A comparative pilot study was conducted to determine the difference in the reduction of total serum bilirubin in a group of infants who had phototherapy at home compared to an in-patient group on hospital phototherapy. Eighteen infants with unconjugated hyperbilirubinaemia who fitted the selection criteria were put under the mobile home unit (Bluelite Portable Light) placed in the home. A control group of 18 infants with the same matching characteristics had intense phototherapy in the hospital using a unit with top and bottom light sources. The infants were matched for race, starting total serum bilirubin level, birth weight (up to 250 grams) and age of baby at initiation of phototherapy (up to one-day difference). It was observed that the mean daily decrease in serum bilirubin concentration was significantly more in the home group as compared to the hospital group (t=2.95, df=17, P<0.05). The mean duration of treatment was significantly less for the home group as compared to the hospital group (t=2.84, df=17, P<0.05). None of the infants who had home phototherapy were re-hospitalized. Phototherapy related complications were mild and comparable in both groups. The result suggests that home phototherapy is safe and effective in bringing down the concentration of serum bilirubin for term babies with uncomplicated hyperbilirubinaemia.
The displaced supracondylar fracture of the humerus in children (Gartland type 3) is a most challenging injury to treat. There is controversy regarding the initial treatment either closed manipulation and splint immobilization or open reduction and internal fixation. This is a retrospective study comparing two groups of patients with displaced supracondylar fracture of the humerus (Gattland 3) treated in the Orthopaedic Unit, Universiti Kebangsaan Malaysia. The first group, 13 patients treated with closed reduction and splint immobilization and a second group, 15 patients treated with open reduction and internal fixation as initial definitive treatment. The results showed a high failure rate of closed reduction and splint immobilization. This was due to difficulty in reduction, loss of reduction post operatively or during follow-up. Open reduction and internal fixation was more advantages with reduced hospitalization time, fewer complications, more stable fixation and better anatomical reduction with minimal complications for type 3 supracondylar fracture of humerus. We would recommend that all Gartland 3 supracondylar fracture of the humerus be treated with open reduction and two K-wire fixation.
Existing criteria for admission of newborns to the special care nursery, Sarawak General Hospital, resulted in the admission of many neonates with certain risk factors ("at risk" neonates). To test whether such babies could be safely and better cared for in postnatal wards, 392 of these babies were randomly allocated into two groups. One group of 196 was admitted to the special care nursery and the other group of 196 was cared for with their mothers in the postnatal wards. The two groups were compared for mortality, morbidity and breastfeeding. There was no significant difference in mortality and morbidity between the two groups. While in hospital a larger proportion of babies cared for in postnatal wards were breastfed, compared to babies admitted to the special care nursery. In addition, they initiated their breastfeeding earlier. Babies with these risk factors should therefore be cared for with their mothers in the postnatal wards.
Twenty-six patients with frozen shoulder syndrome (Stage 2 and 3) were included in this study conducted at Dr. Kariadi General Hospital, Semarang, Indonesia and randomly allocated into 2 groups: 40 mg triamcinolone intra-articular injection and triamcinolone oral tablets. The result showed that triamcinolone intra-articular injection group "cured" rate was 5.8 times higher at week one compared to the triamcinolone tablet group. Sixty-two percent of the cases with triamcinolone intra-articular injection achieved their "cured" condition after one week of therapy, compared with only 14% of the triamcinolone tablets group. We conclude that, intra-articular corticosteroid injection provide faster improvement compared to oral route.
Thirty-one healthy women who underwent Caesarean section were studied in a double-blind trial to compare the effectiveness of epidural 0.5% bupivacaine plain, 0.5% bupivacaine plus 100 micrograms fentanyl and 0.5% bupivacaine plus 50 micrograms fentanyl in the prevention of intraoperative pain. There was no difference in the quality of analgesia between the three groups. The incidence of complications was significantly higher in the 0.5% bupivacaine plus 100 micrograms fentanyl group compared with the other two groups.
Allergic rhinitis is the single most common chronic allergic disease affecting an estimated four million people in Malaysia. House dust mites, grass pollens and fungal spores play has been identified to play a major role in the pathogenesis of allergic rhinitis. However, sensitization to pollen and spores in Malaysia is not well documented. On the basis of the results of an aerobiological survey of the common mold spores and pollens in the Klang Valley, twelve local extracts of molds and two local extracts of grass pollens were prepared by the Institute for Medical Research for this study. The study evaluated the prevalence of skin prick test (SPT) reactivity to the extracts of those airborne molds and pollens in allergic rhinitis patients in the Klang Valley. A total of 85 allergic rhinitis patients were recruited. All molds and grass pollens extracts tested, elicited positive response to SPT. Among the molds extracts, Fusarium was observed to have the highest prevalence of SPT reactivity (23.5%), followed by Aspergillus flavum (21.2%), Dreselera orysae (18.8%), Alternaria sp (17.6%), Curvularis eragrostidis (17.6%), Penicillium oxa (16.5%), Pestolotriopsis gtuepini (16.5%), Rhizopphus arrhi (16.5%), Aspergilluls nigus (15.3%). Penicillium choy (12.9%), Aspergillus fumigatus (11.8%), and Cladosporium sp (4.7%). In the grass pollen, the SPT reactivity to Ischaemum and Enilia is 14.1% and 5.9% respectively. However, the prevalence of SPT reactivity was not influenced by the age, sex, ethnicity, symptomatology and concurrent allergic condition. We have documented the prevalence of skin prick test reactivity to common molds and grass pollens in the Klang valley, which is comparable to the neighboring countries. Its prevalence in our allergic rhinitis patients suggests that it has a role in pathogenesis of allergic diseases. A larger representative sample involving multi-centric centers in Malaysia should be encouraged in the near future.
Study site: ENT
Department, Pusat Perubatan University Kebangsaan Malaysia
(PPUKM)
Tonsillectomy is the single most common operation performed in Ear Nose and Throat Department. Various methods of tonsillectomy have been practiced over the century aimed at reducing or eliminating intraoperative and postoperative morbidity. Due to various blood supplies received, intraoperative bleeding is the most difficult problem and securing it is time-consuming. The time taken to control the bleeding would invariably determine the length of operation. Common postoperative complications are bleeding and pain. This study evaluated the operative time, intraoperative blood loss, postoperative pain and other postoperative complications of tonsillectomy performed by laser as compared to conventional dissection technique. This is a prospective randomized study whereby sixty patients were divided into two groups of equal number. In one group, the tonsillectomy performed by laser and in the other group the tonsillectomy performed by conventional dissection technique. Operative time and amount of blood loss is significantly reduced in the laser group. Total postoperative pain and post operative complications were not significantly different between the two groups. Tonsillectomy by using laser have shown less intraoperative bleeding and shortened the operative time. In the hospital where laser machine and expertise are available, it is justifiable to use this technique as effective method of performing tonsillectomy.
The use of tissue adhesives has been widely studied since the 1960s. Since then they have found use in specialties like plastic surgery, neurosurgery, ENT surgery and dental surgery. Several papers have reported their safe use, both clinically and experimentally, particularly of the newer homologue n-butyl/2-cyanoacrylate (Histoacryl). In this study 43 patients (46 wounds) whose operations involved a groin incision were randomised into two groups for skin closure either with Dexon subcuticular suture (23 wounds) or Histoacryl glue (23 wounds). We found that both sets of wounds healed well with no wound infections or excessive inflammation when assessed at one week and four weeks. However the glued wounds had consistently better cosmesis scores (mean score 4.71 at four weeks) compared to the subcuticular Dexon wounds (mean score 4.00 at four weeks) and P value of less than 0.05. We feel that there is a place for tissue adhesives in skin closure for some general surgical wounds.
We assessed the effectiveness of an educational intervention in reducing antibiotic prescribing in public primary care clinics in Malaysia. Twenty-nine medical officers in nine clinics received an educational intervention consisting of academic detailing from the resident Family Medicine Specialist, as well as an information leaflet. The antibiotic prescribing rates were assessed for six months - three months before and three months after the intervention. A total of 28,562 prescriptions were analyzed. Among participating doctors, general antibiotic prescribing rates for pre- and post-intervention phases were 14.3% and 11.0% (post-intervention vs pre-intervention RR 0.77, 95% CI 0.72 to 0.83). The URTI-specific antibiotic prescribing rates for pre- and post-intervention phases were 27.7% and 16.6%, respectively (post-intervention vs pre-intervention RR 0.60, 95% CI 0.54 to 0.66). No significant change in antibiotic prescribing rates was observed among primary care practitioners who did not participate in the study. This low cost educational intervention using both active and passive strategies focusing on URTI produced a statistically significant (and clinically important) reduction in antibiotic prescribing.
Study site: Klinik Kesihatan, Negeri Sembilan, Malaysia
This is a prospeve randomised study designed to clarify the impact of various luteal support regimes (HCG and progesterone) on progesterone profiles and pregnancy outcomes. This study involved subjects undergone down regulated. stimulated IVF cycles using various types of luteal support, namely: Cyclogest (n=35). Crinone gel (n=36), various doses of Utrogestan (n=55) and HCG (n=35). Various doses of Utrogestan (administered vaginally), Crinone gel (progesterone administered vaginally) and Cyclogest (progesterone administered rectally) supplementation induced similar end plasma progesterone concentrations ranging from 26 to 32 mmnl/l. These progesterone regimes produced no significant differences. Hence, the impact of exogenous proge,terone supplement was relatively trivial and did not 'stabilise' the sub-optimal luteal phase. In contrast, two small HCG injections during the early and mid-luteal phase possessed a much greater ability to 'stabilise' progesterone profiles. Despite this additional advantage, implantation and pregnancy rates with either HCG or progesterone supplements were similar. Although none of these forms of luteal support adequately 'normalised' luteal progesterone profiles, this did not appear to be detrimental to the process of implantation.
A prospective randomised study was done to assess the effect of supplemental oestradiol in addition to progesterone on the luteal steroid profiles and pregnancy outcome in stimulated cycles with and without pituitary down regulation. Women undergoing stimulated cycle IVF with GnRH-a and FSH (Group A, n = 63) or stimulated intrauterine insemination using CC and FSH (Group B, n = 55) were studied. These subjects were randomly allocated to receive either 400 mg daily of vaginally administrated Cyclogest (progesterone) alone or in combination with 2 mg daily of oral Oestradiol Valerate (E2V) during the luteal phase. Significant lower concentrations of plasma progesterone were observed in those subjects supplemented with both E2V and progesterone compared to those in whom progesterone only was given during the luteal phase (P < 0.05). Exogenous E2V had a minimal impact on plasma oestradiol concentrations and did not disguise the characterised mid luteal decline in oestradiol secretion. The suppressive effect of E2V on plasma progesterone was lost if implantation occurred normally because any small change in steroid concentrations was reversed by the rapidly increasing concentrations of HCG. Similar pregnancy rates were observed among subjects supplemented with or without oestradiol. The addition of oestradiol to the luteal supplement suppresses endogenous corpus luteum progesterone secretion irrespective of the type of assisted conception cycle and that its use is unlikely to be beneficial to the process of implantation.
Thirty-one patients with endoscopically proven chronic gastric ulcer completed a randomised double-blind trial comparing the effects of cimetidine and placebo on ulcer healing. Seventeen patients received cimetidine 400 mg bid and 14 patients received placebo. Repeat endoscopy at six weeks showed that the ulcer had healed in 12 patients (71%) receiving cimetidine and in four patients (29%) receiving placebo (p=O.032). Non-smokers healed their ulcers better than smokers (83% vs 35%, p=O.023). The use of cimetidine was not associated with any adverse effects.
Twenty eight patients who satisfied the entry criteria and had completed an initial 2 weeks treatment with placebo were titrated fortnightly with doses of Nicardipine ranging from 30 mg to 90 mg daily in two or three divided doses. Nicardipine treatment significantly reduced blood pressures both in the supine and standing positions (p < 0.0004) when compared with placebo treatment. Heart rates however did not change significantly. Forty six percent (13/28) of patients on 20 mg twice daily, 25% (7/28) on 10 mg three times daily, 18% (5/28) of patients on 20 mg three times daily and 11% (3/28) on 30 mg three times daily achieved supine diastolic blood pressures < 90 mm Hg. Nicardipine treatment at 16 weeks and at 24 weeks did not significantly alter the lipid profile when compared to the end of placebo treatment period. No other biochemical abnormalities were reported during the study period. Except for 2 cases of mild pedal oedema and 2 cases of transient headaches, no serious side-effects were encountered.
BACKGROUND: Co-infection by human immunodeficiency and hepatitis C viruses (HIV/HCV) is common and results in significant morbidity and mortality despite effective antiretroviral therapies (ART).
METHOD: A retrospective and prospective evaluation of the efficacy and safety of pegylated interferon alfa 2a/2b plus ribavirin (PEG-IFN/RBV) in consecutive HIV/HCV co-infected patients treated in real life clinical practice in Malaysia.
RESULTS: Forty-five HIV/HCV co-infected patients with a median age (interquartile range, IQR) of 41 years (37; 47) were assessed for treatment with PEG-IFN/RBV. All except one are of male gender and the most common risk behaviour was injecting drug use. At baseline 75.5% was on ART and the median (IQR) CD4 count was 492 cells/μl (376; 621). The HCV genotypes (GT) were 73 % GT3 and 27% GT1. Liver biopsies in forty patients showed 10% had liver cirrhosis and another 50% had significant liver fibrosis. The treatment completion rate was 79.5% with 15.9% dropped out of treatment due to adverse effects (AE) or default and 4.6% due to lack of early virological response. The AE causing premature discontinuations were neuropsychiatric and haematological. The overall sustained virological response (SVR) was 63.6% with a trend towards higher SVR in GT3 compared with GT1 (71.9% vs. 41.7%; p=0.064). In patients with bridging fibrosis plus occasional nodules or cirrhosis on liver biopsy, the SVR was significantly lower at 20% (p=0.030) compared to those with milder fibrosis.
CONCLUSION: HIV/HCV co-infected patients can be successfully and safely treated with PEG-IFN/RBV achieving high rates of SVR except in cirrhotic patients.
Study site: co-infection clinics at Sungai Buloh Hospita
The severity of pulmonary aspiration depends mainly on the acidity of the aspirate. Mist magnesium trisilicate (MMT) has been used for many years at the maternity unit in General Hospital, Kuala Lumpur, to neutralise the acidic gastric contents in all obstetric patients requiring caesarian section. This preliminary study shows that a single dose of 15 mls of MMT before general anaesthesia raises the intragastric pH to above the critical level of 2.5 in 80% of the patients. Recently there have been doubts over the protective role of MMT. Sodium citrate which is the other antacid available may be a better alternative.
Ergot-derived dopamine D2 receptor agonists are the usual treatment of hyperprolactinemia and Parkinson's disease and recently bromocriptine has been approved for the treatment of type 2 diabetes. The aim of this study was the evaluation of short-term effect of cabergoline in poorly controlled diabetic patients with oral agent failure who refused insulin therapy.