MyMedR

Fulltext Budesonide/formoterol combination therapy as both maintenance and reliever medication in moderate-to-severe asthma: a real-life effectiveness study of Malaysian patients

Loh LC, Lim BK, Raman S, Vijayasingham P, Mohd Yusuf S

Med J Malaysia, 2008 Aug;63(3):188-92.

PMID: 19248687

Budesonide/Formoterol (Symbicort) combination therapy as both maintenance and reliever treatment (SMART) is a novel approach in asthma management. We examined its 'real-life effectiveness' in treating Malaysian patients with moderate-to-severe asthma in whom despite on combined inhaled corticosteroids and long-acting beta2-agonist, were still inadequately controlled. In a retrospective study, 22 eligible adult patients on SMART [mean (range) age: 49 (36-65) years; FEV1: 41 (21-74)% predicted] were identified from medical records of an urban-based university hospital chest clinic, and their clinical outcomes studied at three months. Another 16 patients [50 (14-66) years; 48 (20-91)% predicted] of similar severity and treatment (i.e. Symbicort maintenance treatment plus short-acting beta2-agonist as reliever), but not on SMART, were used as comparator over the same assessment period. In addition, the patients were separately interviewed with standard questionnaire on their satisfaction and compliance to the SMART approach. In SMART group, rescue treatment requirement (p<0.001) and FEV1 [median difference = 2.5%, p=0.015; mean difference: 90 ml, p=0.013] showed significant improvement while in comparator, there was significant improvement only in the requirement for rescue treatment (p=0.023). Hospital admission rates were significantly reduced in SMART group compared to the other (p=0.039), but not in emergency treatment. Five patients asked to discontinue SMART while all others were satisfied, compliant and perceived improvement of their asthma with SMART. The maximum daily doses of inhaled budesonide and formoterol were 1400 microg and 31.5 microg respectively. Our preliminary findings suggest that SMART approach can be attempted as an effective and safe treatment option for patients with inadequately controlled moderate-to-severe asthma in Malaysian setting.
Study site: Chest clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia

Adverse hospital outcomes associated with the choice of empiric antibiotics in Klebsiella pneumoniae pneumonia: a retrospective observational study

Loh LC, Rosdara Masayuni MS, Nor Izran Hanim AS, Raman S, Thayaparan T, Kumar S

Ann Acad Med Singap, 2007 Aug;36(8):642-6.

PMID: 17767334

INTRODUCTION: In Malaysia, Klebsiella pneumoniae ranks high as a cause of adult pneumonia requiring hospitalisation.

PATIENTS AND METHODS: With concern over its rising microbial resistance, we explored the association of empiric antibiotics choices with the hospital outcomes of patients treated for microbial proven K. pneumoniae pneumonia in an urban-based teaching hospital.

RESULTS: In 313 eligible cases reviewed retrospectively, hospital mortality and requirement for ventilation were 14.3% and 10.8% respectively. Empiric regimes that had in vitro resistance to at least one empiric antibiotic (n = 90) were associated with higher hospital mortality (23.3% vs. 10.8%, P = 0.004) with risk increased by about two-fold [Odds ratio (OR), 2.5; 95% confidence interval (CI), 1.3 to 4.8]. Regimes (n = 84) other than the commonly recommended "standard" regimes (a beta-lactam stable antibiotic with or without a acrolide) were associated with higher ventilation rates (16.7% vs. 8.8%, P = 0.047) with similar increased risk [OR, 2.0; 95% CI, 1.0 to 4.3].

CONCLUSIONS: Our findings reiterate the clinical relevance of in vitro microbial resistance in adult K. pneumoniae pneumonia and support empiric regimes that contain beta-lactam stable antibiotics.

Effect of time delay on survival in patients with non-small cell lung cancer--a Malaysian study

Loh LC, Chan LY, Tan RY, Govindaraju S, Ratnavelu K, Kumar S, et al.

Asia Pac J Public Health, 2006;18(1):69-71.

PMID: 16629441

The prognosis of lung cancer remains poor with overall five year survival figures varying between five and 10% worldwide, However, it has been shown that surgery in patients with early stage disease in non-small cell lung cancer can achieve five year survival rates up to 80%, suggesting that early or delay diagnosis can influence prognosis. Nevertheless, studies addressing this have been inconclusive and mostly derived from Western countries.

Ethnicity as a determinant of asthma-related quality of life in a multiracial country

Loh LC, Teh PN, Seth KD, Raman S, Vijayasingham P, Thayaparan T

Asia Pac J Public Health, 2006;18(1):49-55.

PMID: 16629438 DOI: 10.1177/10105395060180010801

In a multiracial country like Malaysia, ethnicity may influence the measurement of health-related quality of life (HRQL) in asthmatic patients. We invited 131 adult patients [44 Malays, 42 Chinese and 45 Indians; mean (95% CI) age: 43 (40.2-45.7) yrs; 28.2% male] with moderate-to-severe persistent asthma followed up in an urban-based hospital outpatient clinic to complete a disease-specific HRQL questionnaire [St Georges' Respiratory Questionnaire (SGRQ)] and to provide socio-demographic and asthma-related data. Indians reported significantly worse SGRQ total score, compared to Malays [mean (95% CI) difference: 10.15 (0.51-19.78); p = 0.037] and SGRQ activity score, compared to Malays [13.50 (1.95-25.05); p = 0.019] and Chinese [11.88 (0.19-25.05); p = 0.046]. Further analysis using multivariate linear regression showed that Indian ethnicity remained independently associated with SGRQ scores. Our finding highlights the relevance of ethnicity in assessing HRQL of asthmatic patients in a multiracial country such as Malaysia.

Study site: chest clinic of an urban-based
university teaching hospital

Fulltext Klebsiella pneumoniae respiratory isolates from 2000 to 2004 in a Malaysian hospital: characteristics and relation to hospital antibiotics consumption

Loh LC, Chin HK, Chong YY, Jeyaratnam A, Raman S, Vijayasingham P, et al.

Singapore Med J, 2007 Sep;48(9):813-8.

PMID: 17728961

Klebsiella pneumoniae ranks high as a cause of community-acquired pneumonia in hospitalised patients in Malaysia.

Fulltext Hospital outcomes of adult respiratory tract infections with extended-spectrum beta-lactamase (ESBL) producing Klebsiella pneumoniae

Loh LC, Abdul Samad NIH, Mohd Sani RM, Raman S, Thayaparan T, Kumar S

Malays J Med Sci, 2007 Jul;14(2):36-40.

PMID: 22993489 MyJurnal

Klebsiella pneumoniae ranks high as a cause of adult pneumonia requiring hospitalization in Malaysia. To study whether extended-spectrum b-lactamase (ESBL) producing K. pneumoniae was linked to hospital outcomes, we retrospectively studied 441 cases of adult respiratory tract infections with microbial proven K. pneumoniae from an urban-based university teaching hospital between 2003 and 2004. 47 (10.6%) cases had ESBL. Requirement for ventilation and median length of hospital stay, were greater in 'ESBL' than in 'non-ESBL' group [34% vs. 7.4%, p<0.001; 14 days vs. 5 days, p<0.001 respectively] but not crude hospital mortality rate [21.3% vs. 12.4%, p=0.092]. There was a four-fold increased risk of requiring ventilation [4.61 (2.72-7.85)] when ESBL was present. Our findings support the association of ESBL producing K. pneumoniae with adversed hospital outcomes and reiterate the need for vigilance on the part of treating clinicians.

Fulltext Incentive spirometry as a means to score breathlessness

Loh LC, Teh PN, Raman S, Vijayasingham P, Thayaparan T

Malays J Med Sci, 2005 Jan;12(1):39-50.

PMID: 22605946 MyJurnal

Perceived breathlessness played an important role in guiding treatment in asthma. We developed a simple, user-friendly method of scoring perception of dyspnoea (POD) using an incentive spirometer, Triflo II (Tyco Healthcare, Mansfield, USA) by means of repetitive inspiratory efforts achieved within three minutes in 175 normal healthy subjects and 158 asthmatic patients of mild (n=26), moderate (n=78) and severe (n=54). Severity was stratified according to GINA guideline. The mean POD index in normal subjects, and asthmatic patients of mild, moderate and severe severity were: 6 (4-7) 16 (9-23), 25 (14-37), and 57 (14-100) respectively (p<0.001 One-Way ANOVA). Based on 17 asthmatic and 20 normal healthy subjects, intraclass correlation coefficients for POD index within subjects were high. In 14 asthmatic patients randomized to receiving nebulised b(2)-agonist or saline in a crossover, double-blind study, % FEV(1) change correlated with % changes in POD index [r(s) -0.46, p=0.012]. Finally, when compared with 6-minutes walking test (6MWT) in an open label study, respiratory POD index correlated with walking POD index in 21 asthmatic patients [r(s)= 0.58 (0.17 to 0.81) (p=0.007] and 26 normal subjects [0.50 (0.13 to 0.75) (p=0.008)]. We concluded that this test is discriminative between asthmatic patients of varying severity and from normal subjects, is reproducible, responsive to bronchodilator effect, and comparable with 6MWT. Taken together, it has the potential to score disability and POD in asthma effectively and simply.

Fulltext Time delay and its effect on survival in malaysian patients with non-small cell lung carcinoma

Loh LC, Chan LY, Tan RY, Govindaraju S, Ratnavelu K, Kumar S, et al.

Malays J Med Sci, 2006 Jan;13(1):37-42.

PMID: 22589589 MyJurnal

While evidence indicates that early stage disease has better prognosis, the effect of delay in presentation and treatment of patients with non-small cell lung cancer (NSCLC) on survival is debatable. A retrospective study of 122 Malaysian patients with NSCLC was performed to examine the presentation and treatment delay, and its relation with patient survival. Median (25-75% IQR) interval between onset of symptoms and first hospital consultation (patient delay) and between first hospital consultation and treatment or decision to treat (doctor delay) were 2 (1.0- 5.0) and 1.1 (0.6-2.4) months respectively. The median survival rates in patient delay of <1, 1 to 3, and >3 months were 4.1 (9.9-1.7), 5.1 (10.9-3.2) and 5.7 (12.3-2.1) months respectively (log rank p=0.648), while in doctor delay, <30, 30-60, >60 days, the rates were 4.1 (10.8-1.8), 7.6 (13.7-3.2) and 5.3 (16.0-3.0) months respectively (p=0.557). Most patients presented and were treated in a relatively short time, and delays did not appear to influence survival. This Asian data is consistent with those from Western population, reiterating the need for public health measures that can identify disease early..

Survival in Patients with Non-Small Cell Lung Cancer Who Opted out of Cancer-Specific Therapy

Loh LC, Tan RY, Chan LY, Govindaraju S, Ratnavelu K, Kumar S, et al.

Malays J Med Sci, 2006 Jul;13(2):24-9.

PMID: 22589601 MyJurnal

In Malaysia, many patients opted out of cancer-specific treatment for various reasons. This study was undertaken to investigate the survival rate of patients with stages I to III non-small cell lung cancer (NSCLC) who opted out of treatment, compared with those who accepted treatment. Case records of 119 patients diagnosed with NSCLC between 1996 and 2003 in two urban-based hospitals were retrospectively examined. Survival status was ascertained from follow-up medical clinic records or telephone contact with patients or their next-of-kin. Median (25-75% IQR) survival rate for 79 patients who accepted and 22 patients who opted out of treatment, were 8.6 (16.0-3.7) and 2.2 (3.5-0.8) months respectively [log rank p< 0.001, Kaplan-Meier survival analysis]. Except for proportionately more patients with large cell carcinoma who declined treatment, there was no significant difference between the two groups in relation with age, gender, ethnicity, tumour stage, and time delays between symptom onset and treatment or decision-to-treat. We concluded that there was a small but significant survival benefit in accepting cancer-specific treatment. The findings imply that there is no effective alternative therapy to cancer-specific treatment in improving survival. However, overall prognosis for patients with NSCLC remains dismal.

Fulltext Modelling cost-effectiveness of replacement strategies for ambulance services in the Ministry of Health Malaysia

Mohd Hassan NZA, Bahari MS, Raman S, Aminuddin F, Mohd Nor Sham Kunusagaran MSJ, Zaimi NA, et al.

BMC Health Serv Res, 2024 Feb 06;24(1):168.

PMID: 38321452 DOI: 10.1186/s12913-024-10557-4

BACKGROUND: Emergency Medical Service (EMS) is a very crucial aspect of the healthcare system in providing urgent management and transportation of patients during emergencies. The sustainability of the services is however greatly impacted by the quality and age of ambulances. While this has led to numerous replacement policy recommendations, the implementations are often limited due to a lack of evidence and financial constraints. This study thus aims to develop a cost-effectiveness model and testing the model by evaluating the cost-effectiveness of 10-year and 15-year compulsory ambulance replacement strategies in public healthcare for the Malaysian Ministry of Health (MOH).

METHODS: A Markov model was developed to estimate the cost and outcomes ambulance replacement strategies over a period of 20 years. The model was tested using two alternative strategies of 10-year and 15-year. Model inputs were derived from published literature and local study. Model development and economic analysis were accomplished using Microsoft Excel 2016. The outcomes generated were costs per year, the number of missed trips and the number of lives saved, in addition to the Incremental Cost-Effectiveness Ratio (ICER). One-Way Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were conducted to identify the key drivers and to assess the robustness of the model.

RESULTS: Findings showed that the most expensive strategy, which is the implementation of 10 years replacement strategy was more cost-effective than 15 years ambulance replacement strategy, with an ICER of MYR 11,276.61 per life saved. While an additional MYR 13.0 million would be incurred by switching from a 15- to 10-year replacement strategy, this would result in 1,157 deaths averted or additional live saved per year. Sensitivity analysis showed that the utilization of ambulances and the mortality rate of cases unattended by ambulances were the key drivers for the cost-effectiveness of the replacement strategies.

CONCLUSIONS: The cost-effectiveness model developed suggests that an ambulance replacement strategy of every 10 years should be considered by the MOH in planning sustainable EMS. While this model may have its own limitation and may require some modifications to suit the local context, it can be used as a guide for future economic evaluations of ambulance replacement strategies and further exploration of alternative solutions.

Fulltext Coital injuries: a study of three cases

Narkunam R, Raman S, Kulenthran A, Sinnathuray TA

Med J Malaysia, 1984 Mar;39(1):78-81.

PMID: 6513845

This study reviews experiences in the management of three cases of lacerations of the vagina following coitus. A brief review of the recent literature is made. Although the extent of injuries can be very variable, the principles of management consist of prompt
resuscitation and arrest of haemorrhage, appropriate surgical repair under general anaesthesia, and systemic or local antibiotic therapy to combat infection. Avoidance of vigorous or abnormal coital practices, especially in single women, in the immediate postpartum period, and in postmenopausal women, can help to reduce the frequency and severity of such injuries.

Fulltext Early warning of fetal compromise--absent end diastolic flow?

Neoh HS, Kumarasamy S, Raman S

Med J Malaysia, 1990 Mar;45(1):37-41.

PMID: 2152067

This report deals with the use of a relatively new investigative technique (Doppler ultrasound) in the management of a case of early onset pre-eclampsia and discusses the benefit of this new technique over conventional methods of fetal monitoring.

Autoimmune haemolytic anaemia in pregnancy: a case report

Ng SC, Wong KK, Raman S, Bosco J

Eur J Obstet Gynecol Reprod Biol, 1990 Oct;37(1):83-5.

PMID: 2376282

A young primigravida had idiopathic warm antibody (IgG) autoimmune haemolytic anaemia (AIHA) occurring in the third trimester of pregnancy. Her haemolytic process was responsive to steroid therapy and no transfusion was needed. She delivered a healthy baby with no evidence to haemolysis, though his red cells were coated with IgG which was probably of maternal origin.

Acute puerperal inversion of the uterus--an obstetric emergency

Rachagan SP, Sivanesaratnam V, Kok KP, Raman S

Aust N Z J Obstet Gynaecol, 1988 Feb;28(1):29-32.

PMID: 3214380

Over a 17-year period, 15 patients with acute puerperal inversion of the uterus were managed at the University Hospital, Kuala Lumpur, an incidence of 1 in 4,836 deliveries. Injudicious traction on the umbilical cord before the uterus was well contracted, was probably the most important causative factor. Haemorrhage was more severe when removal of the placenta was done prior to correction of the inversion. Either the hydrostatic method or manual replacement were used but more often a combination of both techniques was found necessary. With careful management of the third stage of labour, this complication can be avoided.

Fulltext Sickle cell anaemia in pregnancy: a case report

Rachagan SP, Raman S, Cherian R

Med J Malaysia, 1984 Sep;39(3):243-5.

PMID: 6544928

To our knowledge, sickle cell anaemia in pregnancy has not been reported in Malaysia. We describe here such a case with emphasis on modern methods of management.

Rupture of the pregnant uterus--a 21-year review

Rachagan SP, Raman S, Balasundram G, Balakrishnan S

Aust N Z J Obstet Gynaecol, 1991 Feb;31(1):37-40.

PMID: 1872771

Uterine rupture is still a common problem in developing countries although even here the incidence varies from urban to rural settings. This article is a review of uterine rupture in an urban referral hospital in Malaysia. It examines aetiology, clinical presentation, complications and management of the problem. Meticulous screening of patients together with optimal antenatal and intrapartum care will markedly reduce the incidence of uterine rupture. Early diagnosis and prompt treatment will further help reduce morbidity and mortality to both mother and fetus.

The use of intrapartum fetal pulse oximetry in the presence of fetal cardiac arrhythmia due to a cardiac tumour

Raman S, Lim JM, Hanifullah K, Omar A

J Obstet Gynaecol, 1999 Mar;19(2):200-1.

PMID: 15512273

Changes in contraceptive practice in a multiracial urban-based community over a ten-year period

Raman S, Kishen D, Hamidah K, Ang ES

Adv Contracept, 1992 Jun;8(2):129-40.

PMID: 1519495 DOI: 10.1007/BF01849750

There have been changes in the national policy regarding population growth in Malaysia from 1982. This report studies the changes in contraceptive practice among the three racial groups in this country, i.e. Malays, Chinese and Indians, over a 5-year period with an interval of 10 years. This is a retrospective study based on the attendance at the same family planning clinic in an urban setting. The striking change noted is the change in the racial composition of contraceptive usage in the two study periods with a shift from the Chinese being predominant in 1975-1979 to Malays in 1985-1989. There was no change among the numbers of Indians using contraception. The results also reveal a significant trend of change for users of the pill and those undergoing sterilization. There were no significant changes in IUD, condom and injectable usage. The study demonstrates how national policies, level of education and rural urban migration can significantly alter contraceptive practice.

Fulltext Menopause and hormone replacement therapy. Facts and misconceptions

Raman S, Damodaran P

Med J Malaysia, 1996 Dec;51(4):407-8.

PMID: 10968025

Clinical versus ultrasound estimation of fetal weight

Raman S, Urquhart R, Yusof M

Aust N Z J Obstet Gynaecol, 1992 Aug;32(3):196-9.

PMID: 1445124

A prospective study was carried out on 50 patients who had their fetal weight estimated by 3 clinicians of different seniority and compared to the ultrasound estimated fetal weights using 3 different formulas. All the patients delivered within 24 hours of their clinical and ultrasound estimates. A wide range of birth-weights (1,800-4,500 g) was estimated among the 3 different races (Malay, Chinese and Indians). The results showed that there was no significant difference in birth-weight estimation amongst the 3 clinicians as well as between the 3 ultrasound formulas used. There was however significant difference between these 2 groups when compared with the actual birthweight with clinical estimation being superior to ultrasound estimation in our population. This level of significance did not extend beyond 4,000 g fetal weight (actual) thus making both clinical and ultrasound estimation of fetal weight equally accurate after 4,000 g. This has important implications for developing countries where there is a lack of technologically advanced ultrasound machines capable of doing sophisticated functions like fetal weight estimations but has experienced clinicians who could perform this function equally well if not better.

Displaying publications 21 - 40 of 62 in total