Uncovering the Hidden Burden of Pharmaceutical Poisoning in High-Income and Low-Middle-Income Countries: A Scoping Review.

Pharmaceutical poisoning is a significant global public health concern, causing approximately 190,000 deaths annually. This scoping review aims to comprehensively map the available literature on pharmaceutical poisoning and compare patterns between high-income countries (HICs) and low-middle-income countries (LMICs). A systematic search was performed across the following databases: Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL. Studies included were from 1 January 2011 to 31 December 2020, in English, with full text available. Seventy-nine articles were included in the study; 21 were from LMICs and 58 were from HICs. Toxic exposure was largely intentional (77%) in LMICs and accidental (68%) in HICs. Drugs acting on the nervous system were responsible for 95% of toxicities worldwide with analgesics accounting for the largest subtherapeutic group in both LMICs (40%) and HICs (58%). Notable statistics were that HICs accounted for 99% of opioid overdoses, and LMICs accounted for 19% of anti-epileptic-induced toxicities. Overall, the medical outcomes due to poisonings were generally worse in LMICs. The review provides possible interventions to target specific geographic locations, based on the trends identified, to reduce the burden worldwide. Many gaps within the literature were recognised, calling for more robust analytical research.

Predictive model of recurrent ischemic stroke: model development from real-world data.

Background: There are established correlations between risk factors and ischemic stroke (IS) recurrence; however, does the hazard of recurrent IS change over time? What is the predicted baseline hazard of recurrent IS if there is no influence of variable predictors? This study aimed to quantify the hazard of recurrent IS when the variable predictors were set to zero and quantify the secondary prevention influence on the hazard of recurrent ischemic stroke. Methods: In the population cohort involved in this study, data were extracted from 7,697 patients with a history of first IS attack registered with the National Neurology Registry of Malaysia from 2009 to 2016. A time-to-recurrent IS model was developed using NONMEM version 7.5. Three baseline hazard models were fitted into the data. The best model was selected using maximum likelihood estimation, clinical plausibility, and visual predictive checks. Results: Within the maximum 7.37 years of follow-up, 333 (4.32%) patients had at least one incident of recurrent IS. The data were well described by the Gompertz hazard model. Within the first 6 months after the index IS, the hazard of recurrent IS was predicted to be 0.238, and 6 months after the index attack, it reduced to 0.001. The presence of typical risk factors such as hyperlipidemia [HR, 2.22 (95%CI: 1.81-2.72)], hypertension [HR, 2.03 (95%CI: 1.52-2.71)], and ischemic heart disease [HR, 2.10 (95%CI: 1.64-2.69)] accelerated the hazard of recurrent IS, but receiving antiplatelets (APLTs) upon stroke decreased this hazard [HR, 0.59 (95%CI: 0.79-0.44)]. Conclusion: The hazard of recurrent IS magnitude differs during different time intervals based on the concomitant risk factors and secondary prevention.

Abstinence Rate, Adverse Events and Withdrawal Symptoms after Varenicline Use and Predicting Factors of Smoking Abstinence: A Multicentre Single-State Study in Malaysia.

(1) Background: Varenicline is a widely prescribed agent in smoking cessation. However, the abstinence rate, the incidence of adverse events and withdrawal symptoms, have not been widely studied locally. This study aimed to determine the prevalence of smoking abstinence, adverse events and withdrawal symptoms associated with varenicline use, as well as possible factors contributing to successful smoking abstinence. (2) Methods: This was a retrospective, cohort study conducted in twenty-two government-operated smoking cessation clinics across the state of Perak, Malaysia. The medical records of adult smokers (age ≥ 18 years old) who were prescribed with varenicline between January 2017 and June 2018 were traced. The medical records of smokers who used pharmacotherapy other than varenicline, those who received less than four weeks of varenicline treatment, and with missing data were excluded. (3) Results: Sixty-eight out of 114 subjects (59.6%) successfully achieved smoking abstinence. Probable varenicline-induced chest pain was documented in three subjects. Altered behaviour (n = 2) and auditory hallucinations (n = 1) were also reported. Varenicline treatment duration is a significant predictive factor for successful smoking abstinence (odds ratio (OR) = 2.45; 95% confidence interval (CI) 1.74−3.45; p < 0.001), followed by age (OR = 1.25; 95% CI 1.005−1.564; p = 0.045), the presence of adverse events (OR = 0.096; 95% CI 0.014−0.644; p = 0.016) and withdrawal symptoms (OR = 0.032; 95% CI 0.016−0.835; p = 0.032). (4) Conclusion: Almost two-thirds of the subjects achieved smoking abstinence with varenicline. The duration of the treatment, as well as the patients' ages had a significant influence on successful smoking abstinence. Rare cases of cardiovascular and neuropsychiatric-related adverse events were reported, warranting continuous surveillance and adverse drug reaction reporting.

Poisoning among children in Malaysia: A 10-years retrospective study.

BACKGROUND: Poisoning commonly occurs among children due to their curiosity, where they tend to explore and investigate their surroundings. They frequently put what they find into their mouths as they do not understand the danger and probably cannot read the warning label. As this issue has not been extensively studied in Malaysia; hence, a retrospective analysis of records was carried out to determine the profile of phone call enquiries regarding poisoning among children at the National Poison Centre (NPC). METHODOLOGY: The records of all cases of poisoning among children below the age of 18 years were retrospectively reviewed over a period of 10 years from 2006 to 2015. The data on the cases were analysed according to age group and gender, the circumstances and the toxic agent implicated in the poisoning. RESULTS: During the 10-year study period, 13,583 calls that met the criteria for this study were referred to the NPC. Of these calls, 62.2% involved children between the age of 0 to 5 years, 9% were children aged between 6 to 12 years, and 28.8% were children between 13 to 18 years. Unintentional poisoning accounted for 96.7% of the incidents involving children between the age of 0 to 5 years, although among the children who were between the age of 13 to 18 years, 76% of the cases were intentional. In all the cases involving children, pharmaceutical agents were the most frequent source of the poisoning. More than 95% of the cases were exposed to poisoning through the oral route. CONCLUSION: Poisoning in children between the age of 0 to 5 years was mainly unintentional, while poisoning in children between the age of 13 to 18 years was mainly intentional, where pharmaceutical and household agents were responsible for more than two-thirds of the poisoning cases. Most of these incidents could have been prevented if protective measures, such as child-resistant enclosures, had been implemented and if the parents and guardians had been educated about preventive measures, such as keeping poisoning agents out of the reach of children.

Physicians' perceived barriers and enablers for deprescribing among older patients at public primary care clinics: a qualitative study.

Background Increased harmful effects of medication resulting from polypharmacy, especially among older patients, is a significant concern globally. Hence, continuous medication review and withdrawal of inappropriate medications are essential to improve patient safety. Objective To explore physicians' perceived barriers and enablers of deprescribing among older patients in the public primary healthcare setting. Setting Public primary care clinics in the northern states of Malaysia. Methods A semi-structured, face-to-face interview was conducted among physicians working in eight primary care clinics in northern Malaysia using a purposive sampling approach. Interviews were conducted using validated topic guides. All the responses were recorded, transcribed verbatim, validated, and analysed for the emerging themes using thematic analysis. Main outcome measure Physicians perceived barriers and enablers of deprescribing among geriatric patients. Results A total of eleven physicians were interviewed. Seven emerging themes were identified, which are categorised under barriers and enablers of deprescribing. The barriers were patient-specific, prescriber-specific, and healthcare provision and system. Prescriber deprescribing competencies, medication-specific outcomes, availability of empirical evidence, and pharmacist's role were the enablers identified. Conclusion Patient-specific barriers were identified as a significant challenge for deprescribing. Improving competencies on deprescribing was the repeatedly adduced enabler by physicians. The development of targeted educational training can help to reduce the obstacles faced by prescribers.

Population-based Study Comparing Predictors of Ischemic Stroke Recurrence After Index Ischemic Stroke in Non-elderly Adults with or without Diabetes.

BACKGROUND AND PURPOSE: Factors associated with ischemic stroke (IS) recurrence and the contribution of pharmacological treatment as secondary preventions among nondiabetics especially in the non-elderly population are unclear and not widely investigated. This was a population-based study that aimed to identify recurrent IS predictors and to determine the possible impact of secondary preventive medications on the IS recurrence in non-elderly adults with or without diabetes. METHODS: Data of 3386 patients <60 years old who had a history of index IS were extracted from the Malaysian National Neurology Registry (NNEUR) from 2009 to 2016. Recurrent IS was defined as any IS event recorded after the index IS in the NNEUR database. Multivariate logistic regression analysis was performed by using SPSS version 22. RESULTS: Ischemic heart disease (IHD) was the significant predictor of IS recurrence in non-elderly adults both with or without diabetes (adjusted odds ratio (AOR) of 3.210; 95%CI: 1.909-5.398 and 2.989; 95%CI: 1.515-5.894) respectively). Receiving antiplatelet as secondary stroke prevention (AOR: 0.194; 95%CI: 0.046-0.817) and continuation of antidiabetic medication after the index IS event (AOR: 0.510; 95%CI: 0.298-0.872) reduced the odds of IS recurrence only in non-elderly diabetic adults. Among non-elderly adults without diabetes, hyperlipidemia and every increased in 1 mmHg of systolic blood pressure significantly increased the odds of IS recurrence following the indexing event (AOR: 1.796; 95%CI: 1.058-3.051 and 1.009; 95%CI: 1.002-1.016 respectively). CONCLUSION: IHD was found as the main predictor of IS recurrence regardless of diabetes status in non-elderly adults after the index IS event. Receiving antidiabetic and antiplatelet medications upon discharge after index IS were significant predictors of recurrent IS in non-elderly diabetic adults. A proper randomized clinical trial may be required to determine the impact of secondary preventive medication on IS recurrence, especially in non-elderly adults.

Predictors of Recurrent Ischemic Stroke in Obese Patients With Type 2 Diabetes Mellitus: A Population-based Study.

BACKGROUND: Diabetes and obesity are established risk factors for stroke. The current study aimed to assess risk factors of ischemic stroke recurrence in diabetic patients based on their body mass index (BMI). METHODS: A total of 4005 diabetic patients who had a history of ischemic stroke were identified in a retrospective cross-sectional dataset from the Malaysian National Neurology Registry. Patients were classified based on BMI, and multivariable regression analysis was used to evaluate the association between risk factors and recurrent ischemic stroke. RESULTS: Among obese patients, those with ischemic heart disease (aOR, 1.873; 95% CI, 1.131-3.103), received formal education (aOR, 2.236; 95% CI, 1.306-3.830), and received anti-diabetic medication (aOR, 1.788; 95% CI, 1.180-2.708) had a higher stroke recurrence risk, while receiving angiotensin receptors blockers (aOR, 0.261; 95% CI, 0.126-0.543) lowered the odds of recurrence. Overweight patients with hypertension (aOR, 1.011; 95% CI, 1.002-1.019) for over 10 years (aOR, 3.385; 95% CI, 1.088-10.532) and diabetes prior to the first stroke (aOR, 1.823; 95% CI, 1.020-3.259) as well as those received formal education (aOR, 2.403; 95% CI, 1.126-5.129) had higher odds of stroke recurrence, while receiving angiotensin-converting enzyme inhibitors (aOR, 0.244; 95% CI, 0.111-0.538) lowered the recurrence risk. Normal weight East Malaysians (aOR, 0.351; 95% CI, 0.164-0.750) receiving beta-blockers (aOR, 0.410; 95% CI, 0.174-0.966) had lower odds of stroke recurrence. CONCLUSIONS: Ischemic heart disease, hypertension, receiving anti-hypertensive agents, and educational level were independent predictors of recurrent stroke in obese patients. Managing the modifiable risk factors can decrease the odds of stroke recurrence.

Knowledge and practices of community pharmacists towards non-prescription dispensing of antibiotics in Northern Nigeria.

Background Non-prescription dispensing of antibiotics is common in Nigeria and this could contribute to the emergence of microbial resistance. Objectives To evaluate knowledge, perception and practices of community pharmacists towards dispensing antibiotics without prescription. Setting Community pharmacies in two cities in Northern Nigeria. Methods A prospective cross-sectional study was conducted among community pharmacists in two cities in Northern Nigeria, using a validated and pilot-tested questionnaire. The questionnaire was self-administered and data was collected between 06th April and 31st May 2019. The data was analyzed using descriptive and inferential analyses. Main outcome measure Knowledge, perception and practices towards dispensing antibiotics without prescription. Results A total of 98 out of 130 community pharmacists completed and returned the questionnaire (response rate: 75.3%). About two-third (64.3%) of the community pharmacists were aware that dispensing antibiotics without prescription is illegal. However, this malpractice was common as 39.7% of the respondents indicated that they dispensed antibiotics without prescription five times or more in a day. Antibiotics dispensed without prescription were used for the treatment of urinary tract infections (83.7%), typhoid fever (83.7%) and sexually transmitted infections (66.3%). Pharmacist's confidence in knowledge of antibiotic therapy was the most common reason for non-prescription dispensing of antibiotics. Respondents with less than 5 years of working experience (66.7%) were significantly more likely to dispense antibiotics without prescription 5 times or more in a day compared to those with more than 5 years community pharmacy experience (33.3%), P = 0.031. Conclusion Non-prescription dispensing of antibiotics was common among community pharmacists despite awareness about its prohibition and implications. The malpractice was associated with number of years of community pharmacy experience. Confidence in knowledge of antibiotic therapy was the main reason community pharmacists dispensed antibiotics without prescription. Continuous pharmacy education and training on handling of antibiotics may help to reduce inappropriate practices among community pharmacists.

Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke.

BACKGROUND: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored. OBJECTIVE: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. METHODS: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients' baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal. RESULTS: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05). CONCLUSIONS: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.

Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke

BACKGROUND: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored. OBJECTIVE: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. METHODS: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients' baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal. RESULTS: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p = 0.05). CONCLUSIONS: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients

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Prevalence and predictors of antibiotic use among children visiting the Emergency Department in a Tertiary Hospital in Malaysia.

Inappropriate use of antibiotics in human and animal is one of the causes of antimicrobial resistance. This study evaluates the prevalence and predictors of antibiotic use among pediatric patients visiting the Emergency Department (ED) in Malaysia. A retrospective cross-sectional study was conducted in the ED of a tertiary hospital. Data of children aged 2 to 11 years who visited the ED from January-May 2015 were extracted from the patient's assessment forms. A total of 549 children were included in the analysis (median age 5 years) of which 54.3% were boys. Upper respiratory tract infections (URTI) were the most common diagnosis. Antibiotic was prescribed in 43.5% of the children. Children who visited the ED during the weekend (OR, 1.65; 95% confidence interval (CI) 1.13-2.40, P = 0.009), those diagnosed with URTI (OR 3.81; 95% CI, 2.45-5.93, P < 0.001) and those with a longer duration of fever (OR, 1.31; 95% CI, 1.15-1.48, P < 0.001) were more likely to have an antibiotic prescription.Conclusions: Antibiotic was prescribed in more than one-third of children who visited the ED and antibiotic use was associated with visits during the weekend, URTI, and duration of fever. Antimicrobial stewardship program is recommended in the pediatric ED to improve appropriate use of antibiotics.What is Known:•Use of antibiotic among children increases the risk of antibiotic resistance and adverse drug reactions.•Patient-, clinical-, and prescriber-related factors are three important domain associated with antibiotic use in children.What is New:•Fever and upper respiratory tract infections account for majority of antibiotic prescriptions.•The "weekend effect" influences the use of antibiotics in the ED while upper respiratory tract infection is the strongest predictor of antibiotic use among children visiting the ED.

Pharmaceuticals Poisoning: Reported by the National Poison Centre in Malaysia between 2010 and 2015.

BACKGROUND AND PURPOSE: The wide availability of medications has led to an increased exposure of humans to the possibility of poisoning. An unavoidable effect due to the availability of these medications has also led to a rising increment in the number of poisoning cases. All drugs, especially when administered in large doses or overextended periods, can initiate a toxic condition. Therefore, the objective of this study was to examine nationwide, the patterns attributed to poisoning, and to describe the sociodemographic, and geographic distribution of poisoning, by identifying the category of substances implicated in these cases. DATA SOURCES AND METHODS: A retrospective study based on telephone calls reported on poisoning caused by pharmaceutical products undertaken by the National Poisoning Centre (NPC) in Penang (Malaysia) was used as the basis of this study covering the period between 2010 and 2015. The study included the mode and type of poisoning, exposure routes as well as the incidence locations. RESULTS: A total of 10,998 cases were examined, finding that females represented 5,899 cases (53.6%) being intoxicated more frequently compared to the number of males, 3,839 (34.9%). The age group of poisoning cases ranged between 20 and 29 years representing 2,579 (23.4%) of reported cases. The common mode of poisoning was attributed to suicide 5,203 (47.3%) from among the 10,998 cases and the highest poisoning agents reported were from the psychiatric group of pharmaceutical products of 2,287 (21%). CONCLUSION AND IMPLICATIONS: These findings indicate a rising trend of suicidal poisoning attempts between 2013 and 2015, which emphasizes the need for more stringent and effective enforcement protocols to limit the rising incidence of poisoning. As such, analyzing the trends in poisoning in a particular zone periodically could help health policy-makers to develop management policies and prevention strategies.

Nationwide survey of pharmacists' involvement in antimicrobial stewardship programs in Nigerian tertiary hospitals.

OBJECTIVES: To evaluate the activities and barriers to hospital pharmacists' participation in antimicrobial stewardship programs (ASP) in Nigerian tertiary hospitals. METHODS: A cross-sectional nationwide online survey was conducted over a 6-week period between May and June 2019. Invitation was sent to all the Heads of pharmacy department or pharmacists in charge of infectious diseases (ID) or antimicrobial pharmacists in tertiary hospitals in Nigeria. A validated questionnaire that consist of 24-items was used for data collection. RESULTS: Forty-five hospitals were invited and 37 completed the survey (response rate, 82.2%). Five (13.5%) hospitals had a formal antimicrobial stewardship (AMS) team, with each of them having pharmacist representation. Regardless of the existence of an AMS team, hospital pharmacists have implemented AMS strategies, including evaluation of the appropriateness of antimicrobial prescriptions (54.1%) and monitoring of antimicrobial consumption (48.6%). The most common barriers to pharmacists' involvement in ASP were lack of training in AMS and ID (51.4%), lack of pharmacists with ID specialisation (40.5%) and lack of support from hospital administrators (37.8%). The majority of the pharmacists recommended training in AMS and ID (100%), participation on ward rounds (89.2%) and employment of more pharmacists (73%) as strategies to improve pharmacists' participation in ASP. CONCLUSIONS: Hospital pharmacists are actively involved in AMS activities despite the lack of established AMS teams in most tertiary hospitals in Nigeria. However, lack of training and personnel were major barriers to pharmacist's involvement in ASP.

Gender Differences and Risk Factors of Recurrent Stroke in Type 2 Diabetic Malaysian Population with History of Stroke: The Observation from Malaysian National Neurology Registry.

BACKGROUND AND PURPOSE: Diabetes mellitus has been reported as a strong independent risk factor for stroke recurrence. Data on the modifiable factors contributing to the recurrence of stroke in type 2 diabetic Malaysian population with a history of stroke stratified by genders are lacking, and this supports the importance of this study. METHOD: The data of 4622 patients with T2DM who had a history of stroke was obtained from the Malaysian National Stroke Registry. Univariate analysis was performed to differentiate between genders with and without stroke recurrence in terms of demographics, first stroke attack presentations, and other clinical characteristics. The significant factors determined from the univariate analysis were further investigated using logistic regression. RESULTS: Ischemic heart diseases were found significantly associated with the stroke recurrence in males (OR = 1.738; 95% CI: 1.071-2.818) as well as female (OR = 5.859; 95% CI: 2.469-13.752) diabetic patients. The duration of hypertension, as well as the duration of diabetes, has been associated with the recurrence in both male and female subjects (p value < 0.05). Smoking status has an impact on the stroke recurrence in male subjects, while no significant association was observed among their peers. CONCLUSIONS: Most of the predictive factors contributing to the recurrence of stroke in type 2 diabetic Malaysian population with a history of stroke are modifiable, in which IHD was the most prominent risk factor in both genders. The impact of optimizing the management of IHD as well as blood glucose control on stroke recurrence may need to be elucidated. No major differences in recurrent stroke predictors were seen between genders among the Malaysian population with type 2 diabetes mellitus who had a previous history of stroke.

Evaluation of illness perceptions and their associations with glycaemic control, medication adherence and chronic kidney disease in type 2 diabetes mellitus patients in Malaysia.

BACKGROUND: Illness perceptions (IP) involve coping strategies and behavioural responses that can influence glycaemic control. Despite the importance of good glycaemic control, the majority of patients in Asia are not achieving glycaemic targets. An evaluation of IP in association with glycaemic control, medication adherence and chronic kidney disease (CKD) in Type 2 diabetes mellitus patients (T2DM) was carried out in an outpatient setting in Malaysia METHOD: A cross-sectional study was conducted using the Revised Illness Perception Questionnaire in a purposive sample of 384 T2DM patients. RESULTS: There were 55.7% females, median age was 58.2 years and median duration of diabetes was 13 years. The majority (79.4%) of patients had poor diabetes control (HbA1c ≥ 7.0%) and 39.6% of patients had low medication adherence. Patients with good glycaemic control had a higher Timeline Acute/Chronic and Emotional Representations score, hence they held the correct belief that diabetes is chronic and experienced negative emotions. Highly adherent patients had a higher Illness Coherence (χ2 = 21.385, p < 0.001) score but a lower Consequences (χ2 = 17.592, p < 0.001) and Emotional Representations (χ2 = 16.849, p < 0.001) score indicating good understanding and less negative perceptions of disease burden. Patients in a more advanced stage of CKD had a significantly higher Timeline Cyclical score (χ2 = 18.718, p = 0.001), believing that diabetes was unpredictable. CONCLUSION: Dimensions of IP have been shown to be significantly associated with the assessed variables, therefore intervention studies with education, support and counselling should be conducted in Asia with the ultimate aim of empowering patients through IP-targeted management.

Evaluation of chemotherapy-induced toxicity and health-related quality of life amongst early-stage breast cancer patients receiving Chinese herbal medicine in Malaysia.

PURPOSE: This observational study aimed to compare the outcome and health-related quality of life (HRQOL) amongst breast cancer patients using Chinese herbal medicine (CHM) and those not using CHM during chemotherapy. METHODS: A prospective, non-randomised longitudinal study was conducted in two government integrated hospitals over an 8-month period. Early-stage breast cancer patients who were (1) either already using complementary and alternative medicine (CAM) or not and (2) who were on a regime of 5-fluorouracil, epirubicin, and cyclophosphamide were included in the study. Patients who agreed to receive CHM were assigned to receive individualised CHM prescriptions deemed suitable for the individual at a particular time. Those who were not willing to take Chinese herbal medicines (CHM) were assigned to the non-CHM control group. Blood profile and chemotherapy-induced AE were recorded whilst HRQOL assessment was done using the EORTC QLQ-C30 questionnaire on first, third, and sixth cycles. RESULTS: Forty-seven patients [32 female vs. 1 male, p = 0.31; mean year of age: 52.2(SD = 7.6), p = 0.28)}] were recruited during the study period. Demographics of both groups were comparable. Fifty percent of respondents reported using some kind of CAM before chemotherapy. Diet supplements (40.6%) were the most common CAM used by the respondents. The study showed that patients using CHM had significantly less fatigue (p = 0.012), nausea (p = 0.04), and anorexia (p = 0.005) during chemotherapy. There were no significant differences in patients' HRQOL (p = 0.79). There were no AEs reported during the study. CONCLUSION: The use of CHM as an adjunct treatment with conventional chemotherapy have been shown to reduce fatigue, nausea, and anorexia in breast cancer patients but did not reduce chemotherapy-associated hematologic toxicity. The sample size of this study was not powered to assess the significance of HRQOL between two groups of patients.

Evaluation of types of poisoning exposure calls managed by the Malaysia National Poison Centre (2006-2015): A retrospective review.

OBJECTIVE: Accidental or intentional poisoning is a public health concern requiring intervention. The current study designs to evaluate the types of poisoning exposure calls received by the Malaysia National Poison Centre (NPC) over a 10-year period. SETTINGS AND DATA SOURCES: The poisoning enquiries database (2006-2015) from the Malaysia NPC was used for the analysis. PARTICIPANTS: The NPC records all telephone calls that it manages using a validated and standardised form. Demographics and types of the poisoning exposure calls were extracted and descriptive analysis was applied. PRIMARY AND SECONDARY OUTCOMES: The primary outcome of this study is to evaluate NPC data for trends in the poisoning exposure calls based on the types and modes of poisoning over a 10-year period. The secondary outcome is to evaluate the characteristics of human exposure cases based on the calls received by the NPC. RESULTS: There was a notable increase in the number of poisoning exposure calls noticed during the 10-year period but dropped significantly in 2012. The highest number of poisoning exposure calls came from Selangor (21.0%), Perak (18.0%) and Negeri Sembilan (9.8%). More than half of the exposure was intentional (53.8%) involving more women (50.3%) as compared with men (41.9%), and in the 20-29 years age group category (33.5%). Exposure mostly occurred at home (96%) through the ingestion route (94.1%). Pharmaceutical products (40.5%), pesticides (31.7%) and household products (20.1%) were the common agents implicated for intentional exposure. CONCLUSIONS: There is an increasing trend in enquiries on poisoning exposure calls made to the NPC. Most of the intentional poisoning exposures occurred among younger women and involved pharmaceuticals, pesticides or household products. Poisoning safety education and other interventions are needed to curb poisoning incidents.

Comparison of nurses and general caregivers' knowledge, attitude, and practice on medication administration process and their distress level in long-term care facilities across Penang, Kuala Lumpur, and Selangor of Malaysia.

AIM: Comparing nurses and general caregivers' knowledge, attitude, and practices (KAP) on medication administration process in long-term care (LTC) setting and an assessment of their stress, anxiety, and depression (SAD) level. METHODS: A cross-sectional survey was conducted among nurses and general caregivers working in LTC using a validated questionnaire. Consisting of demographic characteristics (Section 1); 40 questions on KAP (Section 2); and assessment of Depression, Anxiety, and Stress Scale (DASS-21) (Section 3). RESULTS: 155 formally paid staffs in 26 LTC facilities were recruited. Nurses scored significantly higher in the knowledge section compared to caregivers (12.4 ± 1.7 vs. 4.5 ± 3.8; P < 0.001); better attitude (41.5 ± 4.8 vs. 30.8 ± 7.3; P < 0.001); and better practice (65.2 ± 8.5 vs. 40.3 ± 10.9; P < 0.001), respectively. SAD scores reveal that caregivers had significantly higher level of stress, anxiety, and depression compared to the nurses. DISCUSSION: General caregivers exhibit poorer knowledge on aspects pertaining to posology, appropriate methods of drug administration, and side effects of common drugs used by the elderly. Compared to nurses, the general caregivers also reported poorer medication administration practices; including not checking labels and expiry dates prior to administration, and not providing basic information about medication therapy to the residents. However, both nurses and general caregivers reported positive attitudes in their role as caregivers. They take pride and satisfaction in their occupation providing support to the elderly. CONCLUSION: General caregivers demonstrated lesser knowledge, poorer attitude, and practices towards medication administration processes, in addition to higher SAD score in LTC facilities.

Barriers and facilitators of adherence to antidepressants among outpatients with major depressive disorder: A qualitative study.

BACKGROUND: One of the major challenges in treating major depressive disorder (MDD) is patients' non-adherence to medication. This study aimed to explore the barriers and facilitators of patients' adherence to antidepressants among outpatients with MDD. METHODS: Semi-structured and individual in-depth interviews were conducted among patients with MDD who were taking antidepressants, in the psychiatric clinic of a government-run hospital in Malaysia. Participants were purposively sampled from different genders and ethnicities. Interviews were conducted using a validated topic guide, and responses were audio-recorded, transcribed verbatim, checked, and analyzed using the grounded theory approach. RESULTS: A total of 30 patients were interviewed. Forty different themes and sub-themes were identified which were conceptually divided into two distinct categories related to barriers and facilitators to adherence. The barriers were: patient-specific, medication-specific, healthcare provision and system, social-cultural, and logistics. The facilitators were: having insight, perceived health benefits, regular activities, patient-provider relationship, reminders, and social support networks. CONCLUSIONS: Patient-specific barriers and medication side effects were the major challenges for adhering to treatment. Perceived health benefits and having insight on the need for treatment were the most frequently cited facilitators. Targeted interventions should be developed to address the key barriers, and promote measures to facilitate adherence in this group of patients.

Drug-drug Interaction-related Uncontrolled Glycemia.

CONTEXT: The literature of drug-drug interaction (DDI)-related uncontrolled causality, and preventability of DDI-induced UCG (HbA1c >7%) in outpatients glycemia (UCG) among outpatients with Type 2 diabetes mellitus is still limited. AIMS: The aim of this study is to identify the prevalence, mechanism, severity, with Type 2 diabetes. SETTINGS AND DESIGN: A cross-sectional study was conducted in Penang General Hospital. METHODS: A computerized system for DDI checking was used to assess the severity and mechanism of DDIs. Drug interaction probability scale was used to evaluate the likelihood of DDIs. Preventability of DDIs has been determined by the instrument of Hallas. The UCG prevalence related to DDIs was further assessed. STATISTICAL ANALYSIS USED: SPSS 21.00 was used in this study. RESULTS: From 425 outpatients with HbA1c% test, their mean age was 58.7 ± 12.8 years. Only 225 (52.9%) cases had controlled glycemia while 200 (47.1%) cases with UCG. They had multiple comorbidities, with a mean number of 3.8 ± 2.2/patient and often prescribed with multiple medications, with a mean number of 6.33 ± 4.67/patient. It has been detected that 86 DDIs causing UCG in 46 patients (23%) with range of (1 - 4) DDIs per patient. Drugs with DDI-induced UCG were as follows: diuretics (79%), salbutamol (9.2%), cortisones (5.8%), and others (6%). The majority of these DDIs were categorized as possible (77.9%) and preventable (37%). CONCLUSION: Nearly one-quarter of UCG was induced by DDIs; most of these DDIs are possible, and more than one-third are preventable. It was concluded that thiazide diuretics have the highest prevalence of DDI-related UCG.