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  1. Fulltext COVID-19: Four Paediatric Cases in Malaysia
    See KC, Liew SM, Ng DCE, Chew EL, Khoo EM, Sam CH, et al.
    Int J Infect Dis, 2020 May;94:125-127.
    PMID: 32304822 DOI: 10.1016/j.ijid.2020.03.049
    OBJECTIVE: This is a brief report of 4 paediatric cases of COVID-19 infection in Malaysia BACKGROUND: COVID-19, a coronavirus, first detected in Wuhan, China has now spread rapidly to over 60 countries and territories around the world, infecting more than 85000 individuals. As the case count amongst children is low, there is need to report COVID-19 in children to better understand the virus and the disease.

    CASES: In Malaysia, until end of February 2020, there were four COVID-19 paediatric cases with ages ranging from 20 months to 11 years. All four cases were likely to have contracted the virus in China. The children had no symptoms or mild flu-like illness. The cases were managed symptomatically. None required antiviral therapy.

    DISCUSSION: There were 2 major issues regarding the care of infected children. Firstly, the quarantine of an infected child with a parent who tested negative was an ethical dilemma. Secondly, oropharyngeal and nasal swabs in children were at risk of false negative results. These issues have implications for infection control. Consequently, there is a need for clearer guidelines for child quarantine and testing methods in the management of COVID-19 in children.

  2. Fulltext We have to write and share valid and reliable information on COVID-19
    Liew SM, Khoo EM, Cheah WK, Goh PP, Ibrahim HM
    Malays Fam Physician, 2020;15(1):1.
    PMID: 32284797
  3. Fulltext Bibliography of primary care research in Malaysia
    Khoo EM, Teng CL, Ng CJ, Jaafar S
    ISBN: 978-983-100-450-0
    Citation: Khoo EM, Teng CL, Ng CJ, Jaafar S. Bibliography of primary care research in Malaysia. Kuala Lumpur: University of Malaya; 2008
  4. Fulltext Tuberculosis in Malaysia: predictors of treatment outcomes in a national registry
    Liew SM, Khoo EM, Ho BK, Lee YK, Mimi O, Fazlina MY, et al.
    Int J Tuberc Lung Dis, 2015 Jul;19(7):764-71.
    PMID: 26056099 DOI: 10.5588/ijtld.14.0767
    OBJECTIVES: To determine treatment outcomes and associated predictors of all patients registered in 2012 with the Malaysian National Tuberculosis (TB) Surveillance Registry.
    METHODS: Sociodemographic and clinical data were analysed. Unfavourable outcomes included treatment failure, transferred out and lost to follow-up, treatment defaulters, those not evaluated and all-cause mortality.
    RESULTS: In total, 21 582 patients were registered. The mean age was 42.36 ± 17.77 years, and 14.2% were non-Malaysians. The majority were new cases (93.6%). One fifth (21.5%) had unfavourable outcomes; of these, 46% died, 49% transferred out or defaulted and 1% failed treatment. Predictors of unfavourable outcomes were older age, male sex, foreign citizenship, lower education, no bacille Calmette-Guérin (BCG) vaccination scar, treatment in tertiary settings, smoking, previous anti-tuberculosis treatment, human immunodeficiency virus infection, not receiving directly observed treatment, advanced chest radiography findings, multidrug-resistant TB (MDR-TB) and extra-pulmonary TB. For all-cause mortality, predictors were similar except for rural dwelling and nationality (higher mortality among locals). Absence of BCG scar, previous treatment for TB and MDR-TB were not found to be predictors of all-cause mortality. Indigenous populations in East Malaysia had lower rates of unfavourable treatment outcomes.
    CONCLUSIONS: One fifth of TB patients had unfavourable outcomes. Intervention strategies should target those at increased risk of unfavourable outcomes and all-cause mortality.
  5. Tuberculosis Incidence and Factors Associated With Mortality Among Health Care Workers in Malaysia
    Liew SM, Khoo EM, Ho BK, Lee YK, Mimi O, Fazlina MY, et al.
    Asia Pac J Public Health, 2019 01;31(1):61-71.
    PMID: 30541329 DOI: 10.1177/1010539518817980
    This study aims to determine tuberculosis incidence, all-cause mortality, and its associated factors among health care workers (HCWs) registered in 2012 to 2014 with the Malaysian National Tuberculosis (MyTB) Surveillance Registry. Regression analysis was used to determine factors associated with all-cause mortality. Incidence rates ranged from 135.18 to 156.50/100 000 and were higher for HCWs compared with the general population (risk ratio = 1.70-1.96). The mean age at notification was 34.6 ± 10.55 years; 68.9% were female. Most were paramedics (44.3%) followed by other HCWs (41.9%) and doctors (13.8%). Nearly a quarter (23.8%) had extrapulmonary tuberculosis. There were 23 deaths giving a case fatality rate of 2.4%. Factors associated with death were older age (odds ratio [OR] =1.05; confidence interval [CI] =1.01-1.10), diabetes (OR = 3.83; CI = 1.32-11.08), HIV positivity (OR = 18.16; CI = 4.60-71.68), and not receiving directly observed therapy (DOTS) (OR = 10.97; CI = 3.61-33.38). It is important for HCWs to be aware of these increased risks and for authorities to implement protective measures.
  6. Infant Feeding Guidelines for the Asia Pacific Region
    Binns C, Lee MK, Kagawa M, Low WY, Scott J, Lee A, et al.
    Asia Pac J Public Health, 2018 Nov 23.
    PMID: 30466298 DOI: 10.1177/1010539518809823
    Good nutrition for infants, during the first 1000 days from conception, is one of the most important determinants of a healthy long life. Breastfeeding is the most important component of infant nutrition and reduces morbidity and mortality. With the changes to the climate currently occurring, issues of nutrition and food supply are only going to increase in importance. The Sustainable Development Goals of the United Nations, place nutrition at the forefront of world development and a sustainable planet. The vision of Asia-Pacific Academic Consortium for Public Health (APACPH) is to "achieve the highest possible level of health of all the people of the nations of the Asia-Pacific region." Much of the burden of disease, early deaths, and disability in the Asia Pacific region could be reduced with public health efforts to address the major risk factors, including nutrition-related causes and smoking. The United Nations Decade of Action on Nutrition 2016-2025 has recently been launched with the aim of reducing the global burden of inappropriate nutrition. The goals include increasing rates of exclusive breastfeeding to 6 months, reducing wasting and stunting, and reducing the rates of low birthweight. This is the position endorsed in these guidelines along with the principles of the Baby Friendly Hospital Initiative. These guidelines expand the information on infants that was included in the 2016 APACPH Dietary Guidelines. APACPH covers many different environments, geographical areas, cultures, and socioeconomic groups. These guidelines are generally applicable to all infants in our region, specific local advice may sometimes be needed.
  7. A mentally retarded patient with schizophrenia
    Rabia K, Khoo E
    Malays Fam Physician, 2008;3(3):146-50.
    PMID: 25606140 MyJurnal
    Schizophrenia is one of the most incapacitating forms of mental disorder that runs a chronic and relapsing course. It typically starts in adolescence or early adulthood and can be life-long. It is more common in people with learning disabilities than in the general population. Its prodromal features include depression, anxiety, suspiciousness, social isolation and bizarre behaviour. It may result in significant functional, social and economic impairments. The care of patients with schizophrenia places a considerable burden on all carers including patient's family, health and social services. Treatment includes pharmacotherapy and psychosocial interventions. In this case report we describe a thirteen-year-old patient with schizophrenia who has a background history of mental retardation.
  8. Fulltext Health profiles of foreigners attending primary care clinics in Malaysia
    Ab Rahman N, Sivasampu S, Mohamad Noh K, Khoo EM
    BMC Health Serv Res, 2016 06 14;16:197.
    PMID: 27301972 DOI: 10.1186/s12913-016-1444-0
    BACKGROUND: The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia.

    METHODS: Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care.

    RESULTS: Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters.

    CONCLUSIONS: More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public clinics suggests a need for improved access to maternal care and pregnancy related care. This has implication on policy and health care provision and access for foreigners and future studies are needed to look into strategies to solve these problems.
  9. Fulltext Statins use is associated with poorer glycaemic control in a cohort of hypertensive patients with diabetes and without diabetes
    Liew SM, Lee PY, Hanafi NS, Ng CJ, Wong SS, Chia YC, et al.
    Diabetol Metab Syndr, 2014;6:53.
    PMID: 24782916 DOI: 10.1186/1758-5996-6-53
    BACKGROUND:The US Federal and Drug Administration (FDA) recently revised statin drug labels to include the information that increases in fasting serum glucose and glycated haemoglobin levels have been reported with the use of statins. Yet in a survey, 87% of the doctors stated that they had never or infrequently observed increases in glucose or HbA1c levels in patients on statin. In this study we would like to determine the association between the use of statins and glycaemic control in a retrospective cohort of patients with hypertension.
    METHODS: A retrospective review of 1060 medical records of patients with hypertension at a primary care clinic was conducted. These records were selected using systematic random sampling (1:4). Data on patient socio-demographic factors; clinical profile; investigation results and prescribed medications were collected. Independent t-test was used for continuous variables while Pearson's χ2 test was used for categorical variables. Logistic regression was done to adjust for confounders.
    RESULTS: 810 (76.4%) patients with hypertension were on statins, out of which 792 (97.8%) were taking simvastatin 10 mg or 20 mg daily. Analysis of the whole group regardless of diabetes status showed that the statin user group had higher HbA1c and fasting blood glucose values. The difference in HbA1c levels remained significant (adjusted OR = 1.290, p = 0.044, 95% CI 1.006, 1.654) after adjustment for diabetes, diabetic medication and fasting blood glucose. In the study population who had diabetes, statin users again had significantly higher HbA1c level compared to statin non-users. This difference remained significant (adjusted OR 1.208, p = 0.037, 95% CI 1.012, 1.441) after adjustment for age and diabetic medications.
    CONCLUSIONS:Stat ins use is associated with increased HbA1c levels among hypertensive patients and hypertensive patients with diabetes. Clinicians managing hypertensive patients on statins should consider monitoring the HbA1c level and ensure that those with diabetes have their hyperglycaemia kept under control.
    KEYWORDS: Diabetes mellitus; HbA1c; Hypertension; Statin
    Study site: primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  10. Fulltext Unintentional injury and its prevention in infant: knowledge and self-reported practices of main caregivers
    Ramdzan SN, Liew SM, Khoo EM
    BMC Pediatr, 2014;14:132.
    PMID: 24885332 DOI: 10.1186/1471-2431-14-132
    BACKGROUND:
    Unintentional injuries are the major cause of morbidity and mortality in infants. Prevention of unintentional injuries has been shown to be effective with education. Understanding the level of knowledge and practices of caregivers in infant safety would be useful to identify gaps for improvement.

    METHODS:
    A cross-sectional study was conducted in an urban government health clinic in Malaysia among main caregivers of infants aged 11 to 15 months. Face-to-face interviews were conducted using a semi-structured self-designed questionnaire. Responses to the items were categorised by the percentage of correct answers: poor (<50%), moderate (50% - 70%) and good (>70%).

    RESULTS:
    A total of 403 caregivers participated in the study. Of the 21 items in the questionnaire on knowledge, 19 had good-to-moderate responses and two had poor responses. The two items on knowledge with poor responses were on the use of infant walkers (26.8%) and allowing infants on motorcycles as pillion riders (27.3%). Self-reported practice of infant safety was poor. None of the participants followed all 19 safety practices measured. Eight (42.1%) items on self-reported practices had poor responses. The worst three of these were on the use of baby cots (16.4%), avoiding the use of infant walkers (23.8%) and putting infants to sleep in the supine position (25.6%). Better knowledge was associated with self-reported safety practices in infants (p < 0.05). However, knowledge did not correspond to correct practice, particularly on the use of baby cots, infant walkers and sarong cradles.

    CONCLUSION:
    Main caregivers' knowledge on infant safety was good but self-reported practice was poor. Further research in the future is required to identify interventions that target these potentially harmful practices.
  11. Fulltext Managing dengue fever in primary care: A practical approach
    Lum LCS, Ng CJ, Khoo EM
    Malays Fam Physician, 2014;9(2):2-10.
    PMID: 25893065 MyJurnal
    Dengue is a common cause of illness seen in primary care in the tropical and subtropical countries. An understanding of the course of disease progression, risk factors, recognition of the warning signs and look out for clinical problems during the different phases of the disease will enable primary care physicians to manage dengue fever in an appropriate and timely manner to reduce morbidity and mortality.
  12. Prevalence and correlates of premature ejaculation in a primary care setting: a preliminary cross-sectional study
    Tang WS, Khoo EM
    J Sex Med, 2011 Jul;8(7):2071-8.
    PMID: 21492404 DOI: 10.1111/j.1743-6109.2011.02280.x
    INTRODUCTION: Premature ejaculation (PE) is common. However, it has been underreported and undertreated.
    AIMS: To determine the prevalence of PE and to investigate possible associated factors of PE.
    METHODS: This cross-sectional study was conducted at a primary care clinic over a 3-month period in 2008. Men aged 18-70 years attending the clinic were recruited, and they completed self-administered questionnaires that included the Premature Ejaculation Diagnostic Tool (PEDT), International Index of Erectile Function, sociodemography, lifestyle, and medical illness. The operational definition of PE included PE and probable PE based on the PEDT.
    MAIN OUTCOME MEASURE: Prevalence of PE.
    RESULTS: A total of 207 men were recruited with a response rate of 93.2%. There were 97 (46.9%) Malay, 57 (27.5%) Chinese, and 53 (25.6%) Indian, and their mean age was 46.0 ± 12.7 years. The prevalence of PE was 40.6% (N = 82) (PE: 20.3%, probable PE: 20.3% using PEDT). A significant association was found between ethnicity and PE (Indian 49.1%, Malay 45.4%, and Chinese 24.6%; χ(2) = 8.564, d.f. = 2, P = 0.014). No significant association was found between age and PE. Multivariate analysis showed that erectile dysfunction (adjusted odds ratio [OR] 4.907, 95% confidence interval [CI] 2.271, 10.604), circumcision (adjusted OR 4.881, 95% CI 2.346, 10.153), sexual intercourse ≤5 times in 4 weeks (adjusted OR 3.733, 95% CI 1.847, 7.544), and Indian ethnicity (adjusted OR 3.323, 95% CI 1.489, 7.417) were predictors of PE.
    CONCLUSION: PE might be frequent in men attending primary care clinics. We found that erectile dysfunction, circumcision, Indian ethnicity, and frequency of sexual intercourse of ≤5 times per month were associated with PE. These associations need further confirmation.
    Study site: primary care clinic at the University Malaya Medical Center (UMMC), Kuala Lumpur, Malaysia
  13. Menstrual-related attitudes and symptoms among multi-racial Asian adolescent females
    Wong LP, Khoo EM
    Int J Behav Med, 2011 Sep;18(3):246-53.
    PMID: 20440593 DOI: 10.1007/s12529-010-9091-z
    Menstruation has important implications on the physical and emotional well-being of adolescents' reproductive health.
  14. Dysmenorrhea in a multiethnic population of adolescent Asian girls
    Wong LP, Khoo EM
    Int J Gynaecol Obstet, 2010 Feb;108(2):139-42.
    PMID: 19944416 DOI: 10.1016/j.ijgo.2009.09.018
    Objective: To determine the prevalence of dysmenorrhea, its impact, and the treatment-seeking behavior of adolescent Asian girls.
    Method: A cross-sectional study with 1092 girls from 15 public secondary schools and 3 ethnic groups in the Federal Territory of Kuala Lumpur, Malaysia.
    Results: Overall, 74.5% of the girls who had reached menarche had dysmenorrhea; 51.7% of these girls reported that it affected their concentration in class; 50.2% that it restricted their social activities; 21.5% that it caused them to miss school; and 12.0% that it caused poor school performance. Ethnicity and form at school were significantly associated with the
    poor concentration, absenteeism, and restriction of social and recreational activities attributed to dysmenorrhea. Only 12.0% had consulted a physician, and 53.3% did nothing about their conditions. There were ethnic differences in the prevalence, impact, and management of dysmenorrhea.
    Conclusion: There is a need for culture-specific education regarding menstruation-related conditions in the school curriculum.
  15. Fulltext Missing an osteoporotic vertebral fracture
    Cheong AT, Khoo EM
    Malays Fam Physician, 2009;4(1):33-6.
    PMID: 25606157 MyJurnal
    This case illustrates an 80-year-old lady who presented with acute low back pain and finally succumbed from complications of osteoporotic vertebral fracture. Among the contributing factors are delayed diagnosis and a lack of continuity of care. It reminds the practitioners of the importance to look out for red flag symptoms and to have a high index of suspicion for vertebral fracture in high risk patients presenting with low back pain.
    Study site: Accident and Emergency Unit, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  16. Fulltext A primary care experience of open access to exercise stress test
    Ng CJ, Khoo EM
    Med J Malaysia, 2007 Aug;62(3):241-4.
    PMID: 18246916 MyJurnal
    This study described the practice profile of an open access exercise stress test (EST) service to the primary care physicians at a teaching hospital in 2000. We performed a retrospective review of all ESTs ordered and conducted by the primary care physicians. A total of 145 ESTs were conducted, of which 80.7% were referred for assessment of chest pain. Proportions of positive, negative, uninterpretable and inconclusive ESTs were: 22.1%, 52.8%, 18.1% and 6.9%. Typical chest pain was independently associated with a positive EST in this study (p = 0.008, OR 5.50, 95% CI 1.56-19.37). Although referral to the open access EST service seemed appropriate, there is a need to reduce the number of uninterpretable and inconclusive results.
  17. Prevalence of rubella susceptibility among pregnant mothers in a community-based antenatal clinic in Malaysia: a cross-sectional study
    Cheong AT, Khoo EM
    Asia Pac J Public Health, 2008;20(4):340-6.
    PMID: 19124328 DOI: 10.1177/1010539508322698
    INTRODUCTION: routine rubella antibody screening is not done for antenatal mothers in community health clinics in Malaysia. However, congenital rubella syndrome has persisted with its associated health burden.
    OBJECTIVES: to determine the prevalence of rubella susceptibility among pregnant mothers and its associated risk factors.
    METHODOLOGY: a cross-sectional study was carried out in the Petaling district, Selangor, Malaysia, where 500 pregnant mothers were recruited, and face-to-face interviews were conducted. Rubella IgG tests were performed.
    RESULTS: the prevalence of rubella susceptibility among pregnant mothers was 11.4%. Using logistic regression, a history of not having received rubella vaccination or having unknown rubella vaccination status was found to be a significant predictor for mothers to be rubella susceptible (odds ratio = 2.691; 95% confidence interval = 1.539-4.207).
    CONCLUSIONS: routine rubella IgG screening tests need to be offered to all antenatal mothers in view of the high prevalence found.
    Study site: Antenatal clinics (klinik kesihatan), Petaling, Selangor, Malaysia
  18. Fulltext Prevalence of peripheral arterial disease in patients with diabetes mellitus in a primary care setting
    Khatoon R, Khoo EM
    Med J Malaysia, 2007 Jun;62(2):130-3.
    PMID: 18705445 MyJurnal
    The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.
    Study site: primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
  19. How well were asthmatic patients educated about their asthma? A study at the emergency department
    Lee PY, Khoo EM
    Asia Pac J Public Health, 2004;16(1):45-9.
    PMID: 18839867 DOI: 10.1177/101053950401600108
    70 patients presented with acute asthma exacerbation requiring nebulised bronchodilator treatment at the emergency department of a teaching hospital in Kuala Lumpur, Malaysia, were interviewed over a two-week period in July 2001. The results showed that 45 (64%) patients had not been educated on the nature of asthma; 30 (43%) had not been advised on preventive measures or avoidance of triggers; 54 (77%) were not advised about the medications used and their side effects; 42 (60%) patients did not know the difference between reliever and preventive medications; 37 (53%) were unable to recognize features of worsening asthma and 68 (97%) were not told about the danger of non-prescribed self-medication or traditional medications. Only six (9%) patients were using peak flow meters and were taught self-management plans. The multiple regression results suggest that patients who were followed up at teaching hospital based clinics were better educated on asthma. In conclusion, asthmatic patients are still not educated well about their disease. Health care providers need to put more emphasis on asthma education so that the number of emergency room visits can be reduced.
    Study site: Emergency department, University Malaya Medical Centre, Kuala Lumpur, Malaysia
  20. Fulltext Peripheral arterial disease in general and diabetic population
    Khatoon R, Khoo EM
    Med J Malaysia, 2007 Jun;62(2):182-5; quiz 186.
    PMID: 18705464 MyJurnal
    Peripheral arterial disease (PAD) is stenosis or occlusion of peripheral arterial vessels by atherosclerotic plaque. It may present as intermittent claudication, rest pain and impotence. PAD of the lower limbs is the third most important site of atherosclerotic disease after coronary heart disease and cerebrovascular disease. Increasing age, family history, smoking, hypertension, dyslipidemia and more decisively diabetes are significant risk factors. PAD is a clinical condition that has often been neglected, underdiagnosed, undertreated and has a serious outcome. It may lead to nonhealing wounds, gangrene and amputation of the lower limbs. Hence, early identification of patients at risk of PAD and timely referral to the vascular surgeon in severe cases is crucial.
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