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A comparison of medication adherence between subsidized and self-paying patients in Malaysia

Ernieda Hatah ; Hamiza Aziz ; Mohd Makmor Bakry ; Farida Islahudin ; Najwa Ahmad Hamdi ; Ivy Mok Pok Wan

Malaysian Family Physician.2018;13(2):2-9.

Background: Limited efforts have been made to evaluate medication adherence among subsidized and self-paying patients. Objective: To investigate medication adherence among patients with and without medication subsidies and to identify factors that may influence patients’ adherence to medication. Setting: Government healthcare institutions in Kuala Lumpur, Selangor, and Negeri Sembilan and private healthcare institutions in Selangor and Negeri Sembilan, Malaysia. Methods: This cross-sectional study sampled patients with and without medication subsidies (self-paying patients). Only one of the patient’s medications was re-packed into Medication Event Monitoring Systems (MEMS) bottles, which were returned after four weeks. Adherence was defined as the dose regimen being executed as prescribed on 80% or more of the days. The factors that may influence patients’ adherence were modelled using binary logistic regression. Main outcome measure: Percentage of medication adherence. Results: A total of 97 patients, 50 subsidized and 47 self-paying, were included in the study. Medication adherence was observed in 50% of the subsidized patients and 63.8% of the self-paying patients (χ²=1.887, df=1, p=0.219). None of the evaluated variables had a significant influence on patients’ medication adherence, with the exception of attending drug counselling. Patients who attended drug counselling were found to be 3.3 times more likely to adhere to medication than those who did not (adjusted odds ratio of 3.29, 95% CI was 1.42 to7.62, p = 0.006). Conclusion: There is no significant difference in terms of medication adherence between subsidized and self-paying patients. Future studies may wish to consider evaluating modifiable risk factors in the examination of non-adherence among subsidized and self-paying patients in Malaysia.

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Achieving triple treatment goals in multi-ethnic Asian patients with type 2 diabetes mellitus in primary care

Goh Chin Chin ; Kim Hwee Koh ; Soo Chye Paul Goh, ; Yi Ling Eileen Koh ; Ngiap Chuan Tan

Malaysian Family Physician.2018;13(2):10-18.

Introduction: Achieving optimal glycated hemoglobin (HbA1c), blood pressure (BP), and LDLCholesterol (LDL-C) in patients mitigates macro- and micro-vascular complications, which is the key treatment goal in managing type 2 diabetes mellitus (T2DM). This study aimed to determine the proportion of patients in an urban community with T2DM and the above modifiable conditions attaining triple vascular treatment goals based on current practice guidelines. Methods: A questionnaire was distributed to adult Asian patients with dyslipidemia at two primary care clinics (polyclinics) in northeastern Singapore. The demographic and clinical data for this sub-population with both T2DM and dyslipidemia were collated with laboratory and treatment information retrieved from their electronic health records. The combined data was then analyzed to determine the proportion of patients who attained triple treatment goals, and logistic regression analysis was used to identify factors associated with this outcome. Results: 665 eligible patients [60.5% female, 30.5% Chinese, 35% Malays, and 34.4% Indians] with a mean age of 60.6 years were recruited. Of these patients, 71% achieved LDL-C ≤2.6 mmol/L, 70.4% had BP <140/90 mmHg, and 40.9% attained HbA1c ≤7%. Overall, 22% achieved the triple treatment goals for glycemia, BP, and LDL-C control. The major determinants were the number of diabetic medications and intensity of statin therapy. Conclusion: Eight in ten patients with T2DM failed to achieve concurrent glycemic, BP, and LDL-C treatment goals, subjecting them to risks of vascular complications. Primary healthcare professionals can mitigate these risks by optimizing therapeutic treatment to maximize glycemia, dyslipidemia, and BP control.

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A forgetful and angry old lady

Mah Sue Lynn ; Philip George

Malaysian Family Physician.2018;13(2):26-28.

Dementia is typically characterized by the deterioration of cognitive abilities and is a common disorder among the elderly in Malaysia. However, behavioral and psychological symptoms are also present in approximately 90% of dementia patients.1 We report the manifestation of these symptoms in an elderly woman with dementia and the treatment thereof

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Chest discomfort in a patient with dengue – is it an acute myocardial infarction?

Koh Kwee Choy ; Hong Hooi Chuen

Malaysian Family Physician.2018;13(2):29-31.

Cardiovascular symptoms presenting in a patient with dengue fever may post a diagnostic dilemma. We describe a case of dengue myocarditis mimicking an acute myocardial infarction in a 56-year-old woman.

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Kimura Disease: A differential diagnosis in a nephrotic child

Azliana Aziz ; Irfan Mohamad ; Norzaliana Zawawi

Malaysian Family Physician.2018;13(2):32-35.

Kimura disease presents as benign lesion and is commonly present among the Asian population. It is a disease with a favourable prognosis and a peak age of onset in the third decade. It is a chronic inflammatory disorder of unknown etiology that involves the lymph nodes and subcutaneous tissues of the head and neck region. We report a case of a 15-year-old boy with multiple Kimura lymphadenopathies involving the left posterior auricular region as well as the anterior and posterior triangles of the neck.

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Non-specific skin purpura

Mohd Shaiful Ehsan Shalihin ; Zulkifli Harun ; Iskandar Firzada Osman

Malaysian Family Physician.2018;13(2):39-41.

Essential thrombocythemia is one of the myeloproliferative neoplasms. Palpable purpura is a rare manifestation that may delay diagnosis and treatment. We report a case of essential thrombocythemia in a 50-year-old man, who presented with recurrent thigh pain for the past one year with nonspecific localized purpura. His full blood count revealed isolated thrombocytosis of 880,000/µL with an impression of myeloproliferative disorder from peripheral blood film. He was referred urgently to the hematology team, which proceeded with a venesection. His condition improved with hydroxyurea. This was a rare case of chronic presentation of myeloproliferative neoplasm detected at a primary care clinic

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Purple urine bag syndrome: A startling phenomenon of purple urine in a urine drainage bag. A primary care approach and literature review

Eva Wong Yi Wah ; Nurdiana Abdullah

Malaysian Family Physician.2018;13(2):42-44.

Purple urine bag syndrome (PUBs) is a rare and startling phenomenon of purple discolouration in the urine or urinary catheter and bag. It is reported in chronically debilitated elderly patients, mostly in women on long-term urinary catheters. Its prevalence is strikingly more common in nursing home residents. Several factors contribute to the formation of indigo (blue) and indirubin (red) pigments from a breakdown of dietary tryptophan, which stains the urine purple. These factors include constipation, dysmotility of the bowel, bowel bacterial overgrowth, dehydration, and urinary tract infection. The presence of purple urine may cause undue alarm to both the patient and the doctor. Thus, we present this case report on an 86-year-old woman, a nursing home resident on a long-term urinary catheter, who presented to the primary care clinic. Her urine cleared after antibiotic therapy, replacement of her urinary catheter, and supportive management, which included hydration and nutrition. In addition to these measures, reducing the time between urinary catheter changes was recommended to prevent recurrence of this condition.

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No thumbs up for the boy!

Ferdhany Muhamad Effendi ; Mohd Faizal Sikkandar

Malaysian Family Physician.2018;13(2):45-46.

A 7-year-old boy presented with both of his thumbs flexed (Figure 1), the inability to perform the ‘thumbs-up’ gesture, and difficulties in opposing thumbs and fingers in activities such as holding a pencil during writing, pincer movements, and picking up small objects. His mother only observed the deformity for one month after the boy complained of difficulty in writing during class. He had no prior history of trauma to the thumbs or pain and swelling in other joints. There were no other birth anomalies noticed by his parents. Upon examination, the boy had flexion deformities of the interphalangeal joint (IPJ) on both of the thumbs. Passive range of motion of the IPJ was not possible and both were fixed at 60° of flexion. Power of both thumbs could not be assessed as there was no motion of the joint. The range of motion of the metacarpophalengeal joints (MCPJ) of both thumbs and all other finger joints was normal. A 0.5cm x 0.5cm subcutaneous nodule was palpable at the volar crease of the MCPJ bilaterally. The nodule was tender on palpation; however, no overlying skin changes were evident.

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Does the attire of a primary care physician affect patients’ perceptions and their levels of trust in the doctor?

Haymond Prasad Narayanan ; Zahrina Azian binti Zohadie ; Rosanna Patricia Chryshanthi Gregory ; Rosalind Ho Wan Ying ; Rajini Ann S. Ratnasingam ; Low Boon Teck ; Ping Yein Lee

Malaysian Family Physician.2018;13(3):3-11.

Introduction: With increasing evidence of disease transmission through doctors’ white coats, many countries have discouraged doctors from wearing their white coats during consultations. However, there have been limited studies about patients’ preferences concerning doctors’ attire in Malaysia. This study, therefore, aimed to investigate patients’ perceptions of doctors’ attire before and after the disclosure of information about the infection risk associated with white coats. Method: This cross-sectional study was conducted from 1st June 2015 to 31st July 2015 at three different primary care settings (government, private, and university primary care clinics) using a self-administered questionnaire. A 1:5 systematic random sampling method was employed to select the participants. The respondents were shown photographs of male and female doctors in four different types of attire and asked to rate their level of confidence and trust in and ease with doctors in each type of attire. Subsequently, the respondents were informed of the risk of white coat-carried infections, and their responses were reevaluated. Data analysis was completed using SPSS Version 24.0. Associations of categorical data were assessed using the Chi-Square test, while the overall change in perceptions after the disclosure of additional information was examined using the McNemar test. Results with p-values < 0.05 were considered statistically significant. Results: A total of 299 respondents completed the questionnaire. Most of the respondents had more confidence and trust in the male (62.5%) and female (59.2%) doctors wearing white coats. A high proportion of the respondents from the government clinic (70.5%) felt more confidence in male doctors dressed in white coats (p-value = 0.018). In terms of ethnicity, male doctors in white coats were highly favored by Malays (61.0%), followed by the Chinese (41.2%) and Indians (38%) (p = 0.005). A similar preference was observed for the female doctors, whereby the highest number of Malays (60.3%), followed by the Chinese (41.2%) and Indians (40.0%) (p = 0.006), had a preference for female doctors wearing white coats. Only 21.9% of the initial 71.9% of patients who preferred white coats maintained their preference (p < 0.001) after learning of the risk of microbial contamination associated with white coats. Conclusion: Most patients preferred that primary care doctors wear white coats. Nevertheless, that perception changed after they were informed about the infection risk associated with white coats.

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Insomnia and its correlates among elderly patients presenting to family medicine clinics at an academic center

Hamida Farazdaq ; Marie Andrades ; Kashmira Nanji

Malaysian Family Physician.2018;13(3):12-19.

Objective: The objective of this study is to determine the frequency and correlates of insomnia among elderly patients presenting to family medicine clinics at an academic center in Karachi, Pakistan. Study design: This is a cross-sectional study. Place and duration of study: The study was conducted at the Outpatient Family Medicine Clinics at Aga Khan University Hospital between February 2013 and June 2013. Methodology: Patients 60 years old and above were recruited (n=152) through non- probability consecutive sampling. Information was collected on a pretested structured questionnaire on demographics, insomnia symptoms, medical co-morbidities, lifestyle factors and sleep disorders. Data was analyzed on SPSS 19. Proportions and the Chi-Square test were used in the analyses, along with binary logistic regression. Results: The mean age of the participants was 65.68 years, and 38.80% of the participants were male and 61.20% were female. The prevalence of insomnia was 42.1%. It was more common in women than in men (64.10% vs. 35.9%). Increasing age [ORadj: 4.54; 95%CI: 1.85-11.17], being divorced/widowed [ORadj: 10.26; 95%CI: 2.79- 37.73] and having an average household income of over Rs.50, 000, were significantly related to insomnia. The other factors associated with insomnia were Gastro Esophageal Reflux Disease [ORadj: 4.30; 95% CI: 1.67-11.04], depression [ORadj: 2.88, 95% CI: 1.13-7.33], caffeine consumption [ORadj: 6.50; 95% CI: 2.27-18.57], and cigarette smoking close to bed time [ORadj: 4.78; 95% CI: 0.88-25.90]. Conclusion: The study showed that older adults with multiple diseases were at high risk of insomnia. Certain life style practices enhanced the risk; hence, physicians should incorporate sleep history and tailor treatment to target both insomnia and related factors to optimize quality of life.

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