Barriers to scaling up hepatitis C treatment in Malaysia: a qualitative study with key stakeholders.

BACKGROUND: While the availability of generic direct-acting antivirals (DAAs) opens the door for large-scale treatment, the care for people living with hepatitis C virus (HCV) in Malaysia is shifting toward a tripartite partnership between the public health system, correctional settings and civil society organizations (CSOs). This study aimed to explore the barriers to scaling up HCV treatment in Malaysia from the perspective of key stakeholders. METHODS: Eighteen focus-group discussions (FGDs) were conducted with 180 individuals, who actively engaged in coordinating, executing or supporting the implementation of the national strategic plan for HCV. An analytical framework was adapted to guide the data collection and thematic analysis. It covered four key aspects of HCV treatment: geographical accessibility, availability, affordability and acceptability. RESULTS: Movement restrictions in times of coronavirus disease 2019 (COVID-19) outbreaks and being marginalized translated into barriers to treatment access in people living with HCV. Barriers to treatment initiation in health and correctional settings included limited staffing and capacity; disruption in material supply; silos mentality and unintegrated systems; logistical challenges for laboratory tests; and insufficient knowledge of care providers. Although no-cost health services were in place, concerns over transportation costs and productivity loss also continued to suppress the treatment uptake. Limited disease awareness, along with the disease-related stigma, further lowered the treatment acceptability. CONCLUSIONS: This study disclosed a series of supply- and demand-side barriers to expanding the treatment coverage among people living with HCV in Malaysia. The findings call for strengthening inter-organizational collaborations to overcome the barriers.

Adequacy of Empiric Antibiotics Therapy and Its Impact on Outcomes in Adult Critically Ill Sepsis Patients: A Review.

Sepsis is a medical emergency that involves a systemic immunological response due to an infection, resulting in the end-stage-organs malfunction and death. It is associated with high mortality rate despite a better understanding of the disease pathology and the mechanism involved. This review was designed to summarise the available evidences regarding the adequacy of the empiric antimicrobial therapy (EAMT), its predictors and its impact on the outcomes in intensive care unit (ICU) sepsis patients. Providing an adequate EAMT is considered one of the cornerstones of sepsis management as it has been found to be associated with better survival and is a good predictor for shorter ICU-length-of-stay. In contrast, inadequate EAMT in sepsis patients is associated with poor clinical outcomes including increased mortality and prolonged hospital stay. Evidence from this review suggest that it is important to identify determinants of inadequate EAMT to optimise the antimicrobial therapy provided to sepsis patients. Predictors of inadequate EAMT included co-morbidities (cancer), source and type of infection, higher Acute Physiology and Chronic Health Evaluation (APACHI-II) score and long hospital stay prior to the infection. As EAMT is considered as one of the effective treatment strategies to prevent sepsis associated death, healthcare providers should ensure the adequate antimicrobial therapy is provided for sepsis patients to improve and optimise their management.

WHO key access antibiotics price, availability and affordability in private sector pharmacies in Pakistan.

BACKGROUND: Poor availability and unaffordability of key access antibiotics may increase antimicrobial resistance in the community by promoting inappropriate antibiotic selection and abridged therapy compliance. OBJECTIVE: To check the prices, availability, and affordability of the World Health Organization (WHO) key access antibiotics in private sector pharmacies of Lahore, Pakistan. METHODOLOGY: A survey of WHO key access antibiotics from WHO essential medicine list 2017 was conducted in private sector pharmacies of 4 different regions of Lahore employing adapted WHO/HAI methodology. The comparison of prices and availability between originator brands (OB) and lowest price generics (LPG) were conducted followed by the effect of medicine price differences on patient's affordability. The data were analyzed using a preprogrammed WHO Microsoft excel workbook. RESULTS: The mean availability of OB products was 45.20% and the availability of LPGs was 40.40%. The OBs of co-amoxiclav, clarithromycin and metronidazole and LPGs of azithromycin and ciprofloxacin were easily available (100%) in all private sector pharmacies. Whereas, antibiotics like chloramphenicol, cloxacillin, nitrofurantoin, spectinomycin, and cefazolin were totally unavailable in all the surveyed pharmacies. The OBs and LPGs with high MPRs were ceftriaxone (OB; 15.31, LPG; 6.38) and ciprofloxacin (OB; 12.42, LPG; 5.77). The median of brand premium obtained was 38.7%, which varied between the lowest brand premium of 3.97% for metronidazole and highest for ceftriaxone i.e. 140%. The cost of standard treatment was 0.5 day's wage (median) if using OB and 0.4 day's wage (median) for LPG, for a lowest paid unskilled government worker. Treatment with OB and LPG was unaffordable for ciprofloxacin (OB; 2.4, LPG; 1.1) & cefotaxime (OB; 12.7, LPG; 8.1). CONCLUSION: There is dire need to properly implement price control policies to better regulate fragile antibiotic supply system so that the availability of both OB and LPG of key access antibiotics should be increased. The prices could be reduced by improving purchasing efficiency, excluding taxes and regulating mark-ups. This could increase the affordability of patients to complete their antibiotic therapy with subsequent reduction in antimicrobial resistance.

Translation and validation of the Test of Adherence to Inhalers (TAI) questionnaire among adult patients with asthma in Malaysia.

OBJECTIVE: The Test of Adherence to Inhalers (TAI) is a validated self-reported questionnaire that can reliably assess adherence to inhalers through patient self-report. However, it was not available in Bahasa Melayu (BM) language, nor has it been validated for use in the Malaysian population. The study aimed, therefore, to translate the 10-item TAI questionnaire into BM and evaluate its psychometric properties. METHODS: The translation of the English version of the valid 10-item TAI questionnaire into BM was followed by subjecting it to a series of tests establishing factorial, concurrent and known group validities. Concurrent validity was assessed through Spearman's rank correlation coefficient against pharmacy refill-based adherence scores. Known group validity was assessed by cross-tabulation against asthma symptom control and using chi-square test. The internal consistency of the test scale was determined by a test-retest method using Cronbach's alpha (α) value and intraclass correlation coefficients. RESULTS: A total of 120 adult asthma patients participated in the study. A 2-factor structure was obtained and confirmed with acceptable fit indices; CFI, NFI, IFI, TLI >0.9 and, RMSEA was 0.08. The reliability of the scale was 0.871. The test-retest reliability coefficient for the total sum score was 0.832 (p < 0.01), which indicated good reliability. The 10-item TAI-BM established concurrent and known group validities. The sensitivity and specificity of the tool were >85%. CONCLUSIONS: The scale successfully translated into BM and validated. The 10-item TAI-BM appears fit for use in testing inhaler adherence of Malaysian patients with asthma.

Medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia.

BACKGROUND: Caregivers' knowledge, practice and adherence in medication administration who care for children with chronic illness requiring long-term pharmacological treatments are factors associating with children medication safety at home. This study aimed to determine the medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia. This cross-sectional study was conducted at the paediatric outpatient clinic of a tertiary public hospital. Caregivers of chronically ill children, who engaged in medication administration at home for at least 3 months, were conveniently recruited. Their medication-related knowledge and administration practice were evaluated based on a checklist, while their adherence to medication administration was assessed using a validated 5-point scale. The associated factors were also explored. RESULTS: Of the 141 participants, most were mothers (90.8%) and had a full-time job (55.3%). Most of them had adequate medication-related knowledge (71.6%) and an appropriate administration practice (83.0%). The majority of them (83.0%) also rated themselves as adherent to medication administration. The participants with a child above 5 years of age (91.2%) were found to have a better practice than those with younger children (75.3%) in medication administration (p = 0.012). However, those with a child taking two (adjusted OR: 12.53) or three (adjusted OR: 8.29) medications, getting their refills from private health institutions apart from this hospital (adjusted OR = 7.06) and having multiple illnesses (adjusted OR = 21.25) were more likely to be not adherent to medication administration. CONCLUSION: Caregivers of chronically ill children in Malaysia generally have sufficient knowledge and an appropriate practice of medication administration at home. Yet, strategies to improve the adherence to medication administration, particularly in those who care for children with complicated health conditions, are warranted.

Development, translation, and validation of a bilingual questionnaire on unused medications in homes.

BACKGROUND: Unused medications in homes pose significant health, economic, and environmental risks. Patients are the medications end users and their knowledge, attitude, and practices (KAP) play an important role towards medication use, unuse and wastage. Thus, a valid instrument to reliably measure patients' KAP towards unused medications in homes may help manage the associated risks. OBJECTIVE: To develop, translate, and validate a questionnaire for the assessment patients' KAP towards unused medications in Qatar homes (i.e., QUM-Qatar). SETTING: This cross-sectional validation study was conducted among randomly selected outpatients visiting various public and private pharmacies in Qatar between September 2019 and February 2020. METHOD: Nine experts in the field of pharmacy practice with Qatar contextual background established the content validity of the instrument. The validity was quantified using content validity index (CVI). Furthermore, construct validity was performed using principal component analysis (PCA), whereas internal consistency reliability of items was determined using Cronbach's alpha. Statistical analyses were performed using STATA 15 statistical software. MAIN OUTCOME MEASURE: The psychometric properties of the QUM-Qatar assessment instrument. RESULTS: An English/Arabic questionnaire was developed and validated. Content validity in the form of scale-level-CVI (S-CVI)/Average and S-CVI/UA was 0.88 and 0.84, respectively, suggesting adequate relevant content of the questionnaire. Variation explained by the multivariate model was 85.0% for knowledge, 94.8% for attitude, and 89.8% for practice. Cronbach's alpha coefficients were 0.68, 0.82, and 0.84, for knowledge, attitude, and practice domains, respectively. From the psychometric results obtained, the questionnaire's validity and reliability were attained. CONCLUSION: The QUM-Qatar instrument has acceptable psychometric properties and has the potential for future use in research and practice to assess KAP towards unused medications in Qatar and elsewhere. It may consequently help in improving medication use and mitigating the negative health, economic, and environmental impacts of unused medications.Impacts on practice.•There is now a valid and reliable English/Arabic language questionnaire to assess patients' KAP towards unused medications.•Policymakers can utilize this questionnaire to develop evidence-based policies and strategies for managing unused medications and their disposal.•To improve medication use review, rational use of medicines, and adherence, it is necessary to consider patient-reported outcomes that may eventually reflect on saving health, economic resources, and environment.

Knowledge and Barriers Among Physicians Toward Adverse Drug Reaction Reporting at a Tertiary Care Hospital in Saudi Arabia.

BACKGROUND: Spontaneous reporting systems are essential as they help detect serious unknown adverse drug reaction (ADR). However, underreporting of ADR is a commonly associated problem. This research work aims to assess knowledge, barriers, and factors that encourage the reporting of ADR among physicians. METHODS: A total of 600 physicians working at a tertiary referral hospital in Riyadh, Saudi Arabia, were included in this cross-sectional study. A pretested questionnaire was used. RESULTS: Out of the 600 physicians, 240 (40%) completed the questionnaire. Most of the participants (85.4%) could correctly define ADR; nearly 75% physicians were unaware of the spontaneous reporting of ADR in Saudi Arabia. A total of 175 (72.9%) physicians had not reported any ADR among their patients in the last year; 40% of the physicians said that they did not report ADR because they were unaware of the online reporting of ADR. Providing guidelines and regular bulletins on the reporting of ADR is a critical aspect that encourages physicians to report ADR (51%). Education and training are the most recognized measures for improving the reporting of ADR. CONCLUSION: Physicians were adequately aware of ADR but inadequately aware of the reporting system and reporting authorities. Continuing medical education, training, and integration of the reporting of ADR into physicians' various clinical activities may improve ADR reporting.

Post-COVID-19 Outbreak of Severe Kawasaki-like Multisystem Inflammatory Syndrome in Children.

With the continuation of the second wave of a novel coronavirus disease (COVID-19), which is likely to be even more devastating, there are several associated health problems. COVID-19 is usually mild and non-fatal in children. However, in rare cases, children could severely be affected, and clinical manifestations may differ from adults. A multisystem inflammatory syndrome in children (MIS-C) is a rare but serious complication associated with COVID-19, initiated by an overactive immune response in kids that usually hits weeks after exposure to the COVID-19. MIS-C is a disorder in which inflammation could occur in different parts of the body. The disease puts pressure on the heart, as blood vessels leading towards the heart get inflamed and incapable of carrying adequate blood, hence producing cardiac complications in children hospitalised with MIS-C. The problem seems to be associated with COVID-19 in children; however, the association between MIS-C and COVID-19 is still unidentified. There is very little understanding of what triggers the MIS-C, which necessitates a rigorous mapping of the disease and associated risk elements for better disease management and navigating through this crisis.

Validation and clinical interpretation of the St George's respiratory questionnaire for COPD (SGRQ-C) after adaptation to Malaysian language and culture, in patients with COPD.

BACKGROUND: Cultural differences affect the administration and results of health status questionnaires. "Cross cultural adaptation" ensures retention of psychometric properties such as validity and reliability at an item and/or scale level. OBJECTIVE: To develop a Malaysian version of St George's respiratory COPD specific questionnaire (SGRQ-CM), to evaluate the full spectrum of psychometric properties (reliability, validity and responsiveness), to test the factor structure and to assess minimum clinically important difference for the SGRQ-CM, to be used in population of Malaysia. METHODOLOGY: SGRQ-C was translated to Bahasa Malaysia using a standard protocol. 240 COPD patients were included in the study. All patients were followed-up for six months. Construct validity, internal consistency, item convergent validity, test-retest ability, responsiveness, factor analysis and MCID of the Malaysian version of SGRQ-C to be used in population of Malaysia were evaluated. RESULTS: The Cronbach alpha coefficient and intraclass correlation coefficients (ICC) for SGRQ-CM were reported as 0.87, and 0.88 respectively. Correlation of SGRQ-CM with CAT, EQ-5D-5 L, mMRC dyspnea scales and FEV1%predicted were reported as 0.86, - 0.82, 0.72 and - 0.42 respectively. Correlation coefficient between the subscales and other clinical and health status measures ranged from r = - 0.35 to r = - 0.87. The MCID was reported as 5.07 (- 2.54-12.67). CONCLUSION: The Malaysian version of SGRQ-C has a good psychometric property comparable to those of the original version and has a strong evidence of validity, reliability and responsiveness towards disease severity in Malaysian COPD patients. It can be recommended as a reliable quality of life measure for future research.

Knowledge and practice of adolescent females about menstruation and menstruation hygiene visiting a public healthcare institute of Quetta, Pakistan.

BACKGROUND: The current study is aimed to assess menstruation-related knowledge and practices of adolescent females visiting a public health care institute of Quetta city, Pakistan. METHODS: A questionnaire-based cross-sectional survey was conducted. Nine hundred and twenty three female adolescents attending general out-patient departments of Mohtarma Shaheed Benazir Bhutto Hospital Quetta, Balochistan, was approached for data collection. Based on the objectives of the study, descriptive analysis was conducted and SPSS v. 21.0 was used for the data analysis. RESULTS: Demographic characteristics revealed that the mean age of the respondents was 15 years. Mothers' (67%) were the main source of menstruation-related information. Majority (77.7%) of our respondents never had a class or session regarding menstruation-related education in their schools. About (44%) knew that menstruation is a physiological phenomenon while 60.2% knew that menstrual blood comes from the vagina. Nearly 40% of our study respondents missed their schools because of menarche. The use of absorbent material was frequent (90%) among the adolescent females and (68.7%) used commercially available sanitary napkins/pads. Although majority of the respondents (58.2%) were not taking baths during menstruation, 80.5% do cleaned their genitalia with water during menstruation. CONCLUSION: Female adolescents of our study had certain misconception regarding menstruation because of poor access to health-related education. Education can be provided at healthcare facilities, residential area as well as religious centers. Adolescent reproductive health should be included in the school curriculum; this will influence general reproductive health of females.

The effect of tailored consumer medicine information on patients with type 2 diabetes mellitus: A randomised controlled interventional study.

INTRODUCTION: In patients with diabetes, better health communication is associated with better health outcomes including medication adherence and glycaemic control. The conventional patient information leaflet does not consider the cultural and behavioral perspectives of diverse patient populations. Consumer medicine information (CMI) is a written information about the prescription drugs developed by organisations or individuals other than a drug manufacturer that is intended for distribution to consumers at the time of medication dispensing. OBJECTIVE: This study aimed to evaluate the impact of CMI on medication adherence and glycaemic control among patients with type 2 diabetes in Qatar. METHODS: We developed and customised CMI for all the anti-diabetic medications used in Qatar. A randomised controlled trial in which the intervention group patients (n = 66) received the customised CMI with usual care, while the control group patients (n = 74) received usual care only, was conducted. Self-reported medication adherence and haemoglobin A1c (HbA1c ) were the primary outcome measures. Glycaemic control and medication adherence parameters were measured at baseline, 3 months, and 6 months in both groups. Medication adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). RESULTS: Although the addition of CMI resulted in better glycaemic control, this did not reach statistical significance, possibly because of the short-term follow-up. The median MMAS-8 score improved from baseline (6.6 [IQR = 1.5]) to 6-month follow-up (7.0 [IQR = 1.00]) in the intervention group. In addition, there was a statistically significant difference between the intervention and the control groups in terms of MMAS-8 score at the third visit (7.0 [IQR = 1.0]) vs 6.5 (IQR = 1.25; P-value = .010). CONCLUSION: CMI for anti-diabetic medications when added to usual care has the potential to improve medication adherence and glycaemic control among patients with type 2 diabetes. Therefore, providing better health communication and CMI to patients with diabetes is recommended.

Effect of smoking on treatment outcome among tuberculosis patients in Malaysia; a multicenter study.

BACKGROUND: Smoking plays a key role in the development of tuberculosis (TB) infection and is also a predictor of poor TB treatment prognosis and outcomes. The current study was conducted to determine the prevalence of smoking and to assess the effects of smoking on treatment outcomes among TB patients. METHODS: A multi-center retrospective study design was used to collect data from TB patients in four different states of Malaysia, namely Penang, Sabah, Sarawak, and Selangor. The study included medical records of TB patients admitted to the selected hospitals in the period from January 2006 to March 2009. Medical records with incomplete data were not included. Patient demographics and clinical data were collected using a validated data collection form. RESULTS: Of all patients with TB (9337), the prevalence of smokers was 4313 (46.2%). Among smokers, 3584 (83.1%) were associated with pulmonary TB, while 729 (16.9%) were associated with extrapulmonary TB. Male gender (OR = 1.43, 95% CI 1.30-1.58), Chinese ethnicity (OR = 1.23, 95% CI 1.02-1.49), Sarawak indigenous ethnicity (OR = 0.74, 95% CI 0.58-0.95), urban residents (OR = 1.46, 95% CI 1.33-1.61), employed individuals (OR = 1.21, 95% CI 1.09-1.34), alcoholics (OR = 4.91, 95% CI 4.04-5.96), drug abusers (OR = 7.43, 95% CI 5.70-9.60) and presence of co-morbid condition (OR = 1.27, 95% CI 1.16-1.40) all showed significant association with smoking habits. This study found that 3236 (75.0%) patients were successfully treated in the smokers' group, while 4004 (79.7%) patients were non-smokers. The proportion of deaths (6.6%, n = 283), defaulters (6.6%, n = 284) and treatment interruptions (4.7%, n = 204) was higher in the smokers' group. CONCLUSIONS: Smoking has a strong influence on TB and is a major barrier towards treatment success (OR = 0.76, 95% CI 0.69-0.84, p < 0.001). Therefore, the findings indicate that smoking cessations are an effective way to decrease treatment failure and drug resistance.

Development and validation of the General Rehabilitation Adherence Scale (GRAS) in patients attending physical therapy clinics for musculoskeletal disorders.

BACKGROUND: Non-adherence to physical therapy ranges from 14 to 70%. This could adversely affect physical functioning and requires careful monitoring. Studies that describe designing and validation of adherence measuring scales are scant. There is a growing need to formulate adherence measures for this population. The aim was to develop and validate a novel tool named as the General Rehabilitation Adherence Scale (GRAS) to measure adherence to physical therapy treatment in Pakistani patients attending rehabilitation clinics for musculoskeletal disorders. METHODS: A month-long study was conducted in patients attending physical therapy sessions at clinics in two tertiary care hospitals in Karachi, Pakistan. It was done using block randomization technique. Sample size was calculated based on item-to-respondent ratio of 1:20. The GRAS was developed and validated using content validity, factor analyses, known group validity, and sensitivity analysis. Receiver operator curve analysis was used to determine cut-off value. Reliability and internal consistency were measured using test-retest method. Data was analyzed through IBM SPSS version 23. The study was ethically approved (IRB-NOV:15). RESULTS: A total of 300 responses were gathered. The response rate was 92%. The final version of GRAS contained 8 items and had a content validity index of 0.89. Sampling adequacy was satisfactory, (KMO 0.7, Bartlett's test p-value< 0.01). Exploratory factor analysis revealed a 3-factor model that was fixed and confirmed at a 2-factor model. Incremental fit indices, i.e., normed fit index, comparative fit index and Tucker Lewis index, were reported > 0.95 while absolute fit index of root mean square of error of approximation was < 0.03. These values indicated a good model fit. The value for Cronbach (α) was 0.63 while it was 0.77 for McDonald's (ω), i.e., acceptable. Test-retest reliability coefficient was 0.88, p < 0.01. Education level was observed to affect adherence (p < 0.01). A cut-off value of 12 was identified. The sensitivity and accuracy of the scale was 95%, and its specificity was 91%. CONCLUSION: The scale was validated in this study with satisfactory results. The availability of this tool would enhance monitoring for adherence as well as help clinicians and therapists address potential areas that may act as determinants of non-adherence.

Medication Management Program: Adherence, Disease-related Knowledge, Health-related Quality of Life, and Glycemic Control for Type 2 Diabetes Mellitus.

CONTEXT: Escalation in rates of diabetes in Pakistan is posing threats to the economy and to the people's quality of life due to poor glycemic control and very high rates of complications. Cost of care is very high, and many barriers to quality care exist. Most often patients are unable to afford the high cost of treatment. Patients' knowledge about diabetes is associated with better medication adherence and better glycemic control. OBJECTIVE: The current study intended to evaluate the effects of an educational intervention in a pharmacist led, medication management program (MTM) tailored for patients with type 2 diabetes (T2DM). DESIGN: The research team conducted a nonclinical, randomized controlled trial. SETTING: The study took place at District Headquarters and Teaching Hospital, a public-sector hospital (Sargodha, Pakistan). PARTICIPANTS: Participants were 392 individuals with T2DM. INTERVENTION: Participants were randomly assigned to one of 2 groups-intervention and control-with 196 patients in each. The intervention group, instead of receiving standard care, received pharmaceutical care through the Medication Therapy Management program, whereas the control group received standard care. OUTCOME MEASURES: At baseline and 3 mo post ntervention, the study assessed participants' diabetes-related knowledge, medication adherence, and health-related quality of life (HRQoL) using the 14-item Michigan Diabetes Knowledge Test, the 8-item Morisky Medication Adherence Scale, and the European Quality of Life scales, respectively. To determine glycemic control, participants' baseline HbA1c levels were taken from their medical records, and the final HbA1c result was obtained postintervention. RESULTS: For the intervention and control groups at baseline, diabetes-related knowledge was average, at 7.99 ± 2.65 and 8.03 ± 2.49, respectively; medication adherence was low, at 4.54 ± 1.69 and 4.41 ± 1.84, respectively; and glycemic control was poor, at 9.47 ± 1.57 and 9.41 ± 1.57, respectively. After the educational intervention, the intervention group had increased its diabetes-related knowledge, medication adherence, and HRQoL scores, with the results being 10.55 ± 2.56, 5.24 ± 1.48, and 0.6115 ± 0.286, respectively. The group's glycemic control has also improved to 8.97 ± 1.362. A statistically significant difference between the groups had occurred, with P < .001. The control group's scores had remained approximately the same for medication adherence, HRQoL, and glycemic control, and little difference had occurred as compared with the group's baseline analysis. CONCLUSION: The study found that the educational program increased the intervention group's level of diabetes-related knowledge, and improved its adherence to medication and its glycemic control, all due to its improved HRQoL. Patients' beliefs about the effects of long-term use of medicines were also addressed by the MTM program. The program was successful because it decreased participants' HbA1c values, which is a positive indicator of successful T2DM therapy.

Translation and validation of the Arabic version of the General Medication Adherence Scale (GMAS) in Saudi patients with chronic illnesses.

PURPOSE: The study aimed to translate and validate the Arabic version of General Medication Adherence Scale (GMAS) in Saudi patients with chronic diseases. METHODS: A multi-center cross sectional study was conducted for a month in out-patient wards of hospitals in Khobar, Dammam, Makkah, and Madinah, Saudi Arabia. Patients were randomly selected from a registered patient pools at hospitals and the item-subject ratio was kept at 1:20. The tool was assessed for factorial, construct, convergent, known group and predictive validities as well as, reliability and internal consistency of scale were also evaluated. Sensitivity, specificity, and accuracy were also evaluated. Data were analyzed using SPSS v24 and MedCalc v19.2. The study was approved by concerned ethics committees (IRB-129-25/6/1439) and (IRB-2019-05-002). RESULTS: A total of 282 responses were received. The values for normed fit index (NFI), comparative fit index (CFI), Tucker Lewis index (TLI) and incremental fit index (IFI) were 0.960, 0.979, 0.954 and 0.980. All values were >0.95. The value for root mean square error of approximation (RMSEA) was 0.059, i.e., <0.06. Hence, factorial validity was established. The average factor loading of the scale was 0.725, i.e., >0.7, that established convergent validity. Known group validity was established by obtaining significant p-value <0.05, for the associations based on hypotheses. Cronbach's α was 0.865, i.e., >0.7. Predictive validity was established by evaluating odds ratios (OR) of demographic factors with adherence score using logistic regression. Sensitivity was 78.16%, specificity was 76.85% and, accuracy of the tool was 77.66%, i.e., >70%. CONCLUSION: The Arabic version of GMAS achieved all required statistical parameters and was validated in Saudi patients with chronic diseases.

Evaluation of Antimicrobial Stewardship Programs (ASPs) and their perceived level of success at Makkah region hospitals, Kingdom of Saudi Arabia.

Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. The general administration of pharmaceutical care in the Saudi ministry of health (MOH) is putting outstanding efforts in implementing antimicrobial stewardship in Saudi health care settings. Several surveys have been conducted globally and reported many types of antimicrobial stewardship strategies in health institutions and their effectiveness. This study aims to identify ASPs in Makkah region hospitals and their perceived level of success. We administered a regional survey to explore current progress and issues related to the implementation of ASPs in Makkah region hospitals at the pharmacy level (n = 25). Among responding hospitals, 19 (76%) hospitals, the most commonly reported ASP were as following: formulary restrictions (90%) for broad-spectrum antimicrobials and use of prospective feedback on antimicrobial prescribing (68%), use of clinical guidelines and pathways (100%), and use of automatic stop orders (68%) to limit inappropriate antimicrobial therapy. The study outcomes will also be of pivotal importance to devise policies and strategies for antimicrobial stewardship implementation in other non-MOH settings in the Makkah region. Based on our results, all reported institutions have at least one antimicrobial stewardship program in a process with a high success rate. A multidisciplinary ASP approach, active involvement of drug & therapeutic committee, formulary restrictions, and availability of education & training of pharmacists and physicians on ASP are the primary elements for perceived successful antimicrobial stewardship programs in the Makkah region hospitals.

Medication Safety at Home: A Qualitative Study on Caregivers of Chronically Ill Children in Malaysia.

Introduction: Medication errors are more likely to occur in chronically ill children, who are highly dependent on caregivers for medication administration. This study aimed to explore the issues related to medication safety among pediatric outpatients in Malaysia from the caregivers' perspective. Methods: This was a qualitative study conducted between May and June 2018 at a pediatric clinic of a regional referral hospital. Caregivers of children who (1) were under 6 years of age and (2) had hypothyroidism, epilepsy, thalassemia, asthma, or other chronic diseases were recruited via purposive sampling. Each selected disease was represented by at least 3 caregivers, who were identified from the medical records of their children. Face-to-face interviews were conducted with each of them, facilitated by a semi-structured interview guide. All the interviews were audio-recorded, transcribed verbatim, and analyzed using the thematic analysis approach. Results: A total of 15 mothers with a median age of 34 years were interviewed. Three themes emerged from the interviews: (I) actual experiences with medication errors, (II) underlying risk factors for medication errors, and (III) recommendations to improve medication safety. Several cases of administration errors, including missed doses and self-decided dose adjustment, were detected. Furthermore, the caregivers were found to have inadequate understanding of the medications in general. Conclusions: While children were shown to be consistently exposed to medication errors at home in Malaysia, the recommendations of the caregivers, including the use of written instructions and a diary, could be effective strategies to improve the out-of-hospital medication safety in children.

A cross sectional study on assessing the knowledge, attitude and perception towards allergic reactions of paracetamol in Malaysia.

Recent years, the prevalence of paracetamol allergy becomes great concerns. However, data on knowledge, attitude and perception towards allergic reactions of paracetamol are lacking. This study aimed to investigate knowledge, attitude, and perception towards allergic reactions of paracetamol (KAP-ARP). A cross-sectional survey was conducted using a validated self-administered questionnaire around Pasar Siti Khadijah, Kelantan from February 2016 to January 2017 among the general population. A total of 177 respondents participated in this study. The mean percentage scores for knowledge, attitude and perception towards allergic reactions of paracetamol were 31.7% (SD 23.6), 53.1% (SD 19.2) and 53.3% (SD 23.9), respectively. This study revealed that respondents demonstrated a poor level of knowledge, a fair level of attitude and negative perception towards allergic reactions of paracetamol. These results may lay a basis for conducting a study of knowledge, attitude and perception towards allergic reactions among general population in other different setting or around Malaysia.

It is time to change the way we manage mild asthma: an update in GINA 2019.

Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation. Although evidence-based treatments are available in most countries, asthma control remains suboptimal, and asthma-related deaths continue to be an ongoing concern. Generally, it is believed that between 50 to 75% of patients with asthma can be considered as having mild asthma.Previous versions of Global Initiative for Asthma (GINA) suggested that mild asthma in adults can be well managed with either reliever medications, for example, short-acting beta2 agonists (SABA) alone or with the additional use of controllers such as regular low-dose inhaled corticosteroids (ICS). Given the low frequency or non-bothersome nature of symptoms in mild asthma, patients' adherence towards their controller medications, especially to ICS is usually not satisfactory. Such patients often rely on SABA alone to relieve symptoms, which may contribute to SABA over-reliance. Overuse of relievers such as SABAs has been associated with poor asthma outcomes, such as exacerbations and even deaths. The new GINA 2019 asthma treatment recommendations represent significant shifts in asthma management at Steps 1 and 2 of the 5 treatment steps. The report acknowledges an emerging body of evidence suggesting the non-safety of SABAs overuse in the absence of concomitant controller medications, therefore does not support SABA-only therapy in mild asthma and has included new off-label recommendations such as symptom-driven (as-needed) low dose ICS-formoterol and "low dose ICS taken whenever SABA is taken".The GINA 2019 report highlights significant updates in mild asthma management and these recommendations represent a clear deviation from decades of clinical practice mandating the use of symptom-driven SABA treatment alone in those with mild asthma. While the new inclusions of strategies such as symptom-driven (as-needed) ICS-formoterol and "ICS taken whenever SABA is taken" are based on several key trials, data in this context are still only emergent data, with clear superiority of as needed ICS-formoterol combinations over maintenance ICS regimens yet to be established for valid endpoints. Nevertheless, current and emerging data position the clinical asthma realm at a watershed moment with imminent changes for the way we manage mild asthma likely in going forward.

Treatment outcomes and risk factors of extra-pulmonary tuberculosis in patients with co-morbidities.

BACKGROUND: Extra-pulmonary tuberculosis (EPTB) represents about 14% of all cases of tuberculosis (TB) in Malaysia. The aims of the study include evaluation of socio-demographic factors, clinical manifestations, co-morbidities among patients with EPTB and their treatment outcomes. METHODS: A retrospective study was conducted to recognize the epidemiology facts of EPTB. Individual data for EPTB patients were collected from TB registers, laboratory TB registers, treatment cards and TB medical personal files into a standardized study questionnaire. Crude (COR) and adjusted odds ratios (AOR) and 95% confidence intervals (CI) were determined to assess the risk factors for EPTB and unsuccessful treatment outcomes. RESULTS: There were 1222 EPTB patients presenting 13.1% of all TB cases during 2006-2008. Pleural effusion and lymph node TB were the most frequent types and accounted for 45.1% of all EPTB cases among study participants. Treatment success rate was 67.6%. The best treatment completion rates were found in children ≤15 years (0.478 [0.231-1.028]; p = 0.05). On multivariate analysis, age group 56-65 years (1.658 [1.157-2.376]; p = 0.006), relapse cases (7.078 [1.585-31.613]; p = 0.010), EPTB-DM (1.773 [1.165-2.698]; p = 0.008), patients with no formal (2.266 [1.254-4.095]; p = 0.001) and secondary level of education (1.889 [1.085-3.288]; p = 0.025) were recorded as statistically positive significant risk factors for unsuccessful treatment outcomes. Patients at the risk of EPTB were more likely to be females (1.524 [1.311-1.746]; p <  0.001), Malays (1.251 [1.056-1.482]; p = 0.010) and Indians (1.450 [1.142-1.842]; p = 0.002), TB-HIV (3.215 [2.347-4.405]; p <  0.001), EPDM-HIV (4.361 [1.657-11.474]; p = 0.003), EPTB-HIV-HEP (4.083 [2.785-5.987]; p <  0.001), those living in urban areas (1.272 [1.109-1.459]; p = 0.001) and no formal education (1.361 [1.018-1.820]; p = 0.037). CONCLUSION: The findings of this study extend the knowledge of EPTB epidemiology and highlight the need for improved EPTB detection in Malaysia, especially in subpopulations with high risk for EPTB and unsuccessful treatment outcomes.