The only potential curative therapy for gastric cancer is the resection of both the tumor and the regional lymph nodes at the early stage of the disease. The majority of patients with gastric cancer in Malaysia have an advanced disease at initial diagnosis, and curative surgery is possible in less than 20% of operated cases. Acurate preoperative staging is crucial in determining the most suitable therapy and avoiding unnecessary attempts at curative surgery. While computed tomography remains as the most widely used imaging modality for gastric cancer staging, its ability to detect local invasion, peritoneal and liver metastases is limited. In the recent years laparoscopy has become an important component in the staging algorithm of gastric cancer. The aim of this review is to evaluate the efficacy of routine preoperative laparoscopic staging in the management of gastric cancer, and in particular describe the Malaysian experience.
This is a cross sectional study conducted in July 2010 at the International Medical University, Seremban, Malaysia. The objective of this study was to ascertain the relationship between working memory capacity of final MBBS medical students using the digit span backward test and their academic achievement based on the total score at the modified
essay questions (MEQ) which was the principal component of the theory examination. Seventy eight final year medical students were recruited,41 (52.6%) were females and remaining 37 (47.4%) were males. Working memory capacity was measured by digit span backward test (DSBT) which ranged from3 to 8 digits. The mean digit score was 6.6 ± 1.1 falling under the category of ‘above average’ score. There was no significant difference between working memory capacity and gender (p>0.05). There was no significant difference in the MEQ mean score and the different categories of working memory capacity (p>0.05).
The DBST shows uniformity in working memory adequate to pass the modified essay questions. Medical students appear to use encoding and retrieval process in problem solving based on functionality and pattern recognition in tackling the problems in the MEQ.
Mentoring in academic medicine requires the trained mentor to commit time, purpose and dedication for the personal and professional development of three categories of protégés or mentees i.e. medical students, the clinician-trainee and the clinical-educator. Conventionally, assigned mentors monitor the progress of the first two categories of personnel as their career pathway is clearly defined. On the other hand the clinician–educator in academic medicine could be a scientist or a career clinician expected to contribute to medical education activities and research. The clinician educator has grown in complexity as he multitasks in providing clinical care, assists in delivering the medical curriculum and is expected to do research and publish. Although there is dearth of research in mentoring the clinician-educator, it is clear that mentored clinicaleducators are more productive by way of scientific publications. Trained mentors are expected to identify the needs of the mentee with regards to the level of his career development and his aptitude to move up the academic ladder, successfully nurturing the maturation process. Processes of mentoring in the clinical setting, attributes of the successful mentor and facilitating the mentee in overcoming challenges in academic medicine are discussed.
There has been a significant decline in maternal mortality from 540 per 100,000 live births
in I957 to 28 per 100,000 in 2010. This decline is due to several factors. Firstly the introduction of the rural health infrastructure which is mainly constructing health centres and midwife clinics for the rural population. This provided the accessibility and availability of primary health care and specially, antenatal care for the women. This also helped to increase the antenatal coverage for the women to 98% in 2010 and it increased the average number of antenatal visits per women from6 in 1980 to 12 visits in 2010 for pregnant women. Along with the introduction of health centres, another main feature was the introduction of specific programmes to address the needs of the women and children. In the 1950s the introduction of Maternal and Child Health (MCH) programme was an important
step. Later in the late 1970s there was the introduction of the High Risk Approach in MCH care and Safe Motherhood in the 1980s. In 1990, an important step was the introduction of the Confidential Enquiry into Maternal Deaths (CEMD). Another significant factor in the reduction is the identification of high risk mothers and this is being done by the introduction of the colour coding system in the health centres. Other factors include the increase in the number of safe deliveries by skilled personnel and the reduction in the number of deliveries by the Traditional Birth Attendants (TBAs). The reduction in fertility rate from 6.3 in 1960 to 3.3 in 2010 has been another important factor. To achieve the 2015 Millennium Development Goals (MDG) to further reduce maternal deaths by 50%, more needs to be done especially to identify maternal deaths that are missed by omission or misclassification and also to capture the late maternal deaths.
In the developing world, clinical knowledge management in primary care has a long way to go. Clinical decision support systems, despite its promise to revolutionise healthcare, is slow in its implementation due to the lack of financial investment in information technology. Point-of-care resources, such as comprehensive electronic textbooks delivered via the web or mobile devices, have yet to be fully utilised by the healthcare organisation or individual clinicians. Increasing amount of applicable knowledge of good quality (e.g. clinical practice guidelines and other pre-appraised resources) are now available via the internet. The policy makers and clinicians need to be more informed about the potential benefits and
limitations of these new tools and resources and make the necessary budgetary provision and learn how best to harness them for patient care.
Realising possible unmet needs of final year medical students we initiated a weekly informal face-toface discussion forum between them and the teaching faculty of the department of medicine. Various academic and non-academic topics, as dictated by the students, were discussed in 19 weekly sessions. Evaluation by the students was subsequently done by means of an on-line questionnaire after the final examinations. The aim of this study was to evaluate this forum, undertaken for the first time in our institution, by assessing student feedback. We conclude that although the number of attendees and responders were small, feedback was generally positive. This type of forum can be improved upon and serve as another portal for benefitting students.
This paper reviews available reports on the omega-6 (linoleic acid, LA) and omega-3 fatty acid
[alpha-linolenic acid (ALA) + eicosapentaenoic acid (EPA) + docosahexaenoic acid) intakes amongst Malaysians against Malaysian Recommended Nutrient Intakes (RNI), focussing particularly on pregnant and lactating women because of the availability of data for these latter vulnerable groups. Overall, the omega-6 and omega-3 fatty acid nutrition amongst Malaysians are poor and far from desirable. The nutritional situation regarding these long-chain polyunsaturated fatty acids
(LCPUFA) amongst Malaysian pregnant and lactating women is alarming and warrants urgent attention in nutrition promotion activities/counselling. Daily consumption of LA by these women and other Malaysians studied ranged from 3.69 - 5.61 % kcal with 38-60% of individuals not meeting their RNIs. Daily intakes of omega-3 fatty acids faired worse, averaging 0.21- 0.33 % kcal with as high as 92% of subjects in one study not meeting their RNIs. The omega-6 to omega-3 fatty acid
ratios obtained in the studies reviewed are about 20:1, which is way above the World Health Organisationrecommended ratio of 5-10:1. Dietary sources of these omega- fatty acids in the subjects studied are chicken, fish and milk. Since local foods are not particularly rich in LCPUFA such as EPA and DHA, the options to improve EPA/DHA nutrition amongst Malaysians are
the greater consumption of omega-3 enriched foods and in the case of pregnant and lactating women, LCPUFA supplementation may warrant serious consideration.
The research mentorship programme is unique in that it is a planned journey undertaken by the mentor and mentee, preferably with well-defined milestones along the journey. During the journey, familiar landmarks will be pointed out by the mentor. In path-finding situations the experience and wisdom of the mentor and the critical appraisal of both mentor and mentee will contribute to learning from the encounter. In most mentor-mentee partnerships, a formal acceptance to the relationship, well-defined landmarks measuring progress in the journey, regular appraisal of the skills developed and acquired, and phased, judicious modification in the individual roles of that relationship will be required. Although there is no consensus on the elements of mentorship, there are some strategies which can contribute to the success of the relationship. Critical success factors include convergence of the research area within the broad expertise of the research mentor. The research mentor should have a proven research track record and is committed to serve in that official capacity. The research mentoring process is dynamic and characteristics of both mentor and mentee contribute to the robustness of that relationship. The mentee would have identified some attributes of the mentor that are desirable and is willing to work hard to achieve, build on, and improve upon. In the research setting endpoint measurements of success will be based on recognition of the research standing of the mentee, measurable outcomes such as number of papers in top tier journals, citation indices, etc. consultancies attracted as well as invitations to deliver plenaries in scientific conferences, patents filed and research findings translated and applied, and other measures of research productivity. In the pursuit of research excellence the mentee would have imbibed values of professionalism and ethics in research and would have constantly kept in mind that to be successful, the mentee would be able to excel beyond his mentor and that the next generation of researchers will seek mentorship from him.
Outcome and competency-based undergraduate and graduate medical education is the desired standard embraced by many medical educationists worldwide. Reflective capacity is an integral component of that strategy and reflective writing has shown tremendous potential as a delivery tool. But there are various challenges in the implementation of the initiative. Efficacy as a delivery tool, achievement of pedagogical outcomes, reliability issues, challenges in assessment outcomes/tools, and whether it can be taught and learnt, need to be addressed. Many questions are still not satisfactorily answered, and this review attempts to offer some perspective on the issues.
The immune system is the host natural defence against cancer. Cancers are caused by progressive growth of the progeny of a single transformed host cell. The immune system is generally not able to mount immune responses to “self-antigens”, due to various mechanisms of immunological tolerance that are in place. This means that despite possessing a natural defence against tumours, many of the cancer patients may not be able
to mount an effective immune response to fight the tumours. Dendritic cells (DC) are highly specialised in antigen presenting that can initiate and stimulate immune responses. These cells have the ability to stimulate naïve T cell proliferation and perform specific stimulatory and tolerogenic functions respectively. When the DC are activated by antigens, these cells
undergoes further maturation and migrate to secondary lymphoid tissues, present antigen to T cells and finally induce an immune response. The ability of the DC to activate naïve and primed T-lymphocytes makes these cells a good candidate to be explored as a potential immunotherapeutic agent that can modulate antitumour immune responses in the affected host.
Oral health diseases are common in all regions of the world and their impact on anatomical
and social functioning is widely acknowledged.Their distributions are unequal between and within countries, with the greatest burden falling on disadvantaged and socially marginalized populations. The risk factors and social determinants for oral diseases have been comprehensively documented, and the evidence base for their prevention is growing. However, decisions on health care are still often made without a solid grounding in research evidence. Translation of research into policy and practice should be a priority for all. Both community and individual interventions need tailoring to achieve a more equal and person-centered preventive focus and reduce any social gradient in health. The major challenges of the future will be to translate knowledge and experiences in oral disease prevention
and health promotion into action programmes.The international oral health research community needs to engage further in research capacity building and in strengthening the work so that research is recognized as the foundation of oral health policy at global level.
Shock, a major cause of morbidity and mortality in children, is the the most anxiety-provoking emergency that needs to be addressed urgently and effectively by the attending paediatrician. It is a state where the metabolic demands of the tissue are not met due to circulatory dysfunction. Unlike adults, hypotension is a very late feature of shock in children. As the child’s condition worsens, the clinical presentation of the different causes of shock become similar, and nullify any aetiological differences. Regardless of the type of shock, the final common pathway is inadequate tissue perfusion and oxygen supply to meet cellular demands. Delayed recognition and treatment result in progression from compensated reversible shock to uncompensated irreversible shock with widespread multiple system
organ failure to death. This paper reviews the physiological basis, and pathophysiological classification of the various types of shock and their respective aetiologies. The clinical features of the different types of shock are described, and current diagnostic and therapeutic strategies are applied for the most effective and appropriate treatment for resuscitating the child in shock. A strong index of suspicion, early recognition, timely intervention and transfer to an intensive care unit are critical for successful outcomes in the management of paediatric shock.
This article presents an overview of long acting products used in animal health, production
and reproduction. The topic represents a niche field of controlled release that few formulation scientists become specialists and experts in, but it is a field which has made significant contribution to the area of controlled release technology, and one which is of major importance to human kind due to their dependence on farmed animals as a source of hide, protein, milk and eggs.
Background: Peripheral venous catheterisation is indispensable in modern practise of medicine. The indications of venous access should be weighed against the risk of complications, the commonest being thrombophlebitis. Thrombophlebitis causes patient discomfort and the need for new catheter insertion and risk of developing further widespread infections. Methodology: This observational study was conducted on adult patients admitted to the surgical and medical ward of a tertiary hospital in Negeri Sembilan Malaysia in 2011. Four researchers visited patients daily and examined for signs of thrombophlebitis; warmth, erythema, swelling, tenderness or a palpable venous cord. Risks factors that were studied in this research were patient/s age and gender, duration of catheterization, use of catheter for infusion, size of catheter, site of catheter insertion and types of infusate. Thrombophlebitis was graded using a scale adapted from Bhandari et al. (1979). Results: In total, 428 patients were recruited with an incidence rate of thrombophlebitis of 35.2%. Among those who developed thrombophlebitis, 65% had mild thrombophlebitis, 19% moderate and 8% severe thrombophlebitis. Results showed that female patients had a significant increased risk of developing thrombophlebitis. Also risk increased significantly with increased duration of catheterization and usage of the catheter for infusion. The age of a patient, types of infusate use, size of catheter and site of catheter insertion did not significantly influence the development of thrombophlebitis. Conclusion: The study showed that risk of developing thrombophlebitis is significantly increased among female patients, and also with increased duration of catheterization and use of the peripheral venous catheter for infusion. We recommended elective replacement of catheter every 72 hours and daily examination of catheters for signs of thrombophlebitis by a healthcare personnel.
Background: Facebook is a popular social networking site with more than five hundred million users. This study assessed whether Facebook Groups can be used to teach clinical reasoning skills.
Methods: Sixty-seven final year medical students from the International Medical University, Malaysia, were exposed to interactive online learning through a Facebook Group for a period of six months in this study. The purpose was to determine if supervised interactive online learning could be used to augment the deep learning that comes from learning medicine at the bedside of patients. The interactive online discussions were entirely triggered by clinical problems encountered in the medical wards of the general hospital to which these students were attached.
Results: A total of 10 topics were discussed in this forum during the duration of this study and an example of one such discussion is provided to illustrate the informal nature of this kind of learning. The results showed a high degree of student involvement with 76 percent of students actively participating in the discussions.
Conclusion: The high degree of voluntary participation in the clinical discussions through the Facebook Group in this study tells us that Facebook Groups are a good way of engaging students for learning and can be used in medical education to stimulate creative clinical thinking.
Each nursing student comes to nursing with a lay image of nursing portrayed by nurses they have seen. This lay perception of nursing that a nursing student holds is transformed to a more professional understanding that is acquired in nursing schools. This process is known as professional socialization. It is a process of learning the norms, attitudes, behaviours, skills, roles, and values of the profession. It involves the internalization of the values and norms of the profession in the individual’s own behaviour and self-concept. The ultimate goal of professional socialization is to internalize a professional identity of the profession. Professional socialization sets in to reduce the tension from the scenario of reality shock and facilitate adaptation during the transition process. This paper serves as a concept paper with the main purpose of introducing and explaining the concept of professional socialization in nursing to help the readers in gaining further understanding of the concept, especially within the local context. The first author has also incorporated her own personal reflections with regards to her socialization process to nursing.
Morning surge in blood pressure is an independent cardiovascular risk factor in the middleaged and the elderly. Whether such a surge occurs in young subjects is not known. Eighty normotensive subjects (age: 21.8 ± 1.3 yr) measured their own blood pressure (BP) using an automatic device (Omron HEM-7080,) on going to bed and on waking up, for 2 consecutive days. In contrast to large morning BP surges reported for older age groups, there was much smaller but significant (P
Background: Clinical clerkship in a busy hospital environment forms an important part of undergraduate medical training. Regular objective assessment of this activity with feedback would be expected to improve outcome.
Methods: We implemented fortnightly clinical assessments using modified OSLER (Objective Structured Long Examination Record), and over a 6-week clinical rotation. Modifications included provision of individualized feedback. The assessment process was evaluated by both students and teachers via a questionnaire measuring their perceived educational impact, feasibility and acceptability.
Results: Students agreed that the patient spectrum was appropriate and fair, resulting in improved history taking and presentation skills (96.6%), clinical examination skills (89%) and clinical reasoning skills (90.7%). It was graded to have helped learning “tremendously” and “moderately” by 64.7% and 32.8% of students respectively. Perceived improvement was attributable mainly to the repetitive nature of the assessments since only 63% of students were provided with feedback. 96.6% of students and 94.1% of assessors perceived the format created a stressful but positive learning environment. 52.9% of assessors agreed that the exercise consumed significant time and resources but 88.2% rated it as manageable and supported its continuation.
Conclusion: Frequent and regular in-course clinical assessments with emphasis on individual feedback is feasible, acceptable and has significant positive educational impact.
Background: Database on hospital records like discharge data, birth and death certificates are widely used for epidemiological and research studies. However there are a very few validation studies on these data. The aim of this study was to validate and assess the accuracy of the ICD 10 database on congenital anomalies in the state of Penang. This study was carried out for three years, from 2002 to 2004.
Methods: The list of cases coded under the general coding “Q” was extracted and approximately 30% of cases were randomly selected from the list. Medical records for the selected cases were checked and discrepancies for the diagnoses between the medical records and the ICD 10 data base were recorded for three years. Verification was done for basic demographic variables and the coding of the diseases. Discrepancies, sensitivity and specificity were calculated.
Results: The ICD 10 database for congenital anomalies are classified into two types: Type 1 and Type 2. Discrepancies on demographic information were found among the age of patients (babies with congenital anomalies). In Type 1, there was a discrepancy of about 0.02 % to 0.05% probability that a congenital anomaly case can be recorded as non congenital anomaly in the ICD 10. In Type 2 there was a discrepancy that a non-congenital anomaly was classified as congenital anomaly and this ranged from 26.7% to 50.0%. The sensitivity ranged from 96.85% to 97.98%, thus it can be concluded the ICD 10 database is highly sensitive while the specificity ranged from 50.00% to 78.57 %. In other words the ICD 10 is not accurate when classifying the non- congenital anomaly cases. A fair percentage of non-congenital anomaly cases were classified as CA in the ICD 10 database.
Conclusion: Even though hospital databases are used as a baseline data for a number of research and epidemiological studies it cannot be used at face value. Validation of these data is necessary before any conclusions can be drawn or intervention measures are undertaken.
Climate change is a product of human actions. The extreme events such as flash floods, droughts, heat waves, earthquakes, volcano eruptions and tsunamis seen in the world today are the result of indiscriminate human intrusion into the environment. Vulnerable countries and populations are the most affected by these climatic events. This places a burden on the resources of these countries. The Kyoto Protocol is a milestone in environmental management and the impetus created by it must be maintained by carrying out the much needed research into appropriate mitigating measures that will alleviate the climate
change impact globally. A paradigm shift is needed in addressing the associated risks on human health to assess socioeconomic determinants and the related impacts on disease burden. Some wealthy nations emphasize economic benefits and downplay sustainability goals, health and equality. However the rising cost of energy is beginning to influence their outlook towards this issue. The implications on economics, human health and wellbeing are implicit. In order to strike a balance between disadvantaged and privileged nations, many
international agencies are spearheading various research agenda to improve adaptation programmes on effects of changing climatic conditions on health. Malaysia too has such programmes initiated under its 5-year development plans.