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The use of glycerol-preserved skin allograft in conjunction with reconstructive and flap surgery: seven years of experience

Saad AZ, Halim AS, Khoo TL

J Reconstr Microsurg, 2011 Feb;27(2):103-8.
PMID: 20976667 DOI: 10.1055/s-0030-1268208

Major reconstructive surgery may be extensive and prolonged, and it may cause edema and compromise the flap pedicle if closed under tension. Glycerol-preserved skin allograft (GPA) can provide a means for tension-free closure and temporary cover of the wound. Seven years of analysis on GPA used in conjunction with major reconstruction was undertaken to highlight its indications, results, and outcomes. Forty-seven patients were included, aged between 9 and 73 years. Majority of patients had reconstruction following tumor resection and trauma. The main indication for use of GPA was temporary, loose cover of the wound in 44% of cases; flap pedicle protection in 31% of cases; donor site wound cover in 10%; flap monitoring in one case; and management of flap-related complications in 6% of cases. Free flap reconstruction was performed in 72% of cases. In conclusion, GPA is a useful adjunct in reconstructive surgery. It can be used temporarily to allow tension-free wound closure, as well as to protect the flap pedicle until edema subsides and the pedicle becomes stable. This latter approach allows secondary wound closure and good esthetic outcome.
Compatibility of Porous Chitosan Scaffold with the Attachment and Proliferation of human Adipose-Derived Stem Cells In Vitro

Gomathysankar S, Halim AS, Yaacob NS, Noor NM, Mohamed M

J Stem Cells Regen Med, 2016;12(2):79-86.
PMID: 28096632

Adipose-derived stem cells (ASCs) have potential applications in the repair and regeneration of various tissues and organs. The use of various scaffold materials as an excellent template for mimicking the extracellular matrix to induce the attachment and proliferation of different cell types has always been of interest in the field of tissue engineering because ideal biomaterials are in great demand. Chitosan, a marine polysaccharide, have wide clinical applications and it acts as a promising scaffold for cell migration and proliferation. ASCs, with their multi-differentiation potential, and chitosan, with its great biocompatibility with ASCs, were investigated in the present study. ASCs were isolated and were characterized by two different methods: immunocytochemistry and flow cytometry, using the mesenchymal stem cell markers CD90, CD105, CD73 and CD29. The ASCs were then induced to differentiate into adipogenic, osteogenic and chondrogenic lineages. These ASCs were incorporated into a porous chitosan scaffold (PCS), and their structural morphology was studied using a scanning electron microscope and hematoxylin and eosin staining. The proliferation rate of the ASCs on the PCS was assessed using a PrestoBlue viability assay. The results indicated that the PCS provides an excellent template for the adhesion and proliferation of ASCs. Thus, this study revealed that PCS is a promising biomaterial for inducing the proliferation of ASCs, which could lead to successful tissue reconstruction in the field of tissue engineering.
Fulltext The outcomes of salvage surgery for vascular injury in the extremities: a special consideration for delayed revascularization

Jagdish K, Paiman M, Nawfar A, Yusof M, Zulmi W, Azman W, et al.

Malays Orthop J, 2014 Mar;8(1):14-20.
PMID: 25279079 MyJurnal DOI: 10.5704/MOJ.1403.012

A seven years retrospective study was performed in 45 consecutive vascular injuries in the extremities to investigate the pattern of injuries, managements and outcomes. Motor-vehicle accidents were the leading cause of injuries (80%), followed by industrial injuries (11.1%) and iatrogenic injuries (4.4%). Popliteal and brachial artery injuries were commonly involved (20%). Fifteen (33.3%) patients had fractures, dislocation or fracture dislocation around the knee joint and 6 (13.3%) patients had soft tissue injuries without fracture. Traumatic arterial transection accounted for 34 (75.6%) cases, followed by laceration in 7 (15.6%) and 9 (6.7%) contusions. Associated nerve injuries were seen in 8 (17.8 %) patients using intra-operative findings as the gold standard, both conventional angiogram (CA) and computerized tomography angiogram (CTA) had 100% specificity and 100% sensitivity in determining the site of arterial injuries. The mean ischemic time was 25.31 hours (4 - 278 hours). Thirty-three (73.3 %) patients were treated more than 6 hours after injury and 6 patients underwent revascularization after 24 hours; all had good collateral circulation without distal pulses or evidence of ischemic neurological deficit. The mean ischemic time in 39 patients who underwent revascularization within 24 hours was 13.2 hours. Delayed amputation was performed in 5 patients (11.1%). Of the 6 patients who underwent delayed revascularization, one patient had early amputation, one -had delayed amputation following infection and multiple flap procedures while the rest of the patients' limbs survived. Joint stiffness was noted in 10 patients (22.2%) involving the knee joint, elbow and shoulder in two patients each. Infection was also noted in 5 patients (11.1%) with two of them were due to infected implants. Other complications encountered included nonunion (2 patients, 4.4%), delayed union (1 patient, 2.2%),limb length discrepancy (1 patient, 2.2%), hematoma (1 patient, 2.2%) and leaking anastomosis in one patient (2.2%). Volkmann's ischemic contracture occurred in 3 (6.7%) patients. There was no complication noted in 8 (17.8%) patients Three patients (6.7%) died of whom two were not due to vascular causes. We conclude that early detection and revascularization of traumatic vascular injuries is important but delayed revascularization also produced acceptable results.
Reproducibility of laser Doppler fluximetry and the process of iontophoresis in assessing microvascular endothelial function using low current strength

Al-Tahami BA, Yvonne-Tee GB, Halim AS, Ismail AA, Rasool AH

Methods Find Exp Clin Pharmacol, 2010 Apr;32(3):181-5.
PMID: 20448860 DOI: 10.1358/mf.2010.32.3.1423887

Iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) combined with laser Doppler fluximetry (LDF) is a tool used to determine microvascular endothelial function. Our aim was to study the reproducibility of different parameters of this technique using iontophoresis with low current strength on the forearm skin of healthy subjects. Baseline skin perfusion was done before application of five current pulses with 1 min of current-free interval. Current strength of 0.007 mA, current density of 0.01 mA/cm(2) and charge density of 6 mC/cm(2) were used, along with 1% ACh and 1% SNP. The absolute maximum change in perfusion (max), percent change in perfusion (% change), peak change in perfusion (peak) and area under the curve during iontophoresis (AUC) at the anodal and cathodal leads were recorded. Measurements were performed in three sessions for 2 days. The coefficient of variation (CV) was calculated for each parameter. Among the parameters studied, maximum change in perfusion and peak flux were the most reproducible parameters.
Endothelial nitric oxide synthase G894T gene polymorphism and response to skin reactive hyperemia

Rasool AH, Ghazali DM, Abdullah H, Halim AS, Wong AR

Microvasc Res, 2009 Sep;78(2):230-4.
PMID: 19481100 DOI: 10.1016/j.mvr.2009.05.005

Post occlusive skin reactive hyperemia (PORH) is a tool used to assess microcirculation. Endothelial nitric oxide synthase (eNOS) mediates nitric oxide (NO) production; polymorphism of the eNOS gene may affect response to the PORH process. This study aims to determine whether eNOS G894T gene polymorphism affects response to skin PORH. 230 normotensive male and females between 18 and 40 years participated in this cross-sectional study. 170 subjects were of the homozygous GG genotype, whereas 60 were of the GT genotype. Skin PORH was performed by occlusion of the upper arm at 200 mm Hg for 3 min. Skin perfusion and temperature were monitored before, during and after occlusion release using the laser Doppler fluximetry. There were no significant differences between genotypes in their baseline blood pressure, serum cholesterol, BMI and age. Maximum change in perfusion after occlusion release (PORHmax) for the GG and GT genotypes were not significantly different at 50.15+/-1.29 vs. 47.92+/-2.17 AU; ANCOVA, p=0.351. Peak perfusion (PORHpeak) were also not significantly different between the two genotypes (61.23+/-1.36 vs. 57.72+/-2.32 AU; p=0.169). Minimum baseline perfusion were however higher in the GG compared to the GT genotype (10.83+/-0.29 vs. 9.61+/-0.50, p=0.029). We conclude that microvascular reactivity, assessed by change in perfusion after temporary ischemia was not significantly different between the GG and GT genotypes of the eNOS G894T gene. eNOS 894T allele carriers however, have lower baseline perfusion compared to the homozygous G894 allele carrier.
Fulltext Two novel genes TOX3 and COL21A1 in large extended Malay families with nonsyndromic cleft lip and/or palate

Mohamad Shah NS, Sulong S, Wan Sulaiman WA, Halim AS

Mol Genet Genomic Med, 2019 May;7(5):e635.
PMID: 30924295 DOI: 10.1002/mgg3.635

BACKGROUND: Nonsyndromic cleft lip and/or palate is one of the most common human birth defects worldwide that affects the lip and/or palate. The incidence of clefts varies among populations through ethnic, race, or geographical differences. The focus on Malay nonsyndromic cleft lip and/or palate (NSCL/P) is because of a scarce report on genetic study in relation to this deformity in Malaysia. We are interested to discuss about the genes that are susceptible to cause orofacial cleft formation in the family.
METHODS: Genome-wide linkage analysis was carried out on eight large extended families of NSCL/P with the total of 91 individuals among Malay population using microarray platform. Based on linkage analyses findings, copy number variation (CNV) of LPHN2, SATB2, PVRL3, COL21A1, and TOX3 were identified in four large extended families that showed linkage evidence using quantitative polymerase chain reaction (qPCR) as for a validation purpose. Copy number calculated (CNC) for each genes were determined with Applied Biosystems CopyCallerTM Software v2.0. Normal CNC of the target sequence expected was set at two.
RESULTS: Genome-wide linkage analysis had discovered several genes including TOX3 and COL21A1 in four different loci 4p15.2-p16.1, 6p11.2-p12.3, 14q13-q21, and 16q12.1. There was significant decreased, p
Tualang honey has higher phenolic content and greater radical scavenging activity compared with other honey sources

Kishore RK, Halim AS, Syazana MS, Sirajudeen KN

Nutr Res, 2011 Apr;31(4):322-5.
PMID: 21530807 DOI: 10.1016/j.nutres.2011.03.001

Many chronic diseases are associated with increased oxidative stress caused by an imbalance between free-radical production and the antioxidant level. Antioxidants, which are abundant in natural honey, are free-radical scavengers that either reduce the formation of or neutralize free radicals. The composition and source of honey greatly dictates its biochemical properties. We performed a comparative analysis of the total phenolic content and antioxidant potential of common commercially available honeys along with Malaysian tualang honey. In vitro biochemical analysis of the phenolic content by the Folin-Ciocalteau method revealed a significantly elevated phenolic content (83.96 ± 4.53 mg gallic acid equivalents per 100 g) in tualang honey. In addition, the antioxidant capacity (53.06 ± 0.41 mg ascorbic acid equivalents per gram) of tualang honey was greater, as assessed by the phosphomolybdenum method, 2,2-diphenyl-1-picryl-hydrazyl assay, and ferric reducing/antioxidant power assay. Peroxynitrite and superoxide radical scavenging activity was determined by spectrophotometric analysis in different honey types. Our data suggest that the elevated free-radical scavenging and antioxidant activity observed in tualang honey is due to the increased level of phenolic compounds. In addition to its antibacterial, anticarcinogenic, and anti-inflammatory properties, our study highlights the favorable antioxidant properties of tualang honey, which may be important to human nutrition and health.
Fulltext Report on von Willebrand Disease in Malaysia

Periayah MH, Halim AS, Saad AZ, Yaacob NS, Karim FA

Open Access Maced J Med Sci, 2016 Mar 15;4(1):112-7.
PMID: 27275342 DOI: 10.3889/oamjms.2016.030

BACKGROUND: Von Willebrand disease (vWD) is an inherited hemostatic disorder that affects the hemostasis pathway. The worldwide prevalence of vWD is estimated to be 1% of the general population but only 0.002% in Malaysia.
AIM: Our present paper has been written to disclose the statistical counts on the number of vWD cases reported from 2011 to 2013.
MATERIAL AND METHODS: This article is based on sociodemographic data, diagnoses and laboratory findings of vWD in Malaysia. A total of 92 patients were reported to have vWD in Malaysia from 2011 to 2013.
RESULTS: Sociodemographic-analysis revealed that 60% were females, 63% were of the Malay ethnicity, 41.3% were in the 19-44 year old age group and 15.2% were from Sabah, with the East region having the highest registered number of vWD cases. In Malaysia, most patients are predominately affected by vWD type 1 (77.2%). Factor 8, von Willebrand factor: Antigen and vWF: Collagen-Binding was the strongest determinants in the laboratory profiles of vWD.
CONCLUSION: This report has been done with great interest to provide an immense contribution from Malaysia, by revealing the statistical counts on vWD from 2011-2013.
Fulltext Chitosan: A Promising Marine Polysaccharide for Biomedical Research

Periayah MH, Halim AS, Saad AZ

Pharmacogn Rev, 2016 Jan-Jun;10(19):39-42.
PMID: 27041872 DOI: 10.4103/0973-7847.176545

Biomaterials created 50 years ago are still receiving considerable attention for their potential to support development in the biomedical field. Diverse naturally obtained polysaccharides supply a broad range of resources applicable in the biomedical field. Lately, chitosan, a marine polysaccharide derived from chitins-which are extracted from the shells of arthropods such as crab, shrimp, and lobster-is becoming the most wanted biopolymer for use toward therapeutic interventions. This is a general short review of chitosan, highlighting the history, properties, chemical structure, processing method, and factors influencing the usage of chitosan derivatives in the biomedical field.
Fulltext Outcomes of infected grade IIIB open tibial fractures

Yusof NM, Halim AS

Singapore Med J, 2012 Sep;53(9):591-4.
PMID: 23023900

Infection following grade IIIB open tibial fracture is common. The primary aim of managing this condition is to achieve control of infection before the bone reconstruction procedure is performed. The outcomes for such patients have not been evaluated in the literature. This study was conducted to examine the outcome of a multi-stage procedure for the treatment of infected grade IIIB open tibial fractures.
Fulltext Skin paddle as an indicator of the viability of vascularised fibular graft

Imran Y, Zulmi W, Halim AS

Singapore Med J, 2004 Mar;45(3):110-2.
PMID: 15029411

Immediate recognition of anastomotic failure is important to ensure the viability of the vascularised fibular graft. The problems associated with post-operative bone scanning and angiography for immediate detection of anastomotic failure have been described.
Fulltext Skeletal union following long bone reconstruction using vascularised fibula graft

Imran Y, Zulmi W, Halim AS

Singapore Med J, 2003 Jun;44(6):286-7.
PMID: 14560858

Thirteen patients had skeletal reconstruction using vascularised fibula graft following resection of the diseased bone. Eleven patients had reconstruction of the lower limbs and two patients of the upper limbs. Clinical and radiographical evidence union were achieved with the average time of 32 weeks (earliest eight weeks). Six out of 11 patients (54%) in lower limb reconstruction started weight bearing at the average of 27 weeks. Bony union in this study is comparable with other studies using vascularised fibula graft.
Fulltext Reconstruction of severe patellar infera syndrome with free vascularised composite tensor fascia lata flap

Sulaiman AR, Halim AS, Azman WS, Eskandar H

Singapore Med J, 2008 Aug;49(8):e205-7.
PMID: 18756334

Post-traumatic severe patella infera and intra-articular adhesion may lead to a severe knee stiffness. We report a 29-year-old man, a muslim prayer leader, who had a previous knee injury. He presented with knee movement from ten degrees to 30 degrees, patellar infera with a length of patella to length of patellar tendon ratio of 2:5, and severe knee arthrofibrosis. He underwent incision of the patella ligament and open arthrofibrosis release, leaving a tendon gap and skin defect of 5 cm. Reconstruction was successfully done using a free vascularised composite tensor fascia lata flap. He regained full range of knee motion with normal strength quadriceps mechanism at five months after surgery, and remained in full function at 18 months follow-up.
Fulltext Extended double pedicle free tensor fascia latae myocutaneous flap for abdominal wall reconstruction

Dorai AA, Halim AS

Singapore Med J, 2007 May;48(5):e141-5.
PMID: 17453087

Extensive full thickness anterior abdominal wall defects pose a difficult challenge to the reconstructive surgeon. The objectives of reconstruction are the support of the intra-abdominal structures in order to preserve the functional integrity and achieve an aesthetically-acceptable appearance. Autologous tissues are versatile and provide the best reconstructive option in this type of defects. The tensor fascia latae myocutaneous flap provides identical abdominal wall musculofascial cover for full thickness defects. In extensive defects, the extended tensor fascia latae flap is a versatile option with a second microvascular anastomosis at the distal end of the flap. A total anterior abdominal wall soft tissue tumour resection defect was reconstructed with the use of the double pedicle extended free tensor fascia latae myocutaneous flap in a 60-year-old man. The patient however succumbed to the disease process six months post-reconstruction. During the follow-up period, there was no evidence of hernia at the anterior abdominal wall.
Fulltext Aggressive giant cell tumour of bone

Faisham WI, Zulmi W, Halim AS, Biswal BM, Mutum SS, Ezane AM

Singapore Med J, 2006 Aug;47(8):679-83.
PMID: 16865207

The surgical treatment of Stage III or aggressive giant cell tumour of the bone, whether to perform intralesional or en-bloc resection, remains controversial. The aim of this study is to identify the effectiveness of en-bloc resection for local control and final oncological outcome of the disease.
Fulltext In vitro characterization of a chitosan skin regenerating template as a scaffold for cells cultivation

Hilmi AB, Halim AS, Hassan A, Lim CK, Noorsal K, Zainol I

Springerplus, 2013 Dec;2(1):79.
PMID: 23503998 DOI: 10.1186/2193-1801-2-79

Chitosan is a marine-derived product that has been widely used in clinical applications, especially in skin reconstruction. The mammalian scaffolds derived from bovine and porcine material have many limitations, for example, prion transmission and religious concerns. Therefore, we created a chitosan skin regenerating template (SRT) and investigated the behavior of fibroblast cell-scaffold constructs. Primary human dermal fibroblasts (HDF) were isolated and then characterized using vimentin and versican. HDF were seeded into chitosan SRT at a density of 3×10(6) cells/cm(2) for fourteen days. Histological analysis and live cells imaging revealed that the cell-chitosan constructs within interconnected porous chitosan showed significant interaction between the cells as well as between the cells and the chitosan. Scanning electron microscopy (SEM) analysis revealed cells spreading and covering the pores. As the pore sizes of the chitosan SRT range between 40-140 μm, an average porosity is about 93 ± 12.57% and water uptake ratio of chitosan SRT is 536.02 ± 14.29%, it is a supportive template for fibroblast attachment and has potential in applications as a dermal substitute.
Dentoalveolar relationships of Malay children with unilateral cleft lip and palate

Zreaqat M, Hassan R, Halim AS

Cleft Palate Craniofac J, 2009 May;46(3):326-30.
PMID: 19642750 DOI: 10.1597/07-210.1

To determine the treatment outcome based on dentoalveolar relationships among Malay children born with nonsyndromic complete unilateral cleft lip and palate (UCLP).
The hyoid bone in malay infants with cleft lip and palate

Rajion ZA, Townsend GC, Netherway DJ, Anderson PJ, Hughes T, Shuaib IL, et al.

Cleft Palate Craniofac J, 2006 Sep;43(5):532-8.
PMID: 16986987

To compare morphological and positional variations of the hyoid bone in unoperated infants with cleft lip and palate (CL/P) with those in noncleft infants.
A three-dimensional computed tomographic analysis of the cervical spine in unoperated infants with cleft lip and palate

Rajion ZA, Townsend GC, Netherway DJ, Anderson PJ, Yusof A, Hughes T, et al.

Cleft Palate Craniofac J, 2006 Sep;43(5):513-8.
PMID: 16986980

To investigate anatomical variations and abnormalities of cervical spine morphology in unoperated infants with cleft lip and palate.
Cultural Beliefs on the Causes of Cleft Lip and/or Palate in Malaysia: A Multicenter Study

Hussin I, Halim AS, Ibrahim MI, Markos ZO, Effendie ESAB

Cleft Palate Craniofac J, 2022 02;59(2):209-215.
PMID: 33813904 DOI: 10.1177/10556656211003797

OBJECTIVE: To identify the cultural beliefs about the causes of cleft among parents of patients with nonsyndromic cleft lip and/or palate in a multiethnic society in Malaysia and the difficulties encountered in receiving cleft treatment.
DESIGN: A descriptive cross-sectional multicenter study based on a study questionnaire was conducted of parents of patients with cleft lip and/or palate.
SETTING: Three centers providing cleft care from different regions in Malaysia: the national capital of Kuala Lumpur, east coast of peninsular Malaysia, and East Malaysia on the island of Borneo.
PARTICIPANTS: Parents/primary caregivers of patients with cleft lip and/or palate.
RESULTS: There were 295 respondents from different ethnic groups: Malays (58.3%), indigenous Sabah (30.5%), Chinese (7.1%), Indian (2.4%), and indigenous Peninsular Malaysia and Sarawak (1.7%). Malay participants reported that attributing causes of cleft to God's will, superstitious beliefs that the child's father went fishing when the mother was pregnant or inheritance. Sabahans parents reported that clefts are caused by maternal antenatal trauma, fruit picking, or carpentry. The Chinese attribute clefts to cleaning house drains, sewing, or using scissors. Cultural background was reported by 98.3% of participants to pose no barrier in cleft treatment. Those from lower socioeconomic and educational backgrounds were more likely to encounter difficulties while receiving treatment, which included financial constraints and transportation barriers.
CONCLUSION: There is a wide range of cultural beliefs in the multiethnic society of Malaysia. These beliefs do not prevent treatment for children with cleft. However, they face challenges while receiving cleft treatment, particularly financial constraints and transportation barriers. Such barriers are more likely experienced by parents from lower income and lower education backgrounds.

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