BACKGROUND: Antiphospholipid syndrome (APS) is an autoimmune disorder characterised by thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies (aPLs) based on the Sydney criteria. We aimed to explore the clinico-laboratory features and treatment strategies of APS patients retrospectively.
METHODOLOGY: The medical records of APS patients registered under Hospital Universiti Sains Malaysia (Kelantan state) between 2000 and 2015 were reviewed.
RESULTS: A total of 17 APS subjects (age 40.7 ± 12.8 years) including 11 primary (64.7%) and six secondary APS (35.3%) patients were identified. The follow-up period was 9.5 ± 6.7 years with male:female ratio of 1.0:4.7. Pregnancy morbidity was the most common clinical manifestation (11/14; 78.6%) followed by recurrent venous thrombosis (10/17; 58.8%). For other clinical features, menorrhagia was the most frequently observed manifestation (4/14; 28.6%) followed by aPLs-associated thrombocytopenia (4/17; 23.5%) and ovarian cyst (3/14; 21.4%). LA and aCL were positive in 94.1% (16/17) and 81.8% (9/11) of the patients, respectively. APTT value (76.7 ± 17.0 sec) was significantly high (p < 0.05). Low intensity warfarin alone was successful to maintain target INR (2.0 - 3.0) and prevent recurrence of thrombosis.
CONCLUSION: The tendency of pregnancy morbidity in this cohort of Malaysian Kelantanese APS patients was high compared to other previously reported APS cohorts. Low intensity warfarin was successful in preventing recurrence of thrombosis, however, APS women receiving long-term anticoagulants should be monitored for possible occurrence of menorrhagia and ovarian cysts.
Background: Plasma calcitonin gene-related peptide (CGRP) plays a key role in the migraine pathophysiology. This study aimed to investigate its role in predicting diagnosis and outcome of pharmacotherapy in pediatric migraine. Methods: We prospectively recruited 120 subjects, who never took migraine-preventive agents in a pediatric clinic, including 68 patients with migraine, 30 with non-migraine headache (NM), and 22 non-headache (NH) age-matched controls. Short-term therapeutic response was measured for at least 2 weeks after the start of therapy. Responders were defined with >50% headache reduction. Plasma CGRP concentrations were measured by ELISA. Results: In the migraine group, more patients required acute therapy, as compared to the NM group (62/68, 91% vs. 5/30, 15%, p = 0.001). The mean plasma CGRP level in migraineurs either during (291 ± 60 pg/ml) or between (240 ± 48) attacks was higher than in NM patients (51 ± 5 pg/ml, p = 0.006 and 0.018, respectively) and NH controls (53 ± 6 pg/ml, p = 0.016 and 0.045, respectively). Forty-seven patients (69%) needed preventive treatments and had higher plasma CGRP levels (364 ± 62 pg/ml, n = 47) than those not (183 ± 54 pg/ml, n = 21) (p = 0.031). Topiramate responders had higher plasma CGRP levels than non-responders (437 ± 131 pg/ml, n = 14 vs. 67 ± 19 pg/ml, n = 6, p = 0.021). Survival curves of plasma CGRP levels also showed those with higher CGRP levels responded better to topiramate. Differences were not found in the other preventives. Conclusion: The plasma CGRP level can differentiate migraine from non-migraine headache. It may also serve as a reference for the therapeutic strategy since it is higher in patients requiring migraine prevention and responsive to short-term topiramate treatment. These results are clinically significant, especially for the young children who cannot clearly describe their headache symptoms and may provide new insights into the clinical practice for the diagnosis and treatment of pediatric migraine.
Study site: Paediatric outpatient clinic,National Taiwan University Hospital (NTUH), Taiwan
Background: Rheumatoid arthritis (RA) patients are at risk of acquiring drug-related problems (DRPs). However, there has been a lack of studies on DRPs in patients with RA up to now.
Method: This retrospective study was conducted in a tertiary hospital in Malaysia from January 2012 to December 2017 with the purpose of assessing DRPs in RA patients and factors associated with its occurrence. A total of 200 patients who had received pharmacological treatment for RA were enrolled in this study. Assessment of DRPs was based on the Pharmaceutical Network Care Europe tool version 5.01.
Results: A total of 289 DRPs with an average of 1.5±1.0 problems per patient were identified, in which 78.5% of the population had at least one DRP. The most common DRPs encountered were adverse reactions (38.8%), drug interactions (33.6%), and drug-choice problems (14.5%). Factors that had significant association with the occurrence of DRPs were polypharmacy (P=0.003), multiple comorbidities (P=0.001), hyperlipidemia (P=0.009), osteo (P=0.040), and renal impairment (P=0.044). These data indicated that the prevalence of DRPs was high among RA patients.
Conclusion: Early identification of types of DRPs and associated factors may enhance the prevention and management of RA.
Study site: Pusat Perubatan Universiti Malaya (PPUM)
BACKGROUND: Osteoarthritis is a common problem affecting the joints in the elderly, caused disability and consequently decrease the quality of life. The conservative treatment includes the usage of analgesia, but the use of herbal medicine is growing. Momordica charantia or bitter melon has been widely described to have anti-diabetic and anti-inflammatory effects. However, its effect on reducing pain in primary knee osteoarthritis is not well studied. We aim to determine the effects of Momordica charantia in reducing pain among primary knee osteoarthritis patients.
MATERIALS AND METHODS: Thirty-eight and thirty-seven primary knee osteoarthritis patients underwent 3 months of Momordica charantia and placebo supplementation respectively. Three 500 mg per capsule of Momordica charantia were taken thrice daily. Rescue analgesia was allowed as needed. Pain and symptoms throughout the Momordica charantia supplementation period were assessed using Knee Injury and Osteoarthritis Outcome Score and EQ-5D-3L Health questionnaire, while rescue analgesia intake throughout the period of supplementation was measured using analgesic score.
RESULTS: After 3 months supplementation period, body weight, body mass index, and fasting blood glucose reduced significantly in the Momordica charantia group. There were also significant improvements in Knee Injury and Osteoarthritis Outcome Score subscales and EQ-5D-3L dimension score, and reduction in analgesic score. The placebo group had also shown significant improvements in certain Knee Injury and Osteoarthritis Outcome Score subscales and EQ-5D-3L dimension score, but with increased of the analgesic score.
CONCLUSION: Momordica charantia supplementation offers a safe alternative to reducing pain and improving symptoms among the primary knee osteoarthritis patients while reducing the need for analgesia consumption. These beneficial effects can be seen as early as 3 months of supplementation.
Study site: Orthopaedic clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
RATIONALE, AIMS, AND OBJECTIVES: Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting.
METHODS: This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach.
RESULTS: Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it).
CONCLUSIONS: Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.
Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
The objective of the study was to compare the physiological responses among COPD patient to Six Minute Walk Test (6MWT) and Incremental Shuttle Walk Test (ISWT). Twenty subjects were recruited for both 6MWT and ISWT that was carried out randomly. The readings of oxygen saturation (SpO2 ), heart rate (HR) and Modified Borg’s Score (MBS) were being taken before, during (each minute) and after each test. There were no significant difference observed in the peak HR and MBS between 6MWT and ISWT. There was no significant difference observed in the end SpO2 after both tests. In the two tests, HR and MBS increased linearly and were proportionate with time. However, our results showed that the distance walked in both test were significantly different and strongly related with more distance covered in 6MWT, with p < 0.05 (p = 0.01) and R = 0.58. Both 6MWT and ISWT elicited similar peak HRs and MBS suggesting both tests could be used to challenge patient to certain levels of cardiovascular and respiratory stress. There was no significant difference found in this study between the two tests. The two field tests could produce similar physiological responses in COPD patient.
Knee osteoarthritis (KOA) is a major cause of disability and significantly reduce quality of life (QOL). There is limited information about knee associated problems and functional mobility among Malaysian adults with KOA. The aim of our study was to examine knee associated problems and functional mobility among this population. Forty-five (45) adults with KOA with mean age of 65.02 ± 8.083 were recruited from Hospital Canselor Tuanku Muhriz, UKM. Knee associated problems and functional mobility were measured using Knee injury and Osteoarthritis Outcome Scores (KOOS) and Timed-Up and Go (TUG) test respectively. The mean score and standard deviation for TUG test was 11.44 ± 2.69 seconds. Median scores (with interquartile ranges [IQR]) for the KOOS subscale domains were; Symptoms: 80.56, (69.44 to 91.67); Pain: 71.43 (50 to 78.57); Functional Activities of Daily Living: 82.3 (67.65 to 86.76); Sports and Recreation Function: 30 (20 to 60); and Knee-Related Quality of Life: 50 (25 to 75). Generally, participants’ TUG test performance showed that time taken to complete the test was higher than the reference values (7.14 to 8.43 seconds) identified among Malaysian community dwelling older adults with low to high risk of falls. The KOOS scores in adults with KOA in our study is similar to previous reports with Sport and Recreation Function and QOL domains been the most affected. It is important to improve functional mobility and balance in order to decrease falls risk and optimise sport and recreation function and QOL among adults with KOA.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Caring behaviours presented by the nurses while providing care is the essence of nursing. However, operation theatre nurses must also adhere to the nursing value in social sciences and humanities to address the patient's needs. The concern of the nurses should not only be for the basic life sustaining needs but also for physiological, psychological, socio cultural and spiritual dimension ofpatient's human responses. The purposes of this study were to determine the perception regarding caring behaviours and the level of caring among the Operation theatre nurses in Hospital Universiti Sains Malaysia. In addition, there were associations when the determination between demographic variables like genders and years of experience of the nurses in relation to their caring behaviours is necessary. It isa quantitative, descriptive survey design and 95 nurses participated in the study. The revised Wolfs Caring Behaviours Inventory was used to measure the dimensions of caring. "Professional knowledge and skill" was identified to be the highest among the five dimensions of caring that was being measured. Findings show that the nurses demonstrated a high level of caring behaviours during their course of work. However, none of the demographic factors studied were significantly associated to their caring behaviours.
Keywords: Caring attitudes, Caring behaviours, Dimensions of caring
Governments in emerging markets face mounting challenges in managing health spending, building capability and capacity, modernizing ageing infrastructure, and investing in skills and resources. One path to overcoming these challenges is to establish new public-private models of health care development and delivery based on United States academic medical centers, whose missions are to advance medical education and clinical delivery. Johns Hopkins Medicine is a participant in the collaboration developing between the Perdana University Hospital and the Perdana University Graduate School of Medicine in Malaysia. These two organizations comprise an academic health science center based on the United States model. The Perdana project provides constructive insights into the opportunities and challenges that governments, universities, and the private sector face when introducing new models of patient care that are integrated with medical education, clinical training, and biomedical research.
The PANSI is a measure designed to assess the risk and protective factors related to suicidal behaviors. The present study evaluated the psychometric properties and factor structure of the Positive and Negative Suicide Ideation (PANSI) Inventory in a sample of clinical outpatients at a major hospital in Malaysia. In this study, 283 psychiatric patients and 200 medical (non-psychiatric) patients participated. All the patients completed the PANSI and seven other self-report instruments. Confirmative factor analysis supported the 2-factor oblique model. The internal consistency of the two subscales of PANSI-Negative and the PANSI-Positive were 0.93 and 0.84, respectively. In testing construct validity, PANSI showed sizable correlation with the other seven scales. Criterion validity was supported by scores on PANSI which differentiated psychiatric patients from medical patients. Logistic regression analyses showed PANSI can be used to classify the patients into suicidal or non-suicidal. The PANSI is a reliable and valid instrument to measure the severity of suicidal ideation among clinical outpatients in Malaysia.
Study site: Psychiatric clinic, Medical clinic, Ear, Nose and Throat (ENT) clinic, Ophthalmology clinic and orthopedic clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Scale, Questionnaire and Device: Positive and Negative Suicide Ideation Inventory (PANSI), Depression Anxiety Stress Scale (DASS-21), Reasons for Living Inventory (RFL), Beck Hopelessness Scale (BHS), Provision of Social Relations (PSR), Satisfaction with Life Scale (SWLS), Rosenberg Self Esteem Scale (RSE), The Adult Trait Hope Scale (ATHS)
OBJECTIVE: The aim of this study was to compare the use of semi-automated (Medax Velox 2; Poggio Rusco, Italy) and automated (Bard Magnum Biopsy Instrument; Covington, GA, USA) core biopsy needles, for ultrasound guided breast biopsy.
MATERIALS AND METHODS: A 14G semi-automatic spring loaded core biopsy needle with a 22-mm-throw (Medax Velox 2; Poggio Rusco, Italy) and 14-gauge automated needle device with a 22-mm-throw biopsy gun (Bard-Magnum Biopsy Instrument, Covington, GA, USA) were used for breast biopsies under ultrasound guidance on alternate months during the study period between July 2009 and May 2011. One hundred and sixty lesions were biopsied and specimens were sent for histological evaluation.
RESULTS: The automated needle obtained a higher number of histology reports at 84% (67/80) as compared with the semiautomated needle at 60% (48/80) (Fisher exact test, p value=0.023). Inadequate samples with the automated needle were much less at 9% (7/60) than with the semiautomated needle at 23% (18/60) (Fisher exact test, p value=0.028). The semi-automated needle showed slightly less fragmented samples. However, the number of fragmented samples with definitive diagnosis was slightly higher with the automated compared with the semiautomated needle, at 16% (13/80) and 13% (10/80) respectively. Compared with histology of 29 lesions that were excised, the semi-automated needle had higher sensitivity (100%) but lower specificity (75%) and accuracy (90%) compared with the automated needle (88% sensitivity, 100% specificity, 95% accuracy).
CONCLUSION: Definitive diagnosis from the study samples slightly favours the use of automated core biopsy needle as compared to semi-automated core biopsy needle.
Study site: Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
INTRODUCTION: HPS is a potentially life-threatening histiocytic disorder that has been described in various viral infections including dengue. Its involvement in severe and fatal dengue is probably more common but is presently under recognized.
CASE DESCRIPTION: A 38-year-old female was admitted after 5 days of fever. She was deeply jaundiced, leukopenic and thrombocytopenic. Marked elevation of transaminases, hyperbilirubinemia and hypoalbuminemia were observed. She had deranged INR values and prolonged aPTT accompanied with hypofibrinogenemia. She also had splenomegaly. She was positive for dengue IgM. Five days later she became polyuric and CT brain image showed gross generalized cerebral edema. Her conditions deteriorated by day 9, became confused with GCS of 9/15. Her BMAT showed minimal histiocytes. Her serum ferritin level peaked at 13,670.00 µg/mL and her sCD163 and sCD25 values were markedly elevated at 4750.00 ng/mL and 4191.00 pg/mL, respectively. She succumbed to the disease on day 10 and examination of her tissues showed the presence of dengue virus genome in the bone marrow.
DISCUSSION AND EVALUATION: It is described here, a case of fatal dengue with clinical features of HPS. Though BMAT results did not show the presence of macrophage hemophagocytosis, other laboratory features were consistent with HPS especially marked elevation of ferritin, sCD163 and sCD25. Detection of dengue virus in the patient's bone marrow, fifteen days after the onset of fever was also consistent with the suggestion that the HPS is associated with dengue virus infection.
CONCLUSIONS: The findings highlight HPS as a possible complication leading to severe dengue and revealed persistent dengue virus infection of the bone marrow. Detection of HPS markers; ferritin, sCD163 and sCD25, therefore, should be considered for early recognition of HPS-associated dengue.
KEYWORDS: Bone marrow; Dengue; Ferritin; Hemophagocytic syndrome; MAS; Macrophage
Study site: University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Spondyloarthropathy (SpA) is a group of inflammatory conditions that include spondylitis, sacroiliitis, asymmetrical peripheral arthritis and enthesitis. This condition is known as juvenile SpA when the diagnosis is made in patients up to 16 years of age. Enthesitis is a highly specific feature that occurs more often in juvenile SpA than in the adult form. In contrast to adult onset SpA, the initial manifestation of juvenile SpA rarely presents as inflammatory back pain. Peripheral arthritis is the more common presenting feature. We report a case of a 12-year-old boy who presented with a 1-year history of progressive low back pain, gluteal pain and thigh pain. There were no clinical symptoms of arthropathy of the distal extremities. MRI of the whole spine was performed twice, which, unfortunately, was unyielding. Finally, MRI of the sacroiliac joints revealed asymmetric sacroiliitis as well as enthesitis of the hips and pelvis. Further laboratory data showed negative rheumatoid factor and positive human leucocyte antigen (HLA) B27. A diagnosis of juvenile SpA with sacroiliitis and enthesitis was made. The imaging characteristics of juvenile SpA are highlighted.
AIM: To determine the pattern of utilization of emergency department (ED) services by older patients in Kuala Lumpur, Malaysia, compared with younger patients in the same setting.
METHODS: The sociodemographics, clinical characteristics and resource utilization of consecutive patients attending the adult ED at the University Malaya Medical Center were recorded during a typical week.
RESULTS: A total of 1649 patients were included in the study; 422/1649 (25.6%) were aged ≥60 years and 1077 (74.4%) were aged <60 years. Older adult patients were more likely to be diagnosed with ischemic heart disease (12.6% vs 2.5%, P
BACKGROUND: Acute pain assessment in the emergency department (ED) is important in particular during the triage process. Early pain assessment and management improve outcome. The objective of this study was to determine the effects of documentation and display of patient's self-assessment of pain using numerical rating scale (NRS) on analgesic use among adult trauma patients in ED.
METHODS: A randomized control trial was conducted recruiting 216 trauma patients who presented to ED of two tertiary centers. Pain score was done using NRS for all patients. They were randomized into pain score display group or not displayed in the control. The outcome measured were proportion of patients receiving analgesics and timing from triage to analgesic administration.
RESULTS: The proportion of patients who received analgesics when pain score was displayed was 6.5% more than when pain score was not displayed. This difference was however not statistically significant. However, stratified categorical analysis using chi-square showed that the displayed severe pain group was 1.3 times more likely to receive analgesics compared to the non-displayed group. The mean timing to analgesic administration for the displayed and non-displayed groups were 81.3 ± 41.2 (95% C.I 65.9, 96.7) and 88.7 ± 45.4 (95% C.I 69.0, 108.3), respectively (p > 0.05).
CONCLUSIONS: The proportion of patients who received analgesics increased when NRS was displayed. However, the pain display has no significant effect on the timing of analgesics.
KEYWORDS: Acute pain; Analgesic; Pain score; Triage
We report a case series of neuroretinitis in ocular bartonellosis and describe the serologic verification for Bartonella henselae. This is a retrospective interventional case series of four patients who presented in the ophthalmology clinic of Hospital Universiti Sains Malaysia from June 2012 to March 2013. All four patients had a history of contact with cats and had fever prior to ocular symptoms. Each patient presented with neuroretinitis characterized by optic disc swelling with macular star. Serology analysis showed strongly positive for B. henselae in all of the patients. All patients were treated with oral azithromycin (except case 4, who was treated with oral doxycycline), and two patients (case 1 and case 3) had poor vision at initial presentation that warranted the use of oral prednisolone. All patients showed a good visual outcome except case 3. Vision-threatening ocular manifestation of cat scratch disease can be improved with systemic antibiotics and steroids.
Study site: Ophthalmology clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
BACKGROUND: The Snaith-Hamilton Pleasure Scale (SHAPS) is a self-assessment scale designed to evaluate anhedonia in various psychiatric disorders. In order to facilitate its use in Malaysian settings, our current study aimed to examine the validity of a Malay-translated version of the SHAPS (SHAPS-M).
METHODS: In this cross-sectional study, a total of 44 depressed patients and 82 healthy subjects were recruited from a university out-patient clinic. All participants were given both the Malay and English versions of the SHAPS, Fawcett-Clark Pleasure Scale (FCPS), General Health Questionnaire 12 (GHQ-12), and the Beck Depression Inventory (BDI) to assess their hedonic state, general mental health condition and levels of depression.
RESULTS: The results showed that the SHAPS-M has impressive internal consistency (α = 0.96), concurrent validity and good parallel-form reliability (intraclass coefficient, ICC = 0.65).
CONCLUSION: In addition to demonstrating good psychometric properties, the SHAPS-M is easy to administer. Therefore, it is a valid, reliable, and suitable questionnaire for assessing anhedonia among depressed patients in Malaysia.
KEYWORDS: Malaysia; anhedonia; depression; neuroscience; pleasure; psychiatry; psychology; validation
Study site: Psychiatric clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Objectives: Anti-cyclic citrullinated peptide (CCP) antibody has recently been used in the classification
of rheumatoid arthritis (RA). This antibody is more specific than rheumatoid factor (RF) for the diagnosis of RA. The study objectives were to determine the sensitivity, specificity, positive and negative predictive values of anti-CCP in RA diagnosis.
Methodology: Eighty RA patients and 80 non-RA individuals were included in the study. Blood was collected from both arms of study subjects and tested for anti-CCP and RF antibodies. Relevant clinical information and laboratory profiles of the RA patients were evaluated using patients’ medical records and Integrated Laboratory Management System (ILMS), respectively.
Results: The sensitivity and specificity of anti-CCP were 35% and 100% respectively. The positive and
negative predictive values were 100% and 61%, respectively. Positive anti-CCP was found significantly
associated with multiple joint pain (p < 0.001) and hand’s joints pain (p=0.01), symmetrical joints
involvement (p=0.015) and high CRP value (p < 0.001). Anti-CCP was also found to have positive association with RF (p < 0.001).
Conclusion: Anti-CCP is highly specific for the diagnosis of RA. High positive predictive value should be taken into consideration for effective treatment.
KEY WORD: Rheumatoid arthritis, anti-CCP, Rheumatoid factor, Sensitivity, Specificity, Positive predictive value, Negative predictive value.
Study site: Rheumatology Unit, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia