This study was conducted to compare the treatment efficacy between a prandial glucose regulator, repaglinide and a new sulphonylurea, glimepiride in Muslim Type 2 diabetic patients who practice Ramadan fasting. Forty-one patients, previously treated with a sulphonylurea or metformin, were divided to receive either repaglinide (n=20, preprandially three-times daily) or glimepiride (n=21, preprandially once daily) 3 months before the month of Ramadan. During Ramadan, patients modified their eating pattern to two meals daily, and the triple doses of repaglinide were redistributed to two preprandial doses. Four point blood glucose monitoring were performed weekly during the month of Ramadan and the subsequent month. Measurements of the 4-point blood glucose were significantly lower in the glimepiride group compared to the repaglinide group both during and after Ramadan. The glycaemic excursion was better in the morning for the repaglinide group and better in the afternoon and evening for the glimepiride group during the Ramadan period. There was no statistically significant difference in the incidence of hypoglycaemia between the two groups during and after Ramadan. There was no difference in the glycaemic excursion post-Ramadan. The longer duration of action of glimepiride may offer an advantage over repaglinide during the 13.5 hours of fast in Ramadan for diabetic patients.
DRE has been used as a diagnostic and screening tool for prostate cancer for decades. However these are based on Western data and its local applicability has yet to be verified. We held a Prostate Health Awareness Week in August 1998 and a total of 2086 men were screened. All men aged 50 years old and above were included for the study. The subjects were evaluated on DRE findings, PSA levels and if indicated a TRUS-guided biopsy results. We concluded that DRE per se might have limited role in the screening of prostate cancer in Malaysia. Screening using DRE and PSA combined are still recognized as the most cost-effective means. Neither DRE nor PSA alone has high enough specificity for diagnosis of prostate cancer cases. Combining DRE and PSA will definitely increase the specificity significantly.
Study site: e Urology
Clinic of Kuala Lumpur Hospital
A study was undertaken to assess the accuracy of the Omron HEM-907 blood pressure measuring device for use in community studies. A modified version of the British Hypertension Society (BHS) and American Association for the Advancement Medical Instrumentation (AAMI) protocol for measuring the accuracy of a blood pressure measuring device was used. A total of 104 subjects were recruited from two clinics. Observer-observer agreement for readings within the 5 mmHg was good; 80.8% and 84.6% of systolic blood pressure (SBP) and diastolic blood pressure (DBP) agreement respectively. Of the two, the better observer-device agreement readings within the 5 mmHg were 66.4% and 50.0% for SBP and DBP respectively, giving an overall grade B. The mean differences and standard deviation of the differences were within < or =5 mmHg with a standard deviation (SD) of < or =8 mmHg. The Omron HEM-907 satisfied both the AAMI and BHS protocols for accuracy for a non-invasive blood pressure monitoring device using single observer readings.
Study site: Klinik Kesihatan Shah Alam, Selangor; Hypertension clinic, Hospital Kuala Lumpur, Malaysia
Device: Standard device: mercury sphygmomanometer (brand?); test device: oscillometric automated electronic BP monitor (Omron HEM-907).
Thirty-one patients with endoscopically proven chronic gastric ulcer completed a randomised double-blind trial comparing the effects of cimetidine and placebo on ulcer healing. Seventeen patients received cimetidine 400 mg bid and 14 patients received placebo. Repeat endoscopy at six weeks showed that the ulcer had healed in 12 patients (71%) receiving cimetidine and in four patients (29%) receiving placebo (p=O.032). Non-smokers healed their ulcers better than smokers (83% vs 35%, p=O.023). The use of cimetidine was not associated with any adverse effects.
AIM: This prospective, single-group, pre-post design trial was conducted to evaluate the effect of individualised Medical Nutrition Therapy intervention administered by a dietitian in individuals with type 2 diabetes mellitus on glycaemic control, metabolic parameters and dietary intake.
METHODS: Subjects (n=104; age=56.4 ±9.9 years; 37% male; years of diagnosis = 6.3 ±4.9 years) treated with diet and on a stabile dose of oral anti-diabetic agents were given dietary advice by a dietitian for a 12 week period. Individualised dietary advice was based on Malaysian Medical Nutrition Therapy for adults with type 2 diabetes mellitus. The primary outcome measure was glycaemic control (fructosamine and HbA1c level) and the secondary outcome included measures of anthropometry, blood pressure, lipid profile, insulin levels dietary intake and knowledge on nutrition.
RESULTS: At week 12, 100 subjects completed the study with a dropout rate of 3.8%. The post-Medical Nutrition Therapy results showed a significant reduction of fructosamine (311.5 ±50 to 297 ±44 umol/L; P< 0.001) and HbA1c (7.6 ±1.2 to 7.2 +1.1%, p<0.001) with pronounced reduction for subjects who had very high HbA1c levels of >9.3% at baseline. Waist circumference (90.7 ±10.2 to 89.1 ±9.8 cm, p<0.05), HDL-cholesterol (1.1 ±0.3 to 1.2 ±0.3 mmol/L, p<0.05), dietary intake and nutrition knowledge score (42 ±19 vs. 75 ±17%; p< 0.001) were significantly improved from the baseline.
CONCLUSIONS: Individualised Medical Nutrition Therapy administered by a dietitian resulted in favourable diabetes outcomes, which were more apparent for individuals with higher than optimal HbA1c levels at the start of the study.
We conducted a prospective study in order to audit our experience of repairing cranial defects using Methyl methacrylate. This included a total of 49 patients undergoing cranioplasty using methyl methacrylate, of which 45 were males and 4 females. The age of patients at the time of surgery ranged from 16 to 40 years old, with an average of 24 years. Malays were the majority (67%), followed by Chinese (23%) and Indian (10%). Cranial defects were mainly caused by motor vehicle accident (94%), while gunshot wounds, industrial accidents and tumours, each contribute 2%. Bone flaps were commonly removed during previous surgery related to traumatic subdural haemorrhage (33%), contusion (21%) and intracerebral haemorrhage (14%). The size of cranial defects ranged from 28 cm2 to 440 cm2, with an average of 201 cm2. Most had right sided (55%) and lateral defects [temporoparietal (52%) followed by temporal (16%), frontal (16%), frontotemporal (14%) and occipital (2%)]. Duration of surgery ranged from 70 to 275 minutes, with an average of 135 minutes. Nine of 12 patients (75%) with neurological disability had some improvement while 85% of symptomatic patients had symptoms improvement after cranioplasty. The infection rate in this series was 4%.
This was a prospective randomized study comparing the ease of insertion, haemodynamic changes, quality of airway seal, oxygenation and ventilation parameters and complications between Laryngeal Tube Suction II (LTS II) with Proseal Laryngeal Mask Airway (PLMA), both are supraglottic airway incorporated with gastric passage. Fifty-four ASA I and II patients were randomly allocated to receive either LTS II or PLMA. Both devices provided a secure airway even under conditions of elevated intra-abdominal pressure up to 17 mmHg. In this study, there were no differences concerning ease of insertion, haemodynamic changes, quality of airway seal, oxygenation and ventilation parameters and complications between LTS II and PLMA.
Several pharmacological agents have been found to alter systemic concentrations and/or the activity of different cytokines via a variety of mechanisms, including changes in biosynthesis, secretion, and/or stability. Pentoxifylline (PTX), which is a methylxanthine derivative for example, has multiple effects on the immune system, but inhibition of pro-inflammatory cytokine release predominates. In this study we aimed to evaluate the influence of PTX on plasma levels of tumor necrosis factor (TNF) alpha and interleukin (IL)-6 in newborn infants with sepsis. The study included 20 infants with neonatal sepsis. In all subjects blood samples for serum C-reactive protein, TNF alpha and IL-6 determinations were received before giving PTX and at the 12th and 24th hours following PTX. In addition, white blood cell was counted before giving PTX and on the 3rd and 7th day following PTX. The infants were randomly divided into two groups. Firstly, PTX was used in infants who were successively admitted to the clinic and the subsequent infants were accepted as a control group. Of 20 infants, 13 infants received PTX and seven infants did not. We did not find any difference in the leukocyte count, serum C-reactive protein level, TNF alpha and IL-6 levels between the two groups of patients (P>0.05). While three infants died in the group of receiving PTX, death was not recorded in the group of non-receiving PTX (P>0.05). Our findings showed that PTX treatment did not affect leukocyte counts, serum CRP levels, TNF alpha and IL-6 levels and death ratio in newborn infants with sepsis. The last result may be due to the fact that the number of patients in the study was very small. We think that more extensive and controlled studies should be performed about this subject.
Forty-two previously untreated male patients with uncomplicated gonococcal urethritis were treated with a single dose oral regimen comprising 3 gm ofamoxycillin and 125 mg of clavulanic acid. Thirty-five patients returned for follow-up and the cure rate among them was 89 percent. The cure rate for patients infected with penicillinase producing Neisseria gonorrhoeae (PPNG) was 73 percent. Further work is required to establish the optimum dosage for this particular regimen.
Study site: Sexually Transmitted Diseases (STD) clinic at the Faculty of Medicine,
Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Retrospective analysis was done on 85 patients (76 female, 9 male) with lupus nephritis who started intravenous cyclophosphamide between 1/1/1989 and 31/12/1998. The initial renal biopsy (World Health Organisation) classification was III (4.7%), IV (89.4%) and V (5.9%). Average serum creatinine at time of biopsy was 0.12 +/- 0.12 mmol/l. Median duration of nephritis before biopsy was 2 months (range 0-133). Median duration of follow-up from time of biopsy to outcome (death or end-stage renal failure) was 3.3 years (range 0.3-11.8). Nineteen patients died. The calculated proportion alive at 5 years was 75% and at 10 years 64%. The calculated proportion alive with renal function was 74% and 54% at 5 and 10 years respectively. Fifty-two patients completed cyclophosphamide therapy at the end of the study. There were ten episodes of herpes zoster, the most common infection seen. No malignancy was reported.
Dacrycystorhinostomy (DCR) is a procedure performed to drain the lacrimal sac in cases of nasolacrimal duct obstruction or in chronic dacryocystitis. It can be performed externally or endoscopically. This is a prospective, nonrandomized study involving twenty-two consecutive patients (16 Females and 6 Males; mean age 45.54 y; range 18-74 y) who presented to the DCR clinic with epiphora secondary to nasolacrimal duct obstruction and recurrent infection. All patients underwent primary powered endoscopic DCR. A total of 24 procedures were performed using a standardized surgical technique. Post-operatively, symptom evaluation and endoscopic assessment of the newly created lacrimal ostium were done. Twenty-two of the 24 DCR's were patent after a mean follow-up of 21.5 months, yielding a success rate of 91.66%. Patency was assessed by symptomatic evaluation and endoscopic visualization at each post-operative visit. Two patients had complications, one orbital fat exposure and the other secondary haemmorhage. The two failures were due to synechiae formation. Therefore, powered endoscopic DCR with mucosal flaps without stenting has a success rate comparable to that achieved with stents and external DCR.
Radiotherapy has been recognized as a valuable modality of treatment in the management of head and neck cancers. It can have a direct bactericidal effect on the normal flora of the oropharynx. The objective of this study is to determine the changes in the oropharyngeal flora after external beam radiation. This prospective non randomized control study was performed to aid in identification of organisms involved in sepsis, as well as aid in choosing appropriate antibiotics for surgical procedures in irradiated patient. Forty patients with various head and neck malignancy and thirty control patients were selected. Oropharyngeal swabs were taken prior to radiotherapy, at the end and one month after radiotherapy. A single swab was taken from the control group. A full bacteriological analysis was performed. There was a statistically significant decrease in Alpha Hemolytic Streptococci and Neisseria species post radiotherapy. B Proteus and Candida Albicans showed a statistical significant increase in patients with head and neck cancer post radiotherapy. These changes remained even one month after radiotherapy.
Allergic rhinitis is the single most common chronic allergic disease affecting an estimated four million people in Malaysia. House dust mites, grass pollens and fungal spores play has been identified to play a major role in the pathogenesis of allergic rhinitis. However, sensitization to pollen and spores in Malaysia is not well documented. On the basis of the results of an aerobiological survey of the common mold spores and pollens in the Klang Valley, twelve local extracts of molds and two local extracts of grass pollens were prepared by the Institute for Medical Research for this study. The study evaluated the prevalence of skin prick test (SPT) reactivity to the extracts of those airborne molds and pollens in allergic rhinitis patients in the Klang Valley. A total of 85 allergic rhinitis patients were recruited. All molds and grass pollens extracts tested, elicited positive response to SPT. Among the molds extracts, Fusarium was observed to have the highest prevalence of SPT reactivity (23.5%), followed by Aspergillus flavum (21.2%), Dreselera orysae (18.8%), Alternaria sp (17.6%), Curvularis eragrostidis (17.6%), Penicillium oxa (16.5%), Pestolotriopsis gtuepini (16.5%), Rhizopphus arrhi (16.5%), Aspergilluls nigus (15.3%). Penicillium choy (12.9%), Aspergillus fumigatus (11.8%), and Cladosporium sp (4.7%). In the grass pollen, the SPT reactivity to Ischaemum and Enilia is 14.1% and 5.9% respectively. However, the prevalence of SPT reactivity was not influenced by the age, sex, ethnicity, symptomatology and concurrent allergic condition. We have documented the prevalence of skin prick test reactivity to common molds and grass pollens in the Klang valley, which is comparable to the neighboring countries. Its prevalence in our allergic rhinitis patients suggests that it has a role in pathogenesis of allergic diseases. A larger representative sample involving multi-centric centers in Malaysia should be encouraged in the near future.
Study site: ENT
Department, Pusat Perubatan University Kebangsaan Malaysia
(PPUKM)
Allergic rhinitis causes an impairment of the mucociliary function in the nose. It is hoped that treatment of perennial allergic rhinitis would be able to revert mucociliary function to normal. This study aims to compare pre and post treatment mucociliary transport time in 3 different treatment modalities. Ninety-two newly diagnosed patients with allergic rhinitis were randomised into 3 groups and started on different treatment regimes. At the end of 8 weeks, the group treated with only intranasal beclomethasone showed some, though not significant, improvement in the mucociliary function. There were no changes in the mucociliary function in the other two groups treated with beclomethasone and loratidine or loratidine alone.
Study site: ENT clinic in Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
UKM
A community study was carried out to evaluate the efficacy of a 3-day course of 400 mg albendazole daily in the treatment of Trichuris trichiura and Giardia intestinalis infection. This treatment regimen was effective in the treatment of Trichuris trichiura and Giardia intestinalis infection with cure rates of 91.5% and 96.6% respectively. Uses of a 3-day course of 400 mg albendazole daily should be considered in mass or targeted soil-transmitted helminths chemotherapy particularly in areas where the prevalence of Trichuris trichiura is high and polyparasitism is common.
Intramedullary nailing is an accepted procedures for femoral fractures gives uniformly good results. Various methods of intramedullary fixation have been practiced in the past. Recently intramedullary fixation without reaming has come into vogue. Preservation of the endosteal blood supply, less blood loss and quicker union have been the alleged benefits of not reaming the medullary canal. This study is a prospective randomised study conducted to compare intramedullary nail fixation of closed femoral fractures with and without a reaming procedure to assess the validity of the above assumptions. One hundred and two consecutive cases of skeletally mature patients with closed fracture of femoral shaft were randomised into two groups, i.e. Reamed (52) and Unreamed (50). The average follow-up was 36 weeks (range 28-86 weeks). Average time taken for various stages of the operation and total operating time were longer in the reamed group (109.9 min vs 78.6 min) and the blood loss was also increased (320 mls vs. 190 mls). Bridging and callus formation were seen to occur earlier in the reamed group compared to the unreamed enabling the patients in the reamed group to return to normal functions earlier. Limb length discrepancy and rotational alignment measured clinically and with CT scan did not however show any significant difference between the two methods. Nails used in this study group were notably of a smaller diameter and of shorter length when compared to those used in the western population highlighting the difference in the femur in the Asian population. Complications were notably more in the unreamed group where these were screw breakage (3/50) delayed unions (9/50) and non-unions (4/50). In the reamed group however there were only delayed union (2/50) and all fractures eventually united without any implant failure. We conclude that closed, reamed, antegrade insertion of an intramedullary nail is the treatment of choice in femoral shaft fractures, especially those involving the distal 1/3. The unreamed procedure should be reserved for certain exceptions, such as in polytrauma, where a shorter operative time and less blood loss is desired.
To assess the efficacy of the trans-septal approach to the mitral valve, 40 patients who underwent mitral valve surgery via this approach were compared to 37 patients who underwent surgery via the standard left atriotomy. Concomitant procedures included tricuspid annuloplasty, aortic valve replacement, closure of atrial septal defect, coronary artery bypass grafting and aortic valve repair. There was one (1.2%) operative mortality. No patients required pacemaker implantation. Follow-up of up to 18 months showed that all patients were in NYHA classes I and II. One third of the patients who had trans-septal approach to the mitral valve achieved conversion from atrial fibrillation to sinus rhythm while none of the patients who underwent conventional left atriotomy had conversion (p < 0.02). The trans-septal approach to the mitral valve is a useful approach in selective patients requiring mitral valve surgery.
Comment in: Lim KG. The trans-septal approach to the mitral valve. Med J Malaysia. 2001 Dec;56(4):513
The effectiveness of sodium citrate as a prophylaxis against acid aspiration syndrome was studied in 3 groups of obstetric patients. Group I was the control group which consisted of 20 patients in established labour who were not likely to require caesarean section. No antacid had been given to these patients. Group II consisted of 20 patients who underwent elective caesarean section, while Group III consisted of another 20 patients who underwent emergency caesarean section. Group II and III were given 30ml of 0.3M sodium citrate as soon as they arrived in the operation theatre. The gastric content was aspirated after the induction of anaesthesia and at the end of surgery just before extubation. The volume was measured and a sample sent for pH analysis. Sodium citrate was found to increase the gastric pH significantly in both Group II and III patients when compared with Group I patients who underwent emergency caesarean section. We conclude that 30ml of 0.3M sodium citrate is effective in increasing gastric pH though it tends to be associated with an increase in gastric volume.