MyMedR

Fulltext A 2-year audit of perioperative mortality in Malaysian hospitals

Inbasegaran K, Kandasami P, Sivalingam N

Med J Malaysia, 1998 Dec;53(4):334-42.

PMID: 10971975

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.

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 Clinical experience with management of "near-miss" cases in obstetrics

Sivalingam N, Looi KW

Med J Malaysia, 1999 Dec;54(4):496-503.

PMID: 11072469

Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.

Study site: Obstetric and Gynaecologic Unit in Ipoh Hospital.

Fulltext Coital injury requiring internal iliac artery ligation

Sivalingam N, Rajesvaran D

Singapore Med J, 1996 Oct;37(5):547-8.

PMID: 9046215

Profuse bleeding after voluntary sexual intercourse is an uncommon reason for admission to the gynaecological wards. Out of 12 such patients admitted to the Ipoh Hospital over a three-year period, one patient had life-threatening upper vaginal injury after coitus. Blood replacement and conventional suturing failed to arrest the bleeding. Bilateral internal iliac artery ligation promptly arrested further haemorrhage. Vigorous intercourse increases intra-abdominal pressure in women causing tensing of the cul-de-sac, decreasing the elasticity of the posterior fornix, resulting in vaginal laceration. Bilateral internal iliac artery ligation produces a 'pelvic compartment hypotension' converting a high arterial flow system to that of a low one resembling venous flow. The useful role of this procedure to contain pelvic haemorrhage is discussed.

Fulltext Complete hydatidiform mole and surviving coexistent twin--a case report

Japaraj RP, Sivalingam N

Singapore Med J, 2000 Mar;41(3):126-8.

PMID: 11063197

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.

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 Delayed diagnosis of cervical pregnancy: management options

Sivalingam N, Mak FK

Singapore Med J, 2000 Dec;41(12):599-601.

PMID: 11296786

Cervical pregnancy is an uncommon variety of ectopic gestation. The aetiology is obscure. Diagnosis can be missed unless early evaluation is done by experienced personnel utilising pelvic ultrasonography. Three cases of cervical pregnancy managed at this hospital are described illustrating difficulties in early diagnosis and possible association with previous uterine scar and prior curettage of the uterus for retained products of conception. Treatment options vary according to the clinical state of the patient at the time of diagnosis. Non-surgical methods including systemic methotrexate administration in one and surgical evacuation of products of conception with subsequent cervical cerclage in another are discussed. Surgical interventions like total abdominal hysterectomy with internal iliac artery ligation to arrest life-threatening pelvic haemorrhage is also described. Other treatment options include potassium chloride (KCl) alone or in combination with methotrexate.

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 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 Fetal heart sound analysis: a preliminary evaluation

Baskaran A, Sivalingam N

Med J Malaysia, 1996 Mar;51(1):64-7.

PMID: 10967981

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.

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.

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.

Internal iliac and ovarian artery ligation in the control of pelvic haemorrhage

Thavarasah AS, Sivalingam N, Almohdzar SA

Aust N Z J Obstet Gynaecol, 1989 Feb;29(1):22-5.

PMID: 2562595

Bilateral ligation of the internal iliac artery with or without ligation of the ovarian arteries was carried out in 17 patients who had life-threatening pelvic haemorrhage; 14 were due to obstetric haemorrhage, 2 followed abdominal hysterectomy and 1 intractable haemorrhage associated with carcinoma of the cervix. The procedure was successful in arresting the haemorrhage in 13 patients but 4 needed hysterectomy in spite of the ligation; 1 patient died from disseminated intravascular coagulation following surgery and 1 had cardiac arrest due to extensive blood loss during surgery and died 12 hours later. A review of the literature, a brief description of the procedure and its indications are discussed.

Fulltext Is there a place for intra-umbilical oxytocin for the management of retained placenta?

Sivalingam N, Surinder S

Med J Malaysia, 2001 Dec;56(4):451-9.

PMID: 12014765

Intra-umbilical injection of oxytocin has been used to hasten placental separation in retained placenta. A randomised controlled trial was done on 35 consequent women who fulfilled the criteria for retained placenta at the Department of Obstetrics & Gynaecology Ipoh Hospital. Nineteen patients who were recruited into the study group received intraumbilical injection of 301U oxytocin in 27mls saline. Another 16 patients who were in the control group received 30mls of 0.9% sodium chloride (placebo). The primary outcome measured was the need for manual removal of placenta (MRP). Nine out of the 19 patients in the oxytocin group required MRP while 10/16 in the control group required MRP. There was a 24% reduction (95% C.I. 0.41 to 1.39) in the need for MRP in the study group compared to the saline group. our results indicate that intra-umbilical vein injection of oxytocin is not clinically useful for the removal of a retained placenta.

Fulltext Issues in emergency contraception for the adolescent

Kwa SK, Sivalingam N

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

PMID: 25606245 MyJurnal

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 Maternal health care at the crossroads

Sivalingam N

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

PMID: 14556320

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 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

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.

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