Lipid profiles and lifestyle habits of stroke survivors in the east coast region of peninsular Malaysia: Preliminary findings.

Background: Stroke survivors are at high risk for recurrent cardiovascular events if no prevention strategies are undertaken. Aim: This study aimed to investigate the fasting serum lipid profiles and lifestyle habits in stroke survivors, and the factors associated with suboptimal lipid profiles. Methods: A cross-sectional retrospective study was conducted in three public hospitals in Malaysia. Stroke survivors' data regarding the socio-demographic characteristics, clinical profiles, fasting serum lipid profiles, dietary adherence, and physical activity levels were acquired. Binary logistic regression was used to examine the factors associated with suboptimal lipid goals. Results: A total of 104 stroke survivors were recruited from patients attending the neurology and rehabilitation departments. Only 22% of the stroke survivors attained the targeted low-density lipoprotein cholesterol level (LDL-C < 1.8 mmol/L). Meanwhile, more than two thirds of patients achieved the targeted total cholesterol, triglyceride, and high-density lipoprotein cholesterol goals. Patients with a longer stroke duration (Adjusted odds ratio, AOR 3.33, 95% confidence intervals, CI: 1.09, 10.13, p = 0.034), elevated blood pressure (AOR 4.74, 95% CI: 1.65, 13.62, p = 0.004), chronic kidney disease (AOR 3.30, 95% CI: 1.05, 10.34, p = 0.041), abdominal obesity (AOR 3.14, 95% CI: 1.20, 8.21, p = 0.020), excessive energy intake (AOR 2.72, 95% CI: 1.07, 6.91, p = 0.036), and excessive saturated fatty acids intake (AOR 2.85, 95% CI: 1.02, 7.93, p = 0.045) were significantly associated with suboptimal lipid profiles. Conclusion: The lipid goals attainment was low, particularly the LDL-C levels among Malaysian stroke survivors. Greater efforts are warranted to fully utilise the lipid-lowering therapy and the lifestyle changes in these high-risk patients.

Glucocerebrosidase (GBA) gene variants in a multi-ethnic Asian cohort with Parkinson's disease: mutational spectrum and clinical features.

GBA variants are associated with increased risk and earlier onset of Parkinson's disease (PD), and more rapid disease progression especially with "severe" variants typified by p.L483P. GBA mutation screening studies from South-East Asia, with > 650 million inhabitants of diverse ancestries, are very limited. We investigated the spectrum of GBA variants, and associated clinico-demographic features, in a multi-ethnic PD cohort in Malaysia. Patients (n = 496) were recruited from seven centres, primarily of Chinese (45%), Malay (37%), and Indian (13%) ethnicities. All GBA coding exons were screened using a next-generation sequencing-based PD gene panel and verified with Sanger sequencing. We identified 14 heterozygous GBA alleles consisting of altogether 17 missense variants (8 classified as pathogenic or likely pathogenic for PD) in 25 (5.0%) patients, with a substantially higher yield among early (< 50 years) vs. late-onset patients across all three ethnicities (9.1-13.2% vs. 1.0-3.2%). The most common variant was p.L483P (including RecNciI, n = 11, 2.2%), detected in all three ethnicities. Three novel variants/recombinant alleles of uncertain significance were found; p.P71L, p.L411P, and p.L15S(;)S16G(;)I20V. The common European risk variants, p.E365K, p.T408M, and p.N409S, were not detected. A severe disease course was noted in the majority of GBA-variant carriers, across a range of detected variants. We report a potentially novel observation of spine posture abnormalities in GBA-variant carriers. This represents the largest study on GBA variation from South-East Asia, and highlights that these populations, especially those with EOPD, would be relevant for studies including clinical trials targeting GBA pathways.

Health-related quality of life profiles and their dimension-specific associated factors among Malaysian stroke survivors: a cross sectional study.

BACKGROUND: Apart from maximizing functional abilities and independence after stroke, improving overall health-related quality of life (HRQoL) should also become part of the stroke treatment and rehabilitation process goals. This study aimed to assess the HRQoL profiles and explore the dimension-specific associated factors of HRQoL among stroke survivors. METHODS: This was a cross-sectional study of stroke survivors attending post-stroke care clinics in three public hospitals in the states of Pahang and Terengganu, Malaysia. The HRQoL was assessed by EuroQol-5 dimension-5 levels. Data on socio-demographic, clinical profiles, malnutrition risk, and physical activity level were collected through an interviewer-administered survey. Descriptive analyses for HRQoL profiles and multiple logistic regression analyses for its associated factors were performed. Crude and adjusted odds ratios were reported. RESULTS: A total of 366 stroke survivors were recruited with a mean age of 59 ± 11 years. The most -commonly reported health problems were mobility (85%), followed by usual activities (82%), pain/discomfort (63%), anxiety/depression (51%) and self-care (41%). The mean of the EQ visual analogue scale and the median of the EQ5D summary index was reported at 60.3 ± 14.2 and 0.67 ± 0.37, respectively. Malnutrition risk (mobility, usual activities, and self-care), wheelchair users (self-care and usual activities), speech impairment (usual activities and pain/discomfort), number of stroke episodes (self-care and pain/discomfort), body mass index, physical activity level and types of strokes (usual activities), age and use of a proxy (anxiety/depression), working and smoking status (mobility), were factors associated with either single or multiple dimensions of HRQoL. CONCLUSION: Routine malnutrition screening, tailored program for speech therapy, prevention of recurrent stroke, and physical activity promotion should be addressed and further reinforced in current rehabilitation interventions to improve the HRQoL among stroke survivors in Malaysia.

Association study of MCCC1/LAMP3 and DGKQ variants with Parkinson's disease in patients of Malay ancestry.

BACKGROUND: Genome-wide association studies (GWAS) have shown that variants in the 3-methylcrotonyl-CoA carboxylase (MCCC1)/lysosome-associated membrane protein 3 (LAMP3) loci (rs10513789, rs12637471, rs12493050) reduce the risk of Parkinson's disease (PD) in Caucasians, Chinese and Ashkenazi-Jews while the rs11248060 variant in the diacylglycerol kinase theta (DGKQ) gene increases the risk of PD in Caucasian and Han Chinese cohorts. However, their roles in Malays are unknown. Therefore, this study aims to investigate the association of these variants with the risk of PD in individuals of Malay ancestry. METHODS: A total of 1114 subjects comprising of 536 PD patients and 578 healthy controls of Malay ancestry were recruited and genotyped using Taqman® allelic discrimination assays. RESULTS: The G allele of rs10513789 (OR = 0.83, p = 0.001) and A allele of rs12637471 (OR = 0.79, p = 0.007) in the MCCC1/LAMP3 locus were associated with a protective effect against developing PD in the Malay population. A recessive model of penetrance showed a protective effect of the GG genotype for rs10513789 and the AA genotype for rs12637471. No association with PD was found with the other MCCC1/LAMP3 rs12493050 variant or with the DGKQ (rs11248060) variant. No significant associations were found between the four variants with the age at PD diagnosis. CONCLUSION: MCCC1/LAMP3 variants rs10513789 and rs12637471 protect against PD in the Malay population.

Predictors of Recurrent Ischemic Stroke in Obese Patients With Type 2 Diabetes Mellitus: A Population-based Study.

BACKGROUND: Diabetes and obesity are established risk factors for stroke. The current study aimed to assess risk factors of ischemic stroke recurrence in diabetic patients based on their body mass index (BMI). METHODS: A total of 4005 diabetic patients who had a history of ischemic stroke were identified in a retrospective cross-sectional dataset from the Malaysian National Neurology Registry. Patients were classified based on BMI, and multivariable regression analysis was used to evaluate the association between risk factors and recurrent ischemic stroke. RESULTS: Among obese patients, those with ischemic heart disease (aOR, 1.873; 95% CI, 1.131-3.103), received formal education (aOR, 2.236; 95% CI, 1.306-3.830), and received anti-diabetic medication (aOR, 1.788; 95% CI, 1.180-2.708) had a higher stroke recurrence risk, while receiving angiotensin receptors blockers (aOR, 0.261; 95% CI, 0.126-0.543) lowered the odds of recurrence. Overweight patients with hypertension (aOR, 1.011; 95% CI, 1.002-1.019) for over 10 years (aOR, 3.385; 95% CI, 1.088-10.532) and diabetes prior to the first stroke (aOR, 1.823; 95% CI, 1.020-3.259) as well as those received formal education (aOR, 2.403; 95% CI, 1.126-5.129) had higher odds of stroke recurrence, while receiving angiotensin-converting enzyme inhibitors (aOR, 0.244; 95% CI, 0.111-0.538) lowered the recurrence risk. Normal weight East Malaysians (aOR, 0.351; 95% CI, 0.164-0.750) receiving beta-blockers (aOR, 0.410; 95% CI, 0.174-0.966) had lower odds of stroke recurrence. CONCLUSIONS: Ischemic heart disease, hypertension, receiving anti-hypertensive agents, and educational level were independent predictors of recurrent stroke in obese patients. Managing the modifiable risk factors can decrease the odds of stroke recurrence.

Prevalence and Predictors of Malnutrition Risk among Post-Stroke Patients in Outpatient Setting: A Cross-Sectional Study.

BACKGROUND: The present study examined the prevalence and predictors of malnutrition risk among post-stroke patients. METHODS: Post-stroke patients who attended the outpatient clinics in three hospitals of Peninsular Malaysia were enrolled in the study. The risk of malnutrition was assessed using the Malnutrition Risk Screening Tool-Hospital. Data including demographic characteristics, clinical profiles, dietary nutrients intake, body mass index (BMI) and hand grip strength were collected during the survey. The crude odds ratio (OR) and adjusted odds ratio (AOR) were reported for univariate and multivariate logistic regression analyses, respectively. RESULTS: Among 398 patients included in the study, 40% were classified as high-risk for malnutrition. In the multivariable logistic regression, tube feeding (AOR: 13.16, 95% confidence interval [CI]: 3.22-53.77), loss of appetite (AOR: 8.15, 95% CI: 4.71-14.12), unemployment (AOR: 4.26, 95% CI: 1.64-11.12), wheelchair-bound (AOR: 2.23, 95% CI: 1.22-4.09) and BMI (AOR: 0.87, 95% CI: 0.82-0.93) were found to be significant predictors of malnutrition risk among stroke patients. CONCLUSION: The risk of malnutrition is highly prevalent among post-stroke patients. Routine nutritional screening, identification of risk factors, and continuous monitoring of dietary intake and nutritional status are highly recommended even after the stroke patient is discharged.

Comparison of concurrent validity of different malnutrition screening tools with the Global Leadership Initiative on Malnutrition (GLIM) among stroke survivors in Malaysia.

Individuals with stroke are at high malnutrition risk in both the acute and chronic phases. This study aimed to assess the validity of different malnutrition screening tools for stroke patients in rehabilitation phase. Participants in this study were 304 stroke patients from three hospitals in the East-Coast region of Peninsular Malaysia from May-August 2019. The concurrent validity of the Malnutrition Risk Screening Tool-Hospital (MRST-H), Mini Nutritional Assessment-Short Form (MNA-SF), Malnutrition Screening Tool (MST), Malnutrition Universal Screening (MUST) and Nutritional Risk Screening (NRS-2002) was assessed with the diagnostic criteria for malnutrition proposed by the Global Leadership Initiative on Malnutrition (GLIM-DCM). Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the curve were computed. MUST and MRST-H demonstrated good validity regardless of different age groups (> 80% sensitivity and specificity); meanwhile, MST and MNA-SF had fair validity, yet NRS-2002 had poor to fair validity with GLIM-DCM. Only MRST-H and NRS-2002 were significantly correlated with all anthropometric indices, dietary energy intake, and health-related quality of life in both age groups. In conclusion, MRST-H and MUST showed good concurrent validity with GLIM-DCM and can be considered as appropriate malnutrition screening tool in discriminating malnutrition among stroke individuals attending rehabilitation centre in Malaysia regardless of their age groups.

A mixed-methods study on the implementation of a mobile health application (mHealth app) for stroke caregivers in Malaysia: healthcare providers' perspective.

Introduction: Recognizing the burden experienced by caregivers of stroke survivors, an intervention using mobile health applications (mHealth apps) has been proposed to support and empower stroke caregivers. This study aimed to assess the acceptability and expectations of healthcare providers, who play a vital role as gatekeepers in the healthcare system, to ensure the effectiveness and sustainability of the intervention. Methods: This was a concurrent mixed-method study design, with healthcare providers involved in stroke care management in the northeast regions of Malaysia as study participants. The qualitative component of the study was conducted using a phenomenological approach that involved in-depth interviews to explore the acceptability and expectations of healthcare providers regarding the adoption of mHealth apps in the context of stroke caregiving. The study was complemented by quantitative data collected through an online survey using an adjusted version of the technology acceptance model tool. Results: In total, 239 participants from diverse backgrounds and professions were enrolled in the study, with 12 in the qualitative component and 227 in the quantitative component. The findings from the quantitative survey showed that over 80% of the participants expressed their intention to use mHealth apps. The qualitative component generated two themes related to the acceptability and expectations of mHealth apps, which were integrated with the quantitative findings. Additionally, in-depth interviews revealed a new theme, namely the key features of mHealth, with three sub-themes: availability of services for caregivers, provision of knowledge skills, and supporting caregivers in managing stroke patients. Conclusion: Healthcare providers demonstrated excellent acceptability of this mHealth intervention as part of caregiving assistance, particularly with the inclusion of essential key features. However, future investigations are necessary to establish the feasibility of integrating the mHealth app into the healthcare system and to ensure its long-term sustainability.

Genetic study of early-onset Parkinson's disease in the Malaysian population.

BACKGROUND: About 5-10% of Parkinson's disease (PD) cases are early onset (EOPD), with several genes implicated, including GBA1, PRKN, PINK1, and SNCA. The spectrum and frequency of mutations vary across populations and globally diverse studies are crucial to comprehensively understand the genetic architecture of PD. The ancestral diversity of Southeast Asians offers opportunities to uncover a rich PD genetics landscape, and identify common regional mutations and new pathogenic variants. OBJECTIVES: This study aimed to investigate the genetic architecture of EOPD in a multi-ethnic Malaysian cohort. METHODS: 161 index patients with PD onset ≤50 years were recruited from multiple centers across Malaysia. A two-step approach to genetic testing was used, combining a next-generation sequencing-based PD gene panel and multiplex ligation-dependent probe amplification (MLPA). RESULTS: Thirty-five patients (21.7%) carried pathogenic or likely pathogenic variants involving (in decreasing order of frequency): GBA1, PRKN, PINK1, DJ-1, LRRK2, and ATP13A2. Pathogenic/likely pathogenic variants in GBA1 were identified in thirteen patients (8.1%), and were also commonly found in PRKN and PINK1 (11/161 = 6.8% and 6/161 = 3.7%, respectively). The overall detection rate was even higher in those with familial history (48.5%) or age of diagnosis ≤40 years (34.8%). PRKN exon 7 deletion and the PINK1 p.Leu347Pro variant appear to be common among Malay patients. Many novel variants were found across the PD-related genes. CONCLUSIONS: This study provides novel insights into the genetic architecture of EOPD in Southeast Asians, expands the genetic spectrum in PD-related genes, and highlights the importance of diversifying PD genetic research to include under-represented populations.

Possible Sarcopenia and Its Association with Nutritional Status, Dietary Intakes, Physical Activity and Health-Related Quality of Life among Older Stroke Survivors.

BACKGROUND: Screening for sarcopenia in the stroke population is an emerging concept in research and clinical practice. Therefore, this cross-sectional study aimed to assess the prevalence of possible sarcopenia and its associated factors among older stroke survivors who visited the neurology and rehabilitation departments of three public hospitals in Malaysia. METHODS: We acquired data on sociodemographic characteristics, clinical profiles, malnutrition risk, dietary intake, physical activity level, and health-related quality of life. Possible sarcopenia was diagnosed in individuals with decreased calf circumference and low handgrip strength, as proposed by the Asia Working Group for Sarcopenia (2019). Finally, we performed descriptive analysis and binary logistic regression. RESULTS: Among 196 older adults with stroke (mean± standard deviation of age: 67.60 ± 5.70 years), 42.3% had possible sarcopenia, with a higher prevalence in the more advanced age group (≥70 years). In univariable analysis, possible sarcopenia was significantly associated with anthropometric indices, malnutrition risk, nutrient intake, physical activity level, and health-related quality of life. In multivariable analysis, body mass index (adjusted odds ratio [AOR]=0.57; 95% confidence interval [CI], 0.43-0.75) was the only factor associated with possible sarcopenia among individuals aged ≥70 years. Recurrent stroke (AOR=3.48; 95% CI, 1.02-11.92), body mass index (AOR=0.64; 95% CI, 0.54-0.76), and EQ-5D index (AOR=0.15; 95% CI, 0.03-0.78) were significantly associated with possible sarcopenia in the 60-69-year age group. CONCLUSION: The prevalence of possible sarcopenia among community-dwelling older stroke survivors was high. Therefore, we recommend routine screening for possible sarcopenia to ensure early nutritional and exercise intervention.

Experiences and needs of the caregivers of stroke survivors in Malaysia-A phenomenological exploration.

Introduction: Informal caregivers play a crucial role in supporting the activities of daily living, rehabilitation, and the road to recovery for stroke survivors. However, these informal caregivers are often reported as experiencing neglect and lack of recognition despite their primary contribution to stroke recovery. This study investigated the experiences of the caregivers of stroke survivors and access to stroke care in Malaysia. Method: This qualitative study with a phenomenological approach utilized in-depth interviews, including ten primary caregivers, one formal caregiver, and stroke healthcare providers as the participants. The interviews were done until the data saturation was achieved, and the data was analyzed using thematic analysis. Result: Three primary themes and 14 subthemes were identified from the interviews. The role of primary caregivers of stroke survivors had tremendous physical, mental and social impact on the caregivers. Caregivers had two primary needs. The need for information about comprehensive stroke care at home and the need for psychological support to themselves. The key internal driver for providing care was identified to be the motivation level of the stroke survivor and the external driver was identified to be the societal support with access to comprehensive stroke care. Conclusion: The role of informal caregivers becomes critical for continuum of stroke care. As caregivers take up the roles and responsibilities of those who contribute to stroke rehabilitation single-handedly soon after hospital discharge. Results of this study highlights the needs for providing systematic support to caregivers for engaging them in effective stroke care, particularly in the community. Stroke service providers, policy makers and program planners must be sensitized to empower caregivers of stroke survivors in effectively supporting stroke survivor in their family on the road of recovery.

Population-based Study Comparing Predictors of Ischemic Stroke Recurrence After Index Ischemic Stroke in Non-elderly Adults with or without Diabetes.

BACKGROUND AND PURPOSE: Factors associated with ischemic stroke (IS) recurrence and the contribution of pharmacological treatment as secondary preventions among nondiabetics especially in the non-elderly population are unclear and not widely investigated. This was a population-based study that aimed to identify recurrent IS predictors and to determine the possible impact of secondary preventive medications on the IS recurrence in non-elderly adults with or without diabetes. METHODS: Data of 3386 patients <60 years old who had a history of index IS were extracted from the Malaysian National Neurology Registry (NNEUR) from 2009 to 2016. Recurrent IS was defined as any IS event recorded after the index IS in the NNEUR database. Multivariate logistic regression analysis was performed by using SPSS version 22. RESULTS: Ischemic heart disease (IHD) was the significant predictor of IS recurrence in non-elderly adults both with or without diabetes (adjusted odds ratio (AOR) of 3.210; 95%CI: 1.909-5.398 and 2.989; 95%CI: 1.515-5.894) respectively). Receiving antiplatelet as secondary stroke prevention (AOR: 0.194; 95%CI: 0.046-0.817) and continuation of antidiabetic medication after the index IS event (AOR: 0.510; 95%CI: 0.298-0.872) reduced the odds of IS recurrence only in non-elderly diabetic adults. Among non-elderly adults without diabetes, hyperlipidemia and every increased in 1 mmHg of systolic blood pressure significantly increased the odds of IS recurrence following the indexing event (AOR: 1.796; 95%CI: 1.058-3.051 and 1.009; 95%CI: 1.002-1.016 respectively). CONCLUSION: IHD was found as the main predictor of IS recurrence regardless of diabetes status in non-elderly adults after the index IS event. Receiving antidiabetic and antiplatelet medications upon discharge after index IS were significant predictors of recurrent IS in non-elderly diabetic adults. A proper randomized clinical trial may be required to determine the impact of secondary preventive medication on IS recurrence, especially in non-elderly adults.

Gender Differences and Risk Factors of Recurrent Stroke in Type 2 Diabetic Malaysian Population with History of Stroke: The Observation from Malaysian National Neurology Registry.

BACKGROUND AND PURPOSE: Diabetes mellitus has been reported as a strong independent risk factor for stroke recurrence. Data on the modifiable factors contributing to the recurrence of stroke in type 2 diabetic Malaysian population with a history of stroke stratified by genders are lacking, and this supports the importance of this study. METHOD: The data of 4622 patients with T2DM who had a history of stroke was obtained from the Malaysian National Stroke Registry. Univariate analysis was performed to differentiate between genders with and without stroke recurrence in terms of demographics, first stroke attack presentations, and other clinical characteristics. The significant factors determined from the univariate analysis were further investigated using logistic regression. RESULTS: Ischemic heart diseases were found significantly associated with the stroke recurrence in males (OR = 1.738; 95% CI: 1.071-2.818) as well as female (OR = 5.859; 95% CI: 2.469-13.752) diabetic patients. The duration of hypertension, as well as the duration of diabetes, has been associated with the recurrence in both male and female subjects (p value < 0.05). Smoking status has an impact on the stroke recurrence in male subjects, while no significant association was observed among their peers. CONCLUSIONS: Most of the predictive factors contributing to the recurrence of stroke in type 2 diabetic Malaysian population with a history of stroke are modifiable, in which IHD was the most prominent risk factor in both genders. The impact of optimizing the management of IHD as well as blood glucose control on stroke recurrence may need to be elucidated. No major differences in recurrent stroke predictors were seen between genders among the Malaysian population with type 2 diabetes mellitus who had a previous history of stroke.