Imran Zainal Abidin

Prevalence and predictors of patient adherence to health recommendations after acute coronary syndrome: data for targeted interventions?

Background: Poor adherence is a significant nursing and public health concern because it affects patients’ quality of life. It compounds the disease burden of the growing coronary heart disease population. Promoting optimal patient adherence to cardiac-health enhancing recommendations by healthcare providers can reduce mortality and morbidity risk after acute coronary syndrome (ACS). Aim: This paper sought to examine rates and predictors of patient adherence to health recommendations after ACS. Methods: A cross-sectional survey of 210 Malaysian patients using consecutive sampling was conducted in early 2009 at a tertiary teaching hospital. The Medical Outcome Study Specific Adherence Scale (MOSSAS) questionnaire was adapted to measure the extent of patient adherence to recalled health recommendations. Logistic regression modelling was applied to determine odds ratio and factors of suboptimal adherence. Results: The suboptimal adherence rate was 65.2% (95% CI 58.8–71.7%). Recall of recommendation rates varied from 38.1% to 95.3%, whereas the adherence rates varied from 22.1% to 95.1% across the six aspects of health recommendation namely medication taking, dietary modification, regular physical exercise, stress reduction, gathering social support and avoidance of substance abuse. Those who had to adhere to more than three aspects of recommendations, active smokers and the Malay ethnic race had higher odds of suboptimal adherence. Conclusion: Monitoring of patient recall and adherence rate may provide information on the effectiveness of patient care management and outcomes. Identifying patients with higher risk for poor adherence is recommended for more targeted interventions.

Failure to improve door-to-needle time by switching to emergency physician-initiated thrombolysis for ST elevation myocardial infarction

Introduction Achieving target door–needle times for ST elevation myocardial infarction remains challenging. Data on emergency department (ED) doctor-led thrombolysis in developing countries and factors causing delay are limited. Objectives To assess the effect on door–needle times by transferring responsibility for thrombolysis to the ED doctors and to identify predictors of prolonged door–needle times. Methodology Data on medical on-call team-led thrombolysis at a tertiary Asian hospital were prospectively collected from May 2007 to Aug 2008 (1st study period). In September 2008, ED doctors were empowered to perform thrombolysis. The practice change was accompanied by new guidelines, tick chart implementation, and training sessions. Data were then consecutively collected from September 2008 to May 2009 (2nd study period). Door-to-needle times for the 1st and 2nd study periods were compared. All cases were analysed for factors of delay by multiple logistic regression. Results 297 patients were thrombolysed, 169 by the medical on-call team during the 1st study period and 128 by the ED doctors during the 2nd study period. Median door–needle times were 54 and 48 min, respectively (p=0.76). Significant delays were predicted by ‘incorrect initial ECG interpretation’ (adjusted OR (aOR) 14.3), ‘inappropriate triage’ (aOR 10.4) and ‘multiple referrals’ (aOR 5.9). No cases of inappropriate thrombolysis were recorded. Conclusions Transfer of responsibility for thrombolysis to the ED doctors did not improve door–needle times despite measures introduced to facilitate this change. Key causative factors for this failure were identified.

The SPEED (sepsis patient evaluation in the emergency department) score: a risk stratification and outcome prediction tool.

Objectives The aim of the study was to identify covariates associated with 28-day mortality in septic patients admitted to the emergency department and derive and validate a score that stratifies mortality risk utilizing parameters that are readily available. Methods Patients with an admission diagnosis of suspected or confirmed infection and fulfilling at least two criteria for severe inflammatory response syndrome were included in this study. Patients’ characteristics, vital signs, and laboratory values were used to identify prognostic factors for mortality. A scoring system was derived and validated. The primary outcome was the 28-day mortality rate. Results A total of 440 patients were included in the study. The 28-day hospital mortality rate was 32.4 and 25.2% for the derivation (293 patients) and validation (147 patients) sets, respectively. Factors associated with a higher mortality were immune-suppressed state (odds ratio 4.7; 95% confidence interval 2.0–11.4), systolic blood pressure on arrival less than 90 mmHg (3.8; 1.7–8.3), body temperature less than 36.0°C (4.1; 1.3–12.9), oxygen saturation less than 90% (2.3; 1.1–4.8), hematocrit less than 0.38 (3.1; 1.6–5.9), blood pH less than 7.35 (2.0; 1.04–3.9), lactate level more than 2.4 mmol/l (2.27; 1.2–4.2), and pneumonia as the source of infection (2.7; 1.5–5.0). The area under the receiver operating characteristic curve was 0.81 (0.75–0.86) in the derivation and 0.81 (0.73–0.90) in the validation set. The SPEED (sepsis patient evaluation in the emergency department) score performed better (P=0.02) than the Mortality in Emergency Department Sepsis score when applied to the complete study population with an area under the curve of 0.81 (0.76–0.85) as compared with 0.74 (0.70–0.79). Conclusion The SPEED score predicts 28-day mortality in septic patients. It is simple and its predictive value is comparable to that of other scoring systems.

Association between body mass index and outcomes after percutaneous coronary intervention in multiethnic South East Asian population: a retrospective analysis of the Malaysian National Cardiovascular Disease Database—Percutaneous Coronary Intervention (NCVD-PCI) registry

Objective To examine the relationship between body mass index (BMI) and outcomes after percutaneous coronary intervention (PCI) in a multiethnic South East Asian population. Setting Fifteen participating cardiology centres contributed to the Malaysian National Cardiovascular Disease Database—Percutaneous Coronary Intervention (NCVD-PCI) registry. Participants 28 742 patients from the NCVD-PCI registry who had their first PCI between January 2007 and December 2014 were included. Those without their BMI recorded or BMI <11 kg/m2 or >70 kg/m2 were excluded. Main outcome measures In-hospital death, major adverse cardiovascular events (MACEs), vascular complications between different BMI groups were examined. Multivariable-adjusted HRs for 1-year mortality after PCI among the BMI groups were also calculated. Results The patients were divided into four groups; underweight (BMI <18.5 kg/m2), normal BMI (BMI 18.5 to <23 kg/m2), overweight (BMI 23 to <27.5 kg/m2) and obese (BMI ≥27.5 kg/m2). Comparison of their baseline characteristics showed that the obese group was younger, had lower prevalence of smoking but higher prevalence of diabetes, hypertension and dyslipidemia. There was no difference found in terms of in-hospital death, MACE and vascular complications after PCI. Multivariable Cox proportional hazard regression analysis showed that compared with normal BMI group the underweight group had a non-significant difference (HR 1.02, p=0.952), while the overweight group had significantly lower risk of 1-year mortality (HR 0.71, p=0.005). The obese group also showed lower HR but this was non-significant (HR 0.78, p=0.056). Conclusions Using Asian-specific BMI cut-off points, the overweight group in our study population was independently associated with lower risk of 1-year mortality after PCI compared with the normal BMI group.

Late intravascular embolization of a chemo port catheter.

A 51-year-old woman was referred for angiographic extraction of a foreign body. She underwent left mastectomy with axillary clearance for breast cancer followed by chemotherapy and radiotherapy 8 years before this. A chemotherapy port was implanted below the right clavicle with catheter access into the right subclavian vein at that time. After she had completed chemotherapy, she was lost to follow-up, until she represented 8 years later with persistent cough. The chest x-ray (Figure 1A) showed a foreign body comprising an ellipsoid head and a flagellating tail on fluoroscopy (see video, Supplemental Digital Content 1 [http:// links.lww.com/JTO/A86]; see video, Supplemental Digital Content 2 [http://links.lww.com/JTO/A87] for a close-up; and see video, Supplemental Digital Content 3 [http://links. lww.com/JTO/A88] for a 180° surround view). A computed tomography scan of chest demonstrated embolization of the fractured chemo port catheter. The catheter segment (Figure 1B, arrow) was lodged between the pulmonary artery trunk and a branch of the left pulmonary artery. The distal end of the catheter was surrounded by a 3.7-mm-diameter calcified tissue mass (Figure 1B, arrowhead). The patient declined angiography in view of the risks associated with extracting a heavily calcified and embedded catheter tip. The chemo port was still located below the right clavicle with a stump of the catheter connected to it. We hypothesize that entrapment (“pinch off”) and friction of the catheter between clavicle and first rib over many years resulted in fracture and embolization of the catheter. Increasingly, specialist nurses are responsible for the care of patients with central venous catheters and the removal of the devices.1 Current guidelines recommend the removal of unused ports.2 Case reports of embolized port catheters or so-called totally implanted venous devices are rare. Only about a third of the embolic events reported were localized in the pulmonary arteries, and about a quarter of patients were asymptomatic at the time of diagnosis.3 Catheter embolism may go undetected for prolonged periods of time and is often diagnosed incidentally. The risk of serious complications for patients with asymptomatic catheter embolism is unknown. Embolized catheter fragments should be removed to prevent further complications.

Individually-tailored multifactorial intervention to reduce falls in the Malaysian Falls Assessment and Intervention Trial (MyFAIT): A randomized controlled trial

Objective To determine the effectiveness of an individually-tailored multifactorial intervention in reducing falls among at risk older adult fallers in a multi-ethnic, middle-income nation in South-East Asia. Design Pragmatic, randomized-controlled trial. Setting Emergency room, medical outpatient and primary care clinic in a teaching hospital in Kuala Lumpur, Malaysia. Participants Individuals aged 65 years and above with two or more falls or one injurious fall in the past 12 months. Intervention Individually-tailored interventions, included a modified Otago exercise programme, HOMEFAST home hazards modification, visual intervention, cardiovascular intervention, medication review and falls education, was compared against a control group involving conventional treatment. Primary and secondary outcome measures The primary outcome was any fall recurrence at 12-month follow-up. Secondary outcomes were rate of fall and time to first fall. Results Two hundred and sixty-eight participants (mean age 75.3 ±7.2 SD years, 67% women) were randomized to multifactorial intervention (n = 134) or convention treatment (n = 134). All participants in the intervention group received medication review and falls education, 92 (68%) were prescribed Otago exercises, 86 (64%) visual intervention, 64 (47%) home hazards modification and 51 (38%) cardiovascular intervention. Fall recurrence did not differ between intervention and control groups at 12-months [Risk Ratio, RR = 1.037 (95% CI 0.613–1.753)]. Rate of fall [RR = 1.155 (95% CI 0.846–1.576], time to first fall [Hazard Ratio, HR = 0.948 (95% CI 0.782–1.522)] and mortality rate [RR = 0.896 (95% CI 0.335–2.400)] did not differ between groups. Conclusion Individually-tailored multifactorial intervention was ineffective as a strategy to reduce falls. Future research efforts are now required to develop culturally-appropriate and affordable methods of addressing this increasingly prominent public health issue in middle-income nations. Trial registration ISRCTN Registry no. ISRCTN11674947

Unruptured Sinus of Valsalva Aneurysm with Right Ventricular Outflow Tract Obstruction and Supracristal Ventricular Septal Defect: A Rare Case

Unruptured right sinus of Valsalva aneurysm that causes severe obstruction of the right ventricular outflow tract is extremely rare. We describe the case of a 47-year-old woman who presented with exertional dyspnea. Upon investigation, we discovered an unruptured right sinus of Valsalva aneurysm with associated right ventricular outflow tract obstruction and a supracristal ventricular septal defect. To our knowledge, only 2 such cases have previously been reported in the medical literature. Although treatment of unruptured sinus of Valsalva aneurysm remains debatable, surgery should be considered for extremely large aneurysms or for progressive enlargement of the aneurysm on serial evaluation. Surgery was undertaken in our patient because there was clear evidence of right ventricular outflow tract obstruction, right-sided heart dilation, and associated exertional dyspnea.

Statements of the Malaysian Society of Gastroenterology & Hepatology and the National Heart Association of Malaysia task force 2012 working party on the use of antiplatelet therapy and proton pump inhibitors in the prevention of gastrointestinal bleeding.

The working party statements aim to provide evidence and guidelines to practising doctors on the use of antiplatelet therapy and proton pump inhibitors (PPIs) in patients with cardiovascular risk as well as those at risk of gastrointestinal (GI) bleeding. Balancing the GI and cardiovascular risk and benefits of antiplatelet therapy and PPIs may sometimes pose a significant challenge to doctors. Concomitant use of anti‐secretory medications has been shown to reduce the risk of GI bleeding but concerns have been raised on the potential interaction of PPIs and clopidogrel. Many new data have emerged on this topic but some can be confusing and at times controversial. These statements examined the supporting evidence in four main areas: rationale for antiplatelet therapy, risk factors of GI bleeding, PPI–clopidogrel interactions and timing for recommencing antiplatelet therapy after GI bleeding, and made appropriate recommendations.