Negative pressure if applied in topical manner to a wound surface has been reported to enhance wound healing due to increase in local blood flow, reduction of tissue oedema, and by stimulating angiogenesis. An air-tight film covering the wound is connected by suction tube to a control unit by which negative pressure is applied to the surface of the wound in the range of 80-125 mm Hg. This method has been called negative pressure wound therapy (NPWT) or vacuum assisted closure (VAC). It has been recommended for virtually all kinds of complex wounds. The duration of the therapy varies from several days to several months. This technology promotes formation of granulation tissue, enhances healing of diabetic foot, and significantly reduces the size of the acute and chronic wounds and ulcers. It lowers the morbidity of Fournier’s gangrene, ensures better healing of lower limb wounds and ulcer of ischemic origin, and can serve as temporary wound cover when no closure technique is available. The limitations to using NPWT are presence of dead tissue, exposed vital structures, untreated osteomyelitis, unexplored fistulae and malignant wounds. The cost of the equipment may constitute another factor in limiting the use of this new technology. In conclusion the NPWT under certain circumstances is more effective than other available local wound treatments.
The brain is considered the most eloquent organ in the human body as its activities impacts on all other systems. Though protected physically (in a bony covering), physiologically through the blood-CSF barrier (from invading organisms and toxins) and hemodynamically through the phenomenon of cerebral autoregulation; the brain is open to insults of various kinds which can critically damage this structure. Intracellular Ca++ accumulation, excessive activation of excitatory amino acid receptors, lipid peroxidation and free radical releaserelated damage are but a few of the pathological processes that occur at the neuronal level leading to damage. The mechanism by which the brain can be provided protection when it is in a compromised state or likely to be compromised is known as cerebral protection. There are various modalities of pharmacologic (use of barbiturates, etomidate, isoflurane, steroids, Ca++, corticosteroids etc) and non-pharmacologic therapies (hypothermia, hyperventilation, induced hypotension, electrophysiologic monitoring, endovascular management etc) available for cerebral protection which finds place in the armamentarium of clinicians managing the critically injured brain. Our knowledge of the functioning of the brain at the molecular level and the various biochemico-pathological processes that are set into motion during critical states continues to evolve. This review article attempts to explain present understanding of the biochemical and pathological processes involved in neuronal damage while also looking at current available therapies (pharmacologic & nonpharmacologic) being utilized in different clinical settings.
Coarctation of the aorta is a congenital anomaly presented by the combination of upper body hypertension and weak or absent femoral pulses. Increased morbidity and shortened life span of infants born with coarctation suggest that the malformation should be treated early in life. Surgical intervention has been recognized as the gold standard of treatment for children born with this defect. Unfortunately, studies in many institutions have shown that the diagnosis of coarctation of the aorta is often missed. As a consequence, many patients with coarctation of the aorta are not detected until adult life. Long-term follow-up of adult patients following surgical intervention for coarctation of the aorta reveals ongoing risks; hence, less invasive endovascular therapy becomes an alternative approach. Literature’s review was performed to compare the results of endovascular therapy (stenting and angioplasty) with surgical techniques to repair adult with coarctation of the aorta. The immediate improvement in hypertension and the morbidity were similar. Although stenting can be expected to show superiority to balloon angioplasty alone, that was not apparent when comparing these two endovascular approaches. The morbidity, mortality, and repeat intervention rates were just as high for stenting as they were for angioplasty or for a combination of both modalities. The majority of surgical complications were minor (i.e., vasculitis, bleeding), whereas the majority of endovascular complications could be considered more severe (i.e., dissection, traumatic aneurysm, stroke). Surgical therapy was associated with a very low risk of restenosis and recurrence, whereas endovascular therapy had a much higher incidence of restenosis and the need for repeat interventions. In conclusion, surgical therapy is superior compared to other modes of interventional therapy for adult with coarctation of the aorta, and it shall remain as current mode of therapy for adult with coarctation of the aorta.
With the introduction of problem-based learning (PBL) in medical and health professionals’ undergraduate courses, self-directed learning (also known as self-regulated learning) becomes an integral component of the learning process. There may be slight variations in how educators and students perceive self-directed learnin .However, self-directed learning provides an opportunity for collaborative discussion of the new information collected and allows learners to construct new knowledge as they address their learning issues. Therefore, self-directed learning is not just about researching for new knowledge or finding answers for questions; self-directed learning is about developing competencies, skills and attitudes that foster the learning processes. Interestingly, not all learners will be able to adapt this approach of learning once they enroll in a PBL course. The process will develop gradually and require a number of actions from the learner, including: (i) Realising the need to change their learning style to suite the needs of the medical curriculum, (ii) constructing a plan that accommodates the new learning objectives, (iii) Practicing self-directed learning and sharing their experiences with peers, and (iv) Continuing evaluation of their self-directed learning approach and improving their learning style. Therefore, the aims of this manuscript are: (i) discuss the meaning of self-directed learning in the context of PBL, and review the research outcomes in this area, (ii) understand the different factors that may affect student’s self-directed learning strategies, and (iii) briefly explore the meaning of construction of knowledge and how it can enforce students’ self-directed learning, integration of knowledge and deeper understanding of topics learnt.
Heart failure (HF) is a major burden in almost all countries. The prevalence of symptomatic HF is still high. Despite our best understanding of its pathophysiologic mechanisms and the recent advances in pharmacologic therapy, it remains a highmortality and morbidity disease. About 30-50% of patients with HF have concurrent electrical delay in the electrocardiogram (ECG), mainly in the form of LBBB.1 This kind of conduction delay commonly occurs in patients with idiopathic dilated cardiomyopathy and ischemic cardiomyopathy as well. The abnormality of left ventricle (LV) conduction will lead to a change in LV contraction pattern resulting dyssynchronized with right ventricle) contraction. Thus, a dyssynchronous LV contractile pattern usually manifested by late activation of the LV lateral wall which in turn impairs LV systolic function, reduces cardiac output, raises filling pressure and worsens mitral regurgitation2. Cardiac resynchronization therapy (CRT) improves cardiac function and exercise capacity leading to an improved survival in patients with advanced heart failure and ventricular conduction delay.3 The underlying mechanisms of these beneficial effects are not fully understood, but they appear to be related to a restored coordination of the left (LV) and right ventricular (RV) contraction and relaxation.4 These effects may directly lead to augmented contractility and reduction of LV filling pressures.5 Echocardiography has been widely used to identify patients who are candidates for CRT and to monitor the response in LV function at follow-up after device implantation. This review addresses the applications of CRT in patients with moderate– severe heart failure and the role of echocardiography in optimizing CRT including patient selection, risk and benefit of CRT and appropriate measures.
The issue of antibiotic resistance has been around ever since the first antibiotic penicillin was introduced to the world. It continues to rise, becoming a major problem across the globe and Malaysia is no exception. Hospital is a critical component of the antibiotic resistance problem worldwide. The problems of antibiotic resistance are typically magnified in a hospital setting due to the common variables in the hospital environment that favour its development. These include a combination of highly susceptible patients, intensive and prolonged antibiotic use, and crossinfection resulting in nosocomial infections with highly resistant bacterial pathogens such as multi-resistant gram-negative rods, vancomycin resistant enterococci (VRE) and methicillinresistant Staphylococcus aureus (MRSA) as well as resistant fungal infections. Transmission of highly resistant bacteria from patient to patient within the hospital environment amplifies the problem of antibiotic resistance and may result in the infection of patients who are not receiving antibiotics. Transmission of antibiotic-resistant strains from hospital personnel to patients or vice versa may also occur. What are the available strategies and what works best in managing antibiotic resistance in the hospital? This review will highlight the seriousness of the resistance problem and identify actions that address it especially in the context of improving the problem in Malaysian hospitals.
Breast cancer is one of the most significant health concerns worldwide. The discovery of molecular changes at the gene level represents a critical milestone toward the development of novel targeted therapy specific to cancer cells. The recognition of the significance of the HER-2/neu oncogene is a landmark in the treatment and prognostication of breast cancer. The human epidermal growth factor 2, HER-2/neu (c-erbB- 2) oncogene, a member of the growth factor receptor family, is amplified in 10-34% of patients with invasive breast cancer and associated with more aggressive disease and poorer prognosis. The development of an immunotherapeutic, trastuzamab (Herceptin), to the extracellular domain of HER-2/neu has provided significant improvements in the outcome of HER2 positive breast cancer patients in the adjuvant, neoadjuvant and metastatic setting. This paradigm shift in breast cancer treatment has made it imperative to measure HER-2/neu amplification status to correctly identify and assign breast cancer patients for Herceptin therapy. There is an increasing demand for the development of clinically meaningful and reproducible assays for HER-2/neu on archived and prospective histological and cytological samples, their integration with prospective molecular methods and therapeutics is a challenge that pathologists must now address. This review focuses on current and future methodologies for measuring HER-2/ neu in breast cancer and also includes a synopsis on the role of HER2/neu gene in breast cancer, its association with histological types and grades, familial and male breast cancer.
Primary care practice with its defining features of continuity, comprehensiveness and coordination, is the cornerstone to provide high quality community-based chronic disease management. Poor chronic disease prevention and control at the primary care level will lead to the massive burden of treating complications at secondary care, burden to the patients and their families with regards to morbidity and premature death, and burden to the country with regards to the loss of human capital. Compelling evidence showed that there are innovative and cost-effective interventions to reduce the morbidity and mortality attributable to chronic diseases, but these are rarely translated into high quality population-wide chronic disease care. Primary health care systems around the world were developed in response to acute problems and have remained so despite the increasing prevalence of chronic conditions. An evolution of primary health care system beyond the acute care model to embrace the concept of caring for long term health problems is imperative in the wake of the rising epidemic of chronic diseases. This paper aims to review the evidence supporting high quality and innovative chronic disease management models in primary care and the applicability of this approach in low and middle income countries.
Robotic surgery is a technique that uses mechanical, computercontrolled arms to conduct surgical operations. It carries the advantages of minimal access associated with laparoscopic surgery, and of precision associated with open surgery. It is also feasible to conduct robotic surgery with the surgeon far away, by “telerobotics”. The robot is more versatile than the human arm, and less susceptible to tremors. The view is excellent, and it is possible to conduct more intricate procedures than are possible with the human hand. Robotics has been in use for over seven years, and the initial experience shows that the success rate is over 90%, with only about 10% of cases needing to be converted to open surgery. Blood loss is low, and tumour margins in cancer surgery are satisfactory. Surgeons have used robotics for procedures in urology, gastrointestinal surgery, gynecology, cardiac surgery, neurosurgery, orthopedics, and other specialties. Presently, robotics suffers from two major disadvantages: one, that it is very expensive, and two, that robotic procedures take significantly longer than do open or laparoscopic procedures.
Glaucoma, recognized as optic neuropathy is the second largest cause of blindness worldwide. The disease is characterized by progressive loss of retinal ganglion cells and visual field defects. The pathophysiological factors involved in the onset and progression of glaucoma are not fully understood. However, it is now well accepted that elevated intraocular pressure is not the only causative factor. The pathophysiology of glaucoma involves multiple factors that interact in a highly complex manner to favor development of glaucomatous optic neuropathy. As the knowledge of molecular mechanisms involved is expanding, more and more therapeutic targets are being recognized for the development of safe and effective pharmacotherapy of glaucoma. Although at present the intraocular pressure lowering drugs are still the first line of treatment, the prospect of introducing neuroprotective therapies that can directly protect and perhaps stimulate regeneration of dying and dead retinal ganglion cells, shows considerable promise. This review presents recent developments in the pathophysiology and pharmacotherapy of glaucoma.
Leptin, a 167 amino-acid product of the ob or LEP gene, was first reported in 1994 after a 40-year search that began following the emergence of a mutant strain of mice with hyperphagia, early on-set obesity, and delayed sexual maturation. Since then, leptin deficiency has also been reported in the rat, and more recently in humans. It is secreted constitutively primarily by the white adipose tissue, and in smaller quantities by a number of non-adipose tissues. It acts by binding to specific membrane bound leptin receptors, belonging to the class 1 cytokine receptor family, and activating the JAK-STAT system. Leptin regulates appetite and body weight mainly through its actions on the hypothalamus involving the NPYmelanocortin pathway, and, to a lesser extent, through increased energy expenditure by way of sympathoactivation and increased substrate cycling. Its effects on reproduction, puberty in particular, are mediated through actions on the hypothalamic-pituitary-gonadal axis and on the gonads. Leptin also appears to have permissive roles in CNS development during the neonatal period, bone growth and development, and in haemopoietic and immune functions. Although it was its deficiency state that first led to its discovery, it now appears that the clinical significance of leptin lies not only in the consequences of its deficiency but also when it is in excess as occurs in obesity. Emerging evidence is implicating leptin as a link between obesity associated cardiovascular disease risks and infertility. Besides this, leptin is also being implicated as a growth factor in cancer. The story that started with a search for a body weight regulating factor is now unfolding into one that is revealing roles for leptin that stretch beyond the regulation of appetite and body weight.
Epilepsy is a common neurological disorder in childhood. In a majority, the cause of epilepsy remains a mystery in spite of extensive investigations. The aim of drug treatment is to effectively stop the seizures with minimum of side effects, causing no impairment of long term learning abilities of the child. Up to 30% of children with epilepsy may continue to have seizures in spite of adequate drug therapy. In this review, an overview of the recent advances that affect the diagnosis, prognosis and therapy of childhood epilepsy including the dilemmas of everyday practice is presented.
The various shortcomings involving issues related to managing patients with mental health are compared to those with physical health which are mainly attributed to attitude, misconception and stigma attached to mental health. There is a strong need to have a comprehensive collective efforts and a paradigm shift on how to deal with these critical issues especially in the area of Primary care for mentally ill.
This review places emphasis on the food and water borne protozoal diseases like, cryptosporidiosis, giardiasis, cyclosporiasis, and toxoplasmosis which are endemic in many parts of the world. The article addresses cryptosporidiosis, giardiasis, cyclosporiasis, and toxoplasmosis. Cryptosporidium and Giardia are widespread in the environment and major outbreaks have occurred as a result of contaminated drinking water. Cyclospora has significance in the preparation and consumption of fresh food that have not received heat treatment. Toxoplasma gondii, transmission occur through contaminated water, unpasteurised milk and also the consumption of raw meat, which has been regarded as a major route of transmission to humans .These parasitic protozoa do not multiply in foods, but they may survive in or on moist foods for months especially in cool and damp environment. Their ecology makes control of these parasites difficult. Transmission, clinical manifestations, outbreaks, public health surveillance and control measures that are used for those diseases will be reviewed in this article.
The consequence of postoperative infections associated with orthopaedic or biomaterial-associated implants is devastating to both the patients and the surgeons. Bacterial microcolonies adhere to the surface of implants, forming biofilms and then detaching part of itself into free-floating planktonic forms may be the cause of recurrent and persistent infections. These bacteria are very resistant towards antibiotics and require a higher drug concentration than usual in order to eradicate them. Quorem-sensing is regarded as one mechanism of communication or integration between these microorganisms in the biofilm and may even be in the transfer of resistant genes. Disruption of this pathway is regarded as one method of inhibiting its growth and formation. Implant design, technique and stability of fixation as well as the surface characteristics, the material and its biocompatibility may also influence bacterial adhesion. It has been suggested that multi-prong strategies such as prevention and disruption of biofilm formation, parenteral antibiotics, use of antibiotic-impregnated construction materials and altering the intrinsic properties of the implant surface may help to eradicate this menace.
The term Developing Nations has to be used with caution as it had traditionally included a wide array of countries outside the developed world of North America, Western Europe and Japan (and a few other countries such as Australia and South Africa). The characteristics which defined these “emerging markets” were a Gross National Product (GNP) per capita which was below that of the developed economies, the potential for market growth and an environment with continued economic and political instability. However, as many of these countries have grown at different rates and have economic and other drivers which are very different and disparate, definitions of this sector have become more fragmented. (Copied from article).
Traumatic brain injury (TBI) is responsible for causing global deaths exceeding 1.27 million per year. Various aspects of traumatic brain injuries have been studied worldwide in order to reduce the mortality and morbidity statistics. One such strategy has been to manage these patients at the scene of the accident itself. This pre hospital strategy has been shown to reduce the mortality in severely head injured patients. The pre hospital “team” consists of paramedics, nursing personnel and occasionally clinicians who are trained in resuscitation as well as managing initially the traumatic brain injury. Though definitive treatment for TBI is started in the intensive care at the trauma unit, primary management of these patients at the accident site itself has its advantages. This article reviews the current practices, pros and cons and the future directions in pre hospital care for TBI.
Health promotion (HP) is the process of enabling people to increase control over the determinants of health and thereby improve their health. It is the corner stone in prevention of diseases and shifting the responsibilities of health care from health care provider into the community where the patient centered approach is an appropriate setting by offering continuous, coordinated and comprehensive care throughout the patient’s family and community. The Faculty of Medicine, University technology MARA has adopted dynamic approach in designing the curriculum to respond to the needs of this rapidly changing socioeconomic paradigm of the country, so that the graduates will be able to address the needs of their country and communities. Population health and preventive medicine component was included in the newly designed problem based curriculum, in which the student is introduced to the concepts of epidemiology, disease prevention, statistical analysis and community research. Health promotion program is part and parcel of population health and preventive medicine; it is incorporated with community health research in a course of four weeks of Year Four Medical Curriculum. The aim of this paper is to describe the rationales of health promotion program in medical curriculum, and critically review the components and methods of implementation.
The burden of caring patients with Schizophrenia was extensive and mental health professionals need to be more aware of the burden of mental illness on family members. There are four main sources of burden, namely restriction on the carer’s social and leisure activities, the strain placed on finances and employment, the emotional impact and the difficulty in dealing with dysfunctional and bizarre behaviors. Effective family intervention programs need to be done including to treat the depressive disorders among the carers.
No vaccination is available to provide doctors with the immunity from errors and mistakes. Humans make mistakes everyday and eventually doctors will make mistakes or errors during their practice. Therefore, knowing how to handle the mistakes is crucial in improving patient safety and management. Disclosure of errors can be argued to play a significant role in respecting the patients’ rights and interest. We need to know that in a doctor-patient relationship, trust and vulnerability exist. If errors occur and doctors try to keep patients away from the truth, patients may no longer maintain their trust and this could lead to a negative turn in the relationship. Moreover, if errors are disclosed, doctors then may face a legal and ethical dilemma on whether to apologize for the errors made. This issue of apology has created debates among health professionals and lawyers in searching for the best answer. Apology can be a powerful tool to reconcile relationships but at the same time can also be a tool of deception.