OBJECTIVES: This study aimed to compare the QTc interval between low and high dose methadone groups and evaluate the pattern of QTc variation.
METHODS: This is a prospective cohort study conducted from December 2010 till August 2011 at Malaysian University of Science's Hospital. Forty six subjects, grouped in high dose (>80mg) and low dose (<80mg) oral methadone, were followed-up at 4-weekly for QTc measurements. Relevant demographic and biochemical profiles were taken at intervals with concurrent QTc measurements.
RESULTS: No significant QTc differences between methadone dosage groups were found at Week 0 (434ms vs 444ms, p = 0.166) and week 8 (446.5ms vs 459ms, p = 0.076), but not at week 4(435ms vs 450ms, p = 0.029). However, there were significant associations between the groups with QTc prolongation at week 0 and 4 (OR 4.29(95% CI 1.01, 18.72) p=0.044 and OR 5.18 (95% CI 1.34, 20.06) p =0.013, respectively) but not at week 8 (OR 2.44 (95% CI 0.74, 8.01) p=0.139). On multivariate analysis, dose group was the sole significant factor for QTc prolongation for week 0 and 4 (p values 0.047 and 0.017, respectively), but not at week 8.
CONCLUSION: High-dose methadone group is more likely to develop prolonged QTc than low-dose group. However, such effects were inconsistent and occurred even during chronic methadone therapy, mandating judicious QTc and serum methadone monitoring.
KEYWORDS: High Dose; Low Dose; Methadone; QTc
BACKGROUND: Aspirin use is known to reduce the recurrence of stroke. However, the clinical response to aspirin has been mixed. The rate of stroke recurrence whilst on aspirin treatment is still unacceptably high. A plausible explanation for this may be resistance to the effects of aspirin. The causes of aspirin resistance are manifold and multi-factorial. We conducted a study to investigate the prevalence rate of biochemical aspirin resistance in a cohort of aspirin-naïve stroke patients. We also sought to determine the inherent factors that may predispose towards the development of aspirin resistance.
METHOD: This was a cross-sectional, observational study conducted on patients admitted to our centre with an acute stroke who were aspirin-naïve. The diagnosis of an acute stroke was confirmed by clinical history and brain imaging. Fifty consecutive patients were prospectively enrolled. Socio-demographic data were collected and baseline blood investigations were performed. Patients were tested for biochemical aspirin resistance using Multiplate platelet analyser (Dynabyte, Munich, Germany) after 5 doses of aspirin, corresponding to a total dose of 900 mg.
RESULTS: The median age of patients was 65.5 years and 54 % of patients were female. There were 11 smokers; of these 10 were male. Twenty-six (52 %) patients were Chinese, 21 (41 %) were Malay and 3 (6.0 %) were Indian. Aspirin resistance was present in 14 % of our patients. There was an inverse relationship between the presence of aspirin resistance and plasma HDL levels (r = -0.394; p = 0.005). There was no relationship observed between aspirin resistance and total cholesterol, triglycerides, LDL, HbA1c, ALT, ALP, urea and creatinine levels. There were no significant differences in demographic profiles or smoking status between the aspirin resistant and non-aspirin resistant groups. We did not find any link between ethnicity and aspirin resistance.
CONCLUSIONS: Our results indicate that a lower HDL level is associated with biochemical aspirin resistance. This may increase platelet aggregation and consequently increase the risk of a recurrent stroke. The clinical implications for aspirin resistance are far reaching. Any evidence that correctable factors may negatively influence the action of aspirin warrants further investigation. The prevalence rate of biochemical aspirin resistance in our study is comparable to the findings in other studies performed in an Asian population. Further research is required to determine how our findings translate into clinical aspirin resistance and stroke recurrence.
KEYWORDS: Asia; antiplatelet therapy; aspirin; aspirin resistance; developing countries; ischaemic stroke; risk factors
OBJECTIVE: To look for any possible coexistence of CACNA1A, ATP1A2, and KCNN3 gene mutations in migraine patients who had human platelet HPA-1a/1b polymorphism, which is also known as PlA1/A2 polymorphism.
METHODS: The study was carried out at the Neurology Clinic, Hospital University Sains Malaysia, Kelantan, Malaysia between April 2004 and March 2005. The DNA from 4 patients who had migraine with the HPA1a/1b polymorphism were analyzed by polymerase chain reaction using the allele specific oligonucleotide technique to detect the presence of CACNA1A, ATP1A2, and KCNN3 genotypes.
RESULTS: We found that the CACNA1A gene mutation alone was present in only one patient who presented with classical migraine with aura. The gene mutations on ATP1A2 and KCNN3 were seen in none of our 4 cases with migraine.
CONCLUSION: There is no coexistence between the platelet HPA-1a/1b polymorphism and the ATP1A2 and KCNN3 gene mutations, though one classical migraine patient with HPA-1a/1b polymorphism had the CACNA1A gene mutation. Larger studies are warranted to confirm these findings.
Study site: Neurology Clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
This paper describes the water compartments in healthy subjects and dengue patients on the day of defervescence of fever using bioelectrical impedance analysis. A total of 223 healthy subjects (65 males and 158 females) and 210 dengue patients (119 males and 91 females) in Hospital Universiti Kebangsaan Malaysia (HUKM), were studied. The ages for healthy subjects vary between 14 and 60 years old with mean age of 26.05 years while the ages for the dengue patients vary between 12 and 83 years old with mean age of 30.14 years. The parameters of water compartments investigated were total body water (TBW), extracellular water (ECW) and intracellular water (ICW). There were significant difference between healthy subjects and dengue patients for both male (p<0.05) and female (p<0.001) beginning on fever day 0 till fever day 4. The mean TBW and ECW values of dengue patients obtained were found to be higher than the normal healthy subjects while the mean ICW was lower. The mean TBW and ICW for male were higher than female while the mean ECW for male was lower than female for healthy subjects and dengue patients.
"Cauliflower Ears" describes the appearance of swelling of the auricular cartilage resulting in gross distortion of the auricle. The underlying pathology is inflammation of the auricular cartilage. We report a case of a patient who presented to the ophthalmology clinic with an ocular inflammation, whose subsequent diagnosis of replapsing polychondritis was clinched with the finding of "Cauliflower Ears". This case emphasizes the importance of an appropriate general examination of ophthalmic patients for early diagnosis and prompt institution of medical treatment, which may prevent life-threatening complications to the patient.
Study site: Eye clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
An analysis of 524 unclaimed prescriptions (which contributed 0.9% of the total prescriptions) showed that 23.8% were for vitamins, 17.7% for anti-inflammatory drugs, 16.4% medications for skin and mucous membrane and 9.9% for antibiotics. The unclaimed prescription rates varied inversely to the staff-strength working in the dispensary. Sixty-eight point nine per cent of the unclaimed drugs could be purchased at the pharmacy shops without doctor's prescription.
A retrospective study of 37 cases of multiple myeloma admitted from 1980 to 1987 to the University Hospital Kuala Lumpur, Malaysia, was carried out to analyse the biodata, clinical presentation, laboratory and radiological profiles. The cases were selected after they had satisfied preset diagnostic criteria. The mean age was 60 years. There was no sex or ethnic preponderance. The most common symptom was bone pain. Pallor was detected in 73% of the patients. Haemoglobin was less than 120 g/L in 95%, and ESR was greater than 100 mm/hr in 70% of cases. Bone marrow and trephine biopsies were diagnostically important. Hypercalcaemia occurred in seven cases out of which three were IgA myelomas. Either serum creatinine or blood urea was raised in nearly 50% of cases. The most common heavy chain paraprotein was IgG while Kappa light chain was the commoner light chain type. 86% of cases had osteolytic lesions. These findings are, in general, similar to those of larger studies on multiple myeloma.
Study site: University Malaya Medical Centre (UMMC)
A survey showed only 27% of our house-officers know how to intubate. Ninety-two percent however recognise the alternative to intubation. On the whole, knowledge centering around intubation is generally lacking.
Despite evidence showing that structured rehabilitation after stroke improves functional outcomes, providing seamless rehabilitation from hospital to community has been elusive. The service provided should be able to accommodate variable degree of impairments and needs of the stroke survivors. This study aimed to assess the outcome of a multidisciplinary-based outpatient rehabilitation service for stroke patients living in the community. Patients who were discharged from Universiti Kebangsaan Malaysia Medical Centre after an acute stroke were referred to the Combined Stroke Rehabilitation Clinic (CSRC). Post stroke patients were assigned individually designed programs which were problem based and used task specific activities to achieve desired goals. Patients were reviewed on a regular basis either up to completion of the 2 year program, or are able to be discharged to the community, whichever is earlier. Modified Barthel Index (MBI) and Berg Balance Scores (BBS) were used for monitoring. A total of 68 patients were managed in CSRC for two years since its initiation, with mean age of 62.4 years (SD 12.4) with the mean duration of stroke when first reviewed in CSRC was 11.5 months (SD 11.9). Majority of patients (64.7%) received either two or three types of intervention. Both MBI and BBS demonstrated significant improvement over 12-months period (p value of 0.006 and 0.017 respectively). CSRC proved that structured rehabilitation intervention was beneficial in terms of functional status and improvement in balance to post-stroke patients.
Study site: Combined Stroke Rehabiltation clinics, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
31 cases of ocular toxoplasmosis were seen at the Ophthalmology Clinic, Uniuersiti Kebangsaan Malaysia, Kuala Lumpur during a one-and-a-half year period. All these cases were diagnosed as congenital ocular toxoplasmosis. As this condition appears not to be uncommon in. Malaysia, greater effort should be made towards its prevention especially among pregnant women.
Study site: Ophthalmology Clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
A review of rhabdomyosarcoma in childhood reveals that the pattern and results of treatment have changed with the introduction of multimodal therapy. Outcome in our series have been poor due to advanced disease, poor compliance to follow up resulting from poor socio-economics and educational levels of our patients and their faith in traditional medicine. Improvement in the prognosis can only be anticipated with earlier diagnosis and reduction in defaulter rate.
AIM: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a recognised cause of severe neonatal hyperbilirubinaemia, and identifying which infants are at risk could optimise care and resources. In this study, we determined if G6PD enzyme activity (EA) and certain gene variants were associated with neonatal hyperbilirubinaemia requiring phototherapy during the first week after birth.
METHODS: Newborn infants with G6PD deficiency and a group with normal results obtained by the fluorescent spot test were selected for analyses of G6PD EA and the 10 commonly encountered G6PD mutations in this region, relating these with whether the infants required phototherapy before discharge from the hospital in the first week.
RESULTS: A total of 222 infants with mean gestation and birth weight of 38.3 ± 1.8 weeks and 3.02 ± 0.48 kg, respectively, were enrolled. Of these, n = 121 were deficient with EA ≤6.76 U/g Hb, and approximately half (43%) received phototherapy in the first week after birth. The mean EA level was 3.7 U/g Hb. The EA had good accuracy in predicting phototherapy use, with area under the receiver-operating-characteristic curve of 0.81 ± 0.05. Infants on phototherapy more commonly displayed World Health Organization Class II mutations (<10% residual EA). Logistic regression analysis showed that deficiency in EA and mutation at c.1388G>A (adjusted odds ratio, 1.5 and 5.7; 95% confidence interval: 1.31-1.76 and 1.30-25.0, respectively) were independent risk factors for phototherapy.
CONCLUSION: Low G6PD EA (<6.76 U/g Hb) and the G6PD gene variant, c.1388G>A, are risk factors for the need of phototherapy in newborn infants during the first week after birth.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
BACKGROUND: Anxious distress in major depressive disorder (MDD) is common and associated with poor outcomes and management difficulties.
AIMS: This post hoc analysis aimed to examine the socio-demographic and clinical correlates of anxiety distress in Asian outpatients with MDD.
METHODS: Instead of two out of five specifiers defined by the Diagnostic and Statistical Manual Version-5, anxious distress defined in this study was operationalized as the presence of at least two out of four proxy items drawn from the 90-item Symptom Checklist, Revised (SCL-90-R). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale, the Sheehan Disability Scale and the Multidimensional Scale of Perceived Social Support.
RESULTS: The data of 496 patients with MDD were included. Anxious distress was found in 371 participants (74.8%). The binary logistic regression analysis found that anxious distress was independently and significantly correlated with working status, higher MADRS scores, severe insomnia and functional impairment.
CONCLUSIONS: Three-fourths of Asian patients with MDD in tertiary care settings may have DSM-5 anxious distress of at least moderate distress. Its prevalence may vary among working groups. The specifier was associated with greater depressive symptom severity, severe insomnia and functional impairment.
Study site: n tertiary care
settings in China, Korea, Malaysia, Singapore, Taiwan and
OBJECTIVE: To determine the correlation between central venous pressure (CVP) measured by conventional central venous access and ultrasonographic measurement of internal jugular vein (IJV) height and inferior vena cava (IVC) diameter.
METHODS: A prospective, cross-sectional, convenience sampling observational study.
RESULTS: 25 patients from the Emergency Department (ED) Universiti Kebangsaan Malaysia Medical Centre (UKMMC) were studied between 1st March and 30th April 2013. The median age was 63 years (95% CI 54-67). There was a significant correlation between IJV height and CVP using central venous access (r=0.64 p<0.001). Correlation between IVC diameter in end expiration and CVP was 0.74 (p<0.001). An IJV height measurement >8cm predicted a CVP >8cm H2O (sensitivity 71.4%, specificity of 83.3%).
CONCLUSION: Measurement of IJV height and IVC diameter by ultrasonography correlates well with invasive CVP and is useful for the assessment of volume status in critically ill patients in the ED.
Study site: Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
Myxoid neurofibroma is benign tumours of perineural cell origin that arise from elements in the peripheral nervous system. We report a case of a 60-year-old female patient presented with history of right ear mass which was slowly growing. Her primary complaint was cosmetic deformity but hearing loss was also present. The mass was excised and histologically revealed a myxoid neurofibroma. To the authors' knowledge, this is the first time that a myxoid neurofibroma arising from external auditory canal is reported. It should be included in the differential diagnosis of a mass originating from this location.
Keywords: Kelantan, Hospital Universiti Sains Malaysia
Aim. Poor sleep quality due to pain has been reported among opioid-dependent male patients on methadone maintenance therapy (MMT) but objective pain data are lacking. This study aimed to investigate the rate of pain-sensitivity using cold pressor test (CPT) and the relationship between pain-sensitivity and sleep quality in this population.
Methods. A total of 168 male participants were included into the study. Objective pain-tolerance was evaluated at 0 h and at 24 h after the first CPT. Malay version of the Pittsburgh Sleep Quality Index (PSQI) and the subjective opiate withdrawal scale (SOWS) questionnaires were administered to evaluate the quality of sleep and withdrawal symptoms, respectively.
Results. The mean age of study participants was 37.22 (SD 6.20) years old. Mean daily methadone dose was 76.64 (SD 37.63) mg/day, mean global PSQI score was 5.47 (SD 2.74) and mean averaged SOWS score was 5.43 (SD 6.91). The averaged pain-tolerance time ranged from 7 to 300 s with a mean time of 32.16 (SE 2.72) s, slightly below the cut-off score of 37.53 s. More specifically, 78.6% (n = 132) of participants were identified as pain-sensitive (averaged pain-tolerance time ≤37.53 s), and 36 (21.4%) participants were pain-tolerant (averaged pain-tolerance time >37.53 s). The pain-sensitive group reported poorer sleep quality with mean (SD) PSQI of 5.78 (2.80) compared with the pain-tolerant group with mean (SD) PSQI of 4.31 (2.18) (p = 0.005). With analysis of covariance, pain-sensitive group was found to have higher global PSQI scores (adjusted mean 5.76, 95% CI 5.29; 6.22) than pain-tolerant participants (adjusted mean 4.42, 95% CI 3.52; 5.32) (p = 0.010).
Conclusions. Majority of opioid-dependent male patients on methadone treatment are pain-sensitive with CPT. Poor sleep quality is associated with cold pressor pain-sensitivity. Pain and sleep complaints in this male population should not be overlooked.
Study site: Hospital Universiti Sains Malaysia (HUSM) and other MMT clinics (Kota Bharu, Pasir Mas, Pasir Puteh and Bachok), Kelantan, Malaysia
BACKGROUND: The aim of this study was to determine the usefulness of end tidal carbon dioxide (ETCO2) monitoring in hypotensive shock patients presenting to the ED.
METHODS: This was a prospective observational study in a tertiary ED. One hundred three adults in shock with hypotension presenting to the ED were recruited into the study. They were grouped according to different types of shock, hypovolemic, cardiogenic, septic and others. Vital signs and ETCO2 were measured on presentation and at 30-min intervals up to 120 min. Blood gases and serum lactate levels were obtained on arrival. All patients were managed according to standard protocols and treatment regimes. Patient survival up to hospital admission and at 30 days was recorded.
RESULTS: Mean ETCO2 for all patients on arrival was 29.07 ± 9.96 mmHg. Average ETCO2 for patients in hypovolemic, cardiogenic and septic shock was 29.64 ± 11.49, 28.60 ± 9.87 and 27.81 ± 7.39 mmHg, respectively. ETCO2 on arrival was positively correlated with systolic and diastolic BP, MAP, bicarbonate, base excess and lactate when analyzed in all shock patients. Early ETCO2 measurements were found to be significantly lower in patients who did not survive to hospital admission (p = 0.005). All patients who had ETCO2 ≤ 12mmHg died in the ED. However, normal ETCO2 does not ensure patient survival.
CONCLUSION: The use of ETCO2 in the ED has great potential to be used as a method of non-invasive monitoring of patients in shock.
Study site: Emergency department, Hospital Universiti Sains Malaysia
At the University Hospital only 24.3% of Malays, 3.8% Chinese and 5.9% Indians are fully breast fed at 6-8 weeks postnatally. The majority of Chinese infants are exclusively on infant formula (68.6%) and this holds true for the Indians (52.9 %).These figures were obtained 3-4 months after the introduction of the Baby Friendly Hospital Initiative at the University Hospital. Comparing our data with previous studies we believe that there has been a decline in breast feeding in urban Kuala Lumpur, especially amongst the Indians and Chinese.
INTRODUCTION: Although the Feldenkrais method of rehabilitating chronic obstructive pulmonary disease (COPD) patients have been suggested, its use among practitioners is not widespread owing to preference of the more familiar standard program presently available. Several advantageous of the Feldenkrais Method have been suggested which includes improving the efficiency of movement, posture and, breathing. However how this compares to the standard rehabilitation protocol or pulmonary rehabilitation program (PRP) have not been previously demonstrated. The present study was thus conducted to compare the effectiveness of the Feldenkrais Method to the standard PRP using Borg score and 6 minute walked distance (6MWD) as outcome measurement tools.
RESULTS: There were 17 subjects in the Feldenkrais group (FG) and 19 subjects in the pulmonary group (PG), both of which received therapy for 8 weeks and assessed before and after receiving therapy. There were no improvements observed in the Borg score for the FG (after and before; 6.06+ 1.09 vs. 6.00+0.94). However, improvements in the PG group could be seen (after and before; 3.58+ 1.17 vs. 5.84 +1.01). Improvements in the 6MWD was observed in both groups with no significance differences noted (FG vs. PG; 379+129m vs. 374+80m).
CONCLUSION: The Feldenkrais method does not offer any advantage over the present PRP and in fact the latter offers better improvement in terms of the Borg score. However in view of the small study sample, further study would be needed before a final conclusion can be made.
Study site: Respiratory clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Stroke is among the main cause of death and loss of work capability in Malaysia. Government hospitals statistic shows drastic increase of stroke cases and deaths resulting from it. Hospital Kuala Lumpur's statistic recorded about 30% to 35% fatality in cases of stroke. The study was carried out to identify the level of stroke recovery and its associated factors. The study was carried out at University Kebangsaan Malaysia Medical Center (UKMMC), Hospital Kuala Lumpur (HKL) and National Stroke Association of Malaysia (NASAM). The sampling method was universal sampling and respondents were interviewed using guided questionnaire. The stroke recovery was studied to identify the relationshiP with social support, age, coping, stroke severity and lifestyle. The response rate of this study was 50.3%. A total of 47.0% ofstroke patient received high stroke recovery. Among five factors studied, three factors have shown the significant relationship with stroke recovery; coping style OR 0.293 (95% Confidence Interval (CI), 0.129·0.668, P "0.004); lifestyle, OR 0.347 (95% Confidence Interval (CI), 0.154· 0.782, p" 0.01) dan social support OR 0.291 (95% Confidence Interval (CI), 0.128· 0.664, P"0.004), Establish significant relationshiP of stroke recovery with three studied factors which were social support, coping style and lifestyle. Most of the stroke patients in this study are retirees and housewives. These three factors are required further attention to ensure stroke patients recover.
Key words: Recovery, stroke, social support, coping, lifestyle