National expert consensus on short-acting beta2-agonist overreliance in asthma care in Malaysia.

OBJECTIVE: Inappropriate use of short-acting beta2-agonists (SABA) in asthma has been associated with undesired outcomes. This national expert consensus was developed to increase awareness of SABA overuse and provide recommendations on the ways to eliminate SABA overprescription and overreliance in Malaysia. DATA SOURCES: This expert consensus was developed by searching the PubMed database, using index terms to identify SABA overuse-related burden and recommendations made in asthma guidelines. Consensus recommendations were made via the Delphi method, involving a Malaysian expert committee comprising 13 healthcare professionals (five pulmonologists, four family medicine specialists, two emergency medicine physicians and two pharmacists). STUDY SELECTIONS: The articles reviewed include randomized controlled trials, systematic reviews, meta-analyses, observational studies, guidelines, and surveys, with abstracts in English and published up until June 2023. Relevant recommendations were also sourced from verified websites of medical organizations and societies. RESULTS: Eleven consensus statements were developed, each statement achieving a priori agreement level of at least 70%. The statements reflect SABA overreliance in asthma care, as well as recommendations to eliminate SABA overprescription and overreliance in Malaysia. Supporting evidence in the literature as well as expert committee discussions leading to the development of the finalized statements were elaborated. CONCLUSION: This national expert consensus discussed the burden of SABA overreliance and made specific recommendations to eliminate SABA overprescription and overreliance in the Malaysian context. This consensus document is anticipated to impart better awareness among Malaysian healthcare providers and contribute to the continuous improvement of asthma care in the country.

A comparison between the effectiveness of a gamified approach with the conventional approach in point-of-care ultrasonographic training.

BACKGROUND: Although gamification increases user engagement, its effectiveness in point-of-care ultrasonographic training has yet to be fully established. This study was conducted with the primary outcome of evaluating its effectiveness in point-of-care ultrasonographic training as compared to conventional approach. METHODS: Participants consisting of junior doctors were randomized into either the (1) gamified or the (2) conventional educational approach for ultrasonographic training. RESULTS: A total of 31 junior doctors participated in this study (16 participants in gamified arm, 15 in the conventional arm after one participant from the conventional arm dropped out due to work commitment). Two-way mixed ANOVA test showed that there was no statistically significant interaction between the types of educational approach and time of testing (pre-test, post-test, 2 months post-training) for both theoretical knowledge score and practical skills score, with F(2, 58) = 39.6, p < 0.001, partial η2 = 0.4 and F(2, 58) = 3.06, p = 0.06, partial η2 = 0.095, respectively. For theoretical knowledge score, pairwise comparisons showed that the mean 2 months post-training scores (20.28 +/- 0.70, 95% CI 18.87-21.69) and mean post-test scores (20.27 +/- 0.65, 95% CI 18.94-21.60) were better than the pre-test scores (12.99 +/- 0.50, 95% CI 11.97-14.00) with p-values < 0.001 for both comparisons respectively. Similarly, for practical skill score, pairwise comparisons showed that the mean 2 months post-training scores (20.28 +/- 0.70, 95% CI 18.87-21.69) and mean post-test scores (20.27 +/- 0.65, 95% CI 18.94-21.60) were also better than the pre-test scores (12.99 +/- 0.50, 95% CI 11.97-14.00) with p-values < 0.001 for both comparisons respectively. Participants in the gamification arm generally perceived the various game elements and game mechanics as useful in contributing and motivating them to learn ultrasonography. CONCLUSIONS: Gamification approach could be an effective alternative to conventional approach in point-of-care ultrasonographic training.

Radial artery injury by a cat fish (Pangasius sutchi) spine sting.

Peripheral vascular injuries result from penetrating or blunt trauma to the extremities. We describe here an unusual cause of a radial artery injury by the spine from the pectoral fin of Pangasius sutchi in a 51 year-old man and we review the literature.

A cross-sectional study of assessing knowledge, attitude, and practice of COVID-19 resuscitation among health care workers in a hybrid hospital for COVID-19 in Malaysia.

BACKGROUND: The COVID-19 pandemic is an international public health emergency. As hospitals receive more severe forms of COVID-19 that necessitate resuscitation, emergency health care workers (HCW) must follow interim COVID-19 resuscitation guidelines. OBJECTIVE: The aim is to evaluate the levels of knowledge, attitude, and practice among emergency HCW of the COVID-19 resuscitation protocol by the European Resuscitation Council (ERC). METHODS: A cross-sectional study using a validated questionnaire was conducted among HCW in the emergency department of University of Malaya Medical Centre (UMMC), Malaysia from April to June 2021. RESULTS: A total of 159 respondents were included in the analysis (89% response rate). Sixty-eight percent of respondents had adequate knowledge regarding COVID-19 resuscitation. Majority of the respondents had knowledge on airborne-precaution personal protective equipment (PPE) (99%) and infection control measures (98%). Nearly 73% were pessimistic about the COVID-19 prognosis. Seventy-three percent of respondents thought an arrested COVID-19 patient may benefit from cardiopulmonary resuscitation (CPR) and 94% were willing to administer CPR provided airborne-precaution PPE was available. Ninety percent of respondents reported adherence to resuscitation guidelines. There were significant differences in the mean knowledge scores between designation, education levels, and COVID-19 training. Overall, the respondents' level of practice was insufficient (27%), with a mean score of 53.7%(SD = 14.7). There was a lack of practicein the resuscitation oftheintubatedand patients who were beingprone. There was insufficient practice about ventilation technique, use ofsupraglotticdevices, and intubation barriers. There was a positive correlation between adequate knowledge and good practice. CONCLUSION: Emergency HCW have adequate knowledge, but poor compliance to the ERC COVID-19 guidelines. Emergency HCW were willing and confident to resuscitate COVID-19 patients, despite fears of nosocomial infection and expectation of poor patients' prognosis. Ongoing education and trainingprogramsare recommended to improve their knowledge, cultivate a positive attitude, andachievegood compliance with COVID-19 resuscitation guidelines.

Motivations, barriers and exercise preferences among female undergraduates: A need assessment analysis.

INTRODUCTION: The decreasing level of physical activity among female undergraduates is worrying as it is associated with the increased risk of non-communicable diseases. Thus, this study aimed to identify the motivations, barriers and preferences towards exercise among female undergraduates in Malaysia. METHODS: A non-probability purposive sampling was used for the recruitment process. The inclusion criteria of the participants were registered female undergraduates and aged between 18-30 years old. A semi-structured in-depth interview was used to collect topic-related information from the participants and signed consents were obtained prior to the interview. The interview questions were on respondents' understanding of exercise, motivation and barriers to exercise, and exercise preferences. The recruitment process was conducted until the data was saturated. All interviews were audio recorded and manually transcribed verbatim. NVivo 11 was used to conduct the inductive analysis of the data to develop themes for motivation and barriers to exercise. For exercise preferences, four predetermined themes were used. FINDINGS: A total of 26 respondents participated in this study. Eight themes were found for motivation to exercise, with the most common themes being maintaining or improving appearance, health benefits and togetherness. For barriers of exercising, five themes were found, and the most common ones were disliking exercise and no motivation. For exercise preferences, most respondents preferred a structured exercise program with flexibility in terms of when and where the exercise could be conducted. Light or moderate intensity exercise for 10-30 minutes with a frequency of 1-2 times a week was desired the most among the respondents. CONCLUSION: In conclusion, personal and environmental factors play important roles in motivating or hampering female undergraduates to exercise, and a structured program was the preferred mode of exercise of these respondents. A new exercise module was designed based on this needs assessment with a 70% acceptance rate among the participants. These findings can help the future development of more exercise modules tailored to female university students.

The use of end-tidal capnography to monitor non-intubated patients presenting with acute exacerbation of asthma in the emergency department.

STUDY OBJECTIVE: To determine if the slope of Phase II and Phase III, and the alpha angle of the expiratory capnographic waveform, as measured via computer-recognizable algorithms, can reflect changes in bronchospasm in acute asthmatic non-intubated patients presenting to the emergency department (ED). METHODS: In this prospective study carried out in a university hospital ED, 30 patients with acute asthma were monitored with clinical severity scoring and peak flow measurements, and then had a nasal cannula attached for sidestream sampling of expired carbon dioxide. The capnographic waveform was recorded onto a personal computer card for analysis. The patients were treated according to departmental protocols. After treatment, when they had improved enough for discharge, a second set of results was obtained for capnographic waveform recording. The pre-treatment and post-treatment results were then compared with paired-samples t-test analysis. RESULTS: On the capnographic waveform pre- and post-treatment, there was a significant difference in the slope of Phase III (p < 0.001) and alpha angle (p < 0.001), but not in the Phase II slope (p = 0.35). There was significant change in peak flow meter reading, but it was poorly correlated with all the capnographic indices. CONCLUSION: The study provides some preliminary data showing that capnographic waveform indices can indicate improvement in airway diameter in acute asthmatics in the ED. Capnographic waveform analysis presents several advantages in that it is effort-independent, and provides continuous monitoring of normal tidal respiration. With further refined studies, it may serve as a new method of monitoring non-intubated asthmatics in the ED.

The Proportion of Infectious Disease Cases, Its Associated Factors, and the Appropriateness of Antimicrobial Prescription Among Rohingya Refugee Pediatric Patients in IMARET Mobile Clinics.

The Rohingyas fled from their home to escape ethnic persecution. Due to their status as refugees they have difficulties in accessing healthcare leading to avoidable mortality and morbidity. Infectious diseases are reported to be among the causes. To ease access to healthcare, IMAM Response and Relief Team (IMARET) provides a free monthly clinic for them. The objective of this study is to determine the proportion of infectious diseases and appropriateness of antimicrobial usage among its pediatrics patients. It was conducted in 2017, through universal sampling. Information retrieved were via interviews and medical records. The majority diagnosis were infectious diseases (57.1%), which include respiratory infections (77.3%), skin (13.6%), gastrointestinal (4.5%), eye and ear infection (both 1%). Albendazole (40.7%) was the most prescribed. Only 7.4% were appropriately prescribed antimicrobials. Age (p = 0.005) and BMI (p = 0.006) were significantly associated with infections.

The impact of adult trauma triage training on decision-making skills and accuracy of triage decision at emergency departments in Malaysia: A randomized control trial.

INTRODUCTION: Patients who visit emergency departments need to undergo a precise assessment to determine their priority and accurate triage category to ensure they receive the right treatment. AIM: To identify the effect of triage training on the skills and accuracy of triage decisions for adult trauma patients. METHOD: A randomized controlled trial design was conducted in ten emergency department of public hospitals. A total of 143 registered nurses and medical officer assistants who performed triage roles were recruited for the control group (n = 74) and the intervention group (n = 69). The skill and accuracy of triage decisions were measured two weeks and four weeks after the intervention group were exposed to the intervention. RESULTS: There was a significant effect on the skill of triage decision-making between the control and the intervention group p < 0.001, η2partial = 0.31. Concerning the accuracy of triage decisions, the effect was significantly different between the control group and the intervention group p < 0.001, η2partial = 0.66 across time. CONCLUSION: The triage training improved the skills of the participants and the accuracy of triage decision-making across time.

MDMA and the Brain: A Short Review on the Role of Neurotransmitters in Neurotoxicity.

N-Methyl-3, 4-methylenedioxyamphetamine (MDMA), or ecstasy is a recreational drug of abuse. It is a synthetic substance that affects the body's systems, which its mechanism of action and treatment should be more investigated. MDMA provides an immediate enjoyable feeling by stimulating the release of neurotransmitters, such as dopamine and serotonin in the brain. Unfortunately, abnormal regulation of the brain neurotransmitters, as well as the increased oxidative stress causes damage to the brain neurons after the MDMA exposure. Only a few studies have been done regarding its treatment. Thus, the treatment of MDMA complications should be further explored mainly by targeting its mechanism of action in the neurotransmitter systems. Hence, this study presents a short review regarding the recent findings on the role of neurotransmitters to cause MDMA neurotoxicity. The results will be useful for future research in elucidating the potential treatment based on the targeted mechanisms to treat the neurotoxic effects of MDMA.

A traditional Malay myth leading to unintentional self intoxication with kecubung fruit.

Traditional Malay herbal medicine is still used in Malaysia especially in rural areas, instead of using modern medicine. Datura or "kecubung" has been used to treat allergic rhinitis in certain places. Inaccurate doses can potentially cause severe or fatal neurologic anti-cholinergic toxidromes. A good knowledge of toxidromes with optimization of supportive care can prevent fatal complications and lead to a more speedy recovery. We present a case of kecubung poisoning.

Demographic and clinical characteristics of red tag patients and their one-week mortality rate from the emergency department of the Hospital Universiti Sains Malaysia.

Early identification and rapid treatment of red tag patients may decrease morbidity and mortality. We examined the clinical characteristics, etiologies and one week mortality rate of red tag (life threatening and potentially life threatening illness) patients at the Hospital Universiti Sains Malaysai (HUSM). A cross-sectional study was conducted at the Emergency Department of the HUSM from 1 August 2006 to 31 January 2007; 440 eligible patients were analyzed. The group had a mean age of 47.2 +/- 22 years, with 67.3% of the patients being male. Twenty-three percent were trauma cases with motor vehicle accident being the major mechanism of injury. Fifty-four percent of the cases had cardiac related illnesses. The mean duration of stay in the Emergency Department (ED) was 3.9 +/- 1.5 hours. The survival rate at one week was 76.6%. The non-trauma group comprised 74.0% of death cases. Acute coronary syndrome and road traffic accidents comprised 22.0% of total death cases at one week. Red tag patients constitute a large proportion of ED cases and may remain in the ED for significant periods of time.

Theophylline toxicity: A case report of the survival of an undiagnosed patient who presented to the emergency department.

Theophylline toxicity is a life-threatening toxidrome that can present to an emergency department. To ascertain an immediate provisional diagnosis in toxicology at the emergency department is very challenging, especially when the patient presents with altered mental status, because the clinical features of several toxidromes overlap. We report a case of survival of undiagnosed theophylline toxicity that required intubation for two days in the intensive care unit. This was the first case to have been reported from our department. Accurate diagnosis of a toxidrome by gaining adequate history and conducting a thorough physical examination and early serum toxicology screening, coupled with good knowledge of toxicology, will lead to better patient outcomes.

A Double-Blind, Randomized Control Trial of Rapidly Infused High Strong Ion Difference (SID) Fluid Versus Hartmann's Solution on Acid-Base Status in Sepsis Patients in the Emergency Department.

BACKGROUND: Balanced fluids are preferred in initial resuscitation of septic patients based on several recent studies. The Stewart's concept on acid-base balance predicts that high strong ion difference (SID) fluid thus will increase the pH level. To date, the impact of high SID fluid in septic patient with metabolic acidosis remains uncertain. We conducted single center, randomized, double-blind trial to compare the effect of high SID fluid vs. Hartmann's solution on acid-base status in selected sepsis patients in the Emergency Department. METHODS: Septic patient with hyperlactatemia and metabolic acidosis were randomized to receive either high SID fl uid or Hartmann's solution during initial fl uid resuscitation. The primary outcome measures the pH and bicarbonate levels difference pre- and post- resuscitation. RESULTS: One hundred and sixty-two patients underwent randomization, 81 were assigned each to receive high SID fluid or Hartmann's solution. Both groups had similar baseline characteristics. High SID group received 23.5 mL/kg and the Hartmann's group received 22.7 mL/kg (p = 0.360). High SID fluid increased the mean (± SD) pH by 0.107 (± 0.09) vs. Hartmann's solution by 0.014 (± 0.12), p ≤ 0.001. Mean bicarbonate level increased signifi cantly in high SID group compared to Hartmann's (4.30 ± 3.76 vs. 1.25 ± 3.33, p ≤ 0.001). High SID group had higher post resuscitation lactate clearance than Hartmann's group (25.4 ± 28.3% vs. 12.0 ± 34.1%, p = 0.009). Shorter hospital stay was observed in highSID group 8.04 ± 5.96 days vs. Hartmann's group 12.18 ± 12.41 days (p = 0.048). Both groups showed no difference in incidence of pulmonary oedema, acute kidney injury and mortality. CONCLUSIONS: Initial resuscitation using high SID fluid in selected septic patient improves pH and bicarbonate levels. The high SID group had better post resuscitation lactate clearance and shorter hospital stay.

An unusual case of urethral hiriduniasis.

Bleeding as the result of a leech in the male urethra is very rare. We describe a 13-year-old boy who had a leech in his urethra. In the emergency department he persistently squeezed his penis in an attempt to prevent the leech from going deeper into his urethra. Manual removal by forcep failed and cystoscopic removal was recommended. Penile block with lidocaine 1% relieved the pain and enabled him to squeeze his penis harder until the leech was pushed out making forcep removal easier. Post-removal he had hematuria and penile pain for 2 days. A description of his presentation and management, along with a review of the literature is presented.

Health major incident : the experiences of mobile medical team during major flood.

Disaster is a sudden event that associated with ecological changes, disruption of normal daily activities, destruction of infrastructures, loss of properties, and medical disabilities. In disaster, there is a mismatch between available resources and patients need for healthcare service. During flood disaster, the victims were predisposed to different type of illnesses for various reasons such as inadequate supply of clean water, poor sanitation or drainage system, unhealthy foods, and over-crowded relief centers. Mobile clinic is an option for delivering medical care for the disaster victims who often have a difficulty to access to the medical facilities. In this article we would like to share our experiences during the provision of humanitarian services for flood victims at District of Muar Johor. Common illnesses among the flood victims at visited relief centers and advantages of Mobile Medical Relief Team were also highlighted and discussed.

Myalgia Cruris Epidemica: an unusual presentation of dengue fever.

We describe a 5-year-old girl who had sudden onset difficulty in walking after 3 days of febrile illness. In the emergency department her creatine kinase level was elevated but urine myoglobin was normal. She was diagnosed as having benign acute childhood myositis. Because of poor oral intake and dehydration, she was admitted to the pediatric ward. The next day she had a petechial rash over the antecubital fossa, and dengue IgM back was positive. She was treated conservatively and recovered uneventfully. Despite dengue fever being endemic in Malaysia, this is the first case report of myositis following dengue infection in Malaysia.

Hand grenade blast injuries: an experience in hospital universiti sains malaysia.

Hand grenade explosion is a rare occasion in our local community. Most of us have seen or heard about the injuries only from the TV news or newspaper. We report two cases of bomb blast injury that occurred in an army camp in September 2000. These case studies illustrate the clinical presentations of hand grenade blast injures that present with multiple organ involvement. We would like to share our experience in managing such cases in a busy emergency department and highlight the outcome of those two cases. Certain issues pertaining to the complexity of the injuries and mass casualty management are also highlighted.

Post-impact disaster surveillance - a medical reconnaissance team at tsunami-struck sri lanka.

Emergency Medicine and Disaster Medicine are two specialties which are similar in the multidisciplinary involvement during the acute phase of the disaster. Recently, there was an increase in the number of disasters in the world but not many physicians are familiar with the principles for dealing with such situations, the unique organizational demands, coordination and the urgent need for medical assistance and relief. This case report delineates our experiences at a tsunami disaster area and the approach to setting up a medical relief team in the affected area. A medical reconnaissance team comprising of an emergency doctor from Hospital Universiti Sains Malaysia (H.U.S.M) and two MERCY Malaysia members was assembled. The team flew to Colombo on day 5 after the tsunami with medical supplies and related materials. The mission started from December 31(st) 2004 until January 8(th) 2005. Our surveillance area covered the Southern and Eastern Province with a total distance of 1700 km along the coast. The strategies employed during this medical reconnaissance included risk analysis, devising a resources matrix, developing lines of communication and rapport with other relief teams, Sri Lankan government agencies, and local and international non-government organizations. As a result, our team was able to set up a medical relief camp and distribute the relief items to the tsunami victims. In conclusion, the Disaster Emergency Medical Assistant Team (DEMAT) from H.U.S.M and MERCY Malaysia were able to set up and provide medical relief with our limited resources to a large scale disaster situation.

Ultrasonographic assessment of inferior vena cava/abdominal aorta diameter index: a new approach of assessing hypovolemic shock class 1.

BACKGROUND: We designed this study to expand the usage of ultrasound to detect early occurrence of hypovolemia. We explore the potential use of inferior vena cava (IVC) and abdominal aorta (AA) diameter index (IVC:AA) measured ultrasonographically to detect class 1 hypovolemic shock with blood loss less than 15%.ᅟ METHODS: The aim of this study was to determine the changes in the diameter of inferior vena cava and abdominal aorta in blood donors by using ultrasound, pre and post blood donation. The result of the study would be further explorated to determine the inferior vena cava (IVC) abdominal aorta (Aorta) diameter index (IVC:Aorta). This was a prospective study done in the blood bank of a university hospital. Researcher was trained by a senior radiologist to assess inferior vena cava and abdominal aorta diameter. Fifty-two healthy blood donors were included in the study. Inclusion criteria were same with the blood bank criteria to donate blood. Demographic data and vital signs were taken before the ultrasound measurement done for inferior vena cava and abdominal aorta diameter. Once the volunteers donated their blood of approximately 450 mls; the measurements were repeated using the same methods. RESULTS: There were differences in IVC, abdominal aorta and inferior vena cava:aorta diameters index pre and post donation. With mathematical analysis, we suggested the number of IVC:Aorta index as 1.14±2SD with SD 0.18 as a cut off value for class 1 hypovolemic shock. CONCLUSION: The IVC:Aorta diameter index can be used as a parameter for detecting early phase (Class 1) of hypovolemic shock.

Ambulance services at hospital universiti sains malaysia and hospital kota bharu: a retrospective study of calls.

This retrospective study attempted to identify the pattern of ambulance calls for the past two years at the Hospital Universiti Sains Malaysia (HUSM) and Hospital Kota Bharu (HKB). This study will provide a simple method of acquiring information related to ambulance response time (ART) and to test whether it met the international standards and needs of the client. Additionally, this paper takes into account the management of emergency calls. This included ambulance response time, which was part of Emergency Medical Services (EMS) episode: onset of ART, which started when details like phone number of the caller, exact location of the incident and the nature of the main complaint had been noted. ART ended when the emergency team arrived at the scene of incident. Information regarding ambulance calls from the record offices of HUSM and HKB was recorded for the year 2001 and 2002, tabulated and analyzed. There was a significant difference in the total number of calls managed by HUSM and HKB in the year 2001. It was noted that 645 calls were managed by HUSM while 1069 calls were recorded at HKB. In the year 2002, however, HUSM led with 613 extra numbers of calls as compare to HKB with 1193 numbers of calls. The pattern of ambulance calls observed is thought to possibly be influenced by social activities like local festivities, school holidays and the seasons. Further, it is observed that no studies were previously undertaken to compare the ART at both the HUSM and HKB to that of the international standards. In fact, a literature review undertaken so far showed no similar studies have been done for the whole Malaysia.