Delirium in the elderly is a challenging and under-recognized problem in the community. Early detection and management improves outcomes and quality of life for the elders with delirium at home.1 Family physicians (FP) play a key role in the assessments, early identification, and management of delirium and in the support and education of patients and their family caregivers.1 Clinical analysis of this case illustrates the bio-psychosocial spiritual model of approach to management of delirium in an elderly patient in the home setting.
Academic mobbing is a non-violent, sophisticated, 'ganging up' behaviour adopted by academicians to "wear and tear" a colleague down emotionally through unjustified accusation, humiliation, general harassment and emotional abuse. These are directed at the target under a veil of lies and justifications so that they are "hidden" to others and difficult to prove. Bullies use mobbing activities to hide their own weaknesses and incompetence. Targets selected are often intelligent, innovative high achievers, with good integrity and principles. Mobbing activities appear trivial and innocuous on its own but the frequency and pattern of their occurrence over long period of time indicates an aggressive manipulation to "eliminate" the target. Mobbing activities typically progress through five stereotypical phases that begins with an unsolved minor conflict between two workers and ultimately escalates into a senseless mobbing whereby the target is stigmatized and victimized to justify the behaviours of the bullies. The result is always physical, mental, social distress or illness and, most often, expulsion of target from the workplace. Organizations are subjected to great financial loss, loss of key workers and a tarnished public image and reputation. Public awareness, education, effective counselling, establishment of anti-bullying policies and legislations at all levels are necessary to curb academic mobbing. General practitioners (GPs) play an important role in supporting patients subjected to mental and physical health injury caused by workplace bullying and mobbing.
This case history illustrates the real life experience and dilemma of an 80-year-old woman in pursuit of medical care for her left shoulder pain. Points for discussion range from clinical features of Pancoast tumor, importance of pain management, good principles of Family Medicine and Palliative care to ethical issues of conspiracy of silence, limited treatment plan and palliative versus curative radiotherapy treatment without a known biopsy report. This paper provides opportunity for analysis of a real complex clinical situation, application of medical knowledge to problem solving in clinical practice and relevant topics for discussions. (For anonymity sake, the names of patient, doctors, general and private hospitals are not mentioned. The aim of this paper is solely for continuous medical education without any intention to ridicule any party).
Cancers and related treatments have devastating effects on psychosexual life of patients. This study helps us to understand the cultural perspectives of 50 Asian women diagnosed with cancer. Median age was 50+ years. Median duration of time from diagnosis to interview was 23 months. Thirty-eight per cent stopped sex before illness, 36% stopped sex completely whereas 18% stopped gradually after diagnosis; 8% continued to have sex till time of interview. Overall, 70% were living with spouse but not engaged in sexual intercourse; 31.4% slept in different room, 48.6% slept in the same room but without any form of sexual contact. Thirty-eight per cent believed sexual activity could cause cancer recurrence, and 30% believed cancer could be sexually transmitted. Eighty-two per cent reported acceptance of changes to physical appearance. Approximately 70-86% did not discuss sexuality with their doctor or spouse; 90% agreed doctors should ask about psychosexual issues on a routine basis. Approximately 74.4% reported good cooperation from spouse. Cultural beliefs of Asians pose as barriers to providing and receiving psychosexual affection between women diagnosed with cancer and their spouse. However, these beliefs also serve as protective factors in their mutual acceptance of change in psychosexual activities. Health-care professionals need to be sensitive to the vast cultural differences in psychosexual expressions and needs of women diagnosed with cancer.
Many cluster headache (CH) patients waited several years to be accurately diagnosed because their symptoms are often mistaken for sinusitis or a dental disorder.1 Patients have also been mistakenly diagnosed as analgesic drug abusers or suffering from a psychiatric illness. This case report illustrates how a young lady was diagnosed to have cluster headache after several years of consultations with ophthalmologists for eye swelling and redness. It also highlights the importance of pain assessment and a general and holistic approach to medical care which is the main distinguishing feature of Family Medicine.
Recommendation of oxygen therapy must include clear indication and benefits of its use, appropriate prescription, vigilant monitoring and appropriate methods of delivery. Home oxygen therapy is expensive, inconvenient and cumbersome; it should be recommended only if benefits outweigh the disadvantages and adverse effects of oxygen. GPs play an important supportive and supervisory role in the use of long-term oxygen therapy (LTOT) to improve mortality of patients with chronic hypoxaemia. Prescription of short burst oxygen therapy (SBOT) for palliation of breathlessness is without clear evidence of its efficacy. GPs can prescribe SBOT when other secondary causes of breathlessness are excluded or treated, when breathlessness is not relieved by other treatments and if an improvement can be documented in patients.
The concept of Palliative Care is still quite new in Malaysia and there is a need to promote the awareness of its importance for patients with incurable and advanced illnesses, not only to the public but also to the nursing and medical professionals. These patients especially the poor ones very often have no one to turn to; they cannot afford to seek treatment from the private hospitals, they are turned away from acute General Hospitals and are told that there is nothing more to be done because their illnesses are no longer curable, they cannot pay for GPs to come to their homes, and there is difficulty in purchasing opiate drugs for pain relief. This is a retrospective observational study of the palliative care services we try to provide to those few patients referred to us. This study showed that out of the total of 156 patients, majority were Chinese, peak age between 50-59 years, referrals were mainly from the community and the Obstetrics + Gynaecology department, patients were referred rather late, 60% of patients died at home, most common malignancies being those of the breast, colorectal and cervix, common sites of metastases being the lungs, liver, bones, peritoneum and local infiltration, 87% of patients experienced pain, about 40% of patients were not fully aware of both diagnosis and prognosis, common drugs used being opiate analgesics followed by dexamethasone, H2 antagonist, antiemetics and NSAID.
Anaemia is the most common haematological problem in the elderly population. Using WHO criteria for anaemia (Hb of <12 g/dL in women and <13 g/dL in men), the prevalence of anaemia in the elderly has been found to range from 8-44% with the highest prevalence in men 85 years and older. Anaemia must not be considered simply as part of ageing because in 80% of cases, there is an underlying cause for Hb
levels of <12 g/dL in the elderly. Anaemia has negative impacts on the quality of life for the elderly and there is evidence of improved morbidity and
mortality after correction of anaemia. Chronic disease and thalassaemia may also cause microcytic anaemia besides iron deficiency and not all vitamin B12 and folate deficiency present with macrocytic megaloblastic anaemia. Nutritional deficiency anaemias are common, easily diagnosed, treatments are simple, inexpensive and effective. Tests for nutritional anaemia have to be given priority in the assessment before a patient is subjected to invasive tests to look for less common causes of anaemia. Serum ferritin which is the best non-invasive test for the diagnosis of iron deficiency anaemia may be increased in the elderly while serum iron and transferrin decrease with ageing. Serum methylmalonic acid (MMA) and homocysteine (HC) levels are sensitive for detecting subclinical vitamin B12 and folate deficiency. Routine iron therapy in non-anaemic elderly or in those without iron deficiency anaemia is of no use and may be detrimental to their health. Folate therapy may improve anaemia but may mask the signs and symptoms of neurological damage due to concomitant
vitamin B12 deficiency. Blood transfusion offers prompt symptom relief of anaemia in patients with terminal malignancy irrespective of the causes for the anaemia.
The concept of palliative care is still quite new in Malaysia. Through the experience of delivering palliative care in both the hospital and community settings, the author has realized that there are many false beliefs among the medical and nursing professionals, as well as patients and their caregivers. By exploring and providing factual explanations to these beliefs, the present article highlights the differences in approach between acute and palliative management and the importance of good communication skills, as well as correcting the myths of patients and their caregivers, with the aim of improving the understanding of palliative care., (C) 2003 Blackwell Science Ltd
Background: A community-based general practice course has been developed in the Penang Medical College (PMC) (a joint Ireland-Malaysia venture) that simultaneously satisfies the medical regulatory authorities in Ireland and re-orients the current medical education to the health needs of the Malaysian community. Objectives: This paper describes the community-based general practice course in PMC, explores student evaluation of the various course objectives, student perception of general practice in Malaysia, and whether course experience has any influence on their choice of general practice specialty as a future career. Methods: Two consecutive classes of students (n = 78) were invited to complete anonymous, confidential pre-general practice rotation and post-general practice rotation course questionnaires. Results: Overall responses from both classes were 75/78 (96.1%) for pre-course and 73/78 (93.6%) for post-course questionnaire. Although students had minimal knowledge of Irish and Malaysian primary health care before the course, 60% were keen to learn about Irish primary healthcare and 54.7% expected to learn about the Malaysian healthcare system in the course. Overall, there was a slight reduction of 'No' response and increment of 'Maybe' response after the course with regard to working as a general practitioner in both countries but statistical tests show that there is no significance in the difference. Conclusions: An innovative community-based general practice course has been implemented in PMC but course experience of students does not seem to have any influence on their choice of general practice specialty as a future career. Key words: community, general practice course, Ireland, Malaysia, primary healthcare
Patients who are entering the last phase of their illness and for whom life expectancy is short, have health needs that require particular expertise and multidisciplinary care. A combination of a rapidly changing clinical situation and considerable psychosocial and spiritual demands pose challenges that can only be met with competence, commitment and human compassion. This article is concerned with the definition of suffering, recognition of the terminal phase and application of the biopsychosocial-spiritual model of care where family physicians play an important role in the community. Key words: biopsychosocial-spiritual care, dying, family medicine, good death, palliative care, suffering.
Background: Understanding the sociocultural dimension of a patient’s health beliefs is critical to a successful clinical encounter. Malaysia with its multi-ethnic population of Malay, Chinese and Indian still uses many forms of traditional health care in spite of a remarkably modern rural health service.
Objective: The objective of this paper is discuss traditional health care in the context of some of the cultural aspects of health beliefs, perceptions and practices in the different ethnic groups of the author’s rural family practices. This helps to promote communication and cooperation between doctors and patients, improves clinical diagnosis and Management, avoids cultural blind spots and unnecessary medical testing and leads to better adherence to treatment by patients.
Discussion: Includes traditional practices of ‘hot and cold’, notions of Yin-Yang and Ayurveda, cultural healing, alternative medicine, cultural perception of body structures and cultural practices in the context of women’s health. Modern and traditional medical systems are potentially complementary rather than antagonistic. Ethnic and cultural considerations can be integrated further into the modern health delivery system to improve care and health outcomes.
KEY WORDS: alternative medicine, child health, cultural healing, traditional medicine, women’s health
Background: Penang Medical College is a joint Ireland-Malaysia project in which Malaysian students spend their initial 3 years in Ireland and complete their clinical training in Penang and receive Irish qualifications and registration. The educational foundations for such a program, particularly in general practice/primary care, are complex. Objectives: To explore the experiences of current students undertaking clinical training at Penang. Methods: All students were invited to complete an anonymous, confidential questionnaire dealing with foundation course availability and participation, the perceived value of such courses and suggestions for change. Results: Two thirds of all students responded. Attendance at foundation courses varied greatly as did the perceived value of such courses for clinical training. Early patient contact and communications skills courses scored most highly. More 'hands-on' clinical skills training was requested. No student raised ethical, legal or economic issues although these areas include very significant differences between the countries. Discussion: Educational bridges which link the learning and healthcare environments in which students work are crucial in this novel undergraduate setting. Conventional educational structures have value for students but access and relevance can be improved. Students are highly conscious of the differences between these environments but prize familiar themes such as clinical skills training over less tangible areas such as ethical or social structures.
The synthesis and characterization of two cobalt(II) complexes, Co(phen)(ma)Cl 1 and Co(ma)(2)(phen) 2, (phen=1,10-phenanthroline, ma(-)=maltolate or 2-methyl-4-oxo-4H-pyran-3-olate) are reported herein. The complexes have been characterized by FTIR, CHN analysis, fluorescence spectroscopy, UV-visible spectroscopy, conductivity measurement and X-ray crystallography. The number of chelated maltolate ligands seems to influence their DNA recognition, topoisomerase I inhibition and antiproliferative properties.