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

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

Perceived barriers among cardiac patients towards cardiac rehabilitation programme

Introduction: Cardiac rehabilitation is one of the secondary prevention programme to reduce morbidity and mortality in cardiac patients. However, adherence towards this programme is still sub optimal. The objective of this study isto determine the perceived barriers on cardiac rehabilitation programme among cardiac patients and its association with the sociodemographiccharacteristics. Methods: A preliminary study using the Cardiac Rehabilitation Barrier Scale (CRBS) was conducted in a tertiary hospital among 40 patients. The CRBS tool was validated and tested for reliability.Convenience sampling method was used among those who have attended the cardiac rehabilitation programme. Ethical approval was obtained from the institution ethical committee. There were total of 22 items in the CRBS except for the last item (22nd) being an open-ended item to enable the patients to share their opinion on any other barriers towards attendance to cardiac rehabilitation programme. The 21 items assessed on patients’ opinion on the perceived barriers during their attendance to the cardiac rehabilitation programme in a form of Likert scale. Results: The overall mean (SD) score for the 21 items was 60.70 (8.77) showed that the patients were able to understand gave their best options on the opinions towards CRBS. The highest mean on item 11 on ‘time constraints’ at 3.58 (0.75). Thus, the majority of the patients scored the item “time constraints’ as the highest perceived barrier during attendance in the cardiac rehabilitation programme. The association of the sociodemographic status had significance difference (p<0.05) for gender with item 4 on ‘family responsibilities’ and item 13 on ‘I don’t have energy’ with (p=0.035) and (p=0.020) respectively. Level of education too showed significant difference to item 9 on I find ‘exercise tiring and painful’ and item 12 on ‘work responsibilities’ with (p=0.034) and(p=0.048). Conclusion: Thus, measures should be taken for other barriers to ensure patients’ adherence to the cardiac rehabilitation programme

Risk of eczema, wheezing and respiratory tract infections in the first year of life: a systematic review of vitamin D concentrations during pregnancy and at birth

Background Allergic conditions and respiratory tract infections (RTIs) are common causes of morbidity and mortality in childhood. The relationship between Vitamin D status in pregnancy (mothers), early life (infants) and health outcomes such as allergies and RTIs in infancy is unclear. To date, studies have shown conflicting results. Objective This systematic review aims to gather and appraise existing evidence on the associations between serum Vitamin D concentrations during pregnancy and at birth and the development of eczema, wheezing, and RTIs in infants. Data sources PubMed, MEDLINE, ProQuest, Scopus, CINAHL, Cochrane Library and Academic Search Premier databases were searched systematically using specified search terms and keywords. Study selection Articles on the associations between serum Vitamin D concentrations during pregnancy and at birth and eczema, wheezing, and RTIs among infants (1-year-old and younger) published up to 31 March 2019 were identified, screened and retrieved. Results From the initial 2678 articles screened, ten met the inclusion criteria and were included in the final analysis. There were mixed and conflicting results with regards to the relationship between maternal and cord blood Vitamin D concentrations and the three health outcomes-eczema, wheezing and RTIs-in infants. Conclusion Current findings revealed no robust and consistent associations between Vitamin D status in early life and the risk of developing eczema, wheezing and RTIs in infant

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

Understanding brief illness perception among cardiac patients: a preliminary study

Introduction: Illness perceptions involve personal beliefs that patients have about their illness and may influence health behaviour considerably. This preliminary study evaluates the understanding of illness perception among cardiac patients’ and correlations of each of the items. Methods: A preliminary study was conducted using the on Brief Illness Perception Questionnaire (BIPQ) in a tertiary hospital among 40 cardiac patients. Ethical approval was obtained from the institution ethical committee. There are 9 items in the BIPQ with 0-10 response scale measuring causal factors and an open-ended item. Items 1 to 5 assesses on the cognitive illness perception which comprises of consequences, timeline, personal control, treatment control and identity. Item 6 and 8 are on emotional response and item 7 is on coherence. Results: The overall mean score of the 8 items of BIPQ was 7.04 (1.07) with the highest mean for item 4 on treatment control and item 6 on personal control at 8.02 (0.92) and 7.03 (1.77) respectively while the lowest mean was item 7 on understanding at 6.63 (1.83). The causal factor for the open-ended question was mostly on consumption of fatty food intake, sedentary lifestyle and stress at work. Perceiving personal control was significantly being affected by perceiving treatment control for the cardiac disease (r=0.50) and being concerned about their cardiac symptoms was significantly related to perceiving consequences of the disease (r =0.54), perceiv¬ing identity (r=0.75) and perceiving emotional control (r=0.67). Perceiving emotional control on their symptoms was significantly related to perceived consequences on cardiac disease (r=0.51), perceived identity (r=0.53) and perceived concern on cardiac disease (r=0.67). Conclusion: The results shown significant correlations with relevant outcomes measures. It is useful in clinical practice to assess and potentially modify patient’s perceptions on under¬standing, emotional control, personal control, consequences and perceived concerned over their cardiac disease

Refractive Error and Visual Impairment in School-Age Children in Gombak District, Malaysia

Purpose: To assess the prevalence of refractive error and visual impairment in school-age children in Gombak District, a suburban area near Kuala Lumpur city. Design: Population-based, cross-sectional survey. Participants: Four thousand six hundred thirty-four children 7 to 15 years of age living in 3004 households. Methods: Random selection of geographically defined clusters was used to identify the study sample. Children in 34 clusters were enumerated through a door-to-door survey and examined in 140 schools between March and July 2003. The examination included visual acuity measurements; ocular motility evaluation; retinoscopy and autorefraction under cycloplegia; and examination of the external eye, anterior segment, media, and fundus. Main Outcome Measures: Distance visual acuity and cycloplegic refraction. Results: The examined population was 70.3% Malay, 16.5% Chinese, 8.9% Indian, and 4.3% of other ethnicity. The prevalence of uncorrected (unaided), presenting, and best-corrected visual impairment (visual acuity Յ20/40 in the better eye) was 17.1%, 10.1%, and 1.4%, respectively. More than half of those in need of corrective spectacles were without them. In eyes with reduced vision, refractive error was the cause in 87.0%, amblyopia in 2.0%, other causes in 0.6%, and unexplained causes in 10.4%, mainly suspected amblyopia. Myopia (spherical equivalent of at least Ϫ0.50 diopter [D] in either eye) measured with retinoscopy was present in 9.8% of children 7 years of age, increasing to 34.4% in 15-year-olds; and in 10.0% and 32.5%, respectively, with autorefraction. Myopia was associated with older age, female gender, higher parental education, and Chinese ethnicity. Hyperopia (Ն2.00 D) with retinoscopy varied from 3.8% in 7-year-olds, 5.0% with autorefraction, to less than 1% by age 15, with either measurement method. Hyperopia was associated with younger age and &quot;other&quot; ethnicity. Astigmatism (Ն0.75 D) was present in 15.7% of children with retinoscopy and in 21.3% with autorefraction. Conclusions: Visual impairment in school-age children in urban Gombak District is overwhelmingly caused by myopia, with a particularly high prevalence among children of Chinese ethnicity. Eye health education and screening may help address the unmet need for refractive correction. Ophthalmology 2005;112:678 -68