Kulenthran Arumugam

Menstrual characteristics associated with endometriosis

This case‐controlled study investigates whether the presence of menstrual characteristics, which may increase the exposure of the peritoneal cavity to retrograde menstruation, increases the risk of developing endometriosis. The menstrual characteristics considered were 1. age at menarche of less than 12 years, 2. duration of menstrual flow greater than five days and 3. menstrual cycle lengths of < 28 days. The frequency with which these menstrual characteristics occurred in 305 women with proven endometriosis was compared with their frequency in 305 age‐matched women without endometriosis. Adjusting for the confounding factors of parity, age at first childbirth and social class, the only menstrual characteristic that was significantly associated with endometriosis was menstrual cycle lengths of less than 28 days (odds ratio 1.83; 95% confidence intervals 1.60–2.55). There was insufficient evidence to conclude that the presence of menstrual characteristics which may increase the exposure of the peritoneal cavity to retrograde menstruation, increase a womans risk of developing endometriosis. The association of short menstrual cycle lengths with endometriosis may have been consequential rather than causal.

De novo formation of adhesions in endometriosis: the role of iron and free radical reactions

OBJECTIVE To show that raised iron levels in the peritoneal fluid (PF) of patients with endometriosis catalyze free radical reactions that results in the tissue destruction and fibrosis seen in these patients. DESIGN A case-controlled study of the iron levels (microgram/mL) in the pelvic PF of 12 patients with moderate-to-severe disease, 15 patients with minimal-to-mild disease and in 17 women with normal pelvises were compared. As an index of free radical reactions through lipid peroxidation, the levels of malondialdehyde levels (ng/mL) were assessed simultaneously in the same specimens. RESULTS Controlling for the phase of the menstrual cycle, significantly higher levels of iron were seen in patients with endometriosis, the levels being correlated with the severity of the disease. However no such corresponding relationship was seen in the malondialdehyde levels in the PF. CONCLUSIONS These results suggest that raised iron levels in the PF do not play a role in catalyzing free radical reactions as judged by the degree of lipid peroxidation.

Endometriosis and Race

Summary: The pelvic findings of 202 infertile women undergoing diagnostic laparoscopy in Kuala Lumpur, Malaysia were compared to that of 464 infertile women undergoing diagnostic laparoscopy in Aberdeen, United Kingdom. Endometriosis was significantly more common in the women from Kuala Lumpur (51% against 22%, p < 0.001). There was however no significant difference seen in the severity of the disease (AFS Classification, 1985). These findings confirm our clinical impression that endometriosis is more common in Asian women when compared to Caucasian women.

Endometriosis and infertility: the role of exogenous lipid peroxides in the peritoneal fluid

OBJECTIVE To determine if lipid peroxides were raised in the pelvic peritoneal fluid of patients with endometriosis. DESIGN Control study involving patients with and without endometriosis. METHODS The lipid peroxide (malondialdehyde) levels in the pelvic PF of 12 patients with moderate-to severe endometriosis, 15 patients with minimal-mild endometriosis and 13 patients with normal pelvises were compared. RESULTS The level of lipid peroxides were not affected by the presence nor the severity of endometriosis. CONCLUSION Accelerated lipid peroxidation does not appear to play a role in the causal relationship between endometriosis and infertility.

Performance of emergency physicians in point-of-care echocardiography following limited training

Objectives The aim of this study was to evaluate if emergency medicine trainees with a short duration of training in echocardiography could perform and interpret bedside-focused echocardiography reliably on emergency department patients. Methods Following a web-based learning module and 3 h of proctored practical training, emergency medicine trainees were evaluated in technical and interpretative skills in estimating left ventricular function, detection of pericardial effusion and inferior vena cava (IVC) diameter measurements using bedside-focused echocardiography on emergency department patients. An inter-rater agreement analysis was performed between the trainees and a board-certified cardiologist. Results 100 focused echocardiography examinations were performed by nine emergency medicine trainees. Agreement between the trainees and the cardiologist was 93% (K=0.79, 95% CI 0.773 to 0.842) for visual estimation of left ventricular function, 92.9% (K=0.80, 95% CI 0.636 to 0.882) for quantitative left ventricular ejection fraction by M-mode measurements, 98% (K=0.74, 95% CI 0.396 to 1.000) for the detection of pericardial effusion, and 64.2% (K=0.45, 95% CI 0.383 to 0.467) for IVC diameter assessment. The Bland–Altman limits of agreement for left ventricular function was −9.5% to 13.7%, and a Pearsons correlation yielded a value of 0.82 (p<0.0001, 95% CI 0.734 to 0.881). The trainees detected pericardial effusion with a sensitivity of 60%, specificity of 100%, positive predictive value of 100% and negative predictive value of 97.9%. Conclusions Emergency medicine trainees were found to be able to perform and interpret focused echocardiography reliably after a short duration of training.

Macrosomia is the only reliable predictor of shoulder dystocia in babies weighing 3.5 kg or more

OBJECTIVE To determine if shoulder dystocia can be predicted in babies born weighing 3.5 kg or more. STUDY DESIGN A case-control study nested in a perinatal database of 899 mothers and their babies who weighed 3.5 kg or more. All were term pregnancies and delivered vaginally. A case was defined as any baby that encountered shoulder dystocia at delivery. Controls were deliveries over the same period that were not complicated by shoulder dystocia. A logistic regression model was created with macrosomia, parity, previous delivery of more than 3.5 kg, diabetes in pregnancy, prolonged labor, prolonged second stage and instrumental delivery as the independent variables. The adjusted odds ratio and the receiver operator characteristics (ROC) curves were used to see if these variables, both individually and as a model, were associated with or were discriminative enough to predict shoulder dystocia; an ROC curve of more than 0.7 showing good prediction. RESULTS There were 36 cases of shoulder dystocia during the study period, an incidence of 4%. Previous delivery of more than 3.5 kg, prolonged labor and prolonged second stage were not associated with shoulder dystocia. Although diabetes and instrumental delivery were independently and significantly associated with shoulder dystocia their importance as a predictor became relevant only in the presence of macrosomia. CONCLUSION Macrosomia is the only reliable predictor of shoulder dystocia.

Increased Fracture Risk and Osteoporosis Not Associated With Vitamin D Levels in Malaysian Patients With Inflammatory Bowel Disease

INTRODUCTION Osteoporosis and osteopenia are well-recognized complications of inflammatory bowel disease. Previous studies have suggested that vitamin D deficiency is an important risk factor for the development of osteoporosis. We hypothesized that low vitamin D levels is the main reason for reduced bone mineral density in patients with inflammatory bowel disease. We aimed to study its potential role in Malaysia, which is a tropical country with 3 large ethnic groups. We also sought to examine the relationship between fracture risk and bone mineral density in this group. METHODOLOGY Relevant history as well as 25-hydroxycholecalciferol (vitamin D) levels and bone mineral density were obtained. Normal, inadequate, and low vitamin D levels were defined as 61-160 nmol/L (24-64 ng/mL), 30-60 nmol/L (12-24 ng/mL), and less than 30 nmol/L (<12 ng/mL), respectively. RESULTS Seventy-two patients were recruited. The prevalence of osteopenia and osteoporosis, respectively, were 58% and 17% in the spine and 51% and 14% in the hip. Mean vitamin D level in the group was low at 45.12 ± 17.4 nmol/L (18.05 ± 6.96 ng/mL), but there was no significant association between bone mineral density and vitamin D level. Twelve patients (16.7%) had a fragility fracture after the diagnosis of inflammatory bowel disease. The cumulative fracture incidence was 10% at 5 years and 35% at 10 years. There was a statistically significant association between osteoporosis of hip and a history of fracture (odds ratio 5.889; 95% confidence interval 1.41-24.53, P = .009). CONCLUSION Osteoporosis is prevalent among Malaysian patients with inflammatory bowel disease and is associated with a 6-fold increased risk of fractures. Most inflammatory bowel disease patients had inadequate or low vitamin D levels, but there was no association between vitamin D levels and BMD.

THE USE OF THE SEMEN ANALYSIS IN PREDICTING FERTILITY OUTCOME

This paper is a timely reminder of the poor relationship between semen analysis and fertility. On one hand low sperm motility and morphology did not reduce the pregnancy rates; on the other, the pregnancy rates were low despite normal semen, with over 50% not pregnant after 2 years.

Physical, psychological and sexual effects in multi‐ethnic Malaysian women who have undergone hysterectomy

Aim:  The postoperative effects on Asian women after hysterectomy have not been fully explored. This study was undertaken to investigate the physical, psychological and sexual functioning effects in multi‐ethnic Malaysian women who have undergone hysterectomy.

Awareness, perception and barriers to seeking information from online academic databases and medical journals as sources of information

ABSTRACT Medical students’ use of online medical journals as a source of information is crucial in the learning pathway to become medical doctors. We conducted a cross-sectional survey study among University medical students between December 2012 and March 2013 to assess their awareness, perceived usefulness, practices, and barriers to seeking information from online academic databases and medical journals. The response rate was 67.53%. The majority of the students knew of the availability of online academic databases and medical journals. The mean score for awareness (4.25 of possible 11.0), perceived usefulness (13.95 of possible 33.0), and practice (10.67 of possible 33.0) were low. The mean barrier score toward using online academic databases and medical journals was 25.41 (of possible 45.0). Multivariate findings showed that significant barriers associated with overall usage of online databases and medical journals were 1) not knowing where or how to locate databases and 2) unsureness of using the Boolean operators. Availability of full text subscriptions was found to be an important factor in using online databases. Study findings highlighted the need to increase awareness of academic databases’ availability and increase training on ways to search online academic databases and medical journals.