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Background: The Global Initiative for Asthma (GINA) has suggested the need for more studies on inhaled corticosteroid (ICS)-formoterol in the Emergency Department (ED)., Objectives: We aimed to compare the outcomes of budesonide/formoterol (160/4.5 mcg/inhalation) turbuhaler versus pressurized metered-dose inhaler (pMDI) salbutamol (100 mcg/puff) in acute asthma in the outpatient ED., Methods: This single-centre, prospective, randomized, and open-label study involved adult asthma patients with mild to moderate asthma exacerbation who attended the outpatient ED of a tertiary hospital in Malaysia. The intervention arm received budesonide/formoterol (Symbicort ® 160/4.5 mcg) turbuhaler, while the control arm received pMDI salbutamol with a valved holding chamber. Stratified randomization with variable baseline ICS use was employed. Direct discharge rate from outpatient ED was the primary outcome. Vital signs pre- and post-treatment between the two arms were also compared., Results: Seventy-four ( n  = 37 for each arm) asthma patients were recruited. Baseline clinical characteristics were comparable between the two arms. Direct discharge rates from ED were comparable between the intervention (94.6%) and the control (91.9%) arms ( p  = 1.000). Post-treatment outcomes (respiratory rate, oxygen saturation, peak expiratory flow rate) were similar between the two arms, except for the higher increment of heart rate ( p  < 0.001) and lesser reduction of blood pressure in the control arm ( p  = 0.013). Intravenous hydrocortisone use was significantly higher in the control arm ( n  = 19, 51.4%) than in the budesonide/formoterol arm ( n  = 6, 16.2%) ( p  = 0.001)., Conclusion: Budesonide/formoterol turbuhaler is as effective as pMDI salbutamol in treating asthma exacerbation in the outpatient ED with less effect on heart rate and lower usage of intravenous corticosteroids.

Understanding the patients' clinical profile, barriers to optimal inhaler use, and adherence are crucial in achieving the treatment goal for asthma and chronic obstructive pulmonary disease (COPD). This study aimed to assess the inhaler technique and identify the predictors of inhaler adherence among asthma and COPD patients who presented to the Emergency Department (ED). This prospective cross-sectional study recruited patients who presented to the outpatient ED of a tertiary hospital for mild-to-moderate exacerbation from March 2022 to February 2023. Convenience sampling was used in this study. The inhaler techniques and adherence of all subjects were evaluated. Regression analysis was used to identify predictors of inhaler adherence. We recruited 120 subjects with a mean age of 47.8 ± 16.0 and were predominantly asthma patients (n = 85, 70.8%). Most were on regular follow-up (n = 72, 60.0%) and adhered to their inhaler(s) (n = 86, 71.7%). Less than half of the subjects use their inhaler(s) correctly (n = 45, 37.5%). Three predictors of inhaler adherence were identified: regular follow-up (aOR 2.072, p = 0.041), correct inhaler technique (aOR 3.071, p = 0.039), and ability to explain inhalers' mode of action (aOR 10.906, p = 0.031). The high rate of wrong inhaler techniques among asthma and COPD patients is worrisome. Identified predictors of inhaler adherence should be targeted when managing this group of patients. In addition to the exacerbation treatment in the ED, referrals to public primary health clinics for regular follow-ups, evaluation of inhaler techniques, and counseling to enhance patient knowledge are crucial., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Background: Bleeding outcomes are crucial primary safety endpoints in studies involving thrombolytic agents. This study aimed to determine the incidence, characteristics and mortality outcomes of bleeding following ST-elevation myocardial infarction (STEMI) thrombolysis in an Asian population., Methods: This single-centre retrospective study included all STEMI patients who received thrombolytic therapy from 2016 to 2020 in a Malaysian tertiary hospital. Total population sampling was used in this study. The primary outcome was bleeding events post-thrombolysis, categorised using the Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria. Inferential statistics were used to determine the associations between relevant variables., Results: Data from 941 patients were analysed. A total of 156 (16.6%) STEMI patients bled post-thrombolysis. Major, minor, and minimal TIMI occurred in 7 (0.7%), 17 (1.8%), and 132 (14.0%) patients, respectively. Age 65 years ( P =0.031) and Malaysian Chinese ( P =0.008) were associated with a higher incidence of bleeding post-thrombolysis. Conversely, foreigners ( P =0.032) and current smoker ( P =0.007) were associated with a lower incidence of bleeding. Both TIMI major ( P <0.001) and TIMI minor ( P <0.001) were associated with a higher incidence of all-cause in-hospital mortality among STEMI patients. TIMI minor bleeding was significantly higher in the streptokinase recipients. The bleeding sites were comparable between streptokinase and tenecteplase recipients, except for a significantly higher incidence of gastrointestinal bleeding in the streptokinase recipients ( P =0.027)., Conclusion: In our Asian population, the incidence of total bleeding events following STEMI thrombolysis is comparable to that previously reported. The development of TIMI major and minor bleeding complications is associated with higher mortality., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest., (Copyright: © World Journal of Emergency Medicine.)

Pharmacological reperfusion remains the primary strategy for ST-elevation myocardial infarction (STEMI) in low- and medium-income countries. Literature has reported inconsistent incidences and outcomes of failed thrombolysis (FT). This study aimed to identify the incidence, mortality outcomes and predictors of FT in STEMI pharmacological reperfusion. This single-centre retrospective cohort study analyzed data on consecutive STEMI patients who received thrombolytic therapy from 2016 to 2020 in a public tertiary hospital. Total population sampling was used in this study. Logistic regression analyses were used to assess independent predictors of the mortality outcomes and FT. We analyzed 941 patients with a mean age of 53.0 ± 12.2 years who were predominantly male (n = 846, 89.9%). The in-hospital mortality was 10.3% (n = 97). FT occurred in 86 (9.1%) patients and was one of the predictors of mortality (aOR 3.847, p < 0.001). Overall, tenecteplase use (aOR 1.749, p = 0.021), pre-existing hypertension (aOR 1.730, p = 0.024), history of stroke (aOR 4.176, p = 0.004), and heart rate ≥ 100 bpm at presentation (aOR 2.333, p < 0.001) were the general predictors of FT. The predictors of FT with streptokinase were Killip class ≥ II (aOR 3.197, p = 0.004) and heart rate ≥ 100 bpm at presentation (aOR 3.536, p = 0.001). History of stroke (aOR 6.144, p = 0.004) and heart rate ≥ 100 bpm at presentation (aOR 2.216, p = 0.015) were the predictors of FT in STEMI patients who received tenecteplase. Mortality following STEMI thrombolysis remained high in our population and was attributed to FT. Identified predictors of FT enable early risk stratification to evaluate the patients' prognosis to manage them better., (© 2023. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Introduction: Some guidelines had recommended "thrombolysis first" in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre., Methods: This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays., Results and Discussion: We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02-4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic., Conclusion: STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Fibrinolysis remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries. The outcomes and factors affecting mortality in STEMI fibrinolysis in the Asian population are lacking despite being widely used., Objectives: This study aimed to assess the clinical profile of patients and predictors affecting STEMI mortality in an Asian population., Methods: This single-center retrospective study analyzed data from STEMI patients who received fibrinolytic therapy from 2016 to 2020 in a tertiary hospital. Logistic regression analysis was performed to identify the significant predictors of the 30-day all-cause mortality, the primary outcome., Results: A total of 859 patients were included. Their mean age was 53.6 ±12.1 years and they were predominantly male (n=769, 89.4%). The majority of them had anterior involvement STEMI (n = 477, 55.5%) and presented with Killip ≥ II (n = 424, 49.4%). The 30-day all-cause mortality was 12.0% (n =  103). The final model found six predictors for 30-day mortality: age ≥75 (aOR 4.784, p < 0.001), female gender (aOR 2.869, p = 0.001), pre-existing hypertension (aOR 1.623, p = 0.046), anterior myocardial infarction (MI) (aOR 1.947, p < 0.001), Killip class (p < 0.001) and heart rate ≥100 at presentation (aOR 1.823, p =  0.016). Following fibrinolytic therapy, five predictors were found to affect 30-day mortality, i.e. failed fibrinolysis (aOR 2.094, p = 0.041), bleeding events, congestive heart failure (aOR 3.554, p = 0.046), ventricular fibrillation/ tachycardia (aOR 5.920, p < 0.001), and atrial fibrillation/ flutter (aOR 2.968, p = 0.016)., Conclusion: Our STEMI patients were younger and more ill at presentation. The risk predictors on 30-day all-cause mortality identified in our Asian population allow the clinicians to better triage and manage STEMI patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Fibrinolysis using streptokinase or tenecteplase remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries, including Malaysia. Comparative outcomes of these two fibrinolytic agents in the Asian population were inconclusive despite being widely used. Aim We aimed to assess and compare the outcomes of streptokinase versus tenecteplase in STEMI reperfusion of an Asian population. Method This single-centre retrospective study analysed data on STEMI patients who received fibrinolytic therapy from 2016 to 2020 in the Emergency Department of the largest tertiary hospital in Malaysia. Total population sampling was used in this study. Based on the propensity score matching, 359 patients receiving streptokinase were matched against 359 patients receiving tenecteplase by incorporating 16 variables that potentially affect mortality. 30-day mortality, stroke and major bleeding were the primary outcome measures. Results There was no significant difference in 30-day mortality between streptokinase (n = 39, 11.2%) and tenecteplase (n = 46, 13.2%) groups (p = 0.418). The rates of ischemic strokes [streptokinase (n = 1, 0.3%) versus tenecteplase (n = 3, 0.9%), p = 0.624], intracranial haemorrhage [streptokinase (n = 3, 0.9%) versus tenecteplase (n = 1, 0.3%), p = 0.624] and major bleeding [streptokinase (n = 4, 1.1%) versus tenecteplase (n = 3, 0.9%), p = 0.624], were comparable for the two groups. The incidences of failed thrombolysis were significantly higher in the tenecteplase arm. Hypotension and allergic reaction were significantly higher in the streptokinase arm. Conclusion Streptokinase and tenecteplase are fibrinolytic agents with similar efficacy and safety in STEMI reperfusion therapy in our Asian population., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background Appropriate antimicrobial prescribing in the emergency department (ED) is a challenge due to diagnostic uncertainty, time pressure, and clinical inertia. Objective To assess the appropriateness of antimicrobial prescribing in the ED. Setting This study was conducted in the inpatient ED of a tertiary hospital in Malaysia. Method We conducted a 6-month retrospective antimicrobial prescriptions analysis among ED patients who received intravenous antimicrobial. Antimicrobial prescriptions of conveniently selected adult patients were evaluated with the medication appropriateness index. Main outcome measure Appropriateness of antimicrobial prescribing was the primary outcome measure. Results We analysed 310 patients with 326 antimicrobial prescriptions. Ceftriaxone (41.1%, n = 134) and amoxicillin-clavulanate (36.5%, n = 119) were the most common antimicrobials prescribed. Respiratory infections (71.5%, n = 233) was the main indication for antimicrobial therapy in the ED. All antimicrobials prescribed were indicated as per the Malaysian antimicrobial guidelines. The overall rate of inappropriate antimicrobial prescribing was 53.1% (n = 173). Thirty-two (9.8%) antimicrobials were prescribed with inappropriate doses; the majority was related to beta-lactam/beta-lactamase dose (p = 0.002). One hundred and forty-three (43.9%) antimicrobials prescribed had alternatives with similar efficacy but were less costly; which referring to ceftriaxone usage (p < 0.001). Conclusions The inappropriate antimicrobial prescribing in the emergency department is prevalent. This emphasises the importance of conducting antimicrobial stewardship initiative in the ED to improve the appropriate dosing of beta-lactam/beta-lactamase inhibitors as well as the judicious use of ceftriaxone., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

There is a wide variation on the efficacy of three-factor Prothrombin Complex Concentrate (3F-PCC) in warfarin reversal. We aimed to determine the efficacy and safety of 3F-PCC in warfarin reversal. This multicentre prospective study analysed data from adult patients on warfarin who received 3F-PCC (Prothrombinex-VF®) for anticoagulation reversal between June 2019 to October 2020. Purposive sampling was used in this study. Study endpoints included target INR achievement, adverse drug reactions (ADRs), and in-hospital all-cause mortality. Logistic regression analyses were used to assess independent predictors of study endpoints. One-hundred thirty-seven patients with a median age of 68 (59-76) years were recruited, who were predominantly male (59.9%, n = 82). A total of 102 patients required 3F-PCC for life-threatening (40.9%, n = 56) and clinically significant bleeding (33.6%, n = 46). Initial INRs ranged from 1.55 to undetectable high (> 26). All patients had INR reduction, of which 62% (n = 85) achieved target INR, whereas 12.4% (n = 17) achieved INR below the target range. Median INR was reduced from 4.76 (3.14-8.32) to 1.54 (1.27-1.88) post-3F-PCC (p < 0.001). The use of adjunctive reversal agents and initial INR < 3.6 were the significant predictors for target INR achievement. Six (4.4%) ADRs were observed. Two (1.5%) cases with the suspected acute coronary syndrome were associated with mortality. Ischemic stroke occurred in one (0.7%) patient. The incidence of in-hospital all-cause mortality was 21.2% (n = 29). The rate of INR achievement was 62% in our study without apparent increased risk of thromboembolic events and in-hospital all-cause mortality., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

What Is Known and Objective: Nebulizer use has been suspended in Malaysian public health facilities due to the potential to aggravate COVID-19 nosocomial transmission. Currently, our facility uses the pressurized metered-dose inhaler (pMDI) bronchodilator with Venturi mask modified spacer (VMMS) in patients visiting the Emergency Department (ED) for mild to moderate exacerbation of asthma and chronic obstructive pulmonary disease (COPD). We sought to assess the outcomes and acceptance of pMDI-VMMS in the outpatient ED of a tertiary hospital in Malaysia., Methods: We analysed the total visits and discharge rates during periods of using the nebulizer and current pMDI-VMMS methods. The acceptance of pMDI-VMMS by patients and assistant medical officers (AMOs) were assessed by questionnaire., Results and Discussion: We analysed 3184 ED visits and responses from 103 patients and 32 AMOs. The direct discharge rate was similar for both nebulizer (n = 2162, 92.5%) and pMDI-VMMS method (n = 768, 90.7%) (p-value = 0.120). Twenty-eight patients (27.2%) favoured the pMDI-VMMS over the nebulizer, whereas 36 patients (35.0%) had no preference for either method. Sixty-four patients (62.1%) felt that the current pMDI-VMMS method was better or at least as effective in relieving their symptoms as a nebulizer. The current method was favoured over the nebulizer by twenty-seven AMOs (84.4%). Twenty-eight (87.5%) AMOs suggested that the current method was more effective than the nebulizer., What Is New and Conclusion: The bronchodilator delivered via pMDI-VMMS appeared to be comparable to nebulizer in treating mild to moderate asthma and COPD exacerbations in the outpatient ED. Most patients and AMOs accepted the use of pMDI-VMMS in the outpatient ED during the current COVID-19 pandemic. The Venturi mask modified spacer can be a cheap and effective alternative to the commercial spacer in a resource-limited situation., (© 2021 John Wiley & Sons Ltd.)