High prevalence of methicillin-resistant Staphylococcus aureus (MRSA) on doctors' neckties.

We set out to investigate whether neckties worn by doctors are more likely to be contaminated with Methicillin resistant Staphylococcus aureus (MRSA) compared to neckties worn by preclinical medical undergraduates who have never been exposed to a hospital environment. We discovered that more than half (52%) of neckties worn by doctors were contaminated with Staphylococcus and out of these, 62% of them were identified as MRSA. In contrast, none of the student's ties were contaminated with MRSA. Due to the high prevalence of staphylococcus detected on doctors' neckties, we recommend that health care workers do not wear neckties.

Handling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalers.

BACKGROUND: Handling of inhaler devices such as pressurized metered-dose inhalers (MDIs) and dry-powder inhalers (DPIs) in actual pulmonary practice is not well studied. OBJECTIVE: The aim of this study was to evaluate patients' proper handling of inhaler devices during actual pulmonary practice. METHODS: Prospective observational evaluations were conducted at 3 pulmonary clinics in Jordan, from February 2006 until August 2006. MDI (without spacer), Turbuhaler, Diskus, and Aerolizer devices were studied. Incorrect handling was defined as improper technique in any of the predefined essential steps. RESULTS: Patients (n = 300) were recruited and 525 inhaler-device handling technique evaluations were completed. Diskus inhaler had the lowest rate of incorrect handling (7/103, 6.8%) and MDI had the highest rate of incorrect handling (144/193, 74.6%). Turbuhaler and Aerolizer were handled incorrectly by 63/146 (43.2%) and 14/83 (16.9%) patients, respectively. DPI had a lower rate of incorrect handling, when compared with the MDI (p < 0.001). Among the DPI devices, the Diskus had the lowest rate of incorrect handling (p < 0.031). CONCLUSIONS: In actual pulmonary clinical practice the majority of patients were unable to use MDI correctly, whereas correct handling of DPI devices was variable. Regular checking of inhalation technique and proper teaching by health care providers is crucial for optimum use of most inhaler devices.

A report of the Malaysian dialysis registry of the National Renal Registry, Malaysia.

The Malaysian National Renal Registry was set up in 1992 to collect data for patients on renal replacement therapy (RRT). We present here the report of the Malaysian dialysis registry. The objectives of this papar are: (1) To examine the overall provision of dialysis treatment in Malaysia and its trend from 1980 to 2006. (2) To assess the treatment rate according to the states in the country. (3) To describe the method, location and funding of dialysis. (4) To characterise the patients accepted for dialysis treatment. (5) To analyze the outcomes of the dialysis treatment. Data on patients receiving dialysis treatment were collected at initiation of dialysis, at the time of any significant outcome, as well as yearly. The number of dialysis patients increased from 59 in 1980 to almost 15,000 in 2006. The dialysis acceptance rate increased from 3 per million population in 1980 to 116 per million population in 2006, and the prevalence rate from 4 to 550 per million population over the same period. The economically advantaged states of Malaysia had much higher dialysis treatment rates compared to the less economically advanced states. Eighty to 90% of new dialysis patients were accepted into centre haemodialysis (HD), and the rest into the chronic ambulatory peritoneal dialysis (CAPD) programme. The government provided about half of the funding for dialysis treatment. Patients older than 55 years accounted for the largest proportion of new patients on dialysis since the 1990s. Diabetes mellitus has been the main cause of ESRD and accounted for more than 50% of new ESRD since 2002. Annual death rate averaged about 10% on HD and 15% on CAPD. The unadjusted 5-year patient survival on both HD and CAPD was about 80%. Fifty percent of dialysis patients reported very good median QoL index score. About 70% of dialysis patients were about to work full or part time. There has been a very rapid growth of dialysis provision in Malaysia particularly in the older age groups. ESRD caused by diabetes mellitus, despite being a preventable and treatable cause of ESRD--has increased and accounted for more than 50% of incident dialysis patients. Death and survival rates on dialysis are comparable to those from other countries.

Perspectives on the nutritional management of renal disease in Asia: people, practice, and programs.

The high prevalence of end-stage renal disease (ESRD) in many Asian countries is attributed to diabetes and hypertension. Health care expenditure in relation to per capita income and government share of this expenditure vary among Asian countries and are affected by large populations and the poverty factor. The impact of ESRD on nutritional management in Asia reveals the need for clinicians to balance the requirements for higher standards of dietetic practice as they implement optimal care algorithms with the goal of improving outcomes, against the backdrop of staffing limitations, limited expertise in renal nutrition practice, and cultural diversity among Asian people. This paper discusses current aspects of dietetic practice and the likelihood that a change in practice is required if dietitians are to play an active role in preventing or slowing down ESRD.

A comparison of valsartan and perindopril in the treatment of essential hypertension in the malaysian population.

This study was conducted to determine the tolerability and efficacy of valsartan (DIOVAN) compared to perindopril (COVERSYL) in Malaysian patients with mild to moderate hypertension. Two hundred and fifty adult Malaysian patients with a mean sitting diastolic blood pressure of more than 95 mmHg and less than 115 mmHg after a 14 day washout period were randomized to receive either valsartan 80 mg once daily (n=125) or perindopril 4 mg daily (n=125) for eight weeks. The primary end point for efficacy was the change in mean sitting systolic and diastolic blood pressure (SiSBP and SiDBP). The primary criteria for evaluation of tolerability was the incidence of adverse events. There were no significant differences between the two groups with respect to sex, age, weight, baseline sitting and standing systolic and diastolic blood pressure. At 0, 4 and 8 weeks the mean SiDBP in the valsartan group were 101.4, 92.8 and 91.0 mmHg respectively. The corresponding BP for the perindopril treated group was 102.6, 93.8 and 93.2 mmHg. (95% CI -1.39 to +3.27). There were no significant differences in the mean BP measurements between the valsartan and perindopril group at 0, 4 and 8 weeks. In each group there were significant differences between the BP at 4 and 8 weeks compared to baseline. A similar pattern was seen with SiSBP. At 4 weeks 28.7% of the valsartan and 25% of the perindopril group had their BP normalized (SiDBP <90 mmHg) The percentages of patients who responded (SiDBP reduction >10 mmHg but SiDBP >90 mmHg) were 21.3 in the valsartan group and 20.8 in the perindopril group. At 8 weeks, 31.1% of the valsartan group and 30.8% of the perindopril group had their BP normalized. The response rate was 27% and 22.5% for valsartan and perindopril respectively. The major adverse event was cough which occurred in 18 patients (14.4%) in the perindopril and 1 (0.8%) in the valsartan group at 4 weeks. At 8 weeks the figures were 24 (19.2%) and 2 (1.6%) respectively. The results indicate that Valsartan is safe and efficacious in the treatment of mild to moderate hypertension. It is equally efficacious to Perindopril and not associated with any major adverse event. It has a better tolerability profile with respect to dry cough.

Quality of life in cadaver and living-related renal transplant recipients in Kuala Lumpur hospital.

OBJECTIVE: To examine the quality of life in cadaver (CAD) and living-related (LRRT) renal transplant recipients. METHODS: A cross-sectional study was done on patients followed in renal transplant clinic from 1/4/03 to 1/7/03 using the SF-36 questionnaire. Inclusion criteria were age >16 years,minimum of 3 months' posttransplant, and informed consent. Exclusion criteria were current treatment for rejection or infection or any life-threatening conditions. Information on duration of transplant, duration of dialysis prior to transplant, number of co-morbidities, and sociodemodraphic data were collected. RESULTS: Sixty-four among 110 patients (58.1%) completed the SF36 questionnaire. The LRRT recipients were younger, had a longer duration of transplant, and had spent significantly less time on dialysis prior to transplant compared to CAD transplant patients. Overall, the physical composite and the mental composite scores were not significantly different between the two transplant groups. Age was negatively associated with the physical composite score (Spearman's rho -0.251, P < .05) and bodily pain (Spearman's rho -0.266, P < .05). Duration of dialysis prior to transplant was negatively correlated with social functioning (Spearman's rho -0.28, P < .05) and mental health (Spearman's rho -0.39, P < .005). In multiple regression analysis, age was a significant predictor of the SF36 physical composite score (P < .05). CONCLUSION: This study shows that the quality of life between LRRT and CAD recipients was not significantly different. Increased age was associated with poorer physical capacity.

A survey on the prevalence and management of hepatitis B after renal transplantation in Asian-Pacific countries.

The carrier rate for hepatitis B virus (HBV) varies from 1% to 2% to 10% in Asian-Pacific countries. A survey involving 12 transplant centers from 11 countries in this region showed that 1% to 25% of kidney transplant recipients were infected with HBV, and up to 60% of these subjects showed abnormal liver biochemistry. While nearly all centers tested anti-HBs in potential kidney transplant recipients, HBV vaccination of nonimmune subjects was routine in only 66.7%. One-third of the surveyed units rejected HBsAg-positive subjects as kidney donors, while the others demonstrated differing policies in choosing the respective recipients. Two units (16.7%) excluded HBsAg-positive patients from kidney transplantation, whereas the others only excluded those with severe liver disease. Heterogeneity also applies to the immunosuppressive regimens, the use of HBV DNA in serial monitoring, and the timing of antiviral therapy in HBsAg-positive kidney transplant recipients. The data showed that despite HBV infection being a significant problem in kidney transplantation, there is a lack of uniform management policy, attributable to the clinical complexity and deficiency of research data. Although improvement in clinical outcome is likely with the advent of nucleoside analogue therapy and better monitoring, the financial implications in the adoption of these recent advances remain realistic concerns.

Risk factors and incidence of posttransplant diabetes mellitus in renal transplant recipients.

OBJECTIVE: This study reviewed the incidence of post-transplantation diabetes mellitus (PTDM) and risk factors for its development among renal transplant recipients in Malaysia. METHODS: Records of all kidney recipients with no known diabetes mellitus prior to transplantation and followed for at least 6 months posttransplant were selected for this retrospective study. PTDM was diagnosed according to American Diabetic Association/WHO criteria or the need to start insulin or an oral hypoglycemic agent. The data set included recipient age, gender, race, weight, donor type, duration of transplant, HCV antibody status, and immunosuppressive medication. RESULTS: Of the 316 patients who fulfilled the selection criteria, 13.3% had PTDM. Gender, race, type of donor, HCV serologic status, and use of tacrolimus did not differ significantly between recipients with versus without PTDM. However, recipients who developed PTDM were significantly older (median age 50.5 versus 42.0 years, P < 0.0001), had significantly longer posttransplant follow-up (median duration 125.5 versus 85.0 months, P = .0030) and weighed more at transplantation/first follow-up (median weight 57.6 versus 52.3 kg, P = .0103). CONCLUSION: The overall cumulative incidence of PTDM in this study was similar to the published reports. Older age, longer posttransplant duration, and heavier weight were the only variables significantly associated with PTDM.

Body composition by bioelectrical impedance analysis in renal transplant recipients.

UNLABELLED: Bioelectrical impedance analysis was introduced more than a decade ago to measure body composition and nutritional status. There are presently limited data on the nutritional status and body composition measured with bioelectrical impedance analysis in renal transplant recipients, especially among the Asian population. The normal values for these data in renal transplant recipients remain unknown. METHODS: All renal transplant recipients with stable graft function who attended the outpatient renal transplant clinic in June 2003 were recruited for this cross-sectional study. Demographic and clinical data were obtained from participating patients and their outpatient clinic notes. Body composition and bioelectrical impedance data were obtained using the Metron BioScan 916 v3 analyzer. RESULTS: Out of a total of 168 renal transplant recipients, 110 participated in this study of body composition and bioelectrical impedance for comparison with data from a previous study of 419 normal healthy volunteer controls. When compared to the healthy Malaysians, renal transplant recipients showed similar body composition in terms of body mass index, body cell mass, muscle bulk, percentage of body fat, percentage of fat free mass, and percentage of total body water. However, renal transplant recipients have more extracellular water, a lower phase angle, and a lower reactant. CONCLUSION: Malaysians who have undergone renal transplantation have similar body composition to the healthy Malaysians when measurements are obtained using bioelectrical impedance analysis.

Prevalence, awareness, treatment and control of hypertension in the Malaysian adult population: results from the national health and morbidity survey 1996.

We determined the prevalence of hypertension and the level of awareness, treatment and control of hypertension among Malaysian adults in a population based cross-sectional survey. Twenty-one thousand and three hundred ninety-one adults aged 30 or older in all 13 states of Malaysia in 1996 were sampled using a stratified two-stage cluster sampling design. Thirty-three percent of adults had hypertension with a higher percentage among women. Among hypertensives, 33% were aware of their hypertension, 23% were currently on treatment and a mere 6% had controlled hypertension. There was practically no difference in mean BP between treated and untreated hypertensives. Concerted public health effort is urgently required to improve the detection, treatment and control of hypertension in Malaysia.

CD54 and CD62L expression by lymphoid cells in acute lymphoblastic leukaemia in children.

Altered expression or function of adhesion molecules on leukaemic blasts may contribute to the evolution and biological behaviour of acute leukaemia. This work studies the expression of CD54 and CD62L by lymphoid cells and the serum level of the shed form of L-selectin (sL-selectin) in children with acute lymphoblastic leukaemia (ALL) at initial diagnosis and after first remission, and their relationship to disease activity and subtype. The study is conducted on 20 children (age range 2-10 years) newly diagnosed with ALL and admitted to Alexandria University Children's Hospital. Ten apparently healthy children of matched age and sex serve as a control group. Expression of CD54 and CD62L on mononuclear cells is detected by monoclonal antibodies using flow cytometry. Serum sL-selectin is measured by enzyme-linked immunosorbent assay (ELISA). B-cell ALL was the most common subtype (45%), followed by T-ALL (35%) and C-ALL (20%). CD54 and CD62L mean cellular expression, as well as serum sL-selectin level, were significantly higher at diagnosis than both after remission and in the control group. Univariate analysis showed that the presence of mediastinal mass, high leucocyte count, central nervous system involvement and low CD54 were significant predictors of mortality in children with ALL.

Assessing doctors' competence: application of CUSUM technique in monitoring doctors' performance.

BACKGROUND: Quality assurance of medical practice requires assessment of doctors' performance, whether informally via a system such as peer review or more formally via one such as credentialing. Current methods of assessment are, however, subjective or implicit. More objective methods of assessment based on statistical process control technique such as cumulative sum (CUSUM) procedure may be helpful. OBJECTIVE: To determine the usefulness and acceptability of CUSUM charting for assessing doctors' performance. METHOD: We applied CUSUM charting to assess doctors' performance of endoscopic retrograde pancreatography, renal and breast biopsies, thyroidectomy, and instrumental deliver. A CUSUM chart is a graphical representation of the trend in the outcome of a series of consecutive procedures. At acceptable levels of performance, the CUSUM curve is flat, while at unacceptable levels of performance, the curve slopes upward and eventually crosses a decision interval. When this occurs, the CUSUM chart indicates unsatisfactory performance. Thus, it provides an early warning of an adverse trend. RESULTS: All participating doctors found the technique useful to objectively measure their proficiency. CUSUM charts showed the progress of trainees in acquiring new skills. As they become more skillful with training, their CUSUM curves flatten. Among consultants, level CUSUM curves demonstrated ongoing maintenance of competence. All participants found the technique acceptable as a self-assessment tool. They were, however, less certain of its acceptability as a basis for credentialing. CONCLUSION: We recommend the use of CUSUM charting as a tool for personal audit at an individual level. It may also be used to show proof of technical competence for the purpose of credentialing.

Cost effectiveness evaluation of the Ministry of Health Malaysia dialysis programme.

We determine the cost effectiveness of centre and home haemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD) and intermittent peritoneal dialysis (IPD) treatment in the Ministry of Health (MOH) programme. The viewpoint taken for this evaluation is that of MOH. Cost categories identified were capital cost, dialysis operational cost, medical cost and general hospital cost. Cost estimates were mostly based on actual resource utilisation. Life years saved were estimated based on Dialysis Registry data on 2480 HD and 732 CAPD patients. Overall, the cost-effectiveness ratio (CER) of centre HD was RM21620/life year saved. Those of home HD, CAPD and IPD were RM23375, RM30469 and RM36016 respectively. Sensitivity analyses did not change the ranking of the CER. We conclude the MOH dialysis programme was cost-effective, and among the various dialysis modalities centre HD was the most cost-effective.

Outcome assessment of the Ministry of Health Malaysia dialysis programme.

We describe the outcomes on haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) provided by the Ministry of Health (MOH). The assessment was based on data from the Malaysian Dialysis Registry on 2480 HD and 732 CAPD patients who commenced dialysis between 1980 and 1996. Young patients (age < 40) have remarkable long term survival (life expectancies of 16 years on HD, 18 years on CAPD). Adjusting for background mortality, relative survival of older patients was as good as younger ones. Diabetics did poorly. 52% of HD and 26% of CAPD patients were employed in 1996. 71% of HD patients scored 10(normal) on QL index (a measure of quality of life) while 60% of CAPD patients have similar score. Differences in rehabilitation and QL index scores by age, gender and diabetes were also observed. Outcomes of dialysis in the MOH programme are reassuring.

Reliability, validity and discriminatory ability of Spitzer's QL-index in dialysis patients.

Quality of life outcome (QOL) on dialysis is important. We determined the measurement properties of Spitzer's QL-index, a QOL measure, in our patients on chronic haemodialysis. The QL-index measures 5 dimensions of QOL (activity, daily activities, general health, social support and psychological outlook). 59 haemodialysis (HD) patients from 2 centres were rated by 5 raters. Inter-rater agreement for the total score was good with a mean intra-class correlation coefficient 0.66 (range 0.47-0.81). That for dimension scores however was poor (weighted kappa range 0.07-1). Systematic differences between raters were also observed. Intra-rater agreement was generally better than inter-rater agreement. Significant gradients in scores were observed by age, serum albumin, comorbid disorders, previous hospitalisation, capacity for self care HD and rehabilitation status thus providing evidence for construct validity. The distribution of total scores was skewed indicating poor discriminatory ability. Nevertheless, QL-index has acceptable measurement properties for application in dialysis patients.