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Background: In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia., Methods: This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis., Results: We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors., Conclusion: The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship., (© 2024. The Author(s).)

Purpose: This study highlights trends in available physician assistant (PA) applicant and matriculant data over the first 15 years of the Central Application Service for Physician Assistants (CASPA) service (2002-2016). This study expands knowledge identified in the CASPA 10-year data report., Methods: This was a retrospective analysis of CASPA data from all CASPA-participating PA programs between 2002 and 2016. Central Application Service for Physician Assistants staff verified all applicant academic information. In addition, beginning in 2007, the online CASPA admissions portal linked matriculant data with applicant data., Results: During the first 15 years of the CASPA service, there was a 194% increase in the number of CASPA-participating programs (from 68 to 200) and a 409% increase in the number of total applicants. Several trends identified in the CASPA 10-year report persisted, including increasing grade point averages among applicants and matriculants and lower matriculation rates among underrepresented minority applicants and applicants who reported economic disadvantage., Conclusion: This 15-year comprehensive analysis of the CASPA data will benefit the profession by providing historical information that faculty and policymakers can use as a basis for developing and evaluating future admissions policies and practices., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 PA Education Association.)

Abstract: Latinx children face psychosocial, linguistic, and economic challenges that put them at an increased risk of developing mental health conditions. Primary care providers should be equipped to recognize the complex mental health needs of this growing population. This article explores some of the barriers to mental health screenings in Latinx children and presents culturally sensitive, validated screening tools for primary care providers., (Copyright © 2023 American Academy of Physician Associates.)

Introduction: Literature exploring smoking status and its association with depression among the elderly population using nationwide data in Malaysia is limited. Hence, a nationwide survey to determine the prevalence of smoking and depression among the elderly (aged ≥60 years) population was undertaken., Methods: This secondary dataset analysis used data from the National Health and Morbidity Survey (NHMS) 2018. Data from 3914 participants were collected on elderly health in the Malaysian population. Sociodemographic characteristics were recorded. Smoking status was grouped as current smokers, former smokers, and non-smokers. A validated Malay language version of the Geriatric Depression Scale (M-GDS-14) was used to screen for depression among the elderly., Results: There was a significant association between smoking status with location, gender, employment status, marital status, ethnicity, education level, income, and depression. Current smokers are significantly higher in rural than urban areas. Among depressed participants, 65.7%, 17.1% and 17.2% were non-smokers, former smokers and current smokers, respectively. Multiple logistic regression showed that single (unmarried/separated/ divorced/widowed) participants were more likely to be depressed compared to married participants (AOR=1.68; 95% CI: 1.16-2.43). Whilst unemployed participants were more likely to be depressed than those who were employed (AOR=1.72; 95% CI: 1.22-2.44). Other Bumiputras were more likely to have depression compared to Malay, Chinese and Indian participants. Participants without formal education were more likely to be depressed compared to those having tertiary education. These participants have a 2-fold increased risk of depression (AOR=2.13; 95% CI: 1.02-4.45). Participants whose monthly salaries were <2000 MYR (AOR=3.67; 95% CI: 1.84-7.31) and 1000-1999 MYR (AOR=2.71; 95% CI: 1.23-5.94) were more likely to have depression compared with those who had received ≥3000 MYR. Ever smokers were more likely to be depressed than non-smokers (AOR=1.68; 95% CI: 1.23-2.29)., Conclusions: Elderly Malaysians are indeed at risk of developing depression particularly if they had ever smoked. Public health awareness and campaigning are pertinent to disseminate these outcomes in order to spread the awareness associated with smoking-related depression., Competing Interests: The authors have each completed and submitted an ICMJE form for Disclosure of Potential Conflicts of Interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. C.C. Kee, R. Sanaudi and M.A. Omar report that since the initial planning of the work they received support for study materials, medical writing and article processing charges from the National Institutes of Health and Ministry of Health Malaysia., (© 2023 Ariaratnam S. et al.)

Background: Globally, the average age of the world's population of older people continues to rise and having a good social support network becomes increasingly relevant with the aging populace. Overall, in Malaysia, social support prevalence was low among older persons. This study was conducted to determine the association between social support and smoking status among the older Malaysian population., Methods: Data were obtained from the National Health and Morbidity (NHMS) 2018 survey on the health of older Malaysian adults and analyzed. This cross-sectional population-based study used a two-stage stratified random sampling design. Sociodemographic characteristics, smoking status, and social support data were collected from respondents aged 60 years and more. A validated Malay language interviewer-administered questionnaire of 11-items, the Duke Social Support Index, was utilized to assess the social support status. A multivariable logistic regression analysis was used to assess the association of social support and smoking status among the respondents., Results: The prevalence of good social support was significantly higher among the 60-69 years old (73.1%) compared to the ≥80 years old respondents (50%). Multivariate logistic regression analysis showed that respondents aged ≥80 years old were 1.7 times more likely to have poor social support compared to those aged 60-69 years. Respondents with no formal education were 1.93 times more likely to have poor social support compared to respondents who had tertiary education. Respondents with an income of MYR 3000. Former smokers had good social support compared to current smokers (73.6% vs. 78.7%). For current smokers, they had poor social support, which is almost 1.42 times higher than that for non-smokers., Conclusion: There was poor social support among older people who were current smokers, had an increased age, had no formal education and had a low income. The findings obtained from this study could assist policymakers to develop relevant strategies at the national level to enhance the social support status among older smokers and aid in their smoking cessation efforts.

Background and Aims: Asthma is common in Malaysia but neglected. Achieving optimal asthma control and care is a challenge in the primary care setting. In this study, we aimed to identify the risk factors for poor asthma control and pattern of care among adults and children (5-17 years old) with asthma attending six public health clinics in Klang District, Malaysia., Methods: We conducted a cross-sectional study collecting patients' sociodemographic characteristics, asthma control, trigger factors, healthcare use, asthma treatment, and monitoring and use of asthma action plan. Descriptive statistics and stepwise logistic regression were used in data analysis., Results: A total of 1280 patients were recruited; 85.3% adults and 14.7% children aged 5-17 years old. Only 34.1% of adults had well-controlled asthma, 36.5% had partly controlled asthma, and 29.4% had uncontrolled asthma. In children, 54.3% had well-controlled asthma, 31.9% had partly controlled, and 13.8% had uncontrolled asthma. More than half had experienced one or more exacerbations in the last 1 year, with a mean of six exacerbations in adults and three in children. Main triggers for poor control in adults were haze (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.13-2.01); cold food (OR 1.54; 95% CI 1.15-2.07), extreme emotion (OR 1.90; 95% CI 1.26-2.89); air-conditioning (OR 1.63; 95% CI 1.20-2.22); and physical activity (OR 2.85; 95% CI 2.13-3.82). In children, hot weather (OR 3.14; 95% CI 1.22-8.11), and allergic rhinitis (OR 2.57; 95% CI 1.13-5.82) contributed to poor control. The majority (81.7% of adults and 64.4% of children) were prescribed controller medications, but only 42.4% and 29.8% of the respective groups were compliant with the treatment. The importance of an asthma action plan was reported less emphasized in asthma education., Conclusion: Asthma control remains suboptimal. Several triggers, compliance to controller medications, and asthma action plan use require attention during asthma reviews for better asthma outcomes., Competing Interests: Ee Ming Khoo, Ping Yein Lee, Ai Theng Cheong, Hilary Pinnock and Aziz Sheikh report grants from the National Institute for Health Research (NIHR) Global Health Research Unit on Respiratory Health (RESPIRE). Ee Ming Khoo reports personal fees from AstraZeneca; and is the President of the International Primary Care Respiratory Group and the Primary Care Respiratory Group Malaysia. Yong Kek Pang is the President of the Malaysian Thoracic Society and advisory committee for Novartis, AstraZeneca and Boehringer Ingelheim. Aziz Sheikh reports on grants from Asthma UK and HDR UK. All other authors declare no conflicts of interests. The National Institute for Health Research (NIHR) Global Health Research Unit on Respiratory Health (RESPIRE) funded this study, however, there is no direct involvement of decision in study design; collection, analysis, and interpretation of data; writing of the report except needing their approval to report for publication. For other financial bodies, there is no involvement. All authors have read and approved the final version of the manuscript. Honorary Professor Dr. Ee Ming Khoo (corresponding author) has full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: Shared decision-making has been shown to improve the quality of life in metastatic breast cancer patients in high-literacy and high-resource settings. However, limited studies have examined the cultural preferences of metastatic breast cancer patients with shared decision-making implementation and the barriers encountered in an Asian setting where societal norms predominate and physician decision-making is at the forefront. This paper aims to identify (1) barriers to practising shared decision-making faced by healthcare professionals and patients and (2) strategies for implementing shared decision-making in the context of metastatic breast cancer management in Malaysia., Methods: We conducted a qualitative study involving 12 patients diagnosed with metastatic breast cancer, 16 healthcare professionals and 5 policymakers from surgical and oncology departments at public healthcare centres in Malaysia. Semi-structured in-depth interviews and focus group discussions were conducted. The interviews were recorded, transcribed verbatim and analysed using the thematic approach. Nvivo software was used to manage and analyse the data., Results: Five main themes emerged from the study: healthcare provider-patient communication, workforce availability, cultural and belief systems, goals of care and paternalism versus autonomy. Other strategies proposed to overcome barriers to implementing shared decision-making were training of healthcare professionals and empowering nurses to manage patients' psychosocial issues., Conclusion: This study found that practising shared decision-making in the public health sector remains challenging when managing patients with metastatic breast cancer. The utilization of decision-making tools, patient empowerment and healthcare provider training may help address the system and healthcare provider-patient barriers identified in this study., Patient or Public Contribution: Patients were involved in the study design, recruitment and analysis., (© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Much has been claimed on the health benefits of alkaline water including metabolic syndrome (MetS) and its features with scarcity of scientific evidence. Methods: This cross-sectional comparative study was conducted to determine whether regular consumption of alkaline water confers health advantage on blood metabolites, anthropometric measures, sleep quality and muscle strength among postmenopausal women. A total of 304 community-dwelling postmenopausal women were recruited with comparable proportion of regular drinkers of alkaline water and non-drinkers. Participants were ascertained on dietary intake, lifestyle factors, anthropometric and biochemical measurements. Diagnosis of MetS was made according to Joint Interim Statement definition. A total of 47.7% of the participants met MS criteria, with a significant lower proportion of MetS among the alkaline water drinkers. The observed lower fasting plasma glucose (F(1,294) = 24.20, p = 0.025, partial η2 = 0.435), triglyceride/high-density lipoprotein concentration ratio (F(1,294) = 21.06, p = 0.023, partial η2 = 0.360), diastolic blood pressure (F(1,294) = 7.85, p = 0.046, partial η2 = 0.258) and waist circumference (F(1,294) = 9.261, p = 0.038, partial η2 = 0.263) in the alkaline water drinkers could be considered as favourable outcomes of regular consumption of alkaline water. In addition, water alkalization improved duration of sleep (F(1,294) = 32.05, p = 0.007, partial η2 = 0.451) and handgrip strength F(1,294) = 27.51, p = 0.011, partial η2 = 0.448). Low density lipoprotein cholesterol concentration (F(1,294) = 1.772, p = 0.287, partial η2 = 0.014), body weight (F(1,294) = 1.985, p = 0.145, partial η2 = 0.013) and systolic blood pressure (F(1,294) = 1.656, p = 0.301, partial η2 = 0.010) were comparable between the two different water drinking behaviours. In conclusion, drinking adequate of water is paramount for public health with access to good quality drinking water remains a critical issue. While consumption of alkaline water may be considered as a source of easy-to implement lifestyle to modulate metabolic features, sleep duration and muscle strength, further studies are warranted for unravelling the precise mechanism of alkaline water consumption on the improvement and prevention of MetS and its individual features, muscle strength and sleep duration as well as identification of full spectrum of individuals that could benefit from its consumption., Competing Interests: The authors have declared that no competing interests exist.

Background: Pharyngitis is a common presentation seen in general practice, but it is difficult to differentiate whether its etiology is viral or bacterial. The Centor score gives an approximation of the etiology of the pharyngitis, which informs physicians of the need to prescribe antibiotics. This study aimed to assess the validity of the Centor score in diagnosing Group A streptococcal (GAS) pharyngitis amongst adults in Malaysia., Methods: This cross-sectional study was conducted to compare the clinical criteria of the Centor score to the gold standard throat swab culture results amongst 215 adults presenting with sore throat in primary care clinics. The participants were adult patients who complained of sore throat and visited the three public primary care clinics in Sepang, Malaysia. The convenience sampling method was used. The throat swabs were analysed for β-haemolytic streptococci. Demographic and clinical data, including the Centor score, were analysed in relation to the pathogen., Results: Pharyngitis was diagnosed in 130 (60.5%) of the participants. Six isolates (2.4%) were identified as GAS pharyngitis. Both Centor scores 3 and 4 had a sensitivity of 50%, and specificities of 97.6% and 100%, respectively., Conclusion: A Centor score < 3 is favourable for excluding a diagnosis of GAS pharyngitis. Centor scores 3 and 4 require further examination to confirm a diagnosis of GAS pharyngitis., Competing Interests: Conflict of Interest None., (© Penerbit Universiti Sains Malaysia, 2022.)

Background: There is limited evidence on the association of anemia with chronic diseases and disabilities among older persons in Malaysia. We assessed the prevalence of anemia and its associated factors among community-dwelling older persons., Methods: This was a cross-sectional study using data from the nationwide National Health and Morbidity Survey 2015 (NHMS 2015) on the health of older adults conducted by the Institute for Public Health, National Institutes of Health, Malaysia. A two-stage stratified random-cluster sampling design was utilized. Data were collected on the sociodemographic profiles, non-communicable disease (NCD) comorbidities (hypertension, diabetes and hypercholesterolemia status) and disabilities among the older persons. Anemia was defined based on the World Health Organization's standards. A multivariable logistic regression analysis was used to assess the association of anemia with chronic diseases and disabilities., Results: The prevalence of anemia was 35.3% (95% CI: 33.1, 37.4) in the older persons. Chronic disease profiling showed that the prevalence rates of anemia among the older persons with diabetes, hypertension and hypercholesterolemia were 38.6%, 35.3% and 34.1%, respectively. In the multivariable analysis, persons aged 80 years and above (adjusted OR (aOR): 2.64; 95% CI: 2.00, 3.47), 70-79 years (aOR: 1.42; 95% CI: 1.21, 1.66), with diabetes (aOR: 1.30; 95% CI: 1.13, 1.51) and with disabilities in walking (aOR: 1.31; 95% CI: 1.11, 1.54) and self-care (aOR: 1.58; 95% CI: 1.22, 2.05) had higher odds of anemia compared to their respective reference categories. Among the persons with diabetes, the respondents aged 80 years and above (aOR: 2.48; 95% CI: 1.56, 3.94), 70-79 years old (aOR: 1.38; 95% CI: 1.08, 1.76) and with disabilities in vision (aOR: 1.29; 95% CI: 1.02, 1.63) and walking (aOR: 1.50; 95% CI: 1.18, 1.91) were more likely to be anemic. Furthermore, among the older persons without diabetes, persons aged 80 years and above (aOR: 2.89; 95% CI: 2.05, 4.07), 70-79 years old (aOR: 1.46; 95% CI: 1.19, 1.80) and with difficulty in self-care (aOR: 1.87; 95% CI: 1.30, 2.69) were more likely to be anemic., Conclusions: The resilient predictors of developing anemia were advancing age and diabetes, based on our study. Anemia is significantly associated with walking and vision disabilities among older persons with diabetes and with self-care difficulties in those without diabetes. There is a need for future studies to evaluate strategies to prevent anemia among older adults in order to promote healthy aging.

Background: Asthma was one of the top causes of hospitalization and unscheduled medical attendances due to acute exacerbations and its complications. In Malaysia, all pilgrims must undergo a mandatory health examination and certified fit to perform pilgrimage. We studied the current organisational and clinical routines of Hajj health examination in Malaysia with a focus on the delivery of care for pilgrims with asthma., Methods: We conducted non-participant observation to obtain ethnographic understanding of Hajj health examination activities for 2019. Observations were guided by a checklist and recorded as notes that were analysed thematically. The study was conducted at 11 public (from each region in Malaysia, namely, North, South, East, West of Peninsular Malaysia, and Sabah and Sarawak of East Malaysia) and two private primary care clinics., Results: We observed considerable variation in the implementation and practice of Hajj health examinations among the 11 public clinics but no marked variation among the private clinics. The short time span of between three to four months was inadequate for disease control measures and had put pressure on health care providers. They mostly viewed the Hajj health examination as merely a certification of fitness to perform the pilgrimage, though respiratory health assessment was often inadequate. The opportunity to optimise the health of pilgrims with asthma by providing the appropriate medications, asthma action plan and asthma education including the preventive measures was disregarded. The preliminary health screening, which aimed to optimise pilgrims' health before the actual Hajj health examination was not appreciated by either pilgrims or health care providers., Conclusions: There is great potential to reform the current system of Hajj health certification in order to optimise its potential benefits for pilgrims with asthma. A systematic approach to restructuring the delivery of Hajj health examination could address the time constraints, clinical competency of primary health care providers and resources limitations., Competing Interests: Competing interests: This study is written on behalf of the RESPIRE collaborators. E.M.K. reports grant from the National Institute for Health Research Global Health Research Unit on Respiratory Health (RESPIRE) and Seqirus UK; personal fees from AstraZeneca and GlaxoSmithKline; and is board director of the International Primary Care Respiratory Group. The other authors have completed the ICJME Declaration of Interest Form (available upon request from the corresponding author) and declare no further conflicts of interest., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Background: Over-prescription of antibiotics for upper respiratory tract infection (URTI) is a continuing problem in Malaysia, leading to increased antimicrobial resistance and unnecessary cost incurred for treatment. In a patient presenting with a sore throat, it is recommended to only prescribe antibiotics to group A streptococcus (GAS) pharyngitis confirmed by a throat culture, rapid antigen test or in patients with a Centor score of 4., Methods: This cross-sectional study assessed the proportion of antibiotics prescribed and antimicrobial susceptibility patterns of GAS pharyngitis in the Malaysian primary care setting. Two-hundred and fifteen adult patients presenting with sore throat were recruited in three primary care clinics. Demographic data and clinical information were collected and analysed. Centor scores were calculated according to the clinical information and throat swabs were collected from all participants for GAS identification., Results: Only six throat swabs isolated GAS and indicated for antimicrobial treatment (2.8%). However, 48 participants (22.3%) were prescribed antibiotics out of which only four (8.3%) patients with isolated GAS, including three (6.2%) patients who clinically had a Centor score of 4 and one patient with a score of 3. Amoxicillin and erythromycin were the most commonly prescribed antibiotics (58.3% and 25% of all antibiotics, respectively)., Conclusion: There is a high proportion of antibiotic prescriptions which were not indicated in patients with sore throat in this study. This may reflect a common practice of antibiotic overuse for sore throat in primary care settings in Malaysia. Concerted interventions to reduce the inappropriate prescribing of antibiotics are urgently needed., Competing Interests: Conflicts of Interest None., (© Penerbit Universiti Sains Malaysia, 2022.)

Asthma self-management is a crucial component of asthma management. We sought to explore healthcare professionals' (HCPs') perceptions on barriers to asthma self-management implementation in primary care. We recruited 26 HCPs from six public primary care clinics in a semi-urban district of Malaysia in 2019. The analysis was done inductively. HCPs described barriers that resonated with the "COM-B" behaviour change framework. Capability-related issues stemmed from a need for specific self-management skills training. Opportunity-related barriers included the need to balance competing tasks and limited, poorly tailored resources. Motivation-related barriers included lack of awareness about self-management benefits, which was not prioritised in consultations with perceived lack of receptiveness from patients. These were compounded by contextual barriers of the healthcare organisation and multilingual society. The approach to implementation of asthma self-management needs to be comprehensive, addressing systemic, professional, and patient barriers and tailored to the local language, health literacy, and societal context.

Background: Engaging students in the e-learning development process enhances the effective implementation of e-learning, however, students' priority on the topics for e-learning may differ from that of the educators. This study aims to compare the differences between the students and their educators in prioritising the topics in three healthcare curricula for reusable e-learning object (RLO) development., Method: A modified Delphi study was conducted among students and educators from University Malaya (UM), Universiti Putra Malaysia (UPM) and Taylor's University (TU) on three undergraduate programmes. In Round 1, participants were asked to select the topics from the respective syllabi to be developed into RLOs. Priority ranking was determined by using frequencies and proportions. The first quartile of the prioritised topics was included in Round 2 survey, which the participants were asked to rate the level of priority of each topic using a 5-point Likert scale. The mean score of the topics was compared between students and educators., Result: A total of 43 educators and 377 students participated in this study. For UM and TU Pharmacy, there was a mismatch in the prioritised topics between the students and educators. For UPM, both the educators and students have prioritised the same topics in both rounds. To harmonise the prioritisation of topics between students and educators for UM and TU Pharmacy, the topics with a higher mean score by both the students and educators were prioritised., Conclusion: The mismatch in prioritised topics between students and educators uncovered factors that might influence the prioritisation process. This study highlighted the importance of conducting needs assessment at the beginning of eLearning resources development., Competing Interests: The authors have declared that no competing interests exist.

Background: Hypertension is one of the most important risk factors for cardiovascular diseases. Thus, it is an important public health challenge worldwide. In Malaysia, only a few studies have focused on the trends of hypertension specifically for the aging population. In view of the rapid growth of the elderly population in Malaysia, there is an urgent need to explore the condition of hypertension in this aging population. Hence, the objectives of this study were to determine the trends of population mean systolic and diastolic blood pressure (BP) levels, the prevalence, awareness, treatment and control of hypertension, and its' associated factors among older persons in two cross-sectional national surveys that were conducted in 2006 and 2015 in Malaysia., Methods: This was a subanalysis of secondary data collected from the two cross-sectional national population-based surveys conducted in Malaysia in 2006 and 2015. Adults aged 60 and older who had participated in these two surveys were included in the study., Results: A total of 4954 (2295 males and 2659 females) and 3790 (1771 males and 2019 females) respondents completed the hypertension module surveys in 2006 and 2015, respectively. The mean age of the respondents was 68.5±6.9 years in 2006 and 68.6±7.1 years in 2015 and the difference was not significant. The prevalence of hypertension significantly reduced from 73.8% in 2006 to 69.2% in 2015 (p<0.001). Among the respondents with hypertension, the awareness, treatment and control of hypertension significantly increased from 49.7% to 60.2%, 86.7% to 91.5% and 23.3% to 44.8%, respectively, from 2006 to 2015. Logistic regression analysis showed that female sex and unemployed/retiree were significantly associated with higher hypertension prevalence in both 2006 and 2015. Being unemployed/ retiree was significantly associated with higher awareness of hypertension in both 2006 and 2015. In both 2006 and 2015, Chinese ethnicity were significantly associated with higher awareness and control of hypertension., Conclusions: The mean population BP levels and hypertension prevalence among the elderly population in Malaysia have reduced significantly over the past decade. Although the awareness, treatment and control of hypertension among older adults have improved significantly, the awareness and control rates remain suboptimal. As population aging is inevitable, appropriate public health programs and optimal treatment strategies targeting this vulnerable group are urgently needed to improve the overall awareness and control of hypertension and to prevent hypertension-related complications., Competing Interests: The authors have declared that no competing interests exist.

Introduction: House Officer (HO) Preparatory Courses in Malaysia are designed to prepare medical graduates to work as a HO. The courses are designed to address the issues related to lack of confidence and readiness to work, which could lead to stress and HO dropping out of work. The modules focus on how to prepare medical graduates into the real-life working scenario. Hence, we determined the effectiveness of a HO Preparatory Course on the level of confidence and readiness to work among medical graduates., Methodology: A quasi-experimental study was conducted at three time-points (pre-intervention, post-intervention and one-month after working as a HO) on the level of confidence and readiness of medical graduates. The intervention was the Medicorp module, which included information and training needed for the HO such as common clinical cases in the wards, case referrals, experience sharing and hands on clinical training. We recruited eligible participants undergoing the course between April-November 2018. The adapted IMU Student Competency Survey was used to measure the confidence and readiness levels, which were scored from a Likert scale of 1-5. The higher score indicated higher levels of confidence or readiness., Results: A total of 239 participants were recruited at baseline (90% response rate). They were mostly female (77.8%), Malays (79.1%), single (90.0%), graduated overseas (73.6%), in 2018 (65.3%). The mean (SE) confidence scores significantly increased from 2.18 (1.00) pre-course to 3.50 (0.75) immediately after course and 3.79 (0.92) after one-month of work (p <0.001, η2 = 0.710). The mean (SE) readiness scores at pre-course, immediately and one-month post work were 2.36 (1.03), 3.46(0.78) and 3.70(0.90), respectively (p< 0.001, η2 = 0.612)., Conclusion: The HO Preparatory Course module was effective in increasing levels of confidence and readiness for medical graduates, most of whom are overseas graduates; namely Egypt, Russia and Indonesia., Competing Interests: The authors have declared that no competing interests exist.

Background: Supported asthma self-management improves health outcomes. However, people with limited health literacy, especially in lower-middle-income countries (LMICs), may need tailored interventions to enable them to realise the benefits. We aimed to assess the clinical effectiveness of asthma self-management interventions targeted at people with limited health literacy and to identify strategies associated with effective programmes., Methods: Following Cochrane methodology, we searched ten databases (January 1990 - June 2018; updated October 2019), without language restriction. We included controlled experimental studies whose interventions targeted health literacy to improve asthma self-management. Selection of papers, extraction of data and quality assessment were done independently by two reviewers. The primary outcomes were clinical (asthma control) and implementation (adoption/adherence to intervention). Analysis was narrative., Results: We screened 4318 titles and abstracts, reviewed 52 full-texts and included five trials. One trial was conducted in a LMIC. Risk of bias was low in one trial and high in the other four studies. Clinical outcomes were reported in two trials, both at high risk of bias: one of which reported a reduction in unscheduled care (number of visits in 6-month (SD); Intervention:0.9 (1.2) vs Control:1.8 (2.4), P  = 0.001); the other showed no effect. None reported uptake or adherence to the intervention. Behavioural change strategies typically focused on improving an individual's psychological and physical capacity to enact behaviour (eg, targeting asthma-related knowledge or comprehension). Only two interventions also targeted motivation; none sought to improve opportunity. Less than half of the interventions used specific self-management strategies (eg, written asthma action plan) with tailoring to limited health literacy status. Different approaches (eg, video-based and pictorial action plans) were used to provide education., Conclusions: The paucity of studies and diversity of the interventions to support people with limited health literacy to self-manage their asthma meant that the impact on health outcomes remains unclear. Given the proportion of the global population who have limited health literacy skills, this is a research priority., Protocol Registration: PROSPERO CRD 42018118974., Competing Interests: Competing interest: The authors have completed the ICMJE Unified Competing Interest form (available on request from the corresponding author) and declare no conflict of interest., (Copyright © 2020 by the Journal of Global Health. All rights reserved.)

Introduction: There are no long-term, prospective clinical studies assessing outcomes of endodontically treated cracked teeth with radicular extensions. The purpose of this prospective study was to examine the 2- to 4-year success and survival rates of endodontically treated, coronally restored, cracked teeth, specifically where the crack extends beyond the level of the canal orifice internally., Methods: Seventy consecutive teeth requiring endodontic treatment with cracks extending to the level of the canal orifice and up to 5 mm beyond were included in the cohort. Treatment was performed by a single endodontist using current techniques, and cases were followed over time. Specific treatment and posttreatment protocols were used. A tooth was "survived" if it was present, asymptomatic, and functional. The category of "success" was given to a case if strict radiographic and clinical criteria were met., Results: Fifty-nine teeth were eligible for survival analysis, and 53 teeth were available for success analysis. There was a 100% survival rate in the first 2 years and 96.6% survival up to the 4-year period; 90.6% were classified as "success" in the 2- to 4-year term. No significant differences (P < .05) were found for periodontal pocketing (up to 7 mm) at the site of the crack, marginal ridge involvement, crack depth, or pretreatment diagnoses., Conclusions: This study showed that the success and survival rates for cracked teeth with radicular extensions may be similar to endodontically treated teeth in general and may be higher than previously reported in cracked tooth studies. Treatment outcomes in cracked teeth with radicular extensions may be improved by using the following protocols: microscope-assisted intraorifice barriers placed apical to the extent of the crack, complete occlusal reduction, specific postoperative instructions, and expeditious placement of a full-coverage restoration., (Copyright © 2019 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

The ability for PAs to easily move from one specialty to another without additional formal training is a unique feature of the profession that is valued by PAs and their employers. Specialty certification has been viewed as a threat to this flexibility, yet 73% of PAs are in specialty practice. How can the desire to preserve flexibility be balanced against the desire of specialized PAs to distinguish themselves in their chosen specialty? This article reviews the issue of specialty certification in the context of contemporary PA practice and concludes that although specialty certification remains a threat to the flexibility of the PA model, it may be appropriate in some situations. In particular, specialty certification may be appropriate as a means for promotion within healthcare systems so long as it is not used as a requirement for entry into specialty practice, credentialing, or third-party reimbursement. A portfolio model may give stakeholders an alternative way to assess the experience and competencies of PAs in specialty practice areas.

Background: Blended learning (BL) is a learning innovation that applies the concept of face-to-face learning and online learning. However, examples of these innovations are still limited in the teaching of postgraduate education within the field of family medicine. Malaysian postgraduate clinical training, is an in-service training experience and face-to-face teaching with the faculty members can be challenging. Given this, we took the opportunity to apply BL in their training. This study provides an exploration of the perceptions of the educators and students toward the implementation of BL., Methods: A qualitative approach was employed using focus group discussions (FGD) and in-depth interviews (IDI) at an academic centre that trains family physicians. Twelve trainees, all of whom were in their hospital specialty's rotations and five faculty members were purposively selected. Three FGDs among the trainees, one FGD and two IDIs among the faculty members were conducted using a semi-structured topic guide. Data were collected through audio-recorded interviews, transcribed verbatim and checked for accuracy. A thematic approach was used to analyse the data., Results: There were four main themes that emerged from the analysis. Both educators and trainees bill the perspective that BL encouraged continuity in learning. They agreed that BL bridges the gap in student-teacher interactions. Although educators perceived that BL is in concordance with trainees learning style, trainees felt differently about this. Some educators and trainees perceived BL to be an extra burden in teaching and learning., Conclusion: This study highlights a mix positive and negative perceptions of BL by educators and trainees. BL were perceived positively for continuity in learning and student-teacher interaction. However, educator and learner have mismatched perception of learning style. BL was also perceived to cause extra burden to both educators and learners. Integrating BL to a traditional learning curriculum is still a challenge. By knowing the strengths of BL in this setting, family medicine trainees in Malaysia can use it to enhance their current learning experience. Future study can investigate different pedagogical designs that suit family medicine trainees and educators in promoting independent learning in postgraduate training.

Objective: If presented with serious mental illness (SMI), individuals' low help-seeking behaviors and poor adherence to treatment are associated with negative stereotypes and attitudes of healthcare providers. In this study, we examined the effects of a brief psychoeducational program on reducing stigma in pre-clinical medical students., Methods: One hundred and two pre-clinical medical students (20-23 years old) were randomly assigned to face-to-face contact + educational lecture (n = 51) condition or video-based contact + educational lecture (n = 51) condition. Measures of pre-clinical medical students' mental illness-related stigma using the Opening Minds Stigma Scale for Health Care Providers (OMS-HC) were administered at pre-, post-treatment, and 1-month follow-up., Results: A 2 (condition: face-to-face contact + educational lecture, video-based contact + educational lecture) by 3 (time: pre-treatment, post-treatment, and 1-month follow-up) mixed model MANOVA was conducted on the Attitudes, Disclosure and Help-Seeking, and Social Distance OMS-HC subscales. Participants' scores on all subscales changed significantly across time, regardless of conditions. To determine how participants' scores changed significantly over time on each subscale, Bonferroni follow-up comparisons were performed to access pairwise differences for the main effect of time. Specifically, pairwise comparisons produced a significant reduction in Social Distance subscale between pre-treatment and post-treatment and between pre-treatment and 1-month follow-up, and a significant increase between post-treatment and 1-month follow-up, regardless of conditions. With respect to the Attitudes and Disclosure and Help-Seeking subscales, pairwise comparisons produced a significant reduction in scores between pre-treatment and post-treatment and a significant increase between post-treatment and 1-month follow-up., Conclusions: Our findings provide additional evidence that educational lecture on mental illness, coupled with either face-to-face contact or video-based contact, is predictive of positive outcomes in anti-stigma programs targeting future healthcare providers.

Providing effective medical care for older patients with type 2 diabetes mellitus (T2D) that may contribute to their active aging has always been challenging. We examined the independent effect of age ≥ 60 years on disease control and its relationship with diabetes-related complications in patients with T2D in Malaysia. This was a cross-sectional study using secondary data from the electronic diabetes registry database Adult Diabetes Control and Management (ADCM). A total of 303 centers participated and contributed a total of 70,889 patients from May 2008 to the end of 2009. Demographic data, details on diabetes, hypertension, dyslipidemia and their treatment modalities, various risk factors and complications were updated annually. Independent associated risk factors were identified using multivariate regression analyses. Fifty-nine percent were female. Malay comprised 61.9%, Chinese 19% and Indian 18%. There were more Chinese, men, longer duration of diabetes and subjects that were leaner or had lower BMI in the older age group. Patients aged ≥ 60 years achieved glycemic and lipid targets but not the desired blood pressure. After adjusting for duration of diabetes, gender, ethnicity, body mass index, disease control and treatment, a significantly higher proportion of patients ≥ 60 years suffered from reported diabetes-related complications. Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors. Our findings caution against the currently recommended control of targets in older T2D patients with more longstanding diseases and complications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Powders composed of four morphologically different calcium phosphate particles were prepared by precipitation from aqueous solutions: flaky, brick-like, elongated orthogonal, and spherical. The particles were then loaded with either clindamycin phosphate as the antibiotic of choice or fluorescein, a model molecule used to assess the drug release properties. A comparison was carried out of the effect of such antibiotic-releasing materials on: sustained drug release profiles; Staphylococcus aureus growth inhibition; and osteogenic propensities in vitro. Raman spectroscopic analysis indicated the presence of various calcium phosphate phases, including monetite (flaky and elongated orthogonal particles), octacalcium phosphate (brick-shaped particles), and hydroxyapatite (spherical particles). Testing the antibiotic-loaded calcium phosphate powders for bacterial growth inhibition demonstrated satisfying antibacterial properties both in broths and on agar plates. All four calcium-phosphate-fluorescein powders exhibited sustained drug release over 21 days. The calcium phosphate sample with the highest specific surface area and the smallest, spherical particle size was the most effective in both drug loading and release, consequently having the highest antibacterial efficiency. Moreover, the highest cell viability, the largest gene expression upregulation of three different osteogenic markers--osteocalcin, osteopontin, and Runx2--as well as the least disrupted cell cytoskeleton and cell morphologies were also noticed for the calcium phosphate powder composed of the smallest, spherical nanosized particles. Still, all four powders exerted a viable effect on osteoblastic MC3T3-E1 cells in vitro, as evidenced by both morphological assessments on fluorescently stained cells and measurements of their mitochondrial activity. The obtained results suggest that the nanoscale particle size and the corresponding coarseness of the surface of particle conglomerates as the cell attachment points may present a favorable starting point for the development of calcium-phosphate-based osteogenic drug delivery devices.

Transient osteoporosis is a rare cause of pain in the foot. There is a broad differential diagnosis. A multidisciplinary assessment by both an orthopaedic surgeon and rheumatologist with review of the imaging by a radiologist is useful, as this condition is a diagnosis of exclusion.

The Lauge-Hansen classification of ankle fractures is a historical landmark in fracture research. Despite this there are, however, some shortcomings in methodology and several papers have demonstrated poor reproducibility. This paper reviews Lauge-Hansen's work and the literature evaluating his classification.

Calix[4]arenes, calix[4]resorcarenes, and anionic cyclodextrin derivatives were examined as chiral NMR solvating agents. The calix[4]arenes were prepared by attachment of amino acids through the hydroxyl groups of the phenol rings. Chloroform-, methanol-, and water-soluble derivatives were prepared and tested with a range of substrates. Chloroform-soluble chiral calix[4]resorcarenes were prepared by attachment of chiral primary and secondary amines and examined in NMR applications with a variety of substrates. Sulfated and carboxymethylated beta-cyclodextrin are effective at causing enantiomeric discrimination in the (1)H NMR spectra of organic cations. Lanthanide ions associate at the carboxymethyl groups and cause sizeable shifts and enhancements in enantiomeric discrimination in the spectra of organic cations. The enhancements caused by the lanthanide ion are large enough that much lower concentrations of the cyclodextrin can be used as compared to conventional analyses., (Copyright 2003 Wiley-Liss, Inc.)

The majority of rheumatoid arthritis patients with C1/2 instability causing neck pain and neurological compromise can be treated with unisegmental fusion. However, a minority will require decompression and more extensive craniocervical fusion. Two cohorts of patients with rheumatoid arthritis requiring decompression and craniocervical fusion were included in a retrospective study comparing sublaminar wiring (Ransford Loop, n = 10, follow-up = 36 +/- 9.5 months) and lateral mass screws (Cervifix system, n = 11; follow-up = 39.7 +/- 7.9 months). Both cohorts of patients experienced significant improvements in high cervical pain scores [McGill 5-point score; preop = 4.5 +/- 0.75 for Cervifix and 4.5 +/- 0.75 for Ransford loop; postop = 1.17 +/- 0.9 (p = 0.003) for Cervifix (at 39.7 months +/-7.9) and 2.8 +/- 1.6 (p = 0.011) for Ransford loop (at 36 +/- 9.5 months)]. Lateral mass screws for craniocervical fusion (seven out of 11 pain free) appear to produce better early results for rheumatoid arthritis patients suffering high cervical neck pain than sublaminar wire techniques (three out of 10 pain free).