Gamma and delta tocotrienols are isomers of Vitamin E with established potency in pre-clinical anti-cancer research. This single-dose, randomized, crossover study aimed to compare the safety and bioavailability of a new formulation of Gamma Delta Tocotrienol (GDT) in comparison with the existing Tocotrienol-rich Fraction (TRF) in terms of gamma and delta isomers in healthy volunteers. Subjects were given either two 300 mg GDT (450 mg γ-T3 and 150 mg δ-T3) capsules or four 200 mg TRF (451.2 mg γ-T3 &102.72 mg δ-T3) capsules and blood samples were taken at several time points over 24 hours. Plasma tocotrienol concentrations were determined using HPLC method. The 90% CI for gamma and delta tocotrienols for the ratio of log-transformation of GDT/TRF for Cmax and AUC0-∞ (values were anti-logged and expressed as a percentage) were beyond the bioequivalence limits (106.21-195.46, 154.11-195.93 and 52.35-99.66, 74.82-89.44 respectively). The Wilcoxon Signed Rank Test for Tmax did not show any significant difference between GDT and TRF for both isomers (p > 0.05). No adverse events were reported during the entire period of study. GDT was found not bioequivalent to TRF, in terms of AUC and Cmax. Gamma tocotrienol in GDT showed superior bioavailability whilst delta tocotrienol showed less bioavailability compared to TRF.
Study site: Clinical examination ward, Universiti Malaya Medical Centre UMMC, Malaysia.
Endometrial cancer (EC) is the most common gynaecological cancer amongst women in the UK. Although previous studies have found that women with polycystic ovary syndrome (PCOS) have at least a three-fold increase in endometrial cancer (EC) risk compared to women without PCOS, the precise molecular mechanisms which link between PCOS and EC remain unclear. It has been suggested that insulin resistance may contribute to the increased risk of EC in PCOS. The specific expression of genes related to the insulin-signalling pathway including the IGF system in the endometrium of women with PCOS has however never been measured and compared to that in women with EC without PCOS and control women without EC or PCOS. .
Study site: University teaching hospital in the United Kingdom
Nurses’ job performance is defined as the effectiveness of a person in carrying out his or her duties related to patient care. Aim of this study is to measure job performance among nurses in a tertiary hospital and its associated factors. A cross-sectional study was conducted among nurses selected from four departments, which were Obstetrics & Gynecology (O&G), medical, surgical and Cardiac Care Unit (CCU)/High Dependency Unit (HDU). A Malay validated Six-Dimension Scale of Nursing Performance (6-DSNP) questionnaire was used to measure job performance. Nurses who have one child more compared to other nurses had significantly lower total mean score of job performance by -0.06 (95% CI 0.11, 0.01). Nurses working in medical department [adj.β=0.16 (95% CI 0.01, 0.30)] and CCU/HDU [adj.β= 0.33(95% CI: 0.17, 0.50)] had significantly higher total mean scores of jobs performance compared to O&G department. Effective strategies and re-examining work conditions are imperative for better job performance.
Study site: Department of
Medical, Department of Surgical, Department of
Obstetrics & Gynecology (O&G) and Cardiac Care
Unit/ High Dependency Unit (CCU/HDU) of Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Gout is a disease where an abnormal collection of uric crystals (gouty tophi) can often be found in the foot and ankle. Occasionally such tophies are found at unusual sites and this can pose a challenge to the clinician where diagnosis and treatment is concerned. We describe a patient who presented to our oncology department with a swelling on his right thigh which was clinically diagnosed to be a soft tissue sarcoma, but after further investigations it turned out to be a gouty tophi. The purpose of this case report is to emphasise the variable presentation of gout and the challenges that can be faced by clinicians in diagnosing a soft tissue swelling.
In response to the introduction of an integrated dental education program at University of Malaya (UM) in 2011, a study was conducted to develop a caries risk assessment model (CRA) for use in non-surgical caries management for Year 3 and 4 students of the new integrated program. Methods: The CRA model was based on risk indicators used by dental students in the Preventive Dental Clinic (PDC). Patients aged 15 years and above who attended the PDC for the first time in year 2009 and 2010 were used as study sample. Four hundred and fourteen patient names were identified from the student PDC logbook. Of the 414, 359 dental records had complete data and included in the analysis. Data were analysed using SPSS version 17.0. Chi-square test was used for group comparison and associated factors for coronal caries were analysed using Multiple Logistic Regression (MLR). Results: The final model showed that adults, brushing teeth once daily, and not having dental prosthesis/appliance were 3.31 (CI=1.64-6.69), 2.53 (CI=1.19-5.40), and 2.25 (CI=1.25-4.10) more likely to develop coronal caries, respectively, than adolescents, brushing teeth at least twice a day, and having dental prosthesis/appliance. Conclusions: The results indicate that age group, toothbrushing frequency and dental prosthesis status are significant indicators for coronal caries among patients. Outcomes of the study contributed towards bridging the gap between cariology
and preventive modules in the new integrated dental program.
Background: The efficacy and acceptance of a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet in Asian adults with irritable bowel syndrome (IBS) remain uncertain. We aimed to describe our early experience in a single center with a dedicated gastroenterology dietetic service.
Methods: Consecutive patients with IBS referred to our dedicated Dietetic Gastroenterology Clinic between February 2016 and May 2016 were screened. A low FODMAP diet was instituted as per standard protocol. Data on demographic and clinical variables were obtained from patients' records and prospective telephone interviews.
Results: A total of 16 patients, with a median age of 67 ± 13.57 years; female gender n = 10 (62.5%); ethnicity: Chinese n = 8 (50%), Indian n = 5 (31.25%), and Malay n = 3 (18.75%) with IBS, were included in the study. Compliance with the low FODMAP diet was complete in 8 of 16 (50%) patients, partial in 4 of 16 (25%), and 4 of 16 (25%) could not comply with the diet at all. Improvement in symptoms were reported in 11 of 16 (68.8%) patients. Among patients who complied (complete/partial) with the low FODMAP diet, predominant symptom improvement was reported as follows: abdominal pain 3 of 5 (60%), abdominal bloating/distension 7 of 10 (70%), and flatulence 7 of 8 (87.5%). Patients with the IBS-D subtype appeared to have the greatest improvement in stool consistency (87.5% IBS-D vs 12.5% non-IBS-D, P = 0.009).
Conclusion: Based on our pilot observational study of a relatively small sample of Asian IBS patients, compliance with a low FODMAP diet appears to be low. Further larger studies are required to verify our observation.
Study site: Universiti Malaya Medical Centre (UMMC)
Amalgam has been widely used in dentistry and its components may cause some oral mucosal changes (OMC), commonly presenting as oral lichenoid lesions (OLLs), acute or generalized sensitivity reaction or amalgam tattoo. Our objective was to determine the demographic and clinical profile of patients with and without OMC adjacent to their amalgam restorations (AR) and to evaluate the prevalence and types of AR-related OMC and associated clinical parameters. Materials and methods: In this retrospective crosssectional study, 83 outpatients attending the Primary Dental Care Unit at the Faculty of Dentistry, University Malaya were examined for the presence of AR-related OMC. The study period was from early to mid July 2016. Firstly, patients’ personal details (age, gender, medical status, social habits) were analyzed and history of AR (the age, condition and number of restorations) was determined. Clinical examination of patient’s oral cavity was carried out to detect any AR-related OMC. The data collected was analyzed using SPSS 12.0.1 Result: Approximately 14.6 % patients had OMC. OLLs and amalgam tattoo made up 1.2% and 13.4% respectively. Females (8.4%) had higher predilection and Chinese were more commonly affected (8.4%). Social habits were not associated with OMC. Certain systemic diseases, age (p=0.005) and duration of amalgam (p=0.007) in the oral cavity were significant risk factors for OMC. Conclusions: Present findings suggest that AR-related OMC is uncommon. Three key parameters namely systemic diseases, patient’s age and duration of AR were identified as significant risk factors predisposing to the development of OMCs.
Trauma is an ever increasing problem and it is the leading cause of morbidity and mortality in the under 40s age group. The main purpose of this study is to determine the pattern of death related to trauma cases presenting to the emergency department (ED) of a university hospital. This was a retrospective analysis of 75 consecutive trauma case records at a university hospital for a one year period. The most common cause of deaths is motor vehicle crashes. The mean score for the injury severity score (ISS) and revised trauma score (RTS) on arrival to the ED among the succumbed patients were 27.8 (s.d 8.6) and 5.7 (s.d 1.1) respectively. 58.7% of deaths occurred within 48 hours after the admission. Less than 50% of studied patients were still alive beyond 45 hours post admission and less than 10% still alive beyond 11 days. Our analysis also showed that 28% (n=21) and 56% (n=41) of the studied sample had a probability of survival between 50% to 75% and more than 75% respectively upon arrival based on the initial vital signs in the ED and the trauma and injury severity score (TRISS) methodology. Overall, we observed similar injury mechanisms, demographics and causes of death compare to other studies. The figures from this study, mandate further exploration of preventive issues and management improvements that should be applied not only to the current trauma system, but also to the health care system in general.
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
Objective. To compare ultrasound synovial thickness of the 2nd, 3rd and 4th metacarpophalangeal joints (MCPJ) in a group of patients with proven rheumatoid arthritis (RA) and a control group of normal individuals. Materials and Methods. This is a cross-sectional study comprising 30 rheumatoid arthritis patients and 30 healthy individuals. Ultrasound scans were performed at the dorsal side of 2nd, 3rd, and 4th MCPJ of both hands in RA patients and the healthy individuals. Synovial thickness was measured according to quantitative method. The synovial thickness of RA patients and healthy individuals was compared and statistical cut-off was identified. Results. Maximum synovial thickness was most often detected at the radial side of the 2nd MCPJ and 3rd MCPJ and ulnar side of the 4th MCPJ of both hands which is significantly higher (p < 0.05) in RA patients compared to healthy individuals. With high specificity (96%) and sensitivity (90%) the optimum cut-off value to distinguish RA patients and healthy individuals' synovial thickness differs for the radial side of the 2nd and 3rd MCPJ and ulnar side of the 4th MCPJ. Conclusion. Patients with early RA appear to exhibit a characteristic pattern of synovitis which shows radial side predominance in the 2nd and 3rd MCPJ and ulnar side in the 4th MCPJ.
Study site: University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Available data for obstetric care in the University Malaya Medical Centre, Kuala Lumpur from 1987 to 1999 were reviewed. Despite incomplete data, we were able to determine fairly well the practice of obstetric anaesthesia and analgesia in the unit, and the changes over the years. There was a decline in the use of general anaesthesia for both elective and emergency caesarean sections from 41.3% and 69.4% respectively in 1995 to 21.6% and 26.9% respectively in 1999. By 1999, regional anaesthesia had become the most common method of anaesthesia administered in both elective (14.3% epidural and 63.5% spinal) and emergency (30.2% epidural and 42.6% spinal) caesarean sections. The percentage of patients delivering vaginally who received epidural analgesia appeared to have stabilised at about 8 to 9% in the last few years, with a gradual decline in the total instrumental delivery rate from a high of about 12% to the pre-epidural rate of 7%.
Chronic lymphocytic leukaemia (CLL) is rare locally. Seven CLL patients which constituted 0.9% of the total 747 cases of leukaemic patients were diagnosed over a 5 year period. They had similar haematological profiles as Western patients though most of them had advanced disease at presentation. Treatment of CLL patients was palliative and should be reserved for symptomatic patients and/or patients with progressive disease.
OBJECTIVES: To evaluate aspirin and clopidogrel resistance/non-responders in patients with acute coronary syndrome (ACS) by using adenosine diposphate and aspirin tests.
METHODOLOGY: In the study patients with ACS loaded with 300 mg of clopidogrel and 300 mg aspirin and patients on stable daily dose of 75 mg of clopidogrel (more than 3 days) underwent PCI. Response to clopidogrel and Aspirin was assessed by Adenosine Diphosphate (ADP) Test (20 µmol/L) and Aspirin Test (Acetyl Acid) (ASP) 20 µmol/L, respectively, using the Multiplate Platelet Function Analyzer (Dynabyte Medical, Munich, Germany).
RESULTS: Sixty four patients were included in this study out of which 57 were with ACS and 7 scheduled for percutaneous coronary intervention (PCI) electively. The proportion of Aspirin good responders and adequate responders were 76.56% and 18.75%, respectively while adequate response and good response to Clopidogrel accounted for 29.7 and 48.4%, respectively Hyperlipidaemia was only co-morbidity associated with higher AUC ADP value (p: 0.046). Hypertriglyceridaemia and serum calcium were weakly correlated with higher AUC ADP serum calcium r=0.08, triglyceride r=0.12. Patients admitted for scheduled PCI and on stable dose of 75mg clopidogrel exhibited lower AUC ADP value as compared to those admitted with acute coronary syndrome given loading dose of 300mg of Clopidogrel. Post loading dose measurement of anti-platelet therapy among ACS patients using the Multiplate Platelet Function Analyzer showed comparable results with other methods.
Conclusions : As determined by Multiplate Platelet Function Analyzer, Aspirin resistance/non-responders in this study in acute coronary syndrome patients accounted for 4.69% while Non-responders in Clopidogrel was 21.9%.
KEYWORDS: Acute coronary syndromes; Anti-platelet therapy; Aspirin; Clopidogrel; Hyperlipidaemia
Hemophagocytosis, a phenomenon of which activated macrophages phagocytosed hematopoietic elements was reportedly observed in severe dengue patients. In the present study, we investigated whether markers of macrophage activation syndrome (MAS) can be used as differential diagnostic markers of severe dengue. Two hundred and eight confirmed dengue patients were recruited for the study. Sandwich ELISA was used to determine serum ferritin, soluble CD163 (sCD163), and soluble CD25 (sCD25) levels. The population of circulating CD163 (mCD163) monocytes was determined using flow cytometry. Receiver operating characteristic (ROC) analysis was plotted to determine the predictive validity of the biomarkers. Serum ferritin and sCD163 were found significantly increased in severe dengue patients compared to dengue fever patients (P = 0.003). A fair area under ROC curves (AUC) at 0.72 with a significant P value of 0.004 was observed for sCD163. sCD25 and mCD163 levels were not significantly different between severe dengue and dengue fever patients. Our findings suggest that in addition to serum ferritin, sCD163 can differentiate severe dengue from that of dengue fever patients. Hence, sCD163 level can be considered for use as a predictive marker for impending severe dengue.
Study site: Infectious disease ward (ID ward) of University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Unexpected disease outbreaks and disasters are becoming primary issues facing our world. The first points of contact either at the disaster scenes or emergency department exposed the frontline workers and medical physicians to the risk of infections. Therefore, there is a persuasive demand for the integration and exploitation of heterogeneous biomedical information to improve clinical practice, medical research and point of care. In this paper, a primary triage model was designed using two different methods: an adaptive neuro-fuzzy inference system (ANFIS) and artificial neural network (ANN).When the patient is presented at the triage counter, the system will capture their vital signs and chief complains beside physiology stat and general appearance of the patient. This data will be managed and analyzed in the data server and the patient's emergency status will be reported immediately. The proposed method will help to reduce the queue time at the triage counter and the emergency physician's burden especially duringdisease outbreak and serious disaster. The models have been built with 2223 data set extracted from the Emergency Department of the Universiti Kebangsaan Malaysia Medical Centre to predict the primary triage category. Multilayer feed forward with one hidden layer having 12 neurons has been used for the ANN architecture. Fuzzy subtractive clustering has been used to find the fuzzy rules for the ANFIS model. The results showed that the RMSE, %RME and the accuracy which evaluated by measuring specificity and sensitivity for binary classificationof the training data were 0.14, 5.7 and 99 respectively for the ANN model and 0.85, 32.00 and 96.00 respectively for the ANFIS model. As for unseen data the root mean square error, percentage the root mean square error and the accuracy for ANN is 0.18, 7.16 and 96.7 respectively, 1.30, 49.84 and 94 respectively for ANFIS model. The ANN model was performed better for both training and unseen data than ANFIS model in term of generalization. It was therefore chosen as the technique to develop the primary triage prediction model. This primary triage model will be combined with the secondary triage prediction model to produce the final triage category as a tool to assist the medical officer in the emergency department.
Tonsillectomy is performed for several indications, the two commonest in practice are infective (chronic tonsillitis) and obstructive symptoms such as sleep apnea. The objective of this study is to determine the necessity of routinely performed histopathological examination of fonsillectomy specimens. In this paper, a retrospective evaluation of 480 specimens from 241 patient who had undergone tonsillectomies in Hospital Universiti Sains Malaysia between January 2004 and October 2005 was done. It was found that 462 (96.25 %) were reactive lymphoid hyperplasia and 18 (3.75 %) were follicular hyperplasia. None of them were found to be malignant. The result of this study indicates that routine histopathological examination of tonsillectomy specimens are unnecessary and results only in added cost and a loss of man hours.
Tumor necrosis factor alpha (TNFα) is a multifunctional cytokine which plays a pivotal role in the pathogenesis of rheumatoid arthritis (RA). Apart from its well recognized proinflammatory properties, it is known to interfere with lipid metabolism and erythropoiesis. We evaluated the effects of adalimumab on hematologic, lipid and inflammatory parameters using data from patients on adalimumab 40 mg fortnightly from 2 centers in Malaysia. Mean changes in laboratory values from baseline to Weeks 4, 12 and 24 were compared using paired T test and Wilcoxon signed-rank test. We studied 18 patients with RA who were on adalimumab 40 mg fortnightly. The inflammatory markers i.e. erythrocyte sedimentation rate and C reactive protein showed significant changes as early as at week 4 compared to baseline with p values of 0.003 and 0.005, respectively. From a baseline of high disease activity with a mean Disease Activity Score using 28 joint counts (DAS 28) of 5.3, there was a steady improvement in the disease activity and remission was achieved at week 24 with a DAS 28 of 2.4. The hemoglobin level improved at week 12 (p=0.013) and this was sustained till week 24. As opposed to previous studies, the LDL level significantly decreased at week 12 (p=0.015) and this change persisted till week 24 (p=0.001). The total cholesterol showed a similar pattern as the LDL. The pharmacodynamics of adalimumab therapy in rheumatoid arthritis extend beyond the joints with favorable effects on haemoglobin and lipid profile.
Study site: Putrajaya Hospital and Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
The search for novel biomarkers has taken centre stage in the past decades of research in Rheumatoid Arthritis (RA). The purpose of the present study was to determine the correlation of serum matrix metalloproteinase-3 (MMP-3) with disease activity, joint damage and functional disability in patients with RA. We consecutively recruited RA patients who were under follow-up at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Information on the RA disease characteristics were obtained from the medical records and all RA patients were
assessed for DAS28 (disease activity score based on 28 joints) and Stanford Health Assessment Questionnaire (HAQ) 8-item Disability Index (HAQ-DI). The hand radiographs of the RA patients were assessed for joint damage using the Modified Sharp Score (MSS). Serum MMP-3 levels from RA patients and healthy controls were measured using the ELISA method. We recruited a total of 77 RA patients and 18 healthy controls. The serum MMP-3 levels were significantly higher among the RA patients (p<0.05). There were significant correlations between the serum MMP3 levels and MSS (r =0.327) and HAQ-DI (r=0.256), both p<0.05. The mean serum MMP levels in RA patients with radiographic joint erosions was significantly higher than in patients without erosions (p<0.05). Likewise, the subjects with significant functional impairment i.e HAQ-DI ≥1; had significantly higher mean MMP-3 levels compared to RA patients without significant disability (p<0.05). Using multivariate analysis, HAQ-DI remained the independent predictor of serum MMP-3 in RA patients. Serum MMP-3 is a potential biomarker and predictor of radiographic joint damage and functional disability in RA.
Keywords: acquired joint deformity, matrix metalloproteinases, rheumatoid arthritis
Patients who self-discharge against medical advice (DAMA) are susceptible to life-threatening consequences. By understanding the factors associated with DAMA, healthcare centres can build strategies to assist patients to receive optimal medical care and prevent unfavourable outcome. The objective of this study was to determine the factors associated with DAMA from the Emergency Department (ED) of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a prospective unmatched case control study conducted over a 4-month period. For every DAMA episode, two patients who were admitted on the same day were randomly selected as control. Following patient consent, data was collected using a standardized questionnaire. Patients were contacted by the investigator for information regarding hospitalization within two weeks of DAMA. Ninety three patients were recruited; 31 DAMA patients and 62 admitted patients. Payment method was significantly associated with DAMA (OR 3.17 95% CI 1.29-7.98; p=0.01). The likelihood of self-paying patients to take DAMA was three times higher than those who had a guarantor letter from their employer or insurance provider. Other factors which influence DAMA were family obligations (OR 4.08 95% CI 1.09-15.26; p = 0.03) and work problems (OR 3.83 95% CI 1.13-12.94; p=0.03). A total of 19.4% of DAMA patients left following symptomatic pain relief. A total of 80.6% DAMA patients were admitted to hospital within two weeks of the DAMA episode. Payment method significantly influences DAMA. Payment planning, social welfare services, non-governmental organization funds and the introduction of a national health policy scheme may aid hospital payment, alleviate financial limitation of patients and reduce DAMA episodes.