A systematic review of thromboembolic complications and outcomes in hospitalised COVID-19 patients.

Thromboembolic (TE) complications [myocardial infarction (MI), stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE)] are common causes of mortality in hospitalised COVID-19 patients. Therefore, this review was undertaken to explore the incidence of TE complications and mortality associated with TE complications in hospitalised COVID-19 patients from different studies. A literature search was performed using ScienceDirect and PubMed databases using the MeSH term search strategy of "COVID-19", "thromboembolic complication", "venous thromboembolism", "arterial thromboembolism", "deep vein thrombosis", "pulmonary embolism", "myocardial infarction", "stroke", and "mortality". There were 33 studies included in this review. Studies have revealed that COVID-19 patients tend to develop venous thromboembolism (PE:1.0-40.0% and DVT:0.4-84%) compared to arterial thromboembolism (stroke:0.5-15.2% and MI:0.8-8.7%). Lastly, the all-cause mortality of COVID-19 patients ranged from 4.8 to 63%, whereas the incidence of mortality associated with TE complications was between 5% and 48%. A wide range of incidences of TE complications and mortality associated with TE complications can be seen among hospitalized COVID-19 patients. Therefore, every patient should be assessed for the risk of thromboembolic complications and provided with an appropriate thromboprophylaxis management plan tailored to their individual needs.

Risk factors for tuberculosis-related death among adults with drug-sensitive pulmonary tuberculosis in Selangor, Malaysia from 2013 to 2019: a retrospective cohort study using surveillance data.

OBJECTIVES: Due to the paucity of literature on risk factors for tuberculosis (TB)-related death, we determine the sociodemographic and clinical risk factors associated with TB-related deaths among adult pulmonary TB (PTB) patients on treatment in Selangor, Malaysia. DESIGN: Retrospective cohort study. SETTING: Routinely collected primary care data from all government TB clinics in Selangor. PARTICIPANTS: Data of 24 570 eligible adult PTB patients from 2013 to 2019 were obtained from Selangor's State Health Department surveillance records. We included PTB patients aged at least 15 years old at the time of diagnosis with complete documentation of the dates of diagnosis, treatment initiation, end of treatment/follow-up and treatment outcomes. We excluded patients whose diagnoses were changed to non-TB, post-mortem TB diagnosis and multidrug-resistant TB (MDR-TB) patients. PRIMARY AND SECONDARY OUTCOME MEASURES: TB-related death, determined from the recorded physicians' consensus during the TB mortality meeting. RESULTS: TB-related death was significantly associated with far (adjusted HR (aHR) 9.98, 95% CI 4.28 to 23.28) and moderately advanced (aHR 3.23, 95% CI 1.43 to 7.31) radiological findings at diagnosis; concurrent TB meningitis (aHR 7.67, 95% CI 4.53 to 12.98) and miliary TB (aHR 6.32, 95% CI 4.10 to 9.74) involvement; HIV positive at diagnosis (aHR 2.81, 95% CI 2.21 to 3.57); Hulu Selangor (aHR 1.95, 95% CI 1.29 to 2.93), Klang (aHR 1.53, 95% CI 1.18 to 1.98) and Hulu Langat (aHR 1.31, 95% CI 1.03 to 1.68) residing districts; no formal education (aHR 1.70, 95% CI 1.23 to 2.35); unemployment (aHR 1.54, 95% CI 1.29 to 1.84), positive sputum smear acid-fast bacilli (AFB) at diagnosis (aHR 1.51, 95% CI 1.22 to 1.85); rural residency (aHR 1.39, 95% CI 1.13 to 1.72) and advancing age (aHR 1.03, 95% CI 1.02 to 1.03). CONCLUSIONS: Far and moderately advanced radiological findings, concurrent TB meningitis and miliary TB involvement, HIV positive, Hulu Selangor, Klang and Hulu Langat residing districts, no formal education, unemployment, positive sputum smear AFB, rural residency and advancing age are risk factors of TB-related death. Our findings should assist in identifying high-risk patients requiring interventions against TB-related death.

The Impact of Heat Waves on Health Care Services in Low- or Middle-Income Countries: Protocol for a Systematic Review.

BACKGROUND: Heat waves significantly impact ecosystems and human health, especially that of vulnerable populations, and are associated with increased morbidity and mortality. Besides being directly related to climate-sensitive health outcomes, heat waves have indirectly increased the burden on our health care systems. Although the existing literature examines the impact of heat waves and morbidity, past research has mostly been conducted in high-income countries (HICs), and studies on the impact of heat waves on morbidity in low- or middle-income countries (LMICs) are still scarce. OBJECTIVE: This paper presents the protocol for a systematic review that aims to provide evidence of the impact of heat waves on health care services in LMICs. METHODS: We will identify peer-reviewed studies from 3 online databases, including the Web of Science, PubMed, and SCOPUS, published from January 2002 to April 2023, using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Quality assessment will be conducted using the Navigation Guide checklist. Key search terms include heatwaves, extreme heat, hospitalization, outpatient visit, burden, health services, and morbidity. RESULTS: This systematic review will provide insight into the impact of heat waves on health care services in LMICs, especially on emergency department visits, ambulance call-outs, hospital admissions, outpatient department visits, in-hospital mortality, and health care operational costs. CONCLUSIONS: The results of this review are anticipated to help policymakers and key stakeholders obtain a better understanding of the impact of heat waves on health care services and prioritize investments to mitigate the effects of heat waves in LMICs. This entails creating a comprehensive heat wave plan and ensuring that adequate infrastructure, capacity, and human resources are allocated in the health care sector. These measures will undoubtedly contribute to the development of resilience in health care systems and hence protect the health and well-being of individuals and communities. TRIAL REGISTRATION: PROSPERO CRD42022365471; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=365471. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44702.

Development of the Malay Language of understanding, attitude, practice and health literacy questionnaire on COVID-19 (MUAPHQ C-19): content validity & face validity analysis.

OBJECTIVE: This study aimed to assess the content and face validity index of the development of the understanding, attitude, practice and health literacy questionnaire on COVID-19 (MUAPHQ C-19) in the Malay language. METHODS: The development of the MUAPHQ C-19 was conducted in two stages. Stage I resulted in the generation of the instrument's items (development), and stage II resulted in the performance of the instrument's items (judgement and quantification). Six-panel experts related to the study field and ten general public participated to evaluate the validity of the MUAPHQ C-19. The content validity index (CVI), content validity ratio (CVR) and face validity index (FVI) were analysed using Microsoft Excel. RESULTS: There were 54 items and four domains, namely the understanding, attitude, practice and health literacy towards COVID-19, identified in the MUAPHQ C-19 (Version 1.0). The scale-level CVI (S-CVI/Ave) for every domain was above 0.9, which is considered acceptable. The CVR for all items was above 0.7, except for one item in the health literacy domain. Ten items were revised to improve the item's clarity, and two items were deleted due to the low CVR value and redundancy, respectively. The I-FVI exceeded the cut-off value of 0.83 except for five items from the attitude domain and four from the practice domains. Thus, seven of these items were revised to increase the clarity of items, while another two were deleted due to low I-FVI scores. Otherwise, the S-FVI/Ave for every domain exceeded the cut-off point of 0.9, which is considered acceptable. Thus, 50-item MUAPHQ C-19 (Version 3.0) was generated following the content and face validity analysis. CONCLUSIONS: The questionnaire development, content validity, and face validity process are lengthy and iterative. The assessment of the instruments' items by the content experts and the respondents is essential to guarantee the instrument's validity. Our content and face validity study has finalised the MUAPHQ C-19 version that is ready for the next phase of questionnaire validation, using Exploratory and Confirmatory Factor Analysis.

Design, development, utility and usability testing of the EMPOWER-SUSTAIN Self-Management Mobile App© among primary care physicians and patients with metabolic syndrome.

Objective: This study aimed to design, develop, assess and refine the EMPOWER-SUSTAIN Self-Management Mobile App© among primary care physicians (PCP) and patients with metabolic syndrome (MetS) in primary care. Methodology: Using the software-development-life-cycle (SDLC) iterative model, storyboard and wireframe were drafted; and a mock prototype was designed to illustrate the content and function graphically. Subsequently, a working prototype was developed. Qualitative studies using the 'think-aloud' and cognitive-task-analysis methods were conducted for the utility and usability testing. Topic guide was based on the 10-Nielsen's-Heuristic-Principles. Utility testing was conducted among PCP in which they 'thought-aloud' while performing tasks using the mobile app. Usability testing was conducted among MetS patients after they were given the app for 3 weeks. They 'thought-aloud' while performing tasks using the app. Interviews were audio- and video-recorded, and transcribed verbatim. Thematic content analysis was performed. Result: Seven PCP and nine patients participated in the utility and usability testing, respectively. Six themes (efficiency of use, user control and freedom, appearance and aesthetic features, clinical content, error prevention, and help and documentation) emerged. PCP found the mobile app attractive and relevant sections were easy to find. They suggested adding 'zoom/swipe' functions and some parts needed bigger fonts. Patients commented that the app was user-friendly, has nice interface, and straightforward language. It helped them understand their health better. Based on these findings, the mobile app was refined. Conclusion: This app was produced using a robust SDLC method to increase users' satisfaction and sustainability of its use. It could potentially improve self-management behaviour among MetS patients in primary care.

The Impacts of Supervised Exercise Intervention on Tobacco Withdrawal Symptoms.

This study examined a supervised moderate-intensity aerobic exercise programme's effectiveness in regulating the Tobacco Withdrawal Symptoms (TWS) during temporary abstinence. This was a single group, pre and post-quasi intervention study. Thirty daily smokers participated in an 8-week supervised moderate-intensity aerobic exercise programme. We assessed the TWS, smoking urge, mood and stress-pleasure related hormonal variables after the aerobic exercise intervention. The measurements were conducted after overnight abstinence at baseline, post-intervention (at week-8) and post-detraining (at week-10). TWS components, smoking urge and mood were found to improve. For hormonal variables, cortisol and beta-endorphin except adrenaline showed insignificant changes at post-intervention and de-training. The findings suggest moderate-intensity exercise might help in reducing withdrawal symptoms and its adverse effects. Thus, exercise is an effective adjunct treatment in a smoking cessation programme.

Cognitive Decline and Its Associated Factors in Patients with Major Depressive Disorder.

BACKGROUND: Major Depressive Disorder (MDD) is a significant and common mental health problem occurring worldwide. Cognitive decline is frequently observed during acute and residual phases of MDD, contributing significantly to functional impairment. The aim of this study was to determine the clinical profile and correlates of cognitive decline amongst adult outpatients with MDD. METHODS: The survey was cross-sectional in design. A systematic random sampling method was used to recruit patients. Confirmation of MDD was achieved by using the Mini International Neuropsychiatric Interview (M.I.N.I 7.0). Cognitive decline was measured using the Montreal Cognitive Assessment (MoCA). Descriptive analysis was performed, followed by univariate and multiple logistic regression analyses. RESULTS: Out of 245 patients, 32.7% (n = 80, 95% CI: 26.7, 38.6) had cognitive decline. Multiple logistic regression showed the existence of cognitive decline amongst MDD patients, which was significantly associated with those having secondary and lower levels of education (OR: 6.09; 95% CI: 2.82, 13.16; p < 0.001), five or more depressive episodes (OR: 8.93; 95% CI: 3.24, 24.67; p < 0.001), treatment non-compliance (OR: 3.48; 95% CI: 1.40, 6.59; p = 0.003), and medical comorbidity (OR: 2.74; 95% CI: 1.46, 5.18; p = 0.002). CONCLUSIONS: Cognitive decline is a prevalent condition among outpatients with MDD. Clinicians need to be cognizant about measures of cognition and related risk factors. Timely control of both depression and medical comorbidities would be a reasonable approach to improve functional outcomes in MDD patients.

Association of zinc level with DNA methylation and its consequences: A systematic review.

Background: DNA methylation is an effective epigenetic process that is frequently linked to changes in gene expression. Zinc is a vital micronutrient that plays a crucial role in DNA methylation. Therefore, abnormal zinc levels may cause aberrant DNA methylation and other diseases. Objectives: To investigate the influence of zinc on gene-specific and global DNA methylation in humans and rodents, their tissues and their cells. Method: Systematic literature searches were conducted using Medline, Scopus, Google Scholar, and Web of Science databases. Studies that met the inclusion criteria and were published in English language were included. Data including the first author, sample size, subjects, targeted genes, tissue types or cells analysed, zinc level, molecular techniques, DNA methylation outcomes, and consequences were extracted. Results: From a total of 2360 articles screened by title and abstract, 15 met the inclusion criteria. Qualitative analysis indicates that there are associations between zinc deficiency and gene-specific hypomethylation in humans and between zinc deficiency and hypermethylation in rodents. Zinc did not influence LINE-1 methylation in humans. Depending on cell type, zinc could have a positive or negative effect on global methylation in humans and rodents. As predicted, in general, gene expression was elevated by DNA hypomethylation and the corresponding protein levels were also upregulated. However, some studies showed that zinc deficiency led to reduced gene expression or no alteration in mRNA levels and corresponding protein levels. Conclusion: Our study shows links between zinc levels and DNA methylation. However, greater significance may be achieved if more than one independent investigator analyses the same set of genes in the same cell type. Therefore, gene-cell and animal-specific investigations are recommended to reduce variability and allow comparisons across studies.

A Systematic Review on the Effect of Saffron Extract on Lipid Profile in Hyperlipidaemic Experimental Animal Models.

Saffron is widely used in traditional medicine to treat various medical disorders, including hyperlipidaemia. This study aims to systematically review the effects of saffron extract (SE) on lipid profile in in vivo studies. A strategic literature search was done following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Scopus, PubMed (MEDLINE) and Web of Science databases and hand-searching methods were utilised to identify studies published up to January 2020 that reported the effects of SE on lipid profile in a hyperlipidaemic experimental animal model. A total of six articles met the inclusion criteria. The methods of extraction were aqueous (n = 4), ethanolic (n = 1) and hydroalcoholic (n = 1) extracts. Five doses of SE ranging from 10 mg/kg to 100 mg/kg were administered to rats and hamsters, with a duration ranging from 10 days to 8 weeks. SE at doses of 40 mg/kg/day and 80 mg/kg/day significantly decreased the levels of total cholesterol (21.4%-35.4%), low-density lipoproteins (38.7%-50.0%) and triglycerides (TGs) (29.1%-45.0%) and markedly increased the level of high-density lipoproteins (36.6%-65%) in the treated group compared to the untreated group with a minimum 3-week intervention duration (P < 0.05). This systematic review demonstrated that SE exhibits hypolipidaemic effects compared to a placebo. SE has almost the same ability to reduce cholesterol levels as the standard therapy.

Prevalence, determinants and outcomes of traditional, complementary and alternative medicine use for hypertension among low-income households in Malaysia and the Philippines.

BACKGROUND: Traditional, complementary and alternative medicine (TCAM) is used to treat a broad range of conditions. In low- and middle-income countries (LMICs), TCAM use is particularly common among those with low socio-economic status. To better understand the patterns and impact of TCAM use on the management of non-communicable diseases in these populations, this study examines the prevalence and characteristics of TCAM use for hypertension, its determinants, and its association with hypertension management outcomes and wellbeing among low-income adults in two Southeast Asian countries at different levels of economic and health system development, Malaysia and the Philippines. METHODS: We analysed cross-sectional data from 946 randomly selected adults diagnosed with hypertension from low-income rural and urban communities in Malaysia (n = 495) and the Philippines (n = 451). We compared the prevalence, characteristics and household expenditure on TCAM use between countries and used multi-level, mixed-effects regression to estimate associations between TCAM use and its determinants, and five hypertension management outcomes and wellbeing. RESULTS: The prevalence of TCAM use to manage hypertension was higher in the Philippines than in Malaysia (18.8% vs 8.8%, p < 0.001). Biologically-based modalities, e.g. herbal remedies, were the most common type of TCAM used in both countries, mainly as a complement, rather than an alternative to conventional treatment. Households allocated around 10% of health spending to TCAM in both countries. Belief that TCAM is effective for hypertension was a positive predictor of TCAM use, while belief in conventional medicine was a negative predictor. TCAM use was not strongly associated with current use of medications for hypertension, self-reported medication adherence, blood pressure level and control, or wellbeing in either country. CONCLUSIONS: A small, but significant, proportion of individuals living in low-income communities in Malaysia and the Philippines use TCAM to manage their hypertension, despite a general lack of evidence on efficacy and safety of commonly used TCAM modalities. Recognising that their patients may be using TCAM to manage hypertension will enable health care providers to deliver safer, more patient-centred care.

The association of ultrasound assessment of gallbladder wall thickness with dengue fever severity.

OBJECTIVES: To evaluate the association between ultrasound assessment of gallbladder wall thickness (GBWT) among severe dengue patients and dengue patients with warning signs to their clinical outcomes. METHODS: A prospective, cross-sectional study involving adult dengue patients presented to our emergency department between March until September 2018. The patients were classified based on WHO classification. A gallbladder wall scan was performed on all patients. RESULTS: A total of 44 patients were enrolled into the study; majority of the patients with GBWT had severe dengue, significantly more than the dengue patients with warning signs (90.5% sensitivity; 69.6% specificity). The sensitivity of GBWT in determining admission to critical care areas or general ward was 100% with a specificity of 62.1%. Our analysis showed that the two variables significant in determining the severity of dengue were age (p = 0.045) and GBWT (p < 0.001). Both factors together gave 81.0% sensitivity and 78.3% specificity in predicting patients for severe dengue. The receiver operator characteristic curve revealed that using variable GBWT status can discriminate 87.1% (95%CI 66.3, 93.7%) of having severe dengue or dengue with warning signs. CONCLUSION: The finding of GBWT when consolidated with other clinical parameters may assist clinicians to perform risk stratification in the emergency department and become another adjunct to the assessment of severe dengue.

Adaptation, Translation and Validation of the Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF): The Malay Version.

Food allergy has a significant impact on the quality of life (QoL) of children and can be measured using The Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF). This study aimed to adapt, translate the FAQLQ-PF into Malay and determine the validity and reliability of the translated version. This cross-sectional questionnaire validation study was conducted among parents of children (0 to 12 years old) with food allergies across five sites in Selangor and Kuala Lumpur, Malaysia. The FAQLQ-PF-Malay underwent cross-cultural adaptation, translation, validation (content, face and construct) and reliability assessment. Exploratory factor analysis, internal consistency and test-retest reliability analyses were used to examine its construct validity and reliability. Out of 150 children, the majority were between the age of 7 to 12 years old (41%) and were female (81%). Three subscales were identified, which were: (i) social and dietary implication, (ii) food anxiety and (iii) emotional and physical impact. Four items were eliminated because of weak factor loadings. The Cronbach's alpha for each subscale ranged from 0.88 to 0.94, with an overall Cronbach's alpha of 0.95. The intra-class correlation coefficient ranged from 0.54 (95% CI: 0.10-0.77) to 0.97 (95% CI: 0.90-0.99). The 26-item FAQLQ-PF-Malay retained the three-factor structure of the original FAQLQ-PF. The FAQLQ-PF-Malay is a valid and reliable tool to assess the QoL of Malaysian children with food allergies.

Quality of Life and Child's Autism-Specific Difficulties among Malaysian Main Caregivers: A Cross-Sectional Study.

Caring for children with autism spectrum disorder (ASD) negatively impacts quality of life (QoL). This cross-sectional study aimed to determine the factors associated with perceived QoL and how problematic a child's autism-specific difficulties are among the main caregivers of children with ASD who attend specialized preschool programs at the National Autism Society of Malaysia and IDEAS Autism Centre located in Selangor and Kuala Lumpur. Utilizing the questions from Parts A and B of the Quality of Life in Autism Questionnaire (QoLA), the data from 116 responders were analyzed using univariate and multivariate linear regression. The mean scores of Part A and Part B were 88.55 ± 17.25 and 56.55 ± 12.35, respectively. The QoL was significantly associated with staying in an apartment/flat -11.37 (95%CI: -19.52, -1.17, p = 0.008), main caregivers attending two training sessions 10.35 (95%CI: 1.17, 19.52, p = 0.028), and more than three training sessions 13.36 (95%CI: 2.01, 24.70, p = 0.022). Main caregiver perceptions of their child's autistic-specific difficulties were significantly associated with not receiving additional help for childcare: no maid -13.54 (95%CI: -24.17, -12.91, p = 0.013); no grandparent -8.65 (95%: -14.33, -2.96, p = 0.003); and main caregivers not having asthma 8.44 (95%CI: 0.02, 16.86, p = 0.049). These identified factors can be considered to inform main caregivers and health care providers on targeted ways to improve the QoL of main caregivers.

The Prevalence of Limited Health Literacy and Its Associated Factors among Elderly Patients Attending an Urban Academic Primary Care Clinic in Malaysia.

Limited health literacy (HL) is linked to many negative health outcomes, including poor self-management of chronic diseases and medication adherence among patients. There are a lack of data regarding HL in the elderly population in Malaysia. This study aimed to determine the prevalence of limited HL levels and its associated factors among elderly patients in an urban academic primary care clinic in Selangor, Malaysia. A cross-sectional study was conducted among 413 elderly patients (≥60 years old) who attended this academic primary care clinic between January 2020 and January 2021. Sociodemographic data, clinical characteristics, and health literacy scores were collected. Descriptive statistics (median with interquartile ranges (IQR), frequency, and percentages) and multiple logistic regression were utilized. The prevalence of limited HL in our population was 19.1% (95% CI: 15.3, 23). The middle-old (70-79 years) and very-old (≥80 years) age groups were more likely to have limited HL (aOR 4.05; 95% CI: 2.19, 7.52 and aOR 4.36; 95% CI: 1.02, 18.63, respectively). Those with at least secondary school education (aOR 0.06; 95% CI: 0.02, 0.24) and those who found medical information via the internet/television (aOR 0.21; 95% CI: 0.05, 0.93) had lower odds of having limited HL. In conclusion, having limited HL levels was not common among elderly patients in this primary care clinic. Further studies involving rural and larger primary care clinics in Malaysia are required to support these findings.

Significantly higher atherosclerosis risks in patients with obstructive sleep apnea and non-alcoholic fatty liver disease.

INTRODUCTION: There is limited data on the relationship between Obstructive Sleep Apnea (OSA) and Non-Alcoholic Fatty Liver Disease (NAFLD), each associated with increased cardiovascular risk. This study aimed to determine the relationships between severity of OSA, degree of steatosis in NAFLD and cardiovascular risk via CIMT and atherosclerosis markers ie intracellular adhesion molecule-1 (ICAM-1) an Lipoprotein-a (Lp(a)) in a group of patients with OSA. MATERIALS AND METHODS: This was a cross-sectional, single center study. A total of 110 subjects between 18 to 65 years of age and diagnosed with OSA following sleep study examinations were recruited. Exclusion criteria included seropositive Hepatitis B or Hepatitis C, and significant alcohol intake. RESULT: The prevalence of NAFLD was 81.8%. The mean CIMT (0.08±0.03 vs 0.06±0.01 cm, p = 0.001), ICAM-1 (334.53±72.86 vs 265.46±102.92 ng/mL, p = 0.001) and Lp(a) (85.41±52.56 vs 23.55±23.66 nmol/L, p<0.001) were significantly higher in the NAFLD group compared to the non-NAFLD group. Comparisons between the different groups showed significantly increasing levels of CIMT, ICAM-1 and Lp(a), lowest within the non-NAFLD, followed by the NAFLD 1 and NAFLD 2+3 groups. There was a significant positive correlation between degree of steatosis and the severity of OSA (r = 0.453, p<0.001). Logistic regression analysis revealed that patients with apnea/hypopnea index (AHI) of >30 were 52.77 (CI 6.34, 439.14) times more likely to have NAFLD compared to those with mild AHI (p<0.001). CONCLUSION: The prevalence of NAFLD is alarmingly high in this group of OSA patients. The degree of steatosis in patients with NAFLD was significantly correlated with severity of OSA, CIMT measurements, ICAM-1 and Lp(a). Our findings underscore screening for NAFLD in patients with OSA to ensure prompt risk stratification and management.

Association between elevated carotid intima-media thickness and serum uric acid levels among patients with essential hypertension in primary care setting in Sungai Buloh, Malaysia.

AIMS: Our study aimed to investigate the association between elevated carotid-intima media thickness (CIMT) and serum uric acid (SUA) levels in hypertensive patients attending primary care clinics in Sungai Buloh, Malaysia. METHODS: We conducted a cross-sectional study on 140 hypertensive patients attending outpatient follow-up in two primary care clinics in Sungai Buloh, Malaysia, using a convenient sampling method. SUA levels were measured and divided into four quartiles. Two radiologist specialists performed B mode ultrasonography to assess the thickness of the right and left carotid intima media in all participants. RESULTS: Participants' mean SUA level was 355.75 ± 0.13. Their mean age was 53.44 (± 9.90), with a blood pressure control of 137.09 ± 13.22/81.89 ± 8.95. Elevated CIMT taken at ≥75th percentile was 0.666 for the left and 0.633 for the right common carotid arteries. By using a hierarchical method of multiple logistic regression, compared with the first quartile of the SUA level as reference group, the odd of elevated CIMT in quartile 4 in the common carotid artery was (OR = 2.00; 95% CI = 0.64-6.27, P = .576) for the right and (OR = 0.62; 95% CI = 0.20-2.00, P = .594) for the left. Waist circumference (P = .001), body mass index (P = .013), triglycerides (P < .001), and high-density lipoprotein cholesterol (P = .001) were significantly associated with the SUA quartiles. CONCLUSION: Although there was an increasing trend in the odd of elevated right CIMT across the SUA quartiles, this association, however, was not significant. Preventive effort to tackle the clustering effect of metabolic markers within this study population is needed to reduce the future risk of developing cardiovascular disease.

Health Literacy, Knowledge on Cervical Cancer and Pap Smear and Its Influence on Pre-Marital Malay Muslim Women Attitude towards Pap Smear.

BACKGROUND: Cervical cancer is preventable. In Malaysia, women are found to have good awareness of the disease and yet, the Pap smear uptake is still poor. Measuring health literacy level could explain this discrepancy. This study aims to determine the relationship between health literacy, level of knowledge of cervical cancer and Pap smear with attitude towards Pap smear among women attending pre-marital course. METHODS: A cross sectional study was performed in three randomly selected centres that organised pre-marital courses. All Malay Muslim women participants aged 18 to 40 years old were recruited while non-Malaysian, illiterate, and had hysterectomy were excluded. Validated self-administered questionnaires used were European Health Literacy Questionnaire (HLS-EU-Q16 Malay) and Knowledge and attitude towards Cervical Cancer and Pap Smear Questionnaire. The mean percentage score (mean± SD) was calculated, with higher scores showed better outcomes. Multiple linear regression was used to measure the relationship of independent variables with attitude towards Pap smear. RESULTS: A total of 417 participants were recruited with a mean age of 24.9 ± 3.56 years old. Prevalence of awareness of cervical cancer was 91.6% (n=382, 95% CI: 89.0%, 94.2%) and mean percentage score was 74.7%±7.6. Prevalence of awareness of Pap smear was 59.0% (n=246, 95% CI: 54.2%, 63.8%) and mean percentage score was 80.2% ± 6.5. The health literacy mean score was 13.3±3.6, with minimum score 0 and maximum score 16. The mean percentage score of attitudes towards Pap smear was 64.8%±9.3. Multiple linear regression analysis demonstrated significant relationship between health literacy (p=0.047) and knowledge of Pap smear (p<0.001) with attitude towards Pap smear. CONCLUSION: A higher health literacy with high knowledge of Pap smear improves the attitude towards Pap smear. Pre-marital course is an opportunistic platform to disseminate information to improve health literacy and knowledge of cervical cancer and Pap smear screening.

Factors Associated with High Patient Activation Level among Individuals with Metabolic Syndrome at a Primary Care Teaching Clinic.

Background: High activation level has been associated with higher education background, better self-rated health status, and having adequate health literacy. However, there is a gap in the literature regarding the level of activation and the factors associated with it among patients with metabolic syndrome (MetS) in the Malaysian primary care setting. Objectives: This study aims to determine activation levels and the factors associated with high activation among individuals with MetS in primary care. Methods: A cross-sectional study was conducted at a university primary care clinic. Patient activation was measured using the Patient Activation Measure®-13 Malay version. Activation levels were dichotomized into "low activation" (levels 1 and 2) and "high activation" (levels 3 and 4). To determine the factors associated with high activation, simple logistic regressions (SLogR) followed by multiple logistic regressions (MLogR) were performed. Results: Of 333 participants, 280 (84.1%) were included in the final analysis. The mean activation score was 59.4 (SD ±10.20) and 61.8% had high activation level. Two variables were found to be significant on MLogR. Those who were employed have the odds of 3.135 (95% CI 1.442-6.816) of having high activation compared with those who were unemployed. Those with good self-reported health status have the odds of 6.482 (95% CI 1.243-33.792) of having high activation compared to those with poor self-reported health status. Conclusions: The majority of participants had high activation levels. Those who were employed and those who had good self-reported health status were more likely to have high activation levels. Findings of this study could be used to develop patient activation interventions to improve self-management skills among individuals with MetS in primary care. These may include problem solving support, individualized care plans, peer or family support, and skill building. Those in high activation group can be trained to become mentors to support their peers who have low activation level.

The EMPOWER-SUSTAIN e-Health Intervention to improve patient activation and self-management behaviours among individuals with Metabolic Syndrome in primary care: study protocol for a pilot randomised controlled trial.

BACKGROUND: Epidemiological studies conducted in various parts of the world have clearly demonstrated that metabolic syndrome (MetS) is an increasing global health problem, not only in Western societies but also in Asian populations. Web-based and mobile phone-based self-management applications have been proven to be effective in improving self-management behaviour of patients with MetS components (i.e., diabetes or hypertension). However, evidence is lacking in terms of their effectiveness specifically for patients with MetS. The aim of this pilot study is to evaluate the feasibility and potential effectiveness of the EMPOWER-SUSTAIN Self-Management e-Health Intervention in improving activation and self-management behaviours among patients with MetS. This paper presents the study protocol. METHODS: A pilot randomised controlled trial will be conducted in a university primary care clinic. A total of 232 patients aged 18-60 years with MetS will be recruited; 116 will be randomised to receive the EMPOWER-SUSTAIN intervention for 6 months, and another 116 patients will continue with usual care. The EMPOWER-SUSTAIN intervention is a multifaceted chronic disease management strategy based on the Chronic Care Model and persuasive technology theory. It consists of training primary care physicians, nurses and patients to use the EMPOWER-SUSTAIN web-based self-management mobile app, strengthening the patient-physician relationship and reinforcing the use of relevant clinical practice guidelines to guide management and prescribing. The primary outcome is the mean change in patient activation score using the Patient Activation Measure short form Malay version (PAM-13-M) questionnaire. The secondary outcomes include the changes in waist circumference, body mass index, blood pressure, patient physical activity level, eating behaviour, perception of chronic illness care, satisfaction with patient-physician interaction, and perceived absolute 10-year cardiovascular disease risk. Feasibility of implementing the intervention will be evaluated. This includes acceptability of the intervention, estimating the likely rate of participant recruitment and retention, appropriateness of the outcome measures, calculation of sample size, and the intervention's potential effectiveness. CONCLUSION: To our knowledge, this is the first study in Malaysia that aims to determine the feasibility of a multifaceted e-health intervention, as well as to indicate more useful aspects of this intervention for further exploration in a larger trial. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04120779. Registered on 9 October 2019, protocol version 1.