The aim of this study, is to determine whether the fine characteristics of the fetal heart sounds could be used to identify intrauterine growth retarded fetuses. A preliminary evaluation, was conducted to compare these characteristics between intrauterine growth retarded fetuses and normal fetuses in the antenatal period after 36 weeks of gestation. Altogether, 7 IUGR fetuses were compared with 12 normal fetuses. An instrument named the Fetal Frequency Phonocardiogram was designed for this purpose. When connected to a personal computer and with a software programme specially written, the fetal heart sound characteristics were analysed. After detailed analysis, there were 3 significant differences between IUGR and normal fetuses, all of which gave a p-value of < 0.01. The frequency of the first heart sound was significantly higher in the IUGR fetuses compared to normal fetuses. The ratio of the amplitude of the first heart sound over the second heart sound was higher in the IUGR group. Finally, the ratio of the time between the first and second heart sound over the cardiac cycle was shorter in the IUGR fetuses. Fetal heart sound analysis, may provide a simple non-invasive method of detecting and monitoring fetuses at risk in the antenatal period.
An audit of all perioperative deaths within seven days of surgery in 14 major public hospitals is presented. This study is part of a quality assurance programme examining the surgical and anaesthetic practices in these hospitals. During the study period from July 1992 till June 1994, 211,354 surgeries were performed and 715 deaths were reported out of which 699 were available for analysis. The data was obtained by confidential enquiry using predetermined questionnaires filled by participating surgeons and anaesthetists and analysed by a group of peers. The overall crude mortality rate was 0.34% and the majority of the deaths occurred in severely ill patients in whom the clinical management was satisfactory. Polytrauma including head, intra-abdominal and skeletal trauma accounted for 253 of the deaths (36.19%). The other causes were bowel obstruction with sepsis, burns, ischaemic limbs, congenital malformations in neonates and pregnancy-related hemorrhage. 62.52% of the deaths occurred within two days of surgery and 85.87% were related to emergency procedures. The review identified some shortfalls in perioperative care and these were lack of adequate critical care facilities, lack of supervision, unnecessary surgery in the moribund and inadequate preoperative optimisation. The results of the study have been forwarded to all participating hospitals for implementation of remedial measures.
This is a retrospective study of the prevalence of Human Immunodeficiency Virus (HIV) positive mothers in two states in Malaysia i.e., Perak and Negeri Sembilan since the introduction of the HIV screening programme in antenatal mothers. The study period was from 1/9/97 to 1/9/99. A total of 29 HIV positive antenatal mothers were detected (21 from Perak and 8 from Negeri Sembilan) throughout the study period. Out of the 21 HIV positive mothers from Perak, 8 (38%) were foreign nationals whereas only 1 (12%) out of the 8 from Negeri Sembilan was a foreign national. The main risk factor identified in both the groups was multiple sexual partners. The vertical transmission rates for the patients from Perak were 14.2% and 37.5% in Negeri Sembilan. There was no significant short-term adverse obstetric outcome.
Hydatidiform mole with a coexistent fetus is a rare occurrence with an incidence of I per 22,000-100,000 pregnancies. It is associated with persistent gestational trophoblastic tumour. Hence an early and correct diagnosis is imperative to plan subsequent management of such patients. We report a case of a primigravida who presented with vaginal bleeding at early second trimester. Expectant management was carried out for her pregnancy which finally ended in an abortion. The pathology, clinical findings and current management of this rare entity is discussed.
Pre-eclampsia or pregnancy induced hypertension (PIH) affects 6-8% of all pregnancies. Although the underlying mechanism of PIH is still unknown, it is widely believed that the placenta plays an important role. It was thought that an ischemic placenta due to poor perfusion can precipitate the signs and symptoms of PIH. This study aims to investigate the possible role of Type 1(AT1) and Type 2 (AT2) angiotensin II receptor subtypes in the mechanism of PIH. AT1 receptor stimulation causes vasoconstriction and AT2 receptor stimulation causes vasodilatation. Investigating the interactions of these two receptors in the placenta provides an insight as to the balance that may exist between AT1 and AT2 receptors in normal pregnancy. Any disruption to the balance might cause a disruption of the blood flow in the placenta, leading to PIH. Placentas were collected from 11 PIH patients and 11 normal patients. Immunohistochemistry techniques were performed on the placental tissue to determine the distribution of AT1 and AT2 receptors in the placental tissue qualitatively and quantitatively. It was observed that in normal patients, the balance between AT1 and AT2 receptors is that the level of AT2 receptors is higher than the level of AT1 receptors. However in the PIH patient, it was observed that the normal balance was disrupted. In PIH patients the level of AT1 receptors was observed to be higher than the level of AT2 receptors. This study suggests that disruption of the balance between AT1 and AT2 receptors observed in PIH placentas might cause a decrease in blood flow to the placenta, causing it to be poorly perfused. This may cause placental ischemia which may lead to PIH.
Emergency contraceptive pills (ECP) are effective, safe and cheap, with profound global health and economic benefits. Patient education and easy access to ECP will contribute immensely to avoiding unwanted pregnancies and unsafe abortions. Issues related to morality, its perceived status as an abortifacient and harmful behaviour should it be easily available, has limited the widespread use of ECP in many countries.
INTRODUCTION: We evaluated the progress in the self-perceived competence of medical students in a range of common clinical, practical and personal skills, in their final six months of training.
METHODS: The study was conducted on 65 final-year medical students undertaking their senior clerkship training at International Medical University, Malaysia. Questionnaire surveys were conducted at the beginning and the end of the six-month period, with 44 items covering clinical, practical, personal skills and readiness to work. Correlations were performed for experience and self-perceived competence, with the respective skills.
RESULTS: 64 students returned the first survey and 63 returned the second survey. When the two survey results were compared, significant increases were found in self-perceived competence for the majority of the skills examined. The items with no significant improvement were divided into those which the students were already proficient in before senior clerkship, and those in which experience and confidence remained poor at the end of training. There were significant, but moderate, correlations between the experience and confidence of all common practical skills (correlation coefficients: 0.348-0.522, p-value is less than 0.001 for all items). At the end of training, students were, in general, more prepared to work as house officers (mean rating in the first survey: 3.05, second survey: 3.97, p-value is less than 0.001).
CONCLUSION: Significant progresses in clinical experience and confidence can be observed in the final stages of medical training. The findings of inadequate improvements in some skills call for dedicated training sessions and strengthening of on-site supervision.
Study site: International Medical University, Batu Pahat Campus, Johor, Malaysia
Doctor-patient relationship is a special kind of social. relationship where bonding is planned and carried out with the final objective of helping the patient to achieve the treatment goal. A positive therapeutic relationship encourages active participation of patient in the treatment plan, contributing to success of treatment goals and minimizing malpractice suits. The humanistic approach emphasizes the importance of love, belonging, self esteem, self expression and the final stage of self actualization-the drive to realize one's full potential. In person centered approach to therapeutic relationship, the three most fundamental elements are congruent (genuineness), unconditioned positive regards and empathy. In daily medical consultation, applying these elements can promote greater chance of success in the therapeutic process.
Urinary incontinence is an important and common health care problem affecting the elderly population. Common types of incontinence affecting the elderly are: stress incontinence, urge incontinence, overflow incontinence and mixed type. The elderly patient suffering from urinary incontinence does not often seek treatment voluntary due to a misconception that it is part of a normal ageing process. Without treatment, urinary incontinence may lead to serious psychological and social complications such as depression, anxiety, embarrassment, low self-esteem and social isolation. Overall it is associated with significant poor quality of life for the elderly. Life style modification and behavioural therapy with or without pharmacotherapy help in improving the symptoms. Pelvic floor muscles' training is beneficial for stress incontinence in up to fifty percent of the patients. Elderly patients with urinary incontinence should be encouraged to seek treatment early, as the problem can be treated and they will have a better quality of life.
Nausea and vomiting are common in early pregnancy affecting 70-80 percent of pregnant mothers. In a majority of women vomiting begins between 4-7 weeks of pregnancy. Nausea and vomiting are usually mild and self-limiting, however some of the mothers have a more profound course which lead to hyperemesis gravidarum. Careful clinical evaluation is necessary to exclude underlying medical illnesses or non pregnancy related causes of severe vomiting. Hyperemesis gravidarum poses health risk to both mother and baby, therefore prompt treatment should be initiated without delay. Non pharmacotherapy such as dietary modification and emotional support are useful. Pharmacotherapy with antiemetics, pyridoxine, methylprednisolone are effective and relatively safe. Severe hyperemesis with dehydration and electrolyte imbalance may need hospitalisation for electrolyte and fluid replacement.
Gestational trophoblastic disease is a spectrum of pregnancy disorder arising from the placental trophoblastic tissues. It characterised by the secretion of a distinct tumour marker, the beta-HCG. This condition is highly curable even in the presence of metastasis. The incidence of this disease is higher in the Asian population. The major well-established risk factors for gestational trophoblastic disease are advanced maternal age and a past history of gestational trophoblastic disease. Common clinical presentations include vaginal bleeding in early trimester, uterus larger than gestational age, absence of fetal parts after 20 weeks of gestation. Ultrasonography is a reliable non-invasive tool for diagnosis of gestational trophoblastic disease in the clinical setting. All placental tissue following miscarriage or curettage should have histopathological evaluation to exclude gestational trophoblastic disease. Since this group of disorders is one of the highly curable neoplasms, early diagnosis and prompt treatment is necessary.
Recurrent vaginal candidiasis is one of the most common reasons for patients visiting their primary care doctors. Majority of the cases are caused by Candida albicans. Controlling of risk factors such as diabetes mellitus, used of broad spectrum antibiotics, contraceptive pills and steroid therapy helps in managing recurrent vaginal candidiasis. Initial 14-day course of oral azoles and followed by 6 months maintenance are effective in treating majority of the cases. Failure to treat recurrent vaginal candidiasis can lead to various bio-psycho-social complications.
Urinary tract infections frequently affect pregnant mothers. This problem causes significant morbidity and healthcare expenditure. Three common clinical manifestations of UTIs in pregnancy are: asymptomatic bacteriuria, acute cystitis and acute pyelonephritis. Escherichia coli remains the most frequent organism isolated in UTIs. All pregnant mothers should be screened for UTIs in pregnancy and antibiotics should be commenced without delay. Urine culture and sensitivity is the gold standard in diagnosing UTIs. Without treatment, asymptomatic bacteriuria in pregnancy is associated with preterm delivery, intrauterine growth retardation, low birth weight, maternal hypertension, pre-eclampsia and anaemia. Acute pyelonephritis can lead to maternal sepsis. Recurrent UTIs in pregnancy require prophylactic antibiotic treatment.
Two identical groups of females underwent caesarean operations. One group was induced with propofol 2.04 (SD 0.023) mg per kilogram and the other group induced with methohexitone 1.05 (SD 0.15) mg per kilogram body weight. Maintenance of anaesthesia was identical in both groups. Post-intubation blood pressure in the methohexitone group was significantly raised whereas with propofol the changes were not significant. There were no significant differences in the Apgar scores, uterine contractility and umbilical venous or arterial blood gases. There was a significant difference in the analgesic requirement in the first hour of the post-operative period; in the propofol group, patients needed less analgesia compared to the methohexitone group. There was no maternal awareness in both groups.
A prospective randomised controlled study was conducted over a 6 month period on the value of administering prophylactic antibiotics in patients undergoing emergency caesarean section at the Ipoh General Hospital. A total of 222 patients were randomised to receive 24 hours of ampicillin (500 mg per dose), cefoperazone (1 gm per dose) or no antibiotics. In all parameters of patient morbidity, the group receiving cefoperazone showed significantly better results as compared to the group not receiving antibiotics. The ampicillin group also had favourable results but generally not achieving statistical significance. Prophylactic antibiotics appear to be beneficial and consideration should be given to make it a routine in all emergency caesarean sections.
The 'overactive bladder' is a common problem affecting the elderly female population especially after the menopause. Urgency with or without urge incontinence accompanied by frequency of micturition and nocturia are presenting symptoms. The diagnosis is established after excluding other diseases of the lower urinary tract which have similar presenting features. The aetiology is multifactorial and this problem often causes physical, psychological and emotional distress to the patient. Management can be provided by primary care physicians initiating behavioral changes which include life style interventions and bladder drills with or without antimuscarinic drugs. The recalcitrant patient not responding to conventional therapy should be referred for specialist care. Non-conventional treatment using acupressure, neuromodulation and surgical methods are only instituted in indicated cases.
Pelvic inflammatory disease (PID) describes the clinical features of sexually transmitted pelvic infection ranging from acute salpingitis to salpingo-oophoritis and ultimately pelvic abscess. Intra-tubal adhesions and pelvic adhesive disease are the long-term sequelae of PID which may lead to both sub-fertility and tubal ectopic pregnancy. Laparoscopy is the definitive diagnostic modality, but is invasive and not suitable for routine clinical practice especially in the primary care setting. Ascending infection by Neiserria gonorrhoea, Chlamydia trachomatis and less commonly bacterial vaginosis and mycoplasma have been traditionally associated as causative pathogens in PID. As polymicrobial infections are being implicated in PID before culture and sensitivity results are available empirical treatment based on clinical guidelines is justified initially. Pre-emptive testing and treatment for woman at increased risk of chlamydia has been shown to reduce the risk of PID by up to two-thirds. It is imperative that medical practitioners have low thresholds for testing and treatment of both sexually active young women and men.
Concerns about professionalism in medicine have made necessary the explicit teaching and learning of ethics, professionalism and personal development. The noble profession of medicine, taken up as a "calling" by those who are expected to put the needs of the patient above their own, appears to have become a fees-for-service business model and trade. Parental expectations, the diminishing sense of responsibility in teachers, lack of role models, technological advancements, sub-specialisation and third-party involvement in the healthcare delivery system have been identified as reasons for these concerns. The General Medical Council in the United Kingdom, and other professional bodies in both Europe and the Americas, have emphasised the need to enhance the teaching and learning of professionalism in medical schools, particularly the development of good attitudes, appropriate and competent skills, and the inculcation of a value system that reflects the tenets of professionalism in medicine. The medical curriculum will need to be scrutinised so as to introduce the subject of professionalism at all levels of training and education. Barriers to learning professionalism have been identified and students need to be equipped to resolve conflicts and to put the needs of others above their own.