Relationship of Self Efficacy in Medication Understanding with Quality of Life among Elderly with Type 2 Diabetes Mellitus on Polypharmacy in Malaysia.

Self-efficacy (SE) has been shown to be positively correlated with quality of life (QOL) among patients with type 2 diabetes mellitus (T2DM). Medication understanding (MU) on the other hand, leads to good adherence that indirectly improves QOL. Measuring self-efficacy in medication understanding is useful to ascertain patient's confidence in medication adherence. However, there is a lack of studies on the relationship between self-efficacy in medication understanding with QOL. This study aimed to determine the relationship between self-efficacy in medication understanding and QOL, and the factors associated with QOL in elderly with T2DM on polypharmacy. A cross-sectional study was conducted on these populations at primary care specialist clinic. Malay version of MU in SE questionnaire (MUSE) was used. Higher scores showed a better understanding. A revised Version Diabetic Quality of Life-13 (RVDQOL-13) questionnaire was used with lower scores indicating higher QOL. A total of 321 patients participated, with the majority being male (58.3%), Malay (84.7%), a predominant age group of 60−69 (75.7%) with mean age (±SD) of 66.7 (±0.286) years old. The median (IQR) of MUSE was high­30 (4)­while the RVDQOL-13 was low­19 (8)­which demonstrated high QOL. Inverse correlation was found between MUSE and QOL (r −0.14, p < 0.01). Multiple linear regression analysis demonstrated that MUSE score (ß −0.282; 95% CI: (−5.438, −2.581); p < 0.001), low-income group (ß −0.144; 95% CI: (−3.118, −0.534); p = 0.006) and duration of medications ≥240 days (ß −0.282; 95% CI: (−5.438, −2.581); p < 0.001) were associated with better QOL, while medications ≥10 (ß 0.109; 95% CI: 0.214, 4.462; p = 0.031) and those with pills and insulin (ß 0.193; 95% CI: 1.206, 3.747; p < 0.001) were associated with poor QOL. In conclusion, higher MUSE is associated with better QOL. Findings suggest emphasizing self-efficacy in medication understanding in the management of elderly with T2DM on polypharmacy to improve QOL.

Towards Precision Health in Weight Reduction: Thematic Content Analysis of an Open-Ended Survey on Reasons Why Morbidly Obese Patients Want to Lose Weight

@#Introduction: Addressing motivation to lose weight among morbidly obese patients increases successful weight management outcomes. We aimed to understand the motivations and reasons why morbidly obese patients attending hospital-based weight management programmes wanted to lose weight. Methods: A qualitative thematic content analysis was used to analyse responses from a self-administered open-ended question, “What is the main factor why you want to lose your weight?”. A total of 225 new patients attending obesity clinics program run by endocrinologists, dietitians and occupational therapists in two tertiary hospitals in Klang Valley responded to the questionnaire. Results: Patients’ mean BMI was 45.6±8.05 kg/m2 . Four themes emerged and they are health, function, appearance and perceived stigma. Health, the most commonly inferred theme (84%), highlighted concerns over obesity complications and concomitant morbidities, which include infertility, impact on surgical procedures as well as general physical and psychological well-being. Patients regard being functional to care for themselves, family members, religious and career needs as the next most crucial theme (25.8%). They relate to the theme appearance (12.9%) by wanting to look and feel beautiful. The theme perceived stigmatization recount the time when they were mocked and laughed at for their appearance (3.1%). Conclusion: Patients with morbid obesity in this study had expressed their main personal motivational reasons to lose weight. Identifying and addressing these unique personal motivations in a focused approach is vital for health care professionals to manage the complexity of the health, social and psychological needs among patients with morbid obesity.

Complete Androgen Insensitivity Syndrome: Diagnosis and Psychological Impact in Two Adolescents, A Case Report

@#This case report illustrates two cases of complete androgen insensitivity syndrome (CAIS) which is a rare form of sexual development disorder. Both presented with primary amenorrhea at the age of 18 and 19 years old. The hormonal profiles ruled out hypothyroidism, hyperprolactinemia, and primary ovarian failure. Magnetic resonance imaging of both patients showed the absence of uterus, fallopian tubes, ovaries, but the presence of proximal 1/3rd of the vagina. There is a single testis in the left inguinal region with unknown status of spermatogenesis. Women with CAIS are vulnerable to various psychological conditions caused by the appalling fact of being genotypically male when they have been raised female all their life. The gender confusion, reproductive issues, and how others perceive them require sensitive support. Hence, accentuate the need to explore and address the emotional, psychological, and psychiatric vulnerabilities, religious and spiritual beliefs in issues of relationships, infertility, and conception.

Congenital Adrenal Hyperplasia: Diagnostic Pitfalls in Prolonged Neonatal Jaundice.

Congenital Adrenal Hyperplasia (CAH) is a genetic disorder that leads to cortisol deficiency. However, prolonged neonatal jaundice is a rare presentation of CAH. The pathophysiology of hyperbilirubinemia in CAH is still ill-defined. Plausible causes are related to the synthesis of bile, maturity of the liver and adrenal function. This case reported a neonate who presented with severe prolonged jaundice that lasted for more than a month. A short Synacthen test confirmed diagnosis of CAH. He was started on steroid replacement. He had regular follow-up under paediatric endocrinologist and primary care physician for long-term monitoring and overall health care. This case demonstrates the importance of recognizing the clinical and biochemical features of CAH for early detection and referral. Long-term follow-up and monitoring is necessary due to the risk of complications and side effects of medications. This is the first case of CAH presented with persistent hyperbilirubinemia to be reported from Malaysia. The case describes the difficult workup that has been encountered in the patient's care and management.

Management of asthma in adults in primary care

@#Asthma is a chronic inflammatory disease of the airway which is often misdiagnosed and undertreated. Early diagnosis and vigilant asthma control are crucial to preventing permanent airway damage, improving quality of life and reducing healthcare burdens. The key approaches to asthma management should include patient empowerment through health education and selfmanagement and, an effective patient-healthcare provider partnership.

Effectiveness of the EMPOWER-PAR Intervention in Improving Clinical Outcomes of Type 2 Diabetes Mellitus in Primary Care: A Pragmatic Cluster Randomised Controlled Trial.

BACKGROUND: The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting. METHODS: This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c < 6.5%. Secondary outcomes were the change in proportion of patients achieving targets for blood pressure, lipid profile, body mass index and waist circumference. Intention to treat analysis was performed for all outcome measures. A generalised estimating equation method was used to account for baseline differences and clustering effect. RESULTS: A total of 888 type 2 diabetes mellitus patients were recruited at baseline (intervention: 471 vs. CONTROL: 417). At 1-year, 96.6 and 97.8% of patients in the intervention and control groups completed the study, respectively. The baseline demographic and clinical characteristics of both groups were comparable. The change in the proportion of patients achieving HbA1c target was significantly higher in the intervention compared to the control group (intervention: 3.0% vs. CONTROL: -4.1%, P < 0.002). Patients who received the EMPOWER-PAR intervention were twice more likely to achieve HbA1c target compared to those in the control group (adjusted OR 2.16, 95% CI 1.34-3.50, P < 0.002). However, there was no significant improvement found in the secondary outcomes. CONCLUSIONS: This study demonstrates that the EMPOWER-PAR intervention was effective in improving the primary outcome for type 2 diabetes in the Malaysian public primary care setting. TRIAL REGISTRATION: Registered with: ClinicalTrials.gov.: NCT01545401 . Date of registration: 1st March 2012.

Prevalence, awareness, treatment, control and socio demographic determinants of hypertension in Malaysian adults.

BACKGROUND: Hypertension is the leading cardiovascular risk factor globally as well as in Malaysia. This study aimed to estimate the prevalence, awareness, treatment, control and the socio demographic determinants of hypertension among Malaysian adults. METHOD: The analytic sample consisted of 11,288 adults aged ≥ 30 years recruited at baseline in 2007-2011 from the REDISCOVER Study which is an ongoing, prospective cohort study involving 18 urban and 22 rural communities in Malaysia. Socio-demographics, anti-hypertensive treatment details and an average of at least two blood pressure measurements were obtained. RESULTS: The age-adjusted prevalence was 42.0 % (CI: 40.9-43.2) and was higher in men [43.5 % (CI: 41.2-45.0)] than women [41.0 % (CI: 39.8-42.3)]. Participants from rural areas (APR: 1.12, CI: 1.04-1.20); aged at least 40-49 years (APR: 1.86, CI: 1.62-2.14); who were overweight (APR: 1.24, CI: 1.15-1.34) and obese (APR: 1.54, CI: 1.43-1.6) were more likely to have hypertension. The Indigenous ethnic group was less likely to be aware (APR: 0.81, CI: 0.69-0.92) and to be on treatment (APR: 0.66, CI: 0.55-0.79). Those in rural areas were less likely to have their hypertension controlled (APR: 0.61, CI: 0.49-0.75). On the other hand, control was more likely in females (APR: 1.25, CI: 1.01-1.54) and Indigenous group (APR: 1.64, CI: 1.19-2.25). CONCLUSION: Hypertension is common in the Malaysian adults. The control of hypertension has increased over the years but is still quite low. Public health measures, as well as individual interventions in primary care are crucial to reduce their risk of developing complications.

Study protocol of EMPOWER participatory action research (EMPOWER-PAR): a pragmatic cluster randomised controlled trial of multifaceted chronic disease management strategies to improve diabetes and hypertension outcomes in primary care.

BACKGROUND: Chronic disease management presents enormous challenges to the primary care workforce because of the rising epidemic of cardiovascular risk factors. The chronic care model was proven effective in improving chronic disease outcomes in developed countries, but there is little evidence of its effectiveness in developing countries. The aim of this study was to evaluate the effectiveness of the EMPOWER-PAR intervention (multifaceted chronic disease management strategies based on the chronic care model) in improving outcomes for type 2 diabetes mellitus and hypertension using readily available resources in the Malaysian public primary care setting. This paper presents the study protocol. METHODS/DESIGN: A pragmatic cluster randomised controlled trial using participatory action research is underway in 10 public primary care clinics in Selangor and Kuala Lumpur, Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Each clinic consecutively recruits type 2 diabetes mellitus and hypertension patients fulfilling the inclusion and exclusion criteria over a 2-week period. The EMPOWER-PAR intervention consists of creating/strengthening a multidisciplinary chronic disease management team, training the team to use the Global Cardiovascular Risks Self-Management Booklet to support patient care and reinforcing the use of relevant clinical practice guidelines for management and prescribing. For type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving HbA1c < 6.5%. For hypertension without type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving blood pressure < 140/90 mmHg. Secondary outcomes include the proportion of patients achieving targets for serum lipid profile, body mass index and waist circumference. Other outcome measures include medication adherence levels, process of care and prescribing patterns. Patients' assessment of their chronic disease care and providers' perceptions, attitudes and perceived barriers in care delivery and cost-effectiveness of the intervention are also evaluated. DISCUSSION: Results from this study will provide objective evidence of the effectiveness and cost-effectiveness of a multifaceted intervention based on the chronic care model in resource-constrained public primary care settings. The evidence should instigate crucial primary care system change in Malaysia. TRIAL REGISTRATION: ClinicalTrials.gov NCT01545401.

JIS definition identified more Malaysian adults with metabolic syndrome compared to the NCEP-ATP III and IDF criteria.

Metabolic syndrome (MetS) is a steering force for the cardiovascular diseases epidemic in Asia. This study aimed to compare the prevalence of MetS in Malaysian adults using NCEP-ATP III, IDF, and JIS definitions, identify the demographic factors associated with MetS, and determine the level of agreement between these definitions. The analytic sample consisted of 8,836 adults aged ≥30 years recruited at baseline in 2007-2011 from the Cardiovascular Risk Prevention Study (CRisPS), an ongoing, prospective cohort study involving 18 urban and 22 rural communities in Malaysia. JIS definition gave the highest overall prevalence (43.4%) compared to NCEP-ATP III (26.5%) and IDF (37.4%), P < 0.001. Indians had significantly higher age-adjusted prevalence compared to other ethnic groups across all MetS definitions (30.1% by NCEP-ATP III, 50.8% by IDF, and 56.5% by JIS). The likelihood of having MetS amongst the rural and urban populations was similar across all definitions. A high level of agreement between the IDF and JIS was observed (Kappa index = 0.867), while there was a lower level of agreement between the IDF and NCEP-ATP III (Kappa index = 0.580). JIS definition identified more Malaysian adults with MetS and therefore should be recommended as the preferred diagnostic criterion.