ABSTRACTS OF THESES APPROVED FOR THE M.SC., M.MED. AND PHD.
DEGREES AT THE SCHOOL OF MEDICAL SCIENCES, UNIVERSITY SAINS MALAYSIA, HEALTH
CAMPUS, KUBANG KERIAN, KELANTAN, MALAYSIA.
Abstracts
Abstracts of Theses Approved for the M.Sc., M.Med. and Phd.
Degrees at the School of Medical Sciences, University Sains Malaysia,
Health Campus, Kubang Kerian, Kelantan, Malaysia.
(1) IDENTIFICATION OF URIDINE DIPHOSPHATE
GLUCURONOSYL TRANSFERASE 1A1(UGT1A1)
GENE MUTATIONS IN BABIES WITH EARLY ONSET
OF NEONATAL JAUNDICE
Dr. Norlelawati bt. A. Talib
M.Med Pathology
Department of Pathology, School of Medical Sciences,
University Sains Malaysia, Health Campus,
Kelantan, Malaysia.
Background : Neonatal jaundice is common in South-East Asian
and it is a potential cause of permanent brain damage. In most of the
cases, no obvious aetiology is identified. Recently, mutations in the
bilirubin uridine diphosphate glucuronosyl transferaselAl(UGTlAl)
gene attributed to neonatal jaundice and hyperbilirubinemia syndromes
have been reported in many populations. The underlying molecular
defects are heterogeneous and may be attributed to any part of the five
exons of the UGT1 gene.
Objective : There were two main objectives in this study. The first
objective of this study was to apply molecular techniques for the
investigation of the UGT1A1 mutation in three babies [Bl, B2, B3]
who presented with early onset of jaundice. Identifiable causes of
pathological jaundice have been excluded earlier. An inherited
phenomenon of this mutation will be demonstrated by doing family
study and molecular analysis.
The second objective of the study was to develop a screening test
for G71R mutation and to investigate the relationship of this mutation
with neonatal hyperbilirubinemia.
Methodology : For this purpose, sixty-eight Malay neonates were
recruited. The subjects were divided into two groups:-
hyperbilirubinemia and non-hyperbilirubinemia. Blood samples were
taken and were screened for G71R mutation using denatured high
performance liquid chromatography (DHPLC).
Results : Nucleotides sequenced study of the three babies identified
two different novel mutations within the studied gene in two Malay
babies [Bl, B2]. One mutation was transversion G Æ C at nucleotide
1477 in exon 5 corresponding to G493R in Bl. Another mutation was
transition AÆ G at nucleotide 964 in exon 2 corresponding to I322V
in B2. A specific mutation i.e transition GÆA at nucleotide 211 in
exon 1 corresponding to G71R was identified in B3, a Chinese. Previous
studies have identified this specific mutation in Chinese, Korean and
Japanese populations.
Population study for G71R mutation had revealed that it is present
in four out of thirty-two hyperbilirubinemia neonates and one out of
thirty-six non hyperbilirubinemia neonates with allele frequency of
0.03%. However, the association between the presence of this mutation
and neonatal hyperbilirubinemia was insignificant (p> 0.05).
Conclusion : Two novel intraexonic mutations were detected in two
Malay babies [Bl, B2] and a specific G71R mutation was identified in
a Chinese baby [B3}. These results suggest that mutations in UGT1A1
gene may play a role in the pathogenesis of early onset neonatal jaundice
in Malay babies. Population study results showed that G71R mutation
was found in Malay population; however its contribution to neonatal
Malaysian Journal of Medical Sciences
Vol. 12, No. 1, January 2005
hyperbilirubinemia is equivocal due to limited samples sized and thus
warrants further study in near future.
Dr. Narazah Mohd. Yusoff : (Supervisor)
Dr. Rosline Hassan : (Co-Supervisor)
Assoc. Prof. Dr. Amin Hans Van Rostenberghe : (Co-
Supervisor)
(2) THE ASSOCIATION OF HLA CLASS II ANTIGENS
WITH ANTICARDIOLIPIN ANTIBODY EXPRESSION IN
MALAYS WITH SYSTEMIC LUPUS ERYTHEMATOSUS
Dr. Nurul Khaiza bt. Yahya
M.Med Pathology
Department of Pathology, School of Medical Sciences,
University Sains Malaysia, Health Campus,
Kelantan, Malaysia.
Background : Systemic lupus erythematosus (SLE) is a disease of
abnormal immune regulation, characterized by the production of
autoantibodies and the accumulation of immune complexes which
eventually lead to inflammation in multiple organs and cause a wide
range of clinical manifestations. Autoantibody production depends on
the interaction of helper T lymphocytes with HLA Class II molecules
on antigen presenting cells; therefore, the class II genes have a role in
susceptibility through alteration of T cell recognition. The aetiology is
still remain unknown, however genetic predisposition, sex hormones
and environmental factors might play a role in the pathogenesis of
SLE.
Objective : This study was designed to evaluate the frequency of
HLA-DR and -DQ alleles in ethnic Malays with SLE in order to
determine the role of these genes in disease susceptibility. We also
study the frequency of anticardiolipin antibody present in SLE and
evaluate its association with HLA antigens. Finally we tried to correlate
of these two parameters with clinical manifestations.
Methodology : This cross sectional study was conducted in the
Medical clinic and Immunology laboratory, Hospital Universiti Sains
Malaysia from November 2002 until August 2003. Fifty-five Malay
SLE patients who fulfilled the American Rheumatism Association
(ARA) were analysed. HLA typing and anticardiolipin antibody
screening were compared with the control group consisting of 55
healthy unrelated subjects with comparable age and sex from the same
ethnic group. HLA typing of class II antigen were carried out using
MicroSSP Class II generic (DRB/ DQB) from One Lambda Inc.; while
anticardiolipin antibody screening was performed using RELISA
Cardiolipin Antibody Screening Test by Immunoconcepts.
Results : We found a strong association of HLA-DR15 and HLA-
DR17 with SLE compared to healthy subjects (p corr = 0.002 , adjusted
OR = 5.513 ;p con = 0.04, adjusted OR = 7.87 , respectively).
Anticardiolipin antibodies was significantly positive in SLE patients
compared to healthy subjects with p corr < 0.001( adjusted OR =
15.541) however no significant association with HLA Class II antigens
was found. There was a significant positive association ofDR15 with
71
 ABSTRACTS OF THESES APPROVED FOR THE M.SC., M.MED. AND PHD. DEGREES AT THE SCHOOL OF MEDICAL SCIENCES, UNIVERSITY SAINS MALAYSIA, HEALTH
CAMPUS, KUBANG KERIAN, KELANTAN, MALAYSIA.
arthritis, whereas anticardiolipin antibody has no correlation with
clinical manifestations.
Conclusion : Our data suggests the role of the HLA Class II genes
in conferring SLE susceptibility and in clinical expression.
Assoc. Prof. Dr. Mustaffa Musa : (Supervisor)
Dr. Nadeem Afzal : (Co-Supervisor)
Assoc. Prof. Dr. Kamaliah Daud : (Co-Supervisor)
Assoc. Prof. Dr. Mustafa Musa : (Supervisor)
(3) EFFECTS OF SEDATIVE ORAL PREMEDICATION
ON OXYGEN SATURATION IN PATIENTS
UNDERGOING SPINAL ANAESTHESIA
Dr. Swaran Singh A/L Norpa Singh
M.Med Anaesthesiology
Backgroud : This has been a prospective study carried out over a
period of ten months at Hospital University Sains Malaysia, Kubang
Kerian, Kelantan. Oxygen is routinely supplemented to all patients in
the operation theatre undergoing spinal anaesthesia for lower limb or
lower abdominal surgery.
Objectives : This study was undertaken to evaluate the effect of
sedative oral premedication on oxygen saturation of patients undergoing
spinal anaesthesia and if they require oxygen supplement as a routine.
This study also evaluated if oxygen supplement is required as a routine
in patients undergoing Spinal anaesthesia when they were not given
premedication.
Methodology : All the patients belonged to the American Society
of Anaesthesia (ASA) 1 and 2 and in the age group of 18 - 45. Total of
140 patients were included in this study. Premedicated patients group
A;n=70. were from the elective operative list seen one day prior to
their operation and premedicated with tablet midazolam at night and
one hour prior to surgery. Un premedicated patients group B;n=70.
were from the emergency operative list who had not received any
sedation for the last 4 hours.
Results : Of the seventy patients in the orally premedicated group,
7% of the patients had oxygen desaturation of less than 92 % and had
to be given supplemental oxygen of 4 liters per minute by a venturi
mask. Desaturation occurred at 15 to 30 minutes after spinal anaesthesia
and improved soon after oxygen supplement. Haemodynamic
parameters were stable in both the groups and easily managed with no
complications.
Conclusions : We conclude that sedative oral premedication Tablet
Midazolam 7.5 mg did not cause desaturation in patients undergoing
spinal anaesthesia and oxygen supplement was not routinely required
in patient undergoing spinal anaesthesia.
Assoc. Prof. N. Abdullah N. Mohamad : (Supervisor)
Dr. Rhendra Hardy Mohd Zain : (Co-Supervisor)
Dr. Saedah Ali : (Co-Supervisor)
(4) A COMPARATIVE STUDY BETWEEN INVASIVE
BRONCHOSCOPY (BY USING BRONCHOALVEOLAR
LAVAGE TECHNIQUE) AND NON-INVASIVE DEEP
ENDOTRACHEAL ASPIRATION IN DIAGNOSING
VENTILATOR - ASSOCIATED PNEUMONIA
Dr. Wan Rohaidah Wan Ahmad
M.Med Anaesthesiology
Department of Anaesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
72
Background : Approximately 10-50 % of mechanically ventilated
patients will develop ventilator -associated pneumonia at a rate of 1-
3% per day. It is one the main causes of acquired infection in ICU
which contribute to increase length of ventilation, ICU stay,- morbidity
and mortality, hence increase the cost of caring for the critically ill
patients. Optimal management is crucial for confirmation of diagnosis
and identification of pathogen.
Objectives : The aim of this study is to determine the efficiency of
endotracheal aspiration and bronchoscopic bronchoalveolar lavage in
diagnosing VAP. The safety of both techniques will also be assessed.
Methodology : A prospective clinical study of 100 patients with
clinical diagnosis of VAP by a new, progressive infiltration on CXR,
fever, leucocytosis, purulent sputum and Pao2/Fio2 less than 240 were
randomly assigned into one of two groups. Group 1 (n = 50) underwent
endotracheal aspiration and group 2 (n = 50) underwent bronchoscopic
bronchoalveolar lavage. All specimen were sent to microbiology
laboratory immediately. All microorganisms isolated were identified
by standard laboratory methods. Threshold of 105-106 Colony Forming
Unit/ml for endotracheal aspiration and 104 Colony Forming Unit/ml
without antibiotic, 103 Colony Forming Unit/ml with antibiotic for
bronchoalveolar lavage were taken for diagnosis of ventilator-
associated pneumonia. Complications and qualitative bacteriologic
culture were also recorded.
Results : There were no significant demographic differences between
the two groups in term of sex, race, age, height and weight. Ventilator-
associated pneumonia was detected in 36 (72.0 %) patients by using
deep endotracheal aspiration technique as compared to 34 (68.0 %)
patients by using the bronchoalveolar lavage technique with p=0.828.
22 (22.0 %) had Acinetobacter baumanii isolated from the culture, 18
(18.0 %) cases of Klebsiella Pneumonia and Pseudomonas aeruginosa
were isolated respectively.
Other microorganisms for example Methicillin-Resistant
Staphylococcus aureus (MKSA) and E. Coli were isolated in 11 (11.0
%). 31 (31.0 % ) failed to grow any culture. Only 1 (2.0 %) out of 50
patients in the bronchoalveolar lavage group developed hypoxaemia
i.e SaO2 less than 90 %. No other complications occurred in that group.
No complication was noted in the endotracheal aspirate group (p =1.0).
All patients were on antibiotic at the time of sampling. After receiving
the result of colony count and culture and sensitivity, antibiotics were
changed according to the sensitivity in 87 (87.0 %) patients of both
groups. Antibiotics were not changed in 13 (13.0%) patients. Mortality
occurred in 18 (36.0%) patients in endotracheal aspirate group and 25
(50.0%) patients in bronchoalveolar lavage group.
Conclusions : Our study showed that the quantitative culture of
endotracheal aspirate were comparable to those using invasive
bronchoscopic bronchoalveolar lavage technique in patients already
receiving antibiotics. Quantitative endotracheal aspiration is a valuable
way to be a pathogenic diagnostic test for VAP with fewer
complications, simple and inexpensive. It is worth to recommend
quantitative endotracheal aspiration in clinical practice. Invasive
quantitative bronchoalveolar lavage technique can be considered as a
reference standard in confirming or ruling out infection.
Assoc. Prof. N. Abdullah N. Mohamad : (Supervisor)
Dr. Mahamarowi Omar : (Co-Supervisor)
Dr. Asai Abd. Rahman : (Co-Supervisor)
Dr. Ali Salleh : (Co-Supervisor)
(5) INTUBATING CONDITIONS AND HAEMODYNAMIC
CHANGES FOLLOWING INDUCTION WITH
SEVOFLURANE VERSUS INTRAVENOUS
PROPOFOL AND SUCCINYLCHOLINE FOR
TRACHEAL INTUBATION IN ADULTS
Dr. Nazri bin Mohamed
M.Med Anaesthesiology
ABSTRACTS OF THESES APPROVED FOR THE M.SC., M.MED. AND PHD. DEGREES AT THE SCHOOL OF MEDICAL SCIENCES, UNIVERSITY SAINS MALAYSIA, HEALTH
CAMPUS, KUBANG KERIAN, KELANTAN, MALAYSIA.
Department of Anaesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objectives and methodology :A randomized double blinded
prospective study was conducted involving a total of 120 ASA I or II
similarly premedicated adult patients who were allocated into 2 equally
numbered groups. After preoxygenation for 3 minutes and given
intravenous fentanyl (1.5 micrograms/kg). Group S (n=60) received a
mixture of inhaled sevoflurane 8% with 4 litre/min nitrous oxide and
4 litre/mm oxygen for 4 minutes and Group P (n=60) received
intravenous propofol (2mg/kg) followed by suxamethonium (1.5 mg/
kg). Intubating conditions were assessed according to easiness of
laryngoscopy, vocal cord position, jaw relaxation, coughing and limb
movement. Baseline blood pressure, heart rate and mean arterial
pressure were recorded and continued every minute after induction
until 10 minutes post intubation.
Results : Adverse events during induction and immediately post-
operative were also recorded. Comparing born methods of induction,
intubating conditions were more acceptable with propofol induction
compared to sevoflurane (96.7% acceptable and 3.3% unacceptable
intubating conditions in Group P versus 85.0% acceptable and 15.0%
unacceptable intubating conditions in Group S, p< 0.05) and also less
haemodynamic changes during induction in Group P compared to
Group S (p<0.05) but intubations were successful with the first attempt
in all patients without any incidence of trauma or bronchospasm. The
reduction in mean arterial pressure in Group S was less than 25% of
baseline seen mainly at 3 and 4 minutes of induction. 23.3% had
breatholding during induction with sevoflurane and 28.3% had pain
on propofol injection. Incidence of sorethroat, headache, nausea,
vomiting, confusion and agitation were not significant (p> 0.05).
Conclusion : We conclude that induction with intravenous propofol
an suxamerhonium provides better condition for tracheal intubation
and haemodynamic stability but intubation following induction with
sevolurance is a useful alternative without major complications.
Assoc. Prof. N. Abdullah N. Mohamad : (Supervisor)
Dr. Shaiful Azman Zakaria : (Co-Supervisor)
Dr. Saedah Ali : (Co-Supervisor)
Dr. Shamsul Kamalrujan Hassan : (Co-Supervisor)
(6) COMPARISON OF PROPOFOL AND ETOMIDATE
WITH ROCURONIUM FOR RAPID SEQUENCE
INDUCTION OF ANAESTHESIA.
Dr. Zurhayati bt Awang
M.Med Anaesthesiology
Department of Anaesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Background : The choice of hypnotics and opioids for rapid
sequence induction is influenced by the choice of the muscle relaxant.
Suxamethonium has been the 'gold standard' neuromuscular relaxant
for rapid sequence induction but rocuronium has been proposed as a
suitable alternative due to its rapid onset and less undesirable side
effects. Propofol has been proven as the induction agent of choice for
rapid trachea! intubation in haemodynamically stable patients. We were
interested to see ifintubating conditions and cardiovascular changes
under rapid sequence conditions were acceptable if anaestesia was
induced with etomidate and rocuronium, rather than with propofol and
rocuronium.
Objectives : The objectives of this double-blinded, randomized study
were to compare the intubation conditions and cardiovascular effects
by two different induction agents (etomidate and propofol) using
rocuronium as the muscle relaxant in modified rapid sequence
induction. The adverse events related to the drugs used were also noted.
Methods : 140 patients, ASA physical status I or II, were randomized
to two groups. They will received fentanyl (1.5 µg/kg) followed by
etomidate (0.3 mg/kg) or propofol (2.5 mg/kg) and subsequently
rocuronium (0.6 mg/kg) in both groups. Baseline and post induction
blood pressure and heart rate were noted. The end of injection of muscle
relaxant was designed as time zero and another blood pressure and
heart rate reading were taken. Tracheal intubation was commenced 60
s after injection of rocuronium. Intubation conditions were graded on
a scale of I to IV by a single intubator. Patients were also monitored
for excitatory events, nausea and vomiting. Haemodynamic
measurement were repeated every 1 minute until 5 minutes post
induction.
Results : Intubation conditions at 60 seconds were acceptable in
48.6 % of patients in etomidate group and 82.9% of patients in propofol
group. The intubation conditions following etomidate induction were
significantly worse than propofol group (p < 0.05). Etomidate produced
less changes in systolic and diastolic blood pressure as compared to
propofol induction. In comparison, there were statistically significant
differences in the percentage of excitatory events (higher in etomidate
group) between the groups. No differences in the incidence of nausea
and vomiting between the two groups.
Conclusion : The intubation results reported in this study showed
that propofol provides more acceptable intubation conditions at 60
seconds compared to etomidate when rocuronium 2X ED95 were used.
However, etomidate produced less systolic and diastolic blood pressure
changes in comparison with propofol induction. Excitatory events were
significantly higher in etomidate group.
Dr. Saedah Ali : (Supervisor)
Assoc. Prof. N. Abdullah N. Mohamad : (Co-Supervisor)
Assoc. Prof. Dr. Kamaruddin Jaalam : (Co-Supervisor)
(7) A COMPARISON OF HAEMODYNAMIC CHANGES
AFTE ENDOTRACHEAL INTUBATION USING THE
LIGHTWAND DEVICE (TRACHLIGHT) AND THE
LARYNGGOSCOPE
Dr. Tuan Norizan bt Tuan Mahmud
M.Med Anaesthesiology
Department of Anaesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Background : This is a single blinded randomized controlled study
of 140 patients, who had undergone elective surgery under general
anaesthesia in Hospital Universiti Sains Malaysia from November 2002
to August 2003. A comparison was made in terms of haemodynamic
changes after tracheal intubation, intraoperative and postoperative
complications related to tracheal intubation, intubation time and number
of attempts in intubation between lightwand technique and direct
laryngoscopic groups.
Methodology : Subjects were randomly assigned to either LSI
(endotracheal intubation by direct laryngoscope) or LWI group
(endotracheal intubation by trachlight). A standardized anaesthetic
technique was used. Endotracheal intubation was performed after the
induction of anaesthesia with intravenous fentanyl, propofol and muscle
relaxant with vecuronium. Non-invasive systolic blood pressure (SBP),
diastolic blood pressure (DBP) and heart rate (HR) were recorded
preinduction, preintubation, immediately after intubation and every
minute for the first five minutes after intubation. Half an hour
postoperatively, recovery nurse at the recovery room assessed for any
hoarseness of voice, sore throat and dysphagia.
Results : This study demonstrated that, there was no significant
difference in haemodynamic changes between the two techniques. The
number of intubation attempts was similar between the groups, but
73
 ABSTRACTS OF THESES APPROVED FOR THE M.SC., M.MED. AND PHD. DEGREES AT THE SCHOOL OF MEDICAL SCIENCES, UNIVERSITY SAINS MALAYSIA, HEALTH
CAMPUS, KUBANG KERIAN, KELANTAN, MALAYSIA.
intubation time was longer in LWI group (25.7 ± 14.8 vs. 20.0 ± 8.4),
p = 0.003. The incidence of hoarseness of voice was lower in LWI
group (0.1 % vs.7.6 %), P=0.04. there was no difference in other
pharyngolaryngeal morbidity among groups.
Conclusion : As a conclusion, the effect of trachlight intubation on
haemodynamic changes was similar to those of direct laryngoscopic
technique.
Dr. Gnandev Phutane : (Supervisor)
Assoc. Prof. N. Abdullah N. Mohamad : (Co-Supervisor)
Dr. Ghazaimie Ghazali : (Supervisor)
(8) EFFECT OF EPIDURAL ROPIVACAINE WITH
FENTANYL 2 µGML-1 VERSUS INTRAMUSCULAR
PETHIDINE ANALGESIA ON THE PROGRESS OF
LABOUR
Dr. Abu Bakar bin Mohd. Supa’at
M.Med Anaesthesiology
Department of Anaesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : Our purpose was to determine the effect of epidural
analgesia as compared to intramuscular pethidine on the progress of
labour in the perspective of duration of labour and modes of delivery.
Methodology : One hundred and ninety two (192) uncomplicated
full term gravida 2-5 women with tested pelvis in spontaneous labour
were randomized to receive either epidural or intramuscular pethidine
analgesia. Epidural catheter was inserted at first request of pain relief
during active phase of labour at cervical dilatation of 3 to 5 cm.
Ropivacaine 0.2% with fentanyl 2 ug/ml were used as local anesthetic
of choice as it provides good pain relief and less motor block.
Results : There are no significant findings in demographic data.
Epidural significantly provides good analgesia after 15 minutes (Mean
Visual Analogue Score-VAS at 15 minutes was 11.3 mm vs. 68.6 mm,
P = 0.001) and at full dilatation (25.1 mm vs. 94.4 mm, P = 0.001).
86% of patients experienced no motor block (Bromage 0) in epidural
group. From this study we found that there are significant associations
between epidural administration and prolongation of first stage (506.6
min vs 392.1 min. P = 0.001) and second stage (24.0 min. vs.10.1 min.
P = 0.001) of labour. Instrumental delivery but not the cesarean section
rates were increased. (11.7% vs. 2.1%, P = 0.008), (11.7% vs. 7.1%, P
‘=• 0.186) respectively. No difference in neonatal outcome as shown
by Apgar score at 1 and 5 minutes. Patient satisfaction was statistically
significant whereby 84% of patient opted for epidural analgesia for
next delivery.
Conclusions : Epidural ropivacaine 0.2% with fentanyl 2 u.g/ml
provides better labour analgesia than intramuscular pethidine despite
prolongation of labour and increased instrumentation. It was not
associated with increased numbers of cesarean delivery when compared
with intramuscular pethidine analgesia.
Assoc. Prof. Dr. N. Abdullah N. Mohamad : (Supervisor)
Assoc. Prof. Dr. Kamaruddin Jaalam : (Co-Supervisor)
Dr. Nizar Abd. Jalili : (Co-Supervisor)
(9) COMPARISON OF CONJUNCTIVAL IMPRESSION
CYTOLOGY BETWEEN GLAUCOMA PAATIENTS
TREATED WITH TOPICAL TIMOLOT MALEATE 0.5%
AND TOPICAL LATANOPROST 0.005%
Dr. Tan Soo Hoi
M.Med Ophthalmology
74
Department of Ophthalmology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : All topical medications are known to cause
conjunctival reactions, and topical anti-glaucoma drugs are also no
exception. Long term drug induced toxicity to the conjunctiva is
postulated to cause filtering bleb scarring and subsequent filtration
surgery failure. Chronic application of topical timolol maleate 0.5%
and topical latanoprost 0.005% had been shown to alter the morphology
of the conjunctival ocular surface.
Objective : To compare conjunctival surface morphological changes
with the use of the topical timolol maleate 0.5% and topical latanoprost
0.005%.
Methodology : Newly diagnosed glaucoma patients who met the
selection criteria were randomly divided into two groups. One group
treated with topical timolol maleate 0.5%, another group treated with
topical latanoprost 0.005%. Before the treatment was started, the first
conjunctival impression cytology was taken as base line. After three
months of treatment, the second conjunctival impression cytology was
obtained. The changes that occurred between the first and second
conjunctival impression cytology in the individual group were analyzed.
Conjunctival surface changes that occurred with the use of topical
timolol maleate 0.5% were also compared with the conjunctiva surface
changes that occurred with the use of topical latanoprost 0.005%.
Results : Thirty-nine newly diagnosed glaucoma patients were
included in this study. Twenty patients were in the Timolol group and
nineteen patients in the Latanoprost group. In both groups of patients,
there was no change of the conjunctival epithelial cell morphology
after three months of anti-glaucoma therapy. However, there was
statistically significant reduction of the goblet cell and mucous granule
density in both groups of patients after three months of the topical
anti-glaucoma therapy (P- value <0.001). By using the independent T-
test, there was no significant difference of the goblet cell and mucous
granule density between the Timolol group and the Latanoprost group
after three months of treatment.
Conclusion : This study gives evidence that topical timolol maleate
0.5% and topical latanoprost 0.005% cause morphological changes of
the conjunctival surface after short term (three months) therapy.
Dr. Wan Hazabbah b. Wan Hitam : (Supervisor)
(10) A STUDY ON THE USE OF A TRAUMA SCORING
SYSTEM IN THE ASSESSMENT OF TRAUMA
PATIENTS INTRODUCTION
Dr. Mohd. Idzwan bin Zakaria
M.Med Emergency Medicine
Department of Emergency Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Injury is an ever-increasing problem in Malaysia as
in other developing countries. In Malaysia, it is the fifth leading cause
of death in hospital (7.93%) and third leading cause of admission to
government hospitals (9.25%) [Ministry of Health Annual Report,
2000]. Trauma registry serves as a powerful tool for the quality
improvement program. Trauma severity scoring is one of the tools in
trauma registry. Revised Trauma Score(RTS) is one of the physiological
trauma score. This study incorporates RTS in HUSM trauma cases
and hence provides comparison with other trauma centers. This study
also hopefully will introduce HUSM to a standard trauma score in
future.
Objectives : The objectives of this study are:
ABSTRACTS OF THESES APPROVED FOR THE M.SC., M.MED. AND PHD. DEGREES AT THE SCHOOL OF MEDICAL SCIENCES, UNIVERSITY SAINS MALAYSIA, HEALTH
CAMPUS, KUBANG KERIAN, KELANTAN, MALAYSIA.
1. To determine whether is there a relationship between RTS and
mortality in HUSM
2. To determine the difference between the probability of survival in
HUSM compared to expected probability of survival in US based
on RTS
3. To determine the association between age, gender, pre hospital
transport, mechanism of injury, presence of high risk mechanism
of injury and coexistence of pre-morbid condition with mortality
in HUSM
4. To study the socio-demographic patterns of trauma patients seen
in HUSM
5. To compare the outcome of trauma patients with high risk
mechanism of injury or co-existence of pre-morbid condition in
HUSM and mortality of trauma patients with high risk mechanism
of injury or co-existence of pre-morbid conditions according to
weighted RTS of the sample study
Methodology : 462 trauma patients arriving at the emergency
department HUSM fulfilling the inclusion and exclusion criteria were
chosen during a study period of 6 months. The patients were triaged
and proformas were filled. Demographic data were collected and the
RTS were calculated. The data were compiled and analyzed using
various descriptive studies from the Statistics Program for Social
Studies (SPSS) version 11.5. The association between age, gender, pre
hospital transport, mechanism of injury, presence of high risk
mechanism of injury and co existence of pre morbid condition with
mortality in HUSM were analyzed using logistic regression analysis.
RTS and probability of survival in HUSM was analyzed using Pearson's
Correlation and Receiver Operating Characteristic curve. The
probability of survival in HUSM and the probability of survival in US
based from Champion et al was analyzed using one-sample t-test. The
association between probability of survival in HUSM and probability
of survival according to weighted RTS of the sample study with the
high risk mechanism of injury and co-existence of pre-morbid condition
were tabulated.
Results : From this study, it was found that:
1. Trauma patients with high risk mechanism of injury has 2.56 fold
increased mortality risk with a p-value of 0 (0.05) using the logistic
regression analysis. Trauma patients with pre morbid condition
have 0.825 fold increased mortality risk with a p-value 0.011(0.05).
Age, gender, pre hospital transport and mechanism of injury didn't
show any association with mortality in this study.
2. There is a strong correlation between weighted RTS and probability
of survival with Pearson's correlation coefficient of 0.927 and two-
tailed p-value of 0.00. The area under the ROC curve, which is
how well the weighted RTS able to predict death is 0.991 with an
asymptomatic significance of 0 (0.05). This shows that weighted
RTS is able to predict death in 99.1% of the cases.
3. From the one-sample t-test, with a mean difference of 0.3644, t
statistic of 2.56, degree of freedom of 8 and p value 0.034, we can
say that there is a significant difference between the probability
of survival in HUSM and probability of survival in USA with a
95% confidence interval (0.04, 0.69) hence a significant lower
probability of survival compared to the US with the same RTS.
4. This study shows that there is a similarity between the outcome in
high risk mechanism of injury in HUSM and the predicted
mortality based on RTS with high risk mechanism of injury
(outcome in HUSM: 17%, mortality based on RTS: 19%). Outcome
from low risk injury shows a difference of 1.5% lower mortality
compared to the predicted mortality based on RTS (outcome in
HUSM: 17%; predicted mortality: 3%). Co-existence of pre-
morbid condition shows similar outcome when compared with
probability of survival according to RTS. Both were 17.9%
mortality. In trauma patients with no pre-morbid factors, the
outcome in HUSM was 8.7% and the expected mortality based on
RTS was 10.6%.
Conclusions : Based on the results of this study, the following have
been proposed:
1. There is a strong inverse relationship between RTS and mortality
of trauma cases in HUSM and hence RTS is applicable in HUSM
as a form of trauma score in quality assessment.
2. This study shows that there is a significantly lower probability of
survival in HUSM than in US with the same RTS.
3. High risk mechanism of injury and pre morbid conditions increases
the mortality risk. Age, gender, pre hospital transport and
mechanism of injury did not show a significant increase in
mortality risk.
4. There is a strong similarity between outcomes of trauma patients
in HUSM with high risk mechanism of injury or co-existence of
pre-morbid condition and mortality predicted by weighted RTS in
these patients.
Dr. Wan Aasim Haji Wan Adnan (Supervisor)
Dr. N. Hishamuddin N. Ab. Rahman : (Co-Supervisor)
Assoc. Prof. Dr. Kamaruddin Jaalam : (Co-Supervisor)
(11) EXPOSURE TO SECOND-HAND SMOKE AND
THE RISK OF NON-SYNDROMIC CLEFT AMONG
MALAY CHILDREN IN KELANTAN: A MOLECULAR
AND EPIDEMIOLOGICAL ASSOCIATION
Dr. Ayu Abdullah
M.Med Community Medicine
Department of Public Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : The prevalence of cleft lip and palate in human ranges
from 1 in 500 to 1000 live births worldwide. Non-syndromic clefts are
a complex trait with both genetic and environmental etiology.
Transforming Growth Factor Alpha (TGFa) is a modifier gene which
is susceptible to environmental factors, leading to development of
sporadic non-syndromic clefts.
Objectives : The aims of the study were to identify risk factors of
families with cleft and to assess the association between maternal
exposure to second-hand smoke during pregnancy and TGFa gene
polymorphism in cleft children genotype. The study was divided into
two parts: Part I: Unmatched case-control study was carried out among
Malays in Kelantan. Case and control subjects were defined as mothers
of cleft children and mothers of normal children respectively. The cleft
children were recruited from the Combined Cleft Clinic at Kota Bharu
Dental Clinic. Normal children were selected at Orthodontic Clinic,
Kota Bharu.
Methodology : A total of 184 cases and controls with age range
from 17 to 50 years were interviewed using the standard craniofacial
registration form. Part II: Retrospective cohort study was carried out
among cleft children with and without maternal exposure to cigarette
smoke during pregnancy. A total of 33 subjects were identified for
exposed (16 Males: 17 Females) and 32 were identified as non-exposed
(20 Males: 12 Females) with age range from 3 months to 10 years.
DNA was extracted from blood samples and amplified with PCR. Then
RFLP technique was used with enzyme Hinfl and Ncol for K region;
and Taq enzyme for Taq-1 region. Multiple Logistic Regression
modeling was used to estimate adjusted odds ratio of factors associated
with non-syndromic oral cleft.
Results : Significant factors include history of miscarriage (OR:
3.40; 95% CI: 1.05, 11.08) p=0.042; duration of exposure to second-
hand smoke for 15-30 minutes (OR: 2.41; 95% CI:1.42, 4.09) p<0.001;
duration of exposure > 30 minutes (OR: 5.16; 95% CI:2.87,
9.28)p<0.001 and occupation of the mother (OR: 2.26; 95% CI: 1.40,
75
 ABSTRACTS OF THESES APPROVED FOR THE M.SC., M.MED. AND PHD. DEGREES AT THE SCHOOL OF MEDICAL SCIENCES, UNIVERSITY SAINS MALAYSIA, HEALTH
CAMPUS, KUBANG KERIAN, KELANTAN, MALAYSIA.
3.64) p<0.001. Chi-square(X2) test detected a significant difference at
allele 4 at K region between exposed and non-exposed subjects (RR:
2.94, 95% CI:1.07, 8.06) but not at Taq-1 region.
Conclusion : This study showed that maternal exposure to second-
hand smoke during pregnancy was a significant risk factor for getting
a cleft child and also significantly associated with polymorphism of
oral cleft patients.
Dr. Noorliza Mastura Bt. Ismail (Supervisor)
Prof. Mohd. Nizam Isa (Co-supervisor)
(12) EFFECT OF DEWORMING ON COGNITIVE
PERFORMANCE OF RURAL PRIMARY
SCHOOLCHILDREN IN BACHOK, KELANTAN
Dr. Anees Abdul Hamid
M.Med Community Medicine
Department of Public Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Previous studies have found that helminthiasis to be
very common among school-aged children. This may be due to their
outdoor activities, poor personal hygiene and poverty. Helminthiasis
is also related to poor school performance. In this study, we are going
to determine the effect of deworming on cognitive performance of
rural primary school children in Kelantan.
Method : This study was a community trial involving 600
schoolchildren in Bachok from 6 primary schools (aged between 9
and 11 years) was undertaken. The sampling frame involved all 17
rural primary schools in Bachok, Kelantan. Based on the sample size
calculations, manpower and limitation of time, six schools were
randomly selected with 728 schoolchildren. One-stage cluster sampling
was used to choose the schools whereby all Standard 3 and Standard 4
children in the selected schools were recruited. At baseline,
questionnaires on socioeconomic and health data related with
helminthiasis were given, stool analysis and also cognitive performance
tests was done. The cognitive tests administered to each child were the
arithmetic test, coding test, digit span forward and backward tests.
These three tests were taken from the Wechsler Intelligence Scale for
Children. The other test given was the Raven’s colored progressive
matrices test. The schools were then randomly assigned into treatment
and control group. Each child in the treatment group received 400mg
albendazole while children in the control group were not given
anthelmintic until the end of the study. After 6 months all of the
cognitive tests were repeated.
Results : A total of 728 children from 6 schools were invited to join
this study. However, 600 children (82.4%) were enrolled, and 572
children (95.3%) completed the study after 6 months. There were 331
(55.2%) children aged 9-10 years and 269 (44.8%) children aged 10-
11 years. There were 290 (48.3%) girls and 310 (51.7%) boys. The
overall prevalence of total helminthiasis was 74.2% (n=445).
Prevalence of Trichuris trichiuria, Ascaris lumbricoides and
hookworms were 67.2% (95% CI: 63.4%, 70.9%), 49.7% (95%CI:
45.6%, 53.7%) and 1.2% (95%CI: 0.3%, 2.0%) respectively. On
baseline examination, children with helminthiasis scored significantly
lower than those uninfected in arithmetic test, coding test and Raven’s
colored progressive matrices test. However, in the digit span forward
test and digit span backward test, even though the scores were lower
in the infected children compared to those not infected, the differences
was not statistically significant. Male children are 1.57 times more
associated with helminthiasis compared to female students and children
who having number of children in the house- 5 and more were 2.54
times more associated with helminthiasis compared to those having
number of children less than 5. Following deworming with albendazole,
at 6 months, multivariate analysis using repeated measures ANOVA
76
showed significant difference in the coding test (Fi,57 = 5.41, P=^02)
and the Raven’s colored progressive matrices test (Fi,57 = 9.39, p=0.02)
between the treated and control group. However, the digit span
backward test, the arithmetic test and digit span forward test were not
significantly different in the 2 groups. After adjusting for infection
status and family income, almost similar result were noted whereby,
children in the treatment group had significantly higher scores for the
coding (Fi,56 = 5.33, p=0.02) and Raven’s colored progressive matrices
tests ( Fi,56 = 10.10, p=0.00) compared to the control group. However,
for 3 other tests, arithmetic, digit span forward and digit span backward
there were no significant different.
Conclusion : Children who have helminthiasis have generally poorer
cognitive performance. Gender and number of children in the family
were significantly associated with helminthiasis. There were
improvements in certain cognitive tests 6 months after children were
given anthelmintic. Mass deworming with single doses of oral
albendazole should be given to rural schoolchildren as it may improve
some aspects of their cognitive performance.
Assoc. Prof. Dr. Zulkifli Ahmad (Supervisor)
Dr. Azni Alias (Co-supervisor)
Dr. Mohamed Hashim Mohd Hassan (Co-supervisor)
Assoc. Prof. Dr. N. Kumaraswamy (Co-supervisor)
(13) THE EPIDEMIOLOGY OF PHYSICAL DISABILITY
AMONG ELDERLY IN KOTA BHARU, KELANTAN
Dr. Latifah bt Dahlan
M.Med Medicine (Epidemiology & Biostatistics)
Department of Public Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Globally, the decline in fertility and mortality as well
as improvement in life expectancy were said to be responsible for the
aging population. In Malaysia, the elderly population was 1.2 million
or 5.9% of the 20 million total population in the country in 1995. This
number was projected to increase to 11.3% by the year 2020. Elderly
population are prone to get chronic medical illnesses as well as physical
disability. This is a cross-sectional study to determine the prevalence
of physical disability and its associated factors among the elderly, aged
60 years and above.
Methodology : A total of 270 participants were taken randomly from
3 health clinics in the Kota Bharu operational areas by using multistage
sampling. Interviewer assisted -questionnaire were administered and
the subjects were asked to go to clinics or community center on the
appointed date for physical examination and blood taking for fasting
blood sugar and total cholesterol. Physical disability was measured by
activities of daily living (ADLs) and instrumental’s activities of daily
living (lADLs). ADLs is comprised of bathing, dressing, going to toilet,
transferring from bed or chair, continence, and feeding. Whereas IADLs
encompass the following domestic function : using the telephone, using
transportation, shopping, cooking, house-keeping, taking medication
and budgeting. The lADLs methods offer indicators of “ applied “
problem that extend the disability theme of ADLs scales to include
some elements of handicap concept. Physical disability was defined
as the inability to accomplish one or more ADLs or IADLs. Separate
multiple logistic regression was used to determine the associated factors
for both physical disabilities.
Results : The prevalence of physical disabilities in ADLs and lADLs
were 10.7% (95% CI:7.0%, 14.0%) and 34.8% ( 95% CL-29.0%,
41.0%) respectively. Significant risk factors of ADLs were age
(OR=2.67, 95%CI:1.11, 6.64), hearing impairment (OR- 2.54, 95%CI:
1.03,6.23), diastolic blood pressure (OR= 3.80, 95%CI:1.25, 11.58),
and total cholesterol (OR= 1.55, 95%CI: 1.07, 2.20).Whereas for IADL
the associated factors were age (OR=2.39, 95%CI: 1.19,4.83), income
(OR= 0.22, 95%C1.-0.08, 0.62),diastolic blood pressure (OR=2.02,
95%CI: 1.04,3.94), marital status (OR=2.38, 95%CI:1.23,4.61) and
obesity (OR=4.68,95%CI:1.54, 14.18). There was a strong significant
association between ADLs and lADLs (OR=9.01, 95%CI:3.40, 23.89).
The prevalence of physical disability for ADLs and lADLs was similar
with others studies. These findings also suggested that certain socio-
demographic characteristics (i.e age, income & marital status), life-
style behavior (obesity) and medical illnesses (hearing impairment,
total blood cholesterol and high diastolic blood pressure) were
significant risk factors of physical disability in elderly.
Conclusion : Physical disability in ADLs was strongly associated
with physical disability in lADLs. The majority of associated factors
of physical disability that were identified by this study can be modified
either by treatment, life-style change or special device. Public health
efforts to reduce prevalence of all these factors in both sexes should
continue.
Assoc.Prof. Dr. Dr. Aziz Al-Safi Ismail (Supervisor)
Dr. Hamzah Ag. Mat (Co-supervisor)
(14) EFFECT OF SCHOOL SUPPLEMENTARY
FEEDING PROGRAMME ON IMPROVING
NUTRITIONAL STATUS OFPRIMARY SCHOOL
CHILDEN IN RURAL AREAS OF TUMPAT AND
BACHOK DISTRICT
Dr. Che Asiah Taib
M.Med Family Health
Department of Public Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Undernutrition is a serious global problem especially
among developing countries. Undernutrition is still common among
poor rural children in Malaysia. The School Supplementary Feeding
Programme (SSFP) is one of the intervention strategies implemented
to improve the nutritional status of children in Malaysia.
Objectives : The objectives of the study were to determine the
prevalence of malnutrition, associated factors of underweight, stunting
and wasting and to evaluate the effect of School Supplementary Feeding
Programme on improving nutritional status among primary one children
in rural areas of Tumpat and Bachok districts.
Methodology : The study had 2 phases. Phase 1 was a cross-sectional
study and the Phase 2 was a cohort study. The study was done among
primary one children in rural areas of Tumpat and Bachok districts
from February 2002 to March 2003. Nine hundred and thirty seven
children from 18 primary schools were’ selected. Questionnaires
eliciting socio-economic and demographic informations were answered
by the parents. The weight and height of the children were measured
three times; before starting SSFP, after 6 months and after 12 months
of SSFP. The WAZ, HAZ and WHZ were calculated using Epi-Nut
Anthropometry software (Epi Info version 6). The prevalence of
malnutrition were calculated based on cutoff point ofz-score < -2 SD
as Undemutrition and > +2 SD as ovemutrition. The school
administration chose eligible children to participate in the SSFP.
Results : Five hundred and forty one children were enrolled in SSFP
and 396 were in non-SSFP group. The prevalence of underweight,
stunting and wasting at baseline were 25.2%, 21.1% and 6.2%
respectively. Only 1.1% of children were overweight. In multiple
logistic regression analysis the significant risk factors of underweight
were being male children (OR=1.4, P<0 05) Tumpat district (OR=1.5,
p<0.05) and monthly family income of RM 0-250 fOR=2.2, p<0.05)
and RM 251-500 (OR=2.3, p<0.05). Being a male children (OR=1.6,
p<0.05) was the only significant factor for stunting and working mother
(OR=2.1, n<0.05) was the only significant factor of wasting. Repeated
measures ANOVA showed there was significant different of increment
ofWHZ (p = 0.007) between SSFP and non SSFP group with regard to
time and adjusted for gender, district, family income group and baseline
nutritional status. However, no significant different ofWAZ (p=0.126)
and HAZ (p=0.266) with regard to time and group was found. In
conclusion, there is still a high prevalence ofundemutrition among
children in rural areas of Tumpat and Bachok. The condition was
associated with low socio-economic and demographic status of the
population.
Conclusion : The SSFP had significantly improved the nutritional
status of children with wasting. Also, the increment of WAZ, HAZ
and WHZ was better among undernourished children compared to
normal children.
Key words deworming, cognitive performance, rural, primary school children,
Bachok
Assoc. Prof. Dr. Zulkifli Ahmad (Supervisor)
Dr. Mohamed Hashim Mohd Hassan (Co-supervisor)
(15) THE STUDY OF OUTCOME AND SURVIVL OF
PATIENTS WITH CHRONIC MYELOID LEUKAEMIA IN
HOSPITAL UNIVERSITI SAINS MALAYSIA AND
HOSPITAL KOTA BHARU –A RETROSPECTIVE
ANALYSIS
Dr. Mat Zuki Bin Mat Jaeb
M.Med Internal Medicine
Department of Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : The Study of Outcome and Survival of Patients with
Chronic Myeloid Leukaemia in Hospital Universiti Sains Malaysia
and Hospital Kota Bharu - A retrospective analysis. There have been
several studies looking at the prognostic factors of survival in Chronic
Myeloid Leukaemia (CML).
Objectives : We undertook a retrospective study on all eligible CML
patients treated with hydroxyurea or busulphan in Hospital Universiti
Sains Malaysia (HUSM) and Hospital Kota Bharu (HKB) diagnosed
from 1 st January 1986 to 31 st august 2001, to determine the factors
which influence the outcomes and survival.
Methodology : A total of 72 patients were eligible for analysis, with
the assumption of Philadelphia chromosome were present in all of them.
Results :In our study the median age of diagnosis was 41 years old,
range from 14 to 77 years old with male to female ratio of 1.4 to 1.
Almost all (99%) had symptoms at presentation with 100% of patients
had splenomegaly and 87% had hepatomegaly. About 66% of patients
were in high-risk category with Sokal score of more than 1.2. In this
study, 56 patients died and remaining 16 patients still alive at the end
of the study. Overall median survival was 58 months. Univariate
analysis of prognostic factors for survival has revealed, bleeding
symptom, liver and spleen sizes, haemoglobin level, total white count
and percentage of basophil and percentage of blast in peripheral blood,
Sokal score at presentation and the outcomes were the factors that
significantly influenced survival (p <0.05). Multivariate analysis with
Cox regression test only showed bleeding symptom, percentage of
basophil, total white count and all the outcomes after treatment,
significantly influenced survival. From total of 72 patients, 40 (56%)
of them achieved complete haematological response (CHR). Out of
40 patients, 23 patients (57%) achieved CHR after 6 months of
treatment. Mean time that was taken to achieve CHR was 8.5 months.
Spleen size, haemoglobin level percentage of blast and Sokal score
significantly influenced the achievement of CHR (p < 0.05). The
analysis of factors, which influenced the time to achieve remission
showed only the presence of abdominal symptoms and percentage of
77
 basophil in peripheral blood were statistically significant. A total of 36
patients (90%) who had achieved CHR, remained in remission (CHR)
more than 12 months with mean duration of 12.3 months. In the analysis
of factors which influenced duration of CHR; only the time that was
taken to achieve CHR and liver size were statistically significant.
Conclusion : In summary, our study has confirmed several factors
which were proven to influence survival in previous studies. Though
in this study we were unable to show Sokal score as a prognostic factor
of survival in multivariate analysis, we believed that this could be
explained by the fact that majority of patients (66%) were in high-risk
category and our sample size was small.
Prof. Dr. Aziz Baba (Supervisor)
Dr. Abu Dzarr Abdullah (Co-Supervisor)
Dr. Tengku Norbani (Co-Supervisor)
(16) PATTERN OF TYPHOID FEVER AMONG ADULT
PATIENTS IN HUSM AND THE OUTCOME OF
TREATMENT COMPARING CEFTRIAXONE VERSUS
CHLORAMPHENICOL
Dr. Wan Hasnul Halimi bin Wan Hassan
M.Med Internal Medicine
Department of Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Typhoid fever is a well documented infectious disease
worldwide cause by Salmonellatyphi. It remains an endemic health
problem in Malaysia throughout the years and the state of Kelantan
had been reported to have the highest annual incidence. Unfortunately,
this far, there is no published report on the pattern of typhoid fever
among adult in Kelantan. We have taken the opportunity to look into
the pattern of typhoid fever among adult and study the outcome of
treatment using ceftriaxone and chloramphenicol.
Methods : This was a retrospective study. Records of all patients
admitted to Hospital Universiti Sains Malaysia from January 1996 to
March 2003 recorded to have typhoid were analysed. Only those who
were confirmed to have typhoid fever were studied.
Results : A total of 279 patients with confirmed typhoid were
reviewed and analysed. The incidence rate was 10.6 cases per 1000
admissions. The cases appeared to be sporadic through out the month
without any seasonal predilection. Demographic data reveals majority
were Malays (97.5%), almost the same male to female ratio (1.3: 1)
and from Kota Bharu district (72.4%). Most were students (50.9%)
with median age of 20. All patients had fever, mostly with chills and
rigors. Gastrointestinal symptoms predominate. Relative bradycardia
( 40.5%), hepatomegaly (46.2%) and splenomegaly (19.7%) were
among the predominating clinical signs. More than 90% of cases had
uncomplicated typhoid with no mortality. Majority had normal full
blood count results with only 15% anaemia, 14% leucopaenia and
34.1% thrombocytopaenia. Biochemical profile shows 56.6°/ had
hyponatraemia and 39.8% hypokalaemia. We observed that blood C&S
was highly specific but had a low yield ( 61.6%). Widal test provided
even lower yield f43 6%). EIA dot blot test provided a promising result
with high pick up rate (87.5%) and sensitivity (80%). We have found
that fever resolved significantly faster in patients treated with
ceftriaxone compared to chloramphenicol (3.9 days versus 4.8 days,
P0.05). The mean duration of therapy with chloramphenicol were
significantly longer than ceftriaxone ( 13.6 versus 5.2 days, P<0.05).
Patient treated with chloramphenicol also required longer hospital stay
(13.3 days versus 8 days, P0.05).
Conclusion : Typhoid fever in adult showed similar pattern compared
to previous study in terms of the incidence and clinical features.
Treatment of typhoid with ceftriaxone is better than treatment with
chloramphenicol in terms of shorter fever clearance time, duration of
78
treatment and hospital stay. Patient treated with ceftriaxone can be
discharge early compare to patients treated with chloramphenicol.
Assoc. Prof. Dr. Zainal Darus (Supervisor)
Dr. Tengku Norbanee (Co-Supervisor)
Assoc. Prof. Dr. Nazmi Mohd Noori (Co-Supervisor)
(17) METHICILLIN-RESISTANT STAPHYLOCOCCUS
AUREUS IN HUSM : A STUDY ON THE PREVALENCE,
RISK FACTORS AND THE COST OF TREATMENT OF
MRSA BACTERAEMIA
Dr. Sarimah Abdullah
M.Med Internal Medicine
Department of Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Methicillin-resistant Staphylococcus aureus (MRSA),
one of the major concerns of nosocomial infections, is particularly
alarming because due to its association with multiple resistance to other
antibiotics. The prevalence of MRSA infections varies from 5% to
more than 50%, depending on the characteristics and size of the
hospitals. In Malaysia, the prevalence of MRSA has increased from
23% in 1991 to 33% in the year 2000.
Objectives : The aim of this study is to determine the prevalence,
risk factors and treatment costs of MRSA bacteraemia in Hospital
Universiti Sains Malaysia (HUSM).
Methodology : A one-year cross sectional study, from the 1st July
2002 to 30th June 2003 was conducted in HUSM. Respondents included
264 patients with MRSA isolates, 99 patients with S. aureus bacteraemia
and 32 patients on vancomycin.
Results : The majority of patients were Malays. The mean rate of
MRSA isolates was 9.6 (range: 5.9 to 13.7) per 1000 admissions. The
prevalence of MRSA was 40.4% (95% CI; 31.0-50.0). The mean (SD)
duration of hospitalisation before isolation of MRSA was 14.16 (4.68)
days as compared to 3.88(1.11) days of methicillin-sensitive
Staphylococcus aureus (MSSA). The odds for patients to develop
MRSA bacteraemia were 7 times and 9.7 times higher if they were on
ventilation and had taken antibiotics, respectively. Adult patients
seemed to be protected from developing MRSA bacteraemia compared
to paediatric patients. The mean (SD) total cost for the 32 patients on
intravenous vancomycin was RM871.87 (643.15) and the median
(Inter-Quartile Range (IQR)) was RM695.39 (RM751.94). The mean
(SD) laboratory cost was RM63.37 (RM15.31). The median (IQR)
day costs and drug costs were RM381.70 (763.40) and RM266.39
(323.63) respectively. The mean (SD) and median (IQR) days that
attributed to MRSA bacteraemia were 3.13 (3.25) and 2.0 (4.0) days.
The median (IQR) length of hospitalization stay was 31.00 (31.50).
The presence of four significant risk factors and prolonged duration of
hospitalization in MRSA bacteraemia will give impact to patients as
well as hospital.
Conclusion : The current requirement for prolonged parenteral
antibiotic therapy, particularly intravenous vancomycin for MRSA
bacteraemia, remains a major constraint in reducing the length of acute
hospitalization and costs of patient care. The high treatment costs
indicate that the economic burden associated with MRSA is substantial
and these costs are likely to increase if the rate of MRSA continues to
rise further.
Assoc. Prof. Dr. Mohamed Rusli Abdullah (Supervisor)
Assoc. Prof. Dr. Mohd. Radzi Johari (Co-supervisor)
(18) QUALITY OF LIFE AMONG PATIENTS ON
REGULAR HAEMODIALYSIS: COMPARING DIABETIC
VERSUS NON-DIABETIC GROUPS
Dr. Amir bin Ramli @ Shaari
M.Med Internal Medicine
Department of Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Generally, end stage renal failure patients have lower
quality of life compared to healthy individual. Among ESRD group,
diabetic patients on regular haemodialysis have lower quality of life
(QOL) compared to non-diabetic patients. The main objective of this
study is to prove that the lower quality of life seen among diabetic
patients on regular haemodialysis was due to inadequate amount of
dialysis therapy given to them.
Method : This was a cross sectional study done from January to
June 2003 in all haemodialysis patients in Renal Care private
haemodialysis centre and Hospital Universiti Sains Malaysia who
fulfilled our selection criteria. They were interviewed using a set of
WHOQOL-BREF questionnaire (Malay version) contains twenty six
QOL questions; with two questions concerning the general health and
satisfaction of QOL, while the remaining twenty four items made up
physical , psychological, social and environment components. In
addition, their blood parameters such as renal function, haemoglobin,
haematocrit, serum albumin and serum parathyroid hormone were
analysed. At the same time, the adequacy of amount of dialysis was
measured by urea kinetic modelling (Kt/V).
Result :This study demonstrated that end stage renal failure patients
have significant lower mean scores in physical, psychological and
environmental components of QOL compared to the healthy population
despite no significant difference in gender, ethnic composition, marital
status and social class in both groups. However, the mean age of healthy
population was younger compared to end stage renal failure (p=0.05).
At the same time, this study established that among ESRD patients on
regular dialysis, the diabetic group has significant lower physical’s
mean scores (11.4±: 2.5 Vs. 13.2 ± 2.4) and significant lower
psychological mean score (11.9 ± 2.6 Vs. 13.5 ± 2.8) compared to
non-diabetic even with no significant difference in age, gender, ethnic
composition, marital status, social class, haemoglobin, haematocrit,
nutrition, and parathyroid hormone. Even though diabetic patients have
significant lower mean score in physical and psychological components
of QOL, they were given the similar amount of dialysis treatment
compared to non-diabetes (1.2 ± 0.2 Vs. 1.3 ± 0.3) with p = NS.
Conclusion : Despite similar amount of dialysis treatment, diabetic
patients with ESRD on regular haemodialysis still have lower physical
and psychological components of QOL compared to non-diabetic
patients. This may suggest that the reason why diabetic patients have
lower QOL is not due to inadequate dialysis treatment but perhaps
they require higher amount of dialysis prescription for better QOL.
Future interventional study is required to prove this hypothesis.
Assoc. Prof. Zainal Darus (Supervisor)
Assoc.Prof. Dr. Hasanah Che Ismail (Co. supervisor)
(19) RANDOMISED PLACEBO CONTROL TRIAL ON
THE EFFECT OF DIFFERENT DOSES OF RAMIPRIL
ON ARTERIAL STIFFNESS IN PATIENT AT HIGH RISK
O CARDIOVASCULAR EVENTS
Dr. Suhairi Ibrahim
M.Med Internal Medicine
Department of Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : ACE inhibitors have proven benefits in a broad range
of patients at high risk for cardiovascular events. Despite the abundant
evidences for its cardio-protective and vasculo-protective effects, it is
still underutilized and is used sub-optimally. This is because physicians
are worried of the risk for adverse events if a higher dosage of ACE
inhibitors is used. However, the maximum benefit of ACE inhibitors
may not be seen if the dose is underutilized. The main objective of this
study is to compare the effects of different doses of ACE inhibitors on
arterial stifness and microalbuminuria, the proven surrogate markers
for cardiovascular disease.
Methods : A randomised double blind placebo control trial was
designed. There were 4.0 patients randomised into four groups; placebo,
2.5mg, 5mg and l0mg ramipril. Patients were followed up for 3 months.
The primary end point was to look at the effects of different doses
ACE inhibitors on arterial stiffness. Arterial stiffness was assessed by
augmentation index and pulse wave velocity (PWV) using automated
SphygmoCor® machine. Besides arterial stiffness, the study was also
looked at the effects of ACE inhibitors on microalbuminuria. Urine
micro albumin was measured by using dipstick test. Other measurement
obtained were blood pressure, height, weight, full blood count, renal
and liver function test, fasting blood sugar, HbAlc, total cholesterol
and triglyceride.
Result : There were no significant differences in baseline
characteristics between groups except total cholesterol was higher in
the placebo treated group. Towards the end of the study, there was a
clear trend of reduction in augmentation index and pulse wave velocity
(PWV) with l0mg ramipril but not with other doses (placebo, 2.5mg
and 5.0mg ramipril). However, the reduction was statistically not
significant. For microalbuminuria, there was a higher proportion in
placebo treated group to develop positive microalbuminuria compared
to ramipril treated groups at final visit. There were six patients (15%)
who developed adverse events throughout study period and no
significant difference between placebo, 2.5mg, 5.0mg and 10.0mg
treated groups.
Conclusion : Work from this dissertation shows that arterial stiffness
in patients with high cardiovascular risk can be lowered using l0mg
ramipril, but not at the dose of 2.5 or 5.0mg. There was no significant
different in adverse events when comparing l0mg ramipril with lower
doses and even placebo. Ramipril also reduced the progression of
microalbuminuria compared to placebo. This result indirectly showed
that l0mg ramipril should be used in patients with high risk for
cardiovascular disease to get the optimum benefit. These findings are
in line with results from clinical trials which looked at clinical outcomes.
Prof. Dr. Abdul Rashid Abdul Rahman (Supervisor)
Dr. Thann Winn (Co-Supervisor)
Dr. Amir Hakim Hj. Basri (Co-Supervisor)
(20) SEROPREVALEMCE AND DEMOGRAPHIC DATA
OF HEPATITIS C IN TIPLY TRANSFUSED
THALASSAEMIA PATIENTS IN HUSM
Dr. Hasaruddin Ridzal Hanafi
M.Med Pediatrics
Department of Pediatrics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : The population of multiply transfused thalassemic
patients was at higher risk for HCV infection due to its blood-to-blood
route of transmission.
Objectives : The main objective of this study was to determine the
seroprevalence of anti HCV antibody in multiply transfused
thalassaemia children.
Methodology : A retrospective study was done in paediatric
hematology-oncology ward in Hospital Universiti Sains Malaysia, a
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 tertiary unit hospital on the northern-eastern side of peninsula Malaysia
in the state of Kelantan. Subjects included all thalassaemia patients
who required blood transfusion equal or more than twice per year who
are under follow-up in HUSM. Anti-HCV status was determined using
HCV EIA 3.0. Data were analyzed using SPSS version 11.0 and
statistical methods used were Chi Square, Fischer exact test,
independent t-test, Mann-Whitney test and multiple logistic regression.
Result : A total of 39 patients were included in the study. All subjects
come from Kelantan and Besut district in Terengganu. The mean age
of patients was 11.4 years, ranging from 2 to 19 years old. There were
34 Malays, 4 Chinese and 1 Siamese patients. The seroprevalence of
anti-HCV positive was 35.9%. The seroprevalence of anti-HCV
antibody positive was found to be associated with the timing of blood
transfusion before donor screening was started (OR = 10.7, p = 0.007).
However, it was not associated with age of the patient (p = 0.45), gender
(p =0.1), race (p = 0.06), frequency of blood transfusion (p = 0.08),
splenectomy status (p = 0.97) and type of thalassaemia (p = 0.12).
There was no significant difference in ALT levels between anti-HCV
positive and negative patient (p = 0.25).
Conclusion : This is a preliminary data on seroprevalence of anti-
HCV positivity in thalassaemia patients in HUSM Kubang Kerian.
The results showed about 36% of our multiply transfused thalassaemia
patients had positive anti-HCV and it is associated with donor screening
program.
Dr. Ariffin Nasir (Supervisor)
Dr. Noorizan Haji Abdul Majid (Co-supervisor)
(21) NOCTURNAL ENURESIS (NE) IN HEALTHY 8-
YEAR-OLD SCHOOL CHILDREN FROM EAST COAST
OF MALAYSIA: PREVALENCE AND PARENTAL
PERCEPTION.
Dr. Md. Nazim Abu
M.Med Pediatrics
Department of Pediatrics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Enuresis is a common problem among young
children. It has puzzled families and professionals for centuries.
Prevalence figures are therefore needed to estimate the scope of the
problem. The identification of associated risk factors in our society
would assist further intervention and management strategies. Parental
behavior regarding perception of the disease and methods of treatment
were also examined in this study.
Objectives : Our main objective was to determine the prevalence of
enuresis in healthy 8-year old school children in our community. This
study also evaluated the associated risk factors and the effects of family
characteristics on enuretic children. Finally, to identify parental
perception of nocturnal enuresis and the common methods of enuresis
management.
Methodology : A community based, cross-sectional study was
conducted from October to November 2001. A total of 1339 set of
questionnaires were distributed to parents of all standard two, school
children attending eight primary schools in the district of Kota Bharu.
The ICD-10 definition of enuresis was used.
Results : The overall response rate was 83.3%. Nocturnal enuresis
was reported in 121 out of 1075 children (11.3%), primary nocturnal
enuresis in 95 children (8.8%) and secondary nocturnal enuresis in 26
children (2.4%). Fifty-five (45.5%) of these children had two or more
wet nights per week. There were 55.4% (67) boys and 44.6% (54)
girls with enuresis. 52% of those with primary enuresis had a positive
family history. Using multivariate logistic regression analysis,
independent risk factors for nocturnal enuresis were Malay ethnicity
compared to non-Malay ethnicity (OR 1.8, 95% Cl 1.1-2.9%) and loss
80
of loved ones (OR 2.3, 95% Cl 1.2-4.2%). A protective factor was
achieving high score in examination results (OR 0.99, 95% Cl 0.981-
0.999%). The majority of parents with enuretic children 61.8% (63/
102) were not aware that enuresis is abnormal and majority (61.8%)
of these children received punishment. 90.7% (88/97) of the parents
treated the children themselves, 19.6% (19/97) sought modern medicine
and 27.8% (27/97) practiced traditional method. Parental belief
regarding the causes of enuresis and frequent methods of treatment
corresponded well with other studies.
Conclusion : The prevalence of nocturnal enuresis in healthy 8-
year old school children was comparable to that found in western studies
but the parental understanding and its effect on the child was still poor.
Malay ethnicity and loss of loved ones were significant risk factors
and a high score in examination was a protective factor. The
psychosocial impact on the child and the family needs to be addressed,
and the public should be made aware of options for treatment, and
their availability, for this common problem.
Assoc. Prof Dr. Nik Zainal Abidin Nik Ismail (Supervisor)
Assoc. Prof Dr. Amin Hans Van Rostenberghe Co-
Supervisor)
(22) KAWASAKI DISEASE : A 15-YEAR REVIEW OF
CLINICAL SPECTRUM AND OUTCOME AT HOSPITAL
UNIVERSITI SAINS MALAYSIA, KELANTAN
Dr. Nik Rosenorleyaney bt Nik Ibrahim
M.Med Pediatrics
Department of Pediatrics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Kawasaki disease(KD) is not an uncommon disease
in Malaysia. It is a febrile systemic vasculitic illness also known as
Infantile Acute Febrile Mucocutaneous Lymph Node Syndrome
(MCLS). Kawasaki disease was first reported in Japan in 1967 and
later has been reported all over the world. It is more common among
Asian populations, especially the Japanese. The diagnosis of Kawasaki
disease is important because of the associated acquired cardiac lesion
that leads to high morbidity and mortality especially in untreated
children and young adults.
Methods : This study is a 15-year retrospective study (1987-2001)
of paediatric patients at a tertiary health centre Hospital Universiti Sains
Malaysia, situated in the northeast of Penisular Malaysia. All patients
records who had been diagnosed to have Kawasaki disease based on
‘ICD 10’ from the ‘INFORMIX’ and ‘Lifeline 2000’ Hospital Universiti
Sains Malaysia filing systems were reviewed. Subjects were selected
only if they fulfilled the criteria for Diagnostic guidelines of Kawasaki
disease, the 5th Revised Edition, February 2002 for either classic or
atypical Kawasaki disease since no specific etiology or diagnostic test
is available. All the data regarding clinical presentations, laboratory
data, echocardiography and imaging studies, complications, underlying
cardiac abnormality, as well as management in Kawasaki disease
patients were recorded.
Results : From 35 records analyzed, only 28 patients were found to
have Kawasaki disease based on diagnostic criteria of Kawasaki
disease. Patients’ ages range from 3 to 120 months with the median
age of 24 months (mean age of 36 months) with 82% of cases being
less than 5 years. Malay was the commonest ethnic group (82%) with
a male to female ratio of 1.2:1. Of all Kawasaki disease patients,
2(7.1%) patients were diagnosed as atypical KD and 1(3.6%) patient
was diagnosed as recurrent Kawasaki disease. Almost all patient
27(96.4%) presented with a fever duration of 5 days or more. Common
presenting clinical features were development of a body rash in
25(89.3%) patients, extremities changes either swollen or desquamation
in 23(82.0%) patients, cervical lymphadenopathy in 22(78.6%) patients,
mucosal changes in 22(78.6%) patients and conjunctivitis in 18(64.3%)
patients. For associated symptoms in KD, only 4(14.3%) patients had
central nervous systems manifestation, 3(10.8%) patients presented
with acute abdomen for which 2(7.1%) patients underwent laparotomy,
and 4(14.3%) patients had diarrhoea, otitis extema, pneumonia and
upper respiratory tract infection. Most patients had evidence of an acute
phase response with elevation of erythrocyte sedimentation rate, C-
reactive protein and neutrophils. Thrombocytosis occured towards the
end of the second week of illness. Only 2(8%) patients were found to
have hydrops gall bladder by ultrasonography. Twenty five (89.3%)
patients had echocardiography done and of these 7(28%) patients had
abnormal coronary artery dilatation in which 1(4%) patient had a giant
aneurysm of the coronary artery. In this study, a total of 12(42.8%)
patients received intravenous immunoglobulin in which 10(35.7%)
patients received high single dose of immunoglobulin and 2(7.1%)
patients received low dose of immunoglobulin. High dose of aspirin
was administered in 18(64.4%) patients followed by 21(75%) patients
who received low dose of aspirin. Only 1(3.6%) patient received
methylprednisolone for prolonged fever of more than 2 weeks with
unresolved giant aneurysm. All patients who were diagnosed as
Kawasaki disease survived with no long term complications or
disabilities.
Conclusion : Even though the number of cases of Kawasaki disease
patients in this study were small, the disease still accounts for significant
morbidity in the paediatric population. The cardiac complications were
still high in which 7(28%) patients were affected. Lack of awareness,
late recognition and the delayed initiation of treatment in this disease
increase the number of complications. Therefore the diagnosis of
Kawasaki disease should be considered in any child, regardless of the
age, who presents with persistent fever, some signs of mucocutaneous
inflammation and laboratory values associated with severe systemic
inflammation such as elevation in ESR, CRP and thrombocytosis.
Assoc. Prof. Dr. Sharifah Ainon bt. Ismail Mokhtar
(Supervisor)
Dr. Fuziah Md. Zain (Co-Supervisor)
(23) VALIDATION OF MALAY VERSION SHORT-FORM
GERIATRIC DEPRESSION SCALE AND STUDY OF
PREVALENCE OF MAJOR DEPRESSION SCALE
STUDY OF PREVALENCE OF MAJOR DEPRESSION
AND ITS ASSOCIATED PSYCHOSOCIAL FACTORS
AMONG ELDERLY INPATIENTS AT UNIVERSITY
SAINS MALAYSIA HOSPITAL.
Dr. The Ewe Eow
M.Med Psychiatry
Department of Psychiatry
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Depression is prevalent among the elderly physically
ill inpatients and has important clinical implications, but often under
recognized and under treated. There is no previous Malaysian data on
the prevalence of major depression among the elderly inpatients.
Objectives : This study aimed to validate the Malay version of the
short form Geriatric-Depression Scale (GDS) in order to determine
the prevalence of major depression and its associated psychosocial
risk factors among the elderly inpatients hospitalized for general
medical condition.
Methods : The study consisted of 2 stages. First, the validation of
the Malay version-GDS; followed by a cross sectional prevalence study,
participated by 271 elderly inpatients. Data were collected using a self-
administered questionnaire, the validated Malay version-GDS and
WHOQOL-BREF. Major depression was defined as score above the
optimum cut-off point on Malay version-GDS determined at the
validation study.
Results : The validation study showed the item-9 from Malay
version-GDS-15 had no minatory value in differentiating cases and
non-cases and poorly correlated with the total corrected item score.
By omitting the item-9, the newly formed scale, M-GDS-14, has
satisfactory reliability and validity as a screening scale for depression
among physically ill elderly inpatients. At the cut off point of 7/8, the
M-GDS-14 had 100% sensitivity and 92.0% specificity in detecting
major depression. The overall prevalence for major depression was
37.3%, 25.9% for male and 45.8% for female. Under multivariable
analysis, the female to male odds ratio for major depression was 2.2 (p
= 0.03). Those depended on working as the primary source of personal
income, were at significant higher risk than pension group for major
depression (OR = 7.8). The self-rating of relatively having enough
money to meet needs, satisfactory personal relationship, adequate
accessibility to information needed and opportunity for leisure activities
were all significant protective factors against major depression.
Conclusion : The prevalence yielded in this study was relatively
high. Clinician should be aware of this highly comorbid condition along
with patients’ physical illness. Good social resources play important
role in preventing major depression in the elderly inpatients.
Key Words : Geriatric Depression Scale, prevalence, major depression, elderly,
inpatient, physical illness.
Assoc. Prof. Dr. Hasanah Che Ismail (Supervisor)
Dr. Mohd Ayub Haji Sadiq (Co-Supervisor)
Dr. Syed Hatim Noor (Co-Supervisor)
(24) A STUDY ON VALIDATION OF BRIEF PATIENT
HEALTH QUESTIONNAIRE (PHQ-9) AMONG ADULT
ATTENDING FAMILY MEDICINE CLINIC AT HOSPITAL
UNIVERITI SAINS MALAYSIA
Dr. Nor Azah bt Mohamad Nawi
M.Med Family Medicine
Department of Family Medicine,
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : Validation of Malay version of the Brief Patient Health
Questionnaire among adult attending Family Medicine Clinic,
Universiti Sains Malaysia Hospital to determine the suitability of this
questionnaire before it can be used for Malaysian population,
consequently to use it for screening of depression among adult attending
primary health care services.
Material and Method : Initially, the back to back translations of
Brief Patient Health Questionnaire (PHQ-9) were done and a Malay
version was produced. Then, a validation study was conducted
involving 265 adult patients attending Family Medicine Clinic, Hospital
Universiti Sains Malaysia. All of 265 patients were asked to complete
the Malay version of PHQ-9. All of patients with positive scores (141
patients with score more than 5) and few of patients with negative
scores (39 patients with score 4 and less) were then interviewed by
using the Composite International Diagnostic Interview (CIDI). They
were also assessed with Hamilton Depression Rating Scale (HDRS)
and Hospital Anxiety and Depression Scale (HADS). The validity of
PHQ-9 was tested against this clinical diagnosis and the concurrent
validity against HDRS and the Malay version of HADS was also
evaluated.
Results : The best cut-off score of the Malay version of PHQ-9 was
5 with the sensitivity of 69.0% and specificity of 60.5%. The best cut-
off score for severe depression was 10 with sensitivity of 60.9%,
specificity of 80.7% and positive predictive value of 38.6%. The PHQ-
9 was significantly correlated with HDRS (r =0.68, p < 0.001) and
HADS (r =0.69, p < 0.001)
81
 Conclusion : The Malay version of PHQ-9 is a valid and reliable
screening tool for detection of depression in primary care. However
the sensitivity and specificity of this tool is quite low and this is may
be related to the different understanding and cultural variation of
depression between Kelantan population and Western population.
Dr. Shaiful Bahari Ismail (Supervisor)
Dr. Juwita Shaaban (Co-Supervisor)
(25) A CROSS SECTIONAL STUDY ON ORAL
ANOMALIES AND SPEECH ABNORMALITY AMONG
OPERATED NON-SYNDROMIC CLEFT LIP AND
PALATE CHILDREN IN KELANTAN
Dr. Nor Normastura bt Abd. Rahman
M.Med Community Medicine Oral Health
Objectives : To determine the prevalence of various types of dental
anomalies as well as facial profile and speech abnormality and its
association with Non-syndromic CLP children compared to non-cleft
children. The dental arch dimension were also determined and
compared between the two groups.
Methodology : A comparative cross sectional study was conducted
from July 2002 to January 2003. Case group comprised of 98 operated
Non-syndromic CLP children-unilateral (UCLP) and bilateral (BCLP)
who attended the Combined Clinic while the comparison group
comprised of 109 non-cleft children who attended the outpatient clinic
at the Kota Bharu Dental Clinic. Their ages were between 3 to 12
years old. Socio-demographic data were obtained and examination for
oral anomalies in terms of dental (morphology, number and alignment)
and facial profile as well as speech assessment was done. Data were
entered and analyzed in SPSS version 11.0.
Results : The prevalence of anomalies in morphology of teeth in
CLP was 24.5% (95% CL15.82, 33.16) and non-cleft was 10.1% (95%
Cl: 4.35, 15.84), number of teeth in CLP was 44.9% (95%: Cl 34.87,
54.92) and non-cleft was 7.3% (95% Cl: 2.37, 12.31), mal-alignment
in CLP was 79.6% (95% Cl:71.47, 87.71) and non-cleft was 27.5%
(95% Cl: 19.00, 36.04), facial profile in CLP was 26.5% (95% CM
7.63, 35.43) and non-cleft was 9.1 % (95% Cl: 3.67, 14.68) and speech
abnormality in CLP was 61.2% (95% Cl: 51.41, 71.04) and non-cleft
was 0.9% (95% Cl: -0.09, 2.74). The results also showed significant
association between CLP and anomalies in morphology (OR= 3.80,
95% Cl: 1.68, 8.61), number (OR= 15.26, 95% Cl: 6.18, 37.65), mal-
alignment (OR = 23.67, 95% Cl: 9.93, 56.40), abnormality in facial
profile (OR =5.10, 95% Cl: 2.17, 12.00) and speech (OR= 174.45,
95% Cl: 23.04, 1320.67); (p < 0.05). The dental arch dimension also
showed significant difference between CLP and non-cleft group;
maxillary arch dimension (Mean difference = -0.24 cm, 95% Cl: -
0.38, -0.11) and mandibular arch dimension (Mean difference= 0.17
cm, 95% Cl: 0.06, 0.29); (p<0.05).
Conclusion : There were a high prevalence and risk of having dental
anomalies, facial profile and speech abnormalities in CLP children
compared to non-cleft children. The dental arch dimension was also
significantly different between CLP and non-cleft group. Therefore
CLP children required a multidisciplinary management leading to long
duration of treatment and involving high cost. A reasonable protocol
for management should be developed to improve the standard of care
for benefit of these groups of patients.
Dr. Nizam Abdullah (Supervisor)
Dr. Mohd. Ayub Sadiq @ Lin Naing (Co-Supervisor)
(26) A STUDY OF NEEDLE-STICK INJURIES AND
ASSOCIATED FACTORS AMONG STAFF NURSES IN
HOSPITAL UNIVERSITI SAINS MALAYSIA, KUBANG
KERIAN, KELANTAN.
82
Dr. Anita Suriani bt Abdul Shukor
M.Med Community Medicine
Occupation Health
Department of Community Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Needle-stick injury is the commonest injury reported
among health care workers and nurses are being identified as having
the highest risk of needle-stick injuries by several studies.
Objective : To determine the prevalence of needle-stick injury among
nurses and associated factors contributing toward needle-stick injuries.
Methodology : A cross-sectional study was done in January 2003 to
December 2003. Two pilot studies were done to validate the
questionnaire. Out of 386, 355 nurses responded giving a response
rate of 92%. Data was collected through self-administered questionnaire
in nurses randomly selected based on a name list provided by the
Matron. A walk-through survey was subsequently done to assess the
workplace’s safety and risk profile. All 42 workplaces were assessed
using Ministry of Health’s format. For the questionnaire, factor analysis
extracted three common factors for knowledge and 2 common factors
for attitude. Cronbach alpha values from 0.49 to 0.67 in the reliability
analysis showed that the questionnaires were reliable and valid.
Results : Results show that the prevalence of needle-stick injury
among staff nurses was 37% (95% CI 32% - 42%). In this study, there
was no significance difference of mean score of KAP noted between
injured nurses and non-injured nurses. Simple logistic regression
showed that the presence of Hepatitis B immunization (crude OR 2.49,
95% CI 0.88-7.02), working in high-risk area (crude OR 0.58, 95%CI
0.351-0.96) and total practice score (crude OR 0.95, 95% CI 0.89 -
0.99) were significantly associated with needle-stick injuries. However,
multiple logistic regression analysis showed that Hepatitis B
immunization (adjusted OR 2.82, 95% CI 1.03-7.76) was significantly
associated with needle-stick injuries among staff nurses. A walk-
through survey revealed that 95.2% of work places were good in term
of health and safety and only 4.8% were fair. Some of the pitfalls noted
and can be improved.
Conclusion : We conclude that Hepatitis B immunization status was
significantly associated with needle-stick injuries among staff nurses
in HUSM.
Keywords : needle-stick injuries, staff nurses, sharp container, blood-borne
disease, universal precaution, HUSM
Prof. Rusli Nordin (Supervisor)
Dr. Mohd. Ayub Sadiq @ Lin Naing (Co-Supervisor)
(27) A PILOT STUDY: PREVALENCE OF NEGATIVE
PLAIN CT AND POSITIVE PERFUSION CT SCAN IN
CASES OF ACUTE STROKE
Dr. Khoiri bin Man
M.Med Radiology
Department of Radiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Computed Tomography (CT) scan is the usual
imaging modality used to diagnose acute stroke in most major hospitals.
Previously, the purpose of plain CT scan in acute stroke was to exclude
intracerebral haemorrhage. The introduction of recombinant of tissue
Plasminogen Activator (rtPA) as a mode of treatment in acute stroke
has changed the role of CT scan. Stroke patient who received treatment
with rtPA can develop intracerebral haemorrhage. Therefore, correct
selection of patient who is suitable for thrombolysis is important. CT
perfusion study is a new method to diagnose infarction in cases of
normal plain CT scan. It also identifies the area of ischemia and size
of infarction.
Objectives : The aim of this study is to determine the number of
cerebral infarction cases in Hospital USM where there is normal plain
CT scan and abnormal Perfusion CT.
Material and Methods : Forty two consecutive plain and perfusion
CT examinations of brain in patients 12 years and above perform from
August 2002 to August 2003 were evaluated qualitatively. Plain CT
scan was performed in patients presented with acute stroke symptoms
followed by Perfusion CT. A registrar and radiologist reviewed both
CT scans at different sitting. The qualitative parameters were normal
and abnormal plain and Perfusion CT. The area of penumbra was
determined from CT Perfusion.
Result : Twelve out of 42 cases were found to have normal plain CT
scan. Nine out of these 12 patients were positive for infarction in
Perfusion CT scan. Two out of 12 cases turned out to be transient
ischemic attack and one case, CT perfusion was normal even though
patient showed signs and symptoms of acute stroke. The prevalence of
negative plain CT scan and positive perfusion CT for acute stroke in
Hospital USM from August 2002 to August 2003 was 21.3%.
Conclusion : CT perfusion is a useful imaging tool for determining
ischemia and infarction in cases where the plain CT scan is normal. It
is available 24 hours and suitable in emergency situation unlike
Magnetic Resonance Imaging (MRI). The results obtained from CT
perfusion scanning used to determine mode of treatment suitable for
acute stroke patients.
Dr. Mohaideen Abdul Kareem (Supervisor)
Dr. Wan Asim Wan Omar (Co-Supervisor)
Dr. Atul Prasad (Co-Supervisor)
(28) THE DETERMINATION OF BONE MINERAL
DENSITY OF LOCAL MALAY FEMALE AND ITS’
CORRELATION WITH GEOMETRIC PROPERTIES IN
THE EVALUATION OF SKELETAL STATUS
Dr. Lee Cheng Wai
MMed Radiology
Department of Internal Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Currently the recommended method to measure bone
mineral density (BMD) is Dual Energy X-Ray Absorptiometry (DEXA)
which is costly and not widely available. BMD is the ratio of bone
mineral content to bone area and does not represent the real bone
density. Therefore by incorporating geometric properties, a lower cost
tool to measure BMD and screening for osteoporosis can be achieved.
Objectives :
1) To obtain bone mineral density of normal Malay women.
2) To determine the correlation of geometric properties and BMD.
Methods and materials : A total of 137 Malay female volunteers
who had given a written informed consent underwent DEXA of the
spine, dual femur and total body. There were six age group from third
to eight decade. This was followed by radiograph of the non-dominant
hand which was later used for digital x-ray radiogrammetry (DXR)
and geometric properties (GP) calculation. Local Malay female
reference curves derived from BMD of vertebral, dual femur and total
body plotted against age. Correlation of BMD and geometric properties
which consist of inner diameter(ID), outer diameter (OD), cortical
thickness(CT), metacarpal index (MCI), cortical area (CA), polar
moment of inertia (J) and section polar moment (Z) were analysed.
Multiple linear regression were performed to determine variables in
prediction of vertebral BMD(VTBMD), dual femur BMD (DFBMD)
and total body BMD (TBBMD). Rationship between BMD measured
by DXR (DXRBMD) with VTBMD, DFBMD and TBBMD were also
performed.
Results : Graphs of VTBMD, DFBMD and TBBMD versus age
group was obtained from the mean and standard deviation. The highest
BMD of vertebral, dual femur and I total body were from the 40-49,
30-39 and 50-59 age group respectively. The local BMD corresponding
to -2.0SD from the peak adult value for vertebral and total body were
9% and 0.7% respectively lower compared to the Caucasian reference
data (U.S/Europe) whereas the value for dual femur was 5% higher
than the Caucasian. In the statistical analysis of BMD and GP, fair
correlation were found between CT and MCI of second, third and fourth
metacarpal with BMD particularly of dual femur and total body. The
correlation between dual femur and CT was r = 0.299-0.372 and MCI
was r = 0.280-0.310. The correlation between total body and CT was r
= 0.269-0.448 and MCI was r = 0.264-0.320. Cortical area (CA) of
second metacarpal has greater correlation with BMD compared to third
and fourth metacarpal. No correlation between section polar moment
(Z) and polar moment of inertia (J). Good to excellent correlation
between BMD measured by DXR with ID, OD, CT, MCI and CA of
second ( r = -0.404, 0.175, 0.675, 0.526, 0.500) third (r = -0.453, 0.253,
0.753, 0.598, 0.551 and fourth ( r- -0.402, 0.189, 0.618, 0.516, 0.473)
metacarpal. In multiple linear regression analysis, two models age-
CA2 and age-CT2 in addition to weight improved the prediction power
of VTBMD. Age and CT2-age in addition to weight also improved the
prediction power of DFBMD. In the prediction of TBBMD, the
significant variables were derived from models weight-CA2-J2-age-
Z2 and weight-CT2-age. When correlation of GP and BMD were based
on age group, the 20-29 age group has greater association than the rest
of the age group. There were also fair correlation of BMD measured
by DXR with BMD of vertebral (r = 0.369, dual femur (r = 0.455) and
total body (r = 0.443).
Conclusion : A local Malay female BMD reference database has
been established and there were differences in VTBMD, DFBMD and
TBBMD value compared to Caucasian BMD. The combination of GP
and BMD in the assessment of fracture risk are possible. DXR may
become a lower cost tool for follow up cases as well as for screening
of osteoporosis in view of fair correlation between DXRBMD with
VTBMD, DFBMD and TBBMD. Excellent correlation between non-
dominant hand BMD measured by DXR and GP obtained from same
hand radiograph, indicates correlation of GP and BMD is also site
specific.
Dr. Haji Abdul Kareem (Supervisor)
Assoc. Prof. Dr. Hj. Ibrahim Lutfi Shuaib (Co-Supervisor)
Dr. Mohd. Ezane Aziz (Co-Supervisor)
(29) CAROTID INTIMA-MEDIA THICKNESS AS AN
INDEPENDENT PREDICTOR OF CORONARY ARTERY
DISEASE - A STUDY IN HOSPITAL UNIVERSITI SAINS
MALAYSIA (HUSM)
Dr. Wan Mohd. Razin bin Wan Hassan
MMed Internal Medicine
Department of Internal Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : A cross sectional study to measure the common
carotid artery intima-media thickness (IMT) was conducted on patients
who had undergone coronary angiogram in Hospital Universiti Sains
Malaysia since it was started in October 2002.
Objective : The aim of this study is to determine the association
between carotid IMT with the severity of the coronary angiographic
result. This study also aims to look for the association between the
83
 coronary artery disease (CAD) risk factors with IMT.
Methodology : Common carotid IMT was measured by ultrasound
in 274 subjects of mean age 55.8 ± 9.6 (standard deviation) years (range,
30 to 84 years) whether as outpatient or in-patient- i.e. before or after
the procedure.
Results : Mean carotid IMT was 0.818 ± 0.235 (SD) mm (range,
0.374 to 2.060 mm). Coronary angiograms were analyzed for disease
severity by using vessel score (number of vessels with ≥ 70% stenosis),
or stenosis score (Gensini score). It was found that mean carotid IMT
had fair and significant positive correlation with CAD severity, r =
0.279 for vessel score, and r = 0.396 for Gensini score (p < 0.001).
Increasing age, male sex, history of smoker, total-cholesterol, and
duration of diabetes were all associated with a significantly (p < 0.05)
higher value of IMT. However, only male sex, presence of diabetes,
and IMT value were considered as predictors for severity of coronary
artery disease, suggesting differential effects of these traditional risk
factors on the coronary and common carotid arteries.
Conclusion : Measurement of common carotid artery IMT was also
found to become clinically useful as a screening test for coronary artery
disease. It was quite sensitive, and specific. Using receiver operating
characteristic (ROC) curve to predict the absence of coronary artery
disease, 3 IMT value were tested as the cut-off point. At the value of
0.70 mm, it has a sensitivity of 77.5%, and its specificity is 84.2%,
whereas at the value of 0.75 mm, sensitivity reduced to 66.9% whiles
its specificity unchanged. Although the specificity was quite high
(86.8%) if IMT at 0.80 mm is taken, its sensitivity was very low
(53.4%). As a conclusion, carotid IMT is fairly and significantly
correlated with the severity of CAD. It also can be considered as an
independent predictor for coronary artery disease. This method also
may be used as a screening test for coronary artery disease in current
clinical practice.
Prof. Madya Dr. Zurkurnai Yusof (Supervisor)
Dr. Tee Meng Hun (Co-Supervisor)
Dr. Mohd Sapawi Mohamed (Co-Supervisor)
(30) THE PROGNOSTIC VALUE OF INITIAL AND
FOLLOW-UP COMPUTERIZED TOMOGRAPHY (CT)
OF BRAIN IN ADULT PATIENTS WITH MODERATE
AND SEVERE HEAD INJURY FOLLOWING MOTOR
VEHICLE ACCIDENT
Dr. Azman bin Kifle
MMed Radiology
Department of Radiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Head injury is still the most common problem
throughout the world. In Malaysia, the most common cause of head
injury is due to motor vehicle accident. The impact of the head injury
is so great because the younger generation is the highest populations
involved. The outcome may ranges from good recovery and disability
to death. In view of the important of the outcome, the author felt that it
is important to assess the clinical as well as the CT scan of brain of
those patients in order to predict the outcome. Currently, it is believed
that the permanent outcome of the patient can be predicted from a
follow-up CT scan of brain as early as six weeks.
Objective : The aim of this study is to predict the outcome of the
adult patients with moderate and severe head injury in motor vehicle
accident by using clinical parameters (age, Glasgow Coma Scale),
initial CT scan of brain parameter (intracranial haemorrhage, volume
and site of intracranial haemorrhage, midline shift and hydrocephalus)
and follow-up CT scan of brain parameter (residual intracranial bleed,
post-traumatic hydrocephalus, midline shift and gliosis).
Methodology : The patient is assessed clinically on admission for
84
GCS. Those categorised into moderate and severe head injury with
initial and follow-up CT scan of brain 6 weeks later will be selected
for the study. The parameters were analyzed statistically using
univariate analysis, chi square test and logistic regression. The p value
of < 0.05 is taken as significant level.
Results : A total of 31 patients were selected, 67.7% are male and
32.3% are female. The GCS of the patients were statistically significant
as outcome predictors. Other significant predictors analyzed from the
study are midline shift and volume of subdural haemorrhage in the
initial CT scan and post-traumatic hydrocephalus and gliosis in the
follow-up CT scan.
Conclusion : The study showed that the above-mentioned parameters
are significant predictors of outcome. The author also have suggested
a new outcome predictors by using the parameters from follow-up CT
scan i.e. presence of gliosis, site of gliosis and post-traumatic
hydrocephalus.
Assoc. Prof. Dr. Nurul Azman Alias (Supervisor)
Dr. Abdul Kareem (Supervisor)
Prof. Dr. Jafri Malin Datuk Abdullah (Co-supervisor)
(31) HIGH RESOLUTION ULTRASONOGRAPHY OF
THE WRIST AMONG TYPIST IN USM
Dr. Nazihah Mohamad
MMed Radiology
Department of Radiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Atrial fibrillation is the most common cardiac rhythm
abnormality encountered in clinical practice and it is strongly associated
with higher incidence of stroke. Atrial fibrillation in the presence or
absence of rheumatic valvular disease is associated with an increased
risk of stroke. The incidence of stroke is higher in the presence of
additional risk factors such as increasing age, rheumatic heart disease,
poor left ventricular function, previous myocardial infarction,
hypertension and diabetes mellitus and a past history of a
thromboembolic event. Data from numerous clinical trials in both
primary and secondary prevention of thromboembolism in patients
with atrial fibrillation have proven the beneficial effect of
antithrombotic agents, particularly warfarin in reducing incidence of
stroke. Previous studies done documented that utilization of warfarin
in patients with atrial fibrillation varies from 12% in 1989 to 38% in
1993 and did not significantly increase thereafter. Other studies had
reported that between 1998 and 2000 the clinical utilization of
anticoagulants was still at a low rate.
Objectives : This audit aimed to look at local clinical practice in
relation to the percentage of patients with atrial fibrillation who were
prescribed anticoagulants.
Methodology : The subject consists of 372 patients from three
referral centres which were Hospital Universiti Sains Malaysia, Institute
Jantung Negara and Hospital Universiti Kebangsaan Malaysia between
January 2001 and December 2002.
Results : The results showed that 210 patients (56%) of the total
patients were given warfarin and only 92 patients (43.8%) of all
warfarinized patients had their INR level within therapeutic range, it
varies between 41.1% and 51.1% among centers involved. Among those
162 patients that were not on warfarin, 33 patients (20.4%) did not
have any specific reasons mentioned in the case notes. Most of these
patients not on warfarin were aged between 60 - 90 years old. Thirty
five cases (16.7%) on warfarin developed major bleeding and 32 cases
(15.3%) developed minor bleeding complications over 2 years. These
figures are higher than that reported in clinical trials (major
complications range from 1.5% - 2.8% and minor complications 1.5%
-16% per year).
 Conclusions : There were significant differences among these three
centers in the frequencies of patients given warfarin. This might
represent differences in clinical practice of those centers. In conclusion,
this study found that the utilization of warfarin in patients with atrial
fibrillation in these 3 referral centers were still not optimum. The
therapeutic INR achieved can also be improved. As a whole,
complications rate were comparable to reports from previous study. A
strategic plan is needed to optimize utilization of warfarin in order to
reduce complications among atrial fibrillation patients.
Assoc. Prof. Dr. Ibrahim Lutfi Shuaib (Supervisor)
Dr. Mohd. Ezane Aziz (Co-supervisor)
Dr. Mahayidin Haji Muhamad (Co-supervisor)
(32) NEUROBEHAVIOURAL PERFORMANCES IN
CAR SPRAY PAINTERS AND MECHANICS EXPOSED
TO ENVIRONMENTAL LEAD IN KOTA BHARU,
KELANTAN
Dr. Mohd. Nazhari bin Hj. Mohd Nawi
MMed Occupational health
Department of Radiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Lead exposure posed a major public health hazard
and is recognized as the most prevalent and preventable health issue
in many industrialized countries. Lead-based paint poisoning, a well
recognized entity among young children in poor, urban neighbourhoods,
is not confined exclusively to such areas. Worldwide, about 830,000
people died every year through illness linked to exhaust fumes and
industrial smog that engulfed many cities of the Third World. In Latin
America alone, me figure stands at 115,000. In the remaining parts of
Asia, Africa and Eastern Europe, the fumes are loaded with heavy
metal such as lead. Most accurate estimates of health risks due to lead
can be obtained from reliable history of blood lead measurements.
Level of lead in air will consequently lead to contamination of soil,
water and food and subsequently increase exposure to future generation.
Previous study have shown that chronic exposure to inorganic lead
among spray painters, mechanics and battery workers caused
neurobehavioural effect in the workers.
Objectives : To investigate the neurobehavioural performances of
car spray painters and mechanics exposed to environmental lead in the
workplace.
Methodology : This is a cross-sectional comparative study of 44
car spray painters exposed to lead chromate in car paint and 44 car
mechanics working in car spray painting and service premises in Kota
Bharu, Kelantan. Assessment of exposure and outcome were based on
symptoms of possible neurotoxic obtained via WHO standard
questionnaire form; signs of neurotoxic obtained via WHO standard
examination form; blood lead levels checked as exposure consistent
for biological monitoring; neurobehavioural performance tested using
WHO NCTB; and environmental lead level.
Results : Symptoms of lethargy, sleepiness, sudden wakefiilness,
forgetfulness, stress, confusion, irritability, headache, vertigo,
palpitation, excessive sweating and numbness noted more when mere
was high level of blood lead and recognized among car spray painters
and car mechanics. Mean blood lead level among car spray painters
was 10.19 µg/dl and significantly higher as compared to car mechanics
was 7.39 µg/dl. Mean environmental lead level inside the car spray
and painting chambers was 8.07 µg/m 3 and slightly lower than
environmental lead level around services and repairing areas which
was 8.58 µg/m 3.
Discussions : There was a significant difference in mean blood lead
levels between car spray painters as compared to mechanics (p==0.01).
However, neurobehavioural symptoms, neurobehavioural
performances and environmental lead levels were not significant
between car spray painters and mechanics. Also noted mean blood
lead levels of car spray painters and car mechanics were higher as
compared to other group of occupation in Malaysia. Although
environmental lead levels around car servicing and maintaining areas
were slightly higher than inside car spraying chamber, it actually not
showing the true exposure and what actually needed was the personal
air sampling.
Conclusions : Car spray painters had significantly higher in blood
lead level as compared to car mechanics. However, neurobehavioural
symptoms, neurobehavioural performances and environmental lead
levels were not significant between car spray painters and mechanics.
Prof. Dr. Rusli Nordin (Supervisor)
Dr. Abu Hassan Shaari Abdul Kadir (Co-supervisor)
(33) ANTICOAGULATION IN ATRIAL FIBRILATION:
AN AUDIT OF ITS UTILIZATION IN THREE REFERRAL
CENTRES
Dr. Siti Khairani bt Zainal Abidin
MMed (Internal Medicine)
Department of Internal Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Diabetic nephropathy is one of the most feared
complications of diabetes mellitus as it is associated with high
prevalence of morbidity and mortality. Microalbuminuria is a known
predictor of clinical nephropathy. Several risk factors have been shown
to be associated with the presence of microalbuminuria in diabetic
patients. It is important to recognize these risk factors to enable early
detection of microalbuminuria and prevent or delay the development
of nephropathy. This study aimed to determine the prevalence of
microalbuminuria and associated factors in Type 2 diabetic patients in
Hospital Universiti Sains Malaysia (HUSM) , Kelantan.
Method : A cross sectional study was conducted at Family Health
Clinic, HUSM from July 2001 to February 2002. A total of 322 Type 2
diabetic patients with negative proteinuria on dipstick examination were
studied for the presence of microalbuminuria on random morning urine
specimens. Physical examination was performed and blood
investigations for fasting plasma sugar, HbAlc, fasting lipid profile,
serum creatinine, uric acid and C-peptide were done. Microalbuminuria
was defined as urine albumin concentration of equal or more than 30mg/
ml.
Results : The prevalence of microalbuminuria was 32.9%. In
univariate analysis, the significant variables associated with
microalbuminuria were duration of diabetes, diastolic blood pressure,
fasting plasma sugar and HbAlc (p<0.05). However, in multiple logistic
regression analysis, the only significant associated factors were duration
of diabetes (OR=1.43, 95%CI =1.30,1.57), fasting plasma sugar
(OR=1.11, 95%CI=1.04,1.18), mean diastolic blood pressure
(OR=2.46, 95%CI=1.24,4.88), HDL cholesterol level (OR=0.43,
95%CI=0.20,0.93) and being an ex-smoker (OR=1.96, 95%CI=1.02,
3.78), p<0.05.
Conclusions : There is a high prevalence of microalbuminuria in
patients with Type 2 diabetes in HUSM, Kelantan. The associated
factors were duration of diabetes, poor diabetic control, high diastolic
blood pressure, low HDL cholesterol level and being an ex-smoker.
Therefore, it is very important to screen for microalbuminuria in patients
with Type 2 diabetes especially in those with the associated factors.
Prof. Dr. Rashid Abdul Rahman (Supervisor)
Prof. Dato’ Dr. Mustafa Embong (Co-Supervisor)
85
 (34) A STUDY OF IPSILATERAL FEMUR AND TIBIA
OVERGROWTH IN CHILDREN TREATED WITH
DYNAMIC COMPRESSION PLATE IN CLOSED
UNILATERAL FEMORAL SHAFT FRACTURES.
Dr. Joehaimey bin Johari
MMed (Orthopaedics)
Department of Orthopaedics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objectives : A prospective study of ipsilateral femoral and tibial
overgrowth in closed unilateral femoral shaft fracture in children treated
with dynamic compression plate was carried out in General Hospital
Kota Bharu and University Sains Malaysia Hospital. The overgrowth
was defined as acceleration of growth of the injured femur or ipsilateral
tibia in comparison to normal uninjured limb until the growth rate is
equal .The excess of the limb length of the injured femur or ipsilateral
tibia will be taken as the length of overgrowth after the period of growth
was equal on both side of the limbs.
Methodology : All cases of closed simple unilateral femoral shaft
fractures from January 1997 to December 2001 in children aged from
6 to 14 years old were included in the study. Finally, twenty two out of
thirty patients meet the criteria of this study. The overgrowth
phenomenon of the injured femur and ipsilateral tibia were assessed
using Computer Tomographic Scanogram (C.T.Scanogram) after 18
months post injury. C.T .Scanogram was chosen as method of limb
length measurement because of its accuracy and less radiation exposure
to the children. Duration of bone growth acceleration of the injured
femur until the rate is equal to the opposite femur was determined.
The relationship of the overgrowth to age, sex, handedness, site and
type of fracture also were studied.
Results : All children in this group experienced femoral overgrowth
of the plated site ranging from 0.10 cm to 2.00 cm with a mean
overgrowth of 1.18 cm. The study showed that the overgrowth
phenomenon stop at or after 18 months post injury. Age was the only
factor that has been identified to have correlation with the femoral
overgrowth. The femoral overgrowth will become 0.078 cm less with
each subsequent year as the child get older. The younger the patient
injured the femur the more overgrowth the patient will have. Sex,
handedness, site and type of fractures do not contribute to the
overgrowth of the femur. Only 13 out of 22 patients had ipsilateral
tibial overgrowth with a mean overgrowth of 0.060cm which is not
statistically significant after analyzed by Paired t Test and Wilcoxon
Signed Rank Test.
Conclusions : The overgrowth of the femur and ipsilateral tibia did
not cause any clinically significant limb length inequality as the
overgrowth was less than 2.0 cm. All the children or their parents did
not aware of the limb length discrepancy. To our knowledge this is the
first study done to determine overgrowth phenomenon in closed simple
unilateral femoral shaft fractures treated with dynamic compression
plate using C.T Scanogram method. The results showed that plating
does not cause severe limb length inequality and overgrowth stop after
18 months post injury.
Dr. Mohd. Iskandar Mohd Amin (Supervisor)
Dr. Anwar Hau Abdullah (Co-Supervisor)
(35) EFFECT OF HONEY ON HEALING OF DIABETIC
FOOT ULCERS: A COMPARATIVE STUDY BETWEEN
HONEY AND POVIDONE DRESSING
Dr. Mohd Shukrimi Awang
MMed (Orthopaedics)
86
Department of Orthopaedics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Diabetes Mellitus is one of the most important and
common disorder affecting about 100 million people worldwide and
4% of Malaysian population. One of it long term complications are
diabetic foot ulcers. Diabetic foot ulcers are still among the major
reasons of admission to the hospitals in diabetic patients. Diabetic
neuropathy and angiopathy are the most important aetiologic factors,
together with other contributory factors, such as altered foot pressures,
limited joint mobility, glycemic control, ethnic group and so on.
Objectives : This is control clinical trial study to look the efficacy
of honey as a dressing material in diabetic foot ulcer Wagner’s stage 2,
as compared to povidone, which is commonly used in this institution.
Methodology : This study was done from January 2002 till Jun 2003
in HUSM. It involved thirty patients. Both sexes are equally involved
in study. The age of the patient is range from 31 to 65 years, with mean
of 52.1 years. In both group, at the end of the study, the wound become
sterile in about 50% of the cases. In povidone group, 46.7% of the
wound is sterile and in honey group 53.3%. The duration taken for
wound healing after dressing with povidone is 15.4 days and in honey
group is 14.4 days. However, honey has better effect in term of reducing
pain when changing the dressing due the moist environment created
by honey over the wound avoiding sticking to the gauze, reduce the
oedema faster and also suppress the bad odour of the wound faster
than povidone. There are also no local or systemic complications in
both groups. The overall cost of the dressing using honey is cheaper
than povidone.
Conclusions : The study has concluded that the honey dressing has
a comparable result as compared to commonly used dressing, povidone,
for treatment of diabetic foot ulcer in term of sterility of the wound
and the duration taken for wound healing.
Dr. Abdul Halim Yusof (Supervisor)
Dr. Abul Razak Sulaiman (Co-Supervisor)
(36) EFFECTS OF PULSED INFRARED RADIATION
ON FRACTURE HEALING A STUDY IN RABBITS
Dr. Mohamed Azril Mohamed Amin
MMed (Orthopaedics)
Department of Orthopaedics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Biophysical stimulation provides a non invasive
alternatives in enhancement of fracture healing. Effect of Infrared
radiation on bone healing was never evaluated before.
Objectives : This is a pilot study, descriptive in nature carried out in
Medical School University Sains Malaysia Kubang Kerian Kelantan.
Methodology : The population sample consist of 16 adult male
rabbits. Each was subjected to a surgically induced tranverse osteotomy
on the right tibia. The fracture is then reduced with an intermedullary
K-wire and the leg immobilized with Plaster of Paris. They are then
devided into 2 groups eqully. One group is exposed to infrared radiation
for 1 hour a day while the other group serves as a control. 4 from each
group were sacrificed at 3 and 6 weeks. The operated tibia is harvested.
Radiology and histology assessment were then carried out.
Conclusion : Both the group showed fracture union at 3 weeks but
a much higher hard callus volume were noted in the infrared group. At
6 weeks the hard callus volume are almost equal in both the groups. In
conclusion, Infrared Radiation does enhanced fracture healing in
rabbits.
Dr. Abdul Halim Yusof (Supervisor)
Dr. Mohd. Iskandar Mohd. Amin (Supervisor)
(37) A STUDY OF THE FLEXOR TENDON REPAIR OF
THE HAND USING SIX-STRAND TECHNIQUE WITH
EARLY PASSIVE AND CONTROLLED ACTIVE
MOBILIZATION
Dr. Mohammad bin Paiman
MMed Orthopaedics
Department of Orthopaedics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Repair of the ruptured flexor tendon in the hand
particularly in zone I and II was known to have poor outcome. Tendon
adhesion is a well-known complication that contributes to the poor
outcome. Adhesion was associated with delaying in passive or active
rehabilitation program. However, shifting from delay to early passive
and active rehabilitation program was associated with high incidence
of ruptured of the repaired tendon especially in 2-strand Kessler method
of tendon repair (currently is widely used technique of tendon repair
in almost all hospitals in Malaysia). The dilemma is early motion
improves result but requires greater strength. Six -strand method give
immediate strength of 62 N whereas 2-strand give immediate strength
of only 24 N. Therefore this study determines the clinical outcome of
6-trand technique of tendon repair with early motion rehabilitation
program.
Objectives : To measure the performance of selected cut flexor
tendon of the fingers that undergone ‘Six-strand technique of flexor
tendon repair’ in zone I and II with ‘12-week early passive and
controlled active post rehabilitation program’ and to observe the
effectiveness of this technique in producing the end result.
Methods : A prospective well-controlled clinical study was
conducted to observe the performance of flexor tendon repair using
six-strand technique with early passive and controlled active
mobilization for 12 weeks. Each finger will be assessed using Strickland
method of assessment after 12 weeks of rehabilitation program.
Result : Seventeen well-controlled digits, which were cut at zone I
and II, were repaired by this technique within six months of period.
Total active movement of the digital performance using Strickland’s
method of assessment showed 52.9% of the digits had performance of
more than 90%, 17.6% of the digits had performance between 80-
90%, 11.8% of the digits performed between 70-79%, 5.9% of the
digits performed 50-59%, 5.9% of the digits performed 30-39% and
5.9% of the digits was ruptured. International Federation for Hand
Surgeon System Classification of Outcome graded this technique of
repair produced excellent and good result in 88% of the studied samples.
Conclusion : The technique is reliable to be used as a standard
technique for flexor tendon repair in zone I and II of the hand.
Dr. Mohd. Iskandar Mohd. Amin (Supervisor)
Prof. Dr. Zulmi Wan (Co-Supervisor)
Assoc. Prof. Dr. Ahmad Sukari (Co-Supervisor)
(38) PRIMARY PLATING IN DELAYED SURGICAL
TREATMENT OF TYPE II OPEN TIBIA FRACTURE
Dr. Shamsul Kahar bin Kamarul Ghani
MMed (Orthopaedics)
Department of Orthopaedics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objectives : A prospective study to analyse the result of primary
plating of type II open tibia fracture with delayed surgical treatment
was done from November 2001 to November 2002 in Hospital Kota
Bharu.
Result : There were initially 35 patients with type II open tibia
fracture with delayed surgical management, but only 19 of them were
primarily plated and included in the study. Most of the delayed in the
initial surgical debridement was due to a long waiting list for emergency
operation with a mean time of 29 hours. The overall infection rate was
21.1% with 10.5% of deep infection which was noted to be comparable
to other study. Type II open fracture involving the distal third of the
tibia was noted to have a higher risk of infection as compared to the
proximal third and midshaft of the tibia. There was no significant
correlation noted between the pre and postdebridement open wound
culture with the incidence of post plating wound infection. The overall
union rate in this study was 19.6 weeks which is comparable to the
average time to union of type II open tibial fracture. There were three
patients with non-union. Two of them finally unite after treated with
reamed intramedullary nail. One patient ended up with chronic infected
non-union. Sixteen patients have a good lower limb function in terms
of full range of motion of both ankle and knee joint and painless full
weight bearing at union.
Prof. Dr. Zulmi Wan (Supervisor)
Mr. Mohammad Anwar Hau Abdullah (Co-Supervisor)
(39) OUTCOME STUDY OF CLOSED
SUPRACONDYLAR FRACTURE OF FEMUR
TREATED WITH A RETROGRADE SUPRACONDYLAR
NAILING
Dr. John Ooi Tzen Chuong
MMed Orthopaedics
Department of Orthopaedics
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Supracondylar fractures of the femur occur in two
groups of patients. For the young age group it is almost always due to
a road traffic accident. In the elderly , the usual cause is a minor fall at
home. The standard treatment for this type of fractures is open reduction
and fixation with a lateral plate device e.g. an angle blade plate or a
dynamic condylar screw. However the use of such implants is associated
with complications such as bleeding, a lot of periosteal stripping,
nonunion and infection. A relatively new implant, the retrograde
supracondylar nail, is an alternative device that can be used for treatment
of supracondylar fracture of the femur. This devices can be inserted
percutaneously without the need for periosteal stripping, therefore
reduces the risk of bleeding, nonunion and infection.
Objectives : This study is a retrospective analysis of supracondylar
fracture of the femur treated with the supracondylar nail. The clinical
outcome and complications of this procedure were evaluated.
Methodology : During the period from January 1998 to December
2002, a total of 47 patients were treated with the retrograde
supracondylar nail at Hospital Alor Setar. 27 patients fulfilled the
inclusion criteria and were analyzed. The mean age was 27 years old.
Twenty five patients sustained the fracture after a motor vehicle accident
and 2 after a fall. The clinical outcome was evaluated using the Sander’s
Knee Score.
Conclusion : This study concludes that the retrograde supracondylar
nail is an acceptable alternative treatment for supracondylar fracture
of femur. This method of treatment leads to a high union rate without
the need for bone grafting. The average time to union was 3.9 months.
Functional scores were satisfactory in high proportions of patient (70%).
Best results were seen in the young and the extra-articular type of
fractures. However there are a number of specific complications related
87
 with the use of this device.
Dr. Abd. Halim Yusuf (Supervisor)
Prof. Dr. Zulmi Wan (Co-Supervisor)
Assoc. Prof. Dr. A. S. Devnani (Co-Supervisor)
(40) THE DEFINITIVE TREATMENT OF
HIRSHSPRUNG’S DISEASE WITH A MODIFIED
DUHAMEL PROCEDURE
Dr. Mark Jeevan Erudayam
MMed (Surgery)
Department of Surgery
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Hirschsprung’s disease or congenital megacolon is
the most common cause of neonatal intestinal obstruction. Harald
Hirschsprung first described the disease as a separate clinical entity in
1886. Currently three surgical procedures are commonly used in the
management of Hirschsprung’s disease, namely, the Swenson
Procedure, the Duhamel Procedure and the Soave Procedure. The
standard management consists of a staged procedure, in which a
diverting colostomy is created for purposes of bowel decompression
prior to the definitive surgical correction at a later stage. However, in
recent years, a primary approach to the surgical repair at an earlier
age, without the need for a diverting colostomy, has been adopted with
results of this method being comparable to the staged repair.
Objectives : The main objective of this study was to evaluate the
outcome of patients treated with the modified Duhamel procedure.
From current literature, the Duhamel and Soave procedures are more
commonly performed for the correction of Hirschsprung’s disease. The
concept of the modified Duhamel procedure adopted in this study
differed from the original Duhamel procedure in three crucial areas,
namely, the level of the anal incision through which the ganglionic
bowel is pulled and anastomosed to the posterior wall, the use of the
gastro-intestinal stapler for the side-to-side colo-rectal anastomosis and
lastly the utilization of a proximal end-to-side colo-rectal anastomosis
to obliterate a blind rectal pouch. The study was to further evaluate
also, the use of rectal irrigations for bowel decompression as a safe
alternative to a leveling colostomy (that is, a colostomy sited at the
level of the normally innervated and normally functioning bowel) and
to study the outcome of infants less than 4 months of age treated with
this operation as a primary pull-through procedure.
Methodology : During a study period of 4 and a half years, from
January 1998 to June 2002, a total of 84 cases were diagnosed to have
Hirschsprung’s disease and had undergone surgical repair with the
modified Duhamel procedure in Hospital Alor Setar. Data of these
patients were recorded and studied retrospectively.
Results : Of the 84 patients, there were 66 males and 18 females, a
ratio of 4:1. The majority of patients presented within the first week of
life (51.2%). The main presenting clinical features were abdominal
distension, bilious vomiting and delayed passage of meconium. The
majority of patients were diagnosed in the neonatal age group (68%).
The most common length of disease involvement was short segment
aganglionosis (65.5%). The use of rectal irrigations as a method of
bowel decompression prior to a primary surgical repair was attempted
in 66 patients, of which 55 patients (83.3%) had successful bowel
decompression (although only 54 patients actually had a primary repair
done since one patient had to be later converted to a staged procedure
intra-operatively). The most common cause of failure of rectal irrigation
was due to total colonic aganglionosis, where none of the patients could
be maintained on rectal irrigations. Regarding the definitive surgical
repair, 54 cases (64.3%) had a primary repair and 30 patients (35.7%)
had a staged repair. In the immediate and early post-operative period,
a good outcome was seen in 85.71% of patients overall, the most
88
common complication seen was wound infection in 4 patients (4.76%).
The most significant morbidity was seen in one patient who had
developed an anastomotic leak in the primary repair group, hi the group
of patients undergoing a primary repair aged less than 4 months, a
good outcome was seen in 94.9% of patients, with the most significant
morbidity being a reoperation in one infant with prolonged ileus. In
the follow-up period, ranging from 3 months to 4 and a half years,
overall 69% of the patients did not have any significant problems or
complications. The most distressing problems were enterocolitis seen
in 15 patients and recurrence of Hirschsprung’s like symptoms seen in
12 patients. Only one case, an infant with total colonic aganglionosis
had to undergo a redo-Duhamel procedure. In comparison, infants less
than 4 months undergoing a primary repair, 79.5% of patients had a
good outcome, with the two most common problems being also
enterocolitis and recurrence of Hirschsprung’s like symptoms. There
were no mortalities in this study. No significant differences statistically,
were seen when comparing patients undergoing a definitive repair
before or after the age of 4 months (p>0.05) except in case of
enterocolitis, which was significantly higher in those, operated on after
the age of 4 months (p=0.036). No significant differences in outcome
were again seen in patients undergoing a primary repair as compared
to a staged repair (p>0.05). Extent of aganglionosis had an influence
on the outcome, where in the group of patients with long segment
disease or total colonic aganglionosis had a significantly higher
incidence of complications as compared to ultra-short or short segment
disease involvement (p<0.05).
Conclusion : Rectal irrigations can be safely used as an alternative
to a stoma for bowel decompression prior to a primary surgical repair
in all levels of aganglionic bowel involvement except for total colonic
aganglionosis. The outcome of patients undergoing the modified
Duhamel procedure as a definitive procedure for the treatment of
Hirschsprung’s disease, in this study, is comparable to the results of
other types of surgical repair. And, lastly an operative procedure in
infants less than 4 months of age as a primary procedure is feasible
and can be recommended as a standard method of treatment for
Hirschsprung’s disease.
Mr. Mohan Nallusamy (Supervisor)
Dr. Zainal Mahamud (Co-Supervisor)
Dr. Ahmad Zahari (Co-Supervisor)
(41) A COMPARATIVE STUDY OF CORNEAL
THICKNESS AND ENDOTHELIAL CELLS CHANGES
IN TYPE 2 DIABETIC AND NON-DIABETIC PATIENTS
FOLLOWING CATARACT SURGERY
Dr. Rosli bin Mohd. Kassim
MMed (Ophthalmology)
Department of Ophthalmology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Corneal endothelium acts as a cellular barrier. Loss
or damage of endothelial cells 1 eads t o a compromise in its function.
This consequently results in increased corneal hydration and corneal
thickness. Our aim is to observe the effect of extracapsular cataract
extraction surgery on endothelial cells morphometry and central corneal
thickness changes in type 2 diabetes patients.
Objectives : To compare the corneal endothelial cell morphometry
and corneal thickness between type 2 diabetic and non-diabetic patients
and subsequently to observe the changes following cataract surgery.
Methodology : An observational prospective comparative study was
conducted. 25 type 2 diabetic and 20 non-diabetic patients with cataract
were recruited preoperatively. They were electively scheduled for
extracapsular cataract surgery with intraocular lens implant. The
measurements of central endothelial cells density, coefficient of
variation of cell size and percentage of cell hexagonality were taken
preoperatively and, at one month and three months after cataract
surgery. Central corneal thickness measurement was taken
preoperatively, at one month and three month after cataract surgery.
The corneal endothelial cells image and central corneal thickness was
obtained with Topcon SP-2000P specular microscope. During analysis,
the source of image was blinded and retraced method of image analysis
was performed with IMAGEnet cell analytic function.
Results : There was no significant difference (p=0.970) in mean
endothelial cell density in type 2 diabetic patients (2474 ± 332 cells/
mm 2) compared to non-diabetic patients (2478 ±337 cells/mm2).
However there was significantly increased corneal thickness in diabetic
patients (537 ± 36 um) compared to non-diabetic patients (513 ± 30
µm; p = 0.022). There was no significant difference in cell hexagonality
and coefficient of variation between type 2 diabetic and non-diabetic
patients preoperatively. After surgery endothelial cell density was
reduced and a decreased in cell hexagonality in both groups. Coefficient
of variation of cell size decreases following surgery in type 2 diabetics,
however in non-diabetic patients, it was increased. Both groups
demonstrate significant difference in corneal thickness before and after
surgery. Surgically induced endothelial cell losses was not significantly
different (p= 0.664) between type 2 diabetic (291 cells/mm2) and non-
diabetic patients (259 cells/mm2) at three months.
Conclusion : Endothelial cells morphometry was not damage in
type 2 diabetic patients, however central corneal thickness was
increased. After cataract extraction with intraocular lens implant,
damage to the endothelial cells morphometry in type 2 diabetes mellitus
was not significantly different from non-diabetic patients. However,
the damage to the endothelial cell did not resulted into an increase in
the central corneal thickness after cataract surgery. Three month after
cataract surgery, endothelial cell loss in type 2 diabetic was no different
from non-diabetic patients.
Dr. Wan Hazabah Wan Hitam (Supervisor)
Dr. Zunaina Embong (Co-Supervisor)
Dr. Liza Sharmini Ahmad Tajudin (Co-Supervisor)
(42) A STUDY ON CENTRAL CORNEAL THICKNESS
AND MORPHOLOGY IN MYOPIC MALAY
UNDERGRADUATES OF HEALTH CAMPUS,
UNIVERSITI SAINS MALAYSIA.
Dr. Mohd Aziz bin Husni
MMed (Ophthalmology)
Department of Ophthalmology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : To evaluate the central corneal thickness and morphology
in myopic Malay undergraduates of Health Campus, Universiti Sains
Malaysia.
Methodology : A cross sectional observational study was done on
130 subjects (65 were myopes and another 65 were emmetropes).
Patient selection was done according to the inclusion and exclusion
criteria. Central corneal thickness, corneal curvature, spherical
equivalent, endothelial density, morphology (coefficient of variation
and hexagonality) were measured in all subjects. All measurements
were performed between 3 to 5 pm. Spherical equivalent and cornea
curvature was measured with Humphrey Automated Refractor/
Keratometer 599 (Humphrey System, USA). Cornea thickness and
endothelial morphology were measured with non-contact Topcon
SP2000P specular microscope (Topcon Corp, Japan). Comparisons
were made between myopes and emmetropes. The correlation between
each parameter and degree of myopia (spherical equivalent) was tested.
Any parameters that showed a significant correlation were further tested
with linear regression analysis.
Results : Myopes had a significantly thinner central cornea (p =
0.003), lower endothelial cell density (p =0.017) and steeper cornea
curvature (p =0.017) compared to emmetrope. There was no difference
in endothelial hexagonality and coefficient of variation between
emmetropes and myopes. We also noted a positive correlation between
degree of myopia (measured in spherical equivalent) and central corneal
thickness (r =0.262 [95% CI 0.372-4.878], p =0.023). There was
progressive thinning of the central cornea as the degree of myopia
increased.
Conclusion : Myopes have significant corneal changes compared
to emmetropes. This includes thinner central cornea, lower endothelial
density and steeper cornea curvature. Higher degree of myopia is
associated with thinner central cornea. All these factors need to be
considered in managing myopia.
Dr. Mohtar Ibrahim (Supervisor)
Dr. Liza Sharmimi Ahmad Tajuddin (Co-Supervisor)
(43) DETECTION OF HERPES SIMPLEX INFECTION
IN VIRAL CONJUNCTIVITIS USING POLYMERASE
CHAIN REACTION – A PILOT STUDY
Dr. Azma Azalina bt Ahmad Alwi
MMed (Ophthalmology)
Department of Ophthalmology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : To detect the viral conjunctivitis in Hospital Universiti
Sains Malaysia caused by herpes simplex virus using a polymerase
chain reaction method.
Method : A total number of 70 patients with viral conjunctivitis
were seen in the ophthalmology clinic, HUSM during one year period.
The presenting clinical features were identified and conjunctival
scrapping using sterile conjunctival swab was taken from superior and
inferior fornices of the affected eye for PCR analysis. The PCR was
performed with primers obtained from a commercially available primer
kit for HSV. The presence of this amplified target sequence was
determined by agarose gel. A positive result reflected the prevalence
of viral conjunctivitis caused by HSV. Descriptive analysis was
performed using SPSS system.
Results : The prevalence of viral conjunctivitis in HUSM caused by
herpes simplex infection, using PCR method, was found to be 17.1 %
(95 % CI = 8.1, 26.0). Majority of HSV conjunctivitis patients presented
with moderate follicular conjunctivitis with frequent corneal
involvement, commonly subepithelial punctuate keratitis. It was also
observed that a larger portion of HSV conjunctivitis patients presented
with unilateral involvement.
Conclusion : This study showed the prevalence of viral conjunctivitis
caused by herpes simplex infection, in HUSM was higher than other
reported studies. The most important cause for high prevalence is the
PCR method used which is a highly sensitive and specific diagnostic
test. Some of the clinical features of HSV conjunctivitis was similar to
adenoviral conjunctivitis caused by Group D subgenera. The only
possible differentiating feature was the unilaterality which may help
to discriminate HSV conjunctivitis from adenoviral conjunctivitis.
Dr. Elias Hussein (Supervisor)
Dr. V. Gopalakrishnan (Co-Supervisor)
Dr. M. Ravichandran (Co-Supervisor)
(44) THE EFFECTS OF LOW DOSE EPHEDRINE ON
THE ONSET TIME OF ROCURONIUM
89
 Dr. S. Ananda
MMed (Anesthesiology)
Department of Anesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Anaesthetist have employed a multitude of muscle
relaxants for the establishment of neuromuscular blockade, so that
smooth endotracheal intubation can be performed. The ideal
neuromuscular blockers are drugs that is able to establish
neuromuscular blockade in the shortest duration of time with the
minimum side effects. The fast and reliable succinylcholine is the gold
standard against which all other muscle relaxants are compared but
side effects preclude its use in all patients. This has led to a longstanding
interest in decreasing the onset time of nondepolarising neuromuscular
blocking drugs resulting in faster drugs and new techniques of
administration such as the use of priming dose before administration
of intubation dose, increments in the dose and combination of drugs.
The time of loss of consciousness to tracheal intubation is a period
during which patient is at risk of developing hypoxia and pulmonary
aspiration. The length of this period is determined by the establishment
of neuromuscular blockade and so it is desirable to use a muscle relaxant
with the shortest duration of time. The onset is partly determined by
the speed with which these drugs reach the neuromuscular junction, a
factor that appears to be proportional to cardiac output and muscle
blood flow. Ephedrine increases these variables and hence is used in
this study.
Methodology : A total of 44 American Society of Anesthesiology
(ASA) 1 and 2 patients scheduled for elective low to moderate risk
surgical procedures were randomly selected and grouped into 2
population samples. With each of the assigned group receiving either
intravenous ephedrine 50 microgram/kg or intravenous normal saline.
A standardized anaesthetic technique was used for both groups of
patients. Vital signs were monitored and charted before induction which
served as a baseline to the haemodynamic changes. Induction of
anesthesia was performed by using sodium thiopentone 2.5% titrated
to loss of eye lash reflex. The study drug of each allocated population
sample was administered accordingly anesthesia was maintained with
100% oxygen and 1.5% isoflurane while pharmacological paralysis
was maintained with 0.6mg/kg of rocuronium. The onset time of both
groups was determined by stimulating the ulnar nerve usingsurface
electrodes giving supramaximal square wave impulse of 0.2 sec
duration administered 2Hz every l0sec by using a battery operated
stimulator with train of four monitoring. The onset time of rocuronium
was defined as the time from the end of injection of i.v. rocuronium to
the disappearance of all 4 twitches in train of four. Data collection
consist of pulse rate, systolic, diastolic, mean blood pressure and onset
time of rocuronium in seconds.
Results : Findings of this study when comparing the 2 groups show
that the group in which i.v. ephedrine is used has an onset time of 20%
less than the placebo group. Thus the result of this study pointed to
the fact that low dose i.v. ephedrine can decrease the onset time of
non-depolarising muscle relaxant i.v. rocuronium by 20% have minimal
effect on the haemodynamic changes.
Assoc. Prof. Dr. Nik Abdullah bin Nik Mohamad (Supervisor)
Dr. Shamsul Kamalrujan bin Hassan (Co-Supervisor)
Dr. Saedah binti Ali (Co-Supervisor)
(45) COMPARISON OF THE USE OF THE LARYNGEAL
TUBE (VBM) AND LARYNGEAL MASK AIRWAY
UNDER ANAESTHESIA DURING SPONTANEOUS
VENTILATION
Dr. Noor Zairul Muhamad
MMed (Anesthesiology)
90
Department of Anesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objectives : The purpose of this study is to assess whether the newly
developed laryngeal tube (VBM) is a fast, reliable and easy device for
airway management. We compared the use of the laryngeal tube (VBM)
with the laryngeal mask airway in spontaneously ventilating adult
patient undergoing general anesthesia and measured the easiness of
insertion, incidence of airway trauma and sore throat and also the
haemodynamic responses to insertion of these devices.
Methodology : A randomized single blinded prospective study was
conducted involving a total of 121 premedicated, ASA I or II patients,
aged 18 to 65 years and were divided into 2 groups either laryngeal
tube (VBM) or laryngeal mask airway group as for airway management
during elective surgery. After a standardized induction of anaesthesia
with fentanyl 1.5 µg.kg-1 and propofol 2 mg.kg-1, a size 3 or 4 laryngeal
tube (VBM) or laryngeal mask airway was inserted and the patients
breathed spontaneously throughout the surgery with no muscle relaxants
given. Anaesthesia was maintained with nitrous oxide, oxygen and
isoflurane. The airway device was removed at the end of surgery with
the patients fully awake. The speed and ease of insertion and the number
of attempts needed to successfully secure the airway were recorded.
The incidence of airway trauma, sore throat and haemodynamic changes
such as systolic blood pressure, diastolic blood pressure, mean arterial
pressure and heart rate at different time intervals were recorded.
Episodes of airway manipulations intraoperatively and end-tidal CO2
at various time intervals were also recorded.
Results : We found that there was no statistically significant
difference in time required for successful insertion and number of
attempts for both groups. We were able to achieve a clear airway in
75.4% patients in LT group at the first attempt. There were no difference
in incidence of airway trauma and sore throat between laryngeal tube
and laryngeal mask airway. Both groups had no statistical differences
in haemodynamic parameters during spontaneous ventilation under
anaesthesia. Although, the incidence of airway manipulations and end
- tidal CO 2 were higher with laryngeal tube (VBM) compared to the
laryngeal mask airway but it is not likely to be clinically relevant in
this study.
Conclusion : We conclude that during spontaneous ventilation, the
laryngeal tube (VBM) is a suitable alternative to the laryngeal mask
airway.
Assoc.Prof. Dr. Nik Abdullah bin Nik Mohamad (Supervisor)
Dr. Mahamarowi Omar (Co-Supervisor)
(46) A COMPARATIVE STUDY OF INTRAVENOUS
PATIENT-CONTROLLED ANALGESIA MORPHINE
AND TRAMADOL IN PATIENTS UNDERGOING
MAJOR OPERATION
Dr. Rozilah @Abdul Hadi Mohamed
MMed (Anesthesiology)
Department of Anesthesiology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : The success of major surgery depends partly on
providing effective post-operative pain relief, which can be achieved
by morphine administration via PCA system. Tramadol is a weak opioid
analgesic, which act mainly on µ-opioid receptor. The purpose of this
study was to evaluate the effectiveness of intravenous patient-controlled
analgesia (PCA) Tramadol in comparison with PCA Morphine in term
of analgesic properties, sedation and other side effects such as nausea,
vomiting and pruritus.
Methods : A randomized, double-blinded study was conducted on
160 selected ASA I and II patients who were divided into two groups
by a closed envelope technique. Following surgery, the PCA morphine
(M) group (n=80) received a loading dose of 0.1 mg/kg of intravenous
morphine followed by 1 mg (1 mg/ml) of PCA infusion as required.
The PCA tramadol (T) group (n=80) received a loading dose of 2.5
mg/kg of intravenous tramadol followed by 10 mg (10 mg/ml) of PCA
infusion as required. The lockout intervals for both groups were 10
minutes. None of the patients received baseline infusion. In the recovery
room, patients were given oxygen via facemask and monitored for
pain score according to Modified Pain Score, sedation score according
to Ramsay Sedation Score, respiratory rate, nausea, vomiting, pruritus,
blood pressure and pulse rate. Patients were evaluated at the end of 30
minutes in recovery room. After 4 hours, 24 hours and 48 hours post
operation, patients were again evaluated in the ward.
Results : This study showed no difference in the demographic data
between the two groups (p>0.05). The mean pain score in tramadol
group at 30 minutes, 4 hours, 24 hours and 48 hours post operation
were 1.32 ± 0.79, 1.04 ± 0.79, 0.35 ± 0.48 and 0.09 ± 0.33 respectively.
Whereas, the mean pain score in morphine group at 30 minutes, 4
hours, 24 hours and 48 hours post operation were 1.35 ± 0.99, 1.14 ±
0.81, 0.40 ± 0.54 and 0.10 ± 0.34 respectively. There were no significant
differences in the mean pain score between the two groups at each
duration of assessment (p>0.05). The mean sedation score in tramadol
group at 30 minutes, 4 hours, 24 hours and 48 hours post operation
were 0.90 ± 0.74, 0.56 ± 0.59, 0.08 ± 0.27 and 0.02 ± 0.16 respectively.
Whereas, the mean sedation score in morphine group at 30 minutes, 4
hours, 24 hours and 48 hours post operation were 0.84 ± 0.70, 0.46 ±
0.64, 0.08 ± 0.27 and 0.01 ±0.11 respectively. There were no significant
differences in the mean sedation score between the two groups at each
duration of assessment (p>0.05). There were also no significant
differences between the two groups in the incidence of nausea, vomiting
and pruritus.
Conclusion : This study indicates that PCA tramadol is suitable to
be used as an alternative to PCA morphine in controlling pain following
major surgery. The incidence of sedation, nausea and pruritus were
similar in the two groups.
Dr. Shamsul Kamarujan Hassan (Supervisor)
Assoc.Prof. Dr. Nik Abdullah bin Nik Mohamad (Co-
Supervisor)
(47) A STUDY OF THE MORBIDITY ASSOCIATED
WITH SALIVARY GLANDS HYPOSECRETION AMONG
POST-IRRADIATED HEAD AND NECK CANCER
PATIENTS AT HUSM
Dr. Khairudin Abdullah
MMed (Otorhinolaryngology-Head And Neck Surgery)
Department of Surgery
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Head and neck cancer is increasingly common in
developing countries including Malaysia. The main treatment
modalities are mainly radiotherapy besides surgical resection, laser
excision and chemotherapy. It is known from literatures that
radiotherapy caused significant effects to these patients both acute and
long-term complications. One of the important morbidity faced by these
patients is dryness of mouth (xerostomia). Xerostomia results from
salivary glands hypofunction secondary to radiation causing marked
reduction in salivary output. Long-term complications of xerostomia
lead to variety of morbid oral sequelae.
Objectives : To study the oral morbidity as a result of salivary glands
hyposecretion after radiotherapy among patients with head and neck
cancer at HUSM.
Methodology : A cross-sectional study was carried out in
Otorhinolaryngology clinic, Department of Otorhinolaryngology,
Science University of Malaysia (USM) from July 2002 to September
2003. A total of 30 patients with head and neck cancer and had received
radiotherapy treatment were studied. Questionnaires were used to assess
xerostomia and xerostomia-related morbidity of the study subjects.
Oral cavity was examined to determine the dental status and evidence
of xerostomia. The unstimulated and stimulated whole salivary flow
rates were carried out and compared to 30 normal subjects. The study
subjects were also investigated for radiological evidence of dental caries
involving the roots and alveolar bone resorption.
Results : Majority of the patients suffered from xerostomia of various
severity as well as xerostomia-related morbidity. The most predominant
oral presentations in these patients were radiation dental caries, followed
by periodontal diseases, dry lips and mouth ulcers. Both salivary flow
rate parameters of the patients were significantly reduced compared to
the normal subjects. Unstimulated whole salivary flow rate was a good
predictor of xerostomia and its related morbidity. Total dose of
radiotherapy is the only radiotherapy parameters found to have
significant correlation with the studied parameters i.e. xerostomia-
related morbidity. Orthopantomogram (OPT) findings done on the
patients showed significant evidence of radiation dental caries and
alveolar bone resorption.
Conclusions : Salivary gland hyposecretion was found to be a
common problem in post-radiotherapy patients for head and neck
cancer. Salivary glands hypofunction or hyposecretion results in
significant reduction of the whole salivary output often caused dryness
of mouth (xerostomia), its morbid oral sequelae and impairment of
normal oral functions.
Prof. Dr. Rani Samsudin (Supervisor)
Dr. Nizam Abdullah (Co-Supervisor)
Dr. Baharudin Abdullah (Co-Supervisor)
(48) ULTRASOUND GUIDANCE VERSUS THE
LANDMARK TECHNIQUE FOR THE PLACEMENT OF
INTERNAL JUGULAR VENOUS CATHETER IN THE
HOSPITAL UNIVERSITI SAINS MALAYSIA.
Dr. Rushdi Abdullah
MMed (Emergency Medicine)
Department of Emergency Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : To determine if the ultrasound-guided internal jugular
venous cannulation in the Emergency Department and Intensive Care
Unit is safer and faster than the traditional landmark technique.
Methods : We carried out a prospective study involving 150 patients
that required central venous access via the internal jugular vein in the
Emergency Department and Intensive Care Unit, Hospital Universiti
Sains Malaysia, Kubang Kerian. These patients that were then
randomized into 2 groups; those presented on even days had their
internal jugular vein cannulated under direct ultrasound guidance, while
those presented on odd days had their vein cannulated using the
traditional landmark technique. The access time, the number of attempts
made until successful cannulation and the number of acute
complications were then recorded. Results from each technique were
recorded and then compared with independent t-test analysis. A p value
of below 0.05 was taken to be significant.
Results : There were significant improvements in the 3 parameters
measured in the ultrasound guidance technique as compared to the
landmark technique. The access time was shorter (p<0.05), the number
of cannulation attempts were less (p<0.05) and the number of acute
complications were reduced (p<0.05).
Conclusion : The rate of complications from the blind landmark
technique is still low and no serious fatalities were recorded in the
study, hence its use by the experienced operator in the acute medical
91
 setting is still acceptable. In conclusion, the study has shown that both
ultrasound-guided and the landmark techniques are safe procedures in
the emergency settings, the former being shown to be superior to the
latter, as it reduces the access time, cannulation attempts and number
of complications.
Assoc. Prof. Dr. Kamarudin Jaalam (Supervisor)
Dr. Maharomwi Omar (Supervisor)
Dr. Wan Aasim Wan Adnan (Co-Supervisor)
(49) RULING OUT MYOCARDIAL INFARCTION IN THE
EMERGENCY DEPARTMENT IN PATIENTS
PRESENTING WITH CHEST PAIN AND INITIAL
NORMAL OR NON DIAGNOSTIC
ELECTROCARDIOGRAM USING A 6 HOUR
PROTOCOL
Dr. Faizal Salikin
MMed (Emergency Medicine)
Department of Emergency Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : The rapid and correct diagnosis of patients with chest
pain to rule out myocardial infarction is an extremely important aspect
in emergency care. However, acute myocardial infarctions are missed
in up to 6% of patients presenting to the Emergency Department and
are discharged home inappropriately. This study aims to rule out
myocardial infarction in the emergency department within a 6 hour
period using an investigative protocol driven approach for chest pain
patients with normal or non diagnostic electrocardiograms.
Methodology : A diagnostic prospective cohort study was conducted
on 182 patients presenting to the Emergency Department with chest
pain but with nondiagnostic electrocardiogram changes for myocardial
infarction. The protocol involved observation in the Emergency
Department for 6 hours for serial measurements of Creatinine Kinase,
serial electrocardiogram monitoring and evolving clinical symptoms.
Elevated Creatinine Kinase levels prompted further testing with
Troponin T to detect myocardial infarction. The patient was then
admitted to the medical ward for further management. Performance of
the diagnostic 6 hour myocardial infarction rule out protocol in the
Emergency Department using serial electrocardiogram, serum
Creatinine Kinase measurements and/or Troponin T level is compared
with the gold standard consisting of the final hospital discharge
diagnosis according to World Health Organization criteria of diagnosing
myocardial infarction.
Results : Outcome of the gold standard test was available for 162
patients. The diagnostic test for the protocol obtained 22 positive results
and 140 negative results. There were 7 false positive results and one
false negative result.
Sensitivity was 93.8%, specificity was 95.2%, the negative predictive
value was 99.3% and the positive predictive value was 68.2%.
Conclusions : The six hour diagnostic protocol to rule out myocardial
infarction is both clinically accurate and efficacious in patients
presenting to the Emergency Department with low to moderate risk of
myocardial infarction.
Dr. Mahamarowi Omar (Supervisor)
Datuk Dr. Haji Abu Hassan Asaari Abdullah (Co-Supervisor)
(50) A COMPARATIVE PROSPECTIVE STUDY
BETWEEN TWO OXYTOCIN REGIMENS IN
AUGMENTATION OF LABOUR
92
Dr. Roszaman Ramli
MMed (Obstetric and Gynaecology)
Department of Emergency Medicine
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : To compare the cost-effectiveness between the new and
the old oxytocin regimes in the augmentation of labour and to evaluate
the influence on the maternal and fetal outcome.
Methodology : 213 pregnant women in labour at term with obstetric
indication for labour augmentation. The women were randomly
assigned to receive new oxytocin regime of 5U in 500 cc of Dextro-
saline at titration of 5 dpm with increments of 5 dpm to a maximum of
60 dpm, or an old oxytocin regime of 1/2/4 U with titration of 20/40/
60 dpm for primipara and half the dosage for multipara.
Result : There was no significant influence on the maternal and
neonatal morbidity and mortality (p = 0.07). There was no significant
difference in the duration of labour (p = 0 45) and augmentation (p =
0.9) between the two regimes studied. There seemed to be higher
incidence ofcaesarean section in the old oxytocin group (p = 0.001).
Moderate achievement in the reduction of cost per annum was noted
(RM 962.34). The new oxytocin regime was found to be more easy
and convenient to prepare by the labour room staff and avoid
unnecessary and frequent change in oxytocin solution.
Conclusion : The results showed that the new oxytocin regime was
more cost effective and more convenient for the labour room staff to
prepare without apparent increase in the maternal and fetal morbidity
and mortality.
Dr. Ghazali Ismail (Supervisor)
Assoc. Prof. Dr. Mohd Shukri Othman (Co-Supervisor)
(51) A CROSS SECTIONAL STUDY OF NASAL
POLYPOSIS AMONG ASTHMATIC POPULATION
ATTENDING ASTHMA CLINIC, HOSPITAL UNIVERSITI
SAINS MALAYSIA AND HOSPITAL KOTA BHARU,
KELANTAN
Dr. Rosdi Ramli
MMed (Otohinolaryngology) -Head And Neck Surgery
Department of Otohinolaryngology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Nasal polyps have been a medically recognized
condition since the time of the ancient Egyptians. It is the most common
chronic disease affecting the mucous membranes of the nasal cavity
and the paranasal sinuses. The relationship of sinonasal diseases with
bronchial asthma have been known to be associated since the 19 th
century. Causal relationships, tike similarity of the inflammatory
cellular infiltrates have been proposed but not proven. This study aims
to get the prevalence of nasal polyposis among the asthmatic population
and to look for the association of nasal polyp formation in relation to a
few parameters in asthmatic population.
Objectives : To study the prevalence of nasal polyposis among the
asthmatic population at Hospital Universiti Sains Malaysia (HUSM)
and Hospital Kota Bharu (HKB), Kelantan and the association of nasal
polyps with age, gender, duration and severity of bronchial asthma in
established asthmatic patients.
Methodology : A cross-sectional study was carried out in the Chest
Clinic HUSM and HKB from October 2002 till August 2003. One
hundred and thirty (130) asthmatic patients without other lungs
pathology were included in the study. After filling all the patient’s
particulars, selected patients were examined by using a 0 degree Karl
Storz nasoendoscope and findings were recorded. In case where
difficulties found during nasoendoscopy procedure like narrow nostrils
or intolerability to pain, then the nose was packed with cocaine or
lignocaine with adrenaline or lignocaine alone prior to procedure.
Results : From a total of one hundred and thirty (130) asthmatic
patients, the prevalence of nasal polyps noted to be 28.5% which was
nearer to the reference data, 32.0%. The occurrence of nasal polyp
was not associated with sex, races and severity of bronchial asthma.
Nasal polyps formation noted to be significantly related to the age of
the patients. Asthmatic patients above 40 years of age were prone to
develop nasal polyps twice more than compared to the patients below
40 years of age (p=0,053).
Conclusions : Since the prevalence of nasal polyps among asthmatic
patients were high (28.5%) with having a strong association with
increasing age of the patients, it is recommended that all the asthmatic
cases should be examined by Otorhinolaryngologist for regular
endoscopic examinations at least once in a year. To get a clear picture
on the association of these two parameters, a further study using a
large sample size should be conducted in future.
Dr. Shamim Ahmed Khan (Supervisor)
Assoc. Prof. Dr. Kamarudin Jaalam (Co-Supervisor)
(52) IN-VITRO EVALUATION OF THE GROWTH
ENHANCING OR CYTOTOXIC EFFECT OF
STICOPHUS SPECIES (GAMAT) ON ESTABLISHED
HUMAN FIBROBLASTS CELL LINE CULTURES
Dr. Philip Rajan
MMed (Otohinolaryngology) -Head And Neck Surgery
Department of Otohinolaryngology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objectives : The objective of this study was to evaluate the effect of
Gamat, the local term for sea-cucumber extract, of the species Sticophus
sp1 , on an established human fibroblast cell line culture whether it is
cytotoxic or growth promoting.
Methodology : Preliminary Tests : The Gamat extract was diluted
with the growth media (DMEM+ FBS). The test substances (one ml)
were added to fibroblast culture wells (one ml) to obtain Gamat
concentrations of 5 mg/ml, 10 mg/ml, 20 mg/ml and 100 mg/ml. A
neutral red assay was performed at Day-2, Day-4 and Day-6 from the
day the test substances were introduced. The cell density was measured
with a spectrophotometer at 540 nm. Tests were done in triplicates and
repeated. Osmolarity Testing and Chemical Analysis :Based on the
results of the preliminary tests, osmolarity testing and chemical analysis
of the Gamat extract was undertaken. Final Cell Culture Tests : In the
final tests the effective concentrations tested were 5 mg/ml each for
Gamat and NaCI. Comparisons were made against growth media
(DMEM) and supplemented growth media (DMEM+FBS). All the test
solutions were approximately iso-osmolar. The tests were carried out
in a similar fashion to the preliminary tests. Antimicrobial Testing :
The Gamat extract and NaCI were tested for antimicrobial activity
against Staphylococcus aureus. Escherichia coli and Pseudomonas
aeruginosa was undertaken. Concentrations of 10 mg/ml, 50 mg/ml,
100 mg/ml and 200 mg/ml were used.
Results : Preliminary Tests : From concentrations of 10 mg/ml and
above the Gamat extract diluted in growth media was cytotoxic to
fibroblasts. At 5 mg/ml the results were equivocal. Osmolarity Testing
and Chemical Analysis : Osmolarity testing revealed that dilution of
the Gamat extract with the growth media resulted in a hyperosmolar
solution. The chemical analysis showed a high composition of sodium
chloride in the Gamat extract. Final Cell Culture Tests : Gamat
concentrations of 5 mg/ml were neither cytotxic nor growth enhancing
No difference in cell growth was noted between Gamat and NaCI.
Significant growth proliferation was noted in FBS supplemented cell
wells. Antimicrobial Testing : At all concentrations tested Gamat
exhibited antimicrobial activity against S.aureus, E.coli and
P.aeruginosa. NaCI showed no antimicrobial activity against S.aureus
and E.coli at all concentrations tested. However from concentrations
of 50 mg/ml onwards NaCI demonstrated anti-pseudomonal activity.
Conclusion : Gamat concentrations of 5 mg/ml was neither cytotoxic
nor growth enhancing.
The Gamat extract contains substances with antimicrobial activity
against S.aureus, E.coli and P.aeruginosa.
Assoc. Prof. Dr. Din Suhaimi Sidek (Supervisor)
Dr. Rosdan Salim (Co-Supervisor)
(53) A STUDY ON COMMON SEXUALLY
TRANSMITTED DISEASE INFECTION IN INFERTILE
FEMALE ATTENDED TO INFERTILITY CLINIC HUSM,
KOTA BHARU, KELANTAN.
Dr. Nik Ahmad Zuky bin Nik Lah
MMed (Obstetric and Gynaecology)
Department of Otohinolaryngology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : Sexually transmitted disease (STDs), once called
venereal disease, are among the most common infectious diseases in
the world. In Western countries, there has been a dramatic increase in
the reported incidence of sexually transmitted diseases (STD) during
the past 25 years. It is tragic irony that despite medical efforts against
sexually transmitted diseases and the existence, since the 1940s, of
powerful treatments for them, these diseases persist; even thrive in the
twenty first century. This trend was augmented by earlier sexual
maturity in girls and earlier age of onset of sexual activity in both
sexes. Other sociological changes which contribute to the increased
incidence of STD include urbanization, increased mobility among the
young, and the greater ease of world-wide travel. Sexual tourism is
increasingly common. This last factor has also promoted the importation
of unusual tropical STDs and antibiotic-resistant infections.
Traditionally, five diseases have been classified as sexually transmitted
diseases which are syphilis, gonorrhoea, lyphogranuloma venereum,
chancroid, and granuloma inguinale. Lyphogranuloma venereum is one
of disease caused by Chlamydia thrachomatis. To date more than 20
distinct sexually transmitted or transmissible pathogens were identified
which may have different clinical manifestations. However in this study
we are only concentrate on three common sexually transmitted diseases
which are chlamydial infection, gonorrhoea and syphilis. Chlamydial
infection and gonorrhoea are well known to cause pelvic inflammatory
disease (PID) and their sequelae; infertility, chronic pelvic pain and
ectopic pregnancy, whereas syphilis affect the outcome of the baby
before and after the pregnancy. Another important issue is that, the
genital chlamydial infection is increasing in trend worldwide.
Objectives : To determine the local prevalence of common organism
in Sexually Transmitted Diseases (STDs) infections (Chlamydia
trachomatis, gonorrhoea and syphilis) in infertile females attended to
Infertility Clinic Hospital Universiti Sains Malaysia, Kubang Kerian,
Kota Bharu, Kelantan. And to determine the clearance rate of
Chlamydia trachomatis and gonorrhoea infection after a course of
azithromycin 1 gram single dosage.
Methodology : This is a prospective study involving 150 infertile
females under follow up at infertility clinic Department of Obstetrics
and Gynaecology, Hospital Universiti Sains Malaysia between 1st of
March 2002 till 28th of February 2003 . Endocervical samples were
obtained to detect Chlamydia trachomatis by direct
immunofluorescence, Neisseria gonorrhoea by Gram smear and culture
& sensitivity. Blood samples were also obtained for Venereal Disease
Research Laboratory (VDRL) testing and for Ig M antibody toward
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 chlamydia. For VDRL testing positive patient another blood sample
for Treponema pallidum haemagglutination assay (TPHA) will be
taken. In a patient with a positive Chlamydia trachomatis or gonorrhoea
or both infections, she and her partner will be treated with a single
dose of azithromycin 1 gram orally. After 2 weeks of azithromycin,
the respective investigation(s) will be repeated to determine the
clearance of such infection(s). In a natient who was positive for syphilis
she will be treated with intramuscular Benzanthine Penicillin 2.4
Megaunit 3 doses. A repeated TPHA testing will be carried out after a
month of completed treatment.
Results : Chlamydia trachomatis infection was present in 6 (4.0%)
patients. There was no incidence of gonorrhoea or syphilis infection in
the studied population. All repeated investigations after azithromycin
for Chlamydia trachomatis infection showed a negative testing. The
clearance rate of gonorrhoea or syphilis is unable to determine as there
is no incidence of such infections in the studied group.
Conclusion : The prevalence of sexually transmitted diseases
(Chlamydia trachomatis, gonorrhoea and syphilis) infection in infertile
female is low in our studied group. The clearance rate of Chlamydia
trachomatis infection by azithromycin is good. There is statistically
significant correlation between the incidences of tubal factor causing
infertility with Chlamydia trachomatis infection among them. The
prevalence is not a true representation of Malaysian populations as it
is a hospital-based study. A larger scale study involving a few centers
is needed in order to obtain a better representation of Malaysian
populations.
Dr. Nik Hazlina Nik Husain (Supervisor)
Assoc. Prof. Dr. Mohd. Radzi Johari (Co-Supervisor)
(54) DOES THE ULTRASONOGRAPHIC FINDINGS
AND SURGEON’S INTERPRETATION DURING
EVACUATION FOR THE FIRST TRIMESTER
PREGNANCY FAILURE PREDICT THE
HISTOLOGICAL FINDINGS? – A PROSPECTIVE
CROSS SECTIONAL STUDY AT HUSM
Dr. Enie Akhtar bt Nawawi
MMed (Obstetric and Gynaecology)
Department of Otohinolaryngology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Introduction : The practice of sending all tissues obtained during
surgical evacuation varies from one hospital to the other and there is
no local data available regarding the issue.
Objectives : To assess the validity/ accuracy of the ultrasound
findings and surgeon’s observation during surgical evacuation for the
first trimester silent or incomplete miscarriage or uncertain of both in
predicting the histological findings of presence of POC as confirmation
of the diagnosis.
Methodology : A prospective cross sectional study was conducted
from November 2002 to June 2003, there were 200 patients diagnosed
as either silent or incomplete miscarriage or suspicious of both at or
less than thirteen week gestation. These were subjected to surgical
evacuation (D&C). All tissues obtained were sent for HPE and results
were analyzed. They were given follow-up appointment in three months
time or earlier upon discharge and note if any complication arises.
Results : One hundred sixty three patients had histological evidence
of product of conception in the tissue obtained from evacuation of the
uterus. Thirty five had evidence of deciduas and two patients had
features of partial hydatidiform mole . The sensitivity and specificity
of ultrasound was 98 % and 2.7 %, and for surgeons’ interpretation
was 99.4 % and 2.7 % respectively. The Positive Predictive Value and
Negative Predictive Value for ultrasound was 81.6 % and 25 %, and
for surgeons’ interpretation was 82.3 % and 50 % respectively. On
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follow-up, no cases of ectopic pregnancy in those with decidua on
histology, and were uneventful in the other.
Conclusions : Due to the limited number of true negative cases that
caused low specificity for both ultrasound and surgeons’ findings, it is
recommended that case-control study is conducted in future. All tissues
obtained from first trimester silent/incomplete miscarriage or uncertain
of both must be sent for histopathological diagnosis because though
there only 2 cases of PHM, they were not predicted either by ultrasound
or by the surgeons.
Assoc. Prof. Dr. Md. Shukri Othman (Supervisor)
Dr. Wan Abu Bakar Wan Yusuf (Co-Supervisor)
Assoc. Prof. Dr. Manoharan Madhavan (Co-Supervisor)
(55) AN EVALUATIVE STUDY OF DISTRACTION TEST
AND TEOAE IN DETECTION OF HEARING
IMPAIRMENT IN EARLY CHILDHOOD.
Dr. Azah Yusof
MMed (Otorhinolaryngology-Head & Neck Surgery)
Department of Otohinolaryngology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : The objectives for the study were to determine the
validity of distraction test and transient evoked ototacoustic emission
(TEOAE) in detection of hearing impairment in early childhood.
Methodology : This was a cross sectional study done in the children
in the age group of 6 months to 24 months referred for hearing
assessment to the audiology clinic in Hospital Universiti Sains Malaysia
between Nov 2001 to August 2002 and February 2003 to June 2003.
All these children underwent all the 3 tests in a defined order- distraction
test, TEOAE and then auditory brainstem response (ABR). ABR was
considered as gold standard against which the validity of distraction
test and TEOAE were determined.
Results : A total of 127 ears (65 patients) were included in this study
based on the inclusion criteria. It was found that 35 (27.6%) ears had
hearing impairment of more than or equal to 30 dBnHL. Out of these
35 ears, 34 (97%) belonged to the high risk group. The sensitivity and
specificity for distraction test were 88.6% and 93.5% respectively. The
predictive values for positive and negative tests for distraction test
were 83.8% and 95.6% respectively. The sensitivity and specificity of
TEOAE were 91.4% and 88% respectively. The positive and negative
predictive values for TEOAE were 74.4% and 96.4% respectively. The
overall accuracy was 92.1% and 88.9% for distraction test and TEOAE
respectively.
Conclusion : Both distraction test and TEOAE were found to have
good performance. There was a slight drop in the sensitivity of
distraction as it missed out few ears with mild hearing loss of less than
40dB. The specificity and negative predictive value (NPV) of TEOAE
was reduced because of high incidence of middle ear effusion in the
study age group which gave rise to false positive results. One patient
with auditory neuropathy who passed the TEOAE was picked up by
distraction test and ABR. It appears that a combination of hearing tests
is important for complete hearing assessment and no single test in
isolation is efficient.
Dr. Ishak Abdul Samad (Supervisor)
Dr. Hakim Ghaib Bilal (Co-Supervisor)
(56) EARLY ORAL FEEDING AFTER CAESAREAN
SECTION
Dr. Asha Gupta
MMed (Otorhinolaryngology) Head and Neck Surgery
Department of Otohinolaryngology
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.
Objective : To determine whether patients can tolerate immediate
postoperative oral feeding after uncomplicated caesarean section
without substantial adverse effects on the gastrointestinal function.
Methods : A prospective study was conducted whereby patients who
had undergone caesarean section were randomized to one of two groups,
the “early feeding” group or the “traditional feeding” group. Patient’s
information and outcome data were collected by the medical officer
in-charge using a standard questionnaire. Outcomes assessed include
presence of postoperative nausea, vomiting and ileus, postoperative
fever and day of patient’s dischargec2 test and Fisher exact test were
used to compare the two groups.
Results : A total of 152 patients were recruited in the study; 71 in
the “early feeding” group and 81 in the “traditional feeding” group.
There was no significant difference between the two groups in term of
demographic profile and caesarean section profile. Fourteen of the
71patients in the “early feeding” group did not ate within the specified
first 6 hours. There was no significance difference in the presence of
postoperative nausea, vomiting and ileus between the two groups.
Conclusion : Early feeding after uncomplicated caesarean section
was not associated with an increase in gastrointestinal symptoms and
was tolerated by most patients.
were randomly allocated into 2 groups using systematic randomization.
The 1 st group,Group I, n=136 were given succinylcholine 1.0 mg/kg
and the other group, Group II, n=136 were given rocuronium 1.0 mg/
kg. Both groups of patients were induced with fentanyl 1-2 mcg/kg
and thiopentone 2-4mg/kg. Laryngoscopy and tracheal intubations were
carried out by an assessor after the neuromuscular agent was
administered. The intubations conditions were graded on a three point
scale as excellent, good and poor. Data were compiled and analyzed
using ‘Statistical Package for the Social Sciences’ (SPSS)®, version
11.5.
Result : Intubation conditions in RSI using succinylcholine were
78% excellent, 20% good and 2% poor. Intubation conditions in RSI
using rocuronium were 65% excellent, 32 % was good and 3% poor.
There was no significant difference with regard to the intubating
conditions between the two groups (p=0.071). There was also no
significant difference in their complications (p>0.05).
Conclusion : Rocuronium was found to be comparable to
succinylcholine in terms of grading of intubation condition and could
used as an alternative in patients undergoing RSI in the Emergency
Department.
Assoc. Prof. Dr. Nik Abdullah Nik Mohamed (Supervisor)
Dr. Wan Aasim Wan Adnan (Co-Supervisor)

Assoc. Prof. Dr. Din Suhaimi Sidek (Supervisor)

Dr. Mohd. Khairi bin Md Daud (Co-Supervisor)

(57) A COMPARISON BETWEEN THE USE OF

SUCCINYLCHOLINE AND ROCURONIUM FOR RAPID
SEQUENCE INTUBATION IN THE EMERGENCY
DEPARTMENT, KUALA LUMPUR HOSPITAL.

Dr. Mohd. Lotfi Bin Hamzah

MMed (Emergency Medicine)

Department of Emergency Medicine

School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kelantan, Malaysia.

Introduction : Patients who require tracheal intubation in the

emergency department (ED) often require a rapid sequence intubation
(RSI) technique to facilitate intubation and to protect against aspiration
of gastric contents. Traditionally, succinylcholine has been the
neuromuscular blocking drug of choice in rapid sequence intubations
because of its rapid onset of action. However, it can be associated with
many side-effects such as an increase in intra-cranial pressure, an
increase intrao-cular pressure, muscle pains, bradycardia, and increased
plasma concentration of serum potassium. Amongst the currently
available nondepolarising neuromuscular blocking drugs, rocuronium
has the most rapid onset of action and is comparable with those of
succinylcholine i.e.; within 60-90 seconds. Studies had been done to
compare the use of succinylcholine and rocuronium but, most of the
studies were done in anaesthesia settings. In emergency settings, very
few studies had been done but mainly as observational studies. In
Malaysia, so far no study has been done on the comparison in the use
between the two drugs in the emergency department.
Objective : To determine whether the intubation conditions created
by rocuronium are as good as to those of succinylcholine during rapid
sequence induction during each intubation.
Methodology : 272 patients were involved in this study, undertaken
in Kuala Lumpur Hospital (HKL), a main Malaysian referral centre
for government hospitals, performed using data collection form
completed at the time of intubation. The study design was ‘Prospective
Randomized Open-End Study (PROVE) with the study period from
1st February 2003 to 30th July 2003. Patients who required intubations

95