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Introduction: The clinical pathway (CP) is one of the most recommended tools for ensuring the best quality of care and has been proven to reduce the cost and time spent in hospital. The development of a CP for influenza is crucial, especially for the elderly, as they are vulnerable to influenza-related complications. The main aim of this study was to provide a comprehensive protocol for each component of influenza management among the elderly in Malaysia. Methods: An expert group meeting was conducted involving family medicine specialists, public health specialists, geriatricians, respiratory physicians and infectious disease physicians. The CP was designed following a 6-step protocol: 1) Selection of expert panel, 2) discussion and information gathering, 3) development of CP draft, 4) refinement of CP draft, 5) implementation of CP, and 6) finalisation of CP. The CP for influenza was designed based on service type and disease severity. Results: The panel described both outpatient and inpatient CPs for managing elderly patients with influenza. The outpatient CP covered mild and moderate influenza cases, while the inpatient CP addressed the management of moderate and severe influenza. The estimated length of hospital stay for moderate and severe influenza cases with pneumonia was 6 and 14 days, respectively. Conclusions: The CP for influenza supports existing treatment according to illness severity leveraged on current clinical practice guidelines and the best-care practices in primary and tertiary care settings. Continuous use of the CP is required to assess its effectiveness, thereby enabling optimisation of the healthcare process in influenza treatment.

The role of non-dental healthcare personnel (HCP) in promoting oral health is well-accepted yet efforts in training them to be competent in delivering this role are inadequate. This study is aimed to assess the HCP’ oral health and care knowledge, and explore possible challenges faced by HCP in managing oral health problems among their patients in a public primary healthcare clinic. A focus group discussion was carried out involving ten HCP directly involved with patients from different units within the health clinics. Questions were asked in two parts: (i) knowledge on oral health and its link to general health, and (ii) issues and challenges faced by HCP with patients having oral health problems in their daily routine. The session was recorded on a digital audio tape, responses were then transcribed, scripts were grouped and lastly analysed qualitatively. Majority of the participants appeared to have a good knowledge on general and oral health but only very few were aware on the relationship between oral health problems with systemic conditions. Among the main challenges faced by HCP when dealing with patients with oral health problems were limited knowledge on oral health problems including management of medically compromised patient requiring dental treatment and difficulty in changing the mindset of patients regarding oral health issues especially on seeking dental treatment. In conclusion, most of the participants agreed on the need for additional relevant training to enable them to provide coordinated and comprehensive service to patients with oral health problems in the primary healthcare clinics. DOI: https://doi.org/10.17576/jskm-2020-1802-05

Background Satisfaction with post stroke services would assist stakeholders in addressing gaps in service delivery. Tools used to evaluate satisfaction with stroke care services need to be validated to match healthcare services provided in each country. Studies on satisfaction with post discharge stroke care delivery in low- and middle-income countries (LMIC) are scarce, despite knowledge that post stroke care delivery is fragmented and poorly coordinated. This study aims to modify and validate the HomeSat subscale of the Dutch Satisfaction with Stroke Care-19 (SASC-19) questionnaire for use in Malaysia and in countries with similar public healthcare services in the region. Methods The HomeSat subscale of the Dutch SASC-19 questionnaire (11 items) underwent back-to-back translation to produce a Malay language version. Content validation was done by Family Medicine Specialists involved in community post-stroke care. Community social support services in the original questionnaire were substituted with equivalent local services to ensure contextual relevance. Internal consistency reliability was determined using Cronbach alpha. Exploratory factor analysis was done to validate the factor structure of the Malay version of the questionnaire (SASC10-My™). The SASC10-My™ was then tested on 175 post-stroke patients who were recruited at ten public primary care healthcentres across Peninsular Malaysia, in a trial-within a trial study. Results One item from the original Dutch SASC19 (HomeSat) was dropped. Internal consistency for remaining 10 items was high (Cronbach alpha 0.830). Exploratory factor analysis showed the SASC10-My™ had 2 factors: discharge transition and social support services after discharge. The mean total score for SASC10-My™ was 10.74 (SD 7.33). Overall, only 18.2% were satisfied with outpatient stroke care services (SASC10-My™ score ≥ 20). Detailed analysis revealed only 10.9% of respondents were satisfied with discharge transition services, while only 40.9% were satisfied with support services after discharge. Conclusions The SASC10-My™ questionnaire is a reliable and valid tool to measure caregiver or patient satisfaction with outpatient stroke care services in the Malaysian healthcare setting. Studies linking discharge protocol patterns and satisfaction with outpatient stroke care services should be conducted to improve care delivery and longer-term outcomes. Trial registration No.: ACTRN12616001322426 (Registration Date: 21st September 2016.

Background The elderly population in Malaysia are projected to reach almost one third of the total population by 2040. The absence of a National Dementia Strategy (NDS) in preparing the healthcare services for the ageing population is compounded by the lack of assessment of preparedness of future healthcare workers to manage complications related to ageing i.e., dementia. Studies in countries with NDS demonstrated lack of dementia knowledge among medical undergraduates. Hence, this study aimed to assess the knowledge on dementia among final year medical undergraduates in Malaysia and its associated factors, using the Dementia Knowledge Assessment Scale (DKAS). Methods This cross-sectional study, employed multistage sampling method to recruit final year medical undergraduates from eleven selected public and private medical institutions across Malaysia. Online self-administered measures were delivered to final year medical undergraduates through representatives of medical students’ society after approval from Deanery and institutional ethics board of participating universities. The measure collected demographic information, previous dementia exposure (i.e., formal or informal) and the 25-item Likert scale DKAS. Bivariate analysis and linear regression were conducted to confirm factors influencing dementia knowledge components. Results A total of 464 respondents from 7 universities participated in this study. Overall dementia knowledge among respondents with and without exposure, was low, with average score of 29.60 ± 6.97 and 28.22 ± 6.98, respectively. DKAS subscales analysis revealed respondents scored highest in care consideration subscale (9.49 ± 2.37) and lowest in communication and behaviour subscale (4.38 ± 2.39). However, only causes and characteristic subscale recorded significantly higher knowledge score among respondents with previous exposure (7.88 ± 2.58) (p =0.015). Higher knowledge of dementia was associated with previous formal dementia education (p=0.037) and informal occupational/working experience in caring for dementia patients (p = 0.001). Informal occupational/working experience (B = 4.141, 95% CI 1.748–6.535, p = 0.001) had greater effect than formal education (i.e. lectures/workshops) (B = 1.393, 95% CI 0.086–2.700, p = 0.037) to influence respondents’ knowledge on dementia. Conclusion Dementia knowledge among final year medical undergraduates is low. To improve dementia knowledge, Malaysian medical curriculum should be reviewed to incorporate formal education and informal occupational/working experience, as early as in undergraduate training to help prepare future healthcare providers to recognise dementia among ageing Malaysians.

Introduction The sudden undertaking of being a caregiver for a spouse or family member afflicted with a stroke can cause adverse psychological consequences. In Malaysia, the majority of stroke patients return home to be cared for by family members and continue rehabilitation as outpatients. In most local urban communities, the practice of shared caregiving is observed among stroke caregivers either out of necessity or familism. Sole or primary caregivers who share their homes with stroke patients would be more challenged physically and psychologically compared to secondary or joint caregivers. Sharing the caregiving responsibilities is believed to lighten the burden on primary caregivers. This study aims to determine the proportion and associated factors of depression among urban-dwelling caregivers of home-bound stroke patients receiving long-term care from a university-based primary care clinic. Methodology A cross-sectional study involving 123 primary and secondary caregivers of stroke patients was conducted at Klinik Primer PPUKM Cheras (KPPC) and the outpatient Medical Rehabilitation Services Department Hospital Canselor Tuanku Muhriz (HCTM), Cheras Kuala Lumpur. A self-administered questionnaire comprising of sociodemographic characteristics, the Beck Depression Inventory-II (BDI-II), and the Multidimensional Scale of Perceived Social Support questionnaire (MSPSS) was used. The functional status of the stroke patients was assessed using the Modified Rankin Score (MRS). Results The proportion of respondents with depression was 20.3% (n=25). Depression was associated with caregivers’ age (CI=42.23-50.09, p=0.016), presence of illness (p=0.001), and being a sole caregiver (p=0.001). There is also an association found between caregiver depression with longer duration post-stroke (CI= 12.75-16.13, p

Background and objective Despite the widespread use of traditional and complementary medicine (TCM) during pregnancy, very few studies have focused on the use of these practices during the postpartum period among women in Malaysia. This study aimed to evaluate users' profiles and factors associated with the use of TCM during the postpartum period among women attending a community clinic in rural Malaysia. Materials and methods A cross-sectional study was conducted among 210 women at a maternal and child health clinic in Bagan Serai, Perak, Malaysia from January to April 2019. A self-administered questionnaire was used to determine the prevalence, the different types, and reasons for the use of TCM and perceptions toward TCM. Factors associated with TCM use during the postpartum period were derived from multiple logistic regression analyses. Results The prevalence of TCM use during the postpartum period was 66.2% among the subjects. The most common type of TCM used was massage (88.3%), and the most common reason reported was to improve general well-being (72.1%). "Family belief" had the highest mean for influence toward TCM use (mean: 3.63). Malays (adj. OR: 4.52, 95% CI: 1.93-10.59, p=0.001) and those having a low monthly household income (adj. OR: 3.68, 95% CI: 1.24-10.91, p=0.019) were the groups that were more likely to use TCM. Conclusion TCM use during the postpartum period is highly prevalent among Malay women with low household monthly incomes. Further studies should be conducted to address the benefits and risks of using TCM during the postpartum period.

Type 2 diabetes mellitus (T2DM) may be independently associated with testosterone deficiency syndrome (TDS). Both conditions are linked with reduced quality of life and cardiovascular comorbidities. The magnitude of TDS among T2DM men and its predictors has still not been well established in Malaysia. This study aimed to determine the prevalence of TDS and its predictors among men with T2DM attending a government health clinic in Kuching, Sarawak. TDS severity and level of serum total testosterone were also explored. A cross-sectional study was conducted involving 360 respondents. Aging Males Symptoms Scale (AMS) score > 26 and serum total testosterone ≤ 12 nmol/L were used to diagnose TDS. The prevalence of TDS in current study was 19.7%. Multivariate analysis showed that determinants for TDS included age (Adjusted OR 1.061: 95% CI 1.020; 1.103), Iban ethnicity (Adjusted OR 2.469: 95% CI 1.154; 5.283) and a waist circumference equal or greater than 90 cm (Adjusted OR 3.655: 95% CI 1.472; 9.081). However, there was no significant association between TDS and the level of serum total testosterone (p = 0.581). We concluded that the prevalence of TDS in this study was relatively low. The severity of this condition may not be influenced by testosterone level. Physicians might consider a diagnosis of TDS if elder diabetic men with abdominal obesity present to primary care clinics with clinical features of hypogonadism. Health care providers also might consider lowering their threshold to screen for TDS among Iban men with T2DM.

Background Satisfaction with post stroke services would assist stakeholders in addressing gaps in service delivery. Tools used to evaluate satisfaction with stroke care services need to be validated to match healthcare services provided in each country. Studies on satisfaction with post discharge stroke care delivery in low- and middle-income countries (LMIC) are scarce, despite knowledge that post stroke care delivery is fragmented and poorly coordinated. This study aims to modify and validate the HomeSat subscale of the Dutch Satisfaction with Stroke Care-19 (SASC-19) questionnaire for use in Malaysia and in countries with similar public healthcare services in the region.Methods The HomeSat subscale of the Dutch SASC-19 questionnaire (11 items) underwent back-to-back translation to produce a Malay language version. Content validation was done by Family Medicine Specialists involved in community post-stroke care. Community social support services in the original questionnaire were substituted with equivalent local services to ensure contextual relevance. Internal consistency reliability was determined using Cronbach alpha. Exploratory factor analysis was done to validate the factor structure of the Malay version of the questionnaire (SASC10-My TM ). The SASC10-My TM was then tested on 175 post-stroke patients who were recruited at ten public primary care health centres across Peninsular Malaysia, in a trial-within a trial study.Results One item from the original Dutch SASC19 (HomeSat) was dropped. Internal consistency for remaining 10 items was high (Cronbach alpha 0.830). Exploratory factor analysis showed the SASC10-My TM had 2 factors: discharge transition and social support services after discharge. The mean total score for SASC10-My TM was 10.74 (SD 7.33). Overall, only 18.2% were satisfied with outpatient stroke care services (SASC10-My TM score ≥ 20). Detailed analysis revealed only 10.9% of respondents were satisfied with discharge transition services, while only 40.9% were satisfied with support services after discharge.Conclusions The SASC10-My TM questionnaire is a reliable and valid tool to measure caregiver or patient satisfaction with outpatient stroke care services in the Malaysian healthcare setting. Studies linking discharge protocol patterns and satisfaction with outpatient stroke care services should be conducted to improve care delivery and longer-term outcomes.Trial registration: No.: ACTRN12616001322426 (Registration Date: 21st September 2016

Data on post stroke outcomes in developing countries are scarce due to uncoordinated healthcare delivery systems. In Malaysia, the national stroke clinical practice guideline does not address transfer of care and longer term post stroke care beyond tertiary care. Hence, post stroke care delivery may be delivered at either tertiary or primary care facilities. This study aimed at describing patients’ characteristics and outcomes of post stroke care delivered by the primary care teams at public primary care healthcentres across Peninsular Malaysia. Multi staged sampling was done to select public primary care health centres to recruit post stroke patients. At each health centre, convenience sampling was done to recruit adult patients (≥18 years) who received post stroke care between July-December 2012. Baseline measurements were recorded at recruitment and retrospective medical record review was done simultaneously, for details on medical and / or rehabilitation treatment at health centre. Changes in the measurements for post stroke care were compared using paired t-tests and Wilcoxon Rank test where appropriate. Total of 151 patients were recruited from ten public primary care healthcentres. The mean age at stroke presentation was 55.8 ± 9.8 years. Median duration of follow up was 2.3 (IQR 5.1) years. Majority co-resided with a relative (80.8%), and a family member was primary caregiver (75.%). Eleven percent were current smokers. Almost 71.0% of patients achieved BP ≤ 140/90 mmHg. Only 68.9% of the patients had been referred for neurorehabilitation. Percentage of recorded data was highest for blood pressure (88.1%) while lowest was HbA1c (43.0%). For clinical outcomes, systolic and diastolic blood pressure, triglyceride level and calculated GFR (eGFR) showed statistically significant changes during follow up (p

Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking. Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres. Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems. Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services. No.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Electroencephalography (EEG) monitoring is known to be technically feasible and possibly clinically relevant to determine patients with acute ischemic hemispheric stroke. The EEG is very useful tool in understanding neurological dysfunction of stroke plausible improving the treatment and rehabilitation. Most of the existing techniques to diagnose stroke from the EEG signal is mainly based on Fourier Transform (FT). For instance, the Brain Symmetry Index (BSI) employed Fast Fourier Transform (FFT) as coefficients to measure symmetrical of blood flow between left and right brain hemisphere. The symmetrical index ranges between zero and one where one indicates the highest asymmetrical of blood flow. It is known that the conventional FFT has limitation in analyzing non-linear and non-stationary signal. Therefore, the existing BSI and its variations may also suffer from this transformation properties. In this study, we propose BSI based on Hilbert Huang Transform (HHT) which defined as BSI-HHT. HHT is a way to decompose a signal into so-called intrinsic mode functions (IMF) along with a trend, and obtain instantaneous frequency data. The HHT will be used as coefficients instead off FFT in calculating the BSI index. An experiment to validate the performance of BSI-HHT is conducted in this study as to compare with the existing BSI technique. The EEG signal of Middle Cerebral Artery (MCA) subjects and healthy subjects are used for this investigation. The proposed BSI-HHT has offered better interpretation as it correlates to the stimulation procedure on the gathered data especially at specific frequency band. Also, through the analysis, the HHT coefficient is able to capture the non-stationary and non-linear of the interest electrode.

Sodium valproate is one of the most common first-line antiepileptics prescribed for primary and secondary generalised seizures. However, serious complications associated with sodium valproate, such as acute pancreatitis, need to be considered when choosing this medication for treating epilepsy in certain populations such as children and persons with intellectual disability. We report a case of a 21-year-old man with intellectual disability who presented to the emergency department with an acute abdomen, vomiting and diarrhoea. He had to undergo an emergency exploratory laparotomy during which acute necrotising pancreatitis was diagnosed intra-operatively. We believe that the recent increase in sodium valproate dosage for his epilepsy was the cause of the pancreatitis. Carers of such persons should be adequately informed regarding possible life-threatening complications of medications prescribed to avoid delay in diagnosis and unwanted incidents.

Managing chronic cough is diagnostically challenging especially in primary care. This case report highlights the difficulties experienced in approaching a case of chronic cough from a primary care perspective. The discussion also involves the clinical significance and treatment dilemma of M. fortuitum chelonae complex that was isolated from the sputum cultures of an elderly woman who presented with chronic cough for more than a year.

Context: Poststroke care in developing countries is inundated with poor concordance and scarce specialist stroke care providers. A primary care‑driven health service is an option to ensure optimal care to poststroke patients residing at home in the community. Aims: We assessed outcomes of a pilot long‑term stroke care clinic which combined secondary prevention and rehabilitation at community level. Settings and Design: A prospective observational study of stroke patients treated between 2008 and 2010 at a primary care teaching facility. Subjects and Methods: Analysis of patients was done at initial contact and at 1‑year post treatment. Clinical outcomes included stroke risk factor(s) control, depression according to Patient Health Questionnaire (PHQ9), and level of independence using Barthel Index (BI). Statistical Analysis Used: Differences in means between baseline and post treatment were compared using paired t‑tests or Wilcoxon‑signed rank test. Significance level was set at 0.05. Results: Ninety‑one patients were analyzed. Their mean age was 62.9 [standard deviation (SD) 10.9] years, mean stroke episodes were 1.30 (SD 0.5). The median interval between acute stroke and first contact with the clinic 4.0 (interquartile range 9.0) months. Mean systolic blood pressure decreased by 9.7 mmHg (t = 2.79, P = 0.007), while mean diastolic blood pressure remained unchanged at 80mmHg (z = 1.87, P = 0.06). Neurorehabilitation treatment was given to 84.6% of the patients. Median BI increased from 81 (range: 2−100) to 90.5 (range: 27−100) (Z = 2.34, P = 0.01). Median PHQ9 scores decreased from 4.0 (range: 0−22) to 3.0 (range: 0−19) though the change was not significant (Z= −0.744, P = 0.457). Conclusions: Primary care‑driven long‑term stroke care services yield favorable outcomes for blood pressure control and functional level.