Challenges to medical professionalism / Mohammed Fauzi Abdul Rani.

Medical professionalism is the basis of the trust given to doctors by the society. At the heart of it is a doctor who must ensure the well-being of patients at all times and always protect them from harm. In doing so they are expected to be competent, compassionate, open and honest, respect patient’s autonomy and always guard their confidentiality. These qualities enable doctors to earn that trust, and accord them their professional status and privileges, and axiomatic of the essence of a good doctor [1]. As a concept, medical professionalism is defined with four basic characteristics [2]. They are an altruistic vocation linked to public service, adherence to defined standards and ethical codes, the ability to apply a body of specialist knowledge and skills, and a high degree of self-regulation over professional membership and work organization. Other qualities that are fundamental to the understanding of medical professionalism include advocacy and justice, leadership, collaboration and collegiality. These values are timeless but they do not operate in a vacuum, the dynamics of a society change over time leading to different demands and expectations from the medical profession [3]. Doctors therefore must be cognizant that these changing circumstances represent new challenges and require them to adjust and refine their professional values to effectively fulfill their obligation to the society. Two key issues that will be touched here are the changing landscape of healthcare in this country as it moves from public to private healthcare and the question of professional self-regulation and organization

Endobronchial tuberculosis mimicking pulmonary neoplasm

A 64-year-old Chinese lady presented to us with three months history of chronic dry cough and weight loss without haemoptysis. There was no fever. She had never smoked. Initial chest x-ray (CXR) and thoracic CT showed left upper lobe collapse for which she underwent bronchoscopy. The appearance was suggestive of submucosal tumour. She needed a second bronchoscopy that showed caseating granuloma and smear positive for tuberculosis. She made good clinical recovery with anti tuberculosis treatment but review CXR at four months showed a mass lesion in the left apex for which she underwent fine needle aspiration cytology. This showed healing granuloma compatible with tuberculosis. This case was unusual to us because it had led us to believe that we were dealing with malignancy twice

Usefulness of cytological specimens from bronchial brushings and bronchial washings in addition to endobronchial biopsies during bronchoscopy for lung cancer: 3 years data from a chest clinic in a general hospital

retrospective review of all bronchoscopy cases for investigation of lung cancer between January 1997 and December 1999 was done. The cases were included if endobronchial mass was visible (Group A) or when there was an abnormal mucosa and/or bronchial narrowing in the absence of a mass (Group B). All patients in Group A (n = 177) underwent endobronchial biopsy (EB) bronchial brushings (BB) and bronchial washings (BW). All cases in Group B underwent transbronchial biopsy (TBB), BB and BW. Only a small increase in the positive results for cancer was seen when cytology specimens (BB and BW) were added to EB (85.3% vs 88.1%, McNemar's P = 0.06) in Group A but there was a significant increase in Group B (37.3% vs 54.2%. McNemar's, P = 0.001). Therefore although cytology specimens did not significantly add to overall yield of positive results when endobronchial lesions were visible, when mass lesions were not visible, cytology specimens increased the yield by 16.9%

Clinical assessment of watermarked medical images

Problem statement: Digital watermarking provides security to medical images. Watermarking in Region Of Interest (ROI) however distorts medical images but it is known that the resulting loss of fidelity is visually imperceptible. Approach: Clinical assessment will objectively evaluate the distortion on medical images to see whether or not medical diagnosis is altered. We used 75 medical images consisting of x-rays, ultrasound and CT scans. Digital watermarking was inserted in ROI and ROI/Region Of Non Interest (RONI) in all of them. Three assessors were randomly assigned 225 images, each receiving 75, a mixture of watermarked and non watermarked images. Results: Chi square test was used and p<0.05 was considered significant. There was no significant difference between original images and those watermarked in ROI or ROI/RONI. There was no comment on image quality in all the images assessed. Conclusion/Recommendations: Digital watermarking does not alter medical diagnosis when assessed by clinical radiologists. The quality of the watermarked images was also unchanged

Efficiency of Ventilator Associated Pneumonia Prevention Protocol in a mixed intensive care unit in Pahang, Malaysia

Introduction Ventilator-associated pneumonia (VAP) rate in adult ICU varies between 8.0 and 46.3 episodes/1000 ventilator days. A National Audit of Adult Intensive Care Units (NAICU) in 2003 reported a high incidenceof 26.9/1000 ventilator days. A subsequent multiple one day prevalence study found a high VAP rate (42.8/1000 ventilator days) in our ICU in Kuantan. We developed an ICU guidelines called Ventilator Associated Pneumonia Prevention Protocol (VAPP) and conducted a study to asses the efficiency of VAPP in our ICU setup. Methods This comparative study was done in Hospital Tengku Ampuan Afzan (HTAA). The following data were collected pre (from 1st April to 31st March 2004) and post (from 1st September 2004 to 31st August 2005) VAPP: patients’ demographics, medical history, both hospital and ICU admissions and discharges dates, SAPS II scores, admission categories, organ failures, status on ICU and hospital discharge, duration on mechanical ventilation. Results There were a total of 941 patients in pre (n=480) and post (n=461) VAPP periods. Patients’ demographics, SAPS II scores and premorbid states were similar in both. VAP rate was 21.9/1000 ventilator days (37 episodes over 1689 ventilator days) pre VAPP and 8.35/1000 ventilator days (14 episodes over 1676 ventilator days) post VAPP. The relative risk reduction of VAP post implementation of VAPP was 68% with p value < 0.0001. When we look at the NNIS benchmarking on ventilator-associated pmeumonia for quality improvement, the incidence of VAP pre guidelines was 21.9% and this is above 90th percentile of the NNIS benchmark. In the post guideline group, the incidence of VAP has been reduced to 25th percentile. There was also a reducing trend of gram positive organisms as the cause of VAP in the post VAPP group. Conclusion Our study has shown that local evidence-based VAPP guidelines could significantly reduce the rate of VAP in a large state hospital

Project brief for IIUM Hospital (Phase 1), International Islamic University Malaysia (Medical Campus)Kuantan, Pahang Darul Makmur

A project brief on medical requirements for the planning and design of IIUM teaching hospital in IIUM Kuantan Campus. There are two versions of the brief, i.e. the 2009 version and the 2010 version. The march 2010 version was revised after the site visit was made to Kuantan by the bidders and as an outcome of the dialogue

Risk factors for anti tuberculous drugs induced hepatitis: a prospective survey from a chest clinic in a general hospital

A prospective survey on 14 consecutive cases with tuberculous drug induced hepatitis was done at our chest clinic in a state general hospital over a period of 15 months. There were 30 controls chosen randomly from the chest clinic register. The cases had lower mean body mass index (P<0.008), serum albumin (P<0.005) and higher serum globulin (P<0.04). Serum liver transaminases and total bilirubin rose significantly during the acute episode of drug induced hepatitis. Among the risk factors studied, only chronic hepatitis B carrier status was found to be more prevalent among the cases. There was one death (7.1%) over the whole study period

Metabolic changes during ramadan fasting in normal people and diabetic patients

Fasting is obligatory on all Muslims every year during the 9th Islamic lunar month of Ramadan with exemption to sick, travelers and pregnant women. In spite of the fact that Islam provides exemption from fasting to people suffering from illnesses like diabetes, many patients still want to fast for personal convictions. Physicians often face a dilemma as to how to advise them. Several studies have been published on the effects of fasting; some of the results are controversial. The present study was undertaken to establish the effects of Ramadan fasting on various physiological parameters in normal people and in diabetic patients. This could be used as basis for advice to such patients. The study group consisted of 53 diabetic patients (31 male and 22 female) and 56 (21 male 35 female) healthy volunteers as controls. Inclusion criteria of diabetic patients were: to be non-insulin dependent, and be stable and under reasonable control on oral hypoglycemic drugs and or diet control alone. The subjects were evaluated 1-2 weeks before commencement of fasting (visit 1), at the 4th week of Ramadan fasting (visit2) and one month after the end of the Ramadan fast (visit3). Blood samples were collected on each occasion at least 8 hours after the last meal. Our results showed statistically significant weight reduction (P<.001) at the end of Ramadan fast in both groups, however it was not maintained in both groups when values were compared before Ramadan and one month after Ramadan. Fasting blood sugar and HBA1C showed significant reduction (P<.001) among diabetics but not in control group. The other parameters e.g. cholesterol, blood urea and creatinine did not show any significant changes before and during Ramadan. There was statistically significant increase in serum cholesterol and triglyceride and uric acid (P<.001) among healthy volunteers (control group) one month after Ramadan compared to before Ramadan; however no such changes were seen among diabetic group. There was no reported case of serious complication due to fasting in both groups. Conclusion: Ramadan fasting lead to significant body weight reduction and improvement of glycaemic control in diabetic patients with out other significant metabolic changes

Compliance to national guidelines on the management of chronic obstructive pulmonary disease in Malaysia: a single experience

Introduction: Malaysia has a high rate of smoking prevalence and the figure is increasing. Although there has been many local and regional studies on the prevalence and symptomatology of chronic obstructive pulmonary disease patients, data is lacking on the degree of compliance to national management guidelines in the treatment of chronic obstructive pulmonary disease. Methods: 86 patients who attended the respiratory outpatient clinic of the Hospital Universiti Kebangsaan Malaysia were enrolled into a prospective, observational study. Results: 88 percent of the patients were male and the majority was ethnically Chinese (65 percent). The majority of patients were in the moderate to very severe categories, with a mean FEV1 of 0.97 +/− 0.56 L/sec and predicted mean FEV1 percentage of 43.1 +/− 21.3 percent. 58 percent of the patients were on long-acting beta-agonist, 65 percent were on inhaled steroids, and only 16 percent were on scheduled pulmonary rehabilitation. Conclusion: The low uptake rate for long-acting beta-agonist and pulmonary rehabilitation could be attributed to several factors. Financial cost, the need for strict compliance to a structured rehabilitation regime, lack of significant social support and clear up-to-date guidelines are possible reasons