abstracts of theses approved for the mmed at the school of...

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Abstracts Abstracts of Theses Approved for the MMed at the School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia

STUDY TO DETERMINE THE INFLUENCE OF DIFFERENT ANALGESIC DRUGS BETWEEN TRAMODAL SODIUM AND PARECOXIB SODIUM INTRAMUSCULAR ON EXPERIMENTAL PLEURODESIS INDUCED BY ERYTHROMYCIN OR BLEOMYCIN INTRAPLEURAL IN RABBITS

Dr Abdul Gafoor Bin Abdul MubarakMMed (Surgery)

Department of SurgerySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Malignant pleural effusion, recurrentspontaneous pneumothorax, and recurrent benign pleuraleffusionswerecommoncomplicationsencounteredinthedailyclinical practices especially those with advanced malignantdiseases.Thesedebilitatingcomplicationsofadvanceddiseasemaycontributetopoorqualityoflife,recurrencehospitalstay,and increase hospital cost. However, optimal treatment iscontroversialandthereisnouniversallystandardapproach. Objectives: The aim of study is to determine theinfluence of different analgesic drugs between TramadolSodiumandParecoxibSodiumintramuscularonexperimentalpleurodesis induced by Erythromycin or Bleomycinintrapleuralinrabbits. Methods: A pilot study was designed where28 White New Zealand rabbits were divided into 4 groupsof7rabbits(eachabout2monthsofageweighing2to4kg)and scheduled to receive different agents as labelled intogroup A (Erythromycin and Parecoxib Sodium), B(Erythromycin and Tramadol Sodium), C (Bleomycin andParecoxibSodium)andD(BleomycinandTramadolSodium)at right hemithorax. The left hemithorax was subjected ascontrol measures labelled as CONTROL. After 30 days,the rabbits were euthanatised for evaluation of presence ofpleural adhesions macroscopically and microscopically byblindedrespectivepathologist. Result: This preliminary pilot study demonstratedthat the degree of pleurodesis induced by the intrapleuralinjection of Erythromycin was superior compared toBleomycin as sclerosing agent in the experimental rabbits(P=0.003).Theuseofsustainedsystemicadministrationofconcomitant analgesia in this study observed that centrallyacting opiods, Tramadol Sodium surprisingly reduces thedegreeofpleurodesisascomparetoselectivecycloxygenase-2inhibitors, Parecoxib Sodium (P = 0.009)which thought tobeananti-inflammatoryagent. Conclusion: As a conclusion, extrapolation of

these results to human suggests that the use of intrapleuralErythromycin as potent chemical pleurodesis agent andinsensitivetotheactionofconcomitantanalgesiaofParecoxibSodium will give important clinical implication for theeffectivenessofchemicalpleurodesisinfuture.

Supervisors:Assoc Prof Dr Ziyadi GDr Andee D

STUDY OF CONCENTRATION AND MORPHOLOGY OF MECHANORECEPTORS IN THE MUCOSA OF UNCINATE PROCESS OF THE HUMAN NOSE

Dr Adil S. Abd AlrazaqMMed (ORL–Head and Neck Surgery) Department of ORL–Head and Neck SurgerySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Objective: To study the mechanoreceptors in thehumannasalmucosaandtocomparethemeanconcentrationof mechanoreceptors in the uncinate process mucosa inpatientswithandwithoutnasalpolyp. Method: Subjectswere12adultpatients;6participantsinthestudygroup(patientwithnasalpolyp)and6participantsincontrolgroup(patientswithoutnasalpolyp).Bothgroupsunderwent functional endoscopic sinus surgery for theirnasalpathology.Duringoperation1×1cmfromtheuncinateprocessmucosawasexcisedthenfixedwithformalinandsentto the pathology laboratory for staining, each sample wasstained for Calretinin-labeled antibody and Neurofilament-labeled antibody. After the staining process, the slideswereexaminedbylightmicroscope. Result: TherewerenocellsidentifiedtobestainedbyCalretinin antibody in all 12 samples.However sample thatstainedwithNeurofilamentantibodyshowedthepresenceofthenerveterminalsinthemucosaofall12samples.Themeanconcentration of nerve terminalswas significantly higher inpatientswithoutnasalpolyp(20.67±5.046)thanforpatientswithnasalpolyp(11.67±7.257). Conclusion: As a conclusion, the results suggestthat there are no specific cells in the nasalmucosa that actas mechanoreceptors. However the presence of the nerveterminalsinthenasalmucosaandbetweentheepithelialcellssuggeststhattheyareC-mechanoreceptorswhicharethoughttobepolymodalnerveterminals.Inaddition,reductionintheconcentrationofnerveterminalsinpatientswithnasalpolypcanbethereasonforthereductionorabsenceofthefeelingof

87Malays J Med Sci. Jul-Sep 2012; 19(3): 87-116

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Malays J Med Sci. Jul-Sep 2012; 19(3): 87-116

nasalobstructioninsomepatientswithnasalpolyp.

Supervisor:Assoc Prof Dr Rosdan SalimCo-supervisor:Dr Ramiza RamzaDr Sharifah Emila

A RANDOMISED CONTROLLED TRIAL OF MGSO4 THERAPY FOR 24 HOURS VERSUS EARLY CESSATION IN PATIENTS WITH SEVERE PRE-ECLAMPSIA

Dr Affendi YunusMMed (O & G)

Department of Obstetric & GynaecologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction:Magnesium sulphate has been showntobetheoptimalanticonvulsantinpreventingtherecurrenceof seizures in eclampsia and in seizure prophylaxis inpre-eclampsia. Traditionally, seizure prophylaxis has beenadministered before delivery and continued postpartum foranarbitrarytime,usually24hours. Objectives: The primary objectives of this studyweretoevaluatethesafetyandeffectivenessofusingclinicalparameters to signal cessation of postpartum magnesiumsulphatetherapyamongpatientswithseverepre-eclampsia. Methods: A randomised trial of postpartummagnesiumsulphatetherapywasconductedinHospitalRajaPerempuanZainabII,KotaBharuandHospitalUSM,KubangKerianfromDecember2009toSeptember2010.Thecontrolgroup received 24 hours of therapy and the interventiongroup received therapy until fulfilled clinical criteria fordiscontinuationofseizureprophylaxis.Theindependentt-test,Chi-squaretestandFisher’sexacttestwereusedforanalysisofdata.AP-valuewasconsideredstatisticallysignificant. Results: Therewere 52patients in the control groupand 50 patients in the intervention group. The interventiongroup had a significantly shorter duration of therapy(P < 0.05). Therewere no differences in themean bookingBMI,weightonadmission,systolicbloodpressureandplateletlevelbetweenthe2groups.However,thereweresignificancedifferencesinthemeanageofthepatients,deliverygestationalage, diastolic blood pressure, and uric acid level between2groups.Therewasnopatientinthisstudyhadeclampsiaorrequiredthereinitiationoftherapy. Conclusions: Clinical parameters can be usedeffectively and safe to shorten the duration of postpartummagnesium sulphate therapy in patients with severepre-eclampsia.

Supervisor: Associate Professor Dr Nor Aliza Abd. GhaffarCo-supervisor: Dr Zainal Abidin Hanafiah

COMBINED SPINAL EPIDURAL ANALGESIA IN LABOR: COMPARISON BETWEEN INTRATHECAL OF 2 MG PLAIN BUPIVACAINE VERSUS HEAVY BUPIVACAINE WITH FENTANYL

Dr Ahmad Nizam IsmailMMed (Anaesthesiology)

Department of AnaesthesiologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Spinal opioid analgesia utilizinganalgesicshasbeenoneofthemajordevelopmentsduringthepastdecadeinthemanagementofacuteandchronicpain.Therelief ofpain isdue to the interactionof theopioid injectedepidurallyorintrathecallywithaspecificopioidreceptorinthespinalcord. Objectives:Theuseofopiatesintheconjunctionwiththe spinal or epidural local anesthetic such as bupivacaineafford prolonged post-operative pain relief (Aboulish et al.,1988,Akermanetal.,1988).Apossiblesynergisticanalgesiceffect between the local anesthetic and opioids may haveimportantclinicalimplications.However,thiseffectisdifficulttoevaluateinman(Akermanetal.,1988). Methods: As there are only few studies on analgesicduration of plain bupivacaine, a double blind randomisedprospective study was conducted on 90 patients who hadundergoneparturient in labour inHospitalUniversitiSainsMalaysia , Kelantan. The aim of our studywas to ascertainwhetherasmallerdoseofintrathecalbupivacainecanpreservethequalityofanalgesiawhilegeneratingfeweradverseeffects.90 patients with no complicating obstetric and medicalproblem,whose age ranges from 18–42 yearswere selectedrandomly into 2 groups. For group 1, the patients received2mg of plain intrathecal bupivacainewith 25mcg fentanyland group 2 received 2 mg intrathecal heavy bupivacainewith25mcgfentanyl.Thepainwasassessedonthevariablesat time0 (timeat the startof IT injection)andat5, 15and30minutes. Conclusion:Theresultrevealedthattheuseof2mgheavy bupivacaine with 25 mcg fentanyl produce adequatelevelofanalgesiaatT10andnoincidenceofhighsensoryblock.Itwas statistically significant comparingboth groupswith aP-valueof0.003.Intermsofsideeffect,ourstudyhasshownlessincidenceofsideeffectincludingnauseaand/orvomitingaswellasincidenceofpruritusissignificantlyreducedinthestudypopulation(nauseaand/orvomiting P-valueat0.049andpruritusP-value=0.026.

Supervisor: Dr Gnandev Phutane

Abstracts |AbstractsofthesesapprovedfortheMMedattheSchoolofMedicalSciences

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COMPARISON OF EFFECTIVENESS AND SAFETY OF KETAMINE WITH MIDAZOLAM AGAINST HIGHER DOSE OF KETAMINE AS PROCEDURAL SEDATION FOR LUMBAR PUNCTURE IN PAEDIATRIC LEUKEMIC PATIENTS

Dr Ahmed FaisalMMed (Paediatrics)Department of PaediatricsSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction:Childrenwithleukemiaundergoseveralinvasiveprocedures.Sedationisusedtomaketheseproceduresmorecomfortingtothepatientasitisnecessaryforsuccessfuloutcome.Howeversedativescanhavedevastatingeffects. Inour centre as well as others, combination of ketamine withmidazolamhasbeenusedforyearswithoutspecificprotocol. Objectives: To compare the effectiveness and safetyofcombinationketamineandmidazolamagainsthigherdoseof ketamine as procedural sedation for lumbar puncture inpediatricleukemicpatients. Method: A total of 29 paediatric leukaemia patientsunderwent58lumbarpuncturesinadoubleblindedcrossoverclinical trial. The 2 regimes compared were ketamine-midazolam(KM)regimewhoreceivedcombinedintravenousmidazolam0.1mgperkgwithketamine1mgperkgagainstketamine-ketamine(K2)regimewhoreceivedhigherdoseofintravenousketamine(i.e.2mgperkg).Themainoutcomesmeasuredweretimetoachievethedesiredsedation(Ramsaylevelofsedationat6),timetocompletelumbarpuncture,timetoregainconsciousness(Aldreterecoveryscoreofatleast8),andadverseeffects. Result: 27 patients (93%) were successfully sedatedwith each of the regimens. Mean time taken for sedationand mean time to be fully conscious after sedationwere significantly less (P < 0.05) in K2 regime.Mean timetakenforsedationinK2regimewas7.56minutes±4.4andin KM regime it was 8.74minutes ± 3.6. Mean time to befully consciouswas 132minutes±93.5 forK2 regimewhileittook173minutes±88.8forpatientsinKMregime.Thereis no statistically significant difference in mean time takentocompleteLPbetweenthe2regimes(P=0.06).2patientsin K2 regime developed tachycardia and 1 patient had painafterprocedurewhilenopatientinKMregimenhadeitherofthese.5patientsfromeitherofthegroupshaddesaturation.Thiswasnotstatisticallysignificant(McNemertest=0.250)but it could be clinically relevant. 8 patients (30%) in KMregime required top-up doses of ketamine and 7 patients(26%)requiredtop-updosesofketamineinK2regime. Conclusion: Ketamine as a sole agent is as effectiveandsafeascombinationofmidazolamandketamine.Itshouldbe considered in procedural sedation for lumbar puncturein pediatric leukemic patients. It has faster induction andreversibility but it causemore adverse reactions anddonot

reduce time taken for lumbar puncture. An initial dose of2mg per kg is safe to be usedwith another top up dose of0.5mgperkg.Topupdosesarefrequentlyrequired.

Supervisor: Dr Mohd Suhaimi bin Ab WahabCo-supervisors:Dr Norsarwany Mohamad Assoc Professor Dr Saedah Ali

THE EXPRESSION OF INSULIN-LIKE GROWTH FACTOR-RELATED PROTEIN 1 (IGFBP-rP1) IN COLORECTAL CARCINOMA IN HOSPITAL UNIVERSITI SAINS MALAYSIA

Dr Anani Aila Mat ZinMPath (Anatomic Pathology)

Department of PathologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Insulin-like growth factor (IGF)-binding protein-related protein 1 (IGFBP-rP1) is a memberof the IGF axis. IGFs have numerous functions such aspotent mitogens, anti-apoptotic survival factor, promotingcell migration and in glucose metabolism. Type 2 diabetesmellitus or in hyperinsulinemia state is hypothesised topromote colorectal carcinogenesis directly or indirectly byincreasing the insulin-like growth factor-1 (IGFBP-rP1), apotentmitogenandinhibitorofapoptosis. Objectives: To determine the expression andassociationofIGFBP-rP1proteininpatientshavingcolorectalcarcinoma (CRC)with andwithout diabetesmellitus type 2(DM2)inourpopulation. Methods: This is a case control study of 111 cases ofCRC with or without clinically confirmed DM2 in HospitalUniversiti Sains Malaysia (HUSM) Kelantan from January2000–April2010.TheChi-square testwasused to comparethe immunoreactivity of IGFBP-rP1 expression among CRCcaseswithorwithouttype2DM,anditsassociationbyusingmultiple logistic regression test. All calculations performedby using SPSS version 18.0, P-value < 0.05 was taken asstatisticallysignificant. Results: A significant difference in the expression ofIGFBP-rP1amongCRCcaseswithandwithoutDM2.Theover-expressionofIGFBP-rP1stainingwasobservedin(18/26)69%ofCRCcaseswithDM2,whileinCRCcaseswithoutDM2only(24/57)42%.UnivariableanalysisshowedsignificantfindingforDM2(P<0.022)andcancerstage(P<0.005).ThisresultwasfurtherstrengthenedbyusingMultiplelogisticregressiontest whereby both variables, DM2 (P < 0.019; adjustedOR=3.50,95%CI,1.23–9.97)andcancerstage(P<0.005;adjusted OR = 0.25, 95% CI, 0.10–0.66) were statisticallysignificant. Conclusion: In this study, we found that therewas an increased in the expression of IGFBP-rP1 in

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our colorectal cancer patients with DM2. This studysupports the theory, that chronic hyperinsulinemia mayindirectly promotes colorectal carcinogenesis via theIGFBP-rP1, which might play an important role in theinitiationandpromotionofthecancer.

Supervisor: Prof Dr Nor Hayati Othman Co-Supervisor: Dr Sharifah Emilia Tuan Sharif

FACTORS AFFECTING CHOICE OF DELIVERY AMONGST PATIENTS AND DOCTORS AND FETOMATERNAL OUTCOME IN BREECH PRESENTATION IN TWO LARGE HOSPITALS IN MALAYSIA

Dr Bheena VyshaliMMed (O&G)

Department of Obstetrics & GynaecologySchool of Medical Sciences, Universiti Sains MalaysiaHealth campus, 16150, Kelantan, Malaysia

Objectives: To assess the factors leading to thepreferenceofmodedelivery inbreechpresentationamongstwomenanddoctorsin2largehospitalsanditsfeto-maternaloutcome. Methods: 175patients fromHospitalUniversitiSainsMalaysia(HUSM)inKelantanand164patientsfromHospitalTuanku Ja’afar (HTJS) in Seremban, Negeri Sembilan witha term breech presentation were interviewed with standardquestionnaire on the preferred mode of delivery thresholdfor complication rates where patients switch preferencesweredocumented.Atotalof50doctorswerealsointerviewedwith a standard questionnaire on the preferred mode.Difference in preference and factors affecting it were testedusingChi-squaretest. Result: Assisted vaginal breech delivery, externalcephalic version (ECV) and cesarean section was preferredmode in36.6%,38.9%and24.5%ofpatients inHUSMand8.5%,28.7%and62.8%inHTJSrespectively.Thisconfirmeda regional variation in preference. In HUSM and HTJS,a significant amount of women finally did not undergothe mode of delivery they desired (P-value = 0.001). Only64.7%(44outof68women)and35.7%(5outof14women)proceeded with AVBD, 23.4% (15 out of 64 women) and42.6% (19 out of 47women)proceededwithECV.93%and98% had successful LSCS respectively. Education level,occupation, parity, religion, culture and believes werecontributing factors to women in Kelantan while the wideavailabity of knowledge through the internet and makinga combined decision with their doctors were contributingfactors in Seremban in decisionmaking. The fetal outcomeand maternal outcome were similar in both the AssistedVaginal Breech Delivery group and cesarean section group

(P=0.33and0.243,respectively).Vaginalbreechdeliverywasapreferredchoicein62%ofthetraineeswhowereconfidentinthemanagementofvaginalbreechdeliveryaslongasastrictcriteriaofselectionwasdone. Conclusion:Mostwomenarebecomingmoreawareofbreechpresentationasahighriskpregnancyandwouldratheropt forcesareansection.Nevertheless, therearestillwomenwhoarekeenforvaginalbreechdelivery.Therefore,it isnotthebestoption to subject allwomen to cesarean section forbreech.Withproperselectionagoodnumberofwomenwithbreechpresentationwillbeabletoachieveavaginaldeliverywithout complications. Supervision and credentialing ofmedicalofficersneedstobe lookedintoandupdatedas it isproventhatconfidenceandindividualpreferencesofdoctorsdoalsoplaythefinalroleinmodeofdeliveryoftermbreechpregnancies.

Supervisors:Prof Dr Nik Mohamed Zaki Nik MahmoodProf Dato Dr Sivalingam NalliahDr Tham Seng Woh

MAGNETIC RESONANCE MEASUREMENT OF TOTAL INTRACRANIAL VOLUME AMONG MALAY POPULATION: ACCURACY OF ALTERNATIVE MEASUREMENT METHODS

Dr Busro MusaMMed (Radiology)

Department of RadiologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Total intracranial volume (TIV) isdefined as the volume within the cranium, including thebrain,meninges,andcerebrospinalfluid.Itprovidesastableand accurate normalisation factor for estimating volumetricchangesofbrainstructuresinstudiesofageingprocess,variousneurological and neuropsychiatric diseases as it is constantanddidnotchangedwithincreasingageandlessvulnerabletopathologicalchanges.Withtheadvanceofthetechnology,magnetic resonance (MR) imaging has made possibleaccurate measurements of the brain and its substructures.Various methods of MR volumetric measurement of TIVhad been established and manual method is the best. Thebest manual MR volumetry is obtained by measuring eachMR slices that cover the brain.However, obtaining TIV viathe standardmanual method is time consuming. Thereforealternativevolumetricmeasurementmethodswhichreducedthe time consumption in measuring TIV without alterationof their accuracy and reliability should be established. Thisstudyhad calculated the estimationofTIVusingalternativemeasurement and standard methods. Thus, comparison oftheaccuracyofmeasuringTIVusingalternativemeasurementmethods with the standard measurement method can beevaluated.


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Objectives: To compare the accuracy of MRvolumetry of TIV using alternative measurement methodswiththestandardmeasurementmethod. Methods: This was a cross-sectional comparativestudy of TIV measured using alternative measurementmethodsandstandardmeasurementmethodamongnormalMalay population. The study involved the data from totalof59subjects(32femalesand27males)withtheagerangingfrom 15 to 50 years old. All the patients’ data were takenfrom archive images from PACS system. TIV measurementwas performed manually using OsiriX version 3.2.1 using3 methods namely Half Cranial Measurement Method onrightandleftside,AlternateSliceMeasurementMethod,anda StandardMeasurementMethod by 2 observers. The raterwas initially undergone reliability. The mean and standarddeviation (SD) of TIV measured using the alternative andstandardmethods were calculated, analysed and compared.MeandifferenceofTIVbetweengenderswerealsocalculated. Result: Mean total intracranial volume of allsubjects was 1375.67 (148.61) cm3. Mean total intracranialvolume for male and female were 1439.14 (142.49) cm3and1322.12(133.12)cm3respectively.Thereweresignificantdifferences in the total intracranial volume betweenmale and female subjects (P = 0.002). There were goodcorrelation between the TIV obtained from the alternativemeasurement methods and that from the standard method(ICCs[0.977to0.981]andCronbach’sAlpha[0.991]). Conclusion: The study had shown comparablealternative measurement methods for total intracranialvolumewithoutsignificantlossoftheaccuracyandreliabilityofthesemethodsascomparedtothestandardmeasurementmethod.This studyalso revealed that themalesubjectshadsignificantly larger total intracranial volumeas compared tofemalesubjects.

Supervisor:Dr Mohd Shafie AbdullahCo-supervisor:Dr Win Mar @ Salmah Jalaludin

UNIVERSAL AND RISK FACTOR BASED SCREENING FOR GESTATIONAL DIABETES IN HOSPITAL RAJA PERMAISURI BAINUN: A PROSPECTIVE COHORT STUDY

Dr Chandran SinnasamyMMed (O & G)


Introduction: Diabetesmellitusismajorpublichealthandeconomicproblemofglobalsignificance,responsibleforsignificantmortalityandmorbidityamonggeneralpopulation.Prevalence of diabetes continues to rise and increasinglyaffectsindividualsofallages,includingyoungadults,children

and women of childbearing age that who are at increasedrisk of diabetes during pregnancy and the rate is expectedto go higher in the foreseeable future. The World HealthOrganization (WHO) has estimated that in 2030, Malaysiawouldhaveatotalnumberof3milliondiabeticscompareto0.94millionin2000.Inconcordancewiththis,theprevalenceofgestationaldiabetesmellitus is (GDM) increasingaswell.ThemeanprevalenceofGDMliesbetween3%and5%withan upper boundary of 14%. GDM represents the mostcommon metabolic complication of pregnancy, and isassociated with maternal (pre-eclampsia, hypertension andcesarean section) and fetal morbidity (macrosomia, birthtrauma, hypoglycemia, hyperbilirubinemia, hypocalcemiaandrespiratorydistresssyndrome). Objectives: The aim of the study is to determinethe fetomaternal outcomes in GDM mothers (antenatally,intrapartum and postpartum) and to compare the adverseoutcomebetweenglucosechallengetest(GCT)negative,GCTfalsepositiveandGDMmothers. Methods: This is a prospective cohort study carriedoutintheObstetricsandGynaecologyDepartment,HospitalIpohfromJune2009toJanuary2010.AllpregnantwomenattendingantenatalclinicatHospitalPermaisuriBainunwereincludedintothestudyoncetheyfulfilltheinclusioncriteria.Once enrolled the progress of the pregnancy was followedupuntildelivery.All therecruitedmotherweresubjected to50goralglucosechallengetest(OGCT)regardlesstofastingstate.1-hvenousplasmaglucoseconcentrationof>7.2mmol/lwas arbitrarily considered as a positive screening result.Patients with a positive OGCT subsequently underwent a75g2hOGTT,whichwasconsideredastheactualdiagnostictestforGDM.Inaddition,womenwithriskfactors(negativeGCT)forGDMalsounderwenta75gOGTTregardlessoftheresult ofOGCT. In this study,GDMwasdiagnosed if eitherorbothoffastingplasmaglucoseis≥5.6mmol/Lor2hourplasmaglucose is≥ 7.8mmol according toWHOguideline.Thevariousmaternalandfetaloutcomeswerecompiledwiththe help of a questionnaire. All the data entry and analysiswere carried out using the SPSS version 12 (SPSS Inc.,Chicago, IL). A P-value of less than 0.05 was consideredstatisticallysignificant. Results: Number of patients enrolled in this studywas 992. The main bulk of the study population wereMalays (46%), but when analysed individually the highestprevalenceofGDMwasseenamongChinese(25%).MajorityofthestudygroupinGDMcategoryweremultiparous(88.8%)and moderate obesity (BMI range 26–29). There werestrong association between obesity and incidence of GDM(P<0.001).Usingamultivariateanalysisevenafteradjustedfor the possible confounders the following conditions weresignificantly associatedwithGDMmother (odds ratio [OR],95%confidenceinterval[CI],incidenceofpolyhydramnious)(OR:4.21,95%CI,2.43–7.31),incidenceofPPROM(OR:3.21,95%CI, 1.89–5.47), incidence of preterm labour (OR: 3.99,95% CI, 2.53–6.30), incidence of gestational hypertension(OR:2.09,95%CI,1.31–3.34),incidenceofcaesareandelivery

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(OR: 3.80, 95% CI, 2.63–5.49), incidence of instrumentaldelivery (OR: 3.49, 95% CI, 1.69–7.20), incidence ofmacrosomicbaby(OR:1.80,95%CI,1.02–3.19),incidenceofshoulderdystocia (OR:5.60,95%CI, 1.67–18.77), incidenceof extended perineal tears (OR: 3.60, 95% CI, 1.32–9.78).Whereelse amongtheGCTfalseposivemothers:Incidenceof PPROM (OR: 2.03, 95% CI, 1.08–3.84), incidence ofcaesareandelivery (OR:3.74,95%CI,2.51–5.58), incidenceofmacrosomicbabies(OR:2.15,95%CI,1.19–3.88),extendedperinealtears(OR:5.82,95%CI,2.22–15.27).Therewerenosignificant differences were noted in following aspects likepre-eclampsia, babies born with low APGAR score(< 6 in 5 minutes), cord blood pH and delayed dischargefromward followingLSCS. Therewere also noted trends ofadverse fetomaternaloutcomeamongthepatientswithfalsepositiveGCT. Conclusion: Gestational diabetes mellitus is anindependent risk factor for a number of adverse obstetricoutcomes; inourpopulation50gOGCTappears to identifya higher number of GDM than risk factor based screening.Combined with risk factor screening a few more cases ofGDM would be found. GCT false positive mothers had anincreasedlikehoodofanadversepregnancyoutcomeaswell.

THE RELATIONSHIP OF LENS THICKNESS AND ANTERIOR CHAMBER DEPTH WITH INTRAOCULAR PRESSURE DURING HEMODIALYSIS

Dr Chiang Wai SengMMed (Ophthalmology)

Department of OphthalmologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Hemodialysis is a common renalreplacementtherapyintheend-stagerenalfailure.Fluctuationof intraocular pressure occurred during hemodialysis.Individuals with compromised aqueous outflow facilityhave increased risk of symptomatic elevation of intraocularpressure. Lens thickness changes may result in alterationof anterior chamber depth that can further compromiseaqueous drainage. Early detection of the lens thicknesschanges during hemodialysis can prevent elevation ofintraocularpressure andvisual loss.Thus, evaluationof thelens thickness and anterior chamber depthwith intraocularpressure changes during hemodialysis are essential. Objectives: Todeterminethemeanlensthicknessandtherelationshipbetweenlensthicknessandanteriorchamberdepth, between anterior chamber depth and intraocularpressure as well as between lens thickness and intraocularpressureduringhemodialysis. Methods: 70 eyes from 70 study subjects wererecruitedfromHemodialysisUnit,QueenElizabethHospital.Lens thickness, anterior chamber depth and intraocularpressure were measured at 0 hour, 2 hour, and 4 hour of

hemodialysis. The mean lens thickness, anterior chamberdepthandintraocularpressurechangesbasedontimeeffectof hemodialysis were analysed with repeated measuresANOVAandmultiplepairedsamplesT-testwithbonferonnicorrection (P = 0.017). The relationship between studyvariableswereevaluatedwithcorrelationanalysis. Result: There were significant increased mean lensthickness and intraocular pressure among all study subjectsby 0.21 ± 0.69 mm (P = 0.015) and 1.26 ± 3.02 mmHg(P=0.001)inthefirst2hoursofhemodialysis.Theanteriorchamber depth changes was insignificant. The mean lensthickness and intraocular pressure were increased morein diabetic and older age group in the first 2 hours ofhemodialysis but significant for intraocular pressurechangesonly.At2hoursofhemodialysis,therewereinversecorrelation between lens thickness and anterior chamberdepth, inverse correlation between anterior chamber andintraocular pressure and linear correlation between lensthickness and intraocular pressure but not significant. At4 hour of hemodialysis, there was a significant fair inversecorrelation between lens thickness and anterior chamberdepth (r = -0.286, P = 0.016) but the correlation betweenothervariableswerenotsignificant. Conclusion: In the first 2 hours of hemodialysis,there were significant increased mean lens thickness andintraocular pressure but no significant correlation betweenstudy variables suggested other mechanisms of raisedintraocular pressure were involved rather than due to lensthickness changes only. A significant inverse relationshipbetween lens thickness and anterior chamber depth wasestablished at 4 hours of hemodialysis but it did not leadto significant raised intraocular pressure in normal eyes.Intraocularpressurerisemaybecomesignificantifindividualshave compromised aqueous drainage. Diabetes mellitusandagehadsignificantinfluenceonintraocularpressurebutnot on lens thickness and anterior chamber depth duringhemodialysis.

Supervisor:Associate Professor Dr Mohtar IbrahimCo-supervisor: Dr Azhany Yaakub

THE ASSOCIATION OF BODY MASS INDEX (BMI) WITH CLINICAL OUTCOMES IN PATIENTS WITH PULMONARY TUBERCULOSIS

Dr Dzawani Binti MuhamadMMed (Internal Medicine)

Department of MedicineSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: It is accounted for the top 10 leadingcause of death especially in the middle income countries.Globally, according to World Health Organization (WHO),


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therewereanestimated9.4millionnewcasesofpulmonarytuberculosis(TB),in2008with140newcasesper100000population. SeveralstudiesshowedthatpatientswithactiveTBaremore likely tohave lowbodymass index(BMI=wt[kg]/ht[m²])comparedtohealthyindividuals. Objectives: The aim of this study is to identifiedthe use of BMI to predicts clinical outcomes of TB, so thatthis relatively simple measurement can be used for clinicalbenefit especially in resource limited setting. With thisobjective inmind, thepresent studywasaimedat clarifyingthe association of the BMI with the clinical outcomes ofTBpatientsandsubsequentlyhelpinimprovingthetreatmentoutcomesamongTBpatients. Methods: During the study period, a total of127 patients were recruited for this study. The total ofestimatedsamplesize(n=156)cannotberecruitedduetotimeconstraint.Themeanageofpresentationwas44.74± 17.38years. The study population hadmale predominant (53.1%)andMalay’s ethnic contributed to the highest proportion ofthestudysubjects(96.9%).Aquarter(26.6%)ofpatientsdidnothaveformaleducationleveland36.7%hadeitherprimaryor secondary education’s level.Other than that, patient hadbackground of college or university level, 25.0% and 10.9%respectively. Results: The study shows no significant associationbetween thevariables (bodymass index [BMI], age, gender,co-morbidities and smoking) with the sputum conversionrate(P>0.05).NomultivariateanalysiswasperformedsinceallP >0.10.Studyalsoshowssignificantassociationbetweenthe smoking status with the weight gain (P = 0.015). Asidefrom that, there is no significant association between thevariableswiththeadversedrugreactions(P>0.05). Conclusion: Between 64%–100% of smear positivesputum patients had sputum conversion irrespective of theinitialBMI.Between74%–100%ofpatientshadweightgainirrespective of the initial BMI. 12% of patients developedallergicdrugreactionsandmostlyinlowerBMIgroups.

A COMPARISON BETWEEN THE EFFECTIVENESS OF LYCRA AND SILON PRESSURE GARMENTS FOR TREATMENT OF HYPERTROPHIC SCAR IN BURNS

Dr Ehfa Bujang SafawiMMed (Plactic Surgery)

Department of SurgerySchool of Medical Sciences, University Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Hypertrophic scarring after burnsremainsamajorchallenge forburncareproviders.Pressuregarments and silicone sheets have been the mainstay ofhypertrophic scar treatment.This studywas to compare theeffectiveness of the traditional Lycra pressure garment andthesiliconeincorporatedpressuregarment(Silon)andalsotodeterminepatients’satisfactionwithpressuregarmentamong

burnspatientsinHospitalUniversitiSainsMalaysia. Methods: Thisiswasa2-phasedstudy.PhaseIwasaretrospectivestudy,whichinvolvedpatientswhoweretreatedwiththeLycrapressuregarments fromJune2007untilJun2009.Meanwhile,phaseIIwasaprospectivestudy,involvingpatientswhowere treatedwith theSilonpressure garmentsfrom June 2008 until June 2010. Demographic detailscollected included age, type and depth of burn, total burnsurface area (TBSA) and cause of injury. The effectivenessof the treatment was determined based on the VancouverScarScale score.Patients’ scarswereassessed2weeksaftercompletewoundhealingandevery4months,forupto1year. Result: RepeatedmeasuresANOVAshowedsignificantimprovement in terms of scar vascularity, itch, and painwithin each study group (P <0.05).However, therewasnostatisticaldifferencebetweenthe2pressuregarmentgroups(P > 0.05). Meanwhile, there was no significant differencewithin and between the 2 study groups in terms of scarheight, pigmentation and pliability. Majority of the patientcomplainedof itch,sweating,discomfortandtightnessuponwearing the pressure garments. In addition to interferingwiththeirdailyactivities,theyalsoreportednoimprovementof theirscarappearance.Nevertheless, theystillbelieve thatcompliancewiththetreatmentisofgreatimportanceinordertogainoptimalresult. Conclusion: We cannot conclude that the combinedpressure garment and silicone therapy (Silon) was moreeffective than the traditional pressure garment (Lycra).Hypertrophic scars following burns injuries can take up to2yearstoreachmaturity.Thus,itisrecommendedthatscarsshouldbemonitoredandpressuregarmenttreatmentshouldbecarriedoutforatleast2years.

Supervisor: Dr Ananda Dorai

THREE DIMENSIONAL HIGH RESOLUTION MRI MYELOGRAPHY OF CERVICAL SPINE IN PATIENTS WITH CERVICAL SPONDYLOTIC RADICULOPATHY USING MODERATELY T2 WEIGHTED 3D TSE-FS SEQUENCE

Dr Husbani bt. Mohd Amin RebuanMMed (Radiology)


Introduction: Neck pain is themost frequent causeofconsultationinprimarycareworldwide.Themostcommoncause of neck pain in adult more than 50 years of age iscervical spondylosis. These degenerative changes causingimpingement of the nerve root that exit from the foraminaproducingthepatient’sclinicalsymptoms.MRImyelogramisanon-invasiveradiationfreeprocedure.Itsspecialsequenceis a new technique that complement conventional MRI in

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makingdiagnosisbydetectingnerve root impingement.Theadvantageof thisnew techniqueover the conventionalMRIis still under investigation. The agreement of the findingsbetweentheseprocedurescangiveanadditionalinformationin the process of making MR myelography as an effectivescreeningtoolinthefuture. Objectives: The objective of this study is toprospectively associate the clinical variableswithnerve rootimpingementinbothconventionalMRIandMRImyelogram,to determine the agreement of findings (demonstration offoraminal nerve root impingement in cervical spondyloticradiculopathy)betweenthese2proceduresandtodeterminethe interobserver variability between the 2 observers indepictingthenerverootimpingement. Methods: A randomised cross-sectional prospectivestudy todepict thenerve root impingement inpatientswithclinical diagnosis of cervical spondylotic radiculopathyusing both conventional MRI and MRI myelogram of thecervical spine. Images from both 2 imaging findings ofeach patient were reviewed by 2 experienced radiologists.They interpretation of the images were done independentlywithout knowing the symptoms and clinical findings of theinvolved patients. The agreement of findings between theobserverswerecompared. Result: Cervical spondylotic radiculopathy affectsmainlyofhighproductivityagegroup.Therewassignificantcorrelationbetween clinical symptoms and signswithnerveroot compression in both imaging techniques. There weremoderate agreement of findings between MRI myelogramwith conventionalMRIand thereweremoderate agreementof findings between 2 observers in depicting nerve rootimpingement. Conclusion: MRImyelogramalteredtheinterpretationof nerve root impingement in 22 cases out of 47 nerveroots (approximately 50% of the cases). This value is verysignificant that MRI myelogram can be used as acomplementary test to the conventional MRI in detectingnerve root impingement inpatientwith cervical spondyloticradiculopathy.MRImyelogram gave additional information(8nerveroots)thatappearedtoimpingeonMRImyelogrambut did not appear on conventionalMRI. Even though thisvalueisminimaltomakeMRImyelogramasanindependentimagingtechnique,itgivesabigvaluetothepatients.

Supervisor:Ass Prof Dr Mohd Ezane b. Aziz Co-supervisor:Dr Elinah bt. Ali

A STUDY ON KNOWLEDGE, ATTITUDE AND PRACTICE ON COLORECTAL CANCER SCREENING AMONG AVERAGE RISK MALAY PATIENTS ATTENDING SELISING HEALTH CLINIC

Dr Idora Binti IbrahimMMed (Family Medicine)

Department of Family MedicineSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Colorectal cancer (CRC) is rapidlyincreasing inAsia.Despite the rising trend in incidenceandmortality, colorectal cancer screening rates are still low inmostAsian countries. The acceptability of CRC screening isinfluencedbypeople’sknowledgeandattitude.Thisstudywasconducted to evaluate the knowledge, attitude and practiceofMalaypeopletowardCRCscreening. Objectives: Theobjectivesofthestudyaretodeterminethelevelofknowledge,attitude,practiceandtheirassociatedfactorsonCRCscreeningamongaverageriskMalaypatients.Italsotodeterminetherelationshipbetweenknowledgeandattitudescoreandknowledgeandpracticescoreoncolorectalcancerscreening. Methods: It was a cross sectional study conductedfrom October 2009 to December 2009 at Selising HealthClinic. The study used a self-administered questionnairewhich involved 262 Malay participants aged 50 years andabove. The questionnaire consisted of 3 parts, which dealtwithknowledge,attitudeandpracticeoncolorectalcancerandscreening. Result: There were only 6.1% respondents had goodknowledgeand31.7%of the respondentshadgoodattitudeson colorectal cancer screening. Consequently, colorectalcancerscreeninguptakewasextremelypoorwithonly2outof 262 of the respondents had CRC screening. There wasmoderatetogoodpositivecorrelationbetweenknowledgeandattitudescore.Inaddition,theresultsshowmalegender,loweducationlevelandnon-professionalgrouparetheassociatedfactorsforlowlevelofknowledgeonCRCscreening. Conclusion: These findings indicate that averageriskMalaypatientshadinadequateknowledge,poorattitudeon colorectal cancer screening togetherwith extremelypoorpractice on colorectal cancer prevention. This study alsoconcluded that increasing knowledge on colorectal cancerscreening may encourage less negative attitudes aboutcolorectalcancerscreening.Otherthanthat,educationallevelappearstobethemajordeterminantonthelevelofknowledgeand attitudes.While, type of occupation affects the level ofknowledgeandpracticeoncolorectalcancerscreening.

Supervisor:Dr Harmy Mohd YusoffCo-supervisor:Dr Norwati Daud


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A RANDOMISED CONTROLLED TRIAL COMPARING THE EFFECTS OF HONEY VERSUS SUCROSE AS AN ANALGESIA DURING ROUTINE VENEPUNCTURE IN NEWBORNS

Dr Khanisa Md KhalidMMed (Paediatrics) Department of PaediatricsSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Objectives: Todetermine theeffectivenessandshortterm side effects of honey as analgesia in comparison tosucroseduringroutinevenepunctureinnewborn. Methods: Atotalof78 termneonateswere recruitedfrom the Neonatal Intensive Care Unit and Special CareNurseryofHospitalUniversitiSainsMalaysia.Theseneonateswere randomised into 2 equal sized group receiving either2mloforal24%sucroseor2mlofTualanghoney2minutespriortovenepuncture.Thewholeprocedurewasvideotaped.Thedegree of pain scoreusingPIPP anddurationof cryingtimeweredeterminedtwiceby2 independentobserver.TheMann-WhitneyU test was used to compare the pain scoresand duration of cry between the study groups while theWilcoxon signed-rank test was used to compare differenceswithineachgroup. Result: The result showed no significant differencesin the demographic characteristics of the neonates. ThemedianvaluesofPIPPat 30 secondsand 150 secondswerecomparable (P =0.871) betweenboth groups (medianPIPPsucrose=5,3medianPIPPforhoney=5,2respectively).ThemedianPIPPscorewithineachgroupwassignificantlyhigher(P = 0.00) at 30 seconds (median = 5) compared to at150seconds(median=2.5).Thedurationofaudiblecryaftervenepuncturewasnot statistically significant (P=0.803) inneonates receivinghoney (median= 5.5 seconds) comparedtoneonatesreceiving24%sucrose(median=4seconds).Noneonates developed hyperglycemia, diarrhea or glycosuriainthisstudy. Conclusion: In conclusion, this study stronglysuggeststhatTualanghoneyisnotmoreeffectivethansucrosefor procedure related analgesia in neonates. The absence ofadverseeffectsfollowingtheadministrationofsmallamountsof honey to neonates may facilitate further studies usingdifferentdosesordifferenttypesofhoney.

Supervisor:Dr Nor Rosidah Ibrahim

EFFECT OF SEDATION PROPOFOL WITH TARGET CONTROLLED INFUSION ON COGNITIVE FUNCTIONS ON PATIENTS UNDERGOING OPERATIVE PROCEDURES UNDER LOCAL ANAESTHESIA IN HOSPITAL UNIVERSITI SAINS MALAYSIA

Dr Khathija HasanMMed (Anaesthesiology)

Department of AnaesthesiologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kubang Kerian, Malaysia

Introduction: Surgical procedures are increasinglybeing performed under local anesthesia alone but mostpatients prefer to be sedated. Sedation combined withlocal anesthesia is a safe alternative to GA as spontaneousrespiration, protective reflexes, and patient co-operationare retained while fear and apprehensions are reduced.The changes in cognitive function frequently complicate thepost-operative course of patients undergoing non-cardiacsurgery.Somepatientsareatagreaterriskthantheothersofcognitiveimpairmentandwhatdosesofdrugs?Ifyes,thenforhowlong?Hence,theneedforexperimentalstudytoanswerthesequestions. Objectives:TheaimofthisstudywastoevaluatethecognitivechangesafterpropofolsedationviaTCIasmonitoredanestheticcareandfactorsinfluencingitwereexplored. Methods: This was a prospective randomisedcontrolled trial. Study subjectswereplaced in either armasperdoubleblock randomisationpre-operativeafter fulfillinginclusion criteria. Standard monitoring was done duringintra-operative and post-operative period. 104 consentingASA physical status I and II patients scheduled to undergoelective surgical procedures with local infilteration wereassigned,toreceiveeithersedationpropofolinfusionoronlylocalinfiltration(withoutpropofolsedation)intra-operatively,bytheresearcher.Uponarrivalinpre-operativeholdingarea,patients were to undergo 2 cognitive function tests (MMSEandSOMCT)besidethedemographicdataasbaseline.Thesetestswerecarriedoutbyblindedinvestigatortoavoidbias.Thepatientswerethentakenintooperatingroomsandstandardmonitoringwasapplied.After intravenous linewas secured,local infiltration of operative area was done by surgeon.Interventional group received sedation propofol via marshmodeltargetcontrolinfusiontargetingplasmaconcentrationlevelof0.5ug/ml,and those incontrolgroupreceived localinfiltrationonly.Propofolinfusionwasstoppedattheendofsurgery. Patients were brought to post-anesthetic care unit(PACU) and monitored continuously. Cognitive functiontests were repeated at 20 and 60 minutes post-operativelyforboththegroupsbyblindedinvestigator.Standardclinicaldischarge criteria were used to discharge patients fromrecovery room.

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Results: Demographic data were comparable inboth groups. Cognitive status was improved at the end of60minutesinboththestudygroupsbutslowerresponsewasobservedinexperimentalgroupascomparedtocontrolgroup.Analysis of co-variable demonstrated that males showedmore marked cognitive decline as compared to females intheexperimentalgroup,whereasmalesofcontrolgrouphadno observed cognitive drop. Similar changes were observedwith other co-variables like race, age, smoking habits andsubjectswithhistoryofpreviousgeneralanesthesia.Durationof infused sedation seems to have effect on psychomotorfunctionsaslongeroperativeprocedures(>30minutes)hadloss of recoverypattern. Subjectswhohadhigher educationandemployedhadbetterperformanceof cognitive testsbutstill slower recovery as compared to control group.Also theassessmentofboththecognitivetestsweredoneandMMSEwas found to be more sensitive in detecting the cognitivechanges as compared to SOMCT, while SOMCT was morespecific. Conclusion: Based on our study results, we canconclude that as propofol is sedative which explain theimprovementofcognitivescoreswithtimebutaslowrecoverypatternhadbeennotedinexperimentalgroupascomparetocontrolgroup.Hence,weconcludethatthereisnosignificantcognitive function deficit noted after propofol TCI sedationbut the trend of slower recovery has been shown whencomparedtocontrol.Otherco-variablesmayhaveaninfluenceonpost-operativecognitivedecline.

Supervisor:Assoc Prof Dr Wan Aasim Wan AdnanCo-supervisor:Dr Rhendra Hardy Mohamad Zaini

DIAGNOSTIC VALUE OF SONOGRAPHY IN IDENTIFYING AXILLARY LYMPH NODE METASTASIS IN BREAST CANCER PATIENT

Dr Latifah binti Ishahak @ IshakMMed (Radiology)

Department of Radiology and Diagnostic ImagingSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16500 Kelantan, Malaysia

Introduction: Axillary lymph node status has beenthe single most important factor predictive of survival inbreast cancer. Axillary lymph node dissection is performedas part of surgical treatment of breast cancer, mainly forstagingandplanningofsystemicadjuvanttherapy.However,axillary lymphnodedissection isassociatedwithsubstantialcostandmorbidity.Manypre-operativenoninvasiveimagingmethods to obtain accurate diagnosis and assess extentof disease has been utilized. Axillary ultrasound has been

proven to have demonstrated superior diagnostic accuracy.Itisrelativelycheapandwithoutionisingradiationinvolved.Axillarylymphnodeshavespecificultrasoundcharacteristicsto be differentiated between metastatic and non-metastaticnodes.Thisstudywasdonetodeterminethediagnosticvalueandusefulnessof identifyingaxillary lymphnodemetastasisin breast cancer patient and improvise the ultrasoundtechnique inprovidingstaging informationanddeterminingprognosisinwomanwithbreastcancermetastasis.Thisstudyaimed to minimise complications for patients undergoingaxillary clearance surgery as the parameters which arepre-operativelyobservedandevaluatedinsonographiclymphnodes criteria will help the managing surgeons to justifythe indication and benefits of undergoing axillary clearancesurgery. Objectives:Toevaluatethesonographiccharacteristicsofaxillarylymphnodeinbreastcancerpatient. Methods: Thiswasacross-sectionalstudytoevaluatethe sonographic characteristics of axillary lymph node inbreastcancerpatient.ThestudyperiodwasfromJune2009toMarch 2011. The age of the patients ranged from45- to67-years-old. A total of 18 female patients were included.Ultrasound of axilla was performed using a SiemensSONOLINE® Elegra ultrasound machine. High frequencylinearprobe13.7MHzwasused.Thegreyscalemorphologyofaxillarylymphnodewasevaluated.Thepresenceofnodalvascularity was assessed using colour Doppler sonography.The spectralDoppler indexes (resistive indexandpulsatilityindexes)wereevaluatedusingultrasoundsoftware. Result: The relationship between afferent resistiveindexvaluetometastasticandnon-metastaticaxillarylymphnode was significant (P = 0.010). The presence of roundshape (76.7%) heterogenous cortical echogenicity (78.6%),cortical thicknessmore than2mm(77.8%),eccentriccortexmorphology(84.6%),hypoechoicmediastinum(80.0%), lostof hilum (76.9%), presence of no calcification (76.9%) andperipheral colour Doppler vascularity pattern showed highpositivepredictivevaluepercentage.However therewerenosignificant relationship between grey scale morphology andaxillarylymphnodehistopathologicalfindings.Thesensitivityandspecificityinthisultrasoundstudywerefairlylow. Conclusion: This study has proven that spectralDoppler resistive index value of the afferent lymph nodevessel is useful in differentiating metastatic axillary lymphnode. However the grey scale criterias in differentiatingnodal malignancy is not statistically significant. This studydemonstratedreasonablyhighgreyscalemorphologypositivepredictivevaluewithlowsensitivityandspecificity.

Supervisor: Dr Nik Munirah Nik MahdCo-supervisor: Dr Salwah binti Hashim


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RANDOMISE CONTROL STUDY USING VITAMIN D IN PREVENTING POST TOTAL THYROIDECTOMY TRANSIENT HYPOCALCEMIA

Dr Lai Chung KetMMed (Surgery)

Department of SurgerySchool of Medical Science, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Total thyroidectomy is a commonsurgical procedure for thyroid disease. The commoncomplication of thyroid operation is bleeding, injury tothe superior and recurrent laryngeal nerve, thyroid storm,hypothyroidism, transient hypocalcemia and infection.Withthe recent advanced technology and surgical skill, thyroidoperation is very safe andmost can be done as a day careprocedure. However, the risk for transient hypocalcemiastill remain high. Without doubt, this problem causingdiscomforttothepatientandalsoprolongedtheneedstostayinthehospital. Objectives: The aim of our open label randomisedcontrol study was to determine the incidence of transienthypocalcemia developing post-total thyroidectomy inMalaysiaandthebenefitofpre-operativetreatmentusingoralvitaminDintotalthyroidectomy. Methods: This is a randomised control study whichrecruitsa totalof74patients fromHospitalUniversitiSainsMalaysiaandHospitalRajaPerempuanZainabII.Thestudywascarriedoutover1yeardurationsince5thMay2009until30th April 2010. The ethnical approval was obtained fromTheResearchEthnicalCommittee(Human),UniversitiSainsMalaysiaandEthnicalBoardClinicalResearchCenter(CRC),Ministry ofHealth. Sample sizewas calculated usingPowerandSampleSize(PS)calculationsoftware(PSsoftware,1997).74patientsunderwenttotalthyroidectomywererandomisedinto2groups.Forstudygroup;37patientstreatedwithoralvitaminD (calcitriol) 1.5 ug/day for 2 days duration beforeoperation followed by 1.0 ug/day plus oral calcium lactate1800 mg/day for 7 days after operation. While for controlgroup; 37 patients did not receive oral Vitamin D. All thepatient were assessed either clinically or biochemically forhypocalcemia.AlldatawereenteredandanalysedusingSPSSsoftware version 12.0. Studied parameters analysed usingfrequencyandpercentage,univariateandmultivariatelogisticregressionandrepeatedmeasureancova. Result: There was not significant difference betweenthe study and control group in terms of demographicdistribution of age, sex, diagnosis, surgeon, operatingduration, parathyroid gland autotransplant and baselinelevel of serum calcium, phosphate and intact PTH. Theincidenceofpost-totalthyroidectomytransienthypocalcemiain the study group is about 16.7% compared with controlgroup of 75%. Among the cases, 50.0% in study group and64.3% in control group are symptomatic. The incidence of

permanenthypoparathyroidismis2.7%.Therewassignificantdifferenceintermofincidenceofasymptomatichypocalcemiaand symptomatic hypocalcemia between these 2 groups.There was also significant difference between control andstudygroupwithregardstothetrendofpost-operativeserumcalciumchanges.However,therewasnosignificantdifferencein the risk of developing permanent hypoparathyroidism.The post-operative stay is significantly longer in controlgroup,4.59dayscomparedwithstudygroup,3.92days. Conclusion: TheadministrationoforalvitaminDhadsignificantlyreducedtheincidenceoftransienthypocalcemiaposttotalthyroidectomy.

Supervisor: Dr Zaidi ZakariaCo-supervisors:Dr Zainal MahmoodDr Imisairi Haji Abdul Hadi

EVALUATION OF RESULT OF CIRCUMCISION DONE IN HOSPITAL RAJA PEREMPUAN ZAINAB II AND CIRCUMCISION DONE IN THE COMMUNITY SETTING.

Dr Mohammad Hisyam bin SidikMMed (Surgery)


Introduction: Circumcision is an importantmedicalandritualprocedurethatalreadyperformedforthousandofyears.Nowadays,circumcisionispractisedinhospital,inthecommunity settingunder cleanbutnon-sterile environmentand also in the traditional way. The hazards of traditionalcircumcision is clearly documented, however the result ofcircumcision done in the community was not objectivelystudied.Thisraisesthequestionwhethersuchpracticeissafeor other recommendation should be made to improve theoutcomeofthisimportantprocedure. Objectives: Thisstudyaimstoevaluatethedifferencein the incidence of bleeding and infection complication ofcircumcisiondoneinsideandoutsidehospital. Methods: This is a prospective study reviewing75 circumcisions done in Hospital Raja Perempuan ZainabIIand84circumcisionsdoneoutsidehospitalinKotaBharuandPasirMasarea.Thestudyperiodisbetween1stNovember2009 and 31st December 2009. Patients were followed-up1 hour, 3 days and 7 days after the circumcision. Incidenceofbleedingandwoundinfectionwasrecorded.DataanalysiswasdoneusingSPSSsoftwareversion18.0. Result: The incidence of wound infection of outsidehospitalgroupishigherthaninsidehospitalgroup(22.6%vs9.3%,P=0.024)withrelativeriskof2.42.The incidenceofbleeding isnodifferent betweenoutsidehospital and insidehospitalgroup(4.8%vs6.7%,P=0.736).

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Conclusion: This study proves that circumcisionperformedoutsidehospitalhasmoreriskofdevelopingwoundinfection compared to circumcision done in the hospital.However the bleeding complication is identical in betweenthese2groups.

Supervisor:Dr Mehboob Alam PashaCo-supervisor:Dr Mohd Tarmizi Mohd Nor

OPEN RESECTION (OR) VERSUS LAPAROSCOPIC ASSISTED RESECTION (LAR) IN PATIENTS WITH COLORECTAL CANCER AT HOSPITAL TAIPING. A RETROSPECTIVE STUDY

Dr Mohanasundram pillaiMMed (Surgery)


Introduction: Carcinomaofthecolonandrectumwaspreviously considered a disease of the western population.It was uncommon in southern Asia and equatorial Africa,fairlycommoninthemiddleofEuropeandverycommoninnorth-western Europe, the United States, Canada and NewZealand(WHO,1981).Thistrend havechangednowduetochanging polarisation in world development and economy,as the incidence of the disease is very much related to thedegree of development of country (Soybel, Bliss Jr et al.1987).Malaysia,beingrapidlydevelopingnation isprobablywitnessing an increasing trend in colorectal cancers. In thepastdecades,thereweretremendouschangesinthelifestylesof Malaysians including dietary habits, which have becomewesternised. As a country with multiracial population,the incidence of certain diseases among various races ofMalaysiansmight vary from one to the other. It was notedthe incidence and the mortality of colorectal cancers wasmuchhigher in theChinesepopulation compared to that ofthe Malay population in Singapore (Foong and Lee). Thisvariation among racial groupsmay be true for this countryas well. Thus, in this study the epidemiological aspect ofcolorectalcarcinomasislookedinto,inadditiontotheclinicalandtherapeuticaspectsofthisdisease.Thisdissertationisaretrospective study of patients with colorectal cancers whohad underwent curative surgical resection by either OpenResection (OR) or Laparoscopic Assisted Resection (LAR)method in Hospital Taiping, Perak from January 2005 tillDecember2009.TheforaytoLARforcolorectalmalignancywas started in early 2004 by Dr Vimal Vasuedavan andDr Umasangar in their capacity as consultant generalsurgeonatthishospital.Bothofthemhadperformedatleast20laparoscopicresectionsforbenigndiseaseasthelearningcurverecommendedbyAmericanSocietyofColonandRectalSurgeons(SAGES),bytheendof2004beforeembarkingon

LARforcolorectalcancers. Objectives: To study the epidemiology of colorectalcarcinoma in the Larut, Matang and Selama district. Theprimary objective was to evaluate short-term benefits oflaparoscopic assisted resection compared to open resectionin colorectal malignancy and the feasibility of undertakingthisatadistricthospital.Asthescopeofthistopicistoowide,the purpose of this study has been limited to compare theoutcome of the 2modalities of treatment as outlined in thespecific objectives. To review and compare: (1) Length ofhospital stay post surgery (number of days), (2) Length ofoperative time (time in minutes), (3) Early post-operativecomplications(4)Surgicalfreemargin. Methods:Thisisaretrospectivestudyofallcolorectalcancer cases who underwent resection either OR or LAR,from January 2005 tillDecember 2009 atHospital Taipingwhich is 607 bedded hospital, with 105 surgical bed. Thereare 4 general surgeons and 2 of them have special interestin minimal invasive technique and about 30–35 casesof colorectal carcinoma diagnosed yearly. All cases wereidentified by retrospective review of the colorectal cancerfromoncologybook,wardadmissionbookandtheoperationregister book in operation theatre from January 2005 toDecember 2008 at Hospital Taiping. Patients diagnosedwithcolorectalcancerwithinthisperiodofstudybutrefusedsurgical intervention, inoperable due to advance diseaseor patients with incomplete records are excluded from thisstudy. Patient’s medical record, Computerized OperatingTheatre Documentation System (COTDS) notes andhistopathologyreportweretracedandreviewed.Informationneeded entered in the performa. Data will be entered andanalysed through SPSS version 18, descriptive statisticslike frequency, means and their standard deviation will becalculated.ForcomparisonbetweenORandLAR,Chi-squaretestwillbeappliedforcategoricalvariablesandindependent t-test applied for numerical variables. P-value of less than0.05willbeconsideredassignificant. Results: Atotalnumberof 193patientswerestudiedfor5yearsperiodrangingfromJanuary2005tillDecember2009. The ratio of patients underwent open resectioncompared to laparoscopy was 2:1. There was almost equalsex distribution in each group. Majority of patients areMalay followed by Chinese and Indian. The average age atpresentationwas62inORand58inLAR.Almostallpatientsrequiring emergency surgery underwent OR to safeguardoncologicresectionwhichhadresulted to favourablepatientselectionfortheLARgroup.ThedurationofsurgeryinLARgroupwaslongercomparedtoORgroup.Thepost-operativestay inLARgroupwassignificantlyshortercomparedtoORgroup. The post-operative complications was lesser in LARgroupbutnotstatisticallysignificant.Thesurgicalfreemarginfromtheresectedspecimenshowednosignificantassociationbetweensurgicalmethodsandmargin. Conclusion: LAR confers short term advantagecomparetoORandaprospectiverandomisedmulticentertrialwithat least5year follow-upshouldbeconducted, togauge


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thelongtermoutcomeofLARincolorectalmalignancy.Supervisor:Dr Syed Hassan Syed Abdul AzizCo-supervisor: Dr Vimal Vasudeavan

A STUDY OF BODY COMPOSITION AND ITS ASSOCIATION WITH DISEASE SEVERITY IN STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENTS IN HUSM

Dr Mohammad Faisal bin AsmeeMMed (Internal Medicine)


Introduction: Chronic obstructive pulmonarydisease(COPD)isnotjustadiseaseofthelungsalone;ithassystemicmanifestations due to the underlying pathogenesisofinflammatoryreaction.Systemicmanifestationsintermofreduction inbodycomposition (bodymass index [BMI]andfat free mass index [FFMI]) has been shown to be anindependent risk factor fordisease severityandmortality inCOPD. Objectives: Theobjectiveofthisstudyistodeterminethe associationofbody compositionwithdisease severity instable COPD patients (patients who had no exacerbation inthepast3months). Methods: We evaluated 38 stable COPD patientsattending Respiratory Clinic in HUSM and calculated theirBMI and FFMI and determined their 6 minutes walkingdistanceandserumCRP-values. Results: There was no satisfactory significantdifferencebetweenbodycompositionanddiseaseseverity inCOPDpatientsnotedinthisstudy(P >0.05). Conclusion: Body composition (BMI and FFMI)is not suitable for assessment of disease severity in stableCOPDpatients.

Supervisor: Dr Shaharudin Abdullah Co-supervisors:Dr Hamid Jan Dr Rosediani

RAPID PLEURODESIS USING SMALL BORE PIGTAIL CATHETER AND BLEOMYCIN IN MALIGNANT PLEURAL EFFUSIONS: A CASE SERIES

Dr Mohd Nizam Md HashimMMed (Surgery)


Introduction: Pleural drainage is the treatment ofchoice for patients presented with symptomatic malignantpleural effusion. The conventional method of treatment isinsertionoflargeborethoracostomytube(chesttube)beforeproceedingtochemicalpleurodesis. Objectives: The aim of this preliminary prospectivestudy was to investigate the success rate of performingpleurodesis using a small bore pigtail catheter (MarFlow® CH12) in patients with malignant pleural effusion.Pleurodesis was performed within 24 hours after insertionof pigtail catheter with bleomycin as sclerosing agent.Patientswerefollow-upat4weekspostpleurodesiswithchestradiography. The intervention was scored as “successful” ifno radiographic evidence of fluid reaccumulationwasnotedat4weeks.A“partial success”score indicatedaccumulationoffluid thatdidnotproduce symptomsanddidnot requirerepeatpleuraldrainageofanysort.Allotheroutcomeswerescored as “unsuccessful”. 5 patients with malignant pleuraleffusionfromHospitalUniversitiSainsMalaysiaandHospitalRaja PerempuanZainab IIwere included in this studywithmean age of 53.6 year old. The primary diseases includebreast, lung, ovarian, and colon cancers. Themean time ofpleurodesis was 9.5 hours. Of the 5 pleurodesis performed,a complete response (“successful”) was seen in 3 patients(60%), a partial response (“partial success”) was seen in1patient(20%)and1patient(20%)didnotrespondtorapidpleurodesis. In conclusion, pleurodesis in patients withmalignant pleurodesis can be achieved rapidly using smallborepigtailcatheterandbleomycin.

Supervisors: Assoc Prof Dr Ziyadi Hj Ghazali Dr Zulkarnain Hasan

A COMPARISON BETWEEN THE GLIDESCOPE AND THE MCCOY LARYNGOSCOPE IN MANIKIN MODEL WITH MANUAL IN-LINE STABILIZATION TECHNIQUE

Dr Mohd Rosdie bin Mat JahayaMMed (Anaesthesiology)


Introduction: Intubation of the trachea in patientswithcervicalspineinjuryisachallengingsituation.Suchacutetrauma that requires direct laryngoscopy is accomplishedwith a standard manoeuvre of manual in-line stabilisationtechnique.Unfortunately this technique createsunnecessarycause of difficult airway. Ideally intubation should be easy,fast,andcauseminimalcervicalspinemovement incasesofheadandneckinjury. Obejctives: The objective of the study is to comparethe GlideScope with the McCoy laryngoscopes in manualinlinestabilization(MILS)techniqueinmanikins.ThereisahopeofindirectlaryngoscopywiththeGlideScopetoachievethesegoals.

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Methods: This prospective and cross over studyinvolved a total number of 47 participants who wereanestheticresident.Followingabriefdidactic instructiononthe GlideScope and the McCoy each participant took turnperforming laryngoscopy and intubation with each device.Theywereevaluated foreachdeviceon their success rateofintubation,meanintubationtime,glotticscoreimprovementandtheirpreferencesoflaryngoscopy. Result:We found that the success rate of intubationwas91.5%amongtheMcCoylaryngoscopeand87.2%amongthe GlideScope users. Statistically these figures were notsignificant withP-value of 0.727. TheMcCoy laryngoscopeintubationswerefasterthantheGlideScope.Themeantimesof intubation were 24.4 seconds ± 15.97 and 35.3 seconds±17.56,respectively.TheP-valuewassignificant(P<0.001).ThemodifiedCormackLehaneScore (CLS) in class I and IIwere greater with the GlideScope (72.3%) than the McCoy(46.8%).TheCLSatmoderateclassofglottisIIIbtoIIIawasimproved for 60% and class IIIa to II for 73%. Among theparticipants, their preference of laryngoscope was almostthesamewhere53.2%hadchosentheMcCoywhileanother46.8%ofthemfavouredtheGlideScope. Conclusion: In this study using manikins, meanintubation timewassignificantly faster in theMcCoygroup.On the other hand, the glottic score and dental traumacomplicationswerefoundtobeimprovedsignificantlyintheGlideScopeusers.Therewasno significantdifference in thesuccess rate and easiness of intubation. Both laryngoscopeswerebeingequallypreferredamongtheparticipants.Overall,the GlideScope performance has comparable efficacy withtheMcCoyinthisdifficultairway,exceptitconferredgreaterimprovementintheglottisscoreview.Unfortunatelythisdidnot facilitate intubation faster and easier than the McCoy.TheGlideScopemaybeagoodalternative formanaging thedifficultairwaybutclinicaltrialsevaluatingitsuseonpatientswithanactualdifficultairwayareneeded.

Supervisor:Assoc Prof Dr Shamsul Kamalrujan Hassan

CARBAPENEM RESISTANT ACINETOBACTER INFECTION: A RETROSPECTIVE COHORT STUDY IN INTENSIVE CARE UNIT HOSPITAL UNIVERSITI SAINS MALAYSIA

Dr Mohd Samsul PuzizerMMed (Anaesthesiology)


Objectives:Thisstudyaimstodeterminetheincidence,risk factors and the outcome of patients with carbapenem-resistantAcinetobacterinfectioninICU(HUSM). Methodology: This was a retrospective cohort

study from January 2008 until December 2009. List of thepatientswereobtainedfromInfectionSurveillancesunitandICU record. The details of the patients were retrospectivelyreviewed from their medical records in the Record Unitof HUSM. A total of 92 patients were reviewed and only54wereanalysed. Result: The incidence of carbapenem-resistantAcinetobacter infection in ICU (HUSM) was 7.3%. Age wasthe only significant risk factor associatedwith carbapenem-resistantAcinetobacter infections inICU(HUSM),(adjustedOR=1.045,95%CI:1.010,1.081,P=0.011).Therewerenosignificant association of other risk factors such as gender,APACHE II score, multi organ failure, co-morbidities,previoushospitalandICUstay.Mortalityrateofthisinfectionwas 50%. Age was significantly different between survivedand non-survived group; (43.1 ± 21.1 and 57.1 ± 14.3) withP-value=0.006.Therewerenosignificantdifferencesbetweenthe2groupsinotherfactors. Conclusion Mortality rate of carbapenem-resistantAcinetobacter infections in ICU (HUSM) was 50% and agewasasignificantriskfactorforthemortality.

Supervisor:Dr Wan Mohd Nazaruddin b Wan Hassan

BACTEREMIA IN MINOR TRAUMATIC WOUNDS – AN EXPLORATIVE STUDY

Dr Mohd Zaki Fadzil Bin SenekMMed (Emergency Medicine)

Department of Emergency MedicineSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Patient with minor traumatic woundcan be treated in the Alternative Medical Treatment Site(AMTS) or Emergency Department. However, there was noevidencetoprovethatthesepatientsaresafetobedischargewithoutanyriskofbacteremiaaftergettingearly treatment.Wepostulatedthattheriskofbacteremiainthosewithminortraumaticwoundarelowbutcancausemortality.Therefore,we carried out research using the blood culture to find outtheincidentofbacteremiaandtodeterminecharacteristicofpatientandwoundthatpronetodevelopbacteremia. Methods: This was a cross sectional study withalternatepatient selection.Thestudy involved50consentedadult with minor traumatic wound from 1st January 2010until31stDecember2010inEmergencyDepartment,HospitalUniversiti Sains Malaysia. Blood Culture and Sensitivity(BC&S)weretakenonarrivalthenrepeated30minutesafterwoundmanagement.Theprimaryoutcomeinthisstudywasthebacteremia. Result: Median age of the participant was24-year-old. Of these 50 patient, 4 had chronic illness(Hypertension, Diabetes Mellitus, Epilepsy and G6PDdeficiency). Most of the injuries was due to motor vehicle


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accident (82%).Medium time of arrival was 2 hours.Maincomplaint was injury to the hand due to abrasion woundfollowedbylacerationwoundandincisedwound.Foreignbodypresentinthewoundlessthan10%.5patientshadincreaseinthewhite blood cell countmore than 15000 /mmP3P.ThemeanRandomBloodSugar(RBS)was5.1mmol/L±2.1.Onepatient had RBSmore than 10mmol/L and none had RBSlessthan1.1mmol/L.TherewasnopatientinthisstudyhadincreaseCRPlevelandpositivebloodculture. Conclusion: This study suggested that, there wasno bacteremia in minor traumatic wound. The patient canbedirectlybeentreatedat thesiteof incident.However, thewoundshouldbefrequentlyinspectandproperlycareduntilfullyhealed.

Supervisor:Dr Nik Arif Nik MohamedCo-supervisors: Assoc Prof Dr Rashidi AhmadAssoc Prof Dr Habsah Hassan

THE EFFECT OF TUALANG HONEY INGESTION ON REDUCTION OF SYMPTOMS SCORE AND SPECIFIC IgE LEVEL IN ALLERGIC RHINITIS PATIENTS

Dr Mohd Zaki AhmadMMed (ORL–Head and Neck Surgery)

Department of ORL–Head andNeck SurgerySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Allergicrhinitis(AR)isasymptomaticdisorderofthenoseinducedbyanIgEmediatedinflammationafter allergen exposure of the membranes of the nose,characterised by one or more of the following symptomsincluding nasal itchiness, nasal blockage, running nose andsneezing.Skinpricktestisaknownconventionalmethodandiswidelyusedtodiagnoseallergicrhinitis.However,withtheemergingofnewinvitrotechnologymethodstomeasureIgElevel, it may help further in diagnosis and management ofallergicrhinitis.Thereareastandardisedsetpharmacologicaltreatmentsofallergicrhinitiswiththestrongheldbelievedofalternativemedicinesincludeherbsandhoney.Inthisstudy,we were looking for any effect of our local Tualang honeyingestiononspecificIgElevelandpatientssymptomscore. Objectives: The objectives of this study were todetermine the magnitude of allergic rhinitis symptomsimprovement with honey treatment and to determinemagnitudeofspecificIgEreductionafterhoneytreatment. Methods: An open label prospective randomisedcontrolledclinicaltrialwascarriedoutinOtorhinolaryngologyclinicHUSMfromJuly2009tillApril2010.40patientswithhistory suggestive of allergic rhinitis were recruited in thisstudy. They were divided into control and case group. Thepatients particulars and history takings were recorded andcompiled. Selected patients were examined by using nasal

speculumforanteriorrhinoscopyandfindingswererecorded.Patients thenundergone skinprick test andblood taken forserum specific IgE. The allergen included in this study wascat(Felis Domesticus),wheatflour,housedustmite(Blomia tropicalis)andpeanut.SymptomsscoresandserumspecificIgEwererecordedatinitial,day14andday28.Thecontrolgroupwasgivenoralantihistaminewhilethecasegroupwasgiven oral antihistamine and Tualang honey 20 mg per kgbodyweightindivideddoses. Result: The highest prevalence of positive skin pricktest among studied patients was house dust mite (97.5%)and the lowest prevalence was wheat flour (72.5%). Thehighest prevalence of positive serum specific IgE amongstudiedpatientwasalsohousedustmite(65%)andthelowestprevalence was cat (5%). There were significant differencesinoverall symptomsscoreobserved inbothgroupsbetweeninitialweek0,week2andweek4.However, thecasegroupshowedaprogressive improvement in their symptomsscoreascomparedtocontrolgroupbetweenthecomparisonweeks.Nevertheless, there were no significant differences elicitedin specific IgE level in either group between initial, week 2andweek4. Conclusion: Tualang honey had significant effect inimproving the overall symptoms in allergic rhinitis patientas compared to those who are receiving conventionalantihistaminealone.However,noeffectofTualanghoneyinreductionofspecificIgEwaselicited.By theseobservations,honey is found to be beneficial and may prove the heldbelievedtoimprovethepatientsymptoms.However,perhapswithastandardandappropriateallergenmanufactoryinthisAsiatropicalregion,wemightbeableseetheeffectofhoneyinreductionofspecificIgEinfutureasitdoesinanimalstudy.

Supervisor:Dr Wan Shah Jihan Wan DinCo-supervisor:Dr Che Maraina Che Hussin

ASSESSMENT OF KNOWLEDGE AMONG INTENSIVE CARE NURSES TOWARDS THE EVIDENCE-BASED GUIDELINES FOR THE PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA IN HOSPITAL UNIVERSITI SAINS MALAYSIA

Dr Mustaffa Kamil Zainal AbidinMMed (Anaesthesiology)


Introduction:Ventilatorassociatedpneumonia(VAP)leads to a considerable excess in morbidity, mortality andcontribute to a significant economic burden. An evidence-basedguidelineshasbeenestablishedforpreventionofVAP. Objective: This study aimed to determine intensivecarenursesknowledgeevidence-basedrecommendationsfor

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VAPprevention. Methodology: This was a self-reported survey(questionnaires) conducted on 115 GICU, NeuroICU andCCU nurses in HUSM regarding the non-pharmacologicalguidelinesforVAPprevention,conductedinMarch2011. Result: The intensive care nurses mean knowledgescore were 54.0% (SD, 17.2%). Nurses who work in GICUhave a better score than other ICU setting (P < 0.001).Malenurseshasabetterknowledgecomparedtothe female(P<0.001).Therewerenocorrelationonotherdemographicwiththeirknowledge. Conclusion:HUSM intensive carenurses knowledgeregarding recommendations for VAP prevention was stilllacking and need further improvement. GICU nurses andmalenursesweremoreknowledgeableontheVAPpreventionevidence-basedguidelines.

Supervisor:Professor Dr Nik Abdullah Nik Mohammed

REVIEW OF OESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA IN HOSPITAL SULTANAH BAHIYAH, ALOR STAR 2000–2009

Dr Narasimman SathiamurthyMMed (Surgery)


Introduction: Esophageal atresia (EA) andtracheoesophageal fistula (TEF) are one of the congenitalanomalyoccurringinthenewbornswiththeincidenceof1in2,500birthsseenworldwide. Objectives: The aim of this study is to determinethe association of birth weight, time taken for surgicalintervention,presenceofcongenitalanomalyandpneumoniawiththeoutcomeofsurgery. Methods: This is a cross sectional study withretrospective record review among babieswithTEF andEAinHospital Sultanah Bahiyah (HSB) from January 2000 toDecember2009.ItwasconductedinthePaediatricSurgicalUnit, Department of Surgery, Hospital Sultanah Bahiyah,AlorStar. Result: Therewere47patientswithesophagealatresiaadmitted to HSB from January 2000 to December 2009,out of which 26 (55%) were males and 21 (45%) females.The distribution of patients by race were 34Malays (72%),9 Chinese (19%) and 4 Indians (9%).Out of 47 babieswithTEFandEA,36%ofthemhadpolyhdromniosintheantenatalevaluation. Therewere only 3 types of EA/TEF seen; TypeA(9%),TypeC(87%)andTypeE(4%).Thebirthweightofthebabiesrangefrom0.8kgto4.0kg.Thesmallestsurvivingbaby weighing 1.1 kg. There was a significant associationwith the outcome of the surgery (P < 0.05). Most of thebabies (20) were operated within 24 hours of presentation.

Therewerenosignificantassociationbetweentimeofsurgicalintervention and outcome (P > 0.05). 23 (49%) of themwere born with congenital malformation and there wasa significant association with the outcome of the surgery(P < 0.05). Based on the chest roentgenogram, 20 (43%)of them had pneumonia with significant association withthe outcome (P < 0.05). Themortality rate is 23% and thecauses of deathwere severe pneumonia (36%), severe renalfailure(18%),severecardiacmalformation(18%)andmultiplecongenitalmalformations(28%). Conclusion: In conclusion, the outcome of EAand TEF is determined mainly by birth weight, congenitalmalformations, and presence of preoperative pneumonia.Bremen classification is most suitable in determiningthe prognosis of the babies with TEF and EA in HospitalSultanahBahiyah,AlorStar.

Supervisor:Dr Syed Hassan Syed Abdul AzizCo-supervisor: Dato’ Mr Mohan Nallusamy

THE PREVALENCE OF FUNCTIONAL DYSPEPSIA USING ROME III QUESTIONNAIRE AMONG ADULT PATIENTS ATTENDING KLINIK RAWATAN KELUARGA, HOSPITAL UNIVERSITI SAINS MALAYSIA

Dr Noriza Binti WahabMMed (Family Medicine)


Introduction: Functional dyspepsia (FD) is one ofthe functional gastrointestinal disease in which there is nospecificorganicandpathologicalcausecanbe identified.It’sprevalenceissparseasitrequiresanendoscopicexaminationandalsoduetothedifferentcriteriausedindifferentstudies.Objectives: The aims of this study were to determine theprevalenceofFDanditsassociatedfactors. Methods:Thiscross-sectionalstudywasconductedatKlinikRawatanKeluarga,HospitalUniversitiSainsMalaysia(HUSM).Thestudyperiodstartedon1stDecember2009till31stMarch2010.Self-administeredBahasaMalaysiaversionofRomeIIIquestionnairewasused.Endoscopicexaminationwas performed in order to exclude the organic cause ofdyspepsiaamongpatientswhofulfillthecriteriaforFD.Thediagnosis of FDwasmade based on the normal endoscopicfinding. Result: A total of 192 patients were recruited and32 who did not complete the questionnaires and refusedendoscopywereexcluded.Outof160patients,theprevalenceof FD was 10% (n = 16). About 68% of the FD patients(n = 11) had Epigastric Pain syndrome (EPS) and 32% ofthem (n = 5) were those who had mix symptoms of post-


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prandial distress syndrome andEPS. Therewere significantassociation between overweight (BMI 28 vs 25 kg/m2,P < 0.05), being married (P < 0.05) and also havingpsychosocial symptoms (P < 0.05) with FD in univariateanalysis. Multivariate analysis showed psychosocialsymptoms (OR: 3.76, 95% CI, 1.01–13.99) and currentlymarried (OR: 8.08, 95% CI, 1.03–63.51) were predictiveofFD. Conclusion: This study supported that psychosocialsymptoms were related with FD. As most of the patientswho had FD were married, this could have attributed thesignificantassociationbetweenmaritalstatusandFD.

Supervisor:Dr Juwita ShaabanCo-supervisors: Dr Nazri MustaffaDr Norwati Daud

THE VALIDATION OF THE MALAY TRANSLATED SLEEP APNEA QUALITY OF LIFE INDEX (SAQLI) IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA

Dr Nor Idayu Mohd YusofMMed (ORL–Head and Neck Surgery)

Department of ORL–Head and Neck SurgerySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction:TheSleepApneaQualityofLifeIndex(SAQLI)isadiseasespecificinstrumentdevelopedtorecordthekeyelementsofobstructivesleepapneasyndromedisorderthatareimportanttopatientsandactasanoutcomeaswellasanevaluativemeasureinclinicaltrials. Objectives: The objectives of this study were totranslate SAQLI into theMalay language and to determinethe feasibility, validity and reliability of the Malay versionof SAQLI. Methods: Thiswasacrosssectionalstudyconductedat Sleep and General ORL-HNS Clinic, Hospital UniversitiSains Malaysia, Kubang Kerian, Kelantan. 82 respondentswereinvolved.TheMalaytranslatedSAQLIandapreviouslyMalay translatedandvalidatedShortForm36 (SF-36)wereadministered by interviewer. The translation used forward,backwardandrespondent testingandhasbeenreviewedforface and content validity.TheMalay translatedSAQLIwereadministeredagainat2to4weeksinterval.Analysisincludedthe determination of the scaling assumptions, feasibility,reliabilityandvalidity. Result: All subjects completed the questionnairesuccessfully. The Malay version of SAQLI has no floor orceiling effects. The 4 domains of the Malay SAQLI havemeans ranging from 3.59 to 4.82 and standard deviation,SD ranging from 0.846 to 0.945. The Cronbach’s alphawere very high, more than 0.95 for all domains; domaindaily functioning: 0.966, domain social interaction: 0.981

and domain emotional functioning: 0.971 suggested itemsredundancy. The standard of test-retest reliability was alsofulfilledwithintraclasscorrelationcoefficientswereexcellentranging from 0.796 to 0.984. The Pearson’s item-scalecorrelation between item and its hypothesised scale was0.4 or above, thus item-scale convergent and discriminantvalidity were satisfied. Factor analysis showed items in the3 domains all loaded on the hypothesised scales. Knowngroup validity showed no significant correlations betweenSAQLIandAHI(P>0.05).Criterionvaliditywasconfirmedby significant correlations with SF-36 subscale scores. Conclusion: The translation of theMalay version ofSAQLIwasacceptable.Thefeasibilityispresentandthescalingassumptions met. The internal consistency and intraclasscorrelation coefficients were excellent. The content validityhas been established with evidence of acceptable constructandcriterionvalidity.TheMalayversionofSAQLIshouldbeusedinthemanagementandstudiesinvolvingOSASpatientsandashorterversionofSAQLIisrecommended.

A STUDY ON FEASIBILITY OF LAPAROSCOPIC INGUINAL HERNIA REPAIR IN A DISTRICT HOSPITAL (HOSPITAL SULTAN ABDUL HALIM, SUNGAI PETANI)

Dr Norhashimah Binti KhadirMMed (Surgery)


Introduction: Even though hernia repair is a verycommon general surgical procedure, repairing bilateral andrecurrentinguinalherniaalwaysgiveproblemstothesurgeon.Theoperationperformedhavehighertendencytowardscostincrement andmorbidity.With the relatively higher capitalcostbutgoodoutcomes,wedecidedtostudythefeasibilityofperforming laparoscopic inguinal hernia repair in a districthospitalsetting. Objectives: Thestudyobjectiveistocomparethecosteffectiveness of laparoscopic versus open inguinal herniasurgery.Besidesthat,wewouldliketodeterminethedurationof post-operative hospital stay and operative time usage oflaparoscopicsurgery.Inaddition,wewouldliketoidentifythecomplicationsofbothoperativetechniques. Methods: Retrospective analysis of laparoscopic andopentechniqueinbilateralandrecurrentinguinalhernia. Result: The total numbers of patients were 155.Laparoscopicsurgeryconsistedof84patients.53caseswerebilateral,19caseswererightrecurrentand12caseswereleftrecurrent. TEP was performed in 53 cases and 31 cases ofTAPP. In open technique, 48 cases were bilateral, 15 caseswererightrecurrentand8wereleftrecurrent.Only3femalenoted and Malay were predominant (73 %). The mean

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durationofpost-operativehospitalstaywas34hoursinopenand25hoursinlaparoscopicsurgery(P=0.002).Themeanhospitalisation cost of open (RM 194.50) is cheaper thanlaparoscopy (RM 417.35). The difference was significant asP<0.000.Themeanoperativetimeislongerinopenrepair(P = 0.034). The conversion of laparoscopy to open was6.45%.ConversionofTEPtoTAPPwas4%only.Nomajorcomplicationsnoted. Conclusion: It is feasible to perform laparoscopicsurgeryforrecurrentandbilateral inguinalherniaindistrictor non referral centre. However, well-designed study isindicated.

Supervisor: Dr Syed Hassan

THE PREVALENCE OF RELAPSE AND ITS ASSOCIATED FACTORS AMONG SMOKERS ATTENDING KLINIK RAWATAN KELUARGA, HOSPITAL UNIVERSITI SAINS MALAYSIA

Dr Norihan Abu BakarMMed (Family Medicine)


Objectives: To determine the prevalence of relapseand itsassociated factorsamongsmokersatKlinikRawatanKeluarga,HUSM. Methods: This is a cross-sectional study. 294respondents agreed to participate in the study from JuneuntilAugust2010.Thesocio-demographicandassociatedriskfactorswererecordedinthedataquestionnaires. Result: A total of 283 respondents managed tocompletethequestionnaires.Therewas96.3%responserate.Theproportionofsmokerswhorelapsedwas59.4%(n=168).The significant associated factors to relapse were age lessthan40-years-old,maritalstatus,Fagerstromscore,durationofsmokingandstressfullifeevent. Conclusion:Theprevalenceofrelapsedishighwhichis comparative tomany other studies. For smokerswho areattending quit smoking clinics, special attention should begiventothosewiththeassociatedfactorstomaketheprocesstoquitsmokingclinicmoresuccessful.

Supervisor:Dr Harmy Mohd YusoffCo-supervisor:Dr Adibah Hanim Ismail

A TWO YEAR RETROSPECTIVE REVIEW OF LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN PERFORATED APPENDIX IN HOSPITAL IPOH (JUNE 2006–MAY 2008)

Dr Nyanamalar a/p KrishnanMMed (General Surgery)


Introduction: One of the most common generalsurgical procedures that is performed in the surgicaldepartment is appendicectomy. The open approach hasbecome the standard surgical intervention for appendicitis,remaining virtually unchanged for 100 years owing to itsprovenefficacyandsafety(McBurneyetal.,1894). Theoptimalapproachforappendicectomyisstillunderdebate although laparoscopic appendicectomy has beenperformedsince1980(Lityinski,1999).Thelongeroperatingtime,similardurationofhospitalstayandincreasedincidenceof intra-abdominal collection or post-operative ileus withlaparoscopic appendicectomy outweighed any improvementin wound complication, recovery time or cosmesis. Currentstudies however present evidence of reduction in operatingtime, faster recovery and lower wound complication rates,with the reversal in the riskofdeveloping ileus in favouroflaparoscopy(Golubetal.,1998). Objectives: The aim of this study is to comparelaparoscopic and open appendicectomy in the managementof perforated appendicitis to review and compare length ofhospitalstay(numberofdaysofadmission),lengthofoperativetime(timeinminutes),durationofileus(numberofdaysthepatients is not able to tolerate orally), days for temperatureto settle (in number of days), post-operative complications-(readmission, surgical site infection) and analgesia (totalamountofIVanalgesiainmilligramsusedwhileintheward). Methods: All cases of perforated appendicitis thatwere admitted to the surgical ward in Hospital PermaisuriBainun Ipoh from 1st June 2006 till 31st May 2008were included in the study unless they did not fulfill theinclusioncriteria.Thedurationofthedatacollectionwasfor24 months. The names of all the patients perforatedappendicitiswere collected from the COTDS (ComputerisedOperatingTheatreDocumentationSystem)andtheoperatingtheatre log books and their case notes were traced fromthe records office. The relevant details were reviewed anddocumentedaccordingtotheproforma(Appendice1). Result:205patientswithperforatedappendicitiswerereviewed. 56patientshad laparoscopic appendicectomy and149 patients had open appendicectomy. Themedian age inthe laparoscopic groupwas 28 and the open groupwas 30.Thedifferenceinthemedianagegroupswasnotstatisticallysignificant. TheP-value is 0.310. The mean (SD) operatingtimefor laparoscopicappendicectomywas69±29minutes.


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Themean operating time for the open groupwas 63 ± 28minutes. This study showed that there was no significantdifference inthemean lengthofoperatingtimebetweenthe2methods. TheP-value is 0.669. Themean (SD) length ofhospital stay for the patients in the laparoscopic groupwas3.5±1.6days.Intheopengroupthemeanlengthofhospitalstaywas3.1± 1.9days.Thiswas statisticallynot significant(P = 0.382). There was also no statistical significance inthe duration the patients took to tolerate orally and for thetemperature to settle inboth thegroups.Therewerea totalof 6 patientswith the surgical site infection and 7who hadreadmission.Althoughall6patientswithsurgicalsiteinfectionwerefromtheopengroupandnoneinthelaparoscopicgroupthis was not statiscally significant (P = 1.000). 5 patientsin the laparoscopic group and 2 in the open group werereadmitted within a week of their respective surgeries forileus.ThisdifferencewasalsonotstatisticallysignificantwithaP-valueof1.000.Themean(SD)amountofanalgesiausedin laparoscopic appendicectomywas387.5±259.4mg.Themean (SD) for the use of analgesia in the open group was274.5 ± 204.3mg for the open group. Thiswas statisticallysignificantwhereP=0.006. Conclusion: The laparoscopic appendicectomy isa safe and suitable procedure for surgical training and willensurethatlargenumbersofsurgicaltraineescanproceedtomoreadvancedlaparoscopictechniquesduringtheirtrainingprogramme.Perforatedappendicitisisnowroutinelymanagedlaparoscopically in some hospitals and developments insurgicaltrainingwillallowthisapproachtobecomestandardpracticeinthenearfuture.

FUNCTIONAL OUTCOME OF MICROSURGICAL CLIPPING COMPARED TO ENDOVASCULAR COILING

Dr Premananda Raja A/L MurugesuMSurg (Neurosurgery)

Department of NeurosciencesSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Nontraumatic subarachnoidhemorrhageisthesecondmostfrequentcauseofhemorrhagicstrokeandaccounts for3%–5%ofall strokes. Inmore than85%ofcases,itiscausedbyarupturedintracranialaneurysmwith incidence of at 6–8 cases per 100 000 population.The treatment options available for ruptured aneurysmsincludes microsurgical and endovascular means. In recentyears endovascular coiling has beenused increasingly as analternativetomicrosurgicalclippingfortreatingsubarachnoidhemorrhagesecondarytoaneurysmrupture. Objectives: Thepurposeofthisstudywastocomparefunctional outcomes in terms of modified rankining scale,morbidityandmortalityat6monthsaftertreatmentofpost-subarachnoid hemorrhage secondary to cerebral aneurysmrupture in subjects whowere eithermicrosurgically clipped

orendovascularlycoiled.Inaddition,thepresentstudyaimsto identify the predictors in the clinical course of primarysubarachnoidhemorrhage. Methods:AretrospectivecasereviewonthetreatmentmethodsofaneurysmruptureinHospitalKualaLumpuroverthe period of 5 years (2005–2009). A total of 268 patientswho fulfilled the inclusion criteria were included in thisstudy.Thesepatientswerebroadlycategorisedinto2groupsbased on their treatmentmode for ruptured aneurysm.Thecase notes, CT brain films reports and angiography reportswere analyzed with respect to their clinical, radiological,surgical clipping or endovascular coiling treatments andoutcome data. Statistical analysis was determined usingChi-Squareteststostudytheseassociations. Results: There was a female predominance withmale-to-femaleratio1:1.4.Themeanagewas50.9-years-oldinthisseries.50patientswerelessthan40years(18.7%)and218patientsweremorethan40-years-old(81.3%).37patients(74%) in age group less than 40-years-old had significantgood outcome as compared to 125 (57.3%) patients above40-years-old (P = 0.03). 181 patients (67.5%) presentedwith good WFNS (WFNS1-2) and 87 patients (32.5%)presentedwithpoorWFNS(WFNS3-5)priortointervention.162 patients (60.4%) had good functional outcome(mRS grade 0-2) as compared to 106 patients (39.6%)whohad poor mRS outcome (MRS 3–6) while 50 patients died(18.7%)duringourfollow-upto6months.WhenweanalysedtheWFNSgroupwith functionaloutcome (mRS), therewassignificantassociation(P<0.01).IngoodWFNS,143(79%)had good outcome and in poorWFNS, 68 patients (78.2%)had poor mRS outcome. There were 204 (76.1%) patientsin clipping group and 64 (23.9%) patients in coiling group.Patients who underwent coiling, initially showed a bettermRS outcome with 47 patients (73.4%) than, 115 patients(56.4%) in clipping. Further comparison showed that89 (43.6%) patients in clipping group had poor functional(MRS) outcome as compared to 17 patients (26.6%) coiling,whichwassignificant(P=0.015).Howeverwhenwecontrolledthe WFNS grade of presentation in the treatment groups,we obtained a different result. In goodWFNSgroup, itwasnoted that98patients (76%)outof 129patients in clippinggroup had a goodMRS outcomewhile, 45 patients (86.5%)out of 52 patients in coiling group had goodmRS outcome(P = 0.114). In poorWFNS presentation, it was noted thatin clipping group, 58 patients (77.3%) out of 75 had poormRS outcome. Similarly with poor WFNS presentation,10 (83.3%) out of 12 patient in coiling group had pooroutcome (P = 1.00). Hence, when we control the WFNSgroup,therewasnosignificantassociationbetweentreatmentgroup(clippingandcoiling)andmRSoutcomeat6months.Furtherwenoted that age less than40 andFisher grade of1–2 have better outcome while patients with EVD, CSFinfection and pneumonia have poorer outcome. Usingmultiple logistic regression analysis we have determinedthat goodmRSoutcome is associatedwith goodWFNSand

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absenceofEVD. Conclusion: Clinical severity of the SAH (WFNSgrade) was the most significant predictor of functionaloutcome(mRS)at6months.Thereforethedecisionregardingtreatment option needs to be individualised based on thepresentationofthepatient.

Supervisor: Dr Ramesh NarenthiranathanCo-supervisor:Associate Professor Dr Hillol Kanti Pol

COMPARATIVE STUDY OF DYDROGESTERONE DOSAGE OF THE DUPHASTON 40 MG DAILY AND DUPHASTON 20 MG DAILY IN THE OUTCOME OF PREGNANCY WITH THREATENED MISCARRIAGE IN HUSM

Dr Rahimah bt Abd RahimMMed (O & G)


Objectives: To evaluate the effectiveness and theadverse effect of Duphaston 40 mg daily and Duphaston20mgdailyinthreatenedmiscarriage. Methods: ThisisaprospectiverandomizedcontrolledtrialconductedatHospitalUniversitiSainsMalaysia(HUSM),KubangKerian,Kelantanfrom1stofMarch2009until30thMarch2010.Atotalof130patientswerestudied,65patientsingroupAforthosewhoistakingDuphaston20mgdailyandtheother65patients ingroupBonDuphaston40mgdaily.Besides the effectiveness, the side effect of the 2 differentdosageofDuphastonisalsoevaluated.Thesuccessfulof thepregnancyismeasuredbycontinuityofthepregnancybeyond20weeks of gestation.Resultwas analysedwithChi-squareandFisher’sExactteststodeterminethestatisticalsignificant.ThetestsconsideredsignificantifP-value<0.05. Results: There were higher successful pregnancyinGroupB (Duphaston40mgdaily) compared toGroupA(Duphaston20mgdaily)(86.7%versus81.7%).ButthisisnotstatisticallysignificantastheP-valueinmultivariateanalysisis 0.50 (P > 0.05). There were no significant differences inadverseeffectofthe2differentdosageofDuphaston. Conclusion: Duphaston 40 mg daily was notassociated with higher chances of successful pregnancy inthreatened miscarriage (P = 0.50 in multivariate analysis).Therewerealsonosignificantdifferencesofadverseeffectofthedrugsinbetweenthe2groups.

COMPARISON BETWEEN TRIAMCINOLONE INJECTION AND HYDROCORTISONE INJECTION IN TREATMENT OF TRIGGER FINGER: A PROSPECTIVE SINGLE-BLINDED RANDOMIZED CONTROLLED STUDY

Dr Radzeli Mohd RamliMMed (Orthopaedic)

Department of OrthopaedicSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Trigger finger is a term for stenosingtenovaginitisaffectingtheexcursionofthe longflexorofthehand at the area of zone II of the digit. Steroid injection isone of the treatment option. Triamcinolone is the steroidmainly used for trigger finger treatment. Hydrocortisoneis used only in peditric trigger finger. Therefore result andoutcomeofhydrocortisoneintreatmentofadulttriggerfingerstillnotestablish. Objectives: This study was designed to test the nullhypothesisthatthereisnodifferenceinresolutionoftriggerfinger in term of pain, tenderness and triggering/locking in3monthsafterinjectionwithtriamcinolone,adepotformofpotentsteroidorhydrocortisone,ahighlysolubleformbutlesspotentsteroid. Methods: Seventy patients were enrolled in aprospective randomised controlled study comparingtriamcinolone and hydrocortisone injection for idiopathictrigger finger. They were randomised into 2 groups;triamcinolone group and hydrocortisone group. All patientsrequired to answer Disabilities of the Arm, Shoulder andHand(DASH)questionnaire,giveVisualAnalogScale(VAS)score and evaluated for triggering/locking and tendernessat A1 pulley before injection, immediately after injectionand 3 months after injection. 59 patients completed the3monthsfollow-up(28triamcinolonearm,31dexamethasonearm).Outcomemeasures included theDASHquestionnaire,presence/ absence of triggering/locking finger, presence/absence of A1 pulley tenderness and pains severity base onvisualanalogscale.AChi-squaretestandstudentt-testwereusedtocomparebothgroups. Result: Immediately after injection, absence oftriggering was documented in 24 of 34 patients (70.6%) inthe triamcinolone group and in 28 of 36 patients (77.8%)in the hydrocortisone group. The rates of resolution oftriggering 3 months after injection were 22 of 28 (78.6%)in the triamcinolone group and 26 of 31 (83.9%) in thehydrocortisone group. In term of tenderness of A1 pulley,immediately after injection, absence of tenderness wasdocumentedin26of34patients(76.5%)inthetriamcinolonegroupandin28of36patients(77.8%)inthehydrocortisonegroup. The rates of resolution of tenderness 3months afterinjectionwere 18 of 28 (64.3%) in the triamcinolone group


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and22of31 (71%) in thehydrocortisonegroup.Therewereno significant differences between DASH scores and VASscore for pain immediately after injection and the 3-monthfollow-up. After the close of the study, there was nocomplicationinbothtreatmentgroups. Conclusion: There isno significantdifferent in termof resolutionof tenderness over A1 pulley, resolutiontriggering/locking, pain and physical disabilities scoreimprovementbetweenthe2typesofsteroidinjection.

Supervisor: Dr Abdul Nawfar Sadagatullah

IN VITRO AND IN VIVO COMPARISON OF DIFFERENT GRADES OF CHITOSAN WITH COMMON SURGICAL HEMOSTATS

Dr Ramesh SasidaranMMed (Plactic Surgery)


Introduction:Themostcommoncauseofsignificantintra-operative bleeding is inadequate surgical hemostasis.Nearlyallreviewsofintra-operativeandearlypost-operativebleeding point that 75% to 90% of all bleeding is technicalin nature. Whatever the cause, uncontrolled bleedingcan lead to a combination of factors which may furtherexacerbate theproblemofaviciousbloodycircle.Dilutionalthrombocytopenia, platelet dysfunction and consumptionof clotting factors present a difficult problem to address ascontinualbloodlosscontinuetocompoundtheproblemwhileblood component replacement therapy attempts to correctthedeficiency. Objectives: Our study aims to compare hemostaticefficacy of different grades of chitosan compared to thecommon hemostatic surgical hemostats. We hypothesisethat chitosan based hemostats are superior to the commonsurgicalhemostatsininducingplateletaggregation,affectingProthrombin Time (PT) and Partial Thromboplastin Time(PTT)andredcellaggregation. Methods: Therewere 2 parts to the study. In the invitrostudybloodsamplewasobtainedfromthebloodbank.BloodsamplewascollectedutilizingtheCP2D/AS-3systemswith additive solution (AS-3, Nutricel®) to maintain redblood cell viability. Collected whole blood was separatedinto4separatecomponents(wholeblood,heparinisedwholeblood,plateletrichandplateletpoorplasma).Intheplateletaggregation test, stirred citrated PRP was contacted with3.5 mg of each hemostatic agent premoistened with100micro liter of phosphate-buffered saline (PBS) in a testtube(aswouldbeusedintraditionalplateletaggregometry).Aliquots of supernatant (100 micro liter) were removedevery 5 minute for a total of 15 minutes and the platelet

count wasmeasured in triplicate utilizing an electronic cellcounter (XT2000i Sysmax Analyzer, Sysmex America Inc.,Mundelein, IL); platelet counts from each experimentalaliquot were normalized using counts from unreacted PRP.Foreachhemostaticagent3independentsetsofexperimentswere performed. A similar set of platelet aggregationexperiments was performed using the hemostatic spongeagents (3 different grades of Chitosan, Lyostypt® andSurgicel®) premoistened with PBS. In the PT/PTT test,each hemostatic agent was reacted with platelet rich andplateletpoorplasma. Theserumwascentrifugedtoremovepossible deposition. 6 parallel experiments were conductedto measure PT and APTT of the serum using a hemostasisanalyzer (Stago STA Compact Haemostatic Analyzer,DiamondDiagnostics,MA.USA) In the red cell aggregationtest, each haemostatic agent was reacted with wholeblood, heparinized blood and platelet poor blood. Theblood with hemostatic agents were left to stand and theerythrocyte sedimentation ratewasmeasuredwith the Sedy400 sedimentation analyzer. In the animal experiment,36 Sprague-Dawley rats were utilised. Under generalaesthesia,viaamidlinelaparotomytherightandleftkidneyswere isolated. Heminephrectomies were carried out andhemostatswereapplied to thecutsurfaceandtimetakentohemostasiswastabulated. Result: In the platelet aggregation test, no definitetrend in platelet aggregation was observed. NoCMC 36 3%showed the lowest platelet count of all hemostatic agentsat 5 minutes. Lyostypt® and Surgicel® were superiorcompared to chitosan hemostats at 10 minutes of contact.In the coagulation test (PT/PTT ) mean prothrombin timefor Chitosan (NoCMC 8%) was the shortest in plateletrich plasma. Mean partial thromboplastin time was theshortest for Chitosan (NoCMC 3%) in platelet rich plasma.In platelet poor plasma, the shortest prothrombin timewas seen in both the Chitosan hemostats (NoCMC 3% andNoCMC 8%). Partial thromboplastin time was shortest forChitosan(NoCMC3%)hemostat. In theredcellaggregationtest, Chitosan hemostat (NoCMC 3%) demonstrated thehighest erythrocyte sedimentation ratio in platelet poorblood as well as heparinised blood specimens. Chitosanhemostat(NoCMC8%)demonstratedthehighesterythrocytesedimentationratioinheparinisedwholeblood. Conclusion: In the animal experiment, there wasno statistical difference between the hemostats in arrestingbleeding from heminephrectomy specimens. The Chitosanhemostat(NoCMC363%)howeverdemonstratedtheshortesttime to hemostasis compared to the other hemostats. Fromthe study we concluded that Chitosan hemostats causesplatelettoaggregatetheearliestcomparedtootherhemostats.They shortenprothrombin andpartial thromboplastin time.They have been also found to aggregate red blood cells themostcomparedtootherhemostaticagents.

Supervisor:Professor Dr Ahmad Sukari Halim

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KNOWLEDGE, ATTITUDE AND PRACTICE ON CARDIOVASCULAR DISEASE AMONG WOMEN ATTENDING PRIMARY HEALTH CARE FACILITIES IN KELANTAN

Dr Ranimah YahyaMMed (Family Medicine)


Introduction:Althoughcoronaryheartdiseasecausesmorethan455000deathsinwomeneachyear,muchoftheresearch on coronary heart disease in the last 20 years haseither excluded women or include very few women sincecardiovascular was perceived as a disease which primarilyaffectedmen.This resulted in lesswomenbeing exposed totheinformationregardingheartdisease. Objectives: To study the knowledge, attitude andpractice on cardiovascular disease among women attendinghealthcarefacilitiesinKelantan. Methods: This is a cross-sectional study involving448patients,agebetween25to65yearsoldattendinghealthcare facilities in Kelantan from Jun till December 2010.The sampling method using multistage random samplingwhichwasonly7 clinicswere selectedusingsimple randomsampling and 64 patients from each clinic were selectedusing systematic random sampling 1:2. Self-administratedstructuredquestionnairewasgivenfordatacollection. Result: All 448 patients complete the entirequestionnaire that make the response rate of 100%. Thedatawere analysis using descriptive statistic for knowledge,attitude,andpractice level.Themean(SD)knowledgescorewas 70.6 ± 13.76. Only 55.6% had good knowledge score.Fortheattitudescore,median(IQR)was88.2±14.71.Goodattitude score consists of 55.1% of respondents. The mean(SD) for practice score was 63.7 ± 13.59. About half ofrespondents (51.1%)had goodpractice score.General linearregression showed a significant (P < 0.001) associationbetween attitude and knowledge, practice and knowledgeand practice and attitude after controlling for age, ethnic,maritalstatus,occupation,educationlevel,householdincome,medicalillnessandfamilyhistoryofmedicalillness. Conclusion: The knowledge, attitude and practicelevel are equal between good and poor score amongKelantanese women. So a better structured educationalprogrammed on cardiovascular disease should be enforcedthat specially target women since they are the pillars forthefamily.

Supervisor:Dr Rosediani Muhamad Co-supervisor:Dr Harmy Mohd Yusoff

THE INFLUENCE OF ORAL AND TOPICAL CHANNA STRIATUS ON TENSILE STRENGTH, EPITHELIAZATION, FIBROBLAST COUNT AND HYDROXYPROLINE ASSAY IN LAPAROTOMY WOUND HEALING OF MALNOURISHED RATS

Dr Rezqa HusinMMed (Surgery)


Introduction: Channa striatus has been used intraditionalmedicineforcenturiestoacceleratewoundhealing.Recently several scientific studies have shown the healingpropertiesofChanna striatus.Howeverstudyyettobedoneonitshealingeffectonlaparotomywoundhealingwhichhasgreatermorbidity andmortality in the event of laparotomywoundfailure.There isalsonostudyonitshealingeffect inmalnourishedpatientwhommaybenefitthemost. Objectives: The aim of the study is to evaluate theeffectofChannastriatusontensilestrength,epitheliasation,fibroblast count and hydroxyprolene level in the healing oflaparotomywoundinmalnourishedrat. Methods: 40 malnourished wistar rat underwentlaparotomy and the wound closed primarily. The rats weredivided into 2 groups by block randomization. Group 1is the control group. Group 2 received oral and topicalChanna striatus daily. The rats were euthanised and fullthickness strips of the wound were subjected to tensilestrength measurement, histopathological examination forepitheliasationandfibroblastcounts.Hydroxyproleneassayswasnotdoneduetotechnicalproblem. Result:Theresultsdemonstratesthatthegrouptreatedwith oral and topical Channa striatus were significantlyhigherintensilestrength,epithelialandfibroblastcellcounts(P-value<0.001). Conclusion: ThisstudysuggeststhatoralandtopicalChanna striatus enhances laparotomy wound healingin malnourished rat by increasing the tensile strength,epithelialisationandfibroblastcount.

Supervisor: Dr Syed Hassan Syed Abd Aziz

RETROSPECTIVE SEVEN YEARS ANALYSIS OF DEXAMETHASONE THERAPY IN PRETERM PREGNANCY ADMITTED TO HOSPITAL UNIVERSITY SAINS MALAYSIA FROM THE YEAR 2003 TO 2009

Dr Roslan bin RidzuanMMed (O&G)



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Introduction: Prematurity is the main cause ofneonatal morbidity and mortality. Antenatal corticosteroidtherapyhasbeen shown tomarkedly reduced complicationsofprematurity.Acompletecourseofantenatalcorticosteroidtreatment is recommended to prevent pulmonarycomplications of preterm infants. Repeating courses ofantenatalcorticosteroidinmotherswhoareatriskofpretermdeliveryisstilldebatable. Objectives: The primary objective of the study is toexaminetheassociationbetweendifferentdosesofantenatalintramuscular (IM) dexamethasone therapy and fetalrespiratoryoutcomes. Methods: Retrospective study on case records ofpatients who delivered preterm and received antenatal IMdexamethasone therapy in HUSM from the year 2003 to2009.ThosewhoreceivedIMdexamethasone12.5mguponadmission or diagnosis, followed by another dose of IMdexamethasone12.5mg,12hourslater(totalof25mgperday),isdefinedtoreceiveacompletecourseofIMdexamethasone.Those who did not complete 2 doses of IM dexamethasone12.5mg,12hoursapartisdefinedtoreceiveincompletecourseofIMdexamethasone.ThosewhoweregivenanotherdoseofIMdexamethasone after 1week ormore of the first course,is defined to receive repeat course of IM dexamethasone.Their babies’ case recordswere reviewed to assess the fetalrespiratoryoutcomes. Result: Wereviewed927caserecordsofmotherswhodelivered preterm in HUSM from the year 2003 to 2009,and 980 case records of their newborns. Therewere 407 ofmothers received incomplete, 484 received complete and36 received repeat course of IM dexamethasone. Then,435 infants exposed to incomplete, 503 infants exposedto complete and 42 infants exposed to repeated coursesof antenatal IM dexamethasone for analysis. There were61infantsdeliveredat24to28completedweeks,515infantsdelivered at more than 28 to 34 completed weeks and404 infants delivered at more than 34 to less than 37completedweeks.Inthegroupofinfantswhoweredeliveredatmorethan28to34completedweeksgestation,acompletecourse of antenatal IM dexamethasone is significantlyassociated with better respiratory outcomes compared tothose infants who were exposed to an incomplete courseof antenatal IM dexamethasone. However, in the group ofinfants who were delivered at 24 to 28 completed weeksgestation aswell as those delivered atmore than 34 to lessthan 37 completed weeks period of gestation, there was nosignificant association between complete or incompletecourse of antenatal IM dexamethasone and the respiratoryoutcomes. Conclusions: A complete course of antenatal IMdexamethasone therapy significantly reduces the respiratorycomplications in thepreterm infantsdeliveredatmore than28 to 34 completed weeks period of gestation compared tothose who were exposed to incomplete course of antenatalIMdexamethasone.

Supervisor: Assoc Prof Dr Shah Reza Johan NorCo-supervisor: Dr Mohd Ismail Ibrahim

PREVALENCE OF SEXUAL DYSFUNCTION AND ASSOCIATED FACTORS AMONG ESSENTIAL HYPERTENSIVE WOMEN ATTENDING HYPERTENSIVE AND OUT-PATIENT CLINICS, HUSM

Dr Rozimah Binti Abdul LatifMMed (Family Medicine)


Introduction: Hypertension is one of the chronicdiseasesthathasbecomeaglobalpublichealthcareconcern.InMalaysia, prevalence increases over the year and femalepredominate from age 40-years-old with theMalay womenpredominate in terms of race. Hypertension does not onlyaffectthebrain,heartandkidneys,butitalsowillaffectsexualfunctionoftheperson.Eventhoughtheprevalenceoffemalesexual dysfunction was high, not much attention has beenpaid on it andmost of the theories and belief about femalesexualityarestillinconclusive(2). Objectives: Theaimofthisstudyistodeterminetheprevalenceofsexualdysfunctionandassociatedriskfactorsinhypertensivewomen.Researchdesignandmethodsdatawascollected from348hypertensivewomenintheHypertensiveandOutPatientClinicofHospitalUniversitiSainsMalaysia(HUSM) using Malay Version of Female Sexual FunctionIndex. Socio-demographics, marital profiles, obstetric andgynecological problems, presence of hypertension, presenceof other medical illness, and husband chronic illness wererecorded. Results:Theprevalenceof sexualdysfunctionamonghypertensivewomenwas21.3%(95%CI,17.00,25.60).Desiredisorder was reported as the highest percentage (42.8%),followed by lubrication disorder (24.1%), arousal disorder(22.7%), satisfaction and sexual pain disorder (19.0%) andorgasm disorder (14.1%). Less frequent sexual intercourse,lack of satisfaction with husband’s sexual performance,unhappy marriage, having urinary incontinence and ACE Iadministrationwere significant associated factors for sexualdysfunctioninhypertensivewomen. Conclusion: The result showed that almost 1 in5hypertensivewomensufferedfromsexualdysfunction.Thisindicates that sexual dysfunction is a major public healthconcernandhealthcareprovidersshouldbemoreseriousinevaluatingthisissue.

Supervisor:Dr Rosediani MuhammadCo-supervisor:Professor Dr Hatta Sidi

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A STUDY TO DETERMINE THE ASSOCIATION BETWEEN PATTERN OF CALCIFICATION IN CT SCAN AND STAGING OF RETINOBLASTOMA IN HOSPITAL UNIVERSITY SCIENCE MALAYSIA (HUSM)

Dr Rozita GoonMMed (Radiology)

Department of RadiologySchool of Medical Sciences, University Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Retinoblastoma is one of themost common intraocular malignancy in children under15-years-old. About 80% of cases occurs in patients under3-years-old.Theincidencevariesformcountriestocountries.InUnitedStatesofAmerica,itoccursin1ofevery15000livebirth.Mostincidenceofretinoblastomaisunilateral,bilateralinvolvement is seen inapproximately30%of casesand it isdetectedearlier.Physicalandradiologicalexaminationhelpsindiagnosing retinoblastoma.CT scanof theorbit is oneoftheimportanttoolsindiagnosingretinoblastoma.Intraocularcalcificationcanbedetected inabout80%of theCTscanoforbit.Many researcheshave beenperformed since 1980s todetermine association between intraocular calcification inretinoblastomawithprognosisandsizeofthetumour. Objectives: To determine frequency of intraocularcalcification in retinoblastoma and association between thepattern of calcification with histopathological examination,clinicaldataandstaging. Methods: This was a retrospective descriptive study.Allpatientshadundergonepre-treatmentCTscanoftheorbitand enucleation. Characteristic of calcification on CT scanimages which were presence of calcification, size, site andHounsfieldUnitofcalcificationwererecorded.CTscanimageswerereviewedviaGECentricityPACS-IW(Intregratedweb)version 3.71. Histological findings which were presence ofcalcification,size,siteoftumourandopticnerveinvolvementwere recorded.History of presenting illness, family history,demographic data and clinical classification were soughtform medical record and recorded. Association betweencharacteristicofcalcificationandhistologicalfindings,clinicaldataandstagingweredetermined. Result: There was 95% intraocular CT calcificationseen in retinoblastoma in this study. There was significantassociation between presence of calcification on CT andpresenceofcalcificationonHPE(P=0.042).TherewasalsosignificantassociationbetweenpresenceofHPEcalcificationandCT calcification site (P = 0.016). Significant associationnoted between CT calcification size, and strabismus(P = 0.035). However, there was no significant associationbetween the patterns of calcification on CT with staging ofretinoblastoma. Conclusion: Although presence of calcification onCT scanwasusedasa criteria todiagnosed retinoblastoma,

there is no significant association between patterns of thecalcificationwithstaginginretinoblastoma.

Supervisor:Assoc Prof Noreen Nurfaraheen Lee Abdullah

THE EFFECTS OF HORMONE REPLACEMENT THERAPY ON MAMMOGRAPHIC DENSITY AMONG POST-MENOPAUSAL WOMEN IN HOSPITAL RAJA PEREMPUAN ZAINAB II, KOTA BHARU, KELANTAN

Dr Santhi KamaravelMMed (Radiology)


Introduction:Hormone replacement therapy (HRT)iscommonlyprescribedtopost-menopausalwomentoimprovetheirpost-menopausalsymptoms.Post-menopausalhormoneuseisassociatedwithincreaseinmammographicdensityandincreasedincidenceofbreastpain.Mammographicdensityisanindependentriskfactorforbreastcancer. Objectives:ThepurposewastoevaluatetheeffectsofHRTonmammographicdensity inpost-menopausalwomeninKotaBharu,Kelantan,Malaysia. Methods:Anobservationalstudywasconductedforaperiodof 18months.A total of 33post-menopausalwomenwho received combined HRT (containing estrogen andprogesterone)wereincludedasstudysubjects.Mammogramswereperformedatbaselineandafter12monthsofreceivingHRT. Mammographic density was evaluated according toBIRADS classification of breast density. During follow-up,patientswerealsoenquiredaboutbreastpainandtheywereaskedtoclassifyaccordingtoaspecifiedscale. Result: The categorical assessments showed thatthere was a significant shift in categorical classification asassessedbyBIRADScategories among thepost-menopausalwomen receiving HRT. Amongst these women, 30.3% hadincreasedmammographicdensityaftertreatmentwithHRT.There was also significant association between breast painand increase inmammographic density. Amongst the studypopulation, 33.3% complained of breast pain after HRT.Wealsoconcludedthat thestudy factors (grade,age,parity,BMI,durationofmenopauseandageatmenopause)didnotsignificantlyinfluencechangeinmammographicdensity. Conclusion: HRT significantly affects themammographicdensityandincreasedmammographicdensitywasassociatedwithbreastpaininwomenreceivinghormonaltherapy.

Supervisor:Assoc Prof Dr Noreen Norfaraheen LeeCo-supervisor:Dr Md Ariff Abas


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A STUDY TO INVESTIGATE THE EFFECT OF HORMONE REPLACEMENT THERAPY (HRT) ON PLATELET ACTIVATION MARKERS (CD62P & PAC-1) DETERMINED BY FLOW CYTOMETRY IN HEALTHY POSTMENOPAUSAL WOMEN

Dr Shabbir Ahmad SheikhMMed (O&G)


Introduction: In healthy post-menopausal womenincreased platelet activation has been associated with theadverse cardiovascular events including unstable angina,myocardial infarction, stroke and other thrombotic states.Thereismuchdebateabouttherelationshipbetweenplateletfunctionandserumestradiollevelsinsuchpost-menopausalwomen.Itispostulatedthatestrogenmayresultindecreasedplateletactivation. Objectives:Theaimofthestudywastodeterminetheeffect of HRT on the platelet activationmarkers (CD62P &PAC-1)inhealthypost-menopausalwomenandtodeterminethecorrelationbetweenplateletactivationmarkersandserumestradiol,BMIandageofpost-menopausalwomen. Methods: Aprospectivecasecontrolstudyon48post-menopausal women was conducted at Hospital UniversitiSainsMalaysia(HUSM).GroupAconsistedof48womennotonhormonereplacementtherapy(HRT)(ControlGroup)andgroupBcomprisedofsame48womenwhoweregivenHRT(conjugatedequine estrogen0.625mgorallyoncedaily) for2 weeks (study group). Platelet activation was evaluated atbaseline and after 2 weeks of treatment by flow cytometricanalysis using CD62P and PAC1 as activation markers.Comparisons within groups (before and after HRT) wereanalyzedusingthepairedt-tests. Results:TheexpressionsofCD62PandPAC1showeda decreased platelet activation status in postmenopausalwomen who were given HRT. Platelet activation markers(CD62P & PAC-1) among healthy post-menopausal womenin the group A were 7.00% ± 5.91 (CD62P) and 41.75% ±26.85 (PAC-1) respectively (increased platelet activation inthis group) which were reduced to 3.05% ± 2.47 (CD62P)and20.86%±19.02(PAC-1)respectivelyinthegroupBafter2weeksofHRTadministration(P-value<0.001). Conclusion: HRT decreases the platelet activationmarkers (CD62P & PAC-1) in healthy post menopausalwomen. Platelet activation markers (CD62P & PAC-1) arefoundtobeincreasedinhealthypost-menopausalwomenascompared to thepost-menopausalwomenwhowere treatedwith HRT. There is a significant negative fair correlationbetween estradiol andmplatelet activation markers(CD62P&PAC-1).However,therewasnosignificantrelationamong BMI, age and platelet activation markers. It isconcluded thatshort termuseofHRThasa favorableeffect

on reduction of platelet activity in post-menopausalwomenand thus it is postulated to be cardio protective. Furtherstudyonthelong-termeffectofHRTonplateletsisneeded.

Supervisor:Professor Dr Nik Mohamed Zaki Nik MahmoodCo-Supervisor:Assoc Prof Shah Reza Johan NoorDr Tariq Mahmood Roshan

ANTHROPOMETRIC MEASUREMENT OF THE LIP-NOSE COMPLEX AMONG YOUNG ADULTS IN KUALA LUMPUR, MALAYSIA

Dr Shamala DurairajanayagamMSurg (Plastic Surgery)

Reconstructive Sciences UnitSchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: The lip-nose complex is an importantaestheticsubunitofthemidandlowerface.Todate,thereisnopublisheddataonlip-nosecomplexanthropometryfortheMalaysianpopulation. Objectives: This cross-sectional descriptive studyaims to establish the norms of the lip-nose complex amongMalaysianMalays,Chinese,andIndiansandtocomparethetransgenderandtransethnicvariationbetweenthem. Methods: 7parametersofthelip-nosecomplexnamelymouth width, cupids bow width, columellar width, nasalwidth, lip height, columellar height and dome height weremeasuredusingstandardanthropometricmeasurementtools.316studentswererandomlyselectedfrom3schoolsinKualaLumpur,withequalgenderandethnicdistribution. Result:All7parametersthelip-nosecomplexinMalay,Chinese,andIndianmaleswereconsistentlylargerthantheirrespective female counterparts (P<0.05).Thedifference inlip-nosecomplexmeasurementsformouthwidth,nasalwidth,lipheightanddomeheightwerestatisticallydifferentbetweenMalays,Chinese,andIndians.MouthwidthandnasalwidthwerewidestamongMalays.LipheightwashighestamongstIndians.DomeheightwashighestamongsttheChinese.Thecupids bow distance, columellar width and height showedminimal difference within the 3 races (P > 0.05). Malaysand Chinese differed in all parameters except cupids bowwidth.MalaysandIndiansonlydifferedinmouthwidthandnasal width. Chinese and Indians differed in lip height anddomeheight. Conclusion: Malays and Chinese show differencesin their lip-nose complex profile despite having originatedfromtheEastAsiancontinent.MalaysandIndiansdifferedinwidth measures, while the Chinese and Indians differedin height measures. The variation of anthropologicalmeasurementsamongthe3ethnicgroupsreinforcestheneedtohaveindividualisednorms.Thesefindingsformabaselineforfuturestudiesthatareagebasedwhichwouldthenserve

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asaninvaluableguidetothereconstructivesurgeonespeciallywhendealingwithunilateralandbilateralcleftliprepairs.

Supervisor: Prof Dr Ahmad Sukari Halim Co-supervisor:Dr Normala Hj Basiron

KNOWLEDGE REGARDING MANAGEMENT OF DIABETIC NEPHROPATHY AMONG MEDICAL OFFICERS (MO) AT HUSM AND ITS ASSOCIATION WITH MO PROFILES

Dr Siti Kamariah OthmanMMed (Internal Medicine)


Introduction: Many studies had assessed theknowledge and practices among the physicians in themanagementofchronickidneydisease(CKD)butnospecificstudy to assess the knowledge of medical officers (MOs)regarding the management of diabetic nephropathy. Manypatient with diabetic nephropathy are seen by MOs level,who are less experienced than nephrologists to offeroptimal care. It is not knownwhether knowledge regardingmanagement of diabetic nephropathy among MOs areadequateincareofdiabeticnephropathypatientandwhethercharacteristics ofmedical officer are associatedwith havingadequateknowledge. Methods: Self-administeredquestionnaire tomedicalofficersat2medicalbaseddepartmentHUSM(n=102)withdistributionof51InternalMedicineand51FamilyMedicinein April 2011. The questionnaire consist of 4 knowledgedomainsregardingmanagementofdiabeticnephropathyandhadestablishedvalidation. Result: Total 102 out of 108 (94%) eligible medicalofficers returned a completed survey. Overall, 49% of MOshave adequate level of knowledge. All MOs have manageddiabetic nephropathy cases but even so, only 78% of themhave attended seminars/talks or workshops regardingdiabeticnephropathy.Overall,no relationshipbetween levelof knowledge and MO specialties (Internal Medicine VsFamilyMedicinedepartment).Therewerealsonosignificantrelationship between level of knowledge and status ofMOs (service MO or master MO). There were significantrelationship between level of knowledge and the year ofmaster (P = 0.016) and year 4mastersMO hadmore than7foldgreateroddsofshowingaadequatelevelofknowledgecompared with MO who are not yet joining master(95%CI,1.44,36.20,P=0.016). Conclusion:Wefoundthatmedicalofficershavesignificant gaps in their knowledge regarding managementof diabetic nephropathy that might require furtherimprovement for better future patient care.Master training

may offer the best opportunity to improve the awarenessand knowledge of diabetic nephropathy guidelines throughmorefocusededucationalefforts.

A PROSPECTIVE STUDY OF RELATIONSHIP OF VASCULAR PEDICLE WIDTH AND CARDIOTHORACIC RATIO IN ADULT PULMONARY OEDEMA PATIENTS DURING TREATMENT IN ICU

Dr Siti Aishah Ahmad MaulanaMMed (Radiology)

Department of RadiologySchool of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kelantan, Malaysia

Introduction:Determinationofintravascularvolumestatusincriticallyillpatientisveryimportant.Traditionally,invasive hemodynamic pressure measurements have beenused to assess the volume status in this group of patients.However, the information available from vascular pediclewidth (VPW) in portable supine chest radiographs areleast costly and least invasive of determining volume statusin critically ill patient. The true utility of VPW reflectingintravascularvolumestatusseeninfewstudiesfromportablesupine chest radiographs especially in monitoring patientswhohavevolumeoverloadandarereceivingtreatment. Objectives: To determine the relationship of VPW,cardiothoracicratio(CTR)andnetfluidbalancebyusingserialportablesupinechestradiographinadultpulmonaryoedemapatients during treatment in Intensive Care Unit (ICU) inHospitalUniversitiSainsMalaysia(HUSM). Methods:AprospectivestudywasdonefromJun2008untilJun2009involving51patientswhohadbeendiagnosedto have pulmonary oedema in ICU and Neuroscience ICU,HUSM.Serial supineportable chest radiographswere takenfromday1oftheonsetofpulmonaryoedemainICUuntilday3consecutively.Firstchestradiographwastakenbeforestartingtreatment. Subsequent chest radiographs were taken about24hoursapart.3consecutive24hoursnetfluidbalancedatawere taken fromICUmonitoring chart according to thedayof CXRs. Computed chest radiograph is used for evaluationof theVPWandCTR.TheVPWandCTRweremeasuredbyresearcherinseparatedoccasionwithoutclinicaldatarelatedtopatientavailable. Result: 51patientinvolvedinthisstudywiththemeanageof54.43.Totalof39patients(76.5%)receivedintravenous(IV)Frusemideand12patients(23.5%)receivedIVFrusemidein combination with dialysis as treatment of pulmonaryoedema. There was a weak but not significant correlationbetween VPW and CTR in each day from day 1 (r1 = 0.10,P=0.34),day2(r2=-0.01,p=0.92)andday3(r3=0.02,P = 0.91). Similar findings of a weak but not significantcorrelationwasalsoseenbetweenVPWandnetfluidbalanceonday1(r1=0.10,P=0.47),onday2(r2=-0.05,P=0.73)andonday3(r3=-0.05,P=0.74).However,byusingpaired


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t-test significant mean changes of VPW between day 1 today 2 and between day 2 to day 3 (P < 0.001). Significantmean changes of net fluid balance were also seen betweenday 1 to day2 andbetweenday2 today3 (P <0.001).Nosignificantmean changesofCTR seenbetweenday 1 today2andbetweenday2 today3 (P=0.58). Inaddition, thereweredailyreductionofthemeanofVPWandnetfluidbalancein 3 days duration with IV Frusemide and combinationtreatment. However, no significant difference between bothtreatmentswiththemeanofVPW(P=0.099)andnetfluidbalance(P=0.162)in3daysperiod. Conclusion: Thisstudyshowedthattherewasstrongsignificant mean changes of VPW and net fluid balancebetweenday1today2aswellasday2today3.However,nosignificantmeanchangesofCTRbetweenday1today2andday2today3.

Supervisors :Dr Nik Munirah Nik MahdiDr Mohd Shafie AbdullahCo-supervisors:Dr Mohd Ariff AbasDr Mahamarowi Omar

STONE FREE RATE OF EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) FOR TREATMENT OF RENAL STONES

Dr Siti Rahmah Bt Hashim Isa MericanMMed (Surgery)


Introduction: Renal stones or renal calculi is acommon disease encountered in the population worldwide.The cause of renal stones in majority of the cases areidiopathic.Managementofrenalstoneshaschangedovertheyears.Before1980s,opensurgerywasthetreatmentofchoice.However,minimally invasiveinterventionhasreplacedopensurgery inthetreatmentofmostrenalstones.This includedextracorporealshockwavelithotripsy(ESWL). ESWLused shockwaves tobreak the stone into smallpiecesorfragmentswhichcanbepassedthroughtheurinarytract. Therefore, it is more preferred method for treatmentofrenalstonesandseveralureteralstones.Ithasfavourableclinical outcome, low complications rate and few absolutecontraindications. Objectives: The objective of this study is to obtainan epidemiological data of patients with renal stones whounderwent ESWL in Hospital Universiti Sains Malaysia(HUSM).We also would like to review the outcome of thistreatment in terms of stone clearance including the factorsthatmayinfluencesitssuccessrateinourcenter. Methods: Aretrospectivecohortstudyhadbeendoneinvolving patients with renal stones who underwent ESWL

for their treatment inUrologyUnit,DepartmentofSurgery,HUSM.Thisstudywasdonein18monthsduration,from1stMay2007until30thOctober2008.AllpatientsweretreatedwithESWLmachineSONOLITH®Vision.Theradio-opaquestonewaslocalisedwithX-rays.Patient’smedicalrecordandKUB X-rays before and after the treatment were reviewed.DatawasanalysedusingSPSSversion12withP-valueoflessthan0.05wasconsideredsignificant. Result: During the study period fromMay 2007 tillOctober 2008, 104 patients were involved. In this study,56 (53.8%)patientsweremale and48 (46.2%)were femalewithmale:femaleratio1.1:1.Themeanagewas50.8-years-old(range 16–83yearsold).Majority of thepatientswere fromMalayethnics (97.1%) followedbyChinese (1.9%)andotherethnicgroups(1.0%).Themeanstonesizewas13.07mmwith42(40.4%)stonesmeasuring10mmorlessand62(59.6%)more than10mmbutnotmore than20mm.Mostof renalstoneswerelocatedatthemiddlecalyx(32.7%),followedbylower calyx (28.9%), upper calyx (23.1%) and renal pelvis(17.3%). 78 point eight percent (78.8%) had single stonewhile another 21.2% hadmultiple stones. Our overall stoneclearance ratewas53.8%.However inour study, stone size,location of the stones and numbers of stone did not affectoverallstoneclearance. Conclusion: In conclusion, ESWL was a goodtreatment for renal stones measuring less than 20 mm.However,weneedtoselectpatients that isgoingtobenefitsfromthistreatmentandhavearegularorproperfollow-upinordertohaveabetteroutcome.

Supervisor:Dr Mohd Nor Gohar RahmanCo-supervisors:Dr Mohamed Ashraf Mohamed Daud Dr Mossadeq A

A STUDY ON THE EFFECTS OF ANDROGRAPHIS PANICULATA (HEMPEDU BUMI) ON SERUM PROTEIN C, PROTEIN S ACTIVITY AND FASTING BLOOD GLUCOSE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

Dr Sulaila BasiamMMed (Internal Medicine)


Introduction: Patientswith type 2 diabetesmellitus(DM2) show enhanced activation of the blood coagulationsystem and decrease level of natural anticoagulant such asproteinCandproteinS.Thisisbelievedtocontributetothehigh incidence of premature atherosclerosis attributable tomyocardialinfarction,cardiovasculardisease,andperipheralvasculardiseaseindiabeticpatients.Andrographis paniculata(Hempedu bumi) has beenwell known to have blood sugar

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lowering properties in diabetes patients and has been usedby local Malaysians as an alternative to current oralhypoglycaemic agents. With the benefit of its blood sugarloweringpropertiesitishopedthatAndrographis paniculatamay also increases level serum protein C and protein S indiabetic patients, thus reducing the risk of atheroscleroticdisease. Objectives: This study was conducted to determinethe changes in fasting blood sugar levels and to assess thechanges in serumproteinC andproteinS activity followingoral administration of Andrographis paniculata amongDM2patientsinHospitalUniversitiSainsMalaysia(HUSM)DiabeticMedicalClinic. Methods: This is an open-labelled, randomisedtreatmentversus control studywhichwas conductedamongDM2patienton followupatHUSMDiabeticMedicalClinicfromAugust2010tillNovember2010.Atotalof34subjectswererecruitedinthisstudy.Ofthis,17wererandomlygiventhe study medication; 2 tablets each containing 250 mg ofAndrographis paniculata for 2 weeks duration while theother17patientswereallowedtocontinuewiththeirpreviousmedicationwithoutanyalteration.Bloodsamplescontainingfastingblood glucose (FBG), serumproteinC andproteinSweretakenatbaselineandafter2weeksinterventionforbothgroups. Result: A total number of 34 patients were involvedin this study. The mean age was 55.2 ± 9.8 years. ThebaselineHbA1cwas9.2%±2.4%inbothgroups.Themeanfasting blood sugar during pre-intervention in the controlgroup was 8.6 mmol/L ± 3.7 while in treatment group is9.1 mmol/L ± 5.0 and post-treatment, the mean fastingblood sugar was 8.3mmol/L ± 2.9 and 9.3mmol/L ± 4.0,respectively. ThemeanofproteinC in thepre-interventionforcontrolgroupwas117.2%±17.3andinthetreatmentgroupwas 125.1%± 21.3. Post-interventionmeanproteinC in thecontrolgroupwas121.1%±25.4andinthetreatmentgroupis125.9%±18.9.ThemeanproteinSinthepre-interventionforcontrolgroupwas202.4%±128.0andfortreatmentgroupis 135.4% ± 30.1 while in the post-intervention mean forcontrolgroupwas208.3%±129.5andinthetreatmentgroup134.1% ± 25.3. Themean difference of fasting blood sugar,proteinC andprotein S betweenpre- andpost-interventionforbothgroupswerestatisticallynotsignificant. Conclusion: Our study demonstrated that generallythe blood sugar control among DM2 patients is still poorwithmeanHbA1cof 9.2%±2.4.Therewereno significantchangesinmeanserumfastingbloodglucose,proteinCandproteinS forpre-andpost-treatmentoforaladministrationof500mgofAndrographis paniculatafor2weeksdurationin the treatment group when compared to control group.These findings were probably related to inadequate doseof Andrographis paniculata since there was no study ofbioequivalence in this study and also inadequate studydurationtoproducedesirableeffectsinthisstudy.

A CLINICOPATHOLOGIC STUDY ON TRIPLE-NEGATIVE BREAST CANCER PATIENTS: HUSM EXPERIENCE

Dr Usman Sani Bin SaidinMPath (Anatomic Pathology)

Department of PathologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Breast cancer is the most commoncanceramongMalaysianwomen.Therearemanyprognosticfactors contributing to the disease and the outcome of thepatients.Triplenegativebreastcancersaredefinedbyalackofexpressionofoestrogen,progesterone,andcerbB-2receptors.They tend to have a higher grade with a poorer outcomecomparedtonon-triplenegativebreastcancers. Objectives: The study was carried out aiming toobservetheassociationoftriplenegative;(oestrogenreceptor[ER],progesteronereceptor[PR]andcerbB-2)breastcancerpatients to the pathological (histological subtype, tumourgrade, tumour size, and lymphnode involvement) andnon-pathologicalparameters(patient’sageandethnicity). Methods: Retrospective review of histopathologyreportsinHospitalUniversitiSainsMalaysiafrom1stJanuary2002to31stDecember2004.23casesoftriplenegativebreastcanceramong115casesofbreastcancerdiagnosedin3years(2002 to 2004) were reviewed. They represented 20.0% oftotalbreastcancerpatients. Result: There were significant association betweentriple negative breast cancer with tumour size, lymph nodeinvolvement, and lymphovascular invasion. However, age,race,histologicalsubtypeandhistologicalgradedidnotshowsignificantassociation. Conclusion: From these findings, we conclude thattumoursize is thestrongest factorassociatedwith the triplenegativebreastcancer.Besidesthat,lymphnodeinvolvementisalsoassociatedwithtriplenegativebreastcancer.However,lymphvascularinvasionisnotassociatedwithtriplenegativevascularbreastcancer.

SupervisorDr Venkatesh R Naik

COMPARISON OF ANXIETY AND DEPRESSION BETWEEN PATIENT WITH AND WITHOUT FIXED AIRFLOW LIMITATION IN SEVERE ASTHMATICS IN HOSPITAL UNIVERSITI SAINS MALAYSIA (HUSM) AND HOSPITAL RAJA PEREMPUAN ZAINAB II (HRPZ II)

Dr Wan Hasmawati Wan IsmailM.Med (Family Medicine)


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Introduction: Asthma is a common chronic diseaseworldwide. Despite important advances in diagnosis andtreatment, asthma has become a public health problem forallcountries.Poorlycontrolledasthmaexertsahighcostforbothpatientsandsociety.Fixedairflowlimitationcandevelopinpatientswithsevereasthma.Anxietyanddepressionweresignificantly more common among asthmatic patients andpsychiatric co-morbidity is associated with poor asthmaoutcome. Objectives:Tocomparetheprevalenceofanxietyanddepression between patients with and without fixed airflowlimitationamongsevereasthmaticpatientsandtodeterminetheassociationbetweenanxietyanddepressionwithairflowlimitationinsevereasthmaticpatients. Methods: This was a comparative cross-sectionalstudy among 158 severe asthmatic patients attending thechest clinic follow-up inKlinikPakarPerubatanHUSMandHRPZIIfrom15August2009till15April2010.Eachpatientwas interviewed and their medical notes were reviewed toassess their medications as well as their asthma severity.Spirometry test was performed to determine the presenceof fixed airflow limitation. They were then given 2 sets ofself-administeredquestionnaires;(1)thesocio-demographicquestionnaireand(2)theMalayHADSquestionnaire. Result: There were 81 patients in the fixed airflowlimitation group with mean age (SD) of 54.1 ± 9.8 and77 patients in the group without fixed airflow limitationwithmeanageof50.1±12.3.Theprevalenceofanxietyanddepression in the fixed airflow limitation group was both29.6%whereas in the groupwithoutfixedairflow limitationwere 24.7% and 18.2% respectively. Simple and multiplelogisticregressionsfoundnosignificantrelationshipbetweenanxietyordepressionandpresenceoffixedairflowlimitation. Conclusion: Theprevalenceofanxietyanddepressionin severe asthmaticpatientswithfixed airflow limitations issimilar to thosewithoutfixedairflow limitation.There isnoincreasedriskofdevelopinganxietyordepressionassociatedwithhavingfixedairflowlimitationinsevereasthmatics.

Supervisor: Dr Norwati Daud

A PILOT STUDY OF INTRASTROMAL INJECTION OF AMPHOTERICIN B 0.0005% IN FUNGAL KERATITIS

Dr Yanti MuslikhanMMed (Ophthalmology)

Department of OphthalmologySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Fungal keratitis is an importantinfectiouskeratitisindevelopingcountriessuchasMalaysia.It is difficult to diagnose and treat. The current availableantifungalagentshavepoorocularpenetration.Newmethodof drug delivery which was the intrastromal injection ofamphotericinBwas evaluated to see its effectiveness in thetreatmentoffungalkeratitis. Objectives:Theobjectiveofthisstudyistodeterminethe effectiveness of intrastromal amphotericin B 0.0005%injectioninhumanfungalkeratitis. Methods:Thiswasapilotstudyinvolving20subjects.10 subjects received intrastromal injection of amphotericinB and 10 subjects were in the control group in which theyreceivedthestandardtopicalantifungaltherapy. Result: About 30% of patients with very poor visualacuity had improved vision to good visual acuity in theintervention group. Complete re-epithelialisation was seenin 30% of patients in the intervention group compared to20%inthecontrolgroup.Resolutionofstromalabscessandreductioninthelevelofstromalinfiltratewereseenearlierinthe intervention group. 40% of subjects in the interventiongroup showed complete healing of the stromal compared to10%incontrolgroup. Conclusion: IntrastromalinjectionofamphotericinB0.0005%(5µg/ml)wasfoundtobeeffectiveintreatingfungalkeratitisinhuman.

Supervisor: Associate Prof Mohtar IbrahimCo-supervisor: Dr Adil Hussein Dr Noram Azlan Ramli

PREVALENCE OF EOSINOPHILIC NASAL POLYPS AND ANALYSIS OF THEIR PRESENTATION IN HUSM KUBANG KERIAN, KELANTAN

Dr Yahia F HusseinMMed (ORL–Head and Neck Surgery)

Department of ORL–Head and Neck SurgerySchool of Medical Sciences, Universiti Sains MalaysiaHealth Campus, 16150 Kelantan, Malaysia

Introduction: Nasalpolyppathogenesesandetiologyis still unknown, but now it is regarded as one form of thechronicinflammatoryreactionofthesinonasalmucosawhicheosinophiles are mainly involved in the mechanism of itsformation.Itisquitecommondiseaseaffecting1%–2%oftheadult population and has the potential for high recurrence.Clinically most of the patients are complaining of nasalblockage and reduce sense of smell. The easy accessibilityto the nasal polyp facilitates histological examination of itand broadly divided them into 2 histological subtypes theeosinophilicandnon-eosinophilictypes.

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Objectives: The aim of the study was to determinethepercentageofeachhistologicalsubtypeofthenasalpolypand to study the association of the clinical presentation ofeachtype. Methods: 62 patients with nasal polyp underwentfunctionalendoscopicsinussurgery(FESS)inHUSMovertheperiodof4yearsextendingfrom2004to2008wereincludedinthestudyandtheirhistopathologicalreportswerereviewedand their clinical presentation was studied in relation tothe symptoms and the findings were written in specificallypreparedformforthispurpose. Result: 87% of the sample had eosinophilic type ofnasal polyp and 13% had non-eosinophilic.There was nostatistically significantdifference in the clinicalpresentationin relation to nasal blockage or loss of smell between the2 histological subtypes. High recurrence rates was notedamong our subjects compared to published figures for thesamesurgicalintervention(FESS). Conclusion: The study showed that the incidenceof histological subtypes of nasal polyp is almost the sameas that found in other parts of the world (Europe andNorth America) which will reduce the possibility of racialor geographical influence on the pathogenesis of the nasalpolyp. Clinical symptoms and presentation alone are notenough to differentiate the type of the nasal polyp withoutthehistologicalstudies.

Supervisor:Dr Ramiza Ramza bin RamliCo-supervisor:Dr Irfan Mohammed

PREMATURE CORONARY ARTERY DISEASE AMONG ANGIOGRAPHICALLY PROVEN ATHEROSCLEROTIC CAD IN HUSM

Dr Zahrni MudaM.Med (Family Medicine)


Objectives:Todeterminetheproportionofprematurecoronary artery disease (CAD) among angiographicallypositive CAD patients inHospital Universiti SainsMalaysia(HUSM)andtoidentifyitsriskfactors.

Methods: Thisisacross-sectionalstudy.350medicalrecords of patients undergoing coronary angiogram dueto CAD from October 2002 till 2004 were reviewed. Thesocio-demographic, associated risk factors and angiographicfindingswererecordedinadataquestionnaire. Result: A total of 165 cases were included, which55% (n = 91) were premature CAD and 45% (n = 74) wereolderCAD.ThemeanageofprematureCADwas49.7yearsof male and 51.4 years for female and male gender waspredominantby80%.Thesignificantfactorsassociatedwithpremature CAD were family history of heart disease 38.5%(P<0.05)andlowHDLlevel1.2±0.30(P<0.05).Comparedwith older patients, younger patient had pre-ponderance ofdouble-vesseldisease. Conclusion: TherewasahighprevalenceofprematureCADpatientsamongangiographicallyprovenatheroscleroticCAD.Familyhistoryofheartdiseaseand lowHDL levelareassociated with premature CAD. Thus early cardiovascularscreeninginfamilymemberofpatientwithheartdiseaseandaggressive treatment to increaseHDL levelare thefirst stepforpreventionofCADinyoungage.

Supervisor:Assoc Prof Dr Zurkurnai YusofCo-supervisor: Dr Azidah Abd Kadir

abstracts of theses approved for the mmed at the school of...

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