Delay in diagnosis of lung cancer: a case report

This case report highlights delay in the diagnosis of adenoma carcinoma of the lung in a female patient who has never smoked. It took three months to reach the diagnosis of stage IV lung carcinoma despite the presence of symptoms and an abnormal chest radiograph finding from the beginning. The clinical characteristics and predictors of missed opportunities for an early diagnosis of lung cancer are discussed. In this case, patient and doctor factors contributed to the delay in diagnosis. Thus, early suspicions of lung cancer in a woman with the presence of respiratory symptoms despite being a non-smoker are important in primary care setting

Quality of care for adult Type 2 diabetes mellitus at a University Primary Care Centre in Malaysia.

Background: Type 2 Diabetes Mellitus (T2D) with its concurrent cardiovascular risk factors such as hypertension and dyslipidaemia and its complications has now accounted for the majority of national and global morbidity and mortality. Aims & Objective: The study aimed to determine the prevalence of complications appearing in diabetic patients despite therapy, addressing to an urban academic primary care centre. Methods: This was a sub-analysis of a cross-sectional study on 212 patients with Type 2 diabetes mellitus (T2D) conducted from June to September 2006. Patients aged ≥ 30 years, non-smokers and under follow-up care of senior doctors were recruited. The average of the three most recent readings of fasting plasma sugar, HbA1c, systolic and diastolic blood pressure, and lipid profiles was taken as measures of respective disease control. Results: Two thirds of the patients were female. The mean age was 62.7 (SD± 10.8) years and the duration of T2D was 11.74 (SD± 6.7) years. A total of 23.6% achieved HbA1c ≤ 7.0%, 26.2% attained LDL-C ≤ 2.6 mmol/L and 24.5% achieved target blood pressure < 130/ 80 mmHg. The most prevalent co-morbid condition was hypertension (77.3%). A total of 27.2% patients had diabetic complications, out of which 86.5% had one complication. Proteinuria < 1gm/L and coronary artery disease were the two most common complications. There were only 16% on subcutaneous insulin and this was significantly associated with fasting plasma glucose (t = 5.38, df= 204, p < 0.0001) and HbA1c (t = 4.31, df= 206, p < 0.0001). Conclusions: Many T2D patients at this centre did not achieve treatment goals. Insulin and lipid-lowering drugs use should be optimized to improve control rates. More structured care processes are urgently needed in order to achieve good glycaemic control

Does use of pooled cohort risk score overestimate the use of statin?: a retrospective cohort study in a primary care setting

BACKGROUND: Initiation of statin therapy as primary prevention particularly in those with mildly elevated cardiovascular disease risk factors is still being debated. The 2013 ACC/AHA blood cholesterol guideline recommends initiation of statin by estimating the 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the new pooled cohort risk score. This paper examines the use of the pooled cohort risk score and compares it to actual use of statins in daily clinical practice in a primary care setting. METHODS: We examined the use of statins in a randomly selected sample of patients in a primary care clinic. The demographic data and cardiovascular risk parameters were captured from patient records in 1998. The pooled cohort risk score was calculated based on the parameters in 1998. The use of statins in 1998 and 2007, a 10-year interval, was recorded. RESULTS: A total of 847 patients were entered into the analysis. Mean age of the patients was 57.2 ± 8.4 years and 33.1% were male. The use of statins in 1998 was only 10.2% (n = 86) as compared to 67.5% (n = 572) in 2007. For patients with LDL 70-189 mg/dl and estimated 10-year ASCVD risk ≥7.5% (n = 190), 60% (n = 114) of patients were on statin therapy by 2007. There were 124 patients in whom statin therapy was not recommended according to ACC/AHA guideline but were actually receiving statin therapy. CONCLUSIONS: An extra 40% of patients need to be treated with statin if the 2013 ACC/AHA blood cholesterol guideline is used. However the absolute number of patients who needed to be treated based on the ACC/AHA guideline is lower than the number of patients actually receiving it in a daily clinical practice. The pooled cohort risk score does not increase the absolute number of patients who are actually treated with statins. However these findings and the use of the pooled cohort risk score need to be validated further

Determinants of left ventricular hypertrophy among elderly hypertensive in Malaysia

Left ventricular hypertrophy (LVH) has high prognostic value on cardiovascular mortality and morbidity. However, echocardiography is not routinely performed among elderly hypertensives in the primary-care setting due to limited resources. The aim of this study was to determine the prevalence of LVH and its associated risk factors in a multi- ethnic elderly hypertensive population in a primary-care clinic in Malaysia. This study was a sub-analysis of a cross-sectional study of 359 patients with hypertension in a primary-care clinic. All test subjects recruited for the study were hypertensive patients aged 60 and above. Blood pressure, height and weight were measured. All patients underwent an echocardiogram examination for diagnosis of LVH. One hundred and ninety-nine patients were studied for the analysis. The mean age and duration of hypertension was 64.8 (SD 2.9) and 10.4 (SD 7.7) years, respectively. The study found that 44.7% of respondents achieved target blood pressure. The prevalence of LVH was 23.6%. Using multiple logistic regression, factors associated with LVH among elderly patients with hypertension were diabetes (odds ratio [OR] 3.346, 95% confidence interval [CI] 1.458-7.676), higher diastolic blood pressure (OR: 1.088; 95% CI: 1.024-1.156), higher body mass index (OR: 1.113; 95% CI: 1.031-1.203) and poorer blood pressure control was 23.6%. Using multiple logistic regression, factors associated with LVH among elderly patients with hypertension were diabetes (odds ratio [OR] 3.346, 95% confidence interval [CI] 1.458-7.676), higher diastolic blood pressure (OR: 1.088; 95% CI: 1.024-1.156), higher body mass index (OR: 1.113; 95% CI: 1.031-1.203) and poorer blood pressure control (OR: 2.924; 95% CI: 1.180-7.258). Poor hypertension control, higher diastolic blood pressure, presence of diabetes and obesity are the predictors for the development of LVH in elderly hypertensive

Antihypertensive prescribing pattern and blood pressure control among hypertensive patients over a ten year period in a primary care setting in Malaysia

Suboptimal control blood pressure (BP) leads to multiple complications. This study aims to examine BP control and the change in prescribing pattern of antihypertensive agents over a 10-year period. Data was obtained from the 10-year retrospective cohort of randomly selected adult patients registered with the Department of Primary Care Medicine Clinic at the University of Malaya Medical Centre. Demographic data, BP and anti-hypertensive drug use in 1998, 2002 and 2007 were captured from patient records. Target BP control was defined as BP <140/90mmHg for those with hypertension alone and <130/80mmHg for those hypertensives with concomitant diabetes mellitus or chronic kidney disease. A total of 886 hypertensives patients were recruited. The mean age was 57.2 years (SD±9.6); 63.1% were female. The mean BP at baseline and at the end of 10-year were 146 / 87 (18/10) mmHg and 136/80 (16/9) mmHg respectively. In 1998, 74.3%, 22.5% and 1.6% were on monotherapy, 2 agents and ≥3 agents respectively. In 2007 after 10 years, 24.9%, 46.5% and 26.9% were on monotherapy, 2 agents and ≥3 agents respectively. At the end of 10 years there was improvement in overall blood pressure control, increasing from 15.6% in 1998 to 43.7% in 2007. However, the control rate of BP is still far from optimal in spite of an increase in the number of agents per patients used over a10 year follow-up. Based on our study the majority of patients with hypertension will need 2 or more agents to achieve target BP

Visit-to-visit SBP variability and cardiovascular disease in amultiethnic primary care setting:10-year retrospective cohort study

Objectives: The current study aims to determine the relationship of long-term visit-to-visit variability of SBP to cardiovascular disease (CVD) in a multiethnic primary care setting. Method: This is a retrospective study of a cohort of 807 hypertensive patients over a period of 10 years. Three-monthly clinic blood pressure readings were used to derive blood pressure variability (BPV), and CVD events were captured from patient records. Results: Mean age at baseline was 57.2 ± 9.8 years with 63.3% being women. The BPV and mean SBP over 10 years were 14.7 ± 3.5 and 142 ± 8 mmHg, respectively. Prevalence of cardiovascular event was 13%. In multivariate logistic regression analysis, BPV was the predictor of CVD events, whereas the mean SBP was not independently associated with cardiovascular events in this population. Those with lower SBP and lower BPV had fewer cardiovascular events than those with the same low mean SBP but higher BPV (10.5 versus 12.8%). Similarly those with higher mean SBP but lower BPV also had fewer cardiovascular events than those with the same high mean and higher BPV (11.6 versus 16.7%). Other variables like being men, diabetes and Indian compared with Chinese are more likely to be associated with cardiovascular events. Conclusion: BPV is associated with an increase in CVD events even in those who have achieved lower mean SBP. Thus, we should prioritize not only control of SBP levels but also BPV to reduce CVD events further

Manpower cost for a hypertension health campaign: A cross-sectional study

Introduction: The overall prevalence of hypertension is high, and many people are unaware of their condition. Screening campaigns can effectively identify this group of patients. The study aimed to determine the cost of manpower for a health campaign for detecting undiagnosed hypertension and the prevalence of hypertension. Methods: This cross-sectional study was conducted at two health centres. Sociodemographic characteristics, hypertension and treatment statuses were recorded. Blood pressure (BP) was measured by either doctors or nurses using automated BP machines. The cost of manpower was calculated as the average salaries of manpower during the 3-day health campaign divided by the total number of days. The final sum was the cost of detecting undiagnosed hypertension. Results: A total of 2009 participants median age = 50 (IQR = 18-91) were included in the study. The overall prevalence of hypertension was 41.4% (n=832). Among the patients with hypertension, 49.2% (n=409) were unaware of their hypertension status. Conversely, 21.1% (n=423) were known to have hypertension, among whom 97.4% (n=412) were on medications. Among those who were on medications, 49% (n=202) had good BP control. The average total cost of manpower during the 3-day health campaign was RM 5019.80 (USD 1059). The cost of detecting an individual with elevated BP was RM 12.27 (USD 2.59). Conclusion: The prevalence of hypertension and unawareness is high. However, the average cost of manpower to detect an individual with elevated BP is low. Therefore, regular public health campaigns aiming to detect undiagnosed hypertension are recommended

Health innovation in cardiovascular diseases

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. Despite efforts to tackle CVD, its prevalence continues to escalate in almost every country. The problem requires an exploration of novel ways to uncover solutions. Health innovations that embrace new knowledge and technology possess the potential to revolutionize the management of CVD. Using findings from published studies on CVD, researchers generated innovations in the areas of global risk assessment, home and remote monitoring and bedside testing. The use of pharmacogenetics and methods to support lifestyle changes represent other potential topics for innovations. Gaps in existing knowledge and practice of CVD provide opportunities for the development of new ideas, practices and technology. However, healthcare professionals need to be cognisant of the limitations of health innovations and advocate for safeguarding patients’ wellbeing

Number of blood pressure measurements needed to estimate long-term visit-to-visit systolic blood pressure variability for predicting cardiovascular risk: a 10-year retrospective cohort study in a primary care clinic in Malaysia

Objective: To determine the reproducibility of visit-to-visit blood pressure variability (BPV) in clinical practice. We also determined the minimum number of blood pressure (BP) measurements needed to estimate long-term visit-to-visit BPV for predicting 10-year cardiovascular (CV) risk. Design: Retrospective study Setting: A primary care clinic in a university hospital in Malaysia. Participants: Random sampling of 1403 patients aged 30 years and above without any CV event at baseline. Outcomes measures: The effect of the number of BP measurement for calculation of long-term visit-to-visit BPV in predicting 10-year CV risk. CV events were defined as fatal and non-fatal coronary heart disease, fatal and non-fatal stroke, heart failure and peripheral vascular disease. Results: The mean 10-year SD of systolic blood pressure (SBP) for this cohort was 13.8±3.5 mm Hg. The intraclass correlation coefficient (ICC) for the SD of SBP based on the first eight and second eight measurements was 0.38 (p<0.001). In a primary care setting, visit-to-visit BPV (SD of SBP calculated from 20 BP measurements) was significantly associated with CV events (adjusted OR 1.07, 95% CI 1.02 to 1.13, p=0.009). Using SD of SBP from 20 measurement as reference, SD of SBP from 6 measurements (median time 1.75 years) has high reliability (ICC 0.74, p<0.001), with a mean difference of 0.6 mm Hg. Hence, a minimum of six BP measurements is needed for reliably estimating intraindividual BPV for CV outcome prediction. Conclusion: Long-term visit-to-visit BPV is reproducible in clinical practice. We suggest a minimum of six BP measurements for calculation of intraindividual visit-to-visit BPV. The number and duration of BP readings to derive BPV should be taken into consideration in predicting long-term CV risk

Prevalence of left ventricular diastolic dysfunction among hypertensive adults in Klang Valley, Malaysia

A large number of patients with heart failure suffer from Left Ventricular Diastolic Dysfunction (LVDD), but little is known about its prevalence among hypertensive adults, especially in the primary care setting. Thus, this quantitative study aims to evaluate the prevalence and factors associated with LVDD. A cross-sectional study was conducted among 359 hypertensive patients who underwent echocardiography tests to define their cardiac structure and function. The ratio peak of early to late diastolic filling velocity was used to assess the LVDD. The Framingham risk score was derived from the most recent blood test available in the previous year. SPSS version 19 was used to analyze the data. Echocardiography LVDD was found in 68% of the participants. Of the 243 hypertensive subjects who had LVDD, 69.5% had no left ventricular hypertrophy (LVH) while 30.5% had LVH. Age (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07-1.15), fasting blood sugar (OR 1.18, 95% CI 1.02-1.37), poor blood pressure control (OR 1.93, 95% CI 1.12-3.32), central obesity (OR 2.06, 95% CI 1.17-3.64), and LVH (OR 2.76, 95% CI 1.29- 5.90) were found to have a significant positive relation with LVDD. Poor hypertension control, diabetes, older age, central obesity, and LVH are the predictors for the development of diastolic dysfunction