Theses (Master Of Pharmacy Practice)

Background: Vancomycin, is a first-line therapy for late-onset neonatal sepsis. Limited information on renal elimination and the immediate and long-term adverse effects of vancomycin in premature neonate is available. Objectives: To evaluate the renal elimination of vancomycin and the immediate and long-term vancomycin-associated adverse effect in infants receiving vancomycin for neonatal sepsis during a 4-year follow-up period in UMMC. Methods: This study comprises of retrospective and prospective data collection. In the retrospective study, all neonatal patients with a gestational age of 34 weeks or below, receiving intravenous vancomycin were reviewed between November 2012 to December 2014. The risk and incidence of nephrotoxicity, ototoxicity, and the growth development of the study subjects were recorded and analysed. As for the prospective study, urine samples from premature neonates receiving vancomycin therapy were collected and serum creatinine and vancomycin concentration were measured and analysed. Results: Only 14.3% out of 42 study subjects were found to have vancomycin trough level of more than 20 mg/L. Nephrotoxicity was defined using KDIGO and 33% of study subjects met the criteria. Ototoxicity was not discovered in patient’s receiving vancomycin. As for the growth development, most patients were documented to be underweight. In regards with the renal elimination of vancomycin and creatinine, the average amount of vancomycin per hour and concentration of creatinine excreted was 4.09 ± 10.295 mg and 241.056 ± 166.336 μmol/L respectively. Conclusion: The use of vancomycin in premature neonates correlates with nephrotoxicity. Ototoxicity was not observed in the patients. However, monitoring of serum vancomycin levels are routinely done to ensure safe dosing. Premature neonates in this study turn out to be underweight in their infant years, thus their growth development and quality of life may be negatively impacted during adolescence and adulthood. Keywords: Vancomycin; renal elimination; nephrotoxicity; premature neonates

Objective: This systematic review aimed to determine the analgesic efficacy and safety of transdermal fentanyl patch as compared to other opioid therapy or placebo in pain management among the patients from different medical condition. Methods: 30 studies (22 randomised controlled trials and eight observational studies) were included for data synthesis, after searching and screening through PubMed, Excerpta Medica database (Embase), International Pharmaceutical Abstracts (IPA), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Turning Research into Practice (TRiP) databases. Two authors independently screened the articles and assessed the quality of the studies. SIGN checklist and Cochrane Collaboration’s tool were applied to assess the risk of bias in observational and randomized controlled studies. Data on study background, interventions, outcomes measured and outcomes were synthesized into table forms. Results: Pain scores, adverse events and addiction risks were the primary outcomes in this systematic review. Transdermal fentanyl patch showed significant improvement in terms of pain scores when compared to placebo. When fentanyl patch was compared to other opioid treatment, the results were mostly comparable. In terms of adverse events, fentanyl patch and opioid treatment shared similar incidence adverse events with no significant difference. Conclusions: Transdermal fentanyl patch improved pain scores significantly compared to placebo while the opioid efficacy and safety were similar when compared with other opioid therapies. Other than that, the adverse events reported in fentanyl patch group has no statistical significant difference as compared to other opioid treatment. This result showed that transdermal fentanyl patches could be use as an alternative treatment in patients with moderate-to-severe chronic pain and who prefer non-invasive route of administration and much less frequent dosing. However, the outcome on addiction risk is limited.

Background: The optimal duration of dual antiplatelet (DAPT) after the implantation of drug-eluting stents (DES) remains uncertain, as the randomized controlled trials (RCTs) available were inadequate to detect a significant difference in reducing risk of major adverse cardiac events (MACE). The AHA/ACC guideline has recommended 12 months while European guideline suggested 6 months of DAPT. Objectives: This meta-analysis aims to compare the efficacy and safety of four different durations of DAPT, from 3 months (VSDAPT), 6 months (SDAPT), 12 months (LDAPT) to ≥12 months (EDAPT), after the implantation of DES by performing an individual patient data pairwise and network meta-analysis. Methods: Electronic databases such as The Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were used to identify relevant randomized controlled trials. Our primary endpoint was MACE (Major Adverse Cardiovascular Events), which was defined as all death, myocardial infarction, stroke and any revascularization. Safety outcome measured were major bleeding. Relative risk (RR) and 95% confidence interval (CI) were used to determine random-effect and fixed models. Surface area under the cumulative ranking (SUCRA) was also performed to identify the rank the durations by its efficacy. Results: We identified 13 RCTs with a total of 30,901 participants. Compared to LDAPT, EDAPT significantly reduces the risk of myocardial infarction (RR: 0.55, 95% CI: 0.39 to 0.79) but increases the risk of major bleeding concurrently (RR: 1.72, 95% CI: 1.36 to 2.19). In summary, longer DAPT significantly reduces the risk of myocardial infarction (RR: 0.75, 95% CI: 0.62 to 0.91), stent thrombosis (RR: 0.61, 95% CI: 0.40 to 0.92), non-cardiovascular related death (RR: 1.31, 95% CI: 1.02 to 1.68) and MACE (RR: 0.90, 95% CI: 0.82 to 0.99) but similarly increases the risk of major bleeding (RR: 1.60, 95% CI: 1.31 to 1.97) when compared to shorter DAPT. Conclusion: Compared with shorter DAPT, longer DAPT significantly reduces the risk of myocardial infarction, stent thrombosis, non-cardiovascular related death and MACE but comes with a price of a higher major bleeding rate. However, EDAPT was only seen to be beneficial in reducing risk of myocardial infarction. Thus, EDAPT may be favourable in patients with a higher risk of ischemic events and a lower risk of bleeding. Moreover, VSDAPT/SDAPT were non-inferior to LDAPT in any primary endpoint outcomes but also with an increased risk of major bleeding. Therefore, the portfolio of each individual should be taken into consideration during decision-making. Keywords: Dual antiplatelet therapy, drug-eluting stents, network meta-analysis, aspirin, clopidogrel

Introduction: Acute burn wound involves complex injury and will cause systemic consequences if it is not managed well. There are a variety of dressings available in the market and the main goal of burn management is to promote healing. Selection of dressing for partial thickness burn (PTB) often causes a dilemma in healthcare professional as there are many factors which are needed to be considered besides healing rate. Objectives: To compare the effectiveness of traditional wound dressing versus advanced wound dressing in PTB. Methods: Relevant studies were identified by authors from an electronic database. We restricted the language to English publications. The electronic database search was done on 1st April 2018. We selected only randomized controlled trials (RCT) assessing the effectiveness of burn wound dressings in partial thickness burn. Data were extracted and risk of bias of each study was assessed by an investigator and then verified by another author. Analyses were done using software of RevMan 5.3. Results: Fifteen RCTs were included in this review, which includes a total of 726 wounds. Our analysis showed that burn wounds with advanced wound dressing had 3.35 day faster (CI -5.50 to -2.35) healing time compared with burn wounds on traditional dressing, although a substantial heterogeneity was observed. Wounds that applied advanced dressing appeared to. However, this analysis showed that there was no significant difference (P=0.94) in the frequency of wound infection (RR 1.05 with CI 0.29 to 3.62) between patients on the advanced and traditional wound dressing. Conclusion: Advanced wound dressing was shown to be superior in terms of wound healing time, but not in wound infection rate. However, this statement is limited by non-standardization of method part and risk of bias within studies and unexplained heterogeneity.

Background Stroke is the second leading cause of death and it contributes tremendous burden to the society in terms of mortality, morbidity and costs globally. Non-cardioembolic ischaemic stroke accounts for 80% of the ischaemic stroke events. Antiplatelet therapies (APTs) remained the first-line treatment modality for the secondary prevention of stroke. However, randomised controlled trials (RCTs) have demonstrated that oral anticoagulants (ACs) could also be effective for the secondary prevention of stroke. There is no network meta-analysis, comparative efficacy and safety of ACs and APTs together for the secondary prevention of stroke. Hence, the primary objective of this study is to evaluate the comparative effectiveness and safety of different ACs and anti-platelets (monotherapy or combination) for the secondary prevention of stroke in patients with a history of non-cardioembolic ischaemic stroke or transient ischaemic attack (TIA). Methods This systematic review combined pairwise and network meta-analysis of RCTs to analyse the efficacy and safety of ACs and APTs (monotherapy or combination) for the secondary prevention of stroke in patients following either non-cardioembolic stroke or TIA. The primary outcome was the occurrence of recurrent stroke while the safety outcome was an event of major bleeding. Secondary outcomes were all-cause mortality, major cardiovascular events and the occurrence of myocardial infarction. A random-effects network meta-analysis was performed. The relative ranking of interventions was assessed by the surface under the cumulative ranking (SUCRA) probability curve. A higher SUCRA rank (0 to 1) denotes that the intervention is more effective and safer as compared to other candidate interventions. Further subgroup analysis based on different dosing regimens of aspirin was also performed. Results Fifty-two trials with approximately 127,130 participants comparing 16 interventions were selected for analysis. In the primary analysis, all interventions except for vorapaxar statistically significantly reduced the incidence of recurrent stroke compared to placebo. Cilostazol was ranked as the best treatment modality for preventing recurrent stroke (RR: 0.55, 95%CI, 0.44-0.68; SUCRA: 0.94), followed by aspirin-clopidogrel combination (RR: 0.64, 95%CI, 0.54-0.74; SUCRA: 0.82), AC (RR: 0.66, 95%CI 0.51-0.86, SUCRA: 0.72) and aspirin-extended release Dipyridamole combination (RR: 0.69, 95%CI 0.61-0.78, SUCRA: 0.66). For major bleeding events, no intervention demonstrated a statistical significant effect. Network meta-analyses of secondary outcomes demonstrated that aspirin-extended release dipyridamole combination reduced all-cause mortality (RR: 0.83; 95%CI, 0.72-0.96, SUCRA: 0.96), CVD deaths (RR: 0.69, 95%CI, 0.56-0.85, SUCRA: 0.83) and myocardial infarction (RR: 0.66, 95%CI, 0.52-0.84, SUCRA: 0.80) compared to placebo. Overall, the results were robust to the changes in sensitivity analyses and cilostazol remained superior to the other interventions. Subgroup analysis based on different doses of aspirin demonstrated that the very low dose aspirin-clopidogrel combination (RR: 0.62, 95%CI, 0.46-0.84, SUCRA: 0.76) and low dose aspirinclopidogrel combination (RR: 0.63, 95%CI, 0.44-0.90, SUCRA: 0.73) demonstrated the highest probability of being best after cilostazol (RR: 0.55, 95%CI, 0.40-0.78, SUCRA: 0.86) for the efficacy outcome. Conclusion Cilostazol is the most effective and safe intervention for the secondary prevention of stroke in patients with prior non-cardioembolic ischaemic stroke or TIA. However, considering the overall benefit in terms of mortality, aspirin-extended release dipyridamole combination could be the preferred treatment in patients with previous non-cardioembolic stroke or TIA.

Introduction: Zika, infection, which is a mosquito-borne virus of which unknown to many until this present day and now the focus of serious warnings from the World Health Organization (WHO) and the Center for Disease and Control and Prevention which declare the virus outbreak a Public Health Emergency of International Concern (PHEIC). Zika virus does not limit only through vector-borne transmission. It can also be through sexual and feto-maternal transmission. Currently, there is no antiviral treatment or vaccine available for Zika virus infection. Preventive strategies were an option. This study aimed to assess awareness, attitudes and perception of women towards Zika virus and their acceptance of Zika vaccine once it will be made available. Methods: A descriptive cross-sectional study was conducted with 516 women aged 18 to over 35 years old in Cebu City Philippines. A validated and pre-tested questionnaire was utilized in this study self-administered to the respondents. Data collected and SPSS was utilized for simple qualitative analysis. Results: Most respondents were 18-24 years old who never had pregnancy before. Awareness about Zika is low, have heard ofit, but don’t know much about Zika virus infection and only know a little about it. Subjects were not sure if they were living in or been travelling to places with Zika. However, knowledge about the transmission of Zika is quite high. Seventy six percent thought transmission through a bite of a mosquito. Attitudes of women were significantly associated with Zika virus and precautionary measures were thought out as well as preventive strategies considered as not at all hard. Respondents express that development of Zika vaccine is vital and substantially associated with the willingness to get vaccinated. Conclusion: Regardless of socioeconomic status, there were gaps on the level of awareness and knowledge towards Zika virus infection. Respondents had a low level of awareness how the Zika virus can be transmitted other than through mosquito bites. Consider preventive measures to prevent the infection and their willingness to accept Zika vaccine once a safe and effective be available. Keywords: Zika virus infection, Awareness, Attitudes, Perception, Vaccination

Introduction: Diabetes is one of the main public health concerns in Malaysia as uncontrolled diabetes is closely associated with increased macro and microvascular complications as well as premature and preventable mortality. Good glycemic control remains a problem for patients despite the introduction of innovative pharmacological treatment options. Other factors may play a role in maintaining good glycemic control. Objectives: The aim of this study was to identify factors that affect the glycemic control in T2DM patients. Methodology: A cross-sectional study design was used, and the study was conducted in Johor Bahru, Johor. Patients were recruited using convenient sampling method and a total of 270 patients were included. Data was collected by face-to-face interview and knowledge were assessed using Diabetes Knowledge Test developed and used by the diabetic MTAC clinic, MOH, Malaysia. Fasting blood sugar (FBS) and glycated hemoglobin (HbA1c) values were determined to assess the glycemic control. Statistical analysis was done using SPSS version 22.0. Findings are indicated in proportion with 5% significance level and 95% confidence level. Results: 47.8% of the patients achieved glycemic target and 52.2% of patients did not achieve target. Factors affecting the glycemic control significantly were level of education, monthly income, duration of diabetes, whether patients on insulin or not, correct consumption of medicines and level of knowledge. Conclusion: Majority of patients are still not well controlled in terms of their blood glucose. This study identified the modifiable factors which might help health care professionals to develop a care plan aiming to help patients achieve their glycemic target. Keywords: Glycemic control, Glycated Hb, Fasting blood glucose, Type 2 Diabetes Mellitus

Introduction The extent to which the community pharmacist contribute in patient counselling and health education is unclear. The purpose of this study was to derive an accurate and account of community pharmacist, activities and health education services to words the role of community pharmacist in patient counselling and health education services in type 2 diabetes mellitus patients. Secondly to identify the barriers involved in the process of health education services. Methods A descriptive, cross-sectional study was conducted in Klang valley involving 254 community pharmacists. Data collection was done by self-administrated questionnaire. As descriptive statistics were used for characteristics of the respondents and the response for each question by reporting frequency and percentages. The association between two categorical variables was examined using Pearson’s chi-square test. Results Out of 254 participants, Majority of pharmacist were females 163 (64.2%), Chinese ethnicity 218 (85.8%) and highest educational qualification possess was bachelor’s degree 211 (83.1%). Most of the pharmacists attended to counsel patients mainly on diabetic diet 252 (99.2%), diet management 249 (98.0%), timing and administration of medication 245 (96.5%), weight control 242 (95.3%), symptoms and treatment of hypoglycaemia 236 (92.9%) and foot care 205 (80.7%). Pharmacist has identified the common concerns of diabetic patients were retinopathy 248 (97.7%) and nephropathy 246 (96.9%). As from pharmacist’s perspective, priority should be given mostly on diet 129 (50.8%) and compliance 113 (44.5%) to improve patient knowledge on diabetic management. Conclusion The findings suggest the community pharmacist professionals performing in diabetic health education services is appropriate especially in lifestyle relating counselling activities. The most common barriers identified by community pharmacist were cost, diet and side effect. training is required to equip pharmacist to deliver these services effectively furthermore the role in diabetic care are recommended.

INTRODUCTION Adverse drug reaction, being one of the contributing causes of morbidity and mortality worldwide, continues to pose a threat to the general public as medications are being utilized for the treatment of various diseases. Spontaneous reporting systems (SRS) remains one of the most effective strategies for gathering post- marketing data on drug safety. However, as evident by numerous studies, spontaneous reporting systems are plagued with under-reporting by healthcare professionals. This study was conducted among hospital pharmacists in a tertiary healthcare setting to examine their knowledge, attitude and practice on pharmacovigilance and ADR reporting before and after an educational intervention. METHODS This was a pre- post interventional study. Participants were equally divided into two groups: a test group that received educational training intervention; and a control group that did not receive any training. The knowledge, attitudes and practice of pharmacovigilance and ADR reporting amongst the hospital pharmacists were assessed based on pretested questionnaire administered before and 1st, 3rd and 5th week after the intervention. The survey instrument was a modified version of similar studies conducted both locally and internationally done previously. RESULTS A total of 40 hospital pharmacists were involved in the study. At baseline, the difference of mean score between control and test group is considered to be infinitesimal (Control: 10.60 ± 1.39, Test: 11.65 ± 1.46). The mean ± SD of the total knowledge scores in the test group participants after the educational intervention significantly increased to 17.90 ± 0.91 (Week 1), 18.30 ± 0.87 (Week 2) and 18.60 ± 0.60 (Week 3) respectively compared to control group (Week 1: 12.40 ± 1.67, Week 3: 12.20 ± 2.07 and Week 5: 12.50 ± 1.82 . As for the ‘Attitude’ and ‘Practice’ aspects of the study material, both group of participants portrayed a positive attitude and practice when they are confronted with an adverse drug reaction, however, the test group participants have indeed showed a much significant positive response compared to control group following the educational intervention. CONCLUSION Educational intervention has an influential role in improving hospital pharmacists’ knowledge, attitude and practice on pharmacovigilance and ADR reporting. Hence, to improve the quantity and quality of ADR reporting, workshops and Continuous Pharmaceutical Development (CPD)programs need to be conducted in a timely manner. Keywords: Hospital pharmacist, adverse drug reaction reporting, educational intervention, knowledge, attitude and practices

Unwanted teen pregnancy is a serious social problem in Malaysia. Community pharmacists may play a vital role in advising teenagers on contraception. The aim of this study was to assess the knowledge, attitude, and practice of emergency contraception (EC) among teenagers among Malaysian community pharmacists. Methods A 33-item survey was conducted using Google form on fully or provisionally registered community pharmacists throughout Malaysia. The demographic, educational and professional characteristics of these pharmacist were recorded, and the scores of the various study components of the questionnaire between different groups were compared. Results A total of 311 community pharmacists completed the survey, and the response rate was 61% (311/510). In our survey, 90% of participants rated themselves to have good EC knowledge, however, only 66% of respondents showed having adequate EC knowledge in answering the knowledge questions. The two main barriers for EC supply are the concerns about safety or efficacy of EC and the possibility of discouraging regular oral contraceptives. Those aged above 30 years, male sex, owners of a community pharmacy, longer working experience, and members of a pharmacy professional organization have a significantly higher knowledge score than those who were not. There was no significant differences in knowledge scores and attitude scores between fully registered pharmacists and provisionally registered pharmacists. But statistically significant difference in the perceived barriers was noted between these two groups. Conclusion The present study shows that community pharmacists in Malaysia generally lack in knowledge of EC. Efforts should be directed at promoting knowledge in EC among community pharmacists through ongoing professional development or training courses and ongoing education programmes so that they are more prepared to advice customers especially teenagers on EC. Keywords: emergency contraceptive, teenagers, knowledge, attitude, barriers, unwanted teenage pregnancy, morning after pills

Introduction In Malaysia, healthcare consumers often receive free pharmacist professional services (PPS) such as point-of-care testing (POCT), blood pressure monitoring, medication review and smoking cessation consultation without purchasing pharmaceutical products. Examples of POCT are blood glucose and lipid profile checking. Altruistic behavior of community pharmacists posed financial constraints to pharmacists and pharmacies to sustain PPS. Remuneration can aid sustainable PPS service. Therefore, it is vital to identify the drivers influencing healthcare consumers’ willingness to pay (WTP) for PPS. Objective PPS has posed financial burden to community pharmacists who constantly provide PPS out of altruism. Sustainability and provision of PPS will be challenged if no proper compensation scheme is implemented to community pharmacists. Hence, this study aims to identify if and how much a healthcare consumer is willing to pay for different types of PPS and to explore the factors influencing their WTP for PPS. Methods A qualitative approach using combination of purposive and convenience sampling methods was engaged in recruitment of healthcare consumers to participate in semi-structured individual interviews. A total of 20 semi-structured interviews were conducted from May 2019 to July 2019. All interviews were audio-recorded and transcribed verbatim. NVivo 10 was employed to facilitate the thematic analysis. Results Majority of participants were willing to pay RM 10 to RM 50 for dispensing, medication review and smoking cessation services. Four major themes were established: (1) Perceived trustworthiness of the pharmacists, (2) Consumer’s individual motivation, (3) Quality of PPS, and (4) Attractiveness of pharmacy stores. The primary factor influencing WTP for PPS is consumer’s individual motivation which comprises of several sub-themes, including perceived need and value of PPS, complexity of consumers’ conditions, “financial commitment” as the motivator and consumers’ characteristics. Nevertheless, some participants were not willing to pay because they perceived it was pharmacist’s role to provide the PPS. Conclusion This qualitative research offers better insights to community pharmacists on the drivers influencing healthcare consumers’ WTP for PPS. Keywords: Pharmacists; Willingness to pay; Pharmacist professional services; Healthcare consumers; Qualitative research; Malaysia

Background: Recent studies have reported on-time antiretroviral (ART) drug pick-up, the fourth Early Warning Indicator (EWI) described by World Health Organization (WHO) to be the strongest predictor of clinic-level viral load suppression. The primary objective of this study was to assess the impact of pharmacist counselling at the point of late ART refill and identify modifiable predictors for refill non-adherence. Methods: A cross sectional study was conducted among 691 Malaysian HIV-infected individuals receiving ART from May 2019 until July 2019. Patients with late refills were actively absorbed for a comprehensive counselling session and follow-up pharmacy refills were evaluated using medication possession ratio (MPR) for duration of 6 months. MPR of more than 90% was categorized as optimal refill adherence. Paired T-test was used to test the effectiveness of counselling at late refills whilst multivariate regression models were used to examine predictors of late refills. Results: Among 691 HIV-infected patients, 85% had on-time refills. Patients with late refills (n= 101) were predominantly male (88%). Mean age was 40 years and mean duration on ART was 4 years. Work commitment accounted for the highest reasons for late refills (25.7%) followed by intentional poor adherence (23.7%). Identifying patients and providing counselling at late refills, increases MPR or refill adherence significantly in patients who had iii previously poor MPR scores (MD=14.43; SD= 13.14; p <0.001). Multivariate binary logistic regression analysis found history of self-reported non-adherence (AOR= 0.259; 95% CI [0.119 -0.563]; P<0.001) travelling more than 20km to the hospital (AOR= 0.184; 95% CI [0.079-0.427]; p< 0.001) and having medication possession ratio percentage of less than 90 % (AOR= 0.141; 95% CI [0.067-0.296]; p< 0.001) were significant predictors of late refill. Conclusion: The proportion of patients with on-time drug pick up was only a fair performance according to World Health Organization standards. Our study further suggests integration of identifying and counselling patients with late refills as part of the dispensing process as it increases pharmacy refill adherence significantly. This targeted intervention could serve as an early proxy of retention in care especially in resource-limited settings. Keywords: On-time drug pick-up, adherence, medication possession ratio, refill adherence, antiretroviral drugs

Introduction Falls occur often because of complex interacting risk factors. As such, identifying the risk factors of falls and providing suitable interventions including lifestyle modification are important in elderly care. Methods This epidemiology study utilized data extracted from the MyFAIT study, a randomized controlled individually tailored multifactorial interventional trial. Community- dwelling elderly aged 65 years and above with a history of falls (fallers) or without a history of falls (non-fallers) were recruited. The demographic and clinical data of the fallers and non-fallers were compared. The fallers were then randomized to receive either interventions or standard care and followed up after 12 months. Patients with dementia, major psychiatric illness, non-ambulatory patients or inability to stand were excluded in the intervention trials. The primary outcome variable is the occurrence of falls. Chi-square tests or Fisher Exact tests were used to estimate the association between risk factors and fall history; or interventions and recurrent falls. Logistic regression was used to determine the association of independent variables and the event of falls. A p-value of <0.05 was statistically significant in all tests. Results Data extracted from 483 subjects were analysed. Among them, 268 were fallers and 215 non-fallers. Logistic regression analyses were performed to estimate the effects of influencing factors on the likelihood of having events of falls. Increasing age is found to be associated with an increased risk of falls but higher mean systolic blood pressure iii was associated with a reduced likelihood of falls in the elderly. Elderly who were diagnosed with cataracts have a 1.91-time [Odds Ratios = 1.91 (95% CI 1.10-3.31)] risk to have fall events compared with patients without cataract. In a sub-analysis of individually tailored multifactorial interventions, the results showed that fallers who received 5 types of interventions seem to have a higher risk of recurrent falls [Odd Ratio = 2.07 (95% CI 0.89-4.83)] than those receiving less or more than 5 types of interventions, but the risk is not statistically significant. Dizziness conditions (44.7%), osteoporosis (19.9%), and alcohol consumption (14.9%) were commonly found in the elderly with recurrent falls. Conclusion Multiple risk factors such as aging, low systolic blood pressure, and cataract disease were found to be associated with the risk of falls in the elderly. This study also found that dizziness, osteoporosis, and alcohol consumption and are commonly observed in patients with recurrent falls despite the implementation of fall prevention interventions. This study highlights the importance of lifestyle modification during and after the implementation of fall prevention interventions. Keywords: fall prevention interventions, elderly falls, community-dwelling elderly, lifestyle modification

Introduction: Currently there is an uptrend in the provision of Extended Pharmacy Services (EPS) among community pharmacists (CPs). EPS referred to various services that beyond the traditional pharmacists’ roles of dispensing medicines such as public health educational program, clinical services and medicine use review. However, such services were only reported in other developed countries but not in Malaysia. Within this context, the present study aimed to explore the types of EPS available, CPs’ perceptions and attitudes towards the provision of EPS. This study also identified the perceived barriers and facilitators towards the provision of EPS. Methods: A descriptive cross-sectional study was conducted. A total of 236 samples were collected through convenience sampling around Selangor and Kuala Lumpur region. The questionnaire consisted of 6 domains including demographic profile, the type of EPS, pharmacist’s perception, perceived barriers, perceived facilitator and pharmacist attitude towards the provision of EPS. All questions were scored using five-point Likert Scale. All the data were analysis through SPSS using descriptive statistics analysis, Mann-Whitney and Kruskal Wallis test. Results: CPs are willing to provide EPS in near future. For the time being, health screening test were the most performed EPS. CPs often/always performed blood pressure test, (97.8%), glucose test (96.6%) and cholesterol test (83.0%). Besides that, the often/always performed counselling sessions for cough and cold (95.8%) and nutritional supplement (94.5%). However, other advanced services like smoking cessation and weight management services were not frequently performed. The top 5 perceived barriers identified includes the lack of standardized practice model for EPS (87.3%), high pressure on generating sales (86.4%), lack of patient awareness (84.4%), 4 lack of access to patient medical record (83.5%) and shortage of time (80.5%). Whereas the support and encouragement from government and other pharmacy organization were identified as the most prominent facilitator towards the implementation of EPS. Conclusion: CPs showed a positive attitude towards the provision of EPS. For the time being, there are various EPS that had already been developed and implemented. However, the identified barriers should be intervened, and facilitators should be executed to implement EPS successfully in near future. Keywords: Pharmaceutical Care Services, Extended Pharmacy Services, Expanded Pharmacy Services, Enhanced Pharmacy Services, Barriers, Facilitators, Community Pharmacy

Introduction: Cigarette smoking kills nearly 8 million people worldwide yearly and in Malaysia, it is estimated at least 20,000people died in a year. Cessation of cigarette smoking is associated with significant health benefits. Although pharmacotherapies can help smokers to quit smoking, rates of smoking relapse remains reasonably high and stays as one of the major health concerns globally. In order to ensure an effective treatment outcome, the health care providers, including pharmacists need to know the effectiveness of the available pharmacological interventions to help quitters remain long term abstinent. This study aims to assess the comparative effectiveness of pharmacological interventions to prevent smoking relapse in recent quitters. Methodology: This research was conducted based on Cochrane methodology and reported as per PRISMA-NMA guideline. Relevant human studies up to 31/10/2019 was searched through databases such as Medlines, Embase, and CENTRAL. Once identified the related RCTs, those relevant data were extracted in a standard data extraction form. RoB tool was used to evaluate the quality of trials. The random effect model was performed for both pairwise meta-analysis and NMA as summary statistics. Publication bias was also assessed sing comparison-adjusted funnel plot. The interventions were then ranked using SUCRA scores. All the above analyses were conducted using STATA software version 15.0. Lastly, GRADE methodology was used to rate the quality of evidence for all included RCTs. Results: This research included a total of ten RCTs involving 7,751 participants with comparing the five major interventions Bupropion (BUP), Nicotine based therapy (NI), combination of nicotine based therapy and bupropion (NI+BUP), Rimonabant (RNB), and Varenicline (VRN)to evaluate the comparative effectiveness for the prevention of smoking relapse. The results from the NMA and pairwise meta-analysis demonstrated that RNB is the most effective relapse prevention intervention according to primary and secondary analysis. It falls under moderate evidence based on GRADE criteria. NI+BUP ranked second with moderate evidence. VRN considered the next most effective pharmacological intervention to reduce smoking relapse, but graded as very low evidence. However, only RNB (RR 1.29 [95%CI, 1.08 –1.55]) and VRN (RR1.22 [95%CI, 1.06 –1.39])shows a statistically significant association in preventing smoking relapse among recent quitters. Conclusion: RNB is the most effective pharmacological agent in smoking relapse prevention. However, due to its unacceptable side effects, including dangerous psychiatric disorders, VRN has been preferred. The extended use of VRN has demonstrated a significant long-term relapse prevention effect and is the most suitable agent to reduce the relapse incidence towards ex-smokers.

Overweight and obesity have been widely acknowledged as the pandemic cause of amplified risk of non-communicable diseases around the world. In 2018, Malaysia became the fattest country in South East Asia with every one out of two Malaysians were either overweight or obese. As frontline healthcare providers, community pharmacists are the ideally positioned healthcare professional to provide weight management services to the public. Nevertheless, the weight management services in Malaysia community pharmacy setting remained underdeveloped and underutilised. This study aimed at exploring community pharmacists’ perspectives on the barriers and enablers of sustainable community pharmacy-based weight management services in Malaysia. Semi-structured interviews were conducted with 16 registered community pharmacists around Klang Valley, Malaysia, with the experienced in providing consultations and interventions on weight management related issues in community setting. All interviews were audio-recorded and transcribed. Data collected were analysed using thematic analysis. A total of eight themes emerged, organised under two categories: barriers and enablers. The three themes identified as barriers are lack of knowledge and skills, lack of motivation by consumers and perceived high costs by consumers. The five themes identified as enablers are interpersonal skills and knowledge development training, interprofessional collaboration with other healthcare providers, guidelines and protocol, record system for follow-up and public education. Community pharmacists expressed the need for skills in approaching and communicating with their customers without offending them. Interpersonal skills development training is also needed to communicate effectively with the public and to create awareness on the available roles and responsibilities of community pharmacists. This findings in this thesis could be taken to further study on the development or improvement in pharmacists’ training, public education, multidisciplinary collaboration between healthcare professionals and weight management protocol or guideline to support the development and sustainability of weight management service in community setting. Keywords: pharmacy-led weight management service, perceptions, pharmacists, barriers, enablers, obesity, Malaysia

Background: This qualitative study explores the understanding and selfmanagement practice among patient with antipsychotic medications prescribed with ‘Pro Re Nata’ basis in Hospital Kajang, Malaysia. Method: A qualitative approach was employed using in-depth interview at psychiatric outpatient clinic in Hospital Kajang, Malaysia. Twelve patients were recruited via a purposive sampling method. An open-ended approach was used to obtain answers from patients. The data was collected through audio-recorded interviews and later was transcribed verbatim and were read repeatedly. Thematic analysis was used to identify themes from the transcripts. A constant comparison approach was used, whereby emerging themes and patterns are continually refined, compared and contrasted with the data as a whole. Organization and coding of data were done manually Results: A total of twelve patients were interviewed. Participant’s view that medication by PRN improve their health status and understand the medication is taken when needed basis. Barriers identified for understanding and self-management practice towards PRN medication include lack of knowledge towards the disease as well as drug and poor education level. Other barriers include individual culture and religion practice, influence of family member, and perceived lack of support from multidisciplinary teams in delivering genuine information regarding psychotropic medications. Conclusion: Managing patients with antipsychotic medications prescribed with PRN basis is still a challenge for Malaysian psychiatry doctors. Future intervention should focus on the identified barriers to improve the medication management and self-care of patient. Keywords: Medical problem, Prescriptions, Barriers, Extra pyramidal symptoms, Hospital Pharmacy, Pharmacists, Pro Re Nata (PRN)

Comparative effectiveness of antimalarial drugs for chemoprevention of malaria in pregnancy: A network meta-analysis Introduction Malaria is a vector -borne parasitic infection. There are currently five species of the Plasmodium parasite that cause human malaria. Malaria during pregnancy can attribute to maternal related outcomes such as maternal anaemia, stillbirth and parasitological outcomes such as peripheral parasitaemia, placental parasitaemia. These consequences can be interrupted by chemoprevention of malaria with appropriate and recommended drugs. Methods We performed a network meta-analysis (NMA), following PRISMA-NMA checklist followed by GRADE approach for overall certainty. Results The present NMA included 12 randomised controlled trials with 2238 participants across 8 malaria endemic countries in the African and South-East Asia regions. These studies assessed 5 antimalarial drugs such as Chloroquine (CQ), Sulfadoxine–pyrimethamine (SP), Proguinil, Pyrimethamine alone, Pyrimethamine‐dapson (Pyr_dapson). The most frequently used drug was SP twice per week administration. The majority of included studies were with low risk of bias in the blinding status, but unclear/high risk of bias in allocation concealment and randomization process of the RCTs. Proguinil and SP (weekly dose) or CQ and placebo had comparable efficacy in reduction of parasitemia in mother, indicating that CQ has no benefit of chemoprevention for malaria in pregnancy. All intervention drugs were not with better efficacy for still births than placebo. According to the GRADE rating the evidence was of moderate certainty that the true effect of CQ is likely to be close to the estimate both the effect of parasite and stillbirth, but there is a possibility that it is substantially different in malaria with pregnancy. Conclusion The findings suggest that the more potent drugs with better schedule (e.g weekly, intermittent etc) for chemoprevention of malaria in pregnancy MiP are required. As SP resistance to malaria parasite is well established, what alternative drugs would be introduced to MiP. A package of care including better quality of maternal and child health care services, ensure the nutritional status of pregnant women along with chemoprevention should be targeted towards the MiP. Keywords: Antimalarial drugs; Chemoprevention; Malaria in pregnancy; Network Metaanalysis

Background: The success of cancer therapy is usually compromised by oral complications such as oral herpes simplex virus (HSV) infection, which can affect cancer treatment progression and the patient's quality of life. This network metaanalysis aimed to identify the best antiviral agent to prevent or treat oral HSV in patients being treated for cancer. Methods: A network meta-analysis was performed on the data from randomized controlled trials that assessed antiviral agents for preventive or therapeutic activity versus placebo, no treatment, or any other active intervention in patients being treated for cancer. A search was conducted for trials published since inception until the 10th of May 2020 in three databases: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. The primary outcome was the incidence of oral HSV infection. The agents were ranked according to their effectiveness in the prevention of oral HSV using surface under the cumulative ranking (SUCRA). GRADE was used to assess the certainty of the evidence. Results: Out of 1883 reviewed articles, 16 articles met the inclusion criteria. The pooled relative risk (RR) to develop oral HSV infection in acyclovir group was RR 0.17 (95% CI: 0.10, 0.30), compared to 0.22 (95% CI: 0.06, 0.77) in the valacyclovir group. Acyclovir ranked highest for the prevention of oral HSV (SUCRA 83%) followed by valacyclovir (SUCRA 66 %). Subgroup analysis with different acyclovir regimens revealed that the best regimens in terms of HSV-1 prevention were acyclovir 750 mg/m2 intravenously followed by 1600 mg per day orally, and 800 mg per day orally. Acyclovir 250 mg/m2 per day intravenously was the least effective against the prevention of oral HSV. The quality of evidence was high-moderate based on GRADE approach. Subgroup analysis could not be performed for valacyclovir due to the limited number of studies. Conclusion: Acyclovir is superior to valacyclovir in the prevention oforal HSV infection for patients being treated for cancer as per the current evidence. Further studies are recommended for valacyclovir to identify the dosing regimen that is most effective. These results can help clinicians in decision making; and can also be used to develop guidelines. Keywords: Herpes simplex virus, cancer, antiviral, prophylaxis, systematic review, network meta-analysis.

Introduction: Community pharmacists are responsible for providing information on the appropriate use of medications and its possible contraindications, so every patient is able to receive the maximum benefit. The amount of control patients should have over their healthcare choices brings about many challenges to the community pharmacists. Thus, this systematic review seeks to answer, whether patients’ decision is adequate in providing the desirable quality of health outcome compared to pharmacists’ intervention in the community pharmacy. Methods: Appropriate studies were identified based on a systematic search using the database of Medline and Scopus and subsequently, articles which cited the studies using Google Scholar and PubMed were also searched. The search included literatures published since year 2005 to year 2019. Selected parameters which include selection bias, detection bias, performance bias and attrition bias were properly assessed. All the appropriate data were narratively analyzed and synthesized. Results: Forest plot was generated to assess the effect of patient autonomy on the health outcome of patients attending community pharmacy. A total of 383 articles were screened and subsequently, 19 articles which met the inclusion criteria were reviewed. These 19 articles were identified to be fit for the inclusion according to the articles full text analysis. It was noticed that all the included studies were conducted in several countries worldwide. Conclusion: Our results suggested that all patients should be encouraged to optimize their decision when acting. This decision should include all the shared information and mutual collaboration with the community pharmacist. It is concluded that, decisions are made through a typical consensus process, which includes the accurate views of both professionals (community pharmacists) and patients, specifically involving minor ailments which are prevalent in the community pharmacy setting. Keywords: patient self-efficacy; patient expectation; patient choice; patient preference; quality use of medicine; patient-centered care; pharmacist-patient interaction