The efficacy of inhaled nedocromil sodium (NS) for children with a persistent cough was studied. Children aged 4-12 years with a persistent cough for >1 month were recruited and entered a 2-week baseline period during which an asthma diary was kept. Children with a cough score of >20 received inhaled NS via a spacer, 4mg qid for 2 weeks followed by 4mg bd for another 4 weeks. Twenty-two (42%) of 52 children recruited fulfilled treatment criteria. Four children were withdrawn from the study (2 developed wheezing and 2 were not compliant). The baseline cough score (29.1 +/- 13.6) improved after 2 weeks of treatment (15.2 +/- 9.3, p < 0.01) and improvement was sustained after 6 weeks (14.2 +/- 13.0, p = 0.01). Parents and patients had a more favourable perception of its efficacy compared to physicians (72% vs 50%, p = 0.01) Inhaled NS may be considered for treatment of persistent cough in children.
Study site: Paediatric clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
The results of a prospective study of 94 patients with history of ear, nose or aerodigestive tract foreign bodies were analysed. Sixty six to 94% of patients presented within 24 hours to a primary care doctor, 80 to 94% was referred to the ENT Department within 24 hours and 89 to 93% of patients had their foreign bodies removed within 24 hours. Overall, 58% of aural foreign bodies, 67% nasal foreign bodies and 94% of aerodigestive tract foreign bodies were removed within 48 hours of insertion. As a result of the prompt removal of foreign bodies in the majority of patients, no significant complications occurred. Foreign bodies in the aerodigestive tract tend to present earlier and more promptly removed compared with ear and nose foreign bodies. There was a significantly higher proportion of foreign body in the right ear and nostril compared to the left.
Vaginal hysterectomy for the large uterus is seldom performed in Malaysia. The traditional operation is abdominal hysterectomy. This is a personal series of vaginal hysterectomies for enlarged uterus of more than 12 weeks size (>280g) carried out in a private hospital between 1/1/97 to 30/9/2000. A total of 40 cases were done with the weights of the uterus ranging from 290g to 790g. The mean weight of the uterus was 434g. The average operating time was 92.1 min. The complications were minimal with 2 cases of blood transfusion for intra-operative hemorrhage, 1 case of fever and 1 case of bladder perforation. This series demonstrates feasibility and safety of the operation. The excellent recovery due to the absence of an abdominal scar should be a strong incentive for specialists to learn the skill.
Purpose: This study aimed at evaluating the educational value of the morbidity mortality meeting and benefits obtained from it so as to implement changes that can improve it.
Methods: Surgeons (n=13) at a university hospital responded anonymously to a questionnaire which was structured to monitor the educational activity of the morbidity mortality meeting. They indicated their perceptions on a five-point scale (very poor, poor, fair, good and very good). Depending on the results of the first questionnaire, these changes were made: 1) Standardisation of the notice of the meeting 2) Organization of the meeting 3) Review of the literature on the specific problems encountered. The participants were not aware of the results of the first questionnaire. Nine weeks later, the same questionnaire was repeated (n=12). Mann Whitney test was used to compare the ratings of the two questionnaires.
Results: The attributes which showed significant improvement between the first and second questionnaires were a) organization (p=0.004; (median (range) 3 (2-5) compared with 5 (3-5)) b) knowledge is up-to-date (p<0.005; (median (range) 3 (2-4) compared with 4 (3-5)), c) discussion related to the problem (0.01; (median (range) 3 (1-4) compared with 4 (3-5)) and d) notice of the meeting (p< 0.026; (median (range) 3 (2-4) compared with 4 (2-5)),
Conclusions: This study showed that specific actions can improve the educational quality of the morbidity mortality meeting.
The current treatment options for beta thalassaemia major patients include conservative treatment with blood cell transfusions and iron chelation or stem cell transplantation. Regular blood transfusions inevitably lead to multi-organ haemosiderosis and are attended by risks of blood-borne infections. Results from stem cell transplantation are good and suggest that this should be offered as first line therapy when a matched sibling donor is available because the patient is often cured and able to live a normal life. Of 38 Malaysian children who underwent bone marrow or cord blood transplantations using matched sibling donors, 29 (76%) are now cured.
Objectives: A child's admission into intensive care is a major cause of stress for parents. However among Malaysian parents, data concerning the perception of stress are virtually absent. Therefore we conducted a study to measure the reliability of the Malay version of Parental Stressor Scale: Pediatric Intensive Care Unit (PSS: PICU) in identifying sources of stress and to study factors that might influence their stress response.
Methods: Over a six-month period, one hundred and twelve parents were requested to answer the questionnaires twice either in Malay or English, a week apart. Spearman's correlation and Cronbach's alpha coefficient was used to assess the repeatability and internal consistency of the questionnaires.
Results: Ninety-four (83.9%) and seventy-one (75.3%) parents responded to the first and second administration of questionnaire respectively. All answered in the Malay language except for three. The correlation ranged from 0.50 to 0.71 with a total score of 0.76. The Cronbach's alpha coefficient ranged from 0.75 to 0.93, with total a score of 0.95.
Alteration in parental roles was the most stressful source of stress. Fathers, parents of children with higher PRISM score and parents with no previous admission into intensive care unit scored significantly higher in staff’s communication.
Conclusion: The Malay version of PSS: PICU is reliable in identifying sources of stress. Alteration in parental roles was the most stressful source of stress. Parents' gender, previous experience and severity of the child illness may influence their stress responses.
Thromboembolic disease remains an important cause of maternal mortality worldwide. The risk assessments for prevention of thromboembolism in pregnancy are controversial due to lack of large-scale randomised controlled trials. Unfractionated heparin is at present, the anticoagulant of choice during pregnancy. However, it may be superseded by low-molecular-weight heparin in the near future because of its safety and efficacy.
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.
The effects of 2% and 4% sevoflurane in oxygen and nitrous oxide for induction of anaesthesia in 60 unpremedicated elderly patients was compared to those obtained during an intravenous Thiopentone induction. Intravenous induction induced anaesthesia in 27 +/- 5 seconds, significantly faster than a 2% or 4% sevoflurane induction (109 +/- 36 and 71 +/- 24 seconds respectively). One patient in both the thiopentone and 2% sevoflurane groups, and 2 patients in the 4% sevoflurane group coughed during induction. The postinduction reduction in mean arterial pressure was greatest in the thiopentone group followed by the 4% and the 2% sevoflurane groups. Heart rate changes were minimal in all groups. We conclude that 2% or 4% sevoflurane offered suitable conditions for induction of anaesthesia in the elderly with minimal cardiovascular derangement.
In the setting of transplantation and chronic hepatitis B viral infection there is a unique histological feature termed cholestatic fibrosing hepatitis. The use of nucleoside analogues in the treatment of this condition has been successful. We describe a case of cholestatic fibrosing hepatitis, which occurred after intense immunosuppression for graft versus host disease in a patient with bone marrow transplantations. She was commenced on lamivudine therapy and showed good clinical, biochemical and virological response. However she succumbed due to sepsis.
A fulminant clinical presentation with high fever and hepatosplenomegaly, together with a course of worsening pancytopenia, coagulopathy and liver failure, is suggestive of the haem syndrome (HPS). Bone marrow examination is diagnostic. We present 3 cases of HPS associated with different aetiologies including acute Ebstein Barr virus infection, T cell lymphoma, and malignant histiocytosis. In all the cases, the diagnosis was made late and the patients succumbed before definitive therapy could be administered.
A case of non-recurrent laryngeal nerve is reported. The non-recurrent laryngeal nerve was found on the right side and was not associated with any vascular abnormalities. The anatomy and surgical implication of this rare condition is discussed
Infantile myofibromatosis (IMF) is a rare tumour with a wide spectrum of disease activity ranging from a solitary cutaneous nodule through to a multicentric form with widespread visceral involvement. It is characterised by its unique ability to spontaneously regress and has a typical histological appearance of actin-positive fibroblasts arranged in whorls or fascicles and vessels in a pericytomatous pattern. A male infant with multiple lesions involving the subcutaneous tissue and bone from birth is described and followed-up for two years. Treatment of IMF is dependent on the location of the tumour/s with surgery or chemotherapy reserved for rapidly progressive or symptomatic disease. However, due to the low rate of recurrence and the possibility of spontaneous tumoral regression, therapeutic abstention, as practised in our patient, is justified.
The preferential utilization of healthcare systems by a rural Malaysian community in Perlis for the treatment of musculoskeletal injuries was studied using focus group discussions. The objectives of the study were to explore the pattern of utilization of healthcare systems, the factors influencing the choice of a healthcare provider, rural residents' expectations of their healthcare provider and their views on integrating traditional and modern scientific healthcare systems. Most participants considered traditional and modern scientific healthcare systems as complementing each other. For musculoskeletal injuries, the traditional system was considered the primary choice of healthcare regardless of the participants' socioeconomic and educational levels. Key factors for preferring traditional care were the nature of treatment, the perceived shorter duration for recovery and inclusion of spiritual elements in the therapy. Barriers to seeking hospital treatment were the perceived longer duration for recovery, fear of surgery, use of metallic implants and casts that were culturally unacceptable and objections from elders. For perceived life-threatening situations, in children, pregnancy, and where injuries to internal organs were suspected, hospital treatment was preferred as the primary choice. Discussions on integrating traditional and modern scientific systems were inconclusive.
The paper presents the results of a health screening programme conducted in 10 major centers in Malaysia--Kuala Lumpur, Penang, Ipoh, Johor Bahru, Alor Star, Kuala Terengganu, Malacca, Kota Bahru, Kuching and Kota Kinabalu during the National Heart Weeks, 1995-1997. There were 6,858 participants of both sexes aged between 6 years to 81 years old. The parameters involved in the screening programme were body mass index, blood pressure, heart rate, cholesterol and glucose. The following are the results of the study:- 1. The mean and standard deviation for the body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), total cholesterol (TC) and non fasting (random) blood glucose (GL) of the volunteers studied were 24.3 +/- 4.0 kg/m2, 128.3 +/- 21.1 mmHg, 79.6 +/- 11.9 mmHg, 77.2 +/- 12.1 bpm, 5.33 +/- 1.37 mmol/l and 5.11 +/- 1.97 mmol/l respectively. 2. There was a rising trend for BMI, SBP, DBP, TC and GL with age. The HR was higher in the younger age group of those below 20 years. Males tended to have higher mean values than females except for HR which was similar in both sexes. 3. The Malays, Chinese and Indians seemed to have closely similar mean values for SBP, DBP and HR but the Indians possessed the highest BMI (25.62 +/- 3.90 kg/m2), TC (5.61 +/- 1.48 mmol/l) and GL (5.41 +/- 2.43 mmol/l) among the three major ethnic groups. While the Ibans had highest TC (6.07 + 1.09 mmol/l), their GL level was the lowest (4.76 +/- 1.15 mmol/l). The Kadazans had the lowest TC level (4.94 +/- 1.39 mmol/l) among all the ethnic groups. 4. Among the participants screened, 31.9% were overweight (BMI > or = 25), 7.6% were obese (BMI > or = 30); 26.8% had raised SBP (> or = 140 mmHg) and 19.3% had raised DBP (> or = 90 mmHg); 13.6% of the participants had increased HR (> or = 90 bpm), 22% had raised TC (> or = 6.20 mmol/l) and 2% had raised GL (> or = 11.00 mmol/l). There was a higher prevalence for abnormal values with increasing age until between the ages of 60 or 70 years, when the values began to fall. 5. Age was positively correlated with SBP (r = 0.41***, df = 4351), DBP (r = 0.27***, df = 4351), TC (r = 0.22***, df = 3303) and GL (r = 0.16***, df = 2442) but negatively correlated with HR (r = -0.13***, df = 4351). The BMI was positively correlated with SBP (r = 0.29***, df = 2769), DBP (r = 0.31***, df = 2769), TC (r = 0.16***, df = 2137) and GL (r = 0.11**, df = 1637) but there was no correlation with HR (r = 0.03NS, df = 2771). The SBP and DBP were highly correlated with each other (r = 0.75***, df = 4351) and they also showed highly significant positive correlation (r = 0.08***-0.13***, df = 2441-3301) with TC and GL. TC was positively correlated with GL (r = 0.05* df = 2319) but only at the 5% probability level.
We attempted to compare the accuracy of our clinical examination and the usage of magnetic resonance imaging (MRI) in evaluating patients suspected of having internal derangement of the knee who were seen in our Orthopaedic clinic. This was done using the findings of arthroscopy as the 'gold standard'. The accuracy of MRI in detecting cruciate ligament tears was between 80-96% against 82-93% for clinical examination. MRI accuracy for meniscus injuries was 80-84% compared to 48-65% for clinical examination. We thus propose that MRI examination is an effective first-line investigation for patients with suspected internal knee derangement, especially menisci injuries; allowing arthroscopy to be reserved for patients in whom surgery is truly indicated.
Study site: Orthopedic clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
This prospective, descriptive study was carried out to determine the pattern and the type of congenital heart disease seen in the Paediatric Departments in 4 government hospitals. The accessibility of surgical or transcatheter interventional treatment was also assessed. Consecutive new patients seen for suspected congenital heart disease from 1/1/95 till 31/12/95 (Group I) were registered. Records of patients seen from 1/1/95 to 31/8/95 (Group Ia) were reviewed 6 months after presentation to determine the nature of treatment received. Group II were cardiac patients who were first seen prior to the year 1995 and had undergone cardiac surgery or transcatheter interventional procedures in 1995. Of the 375 patients registered in the 4 hospitals, 250 were new patients and 125 were patients first seen prior to 1995 and had surgery or transcatheter interventional procedures in 1995. Of the 250 new patients, 83.2% had acyanotic cardiac lesions and 16.8% had cyanotic lesions. Ventricular septal defect was the commonest lesion, constituting 37.2%, followed by patent arterial duct (18.8%) and atrial septal defects (9.6%). At 6 month review, access to close-heart surgery or transcatheter interventional treatment were readily available. However, for patients with ventricular septal defects, 42.1% who required closure were still waiting for surgery 6 months after presentation. Of the 4 patients with Fallot's Tetralogy who required surgery, 2 had modified Blalock-Taussig shunt and 2 were awaiting surgery. In 1995, a total of 204 cardiac procedures were performed, there were 114 (55.9%) open heart procedures, 50 (24.5%) surgical ligation of the arterial duct, 28 (13.7%) modified Blalock-Taussig shunts, 11 (5.4%) transcatheter duct occlusion and 1 (0.5%) balloon valvuloplasty. The mean age of Fallot's Tetralogy repair was 6.4 years. No corrective surgery was performed for patients with complex cardiac lesions from the 4 hospitals in 1995. In conclusion, the pattern of congenital heart disease was similar to that seen world wide. Except for patent arterial duct, access to surgical treatment was inadequate.
A questionnaire survey was conducted on parents of 58 patients admitted with febrile convulsion (FC) over a 4 month period to the University of Malaya Medical Centre, Kuala Lumpur to determine parental response towards febrile convulsion in their child and their understanding of home management of FC.
Results: The majority of parents (93%) were frightened or were in a panic state of witnessing FC in their child. Most (77.6%) of them were able to bring their child to medical attention within 30 minutes, with delays attributed to transport problems. Parental understanding on FC was deficient, particularly with regard to home management of acute seizures. The parents’ main source of information was friends and relatives.
Conclusions: Urgent intervention to counsel and allay fears of parents who have just witnessed an acute FC in their child is required. More effort must be made to educate parents about FC, with particular reference to home management of seizures.