Jurnal Kesihatan 2012.cdr

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] EDITORS DR HJH. MORNI BT ATAN DR SHEILA RANI RAMALINGAM DEPUTY DIRECTOR (MEDICAL) SENIOR PRINCIPLE ASSISTANT DIRECTOR (ORAL HEALTH) HOSPITAL SULTAN ISMAIL JOHOR STATE HEALTH DEPARTMENT TEL: 07-3565000 FAX: 07-3565034 TEL: 07-2245188 FAX: 07-2230467 EMAIL: [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] MEMBERS MS LEE CHING YAN MR JEGATHESWARAN PANDERENGEN PRINCIPAL ASSISTANT DIRECTOR ASSISTANT DIRECTOR (PHARMACY) (TRADITIONAL COMPLEMENTARY MEDICINE) JOHOR STATE HEALTH DEPARTMENT TEL: 07-2211787 FAX: 07-2212787 TEL: 07-2272800FAX: 07-2236146 EMAIL:[email protected] EMAIL: [email protected] MRS FAIZAH BINTI JURAIMI PRINCIPAL ASSISTANT DIRECTOR (HEALTH PROMOTION UNIT) TEL: 07-2224784FAX: 07-2238426 EMAIL: [email protected]

Volume 10 2012 Contents 1 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 Ling 13 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 Maarof 1 17 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 Zaki 23 Evaluation Of Molars Restored With Glass Ionomer Cements In The School Dental Service In Kota Tinggi District Muz'ini M. Premaa S 28 A Study Of Obesity Among Health Staff At Kulaijaya District Health Department (2012) Dr. Mohd Shaiful Ehsan B Shalihin, Poh Lin Chin, Misringaton 33 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 Rahim 42 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 Z 47 The Prevalence Of Hearing Impairment Among The Dental Staff In Kota Tinggi District, Johor Muz'ini M Thilaka C 52 Prescription Intervention and Prescribing Errors Detected by Inpatient Pharmacy Unit in Hospital Segamat Mohd Syahrizam bin Ta'at, Lau Kok Hou 60 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.P 64 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 M 69 Traumatic Abdominal Wall Hernia : A Johor Case Report YJ Lee, TT Yew, AC Chan 71 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 1 Insulin-related Knowledge Among Diabetic Patients In Hospital Sultan Ismail, Volume 10 Johor Bahru 2012 1 3 2 Teoh L.R , Lee C.Y , Wasli M. 1,2,3 Hospital Sultan Ismail, Johor Bahru. Insulin is one of the most commonly prescribed BACKGROUND medications in the hospital as it can be the most effective Diabetes mellitus is an important public health concern drug to achieve glycemic control and prevent long-term both nationally and internationally, due to the increase in comorbidities. The invention of insulin pen devices (ie its prevalence and its social and economic results, such as HumaPen) offers safety, convenience and flexibility, with impairment in productivity, quality of life and survival of higher acceptability by the patients especially among the individuals, early retirement, high treatment costs and elderly. The Joint Commission on Accreditation of complications.1,2 The World Health Organization Healthcare Organizations identified insulin as one of five (WHO) reported that 171 million people were living with “high alert” medications that have the greatest risk of diabetes mellitus in the year 2000, and that amount is causing injury to patients because of medication errors.13 estimated to double by the year 2030.3 In Malaysia, the Insufficient knowledge of insulin and diabetes prevalence of type 2 diabetes for those aged above 30 management on the part of health care providers years was 14.9% in the year 2006. The overall prevalence contributes to errors in insulin use. Consequently, it may of diabetes increased by 80% over a decade (8.3% in lead to dangerous but preventable adverse patient NHMS II year 1996 vs 14.9% in NHMS III year 2006) outcomes such as hyperglycemia and hypoglycemia.14 representing an average 8% rise per year.4 The present study focuses on patients' medication adherence level and insulin-related knowledge; with the According to World Health Organization Adherence ultimate goal of promoting effective and safe use of (2003) and Koneru et al. (2008), medication adherence insulin therapy by improving patients' insulin-related can be defined as the situation to which a person's knowledge, minimizing insulin-related adverse effects, behavior corresponds exactly with medical or health and identifying important criteria to be concerned before advice as directed. Noncompliance with prescribed running up Diabetes Medication Therapy Adherence treatment, especially medications, by patients increases Clinic Hospital Sultan Ismail, Johor Bahru. the cost of healthcare and the likelihood of admission to the emergency room and hospital, and can lead to METHODS additional illnesses or exacerbation of underlying disease A descriptive cross-sectional study of insulin-related (Jean et al., 2006). Poorly controlled diabetes is knowledge among diabetic patients was conducted in associated with development of macro- and micro- Hospital Sultan Ismail, Johor Bahru from 1 May 2011 vascular complications. Therefore, intensive glycaemic until 30 June 2011. The inclusion criteria were diabetes control is important in decreasing microvascular and mellitus patients (either type I or type II diabetes mellitus) macrovascular complications in type 1 and type 2 aged 18 years old and above, who had been using diabetes.5-7 Patients' adherence to medication regimens HumaPen (Humulin® R, Humulin® N or Humulin® is vital to achieve good glycaemic control. However, 30/70) and who was able to read and answer the adherence is still a challenge and many patients are questionnaire independently. The exclusion criteria were noncompliant with their oral hypoglycaemic agents and patients aged below 18 years old, patients who was insulin.8 unable to read and answer the questionnaire independently, and mentally impaired, individuals with Evidence has proven that patient education improves significant cognitive impairment and psychiatric patients' adherence and subsequently improves comorbidity. glycaemic control.9 Pharmacists play a significant role in A questionnaire consisted of 2 parts was prepared. Part I educating patients through routing counseling, which was designed is to obtain insulin adherence level by using helps to improve patient adherence.10 Several studies Morisky Scale. Morisky Scale consists of four-item have shown that collaboration of pharmacists with validated adherence predictor scales, using close-ended physicians in diabetes care improved glycaemic questions with answer 'YER' or 'NO'. Part II consisted of control.11,12 In Malaysia, pharmacists collaborate with 16 multiple-choice questions with a single best answer, physicians in diabetes care through Diabetes Medication designed to evaluate patient's level of knowledge. Therapy Adherence Clinic (DMTAC). Penang Hospital is Questions addressed topics including characteristics of the first centre to start the DMTAC program, which has different insulin (Humulin® R, N or 30/70) formulations, been operating since 2006 in a specialized diabetes storage conditions, causes, symptoms and management endocrine clinic. 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 /or ethnicity. incorrect were considered as presenting knowledge Pilot tests were then given to 5 patients in out-patient deficit. department and 5 patients in medical or surgical wards of Hospital Sultan Ismail. Questions that appeared to be RESULTS ambiguous during pilot testing were either corrected or Study population removed from the final version of the questionnaire. The A total of 85 completed questionnaires were received and questionnaires were then distributed to the diabetic analyzed; 60 from out-patient department, 21 from patients who came and refilled their prescriptions at medical wards and 4 from orthopedic wards. All of the 85 outpatient 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 years during 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 females ask 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 adherence categorized as low, moderate or high adherence. Score 1 Table 1 showed the results for each item in the Morisky was given for every 'YES' answer and score 0 was given Scale. 36% (n=31) of the patients reported that they had for every 'NO' answer. Total score of 0 indicated high been forgotten to take insulin, 32% (n=27) reported adherence; 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 they those participants that answered all categories correctly feel better and 5% (n=4) sometimes stop taking were considered as having acquired knowledge on insulin medication when they feel worse. 4-items in Morisky Scale Yes (%) No (%) 1. Do you ever forget to take your insulin? 36 64 2. Are you careless at times about taking your 32 68 insulin? 3. When you feel better do you sometimes stop 15 85 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 Adherence Results from Morisky Scale showed that 64% (n=54) of Level of insulin-related knowledge the 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 0% 11% 39% 100% 64% 75-99% 50-74% < 50% High adherence Moderate adherence Low adherence 50% Figure 1: Proportion of Patients with High, Figure 2: Overall Scoring Marks for Level of Moderate and Low Adherence 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 of their insulin based on the colour of the strip at the bottom ® of Humulin cartridge whereas 78% were able to symptoms and blood glucose measurement; as well as differentiate their insulin based on the appearance of proper management of hypoglycemic symptoms is important to decrease the risk of hospitalization and ® Humulin formulations. 58% of the participants mortality. presented adequate knowledge on the appearance of ® Humulin formulations which indicates of instability. Upon collecting each completed questionnaire, brief explanation and discussion around the rationale Knowledge on insulin storage and its expiry date behind each correct answer were given. This helps to Majority of the patients (85%) understood the increase participant attention and interest, achieve proper storage conditions for unopened and opened effective and safe use of insulin therapy, and decrease ® Humulin cartridge. However, Only 37% (n=31) of the incidence of insulin-related reactions besides improving participants presented with knowledge that Humulin ® patient adherence to insulin therapy, clinical outcome and cartridge may be used for up to 28 days once in use. quality of life. However, there are some limitations in this study. Study sample and data were obtained from a single Knowledge on symptoms and management of hypoglycemia or hyperglycemia hospital and may not be representative of the whole Malaysian population with diabetes mellitus. Reliability 76% of the patients understood that of Morisky Scale was compromised because of the hypoglycemia is brought about by taking too much dichotomous of the response scale and the small number insulin and hyperglycemia is brought about by stop taking of items in the questions (Voils et al., 2005). insulin or taking less insulin than prescribed. 85% reported that hypoglycemic symptoms may include Using this study as a pre-test may be effective to sweating, hunger and dizziness. Majority of the evaluate the level of insulin adherence and insulin-related participants 93% reported that mild to moderate knowledge among diabetic patients in Hospital Sultan Ismail before establishment of Diabetes MTAC. hypoglycemia can be treated by eating or drinking sugar- Moreover, it can be used to identify important criteria to containing foods. All of the participants claimed that blood glucose monitoring helps patients to confirm be concerned while running up Diabetes MTAC in hypoglycemia or hyperglycemia immediately. Hospital Sultan Ismail and understand how diabetes education can best be optimized. In this sense, future studies should be carried out to assess the impact of DISCUSSION established Diabetes MTAC towards diabetic patients' Lack of knowledge on the medication has had a therapeutic outcome. strong impact in health and quality of life of people The present study showed that majority of the especially those with one or more chronic health patients showed high adherence to insulin therapy and 16 conditions. Clear and accurate information regarding most of them were presented with insulin-related insulin therapy to control diabetes mellitus provided by knowledge as none of the patients scored less than 50%. qualified health professionals may encourage patients to Therefore, the future establishment of pharmacist- self care and adherence to insulin therapy besides managed Diabetes Medication Therapy Adherence Clinic promoting safe and effective use of insulin. Therefore, in Hospital Sultan Ismail may aim to improve patients' pharmacists play vital role in educating patients on ways glycaemic control and therapeutic outcome via HbA1c ® to differentiate various types of Humulin formulations, and fasting blood glucose (FBG) monitoring. proper storage conditions for unopened and opened ® CONCLUSION Humulin cartridge, possible insulin-related reactions such as hypoglycemia and hyperglycemia and how to In summary, 64% of the diabetic patients were reported as treat these effectively. A well-structured Diabetes high adherence, followed by 35% as moderate adherence; Medication Therapy Adherence Clinic may fill the gaps and 1% as low adherence. Majority of the patients were in knowledge of patients with diabetes mellitusfor better presented with insulin-related knowledge. Health care therapeutic outcome. professionals including physicians, pharmacists, nurse practitioners and endocrinologists play vital role in ® Knowledge on the appearance of Humulin educating diabetic patients regarding insulin-related cartridge and formulations helps patients to differentiate knowledge to improve their insulin adherence level. The their insulin type without affected by the problem of poor future establishment of pharmacist-managed Diabetes visual acuity as diabetic retinopathy is one of the common Medication Therapy Adherence Clinic in Hospital Sultan diabetes complications associated with long-standing Ismail may aim to improve patients' glycaemic control 15 diabetes mellitus. Besides that, knowledge on the and therapeutic outcome via HbA1c and fasting blood ® appearance of Humulin formulations which indicates of glucose (FBG) monitoring since majority of the diabetic instability and proper storage conditions for unopened patients showed high adherence to insulin therapy and ® and opened Humulin cartridge is required to ensure were presented with insulin-related knowledge. effective and safe use of insulin therapy for positive therapeutic outcome. Information on the causes of insulin-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, 1. Sociedade Brasileira de Diabetes. Tratamento e Rutten GE. Long-term effects of self-management acompanhamento do diabetes mellitus: diretrizes da education for patients with Type 2 diabetes taking Sociedade Brasileira de Diabetes. Rio de Janeiro: Diagraphic; 2006. maximal oral hypoglycaemic therapy: a randomized trial in primary care. Diabet 2. White paper on the prevention of type 2 diabetes and Med. 2004;21(5):491-496. the role of the diabetes educator. Diabetes Educ. 2002;28(6):964-8, 970-1. 10. Lindenmeyer A., Hearnshaw H., Vermeire E., Van 3. Wild S, Roglic G, Green A, Sicree R, King H. Global Royen P., Wens J., Biot Y. Interventions to improve Prevalence of Diabetes. Estimates for the year 2000 and adherence to medication in people with type 2 diabetes projections for 2003. Diabetes Care. 2004;27:1047-1053. mellitus: a review of the literature on the role of pharmacists. J Clin PharmTher. 2006;31(5):409-419. 4. Mafauzy M. Diabetes Mellitus in Malaysia. Med J Malaysia. 2006;61(4):397-398. PREVALENCE OF 11. Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk DIABETES MELLITUS IN MALAYSIA IN 2006– Van JT, Assendelft WJ. Interventions to improve the RESULTS OF THE 3RD NATIONAL HEALTH AND management of diabetes in primary care, outpatient, and MORBIDITYSURVEY (NHMS III)[cited 2011 Feb 12]. community settings: a systematic review. Diabetes Care. Available from: 2001;24:1821-1833. 5. The DCCT Research Group. The effect of intensive 12. Ramser KL, Sprabery LR, George CM, Hamann GL, treatment of diabetes on the development and progression Vallejo VA, Dorko G.S, Kuhl DA. Physician-pharmacist of longterm complications in insulin-dependent diabetes collaboration mellitus. N Engl J Med. 1993;329(14):977-986. 13. JCAHO suggests ways to prevent medical errors. 6. U.K. Prospective Diabetes Study Group. Association Healthcare Risk Man 22:19 –20, 2000 of glycaemia with macrovascular and microvascular 14. Smith WD, Winterstein AG, Johns T, Rosenberg E, complications of type 2 diabetes (UKPDS 35): Sauer BC: Causes of hyperglycemia and hypoglycemia in p r o s p e c t i v e o b s e r v a t i o n a l s t u d y. B M J . 2000;321(7258):405-412. adult inpatients. Am J Health Syst Pharm 62:714 –719, 7. U.K. Prospective Diabetes Study Group. Intensive 2005 blood-glucose control with sulphonylureas or insulin 15. The Wisconsin epidemiologic study of diabetic compared with conventional treatment and risk of retinopathy. III. Prevalence and risk of diabetic complications in patients with type 2 diabetes (UKPDS retinopathy when age at diagnosis is 30 or more 33). Lancet. 1998;352(9131):837-853. y e a r s . [ c i t e d 2 0 1 1 M a y 5 ] . Av a i l a b l e 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

2 A Pilot study of Drug Administration Errors In A Male Medical Ward Volume 10 At Batu Pahat Hospital 2012 Ng Xin Yi, Nur Amalina Nasis, Nur Ezzati A. Rahman, Lee Chern Chyi, Chua Pei Ling 1.1 Background of Study 1.3 Significance of Study According to the National Coordinating Council for This study is significant because administration errors are Medication 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 administration preventable event that may cause patient harm or lead to errors appear to be a major source of iatrogenic harm to inappropriate medication use while the medication is in hospitalized patients [16]. Drugs are prepared and the 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 staff practice, health care products, procedures, and systems especially nurses concerning such problems. including prescriptions; order communication; product labeling; packaging; and nomenclature; compounding; 1.4 Aim of Study dispensing; distribution; administration; education; The aims of the study are to quantify the type and monitoring; and use” [1,2]. The occurrence of the frequency of drug administration errors committed at the medication errors is not a new issue. In fact it is a common medical wards and to identify contributing factors occurrence faced by health care teams globally. In the towards this blunder. United States of America (USA), there were approximately 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 drug 1991 was caused by such medication errors with 13.6% administration errors at Medical Ward No. 3 leading to death [5]. Medication errors can be classified 2. To identify the drug administration error into prescribing, dispensing and administration errors. 3. To identify factors which contribute to drug Among these errors, administration mistakes account for administration error the majority of events. 4. To identify the types of drug commonly Drug administration errors are the second most frequent wrongly administered type of medication errors after prescribing errors. A drug administration error is a discrepancy between the drug 2.1 Definition therapy received by the patient and the drug therapy Drug administration is an activity that is prone to errors intended by the prescriber [9]. Administration error is the due to rapid development in medical technology because administration of a dose of medication that deviates from of different types of drugs and increasing complexity of the prescription, as written on the patient medication medical devices as well as the number of medications chart, or from standard hospital policy and procedures. being introduced into the market [9, 12]. There are also This includes errors in the preparation, and various routes of administration, different dosages, administration of intravenous medicines in the ward. dosage forms and dosing regimens which are often These errors can be further classified into wrong drugs; changed according to patient's clinical condition and wrong route; wrong dose; wrong patient; wrong timing of diagnostic test results. Lack of awareness for those drug administration; a contra-indicated drug for that various route, dosage and regimen of medication by the patient; wrong site; wrong drug form; wrong infusion staff or nurses during drug administration can lead to rate; expired medication date; or prescription error. errors. Drug administration error is “defined as a discrepancy 1.2 Statement of Problem between the drug therapy received by the patient and that Medication errors (prescribing, dispensing and intended by the prescriber or according to standard administration errors) were an important cause of patient hospital policies and procedures” [5, 9, 13] . Haw et al., morbidity and mortality [1]. Administration errors are a 2007 also defined drug administration error as a common sub-type of medication errors and accounted for “deviation from a prescriber's valid prescription or the 34% of errors in the study carried out by Bates et. a.l, hospital's policy in relation to drug administration, 1995. [23] including failure to correctly record the administration of In the study carried out by Leape and his colleagues, a medication”. administration errors were found to account for 38 percent of drug-related errors. [6] [7] 5

2.2 Incidence of Drug Administration 2.4.1 Incorrect Time The study of drug administration that was conducted at An incorrect time error was defined as the administration St. Andrew's Hospital, Northampton, United Kingdom of drugs more than 60 minutes before or after the had 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 if medication 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 1 administration of a discontinued item [17]. 2.4.2 Incorrect Dose Barker et al, 2002 conducted a study on hospitals Incorrect dose was defined as any dose of preformed accredited by the Joint Commission on Accreditation of dosage units (such as tablets) that contained the wrong Healthcare Organizations, non accredited hospitals, and strength or number. Incorrect dose for an injectable skilled nursing facilities in Georgia and Colorado. In the product means any dose that is ±10% or more different 36 institutions, 19% of the doses (605/ 3216) erred. The from the correct dosage and if any other dosage form, then most frequent errors by category were wrong time (43%), any dose that was ±17% or more of the correct dose [5]. In omission (30%), wrong dose (17%), and unauthorized the case of ointments, topical solutions, and sprays, an drug (4%). Seven percent of the errors were judged error occurs only if the medication order expresses the potential adverse drug events. dose quantitatively for examples 1 inch of ointment or In a local study by S.S.Chua et al, 2009 which was two 1-s sprays [13]. Medications must be administered at conducted 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 Drug two types of errors, giving a total of 135 administration Unauthorized or unordered drug defined as the errors. administration of a dose of medication that had never been ordered for that patient [5]. This category includes a 2.3 Classification of Medication Error Severity drug given to the wrong patient, administration of an Haw et al, 2007 rated the error severity based on a five- unordered drug, duplicate doses and extra doses not point scale which had previously been used in a ordered but administered, and a dose given outside a medication error research and entails the following :- stated set of clinical parameters [8, 13]. Grade 1—errors or omissions of doubtful or negligible importance; Grade 2—errors or omissions likely to result 2.4.4 Wrong Administration Technique in minor adverse effects or worsening condition; Grade Wrong administration technique errors comprised all 3—errors or omissions likely to result in serious effects or errors concerning the administration technique: crushing relapse; Grade 4—errors or omissions likely to result in errors (crushing a tablet that should not be crushed fatality; Grade X—unreadable (due to lack of clinical and because it is enteric coated),unsupervised intake of other information). medication by the patient (for example patient with Administration errors were classified into 9 classes of Alzheimer's disease need to be supervised to take seriousness from the National Coordinating Council for medication), wrong technique for administering Medication Error Reporting and Prevention inhalation preparations (not shaking the pressurized (NCCMERP) taxonomy of medication errors: A—an metered inhaler before use), wrong technique for error has been made but the medication does not reach the dissolving effervescent tablets (crushing instead of client; B—an error has been made and the medication dissolving in water and administering after all bubbles reaches the client, but no harm is done because the have disappeared) [14]. Wrong administration technique medication is not administered; C—medication is a situation which a drug is given via the correct route administered 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 Error in temporary harm necessitating treatment; Van Den Bemt et al, 2009 stated that omission errors F—temporary harm resulting in an increased length of consisted of errors regarding not giving the medication to hospital stay (in hospitalization of the client); the patient, which can arise by forgetting the G—permanent damage; H—client nearly dies; I—an administration or by giving the medication to the wrong error has been made which results in the death of the patient. However, if the patient refused to take the client [19]. medication, no error has occurred. Likewise, if the dose is not administered because of recognized 2.4 Types of Drug Administration Errors Usually contraindications, no error has occurred. (Greengold et al, Occur 2003). Omissions were detected by comparing the Drug administration errors can be classified into 11 medications administered at a given time with doses that categories which are incorrect time, incorrect should have been given at that time based on the administration 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 not specified [5, 12]. 6

2.4.6 Incorrect Rate drug administration errors. Individual staff characteristic Incorrect rate defined as administration of a drug at the (knowledge and skills) is one of the reasons that can cause wrong rate, the correct rate being that given in the drug administration errors. Wakefield et al stated that physician's order or as established by hospital policy. The individual staff characteristics such as lack of knowledge cytarabine 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 medication over 30 minutes were the result of incorrect rate in the are the factors that contribute to medication errors for study of drug administration error by S.S.Chua et al, example, knowledge of pharmacology will allow the 2009. The most common type of administration error in nurse to correlate it with the disease, diagnostic test the ward was wrong rate error (73 out of 83 injections) results and clinical status [9]. Thus it will improve the which 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 errors Incorrect preparation is also one type of administration in medication administration procedures as a result of error. Greengold et al, 2003 stated that incorrect failure to comply with policies and procedures is the main preparation 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, allergy suspension and mixing drugs that are physically or identification wristbands, medication against the chemically incompatible. For example, when medication administration record (MAR) and receiving Amphotericin B is not properly diluted, some powder is medications late from the pharmacy [9]. When a nurse still left in the vial and thus, when a nurse bends the needle administers the medication, they must sign the to syringe the drug out of an ampoule, it will cause a spill medication chart to provide evidence that the medication onto the floor [12]. has been administered to the patient. Signing the medication chart before the medication has been 2.4.8 Incorrect Drug administered is a risk, as the patient may refuse their Incorrect drug is an error in which medication was medication or forget to take them. Similarly, failure to wrongly given to the patient and totally different from the sign when a medication has been administered creates the prescribed medication [10, 15]. This type of errors seems risk that another nurse may assume that it has not been to have high potential to cause harm to the patient. For administered, and repeat that dose [15]. Drug example, 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-risk tranexamic acid 500 mg [12]. These situations happened medications such as chemotherapeutic drugs and because 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. (Pepper 2.4.9 Deteriorated Drug GA, 1995; Wakefield et al, 2005). These may include Use 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 of or no effectiveness towards the treatment. physician's orders, failure to document medications given or omitted and unclear MARs. In spite of how accurate or 2.4.10 Extra Dose complete a prescription is, it may be misinterpreted if it Barker et al, 2002 defined an extra dose as an error in cannot be read. The prescriber is the one who has a which any dose given in excess of the total number of professional responsibility to issue a safe and legible times ordered by the physician i.e. it can be a dose given prescription. However due to haste, fatigue or a lack of based on the expired order, or after a drug has been understanding of the importance of clear prescribing, it discontinued, 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 delivery S.S.Chua et al stated in their study that intravenous (iv) system can also cause drug administration errors. These drug administration is significantly more likely to be include number of consecutive hours worked, staff mix associated 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 to injection or infusion and included preparation of the drug unfamiliar units and hospital-and pharmacy-design dose. Errors associated with i.v. administrations were features. Information resources, such as published drug mainly caused by wrong administration rate and guides, may not be readily available or up to date. Drug technique, similar to that reported by Wirtz et al [20]. manufacturers also contribute to medication errors by Wrong 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 packaging being of major severity [21]. of doses for example multidose vials which similar packaging for different medications [8]. Pharmacies 2.6 Factors that Contribute To Error processes also can cause drug administration errors by There 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 was METHODOLOGY recorded on an observational sheet. 3.1 Study Design 5. The process of drug preparation until This study was of a cross sectional design using (i) direct administration to the patient by the nurse would be observation 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 be Batu Pahat Hospital from 10 May to 23 June 2011 during recorded. The 'near miss' error would also be recorded the 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 for evening 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 that there will be provisionally registered pharmacists to tag 3.3 Outcome Measure with them to observe and study the medication The types of administration errors used in this study are distribution system. Patient's registration number and based on The Guidelines on Medication Error Reporting observational data such as name of the medicine, dose, by Ministry of Health, Malaysia. The administration frequency, and route were taken from CMR and recorded errors are categorized into 13 types of errors which are in 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, deteriorated 3.2 Study Population drug, monitoring, compliance and other medication The male medical ward can accommodate up to 50 errors. patients. The ward consists of Malay, Chinese, Indian and patients of other races whose ages range from 12 to 80 3.4 Data Analysis years old and above. At the time of the study, 5 nurses Descriptive statistics are used to explore the data were working in this ward. There were three working collected in this study. The frequency distribution and shifts 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 by 9.00 p.m to 7.00 a.m.(night shift). The drug using SPSS version 15.0 for windows. Drug administration on morning and evening shifts were administration errors data were analyzed using observed. The nurses were responsible for the preparation descriptive measurement which compared the percentage and 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 compared with the written medication orders by the observers. The RESULTS observers will intervene and inform the nurse prior to 4.1 Frequency of Drug Administration Error drug administration when they detect an error which was A total of 400 doses was observed throughout the two about to be committed by the nurse, known as a 'near miss' weeks of study period. Most of the observed doses were error but was also recorded in the observational sheet as oral (131 errors, 81.37%) and the rest were i.v doses (30 an 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 during the study period. 4.1 Types of Drug Administration Errors 2. The observers would follow the drug The types of drug administration errors are shown in administration for two working shifts of the nurse Figure 4.1 and the percentage of drug administration which comprised the morning and evening shifts. errors are shown in Figure 4.2. Types of Drug A dministration E rrors In c orrec t tim e 89 O m is s ion e rro r 28 Inc orrec t do s e 14 E rro rs Inc orrec t prep aration 13 Figure 4.1 o f Unordered/u nauth oriz ed drug 6 O thers 4 Types of Drug Administration T yp es Deteriorated drug 2 2 Errors In c orrec t drug E xtrado s e 1 Inc orrec t rate 1 Inc o rre c t adm in is tration tec hn iq ue 1 0 10 20 30 40 50 60 7 0 80 90 100 Fre q u en c y 8

Figure 4.2 Percentage of Drug Administration Errors Amongst the types of administration errors, incorrect timing was highest (89 doses; 55.28%), followed by omission errors (28 doses; 17.4%). The four errors under 'Others' included the usage of the same cup to administer medications to all patients, without cleaning it. 4.3 Factors Which Contribute to Drug Administration Error Table 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 Errors Factors Number of doses with errors Total number of % errors doses Route of administration .v route 30 43 69.77 Oral route 131 357 36.69 Time Morning shift 102 292 34.93 Evening shift 59 108 54.63 4.4 Types of Drug Contribute to Drug Administration Error T yp es o f D ru g C on trib ute to D ru g A dm in is tratio n E rror A c c ord ing to A T C C la s s ific a tio n 37 40 35 35 Drug E rro r 30 24 21 25 of 20 16 10 9 15 Frequ enc y Ad m ini s tratio n 10 5 0 3 2 1 1 1 1 an t iinfect ives nu trition and blood diso rde r ea r, nos e and o ropharnyx ga strointes tina l an alges ic neurolog y ge nit o urinary de rmatology emergency ps ychiatry re spiratory cardiovas cula r s ystem endocrine ATC C la ss ific a tio n Figure 4.3 Types of Drugs Contribute to Drug Administration Error According to ATC Classification System Figure 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 medication 5.1 Frequency of Drug Administration Error trolley can then be returned to the satellite pharmacy for The 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 that The error rate was 40.25% which included incorrect time usually requiring the preparation of the medication in the error. clinical areas before administration to the patient [20, 22]. In this study, i.v. drug administration was more associated 5.2 Type of Drug Administration Error with medication errors than the oral route (93.3% vs. and Incorrect time errors were the most common type of 37.05%). Wirtz [20] also reported i.v. drug administration errors 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 by close serum concentration monitoring especially incorrect time and incorrect drug preparation, similar to antibiotic. Incorrect time errors consisted mainly of that reported by Cousins et al [22]. Incorrect drug medications not given at the time ordered on the preparation was mainly related to wrong suitable diluents medication 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 normal time of intake in relation to meals (before, with or after saline instead of sterile water for injection while i.v meal) which is more clinically relevant. In other study Meropenem 1 g should be diluted with 20 mL of sterile stated 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 injections seriousness which not give harm to the patient [14]. also incompletes. Other errors included administered the intravenous doses at the wrong rate and usually too Omission errors were the second error that mostly quickly and administering the product too late or too early occurred in these four week period of our study. There are after mixed with diluents. For example, the some reasons why the medications were not given to the administration of i.v. bolus Gentamycin should take patients during administration from our observation. about 2 to 3 minutes instead of a minute. Omission occurs because there were no stock of medication during administration and nurses forgot to Aseptic methods for preparation intravenous medications indent medication from pharmacy. Sometimes the nurses were also observed in this study. The preparation process also rushed to do other task in the ward and did not aware include cleaning the preparation area and washing hands about patient's medications. The omission occurs because or wearing gloves, disinfecting vials, ampoules and the nurse did not see the dose that should be given, the additive ports with alcohol impregnated swab [22]. Most drug could not be located in the trolley, or the drug was of the time, the preparation area was cleaned with alcohol not available. Usually they were omitting to give but not with a proper technique. Hands were washed and medication when it was unavailable [10]. non-sterile gloves were worn during drug preparation. The tops of vials were never wiped with alcohol 5.3 Factors Which Contribute to Drug impregnated swabs in all preparation during our study. Administration Errors The techniques of reconstitution of parenteral medication One of the most possible causes of incorrect time errors in and of handling needle and syringe by the staff nurse were the ward was heavy staff workload [8, 12]. The scheduled not followed the proper method. Training in drug time for drug administration in the ward was the busiest administration technique and preparation as well as time when nurses have to make the patient's beds, monitor awareness programmes should be conducted. patients' physical signs, indent and prepare medications in the ward and also assist the doctors on their ward 5.4 Types of Drug Which Contribute to Drug rounds. From this study, there was usually only one nurse Administration Error in charge of three cubicles to dispense medication to all Anatomical Therapeutic Chemical (ATC) classification patients. Sometimes the other nurses will help to give systems provide a global standard for classifying medical medication in which each of them will be assigned to one substances and serves as a tool for drug utilization cubicle to ensure that medication was dispensed in time. research. The WHO recommends the ATC system for Some nurses were also engaged in less important work international comparisons. In this study, ATC rather than give medication on time to the patient. Nurses classification has been used to categorize the type of drug may 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 the answer to this question. Practical or system factors will cardiovascular system drugs commonly contribute to influence the actual time of administration. The guiding drug administration errors. The correlation of antibiotics principle is that medications should be administered as with administration errors was most pronounced which closely to the prescribed time as possible [15]. This may can be explained by the fact that antibiotics are given in be achieved when the drug administration schedule was short courses and thus are not part of the long-term planned such that not all patients take their medication at medication of the patient. The nurse attendant builds up 8.00 am. One other possible solution is to increase the routine with long-term medication but is more likely to number of ward staff especially the number of nurses who make administration errors with medication that is given give medication to patients [12]. When the nurses finish for short-term courses [14]. 10

The 33 antiinfective agents, 24 gastrointestinal drugs, 13 REFERENCES cardiovascular drugs; 10 pain control drugs, 9 central 1) National council focuses on coordinating error nervous system drugs, 8 respiratory system drugs, 7 reduction efforts. USP. Quality Review 1997; 57: 2. steroids, and 11 categorized 'others' were the groups of drugs involved in drug administration errors by Ridge et 2) FIP STATEMENT OF PROFESSIONAL al, 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 S the common errors that involved antiinfectives (37 ASSOCIATED WITH PRESCRIBED MEDICATION. errors). Antiinfectives or antibiotics are generally given International Pharmaceutical Federation for a specific period of time (7-10 days, for example) to be taken at specific intervals (every 4, 6, 8 or 12 hours). This 3) Dellemin Che Abdullah, Noor Shufiza Ibrahim is necessary to keep the right amount of the medication in et. al. 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3 Analysis On Evaluation Of Quality Of Life In Hypertensive Patients By Using Short Form Volume 10 36 In The Muar District, Johor 2012 1 2 1 Mohd Anuar AR , Khadijah Ismail , Amran Maarof 1 Muar District Health Office 2 Hospital Pakar Sultanah Fatimah, Muar Key words: Hypertension, Quality of Life, SF-36, Summary Physical Component, Mental Component, Correlation test Objective: Hypertension is one the most common chronic disease in Muar. This study was done to determine the Introduction impacts on quality of life among hypertensive patients using SF-36. High blood pressure disease is a silent killer. It can cause a lot of serious complications and lead to an early or sudden Materials and Methods: Patients' quality of life using SF- death. The normal complications of high blood pressure 36 was generated from a cross sectional study of 460 or hypertension are strokes, kidney failure, and heart hypertensive patients who had came for treatments at the attack. According to the World Health Organisation government health clinics in Muar district. The data of (WHO) 13% of deaths in the world are contributed by SF-36 was collected by interviews from November 1st hypertension and it is expected that the weightage ratio on 2010 until January 31st 2011. The data was tabulated and unseparated disease especially hypertension will be analyzed using SPSS software. Quantitative data was increasing to 57% by the year 2020 worldwide (WHO, described using median value and interquartil range. 2002). Meanwhile, a correlation test was performed to show the correlation between variables studied. In Malaysia, hypertension is one of the main public health problems. In the year 1996, the disease prevalence of Results: The study showed that among the hypertensive blood pressure (BP) >140/90mmHg among adults aged patients, the physical component (Median=72.50, 30 years old and above is 29.9% and equivalent to 2.1 IQR=56.50-80.75) were more affected compared to the million people. The research showed that hypertension is mental component (Median=73.63, IQR=65.00-80.50). the highest among Malay adults aged 25 years old and Among domains in physical component the lowest score above which is 15% followed by Chinese with 14.1% and was general health (Median=62.00, IQR=52.00-72.00), Indian with 12.3% (MOH, 1996). bodily pain (Median=62.00, IQR=52.00-74.00), physical functioning (Median=80.00, IQR=55.00-90.00) and the Hypertension is one of the most chronic diseases suffered best score was physical role (Median=100.00, by the population. The numbers of average cases (old and IQR=50.00-100.00). Whereas, for mental component the new) annually is 8316.6 people a year from the year 2000 lowest domain score was energy (Median=65.00, to 2005 of which the average for the new cases is 1572.6 IQR=55.00-75.00), mental health (Median=72.00, people a year. Until the end of year 2005, out of 10,631 IQR=64.00-80.00), social functioning (Median=75.00, screened, there were 3,601 (33.87 %) people suffering IQR=62.50-87.50) and the best score was emotional role from hypertension and 21,229 people still receiving (Median=100.00, IQR=100.00-100.00). The correlation treatments (JKN, 2005). Since the disease is affects a test showed the association between physical and mental large number of people, it gives impact on the cost of component (r = 0.695, p<0.001), the association between health care. Additionally, the effects on family and duration of having hypertension to mental component (r = society will surely affect the quality of health among - 0.245, p<0.001) and the association between duration of those patients with hypertension. having hypertension to physical component (r = - 0.218, p<0.001). Since the last two decades, patients' perspectives on their health conditions especially connected to psychosocial Conclusion: The longer duration of hypertension will aspect have been taken into consideration as a main lead to a higher deterioration on the quality of life. component in evaluating health level instead of only the Secondly, better physical components help in controlling clinical aspect (Hopman WM, 2003). The change has the blood pressure, thus avoiding them from created a research scope known as quality of life where complications such as strokes and heart attacks, which in both aspects on physical and mental (psychosocial) turn contribute to patients' better mental health. These health of the patients are given consideration. factors will be able to directly help hypertensive patients' 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 on life in clinical investigations, in addition to determine physical roles, 4 on energy, 3 on emotional role, 2 on different group of patients, predicting the end result of social functions, 2 on body pain and 1 on Health Changes one's patient, but also for evaluating the health and treatment programmes implemented. The evaluation of Statistical Analysis quality 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 the As hopefulness to the disease's condition and ability to descriptive analysis on quantitative data, the median overcome limitations or disease problems can influence value and interquartile range have been used. Correlation patients' perceptions and life satisfaction, therefore it is test have been used in order to show the relationship of the possible for two patients of the same disease to have quantitative data. different level of quality of life. Results Based on the research by Hassan NB et al.2005, it is found that, patients' failure in adhering to treatment needs can From the total number of 460 respondents, the research affect their quality of life besides making them results showed that the median score for mental impossible 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 physical problems, kidney diseases and as well as increasing the component with the value of 72.50 (56.50-80.75) (Table treatment 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 four life. main domains, it is found that the emotional role domain has the highest score with the median value of 100.00 Therefore, this research is very important since there was (100.00-100.00), followed by the social function domain no research on quality of life among hypertensive patients with the median of 75.00 (62.50-87.50), the mental health in 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 65.00 Muar for further studies. It is really important since it can (55.00-75.00) (Table 2). increase the adherence level among hypertensive patient thus preventing complications and decreasing morbidity As for the physical component, out of the four main and mortality (Kyngas, 1998). Furthermore, this research domains, it is found that the highest score goes to the is also important as the majority of the patients in physical role domain with a median score of 100.00 Malaysia are in the range of productive age that (50.00-100.00), followed by physical function with a contributes to the country's huge important resources of median of 80.00 (55.00-90.00), the body pain domain manpower (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 positive This descriptive research is a result from a cross sectional relationship exist between physical and mental scores (r study where the respondents were 460 patients with =0.695, p<0.001). Meanwhile from the aspect of confirmed high blood pressure disease (Systolic ≥ 140 relationship strength, 48.3% of the physical score can be defined by the mental score (Table 4). mmHg, Diatolic ≥ 90 mm Hg) . The respondents came to the government clinics for treatments and were On the other hand, the corelation test on the period of time interviewed from 1st November 2010 to 31st January faced by the hypertensive patients and mental component 2011. score shows that there exist a significant relationship, negative but is too weak between both time period and Sampling Size mental component score with ( r = -0.245, p<0.001 ) where only 6% was defined by the period of time The total sampling size used in this descriptive analysis is suffering from hypertension and the mental component the Software EpiCalc 2000, whereby basing on the score (Table 5). prevalence of 44.2 percent of hypertensive patient Hassan NB et al.2005. It is the same when a corelation test was done on the relationship of time period suffering from hypertension and the physical component score, negative but weak in Study 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 period SF-36 (Short Form-36) which have been translated into suffering from hypertension and the physical component Malay. 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 mental This main purpose of this study is to see in details the level health domain score which intended to evaluate on over of quality of life among patients with hypertension. By worried, depression, lost control in emotion and using SF-36 as an instrument, the results of this study behaviour and physcological and harmony pressures. The have shown that there existed a difference in the scores second highest score is the social function domain which between physical and mental components among the intended to evaluate on the qualiy and quantity of one's respondents with hypertension with a lower level of interaction with another individual as well as the quality of life in the physical aspect compared to the limitations of social activities due to physical and mental aspect. This can be explained based on the earlier emotional problems. The highest score goes to emotion studies where it is known that hypertension is one of the role domain which intended to evaluate on the limitations increasing chronic diseases globally contributing to of one's occupational function due to emotion problems. approximately to 46% (WHO,2002) and it is a main risk factor for other chronic diseases such as coronary heart Just like the physical component, the mental component disease, strokes and heart failure (Mac Gregor GA,2003). can also vary with the time period suffering from hypertension. Correlation test showed a significant Apart from that, hypertension is also identified as can negative relationship between the time period suffering lead to kidney failure and give a big impact in managing from hypertension and the mental component. This the cost of health which complications is more of a burden means that a longer time period suffering from on the physical aspect compared to mental (Hayes hypertension will decrease the quality of life mainly in the RB,1997, Hammond SL,1994). This is similar to the mental aspect. This is an important benchmark since study results by Lim et al.1998), where complications previous studies have shown that psychosocial factor is from failing to control blood pressure properly has given one of the main factors leading to non-adherence to a limitation on the level of life for a hypertensive patient medications among hypertensive patients (Zyczynski to increase up to 75%. TM, 2000, Rahman ARA, 1995). It will impact on the quality of life and lead to failure in their treatments This can be further explained by corelation test which (Jones, 1996). showed a significant relationship between the time period suffering from hypertension and the physical component Finally, there is a difference between physical component score. A negative relationship had been shown score and mental component score among the eventhough it can only defined 5%. However, what can respondents, the results have shown that when a person be analysed is that a longer time suffering from manage to take care of his or her physical quality aspect, it hypertension will further affect the quality of life from the will indirectly help in his or her mental health. This can be physical aspect. shown by the relationship of the physical score and mental score using a correlation test whereby there is a Besides, the lower scores among the four domains are significant relationship, positive and good between the general 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 which fits the evaluation of the body's pain level and how much Meanwhile, from the relationship strength, 48.3% of the it affected daily routines. Meanwhile, for the physical physical score can be defined by the mental score. This function domain which evaluates on the limitations of shows that a better physical of the patients or in other physical activities due to health problems faced, highest words if the patients manage to control their hypertension scored domain is the physical role domain. The physical and avoid from complications such as strokes will role domain has the highest score, it is mainly to evaluate directly helps in improving the quality of mental health on the limitations of occupational function which was where for example they will have no problems in their affected by the physical health problems. social aspects. Eventually, this will help the patients to stay in the better quality of life eventhough suffering from The results have indicated that patients with hypertension chronic diseases that need treatments and medications. have a better mental aspect score compared to the Conclusion physical component and it depicts that the respondents have a better quality of life in the mental aspect generally. As a conclusion, this descriptive research has two This is further explained by monitoring all the four main important findings. The first one is that the longer the domains in the mental component where the average patient suffers from hypertension, the lower will be his or scores are better than the physical domains. The mental her quality of life either from the physical or the mental component is important as previous study has showed aspect. Secondly, the better level of physical well being that 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 being emotional pressure (Wang PS et al.2002). would adhere more to scheduled treatments. Thus, good physical attributes help in controlling the blood pressure However, in the mental component, the energy domain thus avoiding them from complications such as strokes which 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 of healthy life. World Health Organization Report. patients with hypertension and associated factors. 24 2002.2Ministry of Health Malaysia: National Health and (5):997-1005http://202.186.179.7/ovidweb.cgi [19 Julai Morbidity 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: Little 2005.4Hopman WM, Jane Vernar: Quality of life during Brown & Co. and after inpatient stroke rehabilitation. American Heart Association. http//www.google.com .(July 2010).5Gill Please indicate date of access TM, Feinstein AR: A critical appraisal of the quality of life measurements. The Journal of the American Medical Appendixes Association. 1994.6Testa MA, Hollenberg NK, Anderson RB, Williams GH: Assessment of quality of life by patient Table 1: Mental and Physical Components Score in SF-36 and spouse during antihypertensive therapy with atenolol SF-36 Component Descriptive Analysis and nifedipine . Am J Hypertens.4:363-373.1991.7Ware Median IQR JE, Snow KK, Kosinski M, Gandek B: SF-36 Health 25-75 Survey Manual and Interpretation Guide.Boston. New Mental Component 73.63 65.00 - 80.50 E n g l a n d M e d i c a l C e n t e r , T h e H e a l t h Physical Component 72.50 56.50 - 80.75 Institute.1993.8Jenkinson C, Layte R, Lawrence K: Development and testing of the Medical Outcome Study 36-Item Short Form Health Survey summary scale score Table 2: Mental Component Domain Score in SF-36 Component Domain Score in Descriptive Analysis in the United Kingdom. Med Care.35:410- SF-36 Median IQR 416http//www.yahoo.com (July 2010).9Ware JE, 25-75 Kosinski M, Keller SD: SF-36 physical and mental health Emotional Role 100.00 100.00-100.00 summary scales: A user's manual. New England Medical Social Function 75.00 62.50-87.50 Center, The Health Institute.1994.10Mac Gregor GA, He Mental Health 72.00 64.00-80.00 FJ: Cost of poor blood pressure control in the UK: 62,000 unnecessary deaths per year. J Hum Hypertens Energy 65.00 55.00-75.00 (PubMed). 17:455-457 http//www.google.com. (July 2010)11Hayes RB, Taylor DW, Sackett DL: Compliance Table 3: Physical Component Domain Score in SF-36 in health care. John Hopkins University Press Baltimore Physical Component Domain Descriptive Analysis M D . 1 9 9 7 . 1 2 H a m m o n d S L , L a m b e r t B L : Score in SF-36 Median IQR 25-75 Communicating about medications .Directions for research. Health Common (ISI). 6: 247- Physical Role 100.00 50.00-100.00 251http//www.google.com. (July 2010)13Lim LL, Physical Function 80.00 55.00-90.00 Johnson NA O'Connell, RL Heller, RF: Quality of life and Body Pain 62.00 52.00-74.00 later adverse health outcomes in patient with suspected General Health 62.00 52.00-72.00 heart attack. Aus N Z J Public Health 22(5):p 540- 546http//www.google.com.(July 2010)14Wang PS, Bohn RL, Knight E, Glynn RJ, Mogan H, Avorn J: Non Table 4: Correlation Test compliance with antihypertensive medications: The Variable Correlation impact of depressive symptoms and psychosocial Physical Score And Mental r r 2 Score 0.695 0.483(48.3%) f a c t o r s . J G e n I n t e r n M e d . 1 7 ( 7 ) : 5 0 4 - 511.2002.15Zyczynski TM, Coyne KS: Hypertension P<0.001 and current issues in compliance and patient outcomes. Curr Hypertens Rep.2(6):510-514.2000.16Rahman Table 5: Correlation Test Variable Correlation ARA, Hassan Y, Abdullah I: Admissions for severe hypertension: Who and why. Rim Hypertension Time Period Suffering High r r 2 Blood And Mental - 0.245 0.06(6.0%) Conference.Tokyo Japan.1995. 17Jones, D.A. West, RR: Component Psychological rehabilitation after myocardial infarction: P<0.001 Multicentre randomized controlled trial. BMJ.313 (7071); p.1517-21.199618Hassan NB, C I Hasanah, K Table 6: Correlation Test Foong, L Naing, R Awang, S B Ismail, A Ishak, L H Variable Correlation Yaacob, M Y Harmy, A H Daud, M H Shaharom, R Time Period Suffering High r r 2 Conroy, A R A Rahman.2005. Journal of Human Blood And Physical - 0.218 0.05(5.0%) Component Hypertension. Identification of psyshosocial factors of noncompliance in hypertensive patients.20: p23-29 P<0.001 http//www.google.com [21 Ogos 2006]19Wee HL, Cheung YB, Li SC, Fong KY, Thumboo J. 2005. PubMed Central Journal List. The impact of diabetes mellitus and other chronic medical conditions on health –related Quality of Life: Is the whole greater than the sum of its 16

4 Study On Use Of Kaletra® (lopinavir/ritonavir) Among Volume 10 HIV Patients In HSAJB. 2012 1 Ong M.P. 1 Hospital 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 exclusion are relatively well tolerated and provide potent antiviral criteria (those not initiated Kaletra® in HSAJB), 32 activity in human immunodeficiency virus (HIV) patients were included in this study. All relevant data patients. The purpose of this study is to assess the were collected from patients' case notes. As suggested by indication of use of Kaletra® and to study the tolerance of several recent National Institutes of Health-sponsored Kaletra® among HIV patients in Hospital Sultanah conferences on aging and acquired immune deficiency Aminah Johor Bahru (HSAJB). A retrospective cross syndrome, we adopted the age of 50 years as a cut-off sectional study was conducted in Medication Therapy point to define 'older' subjects.2 Using that cut-off point Adherence Clinic (MTAC) Retroviral Disease (RVD) 28% of subjects (n=9) were classified as older. Data HSAJB. 32 patients were included in this study. Kaletra® extracted were managed with Microsoft Excel and was being prescribed mostly due to intolerable side Statistical Package for the Social Sciences (SPSS) 16.0 effects (59%) caused by previous HAART regimen. For system. chi-square and the p-value were calculated using those taking Kaletra®, it was well tolerated, with 82% of SPSS system. Comparisons between groups were made patients without showing any undesirable side effects. with independent t-test. A p-value of less than 0.05 was considered significant. Descriptive statistics were INTRODUCTION. adopted to present the data such as mean ± standard Antiretroviral drugs which are more effective with more deviation, frequency, range and percentage. convenient administration have been developed in order RESULTS to 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 and combination of lopinavir which is an HIV protease majority of them was Chinese. 31.3% of the patients aged inhibitor with ritonavir, which acts as a pharmacokinetic over 50 years old. The reasons of starting Kaletra® were enhancer used for patients who are new as well as for 40.6% patients due to treatment failure where the HIV those experienced with HIV therapy.1 At present, most of RNA more than 400 copies/mL after 24 weeks or 50 the antiretroviral-experienced patients attending HSAJB copies/mL by 48 weeks in a treatment naïve patient and failing their current therapy have been exposed to initiating therapy and 59.4% patients changed their both protease inhibitors and ono-nucleoside reverse regimen to Kaletra® containing regimen due to transcriptase 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 count for 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 load obtain information of HIV patients who had been taking Kaletra® as HIV therapy from date of their initiation up to Table: Mean duration to attain desire CD4 count and December 2010 in order to provide better counseling suppress viral load based on collected data. The purpose of this study is to Age group N Mean Duration assess the indication of use of Kaletra® and to study the tolerance of Kaletra® among HIV patients in HSAJB. Duration for VL attain <50 < 50 years 19 5.74 months (SD 6.35) The results of this study were expected to assist the HIV RNA copies/mL = 50 years 9 8.44 months (SD 11.43) educational practices regarding Kaletra® therapy and to p=0.035* assist doctors, pharmacists and other healthcare Duration for CD4 count <50 years 19 4.11 months (SD 5.23) providers. The information can aid in the management of >200 cells/mm³ = 50 years 10 7.40 months (SD 11.25) HIV patients after their previous highly active anti- p=0.104 retroviral therapy (HAART) regimen failure. MATERIALS AND METHODS. * significant at p<0.05 A retrospective cross sectional study was conducted to review all Kaletra® treated HIV patients in HSAJB. A list 17

DISCUSSIONS. REFERENCES The mean duration for CD4 count attained more than 1. Fazil AM and Newton GO. Lopinavir/Ritonavir 200cells/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 50 HIV RNA copies/mL for older patients (≥ 50years) HAART, and survival in HIV-infected patients diagnosed at the age of 50 or more. BMC Infectious Disease 2006, was 8.44 months (11.43) which is significantly (p=0.035) longer than younger patients (5.74 months). Duration of 6:159. survival is significantly shorter for older people due to 3. Charles HH, David JH, Karen IM, et al. deficiencies in immune system related to age.2 However, Medication adherence in HIV-infected adults: effect of in the study done by Charles HH. et al, the older patients patient age, cognitive status, and substance abuse. AIDS. 2004 January 1; 18(Suppl 1): S19-S25. (≥ 50years) showed better medication adherence compared to younger patients but cognitive impaired occur in older people do affect the medication adherence.3 This may suggest that adherence might not be factors affecting duration of success viral load suppression. There was 93.8% (n=30) of patients continue taking Kaletra®, only 6.2% (n=2) discontinue Kaletra® due to down grade of regimen to reserve Kaletra® as salvage regimen and another patient died caused by lymphoma. Only 18.8% (n=6) reported adverse effects during treatment of Kaletra®, these reported side effects may not be solely due to Kaletra® as patients were given combination regimen. Reported adverse effects among these patients were increase triglycerides, cholesterol; muscle weakness and pain; facial lipodystrophy; dryness of legs and lips, numbness of limbs; and leg edema. The study is a retrospective cross sectional survey. Descriptive studies do not lead themselves to causal inferences. This should be kept in mind when evaluating the results of our study. As all information collected were based solely on the documentation in patients' case notes, data may be incomplete with some missing data due to lack of documentation. Incomplete information in the medical records might lead to underreporting of some adverse effects experienced by patients but not recorded. A prospective study to follow the patients may be carried out to overcome this problem. CONCLUSION. Kaletra® was being prescribed mostly due to intolerable side effects (59%) caused by previous HAART regimen. Kaletra® was well tolerated, with 82% patients show no undesirable side effects after starting it. 18

5 Implementing Fly Control – Kluang Experience 2009, Volume 10 North Macap Rest & Relax Area (R&R) 2012 Norzihan MH, Zuhaida AJ, Mohd Zaki I and passing through this is the North-South Expressway, EXECUTIVE SUMMARY under the purview of PLUS. North Macap R&R is The fly problem in North Macap Highway Rest & provided for the convenience of travelers and it is a Relaxation area (R&R) was mainly due to breeding of facility comprising of food & beverage outlets, flies in nearby poultry farms. Control measures were restrooms, prayer rooms, playground, souvenir shops and staged in 3 steps to assess the effectiveness of each of the petrol station. recommended interventions. It was found that despite physical restructuring of the R&R, the problem did not There is a scheduled garbage collection though decrease as was also noted with the use of pesticides. indiscriminate disposal of food leftovers was found to Though there was a direct reduction of the fly index with contribute towards attracting adult flies to food premises. pesticide usage, the fly density went back to pre- However no source of breeding was identified within the intervention levels within 7 days of last spraying. The use area. Bearing in mind its flying distance, its tendency for of probiotics showed itself to be an excellent method of homing effect and breeding preference, a wider search for control through source reduction with fly index source of housefly breeding was carried out. decreasing from 18.8 to 1.2 at the end of intervention and maintained at that low level for a longer time period. It is The source of breeding was found to be from surrounding recommended that the use of probiotics be introduced to estate areas, with poultry farms. In the Macap area, there poultry farm industries to suppress fly population and are 24 poultry farms with a capacity of 346,000 million indirectly reducing flies problem in nearby R&R. chickens at a time. Eleven (11) of these farms were situated within 6 km from the Macap R&R, the nearest INTRODUCTION (Farm A) being 1.3 km away. In 2008 the issue of fly problem in Kluang became a major concern when it was highlighted through Farm A comprised of 12 chicken coops with a capacity of complaints in the media, involving food premises, 30,000 chickens. At time of investigation, fly density was especially in the Kluang North Macap R&R (Figure 1). It high under the chicken coops, though the coops were was a serious problem, where it marred the image of empty and in the process of cleaning and disinfection. The tourism industry as well as being a threat to public health soil beneath the coops was wet and warm from faeces. as flies are mechanical vectors for food borne diseases There is a 2 month period for each cycle, from the first day such as food poisoning, typhoid, cholera, Hepatitis A etc chicks are introduced to the farm till clearance and 1. cleansing of coops (46 days breeding + 14 days cleaning) The high-density, confined housing systems used in The fly species identified in this case were the common poultry production create conditions that favor the housefly (Musca domestica), which tended to breed in d e v e l o p m e n t o f m a n u r e - b r e e d i n g f l i e s . warm, wet places where its' larvae can feed on upon hatching. Typical breeding grounds include garbage, An integrated approach towards controlling flies rotting food, exposed faeces of any type, and problems consists of four basic management strategies decomposing animal carcasses. They have a high (mechanical, cultural, biological, and chemical) that can preference to poultry farms rather than domestic be strategized into a successful fly control or integrated surroundings 2, where a single female fly can lay 75 to pest management program 4 (Table 1). 150 eggs every 3 to 4 days. Life-cycle for a housefly from In this study, 3 types of fly control interventions can be egg stage to adult takes about 10 days. carried out, that is: Houseflies possess sensory receptors for smell and taste, 1) Mechanical intervention involving renovating important in the search of food, as far as 5 to 7 km away, physical attributes of food premises to discourage adult though they have a tendency to return to breeding sites flies, as in screening, air conditioners with automatic door (homing effect) 3. closer, fly swatter or fly traps etc and ensuring a sanitary establishment Problem area 2) Chemical intervention using adulticides or Macap area is situated about 30 km from Kluang Town larvicides both at problem areas (North Macap R&R) as 19

well as at breeding sites (Farm A). by product) (Table 3). Intervention monitoring was done 3) Biological intervention using beneficial from December 2008 until January 2009. predators (macrochelid mites; hister beetles) or microorganisms that can suppress fly populations. One Impact of each intervention were assessed through such method is the use of probiotics to create an measurement of fly index, that is the number of flies unsuitable environment for fly development. The use of landing on the grill within 30 seconds 7 using the 'Scudder probiotics in fly control is a relatively new endeavor and it Grill' (Figure 3) at the North Macap R&R area. Reading is known to reduce smell from poultry farm faeces as well of index was carried out at the same time (10.00 am) at 6 as reducing its potential to breed flies. different locations (index point), and the average reading is calculated as index value. Proposed fly index threshold As 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 district Health Office convened a committee, which included the RESULTS veterinary department, plantation department, PLUS and The fly index reading in 2007 prior to any intervention of the local poultry farms, to discuss the possible and viable 3.8 is considered to be above accepted value for food methods available. It was decided that the various premises, according to the fly index threshold. interventions were to be carried out separately so that analysis of effectiveness of each method could be undertaken. OBJECTIVE 1) To identify the most effective & efficient control measure available in the long term control flies at the North Macap R&R, Kluang. 2) To make recommendations towards reducing flies in the Macap area. 3) To strengthen inter-agency cooperation towards reducing flies density. METHODOLOGY Three types of interventions were carried out in three phases, starting April 2007 – March 2008 (1st phase), July 2008 – August 2008 (2nd phase) and December 2008 – Chemical spraying January 2009 (3rd phase) involving the North Macap R&R and Farm A. Interventions undertaken were 1) Physical intervention - physical restructuring: staggered with a 3 months pause in between each, to Pre-intervention reading for physical intervention was allow for impact assessment and for the return of normal 3.8. Fly index reading after renovation was carried out at situation of flies population in both R&R Macap and the North Macap R&R showed a continuously high Farm A before the next intervention starts. The 3 months index, averaging 18.3, which is an increase of 381% of period was also taken in view of the poultry cycle from pre-intervention reading. chick introduction to marketing and coop disinfection (46 days for poultry rearing + 14 days cleaning up) 2) Chemical intervention: Pre-intervention reading for chemical control was 18. The overall fly The 3 types of interventions carried out in 3 phases were: index reading showed a 10 day interval where spraying 1) First phase - Physical intervention: renovation schedule was carried out. Low readings were always on was made to the Macap R&R by PLUS from an open the 3 days of spraying; the lowest being 3.3 and fly index premise to a fully air conditioned, closed area (with start to increase when spraying stopped on day 4 onwards, automatic door system) to discourage adult flies from reaching 13.3 by day 7. Subsequent fly index readings entering the food court (Figure 2). Renovation was maintained above 15, similar to pre-intervention. The carried out from June 2007 and resumed operation on pattern was seen throughout the 46 day cycle of chicken December 2007. Intervention monitoring was done for a rearing in Farm A. month before renovation started, in April 2007 and after resume operation, in March 2008. 3) Biological intervention: Pre-intervention fly 2) Second phase - Chemical intervention: Use of index was 18.8 (day -1). Post-intervention readings water–base insecticide via thermal fog and ULV (Ultra showed a steady decline in fly density at the North Macap Low Volume) spraying to control adult flies. Fogging is R&R reaching as low as 1.2 at day 46. This low reading carried out between 6 – 7 am at the R&R , while 'Spot was noted up to day 60 intervention, sustained even Spray' is carried out in Farm A. Fogging / spraying was though the intervention had ended. done at 10 day intervals: 3 days of spraying followed by 7 days of rest (Table 2). Intervention was done from July DISCUSSION 2008 to August 2008. Having a sanitary establishment is still the best way to 3) Third phase - Biological intervention: Spraying avoid fly problems. Areas that are damp and warm with probiotics using dilution ratio of 1: 100 is carried out (standing water, drains, and unchanged mop buckets) in Farm A every day 3, with 2 days rest (as recommended encourage flies infestation. Indiscriminate disposal of 20

food waste will always be an attraction to flies and is Probiotics has given a new dimension to Malaysia's actually 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 of increase in fly index reading despite a major and mixed cultures of beneficial and naturally-occurring expensive renovation carried out. PLUS needs to take microorganisms. Selected species of microorganisms more effective measures in controlling flies in their food including lactic acid bacteria, yeasts and photosynthetic establishments through regular cleaning and maintaining bacteria creating the probiotic are mutually compatible to of problem areas. coexist in liquid culture 8. PROPEL (Projek Penyelenggaraan Lebuhraya Berhad) a The use of probiotic in food and drinking water in poultry company responsible for maintaining PLUS expressways farms reduce the foul smell in chicken dung, conserve the including R&R Macap facility, has daily scheduled environment and at the same time increase the immunity cleaning tasks. This includes mopping of floor, cleaning of chickens for better growth 9. Beneficial bacteria is also of toilets and other facilities, also ensure that waste be a form of biological control of flies population in poultry disposed off daily and not left overnight. Food Quality farm 10. The beneficial bacteria nitrifies toxic gases like Control Unit, Kluang Health Office conducted 8 series of ammonia and hydrogen sulphide into less harmful inspection of food premises, hygiene and cleanliness at organic acids, reduce foul smell and become less the North R&R Macap areas throughout May to August attraction to flies and other winged insects 5. A study in 2008 involving 10 food premises. All food premises in Thailand by Sritoomma, S shows that flies population can operation found to be in satisfying condition with above be reduced up to 60%, BOD (36%) and solid waste 80% 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 in fly problem at breeding sites rather than failure of any reducing flies population. However, proper handling and physical interventions carried out. During this phase no technical advice is highly needed to ensure its control measure had yet been carried out at source of effectiveness. The most important in dealing with breeding. Usually, fly control measures by local probiotic is to stop the usage of pesticides and antibiotics industries relied mostly on pesticides to keep pest that can render probiotic microbes killed and becomes populations below economic injury levels or nuisance ineffective. Continuous usage of probiotic is also thresholds. The fact that major renovations were carried essential to reach stability of beneficial bacteria out through continuous discussions by various agencies population in chicken farm environment thus controlling showed 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 to management programs. However, extensive or improper integrate the use of probiotics in poultry industry as an use of pesticides results in the destruction of biological alternative to pesticides. control agents and the development of pesticide resistance. Improper timing and indiscriminate ACKNOWLEDGEMENT insecticide use, combined with poor manure Authors would like to thank all the agencies involved management, poor moisture control, and poor sanitation throughout this study period, namely; Veterinary Services practices, 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 Farming sprays can be effective for a rapid knockdown and kill of and JB Kim Farm. adult flies, but does not provide long-lasting control as there is no residual effect. While larvicide application will only give a short-term fly control and kill natural biological control agents that are present, initiating a repeated schedule of treatments 4. Chemical control is proven to be highly effective at the point of usage but its effectiveness is not sustained longer than 7 days. Repetition of application is needed weekly involving cost, raising concerns of insecticide resistance as well as destruction of biological agents that naturally exist in the environment. Biological agents co-exist in the environment in various forms ranging from beneficial predators such as hister beetles or microorganisms that can suppress fly populations. In Malaysia, microorganisms is widely used by 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 of 1. 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 Chicken 2. Robert, Lamb. 'How Houseflies Work.' How Farm By Using Effective Microorganisms (Em) H o u s e f l i e s W o r k . 7 D e c . 2 0 0 8 Technology, A. K. Khamis1, M.R. Sarmidi1, N. 'A. <http://animals.howstuffworks.com/insects/housefly2.h Sabri1, N. F. Abd. Rahman1, H. Nohani; 1Chemical tm> Engineering Pilot Plant (CEPP), Universiti Teknologi Malaysia (UTM) 3. Nazni, WA et al. (2005). Determination of the Flight Range and dispersal of the house fly, Musca 9. Ni, Y. and Li, W. (2002). Effects of Effective domestica (L.) using mark release recapture technique. Microorganisms (EM) on Reduction of Odour from Tropical 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). The Guide to Biology, Dispersal, and Management of the use of Effective Micro-organisms in the biological House 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 ublications/bulletins/b1013.pdf> 11. Sritoomma, S. (1995). Application of EM for Improved Management of Swine and Poultry Wastes in 5. Baustista, E. M. (2002). Use of Effective Thailand. Proceedings of Kyusei Nature Farming Microorganisms (EM) to Eliminate Foul Odor in Meat Conference in Paris, p193 Processing Units. 3p. 6. Nazni, WA et al. (2003). Guidelines for Flies Control. Tropical Biomedicine; 20(1):59-63. 22

6 Evaluation Of Molars Restored With Glass Ionomer Cements In The School Dental Volume 10 Service In Kota Tinggi District 2012 2 1 Muz'ini M . Premaa S . 1 Oral Health Division, Johor State Health Department 2 Clinical Research Centre (CRC) Johor, Hospital Sultanah Aminah, Johor Bahru uncooperativeduring conventional restorative Summary treatment3. Recently, dental nurses in Johor generally utilised modified ART technique when restoring teeth of Use of glass ionomer cements (GIC) by dental nurses in schoolchildren in mobile dental squads. Initially dental the school dental service is well accepted due to its nurses used glass ionomer cements for restoring primary anticariogenic potential. Its poor mechanical properties teeth but this practice has been extended to permanent limit their extensive use as a filling material in stress- teeth as well. Electrically driven handpieces were used bearing areas. The objective of this retrospective study is for cavity preparation, caries excavated using excavators to determine survival rate of glass ionomer cements and tooth restored with GIC. (GIC).In 2006, dental nurses retrieved all dental records GIC has similar mechanical properties to dentine. With of Standard 6 students with posterior GIC restorations. the important benefits of adhesion and release of fluoride, Status of tooth at each year after restoration was recorded. it is an ideal material in many restorative situations. Survival rates of GICs were estimated cumulative However, it's relatively poor mechanical properties must survival rates using the Kaplan-Meier method. The be considered4. A study showed no significant difference median survival duration was 5.00 years (s.d. 0.28). in overall failure rates after two years but follow-up of the Survival rate of amalgam restoration at 5 years was restorations up to five years showed that glass ionomer 86.21%whereas the findings from this study indicates restorations had significantly inferior survival time to cumulative survival rate of 84.36%. The quality of amalgam5 posterior Class 1 glass ionomer restorations is competitive with that of amalgam restorations. There is a need to evaluate teeth restored with glass ionomer cements in the school dental service in view of Key words: glass ionomer cement, survival analysis, its relatively poor mechanical properties. Several studies posterior restorations showed that GIC is not recommended for Class II cavities due to unacceptable high fracture rates. Class I cavities 1. Introduction may be restored in the permanent dentition. Retrospective The use of glass ionomer cements (GIC) by dental nurses trials reported unsatisfactory clinical performance in in the school dental service is well accepted due to ease of Class II cavities.Reviews indicated that the annual failure manipulation. It also tolerates moisture and this property rate with GIC is estimated to be around 8%6.The aim of is useful in mobile dental squads where moisture control this study is to evaluate the outcome of restoring posterior poses a problem.GICs are esthetically more attractive cavities with GIC in permanent molars in the school than amalgam restorations. In addition, by incorporating dental service in Kota Tinggi district. fluorine, they exhibit an anticariogenic potential, and they have good biocompatibility and chemical adhesion Objective to mineralised tissue. On the other hand, poor mechanical To determine survival rate of glass ionomer cements as properties, such as low fracture strength, toughness and dental restorations in posterior cavities wear, limit their extensive use in dentistry as a filling material in stress-bearing areas. In the posterior dental region, glass-ionomer cements are mostly used as a 2. Materials and Methods temporary filling1. 2.1 Design Retrospective study A study conducted in 1993 found that the Atraumatic 2.2 Sampling Restorative Treatment (ART) approach using GIC All Standard 6 students in the school incremental dental performed equally well as conventional restorative care system in Kota Tinggi district in year 2006with approaches using electrically driven equipment and history of GICmolar dental restorations in their dental amalgam for treating dentinal lesions in occlusal surfaces records were included in this study. Parents of students after 6 years2.The procedure is gaining acceptance in involved in this study had given written informed consent developed countries forthe treatment of caries, especially 2.3 Data collection in 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, 48 programme. 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.The investigator entered the data on spreadsheets and analysed Survival Function them using statistical software SPSS version 17.0. 1.1 Survival rates of GICs were estimated cumulative 1.0 survival rates using the Kaplan-Meier method. .9 3. Results .8 The following table shows the distribution of all restored teeth included in this study. .7 .6 Table 4.1: Distribution of Restorations According to Location and Tooth Type Survival .5 Maxilla Mandible .4 Survival Function Cum First right First left First left First right Second left Second right .3 Censored molar molar molar molar molar molar 0 1 2 3 4 5 6 1 2 4 4 0 0 duration 5 9 14 16 0 1 Figure 1 : Kaplan Meier Survival Curve 8 8 19 26 1 0 18 16 31 28 1 1 Table 4.3: Cumulative survival of GIC restorations in 32 35 68 74 2 2 permanent molars Follow-up period No of Class 1 No of restorations No. of Survival (%) A total of 213 molars restored with glass ionomer cements restorations at that require redo extracted start of study teeth were included in this study. Majority (68.54%) of molars restored with GIC at all clinics in Kota Tinggi district were 0-12 months 196 16 0 91.83 lower molars. A total of 196 restorations were placed in 13-24 months 180 19 1 88.88 Class I and 17 in Class IIcavities.Records of all teeth 25-36 months 160 13 2 90.62 restored with GIC showed outcomes as shown in Table 4.2 37-48 months 145 2 1 97.93 49-60 months 142 8 0 84.36 Table 4.2 : Status of molars restored with GIC The median survival with censored data was 3.099 years Status Type of cavities Total as shown in Table 4.4 Class I Class II n (%) n (%) n (%) Table 4.4: Kaplan Meier Analysis Indicated for redo 54 (27.6) 4 (23.5) 58 (27.2) Kaplan Meier analysis (with censoring) Restored with amalgam 4 (2.0) 0 (0.0) 4 (1.9) restoration Class 1 Survival time Standard error 95% C.I. Extracted 4 (2.0) 1 (5.9) 5 (2.3) Median 5.00 0.28 (4.45, 5.55) Among 5 teeth that were extracted, 4 were restored with Class I restoration and 1 with Class II. The tooth with Class II restoration failed at 24 months while those with 4. Discussion Class I restoration failed between 24 to 48 months. No Retrospective survival analysis of dental amalgam further analysis was done for Class II restorations as data restorations showed 96.29% survival at one year7. were too few. Percentage survival for glass ionomer cements after 12 Survival rates of GICs were estimated cumulative months in this study was 91.83% at one year. survival ratesusing the Kaplan-Meier method as shown in Table 4.3. The longest duration of study in this sample is five years after placement of GIC restoration in the school dental Table 4.3: Kaplan Meier estimate of survival function service. Percentage survival of amalgam restorations at Survival Table five years using Kaplan Meier method from a previous study was 86.21% 8. Findings from this study shows that Follow-up period Cumulative proportion surviving at end of Interval. (s.e) cumulative survival of GIC restorations at five years was 84.36% 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, Cemal From a total of 142 restorations, the median survival Eronat, PhD, DDS and Timur Kose, PhD, DDS . A duration was 5.000 years (s.d. 0.114). Survival rates of clinical evaluation of resin-based composite and glass amalgam restoration at 5 years was 86.21% whereas the ionomer cement restorations placed in primary teeth findings from this study indicates cumulative survival rate using the ART approach Results at 24 months . J Am Dent of 84.36% Assoc, Vol 137, No 11, 1529-1536. The quality of posterior Class 1 glass ionomer restorations is 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):10-3 Acknowledgement 5. The author expressed her gratitude to dental nurses in http://en.wikipedia.org/wiki/Glass_ionomer_cement Kota Tinggi district for their assistance in data collection and 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 of statistical analysis. Viscous GlassIonomerCement in Posterior Cavities over Two Years. Int J Dent. 2009; 2009: 781462. Published References online 2010 February 22. 1. Ulrich Lohbauer. Dental Glass Ionomer 7. Bogacki RE, Hunt RJ, del Aguila M, Smith Cements as Permanent Filling Materials? —Properties, WR.Survivalanalysis of posteriorrestorations using an Limitations 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 of year success rates of occlusal amalgam and glass-ionomer conventional and bonded (sealed) amalgam restorations restorations placed using three minimal intervention in a private general dental practice.Br Dent J. 2009 Jan approaches.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. Acknowledgements Dental Staff In Kota Tinggi District, Johor (Draft 1)2010 The authors expressed their gratitude to Kota Tinggi District Dental Officer, Kota Tinggi Senior Health The study also found that the three categories of staff who Officer, Director of Sultan Ismail Hospital, staff of ORL suffered hearing impairment were working in high noise Clinic Sultan Ismail Hospital and all dental personnel in area (Kota Tinggi Main Dental Clinic, Sening Dental Kota Tinggi districts who had contributed to the conduct Clinic) 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 1994 6. 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. Occupational attendant worked in a glass factory with exposure to loud health problems in modern dentistry: a review. Ind noise 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/Re years. Another attendant worked as a heavy vehicle driver gulations/AKJ/pua0001y1989s0005.pdf accessed at and claimed that he was exposed to loud noise during his 13:51 7 May 2011 5 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, 2002 personnel experienced distraction and annoyance during 5. Szymanska J. Work-related noise hazards in the dental the exposure. surgery. Ann Agric 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 and Hazard from noise in dental working environment cannot Communication Interference in Dental Practice Journal be 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 effect proper monitoring and Hearing Conservation programme of sound produced in a dental clinic on the hearing of is 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 and 90dBA are advised to wear ear plugs. Regular medical risk control. Department of occupational safety and surveillance of staff exposed to high level of noise must health, Ministry of Human Resources, Malaysia. 2008 be complied as per Factories and Machinery (Noise Exposure) Regulation 1989. This can ensure early detection and management of the patient hence preventing hearing impairment among the dental staff. 27

7 A Study Of Obesity Among Health Staff At Kulaijaya District Volume 10 Health Department (2012) 2012 Dr. Mohd Shaiful Ehsan B Shalihin Poh Lin Chin, Misringaton Kulaijaya Health District Johor the environment which include education background, OBJECTIVE: To study and report prevalence of occupation, household income, culture and lifestyle overweight and obesity among health staff at Kulaijaya (Azmi, et al., 2009; Moy & Atiya, 2003-2005; Richard, District Health Department and describe their association Andrew, & Rodolfo, 2012; Shashikiran, Sudha, & with gender, marital status, respective job scope and Jayaprakash, 2004; Speakman, 2004). Globally, around working environment, using standardized international 12% of adults aged 20 and above were obese in 2008 definitions. METHODS: This cross (World Health Organization (WHO), 2004). This figure sectional study studied body mass index of all the health is increasing in developing countries including Malaysia staff of Kulaijaya Health Department except expectant (Caballero, 2001; Moy & Atiya, 2003-2005; Nor, et al., mothers and females in their first three months 2008; Shashikiran, Sudha, & Jayaprakash, 2004). Based postpartum period. Body mass index (BMI:kg/m2) was on the National Health Morbidity Survey (NHMS) III calculated from measured weight and height, using (2006), the national prevalence of obesity (BMI 18.5- calibrated weighing scales and body meters. Body weight 24.9 kg/m2) was 14% compared to 4.4% in NHMS II in classifications were defined as follows: According to 1996 (Nor, et al., 2008). Rapid pace of industrialization WHO Expert Consultation 2004 for Asian BMI: and urbanization in recent decades in Malaysia had underweight (BMI < 18.5), normal weight (18.5 to 24.9), brought in changes in the lifestyles of Malaysians (Moy pre-obese /overweight (BMI 25.0-29.9), obes e (BMI > or FM, 2003-2005). These include reduction of physical = 30.0). Otherwise, 100% respondent's rate was achieved. activities, changes in dietary habits and food preferences. Descriptive and correlation analysis were performed Generally, Malaysians acquired a taste for high in fat, using SPSS version 15. A significance level of p-value processed fast food and high calorie diets. Furthermore, less than or equal to 0.05 was considered statistically housewives showed the highest prevalence of obesity at s i g n i f i c a n t ( p < 0 . 0 5 ) . 20.3% (CI 0.19–0.21), compared to working mums who RESULTS: The prevalence were found to be 5.8% for engage in regular physical activity (Nor, et al., 2008). underweight (CI 0.03-0.10), 40.2% for normal BMI (CI Obesity has also reached an alarming level at the southern 0.33-0.47), 33.9% for overweight (CI 0.27-0.41) and region of Peninsular Malaysia, specifically Johor, as the 20.1% for obese (CI 0.14-0.26). Higher prevalence of prevalence is highest in this state compared to other obesity was found in males (20.1%) (CI 0.13-0.32), those states. According to the findings of the Malaysian Adult confined in office settings (23.3%) (CI 0.14-0.35) and in Nutrition Survey in 2009, prevalence of obesity in Johor married employees (20.6%) (CI 0.15-0.27). There was a is at 13.81% (CI: 0.12-0.16) (Azmi, et al., 2009). The significant association between marital status and mean body weight was also significantly higher in the overweight (P 0.023). Among all job scopes, medical southern region (64.42 kg) (CI: 63.46), compared to those doctors had the highest prevalence of obesity (38.5%) in Sarawak (60.66 kg) (CI: 59.43, 61.88)] and Sabah (0.18-0.64). Prevalence of normal weight and (58.93kg) (CI: 57.86, 60.01) (Azmi, et al., 2009). Even underweight are higher in those working in clinical though obesity is higher in females 17.4% (CI 0.17-0.18), setting (46.5%)(CI 0.38-0.55) compared to office staff it is unequally distributed by comparing regional factors ( 4 5 . 0 % ) ( C I 0 . 3 3 - 0 . 5 8 ) . and ethnic groups. This finding was attributed to CONCLUSION: There was higher prevalence of obesity underlying individual socioeconomic role (Nor, et al., and overweight amongst male staff, office and 2008)(Richard, Andrew, & Rodolfo, 2012). inspectorate personnel and medical officers at Kulaijaya Currently, obesity and overweight are serious emerging District Health Department in relation to national and global issues among healthcare personnel. A study of 760 state figures. Regular weight management program nurses across 6 different states of United States found should be implemented to all staff regardless of gender, 54% to be overweight or obese (Miller, Alpert, & Cross, marital status, job scope and working environment. 2008). In addition, there were hospitals which implement KEYWORDS: Obesity, health staff. policies barring the employment of obese candidates (Miller J. R., 2012). In Johor, the prevalence of INTRODUCTION: overweight and obesity among health staff was even Obesity is a complex chronic disease that results from higher than national prevalence of 60% (Harian Metro, multi factors such as interaction between genotype and 2009). 28

There are many ways to measure body fat content in answer. It was mandatory that all staff partook in this which 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 mass compared to other weight-for-height indices. BMI is easy index status and their related factors. Weight and height of to calculate and has been recommended as the measure of adults were taken by trained personnel working in pairs obesity for adults to be used in all studies. BMI generally using standard procedures and standardized digital correlates highly with adiposity, although it can weighing scales and body meters which were calibrated sometimes 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, without Speakman, 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 nearest underweight (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), obes e (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 weight previous attempts and suggestion to change this categories based on a modified WHO Classification international BMI classification to interpret BMI cut-off which includes underweight (BMI < 18.5), normal (BMI points for Asia population, the WHO Expert Consultation 18.5 to 24.9), preobese (BMI 25 to 29.9) and obese (BMI 2004 recommends retaining the current international > 30) (World Health Organization (WHO), 2004). The BMI classification for adult regardless where the BMIs were analysed according to the different working population is (Malaysian Association for the Study of areas at Kulaijaya Health District Office. The prevalence Obesity; World Health Organization , 2004). was reported with confidence intervals (CI) and its The present study focuses on the BMI index among health relations with variables of gender, workplace, job scope staff of Kulaijaya Health District Office in Johor. The and marital status were analysed at 5% level of objectives of this study are to describe the prevalence of significance using SPSS statistical software version 15. overweight and obesity among the staff using standardized international definitions. It will compare the RESULTS prevalence in relation to the working environment, job Profile scope, gender and marital status. All health workers (n=189) at Kulaijaya District Health Department except for pregnant mothers and 3 months or METHODOLOGY: 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 2012 among the the health staff of Kulaijaya District respondents were married (89.9%), females (64.6%) and Health Department except expectant mothers and paramedics (43.9%). The mean BMI of the staff was females in their first three months postpartum period. 25.73 kg/m². The respondents were equally distributed This study design was chosen since it was the best method among office and two clinics. for 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: Gender Figure 2: Marital status Figure 3: Job Scope Figure 4: Work area 29

Prevalence and relations The prevalence of overweight (BMI > 25kg/m2) and obesity (BMI>30kg/m²) among the health staff was 33.9% (CI 0.27-0.41) 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). Confidence Interval Prevalen CATEGORY ce Lower border upper border UNDERWEIGHT 5.8 3.3 10.1 NORMAL 40.2 33.5 47.3 OVERWEIGHT 33.9 27.5 40.9 OBESE 20.1 14.1 25.2 TOTAL 100.0 Table 1: BMI prevalence and confidence interval of health staff of Kulaijaya Health District Office. Bar Chart BMI status underweight normal PEJABAT preobese obese o r k p l a c e w KK KULAI KK KULAI BESAR 0 10 20 30 40 Counts Figure 5 Bar chart BMI status and workplace OBESITY overweight Marital status Pearson Correlation -.165(*) Marital Status Pearson Correlation -.036 Sig. (2-tailed) .023 Sig. (2-tailed) .623 N 189 N 189 Jawatan Pearson Correlation .118 Gender Pearson Correlation -.015 Sig. (2-tailed) .105 Sig. (2-tailed) .842 N 189 N 189 Jawatan Pearson Correlation -.096 Gender Pearson Correlation -.054 Sig. (2-tailed) .191 Sig. (2-tailed) .460 N 189 Workplace Pearson Correlation .036 N 189 Sig. (2-tailed) .620 N 189 Workplace Pearson Correlation .089 Sig. (2-tailed) .226 Table 2: Obesity and its correlations with studied factors N 189 * 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 is The mean BMI for staff of Kulaijaya District Health involved in their routine job. This explanation is true as if Department (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 in overweight (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 are 0.27-0.41) and 20.1% (CI 0.14-0.26) respectively which married, in which marriage lifestyle is related with were higher than the national overweight and obesity obesity-prone lifestyle (Hough, 2010). prevalence of 29.1 (CI 0.286-0.297) and 14.4% Males had higher prevalence of obesity and respectively (Nor, et al., 2008). The overweight and obese overweight (58.2%) (CI0.463-0. 693) compared to were also higher than MANS (Azmi, et al., 2009); females (51.6%) (CI 0.429 - 0.603)in this study. Most whereby overweight prevalence was at 26.71% (CI: males were (87.2%) married which could explain the 0.255 – 0.280) and obesity was at 12.15% (CI: 0.113 to underlying reason for the higher prevalence. 0.131). The local (KDHD) prevalence was even higher Furthermore, studies have shown that marital status is an than the overall southern region overweight prevalence of important predictor of obesity in males (Lipowicz, 29.4% (0.266-0.324) and obesity prevalence at 13.8% (CI Gronkiewicz, & Malina, 2002). 0.118-0.161). 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 and growing urbanized and developed capital city in overweight amongst male staff, office and inspectorate Malaysia (Noorsidi, 2009). Urban food environment, personnel and medical officers. Nevertheless, these built environment and technology advancements can lead findings were found to be insignificant. However, there to poorer diets and less physical activity (Harvard School was significant association between marital status and of Public Health) (Reid Ewing, et al., 2008), which result overweight prevalence. Obesity and overweight in obesity (Caballero, 2001;Moy & Atiya, 2003-2005; prevalence of Kulaijaya District Health Department Speakman, 2004). Furthermore, working in a health (KDHD) was also higher than the national and southern community clinic is associated with less physical and zone prevalence figures. There is a need for energy requirement compared to working in a hospital implementation of effective weight management setting. (Chris G., 2009). 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 to higher physical activity required to run clinics rather than ACKNOWLEDGEMENTS offices. 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 that standing (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 Badrul Studies 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 Bin Virtanen, & 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 good among married staff was also significant (p=0.023). The cooperation and assistance during data collection. We findings are similar with previous studies (Jeffery & pray that Allah will reward your benevolence and Rick, 2002; Lipowicz, Gronkiewicz, & Malina, 2002; cooperation in this world or the hereafter. Sobal, 2008). This might be due to significant changes in lifestyle as a couple automatically cease to monitor or control their weight gain or body shape after marriage. Married couple spend more time eating together and often order takeaway ready meals while exercising less (Hough, 2010). Surprisingly, medical doctors have the highest prevalence of obesity among all categories in this study. This might be due to their job scope in clinical setting which were most likely related with counseling patient, establishing long term relationship with patient and family members, emphasizing disease prevention and health promotion (American Academy of Family Physicians, Wikipedia) rather than attendance or involvement in acute or emergency cases as in a hospital 31

REFERENCES communication technology and prevalence of American Academy of Family Physicians. (n.d.). Explore overweight and obesity among adolescents. International Family Medicine - where every facet of medicine is yours Journal of Obesity , 925-933. to discover. Retrieved 2012, from American Academy of Lipowicz, A., Gronkiewicz, S., & Malina, R. M. (2002). Family Physicians: www.aafp.org/explore Body mass index, overweight and obesity in married and Appropriate body-mass index for Asian populations and never married men and women in Poland. American its implications for policy and intervention strategies. Journal of Human Biology , 468-475. (2004, January 10). Retrieved from THE LANCET: Malaysian Association for the Study of Obesity. (n.d.). www.thelancet.com Retrieved August 3, 2012, from Define obesity: Ariënsa, G. A., Bongersa, P. M., Douwesa, M., http://www.maso.org.my/spom/chap3.pdf Miedemaa, M. C., Hoogendoorna, W. E., Walb, G. v., et Miller, J. R. (2012). Texas hospital reportedly bars obese al. (2001). Are neck flexion, neck rotation, and sitting at workers -- and it might be legal. Texas: Foxnews.com. work risk factors for neck pain? Results of a prospective Miller, S. K., Alpert, P. T., & Cross, C. L. (2008). cohort study. Occupation Environment Medicine , 200- Overweight and obesity in nurses, advanced practice 207. nurses, and nurse educators. Journal of American Azmi, M., Junidah, R., Mariam, A. S., Safiah, M., Academy of Nurse Practitioners , 259-265. Fatimah, S., Norimah, A., et al. (2009). Body Mass Index Moy, F., & Atiya, A. (2003-2005). Lifestyle Practices and (BMI) of Adults: Findings of the Malaysian Adult Prevalence of Obesity in a Community within a Nutrition Survey (MANS). Malaysia Journal of Nutrition University Campus. The Journal of Health and 15(2) , 97-119. Translational Medicine , 33-38. Caballero, B. (2001). Obesity in Developing Noorsidi. (2009, November 21). Johor Bahru Countries:Biological and Ecological Factors. Journal of Urbanization and Demographic. Socyberty . Nutrition , 866-870. Nor, M., Khor, N. S., Shahar, G. L., Kee, S. &., Haniff, C. CBC NEWS. (2008). TV viewing, computer use linked to C., Appannah, J. &., et al. (2008). The Third National obesity: StatsCan. Health and Morbidity Survey (NHMS III) 2006: Chris G. (2009, September 14). Hospital or Clinic: Which nutritional status of adults aged 18 years and above. is Better to Work In? Retrieved from Yahoo Contributor Malaysian Journal of Nutrition 14(2) , 1-87. Network: http://voices.yahoo.com/hospital-clinic- Reid Ewing, T. S., Killingsworth, R., Zlot, A., & which-better-work-in-4232039.html Raudenbush, S. (2008). Relationship Between Urban Harian Metro. (2009). Hospital Bukit Mertajam . Sprawl and Physical Activity, Obesity, and Morbidity. Retrieved 2012, from Berita: Kakitangan Hospital Urban Ecology , 567-582. D i m i n t a K u r a n g k a n B e r a t B a d a n : Richard, A. D., Andrew, K. T., & Rodolfo, M. N. (2012). http://hospbm.moh.gov.my/modules/news/article.php?st Obesity inequality in Malaysia: decomposing differences oryid=22 by gender and ethnicity using quantile regression. Harvard School of Public Health. (n.d.). The Obesity Ethnicity and Health . Prevention Source: urbanization and society. Retrieved Shashikiran, U., Sudha, V., & Jayaprakash, B. (2004). August 11, 2012, from Harvard School of Public health: What is obesity. Medical Journal of Malaysia 59(1) , 131- http://www.hsph.harvard.edu/obesity-prevention- 134. s o u r c e / o b e s i t y - c a u s e s / o b e s i t y - a n d - Sobal, J. (2008). Marriage, Obesity and Dieting. urbanization/index.html Marriage and Family Review , 115-139. Hough, A. (2010). Married people 'twice as likely to be Speakman, J. R. (2004). Obesity: The Integrated Roles of fat'. The Telegraph. Environment and Genetics. Journal of Nutrition , 2090- Ismail, M., Zawiah, H., Chee, S., & Ng, K. (1995). 2015. Prevalence of obesity and chronic energy deficiency Wikipedia. (n.d.). Wikipedia. Retrieved 2012, from (CED) in Adult Malaysians. Malaysian Journal of F a m i l y M e d i c i n e : Nutrition , 1-9. http://en.wikipedia.org/wiki/Family_medicine Jeffery, R. W., & Rick, A. M. (2002). Cross-Sectional and World Health Organization . (2004). World Health Longitudinal Associations between Body Mass Index and Organization. Retrieved August 3, 2012, from BMI Marriage-Related Factors. Obesity Research , 809-815. C l a s s i f i c a t i o n : Kautiainen, S., Koivusilta, L., Lintonen, T., Virtanen, S. http://apps.who.int/bmi/index.jsp?introPage=intro_3.ht M., & Rimpelä, A. (2005). Use of information and ml 32

Evaluation of laboratory outcomes of patients (INR) 8 between clinician-managed Warfarin therapy and pharmacist-managed Warfarin Medical Adherence Volume 10 Therapy Clinic (W-MTAC) in HBP over 1 year 2012 Ali Umar Bin Ibrahim, Yvonne Koh Li Ling, Pn. Siti Khairaini Binti Rahim Pharmacy Department, Hospital Batu Pahat, Johor, Malaysia June 2011 Introduction Abstract Warfarin is the most widely used oral anticoagulant agent Evaluation of laboratory outcomes of patients (INR) worldwide, especially in the prevention of between clinician-managed Warfarin therapy and thromboembolic events such as deep vein thrombosis pharmacist-managed Warfarin Medical Adherence (DVT), chronic atrial fibrillation, pulmonary embolism Therapy Clinic (W-MTAC) in HBP over one year and valvular heart disease [1]. Warfarin acts by I. Ali Umar1, Y. L .L Koh1, R. Siti Khairani1 interfering with the cyclic interconversion of vitamin K 1Department of Pharmacy, Hospital Batu Pahat, Johor. and vitamin K epoxide and subsequent modulation of the Background: The clinical quality of warfarin therapy gamma carboxylation of the terminal regions of relies on how successful healthcare professionals and vitamin K proteins. This results in the reduction of patients are in achieving and maintaining levels of clotting factors II, VII, IX, and X [2]. Carboxylation of anticoagulation capable of preventing thromboembolic the regulatory anticoagulant proteins C and S also is events without increasing the risk of hemorrhagic inhibited, potentially contributing to a procoagulant complications. The purpose of this study is to compare effect early in therapy. the clinical outcomes of patients (INR) between clinician-managed Warfarin therapy and pharmacist- Warfarin has its established role in anticoagulation managed warfarin Medication Adherence Therapy Clinic treatment for decades. But a number of challenges have (W-MTAC) in HBP over one year (April 2009-March been identified in managing warfarin therapy practically 2010) and (April 2010-March 2011) respectively. and clinically. These include the need for frequent Methods: The retrospective study was carried out by laboratory monitoring and dose adjustment, drug and measuring the percentage of patient time spent within food interactions, presence of concomitant disease, the targeted INR therapeutic range. The percentage of time influence of co-morbidities on anticoagulant control and spend within the therapeutic range was calculated by the the fear of adverse events [6]. Besides, the variable method described by Rosendaal and colleague. All data biological effect and drug response in patient due to collected will be entered into Microsoft office Excel 2003 variant alleles of the CYP2C9, the hepatic enzyme (Microsoft Corp., Redmond WA, USA) and analysed responsible for oxidative metabolism of the warfarin S- using Statistical package for the Social Sciences (SPSS) isomer, can also influence the optimal dosing of warfarin. version 17TM (SPSS Inc., Chicago, IL, USA). Several genetic polymorphisms in this enzyme have been Results: It was found that there was an increase of described that are associated with lower dose percentage of patient-time in therapeutic range which requirements and higher bleeding complication rates about 10% after W-MTAC managed by pharmacists was compared with the wild-type enzyme CYP2C9 [6,9]. started at HBP. Besides, daily adherence to warfarin is both a persistent Conclusion: The management model for anticoagulation and potentially modifiable contributor to INR instability therapy by clinical pharmacist as the primary care and warfarin efficacy [6,7]. provider with clinician consultation is more effective than a model of care managed solely by clinicians in The clinical quality of warfarin therapy achieving target INR control. relies on how successful healthcare professionals and Keywords : Warfarin therapy, Warfarin Medical patients are in achieving and maintaining levels of Adherence Therapy Clinic (W-MTAC) anticoagulation capable of preventing thromboembolic events without increasing the risk of hemorrhagic Correspondence: Mrs. R. Siti Khairani complications [8]. Successful anticoagulant management Full correspondence address: Hospital Batu Pahat, Jalan requires careful monitoring of the INR, ongoing patient Korma, 83000 Batu Pahat education and good communication between patient and Tel: 07-4363000 ext. 3136 healthcare professionals. It also requires an educated and Fax: 07-4345810 skilled personnel as well as a well-organized framework Email: [email protected] 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 Department suggested that patient education which highlight the side- (MOPD) HBP from year April 2010 to March 2011 are effects of warfarin, the potential for drug–drug and recruited in this study. Before April 2010, outpatient drug–food interactions, advice on birth control, the anticoagulation management in HBP patients was importance 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). In Prior knowledge about warfarin has been associated with April 2010, pharmacists took over the management of a decreased risk of bleeding [11]. Written and verbal warfarin therapy, working closely with Medical information have been shown to improve control of the Department doctors, hence the formation of W-MTAC. In level of anticoagulation [12]. This shows that counselling W-MTAC the pharmacist sees all new patients at their patients with respect to their anticoagulant treatment is first visit for information and counselling regarding fundamental and significantly improves patient's warfarin therapy. In the subsequent visit, the clinic's knowledge 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) test anticoagulation clinics had showed improved care in at the time of arrival. INR results were determined via patient receiving warfarin therapy compared to usual venous blood samples and tested hospital laboratory staff medical care, in which the patient showed improved INR using a fully-automated, high productivity analyzer control, 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, they haemorrhagic and thromboembolic events, decreased are written in the patient's record book and case note health 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 between INR levels and adverse outcomes, the efficacy of warfarin Study Design and Selection Criteria depends 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 group within the designated therapeutic range or time in consists of patients received warfarin therapy from 1st therapeutic range (TTR) during warfarin therapy as there April 2009 to 31st March 2010, who were managed by is an increased risk of haemorrhage at INRs > 3.0 and clinicians. The intervention group consists of patients thromboembolic complications at INRs < 2.0 [19]. White under followed-up W-TAC from 1st April 2010 to 31st et al., 2007 [20] reported that the INR value in the March 2011. Demographic data, indications for warfarin therapeutic range for more than 75% of the time had therapy and the target INR ranges are collected for each significantly fewer episodes of major and minor bleeding. patient. When multiple indications for warfarin therapy Thus patient's INR must remain stable within their were recorded, the indication requiring the highest target therapeutic range in order to minimize the complications INR range or the longest duration of anticoagulation associated with anticoagulation therapy. Therefore, the therapy is chosen as the primary indication. A W-MTAC aim of this study is to evaluate the clinical quality and audit form is designed to collect the data, and a pilot study effectiveness of warfarin clinic managed by the was conducted to review the final audit form (Appendix pharmacists - 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 criteria within targeted INR therapeutic range in a cohort of • Aged > 18 years at initiation of warfarin therapy patient participated in this studies. • At least two INR test values measured during any of the evaluation periods Research Objective • Have been stabilized on warfarin therapy The objective of this research is to compare the laboratory (minimum of 1 month). outcomes of patients (INR) between doctor-managed Warfarin therapy and pharmacist-managed Warfarin Exclusion criteria Medical Adherence Therapy Clinic (W-MTAC) in HBP • INR tests performed as inpatient tests over one year (April 2009 – March 2010) and (April 2010 – March 2011) respectively. Outcome Percentage of time in the therapeutic range in each time Research Hypothesis period was first calculated overall; that is, by considering Alternative hypothesis, H1 : The laboratory all days of follow-up. The outcome is the percentage of outcomes of pharmacist-managed W-MTAC in HBP, patient time spends within the target INR range. The Johor has improved over one year. percentage of time spend within the therapeutic range is Null Hypothesis, H0 : The laboratory calculated by the method described by Rosendaal and outcomes of pharmacist-managed W-MTAC in HBP, colleague as described in Appendix 2 [22]. The method Johor has not improved over one year. utilized is Rosendaal's linear interpolation. The majority of recent studies utilize Rosendaal's linear interpolation Methodology methodology which assumes that a linear relationship Setting exists between two INR values, given that not more than 8 Patients who were treated with warfarin therapy and weeks has elapsed between the two. It allocates a specific 34

INR value to each day between tests for each patient, Statistical Analysis allowing one to calculate INR specific incidence rates of All data collected will be entered into Microsoft Office adverse events, such as bleeding complications. Linear Excel 2003 (Microsoft Corp, Redmond WA, USA) and interpolation is the only method that incorporates time. analysed using Statistical Package for the Social Sciences (SPSS) Version 17 ™ (SPSS INC., Chicago, IL, USA). Results Demographic Characteristics Table 1 shows the demographic characteristics of warfarin patients of HBP from April 2009 until March 2011. The proportion of male to female was about 1:1 (46.5 % male vs 53.5 % female). About three quarter of the W-MTAC patients are made up of Malay, followed by Chinese. The mean age was around 59.62 years old, with standard deviation 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 2011 Year April 2009 – March 2011 No. of Patient (n) 43 n (%) Gender Male 20 46.5 Female 23 53.5 Races Chinese 11 25.6 Melayu 32 74.4 Age Mean age 59.62±13.71 ± SD a Age 34 to 90 Range aSD=Standard deviation Figure 2: Indication of warfain at HBP from 2009-2011 AF=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 for cardiac ischaemic events such as ischaemic cardiomyopathy (ICMP), dilated cardiomyopathy (DCMP) and other events 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 < 0.05 Figure 3 shows the mean percentage of patient-time in medical care [23,24]. In the present study, the warfarin therapeutic range between doctors and pharmacists. patients studied in the pharmacist-managed group spent Overall, the mean percentage of patient-time in more time in the therapeutic INR ranges when compared therapeutic range of W-MTAC managed by pharmacists with those in the clinician-managed group. This showed was 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 INR time in therapeutic range which about 10 % after W- control as shown in Figure 3. Such achievement is MTAC managed by pharmacists was started at HBP. perhaps due to the intense education provided to patients and their caregivers by clinical pharmacist in the Discussion pharmacist-managed group, patients' adherence or Once the targeted intensity of oral anticoagulation is compliance are checked more thoroughly and, as a drug achieved, it must be maintained, as this is directly related expert, pharmacist provides extra attention to the to its derived benefit. The most recognized way to potential warfarin–drug and warfarin–herb interactions at measure the therapeutic effectiveness of warfarin over each clinic visit. Besides, the use of standardized time is to measure time spent in therapeutic range (TTR). anticoagulation monitoring template and separate case TTR has been shown to strongly correlate with the note also makes monitoring of patient's INR become principal clinical outcomes of hemorrhage or thrombosis easier and more easily retrievable. All these may and, thus, TTR is a reliable measure of the quality of W- contribute to the improved INR control in the patients MTAC. Increased TTR has also been associated with managed by the clinical pharmacist [27]. decreased mortality, myocardial infarction and stroke rates. Clinical studies show that under-coagulation and The percentage of patient time spent in therapeutic range over-coagulation enhance the risk of adverse clinical managed by pharmacist in WMTAC since April 2010 to outcomes such as thromboembolism and bleeding March 2011 is higher than that of conventional medical respectively. Literatures have proven that specialized care. A likely explanation is that, in 2008, the new anticoagulation management with pharmacist's warfarin protocol has been implemented. The new intervention has resulted in outcomes at least equal, and protocol came with more detailed information and sometimes superior in term of time spent in therapeutic directions, with a clear dosage adjustment guideline and range. Furthermore, there is also reduction in therapy- also with the list of possible drug-drug or drug herb related complication by 50-90% compared to those interaction that may help pharmacist in warfarin dosing managed 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 for well with hemorrhagic and recurrent thromboembolic clinician-managed anticoagulation clinics. Physicians events [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 time range, and the point-in-time or cross-section of records [32,33]. Clinicians considered pharmacists capable of methodology) and no standardized consensus exists as to monitoring and maintaining warfarin therapy, considered which 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 of improves 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, Medical have been described in detail elsewhere [1]. Next Officers (MO) and Housemanship Officers (HO) should limitation was due to the possibility of incompleteness or be conducted regularly, preferably once per year, this due data loss, this is the common drawback of retrospective to the rapid staff movement in the hospital. The doctors study and not only the problem in this study. Besides, the were introduced to W-MTAC in hope of providing better warfarin complications such as thromboembolic events warfarin management and care to patients. Moreover, the and bleeding risks, which were considered as the ideal existing warfarin book should be amended to provide end 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-food factors, such as medications, diet and concomitant interactions and other precautions. Besides, ongoing disease states can alter the pharmacokinetics of warfarin, education, counsel in case of sustained dysregulation of thus contributing to the limitations of study. Other factors anticoagulation, or advice on interruption of therapy in that may affect therapeutic outcome such as patient case of bleeding or the need to undergo an invasive compliance, transient fluctuations of comorbid procedure are, among others, issues that need to be taken conditions, the addition or discontinuation of care of is also need to be addressed to all warfarin patient medications, the quality of dose-adjustment decisions to improve better warfarin management control [37]. and whether the patient has demonstrated a stable dose response and many others are not considered in this study. Conclusions Overall, the mean percentage of patient-time in In future studies assessment of the major complications therapeutic range of W-MTAC managed by pharmacists of warfarin in this hospital, such as thromboembolic was superior (58.1%), more than that of MOPD managed events, bleeding risks, and rate of hospitalization should by doctors (48.2%). In summary, the management model be conducted. Besides, the future studies should also for anticoagulation therapy including a pharmacist as the correlate the therapeutic efficacy with the compliancy, primary care provider with doctor's consultation is more drug-drug, drug-food interactions, patients' knowledge effective than a model of care managed solely by doctors and education levels. in achieving target INR control.References Change in blood taking method: Point of Care Test 1) Ansell J, Hirsh J, Poller L, Bussey H, Jacobson (POCT) has been shown to a safe and effective approach A, Hylek E. The pharmacology and management of the that may be suitable for all patients [25]. Easy and vitamin K antagonists: the Seventh ACCP Conference on reliable laboratory devices (Coaguchek device) have Antithrombotic and Thrombolytic Therapy [Published become available, which allow the measurement of the correction appears in Chest 2005;127:415-6]. 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