The aim of this study was to determine the prevalence of hypertensive retinopathy, features of hypertensive retinopathy and visual outcome in hypertensive disorders in pregnancy in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. A prospective observational hospital based study involving 154 patients (308 eyes) with hypertensive disorders in pregnancy was conducted. All subjects were examined once during antenatal period, at a minimum of 35 weeks of gestation for blood pressure, visual acuity and funduscopy. The similar protocol was repeated at six weeks postnatal period. Thirty-two point five percent had hypertensive retinopathy. Ninety eight percent had visual acuity 6/6 during antenatal assessment, while 100.00% gained 6/6 at postnatal period. Generalized arteriolar narrowing was the most common retinopathy observed. There was no statistically significant association between presence of hypertensive retinopathy and maternal age, presenting visual acuity, systolic/diastolic blood pressure (p>0.05). We conclude that prevalence of hypertensive retinopathy is 32.5%, and majority had good visual acuity during antenatal and postnatal period. Hypertensive retinopathy is insignificantly associated with maternal age, presenting visual acuity and blood pressure.
Study site: Ophthalmology Clinic, Antenatal Clinic and Obstetric Ward of Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
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)
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)
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)
A retrospective review of 100 walk-in patients at a specialized neurotology clinic in dizziness at a tertiary referral centre is presented. The most common cause of dizziness was BPPV, forming 31% of the cases. Other causes in order of frequency include recurrent vestibulopathy, idiopathic causes, Meniere's disease and central causes.
Study site: Neurotology clinic, Universiti Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Chronic venous disorders range from telangiactasia or spider veins to varicose veins, venous swellings, skin changes and venous ulcerations. The aim of this study is to assess outcome of varicose vein surgery in the ethnically diverse population of Penang, Malaysia. This study is a retrospective analysis of patients seen from 1999 to 2004. All patients who presented to the outpatient clinic of our surgical department with saphenofemoral junction (SFJ) and/or saphenopopliteal junction (SPJ) reflux associated with incompetence of the great saphenous vein (GSV) or small saphenous vein (SSV) respectively underwent classical varicose varicose vein surgery. A single surgeon at a single institution performed the surgeries. Data from pre-operative, post-operative and follow-up procedures were recorded in case report forms. A total of 202 cases were treated. Of these, 200 were qualified by the inclusion criteria and follow-ups, with 23 who were treated bilaterally. Of those treated, Chinese comprised 47.5%, Indians 27.0%, Malays 12.5% and foreigners 13.0% (largely Indonesian Chinese, British and Americans). The average age was 52.1 years. Indians had the highest average BMI of 29.2, compared to the Chinese who had the lowest of 24.6. Based on occupation, housewives (43.0%), blue collar workers (19.0%), salespersons (12.0%) and factory workers (9.5%) were among those afflicted with varicose veins. While local Chinese predominated in the business groups (salespersons and food-related workers), the Indians and Malays in this study were mainly factory workers and/or blue collar workers. Symptomatology in descending order of severity included pain in 80.0% of cases, swelling in 65.5%, heaviness in 53.5%, cramps in 53.0%, lipodermatosclerosis in 39.0%, superficial thrombophlebitis in 33.5%, venous ulceration in 32.0%, eczema 22.0% and cellulitis in 12.5% of patients. Post surgery pains dropped to 9.9%, cramps 6.4%, heaviness 5.5% and swelling 5.3% (p<0.0001 in all groups). Indians had the highest rate of venous ulcers (35.2% of all Indians treated) possibly due to their high BMI and low socioeconomic background. In cases of venous ulcers, gram negative infections (49.8%) were more common than gram positive infections at 18.8%. Operative procedures performed included great saphenous vein high ligation in 96.5% of cases, stripping 93.5% and multiple avulsions in 98.5%, saphenous popliteal junction ligation with multiple avulsions in 13.0% and subfascial ligation in 10.5%. Operative complications included induration (40.0% of cases), bruising in 49.5%, pains in 15.0%, paraesthesia in 3.5%, wound infection in 4.0%, deep venous thrombosis in 3.0% and ulcer recurrence in 7.5%. A total of 96.2% of patients treated expressed satisfaction with varicose vein surgery. Late presentations of chronic venous insufficiency, possibly as a result of poor understanding and inadequate education on diet, weight control, use of stockings and change in lifestyle by patients, employers and general practitioners are probably the cause of high rates of severe chronic venous disease especially venous ulcerations in the local community. However, classical varicose vein surgery is widely applicable across diverse ethnicities with a high rate of success.
Study site: Surgical clinic, Penang Adventist Hospital, Pulau Pinang, Malaysia
Budesonide/Formoterol (Symbicort) combination therapy as both maintenance and reliever treatment (SMART) is a novel approach in asthma management. We examined its 'real-life effectiveness' in treating Malaysian patients with moderate-to-severe asthma in whom despite on combined inhaled corticosteroids and long-acting beta2-agonist, were still inadequately controlled. In a retrospective study, 22 eligible adult patients on SMART [mean (range) age: 49 (36-65) years; FEV1: 41 (21-74)% predicted] were identified from medical records of an urban-based university hospital chest clinic, and their clinical outcomes studied at three months. Another 16 patients [50 (14-66) years; 48 (20-91)% predicted] of similar severity and treatment (i.e. Symbicort maintenance treatment plus short-acting beta2-agonist as reliever), but not on SMART, were used as comparator over the same assessment period. In addition, the patients were separately interviewed with standard questionnaire on their satisfaction and compliance to the SMART approach. In SMART group, rescue treatment requirement (p<0.001) and FEV1 [median difference = 2.5%, p=0.015; mean difference: 90 ml, p=0.013] showed significant improvement while in comparator, there was significant improvement only in the requirement for rescue treatment (p=0.023). Hospital admission rates were significantly reduced in SMART group compared to the other (p=0.039), but not in emergency treatment. Five patients asked to discontinue SMART while all others were satisfied, compliant and perceived improvement of their asthma with SMART. The maximum daily doses of inhaled budesonide and formoterol were 1400 microg and 31.5 microg respectively. Our preliminary findings suggest that SMART approach can be attempted as an effective and safe treatment option for patients with inadequately controlled moderate-to-severe asthma in Malaysian setting.
Study site: Chest clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
Tolerance to colonoscopy varies between populations and data from the South East Asian region is lacking. We aimed to determine tolerance and safety with to colonoscopy; conscious sedation and identify risk factors for complications in Malaysian adults. Consecutive outpatients undergoing colonoscopy were enrolled prospectively. A combination of pethidine and midazolam were used and tolerance to colonoscopy assessed three hours post-procedure using a validated scale. All patients were monitored for cardiorespiratory depression and risk factors for complications were identified. Two hundred and eight patients (mean age 57.2 +/- 14.8 years, 48% female) were enrolled. The population ethnicity consisted of 45 (21.63%) Malays, 101 (48.56%) Chinese and 56 (26.92%) Indians. Conscious sedation was achieved with 5.0 +/- 1.1 mg of midazolam and 43.3 +/- 14.0 mg of pethidine. Thirty (14.4%) patients tolerated the procedure poorly and independent predictors included female gender (OR 2.93, 95% CI = 1.22 to 7.01) and a prolonged duration of procedure (OR 2.85, 95% CI = 1.08 to 7.48). Hypotension occurred in 13 (6.25%) patients, with age > 65 years as the only risk factor (OR 13.17, 95% CI = 1.28 to 137.92). A prolonged duration was the main cause of hypoxia (OR 5.49, 95% CI = 1.54 to 19.49), which occurred in 6 (2.88%) patients. No major complications occurred during the study period. The current practice of conscious sedation is safe and tolerated well by most adults in our population. However, poor tolerance in a notable minority may have significant clinical implications.
Study site: Division of Gastroenterology, Department of Medicine, University Malaya Medical Centre (UMMC)
Empty Nose Syndrome (ENS) is a rare and controversial sequelae from previous radical turbinate surgery. We report on a 50-year-old Chinese gentleman with long-standing nasal problems who has had radical turbinate surgery many years prior to presenting at the ENT clinic with mucoid nasal discharge and chronically blocked nose. His nasal cavities were ironically very patent and there were only minor remnants of his turbinates bilaterally. We treated him medically for several years with nasal steroids, antihistamines and leukotriene receptor antagonists and his nasal symptoms have reduced significantly.
Study site: ENT clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
We audited the standard of care provided to 200 consecutive type 2 diabetic patients attending our hospital general medical clinic. Data on diabetes related processes and outcome measures were collected. Annual testing rates (blood pressure 100%, fasting lipid profile 91.8%, HbA1c 69%) were higher compared to complications screening rates (Eye 69%, albuminuria 51%, foot 22.4%). Lifestyle intervention was lacking with BMI documented in 38.3% of patients and smoking history in 46%. Fifty percent and 41% of patients with HbA1c > 7.5% were referred to diabetes educator and dietitian respectively. For outcome measures, 26% of patients achieved HbA1c < or = 7%, 33% achieved BP < or = 130/80 while 56% achieved LDL < or = 2.6 mmol/L. Aspirin was prescribed in 78% and ACE inhibitor or angiotensin receptor blocker in 91.8% of patients. Lifestyle intervention and complication screening are the two major areas of deficiencies in the care of type 2 diabetic patients in our hospital general medical clinic.
Study site: General medical clinic, Sarawak General Hospital, Kuching, Sarawak, Malaysia
Diabetic Eye Registry, a web based registry hosted at the National Eye Database (www.acrm.org.my/end) collects data in a systematic and prospective nature on status of diabetic retinopathy (DR) among diabetics seen for the first time at Ministry of Health ophthalmology clinics. The 2007 report on 10,586 diabetics revealed that 63.3% of eyes examined had no DR, 36.8% had any form of DR, of which 7.1% had proliferative diabetic retinopathy. Up to 15.0% of eyes had vision threatening DR requiring laser or surgery at their first visit. Data on diabetic eye registry is useful in monitoring the quality of diabetic management, particularly in eye screening as reflected by the proportion of patients with severe DR needing intervention at the first visit to Ophthalmology clinics.
Subclinical cerebral infarcts (SCI) have been increasingly shown to cause a significant clinical impact. However, there are limited data available on Asian patients. The objectives of this study were to determine the prevalence of SCI in ischaemic stroke patients seen in the Hospital Universiti Kebangsaan Malaysia (HUKM) and to identify its associated risk factors. We evaluated the brain computed tomography (CT) evidence of subclinical infarcts in ischaemic stroke patients. The patients were selected from those who were on regular follow up in the neurology clinic following an ischaemic stroke. The risk factors associated with subclinical infarct were documented. The brain CTs were done during acute admission and reviewed for SCI. Sixty-one patients were enrolled in this study. Twenty-two (36.1%) out of the 61 patients had SCI. The risk factors for SCI in our study were hypertension (OR 14.16 CI 2.04-97.89), diabetes mellitus (OR 12.48; CI 1.95-79.77) and leukoaraiosis (OR 28.39; CI 2.33-284.16). Subclinical cerebral infarcts were present in about one third of our ischaemic stroke patients. This finding is higher than in previous studies done on Caucasians. Hypertension, diabetes mellitus and leukoaraiosis independently predict SCI.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.
Study site: primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
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).
An anaesthetist-led outpatient pre-operative assessment (OPA) clinic was introduced in our unit in an effort to improve patient care and cost-effectiveness. To assess the efficiency of the clinic, 112 patients who attended the OPA clinic (attendance rate 98%) during the first year were assessed prospectively and compared with 118 patients who did not undergo OPA the year before. There were fewer cancellations among those who attended the OPA clinic (13.6% compared to 3.6%), and the hospital stay was shortened from an average of 10.7 days to 7.0 days. This has resulted in more efficient utilization of operating theatre, reduced hospital costs and improved patient satisfaction. More extensive use of the pre-admission clinic is recommended and should be explored in other clinical settings.
Study site: Outpatient Preoperative Assessment (OPA) clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Epilepsy patients have a higher mortality rate than the general population. Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality for these patients. The possibility of cardiac involvement in the pathogenesis of SUDEP has been suggested by many previous studies. This study compared the QT interval in epilepsy patients and normal controls, and identified the factors that affected the QT interval. Standard 12-lead ECGs were recorded from 70 consecutive epilepsy patients from the neurology clinic of HUKM and 70 age, race and gender matched controls. The mean QT interval corrected for heart rate (QTc) was calculated and compared. The mean QTc among the epilepsy patients was 0.401 +/- 0.027s. It was significantly shorter than the QTc (0.420 +/- 0.027s) in the control group (p<0.0005). Thirty five epilepsy patients (50%) and 17 matched controls (24.3%) had a mean QTc shorter than 0.40s (p=0.001). Among the epilepsy patients, the mean QTc did not significantly differ between patients in the duration (F=0.836, p=0.438) of the epilepsy, frequency (F=0.273, p=0.845) and types of seizures (p=0.633). There was no significant difference in the mean QTc between the epilepsy patients on different number of antiepileptic agents (F=0.444, p=0.643). Patients with cryptogenic epilepsy had a mean QTc of 0.392 +/- 0.029s, which was significantly shorter than patients with symptomatic epilepsy (QTc = 0.410 +/- 0.027s, p = 0.015). The mean QTc of the same subjects showed no significant interobserver difference (p=0.661). This study, for the first time, demonstrates that epilepsy patients have a significantly shorter QTc than controls, particularly in the subgroup of patients with cryptogenic epilepsy.
Study site: Neurology clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
This is a cross-sectional study to determine the prevalence of insulin resistance and its associated factors in Hospital UKM patients with schizophrenia using the Homeostatic Model Assessment (HOMA) model. Fasting glucose and insulin from 85 patients were obtained. Fasting glucose revealed 15% of the patients were diabetic, while another 15% had impaired fasting glucose. Using the HOMA model, 68% of the patients had insulin resistance. Univariate analyses found BMI (p < 0.001) and waist circumference (p < 0.001) to be associated with insulin resistance. The statistical significance disappeared after multivariate analyses. All patients with schizophrenia should be screened and managed as a group at high risk for development of diabetes with emphasis on body weight management.
Study site: inpatient and outpatients, Psychiatric department, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
A prospective study was conducted at Manipal Teaching Hospital, Pokhara, Nepal to identify and analyze the pattern of the potential DDIs (drug-drug interaction) in diabetes patients. A total of 182 patients who were prescribed 685 drugs (average, 3.76 drugs per prescription) were enrolled. Patients 51 to 60 years of age had a higher risk [43 patients, or (23.6%)] of developing DDIs. It was found that 174 (92.1%) of the potential DDIs were of "moderate" severity. Cardiovascular drugs carried a risk of DDIs (187 drugs, or 49.5%). The most common potential DDI observed was between metformin and enalapril (n = 64).
This study was carried out to determine the association between body mass index and age related cataract among patients attending eye clinic. We conducted a case control study. The outcome of clinical eye assessment determined the patient's status. Mean body mass index among the cases was shown to be higher (25.4 +/- 4.5) than the control group (24.4 +/- 3.9) (p < 0.01). Crude analysis showed that only obese respondents were 2.4 times more likely to develop age related cataract, however this association was not seen in the multivariate analysis after adjusting for other determinants (aOR 1.81; 95% CI 0.91 - 3.62). We conclude that there is no association between body mass index and age related cataract.
Study site: Eye clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Evidence-based heart failure management now includes beta-blockers and spironolactone in addition to diuretics and angiotensin-converting enzyme inhibitors. We aim to determine if these recommendations had been applied in practice for acute and chronic stable heart failure, and what difficulties there might be. Data from 80 consecutive patients hospitalized for decompensated heart failure ('acute') between May and July 2003 were analyzed at admission, upon discharge and at 12 weeks follow-up; along with 74 cardiology clinic out-patients with stable congestive heart failure ('chronic'- no decompensation or admission in previous six months). Less than half of study patients with prior left ventricular dysfunction were on ACE-inhibitors (47%), diuretics (39%), ATII antagonists, spironolactone or digoxin (5% each). All 'acute' patients were commenced on diuretics and ACE-inhibitors in hospital. Six patients died or transferred to another center. Compliance with clinic appointment at 12 weeks was 85% despite telephone reminders. Drug prescription at 12 weeks was significantly lower for diuretics and ACE-inhibitors compared to prescription at discharge (all p < 0.05) but higher compared to patients with chronic HF. Diuretics and ACE inhibitors remain under-utilized for patients with recurrent heart failure. Use of spironolactone and beta-blocker is slow due to limited medical experience and funding. Clinic non-attendance is significant and due to patient factors.