Concerns about professionalism in medicine have made necessary the explicit teaching and learning of ethics, professionalism and personal development. The noble profession of medicine, taken up as a "calling" by those who are expected to put the needs of the patient above their own, appears to have become a fees-for-service business model and trade. Parental expectations, the diminishing sense of responsibility in teachers, lack of role models, technological advancements, sub-specialisation and third-party involvement in the healthcare delivery system have been identified as reasons for these concerns. The General Medical Council in the United Kingdom, and other professional bodies in both Europe and the Americas, have emphasised the need to enhance the teaching and learning of professionalism in medical schools, particularly the development of good attitudes, appropriate and competent skills, and the inculcation of a value system that reflects the tenets of professionalism in medicine. The medical curriculum will need to be scrutinised so as to introduce the subject of professionalism at all levels of training and education. Barriers to learning professionalism have been identified and students need to be equipped to resolve conflicts and to put the needs of others above their own.
Forty patients with tubal ectopic pregnancies seen over an 18 month period are studied. Epidemiological parameters in the three major groups are compared. The diagnostic problems, signs and symptoms are discussed. Aetiological factors in this area are compared with changing trends in other centres. Pelvic inflammatory disease remains an important cause. The role of conservative approach in surgical treatment of ectopic pregnancy Z5 discussed. The crude incidence rate of ectopic pregnancy in Johore Baru Hospital between January 1978 and June 1979 is 1:358 deliveries.
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.
Intra-umbilical injection of oxytocin has been used to hasten placental separation in retained placenta. A randomised controlled trial was done on 35 consequent women who fulfilled the criteria for retained placenta at the Department of Obstetrics & Gynaecology Ipoh Hospital. Nineteen patients who were recruited into the study group received intraumbilical injection of 301U oxytocin in 27mls saline. Another 16 patients who were in the control group received 30mls of 0.9% sodium chloride (placebo). The primary outcome measured was the need for manual removal of placenta (MRP). Nine out of the 19 patients in the oxytocin group required MRP while 10/16 in the control group required MRP. There was a 24% reduction (95% C.I. 0.41 to 1.39) in the need for MRP in the study group compared to the saline group. our results indicate that intra-umbilical vein injection of oxytocin is not clinically useful for the removal of a retained placenta.
The aim of this study, is to determine whether the fine characteristics of the fetal heart sounds could be used to identify intrauterine growth retarded fetuses. A preliminary evaluation, was conducted to compare these characteristics between intrauterine growth retarded fetuses and normal fetuses in the antenatal period after 36 weeks of gestation. Altogether, 7 IUGR fetuses were compared with 12 normal fetuses. An instrument named the Fetal Frequency Phonocardiogram was designed for this purpose. When connected to a personal computer and with a software programme specially written, the fetal heart sound characteristics were analysed. After detailed analysis, there were 3 significant differences between IUGR and normal fetuses, all of which gave a p-value of < 0.01. The frequency of the first heart sound was significantly higher in the IUGR fetuses compared to normal fetuses. The ratio of the amplitude of the first heart sound over the second heart sound was higher in the IUGR group. Finally, the ratio of the time between the first and second heart sound over the cardiac cycle was shorter in the IUGR fetuses. Fetal heart sound analysis, may provide a simple non-invasive method of detecting and monitoring fetuses at risk in the antenatal period.
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.
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.
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 '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.
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.
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.
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.
An audit of all perioperative deaths within seven days of surgery in 14 major public hospitals is presented. This study is part of a quality assurance programme examining the surgical and anaesthetic practices in these hospitals. During the study period from July 1992 till June 1994, 211,354 surgeries were performed and 715 deaths were reported out of which 699 were available for analysis. The data was obtained by confidential enquiry using predetermined questionnaires filled by participating surgeons and anaesthetists and analysed by a group of peers. The overall crude mortality rate was 0.34% and the majority of the deaths occurred in severely ill patients in whom the clinical management was satisfactory. Polytrauma including head, intra-abdominal and skeletal trauma accounted for 253 of the deaths (36.19%). The other causes were bowel obstruction with sepsis, burns, ischaemic limbs, congenital malformations in neonates and pregnancy-related hemorrhage. 62.52% of the deaths occurred within two days of surgery and 85.87% were related to emergency procedures. The review identified some shortfalls in perioperative care and these were lack of adequate critical care facilities, lack of supervision, unnecessary surgery in the moribund and inadequate preoperative optimisation. The results of the study have been forwarded to all participating hospitals for implementation of remedial measures.
This is a retrospective study of the prevalence of Human Immunodeficiency Virus (HIV) positive mothers in two states in Malaysia i.e., Perak and Negeri Sembilan since the introduction of the HIV screening programme in antenatal mothers. The study period was from 1/9/97 to 1/9/99. A total of 29 HIV positive antenatal mothers were detected (21 from Perak and 8 from Negeri Sembilan) throughout the study period. Out of the 21 HIV positive mothers from Perak, 8 (38%) were foreign nationals whereas only 1 (12%) out of the 8 from Negeri Sembilan was a foreign national. The main risk factor identified in both the groups was multiple sexual partners. The vertical transmission rates for the patients from Perak were 14.2% and 37.5% in Negeri Sembilan. There was no significant short-term adverse obstetric outcome.
Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.
Study site: Obstetric and Gynaecologic Unit in Ipoh Hospital.
A prospective randomised controlled study was conducted over a 6 month period on the value of administering prophylactic antibiotics in patients undergoing emergency caesarean section at the Ipoh General Hospital. A total of 222 patients were randomised to receive 24 hours of ampicillin (500 mg per dose), cefoperazone (1 gm per dose) or no antibiotics. In all parameters of patient morbidity, the group receiving cefoperazone showed significantly better results as compared to the group not receiving antibiotics. The ampicillin group also had favourable results but generally not achieving statistical significance. Prophylactic antibiotics appear to be beneficial and consideration should be given to make it a routine in all emergency caesarean sections.