Theses (Master Of Pharmacy Practice)

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: Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used for pain, fever, and inflammation. They are readily accessible over-the-counter (OTC) in community pharmacies without a prescription. Due to the ease with which NSAIDs can be acquired, selfmedication with NSAIDs is an increasing concern as it may result in inappropriate use, leading to drug-related problems and potentially serious adverse effects. Objective: The main purpose of this study was to assess the general public’s current level of knowledge, attitude, perception, and practice regarding the use of OTC NSAIDs, to explore their perspective regarding receiving information on NSAIDs, and also to determine the relationship between the knowledge, attitude, perception, and practice. Methods: A cross-sectional study was conducted among the general public in Selangor who had self-medicated with oral OTC NSAIDs. A structured, validated questionnaire was distributed electronically in community pharmacies and via social media platforms. In addition, a hard copy of the questionnaires was provided for non tech-savvy participants. Respondents were recruited through convenience sampling. Incomplete responses were excluded. Data was analysed using Statistical Package for Social Sciences (SPSS). Results: A total of 358 respondents completed the survey. Findings suggest that overall, the general public in Selangor demonstrated good knowledge (70.95%), positive attitude (PRR=67.88%), and good practice (PRR=58.75%) towards OTC NSAIDs use. However, perception of NSAID risks was poor (PRR=35.64%), especially related to risks of selfmedicating and sharing of NSAIDs among friends and family. Age, gender, and education levels were key determinants affecting knowledge levels. Most respondents (89.39%) showed a positive perspective towards receiving information on NSAIDs, with 94.14% agreeing that healthcare professionals (HCPs) should play a direct role in providing such information Statistically significant positive correlations were observed between knowledge-attitude (r=0.218, p<0.001), knowledge-perception (r=0.294, p<0.001), knowledge-practice (r=0.294, p<0.001), attitude-perception (r=0.270, p<0.001), attitude-practice (r=0.585, p<0.001) and perception-practice (r=0.385, p<0.001). Conclusion: There were potential gaps and misconceptions identified in certain areas, particularly regarding the safety aspects of NSAIDs. The study recommends targeted educational interventions to raise awareness and improve overall medication safety. Keywords: NSAIDs, painkillers, community pharmacy, health, wellbeing

Assessment of patient safety culture among healthcare providers in tertiary hospitals – a multicentre study Introduction: Patient safety culture is the combination of attitudes and behaviours toward patient safety that are addressed when a patient walks into a healthcare institution. The objectives of the present study were to identify the current level of patient safety culture and to evaluate and correlate the healthcare providers’ (HCPs) knowledge, attitude, and perception of patient safety culture in tertiary hospital settings. Methods: A cross-sectional study was carried out among the HCPs of private tertiary hospitals, which were Sunway Medical Centre (Sunway City) and Gleneagles Hospital Medini Johor. A structured validated questionnaire which includes Hospital Survey On Patient Safety Culture (HSOPSC) was used to analyse the level of patient safety culture. Results: A total of 550 HCPs were approached and only 158 of them responded to this online survey and the response rate was 28%. The overall patient safety grade was rated as very good or excellent by 110 (69%) respondents. The study revealed communication about the error (PRR=80), and organizational learning and continuous improvement (PRR=74) were good in the study settings, whereas staffing and work pace (PRR=28), and response to errors (PRR=40) require improvement in terms of patient safety culture. Conclusion: HCPs in the study settings had favourable attitudes towards the culture of patient safety in their organization. Inadequate staffing, work pace, and lack of response to mistakes were commonly seen that may increase the chances of errors, which pose health threats to the patients and needs to be addressed immediately. Every healthcare organization should address the issue of safety culture holistically. Keywords: Patient safety, hospital survey, error reporting, private hospital, healthcare.

Background: There is a growing trend in multimorbidity among the older adult population, which necessitates a complex treatment regimen as well as selfmanagement strategies and health literacy. Older adults who are burdened with their treatment and have poor health literacy may experience difficulty adhering to their medication plans. This study aimed to explore quantitatively how treatment burden and health literacy affect medication adherence in elderly living with multiple chronic conditions. Methods: Face-to-face structured interviews were conducted in 10 general practitioners (GP) clinics in Selangor among elderly aged >60 years to collect data comprising of (1) demographic details, (2) treatment burden assessed using the Burden of Treatment Questionnaire (TBQ-15), (3) health literacy of participants assessed using the Short Form Health Literacy Questionnaire (HLS-SF12) and (4) medication adherence level of participants assessed using the Malaysia Medication Adherence Assessment Tool (MyMAAT). Chi-square test and Pearson correlation coefficient test analyses were conducted to analyze the relationships among the study variables. Results: Hypertension (30.2%), hyperlipidemia (24.0%), and diabetes (18.0%) were the most reported chronic conditions among participants. The mean score of treatment burden was 53.4 out of 150 (SD = 28.2), indicating an acceptable burden of treatment. The mean score of health literacy was 16.4 out of 50 (SD = 12.6), indicating a limited health literacy level among participants meanwhile mean score of medication adherence was 32.6 out of 60 (SD =12.3), indicating medication non-adherence among participants. Medication adherence was significantly correlated with treatment burden (r = -0.22, p <0.0001), health literacy (r =0.36, p <0.0001), number of chronic conditions (r = -0.23, p <0.0001), and age (r = -0.11, p <0.05). Conclusion: The study findings indicate that multimorbid older adults with high treatment burden and low health literacy have poor medication adherence, underlining the importance for clinicians to recognize treatment burden and poor health to improve medication adherence among elderly with multiple chronic conditions. Keywords: Treatment burden; quality of life; medication; adherence, health; literacy, geriatrics.

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: Community pharmacists uphold a pivotal position in delivering primary healthcare services. During the coronavirus 2019 pandemic, community pharmacists demonstrated adaptability and advancement of their roles, highlighting their resilience to challenges. Conversely, if not well supported by the pharmacy management, job dissatisfaction can occur and affect their retention with the organisation. Aim: To evaluate the relationship between community pharmacists’ job retention and six people-orientated pharmacy workforce management domains. This includes management care, management communication, value and trust, management effectiveness, career development and work-life balance. Methods and Materials: A cross-sectional survey was conducted between April 2021 to March 2022 using a self-administered questionnaire distributed to full-time, employed community pharmacists in the urban regions of Kuala Lumpur and Selangor, Malaysia. Face-to-face and convenient distribution methods were used. Data were analysed using descriptive analysis and Spearman’s correlation. Results: A total of 311 pharmacists participated in the study. Community pharmacists were found to have above-average willingness to retain their current job (mean = 3.75; SD = 0.59. Most participants were positively satisfied in all management domains investigated with management effectiveness with the highest mean satisfaction score (mean = 3.82; SD = 0.72). All management domains had a significant, moderate and positive correlation with job retention. The domain with the strongest correlation was the value and trust domain (rs = 0.69; p<0.001), closely followed by management care (rs = 0.68; p<0.001) while career development had the weakest correlation (rs = 0.55; p<0.001). Conclusion: Findings of the study gave an insight into which pharmacy workforce management characteristics will play an important role in maintaining pharmacists’ willingness to retain their current job from the perspective of community pharmacists. Findings may be used by the pharmacy management to guide internal evaluations of the pharmacy management performance. Keywords: community pharmacist, job satisfaction, job retention, workforce, management, primary healthcare

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

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.

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: 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.

INTRODUCTION: Third molar surgery often results in inflammatory complications, such as pain, trismus, and swelling. This study aims to evaluate the effectiveness and safety of various interventions in alleviating postoperative inflammatory complications after third molar surgery. METHODS: A systematic review of PubMed, Ovid and Scopus databases identified randomised controlled trials (RCTs) assessing interventions used to alleviate postoperative inflammatory complications after third molar surgery. The primary outcome was pain measured by visual analogue score (VAS). Interventions were ranked using Surface Under Cumulative Ranking (SUCRA). RESULTS: Analysis of 77 RCTs evaluated intervention efficacy for pain, trismus and swelling. Antimicrobial photodynamic therapy (aPDT) combined with photobiomodulation (PBMT) was ranked as most effective in reducing pain at day three post-surgery (SMD -4.8, SUCRA 95.9%. Betamethasone (BET), ibuprofen (IBU) and paracetamol (PCM) showed similar efficacy by day seven (SMD: -5.66, SUCRA 92.4%, 89.6%, and 88.1% respectively). PBMT and ozone therapy (OT) significantly reduced trismus on day three (PBMT: SMD -5.02, OT: SMD -3.26, both p < 0.05). Oxaprozin (OXA), OT, dexamethasone (DEX) and PBMT were significantly effective by day seven (OXA: SMD -4.4, OT: SMD -2.42, DEX: SMD -1.53, PBMT: SMD 0.008). Diclofenac (DIC) was effective for swelling on day two (SMD -3.22), while OXA was effective on day seven (SMD -4.53). Regarding safety, only 14 studies reported side effects, with 10 of them reporting no adverse events. The most documented adverse events were with piroxicam and ketorolac. CONCLUSION: Antimicrobial photodynamic therapy combined with photobiomodulation was identified as the most effective intervention for alleviating postoperative pain after third molar surgery. PBMT consistently demonstrated statistical significance in its efficacy for pain, trismus and swelling on all evaluation days, but with varying ranks. Since the safety data were limited in all studies, highlighting the need for further research on potential adverse events. Keywords: third-molar surgery, postoperative inflammatory complications, pain, trismus, swelling, oedema, network meta-analysis.

INTRODUCTION: Oropharyngeal candidiasis (OPC) remains one of the most common opportunistic infections among HIV-infected adults. This study assessed the comparative efficacy and safety of different antifungals used for the prevention and management of OPC in adult patients with HIV. METHODS: A systematic literature review was conducted on the 4 major databases (Medline, Embase, CENTRAL and Scopus) to identify randomized controlled trials (RCTs) that evaluated the efficacy of antifungal agents for their therapeutic or preventive effect compared to other antifungal agents or placebo, in HIV patients with OPC. Network meta-analysis was performed from the data extracted from the selected studies. For the therapeutic effect, the primary outcome was the clinical cure; the incidence of OPC was the primary outcome for preventive effect. The agents were ranked according to their efficacy as well as safety in the treatment as well as prevention of OPC using surface under the cumulative ranking (SUCRA). RESULTS: 28 were included in the qualitative analysis and 22 for quantitative analysis RCTs involving 3882 participants. In terms of clinical efficacy, fluconazole was ranked as the most effective antifungal agent in treating OPC (SUCRA=0.87) followed by posaconazole and itraconazole respectively. Gentian violet [RR, 0.61 (95%CI=0.40-0.94)] and nystatin [RR, 0.59 (95%CI=0.43-0.82)] were the least effective in achieving clinical cure when compared to fluconazole. Posaconazole was ranked the most efficacious agent in achieving mycological followed by fluconazole. When compared to placebo, fluconazole was found to be effective in the prevention of OPC [RR, 0.45 (95%CI=0.27-0.77)]. While nystatin was ranked the safest, effect estimates of none of the other systemic antifungal agents were significantly higher than fluconazole. CONCLUSION: Based on the available evidence, fluconazole can be considered as the most effective drug in treatment as well as prevention of OPC among HIV-infected adults and has a favourable safety profile. Keywords: oropharyngeal candidiasis, oral candidiasis, HIV; antifungal agents, prevention, treatment; systematic review, network meta-analysis

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.

Introduction: Bleeding is a significant risk associated with oral anticoagulant (OAC) use, particularly in patients with non-valvular atrial fibrillation (NVAF). Existing bleeding risk scores have shown limited accuracy in predicting clinically relevant bleeding events, necessitating the development of a new predictive model. This study aims to create and validate a novel bleeding risk model that effectively predicts clinically relevant bleeding events. Methods: Using demographic, laboratory, and clinical data collected by Beshir SA et al., five bleeding risk models were developed through machine learning techniques, specifically utilizing recursive feature elimination (RFE) to identify pertinent variables. The dataset was divided into training and internal validation sets at 70:30 ratio. The model performance was assessed with accuracy, precision, sensitivity, specificity, F1 score, and area under the receiver operating characteristic curve (AUROC). Upsampling and downsampling techniques were applied to original dataset with repetition in model building and evaluation. Results: Of 1,017 patients (median age: 67 years, male 52%), 77 patients (7.6%) faced clinically relevant bleeding within first year of observation period. The developed model comprised 10 variables, including renal failure, peripheral vascular disease, history of bleeding, age at diagnosis, hypertension, ischemic heart disease, sex, type II diabetes mellitus, smoking, and race. All five machine learning models had poor predictive performance, with AUROC between 0.49 to 0.50. The SVM-Radial model with upsampling dataset, demonstrated the highest predictive performance, with an AUROC 75.5%, a sensitivity of 86.88%, specificity of 64.18%, accuracy of 75.5.%, precision 70.81%, and F1 score of 78.03%. Conclusions: Feature selection using recursive feature selection – random forest picked 10 clinical predictors for CRB events despite data imbalance in original dataset. Downsampling provided realistic bleeding risk prediction which SVM-Linear performed best among five models. Upsampling improved bleeding risk prediction which SVM-Radial performed best among five models. New techniques to improve bleeding risk prediction are warranted. Keywords: non valvular atrial fibrillation, oral anticoagulants, bleeding, machine learning, bleeding risk score.

Introduction: With the evolving regulatory landscape and economic importance to supply drug products to the market, the demand for regulatory affairs (RA) professionals is increased and it is imperative for them to be equipped with essential competencies to achieve effective performance. Observable skill gaps and talent shortage indicates that the inadequacies in education and training is partially responsible. The importance and usefulness of using adaptable global competency framework (CF) for local context is recognized worldwide for healthcare profession, however there is no study conducted to validate the feasibility in Malaysia. This study was conducted to identify the key competencies for the building of a CF and evaluate its relevance to support capacity building and career development in the RA professionals in the pharmaceutical industry. Methods: A mixed-method design comprised of sequential qualitative and quantitative phases was conducted. Participants were selected based on the inclusion and exclusion criteria. Semi-structured interviews to gather perspectives on the use of CF and key competencies whole cross-sectional survey to validate the competencies adapted from Regulatory Affairs Professionals Society (RAPS) regulatory CF. Qualitative data were thematically analysed, while quantitative data were analyzed descriptively using IBM-SPSS Version 23. Results: Three main overarching themes identified include the utilisation and implementation of CF with the associated benefits and challenges, key competencies required and the hiring challenges. High mean relevance were found for all domains, except for “scientific and health concepts” which remain debatable. Foundational competencies ranked higher in precedence as compared to functional competencies. iii Conclusions: RAPS regulatory CF is feasible to be used and refined for local adaptation. The findings can be used for developing a CF for foundation to intermediate level RA professionals from various background. It can also serve as guidance to identify and improve the level of performance and to address the training and education needs. Keywords: Competencies, Competency framework, regulatory affairs, mixed method, Malaysia, pharmaceutical industry, training, career development

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

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

Background: Falls have a detrimental influence on the quality of life of the elderly, as well as increase the health care cost in managing fall-related injuries. Fall incidences are expected to rise tremendously in the future as the world's elderly population expands, particularly in Southeast Asia. Since medications are one of the main factors that increase the risk of falling, much research has been conducted recently to examine the link between medications and falls. The frequency of falls among the elderly can be decreased by implementing intervention measures into practise. Objectives: The study aimed to assess the knowledge, attitude, and perception (KAP) of falls among the geriatric population in a primary care clinic setting, review the fall risk- increasing drugs (FRIDs), provide educational intervention to improve the awareness of falls and FRIDs, and lastly to analyse the effectiveness of the educational intervention. Methods: This interventional study was carried out in a primary care setting using a validated structured questionnaire to assess the KAP of falls. Elderly patients who were 65 years and above, seeking medical treatment in the primary care setting, and able to read, understand, and respond to the study questionnaire and educational interventional materials were included in the study. Results: In a total of 310 respondents, 74% of them obtained primary-level education, and 46% of them were living alone or with their partner/caregiver. The percentage of elderly patients who experienced falls in the past 12 months was 20%. Significant improvement (p<0.05) was observed in the respondents’ KAP in post-intervention. The findings revealed that the educational intervention provided is suitable to all respondents regardless of education level and prior knowledge of falls and fractures. Conclusion: The educational intervention provided to the elderly population has improved the respondents’ KAP to a certain extend. Future health policy must be crafted to address preventive measures to meet the requirements of the ageing population. Keywords: FRIDS, geriatrics, falls, educational intervention, knowledge, attitude, perspective.