Writing Articles on Continuing Medical Education for Medical Journals.

Sharing of knowledge through Continuing Medical Education (CME) contribute immensely to professional development of skills in clinical medical practice. Thus, the writing of CME articles should adopt an approach that addresses the needs of the readers by attempting to fill gaps in their knowledge, skills, and ethics about clinical care. As such CME articles should be comprehensive and focused on specific areas. The specific learning outcomes should be well defined. In designing and development of such articles, pedagogic principles are to be borne in mind. In this article we outline a guide to writing a CME article, incorporating both the principles of instructional design and directed selflearning. The ideal CME articles will transit through multimedia-enhanced interactive online learning, with greater use of connectivity through the internet. Synchronous and asynchronous learning is in greater need, as distance and online learning are increasingly popular. Authors of CME articles will need to eventually design CME articles to be interactive, enriched with multimedia to engage their readers. Lesson plans employing instructional design principles should aim to promote both instructions for learning and formative assessment ensuring learning have taken place, and outcomes have been achieved. This article describes on how to write effective CME articles for medical journals.

Palliative care in Malaysia: the need to do much more.

No abstract provided.

Incidence of vaginal erosion with different synthetic materials for suburethral sling in the treatment of Stress Urinary Incontinence: A systematic review.

INTRODUCTION: The aim of this systematic review is to compare the vaginal erosion rates in different synthetic materials used in suburethral slings in Tension Free Vaginal Tape (TVT-O /TOT) procedures in management of female stress urinary incontinence. METHODS: PRISMA 2009 framework was adopted for study design. Scholarly literature search was done using MEDLINE, EMBASE, the Cochrane Library and Clinical Trials.gov using selected keywords. Five articles fulfilled the inclusion and exclusion criteria. Our main outcome of interest is to review the ideal properties of the suburethral sling, procedure of insertion and post-surgical complication following the sling insertion primarily vaginal erosion. Results were compared using one way-ANOVA test and independent T- test. RESULTS: Total of 1725 subjects were available for analysis in the five studies. Monofilament polypropylene constituted 92.5% of the total sample size from one study alone. Polyester (n= 16/51) causes higher incidence rate of vaginal erosion compared to monofilament polypropylene (31.4 vs., 4.7; p = 0.01). There was no difference in the vaginal erosion rate between monofilament polypropylene and multifilament polypropylene (4.7 vs, 14.1; p=0.055) as well as between multifilament polypropylene and polyester (14.1 vs, 31.4; p=0.068). Although there was a marginally lower rate of vaginal erosion in TVT-O over TVT, the difference was not significant. (5.6 vs., 6.4, p=0.468). Common presentations of vaginal erosion were vaginal discharge, perineal pain and dyspareunia. CONCLUSION: Given the limited sample size, polyester sling material appears to cause higher rates of vaginal erosion. No difference in erosion rate was seen between TVT and TVT-O.

Views of faculty members in a medical school with regards to error disclosure and reporting to parents and/or higher authorities.

BACKGROUND: Little is known about the views of faculty members who train medical students concerning open disclosure. OBJECTIVES: The objectives of this study were to determine the views of faculty in a medical school on: 1 what constitutes a medical error and the severity of such an error in relation to medication use or diagnosis; 2 information giving following such an adverse event, based on severity; and 3 acknowledgement of responsibility, remedial action, compensation, disciplinary action, legal action, and reporting to a higher body in relation to such adverse event. METHODS: We adapted and contextualized a questionnaire developed from a previous study. The questionnaire had 4 case vignettes that described 1 clear medication error with lifelong disability; 2 possible diagnostic error with lifelong disability; 3 possible diagnostic error without harm; and 4 clear medication error without harm. We invited all faculty members attached to the medical school at the International Medical University to participate in the study. RESULTS: Seventy faculty members took part. Faculty members viewed a medical error as having taken place depending on how clearly an error had occurred (94% and 73% versus 53% and 27%). They viewed cases as more severe based on the severity of complications (85% and 46% versus 5% and 10%). With increasing severity, they tended to attribute responsibility for the event and the duty to disclose towards more senior clinicians. They were also more agreeable with remedial action, compensation, disciplinary action, and reporting to a higher agency. There was no strong evidence of association between these areas and the demographics of faculty members. CONCLUSIONS: Faculty members are more likely to perceive an error had occurred depending on the clarity of the circumstances. They viewed severity based on the presence of complications. Severity determined how they attributed responsibility, duty to disclose, and other areas related to open disclosure.

Parental preferences with regards to disclosure following adverse events occurring in relation to medication use or diagnosis in the care of their children - perspectives from Malaysia.

INTRODUCTION: Open disclosure is poorly understood in Malaysia but is an ethical and professional responsibility. The objectives of this study were to determine: (1) the perception of parents regarding the severity of medical error in relation to medication use or diagnosis; (2) the preference of parents for information following the medical error and its relation to severity; and (3) the preference of parents with regards to disciplinary action, reporting, and legal action. METHODS: We translated and contextualised a questionnaire developed from a previous study. The questionnaire consisted of four case vignettes that described the following: medication error with a lifelong complication; diagnostic error with a lifelong complication; diagnostic error without lifelong effect; and medication error without lifelong effect. Each case vignette was followed by a series of questions examining the subject's perception on the above areas. We also determined the content validity of the questionnaire. We invited parents of Malaysian children admitted to the paediatric wards of Tuanku Jaafar Hospital to participate in the study. RESULTS: One hundred and twenty-three parents participated in the study. The majority of parents wanted to be told regarding the event. As the severity of the case vignettes increased, the desire for information, remedial action, acknowledgement of responsibility, compensation, punishment, legal action, and reporting to a higher agency also increased. The findings did not have strong evidence of a relationship with subject's demographics. CONCLUSION: This study gives insights into previously unexplored perspectives and preferences of parents in Malaysia regarding open disclosure. It also highlights the opportunity for more research in this area with potentially broad applications.

Strategic Interventions in the Management of Gestational Diabetes to Reduce Type 2 Diabetes Mellitus in Women in Malaysia.

No abstract available.

Concepts in the management of the overactive bladder in women.

The 'overactive bladder' is a common problem affecting the elderly female population especially after the menopause. Urgency with or without urge incontinence accompanied by frequency of micturition and nocturia are presenting symptoms. The diagnosis is established after excluding other diseases of the lower urinary tract which have similar presenting features. The aetiology is multifactorial and this problem often causes physical, psychological and emotional distress to the patient. Management can be provided by primary care physicians initiating behavioral changes which include life style interventions and bladder drills with or without antimuscarinic drugs. The recalcitrant patient not responding to conventional therapy should be referred for specialist care. Non-conventional treatment using acupressure, neuromodulation and surgical methods are only instituted in indicated cases.

Enhancing doctor-patient relationship: the humanistic approach.

Doctor-patient relationship is a special kind of social. relationship where bonding is planned and carried out with the final objective of helping the patient to achieve the treatment goal. A positive therapeutic relationship encourages active participation of patient in the treatment plan, contributing to success of treatment goals and minimizing malpractice suits. The humanistic approach emphasizes the importance of love, belonging, self esteem, self expression and the final stage of self actualization-the drive to realize one's full potential. In person centered approach to therapeutic relationship, the three most fundamental elements are congruent (genuineness), unconditioned positive regards and empathy. In daily medical consultation, applying these elements can promote greater chance of success in the therapeutic process.

Emergency contraception pill--controversies and use.

Emergency contraceptive pills (ECP) are effective, safe and cheap, with profound global health and economic benefits. Patient education and easy access to ECP will contribute immensely to avoiding unwanted pregnancies and unsafe abortions. Issues related to morality, its perceived status as an abortifacient and harmful behaviour should it be easily available, has limited the widespread use of ECP in many countries.

Managing pelvic inflammatory disease.

Pelvic inflammatory disease (PID) describes the clinical features of sexually transmitted pelvic infection ranging from acute salpingitis to salpingo-oophoritis and ultimately pelvic abscess. Intra-tubal adhesions and pelvic adhesive disease are the long-term sequelae of PID which may lead to both sub-fertility and tubal ectopic pregnancy. Laparoscopy is the definitive diagnostic modality, but is invasive and not suitable for routine clinical practice especially in the primary care setting. Ascending infection by Neiserria gonorrhoea, Chlamydia trachomatis and less commonly bacterial vaginosis and mycoplasma have been traditionally associated as causative pathogens in PID. As polymicrobial infections are being implicated in PID before culture and sensitivity results are available empirical treatment based on clinical guidelines is justified initially. Pre-emptive testing and treatment for woman at increased risk of chlamydia has been shown to reduce the risk of PID by up to two-thirds. It is imperative that medical practitioners have low thresholds for testing and treatment of both sexually active young women and men.

Urinary incontinence in the elderly population.

Urinary incontinence is an important and common health care problem affecting the elderly population. Common types of incontinence affecting the elderly are: stress incontinence, urge incontinence, overflow incontinence and mixed type. The elderly patient suffering from urinary incontinence does not often seek treatment voluntary due to a misconception that it is part of a normal ageing process. Without treatment, urinary incontinence may lead to serious psychological and social complications such as depression, anxiety, embarrassment, low self-esteem and social isolation. Overall it is associated with significant poor quality of life for the elderly. Life style modification and behavioural therapy with or without pharmacotherapy help in improving the symptoms. Pelvic floor muscles' training is beneficial for stress incontinence in up to fifty percent of the patients. Elderly patients with urinary incontinence should be encouraged to seek treatment early, as the problem can be treated and they will have a better quality of life.

A preliminary finding: immunohistochemical localisation and distribution of placental angiotensin II receptor subtypes in normal and preeclamptic pregnancies.

Pre-eclampsia or pregnancy induced hypertension (PIH) affects 6-8% of all pregnancies. Although the underlying mechanism of PIH is still unknown, it is widely believed that the placenta plays an important role. It was thought that an ischemic placenta due to poor perfusion can precipitate the signs and symptoms of PIH. This study aims to investigate the possible role of Type 1(AT1) and Type 2 (AT2) angiotensin II receptor subtypes in the mechanism of PIH. AT1 receptor stimulation causes vasoconstriction and AT2 receptor stimulation causes vasodilatation. Investigating the interactions of these two receptors in the placenta provides an insight as to the balance that may exist between AT1 and AT2 receptors in normal pregnancy. Any disruption to the balance might cause a disruption of the blood flow in the placenta, leading to PIH. Placentas were collected from 11 PIH patients and 11 normal patients. Immunohistochemistry techniques were performed on the placental tissue to determine the distribution of AT1 and AT2 receptors in the placental tissue qualitatively and quantitatively. It was observed that in normal patients, the balance between AT1 and AT2 receptors is that the level of AT2 receptors is higher than the level of AT1 receptors. However in the PIH patient, it was observed that the normal balance was disrupted. In PIH patients the level of AT1 receptors was observed to be higher than the level of AT2 receptors. This study suggests that disruption of the balance between AT1 and AT2 receptors observed in PIH placentas might cause a decrease in blood flow to the placenta, causing it to be poorly perfused. This may cause placental ischemia which may lead to PIH.

Understanding hyperemesis gravidarum.

Nausea and vomiting are common in early pregnancy affecting 70-80 percent of pregnant mothers. In a majority of women vomiting begins between 4-7 weeks of pregnancy. Nausea and vomiting are usually mild and self-limiting, however some of the mothers have a more profound course which lead to hyperemesis gravidarum. Careful clinical evaluation is necessary to exclude underlying medical illnesses or non pregnancy related causes of severe vomiting. Hyperemesis gravidarum poses health risk to both mother and baby, therefore prompt treatment should be initiated without delay. Non pharmacotherapy such as dietary modification and emotional support are useful. Pharmacotherapy with antiemetics, pyridoxine, methylprednisolone are effective and relatively safe. Severe hyperemesis with dehydration and electrolyte imbalance may need hospitalisation for electrolyte and fluid replacement.

The elderly primigravida--evaluation of 90 cases.

A prospective study was carried out on ninety consecutive elderly primigravidae out of a total of 13,858 deliveries between 1983 to 1985. The aim of the study was to examine the reasons for postponent of childbearing beyond 35 years, the risks alleged to complicate pregnancy at this age, the obstetric performance and foetal outcome. The use of the term 'mature primigravida' as a suitable alternative to 'elderly primigravida' is emphasised. Pregnancy-induced hypertension was the commonest antenatal complication, and together with prolonged labour, the commoner indications for abdominal delivery. The caesarean section rate was 54.4 per cent. There were no maternal deaths. The perinatal mortality rate however, was much lower than that of the hospital population.

Coital injury requiring internal iliac artery ligation.

Profuse bleeding after voluntary sexual intercourse is an uncommon reason for admission to the gynaecological wards. Out of 12 such patients admitted to the Ipoh Hospital over a three-year period, one patient had life-threatening upper vaginal injury after coitus. Blood replacement and conventional suturing failed to arrest the bleeding. Bilateral internal iliac artery ligation promptly arrested further haemorrhage. Vigorous intercourse increases intra-abdominal pressure in women causing tensing of the cul-de-sac, decreasing the elasticity of the posterior fornix, resulting in vaginal laceration. Bilateral internal iliac artery ligation produces a 'pelvic compartment hypotension' converting a high arterial flow system to that of a low one resembling venous flow. The useful role of this procedure to contain pelvic haemorrhage is discussed.

The role of endovaginal ultrasonography and the value of endometrial biopsy in breast cancer patients on tamoxifen therapy.

BACKGROUND: Endometrial changes have been observed when tamoxifen is used as an adjuvant therapy for carcinoma of the breast in postmenopausal women with positive estrogen receptors status. AIM OF STUDY: The aim of this study was to evaluate endometrial response in similar patients in Malaysia. PATIENTS: Between February-July 1995, 38 women who had been receiving tamoxifen therapy were analysed for endometrial thickness by transvaginal ultrasonography and histopathological changes in endometrial biopsy samples. The results were compared with a similar group of postmenopausal women who did not have carcinoma of the breast. In the study group, tamoxifen was administered daily at a dose of 20-40 mg. All patients were above 50 years of age. The mean duration of tamoxifen therapy was 21.2 months (range 8-36 months). RESULTS: Detectable differences in endometrial thickness were seen between tamoxifen and control groups. Eighteen (47%) patients in the study group had endometrial thickness in excess of 10 mm; the mean thickness being 10.7 mm (+/- 4.95 mm) which was significantly greater than the control group. Positive histological findings were found in 17 patients (45%) compared to 7 patients (18%) in the control group. Endometrium was reported to be atrophic when endometrial thickness was less than 5 mm. The study underscores the need for endometrial surveillance in breast cancer patients who are on continuous tamoxifen therapy for more than 12 months and have an endometrial thickness exceeding 8 mm.

Delayed diagnosis of cervical pregnancy: management options.

Cervical pregnancy is an uncommon variety of ectopic gestation. The aetiology is obscure. Diagnosis can be missed unless early evaluation is done by experienced personnel utilising pelvic ultrasonography. Three cases of cervical pregnancy managed at this hospital are described illustrating difficulties in early diagnosis and possible association with previous uterine scar and prior curettage of the uterus for retained products of conception. Treatment options vary according to the clinical state of the patient at the time of diagnosis. Non-surgical methods including systemic methotrexate administration in one and surgical evacuation of products of conception with subsequent cervical cerclage in another are discussed. Surgical interventions like total abdominal hysterectomy with internal iliac artery ligation to arrest life-threatening pelvic haemorrhage is also described. Other treatment options include potassium chloride (KCl) alone or in combination with methotrexate.

Complete hydatidiform mole and surviving coexistent twin--a case report.

Hydatidiform mole with a coexistent fetus is a rare occurrence with an incidence of I per 22,000-100,000 pregnancies. It is associated with persistent gestational trophoblastic tumour. Hence an early and correct diagnosis is imperative to plan subsequent management of such patients. We report a case of a primigravida who presented with vaginal bleeding at early second trimester. Expectant management was carried out for her pregnancy which finally ended in an abortion. The pathology, clinical findings and current management of this rare entity is discussed.

Peripartal cardiomyopathy: problems in diagnosis and management.

Peripartal cardiomyopathy is a rare form of heart disease in pregnancy with an unpredictable outcome. We describe one patient who presented in a decompensated state who was successfully managed with medical antifailure treatment. The etiology, management and future obstetric outcome are discussed.