Primary palliative care. Caring for patients with life-limiting illness in the community

The 9th October 2021, was World Palliative Care Day. This year’s theme for world palliative care is “Leave No One Behind – Equity in Access to Palliative Care”. Evidence for the outcomes of early palliative care is growing. In 2014, the World Health Assembly passed a resolution that was co-sponsored by Malaysia. The resolution called for countries to improve access to palliative care as a core component of health systems, with an emphasis on primary health care and community/home-based care. One study conducted in Malaysia in 2019 estimated that by 2030, with the increase in noncommunicable diseases, 246 000 patients would require palliative care. For Malaysia to achieve equity in access to palliative care, care for these patients must be integrated into primary care. This article discusses some of the tools available for early identification of patients assessment and management of patients with palliative care needs

Hoarseness in an older adult: Ortner syndrome

A detailed examination in an older adult presenting with chronic hoarseness is mandatory to exclude an upper aerodigestive tract malignancy. We describe a 71-year-old chronic smoker with essential hypertension who presented with hoarseness and vocal fatigue for 5 months. Laryngoscopic examination showed left vocal fold paralysis with phonation gap. No growth was seen at all laryngeal and hypopharyngeal subsites. The rest of the head and neck, chest, upper limbs and neurovascular examination were unremarkable. A plain chest radiograph demonstrated a cause for the left recurrent laryngeal nerve palsy. The diagnosis, complications and definitive management of the underlying cause and resultant voice problem will be discussed.

Pharmacist-structured review of proton pump inhibitor utilisation in primary care: A non-randomised control study

Introduction: In the primary care setting, proton pump inhibitor (PPI) overutilisation often stems from the failure to discontinue prophylaxis treatment prior to tertiary care discharge and consider step-down therapy following discharge. Long-term PPI use can result in potential drug-related problems and unnecessary drug expenditure. This study aimed to evaluate the effectiveness of pharmacist-structured review in reducing inappropriate PPI prescriptions and estimate the potential cost saving. Methods: This non-randomised controlled study was conducted for 16 weeks at 17 government health clinics in Selangor, Malaysia. Eligible patients attending the outpatient pharmacies of intervention clinics were recruited consecutively and their consent was obtained. A structured review of PPIs was performed in which pharmacists identified patient demographics, indications and the length of PPI therapy using a PPI intervention form. Recommendations were discussed with physicians before prescription changes were made and documented. Moreover, standard management was conducted in the control clinics. Results: A total of 568 patients with prescriptions containing PPIs were sampled, with a total of 284 patients being placed into the control and intervention groups, respectively. Compared to the control group, inappropriate PPI utilisation in the intervention group significantly decreased from 79.9 to 30.4% (p<0.05). The changes to PPI prescriptions observed in the intervention group included: stop PPI therapy (30.8%), step-down therapy (22.9%), start substitution therapy (15.9%) and no change (30.4%). The physicians’ acceptance rate for pharmacist intervention was 67.8%. A 66.1% reduction in monthly PPI pill count and a 72.0% reduction in monthly medication expenditure (RM44.85/patient/year) were observed. Conclusion: The pharmacist-structured review was effective in increasing appropriate PPI utilisation and led to substantial cost savings.

The association between body mass index and the oral Firmicutes and Bacteroidetes profiles of healthy individuals

Introduction: Microbiome status is considered an important factor that contributes to obesity. Investigations have shown that the oral microbiome comprises a vast array of bacterial species that can influence human health. Objective: To determine the association between the presence of the bacterial phyla Firmicutes and Bacteroidetes and the body mass index (BMI) status of normal, overweight and obese subjects in Duhok, Iraq. Additionally, to investigate the composition of oral Firmicutes and Bacteroidetes profiles for individuals with different BMI statuses. Methods: A total of 155 saliva samples were collected from participants in Duhok, Iraq. Bacterial genomic DNA was then extracted from the collected saliva. The presence of Firmicutes and Bacteroidetes phyla was detected via polymerase chain reaction. Results: Firmicutes and Bacteroidetes were detected in 63.2 and 37.4% of the population, respectively. Differences in the carriage rates of oral Firmicutes in overweight (78%) and obese individuals (83%) were statistically significant when compared to normal weight individuals (36%) (P<0.0001). The percentage rates of Bacteroidetes in obese individuals (26.4%) was statistically significant when compared to normal weight individuals (50.8%) (P=0.0078). The Firmicutes/Bacteroidetes ratios (obese=3.1, overweight=2.5 and normal weight=0.7) were higher with increasing BMI. Conclusion: This study provides evidence of the Firmicutes/Bacteroidetes ratio growing with increasing BMI. High rates of Firmicutes could serve a role in the development of obesity. Further studies are required to clarify the exact relationship between oral bacteria and obesity, which could lead to a promising therapeutic method for improving the physical health of humans.

Barriers to effective research supervision in clinical specialist training: Experience from a medical school in Malaysia

Introduction: A compulsory research component is becoming increasingly common for clinical residents. However, integrating research into a busy clinical training schedule can be challenging. This study aimed to explore barriers to research supervision in specialist training programmes from the perspectives of clinical supervisors and trainees at a Malaysian university hospital. Methods: Qualitative interviews and focus group discussions were conducted (December 2016 to July 2017) with clinical supervisors (n=11) and clinical trainees (n=26) utilising a topic guide exploring institutional guidelines, research culture and supervisor-student roles. Interviews were transcribed verbatim and analysed thematically to identify barriers to research supervision. Results: Supervisors and trainees from 11 out of 18 departments participated. Both clinical supervisors and trainees struggled to successfully integrate a compulsory research component into residency training. Among the reasons identified included a lack of supervisory access due to the nature of clinical rotations and placements, clashing training priorities (clinical vs research) that discouraged trainees and supervisors from engaging in research, poor research expertise and experience among clinical supervisors hampering high-quality supervision, and a frustrating lack of clear standards between the various parties involved in research guidance and examination. Conclusion: Both clinical supervisors and trainees struggled to successfully integrate a compulsory research component into residency training. This was not only an issue of resource limitation since questions regarding clinical priorities and unclear research standards emerged. Thus, institutional coordinators need to set clear standards and provide adequate training to make research meaningful and achievable for busy clinical supervisors and trainees.

Maternal Obesity and Its Associated Factors and Outcomes in Klang Valley, Malaysia: Finding from National Obstetric Registry

Introduction: Maternal obesity presents significant health risks to mothers and their fetuses. This study aimed to determine the proportion, associated factors and outcomes of maternal obesity among pregnant women in Klang Valley, Malaysia. Methods: A retrospective cross-sectional study was conducted between January 2018 and March 2018 using secondary data from the Malaysian National Obstetric Registry (NOR) for the year 2015. All pregnant women with first-trimester booking at 12 weeks and below that were registered with the NOR and met the inclusion and exclusion criteria were included in the study. Descriptive statistics and multiple logistic regression analysis were used. Data were analysed using SPSS version 22.0. A total of 2113 respondents were included in this study to determine the proportion, associated factors and outcomes of maternal obesity. Regarding the univariate and multivariate analyses, respondents were classified into two groups: normal and obese. The obese group comprised overweight and obese mothers. The underweight group was excluded in the subsequent analysis. Results: Out of the 2113 respondents, 7.1% were underweight, 41.7% were of normal weight, 28.6% were overweight, 15.9% were in obese class I, 4.6% were in obese class II, and 2.1% were in obese class III according to the WHO (1995) reference. However, when the MOH (2003) cutoff point was used, there was a marked increase in the proportion of respondents in the overweight categories by 2.7% and obesity class I by 12.8%. The Indian (AdjOR 2.06, 95% CI: 1.11, 3.83, p=0.021) and Malay (AdjOR 1.75, 95% CI: 1.02, 3.00, p=0.040) ethnicities, as well as both multiparity (AdjOR 1.46, 95% CI: 1.23, 1.73, p <0.001) and grand multiparity (AdjOR 2.41, 95% CI: 1.78, 3.26, p <0.001), were significantly associated with maternal obesity. There were significant association between maternal obesity with hypertensive disorder in pregnancy (p=0.025), caesarean section delivery (p=0.002) and macrosomic infant (p <0.001). Conclusion: The identification of risk factors for maternal obesity is important to facilitate intervention programmes focused on improving the pregnancy outcomes for a high-risk group of women.

Distinguishing between isthmic thyroglossal duct cyst and goitre on nuclear thyroid scan: A case report

Thyroglossal duct cysts, which are the most frequently encountered congenital cervical anomalies in children, occur due to embryologic remnants of the thyroglossal duct. Although diagnosis may be challenging, clinicians can be aided by imaging and fine-needle aspiration biopsies. We describe the clinical management of a two-year-old boy with a thyroglossal duct cyst mimicking a goitre on a pertechnetate thyroid scan.

Awareness, knowledge, attitudes and practices on the management of diabetes mellitus patients with periodontitis amongst Malaysian primary care practitioners

Introduction: The bi-directional relationship between periodontitis (PD) and diabetes mellitus (DM) has been confirmed. Medical practitioners (MPs) serve an important role in relaying this information to patients. This study aimed to investigate the awareness, knowledge, attitudes and practices (KAP) in the management of DM patients with PD in primary care clinics under the Ministry of Health (MOH) of Malaysia. Methods: A self-administered questionnaire on KAP in the management of DM patients with PD was posted to 725 medical officers (MOs) and family medicine specialists (FMSs) in MOH clinics in Kedah, Terengganu, Johor and Negeri Sembilan. Collected data were tabulated and analysed using descriptive and regression analyses (simple and multiple). Statistical significance was defined as p < 0.05. Results: A total of 549 MPs responded. The majority of MPs were MOs (92.6%) and female (75.8%). FMSs had a greater awareness of PD when compared to MOs (p = 0.002). All MPs had good knowledge, except for the incorrect notion that excessive sugar causes PD (94.3%). Overall, FMSs had better knowledge when compared to MOs (p=0.026). The majority of MPs agreed that ‘they should update their knowledge on the association between systemic disease and PD’ (89.6%) and claimed that ‘it was not their responsibility to examine DM patients for PD’ (83.1%). Most MPs did not enquire or examine for PD in their DM patients. More FMSs (67.5%) referred patients to dentists compared to MOs (31.6%). Conclusion: Most MPs have sufficient knowledge on PD, but a negative attitude in the management of PD in DM patients. The reasons for not referring included workload and patients refusing referral.