A prospective case controlled study was conducted to determine the incidence of asymptomatic bacteriuria in pregnancy (ASB), causative organisms and fetal outcome. Out of 510 antenatal mothers screened, 46 (9%) had ASB. The main organisms isolated were E. coli (16%), Staphylococcus aureus (15%) and Beta-Haemolytic Streptococcus (11%). Oral Nitrofurantoin and Cefuroxime axetil achieved sensitivity levels of 96%. There was no significant difference in period of gestation at birth and birthweight between the control and study groups. The reasons for routine antimicrobial therapy for ASB are discussed.
985 medical certificates issued by primary care doctors at the Klinik Perubatan Masyarakat and the staff health clinic at Universiti Sains Malaysia were analysed. Most common diagnoses were URTls, conjunctivitis, and gastro-enteritis. Mean duration of absence ranged from 1.3 to 3.4 days. HUSM staff with skin infections were given certificates nearly twice more often than the public. Backache earned more time off for the staff compared to the public. There is a need to formulate guidelines for medical certificates.
Study site: Klinik Perubatan Masyarakat and the staff health clinic at Universiti Sains Malaysia
Malaysia is a rapidly developing country with a very young population, about 36% of which are below the age of 15 years. The standard of child health has improved greatly. However, there are great changes in the morbidity and mortality patterns of childhood diseases relating mainly to an improved standard of living; availability of safe water supply and adequate sanitary latrines; a higher literacy rate; rapid industrialisation and urban migration. The infant mortality rate has droppedfrom 50.1 per 1,000 livebirths in 1986 to 10.4 in 1995, and similar trends apply also to neonatal, perinatal and toddler mortality rates. Nevertheless, current major child health problems are those relating to events in the perinatal period and to infections. Despite improvements in the standard of neonatal care with the use ofhigh technology, the commonest cause of certified deaths still occur in the neonatal period. A rapid and inexpensive screening test for G6PD deficiency, a disease present in 2-3% of the population, is now widely available and, together with the use of phototherapy is largely responsible for the declining incidence of kernicterus in the country. Infections remain an important cause of morbidity and mortality although their patterns have changed. The very high (>95%) WHO-EPI-vaccines coverage rate is linked to the great reduction in the incidence of diphtheria, pertussis, tetanus, poliomyelitis and measles. Childhood tuberculosis is less common now, with about 250 - 300 reported cases per year and TB meningitis is rare with about 30-40 reported cases/year. The hepatitis B carrier rate is high (5%) and the introduction of routine newborn hepatitis B vaccination in 1989 is expected to have a positive impact as is the immunisation of young girls against rubella introduced in 1985 in reducing the incidence of congenital rubella syndrome. The incidence of malaria has declined but remains prevalent in the interiors of PeninsularMalaysia and in Sabah and Sarawak. Filariasis is largely under control. Unfortunately, despite great efforts at mosquito control, dengue virus infection remains a major problem with thousands of cases reported every year. Children are most susceptible to dengue haemorrhagic fever with many dying from the shock syndrome. The incidence of acute gastroenteritis has also dropped with most cases being due to a viral aetiology. Acute respiratory infections, mostly viral in origin, account for most attendances at paediatric outpatient services. Although staphylococcal and streptococcal impetigo and pneumonia are common, the incidence of streptococcal related diseases like rheumatic fever and acute glomendonephritis is rapidly declining. The nutritional status of children has improved in tandem with the rise in the standard of living, but subclinical malnutrition is prevalent, particularly among urban squatters and the rural poor. There is a disturbing decline in breastfeeding among urban working mothers. Poor weaning practices and food habits are responsible for the common occurrence of nutritional anaemia (5%) among infants and young children. Greater prosperity, rapid industrialisation and urbanisation have resulted in changes in the childhood disease pattern where non-communicable diseases assume greater importance as the problems of malnutrition and infection are gradually overcome. Road traffic accidents are a major killer and home accidents, largely preventable, are an important cause of morbidity and mortality. Childhood cancer, with about 550 new cases a year, is an important cause of death beyond infancy. Major congenital malformations, with a 1% prevalence rate, cause much ill-health. Thalassaemia is a particularly common genetic disease with fl thalassaemia gene frequency of about 5%. The prevalence of asthma is increasing, with a rate of 13.9% in the Kiang Valley but the prevalence of asthma-related symptoms is much higher. Physical, sexual child abuse and neglect, abandoned babies, substance abuse are but signs of stress of modern city living and peoples inability to cope with it. Although the general standard of child health has greatly improved, there are several states where it is still not satisfactory. In Sabah where there is a large illegal immigrant population, the infant mortality and infection rates are relatively high. In Kelantan and Trengganu, it is common for parents to refuse permission for a lumbar puncture required to treat meningitis. Other still deeply entrenched, culturally-related adverse health practices include : a fatalistic attitude to illness; a preference for traditional practitioners of medicine resulting in late treatment; and 'doctor-hopping' with unrealistic expectations of 'instant cure'. Childhood illnesses that are uncommon in Malaysia include: cystic fibrosis, coeliac disease, ulcerative colitis, Crohns disease, Sudden Infant Death Syndrome, Encopresis, enuresis and epiglottitis due to Haemophilus Influen:ae.
The Patient's Charter tells about the rights and standard of service a patient can expect. However, little information is available to gauge the reality of the charter in real practice. This survey was performed to determine the validity of the charter to the services provided and to identify areas of improvement if the charter is to be revised. A questionnaire-based survey was used to seek information from 196 patients who attended the Outpatient Department in Banting District Hospital over a period of four days. The overall waiting time for registration, to be seen by a doctor and for medication were 17.4 ± 2.0 minutes, 25.3 ± 2.6 minutes and 15.8 ± 1.3 minutes respectively. The overall waiting time for the whole consultation was 61.4 ± 4.9 minutes. Only 30.8% respondents knew about the Patient's Charter. The Patient's Charter appears to be valid for the actual services provided. There have to be measures to increase the awareness of the charter to the public perhaps via pamphlets and to provide a multi-linguistic charter.
In multiethnic countries such as Malaysia more than six different languages are spoken by patients in publicly-funded clinics. Sometimes doctors are unable to speak the patient's language and there are no professional interpreters. Research on doctor-patient communication has rarely included the language variable and its impact on information exchange and patient outcome in consultations where the doctor does not speak the patient's language. The few studies carried out in linguistically plural societies show that doctors and patients can face language barriers and trained interpreters are not always available. This paper illustrates some of the problems of using untrained interpreters in a primary care setting. Consultations were audiotaped and the transcripts were used to show how messages underwent distortion, condensation, and omission in interpreter-mediated consultations. Research needs to be carried out based on a model of doctor-patient communication which reflects the realities of the multilingual consultation.
A 10-year follow-up of children having exanthem subitum (ES) seen in an outpatient paediatric clinic, Kuala Lumpur, Malaysia shows that uvulo-palatoglossal junctional (UPJ) ulcer is a reliable early clinical sign of ES. During this period, 1,977 children (1,086 males, 891 females) had adequate follow-up from the age of 3 months to 24 months old. 897 children (478 males, 419 females) were noted to have UPJ ulcers. Of these 897 children, 855 (459 males, 396 females) presented with the classical clinical features of ES of maculopapular rash following 3 to 4 days of fever. The positive predictive value and the negative predictive value of UPJ ulcers in the clinical diagnosis of ES are 95.3% and 100% respectively. Among the 855 children with clinical features of ES, a provisional diagnosis of ES could be made in 781 children during the pre-eruptive phase by the presence of the UPJ ulcers. The other 74 children already had the rash at the time of consultation at the clinic. The peak age of occurrence of ES was 6 months old with 98.2% of the total cases of ES seen between the age of 4 and 12 months. There was no significant gender difference in the incidence of ES nor any seasonal variation. Mild to moderate diarrhoea was the other commonly associated clinical feature which usually presented from the third febrile day onwards.
Study site: Paediatric clinic, Assunta Hospital, Petaling Jaya, Selangor, Malaysia
Adolescent pregnancy is associated with long term medical and sociological problems. For intervention, it is important to have information on their profile and obstetric outcome. A study was conducted in 1999 on teenage mothers compared to mothers in the 20-34 year age group. Antenatal records of all these mothers registered in a Malaysian semi-rural Health Clinic in 1998 were reviewed and the relevant information was analysed using descriptive statistics and chi-square for comparison in SPSS 7.5. Only 402 (80.9%) of the 497 antenatal records could be included. There were 40 (9.95%) adolescent pregnancies and 362 (90.05%) pregnancies in mothers aged 20-34 years. Pregnant adolescents were more likely to be Malays (85% versus 66%), unmarried (65% versus 5.5%) and less educated (32.5% versus 12.1%). They have a significantly lower rate of contraceptive usage (2.5% versus 20.2%) and tend to come late for their first antenatal visit (55% versus 18.5%). Their pregnancy complications of anaemia and pregnancy induced hypertension were no worse. But they had a significantly higher preterm delivery rate (37.5% versus 21.8%) and their babies were more likely to have low birth weight (32.5% versus 9.9%). Based on this preliminary finding, further investigations should be carried out and polices should include programmes targeted for this group.
A cross sectional study on Type 2 diabetes patients seeking treatment in the Primary Health Care outpatient clinic of the University Malaya Medical Centre, Kuala Lumpur was undertaken. Two hundred and thirty-three subjects participated. They were asked questions on biodata and dietary intake using face-to-face interview techniques. Dietary intake was assessed using the 24-hour dietary recall. Anthropometric measurements including weight and height were taken and Body Mass Index (BMI) was computed to establish the extent of obesity. Of the 196 subjects, 66.8% were overweight (BMI ≥25 kg/m2) with 15.8% obese (BMI ≥30 kg/m2). The mean BMI of males and females were 25.9±4.3 kg/m2 and 27.2±4.7 kg/m2 respectively. The findings from the dietary survey showed that the mean energy intake of the subjects only achieved about 72% of the Recommended Daily Allowance (RDA) for Malaysia while protein intake of all subjects was adequate. The macronutreint contribution to the total calorie was consistent with the recommendation of the Malaysian Diabetic Association for a healthy diet for diabetes patients. The male subjects were found to meet the RDA requirements for all nutrients while the female subjects did not have sufficient intake of calcium, vitamin A and niacin. No consistent pattern in energy and nutrient intake was observed among different age groups. On the other hand, the Malay subjects seemed to have lower energy and all nutrient intake (except vitamin A and vitamin C) compared to the Chinese and Indian subjects. The Indian subjects seemed to have the highest intake of calcium compared to the others. Advice needs to be given to those who did not have adequate nutrient intake as well as those who need to reduce their weight.
Study site: Primary health care clinic, University Malaya Medical Centre (UMMC)
Many studies have shown that failure in the control of hypertension with oral antihypertensives could be associated with noncompliance. The present study was conducted to assess the compliance rate to antihypertensive therapies and also to determine factors related to any noncompliance. The study was conducted in a teaching hospital in Kuala Lumpur. Data was collected from patients' medical records and via personal interview using a structured questionnaire. Out of a total of 175 respondents recruited in the study, 49.1% missed at least a dose of their antihypertensive agents during a one·month period. The most common reason given by respondents who were not compliant to their antihypertensive therapies was forgetfulness (91.8%), followed by too busy (20.0%) and insufficient medication supplied to them (18.8%). None of the factors analysed, including the demography of the respondents, their knowledge about hypertension and the types of antihypertensive therapies they were on, had any statistically significant influence on the compliance behaviour of the respondents to their antihypertensive therapies. However, more than 80% of the respondents kept their appointment to see their doctor and only this factor appeared to be related to the medication compliance behaviour although it still did not reach any statistical significance. KEYWORDS: Compliance, antihypertensive agent, blood pressure, knowledge
We report two patients, who have used Pneumostat to replace the conventional underwater seal drainage system for recurrent pneumothorax. Both patients had required repeated chest tube insertion for recurrent pneumothorax and needed a longer hospital stay. Both patients were able to be discharged with the Pneumostat device and were reviewed in outpatient clinic. Both patients had optimal clinical improvement and chest X-ray showed no residual pneumothorax.
The aim of this study is to describe the epidemiological features of HFMD outbreak in the Hulu Langat District in 2000. Until November 2000, a total of 60 cases were reported and the worst ever reported to the previous years. The mean age of patients was 3.9; 5.8 years with majority of the cases aged between 1 to 4 years old (53.8 per 100,000 of population), male gender (8.3 per 100,000 of populations), and were of Chinese (12.2 per 11 100,000 of populations) and Malay ethnicity (7.2 per 100.000 of populations). All cases were uncomplicated cases and were diagnosed clinically. Most of the notified cases were front the government facilities, which are 44 cases (73.3%). Thirty-five (35) cases (58.4%) were treated as outpatient and 25 cases (41.6%) as in patients (p>0,05). Only 7 cases (11.7%) have history of contact with HFMD patients. The notified cases were mainly from the densely populated areas which were Cheras, Kajang and Ampang. No differences were noted between HFMD cases which have been breasfed for less than 6 month or more, and twenty nine (29) cases (48.3 %) had completed the immunization schedule. In conclusion, the recent emergence of HFMD brings a new challenge, which have to be faced in the prevention and surveillance activities of public health problems in the district.
Study site: Notified cases from Klinik Kesihatan, hospital, private clinics, Ulu Langat, Selangor, Malaysia
The hand, foot, and mouth disease (HFMD) outbreak occurred in the state of Johor, Malaysia in the months 0f October and November 2000 aber the HFMD outbreak started in Singapore in September 2000. The HFMD notification and investigation forms sent to the Epidemiology Unit of the Johor Health Department from district health offices and hospitals during the outbreak were analysed. Patients’ specimens were sent to the Institute for Medical Research, Kuala Lumpur and the Universiti Malaya Medical Centre, Kuala Lumpur for viral isolation. A total of 1,122 HFMD cases were notified during the outbreak period with 2 deaths giving 0.2% casefatality rate. From all the cases, 544 (48.5%) patients were admitted to the hospital while the rest were treated as outpatients. Majority (81.7%) of children with HFMD were aged below 5 years old with the commonest age group (46.9%) being between 1 to 2 years old. Sixty-eight patients had positive specimens for viral isolation belonging to enteroviruses namely Enterovirus 71 (43 cases), Coxsackievirus Type A16 (11), Echovirus 7 (3), and Coxsackievirus Type B (2); and non-enteroviruses namely Herpes Simplex Virus Type 1
(5), and Adenovirus (4). Fever and mouth ulcer were the two most common symptoms among HFMD children but vesicles on palms and soles were more common than rashes in children with positive enteroviral isolation.
Study site: University Malaya Medical Centre (UMMC)
Aim: To determine the accuracy of urinalysis in the detection of urinary tract infection (UTI) in symptomatic patients at primary care level. Methods: A cross sectional study was undertaken on 100 patients with symptoms of UTI presenting at the Primary Care Clinic of University Malaya Medical Center, Kuala Lumpur, Malaysia during the months of August to November 1999. Their urine samples were tested simultaneously using urine dipstick, urine microscopy and urine culture. Urine culture was used as the gold standard and UTI was diagnosed when the urine culture showed a bacteria count of >= 105 organisms per mL. The sensitivity and specificity of each test was calculated. Results: The prevalence of UTI was 25% in symptomatic patients. The urine dipstick for leukocyte esterase, nitrite and red blood cell had sensitivities of 76, 56 and 76%, respectively. Their specificities were 60, 81 and 61%, respectively. Urine microscopy for leukocytes, red blood cells and bacterial count had sensitivities of 80, 52 and 84%, while their specificities were 76, 80 and 54%, respectively. Conclusion: The prevalence of UTI in the present study was low despite reported symptoms of UTI. Urinalysis is needed to support the diagnosis of UTI. In the present study, while there is accuracy in the urinalysis (as the sensitivities and specificities of various tests are comparable with other studies); lack of precision in each test because of the wide range of 95% confidence interval make it less reliable. Caution should be made in interpreting each test.
Aim: To assess the importance of continuity of care among diabetic patients attending a primary care clinic and to correlate degree of continuity of care with diabetic control. Methods: A cross sectional survey was carried out among diabetic patients (n = 166) attending follow-up consultations in a family practice clinic of a teaching hospital. Face-to-face interviews were carried out on patients' perception of continuity of care and various aspects related to diabetes. Diabetic control was assessed by glycosylated hemoglobin. Retrospective chart audits of each patient over the previous 28 months were done to assess the degree of continuity of care, measured with the Usual Provider Continuity Index (UPCI). Results: The UPCI ranged from 0.18 to 1.00 with a mean value of 0.60. The average number of visits per patient over the 28-month period was 11.7 visits. The majority of patients saw five different doctors for all their visits. There were no statistically significant associations between the degree of provider continuity with diabetic control (r = 0.054) and diabetic self-care behavior (r = 0.065). The majority of patients (89%) felt that it was important to have a regular doctor. The main reason given was that a regular doctor would know the patient's problems. Conclusions: Continuity of care was highly valued by diabetic patients attending a hospital-based family practice clinic. Even though the degree of continuity was not associated with the degree of diabetic control, patients felt that it was important to have doctors who are aware of their problems.
Between 2/10/2000 and 30/1/2001, the organizational structure and management in 4 general practice (GP) clinics & 2 health centers (HC) in Kinta District were studied by 14 Level 4 medical students of Perak College of Medicine. Data collected from work process files and staff interviews / shadowing showed that GPs in the study had more working experience with postgraduate qualifications than HC doctors. All HC nurses but only one GP clinic nurse had formal training. HC organization was more complex with documentation. GP organization was simple and lacked documentation. HC management was by a group while GPs handled all management aspects. This study enhanced students' understanding of Malaysian primary care system.
Musculoskeletal complaints are one of the most common presenting symptoms to primary care physicians. However, in Malaysia, there has been no prospective survey to look at this problem. This was a descriptive study to look at the prevalence of non-traumatic musculoskeletal complaints presenting to the primary care clinic at University Malaya Medical Center, Kuala Lumpur. Over a 3-week period, there were 408/4201 patients (9.7%) with non-traumatic musculoskeletal disorders. The most common regional problem was backache and the most commonly made diagnosis was non-specific musculoskeletal pain. In conclusion, musculoskeletal disorders form a significant proportion of primary care consultations and thus should be included in the curriculum for the primary care physician training. Keywords: musculoskeletal disorders, arthritis, primary care
Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia.
The morbidity patterns and demographics of patients presenting to two government health centers and four private general practice clinics were studied over one week. Results showed little difference in the morbidity patterns but a significant difference in the demographics of the patients. The commonest illnesses seen were minor ones like upper respiratory tract infection and chronic ones like hypertension and diabetes mellitus. A wide spectrum of illnesses was seen in all the clinics. Both places handled few emergencies and referred only occasionally. There was an equal percentage of patients from both sexes. Ages of the patients varied from place to place and the racial distribution was influenced by several factors, including the existing patient population and the race of the doctor.
An open access endoscopy system allows for the direct scheduling of endoscopies by non-gastroenterologist physicians without prior gastroenterology consultation. The aim of our study was to examine our practice of open access endoscopy by evaluating the appropriateness of referrals for colonoscopy and to determine whether there were differences depending on the specialty of the referring clinician. The indication for colonoscopy was assessed in 499 consecutive outpatients referred for colonoscopy at University Hospital, Kuala Lumpur over a 12-month period. The American Society of Gastrointestinal Endoscopy (ASGE) guidelines were used to determine the appropriateness of referrals. 80.6% of colonoscopies requested by the gastroenterologist were performed for accepted indications compared to 50.6% of referrals by the primary care physician (p<0.001) and 67.0% of referrals by the surgeon (p=0.006). The rate of colonoscopies generally not indicated was 2.1% for the gastroenterologist, 25.0% for the internist (p=0.002) and 7.5% for the surgeon (p=0.04). The rate of indications not listed in the ASGE guidelines was significantly lower for requests made by gastroenterologists (17.3%) than those requested by primary care physicians (44.2%; p<0.001). Patients who have had prior consultation with the gastroenterologist were significantly more likely to undergo colonoscopy for appropriate indications than among patients who were referred through an open access system. The rate of inappropriate indications for colonoscopy was also significantly lower when the gastroenterologist made the referral. A substantial proportion of colonoscopies (25.4%) was performed for indications not listed in the ASGE guidelines.
Inefficient metered-dose inhaler (MDI) technique results in poor drug delivery, suboptimal disease control a possibility of inhaled medication overuse. The MDI technique of 134 government hospital and clinic followed-up adult asthmatic patients followed-up in a government hospital and a heath clinic was pragmatically assessed based on the 3 obligatory steps of adequate lip seal, appropriate hand-breath coordination and sufficient breath holding after inhalation. The relationship between technique efficiency and frequency of daily short-acting beta2-agonist (SABA) use via the MDI and asthma exacerbations over a 12-month period was also assessed. Fifty-six patients (42%) had inefficient MDI technique. All demographic and asthma-related variables between the 'efficient' and 'inefficient' technique groups of patients were comparable except for significantly longer mean years of MDI use in the 'efficient' technique group [mean (SD): 10 (7) vs. 7 (5); p=0.003]. There were no significant differences between the two groups in relation to frequency of daily SABA use or asthma exacerbations over the past 12 months. Despite having been available in Malaysia for a considerable period of time, the MDI device is still poorly handled by a large proportion of adult asthmatic patients. Changing to other more user-friendly devices or use of spacer devices to facilitate delivery should be considered for these patients.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan; Klinik Kesihatan Seremban, Malaysia