Sir, I read with interest the elegantly written CME article by Liam C K recently!. The choice of empiric antibiotic(s) in treating hospitalized adult patients with communityacquired pneumonia (CAP) is important as it can influence clinical outcomes 2. As correctly pointed out by the author, patients with CAP requiring hospitalization should, in addition to a ~-lactam stable antibiotic, be covered with a macrolide, to combat atypical pathogens such as Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydia pneumoniae. Such is the recommendation from most foreign guidelines 3. 4. Here I wish to add our own observation based on a prospective study conducted between 2002 and 2004 of 141 adult patients with CAP hospitalized in Seremban Hospital in which we studied the clinical outcomes of patients treated empirically with and without a macrolide added to their ~-lactam stable antibiotic, recently published in Respirology 5.
Academic performance is still primarily judged on publications. Not surprisingly, pressure to publish for the purpose of academic standing or promotion can be huge. People have been put off from an academic career simply because of this necessity. This is unfortunate because publishing our research findings or knowledge is our core business and why we become academicians. The notion that teaching is the academician’s chief duty is only half correct. We should and can enjoy publishing if we accept this as an inseparable part of our job. (Copied from article).
Significant changes have occurred in relation to how chronic asthma is being treated. Emphasis has now shifted from viewing asthma as a condition of smooth muscle dysfunction to one of chronic inflammation. As such, anti-inflammatory therapy forming the cornerstone of treatment represents the first important milestone in the evolution of asthma treatment. For this purpose, inhaled corticosteroid (ICS) is by far the most effective anti-inflammatory therapy. Another important milestone is the recognition of the superiority of adding long-acting β2-agonist (LABA) to ICS over escalating ICS dose alone or other forms of add-on therapies in treating asthmatic patients not responding to regular ICS alone. The effectiveness of adding LABA to ICS in treating asthma logically led to combining the two drugs into one single inhaler (salmeterol/fluticasone and budesonide/formoterol) that has the attractiveness of being user-friendly and ensuring that ICS is not missed out. The unique property of formoterol that allows for repetitive flexible dosing paved way to the concept of using Symbicort for both regular maintenance dosing and as required rescue medication. This revolutionary approach has been recently shown to provide improved asthma outcome, achieved at an overall lower or at least comparable corticosteroid intake, and may represent another evolutionary step in the treatment strategy of chronic asthma.
We prospectively evaluated the use of a simple 3-Minute Respiratory Exerciser Test (3MRET) that estimates perception of dyspnea to identify patients at risk of asthma exacerbations. A total of 146 stable asthmatics (42 under-perceivers, 69 normal perceivers, and 35 over-perceivers) received follow-up for 12 months. The mean (SD) unscheduled visits to doctors among under-, normal, and over-perceivers were 1.8 (1.2), 2.2 (1.8), and 3.1 (2.3), respectively (p = 0.008). The mean (SD) hospital admissions among the groups were 1.3 (0.5), 1.2 (0.6), and 1.7 (1.3), respectively (p = 0.026). Compared to normal perceivers, over-perceivers had increased risks of unscheduled visits (OD: 5.12; 95% CI = 1.59 to 16.47) and hospital admissions (OD: 0.31; 95% CI = 0.23 to 0.41), defined as > or =2 events in 12 months. The association between over-perceiver and unscheduled visits remained significant after adjusting for forced expiratory volume in 1 second (FEV(1)). Sensitivity and specificity of over-perceivers are 77% and 47%, respectively, for unscheduled visits and 37% and 78%, respectively, for hospital admissions, with significantly better area under ROC for unscheduled visits (0.67 [95% CI = 0.56 to 0.77]; p = 0.003) than for hospital admissions (0.58 [0.471 to 0.70]; p = 0.127). We conclude that the 3MRET may have a role in identifying asthmatic patients with over-perception of dyspnea at risk of clinically important asthma exacerbations.
A self-answered, anonymously completed, nationwide questionnaire survey was conducted between June 2002 and May 2003 among Malaysian doctors through post and at medical meetings. Findings based on 116 government and 110 private doctors who satisfactorily completed the forms (effective respondent rate: 30.1%) showed that more than 70% of government and private doctors claimed familiarity with asthma CPGs but proportionately more private doctors considered them "unworkable" and were reluctant to adopt them in their practice setting, quoting cost as the primary reason. Between those who frequently adopted the CPGs and those who did not, there was an equally high proportion of inappropriate prescribing. Despite the shortcomings of such a survey, our findings suggest that medicinal cost and practitioner's prescribing practices are important in the acceptance and execution of asthma CPGs recommendations.
Newly affluent developing world cities increasingly adopt the same unfortunate low-density suburban paradigm that shaped cities in the industrialized world. Identified by a World Bank report as a "mini-Los Angeles," Kuala Lumpur is a sentinel example of the results of unrestrained sprawl in the developing world. Factors driving sprawl included government policies favoring foreign investment, "mega-projects," and domestic automobile production; fragmented governance structures allowing federal and state government influence on local planning; increasing middle-class affluence; an oligopoly of local developers; and haphazard municipal zoning and transport planning. The city's present form contributes to Malaysia's dual burden of disease, with inner-city shantytown dwellers facing communicable disease and malnutrition while suburban citizens experience increasing chronic disease, injury, and mental health issues. Despite growing awareness in city plans targeted toward higher density development, Kuala Lumpur presents a warning to other emerging economies of the financial, societal, and population health costs imposed by quickly-built suburban sprawl.
Publication year: 2013-2014
A self-answered, anonymously completed questionnaire survey was performed between June 2002 and May 2003 where doctors from government and private sectors in Malaysia were invited to participate by post or during medical meetings. One hundred and sixteen government doctors and 110 private doctors provided satisfactorily completed questionnaires (effective respondent rate: 30.1%). The most preferred medications for 'first-line', 'second-line' and 'third-line' treatment were for government doctors: inhaled short-acting beta2-agonist (SABA) (98%), inhaled corticosteroids (CS) (75%), and leukotriene antagonist (52%); and for private doctors: oral SABA (81%), inhaled CS (68%), and oral CS (58%). The first choice inhaler device for most government and private doctors were metered dose inhalers, with cost and personal preferences (for private doctors), and technical ability (for government doctors) as the key considerations when deciding on the choice of device. This benchmark data on the asthma prescribing practices of a healthcare delivery system fully dichotomized into government and private sector, provides evidence for practice differences affected by the nature of the healthcare system, and might have implications on healthcare systems of other countries that share similarities with that of Malaysia.
Current asthma treatment is directed by severity of symptoms and lung function. In Malaysia, spirometry is not widely available and therefore not used in most medical consultations. In 163 asthmatic patients [mean (95% CI) age: 41 (38-44) yrs; 29% male; 32% Malays, 32% Chinese, 34% Indians] who were being followed up in a State Hospital medical outpatient clinic and a large urban-based health clinic, we studied the effect on Global Initiative for Asthma (GINA) disease severity classification and the appropriateness of currently prescribed treatment when forced expiratory volume in one second (FEV1) was considered together with symptom severity. We showed that 52% of the patients were upgraded to a higher severity classification and 71% of the patients were under-treated. If based on symptoms alone to assess severity, 39% of the patients were still under-treated. We concluded that the disease severity in many asthmatic patients might have been underestimated and therefore not adequately treated, because spirometry was not available or used to assess asthma severity. The use of spirometry should be advocated more widely among clinicians treating asthma in Malaysia.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan; Klinik Kesihatan Seremban, Malaysia
In practice, asthmatic patients whose metered-dose inhaler (MDI) technique is inefficient are either corrected or changed to dry powder breath-actuated or spacer device that is easier to handle. Based on 'real life clinic circumstances', we studied 15 symptomatic asthmatic patients whose MDI techniques were inefficient that either received correction in their technique (n=9) or were changed to turbohaler (n=6). For comparison, we also studied a similar group of symptomatic asthmatic patients (n=6) with appropriate MDI techniques that were treated by doubling of inhaled corticosteroid (ICS) dose. After 4 weeks, FEV(1) and symptom scores in the turbohaler group was significantly improved from baseline but not in the corrected MDI group. The group whose ICS dose was doubled also showed significant improvement in symptom scores but not in FEV(1). We question the benefit gained by correcting MDI technique in some asthmatic patients compared to that of switching over to more user-friendly devices such as turbohaler. In our study, the improvement observed with turbohaler appears to be more than a mere doubling of drug delivery to the lungs and may relate to the recognized greater consistency of drug delivery by turbohaler compared to MDI device.
As a standard, significant pleural effusion, whether tuberculous (TB) or not, requires therapeutic thoracocentesis. We tested the hypothesis that standard anti-TB chemotherapy alone can resolve significant pleural effusion.
INTRODUCTION: Medical talks, newsletter circulars, scientific meetings and conferences, and interaction with members of the pharmaceutical industry, have become convenient means of carrying out continuing medical education (CME) for many busy doctors.
MATERIALS AND METHODS: To study the perceived importance of these various CME activities, a self-completed posted questionnaire survey was conducted among registered practitioners of a densely populated urban state in Malaysia.
RESULTS: Of the 172 respondents [male, 77%; hospital-based, 37%; general practitioner (GP), 55%; private practice, 70%; respondent rate of 19.5%], most preferred local conferences and endorsements by local experts to their foreign counterparts. Meetings or conferences sponsored by the pharmaceutical industry were ranked similarly with those without such links, while the reputation of the pharmaceutical firms was of foremost importance. Among GPs (n = 95) and non-GPs (n = 77), medical society newsletters were rated significantly higher by GPs while overseas conferences were rated higher by non-GPs.
CONCLUSION: Our findings provide an important first look at this under-explored area among Malaysian doctors and described a high degree of acceptance for the involvement of the pharmaceutical industry in CME activities.
The concept of diastolic heart failure (DHF) is not new. However awareness and understanding on this subject may remains uncertain among medical practitioners. We wished to examine the extent of awareness of such entity among doctors in Malaysia. A questionnaire was designed and distributed randomly during hospital Continuous Professional Development (CPD/CME) sessions and also in the respective outpatient departments (OPD) between July to October 2008. This cross-sectional survey in three urban-based general hospitals showed that there are a significant proportion of doctors who are lack of understanding and awareness of diastolic heart failure.
Study site: Hospital Pulau Pinang, Georgetown, Pulau Pinang, Hospital Tuanku Ja’afar Seremban, Bukit Rasah, Seremban, Hospital Ampuan Najihah Kuala Pilah, Negeri Sembilan.
Budesonide/Formoterol (Symbicort) combination therapy as both maintenance and reliever treatment (SMART) is a novel approach in asthma management. We examined its 'real-life effectiveness' in treating Malaysian patients with moderate-to-severe asthma in whom despite on combined inhaled corticosteroids and long-acting beta2-agonist, were still inadequately controlled. In a retrospective study, 22 eligible adult patients on SMART [mean (range) age: 49 (36-65) years; FEV1: 41 (21-74)% predicted] were identified from medical records of an urban-based university hospital chest clinic, and their clinical outcomes studied at three months. Another 16 patients [50 (14-66) years; 48 (20-91)% predicted] of similar severity and treatment (i.e. Symbicort maintenance treatment plus short-acting beta2-agonist as reliever), but not on SMART, were used as comparator over the same assessment period. In addition, the patients were separately interviewed with standard questionnaire on their satisfaction and compliance to the SMART approach. In SMART group, rescue treatment requirement (p<0.001) and FEV1 [median difference = 2.5%, p=0.015; mean difference: 90 ml, p=0.013] showed significant improvement while in comparator, there was significant improvement only in the requirement for rescue treatment (p=0.023). Hospital admission rates were significantly reduced in SMART group compared to the other (p=0.039), but not in emergency treatment. Five patients asked to discontinue SMART while all others were satisfied, compliant and perceived improvement of their asthma with SMART. The maximum daily doses of inhaled budesonide and formoterol were 1400 microg and 31.5 microg respectively. Our preliminary findings suggest that SMART approach can be attempted as an effective and safe treatment option for patients with inadequately controlled moderate-to-severe asthma in Malaysian setting.
Study site: Chest clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
To study the nature of endotoxin or lipopolysaccharide (LPS) induced inflammation, we developed a method of quantifying intracellular human neutrophil elastase (HNE) in lysed sputum polymorphs as a means to study the degranulation status of LPS-recruited neutrophils. Induced sputum, blood and exhaled nitric oxide (NO) were collected from 10 healthy non-atopic human subjects after inhaling a single 15 microg dose of Escherichia coil LPS in an open study. At 6 hours, LPS inhalation caused significant increase of sputum and blood neutrophils but without parallel increase in myeloperoxidase, HNE or interleukin-8 (IL-8) in sputum sol and blood, or exhaled NO. Intracellular HNE in lysed sputum polymorphs or purified blood neutrophils did not show any significant changes between inhaled LPS and saline, nor was there any appreciable change in percentage HNE release induced by N-Formyl-Met-Leu-Phe (fMLP) in vitro. We concluded that in healthy humans, the transient neutrophilic inflammation induced by a single dose of inhaled 15 microg LPS is mainly characterized by cell recruitment, not enhanced secretion of granular mediators or increased exhaled NO based on our experimental conditions.
In a multiracial country like Malaysia, ethnicity may influence the measurement of health-related quality of life (HRQL) in asthmatic patients. We invited 131 adult patients [44 Malays, 42 Chinese and 45 Indians; mean (95% CI) age: 43 (40.2-45.7) yrs; 28.2% male] with moderate-to-severe persistent asthma followed up in an urban-based hospital outpatient clinic to complete a disease-specific HRQL questionnaire [St Georges' Respiratory Questionnaire (SGRQ)] and to provide socio-demographic and asthma-related data. Indians reported significantly worse SGRQ total score, compared to Malays [mean (95% CI) difference: 10.15 (0.51-19.78); p = 0.037] and SGRQ activity score, compared to Malays [13.50 (1.95-25.05); p = 0.019] and Chinese [11.88 (0.19-25.05); p = 0.046]. Further analysis using multivariate linear regression showed that Indian ethnicity remained independently associated with SGRQ scores. Our finding highlights the relevance of ethnicity in assessing HRQL of asthmatic patients in a multiracial country such as Malaysia.
Study site: chest clinic of an urban-based
university teaching hospital