Preventable stillbirths and neonatal deaths in Malaysia: An analysis of the under-five mortality surveillance data 2015-2017.

INTRODUCTION: The under-five mortality (U5M) trend in Malaysia significantly declined from 30.0 per 1000 live births (1980) to 8.0 per 1000 live births (2004), and the trend plateaued over the next two decades. Stillbirths and neonatal deaths were the major contributors to U5M. Scarce literature addressing factors associated with preventable U5M in Malaysia. The objective of this study was to describe preventable stillbirths and neonatal mortality, the associated factors and recommendation for improvement. MATERIALS AND METHODS: The U5M surveillance data from 2015 to 2017 was retrieved for Malaysian cases of stillbirths and neonatal deaths with multiple pregnancies as exclusion. Stillbirth and neonatal death cases were analysed descriptively for socio-demographic and clinical characteristics. Logistic regressions were performed to identify the associated factors. RESULTS: There were 15,444 cases selected for analysis, of which 55% of stillbirths and 45% of neonatal deaths. There were 21% of preventable deaths (U5M) and the major contributing causes of preventable stillbirths and neonatal deaths were classified as perinatal death (82.5%), infectious and parasitic diseases (4.1%) and congenital malformations (3.5%). The birth weight (aOR 6.03, 95% CI: 4.14-8.79), hypertensive mother (aOR 1.88, 95% CI: 1.66-2.12) and instrumental delivery (aOR 1.64, 95% CI: 1.16-2.31) were significantly associated with preventable stillbirths and neonatal deaths. Higher household income (>RM3000 per month) was noted as a protective factor (aOR 0.79, 95% CI:0.69,0.89). Mothers with ethnicities other thanBumiputera, single mothers and housewives were identified as the group of mothers with higher odds of poor perinatal services. Among the 3242 cases of preventable stillbirths and neonatal deaths with a complete documented level of adequacy and quality of healthcare, the most frequently identified factors were due to insufficient antenatal care (ANC) (20.4%), non-compliance with medical advice (12.3%) and unsuitable place of delivery (8.6%). CONCLUSION: Increasing trend of preventable stillbirths and neonatal deaths was noted over 3 years (2015-2017), and one-fifth was related to insufficient ANC service-related factors. Remedial measures in improving the quality of ANC services with an emphasis on the targeted high-risk maternal socio-demographic group (other Bumiputera, older antenatal mothers, nonmarried, poor family income neglected family) and enhancing ANC competency skills among the healthcare provider through adequate training are required to decrease preventable stillbirths and neonatal deaths in Malaysia.

Self-reported bone fracture among Malaysian adults: Baseline findings of PURE Malaysia cohort study.

INTRODUCTION: In Malaysia, studies on self-reported bone fractures are scarce. Due to the fact that bone fractures may serve as an indicator of osteoporosis in the community, this study aimed to identify the factors associated with their occurrence among adults in Malaysia. MATERIALS AND METHODS: Epidemiological data for selfreported bone fractures were obtained through direct interviews using a validated questionnaire from the Prospective Urban and Rural Epidemiology (PURE) study. RESULTS: Of 15,378 respondents, 6.63% (n=1019) reported bone fractures, with a higher proportion of men (65.8%, n=671) than women (34.2%, n=348). Higher odds of selfreporting bone fractures were seen in males (aOR, 2.12; 95%CI: 1.69, 2.65), those with a history of injury (aOR 5.01; 95%CI: 3.10, 6.32) and those who were obese (aOR: 1.46; 95% CI: 1.13, 1.89), highly active (aOR 1.25; 95%CI: 1.02, 1.53), smokers (aOR 1.35; 95%CI: 1.11, 1.65) and alcohol consumers (aOR 1.67; 95%CI: 1.20,2.32). CONCLUSION: Adopting a healthier lifestyle that includes a balanced diet and moderate physical activity is critical for weight loss, increased muscle and bone mass and better stability, which reduces the likelihood of fractures following a fall.

Assessment of Implementation of Pre-pregnancy care services in Negeri Sembilan, Malaysia.

INTRODUCTION: Pre-pregnancy care (PPC) is an established health care program for women of reproductive age that has been widely implemented globally. The implementation of these services varies between countries based on the guidelines advocated. Thus, a standard level of assessment on measuring the performance of the service was difficult. This study aimed to measure the status of implementation PPC services among health workers using the transtheoretical model framework. METHODS: A cross-sectional study was conducted among 445 healthcare workers using a validated questionnaire based on local PPC guideline published by the Ministry of Health Malaysia (MOH). RESULTS: The results showed that many respondents were in the implementation action stage (57%), followed by the maintenance stage (20%), preparation stage (19%), contemplation stage (4%) and pre-contemplation stage (<1%). Further categorisation showed that only 43% of the respondents are successfully implementing PPC according to the standard of MOH. Clinics lead by the Family Medicine Specialist (Adjusted Odds Ratio, AOR 2.845; 95% Confidence Interval, 95%CI: 1.839, 4.40), daily usage of teleprimary care system (TPC) in the clinic (AOR 1.563; 95%CI: 1.019, 2.397), and attended TPC training (AOR 3.358; 95%CI: 2.221, 5.075) were significantly determining the success of PPC implementation. CONCLUSION: The emphasis on motivation and rewards among the healthcare workers, provision of good internet connection at health clinics and developing a comprehensive model of PPC training targeting the specific healthcare workers are mandatory to enhance the PPC services implementation.

The association between serum prolactin levels and interleukin-6 and systemic lupus erythematosus activity.

Based on the recent evidence of association between hyperprolactinemia and systemic lupus erythematosus disease activity (SLEDAI), a study was conducted to analyze the association of hyperprolactinemia with lupus nephritis disease activity. In this cross-sectional study, the analysis was conducted on SLE patients who visited the University Kebangsaan Malaysia Medical Centre (UKMMC) Nephrology Clinic from August 2015 till February 2016. The disease activity was measured using the SLEDAI score, with more than 4 indicating active lupus nephritis. Basal resting prolactin level was analyzed in 43 patients with lupus nephritis, in 27.9% of them had raised serum prolactin. The median of serum prolactin level at 0 minutes was 19.91 ng/mL (IQR: 15.95-22.65 ng/ mL) for active lupus nephritis, which was significantly higher compared to the median of serum prolactin level of 14.34 ng/mL (IQR: 11.09-18.70 ng/mL) for patients in remission (p=0.014). The serum prolactin level positively correlated with SLEDAI (rhos: 0.449, p=0.003) and the UPCI level in lupus nephritis patients (rhos: 0.241, p=0.032). The results were reproduced when the serum prolactin was repeated after 30 minutes. However, the serum prolactin levels at 0 minutes were higher than those taken after 30 minutes (p=0.001). An assessment of serum IL-6 levels found that the active lupus nephritis patients had a higher median level of 65.91 pg/ mL (IQR: 21.96-146.14 pg/mL) compared to the in-remission level of 15.84 pg/mL (IQR: 8.38-92.84 pg/mL), (p=0.039). Further correlation analysis revealed that there was no statistical correlation between the interleukin (IL)-6 levels with serum prolactin, SLEDAI and other lupus nephritis parameters. An ROC curve analysis of serum prolactin at 0 minutes and serum prolactin after 30 minutes and IL-6 levels for prediction of SLE disease activity provided the cutoff value of serum prolactin at 0 minutes, which was 14.63 ng/mL with a sensitivity of 91.7% and specificity of 58.1% and AUC of 0.74 (p=0.015). This study concurred with the previous findings that stated that hyperprolactinemia is prevalent in SLE patients and correlated with clinical disease activity and UPCI level. The baseline of the fasting serum prolactin level was found to be a sensitive biomarker for the evaluation of lupus nephritis disease activity.

A tale of two construct validation analysis: Rasch model and exploratory factor analysis approach for Three-Factor Eating Questionnaire (TFEQ-R21) among Malaysian male workers.

INTRODUCTION: This study aims for construct validation using two approaches, i.e., exploratory factor analysis and Rasch Model. METHODS: A cross sectional of 313 male workers from multiple worksites had completed self-administered Malay translated version of Three-Factor Eating Questionnaire- R21. Data quality was assessed by misfit person criteria, dimensionality, summary statistic, item measure and rating (partial credit) scale followed by exploratory factor analysis and internal consistency reliability assessment. RESULTS: The dual approaches of construct validation analysis were complement to each other. Rasch analysis supported the theoretical constructs of three eating behaviour dimensions among respondents. In contrary to exploratory factor analysis, it did show presence of a newfound factor (∝=0.04) came up from the separation of the cognitive restrain and uncontrolled eating however, the correlation between the two respective sub-factors were fair (r=0.39) and weak (r= -0.08). Both analyses had detected three problematic items but those items were psychometrically fit for used for current study setting. The data had adequate psychometric properties. Cronbach's alpha for cognitive restraint, uncontrolled eating and emotional eating were 0.66, 0.79 and 0.87 respectively. Rating scale quality was conformed to standard criteria. CONCLUSION: Malay version TFEQ-R21 with promising psychometric properties and valid measures for eating behaviour dimensions among male workers aged between 20 to 60 years old is now available. Further development should focus on the items in relation to Malaysian cultural adaptation before its use for daily practice in future setting.

Implications of immunosuppressive agents in cardiovascular risks and carotid intima media thickness among lupus nephritis patients.

INTRODUCTION: Patients with systemic lupus erythematosus, particularly with lupus nephritis (LN), are at risk of premature cardiovascular (CV) disease. OBJECTIVE: To determine the association between immunosuppressive medications, traditional CV risk factors and carotid intima media thickness (CIMT) among patients with LN. METHODOLOGY: This was a cross-sectional study in which consecutive LN patients attending the Nephrology/SLE Clinic were evaluated for traditional CV risk factors. Detailed information on their treatment was obtained from their medical records. CIMT, an excellent marker of subclinical atherosclerosis, was measured by B Mode carotid ultrasound. RESULTS: A total of 82 patients with LN with a mean age of 33.9 ± 9.8( )years were recruited. More than half had hypertension (n = 55, 67.1%) and dyslipidemia (n = 43, 52.4%) as traditional CV risks. Longer history and higher cumulative dose of corticosteroids were associated with hypertension, but use of intravenous methylprednisolone was associated with lower systolic and diastolic blood pressure and lower serum total cholesterol and triglyceride levels (p < 0.05 each). Hydroxychloroquine use was associated with lower total serum cholesterol and serum low-density lipoprotein levels (p < 0.05). Although the use of cyclosporine A (CyA) was associated with hypertension (p < 0.05), those who received a lower cumulative dose of CyA had thicker CIMT (r (s) = -0.33, p =0.01) and CyA use remained an independent predictor of CIMT during linear regression analysis. There were no associations between CIMT and cumulative dose and duration of steroids, hydroxychloroquine, azathioprine, mycophenolic acid and cyclophosphamide. CONCLUSION: Aggressive treatment of severe LN and the use of CyA as a steroid-sparing agent may have protective effects against premature atherosclerosis.

The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school.

INTRODUCTION: The stigma attached to mental illness and the mentally ill is a universal phenomenon and a major barrier to the provision of mental health services. Stigmatising attitudes among doctors themselves can result in compromised patient care. The aim of this research project is to study the impact of a clinical posting in psychiatry on the attitudes of medical students to mental illness and to psychiatry. This paper reports the results of the first phase of a longitudinal study. MATERIALS AND METHODS: A total of 122 year 4 medical students responded to this study. The Attitudes Towards Mental Illness (AMI) and Attitudes Towards Psychiatry (ATP) questionnaires were administered before and after an 8-week attachment in psychiatry. RESULTS: We found that students had somewhat favourable attitudes towards psychiatry and mental illness at the start of their attachment, with a mean score of 108.34 on ATP (neutral score, 90) and 68.24 on AMI (neutral score, 60). There was a significant increase in the mean scores of both scales following the psychiatric attachment for female students (ATP: P = 0.003; AMI: P <0.0005), but not male students (ATP: P = 0.435; AMI: P = 0.283). CONCLUSIONS: An 8-week clinical posting of fourth-year medical students in psychiatry was associated with an increase in positive attitudes to mental illness and to psychiatry among female students but not among male students.

Does clinical exposure to patients in medical school affect trainee doctors' attitudes towards mental disorders and patients?--A pilot study.

Stigmatising attitudes towards mental illness may improve with clinical exposure during medical school training. Attitudes of 48 fourth year medical students in Universiti Kebangsaan Malaysia were assessed before and after their compulsory attachment in Psychiatry, using the Attitude Towards Psychiatry-30 (ATP) and the Attitude towards Mental Illness (AMI) questionnaires. ATP scores improved significantly with training (104.8 and 114.4, pre- and post-attachment respectively) as did AMI scores (63.4 and 68.1 respectively). Both improvements were statistically significant. (ATP: z = 4.55, p < 0.0005) (AMI: z = 3.75, p < 0.0005). Attitudes towards mental illness appeared to have become more favourable with clinical training in psychiatry.