Goals, beliefs, knowledge, and barriers for diabetes self-care in a multi-ethnic population in Malaysia: A qualitative study.

INTRODUCTION: Ethnic differences may influence diabetes selfcare practices and glycaemic control among people with type 2 diabetes mellitus. This qualitative study explored goals, beliefs about treatment effectiveness, knowledge, and barriers to and facilitators for diabetes self-care among the three main ethnic groups in Malaysia. METHODS: Patient focus group discussions were conducted in three different ethnic groups: Malays, Chinese, and Indians. Participants were recruited from the primary-care clinic of a university medical centre located in an urban area. Focus group discussions were audio-recorded, transcribed, and analysed using a thematic approach. RESULTS: A total of 31 patients participated in the study: Malays (n=12), Indians (n=10), and Chinese (n=9). There were three sessions for each ethnic group. Reported goals primarily related to quality of life and glycaemic control. Participants expressed the belief that the combination of diet, exercise, and medications is effective for controlling diabetes. Groups described their obtaining information external to a healthcare system and reported a need for more specific, practical counselling from health professionals on diet, exercise, and medications. Barriers to and facilitators for diabetes self-care practices were categorised into three major themes: having discipline, social habits, and "other" themes. CONCLUSION: Emerging themes were similar across the ethnic groups and included quality-of-life goals, confidence in combination treatment, common use of complementary and alternative medicine, need for further counselling, and the challenge regarding self-discipline.

How should Malaysia respond to its ageing society?

As Malaysia ages its health and social care systems will have to adapt to a changing pattern of disease and dependency. Improved public health measures extend life expectancy at the relative expense of increased prevalence of currently incurable conditions such as dementia and Parkinson's disease. In this article we discuss how these demographic changes will impact and suggest possible means of coping with the altered epidemiology of disease and disability. Malaysia will need to swiftly develop sufficient expertise in acute Geriatric Medicine, rehabilitation of older people; the management of long-term conditions in older people with multiple complex problems within Primary Care; as well as an infrastructure for home and institutional care.

Cost-effectiveness of and satisfaction with a Helicobacter pylori "test and treat" strategy compared with prompt endoscopy in young Asians with dyspepsia.

OBJECTIVE: To compare a Helicobacter pylori "test and treat" strategy with prompt endoscopy in young Asians with dyspepsia. METHODS: A randomised, prospective study was carried out on uninvestigated dyspeptics aged <45 years in a single (academic) primary care centre. Patients were randomised to either a [(13)C]urea breath test (UBT) or prompt endoscopy (oesophagogastroduodenoscopy (OGD) and followed-up for 12 months. RESULTS: 432 patients (mean (SD) age 30 (8) years, male 46%, ethnicity: Malays 33.3%, Chinese 30.6%, Indians 34.7%) were randomised to UBT (n = 222) or OGD (n = 210). 387 (89.6%) patients completed the study. At 12 months, there was no difference in symptom change (measured by the Leeds Dyspepsia Questionnaire) between the two groups, but more patients were very satisfied (40.0% vs 21.6%, p<0.0001) in the OGD group. More additional endoscopy was performed in the UBT group (25 vs 10, p = 0.03), but medication consumption was higher in the OGD group (proton pump inhibitor 3.6 (8.8) vs 2.0 (7.5) weeks, p<0.001; H2 receptor antagonist 5.3 (9.7) vs 3.9 (9.2) weeks, p = 0.017; prokinetics 1.4 (4.7) vs 0.4 (2.5) weeks, p<0.001) and no differences in medical consultation were noted. The median cost of the initial prompt endoscopy approach at 12 months was significantly higher than a "test and treat" strategy (US$179.05 vs US$87.10, p<0.0001). CONCLUSION: A H. pylori "test and treat" strategy is more cost-effective but less satisfying than prompt endoscopy in the management of young Asian patients with uncomplicated dyspepsia.

Microalbuminuria prevalence study in hypertensive type 2 diabetic patients in Malaysia.

Microalbuminuria is the earliest indicator of diabetic kidney disease and generalised vascular endothelial dysfunction. The Microalbuminuria Prevalence (MAP) Study was carried out to assess the prevalence of macroalbuminuria, microalbuminuria and normoalbuminuria in Asian hypertensive patients with type 2 diabetes on usual care. This paper presents a subanalysis of data from patients in Malaysia. In 733 analysed patients, the prevalence of macroalbuminuria and microalbuminuria was 15.7% and 39.7%, respectively. The high prevalence of diabetic nephropathy in these high-risk patients is a cause for concern, and the Malaysian Health Care system should be prepared for a pandemic of end-stage renal disease due to diabetic nephropathy.

Social support and glycemic control in adult patients with type 2 diabetes mellitus.

INTRODUCTION: The purpose of this study is to examine the prevalence of social support and its association with glycemic control in patients with type 2 diabetes mellitus (T2D) in an urban primary care center within an academic institution. Social support is important in the management of chronic diseases. However, its association with glycemic control has been controversial. METHODS: This was part of a study examining religiosity in T2D patients. Nonsmoking patients with T2D for at least 3 years and aged 30 years and above were recruited. Social support was measured using The Social Support Survey-Medical Outcomes Study (SS), a self-administered questionnaire; the scores range from 19 to 95, and a high score indicates better social support. Glycemic control was measured using the 3 most recent glycosylated hemoglobin (HbA1c) levels within the past 3 years. RESULTS: A total of 175 participants completed the SS survey (response rate 79.0%). The mean age was 62.7 (standard deviation [SD] = 10.8) years, and the mean duration of diabetes was 11.74 (SD = 6.7) years. The mean HbA1c level was 8.15 (SD = 1.44). The mean SS score was 68.1. The prevalence of high and low social support were 29.7% and 24.0 %, respectively. A significant correlation was found between SS score and number of social supporters (n = 167). No significant correlation was found between the self-reported number of social supporters or the SS score and the mean HbA1c level. CONCLUSIONS: Social support was not associated with glycemic control in adult patients with T2D in this primary care setting.

Late-onset hemorrhagic cystitis associated with urinary excretion of polyomaviruses after bone marrow transplantation.

Hemorrhagic cystitis is a well known complication of allogeneic bone marrow transplantation (BMT) and is normally attributed to the use of high-dose cyclophosphamide in the preparative regimen. Hemorrhagic cystitis occurring late after BMT is unlikely to be due to the effects of this conditioning, and probably has an infective etiology. Three patients undergoing BMT for chronic granulocytic leukemia (CGL) developed terminal dysuria and hematuria at 38, 56, and 149 days post-BMT. Electron microscopy (EM) of urine voided at these times revealed large numbers of papovavirions, which were subsequently identified as BK virus. Urine samples inoculated onto human embryonic lung fibroblasts induced infection of the cells and replication of the virus as detected by EM of tissue culture fluid. Urine from one of these patients was examined by standard cytological techniques, and EM of urothelial cells showed nuclear inclusions consisting of nonencapsulated virus particles of diameter 40 nm, consistent with papovavirus. Five further patients were found to be excreting BK virus without symptoms of cystitis, although one of these patients did experience abnormalities of liver function that were otherwise unexplained. BK virus has already been implicated in hepatic dysfunction posttransplant, and in cystitis in nonimmunosuppressed children. We postulate that it may also be involved in the etiology of late hemorrhagic cystitis after BMT.

Differences in properties between aromatic amino acid: aromatic keto acid aminotransferases and aromatic amino acid: alpha-ketoglutarate aminotransferases.

Homogenates of rat liver transaminate phenylpyruvate (PP), as well as alpha-ketoglutarate (alpha-KG), in the presence of L-tyrosine, 3,4-dihydroxyphenylalanine (L-DOPA) or L-tryptophan. Aminotransferase activity with phenylpyruvate and DOPA, but not with tyrosine, was inhibited by excess phenylpyruvate. Tyrosine and DOPA aminotransferase activities with phenylpyruvate were more heat stable than the corresponding activities with alpha-ketoglutarate. Aminotransferase activities with phenylpyruvate were not significantly induced following intraperitoneal injections of cortisol, glucagon or serotonin, compared with a 3 to 7-fold increase in the aminotransferase activities with alpha-ketoglutarate. Tyrosine:phenylpyruvate aminotransferase activity rose 40% at night, compared with a 300% increase in tyrosine:alpha-ketoglutarate aminotransferase activity. The results suggest that aminotransferases catalysing transfers between aromatic keto acids and aromatic amino acids are separate enzymes from those utilizing alpha-ketoglutarate as the acceptor keto acid.

Streptococcal pharyngitis in a primary care clinic.

A study to determine the sensitivity and specificity of the Directogen Group A Streptococcal Test was carried out in a primary care clinic in University Hospital, Kuala Lumpur. The study also looked at the prevalence of streptococcal pharyngitis in the clinic. We found that the rapid test has a sensitivity of 90.9% and a specificity of 90.7%. Viral pharyngitis is the commonest form (63%) of pharyngitis followed by Group A Beta haemolytic streptococcal pharyngitis (14.2%). The presence of exudates, tonsillar enlargement and the presence of tender cervical lymph nodes have a significantly higher association with streptococcal pharyngitis.

A profile of hypertension among rural elderly Malaysians.

The main objective of this study was to survey the prevalence of hypertension in Malaysians aged 55 years and above who responded to a public health screening campaign in Kuala Langat district, Selangor, Malaysia. The relationship between the detection, treatment and control in the study population was also examined. An epidemiological survey of the elderly was conducted in Kuala Langat, a rural district in Malaysia for a consecutive period of six weeks. The survey was conducted using a standardized questionnaire and interview by trained research assistants. The medical students and nurses were trained on the correct protocol of measuring blood pressure based on the recommendations of the British Hypertension Society. Newly detected persons with blood pressure readings 160/95 mmHg and above, were given a green card to return to the nearest health center for a further 2 visits to check his/her blood pressure. A total of 1,392 people with a mean age of 65 years and comprising of 53.1% males and 46.9% females responded to the health survey. Based on the history 335 (24.1%) of the respondents were known hypertensives and 82.1% of this hypertensive group were on regular treatment. However good control of hypertension was achieved only in 161 (48.1%) of them. Newly detected hypertension was found in 204 (14.6%) of the respondents. The overall prevalence of hypertension in our sample of respondents was 25.6%. There was no significant difference between the sexes and the races in terms of their detection, treatment and control. However there was a significant difference between the persons aged less than 65 years of age and those older than 65 years. There was a large proportion of previously known hypertensives among the survey population. Of those detected, not all were on regular medications and the majority on medications were not well controlled. Education of the public through intensive public health campaigns is vital to improve their knowledge on hypertension and the need for effective control. More community studies are needed to formulate better methods in the detection, treatment and control of hypertension.

Communication skills teaching in primary care medicine.

The teaching of clinical communication skills to undergraduate medical students in the Faculty of Medicine, University of Malaya is described. It is a continuous process throughout the five-year medical curriculum which is divided into Phases I, II and III. Students are introduced to communication skills early in Phase I through an interactive session as well as a workshop on general communication skills. In Phase II, small-group two-day workshops cover the basic principles of clinical communication skills using videotapes, group discussion and role-plays. Direct contact between students and patients in actual clinical setting begin in Phase IIIA. Communication skills teaching with feedback training is carried out by videotaping the consultations. In Phase IIIB the two-way mirror is utilized as well as having workshops on certain difficult areas such as 'breaking bad news' and 'taking a sexual history'. Formal assessment is done by evaluating the behavior, language and actual interview content.

The prevalence of diabetic peripheral neuropathy in an outpatient setting.

This study was undertaken to clinically estimate the prevalence of diabetic peripheral neuropathy amongst patients attending an outpatient clinic and to evaluate their risk factors for developing peripheral neuropathy. It was a cross-sectional study of 134 diabetes mellitus patients who attended the Primary Care Clinic, University Hospital, Kuala Lumpur. The patients were interviewed for their demographic data, past and present medical/surgical history, social history, personal habits and symptoms of peripheral neuropathy. Foot examination and clinical neurological tests were conducted and the presence of peripheral neuropathy was assessed. The main outcome measures were the Neuropathy Symptom Score and the Neuropathy Disability Score. The prevalence of diabetic peripheral neuropathy was found to be 50.7%. Peripheral neuropathy was related to the age of the patient and the duration of diabetes but did not seem to be significantly related to diabetic control. To conclude, there was a high prevalence of peripheral neuropathy amongst the diabetics in this study. These patients developed peripheral neuropathy at a younger age and shorter duration of diabetes compared to a similar study that was done in the UK.

Peak expiratory flow rate in elderly Malaysians.

An epidemiological survey was conducted among 1,414 healthy ambulatory elderly persons aged 55 years and above in the Kuala Langat district, Selangor. The relationship between peak expiratory flow rate (PEFR), demographic variables, socioeconomic status, smoking, alcohol use and respiratory symptoms were examined. The peak expiratory flow declined with age and were lower in women of all ages. Smoking had a modest effect on PEFR in men but not on PEFR in women. The combination of respiratory symptoms of cough, phlegm and wheeze were related to lower PEFR values. Prediction equations are presented derived from the population sample which may be of assistance in assessing observed to expected ratios among elderly people in Malaysia.

Review of tools of cardiovascular disease risk stratification: interpretation, customisation and application in clinical practice.

Cardiovascular Disease (CVD) is the leading cause of death in both developed and developing countries. While it is relatively easy to identify those who are obviously at high risk and those at the lowest risk for CVD, it is often the large group of individuals with what appears to be modestly abnormal risk factors who contributes most to the burden of CVD. This is where estimation of CVD risk is necessary. Many tools for risk assessment have been devised. All these risk scores have their own inherent advantages and disadvantages. Furthermore, they may also not be directly applicable to a local population. Ideally, each country should have its own risk score that takes into account other factors as well. In the interim, it is worthwhile to be familiar with one of these scores, select one that is most appropriate for your patient and discuss treatment options based on the estimated risk.

Efficacy and tolerability of lercanidipine in mild to moderate hypertension among Asians of different ethnic groups.

INTRODUCTION: Calcium channel blockers are well established modalities for the treatment of hypertension. However, in spite of the availability of many efficacious agents, hypertension control continues to be poor. One reason is poor tolerability due to adverse events. Racial differences also exist. Lercanidipine, a third-generation calcium channel blocker, is associated with better tolerability. However, it has not been studied in the Asian population. This study examines its efficacy and tolerability in Asian subjects of different ethnicities. METHODS: This was an eight-week open label study of adults with mild to moderate hypertension. Blood pressure (BP), pulse rate, self-administered symptom check and laboratory evaluations were done at baseline. Patients were prescribed 10 mg lercanidipine, with up-titration to 20 mg if BP was not controlled at Week 4. Baseline evaluations were repeated at Week 8. Adverse events were also enumerated. RESULTS: 27 patients (mean age 53.4 +/- 12.1 years) completed the study. The baseline systolic BP (SBP), diastolic BP (DBP) and heart rate was 159 +/- 12.2, 96.6 +/- 7.7 mmHg and 71 +/- 13/min, respectively. Three racial groups were represented. SBP and DBP decreased significantly after four weeks of therapy. A further reduction to 139 +/- 14.3 and 88 +/- 9.8 (p-value is less than 0.0001) was seen in Week 8. The absolute SBP and DBP reduction was 20.5 mmHg (95 percent confidence interval [CI] 16.5-24.5, p-value is less than 0.0001) and 9.3 mmHg (95 percent CI 6.2-12.5, p-value is less than 0.0001), respectively. All adverse symptoms, except for palpitations, were reduced at the end of the study. CONCLUSION: Lercanidipine is efficacious and well tolerated in Asians of different ethnicities. Its BP lowering effects and tolerability in Asians appear to be similar to other studies on Caucasians and other calcium channel blockers.

Antibiotic prescribing for childhood febrile illness by primary care doctors in Malaysia.

AIM: Fever in children, a mostly benign and self-limiting illness, is often viewed with consternation by the care givers. It results in early consultation and excessive use of antipyretics and antibiotics. In this study, we document the prescribing practice of doctors from three primary care settings in Malaysia and identify the predictors of antibiotic prescription. METHODS: Interview of care givers bringing febrile children (age 7 days), higher temperature (>38 degrees C) and the diagnosis of upper respiratory tract infections. After controlling for demographic and clinical factors, antibiotic prescription in private general practice clinic was seven times higher than public primary care clinic (odds ratio 7.1, 95% confidence interval 4.0-12.7), and 1.6 times higher than university-based primary care clinic (odds ratio 1.6, 95% confidence interval 1.0-2.5). CONCLUSION: Differences in the patients' demographic and clinical characteristics could not adequately explain the high antibiotic prescribing rate in private general practice clinics. This inappropriately high antibiotic prescribing for febrile children in private general practice clinics is a suitable target for future intervention.

The role of platelets in mesangial localization: carbon uptake in thrombocytopenic rats.

The role of platelets in mesangial localization has been studied in Lewis rats following a single intravenous injection of colloidal carbon 32 mg/100 g body weight. Following carbon injection there was an abrupt thrombocytopenia (peripheral platelet count at 10 min 165 +/- 107 X 10(3)/mm3). Temporary sequestration of platelets in lung, liver and spleen was demonstrated using quinacrine-labelled platelets. Carbon was quantitated in blood, lung, liver and spleen by digestion and spectrophotometry and in glomerular mesangium by particle counting of histological sections under oil-immersion microscopy. In thrombocytopenic rats (busulphan 17.5 mg/kg weight) blood carbon levels (up to 1 h after injection) were higher than normal controls (P less than 0.01) and mesangial carbon content at 24 h was significantly increased (P less than 0.01). No significant alteration in mononuclear phagocytic function was detected at 24 h. In platelet-restored thrombocytopenic rats, (busulphan-treated, infused with homologous platelets) blood and mesangial carbon levels were decreased towards normal values. These findings show that (1) platelets are involved in the initial removal of carbon from the blood (2) mesangial localization is related to blood levels and (3) platelet numbers affect both these parameters. The finding of increased mesangial deposition in thrombocytopenic rats may have significance for immune complex glomerulonephritis where platelet numbers may be low due to persistent platelet activation.

Aristolactams and dioxoaporphines from Fissistigma balansae and Fissistigma oldhamii.

Investigation of extracts of Fissistigma balansae and Fissistigma oldhamii resulted in the isolation of 11 aristolactams-stigmalactam (1), piperolactam A (2), piperolactam C (3), aristolactam AII (4), aristolactam AIIIa (5), aristolactam BII (6), aristolactam BIII (7), aristolactam FII (8), goniothalactam (9), enterocarpam I (10), and velutinam (11)-as well as two dioxoaporphines, noraristolodione (12) and norcepharadione B (13). The new compound 1 was identified by spectral data interpretation. Compounds 1-13 were subjected to antiplatelet aggregation testing.