Personalised management of Chronic Obstructive Pulmonary Disease (COPD): Malaysian consensus algorithm for appropriate use of inhaled corticosteroid (ICS) in COPD patients.

BACKGROUND: Regarding the long-term safety issues with the use of inhaled corticosteroids (ICS) and the clinical predominance of dual bronchodilators in enhancing treatment outcomes in chronic obstructive pulmonary disease (COPD), ICS is no longer a "preferred therapy" according to the Global Initiative for Chronic Obstructive Lung Disease except on top of a dual bronchodilator. This has necessitated a change in the current therapy for many COPD patients. OBJECTIVE: To determine a standardised algorithm to reassess and personalise the treatment COPD patients based on the available evidence. METHODS: A consensus statement was agreed upon by a panel of pulmonologists in from 11 institutes in Malaysia whose members formed this consensus group. RESULTS: According to the consensus, which was unanimously adopted, all COPD patients who are currently receiving an ICS-based treatment should be reassessed based on the presence of co-existence of asthma or high eosinophil counts and frequency of moderate or severe exacerbations in the previous 12 months. When that the patients meet any of the aforementioned criteria, then the patient can continue taking ICS-based therapy. However, if the patients do not meet the criteria, then the treatment of patients need to be personalised based on whether the patient is currently receiving long-acting beta-agonists (LABA)/ICS or triple therapy. CONCLUSION: A flowchart of the consensus providing a guidance to Malaysian clinicians was elucidated based on evidences and international guidelines that identifies the right patients who should receive inhaled corticosteroids and enable to switch non ICS based therapies in patients less likely to benefit from such treatments.

Prevalence of Clostridium difficile infection and colonization in a tertiary hospital and elderly community of North-Eastern Peninsular Malaysia.

Little is known about Clostridium difficile infection (CDI) in Asia. The aims of our study were to explore (i) the prevalence, risk factors and molecular epidemiology of CDI and colonization in a tertiary academic hospital in North-Eastern Peninsular Malaysia; (ii) the rate of carriage of C. difficile among the elderly in the region; (iii) the awareness level of this infection among the hospital staffs and students. For stool samples collected from hospital inpatients with diarrhea (n = 76) and healthy community members (n = 138), C. difficile antigen and toxins were tested by enzyme immunoassay. Stool samples were subsequently analyzed by culture and molecular detection of toxin genes, and PCR ribotyping of isolates. To examine awareness among hospital staff and students, participants were asked to complete a self-administered questionnaire. For the hospital and community studies, the prevalence of non-toxigenic C. difficile colonization was 16% and 2%, respectively. The prevalence of CDI among hospital inpatients with diarrhea was 13%. Out of 22 C. difficile strains from hospital inpatients, the toxigenic ribotypes 043 and 017 were most common (both 14%). In univariate analysis, C. difficile colonization in hospital inpatients was significantly associated with greater duration of hospitalization and use of penicillin (both P < 0·05). Absence of these factors was a possible reason for low colonization in the community. Only 3% of 154 respondents answered all questions correctly in the awareness survey. C. difficile colonization is prevalent in a Malaysian hospital setting but not in the elderly community with little or no contact with hospitals. Awareness of CDI is alarmingly poor.

Occupational radiation exposure to anesthetists from fluoroscopic projections during orthopedic operative procedures.

PURPOSE: The role of anesthetists during orthopedic fluoroscopic procedures exposes them to radiation. We conducted a prospective, descriptive study to estimate the radiation exposure to anesthetists during procedures over a six-month period in the orthopedic trauma operating theatres which had the most fluoroscopic usage. MATERIALS AND METHODS: Thermoluminescent dosimeter (TLD) chips were placed two metres away from the radiation source, in three positions to simulate the anesthetist's position in the operating theatre during the fluoroscopic procedures as well as their radiation safety practices. The three positions were above the lead gown, behind the lead gown and behind the protective lead screen. The fourth TLD chip was assigned as a control measure to account for background radiation. The radiation exposure was measured at every end of each month during the period of six consecutive months. The TLD chips were sent to the Malaysian Institute for Nuclear Technology (MINT) for the analysis. RESULTS: From the study, the annual exposure without a protective shield at a 2 metre distance from the projection source was estimated to be 0.70 milliSievert (mSv)/year. With the use of lead gowns and protective lead screens, the annual exposure was estimated to be 0.08 mSv / year. All the radiation levels measured were within the maximum permissible dose of 50 mSv / year. CONCLUSIONS: During fluoroscopic assisted orthopedic procedures, the anesthetists in UKMMC are exposed to a small amount of radiation which is well below the annual maximum permissible limit as determined by local and international regulatory bodies.

Hospital-acquired Clostridium difficile infection among patients with type 2 diabetes mellitus in acute medical wards.

BACKGROUND: Clostridum difficile (C. difficile) infection is increasingly seen among hospitalised patients with type 2 diabetes mellitus but its rate and associated risk factors are not known. We aimed to determine the rate and characteristics of hospital-acquired C. difficile infection in subjects with type 2 diabetes mellitus admitted into acute medical wards. METHODS: Our prospective cross-sectional study involved 159 patients with established type 2 diabetes mellitus admitted into acute medical wards who developed a hospital-acquired C. difficile infection. Stools were tested for C. difficile toxins using a toxin A/B kit and a toxin A kit. Clinical features, laboratory findings, types of antibiotics, and use of a proton pump inhibitor were examined for their association with the infection. RESULTS: Thirteen subjects were positive for toxin A and one for toxin B. Using univariable analysis, we found that patients with type 2 diabetes mellitus and hospital acquired C. difficile infection were younger (mean 53.8 years, p=0.02), had diarrhoea and abdominal pain (p=0.001) but no fever. Sepsis (p=0.02) and use of a proton pump inhibitor (p=0.01) were more commonly implicated as the cause of the infection. Of the various types of antibiotics prescribed, carbapenem (28.6% vs 4.1%, p=0.01) and metronidazole (42.9% vs 19.3%, p=0.04) were significantly associated with hospital acquired C. difficile infection. CONCLUSIONS: Patients with type 2 diabetes mellitus admitted into acute medical wards and who developed hospital-acquired C. difficile infection have distinct characteristics.

Maxillofacial trauma with emphasis on soft-tissue injuries in Malaysia.

Soft-tissue injuries with or without facial bone involvement are the most common presentation following maxillofacial trauma. The objective of this study was to look at the distribution, pattern and type of soft-tissue injury in relation to aetiology. Records of patients over a period of 5 years (1998-2002), who sustained maxillofacial injuries and were treated at Kajang Hospital, a secondary referral hospital, were reviewed. Out of 313 patients with maxillofacial injuries, 295 patients sustained soft-tissue injuries. Males (79%) between 21 and 30 years old (34%) were the majority of patients. Road-traffic accident was the main cause of soft-tissue injuries (75%) with motorcycle accident being the most frequent (40%). The upper lips (23%) and the lower lips (18%) were the most common extraoral site involved, while the labial mucosa and sulcular areas, both accounting for 21%, were the most common intraoral sites. Stringent road-traffic regulations should be practiced in developing countries, as morbidity arising from road-traffic accidents poses a national economic and social problem.

Incidental radiological findings of susuk in the orofacial region.

Susuk, or charm needles, are inserted and worn subcutaneously in the face and other parts of the body, as they are believed to enhance beauty and youth, and for many other reasons such as treatment of headache, aches and pains in the joints, back or abdomen. The practice of inserting susuk is a traditional belief, genuinely cultural and superstitious, and common in the south-east Asian region. We present 13 cases of susuk, which was found incidentally on the radiographs as the patients came for various types of treatment at our centre.

Histologic study of the effects of short and long-term therapy of iodide administration on the periodontium of albino rats.

Iodine is a natural mineral essential for good health and highly concentrated in thyroid tissue. It is used for diagnostic purposes as well as for therapeutic means. The present study was conducted to evaluate the effect of a single dose of iodine administration and multiple doses of the drug for a short and long term therapy on the periodontium. Sixty male albino rats were participated in the study. Twenty rats were used as a control group, the rest of the animals were divided into two experimental groups. The first group received single dose (diagnostic dose) of iodine. The second experimental group was divided into two subgroups. The first subgroup received multiple doses of iodine for a short period of 15 days, while the second subgroup received the same multiple doses for one month. Three rats of the control group and four of each experimental group were sacrificed at the end of the first, second, third and fourth weeks from the beginning of the study. Maxillary and mandibular specimens were dissected, stained with H. & E. and examined microscopically. The results of the study revealed that single diagnostic dose of iodine has no effect on the periodontium while multiple doses of the drug used for therapeutic purposes caused degeneration of periodontal tissues. The effect increased when the drug is used for a long period, the effect of the drug may be related to the direct effect of iodine concentrated in saliva on living cells or indirectly through the effect of xerostomia induced by the drug.

Deletion and translocation of chromosome 11q13 sequences in cervical carcinoma cell lines.

Molecular genetic studies on HeLa cell-derived nontumorigenic and tumorigenic hybrids have previously localized the HeLa cell tumor-suppressor gene to the long arm of chromosome 11. Extensive molecular and cytogenetic studies on HeLa cells have shown chromosome band 11q13 to be rearranged in this cell line. To determine whether q13 rearrangement is a nonrandom event in cervical carcinomas, six different human papilloma virus (HPV)-positive (HeLa, SiHa, Caski, C4-I, Me180, and Ms751) and two different HPV-negative (C33A and HT3) cell lines were studied. Long-range restriction mapping using a number of q13-specific probes showed molecular rearrangements within 75 kb of INT2 probe in three HPV-positive cell lines (HeLa, SiHa, and Caski) and in an HPV-negative cell line (HT3). FISH using an INT2 YAC identified a breakpoint within the sequences spanned by this YAC in two of the cell lines, HeLa and Caski. INT2 cosmid derived from this YAC showed deletion of cosmid sequences in two other cell lines, SiHa and C33A. These two cell lines, however, retained cosmid sequences of Cyclin D1, a probe localized 100 kb proximal to INT2. Deletions being the hallmark of a tumor-suppressor gene, we conclude that the 100-kb interval between the two cosmids might contain sequences of the cervical carcinoma tumor-suppressor gene.

The Mentakab hypertension study project. Part V--Drug compliance in hypertensive patients.

Poor compliance with drug treatment is a barrier to effective management of hypertension. Drug compliance behaviour of 168 patients were studied, their drug compliance was measured by the pill-counting method. The prevalence of non-compliance with medication was 26%. Thirteen variables were examined for their association with compliance; these were age, sex, duration of hypertension since diagnosis, adequacy of blood pressure control, complexity of drug regimen and side-effect of drug, history of previous admission for hypertension related reason, patient's knowledge of hypertensive complications, patient's belief that drug was 'panas' or 'san', previous use of traditional treatment for hypertension, patient's fatalistic attitude, their social support and satisfaction with the health services. None of these variables were significantly related to compliance (p greater than 0.05) except adequacy of blood pressure control. The performance of patient self-report was compared with pill-count as a measure of drug compliance; it was poorly predictive of non-compliance (sensitivity = 71%, specificity = 50%). An inverse relationship was found between non-compliance with medication and patient subsequent drop-out rate. Patients who were compliant were more likely to remain on treatment and vice versa. As a measure of drug compliance, detection of drop-out compared well with pill-count (sensitivity 97%, specificity 66%, positive predictive value 89%, negative predictive value 88%).