MyMedR

Palliative care in Malaysia: the need to do much more

Sivalingam N, Lim RBL, Rampal L

Med J Malaysia, 2021 05;76(3):279-283.

PMID: 34031323

No abstract provided.

Writing Articles on Continuing Medical Education for Medical Journals

Sivalingam N, Rampal L

Med J Malaysia, 2021 03;76(2):119-124.

PMID: 33742616

Sharing of knowledge through Continuing Medical Education (CME) contribute immensely to professional development of skills in clinical medical practice. Thus, the writing of CME articles should adopt an approach that addresses the needs of the readers by attempting to fill gaps in their knowledge, skills, and ethics about clinical care. As such CME articles should be comprehensive and focused on specific areas. The specific learning outcomes should be well defined. In designing and development of such articles, pedagogic principles are to be borne in mind. In this article we outline a guide to writing a CME article, incorporating both the principles of instructional design and directed selflearning. The ideal CME articles will transit through multimedia-enhanced interactive online learning, with greater use of connectivity through the internet. Synchronous and asynchronous learning is in greater need, as distance and online learning are increasingly popular. Authors of CME articles will need to eventually design CME articles to be interactive, enriched with multimedia to engage their readers. Lesson plans employing instructional design principles should aim to promote both instructions for learning and formative assessment ensuring learning have taken place, and outcomes have been achieved. This article describes on how to write effective CME articles for medical journals.

Incidence of vaginal erosion with different synthetic materials for suburethral sling in the treatment of Stress Urinary Incontinence: A systematic review

Sivalingam N, Teng YH, Chong XY, Low CH, Manocha SK, Intan Sabreena MS

Med J Malaysia, 2018 06;73(3):147-153.

PMID: 29962498 MyJurnal

INTRODUCTION: The aim of this systematic review is to compare the vaginal erosion rates in different synthetic materials used in suburethral slings in Tension Free Vaginal Tape (TVT-O /TOT) procedures in management of female stress urinary incontinence.

METHODS: PRISMA 2009 framework was adopted for study design. Scholarly literature search was done using MEDLINE, EMBASE, the Cochrane Library and Clinical Trials.gov using selected keywords. Five articles fulfilled the inclusion and exclusion criteria. Our main outcome of interest is to review the ideal properties of the suburethral sling, procedure of insertion and post-surgical complication following the sling insertion primarily vaginal erosion. Results were compared using one way-ANOVA test and independent T- test.

RESULTS: Total of 1725 subjects were available for analysis in the five studies. Monofilament polypropylene constituted 92.5% of the total sample size from one study alone. Polyester (n= 16/51) causes higher incidence rate of vaginal erosion compared to monofilament polypropylene (31.4 vs., 4.7; p = 0.01). There was no difference in the vaginal erosion rate between monofilament polypropylene and multifilament polypropylene (4.7 vs, 14.1; p=0.055) as well as between multifilament polypropylene and polyester (14.1 vs, 31.4; p=0.068). Although there was a marginally lower rate of vaginal erosion in TVT-O over TVT, the difference was not significant. (5.6 vs., 6.4, p=0.468). Common presentations of vaginal erosion were vaginal discharge, perineal pain and dyspareunia.

CONCLUSION: Given the limited sample size, polyester sling material appears to cause higher rates of vaginal erosion. No difference in erosion rate was seen between TVT and TVT-O.

Fulltext Parental preferences with regards to disclosure following adverse events occurring in relation to medication use or diagnosis in the care of their children - perspectives from Malaysia

Wong CH, Tan TR, Heng HY, Ramesh T, Ting PW, Lee WS, et al.

Med J Malaysia, 2016 Aug;71(4):186-192.

PMID: 27770117

Open disclosure is poorly understood in Malaysia but is an ethical and professional responsibility. The objectives of this study were to determine: (1) the perception of parents regarding the severity of medical error in relation to medication use or diagnosis; (2) the preference of parents for information following the medical error and its relation to severity; and (3) the preference of parents with regards to disciplinary action, reporting, and legal action.

Fulltext Strategic interventions in the management of gestational diabetes to reduce type 2 diabetes mellitus in women in Malaysia

Sivalingam N

Med J Malaysia, 2015 Aug;70(4):211-3.

PMID: 26358015 MyJurnal

No abstract available.

Fulltext Concepts in the management of the overactive bladder in women

Sivalingam N, Loh KY

Med J Malaysia, 2012 Feb;67(1):137-41; quiz 142.

PMID: 22582572

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.

Fulltext Issues in emergency contraception for the adolescent

Kwa SK, Sivalingam N

Malays Fam Physician, 2012;7(1):37-40.

PMID: 25606245 MyJurnal

Fulltext Medical paternalism and patient autonomy; the dualism doctors contend with.

Sivalingam N

Med J Malaysia, 2011 Dec;66(5):421-2.

PMID: 22390093 MyJurnal

Fulltext Enhancing doctor-patient relationship: the humanistic approach

Loh KY, Sivalingam N

Med J Malaysia, 2008 Mar;63(1):85-7; quiz 88.

PMID: 18935748 MyJurnal

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.

Fulltext Managing pelvic inflammatory disease

Sivalingam N, Vanitha NS, Loh KY

Med J Malaysia, 2007 Dec;62(5):425-7; quiz 428.

PMID: 18705484 MyJurnal

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.

Fulltext Medical students in their final six months of training: progress in self-perceived clinical competence, and relationship between experience and confidence in practical skills

Lai NM, Sivalingam N, Ramesh JC

Singapore Med J, 2007 Nov;48(11):1018-27.

PMID: 17975692

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

Fulltext Emergency contraception pill--controversies and use

Kathiravan C, Sivalingam N

Med J Malaysia, 2007 Mar;62(1):90-2; quiz 93.

PMID: 17682587

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.

Fulltext Urinary tract infections in pregnancy

Loh KY, Sivalingam N

Malays Fam Physician, 2007;2(2):54-57.

MyJurnal

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.

Fulltext Urinary incontinence in the elderly population

Loh KY, Sivalingam N

Med J Malaysia, 2006 Oct;61(4):506-10; quiz 511.

PMID: 17243536 MyJurnal

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.

Fulltext A preliminary finding: immunohistochemical localisation and distribution of placental angiotensin II receptor subtypes in normal and preeclamptic pregnancies

Judson JP, Nadarajah VD, Bong YC, Subramaniam K, Sivalingam N

Med J Malaysia, 2006 Jun;61(2):173-80.

PMID: 16898308

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.

Fulltext Understanding hyperemesis gravidarum

Loh KY, Sivalingam N

Med J Malaysia, 2005 Aug;60(3):394-9; quiz 400.

PMID: 16379204

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.

Fulltext Gestational trophoblastic disease

Loh KY, Sivalingam N, Suryani MY

Med J Malaysia, 2004 Dec;59(5):697-702; quiz 703.

PMID: 15889580

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.

Teaching and learning of professionalism in medical schools

Sivalingam N

Ann Acad Med Singap, 2004 Nov;33(6):706-10.

PMID: 15608822

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.

Fulltext Recurrent vaginal candidiasis

Loh KY, Sivalingam N

Med J Malaysia, 2003 Dec;58(5):788-92.

PMID: 15190674

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.

Fulltext Maternal health care at the crossroads

Sivalingam N

Med J Malaysia, 2003 Mar;58(1):1-4.

PMID: 14556320

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