Noor Zurani

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Abstract: The purpose of this systematic review was to analyze and determine the effectiveness of autologous chondrocyte implantation (ACI) when compared with other treatment modalities, which includes microfracture, mosaicplasty, abrasionplasty, bone marrow-derived mesenchymal stem cell (BMSC), and matrix-assisted autologous chondrocyte implantation (MACI). Literature search using online databases PubMed, Scopus, National Institute for Clinical Excellence and Cochrane controlled trial register regarding all cell-based therapies and other interventions for chondral lesions was explored. Data on clinical outcome and repair quality were analyzed. Duplicates and irrelevant articles were omitted. Seventeen (n = 17) studies were included in this review. Among the four trials on ACI versus mosaicplasty, two studies showed no differences in clinical scores, one suggested similar performance while the other suggested better results in tissue quality for ACI. A systematically performed assessment comparing ACI with microfracture shows better clinical outcomes and higher tissue quality after ACI. Studies comparing ACI with MACI or BMSC demonstrated similar results. Although many of these studies had substantial flaws, on the overall, the evidence comparing ACI with other treatment modalities shows better clinical outcomes and higher tissue quality. Despite significant differences between the methodologies employed by different researchers, we can conclude that all except two studies demonstrated ACI being the better treatment for cartilage defects. However, final conclusions regarding long-term effects are still difficult, and therefore, future studies are needed to answer the long-term effects of ACI.

Abstract: Background: The transition of drug policy from prohibition to harm reduction has never been easy. The deeply entrenched belief in prohibition shared by policy makers and religious leaders provided little room for alternatives, and change came only slowly. The non-governmental organisations (NGOs) in Malaysia played a pivotal role in effecting such a change. Understanding how they did so may be instructive for other similarly placed countries. Methods: Data collected via reviews of published secondary sources, media reports and in-depth interviews with pioneers of harm reduction drawn from NGOs, medical practitioners and the police were analysed to construct the paper. Results: The policy change was the outcome of competition between three groups in the drug policy subsystem - the state, the Muslim religious lobby and the NGOs. Developments such as the poor outcomes from the prohibition programmes and the outbreak of HIV/AIDS did not change policy but did lead to a rethink of core beliefs in the state alliance and spawned a state-NGO partnership. The subsequent failure to meet the Millennium Development Goal with respect to HIV/AIDS in 2005 - was seen as a failure of the Health Ministry which then led the final charge for a policy change arguing that a health crisis was imminent. The NGOs played a pivotal role in this process by educating their partners in the state coalition, by drawing academics and medical practitioners into advocacy and by engaging the religious lobby (albeit with varying success). They were also frontline players in implementing harm reduction programmes and successfully deflected criticisms from unconvinced Islamic groups away from the state. Conclusion: Given their central role in the needle-syringe exchange programme, the NGOs are well positioned to convince injecting drug users to opt for voluntary medical treatment. This can potentially reduce both the harm from drug use and the prevalence of it. (C) 2011 Elsevier B.V. All rights reserved.

Abstract: Salivary nicotine and salivary cotinine is widely used in clinical and epidemiological studies to validate smoking cessation. However, the reported collection for salivary nicotine and salivary cotinine vary by technique and duration. This study investigated the influence of salivary collection by unstimulation and stimulation technique of the concentration of salivary nicotine and salivary cotinine. It was found that unstimulated technique produced the highest salivary nicotine concentration, whereas stimulated technique produced the highest salivary cotinine concentration. The results of this study suggest that it is important to standardise salivary nicotine and cotinine collection technique.

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Abstract: Objectives: The objective of the study is to determine the prevalence of substance abuse for alcohol, cannabis, opiates, stimulants, solvent and other substances among patients with schizophrenia in Hospital Bahagia Ulu Kinta (HBUK), Perak , Central Peninsular of Malaysia. This study also aims to determine the association of substance abuse with aggression, the demographic characteristics and total duration of hospitalization. Methods: This was a retrospective cross-sectional study whereby the first 194 subjects diagnosed to have schizophrenia based on International Classification of Disease, 10th edition (ICD-10) criteria were taken from data registry of patients admitted to HBUK from January until February 2004. The subjects� medical files were examined for documentation of substances abuse, aggression and accumulative duration of hospitalization. Results: The results showed the prevalence of substances misuse among patients with schizophrenia in general (including alcohol) was 24.7%. Cannabis 16.7%, alcohol 13.4%, opiates(heroin) 6.7%, Amphetamine type stimulants (amphetamine, metamphetamine, ecstacy) 5.7%, and other substances (benzodiazepine, solvents) 1.5%. Conclusion: There is higher prevalence of substance misuse in patients with schizophrenia as compared to general population. Male patients with history of substance misuse are more likely to have aggression than female. This group needs special precaution and probably in need of specialist help.

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Abstract: Recent advances in the fields of organ donation and organ transplant have introduced new hope for the treatment of serious diseases. However, this promise has been accompanied by several issues. The most common issue raised is ethical implications, but in a multicultural society like Malaysia, additional concerns arise pertaining to social and religious issues. These concerns needs to be addressed as attitudes toward and acceptability of organ donation varies according to social, culture, and religion. The diverse cultural, religious, and traditional concepts pertaining to organ donation may hamper its acceptability and cause a lack of willingness to donate organs. The purpose of this article is to briefly explore the ethical issues involved in organ transplant and the various religious opinions on organ donation. It is hoped that this knowledge and understanding may benefit both health care providers and patients in a multicultural society like Malaysia.

Abstract: Background: Cigarette smoking causes significant morbidity and mortality and is a major public health concern worldwide. Primary care doctors are in a unique position that enables them to promote smoking cessation, as smokers are more aware of their health at the time of their clinic visit. It is thus important to offer effective treatment to help smokers stop smoking. Methods: A search of PubMed was done up to 16 December 2009, using the keywords �varenicline� alone, �varenicline� and �family medicine�, and �varenicline� and �primary care�. The search produced 426 articles on varenicline. The articles that were chosen were case reports, meta-analyses, review articles and clinical trials published in English. Results: A new drug called varenicline has recently been introduced to assist smoking cessation. It is an α4β2 nicotinic acetylcholine receptor partial agonist. Varenicline has a unique action that relieves the cravings and withdrawal symptoms that occur during smoking abstinence, while blocking the receptor and preventing any reward from additional smoking. It has been shown to be efficacious for smoking cessation in normal smokers; however, its safety in smokers with mental health problems needs to be elucidated. Conclusion: The currently available data support the effectiveness of varenicline to treat nicotine dependence, but caution is needed in smokers with mental health problems. Thus, primary care doctors have a new pharmacological option to offer smokers who wish to stop smoking.

Abstract: Smoking cessation programmes have been available for almost 2 decades in Malaysia. However the programmes have mainly focussed on outpatient primary care settings. More attention is needed to address and treat smokers presenting to hospitals with acute and chronic medical illness as hospitals provide good settings to implement smoking cessation intervention. For instance, a tobacco related medical illness may boosts a smoker's motivation to stop, especially when the smoker perceives smoking as he cause of his illness and understands the gains achieved by smoking cessation. Besides bringing a smoker in contact with health personnel who may offer assistance to a smoker to help him stop smoking, a hospital stay also provide an opportunity for the health carer to initiate and practice the government policy of no smoking in the hospitals. This article addresses the importance of having a hospital-based smoking cessation programme for the Malaysian hospitals.

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Abstract: Objective: This case report highlights the risk of Torsade de Pointes (TdP), a life threatening cardiac arrhythmia in a heroin dependent patient receiving methadone substitution therapy who was prescribed erythromycin for upper respiratory tract infection. Method: We report a case of a 35-year-old Malay man on methadone maintenance treatment who developed TdP possibly due to drug interaction between methadone and erythromycin. Results: The patient reported feeling unwell, chest pain and feeling dizzy after consuming 2 doses of erythromycin. ECG monitoring showed prolonged rate-corrected QT interval leading to TdP. The patient was admitted to the ward where the cardiac arrhythmia ceased following methadone discontinuation. This cardiac arrhythmia was most likely due to drug interaction between methadone and erythromycin (an enzyme inhibitor) which led to an increase in methadone concentration and potentiated the adverse effects. Conclusion: As methadone is a beneficial treatment for heroin dependent patients, the risk of cardiac arrhythmia is of great concern. To avoid complications of drug interaction, patients on methadone therapy should be advised to seek medical assessment before taking other drugs. As TdP is life threatening, it is thus important that physicians and psychiatrists involved in the treatment of heroin dependent patients on methadone substitution therapy be made aware of this risk.

Abstract: Substance misuse, in particular heroin addiction contributes to health and social problems. Although effective medical treatment was available, earlier efforts confined the treatment of heroin addicts to in-house rehabilitation which required them to be estranged from the community and their families for 2 years. The in-house rehabilitative programme, implemented for at least three decades has produced low abstinence rates. On the other hand, being �away� meant that many heroin addicts faced employment problems and family relationship difficulties upon completing the in-house rehabilitation. However, recently, the concerted efforts by various government and non-government organisations, and the acknowledgement that heroin addiction is a medical illness has resulted in a revamp to approaching treatment of heroin addiction. At present, methadone substitution programmes have been offered as part of treatment programme for heroin addicts in Malaysia. This new programme has been shown to be effective in treating heroin addiction and would need support and cooperation from all groups involved.

Abstract: Issues. The growing use of illicit ketamine among young adults poses a public health concern in Malaysia. In contrast to medical use of ketamine, illicit use has been reported to produce adverse effects on the urinary tract and, in particular the bladder. Approach and Key Findings. This case report describes a young Malay woman who developed severe bladder symptoms (urinary frequency) after consuming illicit ketamine. A history of illicit ketamine use was initially missed, and she was consequently diagnosed and treated for a urinary tract infection. Her symptoms persisted despite several courses of antibiotics. The patient was subsequently referred to an urologist where cystoscopic examination and biopsy of the bladder found changes consistent with interstitial cystitis. This was despite the absence of haematuria. Renal function was normal. Implication. The patient's ketamine use was the most likely cause for the urinary symptoms and bladder changes. Conclusion. Illicit ketamine use may lead to severe urinary tract problems that can be irreversible even after ketamine has ceased. Early diagnosis is critical although difficult when ketamine use is not divulged during the consultation with the physician. Physician consideration of this new clinical entity is important, particularly in cases where the symptoms do not resolve with usual treatment. [Robson N, Vicknasingam B, Narayanan S. Illicit ketamine induced frequency of micturition in a young Malay woman. Drug Alcohol Rev 2010;29;334-336].

Abstract: Issues. Methadone, a pharmacological agent used to treat heroin dependence is relatively safe, but may cause cardiac arrhythmias in the concurrent presence of other risk factors. Approach and Key Findings. This case report highlights the risk of Torsade de Pointes, a life-threatening cardiac arrhythmia, in a heroin-dependent patient receiving methadone substitution therapy who was prescribed itraconazole for vaginal thrush. The patient presented to the accident and emergency department for chest discomfort and an episode of syncope following two doses of itraconazole (200 mg). Electrocardiogram monitoring at the accident and emergency department showed prolonged rate-corrected QT interval leading to Torsade de Pointes. The patient was admitted for cardiac monitoring, and electrocardiogram returned to normal upon discontinuation of methadone. Implication. This cardiac arrhythmia was most likely as a result of a drug interaction between methadone and itraconazole because the patient presented with no other risk factors. Conclusion. Given the benefits of methadone as a substitution treatment for heroin-dependent individuals, the association between methadone and cardiac arrhythmias is of great concern. Physicians treating heroin-dependent patients on methadone substitution therapy should therefore be cautious of the potential risk of drug interactions that may lead to fatal cardiac arrhythmias. [NoorZurani MHR, Vicknasingam B, Narayanan S. Itraconazole-induced Torsade de Pointes in a patient receiving methadone substitution therapy. Drug Alcohol Rev 2009;28:688-690].

Abstract: Nicotine replacement therapies (NRT) are prescribed in smoking cessation programmes to help smokers stop smoking. The ideal dosage of NRT should control cravings and withdrawal symptoms but avoid adverse reactions. This report describes a case of adverse reaction to nicotine gum in a female Malay smoker. Assays taken 2 h after the gum, showed that her plasma cotinine/nicotine ratio was 0.4, indicating poor nicotine metabolic status. She developed nausea, severe vomiting and diarrhoea with raised blood pressure and pulse rate, following the administration of a piece of 2 mg nicotine gum on an empty stomach. This was observed in the course of a study to determine nicotine metabolism. Nicotine gum may be associated with adverse reactions in those with poor nicotine metabolic rate. Further investigation is required into the clinical effects of nicotine gum in those with poor nicotine metabolic status.

Abstract: Despite being a common skin dermatosis in the tropics, physicians in the tropics may miss the diagnosis of cutaneous larva migrans for other pruritic skin manifestation. This is especially in those who live in urban housing with no history of travel. Cutaneous larva migrans, an intensely pruritic skin pathology is mainly contracted by people with history of beach holiday or contact with moist soft sand which had been contaminated with dog or cat faeces. This article reports a patient who presented with intensely itchy papular spots over the dorsum of his foot after walking barefooted in an urban toilet soiled with cat faeces. The patient had initially seen an urban general practitioner who diagnosed the papular skin lesion as an allergic reaction, and prescribed antihistamines. The patient subsequently developed creeping skin lesions and was seen by the author who prescribed albendazole 400 mg twice daily for three days. The patient reported reduction in itching after two days of albendazole treatment and a follow up at ten days revealed a healed infection.

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Abstract: Objective: To determine the effects of plant extract, nicotine and caffeine on the activities of the liver metabolizing-enzyme induced by pentobarbitone. Materials and Method: Seven groups of mice were pretreated with high doses of sample extracts (0.4 mg/g body weight sample extract, but nicotine at 0.1 mg/g body weight) and one control group was pretreated with saline. On day 5, pentobarbitone (0.005 ml of 8 mg/ml) was administered and the sleeping time was determined. The test was repeated but at low doses (0.1 mg/g body weight sample extract, but nicotine at 0.05mg/g body weight). Results: At high doses, bitter gourd, 'tempeh', nicotine, caffeine, nicotine+bitter gourd, nicotine+'tempeh' and nicotine+caffeine induced the activities of liver metabolizing enzyme significantly compared to control. At low doses, bitter gourd, nicotine, caffeine, nicotine+bitter gourd, nicotine+'tempeh' and nicotine+caffeine induced the enzyme but 'tempeh' did not. Conclusion: The findings suggest that bitter gourd, nicotine and caffeine act as enzyme inducers, but 'tempeh' only demonstrate this ability at high dose.

Abstract: Purpose: To report a case of adverse reaction to nicotine gum in a Chinese female with poor nicotine metabolic status after chewing a piece of 2 mg nicotine gum (NG). Background: NG is prescribed in smoking cessation programs to help individuals stop smoking. In smoking cessation treatment, the dose of NG should control withdrawal symptoms but avoid adverse effects. Case results: We describe a case of an adverse reaction following the administration of 2 mg NG to a female Chinese subject. This study compared a single dose of 2 mg NG with a single low dose cigarette (0.7 mg nicotine). Blood (5mL) was collected at baseline and 2h post exposure to NG. Blood pressure and pulse rate were also recorded. Nicotine metabolic rate was determined by calculation of the ratio of plasma cotinine (ng/mL)/plasma nicotine (ng/mL). The subject developed nausea and severe vomiting with raised blood pressure and pulse rate following administration of NG. The ratio of plasma cotinine/nicotine was 0.4 indicative of poor nicotine metabolic rate. Exposure to nicotine using the subject's normal cigarette did not produce similar adverse effects. Conclusion: NG may be associated with adverse reactions in smokers with low nicotine metabolic rate. Physicians in smoking cessation programs should be aware that some individuals may not tolerate this form of pharmacological treatment.

Abstract: BACKGROUND: xD;The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. xD;OBJECTIVES: xD;The aims of this review were:to determine the effectiveness of the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; to determine its effectiveness compared to other pharmacotherapies. xD;SEARCH STRATEGY: xD;We searched the Cochrane Tobacco Addiction Group trials register in March 2004. xD;SELECTION CRITERIA: xD;Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow up of less than six months. xD;DATA COLLECTION AND ANALYSIS: xD;We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. For each study we calculated summary odds ratios. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed effect model. xD;MAIN RESULTS: xD;We identified 123 trials; 103 contributing to the primary comparison between NRT and a placebo or non-NRT control group. The odds ratio (OR) for abstinence with NRT compared to control was 1.77 (95% confidence intervals (CI): 1.66 to 1.88). The ORs for the different forms of NRT were 1.66 (95% CI: 1.52 to 1.81) for gum, 1.81 (95% CI: 1.63 to 2.02) for patches, 2.35 (95% CI: 1.63 to 3.38) for nasal spray, 2.14 (95% CI: 1.44 to 3.18) for inhaled nicotine and 2.05 (95% CI: 1.62 to 2.59) for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum (OR 2.20, 95% CI: 1.85 to 3.25). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy. In this study quit rates with bupropion were higher than with nicotine patch or placebo. xD;REVIEWERS' CONCLUSIONS: xD;All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase the odds of quitting approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.