Search

Christos V Chalitsios,1,* Ralph K Akyea,2,* Hasidah Abdul-Hamid,2,3 Jo Leonardi-Bee,1,4 Johanes D Kanchau,5 Aisyah Kamal,5 Mohamed-Syarif Mohamed-Yassin,3 Noorhida Baharudin,3,5 Anis Safura Ramli,3,5 Nadeem Qureshi2 1Nottingham Centre for Epidemiology and Public Health, Lifespan and Population Health Unit, School of Medicine, University of Nottingham, Nottingham, UK; 2PRISM Research Group, Centre for Academic Primary Care, Lifespan and Population Health Unit, School of Medicine, University of Nottingham, Nottingham, UK; 3Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; 4Centre for Evidence-Based Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK; 5Institute of Pathology, Laboratory and Forensic Medicine (I‑PPerForM), Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia*These authors contributed equally to this workCorrespondence: Nadeem Qureshi, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK, Email Nadeem.Qureshi@nottingham.ac.uk

Background: Previous literature has demonstrated associations between grit and positive educational and psychological outcomes, such as higher academic grades, lower attrition rates in medical training, and protection from burnout. However, the predictors of grit have yet to be studied, particularly among medical students in Malaysia. This study aimed to determine the level of grit and its predictors among Malaysian medical students., Methods: A cross-sectional study was conducted among 123 medical students from a public university in Malaysia. Data on sociodemographic and educational characteristics were collected. The student's personality traits were determined using the Big Five Inventory (BFI), while grit was assessed using the validated 7-item Short Grit Scale (Grit-S). Grit was expressed as a mean score, ranging from 1 (not at all gritty) to 5 (extremely gritty). Multiple linear regression was used to determine the association between the predictors (personality, sociodemographic and educational characteristics) and grit among these students., Results: The mean grit score was 3.43 (SD 0.57). Based on the multiple linear regression analysis, the grit score was significantly predicted by three personality traits which were extraversion, b = 0.2 (95% CI: 0.07-0.32), agreeableness, b = 0.28 (95% CI: 0.12-0.44) and conscientiousness, b = 0.6 (95% CI: 0.42-0.77). A 1-point increase in the mean extraversion, agreeableness, and conscientiousness scores would independently increase these students' mean grit scores by 0.2, 0.28, and 0.6, respectively. The sociodemographic and educational characteristics did not significantly predict grit among Malaysian medical students., Conclusions: The mean grit score among Malaysian medical students is comparable to other medical students in Asia. Extraversion, agreeableness, and conscientiousness personality traits were associated with higher grit. As grit is a dynamic trait, appropriate interventions should be implemented to foster and increase it among these students., (© 2024. The Author(s).)

Hypertension (HPT) is the leading modifiable risk factor for cardiovascular diseases and premature death worldwide. Currently, attention is given to various dietary approaches with a special focus on the role of micronutrient intake in the regulation of blood pressure. This study aims to measure the dietary intake of selected minerals among Malaysian adults and its association with HPT. This cross-sectional study involved 10,031 participants from the Prospective Urban and Rural Epidemiological study conducted in Malaysia. Participants were grouped into HPT if they reported having been diagnosed with high blood pressure [average systolic blood pressure (SBP)/average diastolic blood pressure (DBP) ≥ 140/90 mm Hg]. A validated food frequency questionnaire (FFQ) was used to measure participants' habitual dietary intake. The dietary mineral intake of calcium, copper, iron, magnesium, manganese, phosphorus, potassium, sodium, and zinc was measured. The chi-square test was used to assess differences in socio-demographic factors between HPT and non-HPT groups, while the Mann-Whitney U test was used to assess differences in dietary mineral intake between the groups. The participants' average dietary intake of calcium, copper, iron, magnesium, manganese, phosphorus, potassium, selenium, sodium, and zinc was 591.0 mg/day, 3.8 mg/day, 27.1 mg/day, 32.4 mg/day, 0.4 mg/day, 1431.1 mg/day, 2.3 g/day, 27.1 µg/day, 4526.7 mg/day and 1.5 mg/day, respectively. The intake was significantly lower among those with HPT than those without HPT except for calcium and manganese. Continuous education and intervention should be focused on decreasing sodium intake and increasing potassium, magnesium, manganese, zinc, and calcium intake for the general Malaysian population, particularly for the HPT patients., (© 2024. The Author(s).)

Objective: This study aimed to determine the usability of the EMPOWER-SUSTAIN Self-Management Mobile App© and evaluate the factors associated with its usability among patients with cardiovascular risk factors in primary care., Methodology: This was a cross-sectional study, conducted among patients aged ≥ 18 years with cardiovascular risk factors attending a university primary care clinic. Patients were given the app to use for at least three months. Those who fulfilled the eligibility criteria were recruited. Data gathered were on sociodemographic, clinical characteristics, self-management support by doctors, utilisation of the app at home and social support in using the app. The previously translated and validated Malay version of the mHealth App Usability Questionnaire was used to measure usability. The mean usability score was calculated and linear regressions analysis was conducted to determine the factors associated with the usability of the app., Results: A total of 247 patients with at least one cardiovascular risk factor(s) were recruited. The mean age was 60.2 (±8.2). The majority were Malays (86.2%) and half of them were males (52.2%). The total mean (±SD) usability score was 5.26 (±0.67) indicating a high usability of the app. Usability of the app declined with increasing age in the simple linear regressions analysis. The multiple linear regressions yielded that being Malay ( b  = 0.31, 95% CI 0.08,0.54), using the app at home to understand their medications ( b  = 0.33, 95% CI 0.12,0.53) and having social support from family members and friends ( b  = 0.28, 95% CI 0.07,0.49) were significantly associated with higher usability of the app., Conclusion: The usability of the EMPOWER-SUSTAIN Self-Management Mobile App© was high among patients with cardiovascular risk factors in our primary care clinic. This finding supports the widespread use of this app among our patients. Involvement of family members and friends should be encouraged to improve the usability of the app., (© The Author(s) 2024.)

Background: Self-management support has been recognized as one of the most essential elements of the Chronic Care Model (CCM). Inspired by the CCM, the EMPOWER-SUSTAIN Global Cardiovascular Risks Self-Management Booklet © was developed to aid and sustain self-management among patients with metabolic syndrome (MetS) in primary care to prevent cardiovascular complications. However, the usability of this booklet among these patients is not known. Therefore, this study aimed to evaluate the usability of this self-management booklet and identify the factors associated with its usability among patients with MetS in primary care., Methods: This cross-sectional study was conducted among patients with MetS attending a university primary care clinic in Selangor, Malaysia. The usability score was measured using a previously translated and validated EMPOWER-SUSTAIN Usability Questionnaire (E-SUQ) with a score of > 68 indicating good usability. Multiple logistic regressions determined the factors associated with its usability., Results: A total of 391 patients participated in this study. More than half (61.4%) had a good usability score of > 68, with a mean (± SD) usability score of 72.8 (± 16.1). Participants with high education levels [secondary education (AOR 2.46, 95% CI 1.04, 5.83) and tertiary education (AOR 2.49, 95% CI 1.04, 5.96)], those who used the booklet at home weekly (AOR 2.94, 95% CI 1.63, 5.33) or daily (AOR 2.73, 95% CI 1.09, 6.85), and those who had social support to use the booklet (AOR 1.64, 95% CI 1.02, 2.64) were significantly associated with good usability of the booklet., Conclusions: The usability of the EMPOWER-SUSTAIN Global Cardiovascular Risks Self-Management Booklet © was good among patients with MetS in this primary care clinic, which supports its widespread use as a patient empowerment tool. The findings of this study also suggest that it is vital to encourage daily or weekly use of this booklet at home, with the support of family members. The focus should also be given to those with lower education to improve the usability of this booklet for this group of patients., (© 2024. The Author(s).)

This study aimed to assess the health literacy (HL) related knowledge, attitude, perceived barriers, and practice among primary care doctors (PCDs) in Malaysia, and to determine the factors associated with HL-related practice. A cross-sectional study was conducted using an online questionnaire. Sociodemographic and work-related details were collected. HL-related knowledge, attitude, perceived barriers, and practice were assessed. Descriptive and inferential analyses using linear regression were performed. 373 PCDs were included in the study with a mean (SD) age of 37.9 (8.1) years old. The mean (SD) HL-related knowledge, attitude, and practice scores were 6.89 (1.27), 36.33 (7.04), and 30.14 (4.7), respectively. 90.9% of the participants had good HL-related knowledge scores, and 89.5% had positive HL-related attitude. More than 80% of participants found that "time constraint to implement health literacy screening" and "lack of human resources to administer HL screening tools in their settings" were among the barriers for them to implement HL practices. PCDs of Chinese and other ethnicities had lower HL-related practice scores compared to those of Malay ethnicity (adjusted b = - 1.74; 95% CI - 2.93, - 0.54, and - 2.94; 95% CI - 5.27, - 0.60, respectively). PCDs who had heard of the term "health literacy" were associated with higher HL-related practice scores (adjusted b = 2.32; 95% CI 1.17, 3.47). Age (adjusted b = 0.10; 95% CI 0.04, 0.16) had significant linear positive relationship with HL-related practice. In conclusion, the HL-related knowledge, attitude, and practice among PCDs in Malaysia were at an acceptable level. Along with educating PCDs on HL, the perceived barriers identified need to be addressed to improve the HL-related practice and ultimately patient care., (© 2023. The Author(s).)

Dyslipidaemia is an established cardiovascular risk factor. This study aimed to determine the pooled prevalence of dyslipidaemia in Malaysian adults. A systematic review and meta-analysis of all cross-sectional, longitudinal observational studies which reported the prevalence of elevated total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), triglycerides (TG), and reduced high-density lipoprotein cholesterol (HDL-c) in adults 18 years old and older, was conducted. A comprehensive search of PubMed and Cochrane Central Register of Controlled Trials (which included Medline, EMBASE and major trial registers) from inception to October 18, 2022, was performed. Risk-of-bias was evaluated using the Johanna-Briggs Institute Prevalence Critical Appraisal Tool, while certainty of evidence was assessed using an adapted version of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Random-effects meta-analyses were performed using MetaXL. This report follows the PRISMA reporting guidelines. The protocol was registered with PROSPERO (CRD42020200281). 26 556 studies were retrieved and 7 941 were shortlisted initially. From this, 70 Malaysian studies plus two studies from citation searching were shortlisted; 46 were excluded, and 26 were included in the review (n = 50 001). The pooled prevalence of elevated TC (≥ 5.2 mmol/L), elevated LDL-c (≥ 2.6 mmol/L), elevated TG (≥ 1.7 mmol/L), and low HDL-c (< 1.0 mmol/L in men and < 1.3 mmol/L in women) were 52% (95% CI 32-71%, I 2  = 100%), 73% (95% CI 50-92%, I 2  = 100%), 36% (95% CI 32-40%, I 2  = 96%), and 40% (95% CI 25-55%, I 2  = 99%), respectively. This review found that the prevalence of all dyslipidaemia subtypes is high in Malaysian adults. Ongoing efforts to reduce cardiovascular diseases in Malaysia should integrate effective detection and treatment of dyslipidaemia., (© 2023. The Author(s).)

Background: Familial hypercholesterolemia (FH) is predominantly caused by mutations in the 4 FH candidate genes (FHCGs), namely, low-density lipoprotein receptor (LDLR), apolipoprotein B-100 (APOB-100), proprotein convertase subtilisin/kexin type 9 (PCSK9), and the LDL receptor adaptor protein 1 (LDLRAP1). It is characterized by elevated low-density lipoprotein cholesterol (LDL-c) levels leading to premature coronary artery disease. FH can be clinically diagnosed using established clinical criteria, namely, Simon Broome (SB) and Dutch Lipid Clinic Criteria (DLCC), and can be identified using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT), a primary care screening tool., Objective: This study aims to (1) compare the detection rate of genetically confirmed FH and diagnostic accuracy between the FAMCAT, SB, and DLCC in the Malaysian primary care setting; (2) identify the genetic mutation profiles, including novel variants, in individuals with suspected FH in primary care; (3) explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing in primary care; and (4) evaluate the clinical utility of a web-based FH Identification Tool that includes the FAMCAT, SB, and DLCC in the Malaysian primary care setting., Methods: This is a mixed methods evaluation study conducted in 11 Ministry of Health primary care clinics located at the central administrative region of Malaysia. In Work stream 1, the diagnostic accuracy study design is used to compare the detection rate and diagnostic accuracy of the FAMCAT, SB, and DLCC against molecular diagnosis as the gold standard. In Work stream 2, the targeted next-generation sequencing of the 4 FHCGs is used to identify the genetic mutation profiles among individuals with suspected FH. In Work stream 3a, a qualitative semistructured interview methodology is used to explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing. Lastly, in Work stream 3b, a qualitative real-time observation of primary care physicians using the "think-aloud" methodology is applied to evaluate the clinical utility of a web-based FH Identification Tool., Results: The recruitment for Work stream 1, and blood sampling and genetic analysis for Work stream 2 were completed in February 2023. Data collection for Work stream 3 was completed in March 2023. Data analysis for Work streams 1, 2, 3a, and 3b is projected to be completed by June 2023, with the results of this study anticipated to be published by December 2023., Conclusions: This study will provide evidence on which clinical diagnostic criterion is the best to detect FH in the Malaysian primary care setting. The full spectrum of genetic mutations in the FHCGs including novel pathogenic variants will be identified. Patients' perspectives while undergoing genetic testing and the primary care physicians experience in utilizing the web-based tool will be established. These findings will have tremendous impact on the management of patients with FH in primary care and subsequently reduce their risk of premature coronary artery disease., International Registered Report Identifier (irrid): DERR1-10.2196/47911., (©Anis Safura Ramli, Nadeem Qureshi, Hasidah Abdul-Hamid, Aisyah Kamal, Johanes Dedi Kanchau, Nur Syahirah Shahuri, Ralph Kwame Akyea, Luisa Silva, Laura Condon, Suraya Abdul-Razak, Alyaa Al-Khateeb, Yung-An Chua, Mohamed-Syarif Mohamed-Yassin, Noorhida Baharudin, Siti Fatimah Badlishah-Sham, Aznida Firzah Abdul Aziz, Noor Alicezah Mohd Kasim, Siti Hamimah Sheikh Abdul Kadir, Joe Kai, Jo Leonardi-Bee, Hapizah Nawawi. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 02.06.2023.)

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., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s) 2023.)

BACKGROUND In Malaysia, the prevalence of genetically confirmed heterozygous familial hypercholesterolemia (FH) was reported as 1 in 427. Despite this, FH remains largely underdiagnosed and undertreated in primary care. CASE REPORT In this case series, we report 3 FH cases detected in primary care due to mutations in the low-density lipoprotein receptor (LDLR), apolipoprotein-B (APOB), and proprotein convertase subtilisin/kexin type 9 (PCSK9) genes. The mutations in case 1 (frameshift c.660del pathogenic variant in LDLR gene) and case 2 (missense c.10579C>T pathogenic variant in APOB gene) were confirmed as pathogenic, while the mutation in case 3 (missense c.277C>T mutation in PCSK9 gene) may have been benign. In case 1, the patient had the highest LDL-c level, 8.6 mmol/L, and prominent tendon xanthomas. In case 2, the patient had an LDL-c level of 5.7 mmol/L and premature corneal arcus. In case 3, the patient had an LDL-c level of 5.4 mmol/L but had neither of the classical physical findings. Genetic counseling and diagnosis were delivered by primary care physicians. These index cases were initially managed in primary care with statins and therapeutic lifestyle modifications. They were referred to the lipid specialists for up-titration of lipid lowering medications. First-degree relatives were identified and referred for cascade testing. CONCLUSIONS This case series highlights different phenotypical expressions in patients with 3 different FH genetic mutations. Primary care physicians should play a pivotal role in the detection of FH index cases, genetic testing, management, and cascade screening of family members, in partnership with lipid specialists.

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events. This study aimed to assess the frequency of inappropriate medication dosages (IMD) for cardiovascular disease prevention among patients with CKD and its predictors in an urban academic primary care clinic in Selangor, Malaysia. All patients who attended the clinic from April to June 2019 and fulfilled the inclusion criteria were included in this cross-sectional study, except for those with an estimated glomerular filtration rate (eGFR) of more than 90 ml/min, diagnosed with urinary tract infection, pregnant or were on dialysis for end stage renal disease. Their prescriptions on the electronic medical record (EMR) system were evaluated for appropriateness using the dose adjustment recommendations based on the 2018 Malaysian Clinical Practice Guidelines on management of CKD. A total of 362 medical records were included in this study. 16.6% (95% Confidence Interval [CI]: 12.9-20.8) or 60 out of 362 of the patient records analysed contained medications prescribed with inappropriate dosages. Patients with higher stages of CKD were associated with higher odds of IMD, namely CKD stage G3b (adjusted Odds Ratio [aOR] 10.41; 95% CI: 2.31-46.88) and CKD stage 4-5 (aOR 15.76; 95% CI: 3.22-77.28). Other predictors of IMD were diagnosis of diabetes mellitus (aOR 6.40; 95% CI: 2.15-19.01), number of prescribed medications of 5 or more (aOR 4.69; 95% CI: 1.55-14.20), and eGFR reduction of more than 25% over one year (aOR 2.82; 95% CI: 1.41-5.65). Within the limitations of this study, we conclude that the occurrence of IMD for CVD prevention was low in CKD patients in this primary care clinic. Medications with inappropriate dosages identified in this study include simvastatin, fenofibrate, hydrochlorothiazide, spironolactone, metformin, gliclazide, sitagliptin, dapagliflozin and empagliflozin. Clinicians should consider the predictors of inappropriate medication dosages listed above when prescribing to patients with CKD to reduce the risk of medications-related toxicities and adverse effects. Limitations of this study should be considered when interpreting the findings presented., (© 2023 The Authors.)

BACKGROUND Herpes zoster is a condition in which there is reactivation of varicella zoster virus (VZV), which is usually seen in the elderly and those with immunocompromised states. Recently, however, there have been many reports of herpes zoster after administration of COVID-19 vaccines, although initial trials showed that these vaccines have good safety and immunogenicity profiles. At the time of writing, about 5 billion people worldwide had received their full course of COVID-19 vaccination. This case report describes an elderly man who developed herpes zoster after receiving a booster dose of the Pfizer-BioNTech (BNT162b2) vaccine, with no adverse effects after the first and second dose. CASE REPORT An 82-year-old man with underlying type 2 diabetes mellitus, hypertension, dyslipidemia, and cerebrovascular disease presented with left-sided chest and upper back pain. The pain was intermittent, burning in nature, and disturbed his sleep. A week prior to his presentation, he received a COVID-19 vaccine (BNT162b2) booster dose. Examination revealed multiple vesicles along his anterior and posterior T3 dermatome. He was diagnosed with herpes zoster and treated with a course of oral acyclovir. Upon review 7 days later, he had recovered well, with resolution of his vesicles and pain. CONCLUSIONS COVID-19 vaccination remains an important measure to prevent transmission of infection and to reduce the mortality and morbidity caused by it. However, healthcare practitioners should be aware of the possible association between COVID-19 vaccination and herpes zoster. Appropriate explanation and safety advice on the possible adverse events following COVID-19 vaccination, including herpes zoster infection, should be given to patients. This will facilitate early recognition and treatment of this condition.

Introduction: Cardiovascular diseases (CVD) remain the world's leading cause of death. About half of Malaysian adults have at least 2 risk factors; thus, rigorous primary preventions are crucial to prevent the first cardiovascular (CV) event. This study aimed to determine the achievement of treatment targets and factors associated with it among high CV risk individuals., Methods: This cross-sectional study included 390 participants from a primary care clinic in Selangor, Malaysia, between February and June 2022. The inclusion criteria were high-CV risk individuals, that is, Framingham risk score >20%, diabetes without target organ damage, stage 3 kidney disease, and very high levels of low-density lipoprotein cholesterol (LDL-C) >4.9 mmol/L or blood pressure (BP) >180/110 mmHg. Individuals with existing CVD were excluded. The treatment targets were BP <140/90 mmHg (≤135/75 for diabetics), LDL-C <2.6 mmol/L, and HbA1c ≤6.5%. Multiple logistic regressions determined the association between sociodemographic, clinical characteristics, health literacy, and medication adherence with the achievements of each target., Results: About 7.2% achieved all treatment targets. Of these, 35.1% reached systolic and diastolic (46.7%) BP targets. About 60.2% and 28.2% achieved optimal LDL-C and HbA1c, respectively. Working participants had lower odds of having optimal systolic (aOR = 0.34, 95% CI: 0.13-0.90) and diastolic (aOR = 0.41, 95% CI: 0.17-0.96) BP. Those who adhered to treatments were more likely to achieve LDL-C and HbA1c targets; (aOR = 1.72, 95% CI: 1.10-2.69) and (aOR = 2.46, 95% CI: 1.25-4.83), respectively., Conclusions: The control of risk factors among high CV risk patients in this study was suboptimal. Urgent measures such as improving medication adherence are warranted.

Primary care doctors (PCDs) play an important role in the early diagnosis and management of dementia. This study aimed to determine the knowledge, attitude, and confidence in managing dementia among PCDs in Malaysia. It also aimed to determine the factors associated with higher confidence levels in dementia management. An online-based cross-sectional study using Google Forms TM was performed. Sociodemographic and work-related data were collected, and Dementia Knowledge among General Practitioners & General Practitioners Attitude and Confidence Scale for Dementia questionnaires were utilized to assess the knowledge, attitude, and confidence scores. Multiple linear regression was conducted to determine the association between sociodemographic factors, knowledge, and attitude with the confidence in dementia management score. A total of 239 PCDs participated, with the majority being female (72.4%) and Malay (64.4%) and working in public primary care clinics (67.4%). The mean (±SD) score for confidence was 2.96 (±0.76). Among the factors associated with higher confidence levels in managing dementia were higher dementia knowledge scores, higher attitude towards dementia scores, prior dementia education, and the availability of nearby referral services for dementia. Malaysian PCDs' confidence in dementia management was comparable to the PCDs of other countries. Strategies addressing these factors should be implemented to improve the confidence of PCDs in managing dementia.

Screening mammograms have resulted in a reduction in breast cancer mortality, yet the uptake in Malaysia was low. This study aimed to determine the prevalence and factors associated with screening mammogram uptake among women attending a Malaysian primary care clinic. A cross-sectional study was conducted among 200 women aged 40 to 74 attending the clinic. The data was collected using questionnaires assessing sociodemographic, clinical characteristics, knowledge and health beliefs. Multiple logistic regression was used to identify factors associated with mammogram uptake. The prevalence of screening mammograms was 46.0%. About 45.5% of women with high breast cancer risk had never undergone a mammogram. Older participants, aged 50 to 74 (OR = 2.57, 95% CI: 1.05, 6.29, p-value = 0.039) and those who received a physician’s recommendation (OR = 7.61, 95% CI: 3.81, 15.20, p-value < 0.001) were more likely to undergo screening mammography. Significant health beliefs associated with mammogram uptake were perceived barriers (OR = 0.81, 95% CI: 0.67, 0.97, p-value = 0.019) and cues to action (OR = 1.30, 95% CI: 1.06, 1.59, p-value = 0.012). Approximately half of the participants and those in the high-risk group had never undergone a mammogram. Older age, physician recommendation, perceived barriers and cues to action were significantly associated with mammogram uptake. Physicians need to play an active role in promoting breast cancer screening and addressing the barriers.

Background: Lipid-lowering medications (LLM) are commonly used for secondary prevention, as well as for primary prevention among patients with high global cardiovascular risk and with diabetes. This study aimed to determine the prevalence of LLM use among high-risk individuals [participants with diabetes, high Framingham general cardiovascular (FRS-CVD) score, existing cardiovascular disease (CVD)] and the factors associated with it., Methods: This is a cross-sectional analysis from the baseline recruitment (years 2007 to 2011) of an ongoing prospective study involving 11,288 participants from 40 rural and urban communities in Malaysia. Multiple logistic regression was used to identify characteristics associated with LLM use., Results: Majority (74.2%) of participants with CVD were not on LLM. Only 10.5% of participants with high FRS-CVD score, and 17.1% with diabetes were on LLM. Participants who were obese (OR = 1.80, 95% CI: 1.15-2.83), have diabetes (OR = 2.38, 95% CI: 1.78-3.19), have hypertension (OR = 2.87, 95% CI: 2.09-3.95), and attained tertiary education (OR = 2.25, 95% CI: 1.06-4.78) were more likely to be on LLM. Rural residents had lower odds of being on LLM (OR = 0.58, 95% CI: 0.41-0.82). In the primary prevention group, participants with high FRS-CVD score (OR = 3.81, 95% CI: 2.78-5.23) and high-income earners (OR = 1.54, 95% CI: 1.06-2.24) had higher odds of being on LLM., Conclusions: LLM use among high CVD-risk individuals in the primary prevention group, and also among individuals with existing CVD was low. While CVD risk factors and global cardiovascular risk score were positively associated with LLM use, sociodemographic disparities were observed among the less-educated, rural residents and low-income earners. Measures are needed to ensure optimal and equitable use of LLM., (© 2022. The Author(s).)

Introduction: Dyslipidaemia is one of the established risk factors for cardiovascular disease. Evidence from large-scale trials showed that effective treatment of dyslipidaemia can reduce all-cause and coronary mortality. To date, there is no published systematic review on the worldwide prevalence of dyslipidaemia in adults. We propose to perform a systematic review on the global prevalence of dyslipidaemia in adults 18 years and older., Methods and Analysis: We will identify observational studies through comprehensive literature searches. We will search: MEDLINE, Cochrane Central Register of Controlled Trials for published studies and trial registries including the WHO International Trial Registry Platform and ClinicalTrials.gov. Two reviewers will independently screen the titles and abstracts, attain full text of eligible articles, extract data, and appraise the quality and bias of the included studies. Disagreement among the authors will be resolved by discussion leading to a consensus. Next, we will perform a narrative synthesis of the study results. Study heterogeneity will be assessed using I 2 statistics. If I 2 is high (≥75%), and plausible heterogeneity contributors are found, we will divide the studies into appropriate subgroups for pooling of results or assess the association of plausible covariates and the prevalence estimates using meta-regression. If I 2 <75%, we will undertake meta-analysis using the random-effects model and transform all prevalence estimates using the Freeman-Tukey transformation for pooling, to obtain a synthesised point estimate of prevalence with its 95% confidence. We will then back-transform the point estimate, and report our results using the back-transformed figures., Ethics and Dissemination: Ethics approval is not a requirement as this study is based on available published data. Results of this systematic review will be presented at conferences, shared with relevant health authorities, and published in a peer-reviewed journal. These results may help quantify the magnitude of dyslipidaemia globally, and guide preventative and therapeutic interventions., Prospero Registration Number: CRD42020200281., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

BACKGROUND Rickets is the deficiency in mineralization of the bone associated with lack of sunlight exposure and inadequate dietary calcium and/or vitamin D in children. Important efforts to eradicate rickets include appropriate sunlight exposure advice and fortification of food and milk with vitamin D. However, there is a growing concern that the current Coronavirus Disease 2019 (COVID-19) pandemic will increase the incidence of rickets due to inadequate sunlight exposure resulting from movement restriction measures imposed by governments across the world. CASE REPORT A 22-month-old girl presented to our primary care clinic in Selangor, Malaysia with abnormal gait and bowing of the legs during the COVID-19 pandemic. She had a history of inadequate sun exposure as she lived in an apartment and there was a Movement Control Order in place because of the pandemic. Calcium intake was also poor as she could not tolerate formula milk and did not consume any other dairy products. Investigations revealed severe hypocalcemia and low vitamin D level. She was diagnosed with nutritional rickets and was referred for admission to correct the hypocalcemia. She was subsequently discharged with oral calcium and vitamin D supplementation. Her calcium and vitamin D levels improved and at her 6-month review, her bilateral bowed legs had improved significantly. CONCLUSIONS This case highlights the importance of having a high degree of suspicion for vitamin D deficiency and rickets in young children growing up during the COVID-19 pandemic. Public health messages on preventing the spread of COVID-19 should also be interlaced with messages addressing the possible effects of our new norms such as inadequate sunlight exposure.

Introduction: This audit was performed to monitor the diagnosis and management of chronic kidney disease (CKD) according to the clinical practice guidelines (CPGs) of CKD 2018 in a primary care clinic., Methods: Patients who attended the clinic from April to June 2019 and fulfilled the diagnosis of CKD were included in this study, except for those diagnosed with a urinary tract infection, pregnant women and those on dialysis. These criteria were set based on the CPGs. The standards were set following discussions with the clinic team members with reference to local guidelines, the 2017 United Kingdom National CKD audit and other relevant studies., Results: A total of 384 medical records were included in this audit. Overall, 5 out of 20 criteria for processes and 3 of 8 clinical outcomes for CKD care did not meet the set standards. These included the following: documentation of CKD classification based on albumin category (43.8%); CKD advice (19.0%); dietitian referral (9.1%); nephrologist referral (45.5%); haemoglobin level monitoring (65.7%); overall blood pressure (BP) control (45.3%); BP readings for diabetic kidney disease (DKD) and non-DKD with > 1 g/day of proteinuria (< 130/80 mmHg, 37.0%); eGFR reduction of < 25% over the past year (77.2%). Identified problems included the absence of a CKD registry, eGFR and albuminuria reports, and a dedicated team, among other factors., Conclusions: Overall, 8 out of 28 criteria did not meet the standards of CKD care set for this audit. The problems identified in this audit have been addressed. Moreover, strategies have also been formulated to improve the diagnosis and management of CKD in this clinic., (© Academy of Family Physicians of 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.

BACKGROUND Trichoblastoma is a rare, benign, cutaneous adnexal neoplasm arising from rudimentary hair follicles. The incidence and prevalence in the general population is unknown. However, most cases occur in adults aged 40 years and older. CASE REPORT A 62-year-old woman presented to our primary care clinic for a hypertension and diabetes followup visit. The doctor, who had never seen the patient before, noticed several small lumps over the patient's eyebrows. After she removed her headscarf and face mask for a thorough examination, numerous skin-colored papules and nodules were seen on her nose, nasal bridge, forehead, and around her eyebrows. She was referred to a dermatologist, and a skin biopsy showed well-circumscribed dermal nests of basaloid cells, with peripheral palisading, and keratin horn cysts surrounded by dense fibrous stroma. These features were consistent with trichoblastoma. She was then referred to a plastic surgeon to discuss further management options. The patient finally chose laser ablation as she was fearful of the other more invasive surgical options. CONCLUSIONS This is a very rare case of extensive facial trichoblastoma. It highlights the need for clinicians to ensure optimal exposure when examining patients. It also highlights the role of biopsies for skin lesions of uncertain etiology. In this case, it helped to rule out basal cell carcinoma, which can be a more locally destructive condition than trichoblastoma. This case also serves as a reminder about the need for ongoing review and referral for further management for conditions for which previous treatment was unsuccessful.

Introduction: Cardiovascular disease is the leading cause of death worldwide. Despite the proven benefit of secondary prevention medications (SPMs), their utilisation remains suboptimal in many countries. This study aimed to assess the use of SPMs in a Malaysian primary care clinic and factors associated with it., Methods: A retrospective review of electronic medical records was conducted to assess the prescription of SPMs among patients with coronary artery disease who attended the clinic between 1st January 2018 and 31st December 2018. Prescriptions of SPMs were documented in numbers and percentages. Multiple logistic regressions were used to analyse factors associated with the prescription of SPMs., Results: Of the 662 patients included in the study, 99.1% were prescribed statins, 97% antiplatelets, 81.7% angiotensin-converting enzyme (ACE)-inhibitors or angiotensin II receptor blockers (ARBs), and 78.7% beta-blockers. Male patients were more likely to be prescribed statins (OR = 8.584, 95% CI: 1.431 - 51.510) and antiplatelets (OR = 6.818, 95% CI: 2.294 - 20.257). Another significant factor for antiplatelets prescription was having diabetes (OR = 3.318, 95% CI: 1.148 - 9.590). Having hypertension was associated with ACE-inhibitors or ARBs prescription (OR = 4.008, 95% CI: 2.522 - 6.370)., Conclusion: Although the majority of patients received SPMs, there were significant disparities for some SPMs prescriptions among female patients. As these medications are widely available in the Malaysian primary care setting, steps should be taken to ensure that these medications are prescribed equally for all eligible patients., (© Academy of Family Physicians of Malaysia.)

Communication is one of the fundamental skills in the medical profession. The Communication Skills Attitude Scale (CSAS) is a widely used questionnaire to measure the attitudes of medical students toward learning communication skills. It has been adapted and translated into many languages. The objective of this study was to adapt and translate the CSAS into the Malay language and determine its psychometric properties in medical students. This is a cross-sectional study involving 218 first-year Universiti Teknologi MARA students. Content validation, cross-cultural adaptation, translation, and face validation of the 26-item CSAS were performed according to established guidelines. Principal component analysis with direct oblimin rotation was used to determine the underlying structure of the CSAS-Malay. The reliability was assessed using Cronbach's α coefficient for internal consistency and using the intraclass correlation coefficient for the test-retest reliability. Although the contents of the CSAS-Malay and the original version were conceptually equivalent, item 11 was removed during the content validation stage due to a low item content validity index (I-CVI < 1.00). Two subscales were derived from the remaining 25 items, which were the Positive Attitude Scale and the Negative Attitude Scale. Items 1 and 15 were removed due to poor factor loadings. The total variance explained by the final two-factor solution with three items removed was 30.8%. Cronbach's α coefficients for both the Positive and Negative Attitude Scales in the final questionnaire were 0.815 and 0.614, respectively. It also showed a good reproducibility with intraclass correlation coefficient (ICC) values of 0.725-0.950 for all the items. This study provided preliminary information about the psychometric properties of the CSAS-Malay. The final 23-item questionnaire had a good construct validity, an acceptable internal consistency, and at least a moderate test-retest reproducibility. It can be used to assess the attitudes of medical students toward learning communication skills. Future research to improve the generalizability of the questionnaire should include medical students from other universities with diverse backgrounds.

Background: Dyslipidaemia refers to lipid abnormalities consisting of either one or any combination of the following: elevated total cholesterol (TC), elevated low-density lipoprotein cholesterol (LDL-c), elevated triglycerides (TG), and low high-density lipoprotein cholesterol (HDL-c). The prevalence of hypercholesterolaemia is steadily increasing in Malaysia. However, data on the prevalence of dyslipidaemia subtypes among Malaysians are lacking. This is important as it may have implications for preventive and management strategies for this increasing public health challenge. This study is aimed at determining the prevalence of dyslipidaemia subtypes and their associated personal and clinical attributes in Malaysians., Methods: REDISCOVER, a prospective study, enrolled 11,288 adults where sociodemographic data, anthropometric and blood pressure measurements, fasting lipid profile and glucose, and history of diabetes, hypertension, and smoking were obtained. The cross-sectional analytic sample presented in this article comprised 10,482 participants from baseline recruitment. The data was analysed by descriptive statistics and multivariable logistic regression., Results: The overall prevalence of elevated TC, elevated LDL-c, elevated TG, low HDL-c, and elevated non-HDL-c were 64.0% (95% CI 63.0-65.0), 56.7% (CI 55.7-57.7), 37.4% (CI 36.5-38.4), 36.2% (CI 35.2-37.1), and 56.2% (CI 55.3-57.2), respectively. Overweight, obesity, and central obesity were highly prevalent and significantly associated with elevated TC and all dyslipidaemia subtypes. Older age was associated with elevated TC, elevated LDL-c and elevated non-HDL-c. Hypertension was associated with elevated TC, elevated TG, and elevated non-HDL-c, while diabetes was associated with elevated TG and low HDL-c., Conclusions: Elevated TC and all dyslipidaemia subtypes are highly prevalent in Malaysia where increased body mass seems the main driver. Differences in the prevalence and associated personal and clinical attributes may facilitate specific preventive and management strategies.

Introduction: The Patient Activation Measure (PAM) is one of the most extensively used, widely translated, and tested instruments worldwide in measuring patient activation levels in self-management. This study aimed to determine the validity and reliability of the PAM-13 Malay version among patients with Metabolic Syndrome (MetS) attending a primary care clinic., Methods: This work is a cross-sectional validation study among patients with MetS attending a university primary care clinic in Selangor. The PAM-13 Malay version underwent a validation process and field testing. Psychometric properties were examined using principal component analysis (PCA) with varimax rotation, scree plot, Monte Carlo simulation, internal consistency, and test-retest reliability analyses., Results: The content of the PAM-13 Malay version and the original version were conceptually equivalent. The questionnaire was refined after face validation by 10 patients with MetS. The refined version was then field-tested among 130 participants (response rate 89.7%). The Kaiser-Meyer-Olkin test was 0.767, and Bartlett's test of sphericity was ≤0.001, indicating sampling adequacy. Two factors were identified and labeled as (1) Passive and Building Knowledge, and (2) Taking Action and Maintaining Behavior. These labels were chosen as they were conceptually consistent with the items representing the levels of activation in PAM-13. The validated PAM-13 Malay version consisted of 13 items, framed into two domains. The overall Cronbach's α was 0.79, and the intraclass correlation coefficient was 0.45., Conclusions: The PAM-13 Malay version is valid, reliable, and fairly stable over time. This questionnaire can be used to evaluate the levels of activation among patients with MetS in primary care in Malaysia., (© Academy of Family Physicians of Malaysia.)

Necrotizing fasciitis is a severe and progressive infection of deep soft tissues which results in destruction of the fascia and overlying subcutaneous fat. We report a case of a 45-year-old diabetic gentleman who initially presented with left shoulder pain, which was treated symptomatically. Upon representation, he had fever and the pain extended to his left upper back. There was a warm, firm and mildly tender purplish swelling on his mid to the left upper back. Blood tests revealed significantly elevated white cell counts and C-reactive protein. A CT thorax showed extensive soft tissue gas within the deep and superficial fascial layers of his left upper back. Necrotizing fasciitis was confirmed intraoperatively. The diagnosis of this condition is often difficult as early symptoms can be mild and nonspecific. A high Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC) score may be helpful to rule in this diagnosis and guide further management., Competing Interests: Conflict of interest: the authors declare no conflict of interest. Verbal informed consent for patient information was obtained from the patient himself., (©Copyright: the Author(s).)

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.

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.