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Fulltext Diabetic foot care practice and its associated factors among type 2 diabetes mellitus patients attending primary health clinics in kuantan, malaysia: a cross sectional study.

Azmi NH, Abdul Hadi A, Md Aris MA, Nasreen HE, Che-Ahmad A

IIUM Medical Journal Malaysia, 2020;19(2):13-19.
MyJurnal

One of the most important and debilitating complication of diabetes mellitus is foot problem such as ulcers, infections and amputations. However, these complications are preventable by simple intervention such as regular foot care practice. This study aims to assess the foot care practice and its associated factors among type 2 diabetes mellitus patients attending primary health clinics in Kuantan. MATERIALS AND METHODS: This was a cross-sectional study conducted at four primary health clinics in Kuantan involving 450 study participants who were selected by using universal sampling method. Level of awareness and practice toward diabetic foot care was assessed using validated self-administered questionnaire. Multiple logistic regressions were performed to identify factors associated with poor foot care practice among the respondents. RESULTS:About 59.6% of respondents had poor foot care practice and 50.9% had poor awareness level. Multivariate logistic regression analysis identified that, increasing age (OR0.97, 95% CI: 0.955-0.993) and good awareness towards foot problem (OR0.43, 95%CI: 0.289-0.643) were less likely to have poor foot care practice. However, Malay ethnicity (OR 1.81, 95% CI: 1.002-3.271) and obesity (OR1.9, 95% CI: 1.225-2.976) were associated with poor foot care practice after controlling other variables. CONCLUSION:Majority of the respondents had poor foot care practice and poor awareness. Respondents who are older and have better awareness are less likely to have poor foot care practice. Diabetic patients who are Malays and/or obese are predicted to have poor diabetic foot practice and hence must be prioritized for a sustainable patient education and compliance towards foot care practice at primary care level.
Fulltext Prevalence and associated factors of diabetic foot at risk among type 2 diabetes mellitus patients attending primary health clinics in kuantan.

Azmi NH, Abdul Hadi A, Md Aris MA, Nasreen HE, Che-Ahmad A

IIUM Medical Journal Malaysia, 2020;19(3):11-19.
MyJurnal

The diabetic foot at risk is the diabetic foot which is at risk of ulceration, hence the importance of identifying the foot at this stage. This study aims to assess the prevalence of diabetic foot at risk and its associated factors among type 2 diabetes mellitus patients’ attending primary health clinics in Kuantan.Methods and methods: This was a cross-sectional study conducted at four primary health clinics in Kuantan involving 450 study participants who were selected by using universal sampling method. Foot examination was carried out and foot at risk was classified based on the Kings’ Classification. Multiple logistic regressions were performed to identify the predictors for diabetic foot at risk. Results: The prevalence of diabetic foot at risk was 31.3%. Multivariate logistic regression analysis identified age (OR 1.04, 95% CI: 1.01-1.06), smoker (OR 4.11, 95% CI: 1.96-8.63) and duration of diabetes more than 10 years (OR1.77, 95% CI: 1.05-2.98) as risk factors for diabetic foot at risk. Respondents with higher diabetic foot practice score (OR 0.87, 95% CI: 0.77-0.98) have lesser risk of developing diabetic foot at risk. Conclusion: Patients who are older, smoker and/or have chronic diabetes are predicted to be at higher risk to develop the diabetic foot at risk. This study also showed that patients with better foot care practice has lesser risk. Therefore, these are the groups of patients that need to be targeted for early detection and intervention to prevent serious complications.
Fulltext Neonatal clavicle fracture: a review of fourteen cases in east coast Peninsular Malaysia

Awang, M.S., Abdul Razak, A.H., Che Ahmad, A., Mohd Rus, R.

International Medical Journal Malaysia, 2017;16(2):79-83.
MyJurnal

Introduction: The purpose of this study is to identify the incidence of clavicle fractures in newborn
associated with fetal, maternal and process of deliveries in Kuantan General Hospital from June 2012 until
January 2014. This study is to determine epidemiological data of clavicle fractures, maternal and baby risk
factors associated with clavicle fractures of newborn and its’ outcome.

Methods: This is a prospective
study. 13 patients were identified to fulfill the inclusion criteria of the study. The data of
sociodemographic, associated fetal and maternal risk factors and the outcomes were recorded using
proforma. The statistical data analysis was done using SPSS 12.0.

Results: Out of 20,257 live births at our
centre during the study period, 13 infants were diagnosed to have clavicle fractures, giving an incidence of
0.64 per 1000 live births. There were 5 (38.5%) left, 7 (53.8%) right and one (7.7%) bilateral fracture. All
fractures located at the mid shaft of the clavicle and none have associated brachial plexus injuries. All
infants were delivered through vaginal delivery (61.5%); five through assisted delivery (instrumental); 2
(15.4%) forcep and 3 (23.1%) vacuum. Two of the babies developed shoulder dystocia. The average birth
weight was 3371 grams (SD 0.269) and mean gestational age was 38.7 weeks (SD 1.16). Five of the mothers
(38.5%) were primigravida and eight (61.5%) were multigravida in which,7 (53.8%)were healthy without
other co-morbidty, 5 (38.5%) having gestational diabetis and one (7.7%) hypertension. The average maternal
weight was 62.0 kg and height 1.58 metres with average BMI of 24.16 (3.29SD). All eventually had a
complete recovery at 6 weeks with clinical and radiological evident of fracture union.

Conclusions: In
conclusion, all patients with clavicle fractures were found following vaginal delivery. There were no
associations between neonatal clavicle fractures with maternal or baby risk factors. All fractures healed
without any complications.
Fulltext CRNC3: Gingival Veneer: A Prosthetic Solution to Enhance Smile by Masking Aesthetically Challenging Gum Recession

Fong FM, Che Ahmad A

J Indian Prosthodont Soc, 2018 Oct;18(Suppl 1):S46.
PMID: 30532476 DOI: 10.4103/0972-4052.244680
Fulltext Surgical Management of Distal Tibia Fracture: Towards An Outcome-based Treatment Algorithm

Rushdi I, Che-Ahmad A, Abdul-Ghani K, Mohd-Rus R

Malays Orthop J, 2020 Nov;14(3):57-65.
PMID: 33403063 DOI: 10.5704/MOJ.2011.010

Introduction: Distal tibia fractures are frequently associated with an extensive soft tissue injury which then leads to a higher risk of complications such as infection, non-union and eventually poor overall outcome. The purpose of this study is to measure the outcome of distal tibia fractures treated with internal fixation, external fixator or Ilizarov external fixator(IEF). We aim to propose an algorithm for management of distal tibia fractures by evaluating the treatment options, outcomes and risk factors present.
Material and Methods: This study is a cross-sectional study of all distal tibia fractures treated surgically in Tengku Ampuan Rahimah Hospital, Klang from 1st January 2016 till 30th June 2018. Patient records were reviewed to analyse the outcomes of surgical treatment and risk factors associated with it.
Results: Ninety-one patients were included with a mean age of 41.5 years (SD = 16.4). Thirty-nine cases (42.9%) were open fractures. Thirty-eight patients (41.8%) were treated with internal fixation, 27 patients (29.7%) were treated with IEF and 26 patients (28.6%) were treated with an external fixator. Among open fractures cases, no significant finding can be concluded when comparing each surgical option and its outcome, although one option was seen better than the other in a particular outcome. Initial skeletal traction or temporary spanning external fixator in close fractures reduced the risk of mal-alignment (p value=0.001). Internal fixation is seen superior to IEF and external fixator in close fractures in term of articular surface reduction (p value = 0.043) and risk of mal-alignment (p value = 0.007).
Conclusion: There is no single method of fixation that is ideal for all pilon fractures and suitable for all patients. This proposed algorithm can help surgeons in deciding treatment strategies in the challenging management of distal tibia fractures to reduce associated complications.
Three-dimensional morphometric study of the trapezium shape of the trochlea tali

Daud R, Abdul Kadir MR, Izman S, Md Saad AP, Lee MH, Che Ahmad A

J Foot Ankle Surg, 2013 Jul-Aug;52(4):426-31.
PMID: 23623302 DOI: 10.1053/j.jfas.2013.03.007

The trapezium shape of the talar dome limits the use of 2-dimensional plain radiography for morphometric assessment because only 2 of the 4 required parameters can be measured. We used computed tomography data to measure the 4 morphologic parameters of the trochlea tali: anterior width, posterior width, trochlea tali length, and angle of trapezium shape. A total of 99 subjects underwent computed tomography scanning, and the left and right talus bones were both virtually modeled in 3 dimensions. The 4 morphologic parameters were measured 3 times each to obtain the intraclass correlation, and analysis of variance was used to check for any significant differences between the repeated measurements. The average intraclass correlation coefficient for the measurements for 2 to 3 trials was 0.94 ± 0.04. Statistical analyses were performed on the data from all 198 talus bones using SAS software, comparing male and female and left and right bones. All 4 morphometric values were greater in the male group. No significant differences were found between the left and right talus bones. A strong positive correlation was observed between the trochlea tali length and the anterior width. The angle of trapezium shape showed no correlation with the other 3 parameters. The measurements were compared with the dimensions of the current talar components of 4 total ankle arthroplasty implants. However, most of them did not perfectly match the trapezium shape of the talus from our population. We successfully analyzed the trapezium shape of the trochlea tali using reliable virtual 3-dimensional measurements. Compared with other published reports, our study showed a relatively smaller dimension of the trochlea tali than the European counterparts.
Long-term effect on foot and ankle donor site following vascularized fibular graft resection in children

Sulaiman AR, Wan Z, Awang S, Che Ahmad A, Halim AS, Ahmad Mohd Zain R

J Pediatr Orthop B, 2015 Sep;24(5):450-5.
PMID: 26049965 DOI: 10.1097/BPB.0000000000000197

This study was carried out to evaluate the long-term effect on the donor side of the foot and ankle following vascularized fibular graft resection in children. Eight patients underwent resection of the fibula for the purpose of a vascularized fibular graft by a surgical team who practiced leaving at least 6 cm residual distal fibula. The age of these children at the time of surgery was between 3 and 12 years. They were reviewed between 3 and 12 years after surgery. Two patients who underwent resection of the middle shaft of the fibula at 3 and 5 years of age developed abnormal growth of the distal tibia, leading to ankle valgus. They were treated with growth modulation of the distal tibial physis and supramalleolar osteotomy with tibiofibular synostosis. Another patient who underwent the entire proximal fibula resection at the age of 6 years had developed hindfoot valgus because of weakness of the tibialis posterior muscle. He required talonavicular fusion and flexor hallucis to tibialis posterior muscle transfer. Patients operated at the age of older than 8 years neither had ankle nor hindfoot deformity. We concluded that resection of the middle shaft of the fibula for the purpose of a vascularized fibula graft, leaving a 6 cm distal fibular stump in children younger than 6 years old, may give rise to abnormal growth of the distal tibial physis, leading to valgus ankle. The entire proximal fibular resection for the similar purpose in a 6-year-old child may give rise to weakness of tibialis posterior and hindfoot valgus.
A novel technique of isolated gastrocnemius recession: A cadaveric comparison with Strayer procedure

Kow RY, Che-Ahmad A, Ayeop MAS, Ahmad MW, Yusof S

J Orthop Surg (Hong Kong), 2021 11 11;29(3):23094990211043987.
PMID: 34753329 DOI: 10.1177/23094990211043987

BACKGROUND: Strayer's gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically.
METHODS: Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques.
RESULTS: There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829).
CONCLUSIONS: Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them.
LEVEL OF EVIDENCE: Level II, randomized controlled trial.
Fulltext Predictors of major lower limb amputation among type II diabetic patients admitted for diabetic foot problems

Yusof NM, Rahman JA, Zulkifly AH, Che-Ahmad A, Khalid KA, Sulong AF, et al.

Singapore Med J, 2015 Nov;56(11):626-31.
PMID: 26668408 DOI: 10.11622/smedj.2015172

Introduction: Diabetes mellitus (DM) is the most common cause of amputations in Malaysia. This study aimed to identify the predictive factors for major lower limb amputation among patients with type 2 DM (T2DM) who were admitted to a hospital, in order to reduce its likelihood.
Methods: This cross-sectional study involved 218 patients with T2DM who were admitted to Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, for diabetic foot problems from June 2011 to July 2012. A form was developed to document the patients' profiles, comorbidities, complications, investigations, treatment and clinical outcomes. The predictors for major lower limb amputations were determined using univariate and stepwise logistic regression analysis.
Results: A total of 31 patients underwent major lower limb amputations (25 transtibial, 6 transfemoral). The following factors were found to be associated with the incidence of major lower limb amputations: T2DM duration ≥ 10 years, diabetic neuropathy, diabetic nephropathy, presentation with gangrene, diabetic foot conditions of Wagner grade 4 or 5, and necrotising fasciitis. Patients who underwent major amputations had significantly lower haemoglobin and albumin levels, and higher total white blood cell counts, erythrocyte sedimentation rates, and C-reactive protein, urea and creatinine levels. However, only T2DM duration ≥ 10 years, positive bacterial culture and albumin levels were significant on stepwise logistic regression analysis.
Conclusion: T2DM duration ≥ 10 years, positive bacterial culture and low albumin levels were found to be significant predictive factors for major lower limb amputation among patients with T2DM admitted for diabetic foot problems.
Keywords: amputation; diabetes mellitus; diabetic foot; lower limb; type II.
Fulltext The Role of Medial Plantar Artery Flap in Heel Pad Reconstruction: A Report of Two Cases

Oon ZS, Kow RY, Ahmad Alwi AA, Ayeop MAS, Low CL, Che Ahmad A

Cureus, 2023 Jul;15(7):e41844.
PMID: 37575710 DOI: 10.7759/cureus.41844

The heel and sole possess unique anatomical characteristics that serve a weight-bearing and shock-absorbing function. The heel is particularly vital, as any defects in this area can lead to gait instability. Reconstructing a heel defect presents challenges, as the donor flap must be durable enough to withstand high force loads while also providing protective sensation. Recently, the medial plantar artery flap has been successfully employed for the reconstruction of defective heel pads. This flap offers glabrous skin capable of weight transmission and intact protective sensation. In this report, we present two cases of heel pad loss secondary to chronic diabetic complications and trauma, respectively, which were treated with medial plantar artery flap reconstruction. Both cases were successfully treated, and they showed a good functional outcome.
Can pictorial narration offer a solution to teacher training on the effective inclusion of students with autism spectrum disorder in low-resource settings? Investigation on knowledge and stigma change

Low HM, Wong TP, Lee LW, Makesavanh S, Vongsouangtham B, Phannalath V, et al.

Autism, 2021 07;25(5):1216-1233.
PMID: 33467885 DOI: 10.1177/1362361320984899

LAY ABSTRACT: In this study, we explored whether pictorial narration could offer a solution to teacher training on effective inclusion of students with autism spectrum disorder in the Lao People's Democratic Republic. For this purpose, pre- and post-training knowledge data were collected from 87 Laotian teachers who participated in teacher training using a pictorial narrative e-module called The Story of KhamdyTM. The teachers' knowledge test results and feedback were analyzed. The findings indicated that teachers' acceptance toward the training method had positive effects on their knowledge changes and supported the use of a pictorial narration approach in imparting knowledge about inclusive education and autism spectrum disorder to teachers in a least developed country.
The potential of 3-dimensional construct engineered from poly(lactic-co-glycolic acid)/fibrin hybrid scaffold seeded with bone marrow mesenchymal stem cells for in vitro cartilage tissue engineering

Abdul Rahman R, Mohamad Sukri N, Md Nazir N, Ahmad Radzi MA, Zulkifly AH, Che Ahmad A, et al.

Tissue Cell, 2015 Aug;47(4):420-30.
PMID: 26100682 DOI: 10.1016/j.tice.2015.06.001

Articular cartilage is well known for its simple uniqueness of avascular and aneural structure that has limited capacity to heal itself when injured. The use of three dimensional construct in tissue engineering holds great potential in regenerating cartilage defects. This study evaluated the in vitro cartilaginous tissue formation using rabbit's bone marrow mesenchymal stem cells (BMSCs)-seeded onto poly(lactic-co-glycolic acid) PLGA/fibrin and PLGA scaffolds. The in vitro cartilaginous engineered constructs were evaluated by gross inspection, histology, cell proliferation, gene expression and sulphated glycosaminoglycan (sGAG) production at week 1, 2 and 3. After 3 weeks of culture, the PLGA/fibrin construct demonstrated gross features similar to the native tissue with smooth, firm and glistening appearance, superior histoarchitectural and better cartilaginous extracellular matrix compound in concert with the positive glycosaminoglycan accumulation on Alcian blue. Significantly higher cell proliferation in PLGA/fibrin construct was noted at day-7, day-14 and day-21 (p<0.05 respectively). Both constructs expressed the accumulation of collagen type II, collagen type IX, aggrecan and sox9, showed down-regulation of collagen type I as well as produced relative sGAG content with PLGA/fibrin construct exhibited better gene expression in all profiles and showed significantly higher relative sGAG content at each time point (p<0.05). This study suggested that with optimum in vitro manipulation, PLGA/fibrin when seeded with pluripotent non-committed BMSCs has the capability to differentiate into chondrogenic lineage and may serve as a prospective construct to be developed as functional tissue engineered cartilage.
Fulltext Malaysian clinical practice guidelines for management of diabetic foot: A synopsis for the primary care physician

Tharumaraja T, Che-Ahmad A, Wong PF, Ahmad Hamid AH, Hasan MI, Bajuri MY, et al.

Malays Fam Physician, 2021 Mar 25;16(1):103-113.
PMID: 33948148 DOI: 10.51866/cpg0001

Diabetic foot requires careful attention and coordinated management by a dedicated team. Screening, prevention, adequate assessment, and appropriate referral are crucial to prevent complications. Multimodal treatment and rehabilitation are recommended to ensure a better quality of life and reduction of amputation rate in people with diabetic foot.

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