A medical narrative is a physician-patient dialogue, where the physician listens carefully to fragments of the patient’s story, while interpreting their hidden messages and word sequences, as well as observing their gestures and body language. This aspect of the therapeutic relationship contributes to deciphering
symptoms which are not apparent in the conventional interview and contributes to a much broader perspective
of illness and health. The arts and the humanities have always been inseparable from each other in medical education. In this biomedical revolution, the humanities are needed now more than ever before to bridge the divides that separate the physician from the patient, from self, from colleagues, and society. Narrative Medicine (NM) which aims to treat the whole person, and not just the illness, is an emerging patient-centred discipline in medical schools that can humanise medical care and promote empathy. NM helps medical students cope with the suffering of their patients as well as their own emotions by reducing the anxiety and threat that come with illness, thereby providing a psychologically-sound foundation for the development of self-reflection and empathy. NM facilitates medical students’ adoption of patients’ perspectives with the hope of ultimately leading to more humane, ethical and empathetic healthcare for their patients. The discipline of NM is critically examined in this review paper from the perspective of external and internal stakeholders.
Shock, a major cause of morbidity and mortality in children, is the the most anxiety-provoking emergency that needs to be addressed urgently and effectively by the attending paediatrician. It is a state where the metabolic demands of the tissue are not met due to circulatory dysfunction. Unlike adults, hypotension is a very late feature of shock in children. As the child’s condition worsens, the clinical presentation of the different causes of shock become similar, and nullify any aetiological differences. Regardless of the type of shock, the final common pathway is inadequate tissue perfusion and oxygen supply to meet cellular demands. Delayed recognition and treatment result in progression from compensated reversible shock to uncompensated irreversible shock with widespread multiple system
organ failure to death. This paper reviews the physiological basis, and pathophysiological classification of the various types of shock and their respective aetiologies. The clinical features of the different types of shock are described, and current diagnostic and therapeutic strategies are applied for the most effective and appropriate treatment for resuscitating the child in shock. A strong index of suspicion, early recognition, timely intervention and transfer to an intensive care unit are critical for successful outcomes in the management of paediatric shock.
Talc’s softness, whiteness, lamellarity, inertness and affinity for organic chemicals make it valuable for industrial and domestic applications. The largest consumers are the paper and ceramic industry; only 5% is used as cosmetics. It is also used for preserving animal feed, and a carrier for drugs, insecticides, pesticides and chemicals. Talc was introduced as baby powder in 1894 and advertised aggressively worldwide. Widespread and indiscriminate use soon raised concerns about its implications for health. The IARC found that talc containing asbestiform fibres is carcinogenic to humans, but inadequate evidence to implicate talc not-containing asbestiform fibres. Pulmonary manifestations of talc inhalation include talcosis, talcosilicosis, and talcoasbestosis. Drug-users administering talc-adulterated oral medications intravenously develop pulmonary granulomas, fibrosis and irreversible pulmonary hypertension. Worldwide reports reveal talc inhalation is fatal to infants; it coats and dries mucus membranes, causes hemorrhage, edema, desquamation of bronchial epithelium, and clogs and compromises mucociliary clearance; larger quantities completely obstruct airways. Progressive diffuse pulmonary fibrosis is a recognized sequel to massive aspiration of baby powder. IARC has classified perineal use of talcum powder as a possible ovarian carcinogen, while a recent study has found that perineal talcum powder increases the risk of endometrial cancer among postmenopausal women. There is a need to raise public awareness of the serious risks associated with the use of talcum powder and for legislation to protect the health of the uninformed who represent the poorer segment of the community, and infants and young children. The dangers associated with cosmetic use of talc outweigh any possible benefits.
Background: In Malaysia the percentage of diploma registered nurses outnumber the percentage of degree registered nurses. Internationally, most registered nurses earn associate degrees or bachelor’s degrees in nursing. Malaysia is in the pipeline of ensuring that its registered nurses are professionally qualified with nursing degree by year 2020. Registered nurses with diploma qualification are feeling the pressure to upgrade their qualification to degree. There are concerns as to why these nurses are not pursuing their post registration nursing degree. Objective: To determine factors that are deterring the registered nurses of a private hospital in Penang from pursuing the post registered nursing degree. Methods: This descriptive study utilised a convenient sample of 150 registered nurses from Lam Wah Ee Hospital in Penang. The instrument of this study was developed based on literature search and the conceptual framework of Force Fields Analysis developed by Kurt Lewin in 1952. Results: The deterring factors for registered nurses not pursuing post registration nursing degree from this hospital were determined through negative mean score, which was valued at less than 2.5. The top 3 deterring factors identified were: high educational cost, with a score of 1.92; financial commitment, with a score of 2.22 and time constraints and high workload, with a score of 2.27. Conclusions: High educational cost, financial commitment, time constraint and high workload were the main factors deterring the registered nurses from this hospital from pursuing their post registration nursing degree. Thus it is timely for the organisational management to consider workable measures to assist and motivate their nurses to upgrade themselves with nursing degree in line with Malaysia’s vision to meet the increasing challenges and complex needs in the care of clients in health services.
Background: Nurses are the highest numbered healthcare professionals who work in a knowledgedriven environment, where accurate and updated information is needed when delivering care to clients. Information literacy has therefore become one of the criteria in determining nurses’ readiness for evidencebased practice in recent years. In the actual day-to-day care practice, are nurses ready for this?
Objective: To determine the information literacy competency in readiness for evidence-based practice among clinical practicing registered nurses in a private hospital in Penang, Malaysia.
Methods: This cross sectional descriptive study was conducted in the selected private hospital. Universal sampling method was used. At the time of study, there were 443 registered nurses who met the eligibility criteria of this study. The registered nurses were asked to complete a self-reporting questionnaire about information literacy for evidence-based practice.
Results: The response rate was 86.2%, with a total of 382 returned questionnaires. Less than half of the participants (47%) stated that they frequently sourced information to support nursing practice. Poor research experiences among these participants were identified where 56% of the registered nurses never identified researchable problems, 59% have not evaluated a research report and 54% have never utilised research into practice. Registered nurses frequently sought information sources from colleagues or peers (65%) rather than from printed resources, where only 43% and 33% respectively make use of CINAHL and MEDLINE bibliography databases as the electronic resources for their practice.
Conclusions: Results demonstrated that information literacy among registered nurses from this hospital was lacking. Organisation efforts are needed to create awareness of information for evidence-based practice as well as to encourage more research activities and the search of bibliography database among its registered nurses.
Study site: Private hospital, Pulau Pinang, Malaysia
Building on two decades as a private health professional university, the International Medical University prepares for the third decade, taking stock of the challenges in changing epidemiology and pattern of disease, changing demography and healthcare, as well as explosion in knowledge and information technology. The Global Independent Commission1 provided a framework for instructional and institutional reforms, and the IMU will use its 3 I’s (insight, imagination & innovation) in adopting these measures. Some of the instructional reforms are already in place, others need to be further nurtured and promoted. In its third decade, competency based curriculum, inter-professional learning, IT, global collaboration, educational resources, new professionalism and emphasis on quality improvement will help ensure IMU train and produce competent, caring and ethical health professionals fit to tackle 21st century challenges.
Community-acquired pneumonia (CAP) is one of the most common infectious diseases and the world’s leading cause of mortality and morbidity, especially in patients aged 65 years and above.1,2 It is the 6th cause of mortality and the most important cause of hospitalisation in Malaysia. According to the British Thoracic Society, the gold standard in diagnosing CAP is based on radiological findings and it is defined into 2 different settings – community and hospital.3
The case report describes the presentation of a 19-year old female with tuberous sclerosis who presented with progressive dyspnoea over 2 days.
Chest radiograph revealed bilateral pneumothorax. Computed tomography showed features of pulmonary lymphangioleiomyomatosis and bilateral renal angiomyolipomas. The coexistence of both conditions may cause devastating morbidity and mortality.
Anaphylaxis in the operating room although infrequent can be potentially fatal. The diagnosis of perioperative anaphylaxis is complex due to a multitude of factors. Firstly, patients under anesthesia cannot verbalize their complaints, the anesthetic agents themselves can alter vital parameters (e.g. heart rate and blood pressure) and cutaneous signs in a completely draped patient may be missed. Secondly, the differential diagnosis of intraoperative anaphylaxis is wide. Conditions such as asthma exacerbation, arrhythmia, hemorrhage, angioedema, mastocytosis, acute myocardial infarction, drug overdose, pericardial tamponade, pulmonary edema, pulmonary embolus, sepsis, tension pneumothorax, vasovagal reaction, venous air embolism, laryngospasm, blood transfusion reaction and malignant hyperthermia need to be considered. Thirdly, the diagnostic workup is challenging due to the multiple medications administered and other exposures encountered such as latex and chlorhexidene. However, through a timely allergy consultation and a systematic approach, identification of the culprit agent and safe alternatives can be established to prevent future occurrences as illustrated in the case below.
Background: Peripheral venous catheterisation is indispensable in modern practise of medicine. The indications of venous access should be weighed against the risk of complications, the commonest being thrombophlebitis. Thrombophlebitis causes patient discomfort and the need for new catheter insertion and risk of developing further widespread infections. Methodology: This observational study was conducted on adult patients admitted to the surgical and medical ward of a tertiary hospital in Negeri Sembilan Malaysia in 2011. Four researchers visited patients daily and examined for signs of thrombophlebitis; warmth, erythema, swelling, tenderness or a palpable venous cord. Risks factors that were studied in this research were patient/s age and gender, duration of catheterization, use of catheter for infusion, size of catheter, site of catheter insertion and types of infusate. Thrombophlebitis was graded using a scale adapted from Bhandari et al. (1979). Results: In total, 428 patients were recruited with an incidence rate of thrombophlebitis of 35.2%. Among those who developed thrombophlebitis, 65% had mild thrombophlebitis, 19% moderate and 8% severe thrombophlebitis. Results showed that female patients had a significant increased risk of developing thrombophlebitis. Also risk increased significantly with increased duration of catheterization and usage of the catheter for infusion. The age of a patient, types of infusate use, size of catheter and site of catheter insertion did not significantly influence the development of thrombophlebitis. Conclusion: The study showed that risk of developing thrombophlebitis is significantly increased among female patients, and also with increased duration of catheterization and use of the peripheral venous catheter for infusion. We recommended elective replacement of catheter every 72 hours and daily examination of catheters for signs of thrombophlebitis by a healthcare personnel.
Introduction: Assessment is an integral aspect of
teaching. One-best-answer (OBA) items, if properly
constructed are able to drive learning. In-house OBA
items are notoriously poorly-constructed. The role of
a central vetting committee is to review test items and
ensure that they adhere to expected standards. Hence,
the objective of this audit is to determine whether
central vetting has improved the construct quality of
OBA items.
Methods: We audited the psychiatry end-of posting
OBA items from before and after central vetting to
compare the quality of the items before and after
central vetting was instituted. Quality was evaluated
on appropriateness of test content, items with higher
cognition and items without flaws. A standard was not
set for this first audit.
Results: Seventy six of 181 psychiatry OBAs items
retrieved from 2011 to August 2012 had undergone
first level (department) vetting only and the remainder
105 (58.0%) had two levels of vetting; department and
central vetting committee (CVC).
Appropriateness of content increased from 92.1% to
98.1%. Items with higher order thinking doubled from
21.1% to 42.9%. Items with clinical scenario increased
by 8.4% to 78.1%. Logical ordering of options however,
remained around 50%.
Two-level vetting markedly reduced problematic
lead-in questions (67.1 to 13.3%), non-homogenous
options (42.1 to 9.5%), vague and implausible options
(39.5 to 6.7%), and spelling and grammar mistakes
(19.7 to 5.7%).
Conclusion: Two-level vetting had improved the
quality of OBAs and should be continued. This could
be enhanced by training all Faculty on writing quality
OBA items and careful selection and empowerment
of CVC members. A re-audit is to be conducted after
Faculty training.
Background: Some argue that Malaysia’s extremely low organ donation rate is attributed to religion, specifically Islam. Testing this argument, this study asked Malaysian Muslims their views regarding various issues on organ donation and examined whether their decisions to donate organs are framed by religious beliefs.
Materials and Methods: This study investigated the perspectives of Malaysian Muslims between October and December 2013 in Kuala Lumpur. Self-administered questionnaires were distributed to 900 people, with 829 responses collected (92% response rate). Respondents’ verbal consent was taken before proceeding with the survey.
Results: The survey found that more than half of respondents felt that organ donation is permitted in
Islam and that it is a communal responsibility. However, the same proportions were unsure on the issues of rewards for organs or on whether Islam permits the procuring of organs from brain dead patients.
Conclusions: Malaysian Muslims are not against organ donation; however, encouraging organ donation requires the state to address public concerns on Islam’s views on this sensitive issue through effective policy tools to help address these gaps in Malaysian Muslims’ understanding of organ donation. The organ donation rate could improve by using Islamic scholars as ambassadors for an organ donation drive to convey the message of Malaysia’s urgent need for organ donation.
Cervical spine injury is commonly associated with
road-traffic accidents. The true incidence of cervical
spine injuries is unknown due to under-reporting of
such injuries. Cervical spine injury is associated with
high morbidity and mortality if it is missed. With the
advancement of imaging modalities, the number of
missed cervical injuries has reduced. Nevertheless, some
clinicians are dependent solely on imaging tools to rule
out cervical spine injury in a trauma victim. We report
two cases of “near miss” C6 fracture to highlight the
importance of a detailed clinical history and clinical
examination with imaging as an adjunct to rule out
cervical injury.
Leiomyosarcoma is a rare cancer and the presence of this type of cancer in the breast is even rarer. Due to its rarity, the management options for leiomyosarcoma of the breast are not well documented. Literature review was done to establish the best treatment options for this type of breast cancer.
Introduction: Standard precautions in health care is the essence of medical practice encompassing the safety of patients and health care workers including medical students. Barriers to the proper use of personal protective equipment (PPE) exist across the world but identification of areas of weaknesses and appropriate remedies will reduce them. This study assesses knowledge and use of PPE among fourth year students after a period of educational interventions.
Objective: To evaluate appropriate use, awareness and knowledge about PPE among fourth year students after interventions.
Method: A cross- sectional study where forty year 4 students (Group B) were randomly observed and later asked to answer a questionnaire. Students had undergone interventions to improve PPE use, which included lectures and video sessions during each posting. Results were compared with a previous group (Group A). Chi-square test or Fisher’s exact test was used to analyse the data.
Results: There was statistically significant improvement in the use of PPE like wearing and removing mask during invasive procedures (p < 0.001) and hand-washing before and after a non- invasive task (p < 0.001) . Comparison of Groups A and B on the results of the questionnaire for ‘Questions in which more than 10% students answered incorrectly’, showed that there was improvement in Group B in all the questions, some being statistically significant with p value=0.01.
Conclusion: An overall improvement in the use of the PPE and knowledge was noted. Sometimes, students’ attitude and personality may be a challenge and these students may defy changes, but this can be overcome if the strategies are embedded in the curriculum and taught from as early as the first semester.
Background: Clinical reasoning is the name given to
the cognitive processes by which doctors evaluate and
analyse information from patients. It is a skill developed
by experiential learning and is difficult to assess
objectively. The script concordance test, an assessment
tool introduced into the health sciences about 15 years
ago, is a way of assessing clinical reasoning ability in
an objective manner and allows comparisons of the
decisions made by medical students and experts in
situations of uncertainty.
Methods: Twenty-six final year medical students from
the International Medical University, Kuala Lumpur,
were tested on their decision making skills regarding a
young febrile patient. The students evaluated different
pieces of information in five different scenarios and
made decisions on a five-point Likert scale in the
standard format of the script concordance test. Their
decisions were compared to the decisions of a panel of
experienced clinicians in Internal Medicine.
Results: The script concordance test scores for the
different scenarios were calculated with higher scores
being indicative of greater concordance between the
reasoning of students and doctors. The students showed
poor concordance with doctors in evaluating clinical
information. Overall, only 20 percent of the choices
made by students were the same as the choices made by
the majority of doctors.
Conclusion: Medical students vary in their ability to
interpret the significance of clinical information. Using
the script concordance test, this preliminary study looked
at the ability of final year medical students to interpret
information about a patient with a febrile illness. The
results showed poor concordance between students and
doctors in the way they interpreted clinical information.
The script concordance test has the potential to be a
tool for teaching and assessing clinical reasoning.
This article presents an overview of long acting products used in animal health, production
and reproduction. The topic represents a niche field of controlled release that few formulation scientists become specialists and experts in, but it is a field which has made significant contribution to the area of controlled release technology, and one which is of major importance to human kind due to their dependence on farmed animals as a source of hide, protein, milk and eggs.
The immune system is the host natural defence against cancer. Cancers are caused by progressive growth of the progeny of a single transformed host cell. The immune system is generally not able to mount immune responses to “self-antigens”, due to various mechanisms of immunological tolerance that are in place. This means that despite possessing a natural defence against tumours, many of the cancer patients may not be able
to mount an effective immune response to fight the tumours. Dendritic cells (DC) are highly specialised in antigen presenting that can initiate and stimulate immune responses. These cells have the ability to stimulate naïve T cell proliferation and perform specific stimulatory and tolerogenic functions respectively. When the DC are activated by antigens, these cells
undergoes further maturation and migrate to secondary lymphoid tissues, present antigen to T cells and finally induce an immune response. The ability of the DC to activate naïve and primed T-lymphocytes makes these cells a good candidate to be explored as a potential immunotherapeutic agent that can modulate antitumour immune responses in the affected host.
Background: At the International Medical University (IMU), a half day cardiac life support teaching session was provided to fourth year medical students which included training on the use of the defibrillator machine, how to handle cardiac or respiratory arrest and drugs used for resuscitation. A new CLS (cardiac life support) training session was introduced and increased to a oneday course where students were given practical training first, which included 5 stations (airway equipment, mega codes, drugs for resuscitation, defibrillator use and cardiac rhythm identification) , MCQ (multiple choice questions) test and a mega code (practical)assessment. Objective: To evaluate the students’ knowledge on cardiac resuscitation after a change in the delivery of the cardiac life support training (CLS).
Methodology: Group I, consisted of 82 students taught using the traditional teaching and Group II consisted of 77 students taught using hands on simulation. The students in both groups had an online manual to read prior to the session, were given an identical written exam six months after the CLS training. Group II, however, had an online pre-test.
Results: There was a statistical difference in the final mean marks between the two groups with group II scoring higher (67.3) than group 1 (62.1). No significant marks difference was noted between male and female students for both the cohorts.
Conclusion: There is a significant difference in medical students’ knowledge when cardiac life support is taught using simulation. IMU has adopted the new teaching method with simulated training for the cardiac life support courses with plans to implement higher fidelity and technology to the existing simulated teaching in other areas of medicine.
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