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 Four children were withdrawn from the study (2 developed wheezing and 2 were not compliant).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
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 paper reports the result of a brief therapy attempt at treating panic in a busy outpatient psychiatric clinic. The patients were cases of panic referred from the various outpatient clinics within the hospital complex. The patients were divided into three groups at random using one of three modalities of treatment, i.e. cognitive behaviour therapy (CBT), CBT and Fluvoxamine (FVX), and FVX alone. The therapy was aimed for a maximum of nine sessions after which the patients were to be discharged. There were 14 patients in each group. The results show that all the groups were similar in the severity and scores pre treatment but after the different types of treatment there was a significant difference among them. The FVX alone group, showed significant improvement from the pretreatment levels but did not show as much improvement as the other groups and the mean score was only 9.07 after nine sessions. The best group was the CBT in combination with FVX. This indicates that the best way to treat panic is to combine drug treatment and psychological treatment. It is also shown from the study that the combination group requires less FVX than the FVX alone group. This finding has implications for the treatment of panic at the family physician clinic.
Study site: Psychiatric clinic, Hospital Universiti Sains Malaysia
Asthma knowledge an important components of asthma education.
Objective: To determine the levels of asthma knowledge in parents of asthmatic children and factors that may influence it.
Methods: This is a prospective study done between March 1998 and July 1998. Sixty-seven parents were interviewed using the 31 item asthma knowledge questionnaire that had been validated and translated. The children asthma severity was classified. The questionnaire includes biodata of children and parents, types of medication and dosage duration of asthma, exposure to cigarette smoke, acute asthma admission and patient’s economic status.
Results: This mean score for asthma knowledge was 15.5. The total score was 31. Asthma knowledge was significantly higher in parents whose children were using steroids [p=0.03, CI (-3.85, -0.02)]. It correlated significantly with steroid dosage (r=0.29, p=0.02), and was significantly higher in parents of higher economic status. Patient’s asthma knowledge had no association with children’s asthma status, age of the child or parents, exposure to cigarette smoke, frequency of admission of asthma duration.
Conclusion: The low asthma knowledge level indicates the need to increase the effort in educating parents. The main indicator for higher knowledge was steroid usage and dosage. Higher asthma knowledge in the high-income group was probably related to levels of education.
Keywords: parent, asthma, knowledge, Kuala Lumpur, Malaysia
Study site: Respiratory clinic, Institut Pediatrik, Hospital Kuala Lumpur, Malaysia
Two hundred outpatients (115 females and 85 males) attending the University Malaya Medical Center (UMMC) eye clinic, aged 20 years and above and without any ocular surface disorder were recruited for this study. Their tear film status was determined subjectively by their symptoms and quantitatively by the cotton thread test, Schirmer's test, marginal tear film meniscus assessment, fluorescein corneal staining and tear break-up time. Dry eye was considered present if at least one symptom was experienced often or always, within the past 3 months. Dry eye was also considered present if one of these tests was positive; Schirmer's test < 5 mm, Phenol red thread (PRT) test < 10 mm and tear film breakup time (BUT) < 8 seconds. The prevalence of dry eye in this sample population as defined by presence of symptoms and an abnormal test result is 14.5%. Presence of dry eye as detected by clinical testing is higher in the Chinese race (p < 0.01), in the group 40-59 years (p = 0.024). There is no difference between females and males. A lower BUT score was more strongly associated with presence of dry eye symptoms (p = 0.02). Elderly patients have a lower BUT and Schirmer's score. There is lack of agreement between PRT and Schirmer's test, although both are measures of tear quantity.
Study site: Eye clinic, University Malaya Medical Center (UMMC), Kuala Lumpur, Malaysia
This is a prospective study of clinical questions generated in primary care consultations and a comparison of two approaches to answering those clinical questions. Twenty-one doctors in a university-based primary care clinic submitted 78 clinical questions arising from patient consultations during 24 clinic days (0.01 question per patient encounter). These doctors subsequently found answers to 40% of their questions but were satisfied with only 67% of these answers. The investigators were able to provide answers for 95% of the questions asked and the doctors rated these answers as satisfactory in 86% of instances. Answers obtained by investigators had significantly higher satisfaction score than those obtained by doctors' search (p = 0.002). The two main findings of this study are (1) almost all questions arising in clinic setting could be answered by intensive search; (2) answers found by intensive searches were judged to be more satisfactory than those found routinely by doctors. Provision of an information retrieval service in addition to training in the searching and appraisal of medical literature are possible solutions to the information needs of busy clinicians.
Study site: Primary Care Clinic,
University Hospital Kuala Lumpur i
The best therapeutic choice in the treatment of lupus nephritis remains open to debate. In addition, there have been little data on the treatment of lupus nephritis in Asian patients. The objective of this study was to look at the response rate and complications of treatment given for lupus nephritis in a group of South East Asian patients with systemic lupus erythematosus (SLE). This was a retrospective, cross-sectional study of 103 patients with lupus nephritis. Detailed analysis was done on 58 patients with Class IV disease. The median time to remission was 12.1 months for azathioprine (AZA), 15.01 months for oral cyclophosphamide (CPM) and 15.25 months for intravenous (i.v.) CPM. The percentage of patients achieving remission after the first course of treatment was 42.9% with AZA, 83.3% with oral CPM and 90.9% with i.v. CPM. Overall, 41/58 (70.7%) of patients went into remission following the first course of treatment. Seventeen (41.5%) subsequently relapsed, requiring a second course of treatment. Fifty-two (50.5%) of all patients had drug-related complications from their treatment. The most frequent complication for the group was amenorrhoea (23.3% of all patients, 40% of those who had CPM previously), which was significantly more frequent in patients given CPM. In conclusion, more patients achieve remission when treated with CPM compared with AZA alone but this is associated with a higher complication rate, especially amenorrhoea.
OBJECTIVE: The aim of this study was to investigate the prevalence of skin prick test (SPT) reactivity to common aeroallergens among Malaysian asthmatic patients with and without rhinitis.
METHODOLOGY: An SPT using eight aeroallergens (Dermatophagoides pteronyssinus, Dermatophagoides farinae, cat fur, cockroach, Acacia sp., Bermuda grass, Aspergillus fumigatus and Aspergillus niger) was performed on 206 asthmatic patients.
RESULTS: One hundred and forty patients (68%) were reactive to at least one of the aeroallergens. Among the SPT-positive patients, a positive prick test reaction to the house dust mites, D. pteronyssinus (93.6%), and D. farinae (81.4%) was most common, followed by cat fur (20.0%), cockroach (7.9%), Bermuda grass (7.9%), Acacia sp. (7.9%), A. fumigatus (0.7%) and A. niger (0.7%). A history of rhinitis was elicited in 111 (53.9%) patients and 95 (85.3%) of these patients were SPT-positive compared with only 45 (47.4%) of 95 patients with asthma symptoms alone (P < 0.001). The presence of rhinitis and a young age of onset of asthma were independent factors for positive SPT reaction to at least one of the aeroallergens.
CONCLUSIONS: The prevalence of SPT reactivity to common aeroallergens is high among Malaysian asthmatics, particularly in those with an early age of onset and in those with coexisting rhinitis.
Study site: Asthma Clinic, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
Objective: To assess if children with Down's Syndrome have a higher prevalence of otological abnormality compared to their normal counterparts in Malaysia.
Methodology: Thirty children with Down’s Syndrome and normal children underwent otoscope ear examination and impedance test in the ENT outpatients clinic in University Hospital Kuala Lumpur, Malaysia.
Results: The study showed that children with Down’s Syndrome had higher ontological disorders. Forty four percent had impacted wax compared to 14.4% in normal children. Twenty one percent of ears in the study group had refracted drums compared to 6.6% of control. Fifteen percent of ears in the study group had middle ear effusion compared to 3.4% in controls, 55% had a type B tympanogram compared to 8.3% in controls and 73.4% had auditory canal stenosis compared to 14.4% in controls.
Conclusion: Children with Down’s Syndrome thus have a higher incidence of ontological disorders.
Study site: ENT outpatient clincs, University Malaya Medical Centre (UMMC)
DRE has been used as a diagnostic and screening tool for prostate cancer for decades. However these are based on Western data and its local applicability has yet to be verified. We held a Prostate Health Awareness Week in August 1998 and a total of 2086 men were screened. All men aged 50 years old and above were included for the study. The subjects were evaluated on DRE findings, PSA levels and if indicated a TRUS-guided biopsy results. We concluded that DRE per se might have limited role in the screening of prostate cancer in Malaysia. Screening using DRE and PSA combined are still recognized as the most cost-effective means. Neither DRE nor PSA alone has high enough specificity for diagnosis of prostate cancer cases. Combining DRE and PSA will definitely increase the specificity significantly.
Study site: e Urology
Clinic of Kuala Lumpur Hospital
A two years retrospective analysis of patients diagnosed as contact allergic dermatitis with positive patch test attending the Dermatology clinic was performed. Of the 346 patients with a positive patch test, 14% had occupational dermatitis. This condition affected mainly young and inexperienced workers. An inverse relationship was seen between age and prevalence of occupational allergic dermatitis. Allergic hand dermatitis was the commonest presentation in occupational allergic dermatitis. This was followed by dermatitis of the exposed skin (face, neck, hands and forearms). The common sensitising agents identified were rubber chemicals and nickel. The two main groups at risk were factory workers and medical personnel. The common allergens found in factory workers were epoxy resin, pewter, nickel and rubber chemicals. Exposure dermatitis occurred in patients working in the pewter industry. Two thirds of medical personnel with hand dermatitis were allergic to rubber gloves. One year follow up after patch testing showed that 19% of patients still suffered from chronic dermatitis. Dermatitis improved in 34% of patients. Forty-seven percent were cured and stopped attending the clinic after patch testing and adequate counselling.
Study site: Dermatology Clinic, Hospital Kuala Lumpur
Ignorance is not bliss when it comes to sexuality. Psychosexual problems lead to shame, fumbling, needless fears, low-self esteem and even subfertility. The demands for help appears to be increasing; as the general population become more aware of its presence and the treatment options available through the mass media and better health education. Sex therapy has traditionally been the realm of the psychiatrist but with the gynaecologist as the first contact for most women, the number of women seeking advice directly from their doctors will only increase with time. A total of 243 new cases of sexual dysfunction were treated at the sexual problem clinic in Kandang Kerbau Hospital between January 1994 and November 1996; majority of which were self-referrals (48.5%). The patient pool consisted of more males than females although the clinical setting is in an obstetrics and gynaecology teaching institute. Vaginismus and erectile problems constituted the main complaints. Erectile problems are more common in the patients above 40 years old (p < 0.001). We report here our experience of such a sexual problem clinic and hope to provide insight into this area of medicine from the perspective of a practising gynaecologist.
Three peak flow meters (PFM), Wright's, Miniwright's II (MPFM), and Pocket, were evaluated in 50 children in a pediatric outpatient clinic. It was found that there was close agreement between the Pocket and the MPFM as shown by an intraclass correlation (rho) of 0.95. Less agreement was noted between the MPFM and the Pocket, respectively, with the Wright's. It was also noted that the coefficient of correlation (r) was not a suitable test for agreement in this study. Both the Pocket and the MPFM also read higher than the Wright's. We conclude that children should be monitored using the same type of peak flow meter.
Study site: Pediatric clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
In this study 200 Malay subjects (100 males and 100 females) were randomly selected from patients attending outpatient clinics of Hospital USM, Kelantan, Malaysia, to find out the incidence, density and direction of hair on the dorsum of phalanges of the hand. These features have not been studied so far in females nor has such a study been conducted in Malays. The probability of density of hair distribution among the digits of both hands showed significant correlation on proximal phalanges (p < 0.05) in both sexes. Significant correlation was not observed, however, in the middle phalangeal hair (MPH) of the hands. The direction of proximal phalangeal hair, from little finger to the thumb, showed significant changes from ulnar to radial in both sexes (p < 0.05). Identification of isolated digits, which is of medicolegal importance, would be more accurate if the direction and the density of hair on the digits are both considered together. MPH was present in 48% of males and in 33% of females studied. Comparisons with presence of MPH in other populations show that Malays are ethnically similar to other Asiatic populations.
Study site: utpatient clinics of Hospital USM, Kelantan, Malaysi
A prospective study on the practicality of an out-patient management protocol for dengue infection in adults was carried out during a 2-month period. Doctors were requested to follow the protocol and assessment was done on the patients' outcome, the admission rate, and the compliance to the protocol by doctors and patients. One hundred and sixty-two patients (mean age 27.3 years) were clinically diagnosed to have dengue illness. Among them, 82.7% had dengue fever (DF); 13.0% had dengue haemorrhagic fever (DHF) and 4.3% had dengue shock syndrome (DSS). Dengue aetiology was confirmed in 69.4% of the DF group and 85.7% of the DHF and DSS groups. There were no deaths among the 162 patients. The admission rate was 43.8%. A high compliance rate of 86.4% by the doctors and a low patient default rate of 16.4% showed that the protocol was practical.
Few attempts have been made to determine the risk factors for diabetic retinopathy which is a major cause of visual impairment and blindness. One hundred and forty patients of diabetes mellitus were studied to determine the prevalence and types of retinopathy, and its relation to various risk factors. Nearly half (48.6%) of the patients suffered from retinopathy. The significant associated risk factors were long duration of diabetes, proteinuria and elevated serum creatinine level. However, there was no significant association between the prevalence of retinopathy and high levels of serum cholesterol, C-peptide levels, associated hypertension, and glycaemic control of diabetes mellitus. An effective screening programme for detection of retinopathy in the patients of diabetes as a regular practice is encouraged.
Study site: Diabetic clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
A study was done on 638 infants with BCG related lymphadenitis seen between August 1990 and December 1993. Most infants (86.5%) had developed symptoms by six months after vaccination and the nodes became suppurative in 317. Surgical procedures were carried out in 82 cases and the rest were managed conservatively. The mean duration to resolution was 6.6 months (range 1 to 29 months). This outbreak was related to a change from the Japan to the Pasteur strain of BCG. The incidence remained high ( > 15 per 1000 live births) despite a dose reduction from 0.1 ml to 0.05 ml, but declined when the Japan strain was reintroduced in April 1992.
Study site: Chest Clinic, Hospital Pulau Pinang, Malaysia
One hundred consecutive patients attending the UKM (Universiti Kebangsaan Malaysia) Cardiology Clinic completed a questionnaire enquiring about their own assessment of their knowledge about their illness, their awareness of cardiac risk factors and their expectations in their management. Only 11% of our patients had graduated from tertiary education. 59% of our patients were being treated for ischaemic heart disease. Although only 28% of our patients considered having considerable knowledge of their illness, a majority of our patients were aware of cardiac risk factors. This was independent of the formal education achieved. However this awareness did not necessarily result in appropriate behaviour; 32% of patients admitted to smoking despite being aware of the harmful effects of smoking. 74% of our patients expected a cure from their doctors; only 37% of our patients thought they required medication indefinitely. Thus, patients could be made aware of their illness regardless of their formal educational status. However this may not necessarily result in appropriate behaviour. The high expectations which the patients have of their doctors is unrealistic and may be detrimental to appropriate long-term management of their chronic illness.
Study site: Cardiology Clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Lipoma of the parapharyngeal space is very rare, only three cases having been reported in the literature. A parapharyngeal space lipoma causing obstructive sleep apnoea has not been reported before. A 60-year-old man presented at the ear, nose and throat (ENT) clinic with a history of loud snoring associated with sleep apnoea secondary to a right parapharyngeal space lipoma. The causes of sleep apnoea and the radiological features of a parapharyngeal space lipoma are discussed.
Study site: ENT clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Dengue fever is endemic in Malaysia with frequent epidemics especially in urban areas. This infection can present in a wide range of severity, from a nonspecific febrile illness to life threatening dengue haemorrhagic fever and dengue shock syndrome. It is worth noting that dengue haemorrhagic fever comprised 11.2% of all reported cases in Malaysia in 1991.Patients tend to consult their primary care physicians early. It is the duty of the primary care physicians to make an accurate diagnosis and to detect the complications. However, there has not been any known reliable predictor for the occurrence of complications during the early stage of the illness. Hence, primary care physicians often face the problem of having to deal with this uncertainty. Referring all these patients to the hospitals for admission is obviously not practical but managing them at home may involve high risks. In order to assist primary care physicians, the Primary Care Unit in the University Hospital uses a set of guidelines for the outpatient management of the infection. These guidelines and their assessment will be discussed.
Study site: Primary Care clinic, University Malaya Medical Centre, Kuala Lumpur, Malaysia