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  1. Fulltext A medication-estimated health status measure for predicting primary care visits: the Long-Term Therapeutic Groups Index
    Dhabali AA, Awang R
    Health Policy Plan, 2010 Mar;25(2):162-9.
    PMID: 19923207 DOI: 10.1093/heapol/czp051
    BACKGROUND: Managed care is one of the means advocated for health care reforms. The Malaysian government has proposed managed care for its citizens. In the Malaysian private health care sector, managed care is practised on a small scale with crude risk adjustment. The main determinant of an individual's health service utilization is their health status (HS). HS is used as a risk adjuster for capitation payment. Prescribed medications represent a useful source for HS estimation. We aimed to develop and validate a medication-based HS estimate and to incorporate it in the Andersen model of health service utilization. This is a preparatory step in studying the feasibility of developing a model for risk assessment in the Malaysian context.
    METHODS: Data were collected retrospectively from an academic year from computerized databases in University Sains Malaysia (USM) about users of USM primary care services. A user is a USM health scheme beneficiary who made at least one visit in the academic year to USM-assigned primary care providers. Socio-demographic variables, enrolment period, medications prescribed and number of visits were also collected. Chronic illness medications and some non-chronic illness medications were used to calculate the Long-Term Therapeutic Groups Index (LTTGI) which is an estimate of the HS of users. Using a random 50% of users, weighted least square methods were used to develop a model that predicts a user's number of visits. The other 50% were used for validation.
    RESULTS: Socio-demographic variables explained 15% of variability in number of primary care visits among users. Adding the LTTGI improved the explanatory power of the model to 36% (P < 0.001). A similar contribution of the LTTGI was noted in the validation.
    CONCLUSIONS: The Long-Term Therapeutic Groups Index was successfully developed. Variability in number of primary care visits can be predicted by LTTGI-based models.
  2. Fulltext A bibliometric analysis of research productivity of Malaysian publications in leading toxicology journals during a 10-year period (2003-2012)
    Zyoud Sh, Al-Jabi S, Sweileh W, Awang R
    Hum Exp Toxicol, 2014 Dec;33(12):1284-93.
    PMID: 24505047 DOI: 10.1177/0960327113514101
    Toxicology in Malaysia has experienced rapid development and made great progress in education and research in conjunction with economic development in Malaysia over the past two decades.
  3. Clinically important drug-drug interactions in primary care
    Dhabali AA, Awang R, Zyoud SH
    J Clin Pharm Ther, 2012 Aug;37(4):426-30.
    PMID: 22081958 DOI: 10.1111/j.1365-2710.2011.01314.x
    WHAT IS KNOWN AND OBJECTIVE: Drug-drug interactions (DDIs) cause considerable morbidity and mortality worldwide and may lead to hospital admission. Sophisticated computerized drug information and monitoring systems, more recently established in many of the emerging economies, including Malaysia, are capturing useful information on prescribing. Our aim is to report on an investigation of potentially serious DDIs, using a university primary care-based system capturing prescription records from its primary care services.
    METHODS: We retrospectively collected data from two academic years over 20 months from computerized databases at the Universiti Sains Malaysia (USM) from users of the USM primary care services.
    RESULTS AND DISCUSSION: Three hundred and eighty-six DDI events were observed in a cohort of 208 exposed patients from a total of 23,733 patients, representing a 2-year period prevalence of 876·4 per 100,000 patients. Of the 208 exposed patients, 138 (66·3%) were exposed to one DDI event, 29 (13·9%) to two DDI events, 15 (7·2%) to three DDI events, 6 (2·9%) to four DDI events and 20 (9·6%) to more than five DDI events. Overall, an increasing mean number of episodes of DDIs was noted among exposed patients within the age category ≥70 years (P=0·01), an increasing trend in the number of medications prescribed (P<0·001) and an increasing trend in the number of long-term therapeutic groups (P<0·001).
    WHAT IS NEW AND CONCLUSION: We describe the prevalence of clinically important DDIs in an emerging economy setting and identify the more common potentially serious DDIs. In line with the observations in developed economies, a higher number of episodes of DDIs were seen in patients aged ≥70 years and with more medications prescribed. The easiest method to reduce the frequency of DDIs is to reduce the number of medications prescribed. Therapeutic alternatives should be selected cautiously.

    Study site: e Universiti Sains Malaysia (USM
  4. Pharmaco-epidemiologic study of the prescription of contraindicated drugs in a primary care setting of a university: a retrospective review of drug prescription
    Dhabali AA, Awang R, Zyoud SH
    Int J Clin Pharmacol Ther, 2011 Aug;49(8):500-9.
    PMID: 21781650 DOI: 10.5414/cp201524
    BACKGROUND: The prescription of contraindicated drugs is a preventable medication error, which can cause morbidity and mortality. Recent data on the factors associated with drug contraindications (DCIs) is limited world-wide, especially in Malaysia.

    AIMS: The objectives of this study are 1) to quantify the prevalence of DCIs in a primary care setting at a Malaysian University; 2) to identify patient characteristics associated with increased DCI episodes, and 3) to identify associated factors for these DCIs.

    METHODS: We retrospectively collected data from 1 academic year using computerized databases at the Universiti Sains Malaysia (USM) from patients of USM's primary care. Descriptive and comparative statistics were used to characterize DCIs.

    RESULTS: There were 1,317 DCIs during the study period. These were observed in a cohort of 923 patients, out of a total of 17,288 patients, representing 5,339 DCIs per 100,000 patients, or 5.3% of all patients over a 1-year period. Of the 923 exposed patients, 745 (80.7%) were exposed to 1 DCI event, 92 (10%) to 2 DCI events, 35 (3.8%) to 3 DCI events, 18 (2%) to 4 DCI events, and 33 patients (3.6%) were exposed to 5 or more DCI events. The average age of the exposed patients was 30.7 ± 15 y, and 51.5% were male. Multivariate logistic regression analysis revealed that being male (OR = 1.3; 95% CI = 1.1 - 1.5; p < 0.001), being a member of the staff (OR = 3; 95% CI = 2.5 - 3.7; p < 0.001), having 4 or more prescribers (OR = 2.8; 95% CI = 2.2 - 3.6; p < 0.001), and having 4 or more longterm therapeutic groups (OR = 2.3; 95%CI = 1.7 - 3.1; p < 0.001), were significantly associated with increased chance of exposure to DCIs.

    DISCUSSION AND CONCLUSIONS: This is the first study in Malaysia that presents data on the prevalence of DCIs. The prescription of contraindicated drugs was found to be frequent in this primary care setting. Exposure to DCI events was associated with specific socio-demographic and health status factors. Further research is needed to evaluate the relationship between health outcomes and the exposure to DCIs.
  5. Reliability of the reported ingested dose of acetaminophen for predicting the risk of toxicity in acetaminophen overdose patients
    Zyoud SH, Awang R, Sulaiman SA
    Pharmacoepidemiol Drug Saf, 2012 Feb;21(2):207-13.
    PMID: 21812068 DOI: 10.1002/pds.2218
    The present study examines the relationship between the dose of acetaminophen reported to have been ingested by patients and the occurrence of serum acetaminophen levels above the 'possible toxicity' line in patients presenting at the hospital after acetaminophen overdose. The prognostic value of patient-reported dosage cut-offs of 8, 10 and 12 g was determined.
  6. Lipase-catalyzed esterification of palm-based 9,10-dihydroxystearic acid and 1-octanol in hexane--a kinetic study
    Awang R, Basri M, Ahmad S, Salleh AB
    Biotechnol Lett, 2004 Jan;26(1):11-4.
    PMID: 15005144
    The esterification of palm-based 9,10-dihydroxystearic acid (DHSA) and 1-octanol in hexane as catalyzed by lipase from Rhizomucor meihei (Lipozyme IM) followed Michaelis-Menten kinetics. The esterification reaction follows a Ping-Pong, Bi-Bi mechanism. The maximum rate was estimated to be 1 micromol min(-1) mg(-1) catalyst in hexane at 50 degrees C, and the Michaelis-Menten constants for DHSA and 1-octanol were 1.3 M and 0.7 M, respectively.
  7. Community-acquired vancomycin-resistant Enterococcus faecium: a case report from Malaysia
    Raja NS, Karunakaran R, Ngeow YF, Awang R
    J Med Microbiol, 2005 Sep;54(Pt 9):901-903.
    PMID: 16091445 DOI: 10.1099/jmm.0.46169-0
    Vancomycin-resistant enterococci (VRE) are formidable organisms renowned for their ability to cause infections with limited treatment options and their potential for transferring resistance genes to other Gram-positive bacteria. Usually associated with nosocomial infections, VRE are rarely reported as a cause of community-acquired infection. Presented here is a case of community-acquired infection due to vancomycin-resistant Enterococcus faecium. The patient had been applying herbal leaves topically to his cheek to treat a buccal space abscess, resulting in a burn of the overlying skin. From pus aspirated via the skin a pure culture of E. faecium was grown that was resistant to vancomycin with a MIC of >256 microg ml-1 by the E test and resistant to teicoplanin by disc diffusion, consistent with the VanA phenotype. The organism was suspected of contaminating the leaf and infecting the patient via the burnt skin. This case highlights the need for further studies on the community prevalence of VRE among humans and animals to define unrecognized silent reservoirs for VRE, which may pose a threat to public health.
  8. A Randomised Single-Blinded Controlled Trial on the Effectiveness of Brief Advice on Smoking Cessation among Tertiary Students in Malaysia
    De Silva W, Awang R, Samsudeen S, Hanna F
    J Health Med Inform, 2016 Feb;7(1).
    PMID: 27081575
    INTRODUCTION: Tobacco smoking, a habitual behavior, is addictive and detrimental to health. Quitting requires personal abilities and environmental opportunities and therefore, improving these abilities and opportunities will undoubtedly act on smokers' motivation to quit.

    METHODS: A prospective single-blinded randomized controlled interventional study was conducted among first year undergraduate students in Malaysia. A total of eighty smokers were randomly allocated to a control or intervention groups (40/40). Randomization remained concealed from research personnel. All participants were followed up for six months to evaluate abstinence.

    RESULTS: Quit line enrolment rate of the intervention group was 55% (22) compared to 7.5% (3) in the control (P < 0.001 95% CI 30.1 - 64.9). In the intervention group 27% (6) sustained quitting for six months compared to none in the control group.

    CONCLUSION: This study has shown that brief advice for smoking cessation is more effective than an information leaflet alone to promote quitting and that to maintain abstinence quit line follow up is necessary. Larger samples size and longer follow up studies are needed to further confirm these findings.

  9. Fulltext Assessing the scientific research productivity of a leading toxicology journal: A case study of Human & Experimental Toxicology from 2003 to 2012
    Zyoud SH, Al-Jabi SW, Sweileh WM, Awang R
    SAGE Open Med, 2014;2:2050312114523424.
    PMID: 26770709 DOI: 10.1177/2050312114523424
    BACKGROUND: Bibliometric studies are increasingly being used for research assessments. Bibliometric indicators involve the application of statistical methods to scientific publications to obtain the bibliographics for each journal. The main objective of this study was to conduct a bibliometric evaluation of Human & Experimental Toxicology retrieved from the Scopus database.
    METHODS: This study obtained data from Scopus published from 1 January 2003 till 31 December 2012. The keywords entered in Scopus to accomplish the objective of this study were 'Human', 'Experimental' and 'Toxicology' as 'Source Title'. Research productivity was evaluated based on a methodology developed and used in other bibliometric studies by analysing (a) total and trends in Human & Experimental Toxicology contributions in research between 2003 and 2012; (b) Human & Experimental Toxicology authorship patterns and productivity; (c) collaboration patterns; and (d) the citations received by the publications.
    RESULTS: There were 1229 research articles published in Human & Experimental Toxicology. Of the articles included, 947 (77.1%) were original articles and 104 (8.5%) were review articles. The Hirsch-index of the retrieved documents was 35. The largest number of publications in Human & Experimental Toxicology was from the United States (19.6%), followed by India (12.8%) and Turkey (10.9%). The total number of citations was 9119, with a median (interquartile range) of 3 (1-9) in 6797 documents. The highest median (interquartile range) number of citations was 8 (2.7-12.7) for France, followed by 7.5 (2-22.5) for Iran and 6 (3-13.5) for the United Kingdom. The country most often citing articles that were published in Human & Experimental Toxicology was the United States, which made citations in 1508 documents, followed by India with citations in 792 documents.
    CONCLUSION: The documents in Human & Experimental Toxicology focus principally on original data, with very few review articles. Review articles tend to have higher citation rates than original articles, and hence, the editors and authors of Human & Experimental Toxicology might usefully promote the submission of reviews in the future to improve the impact of the journal.
    KEYWORDS: Bibliometric; Scopus; citations; human and experimental toxicology
  10. Associations between prescribing nonsteroidal anti-inflammatory drugs and the potential prescription-related problems in a primary care setting
    Dhabali AA, Awang R, Hamdan Z, Zyoud SH
    Int J Clin Pharmacol Ther, 2012 Dec;50(12):851-61.
    PMID: 23006441 DOI: 10.5414/CP201689
    OBJECTIVES: The objectives of this study were 1) to obtain information regarding the prescribing pattern of nonsteroidal anti-inflammatory drugs (NSAIDs) in the primary care setting at a Malaysian university, 2) to determine the prevalence and types of potential NSAID prescription related problems (PRPs), and 3) to identify patient characteristics associated with exposure to these potential PRPs.
    METHODS: We retrospectively collected data from 1 academic year using the electronic medical records of patients in the University Sains Malaysia (USM) primary care system. The defined daily dose (DDD) methodology and the anatomical therapeutic chemical (ATC) drug classification system were used in the analysis and comparison of the data. Statements representing potential NSAID PRPs were developed from authoritative drug information sources. Then, algorithms were developed to screen the databases for these potential PRPs. Descriptive and comparative statistics were used to characterize DRPs.
    RESULTS: During the study period, 12,470 NSAID prescriptions were prescribed for 6,509 patients (mean ± SD = 1.92 ± 1.83). This represented a prevalence of 35,944 per 100,000 patients, or 36%. Based on their DDDs, mefenamic acid and diclofenac were the most prescribed NSAIDs. 573 potential NSAID-related PRPs were observed in a cohort of 432 patients, representing a prevalence of 6,640 per 100,000 NSAIDs users, or 6.6% of all NSAID users. Multivariate logistic regression analysis revealed that patients with a Malay ethnic background (p < 0.001), members of the staff (p < 0.001), having 4 or more prescribers (p < 0.001) or having 2 - 3 prescribers (p = 0.02), and representing 4 or more long-term therapeutic groups (LTTGs) (p < 0.001) or 2 - 3 LTTGs (p < 0.001) were significantly associated with an increased chance of exposure to potential NSAID related PRPs.
    CONCLUSIONS: This is the first study in Malaysia that presents data on the prescribing pattern of NSAIDs and the characteristics of potential NSAID-related PRPs. The prevalence of potential NSAID-related PRPs is frequent in the primary care setting. Exposure to these PRPs is associated with specific sociodemographic and health status factors. These results should help to raise the awareness of clinicians and patients about serious NSAID PRPs.

    Study site: University Sains Malaysia (USM) primary care system.
  11. Impact of serum acetaminophen concentration on changes in serum potassium, creatinine and urea concentrations among patients with acetaminophen overdose
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Pharmacoepidemiol Drug Saf, 2011 Feb;20(2):203-8.
    PMID: 21254292 DOI: 10.1002/pds.2060
    Acetaminophen overdose may be accompanied by electrolyte disturbances. The basis for electrolyte change appears to be due to increased fractional urinary electrolyte excretion.
  12. A cross-sectional observation of the factors associated with deliberate self-poisoning with acetaminophen: impact of gender differences and psychiatric intervention
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Hum Psychopharmacol, 2010 Aug;25(6):500-8.
    PMID: 20737523 DOI: 10.1002/hup.1140
    The objectives of this study were to determine the risk factors and life stressors that are prevalent among the acetaminophen deliberate self-poisoning (DSP) cases, to identify gender differences in the associated factors, and to determine the prevalence of psychiatric diagnosis and the patterns and types of psychotherapeutic interventions provided by psychiatrists.
  13. Fulltext Assessing the impact of vomiting episodes on outcome after acetaminophen poisoning
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Basic Clin Pharmacol Toxicol, 2010 Nov;107(5):887-92.
    PMID: 20456332 DOI: 10.1111/j.1742-7843.2010.00594.x
    Identifying indices of poor prognosis at first presentation after acetaminophen poisoning is the key to both improving clinical care and determining targets for intervention. This study intended to document the prevalence, clinical characteristics and predictors of vomiting and to investigate the relationship between episodes of vomiting at first hospital presentation and outcome in acetaminophen poisoning. This retrospective cohort study included patients who attended the emergency department and were admitted within 24 hr of acetaminophen ingestion. The study was conducted over a period of 5 years from 1 January 2004 to 31 December 2008. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. Data from 291 patients were included. Vomiting was present in 65.3% of patients with acetaminophen poisoning at the time of first presentation. Multiple logistic regression showed that significant risk factors for vomiting were present among patients who reported an ingested dose of acetaminophen ≥10 g (p < 0.001) and a latency time of more than 8 hr (p = 0.030). Overall, an increasing trend in prothrombin time (p = 0.03), serum bilirubin (p < 0.001), serum creatinine (p = 0.005), serum potassium (p < 0.001), length of hospital stay (p < 0.001) and the prevalence of patients who had a serum acetaminophen level above a 'possible toxicity' treatment line (p = 0.001) were associated with an increased number of episodes of vomiting. In conclusion, vomiting was common among patients with acetaminophen poisoning. This study suggests that an increase in episodes of vomiting at first presentation appears to be an important risk marker of subsequent nephrotoxicity and hepatotoxicity.
  14. An analysis of the length of hospital stay after acetaminophen overdose
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Hum Exp Toxicol, 2011 Jul;30(7):550-9.
    PMID: 20630911 DOI: 10.1177/0960327110377647
    Acetaminophen is one of the most commonly encountered medications in self-poisoning, with a high rate of morbidity. The prevalence and characteristics of acetaminophen intoxication associated with long hospital stay in patients are not well defined.
  15. Effects of delay in infusion of N-acetylcysteine on appearance of adverse drug reactions after acetaminophen overdose: a retrospective study
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Pharmacoepidemiol Drug Saf, 2010 Oct;19(10):1064-70.
    PMID: 20712021 DOI: 10.1002/pds.1955
    To investigate the relationship between different types of adverse drug reaction (ADR) and late time to N-acetylcysteine (NAC) infusion in patients presenting to the hospital with acetaminophen overdose.
  16. N-acetylcysteine-induced headache in hospitalized patients with acute acetaminophen overdose
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Fundam Clin Pharmacol, 2011 Jun;25(3):405-10.
    PMID: 20584210 DOI: 10.1111/j.1472-8206.2010.00831.x
    Intravenous N-acetylcysteine (IV-NAC) is usually regarded as a safe antidote to acetaminophen overdose. However, during infusion of the loading dose, adverse drug reactions such as a headache may occur. The objectives of this study were to investigate the prevalence of headache in patients presenting to hospital after acetaminophen overdose and to determine which clinical findings are most predictive of headache among these patients. This is a retrospective cohort study of hospital admissions for acute acetaminophen overdose that was conducted over a period of 4 years from January 1, 2005 to December 31, 2008. Demographic data, clinical characteristics, and predictors of headache were analyzed. spss 15 was used for data analysis. Two-hundred and fifty-five patients were studied; their mean age was 23.1 ± 1.6; 83.9% of them were women and 14.9% had a headache during hospitalization. Headache among patients was significantly associated with IV-NAC administration (P = 0.001), intentional ingestion of drug (P = 0.04), acetaminophen concentration above 'possible toxicity' treatment line (P = 0.04), a high acetaminophen concentration (P = 0.04), and a long hospital stay (P = 0.03). Multiple logistic regression showed a significant risk factor for headache in patients administered IV-NAC (P = 0.04). We recorded a high frequency of headache in patients with acute acetaminophen overdose in our geographical area. This study suggests that among those patients, the use of IV-NAC is associated with an increased risk of headache.
  17. High prevalence of hypokalemia after acute acetaminophen overdose: impact of psychiatric illness
    Zyoud SH, Awang R, Syed Sulaiman SA, Al-jabi SW
    Hum Exp Toxicol, 2010 Sep;29(9):773-8.
    PMID: 20144962 DOI: 10.1177/0960327110361759
    Hypokalemia is not an isolated disease but an associated finding in a number of different diseases. It is also a commonly neglected condition among patients with acute acetaminophen overdose.
  18. Association between gastrointestinal manifestations following acetaminophen poisoning and outcome in 291 acetaminophen poisoning patients
    Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW
    Pharmacoepidemiol Drug Saf, 2010 May;19(5):511-7.
    PMID: 20333776 DOI: 10.1002/pds.1940
    Acetaminophen poisoning is a common clinical problem, and early identification of patients with more severe poisoning is key to improving outcomes.
  19. Profile of poisoning admissions in Malaysia
    Rajasuriar R, Awang R, Hashim SB, Rahmat HR
    Hum Exp Toxicol, 2007 Feb;26(2):73-81.
    PMID: 17370864
    We retrospectively reviewed poisoning admissions to all government health facilities from 1999 to 2001, in an effort to expand our current knowledge on poisoning in Malaysia to a level that better reflects a nationwide burden. There were 21 714 admissions reported with 779 deaths. The case-fatality rate was 35.88/1000 admissions. The majority of admissions (89.7%) and deaths (98.9%) occurred in adults. Some 55.1% of all admissions were female, mostly involving pharmaceutical agents. Male poisoning admissions were more often due to chemical substances. The prevalence of poisoning and death was highest among Indians compared to all other races in Malaysia. Overall, the majority of poisoning admissions were due to pharmaceutical agents, with agents classified as non-opioid analgesics, anti-pyretics and anti-rheumatics the most common. Pesticides accounted for the largest number of fatalities. It was also the commonest substance reported in cases of intentional self-harm. Most cases of poisoning admissions occurred due to accidental exposure (47%), followed by cases of intentional self-harm (20.7%). Overall, this study has managed to contribute substantial additional information regarding the epidemiology of poisoning in Malaysia, highlighting important issues, such as the rampant poisonings involving pesticides and analgesics, as well as the high prevalence of poisoning among Indians in Malaysia.
  20. Comparison of nurses and general caregivers' knowledge, attitude, and practice on medication administration process and their distress level in long-term care facilities across Penang, Kuala Lumpur, and Selangor of Malaysia
    Tangiisuran B, Tye SC, Leow MY, Awang R
    Aging Clin Exp Res, 2018 Feb;30(2):183-191.
    PMID: 28527134 DOI: 10.1007/s40520-017-0772-1
    AIM: Comparing nurses and general caregivers' knowledge, attitude, and practices (KAP) on medication administration process in long-term care (LTC) setting and an assessment of their stress, anxiety, and depression (SAD) level.
    METHODS: A cross-sectional survey was conducted among nurses and general caregivers working in LTC using a validated questionnaire. Consisting of demographic characteristics (Section 1); 40 questions on KAP (Section 2); and assessment of Depression, Anxiety, and Stress Scale (DASS-21) (Section 3).
    RESULTS: 155 formally paid staffs in 26 LTC facilities were recruited. Nurses scored significantly higher in the knowledge section compared to caregivers (12.4 ± 1.7 vs. 4.5 ± 3.8; P 
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