EDITORIAL COMMITTEE PRINCIPAL ADVISER DR MOHD KHAIRI BIN YAKUB DIRECTOR OF HEALTH JOHOR, JOHOR STATE HEALTH DEPARTMENT TEL: 07-2245188 FAX: 07-2232603 EMAIL: [email protected] ADVISER MRS ROSIDAH MD DIN STATE DEPUTY OF HEALTH ( PHARMACY ) JOHOR, JOHOR STATE HEALTH DEPARTMENT TEL: 07-2272800FAX: 07-2236146 EMAIL: [email protected] CHIEF EDITOR DR BADRUL HISHAM BIN ABDUL SAMAD SENIOR PRINCIPAL ASSISTANT DIRECTOR (PUBLIC HEALTH) JOHOR STATE HEALTH DEPARTMENT TEL: 07-2245188 FAX: 07-2277577 EMAIL:[email protected] EDITORSDR HJH. MORNI BT ATAN DR SHEILA RANI RAMALINGAMDEPUTY DIRECTOR (MEDICAL) SENIOR PRINCIPLE ASSISTANT DIRECTOR (ORAL HEALTH)HOSPITAL SULTAN ISMAIL JOHOR STATE HEALTH DEPARTMENTTEL: 07-3565000 FAX: 07-3565034 TEL: 07-2245188 FAX: 07-2230467EMAIL: [email protected] EMAIL: [email protected] MRS KAMALIAH BT MAT SAMAN CHIEF PHARMACIST HOSPITAL PAKAR SULTANAH FATIMAH TEL: 06-9521901 FAX: 06-9526003 EMAIL: [email protected] SECRETARY MR ALI BIN ISMAIL SENIOR PRINCIPAL ASSISTANT DIRECTOR (PHARMACY) JOHOR STATE HEALTH DEPARTMENT TEL: 07-2272800FAX: 07-2236146 EMAIL: [email protected] MEMBERSMS LEE CHING YAN MR JEGATHESWARAN PANDERENGEN ASSISTANT DIRECTOR (PHARMACY)PRINCIPAL ASSISTANT DIRECTOR JOHOR STATE HEALTH DEPARTMENT TEL: 07-2272800FAX: 07-2236146(TRADITIONAL COMPLEMENTARY MEDICINE) EMAIL: [email protected]: 07-2211787 FAX: 07-2212787EMAIL:[email protected] MRS FAIZAH BINTI JURAIMI PRINCIPAL ASSISTANT DIRECTOR (HEALTH PROMOTION UNIT) TEL: 07-2224784FAX: 07-2238426 EMAIL: [email protected]
Volume 10 2012Contents1 Assessment Of Insulin Adherence And Insulin-related Knowledge Among Diabetic Patients In Hospital Sultan Ismail, Johor Bahru Teoh L.R, Lee C.Y, Wasli M.5 A Pilot study of Drug Administration Errors In A Male Medical Ward At Batu Pahat Hospital Ng Xin Yi, Nur Amalina Nasis, Nur Ezzati A. Rahman, Lee Chern Chyi, Chua Pei Ling13 Analysis On Evaluation Of Quality Of Life In Hypertensive Patients By Using Short Form 36 In The Muar District, Johor Mohd Anuar AR, Khadijah Ismail, Amran Maarof117 Study On Use Of Kaletra® (lopinavir/ritonavir) Among HIV Patients In HSAJB Ong M.P.19 Implementing Fly Control – Kluang Experience 2009, North Macap Rest & Relax Area (R&R) Norzihan MH, Zuhaida AJ, Mohd Zaki23 Evaluation Of Molars Restored With Glass Ionomer Cements In The School Dental Service In Kota Tinggi District Muz'ini M . Premaa S28 A Study Of Obesity Among Health Staff At Kulaijaya District Health Department (2012) Dr. Mohd Shaiful Ehsan B Shalihin, Poh Lin Chin, Misringaton33 Evaluation of laboratory outcomes of patients (INR) between clinician-managed Warfarin therapy and pharmacist-managed Warfarin Medical Adherence Therapy Clinic (W-MTAC) in HBP over 1 year Ali Umar Bin Ibrahim, Yvonne Koh Li Ling, Pn. Siti Khairaini Binti Rahim42 Polypharmacy Of Antihistamines In Cough And Cold Products Used Among Children Aged Below 6 Wong L.Y., Fajaratunur A.S, Zakiah A.R., Hazlinda A.H.,Goh P.T., Zakaria M.S., ZulRamli Z47 The Prevalence Of Hearing Impairment Among The Dental Staff In Kota Tinggi District, Johor Muz'ini M Thilaka C52 Prescription Intervention and Prescribing Errors Detected by Inpatient Pharmacy Unit in Hospital Segamat Mohd Syahrizam bin Ta'at, Lau Kok Hou60 A Pilot Study To Assess Patient's Knowledge, Metered-dose Inhaler (mdi) Techniques And Compliance To Treatment After Medication Therapy Adherence Clinic (mtac) Asthma Low Y.B., Tan W.L., Patricia Lim M.H., Yeo L.P64 A Study of The Effect of Home Water Filtration Systems On Fluoride Content of Drinking Water in Johor Loh KH, Yaacob H, Adnan N, Omar S, Jamaludin M69 Traumatic Abdominal Wall Hernia : A Johor Case Report YJ Lee, TT Yew, AC Chan71 Waterborne Bacillus Cereus Gastroenteritis Outbreak In Johor Bahru, Malaysia Badrul H.A.S., Roslinda A.R., Mohtar A., Siti Khatijah A.R., Zuraidah M., Shamshulbahrin S., Norazema S., Mustafa A., Mohd. Ghazali S., Zulfahmi K., Akmalina H., Zaiton Y., Maziah M.N.
Assessment Of Insulin Adherence And 1Insulin-related Knowledge Among DiabeticPatients In Hospital Sultan Ismail,Johor Bahru Volume 10Teoh L.R1, Lee C.Y2, Wasli M.3 20121,2,3 Hospital Sultan Ismail, Johor Bahru.BACKGROUND Insulin is one of the most commonly prescribedDiabetes mellitus is an important public health concern medications in the hospital as it can be the most effectiveboth nationally and internationally, due to the increase in drug to achieve glycemic control and prevent long-termits prevalence and its social and economic results, such as comorbidities. The invention of insulin pen devices (ieimpairment in productivity, quality of life and survival of HumaPen) offers safety, convenience and flexibility, withindividuals, early retirement, high treatment costs and higher acceptability by the patients especially among thecomplications.1,2 The World Health Organization elderly. The Joint Commission on Accreditation of(WHO) reported that 171 million people were living with Healthcare Organizations identified insulin as one of fivediabetes mellitus in the year 2000, and that amount is “high alert” medications that have the greatest risk ofestimated to double by the year 2030.3 In Malaysia, the causing injury to patients because of medication errors.13prevalence of type 2 diabetes for those aged above 30 Insufficient knowledge of insulin and diabetesyears was 14.9% in the year 2006. The overall prevalence management on the part of health care providersof diabetes increased by 80% over a decade (8.3% in contributes to errors in insulin use. Consequently, it mayNHMS II year 1996 vs 14.9% in NHMS III year 2006) lead to dangerous but preventable adverse patientrepresenting an average 8% rise per year.4 outcomes such as hyperglycemia and hypoglycemia.14 The present study focuses on patients' medicationAccording to World Health Organization Adherence adherence level and insulin-related knowledge; with the(2003) and Koneru et al. (2008), medication adherence ultimate goal of promoting effective and safe use ofcan be defined as the situation to which a person's insulin therapy by improving patients' insulin-relatedbehavior corresponds exactly with medical or health knowledge, minimizing insulin-related adverse effects,advice as directed. Noncompliance with prescribed and identifying important criteria to be concerned beforetreatment, especially medications, by patients increases running up Diabetes Medication Therapy Adherencethe cost of healthcare and the likelihood of admission to Clinic Hospital Sultan Ismail, Johor Bahru.the emergency room and hospital, and can lead toadditional illnesses or exacerbation of underlying disease METHODS(Jean et al., 2006). Poorly controlled diabetes is A descriptive cross-sectional study of insulin-relatedassociated with development of macro- and micro- knowledge among diabetic patients was conducted invascular complications. Therefore, intensive glycaemic Hospital Sultan Ismail, Johor Bahru from 1 May 2011control is important in decreasing microvascular and until 30 June 2011. The inclusion criteria were diabetesmacrovascular complications in type 1 and type 2 mellitus patients (either type I or type II diabetes mellitus)diabetes.5-7 Patients' adherence to medication regimens aged 18 years old and above, who had been usingis vital to achieve good glycaemic control. However, HumaPen (Humulin® R, Humulin® N or Humulin®adherence is still a challenge and many patients are 30/70) and who was able to read and answer thenoncompliant with their oral hypoglycaemic agents and questionnaire independently. The exclusion criteria wereinsulin.8 patients aged below 18 years old, patients who was unable to read and answer the questionnaireEvidence has proven that patient education improves independently, and mentally impaired, individuals withpatients' adherence and subsequently improves significant cognitive impairment and psychiatricglycaemic control.9 Pharmacists play a significant role in comorbidity.educating patients through routing counseling, which A questionnaire consisted of 2 parts was prepared. Part Ihelps to improve patient adherence.10 Several studies was designed is to obtain insulin adherence level by usinghave shown that collaboration of pharmacists with Morisky Scale. Morisky Scale consists of four-itemphysicians in diabetes care improved glycaemic validated adherence predictor scales, using close-endedcontrol.11,12 In Malaysia, pharmacists collaborate with questions with answer 'YER' or 'NO'. Part II consisted ofphysicians in diabetes care through Diabetes Medication 16 multiple-choice questions with a single best answer,Therapy Adherence Clinic (DMTAC). Penang Hospital is designed to evaluate patient's level of knowledge.the first centre to start the DMTAC program, which has Questions addressed topics including characteristics ofbeen operating since 2006 in a specialized diabetes different insulin (Humulin® R, N or 30/70) formulations,endocrine clinic. storage conditions, causes, symptoms and management of hypoglycemia or hyperglycemia. In addition, patients 1
were asked for information about their age, gender and and for those that answered partially correct and /orethnicity. incorrect were considered as presenting knowledgePilot tests were then given to 5 patients in out-patient deficit.department and 5 patients in medical or surgical wards ofHospital Sultan Ismail. Questions that appeared to be RESULTSambiguous during pilot testing were either corrected or Study populationremoved from the final version of the questionnaire. The A total of 85 completed questionnaires were received andquestionnaires were then distributed to the diabetic analyzed; 60 from out-patient department, 21 frompatients who came and refilled their prescriptions at medical wards and 4 from orthopedic wards. All of the 85outpatient department, as well as those admitted to participants, 2% (n=2) were of age 18-29 years old, 12%medical or orthopedic wards of Hospital Sultan Ismail (n=10) aged 30-39 years old, 9% (n=8) aged 40-49 yearsduring the period of research study after informed old, 48% (n=40) aged 50-59 years old, and 29% (n=25)consent was obtained. Participants were not permitted to aged 60 years old and above. 54% (n=46) were femalesask questions or refer to reference materials such as and 46% (n=39) were males. As for the ethnicity, 46%product leaflet. A total of 85 questionnaires were (n=39) were Malays, 33% (n=28) were Chinese, 21%distributed and collected. (n=18) were Indians.By using Morisky Scale, the participants can be Level of insulin adherencecategorized as low, moderate or high adherence. Score 1 Table 1 showed the results for each item in the Moriskywas given for every 'YES' answer and score 0 was given Scale. 36% (n=31) of the patients reported that they hadfor every 'NO' answer. Total score of 0 indicated high been forgotten to take insulin, 32% (n=27) reportedadherence; 1 to 2 indicated moderate adherence whereas careless at times about taking the insulin, 15% (n=13)3 to 4 indicated low adherence (Guilera et al., 2006). For reported stop taking medication sometimes when theythose participants that answered all categories correctly feel better and 5% (n=4) sometimes stop takingwere considered as having acquired knowledge on insulin medication when they feel worse. 4-items in Morisky Scale Yes (%) No (%) 36 64 1. Do you ever forget to take your insulin? 32 68 2. Are you careless at times about taking your 15 85 insulin? 3. When you feel better do you sometimes stop taking your insulin? 4. Sometimes if you feel worse when you take 5 95 the insulin, do you stop taking it? Table 1 : Morisky Scale to Evaluate Level of Insulin AdherenceResults from Morisky Scale showed that 64% (n=54) of Level of insulin-related knowledgethe diabetic patients were classified as high adherence,followed by 35% (n=30) as moderate adherence; and 1% For the 16 knowledge-based questions, results(n=1) as low adherence. showed that 11% (n=9) of the patients scored 100%, where all of the questions were answered correctly; 50% Level of insulin adherence (n=43) scored 75-99% and 39% (n=33) scored 50-74%. None of the patients scored less than 50%. 1%35% Overall scoring marks 64% 39% 0% 11% 100% 50% 75-99% High adherence Moderate adherence Low adherence 50-74% < 50%Figure 1: Proportion of Patients with High, Moderate and Low Adherence Figure 2: Overall Scoring Marks for Level of Insulin-Related Knowledge 2
Knowledge on insulin characteristics frequency of administration; and promote patients' adherence to insulin therapy. Self-recognition of 68% of the patients were able to differentiate hypoglycemia or hyperglycemia through monitoring oftheir insulin based on the colour of the strip at the bottom symptoms and blood glucose measurement; as well asof Humulin® cartridge whereas 78% were able to proper management of hypoglycemic symptoms isdifferentiate their insulin based on the appearance of important to decrease the risk of hospitalization andHumulin® formulations. 58% of the participants mortality.presented adequate knowledge on the appearance ofHumulin® formulations which indicates of instability. Upon collecting each completed questionnaire, brief explanation and discussion around the rationaleKnowledge on insulin storage and its expiry date behind each correct answer were given. This helps to increase participant attention and interest, achieve Majority of the patients (85%) understood the effective and safe use of insulin therapy, and decreaseproper storage conditions for unopened and opened incidence of insulin-related reactions besides improvingHumulin® cartridge. However, Only 37% (n=31) of the patient adherence to insulin therapy, clinical outcome andparticipants presented with knowledge that Humulin® quality of life. However, there are some limitations in thiscartridge may be used for up to 28 days once in use. study. Study sample and data were obtained from a single hospital and may not be representative of the wholeKnowledge on symptoms and management of Malaysian population with diabetes mellitus. Reliabilityhypoglycemia or hyperglycemia of Morisky Scale was compromised because of the dichotomous of the response scale and the small number 76% of the patients understood that of items in the questions (Voils et al., 2005).hypoglycemia is brought about by taking too muchinsulin and hyperglycemia is brought about by stop taking Using this study as a pre-test may be effective toinsulin or taking less insulin than prescribed. 85% evaluate the level of insulin adherence and insulin-relatedreported that hypoglycemic symptoms may include knowledge among diabetic patients in Hospital Sultansweating, hunger and dizziness. Majority of the Ismail before establishment of Diabetes MTAC.participants 93% reported that mild to moderate Moreover, it can be used to identify important criteria tohypoglycemia can be treated by eating or drinking sugar- be concerned while running up Diabetes MTAC incontaining foods. All of the participants claimed that Hospital Sultan Ismail and understand how diabetesblood glucose monitoring helps patients to confirm education can best be optimized. In this sense, futurehypoglycemia or hyperglycemia immediately. studies should be carried out to assess the impact of established Diabetes MTAC towards diabetic patients'DISCUSSION therapeutic outcome. Lack of knowledge on the medication has had a The present study showed that majority of thestrong impact in health and quality of life of people patients showed high adherence to insulin therapy andespecially those with one or more chronic health most of them were presented with insulin-relatedconditions.16 Clear and accurate information regarding knowledge as none of the patients scored less than 50%.insulin therapy to control diabetes mellitus provided by Therefore, the future establishment of pharmacist-qualified health professionals may encourage patients to managed Diabetes Medication TherapyAdherence Clinicself care and adherence to insulin therapy besides in Hospital Sultan Ismail may aim to improve patients'promoting safe and effective use of insulin. Therefore, glycaemic control and therapeutic outcome via HbA1cpharmacists play vital role in educating patients on ways and fasting blood glucose (FBG) monitoring.to differentiate various types of Humulin® formulations,proper storage conditions for unopened and opened CONCLUSIONHumulin® cartridge, possible insulin-related reactions In summary, 64% of the diabetic patients were reported assuch as hypoglycemia and hyperglycemia and how to high adherence, followed by 35% as moderate adherence;treat these effectively. A well-structured Diabetes and 1% as low adherence. Majority of the patients wereMedication Therapy Adherence Clinic may fill the gaps presented with insulin-related knowledge. Health carein knowledge of patients with diabetes mellitus for better professionals including physicians, pharmacists, nursetherapeutic outcome. practitioners and endocrinologists play vital role in educating diabetic patients regarding insulin-related Knowledge on the appearance of Humulin® knowledge to improve their insulin adherence level. Thecartridge and formulations helps patients to differentiate future establishment of pharmacist-managed Diabetestheir insulin type without affected by the problem of poor Medication Therapy Adherence Clinic in Hospital Sultanvisual acuity as diabetic retinopathy is one of the common Ismail may aim to improve patients' glycaemic controldiabetes complications associated with long-standing and therapeutic outcome via HbA1c and fasting blooddiabetes mellitus.15 Besides that, knowledge on the glucose (FBG) monitoring since majority of the diabeticappearance of Humulin® formulations which indicates of patients showed high adherence to insulin therapy andinstability and proper storage conditions for unopened were presented with insulin-related knowledge.and opened Humulin® cartridge is required to ensureeffective and safe use of insulin therapy for positivetherapeutic outcome. Information on the causes ofinsulin-related reactions may improve patients'awareness on insulin therapy regarding the dose and 3
REFERENCES 9. Goudswaard AN, Stolk RP, Zuithoff NP, de Valk HW, Rutten GE. Long-term effects of self-management1. Sociedade Brasileira de Diabetes. Tratamento e education for patients with Type 2 diabetes takingacompanhamento do diabetes mellitus: diretrizes da maximal oral hypoglycaemic therapy: a randomized trialSociedade Brasileira de Diabetes. Rio de Janeiro: in primary care. DiabetDiagraphic; 2006. Med. 2004;21(5):491-496.2. White paper on the prevention of type 2 diabetes and 10. Lindenmeyer A., Hearnshaw H., Vermeire E., Vanthe role of the diabetes educator. Diabetes Educ. Royen P., Wens J., Biot Y. Interventions to improve2002;28(6):964-8, 970-1. adherence to medication in people with type 2 diabetes3. Wild S, Roglic G, Green A, Sicree R, King H. Global mellitus: a review of the literature on the role ofPrevalence of Diabetes. Estimates for the year 2000 and pharmacists. J Clin PharmTher. 2006;31(5):409-419.projections for 2003. Diabetes Care. 2004;27:1047-1053. 11. Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk4. Mafauzy M. Diabetes Mellitus in Malaysia. Med J Van JT, Assendelft WJ. Interventions to improve theMalaysia. 2006;61(4):397-398. PREVALENCE OF management of diabetes in primary care, outpatient, andDIABETES MELLITUS IN MALAYSIA IN 2006– community settings: a systematic review. Diabetes Care.RESULTS OF THE 3RD NATIONAL HEALTH AND 2001;24:1821-1833.MORBIDITYSURVEY (NHMS III)[cited 2011 Feb 12].Available from: 12. Ramser KL, Sprabery LR, George CM, Hamann GL, Vallejo VA, Dorko G.S, Kuhl DA. Physician-pharmacist5. The DCCT Research Group. The effect of intensive collaborationtreatment of diabetes on the development and progressionof longterm complications in insulin-dependent diabetes 13. JCAHO suggests ways to prevent medical errors.mellitus. N Engl J Med. 1993;329(14):977-986. Healthcare Risk Man 22:19 –20, 20006. U.K. Prospective Diabetes Study Group. Association 14. Smith WD, Winterstein AG, Johns T, Rosenberg E,of glycaemia with macrovascular and microvascular Sauer BC: Causes of hyperglycemia and hypoglycemia incomplications of type 2 diabetes (UKPDS 35): adult inpatients. Am J Health Syst Pharm 62:714 –719,prospective observational study. BMJ. 20052000;321(7258):405-412.7. U.K. Prospective Diabetes Study Group. Intensive 15. The Wisconsin epidemiologic study of diabeticblood-glucose control with sulphonylureas or insulin retinopathy. III. Prevalence and risk of diabeticcompared with conventional treatment and risk of retinopathy when age at diagnosis is 30 or morecomplications in patients with type 2 diabetes (UKPDS years.[cited 2011 May 5]. Available33). Lancet. 1998;352(9131):837-853. from:http://www.ncbi.nlm.nih.gov/pubmed/6367725/8. Cramer JA. A systemic review of adherence with 16. Williams B. Medication education. Nurs Times.medications for diabetes. Diabetes Care. 1991;87(29):50-2. (Acta)2004;27(5):1218-1224. 4
A Pilot study of Drug Administration 2 Errors In A Male Medical Ward Volume 10 At Batu Pahat Hospital 2012Ng Xin Yi, Nur Amalina Nasis, Nur Ezzati A. Rahman, Lee Chern Chyi, Chua Pei Ling1.1 Background of Study 1.3 Significance of StudyAccording to the National Coordinating Council for This study is significant because administration errors areMedication Error Reporting and Prevention more likely to reach patients and they have a high(NCCMERP), medication error is defined as “any potential for causing patient harm. Drug administrationpreventable event that may cause patient harm or lead to errors appear to be a major source of iatrogenic harm toinappropriate medication use while the medication is in hospitalized patients [16]. Drugs are prepared andthe control of the health care professional, patient, or administered to in-patients by the nurses in the wards.consumer. Such events may be related to professional This study will increase the awareness of ward staffpractice, health care products, procedures, and systems especially nurses concerning such problems.including prescriptions; order communication; productlabeling; packaging; and nomenclature; compounding; 1.4 Aim of Studydispensing; distribution; administration; education; The aims of the study are to quantify the type andmonitoring; and use” [1,2]. The occurrence of the frequency of drug administration errors committed at themedication errors is not a new issue. In fact it is a common medical wards and to identify contributing factorsoccurrence faced by health care teams globally. In the towards this blunder.United States of America (USA), there wereapproximately 1%-2% of patients harmed by such errors 1.4.1 Objectives[4] whereas 3.7% hospitalization in New York, USA in 1. To identify the frequency of drug1991 was caused by such medication errors with 13.6%leading to death [5]. Medication errors can be classified administration errors at Medical Ward No. 3into prescribing, dispensing and administration errors. 2. To identify the drug administration errorAmong these errors, administration mistakes account for 3. To identify factors which contribute to drugthe majority of events.Drug administration errors are the second most frequent administration errortype of medication errors after prescribing errors. A drug 4. To identify the types of drug commonlyadministration error is a discrepancy between the drugtherapy received by the patient and the drug therapy wrongly administeredintended by the prescriber [9]. Administration error is theadministration of a dose of medication that deviates from 2.1 Definitionthe prescription, as written on the patient medication Drug administration is an activity that is prone to errorschart, or from standard hospital policy and procedures. due to rapid development in medical technology becauseThis includes errors in the preparation, and of different types of drugs and increasing complexity ofadministration of intravenous medicines in the ward. medical devices as well as the number of medicationsThese errors can be further classified into wrong drugs; being introduced into the market [9, 12]. There are alsowrong route; wrong dose; wrong patient; wrong timing of various routes of administration, different dosages,drug administration; a contra-indicated drug for that dosage forms and dosing regimens which are oftenpatient; wrong site; wrong drug form; wrong infusion changed according to patient's clinical condition andrate; expired medication date; or prescription error. diagnostic test results. Lack of awareness for those various route, dosage and regimen of medication by the1.2 Statement of Problem staff or nurses during drug administration can lead toMedication errors (prescribing, dispensing and errors.administration errors) were an important cause of patient Drug administration error is “defined as a discrepancymorbidity and mortality [1]. Administration errors are a between the drug therapy received by the patient and thatcommon sub-type of medication errors and accounted for intended by the prescriber or according to standard34% of errors in the study carried out by Bates et. a.l, hospital policies and procedures” [5, 9, 13] . Haw et al.,1995. [23] 2007 also defined drug administration error as aIn the study carried out by Leape and his colleagues, “deviation from a prescriber's valid prescription or theadministration errors were found to account for 38 hospital's policy in relation to drug administration,percent of drug-related errors. [6] [7] including failure to correctly record the administration of a medication”. 5
2.2 Incidence of DrugAdministration 2.4.1 Incorrect TimeThe study of drug administration that was conducted at An incorrect time error was defined as the administrationSt. Andrew's Hospital, Northampton, United Kingdom of drugs more than 60 minutes before or after thehad shown a total of 369 errors committed per 1423 doses scheduled administration time by Barker et al, 2002 [5].(25.9%). The independent pharmacist who reviewed the Some studies count a drug delivered 30 minutes late and ifmedication charts detected 148 administration errors. The the drug delayed until the next dose is due as a wrong-types of errors detected were as follows: 133 omissions, 9 time error [9].unauthorized extra doses, 5 wrong times and 1administration of a discontinued item [17]. 2.4.2 Incorrect DoseBarker et al, 2002 conducted a study on hospitals Incorrect dose was defined as any dose of preformedaccredited by the Joint Commission on Accreditation of dosage units (such as tablets) that contained the wrongHealthcare Organizations, non accredited hospitals, and strength or number. Incorrect dose for an injectableskilled nursing facilities in Georgia and Colorado. In the product means any dose that is ±10% or more different36 institutions, 19% of the doses (605/ 3216) erred. The from the correct dosage and if any other dosage form, thenmost frequent errors by category were wrong time (43%), any dose that was ±17% or more of the correct dose [5]. Inomission (30%), wrong dose (17%), and unauthorized the case of ointments, topical solutions, and sprays, andrug (4%). Seven percent of the errors were judged error occurs only if the medication order expresses thepotential adverse drug events. dose quantitatively for examples 1 inch of ointment orIn a local study by S.S.Chua et al, 2009 which was two 1-s sprays [13]. Medications must be administered atconducted at the hematology ward of a teaching hospital the correct time to ensure therapeutic serum levels [15].in Malaysia, an error rate of 11.4% (95% CI 9.5–13.3)was established. Of the 127 doses with errors, eight had 2.4.3 Unauthorized or Unordered Drugtwo types of errors, giving a total of 135 administration Unauthorized or unordered drug defined as theerrors. administration of a dose of medication that had never been ordered for that patient [5]. This category includes a2.3 Classification of Medication Error Severity drug given to the wrong patient, administration of anHaw et al, 2007 rated the error severity based on a five- unordered drug, duplicate doses and extra doses notpoint scale which had previously been used in a ordered but administered, and a dose given outside amedication error research and entails the following :- stated set of clinical parameters [8, 13].Grade 1—errors or omissions of doubtful or negligibleimportance; Grade 2—errors or omissions likely to result 2.4.4 WrongAdministration Techniquein minor adverse effects or worsening condition; Grade Wrong administration technique errors comprised all3—errors or omissions likely to result in serious effects or errors concerning the administration technique: crushingrelapse; Grade 4—errors or omissions likely to result in errors (crushing a tablet that should not be crushedfatality; Grade X—unreadable (due to lack of clinical and because it is enteric coated),unsupervised intake ofother information). medication by the patient (for example patient withAdministration errors were classified into 9 classes of Alzheimer's disease need to be supervised to takeseriousness from the National Coordinating Council for medication), wrong technique for administeringMedication Error Reporting and Prevention inhalation preparations (not shaking the pressurized(NCCMERP) taxonomy of medication errors: A—an metered inhaler before use), wrong technique forerror has been made but the medication does not reach the dissolving effervescent tablets (crushing instead ofclient; B—an error has been made and the medication dissolving in water and administering after all bubblesreaches the client, but no harm is done because the have disappeared) [14]. Wrong administration techniquemedication is not administered; C—medication is a situation which a drug is given via the correct routeadministered but no harm; D—an error has been made and site but improper technique is used [13].which results in an increased frequency of monitoring,but no harm is done; E—an error has been made resulting 2.4.5 Omission Errorin temporary harm necessitating treatment; Van Den Bemt et al, 2009 stated that omission errorsF—temporary harm resulting in an increased length of consisted of errors regarding not giving the medication tohospital stay (in hospitalization of the client); the patient, which can arise by forgetting theG—permanent damage; H—client nearly dies; I—an administration or by giving the medication to the wrongerror has been made which results in the death of the patient. However, if the patient refused to take theclient [19]. medication, no error has occurred. Likewise, if the dose is not administered because of recognized2.4 Types of Drug Administration Errors Usually contraindications, no error has occurred. (Greengold et al,Occur 2003). Omissions were detected by comparing theDrug administration errors can be classified into 11 medications administered at a given time with doses thatcategories which are incorrect time, incorrect should have been given at that time based on theadministration technique, unauthorized or unordered physician's written order and protocols (Barker et al,drug, incorrect preparation, incorrect dose, omission 2002).errors, incorrect rate, incorrect drug, deteriorated drug,extra dose, incorrect drug and other errors which were notspecified [5, 12]. 6
2.4.6 Incorrect Rate drug administration errors. Individual staff characteristicIncorrect rate defined as administration of a drug at the (knowledge and skills) is one of the reasons that can causewrong rate, the correct rate being that given in the drug administration errors. Wakefield et al stated thatphysician's order or as established by hospital policy. The individual staff characteristics such as lack of knowledgecytarabine to infuse over 3 hours but infused for 2 hours of the patient, or the patient's diagnosis, and the names,and also vancomycin to infuse over 2 hours but infused purposes, and correct administration of the medicationover 30 minutes were the result of incorrect rate in the are the factors that contribute to medication errors forstudy of drug administration error by S.S.Chua et al, example, knowledge of pharmacology will allow the2009. The most common type of administration error in nurse to correlate it with the disease, diagnostic testthe ward was wrong rate error (73 out of 83 injections) results and clinical status [9]. Thus it will improve thewhich were given faster than recommended [20]. detection errors and promote the detection of contraindications and adverse effects.2.4.7 Incorrect Preparation Lack of attention to safeguards intended to prevent errorsIncorrect preparation is also one type of administration in medication administration procedures as a result oferror. Greengold et al, 2003 stated that incorrect failure to comply with policies and procedures is the mainpreparation of the medication dose include incorrect factor in drug administration errors [8, 9]. For example,dilution or incomplete reconstitution, not shaking a staff did not check patient identification, allergysuspension and mixing drugs that are physically or identification wristbands, medication against thechemically incompatible. For example, when medication administration record (MAR) and receivingAmphotericin B is not properly diluted, some powder is medications late from the pharmacy [9]. When a nursestill left in the vial and thus, when a nurse bends the needle administers the medication, they must sign theto syringe the drug out of an ampoule, it will cause a spill medication chart to provide evidence that the medicationonto the floor [12]. has been administered to the patient. Signing the medication chart before the medication has been2.4.8 Incorrect Drug administered is a risk, as the patient may refuse theirIncorrect drug is an error in which medication was medication or forget to take them. Similarly, failure towrongly given to the patient and totally different from the sign when a medication has been administered creates theprescribed medication [10, 15]. This type of errors seems risk that another nurse may assume that it has not beento have high potential to cause harm to the patient. For administered, and repeat that dose [15]. Drugexample, hydrochlorothiazide instead of spironolactone administration errors can also be caused by the lack of[18] given and mefenamic acid 500 mg given instead of standard protocols for the administration of high-risktranexamic acid 500 mg [12]. These situations happened medications such as chemotherapeutic drugs andbecause nurses misread drug names and misread antiarrhythmics [8].medication file [12, 18] Failure or breakdown in communication is another factor that contributed to the drug administration errors. (Pepper2.4.9 Deteriorated Drug GA, 1995; Wakefield et al, 2005). These may includeUse of expired and unusable drugs in administration illegible handwriting, oral orders, transcription errors,drugs are errors in which deteriorated drugs can cause less use of abbreviations, incorrect interpretation ofor no effectiveness towards the treatment. physician's orders, failure to document medications given or omitted and unclear MARs. In spite of how accurate or2.4.10 Extra Dose complete a prescription is, it may be misinterpreted if itBarker et al, 2002 defined an extra dose as an error in cannot be read. The prescriber is the one who has awhich any dose given in excess of the total number of professional responsibility to issue a safe and legibletimes ordered by the physician i.e. it can be a dose given prescription. However due to haste, fatigue or a lack ofbased on the expired order, or after a drug has been understanding of the importance of clear prescribing, itdiscontinued, or after a drug has been put on hold. may contribute to illegibility. In addition, poorly written prescriptions may delay administration of medications.2.5 Types of Drug Contribute To Error System issues such as workload and type of care deliveryS.S.Chua et al stated in their study that intravenous (iv) system can also cause drug administration errors. Thesedrug administration is significantly more likely to be include number of consecutive hours worked, staff mixassociated with medication errors than the oral routes and numbers, nurse-to-patient ratios, distractions and(21.3% vs. and 7.9%). An i.v. dose was defined as an interruptions while administering to perform other duties,administration of a drug directly into the vein via rotating shifts, assignment of floating nurses toinjection or infusion and included preparation of the drug unfamiliar units and hospital-and pharmacy-designdose. Errors associated with i.v. administrations were features. Information resources, such as published drugmainly caused by wrong administration rate and guides, may not be readily available or up to date. Drugtechnique, similar to that reported by Wirtz et al [20]. manufacturers also contribute to medication errors byWrong i.v. administration rate was the second most producing look-alike and soundalike drug names,frequent clinical error with 35.7% of these errors rated as confusing and unclear labeling, and confusing packagingbeing of major severity [21]. of doses for example multidose vials which similar packaging for different medications [8]. Pharmacies2.6 Factors that Contribute To Error processes also can cause drug administration errors byThere are some possible reasons or factors that can cause delivering incorrect doses, not preparing the medications 7
correctly and not labeling the medications correctly 3. The observer would tag the nurse responsible for(Wakefield et al, 2005). the drug administration on that shift. 4. Registration number of the particular patient wasMETHODOLOGY recorded on an observational sheet.3.1 Study Design 5. The process of drug preparation untilThis study was of a cross sectional design using (i) direct administration to the patient by the nurse would beobservation and (ii) medication chart review (CMR). It observed.was conducted at the medical male ward (no. 3) at the 6. Any drug administration errors would beBatu Pahat Hospital from 10 May to 23 June 2011 during recorded. The 'near miss' error would also be recordedthe working hours on weekdays. The observers observed in the observational sheet as an error.the drug administration in the morning (8.00 a.m.) and 7. The observers would intervene upon the nurse forevening shifts (4.00 p.m.). The nurses were unaware of the 'near miss' error prior to drug administration.the objectives of the study. They were only informed thatthere will be provisionally registered pharmacists to tag 3.3 Outcome Measurewith them to observe and study the medication The types of administration errors used in this study aredistribution system. Patient's registration number and based on The Guidelines on Medication Error Reportingobservational data such as name of the medicine, dose, by Ministry of Health, Malaysia. The administrationfrequency, and route were taken from CMR and recorded errors are categorized into 13 types of errors which arein the observational sheet. The observers recorded all the prescribing, omission, wrong time, unauthorized drug,errors that occurred during drug administration. dose, dosage form, drug preparation, routes of administration, administration technique, deteriorated3.2 Study Population drug, monitoring, compliance and other medicationThe male medical ward can accommodate up to 50 errors.patients. The ward consists of Malay, Chinese, Indian andpatients of other races whose ages range from 12 to 80 3.4 DataAnalysisyears old and above. At the time of the study, 5 nurses Descriptive statistics are used to explore the datawere working in this ward. There were three working collected in this study. The frequency distribution andshifts for the nurses, which were 7.00 a.m. to 2.00 p.m. measures of central tendency and variability (mode,(morning shift), 2.00 p.m to 9.00 p.m. (evening shift) and median or mean) of data collected has been analyzed by9.00 p.m to 7.00 a.m.(night shift). The drug using SPSS version 15.0 for windows. Drugadministration on morning and evening shifts were administration errors data were analyzed usingobserved. The nurses were responsible for the preparation descriptive measurement which compared the percentageand administration of the medicines for each patient error of oral administration versus intravenous (i.v.)according to the prescriptions. administration.All the observational data and medicine were comparedwith the written medication orders by the observers. The RESULTSobservers will intervene and inform the nurse prior to 4.1 Frequency of DrugAdministration Errordrug administration when they detect an error which was A total of 400 doses was observed throughout the twoabout to be committed by the nurse, known as a 'near miss' weeks of study period. Most of the observed doses wereerror but was also recorded in the observational sheet as oral (131 errors, 81.37%) and the rest were i.v doses (30an error. errors, 18.63%). The total number of errors was 161 (SD: 1.907). Thus, the error rate was at 40.25%. The study procedures are listed as below: 1. Two observers would be stationed in the ward 4.1 Types of DrugAdministration Errors during the study period. The types of drug administration errors are shown in 2. The observers would follow the drug Figure 4.1 and the percentage of drug administration administration for two working shifts of the nurse errors are shown in Figure 4.2. which comprised the morning and evening shifts. T yp es o f Dru g A d min i s tratio n E rro rs In c orrec t tim e 28 89 O m is s ion e rro r 90 100T yp es o f E rro rs Inc orrec t do s e 14 Figure 4.1 Inc orrec t prep aration 13 Types of Drug Administration Unordered/u nauth oriz ed drug Errors 6 O thers 4 In c orrec t drug 2 D eteriorated drug 2 1 E x trado s e 1 Inc orrec t rate 1 Inc o rre c t adm in is tration tec hn iq ue 0 10 20 30 40 50 60 7 0 80 Fre q u en cy 8
Figure 4.2 Percentage of Drug Administration ErrorsAmongst the types of administration errors, incorrect timing was highest (89 doses; 55.28%), followed by omissionerrors (28 doses; 17.4%). The four errors under 'Others' included the usage of the same cup to administer medicationsto all patients, without cleaning it.4.3 Factors Which Contribute to Drug Administration ErrorTable 4.1 shows the error rate of drug administration errors according to the route and the time of administration.Table 4.1 Factors Which May Be Associated With Drug Administration ErrorsFactors Number of doses with errors Total number of % errors dosesRoute of administration 30 69.77.v route 131 43 36.69Oral route 357Time 102 34.93Morning shift 59 292 54.63Evening shift 1084.4 Types of Drug Contribute to Drug Administration Error T y p es o f D ru g C o n trib u te to D ru g A d m in is tratio n E rro r A c c o rd in g to A T C C la s s if ic a tio n40 37 35Frequ enc y of Drug nue tarir,ctiaonrnodisaoevngaadasnabscldtnorutieloiooainrndronfdtsepodeicchysstirasitoitvrAnnreenedadsymlexrm ini s tratio n E rro r35 an alges ic3024 21 gdeennrietmouarutorilolnooaggryyy25 emerg enc y ps yc hiatry re spiratory20 1615 10 910 5 32 1 11 10 A TC C la ss ific a tio nFigure 4.3 Types of Drugs Contribute to Drug Administration Error According to ATC Classification SystemFigure 4.3 shows that most errors were committed during administration of the antiinfectives class (37 errors),followed by cardiovascular system class (35 errors) and nutrition and blood disorder class (24 errors). 9
DISCUSSION giving medication at the prescribed time, the medication5.1 Frequency of DrugAdministration Error trolley can then be returned to the satellite pharmacy forThe results showed that drug administration errors were the next ward order/ indents/drug requirements.common in male medical ward in Hospital Batu Pahat. Intravenous drug administration is a complex process thatThe error rate was 40.25% which included incorrect time usually requiring the preparation of the medication in theerror. clinical areas before administration to the patient [20, 22]. In this study, i.v. drug administration was more associated5.2 Type of DrugAdministration Error with medication errors than the oral route (93.3% vs. andIncorrect time errors were the most common type of 37.05%). Wirtz [20] also reported i.v. drug administrationerrors in this study but many of these errors were not error rate of 34%. Errors associated with i.v.likely to cause patient harm except for drugs that require administrations in this study were mainly caused byclose serum concentration monitoring especially incorrect time and incorrect drug preparation, similar toantibiotic. Incorrect time errors consisted mainly of that reported by Cousins et al [22]. Incorrect drugmedications not given at the time ordered on the preparation was mainly related to wrong suitable diluentsmedication lists which mostly within a 60 minute margin. being used to dilute certain medicines. For examples, i.v.But other examples from this category concern wrong Amikacin 250 mg was supposed to be diluted with normaltime of intake in relation to meals (before, with or after saline instead of sterile water for injection while i.vmeal) which is more clinically relevant. In other study Meropenem 1 g should be diluted with 20 mL of sterilestated that when medication given too early and too late or water for injection instead of 10 mL normal saline.when intake before and after meal, it falls into class C Sometimes the reconstitution of dry powder injectionsseriousness which not give harm to the patient [14]. also incompletes. Other errors included administered the intravenous doses at the wrong rate and usually tooOmission errors were the second error that mostly quickly and administering the product too late or too earlyoccurred in these four week period of our study. There are after mixed with diluents. For example, thesome reasons why the medications were not given to the administration of i.v. bolus Gentamycin should takepatients during administration from our observation. about 2 to 3 minutes instead of a minute.Omission occurs because there were no stock ofmedication during administration and nurses forgot to Aseptic methods for preparation intravenous medicationsindent medication from pharmacy. Sometimes the nurses were also observed in this study. The preparation processalso rushed to do other task in the ward and did not aware include cleaning the preparation area and washing handsabout patient's medications. The omission occurs because or wearing gloves, disinfecting vials, ampoules andthe nurse did not see the dose that should be given, the additive ports with alcohol impregnated swab [22]. Mostdrug could not be located in the trolley, or the drug was of the time, the preparation area was cleaned with alcoholnot available. Usually they were omitting to give but not with a proper technique. Hands were washed andmedication when it was unavailable [10]. non-sterile gloves were worn during drug preparation. The tops of vials were never wiped with alcohol5.3 F a c t o r s W h i c h C o n t r i b u t e t o D r u g impregnated swabs in all preparation during our study.Administration Errors The techniques of reconstitution of parenteral medicationOne of the most possible causes of incorrect time errors in and of handling needle and syringe by the staff nurse werethe ward was heavy staff workload [8, 12]. The scheduled not followed the proper method. Training in drugtime for drug administration in the ward was the busiest administration technique and preparation as well astime when nurses have to make the patient's beds, monitor awareness programmes should be conducted.patients' physical signs, indent and prepare medicationsin the ward and also assist the doctors on their ward 5.4 Types of Drug Which Contribute to Drugrounds. From this study, there was usually only one nurse Administration Errorin charge of three cubicles to dispense medication to all Anatomical Therapeutic Chemical (ATC) classificationpatients. Sometimes the other nurses will help to give systems provide a global standard for classifying medicalmedication in which each of them will be assigned to one substances and serves as a tool for drug utilizationcubicle to ensure that medication was dispensed in time. research. The WHO recommends the ATC system forSome nurses were also engaged in less important work international comparisons. In this study, ATCrather than give medication on time to the patient. Nurses classification has been used to categorize the type of drugmay wonder how close to the prescribed time a that contributes to drug administration errors.medication should be administered. There is no absolute Anti-infectives (antibiotics) followed by theanswer to this question. Practical or system factors will cardiovascular system drugs commonly contribute toinfluence the actual time of administration. The guiding drug administration errors. The correlation of antibioticsprinciple is that medications should be administered as with administration errors was most pronounced whichclosely to the prescribed time as possible [15]. This may can be explained by the fact that antibiotics are given inbe achieved when the drug administration schedule was short courses and thus are not part of the long-termplanned such that not all patients take their medication at medication of the patient. The nurse attendant builds up8.00 am. One other possible solution is to increase the routine with long-term medication but is more likely tonumber of ward staff especially the number of nurses who make administration errors with medication that is givengive medication to patients [12]. When the nurses finish for short-term courses [14]. 10
The 33 antiinfective agents, 24 gastrointestinal drugs, 13 REFERENCEScardiovascular drugs; 10 pain control drugs, 9 central 1) National council focuses on coordinating errornervous system drugs, 8 respiratory system drugs, 7 reduction efforts. USP. Quality Review 1997; 57: 2.steroids, and 11 categorized \"others\" were the groups ofdrugs involved in drug administration errors by Ridge et 2) FIP STATEMENT OF PROFESSIONALal, 1995. Incorrect time and incorrect preparation were S TA N D A R D S M E D I C AT I O N E R R O R Sthe common errors that involved antiinfectives (37 ASSOCIATED WITH PRESCRIBED MEDICATION.errors). Antiinfectives or antibiotics are generally given International Pharmaceutical Federationfor a specific period of time (7-10 days, for example) to betaken at specific intervals (every 4, 6, 8 or 12 hours). This 3) Dellemin Che Abdullah, Noor Shufiza Ibrahimis necessary to keep the right amount of the medication in et. al. MEDICATION ERRORS AMONG GERIATRICSthe blood stream. 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3Analysis On Evaluation Of Quality Of Life InHypertensive Patients By Using Short Form Volume 10 36 In The Muar District, JohorMohd Anuar AR1, Khadijah Ismail2, Amran Maarof1 2012 1Muar District Health Office2Hospital Pakar Sultanah Fatimah, MuarSummary Key words: Hypertension, Quality of Life, SF-36, Physical Component, Mental Component, CorrelationObjective: Hypertension is one the most common chronic testdisease in Muar. This study was done to determine theimpacts on quality of life among hypertensive patients Introductionusing SF-36. High blood pressure disease is a silent killer. It can cause aMaterials and Methods: Patients' quality of life using SF- lot of serious complications and lead to an early or sudden36 was generated from a cross sectional study of 460 death. The normal complications of high blood pressurehypertensive patients who had came for treatments at the or hypertension are strokes, kidney failure, and heartgovernment health clinics in Muar district. The data of attack. According to the World Health OrganisationSF-36 was collected by interviews from November 1st (WHO) 13% of deaths in the world are contributed by2010 until January 31st 2011. The data was tabulated and hypertension and it is expected that the weightage ratio onanalyzed using SPSS software. Quantitative data was unseparated disease especially hypertension will bedescribed using median value and interquartil range. increasing to 57% by the year 2020 worldwide (WHO,Meanwhile, a correlation test was performed to show the 2002).correlation between variables studied. In Malaysia, hypertension is one of the main public healthResults: The study showed that among the hypertensive problems. In the year 1996, the disease prevalence ofpatients, the physical component (Median=72.50, blood pressure (BP) >140/90mmHg among adults agedIQR=56.50-80.75) were more affected compared to the 30 years old and above is 29.9% and equivalent to 2.1mental component (Median=73.63, IQR=65.00-80.50). million people. The research showed that hypertension isAmong domains in physical component the lowest score the highest among Malay adults aged 25 years old andwas general health (Median=62.00, IQR=52.00-72.00), above which is 15% followed by Chinese with 14.1% andbodily pain (Median=62.00, IQR=52.00-74.00), physical Indian with 12.3% (MOH, 1996).functioning (Median=80.00, IQR=55.00-90.00) and thebest score was physical role (Median=100.00, Hypertension is one of the most chronic diseases sufferedIQR=50.00-100.00). Whereas, for mental component the by the population. The numbers of average cases (old andlowest domain score was energy (Median=65.00, new) annually is 8316.6 people a year from the year 2000IQR=55.00-75.00), mental health (Median=72.00, to 2005 of which the average for the new cases is 1572.6IQR=64.00-80.00), social functioning (Median=75.00, people a year. Until the end of year 2005, out of 10,631IQR=62.50-87.50) and the best score was emotional role screened, there were 3,601 (33.87 %) people suffering(Median=100.00, IQR=100.00-100.00). The correlation from hypertension and 21,229 people still receivingtest showed the association between physical and mental treatments (JKN, 2005). Since the disease is affects acomponent (r = 0.695, p<0.001), the association between large number of people, it gives impact on the cost ofduration of having hypertension to mental component (r = health care. Additionally, the effects on family and- 0.245, p<0.001) and the association between duration of society will surely affect the quality of health amonghaving hypertension to physical component (r = - 0.218, those patients with hypertension.p<0.001). Since the last two decades, patients' perspectives on theirConclusion: The longer duration of hypertension will health conditions especially connected to psychosociallead to a higher deterioration on the quality of life. aspect have been taken into consideration as a mainSecondly, better physical components help in controlling component in evaluating health level instead of only thethe blood pressure, thus avoiding them from clinical aspect (Hopman WM, 2003). The change hascomplications such as strokes and heart attacks, which in created a research scope known as quality of life whereturn contribute to patients' better mental health. These both aspects on physical and mental (psychosocial)factors will be able to directly help hypertensive patients' health of the patients are given consideration.compliance to treatment and medication. 13
According to Gill TM, 1994, the evaluation on quality of function, 5 on mental health, 5 on public health, 4 onlife in clinical investigations, in addition to determine physical roles, 4 on energy, 3 on emotional role, 2 ondifferent group of patients, predicting the end result of social functions, 2 on body pain and 1 on Health Changesone's patient, but also for evaluating the health andtreatment programmes implemented. The evaluation of Statistical Analysisquality of life normally affects patient's physical aspects,psychological and social life. Data have been analyzed using the SPSS software version 12.0. The significant value is p<0.05. Meanwhile, for theAs hopefulness to the disease's condition and ability to descriptive analysis on quantitative data, the medianovercome limitations or disease problems can influence value and interquartile range have been used. Correlationpatients' perceptions and life satisfaction, therefore it is test have been used in order to show the relationship of thepossible for two patients of the same disease to have quantitative data.different level of quality of life. ResultsBased on the research by Hassan NB et al.2005, it is foundthat, patients' failure in adhering to treatment needs can From the total number of 460 respondents, the researchaffect their quality of life besides making them results showed that the median score for mentalimpossible and much more tougher to be cured and also component is higher with the value of 73.63 (65.00-inviting complications such as cardiovascular system 80.50) when compared to the score of physicalproblems, kidney diseases and as well as increasing the component with the value of 72.50 (56.50-80.75) (Tabletreatment costs. Hwee-Lin et al.2005 has also found that 1).hypertension have same level of impacts as diabetes,cancers and serious respiration diseases on the quality of When the mental component is being divided into fourlife. main domains, it is found that the emotional role domain has the highest score with the median value of 100.00Therefore, this research is very important since there was (100.00-100.00), followed by the social function domainno research on quality of life among hypertensive patients with the median of 75.00 (62.50-87.50), the mental healthin Muar before. Besides, the findings will provide base domain with the median score of 72.00 (64.00-80.00),data on the quality of life for hypertensive patients in and energy domain with the median score of 65.00Muar for further studies. It is really important since it can (55.00-75.00) (Table 2).increase the adherence level among hypertensive patientthus preventing complications and decreasing morbidity As for the physical component, out of the four mainand mortality (Kyngas, 1998). Furthermore, this research domains, it is found that the highest score goes to theis also important as the majority of the patients in physical role domain with a median score of 100.00Malaysia are in the range of productive age that (50.00-100.00), followed by physical function with acontributes to the country's huge important resources of median of 80.00 (55.00-90.00), the body pain domainmanpower (MOH, 1996). 62.00 (52.00-74.00) and the general health domain with a median score of 62.00 (52.00-72.00) (Table 3).Methods Corelation test found a significant, good and positiveThis descriptive research is a result from a cross sectional relationship exist between physical and mental scores (rstudy where the respondents were 460 patients with =0.695, p<0.001). Meanwhile from the aspect of relationship strength, 48.3% of the physical score can beconfirmed high blood pressure disease (Systolic ≥ 140 defined by the mental score (Table 4).mmHg, Diatolic ≥90 mm Hg) . The respondents came to On the other hand, the corelation test on the period of timethe government clinics for treatments and were faced by the hypertensive patients and mental componentinterviewed from 1st November 2010 to 31st January score shows that there exist a significant relationship,2011. negative but is too weak between both time period and mental component score with ( r = -0.245, p<0.001 )Sampling Size where only 6% was defined by the period of time suffering from hypertension and the mental componentThe total sampling size used in this descriptive analysis is score (Table 5).the Software EpiCalc 2000, whereby basing on theprevalence of 44.2 percent of hypertensive patient Hassan It is the same when a corelation test was done on theNB et al.2005. relationship of time period suffering from hypertension and the physical component score, negative but weak inStudy Instrument between the time suffering from hypertension and physical component score ( r = -0.218 , p<0.001).Quality data is measured using the standard questions of However, only 5% can be explained by the time periodSF-36 (Short Form-36) which have been translated into suffering from hypertension and the physical componentMalay. The SF-36 questions consist of 36 questions score (Table 6).where 10 questions related to the domains of physical 14
Discussion (subjectively) including energy and exhaustness has the lowest domain score. This is followed by the mentalThis main purpose of this study is to see in details the level health domain score which intended to evaluate on overof quality of life among patients with hypertension. By worried, depression, lost control in emotion andusing SF-36 as an instrument, the results of this study behaviour and physcological and harmony pressures. Thehave shown that there existed a difference in the scores second highest score is the social function domain whichbetween physical and mental components among the intended to evaluate on the qualiy and quantity of one'srespondents with hypertension with a lower level of interaction with another individual as well as thequality of life in the physical aspect compared to the limitations of social activities due to physical andmental aspect. This can be explained based on the earlier emotional problems. The highest score goes to emotionstudies where it is known that hypertension is one of the role domain which intended to evaluate on the limitationsincreasing chronic diseases globally contributing to of one's occupational function due to emotion problems.approximately to 46% (WHO,2002) and it is a main riskfactor for other chronic diseases such as coronary heart Just like the physical component, the mental componentdisease, strokes and heart failure (Mac Gregor GA,2003). can also vary with the time period suffering from hypertension. Correlation test showed a significantApart from that, hypertension is also identified as can negative relationship between the time period sufferinglead to kidney failure and give a big impact in managing from hypertension and the mental component. Thisthe cost of health which complications is more of a burden means that a longer time period suffering fromon the physical aspect compared to mental (Hayes hypertension will decrease the quality of life mainly in theRB,1997, Hammond SL,1994). This is similar to the mental aspect. This is an important benchmark sincestudy results by Lim et al.1998), where complications previous studies have shown that psychosocial factor isfrom failing to control blood pressure properly has given one of the main factors leading to non-adherence toa limitation on the level of life for a hypertensive patient medications among hypertensive patients (Zyczynskito increase up to 75%. TM, 2000, Rahman ARA, 1995). It will impact on the quality of life and lead to failure in their treatmentsThis can be further explained by corelation test which (Jones, 1996).showed a significant relationship between the time periodsuffering from hypertension and the physical component Finally, there is a difference between physical componentscore. A negative relationship had been shown score and mental component score among theeventhough it can only defined 5%. However, what can respondents, the results have shown that when a personbe analysed is that a longer time suffering from manage to take care of his or her physical quality aspect, ithypertension will further affect the quality of life from the will indirectly help in his or her mental health. This can bephysical aspect. shown by the relationship of the physical score and mental score using a correlation test whereby there is aBesides, the lower scores among the four domains are significant relationship, positive and good between thegeneral health domain score which fits the evaluation of physical score and the mental score (r =0.695, p<0.001).one's physical health status and body pain domain whichfits the evaluation of the body's pain level and how much Meanwhile, from the relationship strength, 48.3% of theit affected daily routines. Meanwhile, for the physical physical score can be defined by the mental score. Thisfunction domain which evaluates on the limitations of shows that a better physical of the patients or in otherphysical activities due to health problems faced, highest words if the patients manage to control their hypertensionscored domain is the physical role domain. The physical and avoid from complications such as strokes willrole domain has the highest score, it is mainly to evaluate directly helps in improving the quality of mental healthon the limitations of occupational function which was where for example they will have no problems in theiraffected by the physical health problems. social aspects. Eventually, this will help the patients to stay in the better quality of life eventhough suffering fromThe results have indicated that patients with hypertension chronic diseases that need treatments and medications.have a better mental aspect score compared to the Conclusionphysical component and it depicts that the respondentshave a better quality of life in the mental aspect generally. As a conclusion, this descriptive research has twoThis is further explained by monitoring all the four main important findings. The first one is that the longer thedomains in the mental component where the average patient suffers from hypertension, the lower will be his orscores are better than the physical domains. The mental her quality of life either from the physical or the mentalcomponent is important as previous study has showed aspect. Secondly, the better level of physical well beingthat most of the patients with hypertension who adhere to will contribute to a better mental well being.their medications have a positive relationship with their Hypertensive patients with good physical well beingemotional pressure (Wang PS et al.2002). would adhere more to scheduled treatments. Thus, good physical attributes help in controlling the blood pressureHowever, in the mental component, the energy domain thus avoiding them from complications such as strokeswhich intended to evaluate on the harmony feelings and heart attacks. 15
References parts? 3:2http//www.google.com [20 Ogos 2006]20Kyngas, Helvi R N, Lahdenpera, Tiina MA RN.1World Health Organization. Reducing risks, promoting 1998. Journal of Advanced Nursing .Compliance ofhealthy life. World Health Organization Report. patients with hypertension and associated factors. 242002.2Ministry of Health Malaysia: National Health and (5):997-1005http://202.186.179.7/ovidweb.cgi [19 JulaiMorbidity Survey Report II.1996.3Jabatan Kesihatan 2006]21Hennekens, C.H, Buring, J.E, Mayrent,Negeri Perlis: Laporan tahunan penyakit adrah tinggi. S.L.1987. Epidemiology in medicine. Boston: Little2005.4Hopman WM, Jane Vernar: Quality of life during Brown & Co.and after inpatient stroke rehabilitation. American HeartAssociation. http//www.google.com .(July 2010).5Gill Please indicate date of accessTM, Feinstein AR: A critical appraisal of the quality oflife measurements. The Journal of the American Medical AppendixesAssociation. 1994.6Testa MA, Hollenberg NK, AndersonRB, Williams GH:Assessment of quality of life by patient Table 1: Mental and Physical Components Score in SF-36and spouse during antihypertensive therapy with atenololand nifedipine . Am J Hypertens.4:363-373.1991.7Ware SF-36 Component Descriptive AnalysisJE, Snow KK, Kosinski M, Gandek B: SF-36 Health MedianSurvey Manual and Interpretation Guide.Boston. New IQREngland Medical Center, The Health 25-75Institute.1993.8Jenkinson C, Layte R, Lawrence K:Development and testing of the Medical Outcome Study Mental Component 73.63 65.00 - 80.5036-Item Short Form Health Survey summary scale score Physical Component 72.50 56.50 - 80.75 in the United Kingdom. Med Care.35:410-416http//www.yahoo.com (July 2010).9Ware JE, Table 2: Mental Component Domain Score in SF-36Kosinski M, Keller SD: SF-36 physical and mental healthsummary scales: A user's manual. New England Medical Component Domain Score in Descriptive AnalysisCenter, The Health Institute.1994.10Mac Gregor GA, HeFJ: Cost of poor blood pressure control in the UK: 62,000 SF-36 Median IQRunnecessary deaths per year. J Hum Hypertens 25-75(PubMed). 17:455-457 http//www.google.com. (July2010)11Hayes RB, Taylor DW, Sackett DL: Compliance Emotional Role 100.00 100.00-100.00in health care. John Hopkins University Press BaltimoreMD.1997.12Hammond SL, Lambert BL: Social Function 75.00 62.50-87.50Communicating about medications .Directions forresearch. Health Common (ISI). 6: 247- Mental Health 72.00 64.00-80.00251http//www.google.com. (July 2010)13Lim LL,Johnson NA O'Connell, RL Heller, RF: Quality of life and Energy 65.00 55.00-75.00later adverse health outcomes in patient with suspectedheart attack. Aus N Z J Public Health 22(5):p 540- Table 3: Physical Component Domain Score in SF-36546http//www.google.com.(July 2010)14Wang PS,Bohn RL, Knight E, Glynn RJ, Mogan H, Avorn J: Non Physical Component Domain Descriptive Analysiscompliance with antihypertensive medications: Theimpact of depressive symptoms and psychosocial Score in SF-36 Median IQRfactors. J Gen Intern Med.17(7):504- 25-75511.2002.15Zyczynski TM, Coyne KS: Hypertensionand current issues in compliance and patient outcomes. Physical Role 100.00 50.00-100.00Curr Hypertens Rep.2(6):510-514.2000.16RahmanARA, Hassan Y, Abdullah I: Admissions for severe Physical Function 80.00 55.00-90.00hypertension: Who and why. Rim HypertensionConference.Tokyo Japan.1995. 17Jones, D.A. West, RR: Body Pain 62.00 52.00-74.00Psychological rehabilitation after myocardial infarction:Multicentre randomized controlled trial. BMJ.313 General Health 62.00 52.00-72.00(7071); p.1517-21.199618Hassan NB, C I Hasanah, KFoong, L Naing, R Awang, S B Ismail, A Ishak, L H Table 4: Correlation TestYaacob, M Y Harmy, A H Daud, M H Shaharom, RConroy, A R A Rahman.2005. Journal of Human Variable CorrelationHypertension. Identification of psyshosocial factors ofnoncompliance in hypertensive patients.20: p23-29 Physical Score And Mental r r2http//www.google.com [21 Ogos 2006]19Wee HL, 0.483(48.3%)Cheung YB, Li SC, Fong KY, Thumboo J. 2005. PubMed Score 0.695Central Journal List. The impact of diabetes mellitus and r2other chronic medical conditions on health –related P<0.001 0.06(6.0%)Quality of Life: Is the whole greater than the sum of its Table 5: Correlation Test r2 0.05(5.0%) Variable Correlation Time Period Suffering High r Blood And Mental - 0.245 Component P<0.001 Table 6: Correlation Test Variable Correlation Time Period Suffering High r Blood And Physical - 0.218 Component P<0.001 16
Study On Use Of Kaletra® 4(lopinavir/ritonavir) Among Volume 10 HIV Patients In HSAJB. 2012 Ong M.P.11Hospital Sultanah Aminah, Johor Bahru.Summary of HIV patients was obtained from MTAC RVD HSAJB.Kaletra®, a combination of lopinavir and ritonavir which Finally after taking into account inclusion and exclusionare relatively well tolerated and provide potent antiviral criteria (those not initiated Kaletra® in HSAJB), 32activity in human immunodeficiency virus (HIV) patients were included in this study. All relevant datapatients. The purpose of this study is to assess the were collected from patients' case notes. As suggested byindication of use of Kaletra® and to study the tolerance of several recent National Institutes of Health-sponsoredKaletra® among HIV patients in Hospital Sultanah conferences on aging and acquired immune deficiencyAminah Johor Bahru (HSAJB). A retrospective cross syndrome, we adopted the age of 50 years as a cut-offsectional study was conducted in Medication Therapy point to define 'older' subjects.2 Using that cut-off pointAdherence Clinic (MTAC) Retroviral Disease (RVD) 28% of subjects (n=9) were classified as older. DataHSAJB. 32 patients were included in this study. Kaletra® extracted were managed with Microsoft Excel andwas being prescribed mostly due to intolerable side Statistical Package for the Social Sciences (SPSS) 16.0effects (59%) caused by previous HAART regimen. For system. chi-square and the p-value were calculated usingthose taking Kaletra®, it was well tolerated, with 82% of SPSS system. Comparisons between groups were madepatients without showing any undesirable side effects. with independent t-test. A p-value of less than 0.05 was considered significant. Descriptive statistics wereINTRODUCTION. adopted to present the data such as mean ± standardAntiretroviral drugs which are more effective with more deviation, frequency, range and percentage.convenient administration have been developed in order RESULTSto improve quality of life in patients infected with the The mean age of the sample was 44.8 years (SD 12.53)human immune-deficiency virus (HIV).1 Kaletra®, a with a range of 18-77 years. More than half was male andcombination of lopinavir which is an HIV protease majority of them was Chinese. 31.3% of the patients agedinhibitor with ritonavir, which acts as a pharmacokinetic over 50 years old. The reasons of starting Kaletra® wereenhancer used for patients who are new as well as for 40.6% patients due to treatment failure where the HIVthose experienced with HIV therapy.1 At present, most of RNA more than 400 copies/mL after 24 weeks or 50the antiretroviral-experienced patients attending HSAJB copies/mL by 48 weeks in a treatment naïve patientand failing their current therapy have been exposed to initiating therapy and 59.4% patients changed theirboth protease inhibitors and ono-nucleoside reverse regimen to Kaletra® containing regimen due totranscriptase inhibitors. Therefore, Kaletra® was intolerable adverse effects of previous HAART regimen.prescribed for those who had treatment failure as well as The table show mean duration to attain desire CD4 countfor those experienced intolerable adverse effects. There is and suppress viral load.no wide information about the use of lopinavir/ritonavir Table: Mean duration to attain desire CD4 count and(Kaletra®) among HIV patients. This study intended to suppress viral loadobtain information of HIV patients who had been takingKaletra® as HIV therapy from date of their initiation up to Table: Mean duration to attain desire CD4 count andDecember 2010 in order to provide better counseling suppress viral loadbased on collected data. The purpose of this study is toassess the indication of use of Kaletra® and to study the Age group N Mean Durationtolerance of Kaletra® among HIV patients in HSAJB.The results of this study were expected to assist the Duration for VL attain <50 < 50 years 19 5.74 months (SD 6.35)educational practices regarding Kaletra® therapy and toassist doctors, pharmacists and other healthcare HIV RNA copies/mL = 50 years 9 8.44 months (SD 11.43)providers. The information can aid in the management ofHIV patients after their previous highly active anti- p=0.035*retroviral therapy (HAART) regimen failure.MATERIALSAND METHODS. Duration for CD4 count <50 years 19 4.11 months (SD 5.23)A retrospective cross sectional study was conducted to >200 cells/mm³ = 50 years 10 7.40 months (SD 11.25)review all Kaletra® treated HIV patients in HSAJB. A list p=0.104 * significant at p<0.05 17
DISCUSSIONS. REFERENCESThe mean duration for CD4 count attained more than 1. Fazil AM and Newton GO. Lopinavir/Ritonavir200cells/mm3 was 7.4 months for older patients while (Kaletra) Journal of Gynecology Surgery. 2001; 35-36.only 4.11 months for younger patients (p=0.104). The 2. MaMercedes N, Gemma N, Esperanca A, et al.mean duration for viral load to be suppressed to less than Epidemiological and clinical features, response to HAART, and survival in HIV-infected patients diagnosed50 HIV RNA copies/mL for older patients (≥ 50years) at the age of 50 or more. BMC Infectious Disease 2006, 6:159.was 8.44 months (11.43) which is significantly (p=0.035) 3. Charles HH, David JH, Karen IM, et al.longer than younger patients (5.74 months). Duration of Medication adherence in HIV-infected adults: effect ofsurvival is significantly shorter for older people due to patient age, cognitive status, and substance abuse. AIDS.deficiencies in immune system related to age.2 However, 2004 January 1; 18(Suppl 1): S19-S25.in the study done by Charles HH. et al, the older patients(≥ 50years) showed better medication adherencecompared to younger patients but cognitive impairedoccur in older people do affect the medicationadherence.3 This may suggest that adherence might notbe factors affecting duration of success viral loadsuppression. There was 93.8% (n=30) of patientscontinue taking Kaletra®, only 6.2% (n=2) discontinueKaletra® due to down grade of regimen to reserveKaletra® as salvage regimen and another patient diedcaused by lymphoma. Only 18.8% (n=6) reportedadverse effects during treatment of Kaletra®, thesereported side effects may not be solely due to Kaletra® aspatients were given combination regimen. Reportedadverse effects among these patients were increasetriglycerides, cholesterol; muscle weakness and pain;facial lipodystrophy; dryness of legs and lips, numbnessof limbs; and leg edema. The study is a retrospective crosssectional survey. Descriptive studies do not leadthemselves to causal inferences. This should be kept inmind when evaluating the results of our study. As allinformation collected were based solely on thedocumentation in patients' case notes, data may beincomplete with some missing data due to lack ofdocumentation. Incomplete information in the medicalrecords might lead to underreporting of some adverseeffects experienced by patients but not recorded. Aprospective study to follow the patients may be carriedout to overcome this problem.CONCLUSION.Kaletra® was being prescribed mostly due to intolerableside effects (59%) caused by previous HAART regimen.Kaletra® was well tolerated, with 82% patients show noundesirable side effects after starting it. 18
Implementing Fly Control 5 – Kluang Experience 2009, Volume 10North Macap Rest & Relax Area (R&R) 2012 Norzihan MH, Zuhaida AJ, Mohd Zaki IEXECUTIVE SUMMARY and passing through this is the North-South Expressway,The fly problem in North Macap Highway Rest & under the purview of PLUS. North Macap R&R isRelaxation area (R&R) was mainly due to breeding of provided for the convenience of travelers and it is aflies in nearby poultry farms. Control measures were facility comprising of food & beverage outlets,staged in 3 steps to assess the effectiveness of each of the restrooms, prayer rooms, playground, souvenir shops andrecommended interventions. It was found that despite petrol station.physical restructuring of the R&R, the problem did notdecrease as was also noted with the use of pesticides. There is a scheduled garbage collection thoughThough there was a direct reduction of the fly index with indiscriminate disposal of food leftovers was found topesticide usage, the fly density went back to pre- contribute towards attracting adult flies to food premises.intervention levels within 7 days of last spraying. The use However no source of breeding was identified within theof probiotics showed itself to be an excellent method of area. Bearing in mind its flying distance, its tendency forcontrol through source reduction with fly index homing effect and breeding preference, a wider search fordecreasing from 18.8 to 1.2 at the end of intervention and source of housefly breeding was carried out.maintained at that low level for a longer time period. It isrecommended that the use of probiotics be introduced to The source of breeding was found to be from surroundingpoultry farm industries to suppress fly population and estate areas, with poultry farms. In the Macap area, thereindirectly reducing flies problem in nearby R&R. are 24 poultry farms with a capacity of 346,000 million chickens at a time. Eleven (11) of these farms wereINTRODUCTION situated within 6 km from the Macap R&R, the nearestIn 2008 the issue of fly problem in Kluang became a (FarmA) being 1.3 km away.major concern when it was highlighted throughcomplaints in the media, involving food premises, Farm A comprised of 12 chicken coops with a capacity ofespecially in the Kluang North Macap R&R (Figure 1). It 30,000 chickens. At time of investigation, fly density waswas a serious problem, where it marred the image of high under the chicken coops, though the coops weretourism industry as well as being a threat to public health empty and in the process of cleaning and disinfection. Theas flies are mechanical vectors for food borne diseases soil beneath the coops was wet and warm from faeces.such as food poisoning, typhoid, cholera, Hepatitis A etc There is a 2 month period for each cycle, from the first day1. chicks are introduced to the farm till clearance and cleansing of coops (46 days breeding + 14 days cleaning)The fly species identified in this case were the common The high-density, confined housing systems used inhousefly (Musca domestica), which tended to breed in poultry production create conditions that favor thewarm, wet places where its' larvae can feed on upon development of manure-breeding flies.hatching. Typical breeding grounds include garbage,rotting food, exposed faeces of any type, and An integrated approach towards controlling fliesdecomposing animal carcasses. They have a high problems consists of four basic management strategiespreference to poultry farms rather than domestic (mechanical, cultural, biological, and chemical) that cansurroundings 2, where a single female fly can lay 75 to be strategized into a successful fly control or integrated150 eggs every 3 to 4 days. Life-cycle for a housefly from pest management program 4 (Table 1).egg stage to adult takes about 10 days. In this study, 3 types of fly control interventions can beHouseflies possess sensory receptors for smell and taste, carried out, that is:important in the search of food, as far as 5 to 7 km away, 1) Mechanical intervention involving renovatingthough they have a tendency to return to breeding sites physical attributes of food premises to discourage adult(homing effect) 3. flies, as in screening, air conditioners with automatic door closer, fly swatter or fly traps etc and ensuring a sanitaryProblem area establishmentMacap area is situated about 30 km from Kluang Town 2) Chemical intervention using adulticides or larvicides both at problem areas (North Macap R&R) as 19
well as at breeding sites (FarmA). by product) (Table 3). Intervention monitoring was done3) Biological intervention using beneficial from December 2008 until January 2009.predators (macrochelid mites; hister beetles) ormicroorganisms that can suppress fly populations. One Impact of each intervention were assessed throughsuch method is the use of probiotics to create an measurement of fly index, that is the number of fliesunsuitable environment for fly development. The use of landing on the grill within 30 seconds 7 using the 'Scudderprobiotics in fly control is a relatively new endeavor and it Grill' (Figure 3) at the North Macap R&R area. Readingis known to reduce smell from poultry farm faeces as well of index was carried out at the same time (10.00 am) at 6as reducing its potential to breed flies. different locations (index point), and the average reading is calculated as index value. Proposed fly index thresholdAs a step towards reducing the fly problem and thus the 6 were used throughout as a standard (Table 4).number of complaints from travelers, Kluang districtHealth Office convened a committee, which included the RESULTSveterinary department, plantation department, PLUS and The fly index reading in 2007 prior to any intervention ofthe local poultry farms, to discuss the possible and viable 3.8 is considered to be above accepted value for foodmethods available. It was decided that the various premises, according to the fly index threshold.interventions were to be carried out separately so thatanalysis of effectiveness of each method could beundertaken.OBJECTIVE Chemical spraying1) To identify the most effective & efficient controlmeasure available in the long term control flies at the 1) Physical intervention - physical restructuring:North Macap R&R, Kluang. Pre-intervention reading for physical intervention was2) To make recommendations towards reducing 3.8. Fly index reading after renovation was carried out atflies in the Macap area. the North Macap R&R showed a continuously high3) To strengthen inter-agency cooperation towards index, averaging 18.3, which is an increase of 381% ofreducing flies density. pre-intervention reading.METHODOLOGYThree types of interventions were carried out in three 2) Chemical intervention: Pre-interventionphases, startingApril 2007 – March 2008 (1st phase), July reading for chemical control was 18. The overall fly2008 – August 2008 (2nd phase) and December 2008 – index reading showed a 10 day interval where sprayingJanuary 2009 (3rd phase) involving the North Macap schedule was carried out. Low readings were always onR&R and Farm A. Interventions undertaken were the 3 days of spraying; the lowest being 3.3 and fly indexstaggered with a 3 months pause in between each, to start to increase when spraying stopped on day 4 onwards,allow for impact assessment and for the return of normal reaching 13.3 by day 7. Subsequent fly index readingssituation of flies population in both R&R Macap and maintained above 15, similar to pre-intervention. TheFarm A before the next intervention starts. The 3 months pattern was seen throughout the 46 day cycle of chickenperiod was also taken in view of the poultry cycle from rearing in FarmA.chick introduction to marketing and coop disinfection (46days for poultry rearing + 14 days cleaning up) 3) Biological intervention: Pre-intervention fly index was 18.8 (day -1). Post-intervention readingsThe 3 types of interventions carried out in 3 phases were: showed a steady decline in fly density at the North Macap1) First phase - Physical intervention: renovation R&R reaching as low as 1.2 at day 46. This low readingwas made to the Macap R&R by PLUS from an open was noted up to day 60 intervention, sustained evenpremise to a fully air conditioned, closed area (with though the intervention had ended.automatic door system) to discourage adult flies fromentering the food court (Figure 2). Renovation was DISCUSSIONcarried out from June 2007 and resumed operation on Having a sanitary establishment is still the best way toDecember 2007. Intervention monitoring was done for a avoid fly problems. Areas that are damp and warmmonth before renovation started, in April 2007 and after (standing water, drains, and unchanged mop buckets)resume operation, in March 2008. encourage flies infestation. Indiscriminate disposal of2) Second phase - Chemical intervention: Use ofwater–base insecticide via thermal fog and ULV (UltraLow Volume) spraying to control adult flies. Fogging iscarried out between 6 – 7 am at the R&R , while 'SpotSpray' is carried out in Farm A. Fogging / spraying wasdone at 10 day intervals: 3 days of spraying followed by 7days of rest (Table 2). Intervention was done from July2008 toAugust 2008.3) Third phase - Biological intervention: Sprayingwith probiotics using dilution ratio of 1: 100 is carried outin Farm A every day 3, with 2 days rest (as recommended 20
food waste will always be an attraction to flies and is Probiotics has given a new dimension to Malaysia'sactually a great drawback to fly control. As such a agriculture towards farming systems that are productive,physical barrier from flies in itself does not go a long way environmentally sound, energy and resource conserving,in reducing the problem. This can be seen from the also ensure food safety and quality. Probiotics consists ofincrease in fly index reading despite a major and mixed cultures of beneficial and naturally-occurringexpensive renovation carried out. PLUS needs to take microorganisms. Selected species of microorganismsmore effective measures in controlling flies in their food including lactic acid bacteria, yeasts and photosyntheticestablishments through regular cleaning and maintaining bacteria creating the probiotic are mutually compatible toof problem areas. coexist in liquid culture 8.PROPEL (Projek Penyelenggaraan Lebuhraya Berhad) a The use of probiotic in food and drinking water in poultrycompany responsible for maintaining PLUS expressways farms reduce the foul smell in chicken dung, conserve theincluding R&R Macap facility, has daily scheduled environment and at the same time increase the immunitycleaning tasks. This includes mopping of floor, cleaning of chickens for better growth 9. Beneficial bacteria is alsoof toilets and other facilities, also ensure that waste be a form of biological control of flies population in poultrydisposed off daily and not left overnight. Food Quality farm 10. The beneficial bacteria nitrifies toxic gases likeControl Unit, Kluang Health Office conducted 8 series of ammonia and hydrogen sulphide into less harmfulinspection of food premises, hygiene and cleanliness at organic acids, reduce foul smell and become lessthe North R&R Macap areas throughout May to August attraction to flies and other winged insects 5. A study in2008 involving 10 food premises. All food premises in Thailand by Sritoomma, S shows that flies population canoperation found to be in satisfying condition with above be reduced up to 60%, BOD (36%) and solid waste80% score according to Food Premise Score sheet. sediment of 68% 11.Though there was a marked increase in fly index reading CONCLUSION.despite PLUS efforts, this could be attributed to increased The use of probiotic is shown to have positive effect infly problem at breeding sites rather than failure of any reducing flies population. However, proper handling andphysical interventions carried out. During this phase no technical advice is highly needed to ensure itscontrol measure had yet been carried out at source of effectiveness. The most important in dealing withbreeding. Usually, fly control measures by local probiotic is to stop the usage of pesticides and antibioticsindustries relied mostly on pesticides to keep pest that can render probiotic microbes killed and becomespopulations below economic injury levels or nuisance ineffective. Continuous usage of probiotic is alsothresholds. The fact that major renovations were carried essential to reach stability of beneficial bacteriaout through continuous discussions by various agencies population in chicken farm environment thus controllingshowed a success itself in terms of promoting interagency foul odour and fly population in a long term period.relationship. This positive findings hope to widen the acceptance and use of probiotics in the poultry industry. As a start,Insecticides can play an important role in integrated fly recommendations were made to the relevant agencies tomanagement programs. However, extensive or improper integrate the use of probiotics in poultry industry as anuse of pesticides results in the destruction of biological alternative to pesticides.control agents and the development of pesticideresistance. Improper timing and indiscriminate ACKNOWLEDGEMENTinsecticide use, combined with poor manure Authors would like to thank all the agencies involvedmanagement, poor moisture control, and poor sanitation throughout this study period, namely; Veterinary Servicespractices, will increase fly population and the need for Department of Kluang, Plantation Department of Kluang,additional insecticide applications. Space sprays or mist Section S3 PLUS Highway Berhad, Leong Hup Farmingsprays can be effective for a rapid knockdown and kill of and JB Kim Farm.adult flies, but does not provide long-lasting control asthere is no residual effect. While larvicide application willonly give a short-term fly control and kill naturalbiological control agents that are present, initiating arepeated schedule of treatments 4. Chemical control isproven to be highly effective at the point of usage but itseffectiveness is not sustained longer than 7 days.Repetition of application is needed weekly involvingcost, raising concerns of insecticide resistance as well asdestruction of biological agents that naturally exist in theenvironment.Biological agents co-exist in the environment in variousforms ranging from beneficial predators such as histerbeetles or microorganisms that can suppress flypopulations. In Malaysia, microorganisms is widely usedby farmers to increase the quality and quantity of crops. 21
REFERENCES 7. Scudder, H.I. (1996). Use of the Fly Grill for assessment of house fly populations: An example of1. Arbain, Kadri (1990). Entomologi Perubatan. sampling techniques that creates rough fuzzy sets.Dewan Bahasa dan Pustaka, Kementerian Pendidikan Journal of Vector Ecology 21(2):167-172.Malaysia. Pp. (144-152). 8. Reduction Of Flies Index Number At Chicken2. Robert, Lamb. \"How Houseflies Work.\" How Farm By Using Effective Microorganisms (Em)Houseflies Work. 7 Dec. 2008 Technology, A. K. Khamis1, M.R. Sarmidi1, N. 'A.<http://animals.howstuf fworks.com/insects/housefly2.h Sabri1, N. F. Abd. Rahman1, H. Nohani; 1Chemicaltm> Engineering Pilot Plant (CEPP), Universiti Teknologi Malaysia (UTM)3. Nazni, WA et al. (2005). Determination of theFlight Range and dispersal of the house fly, Musca 9. Ni, Y. and Li, W. (2002). Effects of Effectivedomestica (L.) using mark release recapture technique. Microorganisms (EM) on Reduction of Odour fromTropical Biomedicine 22(1): 53-61. Animal and Poultry Dung. 5p.4. Stafford, K. Fly Management Handbook A 10. Kapongo, J. P. and Giliomee, J. H. (2000). TheGuide to Biology, Dispersal, and Management of the use of Effective Micro-organisms in the biologicalHouse Fly and Related Flies for Farmers, Municipalities, control of house flies associated with poultry production.and Public Health Officials, Connecticut. 2008. Afr. Entom, 8: 289-292 <http://www.ct.gov/caes/lib/caes/documents/p 11. Sritoomma, S. (1995). Application of EM forublications/bulletins/b1013.pdf> Improved Management of Swine and Poultry Wastes in Thailand. Proceedings of Kyusei Nature Farming5. Baustista, E. M. (2002). Use of Effective Conference in Paris, p193Microorganisms (EM) to Eliminate Foul Odor in MeatProcessing Units. 3p.6. Nazni, WA et al. (2003). Guidelines for FliesControl. Tropical Biomedicine; 20(1):59-63. 22
Evaluation Of Molars Restored With Glass 6 Ionomer Cements In The School Dental Volume 10 Service In Kota Tinggi DistrictMuz'ini M1. Premaa S2. 2012 1Oral Health Division, Johor State Health Department2Clinical Research Centre (CRC) Johor, Hospital Sultanah Aminah, Johor BahruSummary uncooperativeduring conventional restorative treatment3. Recently, dental nurses in Johor generallyUse of glass ionomer cements (GIC) by dental nurses in utilised modified ART technique when restoring teeth ofthe school dental service is well accepted due to its schoolchildren in mobile dental squads. Initially dentalanticariogenic potential. Its poor mechanical properties nurses used glass ionomer cements for restoring primarylimit their extensive use as a filling material in stress- teeth but this practice has been extended to permanentbearing areas. The objective of this retrospective study is teeth as well. Electrically driven handpieces were usedto determine survival rate of glass ionomer cements for cavity preparation, caries excavated using excavators(GIC).In 2006, dental nurses retrieved all dental records and tooth restored with GIC.of Standard 6 students with posterior GIC restorations. GIC has similar mechanical properties to dentine. WithStatus of tooth at each year after restoration was recorded. the important benefits of adhesion and release of fluoride,Survival rates of GICs were estimated cumulative it is an ideal material in many restorative situations.survival rates using the Kaplan-Meier method. The However, it's relatively poor mechanical properties mustmedian survival duration was 5.00 years (s.d. 0.28). be considered4. A study showed no significant differenceSurvival rate of amalgam restoration at 5 years was in overall failure rates after two years but follow-up of the86.21%whereas the findings from this study indicates restorations up to five years showed that glass ionomercumulative survival rate of 84.36%. The quality of restorations had significantly inferior survival time toposterior Class 1 glass ionomer restorations is amalgam5competitive with that of amalgam restorations. There is a need to evaluate teeth restored with glassKey words: glass ionomer cement, survival analysis, ionomer cements in the school dental service in view ofposterior restorations its relatively poor mechanical properties. Several studies showed that GIC is not recommended for Class II cavities1. Introduction due to unacceptable high fracture rates. Class I cavitiesThe use of glass ionomer cements (GIC) by dental nurses may be restored in the permanent dentition. Retrospectivein the school dental service is well accepted due to ease of trials reported unsatisfactory clinical performance inmanipulation. It also tolerates moisture and this property Class II cavities.Reviews indicated that the annual failureis useful in mobile dental squads where moisture control rate with GIC is estimated to be around 8%6.The aim ofposes a problem.GICs are esthetically more attractive this study is to evaluate the outcome of restoring posteriorthan amalgam restorations. In addition, by incorporating cavities with GIC in permanent molars in the schoolfluorine, they exhibit an anticariogenic potential, and dental service in Kota Tinggi district.they have good biocompatibility and chemical adhesionto mineralised tissue. On the other hand, poor mechanical Objectiveproperties, such as low fracture strength, toughness and To determine survival rate of glass ionomer cements aswear, limit their extensive use in dentistry as a filling dental restorations in posterior cavitiesmaterial in stress-bearing areas. In the posterior dentalregion, glass-ionomer cements are mostly used as a 2. Materials and Methodstemporary filling1. 2.1 Design Retrospective studyA study conducted in 1993 found that the Atraumatic 2.2 SamplingRestorative Treatment (ART) approach using GIC All Standard 6 students in the school incremental dentalperformed equally well as conventional restorative care system in Kota Tinggi district in year 2006withapproaches using electrically driven equipment and history of GICmolar dental restorations in their dentalamalgam for treating dentinal lesions in occlusal surfaces records were included in this study. Parents of studentsafter 6 years2.The procedure is gaining acceptance in involved in this study had given written informed consentdeveloped countries forthe treatment of caries, especially 2.3 Data collectionin young children with rampant caries who are Dental nurses in mobile dental squads and school dental clinics retrieved all dental records of Standard 6 students 23
during annual dental screening in the school based dental Failure rates after 12 months, 24 months, 36 months, 48programme. After routine examination, all dental records months, 60 months were 8.2%, 20.0%, 9.38%, 33.2%,with posterior GICrestorations were retained and status of 38.8 and 66.0% respectively as shown in Figure 1.tooth at each year after restoration was recorded.Theinvestigator entered the data on spreadsheets and analysed Survival Functionthem using statistical software SPSS version 17.0.Survival rates of GICs were estimated cumulative 1.1survival rates using the Kaplan-Meier method. 1.03. ResultsThe following table shows the distribution of all restored .9teeth included in this study. .8Table 4.1: Distribution of Restorations According to Cum SurvivalLocation and Tooth Type .7 Maxilla Mandible .6First right First left First left First right Second left Second right .5molar molar molar molar molar molar .4 Survival Function .3 Censored1 24 4 0 0 0 12 3 45 65 9 14 16 0 1 duration8 8 19 26 1 0 Figure 1 : Kaplan Meier Survival Curve18 16 31 28 1 1 Table 4.3: Cumulative survival of GIC restorations in permanent molars32 35 68 74 2 2 Follow-up period No of Class 1 No of restorations No. of Survival (%) restorations at that require redo extractedA total of 213 molars restored with glass ionomer cements start of study teethwere included in this study. Majority (68.54%) of molarsrestored with GIC at all clinics in Kota Tinggi district were 0-12 months 196 16 0 91.83lower molars. A total of 196 restorations were placed inClass I and 17 in Class IIcavities.Records of all teeth 13-24 months 180 19 1 88.88restored with GIC showed outcomes as shown in Table 4.2 25-36 months 160 13 2 90.62 37-48 months 145 2 1 97.93 49-60 months 142 8 0 84.36Table 4.2 : Status of molars restored with GIC Status Type of cavities Total The median survival with censored data was 3.099 years as shown in Table 4.4 Class I Class II n (%) 58 (27.2) n (%) n (%) 4 (1.9) Table 4.4: Kaplan MeierAnalysis 5 (2.3)Indicated for redo 54 (27.6) 4 (23.5) Kaplan Meier analysis (with censoring)Restored with amalgam 4 (2.0) 0 (0.0)restoration Class 1 Survival time Standard error 95% C.I.Extracted 4 (2.0) 1 (5.9) Median 5.00 0.28 (4.45, 5.55)Among 5 teeth that were extracted, 4 were restored with 4. DiscussionClass I restoration and 1 with Class II. The tooth with Retrospective survival analysis of dental amalgamClass II restoration failed at 24 months while those with restorations showed 96.29% survival at one year7.Class I restoration failed between 24 to 48 months. No Percentage survival for glass ionomer cements after 12further analysis was done for Class II restorations as data months in this study was 91.83% at one year.were too few.Survival rates of GICs were estimated cumulative The longest duration of study in this sample is five yearssurvival ratesusing the Kaplan-Meier method as shown in after placement of GIC restoration in the school dentalTable 4.3. service. Percentage survival of amalgam restorations at five years using Kaplan Meier method from a previousTable 4.3: Kaplan Meier estimate of survival function study was 86.21% 8. Findings from this study shows thatSurvival Table cumulative survival of GIC restorations at five years was 84.36%Follow-up period Cumulative proportion surviving at end of Interval. (s.e)0-12 months 0.92 (0.02)12-24 months 0.80 (0.03)24-36 months 0.67 (0.04)36-48 months 0.61 (0.05)48-60 months 0.34 (0.08) 24
5. Conclusion 3. Nazan Kocatas Ersin, PhD, DDS, Umit Candan, DDS, Arzu Aykut, DDS, Özant Önça , PhD, DDS, CemalFrom a total of 142 restorations, the median survival Eronat, PhD, DDS and Timur Kose, PhD, DDS . Aduration was 5.000 years (s.d. 0.114). Survival rates of clinical evaluation of resin-based composite and glassamalgam restoration at 5 years was 86.21% whereas the ionomer cement restorations placed in primary teethfindings from this study indicates cumulative survival rate using the ART approach Results at 24 months . J Am Dentof 84.36% Assoc, Vol 137, No 11, 1529-1536.The quality of posterior Class 1 glass ionomer restorationsis competitive with that of amalgam restorations for the 4. Martin John Tyas. Clinical evaluation of glass-same duration of 5 years. ionomer cement restorations. J Appl Oral Sci. 2006;14(sp.issue):10-3Acknowledgement 5.The author expressed her gratitude to dental nurses in http://en.wikipedia.org/wiki/Glass_ionomer_cementKota Tinggi district for their assistance in data collectionand special thanks to Clinical Research Center (CRC), 6. Roland Frankenberger,Franklin Garcia-Hospital Sultanah Aminah, Johor Bahru for her advice on Godoy,,Norbert Krämer4. Clinical Performance ofstatistical analysis. Viscous GlassIonomerCement in Posterior Cavities over Two Years. Int J Dent. 2009; 2009: 781462. PublishedReferences online 2010 February 22.1. Ulrich Lohbauer. Dental Glass Ionomer 7. Bogacki RE, Hunt RJ, del Aguila M, SmithCements as Permanent Filling Materials? —Properties, WR.Survivalanalysis of posteriorrestorations using anLimitations and Future Trends. Materials 2010, 3, 76-96; insuranceclaimsdatabase. Oper Dent. 2002 Sep-doi:10.3390/ma3010076 Oct;27(5):488-92.2. Mandari GJ, Frencken JE, van't Hof MA. Six- 8. Bonsor SJ,Chadwick RG. Longevity ofyear success rates of occlusal amalgam and glass-ionomer conventional and bonded (sealed) amalgam restorationsrestorations placed using three minimal intervention in a private general dental practice.Br Dent J. 2009 Janapproaches.Caries Res. 2003 Jul-Aug;37(4):246-53. 24;206(2):E3; discussion 88-9. Epub 2009 Jan 16. 25
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The Prevalence Of Hearing Impairment Among The 8. AcknowledgementsDental Staff In Kota Tinggi District, Johor (Draft 1)2010 The authors expressed their gratitude to Kota Tinggi District Dental Officer, Kota Tinggi Senior HealthThe study also found that the three categories of staff who Officer, Director of Sultan Ismail Hospital, staff of ORLsuffered hearing impairment were working in high noise Clinic Sultan Ismail Hospital and all dental personnel inarea (Kota Tinggi Main Dental Clinic, Sening Dental Kota Tinggi districts who had contributed to the conductClinic) and with high noise equipment such as of this study.compressor, high speed handpiece and ultrasonic scaler(Table 5.6). References 1. Act 514 Occupational Safety And Health Act 19946. Discussion [Reprint 2002]Hearing impairment of two dental surgery assistants(DSA) may be attributable to past job experience. One 2. Leggat PA, Kedjarune U, Smith DR. Occupationalattendant worked in a glass factory with exposure to loud health problems in modern dentistry: a review. Indnoise for about 14 years before joining the dental Health. 2007 Oct;45(5):611-21.services. He has been working in the dental clinics for 4 3.http://www.dosh.gov.my/doshV2/phocadownload/Reyears. Another attendant worked as a heavy vehicle driver gulations/AKJ/pua0001y1989s0005.pdf accessed atand claimed that he was exposed to loud noise during his 13:51 7 May 20115 years of service before joining the dental services. 4. Noise and hearing loss - Noise, Regardless of Source,Exposure to noise level at 90dBA is quite common in the Can Lead To Hearing Loss Henry P. CIH Robert E.dental environment. Although the duration of exposure Sheriff; Shotwell Courtesy of Atlantic Environmental,does not reach the permissible exposure limit, dental Inc. Jan. 1, 2002personnel experienced distraction and annoyance during 5. Szymanska J. Work-related noise hazards in the dentalthe exposure. surgery.AnnAgric Environ Med 2000 (7): 67-69 6. C.E. Wilson T.K. Vaidyanathan W.R. Cinotti S.M.7. Conclusion Cohen S.J. Wang.Hearing-damage Risk andHazard from noise in dental working environment cannot Communication Interference in Dental Practice Journalbe underestimated. Hearing problems can occur due to of Dental Research, Vol. 69, No. 2, 489-493 (1990)dental field noise due to prolonged exposure. Hence, 7. Bali N, Acharya S, Anup N, An assessment of the effectproper monitoring and Hearing Conservation programme of sound produced in a dental clinic on the hearing ofis required for early detection and management of these dentists. Oral Health Prev Dent. 2007;5(3):187-918.cases. Dental staff working in high noise area above Guidelines for hazard identification, risk assessment and90dBA are advised to wear ear plugs. Regular medical risk control. Department of occupational safety andsurveillance of staff exposed to high level of noise must health, Ministry of Human Resources, Malaysia. 2008be complied as per Factories and Machinery (NoiseExposure) Regulation 1989. This can ensure earlydetection and management of the patient hencepreventing hearing impairment among the dental staff. 27
A Study Of Obesity Among 7 Health Staff At Kulaijaya District Volume 10 Health Department (2012) 2012 Dr. Mohd Shaiful Ehsan B Shalihin Poh Lin Chin, Misringaton Kulaijaya Health District JohorOBJECTIVE: To study and report prevalence of the environment which include education background, occupation, household income, culture and lifestyleoverweight and obesity among health staff at Kulaijaya (Azmi, et al., 2009; Moy & Atiya, 2003-2005; Richard, Andrew, & Rodolfo, 2012; Shashikiran, Sudha, &District Health Department and describe their association Jayaprakash, 2004; Speakman, 2004). Globally, around 12% of adults aged 20 and above were obese in 2008with gender, marital status, respective job scope and (World Health Organization (WHO), 2004). This figure is increasing in developing countries including Malaysiaworking environment, using standardized international (Caballero, 2001; Moy & Atiya, 2003-2005; Nor, et al., 2008; Shashikiran, Sudha, & Jayaprakash, 2004). Baseddefinitions. METHODS: This cross on the National Health Morbidity Survey (NHMS) III (2006), the national prevalence of obesity (BMI 18.5-sectional study studied body mass index of all the health 24.9 kg/m2) was 14% compared to 4.4% in NHMS II in 1996 (Nor, et al., 2008). Rapid pace of industrializationstaff of Kulaijaya Health Department except expectant and urbanization in recent decades in Malaysia had brought in changes in the lifestyles of Malaysians (Moymothers and females in their first three months FM, 2003-2005). These include reduction of physical activities, changes in dietary habits and food preferences.postpartum period. Body mass index (BMI:kg/m2) was Generally, Malaysians acquired a taste for high in fat, processed fast food and high calorie diets. Furthermore,calculated from measured weight and height, using housewives showed the highest prevalence of obesity at 20.3% (CI 0.19–0.21), compared to working mums whocalibrated weighing scales and body meters. Body weight engage in regular physical activity (Nor, et al., 2008). Obesity has also reached an alarming level at the southernclassifications were defined as follows: According to region of Peninsular Malaysia, specifically Johor, as the prevalence is highest in this state compared to otherWHO Expert Consultation 2004 for Asian BMI: states. According to the findings of the Malaysian Adult Nutrition Survey in 2009, prevalence of obesity in Johorunderweight (BMI < 18.5), normal weight (18.5 to 24.9), is at 13.81% (CI: 0.12-0.16) (Azmi, et al., 2009). The mean body weight was also significantly higher in thepre-obese/overweight (BMI 25.0-29.9), obese (BMI > or southern region (64.42 kg) (CI: 63.46), compared to those in Sarawak (60.66 kg) (CI: 59.43, 61.88)] and Sabah= 30.0). Otherwise, 100% respondent's rate was achieved. (58.93kg) (CI: 57.86, 60.01) (Azmi, et al., 2009). Even though obesity is higher in females 17.4% (CI 0.17-0.18),Descriptive and correlation analysis were performed it is unequally distributed by comparing regional factors and ethnic groups. This finding was attributed tousing SPSS version 15. A significance level of p-value underlying individual socioeconomic role (Nor, et al., 2008)(Richard,Andrew, & Rodolfo, 2012).less than or equal to 0.05 was considered statistically Currently, obesity and overweight are serious emerging global issues among healthcare personnel. A study of 760significant (p < 0.05). nurses across 6 different states of United States found 54% to be overweight or obese (Miller, Alpert, & Cross,RESULTS: The prevalence were found to be 5.8% for 2008). In addition, there were hospitals which implement policies barring the employment of obese candidatesunderweight (CI 0.03-0.10), 40.2% for normal BMI (CI (Miller J. R., 2012). In Johor, the prevalence of overweight and obesity among health staff was even0.33-0.47), 33.9% for overweight (CI 0.27-0.41) and higher than national prevalence of 60% (Harian Metro, 2009).20.1% for obese (CI 0.14-0.26). Higher prevalence ofobesity was found in males (20.1%) (CI 0.13-0.32), thoseconfined in office settings (23.3%) (CI 0.14-0.35) and inmarried employees (20.6%) (CI 0.15-0.27). There was asignificant association between marital status andoverweight (P 0.023). Among all job scopes, medicaldoctors had the highest prevalence of obesity (38.5%)(0.18-0.64). Prevalence of normal weight andunderweight are higher in those working in clinicalsetting (46.5%)(CI 0.38-0.55) compared to office staff(45.0%) (CI 0.33-0.58).CONCLUSION: There was higher prevalence of obesityand overweight amongst male staff, office andinspectorate personnel and medical officers at KulaijayaDistrict Health Department in relation to national andstate figures. Regular weight management programshould be implemented to all staff regardless of gender,marital status, job scope and working environment.KEYWORDS: Obesity, health staff.INTRODUCTION:Obesity is a complex chronic disease that results frommulti factors such as interaction between genotype and 28
There are many ways to measure body fat content in answer. It was mandatory that all staff partook in thiswhich the body mass index (BMI) (defined as study and respondents' rate was set and achieved at 100%.weight/height² [kg/m²]) is the most widely used This study is used to measure the prevalence of body masscompared to other weight-for-height indices. BMI is easy index status and their related factors. Weight and height ofto calculate and has been recommended as the measure of adults were taken by trained personnel working in pairsobesity for adults to be used in all studies. BMI generally using standard procedures and standardized digitalcorrelates highly with adiposity, although it can weighing scales and body meters which were calibratedsometimes misclassify total body fat content (Caballero, every morning. Subjects were measured at clinic.2001; Shashikiran, Sudha, & Jayaprakash, 2004; Body weights were measured in light clothing, withoutSpeakman, 2004). The classification of overweight and shoes as done in previous studies (Ismail, Zawiah, Chee,obesity in adults as proposed by WHO includes: & Ng, 1995). Body weight was measured to the nearestunderweight (BMI < 18.5), normal weight (18.5 to 24.9), 0.1 kg while height was measured to the nearest 0.1 cm.pre-obese/overweight (BMI 25.0-29.9), obese (BMI > or All readings were taken and recorded in triplicates. The= 30.0) in which obese further subdivided into obese I BMI was calculated by dividing weight in kilograms by(BMI 30-34.9), obese II (BMI 35-39.9) and obese III height in meters squared. The calculation of the BMIs(BMI >40) (Malaysian Association for the Study of was carried out using SPSS version 15.Obesity; World Health Organization , 2004). Despite Using the BMIs, subjects were assigned to various weightprevious attempts and suggestion to change this categories based on a modified WHO Classificationinternational BMI classification to interpret BMI cut-off which includes underweight (BMI < 18.5), normal (BMIpoints for Asia population, the WHO Expert Consultation 18.5 to 24.9), preobese (BMI 25 to 29.9) and obese (BMI2004 recommends retaining the current international > 30) (World Health Organization (WHO), 2004). TheBMI classification for adult regardless where the BMIs were analysed according to the different workingpopulation is (Malaysian Association for the Study of areas at Kulaijaya Health District Office. The prevalenceObesity; World Health Organization , 2004). was reported with confidence intervals (CI) and itsThe present study focuses on the BMI index among health relations with variables of gender, workplace, job scopestaff of Kulaijaya Health District Office in Johor. The and marital status were analysed at 5% level ofobjectives of this study are to describe the prevalence of significance using SPSS statistical software version 15.overweight and obesity among the staff usingstandardized international definitions. It will compare the RESULTSprevalence in relation to the working environment, job Profilescope, gender and marital status. All health workers (n=189) at Kulaijaya District Health Department except for pregnant mothers and 3 months orMETHODOLOGY: less post natal were involved in this study. This study was A cross sectional study was carried out in June carried out within the month of June 2012. Most of the respondents were married (89.9%), females (64.6%) and2012 among the the health staff of Kulaijaya District paramedics (43.9%). The mean BMI of the staff wasHealth Department except expectant mothers and 25.73 kg/m². The respondents were equally distributedfemales in their first three months postpartum period. among office and two clinics.This study design was chosen since it was the best methodfor this study due to its simplicity and rapid execution of Figure 1-4 depict the descriptive profile of staff of Kulai District Health Office. Figure 1: GenderFigure 2: Marital status Figure 3: Job Scope Figure 4: Work area 29
Prevalence and relationsThe prevalence of overweight (BMI > 25kg/m2) and obesity (BMI>30kg/m²) among the health staff was 33.9% (CI0.27-0.41) and 20.1% (CI 0.14-0.26) respectively. Out of 20.1% of obese staff, 36.8% work in the office whereas 31.6%served at the main Kulaijaya District Health facilities. All in all, the obesity prevalence was higher among office staff(23.3%) (CI 0.14-0.35), males (20.1%) (CI 0.13-0.32), medical doctors (38.5%) (0.18-0.64) and married personnel(20.6%) (0.15-0.27). Prevalen Confidence Interval ce CATEGORY 5.8 Lower border upper border UNDERWEIGHT 40.2 NORMAL 33.9 3.3 10.1 OVERWEIGHT 20.1 33.5 47.3 OBESE 100.0 27.5 40.9 TOTAL 14.1 25.2Table 1: BMI prevalence and confidence interval of health staff of Kulaijaya Health District Office. Bar Chart PEJABAT BMI status KK KULAI underweight normal preobese obese w o rk p la c e KK KULAI BESAR 0 10 20 30 40 Counts Figure 5 Bar chart BMI status and workplace OBESITY overweight -.165(*)Marital Status Pearson Correlation -.036 Marital status Pearson Correlation .023Gender Sig. (2-tailed) .623 Jawatan Sig. (2-tailed)Jawatan N 189 189Workplace Pearson Correlation -.015 N Sig. (2-tailed) .842 .118 N 189 Pearson Correlation .105 Pearson Correlation -.096 Sig. (2-tailed) Sig. (2-tailed) .191 189 N 189 Gender N Pearson Correlation .036 -.054 Sig. (2-tailed) .620 Pearson Correlation .460 N 189 Sig. (2-tailed) 189 Workplace N .089Table 2: Obesity and its correlations with studied factors Pearson Correlation .226 Sig. (2-tailed) 189 N * Correlation is significant at the 0.05 level (2-tailed). Table 3: Overweight and its correlations 30
DISCUSSION: or emergency department. Thus, less physical activity isThe mean BMI for staff of Kulaijaya District Health involved in their routine job. This explanation is true as ifDepartment (KDHD) was 25.73 kg/m², which is higher we add the prevalence of overweight and obesity,than mean BMI of Malaysian adult which is 24.37kg/ m² paramedics had the highest prevalence at 55.4%based on The Malaysian Adults Nutrition Survey (CI0.447-0.656). Paramedics share the same working(MANS) (Azmi, et al., 2009) The prevalence of environment and similar job scope as medical doctors inoverweight (BMI 25-29.9 kg/m²) and obesity the clinic. Furthermore, 80% of these obese medical(BMI>30kg/m²) among the health staff was 33.9% (CI doctors, 93.5% of overweight and obese paramedics are0.27-0.41) and 20.1% (CI 0.14-0.26) respectively which married, in which marriage lifestyle is related withwere higher than the national overweight and obesity obesity-prone lifestyle (Hough, 2010).prevalence of 29.1 (CI 0.286-0.297) and 14.4%respectively (Nor, et al., 2008). The overweight and obese Males had higher prevalence of obesity andwere also higher than MANS (Azmi, et al., 2009); overweight (58.2%) (CI0.463-0. 693) compared towhereby overweight prevalence was at 26.71% (CI: females (51.6%) (CI 0.429 - 0.603)in this study. Most0.255 – 0.280) and obesity was at 12.15% (CI: 0.113 to males were (87.2%) married which could explain the0.131). The local (KDHD) prevalence was even higher underlying reason for the higher prevalence.than the overall southern region overweight prevalence of Furthermore, studies have shown that marital status is an29.4% (0.266-0.324) and obesity prevalence at 13.8% (CI important predictor of obesity in males (Lipowicz,0.118-0.161). Gronkiewicz, & Malina, 2002). These figures can be attributed to the location of CONCLUSION :Kulaijaya itself which is just next to Johor Bahru, a fast There was higher prevalence of obesity andgrowing urbanized and developed capital city inMalaysia (Noorsidi, 2009). Urban food environment, overweight amongst male staff, office and inspectoratebuilt environment and technology advancements can lead personnel and medical officers. Nevertheless, theseto poorer diets and less physical activity (Harvard School findings were found to be insignificant. However, thereof Public Health) (Reid Ewing, et al., 2008), which result was significant association between marital status andin obesity (Caballero, 2001;Moy & Atiya, 2003-2005; overweight prevalence. Obesity and overweightSpeakman, 2004). Furthermore, working in a health prevalence of Kulaijaya District Health Departmentcommunity clinic is associated with less physical and (KDHD) was also higher than the national and southernenergy requirement compared to working in a hospital zone prevalence figures. There is a need forsetting. (Chris G., 2009). implementation of effective weight management program for all the staff at Kulaijaya Health District This study also showed that obesity prevalence Department, regardless of gender, marital status,was higher in those working in office surroundings respective job scope and working environment.compared to clinical settings. This is probably due tohigher physical activity required to run clinics rather than ACKNOWLEDGEMENTSoffices. Furthermore,office work is mostly related with In The Name of Allah, The Most Gracious and Merciful.paper work and entails prolonged sitting rather than We are so blessed with all the courage and strength thatstanding (Ariënsa, et al., 2001). Office workers also has been bestowed upon us.spend lots of time sitting in front of their computers. The deepest appreciation and gratitude toward Dr BadrulStudies have showed strong association between Hisham Bin Hj. Abd Samad for his great comments,computer use and obesity due to physical inactivity (CBC guidance and assistance in the preparation of this writing.NEWS, 2008;Kautiainen, Koivusilta, Lintonen, We extend our gratefulness to Dr Abdul Rahim BinVirtanen, & Rimpelä, 2005) Abdullah, Head of Kulaijaya District Health Department, Kulaijaya, Johor for his support and advice. Higher prevalence of obesity and overweight Special thanks to our beloved staff for giving goodamong married staff was also significant (p=0.023). The cooperation and assistance during data collection. Wefindings are similar with previous studies (Jeffery & pray that Allah will reward your benevolence andRick, 2002; Lipowicz, Gronkiewicz, & Malina, 2002; cooperation in this world or the hereafter.Sobal, 2008). This might be due to significant changes inlifestyle as a couple automatically cease to monitor orcontrol their weight gain or body shape after marriage.Married couple spend more time eating together andoften order takeaway ready meals while exercising less(Hough, 2010). Surprisingly, medical doctors have the highestprevalence of obesity among all categories in this study.This might be due to their job scope in clinical settingwhich were most likely related with counseling patient,establishing long term relationship with patient andfamily members, emphasizing disease prevention andhealth promotion (American Academy of FamilyPhysicians, Wikipedia) rather than attendance orinvolvement in acute or emergency cases as in a hospital 31
REFERENCES communication technology and prevalence ofAmerican Academy of Family Physicians. (n.d.). ExploreFamily Medicine - where every facet of medicine is yours overweight and obesity among adolescents. Internationalto discover. Retrieved 2012, from American Academy ofFamily Physicians: www.aafp.org/explore Journal of Obesity , 925-933.Appropriate body-mass index for Asian populations andits implications for policy and intervention strategies. Lipowicz, A., Gronkiewicz, S., & Malina, R. M. (2002).(2004, January 10). Retrieved from THE LANCET:www.thelancet.com Body mass index, overweight and obesity in married andAriënsa, G. A., Bongersa, P. M., Douwesa, M.,Miedemaa, M. C., Hoogendoorna, W. E., Walb, G. v., et never married men and women in Poland. Americanal. (2001). Are neck flexion, neck rotation, and sitting atwork risk factors for neck pain? Results of a prospective Journal of Human Biology , 468-475.cohort study. Occupation Environment Medicine , 200-207. Malaysian Association for the Study of Obesity. (n.d.).Azmi, M., Junidah, R., Mariam, A. S., Safiah, M.,Fatimah, S., Norimah, A., et al. (2009). Body Mass Index Retrieved August 3, 2012, from Define obesity:(BMI) of Adults: Findings of the Malaysian AdultNutrition Survey (MANS). Malaysia Journal of Nutrition http://www.maso.org.my/spom/chap3.pdf15(2) , 97-119.Caballero, B. (2001). Obesity in Developing Miller, J. R. (2012). Texas hospital reportedly bars obeseCountries:Biological and Ecological Factors. Journal ofNutrition , 866-870. workers -- and it might be legal. Texas: Foxnews.com.CBC NEWS. (2008). TV viewing, computer use linked toobesity: StatsCan. Miller, S. K., Alpert, P. T., & Cross, C. L. (2008).Chris G. (2009, September 14). Hospital or Clinic: Whichis Better to Work In? Retrieved from Yahoo Contributor Overweight and obesity in nurses, advanced practiceNetwork: http://voices.yahoo.com/hospital-clinic-which-better-work-in-4232039.html nurses, and nurse educators. Journal of AmericanHarian Metro. (2009). Hospital Bukit Mertajam .Retrieved 2012, from Berita: Kakitangan Hospital Academy of Nurse Practitioners , 259-265.Diminta Kurangkan Berat Badan:http://hospbm.moh.gov.my/modules/news/article.php?st Moy, F., & Atiya, A. (2003-2005). Lifestyle Practices andoryid=22Harvard School of Public Health. (n.d.). The Obesity Prevalence of Obesity in a Community within aPrevention Source: urbanization and society. RetrievedAugust 11, 2012, from Harvard School of Public health: University Campus. The Journal of Health andhttp://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/obesity-and- Translational Medicine , 33-38.urbanization/index.htmlHough, A. (2010). Married people 'twice as likely to be Noorsidi. (2009, November 21). Johor Bahrufat'. The Telegraph.Ismail, M., Zawiah, H., Chee, S., & Ng, K. (1995). Urbanization and Demographic. Socyberty .Prevalence of obesity and chronic energy deficiency(CED) in Adult Malaysians. Malaysian Journal of Nor, M., Khor, N. S., Shahar, G. L., Kee, S. &., Haniff, C.Nutrition , 1-9.Jeffery, R. W., & Rick, A. M. (2002). Cross-Sectional and C., Appannah, J. &., et al. (2008). The Third NationalLongitudinalAssociations between Body Mass Index andMarriage-Related Factors. Obesity Research , 809-815. Health and Morbidity Survey (NHMS III) 2006:Kautiainen, S., Koivusilta, L., Lintonen, T., Virtanen, S.M., & Rimpelä, A. (2005). Use of information and nutritional status of adults aged 18 years and above. Malaysian Journal of Nutrition 14(2) , 1-87. Reid Ewing, T. S., Killingsworth, R., Zlot, A., & Raudenbush, S. (2008). Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity. Urban Ecology , 567-582. Richard, A. D., Andrew, K. T., & Rodolfo, M. N. (2012). Obesity inequality in Malaysia: decomposing differences by gender and ethnicity using quantile regression. Ethnicity and Health . Shashikiran, U., Sudha, V., & Jayaprakash, B. (2004). What is obesity. Medical Journal of Malaysia 59(1) , 131- 134. Sobal, J. (2008). Marriage, Obesity and Dieting. Marriage and Family Review , 115-139. Speakman, J. R. (2004). Obesity: The Integrated Roles of Environment and Genetics. Journal of Nutrition , 2090- 2015. Wikipedia. (n.d.). Wikipedia. Retrieved 2012, from Family Medicine: http://en.wikipedia.org/wiki/Family_medicine World Health Organization . (2004). World Health Organization. Retrieved August 3, 2012, from BMI Classification: http://apps.who.int/bmi/index.jsp?introPage=intro_3.ht ml 32
Evaluation of laboratory outcomes of patients (INR) 8 between clinician-managed Warfarin therapy andpharmacist-managed Warfarin Medical Adherence Volume 10 Therapy Clinic (W-MTAC) in HBP over 1 yearAli Umar Bin Ibrahim, Yvonne Koh Li Ling, Pn. Siti Khairaini Binti Rahim 2012Pharmacy Department, Hospital Batu Pahat, Johor, Malaysia June 2011Abstract IntroductionEvaluation of laboratory outcomes of patients (INR) Warfarin is the most widely used oral anticoagulant agentbetween clinician-managed Warfarin therapy and worldwide, especially in the prevention ofpharmacist-managed Warfarin Medical Adherence thromboembolic events such as deep vein thrombosisTherapy Clinic (W-MTAC) in HBP over one year (DVT), chronic atrial fibrillation, pulmonary embolismI.Ali Umar1, Y. L .L Koh1, R. Siti Khairani1 and valvular heart disease [1]. Warfarin acts by1Department of Pharmacy, Hospital Batu Pahat, Johor. interfering with the cyclic interconversion of vitamin KBackground: The clinical quality of warfarin therapy and vitamin K epoxide and subsequent modulation of therelies on how successful healthcare professionals and gamma carboxylation of the terminal regions ofpatients are in achieving and maintaining levels of vitamin K proteins. This results in the reduction ofanticoagulation capable of preventing thromboembolic clotting factors II, VII, IX, and X [2]. Carboxylation ofevents without increasing the risk of hemorrhagic the regulatory anticoagulant proteins C and S also iscomplications. The purpose of this study is to compare inhibited, potentially contributing to a procoagulantthe clinical outcomes of patients (INR) between effect early in therapy.clinician-managed Warfarin therapy and pharmacist-managed warfarin Medication Adherence Therapy Clinic Warfarin has its established role in anticoagulation(W-MTAC) in HBP over one year (April 2009-March treatment for decades. But a number of challenges have2010) and (April 2010-March 2011) respectively. been identified in managing warfarin therapy practicallyMethods: The retrospective study was carried out by and clinically. These include the need for frequentmeasuring the percentage of patient time spent within laboratory monitoring and dose adjustment, drug andtargeted INR therapeutic range. The percentage of time food interactions, presence of concomitant disease, thespend within the therapeutic range was calculated by the influence of co-morbidities on anticoagulant control andmethod described by Rosendaal and colleague. All data the fear of adverse events [6]. Besides, the variablecollected will be entered into Microsoft office Excel 2003 biological effect and drug response in patient due to(Microsoft Corp., Redmond WA, USA) and analysed variant alleles of the CYP2C9, the hepatic enzymeusing Statistical package for the Social Sciences (SPSS) responsible for oxidative metabolism of the warfarin S-version 17TM (SPSS Inc., Chicago, IL, USA). isomer, can also influence the optimal dosing of warfarin.Results: It was found that there was an increase of Several genetic polymorphisms in this enzyme have beenpercentage of patient-time in therapeutic range which described that are associated with lower doseabout 10% after W-MTAC managed by pharmacists was requirements and higher bleeding complication ratesstarted at HBP. compared with the wild-type enzyme CYP2C9 [6,9].Conclusion: The management model for anticoagulation Besides, daily adherence to warfarin is both a persistenttherapy by clinical pharmacist as the primary care and potentially modifiable contributor to INR instabilityprovider with clinician consultation is more effective and warfarin efficacy [6,7].than a model of care managed solely by clinicians inachieving target INR control. The clinical quality of warfarin therapyKeywords : Warfarin therapy, Warfarin Medical relies on how successful healthcare professionals andAdherence Therapy Clinic (W-MTAC) patients are in achieving and maintaining levels of anticoagulation capable of preventing thromboembolicCorrespondence: Mrs. R. Siti Khairani events without increasing the risk of hemorrhagicFull correspondence address: Hospital Batu Pahat, Jalan complications [8]. Successful anticoagulant managementKorma, 83000 Batu Pahat requires careful monitoring of the INR, ongoing patientTel: 07-4363000 ext. 3136 education and good communication between patient andFax: 07-4345810 healthcare professionals. It also requires an educated andEmail: [email protected] skilled personnel as well as a well-organized framework of services [8,9]. Poor patient compliance and lack of patient education is often cited as an explanation for out- 33
of-range INR measurements [10]. Past studies had underwent follow-up at Medical Outpatient Departmentsuggested that patient education which highlight the side- (MOPD) HBP from year April 2010 to March 2011 areeffects of warfarin, the potential for drug–drug and recruited in this study. Before April 2010, outpatientdrug–food interactions, advice on birth control, the anticoagulation management in HBP patients wasimportance of compliance and the need for regular managed solely by doctors. For the purpose of this study,monitoring, is associated with better clinical outcomes. this model was named as 'usual medical care' (UMC). InPrior knowledge about warfarin has been associated with April 2010, pharmacists took over the management ofa decreased risk of bleeding [11]. Written and verbal warfarin therapy, working closely with Medicalinformation have been shown to improve control of the Department doctors, hence the formation of W-MTAC. Inlevel of anticoagulation [12]. This shows that counselling W-MTAC the pharmacist sees all new patients at theirpatients with respect to their anticoagulant treatment is first visit for information and counselling regardingfundamental and significantly improves patient's warfarin therapy. In the subsequent visit, the clinic'sknowledge and quality of anticoagulation. Many studies standard procedure is for patients to have their blood[15-20] had proven that pharmacist-managed taken for an international normalized ratio (INR) testanticoagulation clinics had showed improved care in at the time of arrival. INR results were determined viapatient receiving warfarin therapy compared to usual venous blood samples and tested hospital laboratory staffmedical care, in which the patient showed improved INR using a fully-automated, high productivity analyzercontrol, improved patient education, decreased warfarin- (ACL 7000; Instrumentation Laboratory, Milan, Italy).related hospitalisation, lowered the incidence of When the INR results are received later the same day, theyhaemorrhagic and thromboembolic events, decreased are written in the patient's record book and case notehealth care cost or more cost effective therapy. along with dosage instructions, and subsequent review date will be given to patient. Because there is a strong association betweenINR levels and adverse outcomes, the efficacy of warfarin Study Design and Selection Criteriadepends not only on defining the target INR but also the This is a retrospective medical record review,maximal length of time the patient's INR maintained observational study. The historical control groupwithin the designated therapeutic range or time in consists of patients received warfarin therapy from 1sttherapeutic range (TTR) during warfarin therapy as there April 2009 to 31st March 2010, who were managed byis an increased risk of haemorrhage at INRs > 3.0 and clinicians. The intervention group consists of patientsthromboembolic complications at INRs < 2.0 [19]. White under followed-up W-TAC from 1st April 2010 to 31stet al., 2007 [20] reported that the INR value in the March 2011. Demographic data, indications for warfarintherapeutic range for more than 75% of the time had therapy and the target INR ranges are collected for eachsignificantly fewer episodes of major and minor bleeding. patient. When multiple indications for warfarin therapyThus patient's INR must remain stable within their were recorded, the indication requiring the highest targettherapeutic range in order to minimize the complications INR range or the longest duration of anticoagulationassociated with anticoagulation therapy. Therefore, the therapy is chosen as the primary indication. A W-MTACaim of this study is to evaluate the clinical quality and audit form is designed to collect the data, and a pilot studyeffectiveness of warfarin clinic managed by the was conducted to review the final audit form (Appendixpharmacists - also known as Warfarin Medical Adherence 1).Therapy Clinic (W-MTAC), in Hospital Batu Pahat(HBP) by measuring the percentage of patient time spent Inclusion criteriawithin targeted INR therapeutic range in a cohort of • Aged > 18 years at initiation of warfarin therapypatient participated in this studies. • At least two INR test values measured during any of the evaluation periodsResearch Objective • Have been stabilized on warfarin therapyThe objective of this research is to compare the laboratory (minimum of 1 month).outcomes of patients (INR) between doctor-managedWarfarin therapy and pharmacist-managed Warfarin Exclusion criteriaMedical Adherence Therapy Clinic (W-MTAC) in HBP • INR tests performed as inpatient testsover one year (April 2009 – March 2010) and (April 2010– March 2011) respectively. Outcome Percentage of time in the therapeutic range in each timeResearch Hypothesis period was first calculated overall; that is, by considering all days of follow-up. The outcome is the percentage ofAlternative hypothesis, H1 : The laboratory patient time spends within the target INR range. The percentage of time spend within the therapeutic range isoutcomes of pharmacist-managed W-MTAC in HBP, calculated by the method described by Rosendaal and colleague as described in Appendix 2 [22]. The methodJohor has improved over one year. utilized is Rosendaal's linear interpolation. The majority of recent studies utilize Rosendaal's linear interpolationNull Hypothesis, H0 : The laboratory methodology which assumes that a linear relationship exists between two INR values, given that not more than 8outcomes of pharmacist-managed W-MTAC in HBP, weeks has elapsed between the two. It allocates a specificJohor has not improved over one year.MethodologySettingPatients who were treated with warfarin therapy and 34
INR value to each day between tests for each patient, Statistical Analysisallowing one to calculate INR specific incidence rates of All data collected will be entered into Microsoft Officeadverse events, such as bleeding complications. Linear Excel 2003 (Microsoft Corp, Redmond WA, USA) andinterpolation is the only method that incorporates time. analysed using Statistical Package for the Social Sciences (SPSS) Version 17 ™ (SPSS INC., Chicago, IL, USA).ResultsDemographic CharacteristicsTable 1 shows the demographic characteristics of warfarin patients of HBP from April 2009 until March 2011. Theproportion of male to female was about 1:1 (46.5 % male vs 53.5 % female). About three quarter of the W-MTACpatients are made up of Malay, followed by Chinese. The mean age was around 59.62 years old, with standarddeviation of about ±13.71 years old. The youngest patient was 34 and the oldest patient was 91 years old.Table 1: Demographic characteristics of warfarin patients of HBP from April 2009 – March 2011Year April 2009 – March 2011No. of Patient (n) 43 n (%)Gender Male 20 46.5 Female 23 53.5Races Chinese 11 25.6 Melayu 32 74.4Age Mean age 59.62±13.71 ± SD a Age 34 to 90 RangeaSD=Standard deviationFigure 2: Indication of warfain at HBP from 2009-2011AF=atrial fibrillation, HVR= heart valve replacement,DVT= deep vein thrombosis, included pulmonary embolism 35
Figure 2 shows the warfarin indication at HBP. Most of the warfarin was indicated for atrial fibrillation (AF) 81.4%,followed by heart valve replacement (HVR) 14% and deep vein thrombosis (DVT) 4.65%. Warfarin was not used forcardiac ischaemic events such as ischaemic cardiomyopathy (ICMP), dilated cardiomyopathy (DCMP) and otherevents such as antiphospholipid sndrome (APS), and coronary artery bypass graft (CABG). Figure 3: Mean percentage of patient-time in therapeutic range. Results were expressed as the mean percentage, significantly different from the control group; Doctors at P < 0.05Figure 3 shows the mean percentage of patient-time in medical care [23,24]. In the present study, the warfarintherapeutic range between doctors and pharmacists. patients studied in the pharmacist-managed group spentOverall, the mean percentage of patient-time in more time in the therapeutic INR ranges when comparedtherapeutic range of W-MTAC managed by pharmacists with those in the clinician-managed group. This showedwas superior (58.1%) than MOPD managed by doctors that the patients managed by pharmacist-managed group(48.2%). There was an increase of percentage of patient- from April 2010 to March 2011 achieved a better INRtime in therapeutic range which about 10 % after W- control as shown in Figure 3. Such achievement isMTAC managed by pharmacists was started at HBP. perhaps due to the intense education provided to patients and their caregivers by clinical pharmacist in theDiscussion pharmacist-managed group, patients' adherence orOnce the targeted intensity of oral anticoagulation is compliance are checked more thoroughly and, as a drugachieved, it must be maintained, as this is directly related expert, pharmacist provides extra attention to theto its derived benefit. The most recognized way to potential warfarin–drug and warfarin–herb interactions atmeasure the therapeutic effectiveness of warfarin over each clinic visit. Besides, the use of standardizedtime is to measure time spent in therapeutic range (TTR). anticoagulation monitoring template and separate caseTTR has been shown to strongly correlate with the note also makes monitoring of patient's INR becomeprincipal clinical outcomes of hemorrhage or thrombosis easier and more easily retrievable. All these mayand, thus, TTR is a reliable measure of the quality of W- contribute to the improved INR control in the patientsMTAC. Increased TTR has also been associated with managed by the clinical pharmacist [27].decreased mortality, myocardial infarction and strokerates. Clinical studies show that under-coagulation and The percentage of patient time spent in therapeutic rangeover-coagulation enhance the risk of adverse clinical managed by pharmacist in WMTAC since April 2010 tooutcomes such as thromboembolism and bleeding March 2011 is higher than that of conventional medicalrespectively. Literatures have proven that specialized care. A likely explanation is that, in 2008, the newanticoagulation management with pharmacist's warfarin protocol has been implemented. The newintervention has resulted in outcomes at least equal, and protocol came with more detailed information andsometimes superior in term of time spent in therapeutic directions, with a clear dosage adjustment guideline andrange. Furthermore, there is also reduction in therapy- also with the list of possible drug-drug or drug herbrelated complication by 50-90% compared to those interaction that may help pharmacist in warfarin dosingmanaged through standard care. adjustment. Patient satisfaction with pharmacist managed anticoagulation clinics was invariably high and,Time in the therapeutic range has been shown to correlate in comparative studies, higher than that reported forwell with hemorrhagic and recurrent thromboembolic clinician-managed anticoagulation clinics. Physiciansevents [25]. It can be measured by a number of methods surveyed also expressed satisfaction and frequently(Rosendaal method, the percent (fraction) of INRs in acknowledged that such a service would save them timerange, and the point-in-time or cross-section of records [32,33]. Clinicians considered pharmacists capable ofmethodology) and no standardized consensus exists as to monitoring and maintaining warfarin therapy, consideredwhich is the best measure. It was proven that the Pharmacist managed anticoagulation clinics an asset,anticoagulation management service (WMTAC) and did not feel that it infringed upon their control ofimproves time in the therapeutic range for patients on patient management [36].chronic oral anticoagulation compared with usual 36
There are some limitations to this study. First was related Not only that, a continuous medical education (CME)to the problems inherent in a retrospective analysis and with the Head of Department, Specialists, Medicalhave been described in detail elsewhere [1]. Next Officers (MO) and Housemanship Officers (HO) shouldlimitation was due to the possibility of incompleteness or be conducted regularly, preferably once per year, this duedata loss, this is the common drawback of retrospective to the rapid staff movement in the hospital. The doctorsstudy and not only the problem in this study. Besides, the were introduced to W-MTAC in hope of providing betterwarfarin complications such as thromboembolic events warfarin management and care to patients. Moreover, theand bleeding risks, which were considered as the ideal existing warfarin book should be amended to provideend points study of therapeutic efficacy, were not carried more comprehensive information including indication,out in this study. Furthermore, many environmental tablet identification, drug-drug and drug-foodfactors, such as medications, diet and concomitant interactions and other precautions. Besides, ongoingdisease states can alter the pharmacokinetics of warfarin, education, counsel in case of sustained dysregulation ofthus contributing to the limitations of study. Other factors anticoagulation, or advice on interruption of therapy inthat may affect therapeutic outcome such as patient case of bleeding or the need to undergo an invasivecompliance, transient fluctuations of comorbid procedure are, among others, issues that need to be takenconditions, the addition or discontinuation of care of is also need to be addressed to all warfarin patientmedications, the quality of dose-adjustment decisions to improve better warfarin management control [37].and whether the patient has demonstrated a stable doseresponse and many others are not considered in this study. Conclusions Overall, the mean percentage of patient-time inIn future studies assessment of the major complications therapeutic range of W-MTAC managed by pharmacistsof warfarin in this hospital, such as thromboembolic was superior (58.1%), more than that of MOPD managedevents, bleeding risks, and rate of hospitalization should by doctors (48.2%). In summary, the management modelbe conducted. 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Appendix 1 Age: Indication: Target INR:Name: Doctors Visit Date INR Days since INR difference % in rangeVisit Date Pharmacists INR Days since INR difference % in range 40
Appendix 2Rosendaal Method for % INR in range - method which INR-specific person-time is calculated by incorporating thefrequency of INR measurements and their actual values, and assuming that changes between consecutive INRmeasurements are linear over timeExample: Patient has INR reading of 2.4 on October 1st, then reading of 3.2 on October 17th. Assuming the patientgradually moves towards a reading of 3.2 throughout the 16-day period between Oct 1st and Oct 17th, then we canestimate that the patient was within their INR therapeutic range [2 - 3] for a majority of that time period. To calculate thevalue1. calculate amount of the total shift (2.4 to 3.2 = 0.8 increase) that is within the therapeutic range (0.6 of shift is withinrange, [3.0 - 2.4 = 0.6])2. calculate percent of total shift within therapeutic range (0.6/0.8 = 75%)3. estimate number of days since last visit that were within range (75% x 16 days since last visit = 0.75 x 16 = 12 dayswithin range, 4 days out of range). Percentage for that time period is 75% in range, and 12 total days in range.To calculate overall % in range, add total days in range for each time period, and divide by total therapeutic days Sample Patient Visit Date Type INR Days INR Pred% In Since Diff Range 12/20/2005 8:29:19 AM Prior Visit 3.3 50% 100% 1/17/2006 8:32:38 AM Onsite Training 2.7 28 -0.60 100% 100% 2/7/2006 8:32:38 AM Prior Visit 2.3 21 -0.40 67% 3/7/2006 8:32:38 AM Prior Visit 2.4 28 0.10 0% 0% 4/4/2006 3:54:57 PM Scheduled Visit 2.2 28 -0.20 48% 0% 4/12/2006 10:48:08 AM Telephone Contact 1.9 8 -0.30 0% 56% 4/25/2006 4:31:10 PM Scheduled Visit 1.2 13 -0.70 57% 100% 5/2/2006 3:18:50 PM Scheduled Visit 1.8 7 0.60 71% 71% 5/15/2006 3:51:58 PM Scheduled Visit 3.9 13 2.10 100% 5/22/2006 3:39:23 PM Scheduled Visit 3.7 7 -0.20 5/30/2006 3:42:20 PM Scheduled Visit 3.5 8 -0.20 6/14/2006 2:42:54 PM Scheduled Visit 1.7 15 -1.80 6/23/2006 3:09:33 PM Scheduled Visit 2.4 9 0.70 7/25/2006 2:50:16 PM Scheduled Visit 2.5 32 0.10 8/22/2006 2:49:09 PM Scheduled Visit 3.2 28 0.70 8/29/2006 3:07:13 PM Scheduled Visit 2.5 7 -0.70 9/19/2006 3:03:26 PM Scheduled Visit 2.3 21 -0.20 INR In Range % (Traditional) = 47.06% [8 visits within range out of 17 total visits] INR In Range % (Rosendaal) = 71.05% [194 days in therapeutic range out of 273 total therapeutic days] 41
POLYPHARMACY OF ANTIHISTAMINES IN COUGH 9AND COLD PRODUCTS USED AMONG CHILDREN Volume 10 AGED BELOW 6Wong L.Y.1, Fajaratunur A.S1, Zakiah A.R.1, Hazlinda A.H.1, 2012 Goh P.T.1, Zakaria M.S.1, ZulRamli Z.21Pejabat Kesihatan Muar, Johor, 2Institute Health System ResearchSummary (USFDA) that cough and cold medicines that contain one or more decongestants, antihistamines and/or anti-There are high incidences of concurrent use of two or tussives do not work and should not be used by childrenmore antihistamines in cough and cold treatment among aged below 61-7. In the meantime, the FDA'schildren at Klinik Kesihatan Maharani, Muar. This study Nonprescription Drugs and Pediatric Advisoryaims to reduce the polypharmacy of antihistamines in committees voted to ban over-the-counter cough and coldcommon cold treatment among children below 6, and to products that are intended for children who are youngerevaluate its magnitude and characteristic prior to and than 6 years,17 and the FDA is currently considering thefollowing pharmacist intervention. This was a cross- committees' advice. Beside, the Drug Control Authoritysectional, quasi-experimental, two-phase (pre/post) (DCA) recommends all healthcare professionals to takestudy. All prescriptions of cough and cold product(s) for note that many products contain the same medicinalchildren below six were recruited during these periods. ingredient(s) and combined use in children may lead toIncomplete and indecipherable prescriptions were overdose1, 8.excluded. The endpoints were total number ofpolypharmacy in Phase I and II, in different category of Recently, attention has focused on the potential harmfulprescribers, and different combinations. The result effects of these medications18. The adverse eventsshowed total polypharmacy of antihistamines in Phase II reported with these products include death, convulsions,(Npre=559) was significantly reduced to 82 from 238 in rapid heart rates and decreased levels of conciousness12,Phase I (Npost=605, p<0.01). The incidences of 13, 22. Concerns about these toxicities, especially in lightpolypharmacy prescribed by doctors, Medical assistants of data that cough and cold products have not been provedand staff nurse were 10.3%, 34.4% and 0% respectively in effective in treating symptoms of cough and the commonPhase II compared to 46.6%, 37.4% and 17.2% cold in young children, it is advised not to give more thanrespectively in Phase I (p<0.01). The most common one cough and cold product to children as they canpolypharmacy occurred appears to be combination of recover in time on their own. In addition, common cold isdiphenyhydramine and chlorpheniramine in both phases, a mild, viral infection that can be managed by rest,which were 21.5% and 7% respectively (p<0.01). The sufficient fluid intake and comfort measures1, 2.reduction in polypharmacy of antihistamines in cough There is high incidence (42.6% of total prescriptionsand cold products used among children below 6 can be given to children aged below 6 diagnosed with URTI) ofachieved by means of a systematic and comprehensive concurrent use of two or more antihistamines in coughintervention and collaboration between healthcare staffs and cold treatments among chidren aged below 6 atthough there were limitations. Klinik Kesihatan Maharani (KKM), Muar. The antihistamines used are promethazine, diphenhydramine,Keywords: Polypharmacy, antihistamine, children, chlorpheniramine and triprolidine. The polypharmacy ofcough and cold antihistamines may lead to anticholinergic intoxications such as heat intolerance, jerking movements,Introduction disorientation and hallucinations and other adverse events mentioned above4,9,10,11.Cough and cold is the most common symptom for whichpatients seek medical attention15 and cough mixtures are ___________________frequently prescribed in primary care. However, theclinical value of many cough mixtures is debatable16, 23, a Cough and cold: Symptoms of upper respiratory tract24 and their use in children and the elderly is infection19.controversial. b Cough & cold products: Products that containIn August 2007, US Federal Health advisors antihistamines, antitussives and/or decongestants to treatrecommended to U. S. Food and Drug Administration cough and cold symptoms1,20. 42
Objectives 31 January 2009 (20 working days) to aware the prescribers about the polypharmacy that may occur ifThe aims of this study are to reduce polypharmacy of more than one antihistamine given to the children agedantihistamine(s) in cough and cold products and to study below six and hence the adverse events. The interventionsthe magnitude and characteristic of polypharmacy of were conducted by providing short lecture, andantihistamine in the management of couh and cold in distribution of published circular and protocol on rationalPKBM, Muar. prescribing cough and cold product(s) that contains antihistamine(s) to all prescribers. The protocolThe specific objectives are: circulated was approved by Family Medicine SpecialistŸ To calculate the incidences of polypharmacy of and Pharmacy Department of the clinic. This is to improve the physicians' confidence in handling URTI antihistamine prior to and after intervention. cases among children without prescribing polypharmacyŸ To identify the combinations of cough and cold and to reduce the suspicions on the reliability of protocol circulated. Beside, all prescribers who were detected to products in polypharmacy. prescribe two or more antihistamines for children agedŸ To identify the categories of prescribers involved in below 6 in a single prescription were contacted by phone for awareness and clarification purpose. polypharmacy.Ÿ To compare the incidences of polypharmacy prior to Phase 2 was conducted from 2 Februari 2009 to 31 Mac 2009 for another 48 working days. Every and after the intervention. prescription and particulars as stated in Phase 1 will beŸ To estimate the cost of polypharmacy prior to and identified after the intervention (Npost= 605), to compare the incidences of polypharmacy of antihistamines with after the intervention. respect to category of prescriber, and to estimate the cost of polypharmacy prior to and after the intervention. TheMethodology endpoints were total number of polypharmacy in Phase I and II, in different category of prescribers, and in This is a 2 phases cross-sectional, quasi-experimental different combinations of polypharmacy.cohort study that involved the prescribers andpharmacists at Klinik Kesihatan Maharani, Muar. The The raw data were processed and entered for data analysisstudy comprised all prescriptions given to children aged according to the different phases. Data were analysedbelow 6 who diagnosed with upper respiratory tract using SPSS 15.0 programme.infection (URTI) during November 2008 to March 2009(N = 1164). The data was collected by pharmacists at Resultspharmacy counter. A total number of 1164 prescriptions were enrolledPhase 1 was conducted during the period from 3 during the study period. Of these, 559 prescriptions wereNovember 2008 to 31 December 2008 for 48 working recruited in Phase 1 and 605 patients for Phase 2. In Phasedays. Every prescription that contains cough and cold 1, 238 (42.6%) prescriptions were detected to compriseproduct(s) to be given to children aged below six were polypharmacy compared to 82 (13.6%) in Phase 2. Theidentified and recruited in the study (Npre= 559). The difference was found to be significant (p<0.01).inclusion criteria were prescriptions, which URTI as thediagnosis and antihistamine as one or more of the items A total of eight different combinations of polypharmacyprescribed. Prescriptions which were incomplete, in antihistamines were identified in this study. There wereindecipherable, given to children aged 6 and above, not combinations use of (1)diphenhydramine anddiagnosed as URTI were ineligible. chlorpheniramine; (2)diphenhydramine and triprolidine; (3)chlorpheniramine and triprolidine; (4)promethazineEach prescription was described by a series of and diphenhydramine; (5)promethazine andcharacteristics, which were analysed as possible chlorpheniramine; (6)promethazine and triprolidine;explanatory variables for the prevalence of (7)diphenhydramine, chlorpheniramine and triprolidine;polypharmacy of antihistamines: (8)promethazine, diphenhydramine andŸ the category of prescribers (family medicine chlorpheniramine. In both phases, the combination of diphenhydramine and chlorpheniramine was found to be specialist, medical officer, medical officer assistant the most common polypharmacy which was 55.9% and and staff nurse), 59.8% respectively, followed by diphenydramine andŸ types of antihistamine prescribed (promethazine, triprolidine (35.3% and 34.2% respectively). diphenhydramine, chlorpheniramine, and triprolidine),Ÿ types of combination use of antihistamines in one prescription, andŸ cost of antihistamine(s) used for every prescription.___________________ Out of 382 prescriptions by doctors in Phase 1, 178 (46.6%) were detected with polypharmacy and this was Polypharmacy: Concurrent use of two or more reduced to 50 (10.3%) in Phase 2 (npost= 486, p<0.01).medications from the same chemical class21. However, only 3% polypharmacy of antihistamines was decreased from Phase 1(55, 37.4%, npre=147) to Phase 2Remedial action was carried out by means of pharmacist (32, 34.4%, npost=93) in population of medical assistantsinterventions following phase 1, from 1 January 2009 to (p>0.05). Only 5 (17.2%) out of 29 prescriptions were 43
found to contain polypharmacy by staff nurse in Phase 1 polypharmacy from Phase 1 (238, 42.6% of 559and were decreased to 0% in Phase 2 (npost=25, p<0.05). prescriptions) to Phase 2 (82, 13.6% of 605Family medicine specialist did not prescribed prescriptions). A possible explanation for the reductionpolypharmacy of antihistamines during the study period. was an increase awareness and emphasis for concurrentThis study showed a drastic decrease in the total number use of more than one antihistamine should be avoided inof polypharmacy among all prescribers (p<0.01). children and hence, the related adverse reactions.The total cost of antihistamine(s) used (559 prescriptions) In addition, greater awareness of the health carein Phase 1 was RM 1019.64 and RM 945.68 (605 professionals on the incidence of polypharmacy inprescriptions) in Phase 2. The mean antihistamine (s) cost antihistamines used may have resulted in the reductionsper prescription in Phase 1 was RM 1.82 and reduced of seven combinations use of antihistamines amongsignificantly to RM1.56 in Phase 2 (p<0.01) . children in term of total number of polypharmacy, except the combination use of chlorpheniramine andTable 1: The Comparisons between Phase 1 (Before triprolidine, none in Phase 1 but detected one in Phase 2.Intervention) and Phase 2 (After Intervention) in Terms ofNumber of Prescriptions, Total Costs and Mean Cost of Among all prescribers(family medicine specialists,Antihistamine(s) per Prescription medical officers, medical assistants, and staff nurses), the polypharmacy of antihistamines prescribed by medical Comparisons Phase I (before Phase II (after P value officers, decreased drastically from Phase 1 (178, 46.6% intervention) intervention) p<0.01 of 382 prescriptions) to Phase 2 (50, 10.3% of 486Total prescriptions with prescriptions). This reflects that medical officers respondantihistamine(s) Npre=559 Npost=605 perceptively to medical information provided and reactNumber of prescriptions with rapidly for the sake of patients. Besides, this furtherantihistamine polypharmacy 238 (42.6%) 82 (13.6%) explains that the interventions taken were effective andTotal costs comprehensive in inducing and increasing the awareness RM 1019.64 RM 945.68 among health care professionals on the incidence of polypharmacy of antihistamines used in URTI treatmentMean cost of antihistamine(s) per RM 1.82 RM 1.56 p<0.01 and the related adverse reactions. The polypharmacy ofprescription antihistamines prescribed among medical assistants appear to be similar in Phase 1 and Phase 2. This explainsTable 2: The Comparison of Polypharmacy in that the interventions may not give an impressive impactAntihistamines by Different Categories of Prescriber to the medical assistants. According to time captured bybetween Phase 1 and Phase 2 using Queue Management System (QMS), most of the polypharmacy prescribed by medical assistants were Phase I (before intervention) Phase II (after intervention) found after office hour, which is from 5pm to 9.30pm. During this time, most of the covering medical assistantsComparisons P value were from other Klinik Kesihatan, who do not aware of the remedial actions taken by pharmacists. npre Polypharmacy npost Polypharmacy (%) (%) The total cost of antihistamine(s) used was similar between two phases. This was anticipated as the totalFamily medicine specialist 1 0(0) 1 0(0) prescriptions recruited in Phase 2 were higher than that in Phase 1 although the incidence of polypharmacy wasMedical officers 382 178(46.6) 486 50(10.3) p<0.01 contrary between both phases. However, accompany with the fall in the total number of polypharmacy inMedical assistants 147 55(37.4) 93 32(34.4) p<0.05 antihistamines across the phases, the mean cost of antihistamine(s) per prescription decreased significantly.Staff nurse 29 5(17.2) 25 0(0) p<0.05 Several limitations exist with this study. The assessmentTable 3: The Comparison of Different Combinations of of this study was over a relatively short period, and soPolypharmacy in Antihistamines between Phase 1 may not truly reflect the long term impact of these(Before Intervention) and Phase 2 (After Intervention) interventions. Therefore, it is suggested that another phase should be performed in this study for another 48Combinations of polypahrmacy in Phase 1 (before Phase 2 (after working days to reassess the magnitude and characteristicantihistamines of polypharmacy 6 months after Phase 2, and hence the intervention, n =238) intervention, n=82) effectiveness of the remedial actions.chlorpheniramine + triprolidine As with any unblinded study of this type, the potential for 0 (0%) 1 (1.2%) investigator assessment bias existed. As the evaluation of polypharmacy in antihistamines was undertakendiphenhydramine + triprolidine 84 (35.3%) 28 (34.2%) sequentially across phases, potential bias may have been introduced as the investigators who were the pharmacistsdiphenhydramine + chlorpheniramine 133 (55.9%) 49 (59.8%) in this study, gained experience during the process. Similarly, Hawthorne effect may have been introduced asdiphenhydramine + chlorpheniramine + 1 (0.4%) 0 (0.0%)triprolidinepromethazine + triprolidine 2 (0.8%) 1 (1.2%)promethazine + chlorpheniramine 11 (4.6%) 1 (1.2%)promethazine + diphenhydramine 6 (2.5%) 2 (2.4%)promethazine + diphenhydramine + 1 (0.4%) 0 (0.0%)chlorpheniramineDiscussionThe objective of this study was to assess the relativemagnitude and characteristic of polypharmacy ofantihistamines in the management of cough and coldamong children aged below 6 subsequent to the remedialactions.The result showed a reduction of 29% in the number of 44
the respondents who were the prescribers, knowing that Referencesthey were involved in this study, being additional alert inhandling cases of URTI among children. 1. Kementerian Kesihatan Malaysia. Amaran Penggunaan Ubat untuk Rawatan 'Cough and Cold' PadaThe difference in sampling size between Phase 1 (559) Kanak-kanak. Pekeliling Pengurusan Farmasi BIL.and Phase 2 (605) seemed to affect the comparisons of the 1/2008.incidence of polypharmacy in antihistaminies between 2. WHO. Cough and Cold Remedies For the Treatmentboth phases in term of the total number of polypharmacy. of Acute Respiratory Infections In Young Children.However, this was overcome by taking the percentage of Geneva, World Health Organization,polypharmacy and the mean cost of antihistamines per 2001(WHO.FCH.CAH.01.02)prescription into account for the comparisons. 3. Schroeder K, Fahey T. Over-the-counter Medications for Acute Cough in Children and Adults in AmbulatoryThe polypharmacies detected in Phase 2 were found after Settings. Cochrane Database Syst Rev (database online).5pm, from Monday to Friday, which were prescribed by 2004; (4):CD001831.the medical officers and especially medical assistants 4. Cuvillo AD, Sastre J, et al. Use of Antihistamines inwho were coming from other klinik kesihatan and Pediatrics. J Investig Allergol clin Immunol 2007;working part-time at Klinik Kesihatan Maharani, Muar 17(2):28-40.from 5pm to 9.30pm. This explained that the 5. Munday J, Bloomfi eld R, Goldman M, Robey H, etinterventions were limited to prescribers who are al. Chlorfeniramine is no more effective than Placebo inworking at Klinik Kesihatan Maharani. Prescribers from Relieving The Symptoms of Childhood Atopicother clinics may have not received any advices, Dermatitis with a Nocturnal Itching and Scratchingpublished circular and protocol from pharmacists. As the Component. Dermatology. 2002; 205:40-45.recommendations for the study, prescribers from other 6. SutterAI, Lemiengre M, Campbell H, Mackinnon HF.clinics should be given the same interventions as those Antihistamines for the Common Cold. Cochranewho are working at Klinik Kesihatan Maharani. Database Syst Rev. 2003; 3:CD001267. 7. Simons FE. H1 Antihistamines in Children. ClinConclusion Allergy Immunol. 2002; 17:437-464. 8. Cheong PY. What Should Cough Mixtures contain?There was a significant decrease in the incidence of The Singapore Family Physician. 2002; 28(2):59-63.polypharmacy of antihistamines among children aged 9. Simons FE, Fraser TG, et al. Adverse Central Nervousbelow 6 from Phase 1 to Phase 2 subsequent to the System Effects of Older Antihistamines in Children.interventions. The most common polypharmacy occurred PediatricAllergy and Immunology 1996; 7(1):22-7.appears to be the combination use of diphenyhydramine 10. Yasuhara A, Ochi A, Harada Y, Kobayashi Y. Infantileand chlorpheniramine in both phases. Doctors prescribed Spasms associated with a Histamine H1-antagonist.the most polypharmacy of antihistamines among all Neuropediatrics. 1998; 29:320-321.prescribers in Phase 1 but medical assistants in Phase 2. 11. Souter J. OTC Products for: Cough Preparations. SAHowever, the incidences of polypharmacy prescribed by Pharmacist'sAssistant[Jul/Aug 2006].doctors showed the most drastic drop among all 12. Rimsza ME, and Newberry S. Unexpected Infantprescribers. Accompany with the significant fall in the Deaths Associated With Use of Cough and Coldnumber of polypharmacy in antihistamines from Phase 1 Medications. Pediatrics. 2008; 122(2):e318-e322.to Phase 2, the mean cost of antihistamine(s) per 13. Kuo J. Cold Remedies Cause Three Infant Deaths.prescription were decreased significantly following Well Point Next Rx. 2007; 9(1):1interventions. In summary, the reduction in 14. Viktil KK, Blix HS, et al. Polypharmacy aspolypharmacy of antihistamines in cough and cold Commonly Defined is an Indicator of Limited Value inproducts used among children aged below 6 can be the Assessment of Drug-related Problems. Br J Clinachieved by means of a systematic and comprehensive Pharmacol. 2007; 63(2):187-195.intervention and the collaboration between health care 15. Schappert SM. National ambulatory medical carestaffs though the results obtained may be limited by survey: 1991. Summary. In Vital and health statisticscertain factors. Series 1994; 13: 1-110. 16. Schroeder K, Fahey T. Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults. Br Med J 2002; 324: 329-334. 17. Joint Meeting of the Nonprescription Drugs Advisory Committee and the Pediatric Advisory Committee October 18–19, 2007. Available at: www.fda.gov/ohrms/dockets/ac/07/minutes/2007- 4323m1-Final.pdf. 18. Food and Drug Administration. Nonprescription drug advisory committee meeting: cold, cough, allergy, bronchodilator, antiasthmatic drug products for over-the- counter human use—October 18 and 19, 2007. Available at: www.fda.gov/ohrms/dockets/ac/07/briefing/2007- 45
4323b1-02-FDA.pdf.19. Kelly L. F. Pediatric Cough and Cold Preparations.Pediatrics in Review. 2004; 25: 115-123.20. Vernacchio L., Kelly J. P., et al. Cough and ColdMedication Used by US Children, 1999-2006: Resultsfrom the Slone Survey. Pediatrics. 2008; 122(2): e323-e329.21. Viktil, Kristen K., et al. Polypharmacy as commonlydefined is an indicator of limited value in the assessmentof drug-related problems. British Journal of ClinicalPharmacology. 2007; 63(2):187-195.22. Gunn V. L., Taha S. H., et al. Toxicity of Over theCounter Cough and Cold Medication. Pediatrics. 2001;108(3): e52.23. Schroeder K, Fahey T. Should we advice parents toadminister over the counter cough medicines for acutecough? Systematic review of randomized controlledtrials.Arch Dis Child. 2002; 86: 170-175.Hay A. D. and Wilson A. D. The natural history of acutecough in children aged 0 to 4 years in primary care: asystematic review. Br J Gen Pract. 46
The Prevalence Of Hearing Impairment 10 Among The Dental Staff Volume 10 In Kota Tinggi District, Johor.Muz'ini M1 Thilaka C2 2012 Oral Health Division, Johor State Health Department, Malaysia1Public Health Division, Johor State Health Department, Malaysia2Summary from these equipment was too loud and affecting theirSources of dental sounds can cause potential damage to hearing.the hearing. The objective of this cross sectional studywas to determine the prevalence of hearing impairment Noise-induced hearing loss is caused by damage to inneramong dental personnel and also to identify the sources of ear nerve cells due to exposure to both loud and highnoise in the working environment and associated dental pitched sound. These cells never regenerate and they dieequipment. Noise levels during dental procedures and which results in irreversible hearing impairment. Onelaboratory procedures were measured using a sound level may not hear faint sounds, or one may hear peoplemeter. Audiometric test was conducted to assess the speaking normally, but cannot make out or understandhearing status of all dental personnel in the clinics what is being said. This type of deafness is permanentinvolved. Only 7.7% (n=4) was identified had noise and irreversible and is called “Noise Induced Hearinginduced hearing impairment. The study also found that Loss” (NIHL).4the three category of staff suffered hearing impairmentwere working in high noise area which is dental Sources of dental sounds that can cause potential damagesurgery(Kota Tinggi Main Dental Clinic, Sening dental to the hearing are high speed and low speed handpieces,Clinic) and with high noise equipment such as high velocity suction units, ultrasonic instruments andcompressor, high speed handpiece and Ultrasonic scaler. dental laboratory engines. Risk of noise induced hearingHazard from noise in dental working environment cannot loss among dental practitioners depends on personalbe underestimated. Hearing problems can occur due to susceptibility, total daily exposure to the instrument anddental field noise. Proper monitoring and hearing patterns of use. Noise increases in a direct ratio as theconservation programme is required for early detection bearing of handpieces become worn5.and management of these cases. Dental staff working in Sound energy contribution of a typical dental practice ishigh noise area above 90dBA is advised to wear ear plugs about 8% to 12% of the dentist's average 24-hour noiseduring the procedures. exposure. Noise levels during dental procedures result an articulation index of 0.21 to 0.37 which corresponds toKeywords; noise, dental procedures, hearing impairment understanding of about 18% to 48% of nonsense syllables and 52% to 90% of sentences. It appears that hearing-I. Introduction damage risk is slight among dentists using modernUnder Act 514, Occupational Safety and Health Act equipment. However, further noise control in handpieces1994, all employees must be protected from physical, is necessary so that error-free communication duringchemical and biological hazards1. It is the responsibility dental procedures can be ensured8.for stakeholders to take preventive actions and provide a Condition of hearing of dental staff may be affected bysafe working environment in all aspects. Occupational smoking, medication (ototoxic drugs), rock music,health risks among dental personnel includes needle prick personal stereos, CD players and other recreationalinjury, musculoskeletal disorders, exposure to infectious sounds4. Factors influencing the risk of acoustic traumadiseases, radiation, dental materials; dermatitis, are age, physical condition, existing hearing condition ofrespiratory disorders, eye injuries and exposure to noise2. the individual, intensity or loudness of the equipment, length of exposure and the time between exposures.Under the Factories and Machinery (Noise Exposure) There is no way to undo damage caused by noise once itRegulations 1989 Part II – Regulation 5 on Permissible has occurred, so prevention is essential.Exposure Limit, no employee shall be exposed to noiselevel exceeding equivalent continuous sound level of 90 2. BackgrounddBA and no employee shall be exposed to noise level There is need to conduct an evidence based study toexceeding 115 dBA at any time3. Recently much hue and confirm the seriousness of exposure to noise hazardcry was raised by dental technologists and dental nurses among dental personnel in Johor. Permissible limit ofin Kota Tinggi district on noise from compressors in exposure to noise level is not more than 90 decibels withmobile dental squads, micromotors and polishing lathe maximum exposure time not exceeding eight hours asmachines in dental laboratories. They claimed that noise shown in Table 2.13. 47
Table 2.1 Exposure time limits at different sound levels 3. Objective Sound level - Decibels (dBA) Exposure time 3.1 General 90 8 hours 95 4 hours To know the prevalence of hearing impairment among 100 2 hours dental personnel in Kota Tinggi Districts. 105 1 hour 110 30 minutes 3.2 Specific Objective 115 15 minutes 120 7.5 minutes To determine the sources of high noise in dental working environment and its equipment.A study conducted in a dental school in India documented 4. Materials and Methodthat danger to hearing from dental clinic workingenvironment in a dental school cannot be underestimated 4.1 DesignThere were statistically significant shifts of hearing Cross sectional studythreshold at 6 kHz and 4 kHz in the left ear and 6 kHz inthe right ear9. 4.2 Ethical considerations Informed consent obtained from all respondentsHence findings on effect of exposure to noise hazard inthe working environment would be of great importance to 4.3 Study populationall dental personnel involved. Other factors to be taken All categories of personnel working in dental clinicsinto consideration are shown in Figure 2.1. Following thisassessment, the department would take remedial actions, 4.4 Sampleif necessary, to reduce hazard using appropriate Dental personnel working in dental facilities in Kotameasures. Otherwise, reassurance would be sufficient Tinggi districtfollowing this evidence based study.Figure 2.1: Factors influencing Hearing Impairment 4.4.1 Inclusion criteria All personnel working in dental facilities in Kota Tinggi Impacted ear wax Medication Poor district control 4.4.2 Exclusion criteriaLocation Ageing Hearing Underlying Family Past medical history of ear diseasesof home loss medical history Presence of impacted ear wax problem 4.5 Data collectionHobbies Exposure to Exposure to Poor Investigators used questionnaire for demography, excessive excessive noise from maintenance of medical history and past exposure to noise hazard. All respondents underwent audiometric test at the ORL/ENT noise at home dental equipment equipment clinic, Hospital Sultan Ismail, Johor Bahru. Duration of work Hearing OSHA Old equipment Noconservation workplace scheduling programme standards 1 Previous job Job scope5. ResultsA total of 52 respondents from 4 dental clinics in Kota Tinggi district took part in this study. Age of staff ranged from21 to 54 years and duration of service in the oral health division ranged from 1 to 32 years. The mean age andduration of service is shown in Table 5.1.Table 5.1 Characteristics of respondentsCategory Dental Dental Dental Dental Attendant Driver Clerks Total Surgery officer nurse technologist Assistant 2 52 32.50 35.37 N 9 10 5 13 9 4 (9.19) (9.27) 1.00 10.47Mean Age 29.22 37.90 34.60 36.00 34.44 45.25 (0.00) (9.20)(SD) (8.38) (9.35) (10.50) (8.97) (9.33) ( 2.99)Mean Years 6.28 15.30 11.80 10.15 8.56 16.25of service (7.79) (9.62) (10.04) (9.33) (9.58) (4.86)(SD) 48
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