Management of prediabetes in Malaysian population: An experts' opinion.

INTRODUCTION: Prediabetes, typically defined as blood glucose levels above normal but below diabetes thresholds, denotes a risk state that confers a high chance of developing diabetes. Asians, particularly the Southeast Asian population, may have a higher genetic predisposition to diabetes and increased exposure to environmental and social risk factors. Malaysia alone was home to 3.4 million people with diabetes in 2017; the figure is estimated to reach 6.1 million by 2045. Developing strategies for early interventions to treat prediabetes and preventing the development of overt diabetes and subsequent cardiovascular and microvascular complications are therefore important. METHODS: An expert panel comprising regional experts was convened in Kuala Lumpur, for a one-day meeting, to develop a document on prediabetes management in Malaysia. The expert panel comprised renowned subject-matter experts and specialists in diabetes and endocrinology, primary-care physicians, as well as academicians with relevant expertise. RESULTS: Fifteen key clinical statements were proposed. The expert panel reached agreements on several important issues related to the management of prediabetes providing recommendations on the screening, diagnosis, lifestyle and pharmacological management of prediabetes. The expert panel also proposed changes in forthcoming clinical practice guidelines and suggested that the government should advocate early screening, detection, and intensive management of prediabetes. CONCLUSION: This document provides a comprehensive approach to the management of prediabetes in Malaysia in their daily activities and offer help in improving government policies and the decision-making process.

Are interventions to increase the uptake of screening for cardiovascular disease risk factors effective? A systematic review and meta-analysis.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death globally. However, many individuals are unaware of their CVD risk factors. The objective of this systematic review is to determine the effectiveness of existing intervention strategies to increase uptake of CVD risk factors screening. METHODS: A systematic search was conducted through Pubmed, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials. Additional articles were located through cross-checking of the references list and bibliography citations of the included studies and previous review papers. We included intervention studies with controlled or baseline comparison groups that were conducted in primary care practices or the community, targeted at adult populations (randomized controlled trials, non-randomized trials with controlled groups and pre- and post-intervention studies). The interventions were targeted either at individuals, communities, health care professionals or the health-care system. The main outcome of interest was the relative risk (RR) of screening uptake rates due to the intervention. RESULTS: We included 21 studies in the meta-analysis. The risk of bias for randomization was low to medium in the randomized controlled trials, except for one, and high in the non-randomized trials. Two analyses were performed; optimistic (using the highest effect sizes) and pessimistic (using the lowest effect sizes). Overall, interventions were shown to increase the uptake of screening for CVD risk factors (RR 1.443; 95% CI 1.264 to 1.648 for pessimistic analysis and RR 1.680; 95% CI 1.420 to 1.988 for optimistic analysis). Effective interventions that increased screening participation included: use of physician reminders (RR ranged between 1.392; 95% CI 1.192 to 1.625, and 1.471; 95% CI 1.304 to 1.660), use of dedicated personnel (RR ranged between 1.510; 95% CI 1.014 to 2.247, and 2.536; 95% CI 1.297 to 4.960) and provision of financial incentives for screening (RR 1.462; 95% CI 1.068 to 2.000). Meta-regression analysis showed that the effect of CVD risk factors screening uptake was not associated with study design, types of population nor types of interventions. CONCLUSIONS: Interventions using physician reminders, using dedicated personnel to deliver screening, and provision of financial incentives were found to be effective in increasing CVD risk factors screening uptake.

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Somatisation disorder and its associated factors in multiethnic primary care clinic attenders.

BACKGROUND: Somatisation disorder (SD) has been reported as common in all ethnic groups, but the estimates of its prevalence have varied and the evidence for its associated factors has been inconsistent. PURPOSE: This study seeks to determine the prevalence of SD and its associated factors in multiethnic primary care clinic attenders. METHODS: This cross-sectional study was on clinic attenders aged 18 years and above at three urban primary care clinics in Malaysia. The operational definition of SD was based on ICD-10 criteria for SD for research, frequent attendance, and excluded moderate to severe anxiety and depression. The instruments used were the ICD-10 symptom list, the Hospital Anxiety and Depression Scale, a semi-structured questionnaire, and SF-36. RESULTS: We recruited 1,763 patients (response rate 63.8%). The mean age of respondents was 44.7 ± 15.8 years, 807 (45.8%) were male; there were 35.3% Malay, 30.1% Chinese and 34.6% Indian. SD prevalence was 3.7%; the prevalence in Malay was 5.8%, Indian 3.0% and Chinese 2.1%. Significant associations were found between SD prevalence and ethnicity, family history of alcoholism, blue-collar workers and the physical component summary (PCS) score of SF-36. Multivariate analysis showed that SD predictors were Malay ethnicity (OR 2.7, 95% CI 1.6, 4.6), blue-collar worker (OR 2.0, 95% CI 1.2, 3.5) and impaired PCS score of SF-36 (OR 0.92, 95% CI 0.90, 0.95). CONCLUSION: The prevalence of SD was relatively uncommon with the stringent operational criteria used. SD preponderance in blue-collar workers may be attributable to secondary gain from getting sickness certificates and being paid for time off work.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries.

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

How should front-line general practitioners use personal protective equipment (PPE)?

The COVID-19 outbreak continues to evolve with the number of cases increasing in Malaysia, placing a significant burden on general practitioners (GPs) to assess and manage suspected cases. GPs must be well equipped with knowledge to set up their clinics, use Personal Protective Equipment (PPE) appropriately, adopt standard protocols on triaging and referrals, as well as educate patients about PPE. The correct use of PPE will help GPs balance between personal safety and appropriate levels of public concern.

COVID-19: Four Paediatric Cases in Malaysia.

OBJECTIVE: This is a brief report of 4 paediatric cases of COVID-19 infection in Malaysia BACKGROUND: COVID-19, a coronavirus, first detected in Wuhan, China has now spread rapidly to over 60 countries and territories around the world, infecting more than 85000 individuals. As the case count amongst children is low, there is need to report COVID-19 in children to better understand the virus and the disease. CASES: In Malaysia, until end of February 2020, there were four COVID-19 paediatric cases with ages ranging from 20 months to 11 years. All four cases were likely to have contracted the virus in China. The children had no symptoms or mild flu-like illness. The cases were managed symptomatically. None required antiviral therapy. DISCUSSION: There were 2 major issues regarding the care of infected children. Firstly, the quarantine of an infected child with a parent who tested negative was an ethical dilemma. Secondly, oropharyngeal and nasal swabs in children were at risk of false negative results. These issues have implications for infection control. Consequently, there is a need for clearer guidelines for child quarantine and testing methods in the management of COVID-19 in children.

Cervical cancer screening attitudes and beliefs of Malaysian women who have never had a pap smear: a qualitative study.

BACKGROUND: Attitudes toward cervical cancer and participation in early detection and screening services are well known to be profoundly affected by cultural beliefs and norms. PURPOSE: This study explored the attitudes and sociocultural beliefs on cervical cancer screening among Malaysian women. METHOD: In this qualitative study, in-depth interviews were conducted with 20 Malaysian women, ages 21 to 56 years, who have never had a Papanicolaou (Pap) smear. RESULTS: Respondents generally showed a lack of knowledge about cervical cancer screening using Pap smear, and the need for early detection for cervical cancer. Many believed the Pap smear was a diagnostic test for cervical cancer, and since they had no symptoms, they did not go for Pap screening. Other main reasons for not doing the screening included lack of awareness of Pap smear indications and benefits, perceived low susceptibility to cervical cancer, and embarrassment. Other reasons for not being screened were related to fear of pain, misconceptions about cervical cancer, fatalistic attitude, and undervaluation of own health needs versus those of the family. CONCLUSION: Women need to be educated about the benefits of cervical cancer screening. Health education, counseling, outreach programs, and community-based interventions are needed to improve the uptake of Pap smear in Malaysia.

Prevalence of peripheral arterial disease in patients with diabetes mellitus in a primary care setting.

The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.

Peripheral arterial disease in general and diabetic population.

Peripheral arterial disease (PAD) is stenosis or occlusion of peripheral arterial vessels by atherosclerotic plaque. It may present as intermittent claudication, rest pain and impotence. PAD of the lower limbs is the third most important site of atherosclerotic disease after coronary heart disease and cerebrovascular disease. Increasing age, family history, smoking, hypertension, dyslipidemia and more decisively diabetes are significant risk factors. PAD is a clinical condition that has often been neglected, underdiagnosed, undertreated and has a serious outcome. It may lead to nonhealing wounds, gangrene and amputation of the lower limbs. Hence, early identification of patients at risk of PAD and timely referral to the vascular surgeon in severe cases is crucial.

A primary care experience of open access to exercise stress test.

This study described the practice profile of an open access exercise stress test (EST) service to the primary care physicians at a teaching hospital in 2000. We performed a retrospective review of all ESTs ordered and conducted by the primary care physicians. A total of 145 ESTs were conducted, of which 80.7% were referred for assessment of chest pain. Proportions of positive, negative, uninterpretable and inconclusive ESTs were: 22.1%, 52.8%, 18.1% and 6.9%. Typical chest pain was independently associated with a positive EST in this study (p = 0.008, OR 5.50, 95% CI 1.56-19.37). Although referral to the open access EST service seemed appropriate, there is a need to reduce the number of uninterpretable and inconclusive results.

Management of type 2 diabetes mellitus: is it in accordance with the guidelines?

A cross-sectional study was conducted among 517 patients with diabetes mellitus at all health centres in Melaka Tengah District to examine whether these patients and their associated cardiovascular risk factors were managed according to current guidelines. All patients had Type 2 diabetes mellitus with mean age of 57.9 +/- 10.5 years and the mean duration of diabetes was 7.2 +/- 6.0 years. The glycaemic control was poor with 53.6% of the patients having HbAlc above 8% (mean = 8.5%) and 24% of them had microalbuminuria. Among these patients with poor glycaemic control, about 47.6% of them were on monotherapy. Three hundred and fifty (67.7%) patients had hypertension but only 11 (3.1%) achieved target blood pressure of less than 130/80 mmHg. Only 18.3% of the diabetics with hypertension were prescribed angiotensin converting enzyme inhibitors and 0.3% with angiotensin receptor blockers. Nearly two-third of them had low-density lipoprotein cholesterol greater than 2.6 mmol/l (mean = 3.4 mmol/l) but only 6.8% were prescribed lipid-lowering agents. Aspirin was prescribed to 8.2% of diabetics aged above 40 years. Sixteen percent of the patients smoked, 53% did not do any exercise, and the mean BMI was 26.8 kg/mn. The management of diabetes mellitus and its associated cardiovascular risk factors was suboptimal on the basis of current clinical guidelines. A greater effort in educating doctors in the health centres about these management and adherence to the guidelines is important in reducing patients' risk of cardiovascular disease and its associated morbidity and mortality.

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.

Tuberculosis in Malaysia: predictors of treatment outcomes in a national registry.

OBJECTIVES: To determine treatment outcomes and associated predictors of all patients registered in 2012 with the Malaysian National Tuberculosis (TB) Surveillance Registry. METHODS: Sociodemographic and clinical data were analysed. Unfavourable outcomes included treatment failure, transferred out and lost to follow-up, treatment defaulters, those not evaluated and all-cause mortality. RESULTS: In total, 21 582 patients were registered. The mean age was 42.36 ± 17.77 years, and 14.2% were non-Malaysians. The majority were new cases (93.6%). One fifth (21.5%) had unfavourable outcomes; of these, 46% died, 49% transferred out or defaulted and 1% failed treatment. Predictors of unfavourable outcomes were older age, male sex, foreign citizenship, lower education, no bacille Calmette-Guérin (BCG) vaccination scar, treatment in tertiary settings, smoking, previous anti-tuberculosis treatment, human immunodeficiency virus infection, not receiving directly observed treatment, advanced chest radiography findings, multidrug-resistant TB (MDR-TB) and extra-pulmonary TB. For all-cause mortality, predictors were similar except for rural dwelling and nationality (higher mortality among locals). Absence of BCG scar, previous treatment for TB and MDR-TB were not found to be predictors of all-cause mortality. Indigenous populations in East Malaysia had lower rates of unfavourable treatment outcomes. CONCLUSIONS: One fifth of TB patients had unfavourable outcomes. Intervention strategies should target those at increased risk of unfavourable outcomes and all-cause mortality.

How well were asthmatic patients educated about their asthma? A study at the emergency department.

70 patients presented with acute asthma exacerbation requiring nebulised bronchodilator treatment at the emergency department of a teaching hospital in Kuala Lumpur, Malaysia, were interviewed over a two-week period in July 2001. The results showed that 45 (64%) patients had not been educated on the nature of asthma; 30 (43%) had not been advised on preventive measures or avoidance of triggers; 54 (77%) were not advised about the medications used and their side effects; 42 (60%) patients did not know the difference between reliever and preventive medications; 37 (53%) were unable to recognize features of worsening asthma and 68 (97%) were not told about the danger of non-prescribed self-medication or traditional medications. Only six (9%) patients were using peak flow meters and were taught self-management plans. The multiple regression results suggest that patients who were followed up at teaching hospital based clinics were better educated on asthma. In conclusion, asthmatic patients are still not educated well about their disease. Health care providers need to put more emphasis on asthma education so that the number of emergency room visits can be reduced.

A comparative study on the service profiles and practice facilities among urban general practices in east and west Malaysia.

1171 urban general practices in East and West Malaysia were compared regarding their service profiles and practice facilities. In general, practices in both parts put important emphasis on preventive health care. More practices in East Malaysia were providing hormone replacement therapy and sexually transmitted diseases services but less were providing intrapartum care, counselling services including sexual and marital counselling and problems associated with social deviance such as alcohol and drug abuse. Although most practices in East Malaysia were solo practices, they were more comprehensive in terms of the provision of practice facilities when compared to those in West Malaysia. A greater number of them had ultrasound facilities, peak flow meters, ECG machines, computers and blood biochemistry facilities.

Asthma control and prior medical care of patients presenting with acute asthma at the emergency department.

Seventy patients presented with acute asthma at the emergency department of the University of Malaya Medical Centre, Kuala Lumpur were recruited over a two-week period in July 2001. Fifty-one (73%) patients belonged to the poorly controlled group. Fifty-seven (81%) patients were using inhaled salbutamol but 21 (30%) were still using oral short acting salbutamol. Only 32 (46%) patients used inhaled corticosteroids. In the poorly controlled group, 22 (43.1%) patients were not on regular inhaled corticosteroids, 35 (68.6%) were not receiving "add-on" medication and 18 (35%) did not have regular follow up. The emergency department should implement a protocol for asthma management and follow up to achieve better long term patient care.

The management of upper respiratory tract infections.

Upper respiratory tract infections are the commonest reason for consultation in primary care. Group A beta-haemolytic Streptococcus (GABHS), the most important bacterial pathogen in this condition, can be cultured from about 30% of patients, more so in children than adults. Clinical features that are predictive of positive GABHS culture are absence of cough, fever, cervical adenopathy, tonsillar enlargement and tonsillar exudate. Use of a sore throat score can help in the detection of streptococcal throat infection. Symptomatic therapies which are useful include anticholinergic, antihistamine, decongestant, humified hot air and Vitamin C. Antibiotics are universally over-prescribed in this condition as a result of high patient expectation and faulty clinical decision making. Oral Penicillin V for 10 days is the drug of choice. Effective intervention to reduce inappropriate antibiotic prescription probably require a multifaceted approach targeted at both the patients and the prescribers.

Managing dengue fever in primary care: A practical approach.

Dengue is a common cause of illness seen in primary care in the tropical and subtropical countries. An understanding of the course of disease progression, risk factors, recognition of the warning signs and look out for clinical problems during the different phases of the disease will enable primary care physicians to manage dengue fever in an appropriate and timely manner to reduce morbidity and mortality.