Identifying clinical features that differentiate acute febrile thrombocytopaenia from acute febrile illness without thrombocytopaenia can help primary care physician to decide whether to order a full blood count (FBC). This is important because thrombocytopaenia in viral fever may signify more serious underlying aetiology like dengue infection.
A healthy 27 year old Para 3 presenting with abnormal menstruation without a period of amenorrhoea was diagnosed to have left tubal ectopic pregnancy after vaginal examination and abdominal ultrasonography. The case illustrates the need for careful history taking and the need for considering ectopic pregnancy in women in the reproductive age group, who have abnormal menstruation even if they are on contraception.
A proportion of patients with acute viral fever with thrombocytopaenia does not necessary have dengue infection. Managing them indiscriminately as dengue infection may not be appropriate. The prevalence of this problem is not exactly known. The objective of this study is to determine the prevalence of acute non-dengue febrile thrombocytopaenia among adult patients presenting with acute non-specific febrile illness in an outpatient setting. This was a clinic-based cross sectional study. Consecutive patients presenting with non-specific febrile illness of less than two weeks were selected from the Primary Care Centre of Hospital Universiti Kebangsaan Malaysia (HUKM) and the Batu 9 Cheras Health Clinic. Full blood count was done on the day of visit and dengue serology was done on day five of illness for all patients enrolled. Seventy three patients participated in this study from May to November 2003. Among the patients, 35 (47.9%) were noted to have thrombocytopaenia. Fourteen (40%) patients with thrombocytopaenia were serologically negative. The prevalence of non-dengue febrile thrombocytopaenia was 19.2%. A significant number of patients with acute non-specific febrile illness with thrombocytopaenia were negative for dengue serology. These patients should be differentiated from those with acute febrile thrombocytopaenia, as they might differ in their natural history from those with dengue infection, and hence require different management strategies.
Study site: Primary Care Centre of Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Thrombocytopaenia is often relied upon as an important criterion for the diagnosis of dengue infection among patients presenting with an acute non-specific febrile illness. This study was aimed to assess usefulness of thrombocytopaenia in the diagnosis of acute dengue virus infection. This was a clinic based prospective cohort study from May to November 2003. Consecutive patients presenting with acute non-specific febrile illness of less than two weeks were selected from two urban primary care centres. We did full blood count examination (FBC) on the day of visit and dengue serology on day five of illness for all patients enrolled. We repeated the FBC examination for patients who had initial normal platelet counts. Thrombocytopaenia was defined as platelet count < 150 X 10(9)/L. Eighty-seven patients enrolled in the study. Complete data was available for 73 patients. The prevalence of acute dengue virus infection was 27.6%. The sensitivity and specificity were 88% and 71% respectively. The likelihood of acute dengue infection in the presence of thrombocytopaenia was 2.52 and likelihood of not having dengue infection in normal platelet count patients was 5.22. Thrombocytopaenia has fair predictive value in diagnosing acute dengue virus infection. It was more useful to exclude than to diagnose dengue infection.
Study site: Primary Care Centre of Hospital Universiti
Kebangsaan Malaysia (HUKM) and Batu 9 Health Clinic Hulu Langat,
Treatment refusal is a common encounter in clinical practice. The process of deciding to refuse treatment is often complex. It is our responsibility to try and understand this process of decision making and the underlying reasons for treatment refusal. Many of these reasons are often rational in the context where the decision is made. The patients could be making the best decision for themselves even if these decisions are not necessarily the best in our mind. We should at all times discuss our treatment options and assess their ability to make decisions in achieving common goals. These goals should balance our best treatment strategies and the patients' best interest. This article discusses the reasons underlying treatment refusal and how we can achieve a common goal with our patients.
Universally, mothers often use touching to detect fever in their children. We perform a systematic review of published diagnostic studies evaluating the ability of mothers to detect fever in their children by touching. We found 10 studies satisfying our inclusion criteria. The meta-analysis revealed a summary sensitivity of 89.2% and summary specificity of 50%-maternal touch is perhaps more useful to exclude fever rather than to 'rule in' fever. However, due to significant heterogeneity in the included studies, interpretation of the summary data is difficult.
BACKGROUND: Optimum management of dyspepsia in primary care is a debatable subject. Testing for Helicobacter pylori (HP) has been recommended in primary care as this strategy will cure most underlying peptic ulcer disease and prevent future gastro duodenal disease.
METHODS: A total of 98 patients completed Modified Glasgow Dyspepsia Severity Score Questionnaire (MGDSSQ) at initial presentation before undergoing the 13Carbon Urea Breath Test (UBT) for HP. Those with positive UBT received Eradication Therapy with oral Omeprazole 20 mg twice daily, Clarithromycin 500 mg daily and Amoxycillin 500 mg twice daily for one week followed by Omeprazole to be completed for another 4 to 6 weeks. Those with negative UBT received empirical treatment with oral Omeprazole 20 mg twice daily for 4 to 6 weeks. Patients were assessed again using the MGDSSQ at the completion of treatment and one month after stopping treatment.
RESULTS: The prevalence of dyspepsia at Universiti Kebangsaan Malaysia-Primary Care Centre was 1.12% (124/11037), out of which 23.5% (23/98) was due to HP. Post treatment assessment in both HP (95.7%, 22/23) and non HP-related dyspepsia (86.7%, 65/75) groups showed complete or almost complete resolution of dyspepsia. Only about 4.3% (1/23) in the HP related dyspepsia and 13.3% (10/75) in the non HP group required endoscopy.
CONCLUSION: The prevalence of dyspepsia due to HP in this primary care centre was 23.5%. Detection of HP related dyspepsia yielded good treatment outcomes (95.7%).
Non-attendance results in administrative problems and disruption in patient care. Several interventions have been used to reduce non-attendance, with varying degree of success. A relatively new intervention, text messaging, has been shown to be as effective as telephone reminders in reducing non-attendance. However, no study has looked specifically at using text messaging reminders to reduce non-attendance in chronic disease care.
The aging man is becoming a major burden to Asian countries because of the current poor health status of Asian men and the aging Asian population. Life expectancy at birth for men is shorter than women by an average of 4 years in Asian countries and major causes of death are cardiovascular disease, cancers, injuries and infections. However, there are considerable variations between Asian countries because of great disparity in socioeconomic status. Male-specific disorders, such as male sexual health and urological conditions, are other major health burdens because they have a great impact on men's quality of life. More importantly, many risk factors to the causes of mortality and morbidities, such as high-risk behavior and smoking, can be improved with health promotion and early intervention. The current evidence suggests that the poor health status of men is the result of their poor health care utilization, negative health-seeking behavior, the adverse social environment for men and gender-insensitive health care delivery. However, much evidence is still needed as Asian countries have great diversity in culture, societal values and men's needs. Asian time-tested wisdom on a balanced healthy lifestyle to longevity should be explored as potential men's health promotional programs. Taking into account Asian men's health-care needs, a gender-streamlined approach and man-friendly health care delivery should be on the national agenda in managing the aging man.
Background: Overprescription of antibiotics is a continuing problem in primary care. This study aims to assess the antibiotic prescribing rates and antibiotic choices for upper respiratory tract infections (URTI) and urinary tract infections (UTI) in Malaysian primary care.
Method: Antibiotic prescribing data for URTI and UTI was extracted from a morbidity survey of randomly selected primary care clinics in Malaysia.
Results: Analysis was performed of 1163 URTI and 105 UTI encounters. Antibiotic prescribing rates for URTI and UTI were 33.8% and 57.1% respectively. Antibiotic prescribing rates were higher in private clinics compared to public clinics for URTI, but not for UTI. In URTI encounters, the majority of antibiotics prescribed were penicillins and macrolides, but penicillin V was notably underused. In UTI encounters, the antibiotics prescribed were predominantly penicillins or cotrimoxazole.
Discussion: Greater effort is needed to bring about evidence based antibiotic prescribing in Malaysian primary care, especially for URTIs in private clinics.
Keywords: general practice, prescriptions, drug; upper respiratory tract infection; urinary tract infection; antibiotics, guideline; evidence based medicine
Study site: Klinik Kesihatan, Malaysia
BACKGROUND: Although prevalent in primary care settings, men's health issues are rarely discussed. Yet, primary care doctors (PCDs) are well positioned to offer health check-ups during consultations.
OBJECTIVES: This study aims to develop a substantive theory to explain the process of decision making by which PCDs engage men in discussing health check-ups.
METHODS: Grounded theory method was adopted. Data source was from 14 in-depth interviews and 8 focus group discussions conducted with a semi-structured guide. Interviews were recorded and transcribed verbatim for analysis. Initial open coding captured the concepts of processes from the data, followed by selective and theoretical coding to saturate the core category. Constant comparative method was used throughout the process to allow emergence of the theory.
RESULTS: Fifty-two PCDs from private and public settings were interviewed. PCDs engaged male patients in health check-ups when they associated high medical importance with the relevant issues. The decision to engage men also depended on perceived chances of success in negotiations about health check-ups. A high chance of success, associated with minimal negotiation effort, is associated with men being most receptive to health check-ups. When doctors feel the importance of a particular health issue, they place less emphasis on their perceived men's receptivity to discuss that health issue in their intention to engage them in discussing it.
CONCLUSIONS: Engaging male patients in appropriate health check-up activities requires a series of actions and decisions by the PCDs. The decision to engage the patient depends on the perceived balance between the receptivity of male patients and the medical importance of the issues in mind.
Men's health concerns have evolved from the traditional andrology and male sexual health to a more holistic approach that encompasses male psychological, social and physical health. The poor state of health in men compared to their female counterparts is well documented. A review of the epidemiological data from Malaysia noted a similar trend in which men die at higher rates in under 1 and above 15 years old groups and most disease categories compared to women. In Malaysia, the main causes of death in men are non-communicable diseases and injuries. Risk factors, such as risk-taking behaviour, smoking and hypertension, are prevalent and amenable to early interventions. Erectile dysfunction, premature ejaculation and prostate disorders are also prevalent. However, many of these morbidities go unreported and are not diagnosed early; therefore, opportunities for early intervention are missed. This reflects poor health knowledge and inadequate health-care utilisation among Malaysian men. Their health-seeking behaviour has been shown to be strongly influenced by family members and friends. However, more research is needed to identify men's unmet health-care needs and to develop optimal strategies for addressing them. Because the Malaysian population is aging and there is an increase in sedentary lifestyles, optimizing men's health will remain a challenge unless effective measures are implemented. The existing male-unfriendly health-care system and the negative influence of masculinity on men's health behaviour must be addressed. A national men's health policy based on a male-friendly approach to health-care delivery is urgently needed to provide a framework for addressing these challenges.
BACKGROUND: Men have been noted to utilise health care services less readily then women. Primary care settings provide an opportunity to engage men in health care activities because of close proximity to the target group (men in the community). Understanding attitudes towards men's health among Malaysian primary care doctors is important for the effective delivery of health services to men. We aimed to explore the opinions and attitudes of primary care doctors (PCDs) relating to men's health and help-seeking behaviour.
METHODS: A qualitative approach to explore the opinions of 52 PCDs was employed, using fourteen in-depth interviews and eight focus group discussions in public and private settings. Purposive sampling of PCDs was done to ensure maximum variation in the PCD sample. Interviews were recorded and transcribed verbatim for analysis. Open coding with thematic analysis was used to identify key issues raised in the interview.
RESULTS: The understanding of the concept of men's health among PCDs was fragmented. Although many PCDs were already managing health conditions relevant and common to men, they were not viewed by PCDs as "men's health". Less attention was paid to men's help-seeking behaviour and their gender roles as a potential determinant of the poor health status of men. There were opposing views about whether men's health should focus on men's overall health or a more focused approach to sexual health. There was also disagreement about whether special attention was warranted for men's health services. Some doctors would prioritise more common conditions such as hypertension, diabetes and hypercholesterolaemia.
CONCLUSIONS: The concept of men's health was new to PCDs in Malaysia. There was wide variation in understanding and opposing attitudes towards men's health among primary care doctors. Creating awareness and having a systematic approach would facilitate PCDs in delivering health service to men.
BACKGROUND: Knowledge is believed to be a driving factor for patients' early presentation for healthcare. This study was conducted to assess knowledge of colorectal cancer among subjects presenting with rectal bleeding and to determine its association with late presentation.
METHODS: A cross-sectional study of 80 patients with rectal bleeding, aged 40 and above, was conducted between December 2008 and June 2009 in the endoscopy unit, University Kebangsaan Malaysia Medical Centre. The research instruments used in this study was a self-administered questionnaire including data on duration of rectal bleeding, first medical consultation and knowledge of colorectal cancer.
RESULTS: Sixty percent of subjects with rectal bleeding delayed seeking medical advice. Subjects were more aware of symptoms of non-colorectal cancers compared to symptoms of colorectal cancer. The majority of subjects (63.8%) correctly identified rectal bleeding as a symptom but were not aware of the best screening method to detect colorectal cancer. Half of the subjects knew increasing age and genetic background to be risk factors for colorectal carcinoma. However, knowledge of colorectal cancer was not found to be significantly associated with delay in seeking help.
CONCLUSION: Findings indicate poor awareness of colorectal cancer among the subjects. Although public education of colorectal cancer is important for early presentation on rectal bleeding, further studies are advocated to evaluate other factors influencing patients' help seeking behavior other than knowledge.
OBJECTIVES: To compare the morbidity patterns in public and private primary care clinics; determine patients' reasons for encounter (RFE) and diagnoses using the ICPC-2, and compare ten commonest diagnoses and RFEs.
METHODS: A cross-sectional study on randomly selected clinics was conducted nationwide. Doctors completed the Patient Encounter Record (PER) for systematically selected encounters for a week.
RESULTS: Response rate was 82.0% (public clinic) and 33% (private clinic) with 4262 encounters and 7280 RFE. Overall, the three commonest disease categories encountered were respiratory (37.2%), general and unspecified (29.5%), and cardiovascular diseases (22.2%). Public and private clinics handled 27% versus 50% acute cases and 20.0% versus 3.1% chronic cases i.e. 33.7 and 5.6 chronic diseases per 100 RFE respectively.
CONCLUSION: Doctors in public clinics saw more chronic and complex diseases as well as pregnancy related complaints and follow-up cases while in private clinics more acute and minor illnesses were seen. Health services should be integrated and support given to co-manage chronic diseases in both sectors.
KEYWORDS: Malaysia; Primary practice; delivery of health care; morbidity pattern; reasons for encounter
INTRODUCTION: Sexual dysfunction in men, such as erectile dysfunction, hypogonadism, and premature ejaculation, generates considerable attention. Its association with physical and psychological health is an issue which should be addressed seriously.
AIM: A review of the literature pertaining to the correlation between sexual dysfunction and physical and psychological health.
METHODS: PubMed search for relevant publications on the association between sexual dysfunction in men and physical and psychological health.
MAIN OUTCOME MEASURE: Clinical and epidemiological evidence that demonstrates the association between sexual dysfunction in men and physical and psychological health.
RESULTS: Sexual dysfunction, i.e., erectile dysfunction, hypogonadism, and premature ejaculation, has been shown to be associated with physical and psychological health. There is a strong correlation between sexual dysfunction and cardiovascular disease, metabolic syndrome, quality of life, and depression.
CONCLUSION: The association between men's sexual dysfunction and physical and psychological health is real and proven. Therefore, it should not be taken lightly but instead treated as a life-threatening medical problem.
Men's health discourse has been around for more than 2 decades. The higher mortality rates and the shorter life expectancy in Asian men compared with their women counterparts show the disadvantaged status of men's health. Thus, discussions on men's health should address their health needs and not be confined to sex-specific male urology and reproductive health. In Asia, assessing men's health needs is challenging because of the vast differences in the socioeconomic status and the diverse culture among its member countries. Although, the epidemiology of men's health provides the focus for what to address in improving men's health, having an optimal strategy requires the understanding of men's health-seeking behaviors and the social determinants surrounding them. Thus, public health approaches addressing health behaviors and health promotion in the society should be one of the keys in improving men's health status. Locally relevant information is needed to inform effective public health approaches.
Study Type - Therapy (RCT). Level of Evidence 1b. What's known on the subject? and What does the study add? Testosterone deficiency syndrome can be treated with testosterone replacement in the form of injectable, transdermal, buccal and oral preparations. Long-acting i.m. testosterone undecanoate 1000 mg, which is given at 10-14 week intervals, has been shown to be adequate for sustaining normal testosterone levels in hypogonadal men. This study confirms that long-acting i.m. testosterone undecanoate is effective in improving the health-related quality of life in men with testosterone deficiency syndrome as assessed by the improvement in the Aging Male Symptoms scale. Testosterone treatment can be indicated in men who have poor health-related quality of life resulting from testosterone deficiency syndrome.
This study aimed to investigate the effect of intramuscular injection of testosterone undecanoate on overall quality of life (QoL) in men with testosterone deficiency syndrome (TDS). A randomized controlled trial over a 12-month period was carried out in 2009. One hundred and twenty men aged 40 years and above with a diagnosis of TDS (serum total testosterone <12 nmol l(-1) and total Aging Male Symptom (AMS) scores ≥27) were invited to participate. Interventions comprised intramuscular injection of either placebo or 1000 mg testosterone undecanoate, given at weeks 0, 6, 18, 30 and 42. This paper presents the secondary analysis of QoL changes measured in the scores of Short-Form-12 (SF-12) scale at baseline, weeks 30 and 48 after the first injection. A total of 56/60 and 58/60 men from the active treatment and placebo group, respectively, completed the study. At week 48, before adjusting for baseline differences, the QoL of men in the treatment group improved significantly in five out of the eight domains on SF-12. The physical health composite scores improved 4.0 points from a baseline of 41.9±7.0 in the treatment group compared to 0.8 point from a baseline of 43.7±7.1 in the placebo group (F=3.652, P=0.027). The mental health composite scores improved 4.4 points from a baseline of 37.1±9.0 in the treatment group compared to 1.0 points from a baseline of 37.6±7.9 in the placebo group (F=4.514, P=0.018). After adjusting for baseline differences, significant improvement was observed in mental health composite scores, but not in physical health composite scores. Long-acting testosterone undecanoate significantly improved the mental health component of QoL in men with TDS.
Study: Subang Jaya Aging Men's Health Study
Funding: Bayer Schering Pharma