International Islamic University Malaysia Medical Research Articles

Antimicrobial resistance of methicillin-resistant coagulase negative staphylococcal species in two government hospitals in Kuantan, Malaysia

The emergence of nosocomial infections caused by CoNS has led clinicians and researchers to reconsider the role of CoNS and methicillin-resistant CoNS (MR-CoNS) as important agents of nosocomial infections. This study was conducted on clinical isolates of MR-CoNS obtained from inpatients in Hospital Tengku Ampuan Afzan (HTAA) and International Islamic University Malaysia Medical Center (IIUM-MC) to determine their antimicrobial resistance profile. The isolates were cultured from clinical samples of blood, tissues, and swabs. Forty isolates (33 blood, 4 tissues, and 3 swabs) of MR-CoNS were collected through venepuncture, biopsy, and swabbing techniques respectively, and processed by conventional cultural, biochemical methods and antimicrobial susceptibility tests. Methicillin- and vancomycin-resistance profile of the isolates was performed by E-test and broth micro-dilution methods. Of the 40 isolates, 38 were identified to be methicillin-resistant (MIC ³ 0.5 µg/mL). The remaining 2 isolates were considered as susceptible to methicillin (MIC ≤ 0.25). All 40 isolates were found to be susceptible to vancomycin (MIC=1-4 µg/mL). All 40 isolates were also tested for phenotypic antimicrobial susceptibility profile using the Kirby and Bauer disc diffusion method. Resistance rates to linezolid, erythromycin, ciprofloxacin, and ceftaroline were found to be 100%. Resistance rates to trimethoprim-sulfamethoxazole, teicoplanin, and clindamycin were found to be 82.5%, 92.5%, and 97.5% respectively. Thus, all the isolates revealed multi-drug resistance profiles to more than 3 antimicrobials; the highest being resistance to 9 antibiotics, except one isolate from swab. This points toward the need for periodic antibiogram surveillance as they are identified to cause difficult to treat infections.

Arthroscopic Subacromial Decompression in the Treatment of Shoulder Impingement Syndrome: A Prospective Study in Malaysia.

IntroductionShoulder impingement syndrome (SIS) is one of the common problems which lead to shoulder disabilities. This condition has been described as impingement to the rotator cuff by the anterior third of the acromion process and has been classified into three stages. Treatment option varies depending on the grade of the disease. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and has shown to have a good outcome. The purpose of this study is to evaluate the outcomes following ASAD in terms of the functional, clinical, and radiological parameters in treating SIS in the ageing population in Kuantan, Pahang, Malaysia.Materials and methodsThis was an observational study looking at the outcomes of patients with stage 2 and stage 3 (partial cuff tear) impingement syndrome who underwent ASAD in Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre from May 2018 to June 2019. The functional outcomes were evaluated using American Shoulder and Elbow Surgeons (ASES) score taken at pre-operative, six weeks, three months, and six months post-operation. Clinical outcomes were evaluated using Constant score (CS) taken at six months post-operation. Radiological outcomes were measured by comparing acromiohumeral distance pre- and post-operation on anteroposterior (AP) view radiograph of the affected shoulder.ResultsA total of 28 patients were selected for the study. On functional outcome, there was a significant effect of time on the ASES scoring system (p-value <0.05) from pre-operative to six months post-operation. On clinical outcome, the CS at six months showed 13 patients have excellent scores, 10 have good, and five have fair scores. There was a statistically significant difference in mean values of all categories (p-value <0.05). In terms of the radiological outcome, this study observed a significant increase in patients’ subacromial space on X-ray from the pre-operative and post-operative treatment stages. In this study, we also observed that there was no significant difference in outcomes between partial and intact rotator cuff (RC) tears at six-month post-operation.ConclusionIn this study, ASAD was found to be a beneficial intervention in the treatment of patients with shoulder impingement evidenced by the significant outcomes in terms of functional, clinical, and radiological parameters.

Outcome of Differentiated Thyroid Carcinoma at Two Centres in Kuantan, Pahang

Introduction: Differentiated thyroid carcinoma (DTC) is the commonest thyroid malignancy. Several studies had shown that the outcome of DTC depend on the patient’s age at time of diagnosis, tumor characteristics and initial treatment. The aim of this study was to describe the outcome of DTC and its associated factors among patients diagnosed at Hospital Tengku Ampuan Afzan (HTAA) and International Islamic University Malaysia Medical Center (IIUMMC) Kuantan, Pahang. Materials and method: A retrospective cohort study was carried out among all DTC patients in HTAA and IIUMMC from July 2018 to September 2018. Case report form was used for data collection and it consists of four sections that include sociodemography, disease characteristics, treatment modalities and outcome. Descriptive statistics was used to describe the types of DTC, sociodemographic characteristics, disease characteristics, treatment modalities and the outcome, while chi-square test was used to explore the factors that were associated with the outcome. Result: In DTC, majority were diagnosed with papillary carcinoma (93.5%) than medullary carcinoma (6.5%). Three-quarter of the patients had residual disease at 6 months and the disease persistent in more than half of the patients at 12 months. At two-years follow-up, most of the patients (56.5%) were in disease-free state followed by persistent (26.1%) and residual disease (17.4%). However, there were no significant factors that affect the outcome of the patients. Conclusion: The two-year outcome post-treatment in this study revealed most of the patients were in remission.

Periodontal Health Awareness among IIUM Medical Students

Introductions: Proper knowledge of oral diseases is crucial in medical practice because periodontal disease is associated with multiple systemic conditions. A large number of systemic diseases and drugs have oral manifestations as well as adverse reactions. The aim of this study is to assess periodontal awareness, knowledge and attitude among medical students of International Islamic University Malaysia (IIUM). Materials and method: This cross-sectional study utilized questionnaires which were distributed to fourth and final year medical students of IIUM Kuantan. Each participant’s consent was obtained before being recruited into the survey. Questions pertaining to oral health, periodontal disease and its relation with systemic conditions were given. Based on the answers, respondents’ awareness, knowledge and attitude were assessed.The data was analyzed by using Statistical Package for Social Sciences (SPSS) version 21. Results: A total of 93 students completed the survey questionnaires. 3% of them have awareness that periodontal disease is related to gingiva. 10% respondents agreed that the dental plaque is the primary cause of periodontal disease.80% respondents have knowledge of associations between periodontal disease and systemic conditions. 4% of them were able to identify drugs causing gingival enlargement. 97% of respondents showed positive attitude for referral to dentist in the future. Conclusions: The participants have superficial awareness and knowledge about periodontal disease and its relation to systemic conditions. However, they have positive attitude for future practice towards their patients. Hopefully, this research may provide direct suggestion to incorporate basic periodontal knowledge in their medical syllabus.

STAR Protocol for Critically Ill Patients in Malaysia: ICU Staff Survey and Human Factor Assessment

Since 2001, various glycemic control (GC) studies have been conducted to reduce dysglycemia in critically ill patients. To prove their effectiveness, each proposed GC approach requires not only patient clinical results, but also users assessments. This paper presents International Islamic University Malaysia Medical Centre intensive care unit (ICU) staff perceptions and assessments of human factors of Stochastic Targeted (STAR) protocol usage based on a Malaysian pilot trial to analyze the users responses to the protocol in the Malaysian set-up. STAR protocol is a model-based and automated GC that accounts for the individual patient s metabolic variability. The ICU staff feedback on STAR trial was based on 13 survey questions. The survey demonstrated that 87.5% of ICU staff agreed that STAR protocol improved patient s outcome, and is user friendly. Human factor assessment quantifies the different interventions recorded from STAR historical and manual bedside records for a total of 31 diabetes mellitus (DM) and non-diabetes mellitus (NDM) patients. During a total of 6168 hours in ICU stays, the percentage of compliance in blood glucose (BG) measurements, insulin infusion, and nutrition administered for DM and NDM cohorts were 97.3%/97.2%, 74.1%/70.3% and 65%/71.2%, respectively. © 2019 Institute of Electronics and Information Engineers. All rights reserved.

Right Hepatic Artery Encircle the Gallbladder: A Case Report

Detailed knowledge of the vascular anatomy of hepatobiliary system is important for a safe cholecystectomy. We are reporting a case of aberrant type of right hepatic artery originating from superior mesenteric artery and encircles the gallbladder that has been found during laparoscopic cholecystectomy operation. We presented a 39-year-old Malay lady came to International Islamic University Malaysia Medical Centre with features of obstructive jaundice. Ultrasound of hepatobiliary system showed cholelithiasis with choledocholithiasis causing dilatation of the common bile duct. ERCP had been performed and sphincterotomy was done. Patient was planned for laparoscopic cholecystectomy. Intraoperatively, the Calot’s triangle was identified in usual manner. However, the right hepatic artery was identified encircling the gallbladder body anteriorly before entering the liver. The procedure was converted to open cholecystectomy due to anatomical variation via Kocher’s incision. Further identification upon open cholecystectomy revealed right hepatic artery originates from superior mesenteric artery runs anterior to cystic duct and encircles the gallbladder before further branches into right and left lobe of the liver. Right hepatic artery was dissected from the gallbladder and the gallbladder removed after cystic duct ligation and separation from the liver bed. On table cholangiogram showed distal CBD stone which was pushed down to duodenum with forceps? Post-operative was uneventful and patient liver functions improved. Knowledge regarding anatomical structure and variant of hepatic artery as well as cystic artery and cystic duct is important to ensure the inadvertent ligation of right hepatic artery which would leads to hepatic ischemia and necrosis.

Model-based glycemic control in a Malaysian intensive care unit: performance and safety study.

Background: Stress-induced hyperglycemia is common in critically ill patients. A few forms of model-based glycemic control have been introduced to reduce this phenomena and among them is the automated STAR protocol which has been used in the Christchurch and Gyulá hospitals' intensive care units (ICUs) since 2010.Methods: This article presents the pilot trial assessment of STAR protocol which has been implemented in the International Islamic University Malaysia Medical Centre (IIUMMC) Hospital ICU since December 2017. One hundred and forty-two patients who received STAR treatment for more than 20 hours were used in the assessment. The initial results are presented to discuss the ability to adopt and adapt the model-based control framework in a Malaysian environment by analyzing its performance and safety.Results: Overall, 60.7% of blood glucose measurements were in the target band. Only 0.78% and 0.02% of cohort measurements were below 4.0 mmol/L and 2.2 mmol/L (the limitsfor mild and severe hypoglycemia, respectively). Treatment preference-wise, the clinical staff were favorable of longer intervention options when available. However, 1 hourly treatments were still used in 73.7% of cases.Conclusion: The protocol succeeded in achieving patient-specific glycemic control while maintaining safety and was trusted by nurses to reduce workload. Its lower performance results, however, give the indication for modification in some of the control settings to better fit the Malaysian environment.

Magnetic Resonance Imaging Procedure for Ventilated Intensive Care Patient in the International Islamic University Malaysia Medical Centre: Issues and Challenges

Managing a ventilated patient in the Intensive Care Unit (ICU) for Magnetic Resonance Imaging (MRI) procedure requires precise planning. Vigilant anesthetist with adequate MRI compatible monitoring of a critically ill patient and in preparation of any crisis event during transport to MRI suite, during MRI and return journey to ICU is essential. Problems in transporting ICU patient are usually equipment related, deterioration in gas exchange and increased rate of ventilator associated pneumonia. Preparation includes clinical reassessment for swift and systematic transport, airway management, optimum sedation and record keeping close to the patient. This is a case report of a 64 year-old gentleman who presented to International Islamic University Malaysia Medical Centre with right sided headache for one week associated with high intracranial pressure symptoms. His initial Glasgow Coma Scale (GCS) was 15/15 and Computed Tomography (CT) scan of his brain showed bilateral acute-on-chronic subdural haemorrhage, uncal herniation and minimal midline shift. His GCS dropped to 6/15 (E1V1M4) in the ward and proceeded with right craniectomy, evacuation of clot and duraplasty. Post operatively, his GCS improved to 15/15 in ICU and was extubated. On Day 2 post extubation, his GCS dropped to 6/15 (E1V1M4) and intubation was performed. Repeat CT Brain in ICU showed no evidence of new bleeding or mass effect. MRI was performed and it showed acute infarctions at right pons and right occipital region. Tracheostomy was done and the patient was sent to the general ward on fixed performance mask.

Prevalence of Thyroid Disorders in Pregnant Women In Hospital Tengku Ampuan Afzan &amp; International Islamic University Malaysia Medical Centre

Introduction: Data on the burden of thyroid disease in pregnant women in our community is scarce albeit the detrimental effects it brought to both the mother and fetus if left untreated. The aim of this study was to determine the prevalence of thyroid disorders, socio-demography distribution, and method of diagnosis in pregnant women of both tertiary centres in Kuantan, Pahang. Materials and Methods: A retrospective cross sectional study involving patients under follow ups at the Endocrine and Obstetric Clinics of Hospital Tengku Ampuan Afzan (HTAA) and International Islamic University Malaysia Medical Center (IIUM MC) from the 1st January until the 30th June 2017. Out of 923 pregnant women, 29 were found to have thyroid disorders. Detailed demographic data and thyroid function test readings were taken from their medical records and thyroid status were determined from TSH and FT4 readings using the trimester-specific thyroid reference range. Results: The prevalence of thyroid disorders in both centres was 3.14%, with specific prevalence of 2.80% for HTAA and 6.12% for IIUM MC. Nearly half of them were hyperthyroid (47.85%), 17.4% was hypothyroid and Graves’ disease dominated the diagnosis of thyroid disease (30.43%). Significant association was found in weight changes with patients’ thyroid status; reduction in weight in first trimester and increment in weight in second trimester were mainly seen in the hyperthyroid group (p&lt;0.01, p=0.027). Conclusion: The acceptable prevalence of 3.14% for thyroid disorders in pregnancy could be contributed by the iodine availability in this community. High prevalence of Graves’ disease warrants future screening for maternal thyroid stimulating immunoglobulin amongst hyperthyroid women.

Patients’ Knowledge and Perception on Anaesthesiologist And Anaesthesia

Introduction: Anaesthesiologists play vital roles in perioperative patients’ care and chronic pain management. However, not many patients are aware of the role of anaesthesiologists. We aimed to measure the level of patients’ knowledge regarding the role of anaesthesiologist and anaesthesia. Materials and Methods: This was a single-centred, questionnaire-based cross sectional study. The self administered questionnaire was divided into three parts that includes, i) sociodemographic characteristics, ii) knowledge regarding role of anaesthesiologist, iii) knowledge of anaesthesia. Respondents were selected among patients attending several specialist clinics at the International Islamic University Malaysia Medical Centre (IIUM MC). Results: Almost 64% of the selected patients had previous experience of anaesthesia. Majority of the patients (78%) knew that anaesthesiologist is a medical qualified doctor, but only 52.5% of them knew the role of anaesthesiologist in operation theatre. Fifty eight percents of patients realized the fact that anaesthesiologist is primarily responsible to ensures the well-being during operation, 45.1% knew the involvement of anaesthesiologist in case of emergency and in the intensive care unit, 46.7% in managing obstetrics pain, 39.3% in long-standing pain, 52.5% on the issue of pre-operative visits and post-operative recovery. Besides that, 72.1% were well-informed regarding fasting before operation, 59.8% realized that smoking may affect the anaesthesia and surgery, 86.1% knew where anaesthesia will be administered, 66.4% and 62.3% of respondents knew regarding the general and regional types of anaesthesia respectively. Seventy three percents of patients realize how general anaesthesia will be administered. Lastly, only 54.9% of patients had some knowledge regarding complications of anaesthesia. There were also not much impacts of previous exposure of anaesthesia on the level of their knowledge. Conclusion: Patients’ knowledge regarding the role of anaesthesiologist and anaesthesia were average and variable.

Retrospective Study on Upper Gastrointestinal Endoscopic Findings in Patients with Dyspepsia without Alarm Features in International Islamic University Malaysia Medical Centre

Introduction: The purpose of this study was to review the significance of oesophago-gastroduodenoscopy (OGD) findings in patients with dyspepsia but without alarm features. Materials and Methods: OGD data from January 2017 to December 2017 were collected from ipesakit. The demographic details, indications and findings were reviewed. Results: OGDs were performed. Among these 56 (49%) were performed on dyspeptic patients with no alarm features. This subgroup was further analysed. Thirty two (57%) patients in this subgroup were female and 24 (43%) were male. 33 (59%) were 50 years and younger. Twenty (36%) patients were between 51 and 70 years old, while 3 (5%) patients were above 70 years of age. The commonest finding was gastritis (70%, n=39), followed by F3 gastric ulcer (3.5%, n=2), F3 duodenal ulcer (3.5%, n=2), gastric fundic polyp (1.8%, n=1), and hiatus hernia (1.8%, n=1). 11 (20%) patients had normal finding. No malignancy or pre malignancy lesion were found in this cohort. Two patients had positive CLO test. Conclusion: OGD in patients with dyspepsia but without alarm features has low yield of significant findings. This procedure may unnecessarily expose patients to the associated potential risks and may not be cost effective. This can be addressed by introducing a hospital guideline for OGD referral. Low positivity of CLO test may also need further evaluation with regards to its sensitivity and specificity. Alternative tests for H Pylori detection such as stool antigen test or urea breath test may need to be adopted.

Knowledge, Attitude and Practice of Doctors Regarding Perioperative Tobacco Smoking Intervention in Surgical Based Discipline in IIUM Medical Centre

Introduction: Surgery provides an exceptional chance for smoking cessation and apparently surgeons can play an important role in tobacco control. Tobacco intervention in surgical patients benefited them both in the short-term and longterm health outcome. Unfortunately, little is known about the knowledge, attitudes and practices of Malaysian surgeon regarding peri-operative tobacco smoking interventions which triggers this study. Materials and Methods: A survey of written questionnaires was conducted on medical doctors in the surgical based discipline at the International Islamic University Malaysia Medical Centre. Results: The survey response rate was 100%, and 6.7% of respondents themselves were current smoker, 23.3% were former smoker. A high proportion of respondents had accurate perceptions of peri-operative and long-term health risks of smoking. However, most of them also knew how to counsel about smoking or help patients get the help they needed to quit. Majority (93.3%) of them frequently or almost always asked about smoking status; 56.7% advised about the health risk of tobacco use; 80.0% advised patients to stop smoking peri-operatively and 60.0% advised patients to quit smoking permanently. Compared with non-smokers, smokers were significantly less likely to advice about the health risks of smoking and quitting. Not only that, most of the respondents were willing to learn about peri-operative interventions and spend an extra 5 min to help patients quit smoking. Conclusions: Majority of the respondents poised adequate knowledge of health risks of smoking, strong perception of responsibilities, and willingness to participate in tobacco control, IIUM Medical Centre doctors actually play a significant role in tobacco control in which could improve peri-operative outcomes and promote long-term health.

The Quality of Life and Functional Outcome of Hindfoot Reconstructive Surgery in Charcot Foot

Introduction: Charcot foot problem is devastating and a difficult condition to treat. There are limited data and study regarding the quality of life and functional outcome of Charcot foot being treated surgically. This study evaluates the outcome of Charcot foot treated with reconstructive surgery. Materials and Methods: This is a cross-sectional study that compares the quality of life and functional outcome of patient with Charcot foot pre and post tibio-talar-calcaneal (TTC) arthrodesis surgery at Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre between 2016 and 2018. Patients were evaluate using SF-36 scores and AOFAS scores pre and post-operative at average of 6 months (range between 3 to 9 months). Results: Thirty patients had undergone reconstructive foot and ankle surgery using hindfoot arthrodesis nail (HAN) for TTC arthrodesis. The outcome was assessed using paired t-test comparing pre and postoperative for both SF-36 and AOFAS scores. The SF-36 components had significant improvement with a mean of 35 to 45.6 for physical component (PCS) and 46.6 to 52.5 for mental component (MCS) (p&lt;0.0001). The overall AOFAS score had significant improvement from average of 36 to 57.8 out of 100 (p&lt;0.0001). Pain component of AOFAS shows lower score of improvement. Two patients had suffered ulceration post operatively that requires multiple debridement and exostectomy with one patient requires removal of HAN eventually. Conclusions: Tibio-talo-calcaneal arthrodesis using HAN surgery improves the quality of life and functional outcome of Charcot foot.