Pharmacy College

Objective To compare the efficacy of dexmedetomidine versus morphine as a sedative/analgesic among post-operative cardiac surgery patients. Method A randomized controlled open-label study was performed at the cardiothoracic intensive care unit of Penang Hospital, Malaysia. A total of 28 patients who underwent cardiac surgeries were randomly assigned to receive either dexmedetomidine or morphine. Both groups were similar in terms of preoperative baseline characteristics. Efficacy measures included sedation scores and pain intensity and requirements for additional sedative/analgesic. Mean heart rate and arterial blood pressure were used as safety measures. Other measures were additional inotropes, extubation time and other concurrent medications. Results The mean dose of dexmedetomidine infused was 0.12 [SD 0.03] μg kg−1 h−1, while that of morphine was 13.2 [SD 5.84] μg kg−1 h−1. Dexmedetomidine group showed more benefits in sedation and pain levels, additional sedative/analgesic requirements, and extubation time. No significant differences between the two groups for the outcome measures, except heart rate, which was significantly lower in the dexmedetomidine group. Conclusion This preliminary study suggests that dexmedetomidine was at least comparable to morphine in terms of efficacy and safety among cardiac surgery patients. Further studies with larger samples are recommended in order to determine the significant effects of the outcome measures.

Background: Sufficient evidence concludes that tobacco smoking is strongly linked to tuberculosis (TB). It was suggested that a considerable proportion of the global burden of TB may be attributable to smoking. This study aimed to document the prevalence of smoking among newly diagnosed TB patients and to learn about their tobacco use knowledge and attitudes. Methods: Data on smoking prevalence were obtained based on reviews of routinely collated data from January through December 2008 in the state of Penang. The study setting comprised of five chest clinics located within Penang and Wilayah Persakutuan Kuala Lumpur health districts, Malaysia. A validated 58-item questionnaire was used to assess the tobacco use knowledge and attitudes of those TB patients who were smokers. Results: Smoking status was determinant in 817 of 943 new cases of TB during study period. Of this, it was estimated that the prevalence rates of current and ex-smoking among TB patients was 40.27% (329/817) and 13.95% (114/817), respectively. Of 86 cigarette smokers who were eligible for a larger project, 93% responded to the survey. The mean (±SD) total score of tobacco use knowledge items was 4.23±2.66 (maximum possible score=11). More than half of the participants (51.3%) were moderately dependent on nicotine and less than half (47.5%) had knowledge about the body system on which cigarette smoking has the greatest negative effect. The majority wrongly believed that smokeless tobacco can increase athletic performance (60%) and that it is a safe and harmless product (46.2%). However, an overwhelming proportion (>80%) of the patients believed that: tobacco use is dangerous to health and that smokers are more likely to die from heart disease when compared with nonsmokers. The use of smokeless tobacco was moderately prevalent among the participants with 28.8% reporting ever snuffed, but the use of cigar and pipe was uncommon. Conclusion: Smoking prevalence rate was high among patients with TB in Malaysia. These patients generally had deficiencies in knowledge of tobacco use and its health dangers, but had positive attitudes against it. Efforts should be geared towards reducing tobacco use among this population due to its negative impact on TB treatment outcomes.

Background: There is sufficient evidence to conclude that tobacco smoking is strongly linked to tuberculosis (TB) and a large proportion of TB patients may be active smokers. In addition, a previous analysis has suggested that a considerable proportion of the global burden of TB may be attributable to smoking. However, there is paucity of information on the prevalence of tobacco smoking among TB patients in Malaysia. Moreover, the tobacco-related knowledge, attitudes, and behaviors of TB patients who are smokers have not been previously explored. This study aimed to document the prevalence of smoking among newly diagnosed TB patients and to learn about the tobacco use knowledge and attitudes of those who are smokers among this population.

Study objective To determine the incidence of and the risk factors associated with hyperkalemia, induced by ACEI–drug interactions among cardiac patients. Setting Five medical and cardiology wards of a tertiary care center in Malaysia. Subjects Five hundred cardiac inpatients, who received ACEIs concomitantly with other interacting drugs. Method This was a prospective cohort study of 500 patients with cardiovascular diseases admitted to Penang Hospital between January to August 2006, who received ACEIs concomitantly with other interacting drugs. ACEI–drug interactions of clinical significance were identified using available drug information resources. Drug Interaction Probability Scale (DIPS) was used to assess the causality of association between ACEI–drug interactions and the adverse outcome (hyperkalemia). Main outcome measure Hyperkalemia as an adverse clinical outcome of the interaction was identified from laboratory investigations. Results Of the 489 patients included in the analysis, 48 (9.8%) had hyperkalemia thought to be associated with ACEI–drug interactions. Univariate analysis using binary logistic regression revealed that advanced age (60 years or more), and taking more than 15 medications were independent risk factors significantly associated with hyperkalemia. However, current and previous smoking history appeared to be a protective factor. Risk factors identified as predictors of hyperkalemia secondary to ACEI–drug interactions by multi-logistic regression were: advanced age (adjusted OR 2.3, CI 1.07–5.01); renal disease (adjusted OR 4.7, CI 2.37–9.39); hepatic disease (adjusted OR 5.2, CI 1.08–25.03); taking 15–20 medications (adjusted OR 4.4, CI 2.08–9.19); and taking 21–26 medications (adjusted OR 9.0, CI 1.64–49.74). Conclusion Cardiac patients receiving ACEIs concomitantly with potentially interacting drugs are at high risk of experiencing hyperkalemia. Old age, renal disease, hepatic disease, and receiving large number of medications are factors that may significantly increase their vulnerability towards this adverse outcome; thus, frequent monitoring is advocated.

Objectives:  To highlight therapeutic controversies, and present a critical review of the most recent evidence on the management of heparin-induced thrombocytopenia (HIT).Data sources:  A MEDLINE search from October 1996 until October 2006 was carried out. Pertinent literature was identified and other references identified from the bibliographic citations of the articles identified on MEDLINE.Study selection:  Articles related to the treatment of HIT including meta-analyses, systematic reviews, critical reviews, randomized and non-randomized trials, as well as case-reports, were reviewed.Results and conclusion:  The diagnostic and therapeutic dilemmas associated with HIT can be overwhelming and call for an evidence-based approach in the management of this frequently fatal event. HIT is associated with significant morbidity and mortality. The evidence suggests when heparin is stopped, alternative anticoagulant therapy with one of the newer agents such as lepirudin and argatroban is of benefit in avoiding deaths and morbidity.

Objectives:  To report a case of early-decompensated liver cirrhosis secondary to discontinuation of penicillamine therapy in a patient with Wilson's disease.Case summary:  A 33-year-old Chinese female patient was diagnosed with Wilson's disease, for which penicillamine 250 mg p.o. once daily was prescribed. However, the patient developed intolerance and penicillamine was discontinued without alternative treatment. Five months later, she developed decompensated liver cirrhosis with hepatic encephalopathy. Eventually, the patient died because of the complications of sepsis and decompensated liver failure.Discussion:  Chelating agent is the mainstay of treatment in Wilson's disease, which is an inherited disorder of hepatic copper metabolism. Therapy must be instituted and continued for life once diagnosis is confirmed. Interruption of therapy can be fatal or cause irreversible relapse. Penicillamine given orally is the chelating agent of first choice. However, its unfavourable side-effects profile leads to discontinuation of therapy in 20–30% of patients. In most case reports, cessation of penicillamine without replacement treatment causes rapid progression to fulminant hepatitis, which is fatal unless liver transplantation is performed.Conclusion:  In this, we highlight a case of discontinuation of penicillamine in a patient with Wilson's disease without substitution with alternative regimen. This was caused by unavailability of the alternative agents such as trientine in our country. Consequently, the patient progressed to decompensated liver cirrhosis with encephalopathy and eventually passed-away within 5 months. One recent study supports a combination of trientine and zinc in treating patient with decompensated liver cirrhosis. This combination is capable of reversing liver failure and prevents the need of liver transplantation. Both trientine and zinc are not registered in Malaysia. Therefore, liver transplantation was probably the only treatment option for this patient. Hence, non-availability of orphan drugs in clinical practice is certainly a subject of serious concern. Systems for better management of patients with rare diseases need to be instituted by all the institutions concerned.

Objective: The primary objective of this study was to assess and compare the knowledge of diabetes mellitus possessed by patients with diabetes and healthy adult volunteers in Penang, Malaysia. Method: A cross-sectional study was conducted from 20 February 2006 to 31 March 2006. We randomly selected 120 patients with diabetes mellitus from a diabetic clinic at the General Hospital Penang, Malaysia and 120 healthy adults at a shopping complex in Penang. Each participant was interviewed face-to-face by a pharmacist using a validated questionnaire, and they were required to answer a total of 30 questions concerning knowledge about diabetes mellitus using Yes, No or Unsure as the only response. Results: The results showed that patients with diabetes mellitus were significantly more knowledgeable than the healthy volunteers about risk factors, symptoms, chronic complications, treatment and self-management, and monitoring parameters. Educational level was the best predictive factor for diabetes mellitus and public awareness. Conclusion: Knowledge about diabetes mellitus should be improved among the general population. Practice implications: This study has major implications for the design of an educational programme for diabetics and a health promotion programme as a primary prevention measure for the healthy population in general, and especially for those at high risk. The results could be useful in the design of future studies for evaluating patients' and the general public's knowledge about diabetes mellitus. #

Background The association between tobacco smoking and tuberculosis (TB) is increasingly coming to light and the literature is laden with the evidence of this association. However, only a few observational studies specifically investigated the association between smoking and TB treatment outcomes. Aim and methods The present study aims to determine the prevalence of smoking among TB patients in Penang and to compare the treatment outcomes between smoking and non-smoking TB patients. A retrospective estimate of smoking prevalence among patients with TB and a retrospective cohort study comparing smoking and non-smoking TB patients with regards to treatment outcomes was conducted. The data were extracted from medical records of newly diagnosed TB patients who registered at a chest clinic at a tertiary care hospital in the state of Penang, Malaysia from January 2006 to June 2008. Results The prevalence of ever-smoking among TB patients was 53.4%. Smoking was significantly associated with male gender, alcohol use, and intravenous drug use (IVDU). Ever smokers had increased likelihood of treatment failure (OR 7.48), default (OR 7.17) and were less likely to be cured (OR 0.34). After controlling for the effects of confounders using multivariate logistic regression, ever smokers were still less likely to be cured (aOR 0.31) and more likely to default treatment (aOR 3.24). Dying from TB did not reach statistical significance. Conclusion Prevalence of smoking was high among TB patients in Malaysia. This study further reaffirms that smoking is an independent predictor of poor TB treatment outcomes and prognosis.

Background: Gastrointestinal parasites contribute significantly to morbidity and mortality in the developing world. This study provides an analysis of demographic factors that may affect specific parasite infestations. Our hypothesis was that young age, wet season, female gender, and severe malnutrition all positively correlate with increased rates of parasitic infection.

Objective To compare the efficacy of dexmedetomidine versus morphine as a sedative/analgesic among post-operative cardiac surgery patients. Method A randomized controlled open-label study was performed at the cardiothoracic intensive care unit of Penang Hospital, Malaysia. A total of 28 patients who underwent cardiac surgeries were randomly assigned to receive either dexmedetomidine or morphine. Both groups were similar in terms of preoperative baseline characteristics. Efficacy measures included sedation scores and pain intensity and requirements for additional sedative/analgesic. Mean heart rate and arterial blood pressure were used as safety measures. Other measures were additional inotropes, extubation time and other concurrent medications. Results The mean dose of dexmedetomidine infused was 0.12 [SD 0.03] μg kg−1 h−1, while that of morphine was 13.2 [SD 5.84] μg kg−1 h−1. Dexmedetomidine group showed more benefits in sedation and pain levels, additional sedative/analgesic requirements, and extubation time. No significant differences between the two groups for the outcome measures, except heart rate, which was significantly lower in the dexmedetomidine group. Conclusion This preliminary study suggests that dexmedetomidine was at least comparable to morphine in terms of efficacy and safety among cardiac surgery patients. Further studies with larger samples are recommended in order to determine the significant effects of the outcome measures.

Background: Sufficient evidence concludes that tobacco smoking is strongly linked to tuberculosis (TB). It was suggested that a considerable proportion of the global burden of TB may be attributable to smoking. This study aimed to document the prevalence of smoking among newly diagnosed TB patients and to learn about their tobacco use knowledge and attitudes. Methods: Data on smoking prevalence were obtained based on reviews of routinely collated data from January through December 2008 in the state of Penang. The study setting comprised of five chest clinics located within Penang and Wilayah Persakutuan Kuala Lumpur health districts, Malaysia. A validated 58-item questionnaire was used to assess the tobacco use knowledge and attitudes of those TB patients who were smokers. Results: Smoking status was determinant in 817 of 943 new cases of TB during study period. Of this, it was estimated that the prevalence rates of current and ex-smoking among TB patients was 40.27% (329/817) and 13.95% (114/817), respectively. Of 86 cigarette smokers who were eligible for a larger project, 93% responded to the survey. The mean (±SD) total score of tobacco use knowledge items was 4.23±2.66 (maximum possible score=11). More than half of the participants (51.3%) were moderately dependent on nicotine and less than half (47.5%) had knowledge about the body system on which cigarette smoking has the greatest negative effect. The majority wrongly believed that smokeless tobacco can increase athletic performance (60%) and that it is a safe and harmless product (46.2%). However, an overwhelming proportion (>80%) of the patients believed that: tobacco use is dangerous to health and that smokers are more likely to die from heart disease when compared with nonsmokers. The use of smokeless tobacco was moderately prevalent among the participants with 28.8% reporting ever snuffed, but the use of cigar and pipe was uncommon. Conclusion: Smoking prevalence rate was high among patients with TB in Malaysia. These patients generally had deficiencies in knowledge of tobacco use and its health dangers, but had positive attitudes against it. Efforts should be geared towards reducing tobacco use among this population due to its negative impact on TB treatment outcomes.

Background: There is sufficient evidence to conclude that tobacco smoking is strongly linked to tuberculosis (TB) and a large proportion of TB patients may be active smokers. In addition, a previous analysis has suggested that a considerable proportion of the global burden of TB may be attributable to smoking. However, there is paucity of information on the prevalence of tobacco smoking among TB patients in Malaysia. Moreover, the tobacco-related knowledge, attitudes, and behaviors of TB patients who are smokers have not been previously explored. This study aimed to document the prevalence of smoking among newly diagnosed TB patients and to learn about the tobacco use knowledge and attitudes of those who are smokers among this population.

Study objective To determine the incidence of and the risk factors associated with hyperkalemia, induced by ACEI–drug interactions among cardiac patients. Setting Five medical and cardiology wards of a tertiary care center in Malaysia. Subjects Five hundred cardiac inpatients, who received ACEIs concomitantly with other interacting drugs. Method This was a prospective cohort study of 500 patients with cardiovascular diseases admitted to Penang Hospital between January to August 2006, who received ACEIs concomitantly with other interacting drugs. ACEI–drug interactions of clinical significance were identified using available drug information resources. Drug Interaction Probability Scale (DIPS) was used to assess the causality of association between ACEI–drug interactions and the adverse outcome (hyperkalemia). Main outcome measure Hyperkalemia as an adverse clinical outcome of the interaction was identified from laboratory investigations. Results Of the 489 patients included in the analysis, 48 (9.8%) had hyperkalemia thought to be associated with ACEI–drug interactions. Univariate analysis using binary logistic regression revealed that advanced age (60 years or more), and taking more than 15 medications were independent risk factors significantly associated with hyperkalemia. However, current and previous smoking history appeared to be a protective factor. Risk factors identified as predictors of hyperkalemia secondary to ACEI–drug interactions by multi-logistic regression were: advanced age (adjusted OR 2.3, CI 1.07–5.01); renal disease (adjusted OR 4.7, CI 2.37–9.39); hepatic disease (adjusted OR 5.2, CI 1.08–25.03); taking 15–20 medications (adjusted OR 4.4, CI 2.08–9.19); and taking 21–26 medications (adjusted OR 9.0, CI 1.64–49.74). Conclusion Cardiac patients receiving ACEIs concomitantly with potentially interacting drugs are at high risk of experiencing hyperkalemia. Old age, renal disease, hepatic disease, and receiving large number of medications are factors that may significantly increase their vulnerability towards this adverse outcome; thus, frequent monitoring is advocated.

Objectives:  To highlight therapeutic controversies, and present a critical review of the most recent evidence on the management of heparin-induced thrombocytopenia (HIT).Data sources:  A MEDLINE search from October 1996 until October 2006 was carried out. Pertinent literature was identified and other references identified from the bibliographic citations of the articles identified on MEDLINE.Study selection:  Articles related to the treatment of HIT including meta-analyses, systematic reviews, critical reviews, randomized and non-randomized trials, as well as case-reports, were reviewed.Results and conclusion:  The diagnostic and therapeutic dilemmas associated with HIT can be overwhelming and call for an evidence-based approach in the management of this frequently fatal event. HIT is associated with significant morbidity and mortality. The evidence suggests when heparin is stopped, alternative anticoagulant therapy with one of the newer agents such as lepirudin and argatroban is of benefit in avoiding deaths and morbidity.

Objectives:  To report a case of early-decompensated liver cirrhosis secondary to discontinuation of penicillamine therapy in a patient with Wilson's disease.Case summary:  A 33-year-old Chinese female patient was diagnosed with Wilson's disease, for which penicillamine 250 mg p.o. once daily was prescribed. However, the patient developed intolerance and penicillamine was discontinued without alternative treatment. Five months later, she developed decompensated liver cirrhosis with hepatic encephalopathy. Eventually, the patient died because of the complications of sepsis and decompensated liver failure.Discussion:  Chelating agent is the mainstay of treatment in Wilson's disease, which is an inherited disorder of hepatic copper metabolism. Therapy must be instituted and continued for life once diagnosis is confirmed. Interruption of therapy can be fatal or cause irreversible relapse. Penicillamine given orally is the chelating agent of first choice. However, its unfavourable side-effects profile leads to discontinuation of therapy in 20–30% of patients. In most case reports, cessation of penicillamine without replacement treatment causes rapid progression to fulminant hepatitis, which is fatal unless liver transplantation is performed.Conclusion:  In this, we highlight a case of discontinuation of penicillamine in a patient with Wilson's disease without substitution with alternative regimen. This was caused by unavailability of the alternative agents such as trientine in our country. Consequently, the patient progressed to decompensated liver cirrhosis with encephalopathy and eventually passed-away within 5 months. One recent study supports a combination of trientine and zinc in treating patient with decompensated liver cirrhosis. This combination is capable of reversing liver failure and prevents the need of liver transplantation. Both trientine and zinc are not registered in Malaysia. Therefore, liver transplantation was probably the only treatment option for this patient. Hence, non-availability of orphan drugs in clinical practice is certainly a subject of serious concern. Systems for better management of patients with rare diseases need to be instituted by all the institutions concerned.