Epidemiological studies in Malaysia and Sweden on associations between smoking, silica exposure and the risk of developing rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, inflammatory disease, frequently associated with joint destruction. Knowledge regarding the aetiology of RA is mainly generated on Caucasian populations. Less is known about RA in other populations with different genetic backgrounds and lifestyles. The aim of this thesis was to contribute to a better knowledge regarding the aetiology of RA in other populations, particularly Asian populations, by studying the association between airborne exposures and RA risk, here smoking and occupational exposure to silica. We studied the risk of developing RA by different subtypes of the disease, defined by the presence or absence of antibodies to citrullinated protein antigens (ACPA+ RA and ACPA- RA). This thesis is mainly based on data from the Malaysian Epidemiological Investigation of Rheumatoid Arthritis (MyEIRA), Paper I, II and IV. MyEIRA is a population-based case-control study where cases and controls provided extensive information on lifestyle as well as occupational exposures. Cases and controls also provided blood samples for serological and genetic analysis. In Paper III, data from the Swedish Epidemiological Investigation of Rheumatoid Arthritis (EIRA) population-based case control study was used. Information regarding the environmental exposures was gathered by means of a questionnaire. Cases and controls provided blood samples for genetic and serological analysis. Our results in the MyEIRA study indicate that smokers had an increased risk of developing ACPA+ RA, but not ACPA- RA, compared with never-smokers. A significant dose-response relationship between cumulative dose of smoking (expressed by pack-years) and risk of ACPA+ RA was observed. A significant interaction was noted between smoking and the HLA-DRB1 shared epitope (SE) alleles in the risk of developing ACPA+ RA. We also found that the most common SE allele in the Asian population, HLA-DRB1*0405, also showed signs of interaction with smoking with regard to risk of ACPA+ RA. We further studied the relationship between occupational exposure to silica, i.e. another airborne exposure, and the risk of developing RA in the Swedish EIRA study. Men that had been exposed to silica in their work were observed to have a moderately increased risk of ACPA+ RA but not ACPA- RA compared to men without such exposure. A significant interaction between silica exposure and current smoking was observed with regard to the risk of developing ACPA+ RA. The findings from MyEIRA were similar to those from EIRA; thus occupational exposure to silica was associated with an increased risk of developing ACPA+ RA, but not ACPA- RA. Furthermore, there were signs of interaction between silica and smoking with regard to risk of ACPA+ RA, even though small numbers hampered a firm conclusion. In conclusion, this study shows that airborne environmental exposures are strongly associated with risk for RA in Malaysia. The results should have impact on efforts to prevent RA in this large part of the world, as well as for further comparative studies aimed at understanding the aetiology of RA in different populations

Translation, cross-cultural adaptation and validation of the revised-skin management needs assessment checklist questionnaire in Malay language

Pressure injury (PI) related knowledge can be used as an outcome indicator of a PI education program. In Malaysia, no scale has been translated and validated for measuring PI-related knowledge among patients with a PI. The purpose of this study was to cross-culturally adapt, translate and determine the validity and reliability of the Malay version of the revised-Skin Management Need Assessment Checklist (revised-SMnac). The instrument was initially written in English and translated into the Malay language. The internal consistency, construct validity, and test-retest reliability were examined after the item and scale's cross-cultural equivalence and content validity were evaluated. Construct validity was determined through the administration of the instrument amongst 170 hospitalised patients with a PI. Content validity index (CVI) was further determined through validation by a panel of five wound care experts. The instrument's stability was determined by the test-retest model with a two-week interval. The content validity of the item-CVI (I-CVI) was >79%, indicating that all 17-items were appropriate, while the scale-CVI (S-CVI) of >0.83 indicated an acceptable scale. The Cronbach's Alpha was .994 indicated good internal consistency. Test-retest showed a good intra-class correlation coefficient, ICC = 0.955 with 95% CI [0.992–0.996]. The Malay version of the revised-SMnac demonstrated to be a valid and reliable tool to measure PI-related knowledge among the Malay-speaking patient population in Malaysia. The tool is recommended for use to measure the effectiveness of education programs related to PI care in future studies

Knowledge acquisition and retention among nurses after an educational intervention on endotracheal cuff pressure

Background: Nurses play a key role in the proper management of endotracheal tube (ETT) cuff pressure, which is important for patients' safety, so it is vital to improve nurses' knowledge on safe cuff management practices. Aims and objectives: This study aimed to evaluate the effectiveness of an educa- tional intervention related to ETT cuff pressure management on improving and retaining critical care nurses' knowledge. Design: A single group pre-post interventional study was conducted involving 112 registered nurses (RNs) from a 24-bed adult general intensive care unit at a teaching hospital in Malaysia. Methods: The educational intervention included a theoretical session on endotra- cheal cuff pressure management and demonstration plus hands-on practice with the conventional cuff pressure monitoring method. Nurses' knowledge was measured using a self-administered questionnaire pre- and post-intervention. Data were analysed using repeated measure analysis of variance and bivariate analysis. Results: In this study, 92% of the total number of RNs in the unit participated. A sig- nificant difference in mean knowledge score was noted between the pre- (mean = 8.13; SD = 1.53) and post-intervention phases (3 months [mean = 8.97; SD = 1.57) and 9 months post-intervention [mean = 10.34; SD = 1.08), P < .001), indi- cating significant knowledge acquisition and retention between the phases. Knowledge gained between the pre- and 9 months post-intervention phases signifi- cantly differed according to nurses' educational level. Conclusions: This study supports existing evidence that ongoing educational inter- ventions are essential to improve nurses' knowledge. However, further exploration is suggested to assess how well this knowledge is translated into clinical practice. Relevance to clinical practice: Regular educational programmes with current updates would enhance nurses' knowledge through proper practice and clinical decision- making skills; this, in turn, would help to standardize cuff management practices

Catastrophic Health Expenditure Among Colorectal Cancer Patients and Families: A Case of Malaysia

This study aimed to estimate the cost of colorectal cancer (CRC) management and to explore the prevalence and determinants of catastrophic health expenditure (CHE) among CRC patients and their families arising from the costs of CRC management. Data were collected prospectively from 138 CRC patients. Patients were interviewed by using a structured questionnaire at the time of the diagnosis, then at 6 months and 12 months following diagnosis. Simple descriptive methods and multivariate binary logistic regression were used in the analysis. The mean cost of managing CRC was RM8306.9 (US$2595.9), and 47.8% of patients’ families experienced CHE. The main determinants of CHE were the economic status of the family and the likelihood of the patient undergoing surgery. The results of this study strongly suggest that stakeholders and policy makers should provide individuals with financial protection against the consequences of cancer, a costly illness that often requires prolonged treatment. </jats:p

Systematic review of patient education for pressure injury: Evidence to guide practice

Background: Pressure injuries (PIs) are generally regarded as predictable and preventable. Therefore, providing appropriate care for PI prevention and its management is vital. Patient education is a significant component of the PI international guideline recommended strategy in preventing PIs. Despite the availability of evidence supporting patient education, consensus regarding the effect of patient education on knowledge, patient participation, wound healing progress, and quality of life is still lacking. Aims: The main aim was to systematically evaluate the available evidence regarding the effectiveness of structured patient education on their knowledge, participation, wound healing, and quality of life. Methods: The search strategy retrieved studies published between 2009 and 2021 in English across PubMed, MEDLINE, CINAHL, ProQuest, and Cochrane Library. Adult participants aged 18 years and above were included. Randomized controlled trials, quasi-experimental, and interventional studies were all included in this review. Three independent reviewers assessed the methodological quality of the studies, prior to critical appraisal, using standardized tools, that is, the Joanna Briggs Institute checklist for randomized and non-randomized studies. A narrative synthesis was conducted. Results: A total of eight studies (466 participants) were included in this review. Available evidence indicated improved patient knowledge, participation, and quality of life with structured patient education. However, there was insufficient high-quality evidence to conclude the effect on wound healing. Linking Evidence to Action: Structured patient education for PI was deemed to help improve patients' knowledge, participation, and quality of life. More rigorous trials are needed for the effect on wound healing progress. Thus, future educational interventions should include wound care components that describe the patient's role in promoting wound healing. A well-structured patient education program protocol is crucial to ensure the educational intervention was measurable in its effectiveness and reproducibility

Acute Coronary Syndrome in Malaysian Octogenarian: Trends in Demographics and In-Hospital Managements

Abstract Background: Octogenarians have often been neglected in the populational study of disease despite being at the highest point of non-modifiable disease risk burden and the fastest-growing age group for the past decade. This study examined the characteristics and in-hospital management of octogenarian patients with acute coronary syndrome (ACS).Method: This retrospective study utilised the Malaysian National Cardiovascular Disease- ACS (NCVD-ACS) registry. Patients ≥ 80 years old admitted with ACS at 23 participating hospitals from 2008 to 2017 (n=3,080) were identified. Demographics, in-hospital intervention, and evidence-based pharmacotherapies were examined. Binary logistic regression was used.Results: Octogenarians made up 3.8% of patients with ACS in the NCVD-ACS registry (53% men, mean age=83.3, SD±3.4) within the 10-year. The largest ethnic group was Chinese (44%). Hypertension (78%) was the main CV risk factor. Most octogenarians (90.4%) have multiple CV risk factors. Non-ST-elevation myocardial infarction (NSTEMI) predominated (38%, p&lt;0.001). Only 10% of octogenarians with ACS underwent percutaneous coronary intervention (PCI), the majority being STEMI patients (17.5%; p&lt;0.05). More than 80% were prescribed aspirin (91.3%) either alone or combined, dual antiplatelet therapy (DAPT) (83.3%), anticoagulants (89.7%) and statins (89.6%), while less than half were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (47.6%) and beta-blocker (43.0%). From 2008 until 2017, there were positive increments in cardiovascular intervention and pharmacotherapies. Men were more likely to receive PCI than women (Odds Ratio (OR): 0.698; 95%CI: 0.490-0.993). Those with NSTEMI (OR=0.402, 95% CI: 0.278-0.583) and unstable angina (UA) (OR=0.229, 95% CI: 0.143-0.366 were less likely to receive PCI but more likely to be given anticoagulants (NSTEMI, OR=1.543, 95% CI: 1.111-2.142; UA, OR=1.610, 95% CI: 1.120-2.314) than STEMI octogenarians. The presence of cardiovascular risk factors and comorbidities influences management. For example, those with congestive heart failure were more likely to be given PCI and evidence-based pharmacotherapies.Conclusion: Despite being the most vulnerable age group, octogenarians were conservatively treated with evidence-based treatment of ACS. As it is expected that the number of octogenarians with ACS will continue to increase thus the country needs to prepare to improve the management of this specific group of patients.</jats:p

Correlation analysis of air pollutant index levels and dengue cases across five different zones in Selangor, Malaysia

This study investigated the potential relationship between dengue cases and air quality – as measured by the Air Pollution Index (API) for five zones in the state of Selangor, Malaysia. Dengue case patterns can be learned using prediction models based on feedback (lagged terms). However, the question whether air quality affects dengue cases is still not thoroughly investigated based on such feedback models. This work developed dengue prediction models using the autoregressive integrated moving average (ARIMA) and ARIMA with an exogeneous variable (ARIMAX) time series methodologies with API as the exogeneous variable. The Box Jenkins (BJ) approach based on maximum likelihood was used for analysis as it gives effective model estimates and prediction. Three stages of model comparison were carried out for each zone: first with ARIMA models without API, then ARIMAX models with API data from the API station for that zone and finally, ARIMAX models with API data from the zone and spatially neighbouring zones. Bayesian Information Criterion (BIC) gives goodness-of-fit versus parsimony comparisons between all elicited models. Our study found that ARIMA models, with the lowest BIC value, outperformed the rest in all five zones. The BIC values for the zone of Kuala Selangor were –800.66, – 796.22, and –790.5229, respectively, for ARIMA only, ARIMAX with single API component and ARIMAX with API components from its zone and spatially neighbouring zones. Therefore, we concluded that API levels, either temporally for each zone or spatio-temporally based on neighbouring zones, do not have a significant effect on dengue cases