We analysed the outcome of 104 patients from a single institution who underwent allogeneic haematopoietic stem cell transplantation (AHSCT) from their HLA-identical siblings between 1993 and 2006. Sixty-nine percent of patients had peripheral blood stem cell (PBSC) as the stem cell source and the remaining had bone marrow (BM). The majority of patients are Chinese (60%) followed by Malays (24%) and Indians (14%). The median time to reach white cell counts of >1 x 10(9)/L and platelet counts of >30 x 10(9)/L was 13 and 15 days, respectively in patients who had PBSC transplantation compared with 16 and 25 days in patients who had BM transplantation, (p < 0.0001 and p < 0.001). Acute graft-versus-host disease (aGVHD) of grade II to IV was observed in 34% of patients and chronic graft-versus-host disease (cGVHD) in 38% of patients. Although not statistically significant, there was a higher incidence of overall aGVHD in Indian patients (73%) compared to Chinese and Malays (57% and 56% respectively). There was no significant difference in the incidence of aGVHD and cGVHD with the source of stem cells. Overall survival (OS) and disease free survival (DFS) was 50% and 60% at five years respectively. Multivariate analysis showed that patients transplanted in standard risk and those who had limited cGVHD had a significant better OS, (p = 0.05 and p = 0.05). Patients who had cGVHD and transplanted in standard risk had a better DFS, (p = 0.002 and p < 0.001). In summary, AHSCT in standard risk patients is associated with a better outcome than those transplanted in high risk and although not statistically significant, there is a higher incidence of aGVHD in Indian patients.
Depression among elderly primary care patients is a serious problem with significant morbidity and mortality. This is a cross sectional study to determine the prevalence of depression and its associated factors among the elderly patients attending the outpatient clinic, Universiti Sains Malaysia Hospital. This study utilized Malay version Geriatric Depression Scale 14 (M-GDS 14) to screen for elderly depression among Malaysian population. It also looked into associated risk factors for elderly depression using sociodemographic, family dynamics, and medically related questionnaires. Out of 244 subjects, 34 or 13.9% were found to have depression. Three variables were found to be significantly associated with depression. Elderly patient with any illness that limits the patient's activity or mobility has more risk of developing depression (OR 2.68 CI 1.15 - 6.24). Elderly patients who were satisfied with their personal incomes (OR 0.29 CI 0.10 - 0.85), and who had children or son/daughter-in-law to take care of them when they are sick (OR 0.10 CI 0.01 - 0.83) have a lower chance of having depression. Screening the elderly for depression, would help in diagnosing the elderly depression better and offer them the treatment needed.
Study site: Outpatient clinics, Hospital Universiti Sains Malaysia (HUSM)
Ophthalmology consultation is one of the commonest requested services for inpatients in a tertiary hospital. A total of 290 ophthalmology consultation requests were received over a period of six months (average 12 consultation requests per week) and from these, 222 patients were examined. The patient demographics, the hospitalization data, type of consultations (screening, new problem, preexisting problem), reasons for consultations and the ophthalmology diagnosis were determined. Out of 290 consultation requests, internal medicine services requested the highest number (95, 32.8%); the commonest type of consultation was screening for eye diseases (161, 55.5%) and the most common reason for consultation was to rule out diabetic retinopathy (125, 43.1%). The top five ophthalmology diagnoses after examination were diabetic retinopathy (45, 20.3%), diabetic retinopathy ruled out (37, 16.6%), conjunctivitis (12, 5.4%), refractive error (11, 4.8%) and normal ocular examination (11, 4.9%). Inpatient ophthalmologic procedures were performed in 146 patients, the commonest of which was retinal laser photocoagulation. A total of 133 (59.9%) inpatients had a change in their management as a result of the ophthalmology consultation.
Children who would benefit from a haematopoietic stem cell transplantation often lacked a compatible sibling donor. Unrelated cord blood transplantation was offered as an alternative donor source for patients with a variety of malignant and non-malignant diseases who had no further treatment options. Cord blood units were sourced from various international cord blood registries. The median nucleated and CD34+ cell doses were 8.7 x 10(7)/kg and 2.6 x 10(5)/kg respectively. In spite of adequate cell doses, a high rate of non-engraftment of 32% was observed. Acute graft-versus-host disease (GVHD) occurred in 14 out of the 15 patients who engrafted with 53% being grade III to IV GVHD. The five year disease free survival was 40.7% with infection and GVHD being the commonest causes of death. The five year disease free survival was 20.5% and 60.7% for malignant and non-malignant diseases respectively.
This prospective, randomized, study was designed to compare the effect of two different preloading volumes of Ringer's lactate for prevention of maternal hypotension induced by spinal anaesthesia for Caesarean section. Eighty ASA I or II obstetric patients were randomized to two groups. Group 1 (n = 40) received 20 ml/kg of Ringer's lactate and Group 2 (n = 40) 10 ml/kg of Ringer's lactate over 20 minutes before spinal anaesthesia. The lowest mean arterial pressure (MAP) for both groups were recorded at 15 minutes after giving spinal anaesthesia, This difference in the drop of MAP from base-line at 15 minutes (mean decrease of 12.5 mmHg from baseline), between preloading with 10 ml/kg and 20 ml/kg of Ringer's was statistically significant. Twelve patients from Group 1 required bolus doses of ephedrine and 15% of these needed additional crystalloid whereas two patients from Group 2 needed ephedrine boluses and 22% of these required additional crystalloid. The difference in frequency of requirement for treatment of hypotension was not statistically significant. There were five patients in Group 1 and six patients in Group 2 who experienced nausea and vomiting, the frequency of occurrence did not show any statistically significant difference between the two groups. In conclusion, for prevention of hypotension during spinal anaesthesia for Caesarean section, infusing 20 ml/kg or 10 ml/kg of Ringer's Lactate gave similar results and we do not recommend the use of a larger volume of crystalloid for preloading before spinal anaesthesia.
In Malaysia, it is a common belief among health care workers that females and Indians have lower pain threshold. This experience, although based on anecdotal experience in the healthcare setting, does not allow differentiation between pain tolerance, and pain expression. To determine whether there is a difference in the tolerance to pain between the three main ethnic groups, namely the Malays, Chinese and Indians as well as between males and females. This was a prospective study, using a laboratory pain model (ischaemic pain tolerance) to determine the pain tolerance of 152 IMU medical students. The mean age of the students was 21.8 years (range 18-29 years). All of them were unmarried. The median of ischaemic pain tolerance for Malays, Chinese and Indians were 639s, 695s and 613s respectively (p = 0.779). However, statistically significant difference in ischaemic pain tolerance for males and females Indian students were observed. Possible ethnic difference in pain tolerance in casual observation is not verified by this laboratory pain model. Difference in pain tolerance between genders is shown only for Indians.
We aimed to determine the epidemiology and burden of rotavirus (RV) gastroenteritis (GE) in children requiring hospital care in an urban setting in Sabah, Malaysia. A prospective study of all patients younger than 12 years of age admitted with acute GE to Queen Elizabeth Hospital, Sabah, over a six-month period (October 2005 to March 2006) was conducted. During the study period, a total of 167 children with acute GE who had stool samples examined for RV were studied. RV accounted for 16% of all diarrhoeal cases, and 1.7% of all admissions to the children's wards during the study period. There was no difference in severity of GE between RV and non-RV groups. RV infection is a common cause of childhood GE requiring hospital care in Sabah.
The increase in life expectancy observed over the last decade has particular relevance for conditions such as cognitive decline and dementia. This is a cross sectional study to determine the rate of dementia and to identify its associated factors among 399 elderly patients attending outpatient clinics of Universiti Sains Malaysia Hospital. This study was conducted in 2 phases. In the first phase, the literate subjects were screened using validated Malay version of Mini Mental State Examination (MMSE) and the illiterate subjects with Malay version of Elderly Cognitive Assessment Questionnaire (ECAQ). All subjects suspected to have dementia were selected for further evaluation in phase 2 of this study. The second phase involved full clinical examination in order to establish clinical diagnosis of dementia. The proportion of dementia in this study was 2.5% (10). Although history of exposure to pesticide (p < 0.05) and history of stroke (p < 0.05) were significant, they were not significant factors. These were because vast discrepancy in number between those exposed to pesticide and having stroke between dementia and non dementia.
Study site: Outpatient clinics, Hospital Universiti Sains Malaysia (HUSM)
Poor sleep quality and daytime somnolence is reported to be associated with cardiovascular events, road traffic accident, poor academic performance and psychological distress. Some studies documented that it is prevalent in most populations but its frequency among medical students has not been documented in Malaysia. This is a self-administered questionnaire survey of medical students from International Medical University, Malaysia. Daytime sleepiness of medical students was assessed using Epworth Sleepiness Scale (ESS). Student scoring ESS > 11 was regarded as having excessive daytime sleepiness. Psychological distress was measured using 12-item General Health Questionnaire (GHQ-12). A total of 799 medical students participated in this survey (response rate 69.5%). Daytime sleepiness occurred in 35.5%, psychological distress was present in 41.8% and 16.1% reported bad sleep quality. Daytime sleepiness was significantly more common among the clinical students, those with self-reported bad sleep quality and psychological distress; but unrelated to the number of hours sleep at night. We have documented high prevalence of daytime sleepiness, poor sleep quality and psychological distress. Higher frequency among clinical students and the significant relationship with psychological distress suggest possible link to the stressful clinical training.
In recent years, zoonotic RNA viruses such as Nipah, SARS coronavirus, avian influenza (H5N1) and Chikungunya have emerged with global impact. The latest has now been designated by World Health Organization (WHO) as pandemic (H1N1) 2009 virus. It was first reported as an outbreak in Mexico in April, and has now caused the first influenza pandemic since 1968. By July 11, 2009, there were 105,304 confirmed cases and 463 deaths in 143 countries, including 627 cases in Malaysia1 . The rapid spread of the disease has been matched by the speed of dissemination of information and protocols, co-ordinated by WHO. The experiences of SARS and H5N1 have been enormously beneficial in preparing the world for a pandemic.
Umbilical Cord Blood Transplant (UCBT) is a type of allogenic haematopoetic stem cell transplant. Stem cell transplantation as a mode of treatment of diseases was first successfully done by the pioneering work of a Nobel Prize Winner in Physiology or Medicine, E. Donnall Thomas in 1957. Throughout the past 50 years, numerous other researchers have improved the techniques of this previously highly risky procedure. Among the notable landmark in haematopoetic stem cell transplant include: advancement in immunogenetics of HLA, better immunosuppressive preparative regimen, improved control of infections, appearance of donor registries throughout the world and successful transplantation stories using haematopoetic stem cells from peripheral blood and the cord blood. These developments lead to a change in terminology from marrow transplantation to haematopoetic stem cell transplantation .
Major congenital malformations occur in about 3% of newborn. Several studies have suggested that homozygosity for the C677T methylenetetrahydrofolate reductase (MTHFR) variant is a potential risk factor for neural tube defects (NTDs). It has been hypothesized that the maternal folic acid supplementation prevents NTDs by partially correcting reduced MTHFR activity associated with the variant form of the enzyme. This association has not been found in some ethnic groups. In this study, we attempted to assess the association between NTDs and MTHFR C677T in Malaysian Malay population. Results show that MTHFR 677TT genotype was absent in both patient and control groups.
The management of epistaxis remains to be a challenging problem for most ENT surgeon especially posterior epistaxis. Most cases are managed by placement of posterior nasal packs or balloons and failure leads to more invasive techniques, involving ligation of the internal maxillary artery. The above management is associated with significant patient complication and morbidity. Endoscopic ligation or cauterization of the sphenopalatine artery has emerged as a viable and minimally invasive alternative. We have performed endoscopic cauterization of nine sphenopalatine arteries in eight patients with no further episodes of epistaxis and complications, with an average follow-up of 25 months. The mean age of the patients was 52.75 years. Fifty percent of the patients had a history of hypertension.
To investigate the case incidence, causes, clinical profile and outcome of temporal bone fracture complicating head trauma. A 1-year (2005) retrospective study of head injured patients presented to the Emergency Department, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia. Gender distribution, cause of injury, radiological findings and otorhinolaryngological clinical presentations were analyzed. Of 1309 patients, 61 patients were diagnosed to have temporal bone fracture (4.7%). Majority of cases were caused by motor vehicle accident (85.9%) and were predominantly male (88.5%). The right temporal bone was more frequently fractured (62.3%). Most (88.5%) were petro-mastoid fractures. Sixty-seven percent of the petrous fractures were longitudinal type. Clinical presentations mostly reported were blood rhinorrhea (36%) and blood otorrhea (32.7%). Other clinical presentations were hearing loss (9.8%), cranial nerve palsy (8.2%), cerebrospinal fluid oto-rhinorrhea (8.2%) and labyrinth concussion (6.5%). Four out of five cranial nerve palsies were facial nerve. Out of the 61 cases, 16 (26.2%) had no clinical presentation at the time of Emergency Department consultation. Thirteen (21.3%) died due to severe head injury. The case incidence of temporal bone fracture in head injured patients in our centre is 4.7%. The petro-mastoid type fracture predominates. Proper early diagnosis and management minimize complications.
To set the foundation for developing a centre for airway reconstruction, we performed a retrospective database review of patients operated at a tertiary-care university hospital. Over the past 3-year period from 2004 onwards, five paediatric cases of airway reconstruction procedures were performed. All cases had a two stages laryngotracheal reconstruction (TSLTR) for laryngotracheal stenosis (LTS). All patients were children below 15 years and the mean age was 9 years. Only one patient had a Grade IV Myer-Cotton stenosis, the rest all had Grade III stenosis. Three out of four of the Grade III stenosis patients were successfully decannulated within one year, the other one died of causes unrelated to LTS. The grade IV patient was still under followup and surgery was done only recently. This paper highlights the complexity of managing LTS in the paediatric age group and recommends the use of LTR with rib graft as a choice for the management of LTS.
We present the results and conclusions of an observational prospective cohort design study using self-administered questionnaires to determine correlation between psychosocial factors and cancer outcome among 80 consecutive newly diagnosed treatment naïve cancer subjects who were being referred to the Oncology Clinic, Hospital Universiti Kebangsaan Malaysia. Subjects were recruited over a period of 43 weeks from October 2000 till July 2001. Follow-up assessments were carried out at 6-months and 12 to 26 months later. The prediction of survival time was performed by the Cox Regression Analysis method with adjustments for biological and psychosocial risk factors. It was noted that depression (p = 0.001), stage 4 cancer disease (p = 0.016), neurological (p = 0.032), gastrointestinal tract (p = 0.04), head and neck (p = 0.011), gynaecological (p = 0.005) and bone and soft tissue (p = 0.030) malignancies were independent and statistically significant prognostic factor of survival during the study period. It was further shown than depressed patients were found to have almost four fold greater risk of dying than non-depressed patients and patients with stage 4 cancer illness have a five fold greater risk of dying than patients with stage 1 disease. Furthermore, based on tumour types subjects with neurological, gynaecological, head and neck, bone and soft tissue and gastro intestinal tract malignancies were found to have approximately thirty-six, twenty-five, twenty-two, sixteen and seven fold greater risk of dying respectively when compared to subjects with genitourinary cancers. This study further affirms the need for health care providers to be aware of the psychological aspects of the cancer patient and provide appropriate therapy so as to ensure that this group of individuals would have enhanced survival rates.
Study site: Oncology clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
The last decade has witnessed an alarming increase in the worldwide incidence of hypospadias. For non-hypospadiologists, the surgical correction of hypospadias will be increasingly demanding. This paper aims to evaluate the effectiveness of a treatment strategy devised by a single-surgeon practice in Malaysia to tackle this anticipated surge of caseload. Over a period exceeding eight years, 254 boys underwent corrective hypospadias surgery by a single paediatric surgeon at Alor Star Hospital, Malaysia. Patient demographics, racial distribution and meatal location were among the data collected retrospectively. The various types of corrective procedure employed, their outcome as well as complications were evaluated. Distal type of hypospadias dominated this series. There was an explainable peculiarity in the age distribution of hypospadias. For all types of repair, the complication rate was 33% consisting mainly of urethrocutaneous fistula (18%) and meatal stenosis (9%). Complication rate for tubularised incised plate (TIP) urethroplasty, the commonest technique of repair, was 30%, mainly from meatal stenosis (15%) and urethrocutaneous fistula (13%). Univariate analysis revealed that proximal hypospadias, repairs done during the initial four years of study and utilisation of repair other than TIP to be adverse risk factors. Tubularised incised plate urethroplasty was appropriate for almost all types of hypospadias. For the remainder, the two stage repair is satisfactorily employed. This study from a primary referral centre also dispelled the notion that proximal hypospadias predominate in this region. The versatility and reliability of TIP urethroplasty lends itself readily in tackling primary and repeat hypospadias surgery within a single-surgeon practice.
This study to evaluate the relationship between end-tidal carbon dioxide pressure (ETCO2) and arterial partial pressure of carbon dioxide (PaCO2) included 35 patients between the ages of 18 and 65 years, ASA grade 1 and 2, who had elective craniotomies. Measurements of PaCO2 and ETCO2 were taken simultaneously: 1) 10 minutes after induction of general anaesthesia, 2) after cranium opening prior to dural incision, 3) start of dural closure. There was significant correlation between ETCO2 and PaCO2 (correlation coefficient: 0.571, 0.559 and 0.629 respectively). The mean (SD) difference for PaCO2 and ETCO2 were: 3.84 (2.13), 4.85 (5.78) and 3.91 (2.33) mmHg respectively. Although there was agreement, the bias is of significant clinical importance. In conclusion, we find that ETCO2 consistently underestimated the value of PaCO2 during craniotomy.