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Fulltext Students’ feedback on effectiveness of combined flipped classroom and high fidelity simulated teaching on airway and ventilation during accident and emergency posting

Subramaniam T, Valuyeetham PS, Tay JS

Education in Medicine Journal, 2018;10(2):5-13.
MyJurnal DOI: 10.21315/eimj2018.10.2.2

Simulation-based medical education enables knowledge, skills and attitudes to be taught in a safe,
realistic manner. Flipped classroom teaching encourages self-learning. Emergency medicine exposes
students to diverse group of patients and physicians’ decision making. This study aims to determine
students’ perception on knowledge, skills and confidence after combined flipped classroom and
simulated teaching. Two cohorts of Semester 7 students Group 1 (n = 120) and Group 2 (n = 78)
completed a 5-point Likert scale questionnaire. Group 1 completed the questionnaire after a lapse
of six months while Group 2 at the end the posting. Responses from both cohorts were compared
using the Mann-Whitney U test. Of 198 (Groups 1 and 2) students, 91.41% (n = 181) felt the
simulated sessions helped better understand care of emergency patients. The sessions helped identify
knowledge gaps (89.90%; n = 178), improve knowledge and understanding of oxygen therapy devices
(85.35%; n = 169), and airway equipment (90.91%; n = 180). They prepared better for the flipped
classroom teaching than traditional sessions (80.81%; n = 160). They felt that their communication
skills (82.32%; n = 163) and confidence (63.64%; n = 126) improved. Significant differences noted
to questions (p = 0.006, p = 0.005, p = 0.041 respectively) targeting knowledge on oxygen therapy
devices, confidence, and identification of gaps in knowledge respectively. Combined simulation and
flipped classroom teaching was well received by students though this requires more preparation.
Subcutaneous versus intravenous tramadol for extremity injury with moderate pain in the emergency department: a randomised controlled noninferiority trial

Bustam A, Poh K, Zambri A, Mohd Nazri MZA, Subramaniam T, Abdullah AA, et al.

Eur J Emerg Med, 2023 Oct 01;30(5):331-340.
PMID: 37276052 DOI: 10.1097/MEJ.0000000000001047

BACKGROUND AND IMPORTANCE: Musculoskeletal trauma is a common presentation in the emergency department (ED). Tramadol as an analgesic has been recommended by pain management guidelines for musculoskeletal pain. Parenteral tramadol in the ED is commonly administered intravenously. Subcutaneously administered tramadol may have other advantages such as easier and faster preparation, avoids the need for intravenous (i.v.) access, and reduces the incidence of respiratory and gastrointestinal effects. However, studies comparing subcutaneous (s.c.) and i.v. tramadol for the management of acute moderate pain in patients with extremity injury are lacking.
OBJECTIVE: The objective of this study was to compare the clinical efficacy of s.c. tramadol vs. i.v. tramadol in patients with moderate pain due to extremity injury in the ED.
DESIGN, SETTINGS, AND PARTICIPANTS: This non-inferiority randomized controlled trial included adult patients presented to an academic, tertiary hospital ED with moderate pain (pain score of 4-6 on the visual analog scale) due to extremity injury. Intervention patients stratified to pain score were randomized to receive 50 mg of i.v. or s.c. tramadol.
OUTCOMES MEASURE AND ANALYSIS: Primary outcome measure was the difference in the pain score reduction at 30 min after tramadol administration between the two groups. The noninferiority null hypothesis was that the therapeutic difference in terms of pain score reduction of more than 0.8 exists between the two treatment groups at the endpoint.
MAIN RESULTS: In total 232 patients were randomized to i.v. ( n = 115) or s.c. ( n = 117). Although 225 were analyzed in the per-protocol population (i.v. = 113; s.c. = 112). The baseline median pain score was 6 (IQR, 5-6). Median pain score reduction at 30 min after administration was 2 (IQR, 1-3) in the IV group vs. 2 (IQR, 1-2) in the s.c. group with a median difference of 0 (IQR, 0-0), which was below the prespecified noninferiority margin of 0.8. Adverse events in the i.v. group were higher compared to the s.c. group (33.6% vs. 8.9%, P ≤ 0.001).
CONCLUSIONS: The s.c. tramadol is noninferior to i.v. tramadol in the treatment of moderate pain from extremity injuries.
Fulltext The Role of Calcium in Wound Healing

Subramaniam T, Fauzi MB, Lokanathan Y, Law JX

Int J Mol Sci, 2021 Jun 17;22(12).
PMID: 34204292 DOI: 10.3390/ijms22126486

Skin injury is quite common, and the wound healing is a complex process involving many types of cells, the extracellular matrix, and soluble mediators. Cell differentiation, migration, and proliferation are essential in restoring the integrity of the injured tissue. Despite the advances in science and technology, we have yet to find the ideal dressing that can support the healing of cutaneous wounds effectively, particularly for difficult-to-heal chronic wounds such as diabetic foot ulcers, bed sores, and venous ulcers. Hence, there is a need to identify and incorporate new ideas and methods to design a more effective dressing that not only can expedite wound healing but also can reduce scarring. Calcium has been identified to influence the wound healing process. This review explores the functions and roles of calcium in skin regeneration and reconstruction during would healing. Furthermore, this review also investigates the possibility of incorporating calcium into scaffolds and examines how it modulates cutaneous wound healing. In summary, the preliminary findings are promising. However, some challenges remain to be addressed before calcium can be used for cutaneous wound healing in clinical settings.
The impact of energy security on environmental degradation: new evidence from developing countries

Subramaniam Y, Loganathan N, Subramaniam T, Bulut U

Environ Sci Pollut Res Int, 2023 Oct;30(50):108802-108824.
PMID: 37755592 DOI: 10.1007/s11356-023-29965-w

This study investigates the energy security and income roles in testing environmental Kuznets curve (EKC) for developing countries from 1990 to 2019. The panel quantile regression approaches are employed to examine the relationship between the variables, considering that income and energy security effects on carbon emissions may vary across distributions. Findings revealed that the EKC hypothesis was inconsistent at low and high quantiles when estimating energy availability, affordability, and acceptability. The validity of inverted U-shaped EKC is supported at high quantiles for energy affordability and accessibility in developing countries. However, given the energy accessibility and acceptability, the EKC hypothesis becomes invalid in developing countries. Notably, developing countries have yet to progress toward achieving energy security as a switch component to low carbon emissions. This study contributes to the literature by revealing the effect of availability, accessibility, affordability, and acceptability of energy security on carbon dioxide emissions (CO2). Thus, it suggests implications for improving environmental quality in developing countries by enhancing energy security. Diversifying energy sources with nuclear, renewable, and developing technologies reduces dependence risks on a single source while improving efficiency through technology and demand management lowers carbon emissions and strengthens energy security. Beyond energy security, this study emphasises sustainable urban planning to promote compact development, effective transportation, and green infrastructure to reduce energy use and improve environmental sustainability, ultimately reducing carbon emissions.
Fulltext The practice of PPE amongst fourth year medical students at A&E. Where are we?

Subramaniam T, Loo RCN, Poovaneswaran S

International e-Journal of Science, Medicine & Education, 2013;7(2):29-32.
MyJurnal

Background: This cross sectional study was done to identify the areas of lack of knowledge, practice and awareness of students about the effective use of personal protective equipment (PPE).
Methods: A total of 40 students were selected when they were posted to the accident and emergency unit (A&E) in Seremban Hospital; all of them answered a questionnaire and were observed unaware on the effective use of PPE in the A&E.
Results: We found that 17.5% of students were unaware of the right technique of removing the gloves after a procedure and 25% of students were unaware of safety of hand washing. During invasive procedures, 12.5 % of students did not wash their hands before invasive procedures, 65% did not wear aprons and 57.5% did not wear masks. During non- invasive procedures more than 25% of students did not wash hands before or after the procedures.
Conclusion: There is still significant lack of knowledge in students about the effective use of PPE that needs to be addressed.
Keywords: PPE, Personal protective equipment, effective practice of PPE, A&E
Fulltext Treatment of spinal cord injury with mesenchymal stem cells

Liau LL, Looi QH, Chia WC, Subramaniam T, Ng MH, Law JX

Cell Biosci, 2020;10:112.
PMID: 32983406 DOI: 10.1186/s13578-020-00475-3

Background: Spinal cord injury (SCI) is the damage to the spinal cord that can lead to temporary or permanent loss of function due to injury to the nerve. The SCI patients are often associated with poor quality of life.
Results: This review discusses the current status of mesenchymal stem cell (MSC) therapy for SCI, criteria to considering for the application of MSC therapy and novel biological therapies that can be applied together with MSCs to enhance its efficacy. Bone marrow-derived MSCs (BMSCs), umbilical cord-derived MSCs (UC-MSCs) and adipose tissue-derived MSCs (ADSCs) have been trialed for the treatment of SCI. Application of MSCs may minimize secondary injury to the spinal cord and protect the neural elements that survived the initial mechanical insult by suppressing the inflammation. Additionally, MSCs have been shown to differentiate into neuron-like cells and stimulate neural stem cell proliferation to rebuild the damaged nerve tissue.
Conclusion: These characteristics are crucial for the restoration of spinal cord function upon SCI as damaged cord has limited regenerative capacity and it is also something that cannot be achieved by pharmacological and physiotherapy interventions. New biological therapies including stem cell secretome therapy, immunotherapy and scaffolds can be combined with MSC therapy to enhance its therapeutic effects.
Fulltext Viral Aetiology of Acute Flaccid Paralysis Surveillance Cases, before and after Vaccine Policy Change from Oral Polio Vaccine to Inactivated Polio Vaccine

Saraswathy Subramaniam TS, Apandi MA, Jahis R, Samsudin MS, Saat Z

J Trop Med, 2014;2014:814908.
PMID: 24772175 DOI: 10.1155/2014/814908

Since 1992, surveillance for acute flaccid paralysis (AFP) cases was introduced in Malaysia along with the establishment of the National Poliovirus Laboratory at the Institute for Medical Research. In 2008, the Ministry of Health, Malaysia, approved a vaccine policy change from oral polio vaccine to inactivated polio vaccine (IPV). Eight states started using IPV in the Expanded Immunization Programme, followed by the remaining states in January 2010. The objective of this study was to determine the viral aetiology of AFP cases below 15 years of age, before and after vaccine policy change from oral polio vaccine to inactivated polio vaccine. One hundred and seventy-nine enteroviruses were isolated from the 3394 stool specimens investigated between 1992 and December 2012. Fifty-six out of 107 virus isolates were polioviruses and the remaining were non-polio enteroviruses. Since 2009 after the sequential introduction of IPV in the childhood immunization programme, no Sabin polioviruses were isolated from AFP cases. In 2012, the laboratory AFP surveillance was supplemented with environmental surveillance with sewage sampling. Thirteen Sabin polioviruses were also isolated from sewage in the same year, but no vaccine-derived poliovirus was detected during this period.