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A hospital-based study on ischaemic stroke characteristics, management, and outcomes in Sarawak: Where do we stand?

King TL, Tiong LL, Kaman Z, Zaw WM, Abdul Aziz Z, Chung LW

J Stroke Cerebrovasc Dis, 2020 Sep;29(9):105012.
PMID: 32807427 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105012

BACKGROUND: Located on the Borneo Island, Sarawak is the largest state of Malaysia and has a population distinctive from Peninsular Malaysia. The ischaemic stroke data in Sarawak had not been reported despite the growing number of patients annually. We aimed to investigate patient characteristics, management, and outcomes of ischaemic stroke in Sarawak and benchmark the results with national and international published data.
METHODS: We included ischaemic stroke cases admitted to Sarawak General Hospital between June 2013 and August 2018 from Malaysia National Stroke Registry. We performed descriptive analyses on patient demographics, cardiovascular risk factors, prior medications, smoking status, arrival time, thrombolysis rate, Get With The Guidelines (GWTG)-Stroke measures, and outcomes at discharge. We also numerically compared the results from Sarawak with the published data from selected national and international cohorts.
RESULTS: We analysed 1435 ischaemic stroke cases. The mean age was 60.1±13.2 years old; 64.9% were male; median baseline National Institute of Health Stroke Scale was seven points. Hypertension was the most prevalent risk factor of ischaemic stroke; 12.7% had recurrent stroke; 13.7% were active smokers. The intravenous thrombolysis rate was 18.8%. We achieved 80-90% in three GWTG-Stroke performance measures and 90-98% in four additional quality measures in our ischaemic stroke management. At discharge, 57% had modified Rankin Scale of 0-2; 6.7% died during hospitalisation. When compared with selected national and international data, patients in Sarawak were the youngest; Sarawak had more male and more first-ever stroke. Thrombolysis rate in Sarawak was higher compared with most studies in the comparison. Functional outcome at discharge in Sarawak was better than national cohort but still lagging behind when compared with the developed countries. In-hospital mortality rate in Sarawak was slightly lower than the national data but higher when compared with other countries.
CONCLUSION: Our study described characteristics, management, and outcomes of ischaemic stroke in Sarawak. We achieved high compliance with most of GTWG-Stroke performance and quality indicators. Sarawak had better outcomes than the national results on ischaemic stroke. However, there is still room for improvement when compared with other countries. Actions are needed to reduce the cardiovascular burdens for stroke prevention, enhance healthcare resources for stroke care, and improve intravenous thrombolysis treatment in Sarawak.

Matched MeSH terms: Practice Patterns, Physicians'/standards
Global variations in the prevalence, treatment, and impact of atrial fibrillation in a multi-national cohort of 153 152 middle-aged individuals

Joseph PG, Healey JS, Raina P, Connolly SJ, Ibrahim Q, Gupta R, et al.

Cardiovasc Res, 2021 05 25;117(6):1523-1531.
PMID: 32777820 DOI: 10.1093/cvr/cvaa241

AIMS: To compare the prevalence of electrocardiogram (ECG)-documented atrial fibrillation (or flutter) (AF) across eight regions of the world, and to examine antithrombotic use and clinical outcomes.
METHODS AND RESULTS: Baseline ECGs were collected in 153 152 middle-aged participants (ages 35-70 years) to document AF in two community-based studies, spanning 20 countries. Medication use and clinical outcome data (mean follow-up of 7.4 years) were available in one cohort. Cross-sectional analyses were performed to document the prevalence of AF and medication use, and associations between AF and clinical events were examined prospectively. Mean age of participants was 52.1 years, and 57.7% were female. Age and sex-standardized prevalence of AF varied 12-fold between regions; with the highest in North America, Europe, China, and Southeast Asia (270-360 cases per 100 000 persons); and lowest in the Middle East, Africa, and South Asia (30-60 cases per 100 000 persons) (P

Matched MeSH terms: Practice Patterns, Physicians'/trends*
Fulltext Does use of pooled cohort risk score overestimate the use of statin?: a retrospective cohort study in a primary care setting

Chia YC, Lim HM, Ching SM

BMC Fam Pract, 2014;15:172.
PMID: 25388219 DOI: 10.1186/s12875-014-0172-y

BACKGROUND: Initiation of statin therapy as primary prevention particularly in those with mildly elevated cardiovascular disease risk factors is still being debated. The 2013 ACC/AHA blood cholesterol guideline recommends initiation of statin by estimating the 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the new pooled cohort risk score. This paper examines the use of the pooled cohort risk score and compares it to actual use of statins in daily clinical practice in a primary care setting.
METHODS: We examined the use of statins in a randomly selected sample of patients in a primary care clinic. The demographic data and cardiovascular risk parameters were captured from patient records in 1998. The pooled cohort risk score was calculated based on the parameters in 1998. The use of statins in 1998 and 2007, a 10-year interval, was recorded.
RESULTS: A total of 847 patients were entered into the analysis. Mean age of the patients was 57.2 ± 8.4 years and 33.1% were male. The use of statins in 1998 was only 10.2% (n = 86) as compared to 67.5% (n = 572) in 2007. For patients with LDL 70-189 mg/dl and estimated 10-year ASCVD risk ≥7.5% (n = 190), 60% (n = 114) of patients were on statin therapy by 2007. There were 124 patients in whom statin therapy was not recommended according to ACC/AHA guideline but were actually receiving statin therapy.
CONCLUSIONS: An extra 40% of patients need to be treated with statin if the 2013 ACC/AHA blood cholesterol guideline is used. However the absolute number of patients who needed to be treated based on the ACC/AHA guideline is lower than the number of patients actually receiving it in a daily clinical practice. The pooled cohort risk score does not increase the absolute number of patients who are actually treated with statins. However these findings and the use of the pooled cohort risk score need to be validated further.
Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia

Matched MeSH terms: Practice Patterns, Physicians'/statistics & numerical data*
Fulltext Long-term antithrombotic management patterns in Asian patients with acute coronary syndrome: 2-year observations from the EPICOR Asia study

Zheng B, Huo Y, Lee SW, Sawhney JPS, Kim HS, Krittayaphong R, et al.

Clin Cardiol, 2020 Sep;43(9):999-1008.
PMID: 32618009 DOI: 10.1002/clc.23400

BACKGROUND: Despite guideline recommendations, dual antiplatelet therapy (DAPT) is frequently used for longer than 1 year after an acute coronary syndrome (ACS) event. In Asia, information on antithrombotic management patterns (AMPs), including DAPT post discharge, is sparse. This analysis evaluated real-world AMPs up to 2 years post discharge for ACS.
HYPOTHESIS: There is wide variability in AMP use for ACS management in Asia.
METHODS: EPICOR Asia (NCT01361386) is a prospective observational study of patients discharged after hospitalization for an ACS in eight countries/regions in Asia, followed up for 2 years. Here, we describe AMPs used and present an exploratory analysis of characteristics and outcomes in patients who received DAPT for ≤12 months post discharge compared with >12 months.
RESULTS: Data were available for 12 922 patients; of 11 639 patients discharged on DAPT, 2364 (20.3%) received DAPT for ≤12 months and 9275 (79.7%) for >12 months, with approximately 60% still on DAPT at 2 years. Patients who received DAPT for >12 months were more likely to be younger, obese, lower Killip class, resident in India (vs China), and to have received invasive reperfusion. Clinical event rates during year 2 of follow-up were lower in patients with DAPT >12 vs ≤12 months, but no causal association can be implied in this non-randomized study.
CONCLUSIONS: Most ACS patients remained on DAPT up to 1 year, in accordance with current guidelines, and over half remained on DAPT at 2 years post discharge. Patients not on DAPT at 12 months are a higher risk group requiring careful monitoring.

Matched MeSH terms: Practice Patterns, Physicians'/trends*
Use of antidepressants in the treatment of depression in Asia: guidelines, clinical evidence, and experience revisited

Treuer T, Liu CY, Salazar G, Kongsakon R, Jia F, Habil H, et al.

Asia Pac Psychiatry, 2013 Dec;5(4):219-30.
PMID: 23857712 DOI: 10.1111/appy.12090

Major depressive disorder is prevalent worldwide, and only about half of those affected will experience no further episodes or symptoms. Additionally, depressive symptoms can be challenging to identify, with many patients going undiagnosed despite a wide variety of available treatment options. Antidepressants are the cornerstone of depression treatment; however, a large number of factors must be considered in selecting the treatment best suited to the individual. To help support physicians in this process, international and national treatment guidelines have been developed. This review evaluates the current use of antidepressant treatment for major depressive disorder in six Asian countries (China, Korea, Malaysia, Philippines, Taiwan, and Thailand). No remarkable differences were noted between Asian and international treatment guidelines or among those from within Asia as these are adapted from western guidelines, although there were some local variations. Importantly, a shortage of evidence-based information at a country level is the primary problem in developing guidelines appropriate for Asia, so most of the guidelines are consensus opinions derived from western research data utilized in western guidelines. Treatment guidelines need to evolve from being consensus based to evidence based when evidence is available, taking into consideration cost/effectiveness or cost/benefit with an evidence-based approach that more accurately reflects clinical experience as well as the attributes of each antidepressant. In everyday practice, physicians must tailor their treatment to the patient's clinical needs while considering associated external factors; better tools are needed to help them reach the best possible prescribing decisions which are of maximum benefit to patients.

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext Impact of socio-economic class on colorectal cancer patient outcomes in Kuala Lumpur and Kuching, Malaysia

Kong CK, Roslani AC, Law CW, Law SC, Arumugam K

Asian Pac J Cancer Prev, 2010;11(4):969-74.
PMID: 21133609

OBJECTIVE: Research over the past several decades has indicated that low socioeconomic class has a direct effect on health outcomes. In Malaysia, class distribution may differ with the region. The objective of this study was to compare the presentation and survival of colorectal cancer patients in two dissimilar cities, Kuala Lumpur and Kuching, Sarawak.

METHODS: All patients diagnosed with a malignancy of the colon or rectum in Sarawak General Hospital and University of Malaya Medical Center from 1st Jan 2000-31st Dec 2006 were recruited. Data on presentation, socio-economic class and survival were obtained. The survival duration was categorized into more than three years or three years and less. Testing for significance was performed using the chi-square test, with p values less than 0.05 considered statistically significant.

RESULTS: A total of 565 patients in UMMC and 642 patients in SGH had a new diagnosis of colorectal carcinoma. Patients in Kuching had a longer duration of symptoms and more advanced stage at presentation, but this was not statistically significant. Lower socio-economic class was a significant factor for late and more advanced stage at diagnosis, as well as poorer three and five year survival rates. However, survival was lower for patients in Kuching compared to Kuala Lumpur, even after matching for socio-economic class.

CONCLUSION: There is near-zero awareness of colorectal cancer screening in Malaysia. These findings support reaching out to communities of lower socioeconomic backgrounds to improve the colorectal cancer survival rates.

Matched MeSH terms: Practice Patterns, Physicians'
Improving cancer pain management in Malaysia

Lim R

Oncology, 2008;74 Suppl 1:24-34.
PMID: 18758194 DOI: 10.1159/000143215

Within Malaysia's otherwise highly accessible public healthcare system, palliative medicine is still an underdeveloped discipline. Government surveys have shown that opioid consumption in Malaysia is dramatically lower than the global average, indicating a failure to meet the need for adequate pain control in terminally ill patients. Indeed, based on daily defined doses, only 24% of patients suffering from cancer pain receive regular opioid analgesia. The main barriers to effective pain control in Malaysia relate to physicians' and patients' attitudes towards the use of opioids. In one survey of physicians, 46% felt they lacked knowledge to manage patients with severe cancer pain, and 64% feared effects such as respiratory depression. Fear of addiction is common amongst patients, as is confusion regarding the legality of opioids. Additional barriers include the fact that no training in palliative care is given to medical students, and that smaller clinics often lack facilities to prepare and stock cheap oral morphine. A number of initiatives aim to improve the situation, including the establishment of palliative care departments in hospitals and implementation of post-graduate training programmes. Campaigns to raise public awareness are expected to increase patient demand for adequate cancer pain relief as part of good care.

Matched MeSH terms: Practice Patterns, Physicians'
The pattern and clinical manifestations of rheumatoid arthritis in Sarawak General Hospital

Teh CL, Wong JS

Clin Rheumatol, 2008 Nov;27(11):1437-40.
PMID: 18773254 DOI: 10.1007/s10067-008-0945-6

The aim of our study is to describe the pattern, clinical features, treatment regimes, and disease activity among the patients treated for rheumatoid arthritis (RA) in the Sarawak General Hospital. We performed a cross-sectional study of all patients with a diagnosis of RA who received treatment at the General Medical Clinic and the Rheumatology Clinic in Sarawak General Hospital over a 1-year period from 1st June 2006 to 31st May 2007. Demographic data, clinical features, and disease activity of all 154 patients were collected for statistical analysis. Rheumatoid arthritis afflicts all the major racial groups in Sarawak including the native population. Our patients have a mean disease duration of 5.4 years (SD 5.69) and a mean duration of delay in diagnosis RA and initiation of disease-modifying antirheumatic drug (DMARD) treatment of 42.9 months (SD 60.1). They have a low rate of interstitial lung disease (6.5%) and rheumatoid nodules (4.5%). Rheumatoid factor was positive in 65.5% of our patients. They have a mean Disease Activity Score (DAS) 28 score of 4.28 (SD 1.33). Only 12.5% of our patients are in remission with DAS 28 < 2.6 and 30.9% of our patients are having high disease activity with DAS 28 > 5.1. Despite the high usage of DMARDs in Sarawak (>80%), our patients have severe disease with high disease activity indices. This is most likely due to delay in diagnosis and initiating DMARDs in RA patients in Sarawak.

Study site: General Medical Clinic and the Rheumatology Clinic in Sarawak General Hospital

Matched MeSH terms: Practice Patterns, Physicians'
A pilot study on generic medicine substitution practices among community pharmacists in the State of Penang, Malaysia

Ping CC, Bahari MB, Hassali MA

Pharmacoepidemiol Drug Saf, 2008 Jan;17(1):82-9.
PMID: 17879323

The purpose of this study was to evaluate the generic substitution (GS) practices undertaken by community pharmacists in the State of Penang, Malaysia with a focus on the extent of communication between pharmacists and prescribers on issues related to GS, consumer's acceptance on the GS and estimation of cost saving achieved for patients opted for GS.

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext Ethnomedicine and dominant medicine in multicultural Australia: a critical realist reflection on the case of Korean-Australian immigrants in Sydney

Han GS, Ballis H

J Ethnobiol Ethnomed, 2007;3:1.
PMID: 17201916 DOI: 10.1186/1746-4269-3-1

Viewed through the micro focus of an interpretive lens, medical anthropology remains mystified because interpretivist explanations seriously downplay the given context in which individual health seeking-behaviours occur. This paper draws upon both the interpretivist and political economy perspectives to reflect on the ethno medical practices within the Korean-Australian community in Sydney.

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext Choice of antihypertensive drug in the diabetic patient

Ong HT, Cheah JS

MedGenMed, 2005;7(2):74.
PMID: 16369452

The hypertensive patient with type 2 diabetes is especially at risk of adverse cardiovascular events. The United Kingdom Prospective Diabetes Study (UKPDS) and Hypertension Optimal Treatment (HOT) studies suggested that treatment to a lower target blood pressure resulted in better prevention of clinical disease in these patients. Most trials comparing antihypertensive drugs have shown only minimal differences between the various agents. The evidence from the trials suggests that diuretics, beta-blockers, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and the angiotensin-receptor antagonists (ARBs) will all successfully reduce adverse clinical events. The largest of the comparative hypertensive drug trials, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), demonstrated that a diuretic has a better hypotensive effect, and was more successful in preventing many aspects of cardiovascular disease compared with CCBs and ACE inhibitors. The importance of good blood pressure control and the general equivalence of antihypertensive drugs were again shown in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial, which compared an ARB with a CCB. Choice of antihypertensive agent should be individualized and guided by the presence of concomitant clinical disease and the need to protect any specific target organ system in the diabetic hypertensive. Diuretics, being potent hypotensive drugs with clearly demonstrated clinical benefit, should form part of the antihypertensive regimen of most diabetic hypertensives. ACE inhibitors and ARBs are especially useful in preventing nephropathy. Most patients will require a combination of antihypertensive drugs to achieve tight blood pressure control of under 130/80 mm Hg in the diabetic hypertensive. The clinician should concentrate on seeking this lower target blood pressure rather than be excessively concerned about which is the best antihypertensive agent.

Matched MeSH terms: Practice Patterns, Physicians'
Separation of prescribing and dispensing in Malaysia: the history and challenges

Tiong JJ, Mai CW, Gan PW, Johnson J, Mak VS

Int J Pharm Pract, 2016 Aug;24(4):302-5.
PMID: 26777986 DOI: 10.1111/ijpp.12244

This article serves as an update to the work by Shafie et al. (2012) which previously reviewed the benefits of policies separating prescribing and dispensing in various countries to advocate its implementation in Malaysia. This article seeks to strengthen the argument by highlighting not only the weaknesses of the Malaysian health care system from the historical, professional and economic viewpoints but also the shortcomings of both medical and pharmacy professions in the absence of separation of dispensing. It also provides a detailed insight into the ongoing initiatives taken to consolidate the role of pharmacists in the health care system in the advent of separation of dispensing. Under the two tier system in Malaysia at present, the separation of prescribing and dispensing is implemented only in government hospitals. The absence of this separation in the private practices has led to possible profit-oriented medical and pharmacy practices which hinder safe and cost-effective delivery of health services. The call for separation of dispensing has gained traction over the years despite various hurdles ranging from the formidable resistance from the medical fraternity to the public's scepticism towards the new policy. With historical testament and present evidence pointing towards the merits of a system in which doctors prescribe and pharmacists dispense, the implementation of this health care model is justified.

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext A review of the management of 107 dizzy patients at the university hospital

Krishnan G

Med J Malaysia, 1994 Mar;49(1):44-8.
PMID: 8057990

The common investigations done were pure tone audiometry, electronystagmography, X-ray of the internal auditory meatus, CT-scan of the internal auditory meatus and X-ray of the cervical spine. After the examinations and investigations only 52 patients out of the 107 could be given any diagnosis. The most common diagnosis for the vertigo was Meniere's disease.

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext Analgesic Prescription Patterns and Pain Outcomes in Southeast Asia: Findings From the Analgesic Treatment of Cancer Pain in Southeast Asia Study

Thinh DHQ, Sriraj W, Mansor M, Tan KH, Irawan C, Kurnianda J, et al.

J Glob Oncol, 2018 09;4:1-10.
PMID: 30241271 DOI: 10.1200/JGO.17.00055

PURPOSE: To identify patterns of analgesic prescription and to explore patient-reported pain intensity, sleep disturbance, and quality of life among cancer patients with pain in Southeast Asia (SEA).
METHODS: This cross-sectional observational study included 465 adult outpatients prescribed analgesics for cancer pain for 1 month or longer at 22 sites in Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam. Data on analgesic prescription and cancer characteristics were extracted from medical records. Pain intensity, sleep disturbance, and quality of life measures were recorded via questionnaires.
RESULTS: Most patients (84.4%) had stage III or IV cancer. A total of 419 patients (90.7%) were prescribed opioids; of these, 42.2% received only weak opioids, whereas 57.8% received at least one strong opioid. The mean worst pain intensity during the past 24 hours was 4.76 (standard deviation [SD], 2.47) on a scale of 0 (no pain) to 10 (worst possible pain); the mean current pain intensity was 4.10 (SD, 2.61). More than half of patients (54.8%) reported sleep disturbance caused by pain in the past 7 days. The majority of patients reported problems with pain/discomfort (82.3%), usual activities (65.8%), mobility (58.2%), and anxiety/depression (56.3%). The median daily dose prescribed in oral morphine equivalents was 30 mg for both morphine and tramadol.
CONCLUSION: Despite unrelieved pain, sleep disturbance, and issues with quality of life, a notable proportion of patients were prescribed only weak opioids, and opioid doses prescribed were generally low. Efforts focused on encouragement of prescriptions with analgesic strength and/or doses proportional to the pain management needs of patients are vital to improve the status of cancer pain management in the region.

Matched MeSH terms: Practice Patterns, Physicians'
Antimicrobial prescribing and determinants of antimicrobial resistance: a qualitative study among physicians in Pakistan

Saleem Z, Hassali MA, Godman B, Hashmi FK, Saleem F

Int J Clin Pharm, 2019 Oct;41(5):1348-1358.
PMID: 31273588 DOI: 10.1007/s11096-019-00875-7

Background Understanding physicians' perception about antimicrobial use and resistance is essential to ensure that the objectives of the Pakistan national action plan on antimicrobial resistance are met. Little is currently known about physicians' perceptions in Pakistan. Objective Assess physicians' perception surrounding antibiotic use and resistance, factors influencing antibiotic prescribing and potential interventions to improve future antibiotic prescribing. Settings The study was conducted in Lahore, the capital of the province of Punjab, which is the second largest and most populous city of Pakistan. Method Qualitative study was conducted with a semi-structured interview guide involving in-depth face-to-face interviews with purposively selected physicians. Audiorecorded interviews were transcribed verbatim and transcripts analyzed by thematic content analysis. Main outcome measures Themes surrounding the perspectives of physicians on issues of antimicrobial use and resistance. Results Five major themes emerged: (1) knowledge and perception of physicians about antimicrobials, (2) antimicrobial prescribing behaviors of physicians, (3) factors influencing prescribing, (4) determinants of antimicrobial resistance, (5) and potential interventions to reduce antimicrobial resistance. The main challenges and issues associated with antibiotic prescribing were the improvement of knowledge, implementation of hygienic measures, access to and clarity of treatment recommendations and minimizing external factors influencing prescribing including pharmaceutical company activities. Suggestions for the future included stricter regulations for prescribing, improved diagnosis, availability of local guidelines and monitoring of prescribing and resistance patterns. Conclusion Identification of concerns regarding inappropriate antimicrobial prescribing will enable specific initiatives and approaches to improve future antimicrobial use and reduce antimicrobial resistance in Pakistan.

Matched MeSH terms: Practice Patterns, Physicians'
Long-term nasogastric tube feeding in elderly stroke patients--an assessment of nutritional adequacy and attitudes to gastrostomy feeding in Asians

Zaherah Mohamed Shah F, Suraiya HS, Poi PJ, Tan KS, Lai PS, Ramakrishnan K, et al.

J Nutr Health Aging, 2012 Aug;16(8):701-6.
PMID: 23076512 DOI: 10.1007/s12603-012-0027-y

BACKGROUND: Gastrostomy feeding is superior to long-term nasogastric (NG) feeding in patients with dysphagic stroke, but this practice remains uncommon in Asia. We sought to examine the nutritional adequacy of patients on long term NG feeding and identify barriers to gastrostomy feeding in these patients.
METHODOLOGY: A prospective comparison of subjective global assessment (SGA), and anthropometry (mid-arm muscle circumference, MAMC; triceps skinfold thickness, TST) between elderly stroke patients on long-term NG feeding and matched controls was performed. Selected clinicians and carers of patients were interviewed to assess their knowledge and attitudes to gastrostomy feeding.
RESULTS: 140 patients (70 NG, 70 oral) were recruited between September 2010 and February 2011. Nutritional status was poorer in the NG compared to the oral group (SGA grade C 38.6% NG vs 0% oral, p<0.001; TST males 10.7 + 3.7 mm NG vs 15.4 + 4.6 mm oral, p<0.001; MAMCmales 187.9 + 40.4 mm NG vs 228.7 + 31.8 mm oral, p<0.001). 45 (64.3%) patients on long-term NG feeding reported complications, mainly consisting of dislodgement (50.5%), aspiration of feed content (8.6%) and trauma from insertion (4.3%). Among 20 clinicians from relevant speciliaties who were interviewed, only 11 (55%) clinicians would routinely recommend a PEG. All neurologists (100%) would recommend a PEG, whilst the response was mixed among non-neurologists. Among carers, lack of information (47.1%) was the commonest reason stated for not choosing a PEG.
CONCLUSION: Elderly patients with stroke on long term NG feeding have a poor nutritional status. Lack of recommendation by clinicians appears to be a major barrier to PEG feeding in these patients.

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext Anticoagulant management of atrial fibrillation: the influence of dosing algorithm and recall schedule on time in therapeutic range

Swarna Nantha Y

Fam Pract, 2015 Oct;32(5):514-9.
PMID: 26251026 DOI: 10.1093/fampra/cmv066

BACKGROUND: The quality of anticoagulation management in atrial fibrillation patients is reflected by the concept of time spent in therapeutic range (TTR). In a primary care setting, the implementation of a dose nomogram could help increase the mean TTR among these patients.
OBJECTIVE: This study compares the influence of a dose algorithm with an integrated recall on TTR prior to standard care and after the implementation of the protocol.
PATIENTS AND METHODS: In a purposive sample of patients with AF, an uncontrolled 'before' and 'after' study design was utilized to measure the effects of the protocol on TTR. Demographic data, TTR levels, frequency of international normalized ratio (INR) within therapeutic range, clinician adherence to dose nomogram and warfarin dose changes were captured from consultations at the anticoagulation clinic.
RESULTS: A total of 152 patients with AF were entered into the final analysis. The increment in mean TTR in the 'after' intervention phase (2.9%) was not statistically significant (57.5-60.4%, P=0.252). The increase in the frequency of INR values within therapeutic range in the 'after' intervention phase was significant (50.0-56.0%, P<0.05) but with a very low effect size (r=0.04).
CONCLUSIONS: The implementation of a dose nomogram has the potential of reducing unnecessary dose changes for minor fluctuations in INR levels. The findings in this study needs to be confirmed in a future study involving other indications for anticoagulation, various regional primary care clinics and a larger population size.
KEYWORDS: Atrial fibrillation; TTR; dose nomogram; predictors; primary care; warfarin.
Study site: Klinik Kesihatan Seremban, Negeri Sembilan, Malaysia

Matched MeSH terms: Practice Patterns, Physicians'
Fulltext The role of general practitioners in the management of erectile dysfunction-a qualitative study

Ng CJ, Low WY, Tan NC, Choo WY

Int J Impot Res, 2004 Feb;16(1):60-3.
PMID: 14963472 DOI: 10.1038/sj.ijir.3901141

The objective of this study was to explore the roles and perceptions of general practitioners (GPs) in the management of erectile dysfunction (ED). This qualitative study used focus group discussions and in-depth interviews. This study was conducted based on 28 GPs from an urban area in Malaysia who had managed patients with ED and prescribed anti-ED drugs. Main outcome measures included the roles of GPs in managing patients with ED (active or passive), perceptions regarding ED and the treatment, and factors influencing their decision to prescribe. Majority of the GPs assumed a passive role when managing patients with ED. This was partly due to their perception of the disease being nonserious. Some also perceived ED as mainly psychological in nature. The anti-ED drugs were often viewed as a lifestyle drug with potentially serious side effects. The fear of being perceived by patients as 'pushing' for the drug and being blamed if the patients were to develop serious side effects also hampered the management of this disease. GPs who participated in this study remained passive in identifying and treating patients with ED and this was attributed to their perception of the disease, drug treatment and patient's background.

Matched MeSH terms: Practice Patterns, Physicians'
Noncardiac chest pain--an Asia-Pacific survey on the views of primary care physicians

Cheung TK, Lim PW, Wong BC

Dig Dis Sci, 2007 Nov;52(11):3043-8.
PMID: 17436083 DOI: 10.1007%2Fs10620-007-9764-x

Noncardiac chest pain (NCCP) is common and has a significant impact on health care. Primary care physicians (PCPs)' attitudes, clinical approach, preference of diagnostic tests, referral patterns, and comfort in managing patients with NCCP in the Asia-Pacific region are not known. Consequently, we performed this survey in the Asia-Pacific region. The self-completed questionnaire was sent to PCPs in the Asia-Pacific region. A 28-item questionnaire contained questions on demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, treatment plans, and opinion on Helicobacter pylori and NCCP. A total of 108 (74%) PCPs returned the questionnaire. A mean of 18% of the patients were diagnosed with NCCP by PCPs in the past 6 months. Ninety-four percent of PCPs had treated NCCP patients in the last 6 months. Only 38% of the PCPs were comfortable in diagnosing NCCP but 85.2% believed that they should manage NCCP patients. PCPs in Malaysia and Philippines were more likely to refer patients to subspecialists. Fifty-seven and four-tenths percent of PCPs believed that H. pylori infection plays a role in the development of NCCP. The study demonstrates clearly that the understanding, diagnostic strategies, and treatment strategies of NCCP in the Asia-Pacific region are suboptimal and thus highlights the importance of educational and training programs tailored for PCPs in NCCP.

Matched MeSH terms: Practice Patterns, Physicians'
Management of rheumatoid arthritis in clinical practice using treat-to-target strategy: Where do we stand in the multi-ethnic Malaysia population?

Tan BE, Lim AL, Kan SL, Lim CH, Ng YF, Tng SLC, et al.

Rheumatol Int, 2017 Jun;37(6):905-913.
PMID: 28389855 DOI: 10.1007/s00296-017-3705-6

To evaluate the achievement of treat-to-target (T2T) strategy in rheumatoid arthritis (RA) and identify factors associated with failed treatment target in a public rheumatology center. A cross-sectional study was conducted from June 2015 to February 2016. RA patients with disease duration greater than 2 years and under T2T for over a year were invited to the study. Demographic, clinical data, disease activity score of 28 joints (DAS28), and clinical disease activity index (CDAI) were collected in a single routine clinic visit. Treatment target was defined as DAS28 <3.2 or CDAI ≤10. Retrospective chart review was performed to determine reasons of failed treatment target. A total of 371 patients were recruited and 87.1% were female. Mean age and duration of RA were 53.5 years (SD 10.3) and 9.1 years (SD 6.6), respectively. Ethnic distribution was 49% Chinese, 27% Malay, and 24% Indian. T2T was achieved in 81.7% of the cohort. Non-Chinese ethnicity, positive rheumatoid factor, and treatment with three disease modifying anti-rheumatic drugs (DMARDs) were associated with failed treatment target. After controlling for covariates, Malay ethnicity (OR 2.96; 95% CI 1.47-5.96) and treatment with three DMARDs (OR 2.14; 95% CI 1.06-4.35) were associated with failed treatment target. There was no association between age, gender, duration of RA, BMI, smoking status, anti-citrulinated cyclic peptide, and achievement of T2T. The most common reasons of failed treatment target were inability to escalate DMARDs due to side effects (18.8%), lack of biologics fund (15.6%), and persistent disease despite optimum treatment (14.1%). T2T was successfully implemented. Malay patients need aggressive treatment adaptation to achieve optimal outcome.

Matched MeSH terms: Practice Patterns, Physicians'

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