Patient characteristics, disease burden, treatment patterns and outcomes in patients with acromegaly: Real-world evidence from the Malaysian acromegaly registry / Journal of the ASEAN Federation of Endocrine Societies

Objective@#This study aims to report the demographic features of patients with acromegaly the disease burden, and the corresponding treatment patterns and outcomes in Malaysia.@*Methodology@#This is a retrospective study that included patients from the Malaysian Acromegaly registry who were diagnosed with acromegaly from 1970 onwards. Data collected included patient demographics, clinical manifestations of acromegaly, biochemical results and imaging findings. Information regarding treatment modalities and their outcomes was also obtained.@*Results@#Registry data was collected from 2013 to 2016 and included 140 patients with acromegaly from 12 participating hospitals. Median disease duration was 5.5 years (range 1.0 – 41.0 years). Most patients had macroadenoma (67%), while 15% were diagnosed with microadenoma. Hypertension (49.3%), diabetes (37.1%) and hypopituitarism (27.9%) were the most common co-morbidities for patients with acromegaly. Majority of patients had surgical intervention as primary treatment (65.9%) while 20.7% were treated medically, mainly with dopamine agonists (18.5%). Most patients had inadequate disease control after first-line treatment regardless of treatment modality (79.4%).@*Conclusion@#This registry study provides epidemiological data on patients with acromegaly in Malaysia and serves as an initial step for further population-based studies.

Validation of Malay Language Translated Questionnaire on Adult Intensive Care Unit Nurses’ Perception and Involvement in End-of-life Care

@#Introduction: The study’s objective was to validate a Malay language translated questionnaire on end-of-life care to be used among nurses practicing in critical care areas. Methods: The English language questionnaire underwent forward and backward translations by four experts. The translated Malay language questionnaire was pilot tested on 30 subjects and revised accordingly. The validation of the revised questionnaire was carried out on 250 nurses. The reliability of the translated questionnaire was checked. Cronbach alpha value of at least 0.70 suggests adequate internal consistency. The validity of the questionnaire was explored using Confirmatory Factor Analysis (CFA) and model fit tests were run to achieve fit test specific cut off values. The CFAs were run repeatedly with iterative item reductions until acceptable goodness of fit for the model was achieved. Results: All domains of the translated questionnaire showed reasonable to excellent reliability (Cronbach Alpha 0.687 to 0.922). Multiple CFAs were run and 13 out of 46 items were excluded, and the final model fit improved substantially with the indices were within the acceptable threshold of good or reasonably fit, cut off values are in brackets [Chi-Square statistics 1.635 (≤ 2.0), Root Mean Square Error of Approximation 0.050 (< 0.05), Standardised Root Mean Square Residual 0.059 (≤ 0.08), Comparative Fit Index 0.911 (0.90-0.94), Tucker Lewis Index 0.900 (0.90-0.94), Akaike Information Criteria 13024, Bayesian Information Criteria 13334]. Conclusion: The psychometric properties of the final model indicated the Malay language translated questionnaire is reliable and valid to investigate nurses’ perspective and involvement in end-of-life care.

Bilateral Genu valgum in an adolescent with primary hyperparathyroidism / Journal of the ASEAN Federation of Endocrine Societies

@#Primary hyperparathyroidism in children and adolescents is rare and often symptomatic at presentation. A 15-year-old boy presented with bilateral genu valgum for two years. Biochemical results were consistent with primary hyperparathyroidism. Calcium levels normalized two months after removal of a left inferior parathyroid adenoma.

Superficial Angiomyxoma of the Eyelid. A Case Report and Review of the Literature

@#Superficial angiomyxoma (SA) is an angiomyxoid cutaneous tumour. It has predilection for the head and neck, torso, limbs and genital tract. Our case is a 27-year-old female, presented with painless right medial canthal mass for two years. It was associated with tearing when the lesion grew larger. We received a nodular brownish tissue measuring 25x20x15mm with homogenous brownish cut surface. Microscopically, the tumour was partially circumscribed, exhibiting bland stellate to spindle cells of moderate cellularity with pale eosinophilic cytoplasm, indistinct border, in a loose collagenous myxoid matrix with numerous blood vessels of different calibre. The lesional cells were present at the resected margin and were nonreactive towards CD34, SMA and S100. SA of the eyelid is sometimes mistaken clinically as dermoid cyst or lipoma. Reports have shown increased risks of local recurrence following incomplete excision. Close association with Carney’s complex is an important feature. Careful clinicopathologic correlation and proper investigations are needed for optimal patient care.

Sex estimation using subpubic angle from reconstructed three-dimensional computed tomography pelvic model in a contemporary Malaysian population / 대한해부학회지

Research in forensic anthropology is recent in Malaysia due to limited access to documented skeletal collections. However, advanced imaging techniques provide virtual bone samples for use in morphometric studies to establish population-specific standards by virtual anthropology. This study examined sexual dimorphism in the subpubic angle using a three-dimensional computed tomography model of the pelvis, in a contemporary Malaysian population. The sample comprised multidetector computed tomography (MDCT) scans of 50 male and 50 female adults. Segmentation of the MDCT scans was performed using 3D Slicer, and four landmarks were acquired using Stratovan Checkpoint for the subpubic angle measurement. The technical error of measurement (TEM), relative TEM, and coefficient of reliability (R) exhibited high reliability in measurements. Results showed that the subpubic angle in males was 68.6°±7.6° and in females 87.4°±6.5°. The subpubic angle in females was significantly larger than in males (P<0.001). Inverse correlation was found between the subpubic angle and age, in both males (r=–0.449, P<0.01) and females (r=–0.385, P<0.01). The overall accuracy of sex estimation using the subpubic angle was 94% (P<0.001). The subpubic angle, with a demarcating point of 78.6°, showed a sensitivity and specificity of 94% in the classification of female individuals. In conclusion, sex estimation using the subpu bic angle is highly accurate, with a high degree of expected sensitivity and specificity in the Malaysian population.

Sex estimation using subpubic angle from reconstructed three-dimensional computed tomography pelvic model in a contemporary Malaysian population / 대한해부학회지

Research in forensic anthropology is recent in Malaysia due to limited access to documented skeletal collections. However, advanced imaging techniques provide virtual bone samples for use in morphometric studies to establish population-specific standards by virtual anthropology. This study examined sexual dimorphism in the subpubic angle using a three-dimensional computed tomography model of the pelvis, in a contemporary Malaysian population. The sample comprised multidetector computed tomography (MDCT) scans of 50 male and 50 female adults. Segmentation of the MDCT scans was performed using 3D Slicer, and four landmarks were acquired using Stratovan Checkpoint for the subpubic angle measurement. The technical error of measurement (TEM), relative TEM, and coefficient of reliability (R) exhibited high reliability in measurements. Results showed that the subpubic angle in males was 68.6°±7.6° and in females 87.4°±6.5°. The subpubic angle in females was significantly larger than in males (P<0.001). Inverse correlation was found between the subpubic angle and age, in both males (r=–0.449, P<0.01) and females (r=–0.385, P<0.01). The overall accuracy of sex estimation using the subpubic angle was 94% (P<0.001). The subpubic angle, with a demarcating point of 78.6°, showed a sensitivity and specificity of 94% in the classification of female individuals. In conclusion, sex estimation using the subpu bic angle is highly accurate, with a high degree of expected sensitivity and specificity in the Malaysian population.

Development and validation of TaqMan real-time PCR for the detection of Burkholderia pseudomallei isolates from Malaysia

@#Rapid detection of Burkholderia pseudomallei, the etiologic agent of melioidosis, allows for timely initiation of appropriate treatment and better clinical outcomes. In the current gold standard, the culture method is time consuming and suffers from low sensitivity. Meanwhile, previously reported molecular assays are fast and sensitive, but their performance on isolates from Malaysia, an endemic region of melioidosis is under reported. This study designed oligonucleotides targeting orf2 of Type III secretion system (TTSS) genes cluster for the detection of Malaysian B. pseudomallei isolates and evaluated the assay on 95 local B. pseudomallei strains, 58 other microorganisms and 71 clinical specimens from patients. The developed assay exclusively detected all tested B. pseudomallei isolates with a detection limit of 20 fg per reaction (equivalent to ~2.5 copies). Subsequent testing on clinical samples showed that the assay detected all confirmed specimens with the growth of B. pseudomallei (n = 10/10). None of the negative specimens had a detectable signal of our TTSS-orf2 assay (n = 0/61). In conclusion, the present study provides crucial preliminary data for a subsequent study and should be considered as a potential alternative to current time-consuming culture method for the detection of B. pseudomallei.

Diabetes literacy and knowledge among patients with type 2 diabetes mellitus attending a primary care clinic in Seremban, Malaysia

@#Introduction: Good health literacy and knowledge are associated with improved outcomes in diabetes. The purpose of this study was to determine diabetes-specific literacy and knowledge levels, and its associated socio-demographic factors, among adults with type 2 diabetes mellitus (T2DM). Methods: This cross-sectional study was conducted among 196 adults from the Indian, Chinese, and Malay ethnic groups with T2DM who attended a primary care clinic in Seremban, Malaysia. The Literacy Assessment for Diabetes and Diabetes Knowledge Test 2 were used to assess diabetes-specific literacy and knowledge, respectively. Results: The majority of participants (75.0%) had literacy scores that corresponded to Ninth Grade Level but only 3.6% of participants had a good knowledge of diabetes. Literacy scores explained up to 19.8% of the variance in knowledge scores (r=0.445, p<0.01). Indian participants had the lowest literacy and knowledge scores when compared to Chinese and Malays (p<0.05). Participants with higher education had better literacy and knowledge scores (p<0.05). Educational level was more likely than ethnicity to predict both literacy and knowledge scores (p<0.001), while gender and age did not significantly predict either score. The majority of participants could answer general questions about physical activity, diabetes-related complications and healthy eating. Knowledge of diabetes and its relation to specific foods and the effect of diet on glucose control were limited among the participants. Conclusion: Education and ethnicity were associated with literacy and knowledge on diabetes. There existed a deficit of diabetes-related nutrition knowledge among the participants. These findings may help healthcare providers tailor individualised patient educational interventions.

Synthesis, antitubercular activity, and molecular docking studies of Benzyl-modified 8-hydroxyquinolines

@#<p><strong>Background:</strong> Infection with Mycobacterium tuberculosis, the causative agent of TB, is responsible for one of the global epidemics. Thus, new drugs are needed that do not confer cross-resistance with currently administered front-line therapeutics. Quinoline-based natural products and synthetic derivatives have been extensively explored for antitubercular activity.<br /><strong>Objective:</strong> The main goal of this study was to prepare a collection of benzylated 8-hydroxyquinoline derivatives through synthesis and assess their antitubercular activity along with a molecular docking study to clarify their biological mechanism of action.<br /><strong>Methodology:</strong> The benzylated 8-hydroxyquinoline derivatives were synthesized using Williamson synthesis methods. Antitubercular activity was assessed against fast replicating M. tuberculosis H??Rv using Microplate Alamar Blue Assay (MABA) and non-replicating cultures using Low-Oxygen Recovery Assay (LORA). Molecular docking studies were carried out against enoyl-acyl carrier protein reductase (InhA).<br /><strong>Results:</strong> Five benzylated 8-hydroxyquinoline derivatives were synthesized in moderate yields and characterized using NMR spectroscopy. MABA and LORA assays indicate compounds 3-5 as the most inhibitory derivatives with MIC90's ranging from 6.38 to 54.28 ?M. Molecular docking against InhA showed modest 90 binding energies for compounds 4 (-8.5 kcal/mol) and 5 (-8.6 kcal/mol).<br /><strong>Conclusion:</strong> Findings suggest a rationale for the further evolution of this promising series of antitubercular quinoline small molecules. Structure-activity analysis shows that an 8-benzyl moiety with chlorine atom/s is important for improved activity against replicating and non-replicating M. tb. H??Rv. This is also supported by our in silico studies.</p>

Application and validation of the weight efficacy lifestyle (WEL) questionnaire among type 2 diabetes mellitus patients in Malaysia

@#Introduction: Self-efficacy for eating predicts successful weight loss and maintenance in Type 2 Diabetes Mellitus (T2DM) individuals. The Weight Efficacy Lifestyle (WEL) questionnaire determines self-efficacy for controlling eating. This study aims to validate the Malay-translated version of the WEL questionnaire and to establish the cut-off scores to define the level of eating self-efficacy in Malaysian T2DM individuals. Methods: A total of 334 T2DM individuals, aged 55.0±9.0 years, were recruited from a primary healthcare clinic based on sampling ratio. Medical records were reviewed for eligibility. Inclusion criteria included BMI ≥23kg/m2, and no severe diabetes complications. The WEL questionnaire assessed eating resistance during negative emotions, food availability, social pressure, physical discomfort and positive activities, and was back translated into Malay language. Self-efficacy was rated on a 0-9 scale with higher WEL scores indicating greater self-efficacy to resist eating. Factor analysis established the factor structure of the WEL questionnaire. Inter-item and item-total correlations determined construct validity while internal consistency described the reliability of the structure. Results: A two-factor structure accounting for 49% of variance was obtained, and it had adequate reliability, as indicated by Cronbach’s α of 0.893 and 0.781 respectively. Item-total correlations of r>0.700, p<0.01 and inter-item correlations of r<0.500, p<0.01 demonstrated construct validity. Cut-off scores of ≥44 and ≥32, respectively for factor one and two defined high eating self-efficacies in T2DM individuals. Conclusion: The Malaytranslated version of the WEL questionnaire appears to be a valid and reliable tool to assess self-efficacy for controlling eating behaviour in Malaysian T2DM population.

Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction

mortality and an important cause of morbidity in Malaysiafor several years. To reduce global cardiovascular (CV) riskin the population, primary preventive strategies need to beimplemented. Hypercholesterolaemia is one of the majorrisk factors for CVD. This paper is an expert review on themanagement of hypercholesterolemia focusing on high andvery high risk individuals. In low and Intermediate riskindividuals, therapeutic lifestyle changes (TLC) and ahealthy lifestyle alone may suffice. In high and very high riskindividuals, drug therapy in conjunction with TLC arenecessary to achieve the target LDL-C levels which havebeen shown to slow down progression and sometimes evenresult in regression of atherosclerotic plaques. Statins arefirst-line drugs because they have been shown in numerousrandomized controlled trials to be effective in reducing CVevents and to be safe. In some high risk individuals, despitemaximally tolerated statin therapy, target Low DensityLipoprotein Cholesterol (LDL-C) levels are not achieved.These include those with familial hypercholesterolaemia andstatin intolerance. This paper discusses non-statintherapies, such as ezetimibe and the newer Proproteinconvertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

Appraisal of tipu sultan's contributions toward development of unani medicine: a critical analysis

Unani system of medicine has enjoyed the status of being royal since antiquity, and various rulers and governments have paid special attention toward its growth and development. In India, Tipu Sultan, a highly cultured intellectual, academician, physician, scholar, and a great scientist, was one of those who played an important role in the advancement of Unani medicine. He had an imperial library located at Srirangapatna housing more than 2000 manuscripts in Arabic, Persian, Turkish, Urdu, and Hindi, dealing with medicine, military science, music, Hadith, law, Sufism, history, philosophy, grammar, astrology, poetry, and mathematics, of which 62 books were related to medicine. He also possessed vast expertise in treating various diseases, which is inferred from his personal letters and communications. He not only showed interest in preserving Unani manuscripts but also mentioned about 45 books on the subject of medicine in his memoirs. The health system was highly sophisticated in his territory among his contemporary kingdoms. Moreover, physicians and surgeons were regularly inducted to serve the injured and wounded soldiers in every battalion. The present study judiciously inspected the contributions of Tipu Sultan toward the patronage and promotion of Unani medicine, especially in the southern part of India in the 18[th] century

Effect of Time of Measurement on Central Corneal Thickness in a Sample of Young Myopes / Jurnal Sains Kesihatan Malaysia

The aim of this study was to determine the effect of time of measurement on central corneal thickness in young myopes. Seventy healthy myopic subjects (non contact lens wearers) were involved in this study with mean age of 22.43 ± 1.76 years. Subjective refraction was determined using cross-cylinder technique, corneal curvature was measured using keratometer (Shin-Nippon) and central corneal thickness (CCT) was determined using specular microscope (Topcon SP-3000P). The CCT was measured in the morning (between 8 to 11 am) and in the afternoon (between 2 to 5 pm). The results showed that the mean of refraction for all subjects was -2.59 ± 1.85 DS and mean of cornea curvature was 7.74 ± 0.25 mm. Mean CCT in the morning was 517 ± 37 μm and 516 ± 36 μm in the afternon. Statistical analysis showed no significant difference between both measurements (T = 1.713 and P = 0.091). Correlation analysis showed insignificant correlation between CCT and refractive error (r = -0.078, p > 0.05) and CCT with corneal curvature in the horizontal meridian (r = 0.014, p > 0.05) and at vertical meridian (r = 0.029, p > 0.05). This study concluded that there is no significant effect of time of measurement on CCT in young myopes.

Pattern Visual Evoked Potential (VEP) is Unaffected in the Early Stage of Mild Cognitive Impairment / Jurnal Sains Kesihatan Malaysia

The aim of this study was to determine whether pattern-reversal Visual Evoked Potential (PRVEP) is affected in mild cognitive impairment (MCI). Participants aged ≥ 60 years diagnosed as MCI were invited to participate in a study together with a group of controls. PRVEP was measured using A RETI-port/Scan 21 and stimuli of large and small checks sizes, 1° (60 min of arc) and 0.25° (15 min) respectively were used to obtain responses. The amplitude and implicit times of the MCI and control groups were then compared. A total of 18 MCI participants (age 65.7 ± 3.1 years) and 18 controls (65.1 ± 3.8 years) consented to participate in the study. The amplitude and implicit times for the MCI group using the target sizes of 60 min of arc were 9.80 ± 4.06 μV and 108.83 ± 7.63 ms and for 30 min of arc were 11.00 ± 7.44 μV and 123.96 ± 6.18 ms respectively. Consecutively for the control groups the amplitudes and implicit times were 8.96 ± 3.52μV, 105.85 ± 3.60 ms and 11.97± 6.11 μV, 122.57 ± 8.28 ms. PRVEP results did not reveal significant differences in P100-wave amplitude nor implicit time between the two groups under investigation. This study concluded that the visual pathway of MCI participants may be unaffected in the early part of the disease process.

Factors predicting visual improvement post pars plana vitrectomy for proliferative diabetic retinopathy / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To identify factors predicting visual improvement post vitrectomy for sequelae of proliferative diabetic retinopathy (PDR).METHODS: This was a retrospective analysis of pars plana vitrectomy indicated for sequelae of PDR from Jan.to Dec.2014 in Hospital Sultanah Bahiyah,Alor Star,Kedah,Malaysia.Data collected included patient demographics,baseline visual acuity (VA) and post-operative logMAR best corrected VA at 1y.Data analysis was performed with IBM SPSS Statistics Version 22.0.RESULTS: A total of 103 patients were included.The mean age was 51.2y.On multivariable analysis,each pre-operative positive deviation of 1 logMAR from a baseline VA of 0 logMAR was associated with a post-operative improvement of 0.859 logMAR (P<0.001).Likewise,an attached macula pre-operatively was associated with a 0.374 (P=0.003) logMAR improvement post vitrectomy.Absence of iris neovascularisation and absence of post-operative complications were associated with a post vitrectomy improvement in logMAR by 1.126 (P=0.001) and 0.377 (P=0.005) respectively.Absence of long-acting intraocular tamponade was associated with a 0.302 (P=0.010) improvement of logMAR post vitrectomy.CONCLUSION: Factors associated with visual improvement after vitrectomy are poor pre-operative VA,an attached macula,absence of iris neovascularisation,absence of post-operative complications and abstaining from use of long-acting intraocular tamponade.A thorough understanding of the factors predicting visual improvement will facilitate decision-making in vitreoretinal surgery.

Predictors of proliferative diabetic retinopathy among patients with type 2 diabetes mellitus in Malaysia as detected by fundus photography

Objectives: diabetic eye disease is the most common cause of visual loss in adults, and proliferative diabetic retinopathy [PDR] is the main cause of blindness. This study aimed to determine the predisposing factors for PDR that were identified by fundus photography among patients with type 2 diabetes mellitus [DM] at the Diabetic Clinic at Hospital Universiti Sains Malaysia

Methods: in this retrospective study, fundus photo review was performed on patients with type 2 DM who had undergone diabetic retinopathy screening using a nonmydriatic fundus camera from January 2008 until December 2012. Fundus photos were classified into 2 groups, PDR and no apparent diabetic retinopathy [no DR]. Socio-demographic data and clinical and metabolic profiles were obtained from the medical records. Logistic regression was used to determine the factors associated with PDR

Results: a total of 120 patients were selected, with 30 patients in the PDR group and 90 patients in the no DR group. The mean age of patients with PDR was 52 [7.94] years and was 58 [12.31] years in the no DR group. Hypertension and hyperlipidaemia were the most common comorbidities identified in this study. The HbA1c level >6.5% and LDL level >2.6 mmol/L were higher in the PDR group. Age [p = 0.032], duration of DM [p = 0.022], nephropathy [p = 0.002] and peripheral neuropathy [p= 0.001] were significantly associated with PDR

Conclusion: the significant predictors of PDR among patients with type 2 DM as detected by fundus photography were age, duration of DM, nephropathy and peripheral neuropathy

Staged reconstruction of a tessier number 4 facial cleft

Tessier number 4 cleft is an extremely rare facial cleft. We report a case of Tessier number 4 facial cleft recently managed in our center. The approach to facial clefts is multi-disciplinary and may differ between centers. Multiple surgical interventions are required as well as a good psychosocial support. The child underwent a craniofacial reconstruction at 6 months of age, followed by a left macrostomia repair 9 months later and transcranial correction of the right orbital dystopia with eyelid reconstruction

Acute coronary syndrome in the elderly: the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry

<p><b>INTRODUCTION</b>The elderly are often underrepresented in clinical trials for acute coronary syndrome (ACS), and cardiologists commonly face management dilemmas in the choice of treatment for this group of patients, particularly concerning the use of invasive revascularisation. This study analysed the characteristics of hospitalised elderly patients with ACS, and compared the outcomes of treatments.</p><p><b>METHODS</b>From 29 December 2005 to 26 April 2010, 13,545 patients were admitted for ACS in 16 hospitals across Malaysia. These patients were divided into two groups - elderly (≥ 65 years) and non-elderly (< 65 years). The clinical characteristics, treatment received (invasive or non-invasive) and outcomes (in-hospital and 30-day all-cause mortality) of the two groups were compared. The elderly patients were then grouped according to the type of treatment received, and the outcomes of the two subgroups were compared.</p><p><b>RESULTS</b>Elderly patients had a higher cardiovascular risk burden and a higher incidence of comorbidities. They were less likely to receive urgent revascularisation for acute ST-segment elevation myocardial infarction (elderly: 73.9% vs. non-elderly: 81.4%) and had longer door-to-needle time (elderly: 60 minutes vs. non-elderly: 50 minutes, p = 0.004). The rate of cardiac catheterisation was significantly lower in the elderly group across all ACS strata. Elderly patients had poorer outcomes than non-elderly patients, but those who received invasive treatment appeared to have better outcomes than those who received non-invasive treatment.</p><p><b>CONCLUSION</b>Elderly patients with ACS tend to be undertreated, both invasively and pharmacologically. Invasive treatment seems to yield better outcomes for this group of patients.</p>

Estimation of out-of-pocket costs of patients at the methadone maintenance therapy clinic in Malaysia

Out-of-pocket [OOP] payments may burden Methadone Maintenance Clinic patients. Since treatment is fully .subsidized by the government, financial constraint might lead to patients being made to pay or be given incentive for inconvenience of therapy. This study thus evaluates the characteristic and commitment of methadone therapy patient's in terms of OOP cost, Willingness-To-Pay [WTP]and Willingness-To-Accept [WTA]concept. This survey utilizes the questionnaire by Boris ova and Goodman [2003] on the OOP, WTP and WTA. The forty adult patient's selected medical records from year 2009-2011 were from an urban government methadone clinic. Subject's selection was by convenient sampling based on the predetermined criteria. Most were male [95%] and Malay [60%] was the predominant group. Patients were group into three income groups; /=RM1000 - /=RM3000. The average OOP cost per month was RM391.30 [s.d RM337.50], which is about 35% of employed patient's monthly income. The wide variation could be attributed by high inter-individual and significant differences between patients in terms of transport, times taken to clinic, cost per trip and weekly household income [p=<0.05]. Patients with income of less than RM1000 showed the highest tendency to pay for treatment, asked for the least money for inconvenience and many are unwilling to accept any payments. These findings showed that WTP and WTA is less of a concern for patients in the low-income group. To conclude, OOP payment is not a treatment barrier for most of the urban MMT patients