Cardiac myxoma is often discovered as an incidental finding and presents with various subtle symptoms and signs. Electrocardiographic findings are mostly non-specific. Atrial flutter or conduction abnormalities are known to be rare. We report a case of large left atrial myxoma that was diagnosed by transthoracic echocardiography at a primary care clinic. An asymptomatic, 71-year-old woman presented with serial abnormal electrocardiogram changes during a routine consultation. A diagnosis of left atrial myxoma was obtained through transthoracic echocardiography. We report this case with a review of literature on cardiac myxoma associated with arrhythmia.
PURPOSE: To describe the management of mild conduct problems in an adolescent at the primary care level.
CASE REPORT: A 16 year old girl presented with conduct problems with impending school suspension. The cause of her behavioural problems was mainly related to poor parenting skills of her parents and anger in herself. She was successfully managed with counselling and improvement of parenting styles in her parents.
CONCLUSION: This case report illustrates the opportunity for family physicians to manage simple conduct problems at primary care level.
KEYWORDS: Conduct problems; adolescents; anger management; parenting skills
Treatment refusal is a common encounter in clinical practice. The process of deciding to refuse treatment is often complex. It is our responsibility to try and understand this process of decision making and the underlying reasons for treatment refusal. Many of these reasons are often rational in the context where the decision is made. The patients could be making the best decision for themselves even if these decisions are not necessarily the best in our mind. We should at all times discuss our treatment options and assess their ability to make decisions in achieving common goals. These goals should balance our best treatment strategies and the patients' best interest. This article discusses the reasons underlying treatment refusal and how we can achieve a common goal with our patients.
INTRODUCTION: Post-partum depression (PPD) is the most prevalent mental problem associated with childbirth. The purpose of the present study was to determine the incidence of early PPD and possible relevant risk factors among women attending primary health centers in Mazandaran province, Iran for the first time.
MATERIAL AND METHODS: A longitudinal cohort study was conducted among 2279 eligible women during weeks 32-42 of pregnancy to determine bio-psycho-socio-cultural risk factors of depression at 2 weeks post-partum using the Iranian version of the Edinburgh Postnatal Depression Scale (EPDS). Univariate and hierarchical multiple logistic regression models were used for data analysis.
RESULTS: Among 1,739 mothers whose EPDS scores were ≤ 12 during weeks 32-42 of gestation and at the follow-up study, the cumulative incidence rate of depression was 6.9% (120/1,739) at 2 weeks post-partum. In the multivariate model the factor that predicted depression symptomatology at 2 weeks post-partum was having psychiatric distress in pregnancy based on the General Health Questionnaire (GHQ) (OR = 1.06, (95% CI: 1.04-1.09), p = 0.001). The risk of PPD also lower in those with sufficient parenting skills (OR = 0.78 (95% CI: 0.69-0.88), p = 0.001), increased marital satisfaction (OR = 0.94 (95% CI: 0.9-0.99), p = 0.03), increased frequency of practicing rituals (OR = 0.94 (95% CI: 0.89-0.99), p = 0.004) and in those whose husbands had better education (OR = 0.03 (95% CI: 0.88-0.99), p = 0.04).
CONCLUSIONS: The findings indicated that a combination of demographic, sociological, psychological and cultural risk factors can make mothers vulnerable to PPD.
KEYWORDS: depression; incidence; post-partum
Introduction : Selangor’s private clinic registry system had been introduced in 2006 following gazettment of The Private Healthcare Facilities and Services Act. Through the act, data’s from the private clinics can be obtained and its characteristics can be compared between the urban and rural private clinic. An overview of the services can be known and an appropriate action can be planned.
Methodology : A cross-sectional study was done on private clinics registered in state of Selangor. Using databased known as MedPCs (Medical Practice Control System), a purposive sampling was used to select four districts – two urban and two rural. All private clinics in the selected districts were studied and all details shall be collected on line.
Result : District of Gombak and Klang were selected as urban and Sabak Bernam and Kuala Selangor represented rural area. Of a total 625 clinics selected, 90.0% (562) from urban and 10.0% (63) rural. Distributions of clinic were in line with the act. The most prominent services were general treatment (89.4%) and ability to serve more than eight hours daily (89.4%). Medical clinic still dominated at 84.0% compared to dentistry at 16.0%. About 70.6% were operated by male doctors. Though clinic services in rural were relatively as good as urban, the different were significantly observed to the ethnicity of the doctor. Indian doctors more in rural (46.03%), whilst in urban, Malay doctors were more dominant (39.50%). Followed closely by seniority, where rural doctors were much senior (51.02 years old), however, most of the doctors in rural private clinics experienced less exposure in government sectors, compared to those in urban areas.
Conclusion : There were obvious difference in terms of distribution, where more clinics were located in urban compared to rural, but all were still in line to the act and their services were comparable. Most noticeable differences were ethnicity, seniority and past experience working in the public sector. Indian doctors were dominant in rural and Malay in urban. Although rural doctors were more senior, relatively they were less experienced working in the government sector.
The aim of this study was to demonstrate the construct validity of a newly developed cancer screening perception scale as a measure of the perception of cancer screening in general among high-risk but healthy asymptomatic groups.The cancer screening perception scale (CSPS) was developed based on extensive literature reviews guided by The Health Belief Model. Fifty-five written items were initially pooled, reviewed by experts for face validity, pretested by 25 healthcare workers and translated into Malay using simple back translation. The scale was then distributed to 300 respondents from two health clinics for construct validation purposes. The obtained data were analyzed using the varimax rotation method for exploratory factor analysis (EFA). The data was submitted for further confirmatory factor analysis using AMOS software.Based on EFA, the results produced five constructs as predicted: perceived severity, perceived susceptibility, perceived benefits, perceived barriers, and cues for action. Two items with low factor loading and unrelated to the recovered domains were removed. Perceived barriers and cues for action had three and two sub-domains respectively which were further confirmed to fit the measurement and structural models. CFA demonstrated the scale fitted GFI = 0.936, CFI = 0.935, RMSEA = 0.076, NORMEDCHISQ = 2.162. The scale discriminated between the domains. Cronbach's alpha for perceived severity, perceived susceptibility, perceived benefits, perceived barrier, and cues for action were 0.907, 0.877, 0.940, 0.864 and 0.938, respectively.The cancer screening perception scale with its promising psychometric properties is now available to measure risks to high-risk but healthy, asymptomatic groups aged 18 and above and can also be used for larger scale study purposes.
Self-perception is found to be a central predictive factor in experiencing successful aging. The aim of this study was to explore the role of sex, socioeconomic status, and emotional support in elders' aging perception. A cross-sectional design was used with 300 older aged participants recruited from 23 clinics and health centers in Qazvin, Iran. Data were collected included questions to elicit demographic information and Barker's aging perception questionnaire. Exploratory multiple linear regression showed that the level of emotional support (β: -12.10; 95% CI: [-20.72, -3.48]), socioeconomic status (β: 2.84; 95% CI: [0.25, 5.43]), and women (β: -4.34; 95% CI: [-6.91, -1.77]) were associated with aging perception among elders. Educational level and marital status did not significantly contribute to the variance of AP. Findings revealed that aging perception was related to individual differences as well as social and emotional factors. Researchers, health-care professionals, and elders may benefit from thinking about old age as an inevitable life stage.
This is a rare but interesting case of Mr. MZ who had a lifethreatening pericardial effusion presenting to the primary care clinic. Through great clinical acumen and prudent targeted investigations, diagnosis of this rare condition was reached and urgent referral made to the cardiology team which performed an emergency pericardiocentesis which proved to be life -saving. However, the hovering poor prognosis of Mr. MZ may prompt for a referral to the palliative care team to provide quality end of life care for this unfortunate patient.
BACKGROUND: Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
METHOD: Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
RESULTS: A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15-3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98-10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7-15) (OR = 0.96; 95% CI = 0.56-1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26-0.97).
CONCLUSIONS: The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Introduction: Clinical resolution of periodontitis (CRP) of type-2 diabetic patients with chronic periodontitis (T2DM-PD) after receiving non-surgical periodontal treatment (NSPT) has been reported in the previous studies. This study aimed to evaluate CRP of T2DM-PD under medicaldental coordinated care (M-DCC). Materials and Methods: A 6-months follow-up quasi-experimental study was conducted among 20 subjects who received M-DCC in 2016. M-DCC included standard diabetic care provided by medical professional from 3 health clinics and NSPT provided by periodontal specialists from two periodontal specialist clinics. Target glycemic control achievement (TGCA) HbA1c 6.5% was assessed at baseline and 6 months after NSPT. Clinical resolution of PD was measured in terms of BPE, BOP %, CAL(mm), PPD(mm), PPD 4mm, PPD =4 mm and PPD 6mm at baseline, 3 and 6 months. Paired simple t test and ANOVA F test were applied to infer clinical resolution of periodontitis and its relation to TGCA.
Results: Mean (SD) of average BPE at baseline, 3- and 6-months were 3.52(0.34), 3.12(0.33) and 3(0.45) with (p<0.05); average PPD(mm) were 3.33(0.5), 3.23(0.75) and 2.73(0.57) with (p<0.05); PPD(%) 4mm were 71.03(12.33), 82.77(9.9) and 85.85 (8.9) with (p<0.05); PPD(%) =4 mm were 27.94(11.9), 16.97(10.01) and 13.71(9.1) with (p<0.05); PPD(%) 6mm were 8.04(4.32), 2.66(2.3) and 1.87(2.32) with (p<0.05). Significant resolution of BPE, CAL(mm) and PPD(mm) was noticed among two subjects who has changed from uncontrolled TGCA to controlled TGCA.
Conclusion(s): CRP and TGCA results have verified the effectiveness of M-DCC. A further clinical control trial with adequate sample size needs to confirm the results of the present study.
KEYWORDS: clinical resolution, chronic periodontitis, periodontal therapy, target HbA1C%, Type-2 Diabetic Patients with chronic periodontitis
BACKGROUND: The Diabetes Mellitus in the Offspring Questionnaire (DMOQ) assesses the perceptions of Type 2 diabetes mellitus (T2DM) patients on the risk of their offspring developing T2DM and the possibility of intervention to reduce this risk. It has 34 items framed within seven domains. This study aimed to adapt, translate and validate the DMOQ from English into the Malay language.
METHODS: This was a cross-sectional validation study among 159 T2DM patients attending a public primary care clinic in Selangor. The DMOQ English version underwent adaptation, translation, face validation and field testing to produce the Malay version. Psychometric analysis was performed using Exploratory Factor Analysis, internal consistency and testretest reliability.
RESULTS: The DMOQ domains were conceptually equivalent between English and Malay language. A total of 13 items and two domains were removed during the validation process (three items during the content validation, three items due to poor factor loadings, five items as they loaded onto two domains which were not interpretable, one item as it did not fit conceptually into the factor it loaded onto and one openended question as it did not fit into the retained domains). Therefore, the final DMOQ Malay version consisted of 21- items within five domains. The Cronbach alpha was 0.714 and the intraclass-correlation coefficient was 0.868.
CONCLUSION: The DMOQ Malay version is a valid and reliable tool which is consistent over time. It can be used to examine the perception of T2DM patients towards the risk of their offspring developing diabetes and possibility of intervention in Malay-speaking patients.
Data on post stroke outcomes in developing countries are scarce due to uncoordinated healthcare delivery systems. In Malaysia, the national stroke clinical practice guideline does not address transfer of care and longer term post stroke care beyond tertiary care. Hence, post stroke care delivery may be delivered at either tertiary or primary care facilities. This study aimed at describing patients' characteristics and outcomes of post stroke care delivered by the primary care teams at public primary care healthcentres across Peninsular Malaysia. Multi staged sampling was done to select public primary care health centres to recruit post stroke patients. At each health centre, convenience sampling was done to recruit adult patients (≥18 years) who received post stroke care between July-December 2012. Baseline measurements were recorded at recruitment and retrospective medical record review was done simultaneously, for details on medical and / or rehabilitation treatment at health centre. Changes in the measurements for post stroke care were compared using paired t-tests and Wilcoxon Rank test where appropriate. Total of 151 patients were recruited from ten public primary care healthcentres. The mean age at stroke presentation was 55.8 ± 9.8 years. Median duration of follow up was 2.3 (IQR 5.1) years. Majority co-resided with a relative (80.8%), and a family member was primary caregiver (75.%). Eleven percent were current smokers. Almost 71.0% of patients achieved BP ≤ 140/90 mmHg. Only 68.9% of the patients had been referred for neurorehabilitation. Percentage of recorded data was highest for blood pressure (88.1%) while lowest was HbA1c (43.0%). For clinical outcomes, systolic and diastolic blood pressure, triglyceride level and calculated GFR (eGFR) showed statistically significant changes during follow up (p care at public primary care healthcentres showed benefits in stroke risk factors control (i.e. hypertension and dyslipidaemia) but deterioration in renal function. A more structured coordination is needed to optimise post stroke care beyond acute phase management for patients who reside at home in the community.
Nondisclosure of traditional and complementary medicine (T&CM) use may cause individual to be at risk of undue harm. This study aimed to explore patient's experience and views on their decision to disclose the use of T&CM to the doctor. An exploratory qualitative study using in-depth interview involving 10 primary care clinics attendees in Kuching was conducted. The results indicated that disclosure of T&CM use will motivate them to get information, increase doctor's awareness, and get support from family and friends for disclosure. Fear of negative relationship and negative response from doctors was a barrier for disclosure. Doctor's interpersonal and communication skills of being involved, treating patients respectfully, listening attentively, respecting privacy, and taking time for the patient were a critical component for disclosure. Intrapersonal trust regarding doctor influences their satisfaction on healthcare. Women are more open and receptive to a health concern and expressing negative emotions and tend to share problems, whereas men always described themselves as healthy, tended to keep their own personal feeling to themselves, and tended to not share. The doctor should consider gender differences in disclosure, their attitude towards T&CM use, and gained patient's trust in the delivery of healthcare services. Good interpersonal and communication skills must be maintained between doctor and patients.
This study was conducted to find out the psychiatric symptomatology in the patients and their families attending a primary health care facility. The most frequent symptoms found were of depression (13.2%), followed by hypochondriacal symptoms (8.2%), anxiety symptoms (6.1%) and psychotic symptoms. A large proportion (21.5%) of children had psychiatric symptoms. The common symptoms include enuresis, hostility, tantrums, problems of conduct and destructiveness. Surprisingly, concern for these symptoms was lacking in both the patient and their family members.
This audit report assessed the structure, processes and outcome of the pulmonary tuberculosis (PTB) management in adults conducted at eight government health clinics within the high TB burden Gombak district. All newly diagnosed PTB patients from November 2012 to November 2013 were identified from the tuberculosis registry. Patients less than 18 years old, were transferred out or extrapulmonary tuberculosis was excluded from the study. The assessment criteria for PTB were defined according to the latest Malaysian TB clinical practice guidelines (TB CPG) 2012. A total of 117 patients were included in this report and data were extracted and analysed using SPSS version 20.0. The mean age of patients was 40.4 ± 14.4 SD. Majority was men (63.2%). Out of 117 patients, 82.1% were Malaysian citizens and 17.9% were foreigners. Malays were the majority (65%) followed by 7.7% Chinese, 10.3% Indian and 17.1% others. The most common clinical feature was cough (88.0%) followed by loss of weight (58.1%), loss of appetite (57.3%), fever (56.4%), night sweat (30.8%) and haemoptysis (32.5%). Acid-fast bacilli (AFB) smear was positive in 94% of cases. Chest X-ray and human immunodeficiency virus (HIV) screening results were available for 89.1 and 82.1% cases respectively. The results for the sputum culture were available in 27.4% of patients and 54.7% were documented as done but pending results. The clinics have a successful directly observed therapy (DOT) program with 94.0% patients documented under DOT. Out of 53 patients on maintenance phase, 47.2% were identified as cured. Cure rate for those completed treatment was 100%. The defaulter rate was 17.1%. This audit demonstrated the attempt made by the clinics to adhere to the recommended guidelines. However, improvements are to be made in the documentation of medical records, tracing of investigation results and reduction of the number of defaulters.
Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members' burden and suffering.
We report a case of a young Chinese female who developed acute rhabdomyolysis with acute renal failure after a strenuous push-up exercise during a company motivation course. She managed to make full recovery after a period of outpatient treatment.
Increased international collaboration in clinical trials has created a need for cross culturally valid instruments to assess the quality of life and behavioural disorders. Cross cultural studies of depressive symptomatology, in particular, must be preceded by an exhaustive study of the psychometric properties of the instruments to ensure the validity of the comparison. In this article, we examined the validity, reliability and factor structure of the Malay version of the Beck Depression Inventory II (BDI-II) among Malay postpartum women attending selected health centres in Kedah, North West of Peninsular Malaysia. Our findings indicated that the current version of the BDI-II is psychometrically strong and appropriate for use in assessing depressive symptomatology among this group of women.
This survey was carried out to examine the habits of practising optometrists in private practice around Kuala Lumpur and the Klang Valley. A questionnaire survey was prepared that encompassed questions on ophthalmic intruments and appliances, services offered, eye examinatians carried aut and patient management, failure ta carry out comprehensive eye examination, community engagements and their opinion on optometrists as primary eyecare practitioners. The questionnaire was sent to 100 registered optometrists practising in Kuala Lumpur and the Klang Valley. About 64 optometrists responded and returned the questionnaire, but 3 of them were excluded because they were incomplete. The results showed almast all aptornetric practice has all the equipment related to optometry practice except for tonometer and visual ﬁeld measurement. F orty~four percent ( 44%) of aptometrists undertook comprehensive eye examinatians and necessary referred patients far further examinations. Optometrists who did not perform comprehensive eye examinations give reasons of inadequate equipment and clients who want a quick examination. ln conclusion optometric practice provide almost all the equipments required for optometrists to practice as primary health care practioners but only 44% of optometrists carriedout comprehensive eye examinations. Optometrists in private practice need to practice all the skills they learned and play important roles in educating the public in an effort to improve the primary eyecare of society. Keywords: optometric practice, private practice, primary health eyecare
BACKGROUND: Malaysia is an upper middle income country that provides subsidized healthcare to ensure universal coverage to its citizens. The challenge of escalating health care cost occurs in most countries, including Malaysia due to increase in disease prevalence, which induced an escalation in drug expenditure. In 2009, the Ministry of Health has allocated up to Malaysian Ringgit (MYR) 1.402 billion (approximately USD 390 million) on subsidised drugs. This study was conducted to measure patients' willingness to pay (WTP) for treatment of chronic condition or acute illnesses, in an urbanized population.
METHODS: A cross-sectional study, through face-to-face interview was conducted in an urban state in 2012-2013. Systematic random sampling of 324 patients was selected from a list of patients attending ten public primary cares with Family Medicine Specialist service. Patients were asked using a bidding technique of maximum amount (in MYR) if they are WTP for chronic or acute illnesses.
RESULTS: Patients are mostly young, female, of lower education and lower income. A total of 234 respondents (72.2%) were not willing to pay for drug charges. WTP for drugs either for chronic or acute illness were at low at median of MYR10 per visit (USD 3.8). Bivariate analysis showed that lower numbers of dependent children (≤3), higher personal and household income are associated with WTP. Multivariate analysis showed only number of dependent children (≤3) as significant (p = 0.009; 95% CI 1.27-5.44) predictor to drugs' WTP.
CONCLUSION: The result indicates that primary care patients have low WTP for drugs, either for chronic condition or acute illness. Citizens are comfortable in the comfort zone whereby health services are highly subsidized through universal coverage. Hence, there is a resistance to pay for drugs.