide poisonings, physical hazards, keratitis nummularis and snake-bites. The organization of agricultural health services in developing countries is also discussed.
Fulltext Occupational diseases in Malaysia: the need for better notification

Lim HH

Med J Malaysia, 1982 Jun;37(2):98-101.
PMID: 7132840
Fulltext The epidemiology of cancers in the University Hospital, Kuala Lumpur

Lim HH

Med J Malaysia, 1982 Mar;37(1):52-9.
PMID: 7121347

A descriptive study of 1,945 cancer cases discharged from the University Hospital, Kuala Lumpur, during the three-year period from 1972 to 1974, was carried out to analyse cancer patterns and frequency in the various age, sex and ethnic groups, The highest frequency of cancers occurred among the Chinese (68.8 percent) in excess of that expected from their utilization rate of the hospital (50.5 percent). The jive leading cancers in males were lung, liver, stomach, nasopharynx and rectum. In the females, the five leading cancers were cervix uteri, breast, stomach, lung and ovary. This was the pattern reflected among the Chinese, the patterns for the Malays and Indians were different. In addition, the Chinese constituted the highest proportions in most of the selected individual cancers analysed (including cancer of the nasopharynx, lung, liver, stomach, cervix, breast, rectum and colon). However, there was a high proportion of Indians in laryngeal and skin cancer. The age distribution of the patients showed that cancers of the oesophagus, stomach, colon, rectum, liver, lung, skin and bladder, were predominant in the older age groups (55 years and above). Carcinoma of the cervix uteri, ovary and breast were more common in the 45-54 years age group, while leukaemia, thyroid and nasopharyngeal carcinoma were more common in the younger age groups. Comparisons with other studies showed strikingly similar patterns to those found in Singapore, 1968-70.
Fulltext The role of the occupational health nurse

Lim HH

Med J Malaysia, 1982 Mar;37(1):90-5.
PMID: 7121357
Occupational health nursing services in two countries

Lim HH

Public Health, 1983 Jul;97(4):221-7.
PMID: 6622644
Fulltext Noninvasive Bimodal Neuromodulation for the Treatment of Tinnitus: Protocol for a Second Large-Scale Double-Blind Randomized Clinical Trial to Optimize Stimulation Parameters

Conlon B, Hamilton C, Hughes S, Meade E, Hall DA, Vanneste S, et al.

JMIR Res Protoc, 2019 Sep 27;8(9):e13176.
PMID: 31573942 DOI: 10.2196/13176

BACKGROUND: There is increasing evidence from animal and human studies that bimodal neuromodulation combining sound and electrical somatosensory stimulation of the tongue can induce extensive brain changes and treat tinnitus.
OBJECTIVE: The main objectives of the proposed clinical study are to confirm the efficacy, safety, and tolerability of treatment demonstrated in a previous large-scale study of bimodal auditory and trigeminal nerve (tongue) stimulation (Treatment Evaluation of Neuromodulation for Tinnitus - Stage A1); evaluate the therapeutic effects of adjusting stimulation parameters over time; and determine the contribution of different features of bimodal stimulation in improving tinnitus outcomes.
METHODS: This study will be a prospective, randomized, double-blind, parallel-arm, comparative clinical trial of a 12-week treatment for tinnitus using a Conformité Européenne (CE)-marked device with a pre-post and 12-month follow-up design. Four treatment arms will be investigated, in which each arm consists of two different stimulation settings, with the first setting presented during the first 6 weeks and the second setting presented during the next 6 weeks of treatment. The study will enroll 192 participants, split in a ratio of 80:80:16:16 across the four arms. Participants will be randomized to one of four arms and stratified to minimize baseline variability in four categories: two separate strata for sound level tolerance (using loudness discomfort level as indicators for hyperacusis severity), high tinnitus symptom severity based on the Tinnitus Handicap Inventory (THI), and tinnitus laterality. The primary efficacy endpoints are within-arm changes in THI and Tinnitus Functional Index as well as between-arm changes in THI after 6 weeks of treatment for the full cohort and two subgroups of tinnitus participants (ie, one hyperacusis subgroup and a high tinnitus symptom severity subgroup). Additional efficacy endpoints include within-arm or between-arm changes in THI after 6 or 12 weeks of treatment and in different subgroups of tinnitus participants as well as at posttreatment assessments at 6 weeks, 6 months, and 12 months. Treatment safety, attrition rates, and compliance rates will also be assessed and reported.
RESULTS: This study protocol was approved by the Tallaght University Hospital/St. James's Hospital Joint Research Ethics Committee in Dublin, Ireland. The first participant was enrolled on March 20, 2018. The data collection and database lock are expected to be completed by February 2020, and the data analysis and manuscript submission are expected to be conducted in autumn of 2020.
CONCLUSIONS: The findings of this study will be disseminated to relevant research, clinical, and health services and patient communities through publications in peer-reviewed journals and presentations at scientific and clinical conferences.
TRIAL REGISTRATION: ClinicalTrials.gov NCT03530306; https://clinicaltrials.gov/ct2/show/NCT03530306.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13176.
Bimodal neuromodulation combining sound and tongue stimulation reduces tinnitus symptoms in a large randomized clinical study

Conlon B, Langguth B, Hamilton C, Hughes S, Meade E, Connor CO, et al.

Sci Transl Med, 2020 10 07;12(564).
PMID: 33028707 DOI: 10.1126/scitranslmed.abb2830

Tinnitus is a phantom auditory perception coded in the brain that can be bothersome or debilitating, affecting 10 to 15% of the population. Currently, there is no clinically recommended drug or device treatment for this major health condition. Animal research has revealed that sound paired with electrical somatosensory stimulation can drive extensive plasticity within the brain for tinnitus treatment. To investigate this bimodal neuromodulation approach in humans, we evaluated a noninvasive device that delivers sound to the ears and electrical stimulation to the tongue in a randomized, double-blinded, exploratory study that enrolled 326 adults with chronic subjective tinnitus. Participants were randomized into three parallel arms with different stimulation settings. Clinical outcomes were evaluated over a 12-week treatment period and a 12-month posttreatment phase. For the primary endpoints, participants achieved a statistically significant reduction in tinnitus symptom severity at the end of treatment based on two commonly used outcome measures, Tinnitus Handicap Inventory (Cohen's d effect size: -0.87 to -0.92 across arms; P < 0.001) and Tinnitus Functional Index (-0.77 to -0.87; P < 0.001). Therapeutic improvements continued for 12 months after treatment for specific bimodal stimulation settings, which had not previously been demonstrated in a large cohort for a tinnitus intervention. The treatment also achieved high compliance and satisfaction rates with no treatment-related serious adverse events. These positive therapeutic and long-term results motivate further clinical trials toward establishing bimodal neuromodulation as a clinically recommended device treatment for tinnitus.
Fulltext Traumatic posterior rotatory fracture-dislocation of lumbo-sacral spine

Mukundala VV, Lim HH

Singapore Med J, 2001 Feb;42(2):82-4.
PMID: 11358198

Fracture-dislocation of the lumbo-sacral spine was an unusual injury and was divided into anterior, posterior and lateral types depending on the displacement of the cephalad portion of the spine over the caudal portion. According to the authors' knowledge, only 31 cases of traumatic fracture-dislocation of the lumbo-sacral spine were reported in the English literature. Only 3 previous reports referred to this injury with a posterior displacement, which was an even rarer injury. This was the fourth report of this type of injury.
Fulltext Ventilatory function in Malay office workers in Malaysia

Che' Man AB, Lim HH

Singapore Med J, 1983 Jun;24(3):135-9.
PMID: 6635675

A study was carried out to determine ventilatory capacity (Forced Expiratory Volume or FEV1 and Forced Vital Capacity or FVC) in apparently normal Malay office workers in Malaysia. The subjects, 78 males and 113 females, were interviewed using a standardized questionnaire to exclude those with symptoms or past history of cardiopulmonary disease. Measurements of age, height, weight, FEV, and FVC were made on each subject; the FEV, and FVC were measured using Vitalograph spirometers. The mean FEV, and FVC for males were 3.35 litres and 3.76 Iitres, respectively. For females, the mean FEV, and FVC were 3.46 and 2.72 Iitres, respectively. Height was positively correlated with FEV, and FVC (p
Fulltext Cancer mortality in the Federal Capital of Malaysia

Lim HH

Singapore Med J, 1986 Dec;27(6):512-8.
PMID: 3589722

A study of cancer deaths registered in the Federal Capital of Malaysia during a three-year period from 1979-1981 was carried out to analyse the cancer patterns by age, sex and ethnic group. There were altogether 2524 cancer deaths, constituting 14.5% of the total 17,446 deaths in the three years. Analysis was based on the medically certified and inspected deaths, which constituted 98.2% of the total deaths. Classification was based on the Eighth (1965) Revision of the WHO International Classification of Diseases. A detailed description of the most common cancer deaths among males and females in the total study population, and in each of the three major ethnic groups (Malays; Chinese, Indians) was carried out. Ethnic variations in mortality from some of the common cancers were described and discussed, and compared with another series based on hospital admissions.

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