Purpose: The aim of this paper is to demonstrate fundamental photographic techniques and standardized views in oculoplastic disease and surgery outside of a photographic studio.
Methods: A Canon EOS 60D digital single lens reflex (DSLR) camera, which was fitted with a Canon EF-S 60 mm USM macro lens, was used to photograph the subject. A Canon MR-14EX Macro Ringlite was used to illuminate the subject. Informed written consent was obtained for publication of the photographs used in this study. The photographs were taken in an ophthalmology clinic using standardized photographic settings at various magnification ratios. The magnification ratios were recalibrated and adjusted to accommodate the smaller sensor size in-line with standardized medical photography guidelines.
Results: We present a series of core views for various oculoplastic and orbital disease presentations.
Conclusions: It is possible to capture quality standardized digital photographs in a busy clinical environment without the need for a dedicated photographic studio.
BACKGROUND: To report an unusual case of compressive optic neuropathy secondary to a large onodi air cell.
METHOD: Case report.
RESULTS: A 50 year-old gentlemen presented to the eye clinic with left eye painless loss of vision for one day. Visual acuity was counting finger in the left eye with a positive relative afferent pupillary defect (RAPD). Dilated left fundus examination revealed a pale optic disc. A computed tomography of orbit and brain showed a large left sphenoid sinus with onodi-cell-like projection on the left superior margin of left optic canal impinging on the left optic nerve. He was referred to the otorhinolaryngology team and subsequently underwent left optic nerve decompression. Post-operatively, his left visual acuity improved to 6/60 with reversal of RAPD.
CONCLUSION: There are many causes of optic neuropathy and compressive optic neuropathy due to large onodi air cell is uncommon. Acute unilateral loss of vision heralds from a multitude of sinister causes and junior residents should be vigilant that onodi air cell pneumotisation could be one of them.
1. A good opportunity exists in Malaya for any national leprosy control. Institutional care is of the best that is available and it is felt that it has reached the saturation stage. Field work has not been established.
2. Thus leprosy has remained more of a medical problem than health.
3. Owing to the absence of any health education on leprosy, there exists an extensive gulf between the patient and the public thus creating problems of rehabilitation. The main rehabilitation performed by the government is on the employment of a few discharged patients in leprosy institutions. Though the objective of the Malayan Leprosy Relief Association is to rehabilitate, time is needed, and it may be years before the discharged patients can expect any benefits.
4. The apathy of medical officers towards serving in the Leprosaria is evidenced by the fact that since the establishment of the Leprosaria, barring 2-3 local officers, all have been outsiders on contract or otherwise. The World Health Organisation has offered a fellowship for six months and there has been no applicant from the medical officers in the Federation .
BACKGROUND: Budesonide/formoterol used for both maintenance and reliever therapy has been shown to benefit patients with persistent asthma. We evaluated patient satisfaction and asthma control among Malaysian patients prescribed budesonide/formoterol as single maintenance and reliever therapy in a real-life clinical practice.
METHODS: Adult patients diagnosed with partially controlled or uncontrolled asthma were recruited in a 6-month, prospective, open-label study involving ten hospital-based chest clinics in Malaysia. Patients were prescribed one or two inhalations of budesonide/formoterol Turbuhaler (160/4.5 μg per inhalation) twice daily as maintenance therapy and additional inhalation as reliever therapy. Maintenance doses were decided by physicians based on Global Initiative for Asthma-defined treatment objectives. The primary outcome measure was the change in mean Satisfaction with Asthma Treatment Questionnaire (SATQ) scores from baseline to an average of 3 months and 6 months. Secondary outcome was the change in mean Asthma Control Questionnaire 5-item version (ACQ-5) scores from baseline to an average of 3 months and 6 months and the proportion of patients achieving the minimum clinically important difference.
RESULTS: Of 201 eligible patients recruited, 195 completed the study. Overall, SATQ mean (standard deviation) score was significantly improved from 5.1 (0.76) at baseline to 5.5 (0.58) (P < 0.001). The increase was observed in all domains of SATQ and had occurred at 3 months for most patients. ACQ-5 mean (standard deviation) score was significantly reduced from 2.2 (1.13) at baseline to 1.2 (0.95) (P < 0.001). A total of 132 (67.7.1%) patients had achieved the minimal clinically important difference (≥0.5) of ACQ-5 scores at study end.
CONCLUSION: In a nationwide study, budesonide/formoterol maintenance and reliever therapy achieved greater patient satisfaction and better asthma control compared with previous conventional asthma regimes among Malaysian patients treated in a real-life practice setting. Such an approach may represent an important treatment alternative for our local patients with persistent asthma.
KEYWORDS: Malaysia; Symbicort; asthma; asthma control; budesonide/formoterol; maintenance and reliever therapy; satisfaction
Study site: Chest clinics, Hospitals, Malaysia
Objectives: To evaluate the long-term cost-effectiveness of RMTAC (an adjunct
pharmaceutical asthma management) vs. usual physician care clinic by using decision analytic modelling method. Methods: A dynamic adherence asthma Markov
cohort model was developed. The economic evaluation was based on a lifetime
horizon and cycle length of one month, from the healthcare provider‘s (Ministry
of Health) perspective, with the outcomes assessed in cost per QALY gained and
cost per hospitalization averted. Probabilities of asthma control-adherence states
from RMTAC database, costs from national sources, utilities using standard gamble method on Malaysia’s asthma patients, and other inputs from secondary data
sources were used to inform the probabilistic model, according to gender and age
subgroups. A scenario analysis was conducted to test the structural assumption on
follow-up visits after the final treatment visit. Results: In female subgroup, RMTAC
management dominates the usual care by having 0.91 (95% CI 0.24 – 1.69) QALY
gained and 0.58 (95% CI -2.30 – 6.23) hospitalization averted, at a lower cost. For male
subgroup, the ICERs were RM10 (95% CI -RM14431 – RM8323) per QALY gained and
RM18 (95% CI -RM35790 – RM30266) per hospitalization averted. At the willingnessto-pay threshold of RM29000 per an additional QALY gained, the RMTAC intervention
is likely to be cost-effective 99% and 57% of the time (for QALY and hospitalization
outcome, respectively). The analysis was robust to assumptions of follow-up visits
frequency and patients’ gender. Conclusions: Implementing RMTAC in Malaysia
has high probability of being more cost-effective than the usual care management
for both male and female subgroups across all age groups. Further investigation is
necessary to ensure that implementing this decision does not exceed the overall
national healthcare expenditure
Study site : Universiti Sains Malaysia, Penang, Malaysia
Objectives: Health care services in Malaysia are widely available and accessible at a minimal cost. However, in pursuing with the health care reform, policy-makers and hospital managers need to know the unit cost for the purpose of planning and efficiency of providing the services. This study estimated the cost of out-patient services in a public hospital
Methods:The study was conducted in a 341 bedded hospital that provide secondary level care to 24,486 in-patients and 127,389 specialist out-patients in 2010. The costs were estimated using a step-down approach where the costs were allocated to the different cost-centres. Capital costs were annualised cost of capital item with life expectancy of more than 1 year and recurrent cost were all inputs consumed within a year. Total costs were then allocated to the in-patient and out-patient services based on historical financial data with a ratio of 1: 4. This was then followed by a stepwise approach of allocating the ancillary department cost centres to the clinical department cost centres. The unit cost per patient visit was calculated based on the number of visits for each department. Base year of 2010 was used to calculate the cost and patients visits. Costs were calculated from the perspective of the hospital.
Conclusions: The findings provide an estimate of the costs for out-patient visit. At the current minimal fee of MYR 5.00 (USD 1.5), the Ministry of Health is subsidising more than 95.0% of the health care cost for each patient. These estimates provide the policy-makers with an understanding of the cost data should they need to establish a cost basis for payment rates.
A prospective single blinded interventional study was held in Otorhinolaryngology Clinic, Universiti Kebangsaan Malaysia Medical Centre in August 2010 until November 2012 to evaluate the functional outcome of septorhinoplasty objectively and subjectively. Objective assessment was done using rhinomanometry and subjective assessment using Nasal Obstruction Symptoms Evaluation (NOSE) scale and Health-Related Quality of Life Questionnaires (HRQOL) in Rhino Surgery. All measurements were taken preoperatively and 3 months postoperatively. A total of 29 patients were enrolled and completed the study. Septorhinoplasty was commonly performed in Malays and Indians and rare amongst Chinese, with age ranged from 18 to 54 years. Majority had no history of trauma. Twisted nose was the most common external nose abnormality followed by crooked and saddle nose. All patients had internal valve insufficiency. There were significant improvement of the total and of all the parameters in the NOSE scale post septorhinoplasty (p 0.05). Significant correlations were noted in the improvement between the two subjective assessments (NOSE scale and HRQOL score). However, there was no significant correlation in the improvement between the subjective (NOSE scale and HRQOL score) with objective (rhinomanometry score) assessments. Septorhinoplasty improves the nasal airflow and quality of life of patients with nasal obstruction.
Study site: Otorhinolaryngology Clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Medication wastage poses a financial burden on the nation’s economy, as well as, environmental implications associated with wastage disposal. This study was conducted in a public hospital in Brunei and aimed to measure the extent of medication wastage and its disposal. This cross-sectional study used a self-designed questionnaire for patients attending outpatient pharmacy at the Suri Seri Begawan (SSB) hospital in which 253 patients participated over a period of two weeks. Exclusion criteria were: i) patients below 18 yrs, ii) patients visiting the Accident and Emergency Department and iii) patients admitted to the hospital. Majority of the participants were reported to have unused medication at home (75.1%, n=189). Nearly half (54.2%) had unused medicines and this was due to improvements in their medical conditions. Most of the participants (70.8%) were not given necessary advice on how to dispose their medicines in a proper manner. Majority disposed their unused medicines in the household garbage (70%), despite 50.2% (n=189) knowing that disposing of medicines in the garbage can cause detrimental effects on the environment. It was found that 47.7% of the participants would return their unused medicines back to the pharmacy, but in practice, only 18.6% did such. There was no significant association between knowing detrimental effects of medicine on
the environment and returning their medicines to the pharmacy (p=0.065). Results showed that medication wastage exists in SSB hospital and patients’ knowledge and
practices on its proper disposal was relatively poor. Health policy makers should be informed to implement wastage reduction strategies.
AIM: To describe the prevalence and changes in treatment patterns of ranibizumab and photodynamic therapy (PDT) among retinal disease patients who attended the Ophthalmology Clinic in the tertiary care Hospital Selayang from 2010 to 2014.
METHODS: Study subjects were recruited retrospectively using the Electronic Medical Record (EMR) database software in Hospital Selayang. Demographic data, medical history, diagnostic procedure, treatments and diagnosis of patients were recorded.
RESULTS: The five-year analysis included 821 patients with a mean age of 65.9±11.73y. Overall, there were a higher number of males (63.1%) and a higher number of Chinese (47.4%) patients. Among the 821 patients, 62.9% received ranibizumab injection followed by 19.2% PDT therapy and 17.9% had ranibizumab combined with PDT therapy. Age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) were the most common retinal eye diseases reported, recording prevalence of 25.0% and 45.6%, respectively. The trend in ranibizumab treatment was reported to increase while PDT showed a decrease in trend from year 2010 to 2014. In terms of treatment, following multiple logistic regression, AMD was associated with the subjects being more likely to have received ranibizumab monotherapy (P<0.001) while PCV was associated with more likely to have received PDT (P<0.001) and PDT combined with ranibizumab therapy (P<0.001).
CONCLUSION: The tertiary care setting in Malaysia is consistent with management of patients from other countries whereby ranibizumab is the most common treatment given to patients with AMD, while PCV patients most commonly receive PDT and ranibizumab combined with PDT therapy.
Study site: Ophthalmology Clinic, Hospital Selayang
Background: Plasma calcitonin gene-related peptide (CGRP) plays a key role in the migraine pathophysiology. This study aimed to investigate its role in predicting diagnosis and outcome of pharmacotherapy in pediatric migraine. Methods: We prospectively recruited 120 subjects, who never took migraine-preventive agents in a pediatric clinic, including 68 patients with migraine, 30 with non-migraine headache (NM), and 22 non-headache (NH) age-matched controls. Short-term therapeutic response was measured for at least 2 weeks after the start of therapy. Responders were defined with >50% headache reduction. Plasma CGRP concentrations were measured by ELISA. Results: In the migraine group, more patients required acute therapy, as compared to the NM group (62/68, 91% vs. 5/30, 15%, p = 0.001). The mean plasma CGRP level in migraineurs either during (291 ± 60 pg/ml) or between (240 ± 48) attacks was higher than in NM patients (51 ± 5 pg/ml, p = 0.006 and 0.018, respectively) and NH controls (53 ± 6 pg/ml, p = 0.016 and 0.045, respectively). Forty-seven patients (69%) needed preventive treatments and had higher plasma CGRP levels (364 ± 62 pg/ml, n = 47) than those not (183 ± 54 pg/ml, n = 21) (p = 0.031). Topiramate responders had higher plasma CGRP levels than non-responders (437 ± 131 pg/ml, n = 14 vs. 67 ± 19 pg/ml, n = 6, p = 0.021). Survival curves of plasma CGRP levels also showed those with higher CGRP levels responded better to topiramate. Differences were not found in the other preventives. Conclusion: The plasma CGRP level can differentiate migraine from non-migraine headache. It may also serve as a reference for the therapeutic strategy since it is higher in patients requiring migraine prevention and responsive to short-term topiramate treatment. These results are clinically significant, especially for the young children who cannot clearly describe their headache symptoms and may provide new insights into the clinical practice for the diagnosis and treatment of pediatric migraine.
Study site: Paediatric outpatient clinic,National Taiwan University Hospital (NTUH), Taiwan
Six cases of children of divorced parents are discussed. Their presentations are described and other relevant findings are mentioned. It is interesting to note that in the majority of the cases, the caretakers had difficulties in looking after the children and hence brought them to seek treatment.
Study site: Psychiatric clinic, Universiti Kebangsaan Malaysia
Introduction: Osteoarthritis (OA) is the main cause of knee pain. It also affects individual’s physical functioning. Anti- inflammatory drugs and knee replacement are the mainstay methods in the management of knee OA in Malaysia. However, patients with knee OA often suffer pain. The general objective of the study is to evaluate the effectiveness of a cognitive behavioural intervention module on knee pain, functional disability and psychological outcomes among knee OA patients attending Orthopedics Clinics in Hospital Putrajaya and Hospital Serdang, Malaysia. This study aims to determine the baseline level of knee pain and functional disability among knee OA patients.
Methods: Baseline results on the knee pain and functional disability were obtained from a two arm parallel- group randomized controlled study. Three hundred patients aged 35 to 75 years diagnosed with knee OA were recruited. A set of pre tested and validated Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire was used in this study.
Results: Mean baseline of KOOS pain was 56.09 (SD=21.75) and 52.26 (SD=22.08) for the intervention and control groups respectively. Participants in the intervention and control groups had a mean KOOS function in daily living of 61.11 (SD=21.20) and 56.72 (SD=22.13) respectively. Overall mean baseline of KOOS function in sport and recreation was 35.30 (SD=27.38).
Conclusions: Majority of participants had moderate level of knee pain and functional disability in daily living. However, participants had more extreme symptoms of functional disability in sport and recreation. Therefore, interventions to reduce knee pain and functional disability symptoms in knee OA are needed.
Study site: Orthopedics Clinics in Hospital Putrajaya and Hospital Serdang, Malaysia
RATIONALE, AIMS, AND OBJECTIVES: Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting.
METHODS: This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach.
RESULTS: Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it).
CONCLUSIONS: Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.
Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
AIM: To determine the rate, causes and risk factors of non-attendance to the paediatric clinic in a tertiary hospital in Malaysia and to determine the efficacy of one telephone call to confirm a new appointment.
METHODS: For all non-attending patients, during a 2-month period, a pro forma was filled up based on patients' records. During a phone call, additional questions were asked, and a new appointment was offered.
RESULTS: Of 1563 patients who had an appointment, 497 (31.8%) were non-attendees. Weather conditions, the sub-specialty and timing (morning or afternoon) had a significant effect on non-attendance. Forgetfulness was the main cause. Only 160 patients could be successfully contacted. Among the contactable patients, 55 already had an appointment, and 10 had reasons not to get a new appointment. Of the 95 remaining patients, 73 (76.8%) attended the new appointment.
CONCLUSION: The non-attendance rate was high. One telephone call had a reasonable efficacy for the contactable patients, but because a high number of patients were not contactable, overall effectiveness was poor.
Study site: Paediatric clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia,
The reasons why 860 patients visited the general medical clinic at the University Hospital, Kuala Lumpur were studied. 75.3% of the patients came for evaluation of symptoms; 12.4% sought checkups for chronic diseases; 4.9% requested diagnostic checkups and screening tests; 4.8% came to renew prescription. Few visits were made for evaluation of injuries, receiving test results or for administrative examination. This profile reflected the function of the clinic as an acute diagnostic centre. Other applications of the results are discussed.
Study site: General Medical Clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
INTRODUCTION: Gout is an increasingly common medical problem. The traditional risk factors of male sex and high red meat or alcohol consumption have been joined with newer risks such as increased life expectancy, and the metabolic syndrome (hypertension, diabetes, dyslipidaemia, truncal obesity).
METHODS: This was a retrospective study to determine the epidemiology, clinical features, associated conditions as well as renal related conditions in existing gout patients followed-up in Rheumatology outpatient clinic, Hospital Tuanku Ja'afar, Seremban.
RESULTS: Over a three month period, we identified 54 gouty patients on our follow-up, the majority being male, Malay ethnicity, with the age of onset in the third and fourth decades of life. Commonly associated risk factors were hypertension, hyperlipidaemia and obesity. However, underlying history of diabetes mellitus, alcohol consumption, and family history were not commonly associated with gout in our group of patients. Half of our patients had at least two or more joints involvement. About half of the patients with tophaceous gout had renal impairment.
CONCLUSION: Our series of gout patients highlight the high prevalence of cardiovascular risk factors. The high prevalence of tophi and renal impairment is a cause for concern.
Study site: Rheumatology outpatient clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia.
OBJECTIVE: To look for any possible coexistence of CACNA1A, ATP1A2, and KCNN3 gene mutations in migraine patients who had human platelet HPA-1a/1b polymorphism, which is also known as PlA1/A2 polymorphism.
METHODS: The study was carried out at the Neurology Clinic, Hospital University Sains Malaysia, Kelantan, Malaysia between April 2004 and March 2005. The DNA from 4 patients who had migraine with the HPA1a/1b polymorphism were analyzed by polymerase chain reaction using the allele specific oligonucleotide technique to detect the presence of CACNA1A, ATP1A2, and KCNN3 genotypes.
RESULTS: We found that the CACNA1A gene mutation alone was present in only one patient who presented with classical migraine with aura. The gene mutations on ATP1A2 and KCNN3 were seen in none of our 4 cases with migraine.
CONCLUSION: There is no coexistence between the platelet HPA-1a/1b polymorphism and the ATP1A2 and KCNN3 gene mutations, though one classical migraine patient with HPA-1a/1b polymorphism had the CACNA1A gene mutation. Larger studies are warranted to confirm these findings.
Study site: Neurology Clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
Endocrinologists and other clinicians who provide care to diabetic patients have ideal teaching opportunities to connect and deliver tobacco cessation interventions in diabetes care. This study aimed to develop, validate and measure the reliability of a new tool that would be used to evaluate physicians’ attitudes and practices regarding tobacco cessation counselling in patients with diabetes, as well as barriers to deliver tobacco cessation counselling in their clinics.
This study was conducted from March till December 2012 in the endocrine clinic at Hospital Pulau Pinang, Malaysia. A standardised, 22-item, self-administered questionnaire was developed to determine (i) physicians’ attitudes and practices regarding tobacco cessation counselling in patients with diabetes, and (ii) barriers in delivering tobacco cessation counselling in their clinics. Face and content validity were assessed. Six pharmacists, whom were faculty members with experience and expertise in research and in the development of surveys, reviewed the questionnaire to assess its content validity.Reliability test was run along to check whether the new tool questions are correlated with one another adequatly or no.
Reliability test for the tool was pretested on a sample of 25 physicians physicians who ran the endocrine clinic at Hospital Pulau Pinang, Malaysia. Reliability analyses for the attitude domain and practice domain were 0.710 and 0.720, respectively.
The questionnaire was valid and reliable to be use for the evaluation of physician’s barriers, attitude and practice regarding tobacco cessation counselling in the diabetics clinics.