Introduction: Lean sustainability has gained prominence in the health sector for operational and business advantages. However, understanding the link between lean and healthcare sustainability, especially in social and environmental aspects, remains limited. This study introduces a preliminary framework for measuring lean healthcare sustainability in hospitals. The framework aligns Critical Success Factors (CSFs) with sustainability objectives and business strategies to ensure successful and enduring lean deployment. Methods: The study was conducted among 52 Lean Agile Hospitals in Malaysia using a cross-sectional approach. The validated questionnaire was employed for data collection. A reliability test and Exploratory Factor Analysis (EFA) were also performed to assess and validate the framework using Statistical Package for Social Sciences (SPSS) version 27. Results: The content validation was 0.9, which indicates that the instrument is sufficient to measure the research objective. The data screening test was performed to eliminate problem observation. The overall reliability value was over 0.830 which depicts data consistency and stability. The Kaiser-Meyer-Olkin exceeded 0.6, Bartlett’s test was under 0.001 and factor loading was between 0.507 to 0.948, thus indicating a significant correlation matrix among at least some of the variables. Therefore, the latent factors were significant to specific items of the research. Conclusion: It is concluded that important CSF is aligned with the strategic level influence of lean deployment in healthcare, which has a specific impact on certain sustainability performance. Thus, this paper proposed a generic preliminary framework to measure lean healthcare sustainability.

Aims: Proteus species are implicated as serious causes of various human infections. Imipenem has been used to treat infections caused by these organisms. However, Proteus spp. are known to have reduced susceptibility and have elevated minimum inhibitory concentration (MIC) towards imipenem. The aim of this study was to determine the prevalence of Proteus species with reduced susceptibility to imipenem and the antibiotic susceptibility pattern for each Proteus species. Methodology and results: A total of 204 Proteus isolates were collected from routine samples. All isolates were identified by using VITEK® 2 GN ID card. Antibiotic susceptibility tests were done by using disc diffusion method and imipenem E-test. While 5.9% of the Proteus isolates showed reduced susceptibility towards imipenem by disc diffusion, only 1% (2 out of 204 isolates) has reduced susceptibility by E-test. Conclusion, significance and impact of study The prevalence of Proteus species with reduced susceptibility to imipenem is still low. The imipenem zone diameter does not truly reflect the MIC value and thus, in any isolates which are tested to have reduced susceptibility or resistant to imipenem should always be followed by imipenem MIC method.

Introduction: Group B Streptococcus (GBS), infection and recurrence in newborns and pregnant women can lead to chronic medical illness resulting in significant morbidity, and mortality. Pathogenesis of GBS may be due to reasons such as activation of the immune system, followed by the production of inflammatory markers and toxic components by immune cells including macrophages. Methods: The studies on invasive and colonizing GBS strains inoculated either with peripheral or brain macrophages, the expression of nitric oxide (NO), cell viability, and CD40 were also measured by Griess assay, methyl tetrazolium assay (MTT), and flow cytometry, respectively. Furthermore, the clinical manifestations of the selected patients were also assessed for this study. Results: Outcome of inflammatory markers studies, after GBS inoculation indicated that, invasive GBS strains induced higher inflammatory markers in comparison to colonizing GBS strains. Furthermore, patients’ clinical data showed that patients with invasive GBS infections had severe condition unlike among patients with colonizing GBS strains. The fatality rate in patients with invasive GBS strain were 30.8% while there was no death among carriers. Conclusion: This study, aimed to understand the immune response to GBS, and strengthen the knowledge on GBS pathogenesis. It was concluded that invasive GBS strains not only showed higher expression of inflammatory markers on immune cells but also had higher pathogenesis effect in comparison to colonizing GBS strains.
Streptococcus agalactiae ; Pregnancy

Background: Urinary incontinence (UI) demonstrates major prevalence in women of different population groups. Reduced quality of life (QOL) is observed due to incontinence problems. Urogenital Distress Inventory (UDI-6) and Incontinence Impact Quality of Life (IIQ-7) are useful disease-specific questionnaires evaluating the impact of urinary incontinence on the QOL of women which is accepted internationally. Objective: This study aims to translate and validate UDI-6 and IIQ-7 in Malay language. Methods: A cross sectional study, which recruited 100 participants from two urogynecology clinics. Both questionnaires were initially translated from English to Bahasa Malaysia followed by back translation and final correction done by the professional translators. The participants were requested to maintain a urinary record of the upcoming week for three days that assisted in quantifying the severity of symptoms. None of the subjects were assigned any treatment during the study period. Validity and reliability of the translated questionnaires were determined by checking the internal consistency and also by doing test-retest. Results: The internal consistency levels of the UDI-6 and IIQ-7 Bahasa Malaysia questionnaires were 0.73 and 0.90 respectively with good test-retest (0.86 and 0.95). Incontinence episodes were strongly associated with obstructive, irritative, and stress symptoms. The factor of day time voiding had strong correlation with obstructive and irritative symptoms. Conclusion: UDI-6 and IIQ-7 did not measure similar outcomes; however, both questionnaires have their strengths in clinical settings. Analysis has also revealed that the Malaysian versions of both questionnaires had appropriate test-retest validity and reliability. Thus, it can be said that both of the questionnaires had great importance for screening patients with urinary incontinence in Malaysia.

Uterine rupture is a rare life-threatening complication. It mainly occurs in the third trimester of pregnancy and is rarely seen during the first or second trimesters. Our centre experienced three important cases of uterine rupture. First case: spontaneous uterine rupture at 14 weeks of pregnancy, which was diagnosed at autopsy. It was misled by the ultrasound finding of an intrauterine pregnancy, and searching for other non-gynaecological causes delayed the urgent obstetric surgical management. Second case: ruptured uterus at 24 weeks following medical termination due to foetal anomaly. It was diagnosed only at laparotomy indicated for failed medical termination and chorioamnionitis. Third case: uterine rupture at 21 weeks of pregnancy in a patient with gastroenterology symptoms. In these reports, we have discussed the various risk factors, presentations, course of events and difficulties in diagnosing uterine rupture. The study concludes that the clinical presentation of uterine ruptures varies. It occurs regardless of gestational age. Ultrasound findings of intrauterine pregnancy with free fluid do not exclude uterine rupture or ectopic pregnancy. Searching for non-gynaecological causes in such clinical presentations might delay crucial surgical intervention, which leads to unnecessary morbidity, mortality or loss of obstetrics function.

Peripheral vestibular disorder (PVD) is serious and common. Clinically, giving an accurate diagnosis of PVD can be challenging. Vestibular evoked myogenic potential (VEMP) is an objective test to evaluate the integrity of vestibular organs, particularly saccule and/or inferior vestibular nerve. This study was performed to determine the sensitivity and specificity of VEMP using different stimuli. Fourty normal and 65 PVD subjects who fulfilled the inclusion criteria were recruited. While sitting comfortably, VEMP waveforms were recorded with active electrode on sternocleidomastoid muscle and negative electrode on upper forehead. Tone bursts (500, 750 and 1000 Hz) were delivered via headphones at 90 dBnHL and 5/s presentation rate. VEMP parameters for each stimulus (amplitude and latency of P1 and N1 peak) were analyzed accordingly. Receiver operating characteristic (ROC) was performed to determine the sensitivity and specificity of VEMP at different test frequencies. N1 amplitude of 750 Hz stimulus produced the most ideal sensitivity (65% on right and 63% on left) and specificity (83% on right and 78% on left). The importance of using a few tone bursts in VEMP test in order to minimize the false negative in cases might be encountered in clinics as the certain tone burst had inadequate sensitivity in detecting PVD cases. The 750 Hz stimulus produced the most ideal VEMP with adequate values of sensitivity and specificity, at least in this study.
Vestibulocochlear Nerve Diseases

BACKGROUND: We investigated the effects of pre-emptive administration of ketamine and norBNI on pain behavior and the expression of DREAM, c-Fos, and prodynorphin proteins on the ipsilateral side of the rat spinal cord at 2 and 4 hours after formalin injection. METHODS: Eighty-four male Sprague Dawley rats were divided into 4 major groups consisting of control rats (C) (n = 12), rats given only formalin injections (F) (n = 24), and rats treated with pre-emptive administration of either ketamine (K+F) (n = 24) or norBNI (N+F) (n = 24). The non-control groups were further divided into subgroups consisting of rats that were sacrificed at 2 and 4 hours (n = 12 for each group) after formalin injection. Pain behavior was recorded for 1 hour. After 2 and 4 hours, the rats were sacrificed and the spinal cords (L4-L5 sections) were removed for immunohistochemistry and Western blot analysis. RESULTS: The pain behavior response was reduced in the K+F group compared to the other groups during the second phase of the formalin pain response. We detected an increase in the nuclear DREAM protein level in the K+F group at 2 and 4 hours and a transient decrease in the N+F group at 2 hours; however, it increased at 4 hours after injection. Fos-like immunoreactivity (FLI) and Prodynorphin-like immunoreactivity (PLI) neurons decreased in the K+F group but increased in the N+F group at 2 hours after injection. While FLI decreased, PLI increased in all groups at 4 hours after injection. CONCLUSIONS: We suggest that NMDA and kappa opioid receptors can modulate DREAM protein expression, which can affect pain behavior and protein transcriptional processes at 2 hours and bring about either harmful or protective effects at 4 hours after formalin injection.
Animals ; Blotting, Western ; Enkephalins ; Formaldehyde ; Humans ; Immunohistochemistry ; Ketamine ; Male ; N-Methylaspartate ; Neurons ; Pain Measurement ; Protein Precursors ; Proteins ; Rats ; Rats, Sprague-Dawley ; Receptors, Opioid, kappa ; Spinal Cord

Introduction:The Vertigo symptom scale (VSS) is a well established tool for the evaluation of vestibular disorders and the associated symptoms of autonomic arousal and somatosensation. By using a validated Malay version of vertigo symptom scale (MVVSS) questionnaire, the severity of the vertigo from patients’ perspective can be determined and rated. Before MVVSS can be applied clinically among Malaysians, it was of interest to determine its clinical value in identifying vestibular disorders. Method: Forty normal and 65 PVD subjects participated in this cross-sectional study. Normal subjects were recruited amongst Universiti Sains Malaysia (USM) staff and students who had no history of ear and vestibular disorders. Results: Mean total score of MVVSS in normal and PVD subjects were 13.9 ± 11.1 and 30.1 ± 20.9, respectively. When the total scores of normal and PVD group were compared, the Mann-Whitney U test showed that there was a significant difference between the two groups (p<0.05). This is consistent with previous studies. It was also of interest to see if subtypes of PVD [benign paroxymal positional vertigo (BPPV), Meniere’s disease, labyrinthitis and unknown] have different MVVSS results. However, analysis of variance (ANOVA) found no significant difference in term of outcomes of MVVSS among the different PVD pathologies. Using receiver operating characteristic curve (ROC) method, the sensitivity and specificity of MVVSS were 71% and 60%, respectively. Conclusion: MVVSS is able to discriminate clinically among the normal and PVD subjects. However, it is not a good indicator for differential diagnosis of PVD subtypes, at least in this study. Its sensitivity and specificity in clinical diagnosis are reasonably high. Perhaps a bigger sample size would be useful to further study the clinical usefulness of MVVSS.

A 30-years-old Taiwanese female in her second pregnancy spontaneously conceived a monochorionic twin pregnancy. A routine ultrasound at 27 weeks of gestation revealed a selective intrauterine growth restriction (sIUGR) fetus and an appropriate gestational age (AGA) fetus. The AGA fetus was found to have a fetal intra-abdominal umbilical vein (FIUV) varix. Serial ultrasounds showed no changes in the FIUV varix. 2 weeks later, the pregnancy progressed to twin–twin transfusion syndrome (TTTS). Repeated amnioreductions were required at 29 and 30 weeks gestation. The babies were delivered by caesarean section at 31 weeks due to fetal distress in the sIUGR fetus. Both fetuses survived the neonatal period with problems of prematurity. The FIUV varix disappeared a few days after delivery.

Background: The dopamine D2 receptor gene (DRD2) plays a role in many diseases such as schizophrenia, Parkinson’s disease, and addictive behaviour. Methods currently available for the detection of DRD2 polymorphisms are costly and cannot detect all 8 polymorphisms of our research interest simultaneously (Val96Ala, Leu141Leu, Val154Ile, Pro310Ser, Ser311Cys, TaqI A, A-241G, and −141C Ins/Del). Therefore, we developed a nested multiplex polymerase chain reaction (PCR) for simultaneous detection of these polymorphisms. Methods: Genomic DNA was extracted from blood using standardised methods. Primers specific at the 3’-end for the polymorphic sites were designed. A two-step PCR method was developed. In the first PCR, a region from exon 3 to 4, exon 7, the promoter region, and the 3’-region of DRD2 were specifically amplified. The products were subsequently used as templates in the second PCR. Sequencing was performed to validate the test results. Results: Specific bands corresponding to the amplified product of interest were obtained. The method was reproducible and specific when used to genotype patients with schizophrenia. The amplified sequences showed 100% homology to the DRD2 sequence. Conclusion: The method was found to be simple, rapid, specific, and reproducible for the simultaneous detection of the DRD2 polymorphisms.