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Fulltext A comparative study on the service profiles and practice facilities among urban general practices in east and west Malaysia

Khoo EM

Med J Malaysia, 2000 Sep;55(3):341-6.
PMID: 11200714

1171 urban general practices in East and West Malaysia were compared regarding their service profiles and practice facilities. In general, practices in both parts put important emphasis on preventive health care. More practices in East Malaysia were providing hormone replacement therapy and sexually transmitted diseases services but less were providing intrapartum care, counselling services including sexual and marital counselling and problems associated with social deviance such as alcohol and drug abuse. Although most practices in East Malaysia were solo practices, they were more comprehensive in terms of the provision of practice facilities when compared to those in West Malaysia. A greater number of them had ultrasound facilities, peak flow meters, ECG machines, computers and blood biochemistry facilities.
Fulltext Chronic respiratory diseases are neglected

Khoo EM

Malays Fam Physician, 2018;13(3):1-2.
PMID: 30800226
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
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.
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.
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.
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
Fulltext Asthma control and prior medical care of patients presenting with acute asthma at the emergency department

Lee PY, Khoo EM

Med J Malaysia, 2003 Oct;58(4):482-9.
PMID: 15190622

Seventy patients presented with acute asthma at the emergency department of the University of Malaya Medical Centre, Kuala Lumpur were recruited over a two-week period in July 2001. Fifty-one (73%) patients belonged to the poorly controlled group. Fifty-seven (81%) patients were using inhaled salbutamol but 21 (30%) were still using oral short acting salbutamol. Only 32 (46%) patients used inhaled corticosteroids. In the poorly controlled group, 22 (43.1%) patients were not on regular inhaled corticosteroids, 35 (68.6%) were not receiving "add-on" medication and 18 (35%) did not have regular follow up. The emergency department should implement a protocol for asthma management and follow up to achieve better long term patient care.
Social support and glycemic control in adult patients with type 2 diabetes mellitus

Chew BH, Khoo EM, Chia YC

Asia Pac J Public Health, 2015 Mar;27(2):NP166-73.
PMID: 22199159 DOI: 10.1177/1010539511431300

INTRODUCTION: The purpose of this study is to examine the prevalence of social support and its association with glycemic control in patients with type 2 diabetes mellitus (T2D) in an urban primary care center within an academic institution. Social support is important in the management of chronic diseases. However, its association with glycemic control has been controversial.
METHODS: This was part of a study examining religiosity in T2D patients. Nonsmoking patients with T2D for at least 3 years and aged 30 years and above were recruited. Social support was measured using The Social Support Survey-Medical Outcomes Study (SS), a self-administered questionnaire; the scores range from 19 to 95, and a high score indicates better social support. Glycemic control was measured using the 3 most recent glycosylated hemoglobin (HbA1c) levels within the past 3 years.
RESULTS: A total of 175 participants completed the SS survey (response rate 79.0%). The mean age was 62.7 (standard deviation [SD] = 10.8) years, and the mean duration of diabetes was 11.74 (SD = 6.7) years. The mean HbA1c level was 8.15 (SD = 1.44). The mean SS score was 68.1. The prevalence of high and low social support were 29.7% and 24.0 %, respectively. A significant correlation was found between SS score and number of social supporters (n = 167). No significant correlation was found between the self-reported number of social supporters or the SS score and the mean HbA1c level.
CONCLUSIONS: Social support was not associated with glycemic control in adult patients with T2D in this primary care setting.

Study site: Primary care clinic, Universiti Malaya Medical Centre (UMMC)
Fulltext Management of type 2 diabetes mellitus: is it in accordance with the guidelines?

Chan GC, Ghazali O, Khoo EM

Med J Malaysia, 2005 Dec;60(5):578-84.
PMID: 16515108

A cross-sectional study was conducted among 517 patients with diabetes mellitus at all health centres in Melaka Tengah District to examine whether these patients and their associated cardiovascular risk factors were managed according to current guidelines. All patients had Type 2 diabetes mellitus with mean age of 57.9 +/- 10.5 years and the mean duration of diabetes was 7.2 +/- 6.0 years. The glycaemic control was poor with 53.6% of the patients having HbAlc above 8% (mean = 8.5%) and 24% of them had microalbuminuria. Among these patients with poor glycaemic control, about 47.6% of them were on monotherapy. Three hundred and fifty (67.7%) patients had hypertension but only 11 (3.1%) achieved target blood pressure of less than 130/80 mmHg. Only 18.3% of the diabetics with hypertension were prescribed angiotensin converting enzyme inhibitors and 0.3% with angiotensin receptor blockers. Nearly two-third of them had low-density lipoprotein cholesterol greater than 2.6 mmol/l (mean = 3.4 mmol/l) but only 6.8% were prescribed lipid-lowering agents. Aspirin was prescribed to 8.2% of diabetics aged above 40 years. Sixteen percent of the patients smoked, 53% did not do any exercise, and the mean BMI was 26.8 kg/mn. The management of diabetes mellitus and its associated cardiovascular risk factors was suboptimal on the basis of current clinical guidelines. A greater effort in educating doctors in the health centres about these management and adherence to the guidelines is important in reducing patients' risk of cardiovascular disease and its associated morbidity and mortality.
Fulltext Are doctors in the university-based primary care clinic more evidence-based?

Khoo EM, Teng CL, Wong KC

Med J Malaysia, 2004 Mar;59(1):129.
PMID: 15535352
Fulltext Negative Pressure Wound Therapy in Infected Wound following Posterior Spinal Instrumentation using Simple Self-assembled System: A Case Report

Chang C, Chan H, Lim S, Khoo E, Zulkiflee O

Malays Orthop J, 2014 Jul;8(2):49-51.
PMID: 25279094 MyJurnal DOI: 10.5704/MOJ.1407.004

Postoperative wound infection in an instrumented spine patient is often disastrous. Management includes implant removal leading to spine instability. Negative pressure wound therapy (NPWT) applied to the spine surgical wound is one of the wound care technique with successful results. We report a case of a man who sustained Chance fracture of Lumbar 1 (L1) vertebra treated with long segment posterior instrumentation, who unfortunately developed Extended-spectrum beta-lactamase (ESBL) positive E. coli infection one month after the operation. After careful debridement of the wound, the implant became exposed. Three cycles of NPWT were applied and the wound healed with granulation tissue completely covering the implant, and thus negating the need to remove the implant. In conclusion, the NPWT is a good alternative in postoperative wound management especially in an instrumented spine patient.
Fulltext Somatisation disorder and its associated factors in multiethnic primary care clinic attenders

Khoo EM, Mathers NJ, McCarthy SA, Low WY

Int J Behav Med, 2012 Jun;19(2):165-73.
PMID: 21562781 DOI: 10.1007/s12529-011-9164-7

Background Somatisation disorder (SD) has been reported as common in all ethnic groups, but the estimates of its prevalence have varied and the evidence for its associated factors has been inconsistent.
Purpose This study seeks to determine the prevalence of SD and its associated factors in multiethnic primary care clinic attenders.
Methods This cross-sectional study was on clinic attenders aged 18 years and above at three urban primary care clinics in Malaysia. The operational definition of SD was based on ICD-10 criteria for SD for research, frequent attendance, and excluded moderate to severe anxiety and depression. The instruments used were the ICD-10 symptom list, the Hospital Anxiety and Depression Scale, a semi-structured questionnaire, and SF-36.
Results We recruited 1,763 patients (response rate 63.8%). The mean age of respondents was 44.7±15.8 years, 807 (45.8%) were male; there were 35.3% Malay, 30.1% Chinese and 34.6% Indian. SD prevalence was 3.7%; the prevalence in Malay was 5.8%, Indian 3.0% and Chinese 2.1%. Significant associations were found between SD prevalence and ethnicity, family history of alcoholism, blue-collar workers and the physical component summary (PCS) score of SF-36. Multivariate analysis showed that SD predictors were Malay ethnicity (OR 2.7, 95% CI 1.6, 4.6), blue-collar worker (OR 2.0, 95% CI 1.2, 3.5) and impaired PCS score of SF-36 (OR 0.92, 95% CI 0.90, 0.95).
Conclusion The prevalence of SD was relatively uncommon with the stringent operational criteria used. SD preponderance in blue-collar workers may be attributable to secondary gain from getting sickness certificates and being paid for time off work.
Keywords Somatisation disorder . Associated factors . Primary care . Ethnic groups . Prevalence Questionnaire: ICD-10 symptom list; Hospital Anxiety Depression Scale; HADS; SF-36
Cervical cancer screening attitudes and beliefs of Malaysian women who have never had a pap smear: a qualitative study

Wong LP, Wong YL, Low WY, Khoo EM, Shuib R

Int J Behav Med, 2008;15(4):289-92.
PMID: 19005928 DOI: 10.1080/10705500802365490

Attitudes toward cervical cancer and participation in early detection and screening services are well known to be profoundly affected by cultural beliefs and norms.
Fulltext Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: a qualitative study

Wong LP, Wong YL, Low WY, Khoo EM, Shuib R

Singapore Med J, 2009 Jan;50(1):49-53.
PMID: 19224084

INTRODUCTION: Cervical cancer is one of the commonest cancers in women worldwide. Despite the existence of effective screening using Pap smear, the uptake of screening is poor. A qualitative study was undertaken using face-to-face in-depth interviews to investigate knowledge, attitudes and beliefs on cervical cancer screening of Malaysian women.
METHODS: In-depth interviews were conducted with 20 Malaysian women aged 21-56 years and who have never had a Pap smear test, with the aim to explore their knowledge and awareness of cervical cancer and its screening.
RESULTS: A lack of knowledge on cervical cancer and the Pap smear test was found among the respondents. Many women did not have a clear understanding of the meaning of an abnormal cervical smear and the need for the early detection of cervical cancer. Many believe the purpose of the Pap smear test is to detect existing cervical cancer, leading to the belief that Pap smear screening is not required because the respondents had no symptoms. Despite considerable awareness of a link between cervical cancer and sexual activity, as well as the role of a sexually-transmitted infection, none of the respondents had heard of the human papillomavirus.
CONCLUSION: The findings highlight the importance of emphasising accurate information about cervical cancer and the purpose of Pap smear screening when designing interventions aimed at improving cervical cancer screening for Malaysian women.
Fulltext Virulence gene profiles and antimicrobial susceptibility of Salmonella Brancaster from chicken

Khoo E, Roslee R, Zakaria Z, Ahmad NI

J Vet Sci, 2023 Nov;24(6):e82.
PMID: 38031519 DOI: 10.4142/jvs.23053

BACKGROUND: The current conventional serotyping based on antigen-antisera agglutination could not provide a better understanding of the potential pathogenicity of Salmonella enterica subsp. enterica serovar Brancaster. Surveillance data from Malaysian poultry farms indicated an increase in its presence over the years.
OBJECTIVE: This study aims to investigate the virulence determinants and antimicrobial resistance in S. Brancaster isolated from chickens in Malaysia.
METHODS: One hundred strains of archived S. Brancaster isolated from chicken cloacal swabs and raw chicken meat from 2017 to 2022 were studied. Two sets of multiplex polymerase chain reaction (PCR) were conducted to identify eight virulence genes associated with pathogenicity in Salmonella (invasion protein gene [invA], Salmonella invasion protein gene [sipB], Salmonella-induced filament gene [sifA], cytolethal-distending toxin B gene [cdtB], Salmonella iron transporter gene [sitC], Salmonella pathogenicity islands gene [spiA], Salmonella plasmid virulence gene [spvB], and inositol phosphate phosphatase gene [sopB]). Antimicrobial susceptibility assessment was conducted by disc diffusion method on nine selected antibiotics for the S. Brancaster isolates. S. Brancaster, with the phenotypic ACSSuT-resistance pattern (ampicillin, chloramphenicol, streptomycin, sulphonamides, and tetracycline), was subjected to PCR to detect the corresponding resistance gene(s).
RESULTS: Virulence genes detected in S. Brancaster in this study were invA, sitC, spiA, sipB, sopB, sifA, cdtB, and spvB. A total of 36 antibiogram patterns of S. Brancaster with a high level of multidrug resistance were observed, with ampicillin exhibiting the highest resistance. Over a third of the isolates displayed ACSSuT-resistance, and seven resistance genes (β-lactamase temoneira [blaTEM], florfenicol/chloramphenicol resistance gene [floR], streptomycin resistance gene [strA], aminoglycoside nucleotidyltransferase gene [ant(3″)-Ia], sulfonamides resistance gene [sul-1, sul-2], and tetracycline resistance gene [tetA]) were detected.
CONCLUSION: Multidrug-resistant S. Brancaster from chickens harbored an array of virulence-associated genes similar to other clinically significant and invasive non-typhoidal Salmonella serovars, placing it as another significant foodborne zoonosis.
Fulltext The management of upper respiratory tract infections

Teng CL, Shajahan Y, Khoo EM, Nurjahan I, Leong KC, Yap TG

Med J Malaysia, 2001 Jun;56(2):260-6; quiz 267.
PMID: 11771093

Upper respiratory tract infections are the commonest reason for consultation in primary care. Group A beta-haemolytic Streptococcus (GABHS), the most important bacterial pathogen in this condition, can be cultured from about 30% of patients, more so in children than adults. Clinical features that are predictive of positive GABHS culture are absence of cough, fever, cervical adenopathy, tonsillar enlargement and tonsillar exudate. Use of a sore throat score can help in the detection of streptococcal throat infection. Symptomatic therapies which are useful include anticholinergic, antihistamine, decongestant, humified hot air and Vitamin C. Antibiotics are universally over-prescribed in this condition as a result of high patient expectation and faulty clinical decision making. Oral Penicillin V for 10 days is the drug of choice. Effective intervention to reduce inappropriate antibiotic prescription probably require a multifaceted approach targeted at both the patients and the prescribers.
Genetic Diversity and Demographic History of an Upper Hill Dipterocarp (Shorea platyclados): Implications for Conservation

Ng CH, Lee SL, Tnah LH, Ng KKS, Lee CT, Diway B, et al.

J Hered, 2019 12 17;110(7):844-856.
PMID: 31554011 DOI: 10.1093/jhered/esz052

Southeast Asian rainforests at upper hill elevations are increasingly vulnerable to degradation because most lowland forest areas have been converted to different land uses. As such, understanding the genetics of upper hill species is becoming more crucial for their future management and conservation. Shorea platyclados is an important, widespread upper hill dipterocarp in Malaysia. To elucidate the genetic structure of S. platyclados and ultimately provide guidelines for a conservation strategy for this species, we carried out a comprehensive study of the genetic diversity and demographic history of S. platyclados. Twenty-seven populations of S. platyclados across its range in Malaysia were genotyped at 15 polymorphic microsatellite loci and sequenced at seven noncoding chloroplast DNA (cpDNA) regions. A total of 303 alleles were derived from the microsatellite loci, and 29 haplotypes were identified based on 2892 bp of concatenated cpDNA sequences. The populations showed moderately high genetic diversity (mean HE = 0.680 for microsatellite gene diversity and HT = 0.650 for total haplotype diversity) and low genetic differentiation (FST = 0.060). Bayesian clustering divided the studied populations into two groups corresponding to western and eastern Malaysia. Bottleneck analysis did not detect any recent bottleneck events. Extended Bayesian skyline analyses showed a model of constant size for the past population history of this species. Based on our findings, priority areas for in situ and ex situ conservation and a minimum population size are recommended for the sustainable utilization of S. platyclados.
Fulltext Geographic origin and individual assignment of Shorea platyclados (Dipterocarpaceae) for forensic identification

Ng CH, Lee SL, Tnah LH, Ng KKS, Lee CT, Diway B, et al.

PLoS One, 2017;12(4):e0176158.
PMID: 28430826 DOI: 10.1371/journal.pone.0176158

The development of timber tracking methods based on genetic markers can provide scientific evidence to verify the origin of timber products and fulfill the growing requirement for sustainable forestry practices. In this study, the origin of an important Dark Red Meranti wood, Shorea platyclados, was studied by using the combination of seven chloroplast DNA and 15 short tandem repeats (STRs) markers. A total of 27 natural populations of S. platyclados were sampled throughout Malaysia to establish population level and individual level identification databases. A haplotype map was generated from chloroplast DNA sequencing for population identification, resulting in 29 multilocus haplotypes, based on 39 informative intraspecific variable sites. Subsequently, a DNA profiling database was developed from 15 STRs allowing for individual identification in Malaysia. Cluster analysis divided the 27 populations into two genetic clusters, corresponding to the region of Eastern and Western Malaysia. The conservativeness tests showed that the Malaysia database is conservative after removal of bias from population subdivision and sampling effects. Independent self-assignment tests correctly assigned individuals to the database in an overall 60.60-94.95% of cases for identified populations, and in 98.99-99.23% of cases for identified regions. Both the chloroplast DNA database and the STRs appear to be useful for tracking timber originating in Malaysia. Hence, this DNA-based method could serve as an effective addition tool to the existing forensic timber identification system for ensuring the sustainably management of this species into the future.
Fulltext Are interventions to increase the uptake of screening for cardiovascular disease risk factors effective? A systematic review and meta-analysis

Cheong AT, Liew SM, Khoo EM, Mohd Zaidi NF, Chinna K

BMC Fam Pract, 2017 Jan 17;18(1):4.
PMID: 28095788 DOI: 10.1186/s12875-016-0579-8

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death globally. However, many individuals are unaware of their CVD risk factors. The objective of this systematic review is to determine the effectiveness of existing intervention strategies to increase uptake of CVD risk factors screening.
METHODS: A systematic search was conducted through Pubmed, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials. Additional articles were located through cross-checking of the references list and bibliography citations of the included studies and previous review papers. We included intervention studies with controlled or baseline comparison groups that were conducted in primary care practices or the community, targeted at adult populations (randomized controlled trials, non-randomized trials with controlled groups and pre- and post-intervention studies). The interventions were targeted either at individuals, communities, health care professionals or the health-care system. The main outcome of interest was the relative risk (RR) of screening uptake rates due to the intervention.
RESULTS: We included 21 studies in the meta-analysis. The risk of bias for randomization was low to medium in the randomized controlled trials, except for one, and high in the non-randomized trials. Two analyses were performed; optimistic (using the highest effect sizes) and pessimistic (using the lowest effect sizes). Overall, interventions were shown to increase the uptake of screening for CVD risk factors (RR 1.443; 95% CI 1.264 to 1.648 for pessimistic analysis and RR 1.680; 95% CI 1.420 to 1.988 for optimistic analysis). Effective interventions that increased screening participation included: use of physician reminders (RR ranged between 1.392; 95% CI 1.192 to 1.625, and 1.471; 95% CI 1.304 to 1.660), use of dedicated personnel (RR ranged between 1.510; 95% CI 1.014 to 2.247, and 2.536; 95% CI 1.297 to 4.960) and provision of financial incentives for screening (RR 1.462; 95% CI 1.068 to 2.000). Meta-regression analysis showed that the effect of CVD risk factors screening uptake was not associated with study design, types of population nor types of interventions.
CONCLUSIONS: Interventions using physician reminders, using dedicated personnel to deliver screening, and provision of financial incentives were found to be effective in increasing CVD risk factors screening uptake.

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