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The usage of Gellhorn pessary in pelvic organ prolapse and in regards to success, continuity of use and effect on symptoms: a retrospective study of 2 years

Ramanujam S, Balakrishnan S

Med J Malaysia, 2023 Nov;78(6):705-710.
PMID: 38031210

INTRODUCTION: Pelvic organ prolapse (POP) is a condition involving weakened pelvic floor muscles causing organs to protrude. Conservative POP treatment comprises pelvic floor exercises and vaginal pessaries. Besides conservative care, surgery is offered. However, surgery is invasive, risky and unsuitable for those with serious medical conditions. This study aims to assess the acceptance, success and outcomes of the Gellhorn pessary for POP treatment, especially in advanced cases.
MATERIALS AND METHODS: The present study is a retrospective cohort study using hospital medical records (patient files) from October 2019 to November 2021 (for 2 years). This study was performed in Malaysian women (n=53) suffering from advanced stages of POP, in which Gellhorn pessaries of diameter (44-76mm) were inserted by trained personnel. Pelvic Floor Distress Inventory-20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7) were used to measure patients' symptoms and quality of life before and after Gellhorn pessary fitting. Patients were reassessed every three months for two years and their satisfaction scores were recorded.
RESULTS: We observed a significant difference in pre-test (pre-fitting) and post-test (three months post-fitting) scores on all three subscales and the PFIQ-7 total score. Twentyeight (52.83%) patients continued the use of Gellhorn pessary for at least 24 months, whereas 25 (47.20%) patients discontinued during this period. A retrospective analysis of the patients who discontinued Gellhorn pessary showed that 13 (24.52%) patients gave up the use of pessary for definitive surgery. It is noteworthy to mention here that only one out of the 13 patients who were awaiting surgery, chose surgery and the remaining 12 changed their mind after being fitted with the Gellhorn pessary. Seven (13.20%) patients declined reinsertion due to discomfort and voiding difficulties and refused further intervention, whereas three (5.66%) patients requested a ring pessary. Two (3.77%) patients, requested the removal of pessary due to vesicovaginal fistula and rectovaginal fistula (caused by an impacted pessary). The rate of continued use was 79.24% (42 patients) after 1st year and 52.83% (28 patients) at the end of two years.
CONCLUSION: In the current study, the Gellhorn pessary was used to treat stage 3 and 4 POP with significant symptom reduction post-fitting. More than half of the patients continued to use the pessary after 24 months of fitting. Therefore, the Gellhorn pessary can be used as a treatment strategy for stage 3 and 4 POP with reasonable acceptance in the Malaysian population.
Breast feeding in Kelantan

Balakrishnan S, bin Haji Hussein H

Med J Malaysia, 1977 Sep;32(1):22-4.
PMID: 609338
Breast feeding in Kelantan

Balakrishnan S, Hussein HB

J Trop Pediatr Environ Child Health, 1977 Apr;23(2):80-2.
PMID: 585738
Fulltext Hyperbilirubinaemia and erythrocytic glucose 6 phosphate dehydrogenase deficiency in Malaysian children

Hon AT, Balakrishnan S, Ahmad Z

Med J Malaysia, 1989 Mar;44(1):30-4.
PMID: 2626111

Cord blood from 8,975 babies delivered in Hospital Sultanah Aminah Johor Bahru over a period of eight months (1st August 1985 to 31st March 1986) were screened for G6PD deficiency. The overall incidence was 4.5% in Chinese, 3.5% in Malays and 1.5% in Indian babies. One hundred of these babies were observed in the nursery for seven days and their daily serum bilirubin recorded. The serum bilirubin peaked at 96 hours to a value of 12mg%. None of the babies in the nursery developed a serum bilirubin level of more than 15mg%. Six of the babies with G6PD deficiency that were sent home were readmitted with hyperbilirubinaemia that needed exchange transfusion.
Rupture of the pregnant uterus--a 21-year review

Rachagan SP, Raman S, Balasundram G, Balakrishnan S

Aust N Z J Obstet Gynaecol, 1991 Feb;31(1):37-40.
PMID: 1872771

Uterine rupture is still a common problem in developing countries although even here the incidence varies from urban to rural settings. This article is a review of uterine rupture in an urban referral hospital in Malaysia. It examines aetiology, clinical presentation, complications and management of the problem. Meticulous screening of patients together with optimal antenatal and intrapartum care will markedly reduce the incidence of uterine rupture. Early diagnosis and prompt treatment will further help reduce morbidity and mortality to both mother and fetus.
Red cell enzymes in cord blood and plasma bilirubin levels in the first week of life

Lie-Injo LE, Ng T, Balakrishnan S

Clin Chim Acta, 1974 Jan 19;50(1):77-83.
PMID: 4856203 DOI: 10.1016/0009-8981(74)90079-5
Iron incorporated heterogeneous catalyst from rice husk ash

Adam F, Kandasamy K, Balakrishnan S

J Colloid Interface Sci, 2006 Dec 1;304(1):137-43.
PMID: 16996077

Silica supported iron catalyst was prepared from rice husk ash (RHA) via the sol-gel technique using an aqueous solution of iron(III) salt in 3.0 M HNO3. The sample was dried at 110 degrees C and labeled as RHA-Fe. A sample of RHA-Fe was calcined at 700 degrees C for 5 h and labeled as RHA-Fe700. X-ray diffraction spectrogram showed that both RHA-Fe and RHA-Fe700 were amorphous. The SEM/EDX results showed that the metal was present as agglomerates and the Fe ions were not homogeneously distributed in RHA-Fe but RHA-Fe700 was shown to be homogeneous. The specific surface areas for RHA-Fe and RHA-Fe700 were determined by BET nitrogen adsorption studies and found to be 87.4 and 55.8 m(2) g(-1), respectively. Both catalysts showed high activity in the reaction between toluene and benzyl chloride. The mono-substituted benzyltoluene was the major product and both catalysts yielded more than 92% of the product. The GC showed that both the ortho- and para-substituted monoisomers were present in about equal quantities. The minor products consisting of 16 di-substituted isomers were also observed in the GC-MS spectra of both catalytic products. The catalyst was found to be reusable without loss of activity and with no leaching of the metal.
Fulltext Plesiomonas shigelloides associated with diarrhoeal disease in Malaysian children

Lim YS, Young LJ, Balakrishnan S

Singapore Med J, 1987 Dec;28(6):534-6.
PMID: 3441796

Plesiomonas shigelloides was isolated from 5 (2.1%) of the 234 children with diarrhoea and none of the 230 controls. In one child, the organism was found in association with Salmonella. Two strains had Shigella sonnei phase I antigen. All the strains were susceptible to the aminoglycosides, cephalosporins, nalidixic acid, nitrofurantoin, chloramphenicol and cotrimoxazole; but resistant to the penicillins. Alkaline peptone water enrichment subcultured to desoxycholale citrate agar proved to be a useful method for isolating this organism from faeces. As the roie of P. shigelloides in causing gastrointestinal disease remains controversial, further studies are necessary to determine its enteropathogenicily.
Fulltext 'Does the National Antibiotic Guideline- 2008 remain applicable for treating diabetic foot infection?' A new evidence-based regional study on culture and sensitivity patterns in Terengganu population

Balakrishnan S, Shahid Nj, Fairuz T, Ramdhan I

Malays Orthop J, 2014 Mar;8(1):42-4.
PMID: 25347049 DOI: 10.5704/MOJ.1403.017

Diabetic foot infections make up a significant number of orthopaedic ward admissions. The recommended choice of empirical antibiotics used in Malaysia for diabetic foot infections is based on the National Antibiotic Guidelines 2008. The pattern of bacteriology and the effectiveness of the treatment of diabetic foot infections based on this guideline were analyzed through a retrospective study in our hospital. Data over a period of one year (May 2012- April 2013) was analyzed, and 96 patients were included in this study. Polymicrobial growth (58%) was mainly isolated, followed with an almost equal percentage of gram-negative (22%) and gram-positive organisms (20%). The empirical antibiotics based on the national antibiotic guidelines were used as definitive antibiotics in 85% of the cases. Although there was slight variation in the pattern of organisms as compared to other studies conducted in this country, the high rate of positive clinical response proved that the antibiotic guideline was still effective in diabetic foot infection treatment.
KEY WORDS: Diabetic foot infections, National Antibiotic Guidelines, Culture and Sensitivity.
What is the ultimate goal in acid-base regulation?

Balakrishnan S, Gopalakrishnan M, Alagesan M, Prakash ES

Adv Physiol Educ, 2007 Mar;31(1):51-4.
PMID: 17327583

It is common to see chapters on acid-base physiology state that the goal of acid-base regulatory mechanisms is to maintain the pH of arterial plasma and not arterial Pco(2) (Pa(CO(2))) or plasma HCO(3). A hypothetical situation in which the Pa(CO(2)) of arterial plasma is 80 mmHg and the plasma HCO(3) concentration is 48 mM is presented and analyzed to get over this misconception. As per the modified Henderson equation, the pH of arterial plasma would be 7.4; however, we explain that this may be associated with intracellular acidosis due to intracellular hypercapnia and that derangement of homeostasis is evident from the occurrence of respiratory depression and, eventually, coma in the patient described. This suggests that the ultimate goal of acid-base regulatory mechanisms is not just the maintenance of the pH of arterial plasma but the maintenance of the steady-state pH of intracellular fluid as well.
Fulltext Gram-negative infection as an unusual cause of endocarditis in a hemodialysis patient

Balakrishnan S, Aamar A, Rhee S, Zakaria S, Khaliq W

Med J Malaysia, 2016 Jun;71(3):152-3.
PMID: 27495894

Gram-negative endocarditis is rare and it has high mortality if there is a delay in diagnosis and treatment. Gram-negative organisms should be considered in the differential diagnosis of IE in hemodialysis patients. Central lineassociated bloodstream infections (CLABSIs) can be prevented by following sterile measures during catheter insertion and proper management of catheter site.
Gold-nanorod enhances dielectric voltammetry detection of c-reactive protein: A predictive strategy for cardiac failure

Letchumanan I, Md Arshad MK, Balakrishnan SR, Gopinath SCB

Biosens Bioelectron, 2019 Apr 01;130:40-47.
PMID: 30716591 DOI: 10.1016/j.bios.2019.01.042

This paper primarily demonstrates the approach to enhance the sensing performance on antigen C-reactive protein (CRP) and anti-CRP antibody binding event. A nanogapped electrode structure with the gap of ~100 nm was modified by the anti-CRP antibody (Probe) to capture the available CRP. In order to increase the amount of antigen to be captured, a gold nanorod with 119 nm in length and 25 nm in width was integrated, to increase the surface area. A comparative study between the existence and non-existence of gold nanorod utilization was evaluated. Analysis of the sensing surface was well-supported by atomic force microscopy, scanning electron microscopy, 3D nano-profilometry, high-power microscopy and UV-Vis spectroscopy. The dielectric voltammetric analysis was carried out from 0 V to 2 V. The sensitivity was calculated based on 3σ and attained as low as 1 pM, which is tremendously low compared to real CRP concentration (119 nM) in human blood serum. The gold nanorod conjugation with antibody has enhanced the sensitivity to 100 folds (10 fM). The specificity of the CRP detection by the proposed strategy was anchored by ELISA and failure in the detection of human blood clotting factor IX by voltammetry. Despite, CRP antigen was further detected in human serum by spiking CRP to run-through the detection with the physiologically relevant samples.
Fulltext Thickness Dependent Nanostructural, Morphological, Optical and Impedometric Analyses of Zinc Oxide-Gold Hybrids: Nanoparticle to Thin Film

Perumal V, Hashim U, Gopinath SC, Haarindraprasad R, Liu WW, Poopalan P, et al.

PLoS One, 2015;10(12):e0144964.
PMID: 26694656 DOI: 10.1371/journal.pone.0144964

The creation of an appropriate thin film is important for the development of novel sensing surfaces, which will ultimately enhance the properties and output of high-performance sensors. In this study, we have fabricated and characterized zinc oxide (ZnO) thin films on silicon substrates, which were hybridized with gold nanoparticles (AuNPs) to obtain ZnO-Aux (x = 10, 20, 30, 40 and 50 nm) hybrid structures with different thicknesses. Nanoscale imaging by field emission scanning electron microscopy revealed increasing film uniformity and coverage with the Au deposition thickness. Transmission electron microscopy analysis indicated that the AuNPs exhibit an increasing average diameter (5-10 nm). The face center cubic Au were found to co-exist with wurtzite ZnO nanostructure. Atomic force microscopy observations revealed that as the Au content increased, the overall crystallite size increased, which was supported by X-ray diffraction measurements. The structural characterizations indicated that the Au on the ZnO crystal lattice exists without any impurities in a preferred orientation (002). When the ZnO thickness increased from 10 to 40 nm, transmittance and an optical bandgap value decreased. Interestingly, with 50 nm thickness, the band gap value was increased, which might be due to the Burstein-Moss effect. Photoluminescence studies revealed that the overall structural defect (green emission) improved significantly as the Au deposition increased. The impedance measurements shows a decreasing value of impedance arc with increasing Au thicknesses (0 to 40 nm). In contrast, the 50 nm AuNP impedance arc shows an increased value compared to lower sputtering thicknesses, which indicated the presence of larger sized AuNPs that form a continuous film, and its ohmic characteristics changed to rectifying characteristics. This improved hybrid thin film (ZnO/Au) is suitable for a wide range of sensing applications.
A new nano-worm structure from gold-nanoparticle mediated random curving of zinc oxide nanorods

Perumal V, Hashim U, Gopinath SC, Haarindraprasad R, Poopalan P, Liu WW, et al.

Biosens Bioelectron, 2016 Apr 15;78:14-22.
PMID: 26584078 DOI: 10.1016/j.bios.2015.10.083

Creating novel nanostructures is a primary step for high-performance analytical sensing. Herein, a new worm like nanostructure with Zinc Oxide-gold (ZnO/Au) hybrid was fabricated through an aqueous hydrothermal method, by doping Au-nanoparticle (AuNP) on the growing ZnO lattice. During ZnO growth, fine tuning the solution temperature expedites random curving of ZnO nanorods and forms nano-worms. The nano-worms which were evidenced by morphological, physical and structural analyses, revealed elongated structures protruding from the surface (length: 1 µm; diameter: ~100 nm). The appropriate peaks for the face centred cubic gold were (111) and (200), as seen from X-ray diffractogram. The strong interrelation between Au and ZnO was manifested by X-ray photoelectron spectroscopy. The combined surface area increment from the nanoparticle radii and ZnO nanorod random curving gives raise an enhancement in detection sensitivity by increasing bio-loading. 'Au-decorated hybrid nano-worm' was immobilized with a probe DNA from Vibrio Cholera and duplexed with a target which was revealed by Fourier Transform Infrared Spectroscopy. Our novel Au-decorated hybrid nano-worm is suitable for high-performance bio-sensing, as evidenced by impedance spectroscopy, having higher-specificity and attained femtomolar (10 fM) sensitivity. Further, higher stability, reproducibility and regeneration on this sensing surface were demonstrated.
Fulltext A Point-of-Care Immunosensor for Human Chorionic Gonadotropin in Clinical Urine Samples Using a Cuneated Polysilicon Nanogap Lab-on-Chip

Balakrishnan SR, Hashim U, Gopinath SC, Poopalan P, Ramayya HR, Iqbal Omar M, et al.

PLoS One, 2015;10(9):e0137891.
PMID: 26368287 DOI: 10.1371/journal.pone.0137891

Human chorionic gonadotropin (hCG), a glycoprotein hormone secreted from the placenta, is a key molecule that indicates pregnancy. Here, we have designed a cost-effective, label-free, in situ point-of-care (POC) immunosensor to estimate hCG using a cuneated 25 nm polysilicon nanogap electrode. A tiny chip with the dimensions of 20.5 × 12.5 mm was fabricated using conventional lithography and size expansion techniques. Furthermore, the sensing surface was functionalized by (3-aminopropyl)triethoxysilane and quantitatively measured the variations in hCG levels from clinically obtained human urine samples. The dielectric properties of the present sensor are shown with a capacitance above 40 nF for samples from pregnant women; it was lower with samples from non-pregnant women. Furthermore, it has been proven that our sensor has a wide linear range of detection, as a sensitivity of 835.88 μA mIU(-1) ml(-2) cm(-2) was attained, and the detection limit was 0.28 mIU/ml (27.78 pg/ml). The dissociation constant Kd of the specific antigen binding to the anti-hCG was calculated as 2.23 ± 0.66 mIU, and the maximum number of binding sites per antigen was Bmax = 22.54 ± 1.46 mIU. The sensing system shown here, with a narrow nanogap, is suitable for high-throughput POC diagnosis, and a single injection can obtain triplicate data or parallel analyses of different targets.
Fabrication of interdigitated high-performance zinc oxide nanowire modified electrodes for glucose sensing

Haarindraprasad R, Hashim U, Gopinath SC, Perumal V, Liu WW, Balakrishnan SR

Anal Chim Acta, 2016 Jun 21;925:70-81.
PMID: 27188319 DOI: 10.1016/j.aca.2016.04.030

Diabetes is a metabolic disease with a prolonged elevated level of glucose in the blood leads to long-term complications and increases the chances for cardiovascular diseases. The present study describes the fabrication of a ZnO nanowire (NW)-modified interdigitated electrode (IDE) to monitor the level of blood glucose. A silver IDE was generated by wet etching-assisted conventional lithography, with a gap between adjacent electrodes of 98.80 μm. The ZnO-based thin films and NWs were amended by sol-gel and hydrothermal routes. High-quality crystalline and c-axis orientated ZnO thin films were observed by XRD analyses. The ZnO thin film was annealed for 1, 3 and 5 h, yielding a good-quality crystallite with sizes of 50, 100 and 110 nm, and the band gaps were measured as 3.26, 3.20 and 3.17 eV, respectively. Furthermore, a flower-modeled NW was obtained with the lowest diameter of 21 nm. Our designed ZnO NW-modified IDE was shown to have a detection limit as low as 0.03 mg/dL (correlation coefficient = 0.98952) of glucose with a low response time of 3 s, perform better than commercial glucose meter, suitable to instantly monitor the glucose level of diabetes patients. This study demonstrated the high performance of NW-mediated IDEs for glucose sensing as alternative to current glucose sensors.
Fulltext Low Temperature Annealed Zinc Oxide Nanostructured Thin Film-Based Transducers: Characterization for Sensing Applications

Haarindraprasad R, Hashim U, Gopinath SC, Kashif M, Veeradasan P, Balakrishnan SR, et al.

PLoS One, 2015;10(7):e0132755.
PMID: 26167853 DOI: 10.1371/journal.pone.0132755

The performance of sensing surfaces highly relies on nanostructures to enhance their sensitivity and specificity. Herein, nanostructured zinc oxide (ZnO) thin films of various thicknesses were coated on glass and p-type silicon substrates using a sol-gel spin-coating technique. The deposited films were characterized for morphological, structural, and optoelectronic properties by high-resolution measurements. X-ray diffraction analyses revealed that the deposited films have a c-axis orientation and display peaks that refer to ZnO, which exhibits a hexagonal structure with a preferable plane orientation (002). The thicknesses of ZnO thin films prepared using 1, 3, 5, and 7 cycles were measured to be 40, 60, 100, and 200 nm, respectively. The increment in grain size of the thin film from 21 to 52 nm was noticed, when its thickness was increased from 40 to 200 nm, whereas the band gap value decreased from 3.282 to 3.268 eV. Band gap value of ZnO thin film with thickness of 200 nm at pH ranging from 2 to 10 reduces from 3.263eV to 3.200 eV. Furthermore, to evaluate the transducing capacity of the ZnO nanostructure, the refractive index, optoelectric constant, and bulk modulus were analyzed and correlated. The highest thickness (200 nm) of ZnO film, embedded with an interdigitated electrode that behaves as a pH-sensing electrode, could sense pH variations in the range of 2-10. It showed a highly sensitive response of 444 μAmM-1cm-2 with a linear regression of R2 =0.9304. The measured sensitivity of the developed device for pH per unit is 3.72μA/pH.
Fulltext 'Spotted Nanoflowers': Gold-seeded Zinc Oxide Nanohybrid for Selective Bio-capture

Perumal V, Hashim U, Gopinath SC, Haarindraprasad R, Foo KL, Balakrishnan SR, et al.

Sci Rep, 2015 Jul 16;5:12231.
PMID: 26178973 DOI: 10.1038/srep12231

Hybrid gold nanostructures seeded into nanotextured zinc oxide (ZnO) nanoflowers (NFs) were created for novel biosensing applications. The selected 'spotted NFs' had a 30-nm-thick gold nanoparticle (AuNP) layer, chosen from a range of AuNP thicknesses, sputtered onto the surface. The generated nanohybrids, characterized by morphological, physical and structural analyses, were uniformly AuNP-seeded onto the ZnO NFs with an average length of 2-3 μm. Selective capture of molecular probes onto the seeded AuNPs was evidence for the specific interaction with DNA from pathogenic Leptospirosis-causing strains via hybridization and mis-match analyses. The attained detection limit was 100 fM as determined via impedance spectroscopy. High levels of stability, reproducibility and regeneration of the sensor were obtained. Selective DNA immobilization and hybridization were confirmed by nitrogen and phosphorus peaks in an X-ray photoelectron spectroscopy analysis. The created nanostructure hybrids illuminate the mechanism of generating multiple-target, high-performance detection on a single NF platform, which opens a new avenue for array-based medical diagnostics.
Reye and Reye-like syndromes: results of a pilot study in Peninsular Malaya, 1986

Sinniah D, Sinniah R, Yap YF, Singh M, George R, Lim NL, et al.

Acta Paediatr Jpn, 1990 Aug;32(4):385-90.
PMID: 2288220

A pilot epidemiologic study of all cases of Reye and Reye-like syndromes was undertaken at 8 representative major hospitals in Peninsular Malaya from January 1st to December 31st 1986. The cases were classified as definitive Reye's syndrome, clinical Reye's syndrome and encephalo-hepatopathies. Less than 50% of cases reviewed fulfilled the National Center for Disease Control criteria for clinical Reye's syndrome. Causes of Reye-like syndromes/encephalo-hepatopathies included fulminant hepatitis, Japanese B encephalitis, dengue, septicaemia, and complex febrile fits. It was not possible to differentiate clinical Reye's syndrome from the other encephalo-hepatopathies by either the clinical features (except for jaundice) or biochemical parameters. Liver biopsy is necessary for a definitive diagnosis of Reye's syndrome in Malaysia, because of the high prevalence of Reye-like diseases. The mortality rate in the 2 groups of patients is similar. Ingestion of salicylates was not found to be significantly associated with Reye and Reye-like syndromes in this study.
Fulltext Comparative Analysis on Dielectric Gold and Aluminium Triangular Junctions: Impact of Ionic Strength and Background Electrolyte by pH Variations

Letchumanan I, Md Arshad MK, Gopinath SCB, Rajapaksha RDAA, Balakrishnan SR

Sci Rep, 2020 Apr 22;10(1):6783.
PMID: 32321969 DOI: 10.1038/s41598-020-63831-w

Field of generating a surface thin film is emerging broadly in sensing applications to obtain the quick and fast results by forming the high-performance sensors. Incorporation of thin film technologies in sensor development for the better sensing could be a promising way to attain the current requirements. This work predominantly delineates the fabrication of the dielectric sensor using two different sensing materials (Gold and Aluminium). Conventional photolithography was carried out using silicon as a base material and the photo mask of the dielectric sensor was designed by AutoCAD software. The physical characterization of the fabricated sensor was done by Scanning Electron Microscope, Atomic Force Microscope, High Power Microscope and 3D-nano profiler. The electrical characterization was performed using Keithley 6487 picoammeter with a linear sweep voltage of 0 to 2 V at 0.01 V step voltage. By pH scouting, I-V measurements on the bare sensor were carried out, whereby the gold electrodes conducts a least current than aluminium dielectrodes. Comparative analysis with pH scouting reveals that gold electrode is suitable under varied ionic strengths and background electrolytes, whereas aluminium electrodes were affected by the extreme acid (pH 1) and alkali (pH 12) solutions.

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