Displaying publications 1 - 20 of 26 in total

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  1. Upadhyay DK, Manirajan Y, Iqbal MZ, Paliwal N, Pandey S
    J Res Pharm Pract, 2020 10 08;9(3):128-134.
    PMID: 33489980 DOI: 10.4103/jrpp.JRPP_20_8
    Objective: The present study aimed to assess the knowledge, attitude, and practice (KAP) of 3rd- and 4th-year medical, dental, and pharmacy students about hepatitis B (HB) infection at a private medical university, Malaysia.

    Methods: A cross-sectional, questionnaire-based study was conducted among 482 medical, dental, and pharmacy students of 3rd- and 4th-year degree program of Asian Institute of Medicine, Science and Technology University to assess their KAP about HB infection using 34 prevalidated questions by convenient sampling method. A questionnaire was administered to the students, and their responses were measured at "yes" and "no" scale. Students' responses were entered in SPSS version 22, and quantitative analysis was performed using descriptive statistics and nonparametric tests at P < 0.05.

    Findings: The medical, dental, and pharmacy students had good knowledge and practice with positive attitude about HB infection. Mann-Whitney U-test determined a significant difference in knowledge (P < 0.001) and practice (P < 0.001) scores between medical and pharmacy, attitude (P < 0.001) scores between medical and dental, and attitude (P < 0.001) and practice (P < 0.001) scores between pharmacy and dental students. Students' age was correlated with their attitude, practice, and KAP scores and family income with their knowledge, attitude, practice, and KAP scores.

    Conclusion: Although students' knowledge and practice were good with positive attitude, all the students did not participate in health education program, screening, and vaccination of hepatitis B virus (HBV) infection which makes them more vulnerable to occupational HBV infection. Hence, it is recommended to organize a regular health education program for the students on screening and vaccination against HBV to prevent its infection.

  2. Iqbal MZ, Khan AH, Iqbal MS, Syed Sulaiman SA
    J Pharm Bioallied Sci, 2019 10 18;11(4):299-309.
    PMID: 31619911 DOI: 10.4103/jpbs.JPBS_138_19
    A strict and adherence treatment is required by the patient with diabetes mellitus and it demands a proper self-medication by the patient. Pharmacists are involved in providing self-management support to the patients. This review evaluates the interventions of pharmacist for patients to improve self-management with diabetes mellitus and also to improve the clinical outcomes of diabetes mellitus. A comprehensive literature search was performed by using different keywords "pharmacist-led intervention," "diabetes," "effect of pharmacist on outcome of diabetes," and "self-management of diabetes" with the help of various electronic databases such as PubMed, Science Direct, Embase, Web of Science, and the Cochrane Library from the beginning of the database through September 2018. The primary outcome was glycated hemoglobin (HbA1c), whereas the secondary outcomes were blood glucose level, blood pressure (BP) measure, body mass index, lipids, adherence to medication, and quality of life. Twenty-five studies comprising 2997 diabetic patients were included in the analysis. Pharmacist-led intervention was involved in all included studies in the form of education on diabetes and its complications, medication adherence, lifestyle, and education about self-management skills. Pharmacist-led interventions are able to reduce HbA1c levels with a mean of 0.75%. Most studies do not expose the material and methods used in pharmacist-led intervention. The variation in the reduction of HbA1c, fasting blood sugar, BP, and lipid profile was due to the lack of this standardization. The included studies indicated that pharmacist-led interventions in diabetes mellitus can significantly improve the outcomes of diabetes mellitus and its complication later on. Hence, these long-term improvements in outcomes added more value of pharmacists in health-care system of the world.
  3. Iqbal MS, Bahari MB, Darwis Y, Iqbal MZ, Hayat A, Venkatesh G
    J AOAC Int, 2013 6 19;96(2):290-4.
    PMID: 23767352
    A simple and selective RP-HPLC-UV method with SPE was developed and validated for the quantification of cefotaxime in all-in-one total parenteral nutrition (AIO-TPN) admixtures. Chromatographic separation was achieved on a 5 pm particle size C18 DB column (250 x 4.6 mm id) using the mobile phase ammonium acetate (25 mM, pH 4.0)-50% acetonitrile in methanol (80 + 20, v/v). The flow rate was 0.9 mL/min and the detection wavelength was 254 nm. The analyte was extracted from AIO-TPN admixtures by means of an SPE method. The cefotaxime calibration curve was linear over a concentration range of 100-1400 microg/mL with a correlation coefficient of > or = 0.9994. The intraday accuracy and precision for cefotaxime were < or = -3.15 and < or = 3.08%, respectively, whereas the interday accuracy and precision were < or = -2.48 and < or = 2.25%, respectively. The method was successfully applied to stability studies of cefotaxime in the presence of micronutrients together with low and high concentrations of macronutrients in AIO-TPN admixtures. Cefotaxime was degraded by 13.00 and 26.05% at room temperature (25 +/- 2 degrees C) after 72 h in low and high macronutrient concentration formulations of AIO-TPN admixtures, respectively. The values of cefotaxime degradation rates for low and high macronutrient concentration formulations of AIO-TPN admixtures were -0.164 and -0.353, respectively. These results indicated that there was a higher rate of degradation in the AIO-TPN admixture formulations containing high concentrations of macronutrients.
  4. Iqbal MS, Kassab YW, Al-Saikhan FI, Almalki ZS, Haseeb A, Iqbal MZ, et al.
    Saudi Pharm J, 2020 Aug;28(8):936-942.
    PMID: 32792838 DOI: 10.1016/j.jsps.2020.06.014
    Background and aim: The effect of anticoagulation control on overall Health-Related Quality of Life (HRQoL) in patients taking warfarin in Malaysia has not been explored yet. Therefore, this study aimed to evaluate HRQoL among patients on warfarin in Malaysia.

    Methods: HRQoL among patients on warfarin was measured using WHOQOL-BREF (World Health Organization Quality of life Assessment: Brief Version). Descriptive and inferential statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 22.

    Results: Out of 319 patients, more female patients were observed than the males (n = 221, 69.3%, and n = 98, 30.7% respectively). Mean scores for the physical (61.14 ± 15.96), psychological (68.58 ± 16.11), social (63.55 ± 27.06) and environmental domains (62.78 ± 17.58) were observed. Statistically, a significant association was found between the comorbidities other than CVDs with health satisfaction (p = 0.002), physical (p = 0.001), psychological (p 

  5. Iqbal MS, Iqbal MZ, Iqbal MW, Bahari MB
    Value Health, 2015 Nov;18(7):A620.
    PMID: 26533480 DOI: 10.1016/j.jval.2015.09.2170
    Objectives: To evaluate the prevalence and patterns of CAM use among diabetes patients in Pakistan. In addition, the study also focused on the perceived effectiveness of CAM over conventional therapies, information seeking behavior and CAM disclosure to healthcare providers.
    Methods: A prospective, cross-sectional and self-administered questionnaire based study was conducted in tertiary care public hospitals in Pakistan. A prevalence based sample of 350 diabetes patients attending the tertiary hospital in Punjab, Pakistan were selected for the study. All obtained data were analyzed using descriptive and inferential statistics.
    Results: Overall, 327 questionnaires were completed and included in the analysis, showing that 52.8% of diabetics had used CAM, with most (62.4%) believing that CAM therapies assist body’s natural forces to heal. CAM usage was significantly associated with gender (P=0.001), level of education (P=0.001), employment status (P=0.03) and monthly income (P<0.001).
    Conclusions: Diabetes treatment and management requires compliance to effective therapies at early stages. Healthcare providers should engage diabetics in an open non-judgmental dialogue to ascertain better understanding of diabetes and its management options.
  6. Islam MA, Nisa ZU, Almuzel AI, Al Afif HS, Al Rabia LH, Iqbal MS, et al.
    Saudi Pharm J, 2021 Aug;29(8):874-878.
    PMID: 34408547 DOI: 10.1016/j.jsps.2021.07.002
    Purpose: This study aimed to evaluate the concurrent validity of the Arabic version of the General Medication Adherence Scale (GMAS) using two validated scales namely Adherence to Refills and Medications Scale (ARMS) and Medication Adherence Rating Scale (MARS) in Saudi patients with non-communicable diseases.

    Methods: A cross sectional study was conducted for 2 months in out-patient departments at a tertiary care hospital in Khobar, Saudi Arabia. The study collected data from patients with chronic illnesses through convenience sampling. Pearson correlation (ρ) was conducted to report concurrent validity of GMAS. A correlation coefficient value ≥ 0.5 with p-value  SAR 10,000, i.e., USD 2666.2 (56.4%). The mean adherence scores obtained from MARS, ARMS and GMAS were 7.09, 19.9, and 27.4. The correlation (ρ) between GMAS and MARS scores was 0.65, and between GMAS and ARMS scores was -0.79, p 

  7. Naqvi AA, Hassali MA, Iffat W, Shakeel S, Zia M, Fatima M, et al.
    Int J Rheum Dis, 2020 Jul;23(7):918-927.
    PMID: 32525287 DOI: 10.1111/1756-185X.13860
    AIM: To carry out cross-culture adaptation and validation of the English version of Rheumatoid Arthritis Knowledge Assessment Scale (RAKAS) in patients with rheumatoid arthritis (RA).

    METHODS: A cross-sectional study was conducted for 2 months in 2 tertiary care hospitals in Karachi, Pakistan. Sample size was calculated based on item-subject ratio. The translation was carried out using standard procedures for translation and cross-culture adaptation. The validation process included estimation of discrimination power, item difficulty index, factorial, convergent, construct and known group validities and reliability. Reliability of the scale was estimated using Kuder-Richardson Formula 20 and a value of σ2  ≥ 0.6 was acceptable. SPSS v23, Remark Classic OMR v6 software and MedCalc Statistical Software v16.4.3, were used to analyze the data. The study was approved by the relevant ethics committee (IRB#NOV:15).

    RESULTS: The mean score was 7.68 ± 2.52 (95% CI: 7.31-8.05) for 177 patients. The σ2  = 0.601, that is, >0.6, test-retest reliability ρ = .753, P 

  8. Iqbal MS, Muthanna FMS, Kassab YW, Hassali MA, Al-Saikhan FI, Iqbal MZ, et al.
    PLoS One, 2020;15(6):e0234734.
    PMID: 32555595 DOI: 10.1371/journal.pone.0234734
    INTRODUCTION: The effect of anticoagulation control on overall Health-Related Quality of Life (HRQoL) in patients taking warfarin in Pakistan has not been explored yet. Therefore, this study aimed to evaluate HRQoL among warfarin patients in Pakistan.

    METHODS: This cross-sectional study was conducted among patients on warfarin in Pakistan. By purposive sampling, data were collected using demographic data collection form and the World Health Organization Quality of Life: Brief Version (WHOQOL-BREF). The WHOQOL-BREF is comprised of four domains; physical, psychological, social relationships, and environment. Descriptive and inferential statistical analysis was done using SPSS version 22.

    RESULTS: Out of 295 warfarin patients, more females than males (<0.001) were observed (n = 184, 62.4%, and n = 111, 37.6% respectively). One hundred and eighteen (40.0%) patients were less than 30-years of age, whereas one hundred and seventy-seven (60.0%) patients were above 30-years of age. Mean scores for the physical (62.44±15.36), psychological (67.84±15.54), social (64.27±26.28) and environment domains (63.45±17.66) were observed.

    CONCLUSION: Patients had overall lower to moderate but satisfactory HRQoL scores in all four domains. Age, gender, employment status, education level, the indication of use and duration of warfarin therapy was associated with one or more domains of HRQoL among warfarin patients. The findings of this study would serve as a primary database for future studies. This study highlights how non-clinical factors could impact HRQoL in studied patients.

  9. Iqbal MZ, Khan AH, Sulaiman SAS, Ibrahim A, Azmi NSBY, Iqbal MS, et al.
    J Pharm Bioallied Sci, 2021 05 26;13(2):193-198.
    PMID: 34349479 DOI: 10.4103/jpbs.JPBS_488_20
    Background and Objective: Diabetes mellitus is a chronic disease which can lead to different complications in patients if not treated properly. An appropriate intervention from health care providers is needed to stop and decrease the progression of diabetic complication in diabetic patients. This study aimed to measure the effect of pharmacist intervention on improvement in sign and symptoms and progression of diabetic complications in diabetic patients.

    Methodology: Diabetic patients were randomly selected and divided into two groups from two tertiary care hospitals. Control group contained those 200 patients who were receiving usual treatment from hospitals. In contrast, the intervention group included those 200 patients who were receiving conventional treatment from hospitals together with separate counselling sessions with pharmacists from Diabetes Medication Therapy Adherence Clinic departments. The study continued for 1 year and two follow-up visits for both groups. A prevalidated data collection form was used to measure the improvement in sign and symptoms and progression of diabetic complication in diabetic patients. Statistical Package for the Social Sciences (SPSS) version 24 was used to analyze the data.

    Results: The average hemoglobin A1c (HbA1c) values decreased up to 1.43% in the control group and 2.82% in the intervention group. The intervention group showed significant improvement in HbA1c between groups (P < 0.05). The results of univariate and multivariate regression analysis showed that a statistically significant (P < 0.001) improvement was observed in all the predictors of diabetic complications among in the intervention group when compared with the control group.

    Conclusion: Statistically significant reduction in the sign and symptoms of diabetic complications was observed in the intervention group at the end of 1 year. The progression of diabetic neuropathy was significantly reduced in the pharmacist intervention group.

  10. Iqbal MZ, Iqbal MS, Khan AH, Sulaiman SA, Iqbal MW
    Value Health, 2014 Nov;17(7):A353.
    PMID: 27200693 DOI: 10.1016/j.jval.2014.08.744
    Conference abstract:
    OBJECTIVES.. To evaluate doctors’ adherence to Malaysian Clinical Practice Guideline (CPG) 2009 in the management of diabetes mellitus with co-morbidities in Malaysia.
    METHODS. Cross-sectional study was done at a tertiary-care hospital in Malaysia. Total 51 physicians and 1020 patients’ prescriptions written by same physicians (20 prescriptions per physician) were analyzed. All patients had diabetes mellitus with co-morbidities. Depending on the recommendations of CPG 2009, the prescriptions were clustered as adherent and non-adherent prescriptions. All obtained data were analyzed using descriptive and inferential statistics.
    RESULTS. A statistically significant negative association (Ф= 0.094, p-value=0.003) was observed between diabetes mellitus control and co-morbidities. CPG adherent had statistically weak negative association (Ф= - 0.081, p-value=0.010) with patients having co-morbidities (41.6%). No statistically significant association was observed between CPG adherence and any other co-morbidity. Majority of the patients received guidelines-compliant pharmacotherapy. The overall good level of physician adherence with CPG 2009 was observed in the management of diabetes mellitus with co-morbidities.
    CONCLUSIONS. The study explored several features of prescription pattern of the physicians involved in the management of diabetes mellitus with co-morbidities and recognized the need for improvement in their prescription pattern for treating the diabetes mellitus.
  11. Khan AH, Iqbal MZ, Syed Sulaiman SA, Ibrahim A, Azmi NSBY, Iqbal MS, et al.
    J Pharm Bioallied Sci, 2020 12 21;13(1):108-115.
    PMID: 34084056 DOI: 10.4103/jpbs.JPBS_475_20
    Objective: Diabetes mellitus (DM) is a chronic metabolic disorder that can initiate organ damage inside the body if not treated appropriately. Apart from tight glycemic control, a suitable educational intervention is also needed from health-care providers to stop or decrease the progression of organ damage in diabetic patients. This study intended to measure the impact of pharmacist-led educational intervention on improvement in predictors of diabetic foot in two different hospitals in Malaysia.

    Materials and Methods: In two tertiary care selected hospitals, the included diabetic patients were randomly divided into two study arms. In the control group, 200 patients who were receiving usual treatment from hospitals were included. However, in the intervention group, those 200 patients who were receiving usual treatment along with counseling sessions from pharmacists under the Diabetes Medication Therapy Adherence Clinic (DMTAC) program were included. The study continued for 1 year, and there were four follow-up visits for both study arms. A prevalidated data collection form was used to measure the improvement in predictors of diabetic foot in included patients. Data were analyzed by using the Statistical Package for the Social Sciences (SPSS) software program, version 24.0.

    Results: With the average decrease of 1.97% of HbA1c values in the control group and 3.43% in the intervention group, the univariate and multivariate analysis showed a statistically significant difference between both of the study arms in the improvement of predictors belonging to the diabetic foot (P < 0.05). The proportion of patients without any signs and symptoms of the diabetic foot in the intervention group was 91.7%, which increased from 42.3% at baseline (P < 0.05). However, this proportion in the control group was 76.9% at the fourth follow-up, from 48.3% at baseline (P < 0.05).

    Conclusion: A statistically significant reduction in the signs and symptoms of diabetic foot was observed in the intervention group at the end of 1 year. The progression of diabetic foot was significantly decreased in the pharmacist intervention group.

  12. Tahir M, Upadhyay DK, Iqbal MZ, Rajan S, Iqbal MS, Albassam AA
    J Pharm Bioallied Sci, 2020 10 08;12(4):436-443.
    PMID: 33679090 DOI: 10.4103/jpbs.JPBS_263_20
    Introduction: Community pharmacist's knowledge about the uses of herbal medicines and its adverse drug reactions reporting can contribute in better therapeutic outcomes and patient safety. Objectives: To evaluate community pharmacists' knowledge about the use of herbal medicines and its adverse drug reactions reporting in Kedah state, Malaysia.

    Methods: A cross-sectional, questionnaire-based study was conducted among 103 pharmacists from 74 different community pharmacies to assess their knowledge about the use of herbal medicines and its adverse drug reaction reporting by using a pre-validate knowledge questionnaire consisting of 12 questions related to it. The pharmacists' responses were measured at a 3-point Likert scale (Poor=1, Moderate=2, and Good=3) and data was entered in SPSS version 22. The minimum and maximum possible scores for knowledge questionnaires were 12 and 36 respectively. Quantitative data was analyzed by using One Way ANOVA and Paired t-test whereas Chi-square and Fisher exact test were used for qualitative data analysis. A p-value of less than 0.05 was considered statistically significant for all the analyses.

    Results: About 92% of the pharmacist had good knowledge regarding the use of herbal medicines and its adverse drug reaction reporting with a mean knowledge score of 32.88±3.16. One-way ANOVA determined a significant difference of employment setting (p<0.043) and years of experience (<0.008) with mean knowledge scores of Pharmacists. Pharmacists' knowledge was significantly associated with their years of experience with the Chi-square test.

    Conclusion: Pharmacists exhibit good knowledge regarding the use of herbal medicines and its adverse drug reaction reporting. However, with an increasing trend of herbal medicine use and its adverse drug reaction reporting it recalls the empowerment of experienced pharmacists with training programs in this area for better clinical outcomes.

  13. Mohiuddin SG, Aziz S, Iqbal MZ, Naqvi AA, Ahmed R, Mahmoud MA, et al.
    J Pharm Bioallied Sci, 2020 01 29;12(1):57-63.
    PMID: 32801601 DOI: 10.4103/jpbs.JPBS_182_19
    Purpose: The demand of complementary and alternative medicine (CAM) has increased drastically over the past few decades. The perceptions about CAMs among general population are positive. However, the literature highlights that effectiveness and acceptance of alternative therapies among the general population is still a subject of debate.

    Materials and Methods: This is a cross-sectional study and the response along with demographic details was collected through a validated questionnaire; the results were analyzed by using a validated data collection tool. The results were concluded based on good, moderate, and poor responses, which were evaluated through data analysis by using the Statistical Package for the Social Sciences software version 20.0., SPSS Inc., Chicago, III, USA. A value of P < 0.05 was considered statistically significant.

    Results: In total, 182 (44.4%) of male and 228 (55.6%) of female respondents were selected for this study. Studies showed that a greater knowledge level was observed among female respondents (15.55 ± 2.7, P < 0.001). The selected Chinese population had relatively good knowledge (i.e., 15.63, P = 0.006). People practicing Buddhism had also good knowledge. Rural population had lesser family income and showed a good practice pattern and understanding (P = 0.006). The positive attitude was identified among women ( P < 0.001) with a mean score of 15.55 ± 2.7. Postgraduate participants were found to have diverse results with SD ± 6.23, and 77.1% had a good attitude. A statistically significant association was observed between religion and attitude of respondents (P < 0.001).

    Conclusion: Although a better practice was noticed in Malaysian population, more awareness is required and knowledge should be disseminated among the population to improve the overall health and quality of life in Malaysia.

  14. Iqbal MZ, Rathi R, Prajapati SK, Omar K, Bahari MB, Rajan S, et al.
    J Pharm Bioallied Sci, 2021;13(1):123-128.
    PMID: 34084058 DOI: 10.4103/jpbs.JPBS_298_20
    OBJECTIVE: The objective of the study was to evaluate the knowledge, attitude, and practice among pre-final and final year students of pharmacy, medicine, biotechnology, and business faculties about oral hygiene.

    MATERIALS AND METHODS: A cross-sectional observational study was conducted to evaluate the knowledge, attitude, and practice of students towards oral hygiene at a private university in Malaysia. Validated questionnaires were distributed to a convenient stratified sample of 324 students studying in the different selected faculties, namely pharmacy, medicine, biotechnology, and business, respectively. The Statistical Package for Social Science (SPSS) Version 24.0 was used to analyze the data.

    RESULTS: With regard to knowledge, upon evaluation, it was seen that the students of the Faculty of Pharmacy had the highest percentage of adequate knowledge, which was statistically significant with a P-value of 0.001 and the effect size of 0.246. On the evaluation of attitudes, it was seen that the Faculty of Biotechnology had the highest positive attitudes. According to race, Malay students had the highest positive attitude among all the races that participated in the study, which showed a P-value of 0.037 with the effect size of 0.034. Regarding practice, the Faculty of Pharmacy had the lowest practice compared with the other faculties. This variable had a P-value of 0.001 and showed to have significance against the practice with an effect size of 0.193.

    CONCLUSION: Overall, a good attitude was seen amongst the students on their oral hygiene. It was also observed that the attitude, knowledge, and practice of the students in a private university increased with an increasing level of education.

  15. Iqbal MS, Iqbal MZ, Barua A, Veettil SK, Wei LY, Kit LW, et al.
    Value Health, 2014 Nov;17(7):A594.
    PMID: 27202037 DOI: 10.1016/j.jval.2014.08.2046
    OBJECTIVES. Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) appears to be the main reason of hospitalization in COPD patients. Since substantial economic burden of COPD have not been previously studied in Malaysia, this study aimed at estimating and identifying different costs and related burden of illness in patients receiving treatment of AECOPD in a tertiary care hospital in Malaysia.
    METHODS. A prospective follow-up study was performed in Department of Accident and Emergency and Respiratory Medicine of the hospital. Data were derived on the basis of per exacerbation episode. Relationship between direct medical costs and disease severity was analyzed using various descriptive and inferential statistical approaches.
    RESULTS. Median actual direct medical costs and out-of-pocket costs were RM 457.68 (US$ 141.97) and RM 28.25 (US$ 8.76) per exacerbation respectively. Drug cost (41%) was the leading cost driver, followed by unit cost of treatment per bed (33.6%) and lab investigation cost (25.4%). However, food cost (44.2%) represented the largest proportion in out-of-pocket costs. More than 90% of actual direct medical costs were supported by the Government of Malaysia in the patients studied.
    CONCLUSIONS. Impacts of AECOPD in health care resources are worthy of attention. Cost information from pharmacoeconomic studies is important in decision making for health care professionals and policy makers in order to improve health care outcome and minimize costs.
  16. Iqbal MS, Iqbal MZ, Barua A, Veettil SK, Ling TK, Yong NB, et al.
    Value Health, 2014 Nov;17(7):A594.
    PMID: 27202038 DOI: 10.1016/j.jval.2014.08.2045
    Objectives: The cost of acute exacerbations of asthma had not been well studied in literature. The aim of this study was to identify and quantify the (average) cost of moderate and severe exacerbations of asthma in patients attending tertiary-care setup in Malaysia. The related burden of exacerbations was also calculated.
    Methods: The costs including lab investigation charges, unit costs of treatment per bed, medication charges, food costs, transportation costs and loss of productivity were calculated per asthma episode. Data was analysed by Statistical Package for the Social Sciences (SPSS) version 18.0 using various descriptive and inferential statistical tests.
    Results: A median medical cost of acute exacerbation of asthma under Ministry of Health’s (MOH) perspective was USD 105.00 (RM338.47) per episode. Medication cost comprised the majority (52.38%) of the total medical costs. A median medical cost of acute exacerbation of asthma under patient’s perspective was USD 1.55 (RM4.99) per episode. ConclusionsAsthma exacerbation and length of stay in the hospital were proportional to the direct medical costs. In Malaysia, a substantial proportion of the direct medical cost of asthma treatment is heavily subsidised for the locals.
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