Since the outbreak of the novel influenza H1N1 in April 2009 in Mexico, more then half a million cases have been recorded with more then 6000 deaths. In contrast to seasonal flu, this virus appears to have a predilection for the young, obese and pregnant. It’s most important and almost fatal complication is Acute Respiratory Distress Syndrome (ARDS). Intensive care units (ICU) around the world have scrambled to upgrade various treatment modalities including high frequency oscillation ventilation, inotropes, antivirals and antibiotics in an effort to reduce the mortality arising out of this complication. More importantly, this complication appears reversible if adequate and early therapy is instituted. In particular, rescue therapies that allow the lung to rest appear to have brought success in some clinical settings. This article describes the experiences of seven centers that have used various modalities as rescue therapy in patients having Acute Respiratory Distress Syndrome (ARDS). The experiences in 13 patients at the University of Michigan, 58 in Mexico, 168 in Canada, 180 patients at Leicester UK, 194 in Australia and New Zealand and case reports from Hong Kong and Singapore are described.

The disease melioidosis, caused by the soil bacteria Burkholderia pseudomallei, often manifests as acute septicemia with high fatality. Glycogen synthase kinase-3β (GSK3β) plays a key role during the inflammatory response induced by bacteria. We used a murine model of acute melioidosis to investigate the effects of LiCl, a GSK3 inhibitor on experimental animal survivability as well as TNF-α, IL-1β, IFN-γ, IL-10 and IL-1Ra cytokine levels in blood, lung, liver and spleen of B. pseudomallei-infected mice. Our results showed that administration of 100 μg/g LiCl improved survivability of mice infected with 5 X LD50 of B. pseudomallei. Bacterial counts in spleen, liver and lungs of infected mice administered with LiCl were lower than non-treated controls. Our data also revealed that GSK3β is phosphorylated in the spleen, liver and lung of animals infected with B. pseudomallei. However in infected animals administered with LiCl, higher levels of pGSK3 were detected in the organs. Levels of proinflammatory cytokines (TNF-α, IL-1β and IFN-γ) and anti-inflammatory cytokines (IL-10 and IL-1Ra) in sera and organs tested were elevated significantly following B. pseudomallei infection. With GSK3β inhibition, pro-inflammatory cytokines (TNF-α, IFN-γ, IL-1β) were significantly decreased in all the samples tested whilst the levels of anti-inflammatory cytokines, IL-10 (spleen and lung) and IL-1Ra (spleen, liver and sera) were further elevated. This study represents the first report implicating GSK3β in the modulation of cytokine production during B. pseudomallei infection thus reiterating the important role of GSK3β in the inflammatory response caused by bacterial pathogens.

The determination of HIV drug resistance mutations (DRMs) towards antiretroviral (ARV) drugs among HIV-1 treated patients with virological failure is crucial for further management of the patient. This study aimed to assess the most common genomic mutation and to analyse subtypes among the HIV-1 patients with viral load level > 1,000 copies/mL. A total of 101 virological failure HIV-1 patients from four different regions of Peninsular Malaysia with a viral load measurement facility were included in the study. Majority of patients (89.1%) have at least 1 mutation associated with clinical resistance to either protease inhibitors (PIs), nucleoside reverse transcriptase inhibitors (NRTIs) or nonnucleoside reverse transcriptase inhibitors (NNRTIs). Major resistance mutations among the patients towards NRTIs and NNRTIs were 70.3% and 18.8%, respectively. The most common mutation for NRTIs was M184V while K103N mutation was detected in the majority of patients who were treated with NNRTIs. The most commonly observed mutations for major PI and minor PI seen among the study population were V82A/T and L10V, respectively. In HIV-1 subtype analysis, CRF33_01B was the most predominant HIV-1 subtype in this study group. The vast detection of DRMs in this study emphasized the importance of genotypic resistance test in the management of HIV patients as DRMs can alter patient’s susceptibility towards ARV drugs. Further study on larger number of samples is essential for the development of a database on HIV-1 DRMs among patients that experience virological failure in Malaysia.

Objectives: There are a number of validated questionnaires available for the screening of Post-Traumatic Stress Disorder (PTSD), and the PTSD Checklist for Civilians is one of them. However, none was translated into the Malay Language and validated for use in the Malaysian population. The aim of this study is to translate and validate the Malay PTSD Checklist for Civilians (MPCL-C). Methods: The PCL-C was translated into the Malay Language and back-translated. The reliability and validity of the MPCL-C were then determined by administering them to those who presented at the emergency department for motor vehicle accident at least one month before. Results: The MPCL-C has good face and content validity. In terms of reliability, it is also good, with Chronbach’s alpha values of 0.90, 0.77, 0.75 and 0.74 for the full scale, re-experiencing, avoidance and arousal domains respectively. Conclusions: The MPCL-C is a valid and reliable instrument to screen for PTSD in motor vehicle accident victims for the studied population.

Angiography is the gold standard for the diagnosis and treatment of vascular and related diseases. However, the challenges and peculiarities of the procedure may result in increased fluoroscopy time and number of acquired images, which increased personnel and patients‟ radiation exposure. This study determines the dose area product readings following diagnostic and interventional angiographic procedures in an attempt to establish reference values for patient radiation dose optimization. This retrospective study reviewed the cases of 25 patients that were managed at the teaching hospital. Types of angiographic procedure, exposure parameters as well as radiation dose parameters were documented. Fluoroscopy time, number of frames acquired for each examination, fluoroscopy and frame radiation doses were equally recorded. Of the 25 patients, 6 were for 4-vessel cerebral Digital Subtraction Angiography (DSA), 3 for both lower limbs DSA, 4 for both lower limbs DSA and angioplasty, 3 for Inferior Vena Cava (IVC) filter placement, 2 for pulmonary arteriography, 2 for renal artery embolisation, and 5 for unilateral lower limb DSA and angioplasty. Renal artery embolization had the highest fluoroscopy and frame radiation doses (73764 cGy.cm2 and 4090 mGy) compared to others. Measured Dose Area Product (DAP) doses were above the Diagnostic Reference levels (DRLs) available in the literature thereby necessitating the need for radiation dose optimization through, continuous dose management.

Nosocomial blood stream infection (or nosocomial bacteremia) is a common problem in hospitals worldwide, including Malaysia. A three-year prospective cohort study (October 2003-March 2007) of the incidences, risk factors, and patterns of the microorganisms causing bacteremia was conducted using a validated surveillance form in three intensive care units (ICUs) in Malaysia. Center for Disease Control criteria were used to diagnose bacteremia. Patients were monitored from admission until the end point of study, which was the first detection of bacteremia in the blood in each patient. The frequency of occurrence of bacteremia with clinical symptoms was 10.7% (n = 23). Bacteremia was observed to occur within a mean length of stay of 10 days in ICU. The rate of device-related infection was 10.4% per device utilization days with a device utilization rate of 95.9%/1000 patient days. The total number of patient days was 2309 and the period of device utilization was 2211 days. The common bacteria detected were extended-spectrum beta-lactamases (ESBLs) Klebsiella pneumoniae (n = 6); Pseudomonas aeruginosa (n = 6); Acinetobacter species (n = 5); Methicillin-resistant Staphylococcus aureus (MRSA)(n = 3); and (non- ESBL) Klebsiella pneumoniae (n = 2). Multivariable analysis using Cox Proportional Hazard Model showed that the predictors for developing bacteremia were cancer, MRSA carriage, duration of central venous catheter (CVC) infusion, frequency change of CVC, and the administration of hydrocortisone drugs. These results indicate that a combination of nursing and medical interventions as well as patients' severity of illness could lead to bacteremia in ICU. Strategic implementation of quality assurance measures in ICUs could help to control this problem.

Aim: A preliminary investigation to assess the relationshipin the severity of periodontal disease in diabetics whencompared with non-diabetic subjects. Materials andMethods: A retrospective, comparative study usingperiodontal case notes of 40 subjects (20 Type 2 diabetics,20 non-diabetics) who were selected based on theinclusion and exclusion criteria. Severity of periodontaldisease was assessed through number of periodontalpocket ≥5mm. The results were compared betweensubjects whose age, gender and plaque scores are matchedwith the test group. Data obtained was then analyzed bySPSS Version 12. Results: When comparisons were madebetween test (Type 2 diabetic) and control (non-diabetic)groups, there were no significant difference (p>0.05) inthe severity of periodontal disease. However, there wasa clinically mean difference between the two groups.Conclusions: This preliminary investigation indicatedthat the severity of chronic periodontitis, as indicated inperiodontal pocketing, increased in diabetic patients whencompared to non-diabetics clinically, although it was notstatistically significant. The finding of this investigationwas thus not conclusive as it was only a retrospectivestudy using patients’ case notes. However, the resultsare now being further investigated with a proper clinicaltrial which examines periodontal parameters and diabeticstatus (HbA1c) of the subjects to determine the associationbetween periodontal disease and diabetes mellitus.

Background and Objectives: In cochlear implant (CI) surgery, the results and causes of revision and reimplantation may guide surgeons in establishing surgical protocols for revision surgery with safe audiological outcomes. The aim of this study was to review our experience in terms of etiology, surgical strategy, and hearing outcomes in pediatric patients who underwent CI removal and reimplantation. Subjects and Methods: All patients received implants of the same brand. Pre and postoperative Categories of Auditory Performance score and aided free-field pure tone audiometry thresholds were noted. In vivo integrity tests were performed for each patient and the results of ex vivo tests of each implant were obtained from manufacturer. Results: A total of 149 CIs were placed in 121 patients aged <18 years. The revision rate in children was 6.7% (10/121 children). Six patients had a history of head injury leading to a hard failure. The causes of reimplantation in others were soft failure (n=1), electrode migration (n=1), infection (n=1), and other (n=1). All patients showed better or similar postreimplantation audiological performance compared with pre-reimplantation results. Conclusions It is very important to provide a safe school and home environment and educate the family for reducing reimplantation due to trauma. Especially for active children, psychiatric consultation should be continued postoperatively.

Delayed wound healing is one of the major complications of diabetes mellitus where it often leads to amputation. Virgin coconut oil (VCO) is a natural oil widely used to treat wounds and burns traditionally. It possesses potent antioxidant and antibacterial activities. This study aimed to determine the effect of VCO on the fibroblast population in diabetic wound healing. Full thickness cutaneous wound tissues were collected from non-treated, VCO-treated, and silver sulfadiazine (SS)-treated diabetic rats. The tissues were then subjected to Verhoeff eosin staining and immunohistology of fibroblast and myofibroblast. Histological analysis showed increased collagen deposition with intact epidermis in the VCO treated group compared to decreased collagen deposition with damaged epidermis in both non-treated and SS-treated groups. Interestingly, more fibroblasts and myofibroblasts were observed in the non-treated group compared to the VCO- and SS-treated groups. VCO significantly promoted wound healing process in diabetic rats via promoting re-epithelialization, and increasing collagen fibres deposition and wound contraction. The results suggested VCO can be used to treat diabetic wounds.

Purpose: To determine the effect of zinc deficiency on fecal protein, electrolyte, and shortchain fatty acid levels in both heat-stable (ST) and heat-labile (LT) enterotoxigenic Escherichia coli (ETEC)-induced diarrhea in rats. Methods: Albino rats, weighing 100 to 150 g, were divided into 2 groups, with 15 animals each: non-zinc and zinc-deficient. These two groups were sub-divided into three sub-groups with five rats each: control (saline); LT-ETEC; and ST-ETEC. Sodium phytate (30 mmol/L) was added to the animals’ water to induce zinc deficiency, while diarrhea was induced using 5×10 9 ETEC cells/mL. Fecal protein levels were estimated using the Bradford method, while sodium and potassium levels were determined using atomic absorption spectrophotometry. Shortchain fatty acids were measured using gas chromatography-mass spectrometry. Results: Among the non-zinc and zinc-deficient groups, there were significant increases (p=0.04), (p=0.03) in fecal protein concentrations (mg/mL) in the LT-ETEC- (4.50±0.33), (6.50±0.26) and ST-ETEC- (3.85±0.19), (5.98±0.32) induced groups compared to the control groups (2.60±0.52), (3.50±0.11) respectively. Fecal sodium and potassium levels (mg/L) were significantly (v=0.029) increased in non-zinc-deficient rats induced with LT-ETEC (9.35±0.95, 1.05±0.48), and ST-ETEC (9.96±1.02, 1.21±0.45) compared with the control group (8.07±0.44, 0.47±0.17) but the increase were not statistically significant (p=0.059) in the zinc deficient rat groups. Fecal acetate and propionate levels (mg/g) significantly (p=0.032) increased when induced with LT-ETEC and ST-ETEC in non-zinc and zinc-deficient groups compared with the control groups. Conclusion Zinc deficiency among rats with ETEC-induced diarrhea elevated fecal protein loss but may not have an effect on fecal sodium, potassium and short-chain fatty acid levels.