An-Najah Blogs :: Assistant Professor of Clinical Pharmacy and Toxicology http://blogs.najah.edu/author/saedzyoud An-Najah Blogs :: Assistant Professor of Clinical Pharmacy and Toxicology en-us Sun, 19 Nov 2017 21:39:48 IST Sun, 19 Nov 2017 21:39:48 IST webmaster@najah.edu webmaster@najah.edu Associations between prescribing nonsteroidal anti-inflammatory drugs and the potential prescription-related problems in a primary care setting.http://blogs.najah.edu/staff/saedzyoud/article/Associations-between-prescribing-nonsteroidal-anti-inflammatory-drugs-and-the-potential-prescription-related-problems-in-a-primary-care-settingPublished Articles Abdullah AH Dhabali WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Rahmat Awang Sa\ed H Zyoud WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory; WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia;College of Pharmacy An-Najah National University Nablus Palestine Abstract 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 prescriptionrelated 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 12470 NSAID prescriptions were prescribed for 6509 patients mean SD = 192 183 This represented a prevalence of 35944 per 100000 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 6640 per 100000 NSAIDs users or 66 of all NSAID users Multivariate logistic regression analysis revealed that patients with a Malay ethnic background p 0001 members of the staff p 0001 having 4 or more prescribers p 0001 or having 2 - 3 prescribers p = 002 and representing 4 or more long-term therapeutic groups LTTGs p 0001 or 2 - 3 LTTGs p 0001 were significantly associated with an increased chance of exposure to potential NSAIDrelated 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 A Cross-Sectional Observation Of The Factors Associated With Deliberate Self-Poisoning With Acetaminophen: Impact Of Gender Differences And Psychiatric Interventionhttp://blogs.najah.edu/staff/saedzyoud/article/A-Cross-Sectional-Observation-Of-The-Factors-Associated-With-Deliberate-Self-Poisoning-With-Acetaminophen-Impact-Of-Gender-Differences-And-Psychiatric-InterventionPublished Articles Saed H Zyoud Poison Control and Drug Information Center PCDIC College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi Poison Control and Drug Information Center PCDIC College of Pharmacy An-Najah National University Nablus Palestine Abstract: Objectives 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 Methods This is a cross-sectional study a retrospective descriptive case review of hospital admissions for acetaminophen DSP Results : There were 177 incidences of DSP during the study period The mean age of the cases was 23173 years and 841 of them were females The risk factors were more significantly associated with males: chronic ethanol intake pfrac14;004 higher reported dose ingested pfrac14;001 higher latency time pfrac14;004 and longer hospital stay pfrac14;003 The most commonly reported psychotherapeutic interventions used by psychiatrists were psychoeducation of the patient followed by referral to a psychiatric clinic family psychoeducation and psychotropic medication Sertraline SSRI was the most frequently prescribed antidepressant Conclusions : Males have been shown to use more toxic doses and to delay treatment due to high latency time Most DSP patients have different life stressors and psychiatric diagnoses that may be associated with varying degrees of suicidal intent All patients presenting following DSP need to be carefully screened for psychiatric illness Randomized controlled studies need to be conducted on DSP patients with psychiatric illness to determine which treatments are effective Acetaminophen Overdose and Vomiting: Prevalence, Predictors and in-Hospital Outcomeshttp://blogs.najah.edu/staff/saedzyoud/article/Acetaminophen-Overdose-and-Vomiting-Prevalence-Predictors-and-in-Hospital-OutcomesPublished Articles Sa\ed H Zyoud WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia;College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program School of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi Clinical Pharmacy Program College of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia; College of Pharmacy An-Najah National University Nablus Palestine Abstract: Introduction: Vomiting is a common adverse effect following drug ingestion and other toxic exposure Under normalcircumstances as toxicity resolves these symptoms gradually improve Vomiting associated with certain poisons can bedetrimental to the treatment of the patient Although vomiting is commonly the only symptom of early acetaminophenpoisoning It is unpleasant for the patient if uncontrolled can worsen the overall prognosis potentially leading to renalimpairment electrolyte disturbances and prolonged hospital stay There are no data concerning the prevalence of andthe relationship between vomiting and outcome in patients presenting to hospital with acetaminophen poisoningTherefore identifying indices of poor prognosis at first presentation after acetaminophen poisoning is key to bothimproving clinical care and determining targets for intervention Objectives: We hypothesized that since vomiting is an important component of the syndrome of severe acetaminophenpoisoning an increase in the number of episodes of vomiting from the time of acetaminophen ingestion to thetime the patient was presented at the hospital might indicate more severe acetaminophen poisoning and a poorer prognosis To present this hypothesis we carried out this hospital-based study to document the prevalence clinicalcharacteristics and predictors of vomiting and to investigate the relationship between episodes of vomiting at firsthospital presentation and outcomes in acetaminophen poisoning Methods: This is a retrospective cohort study including patients who attended the emergency department and wereadmitted within 24 hours of acetaminophen ingestion The study was conducted over a period of 5 years from 1January 2004 to 31 December 2008 Parametric and non-parametric tests were used to test differences betweengroups depending on the normality of the data SPSS 15 was used for data analysis Results: Data from 291 patients were included Vomiting was present in 653 of patients with acetaminophen poisoningat the time of first presentation Multiple logistic regression showed that significant risk factors for vomiting werepresent among patients who reported an ingested dose of acetaminophen 10 grams p0001 and a latency time ofmore than 8 hours p =0030 Overall an increasing trend in prothrombin time p =003 serum bilirubin p 0001serum creatinine p =0005 serum potassium p 0001 length of hospital stay p 0001 and the prevalence ofpatients who had a serum acetaminophen level above a possible toxicity treatment line p =0001 were associatedwith an increased number of episodes of vomiting Conclusions: Vomiting was common among patients with acetaminophen poisoning Patients with acetaminophenpoisoning commonly experience vomiting in ingested dose of acetaminophen 10 grams and a latency time of morethan 8 hours This study suggests that an increase in episodes of vomiting at first presentation appears to be animportant risk marker of subsequent nephrotoxicity and hepatotoxicity Note:Results of this study have been published as full paper in basic and clinical pharmacology and toxicology Impact Of Angiotensin-Converting Enzyme Inhibitors Administration Prior To Acute Ischemic Stroke Onset On In-Hospital Mortalityhttp://blogs.najah.edu/staff/saedzyoud/article/Impact-Of-Angiotensin-Converting-Enzyme-Inhibitors-Administration-Prior-To-Acute-Ischemic-Stroke-Onset-On-In-Hospital-MortalityPublished Articles ahaya Hassan Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Noorizan Abd Aziz Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi College Of Pharmacy An-Najah National University Nablus Palestine Irene Looi Clinical Research Centre Hospital Pulau Pinang Penang Malaysia Sa\ed H Zyoud Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine saedzyoud@najahedu Abstract: Introduction : Angiotensin-converting enzyme inhibitors ACEIs have shown promising results in decreasing the incidence and the severity of ischemic stroke in populations at risk and in improving ischemic stroke outcomes Objectives: The objectives of this study were to investigate the impact of ACEI use before ischemic stroke onset on in-hospital mortality and to identify the independent predictors of in-hospital mortality among patients with ischemic stroke Methods and Materials : A retrospective cohort study of all patients with acute ischemic stroke attending the hospital from June 1 2008 to November 30 2008 was performed Data were collected from medical records and included demographic information diagnostic information risk factors previous ACEI use and vital discharge status Statistical Package for Social Sciences SPSS version 15 was used for data analysis Results : A total of 327 patients with acute ischemic stroke were studied of which 119 364 had documented previous ACEI use During the study period 52 159 of the patients with acute ischemic stroke died in hospital In-hospital mortality was significantly lower among patients who were on ACEI before the attack P = 0002 The independent predictors for in-hospital mortality among patients with ischemic stroke were age 65 years P 001 the presence of diabetes mellitus P = 012 renal impairment P = 002 and heart failure P = 001 Moreover prior use of ACEI was an independent predictor for survival after ischemic stroke attack P 001 Conclusion : This study provides evidence that the prophylactic administration of ACEI before ischemic stroke may be a potential life-saving strategy Furthermore knowledge of in-hospital mortality predictors is necessary to improve survival rate after acute stroke Analysis Of Prescriptions Dispensed At Community Pharmacies In Nablus, Palestinehttp://blogs.najah.edu/staff/saedzyoud/article/Analysis-Of-Prescriptions-Dispensed-At-Community-Pharmacies-In-Nablus-PalestinePublished Articles AF Sawalha Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine ansam@najahedu WM Sweileh College Of PharmacyAn-Najah National UniversityNablus Palestine waleedsweileh@najahedu SH Zyoud Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine saedzyoud@najahedu SW Al-Jabi College Of PharmacyAn-Najah National UniversityNablus Palestine FF Bni Shamseh Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine AA Odah Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine Abstract: We investigated the prescription quality and prescribing trends of private clinicians in Nablus governorate Palestine A total of 363 prescriptions were collected from a random sample of 36 community pharmacies over a study period of 288 working hours Data regarding elements in the prescription and the types of drugs prescribed were analysed Physician-related variables were mostly noted however patients address and weight were absent in all prescriptions and less than half included age and sex Information regarding strength of the medications prescribed was missing in over 70 of prescriptions Other drug-related variables like frequency and instruction of use were present in over 80 of prescriptions Antimicrobial agents were the most commonly prescribed followed by NSAIDsanalgesics Amoxicillin alone or in combination was the most commonly prescribed antimicrobial agents followed by cefuroxime Prescription writing quality in Nablus is deficient in certain aspects and improvement is required Patterns Of Anti-Hypertensive Therapy In Diabetic Patients With And Without Reduced Renal Functionhttp://blogs.najah.edu/staff/saedzyoud/article/Patterns-Of-Anti-Hypertensive-Therapy-In-Diabetic-Patients-With-And-Without-Reduced-Renal-FunctionPublished Articles Waleed M Sweileh College Of Pharmacy Clinical Pharmacy Graduate Program An-Najah National University Nablus Palestine waleedsweileh@najahedu Ansam F Sawalha Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Palestine ansam@najahedu Sa\ed H Zyoud Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Palestine saedzyoud@yahoocom Samah W Al-Jabi College Of Pharmacy Clinical Pharmacy Graduate Program An-Najah National University Nablus Palestine Eman J Tameem Ministry of Health Palestinian National Authority Jenin Palestine Abstract: Renal function deterioration is a common complication in patients with diabetes mellitus and hypertension Appropriate use of anti-hypertensive agents and tight control of Blood Pressure BP can minimize and delay such complications This study was performed in order to investigate the utilization patterns of anti-hypertensive agents and to evaluate BP control among diabetic-hypertensive patients with and without reduced renal function In a retrospective cohort study all diabetichypertensive patients attending The Al-Watani Medical Governmental Center from August 01 2006 until August 01 2007 were enrolled in the study Patients with congestive heart failure andor endstage renal disease were excluded from the study The proportion of use of five different antihypertensive drug classes were compared for all patients receiving 1 2 3 or 4 drugs and separately among patients with and without reduced renal function Over 60 of patients were receiving angiotensin-converting enzyme inhibitors ACEIangiotensin receptor blocker ARB followed by diuretics 408 calcium channel blockers 251 and -blockers 125 The majority of patients 55 were either on mono or no drug therapy Patients on monotherapy were mostly receiving ACEIARB 60 In patients with reduced renal function use of diuretics but not ACEIARB or CCB was higher and 418 of the patients were on monotherapy compared to 466 in patients with normal renal function The proportion of patients achieving good BP control was 20 with monotherapy and 28 with combination therapy Our study suggests that the pattern of anti-hypertensive therapy was generally consistent with inter-national guidelines Areas of improvement include increasing use of ACEIARB and diuretics decreasing the number of untreated patients and increasing the proportion of patients with well controlled BP in this population Effects Of Delay In Infusion Of N-Acetylcysteine On Appearance Of Adverse Drug Reactions After Acetaminophen Overdose: A Retrospective Studyhttp://blogs.najah.edu/staff/saedzyoud/article/Effects-Of-Delay-In-Infusion-Of-N-Acetylcysteine-On-Appearance-Of-Adverse-Drug-Reactions-After-Acetaminophen-Overdose-A-Retrospective-StudyPublished Articles Sa\ed H Zyoud College Of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program College of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi College Of Pharmacy An-Najah National University Nablus Palestine Abstract: Purpose :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 Methods : This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years 1 January 2004 to 31 December 2008 The primary outcome of interest was the relationship between ADR if any and late time to NAC infusion 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 Results : Of 305 patients with acetaminophen overdose 146 479 were treated with intravenous NAC and 139 456 were included in this study Different types of ADR were observed in 94 676 patients Late time to NAC infusion was significantly associated with cutaneous anaphylactoid reactions when compared to patients without this type of ADR p0001 However there were no significant differences in time to NAC infusion between patients with and without the following ADR: gastrointestinal reactions p=011 respiratory reactions p=077 central nervous reactions p=064 and cardiovascular reactions p=063 Conclusion : Late time to NAC infusion is a risk factor for developing cutaneous anaphylactoid reactions suggesting rather than proving that early NAC infusion 8hours may be protective against this type of ADR Assessing The Impact Of Vomiting Episodes On Outcome After Acetaminophen Poisoninghttp://blogs.najah.edu/staff/saedzyoud/article/Assessing-The-Impact-Of-Vomiting-Episodes-On-Outcome-After-Acetaminophen-PoisoningPublished Articles Zyoud SH College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Sulaiman SA Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Al-Jabi SW Poison Control and Drug Information Center PCDIC College of Pharmacy An-Najah National University Nablus Palestine Abstract: 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 653 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 0001 and a latency time of more than 8 hr p = 0030 Overall an increasing trend in prothrombin time p = 003 serum bilirubin p 0001 serum creatinine p = 0005 serum potassium p 0001 length of hospital stay p 0001 and the prevalence of patients who had a serum acetaminophen level above a \possible toxicity\ treatment line p = 0001 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 Evaluation Of Antihypertensive Therapy Among Ischemic Stroke Survivors: Impact Of Ischemic Heart Diseasehttp://blogs.najah.edu/staff/saedzyoud/article/Evaluation-Of-Antihypertensive-Therapy-Among-Ischemic-Stroke-Survivors-Impact-Of-Ischemic-Heart-DiseasePublished Articles Yahaya Hassan Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia yahaya@usmmy Noorizan Abd Aziz Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi College of Pharmacy An-Najah National University Nablus Palestine Irene Looi Clinical Research Centre Penang General Hospital Penang Malaysia Sa\ed H Zyoud College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Abstract: BACKGROUND : Hypertension and ischemic heart disease IHD are among the most prevalent modifiable risk factors for stroke Clinical trial evidence suggests that antihypertensive medications are recommended for prevention of recurrent ischemic stroke in hypertensive and normotensive patients OBJECTIVES: The objectives of this study were to analyze and evaluate the utilization of antihypertensive medication for acute ischemic stroke AIS or transient ischemic attack TIA survivors in relation to recent recommendations and guidelines and to compare their use among patients with or without IHD METHODS: This was a retrospective cohort study of all patients with AISTIA attending the hospital from July 1 2008 to December 31 2008 Demographic data clinical characteristics different classes of antihypertensive medications and different antihypertensive combinations prescribed to AISTIA survivors were analyzed among patients with and without IHD Statistical Package for Social Sciences SPSS program version 15 was used for data analysis RESULTS: In all 383 AISTIA survivors were studied of which 66 195 had a documented history of IHD Three quarters n = 260; 769 of AIS or TIA survivors received antihypertensive medication mostly as monotherapy at discharge The majority of patients n = 201 595 were prescribed angiotensin-converting enzyme inhibitors ACEIs Patients with IHD were significantly prescribed more -blockers than patients without IHD P = 003 A history of hypertension a history of diabetes mellitus and age were significantly associated with prescription of antihypertensive medications at discharge P 001 P 001 and P 001 respectively CONCLUSION: Patterns of antihypertensive therapy were commonly but not adequately consistent with international guidelines Screening stroke survivors for blood pressure control initiating appropriate antihypertensive medications and decreasing the number of untreated patients might help reduce the risk of recurrent strokes and increase survival Relationship Between Serum Acetaminophen Concentration And N-Acetylcysteine-Induced Adverse Drug Reactionshttp://blogs.najah.edu/staff/saedzyoud/article/Relationship-Between-Serum-Acetaminophen-Concentration-And-N-Acetylcysteine-Induced-Adverse-Drug-ReactionsPublished Articles Saed H Zyoud College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program School of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Halilol Rahman Mohamed Khan WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Ansam F Sawalha College of Pharmacy An-Najah National University Nablus Palestine Waleed M Sweileh College of Pharmacy An-Najah National University Nablus Palestine Samah W Al-Jabi Clinical Pharmacy Program School of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Abstract: Intravenous N-acetylcysteine is usually regarded as a safe antidote However during the infusion of the loading dose different types of adverse drug reactions ADR may occur The objective of this study was to investigate the relation between the incidence of different types of ADR and serum acetaminophen concentration in patients presenting to the hospital with acetaminophen overdose This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years 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 Of 305 patients with acetaminophen overdose 146 479 were treated with intravenous N-acetylcysteine and 139 456 were included in this study Different types of ADR were observed in 94 676 patients Low serum acetaminophen concentrations were significantly associated with cutaneous anaphylactoid reactions but not other types of ADR Low serum acetaminophen concentration was significantly associated with flushing p 0001 rash p 0001 and pruritus p 0001 However there were no significant differences in serum acetaminophen concentrations between patients with and without the following ADR: gastrointestinal reactions p = 077 respiratory reactions p = 096 central nervous reactions p = 082 and cardiovascular reactions p = 037 In conclusion low serum acetaminophen concentrations were associated with higher cutaneous anaphylactoid reactions Such high serum acetaminophen concentrations may be protective against N-acetylcysteine-induced cutaneous ADR Differences in medication adherence, satisfaction and clinical symptoms in schizophrenic outpatients taking different antipsychotic regimens.http://blogs.najah.edu/staff/saedzyoud/article/Differences-in-medication-adherence-satisfaction-and-clinical-symptoms-in-schizophrenic-outpatients-taking-different-antipsychotic-regimensPublished Articles Waleed M Sweileh College of Medicine and Health Sciences An-Najah National University Nablus Palestine waleedsweileh@najahedu Sa\ed H Zyoud Poison Control and Drug Information Center and College of Medicine and Health Sciences An-Najah National University Nablus Palestine saedzyoud@najahedu Abstract: Sweileh WM Ihbesheh MS Jarar IS Sawalha AF Abu Taha AS Zyoud SH Morisky DE Source Department of Pharmacology and Toxicology College of Medicine and Health Sciences An-Najah National University Nablus Palestine Abstract OBJECTIVE: To investigate differences in medication adherence treatment satisfaction and clinical symptoms in schizophrenic outpatients taking different antipsychotic treatment regimens METHODOLOGY: Medication adherence was measured using the 8-item Morisky Medication Adherence Scale MMAS-8 while treatment satisfaction was measured using the Treatment Satisfaction Questionnaire for Medication TSQM 14 Psychiatric symptoms were measured using the 24-item expanded Brief Psychiatric Rating Scale BPRS-E Data were entered and analyzed using SPSS 16 for windows RESULTS: A convenience sample of 131 schizophrenic patients was studied Patients belonged to 7 groups based on their antipsychotic treatment regimens There was no significant difference in the means of adherence P=06 and BPRS domains: positive P=06 negative P=08 manic P=02 and depression P=09 scores among the studied groups Satisfaction with side effect domain was significantly different among studied groups P=0006 F=3 However no significant difference was found in other satisfaction domains: effectiveness P=08 convenience P=03 and global satisfaction P=08 CONCLUSIONS: Medications adherence most treatment satisfaction domains and clinical symptom scores were not significantly different among patients taking different antipsychotic regimens Clinically Important Drug–Drug Interactions In Primary Carehttp://blogs.najah.edu/staff/saedzyoud/article/Clinically-Important-DrugndashDrug-Interactions-In-Primary-CarePublished Articles Abdullah AH Dhabali WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia;College of Pharmacy An-Najah National University Nablus Palestine dahbali@yahoocom Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia rahmat@usmmy Sa\ed H Zyoud Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory saedzyoud@najahedu Abstract: What is known and Objective:Drugdrug 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 carebased 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 8764 per 100 000 patients Of the 208 exposed patients 138 663 were exposed to one DDI event 29 139 to two DDI events 15 72 to three DDI events 6 29 to four DDI events and 20 96 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 = 001 an increasing trend in the number of medications prescribed P 0001 and an increasing trend in the number of long-term therapeutic groups P 0001 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 Effect of Prestroke Use of Angiotensin-Converting Enzyme Inhibitors Alone Versus Combination With Antiplatelets and Statin on Ischemic Stroke Outcomehttp://blogs.najah.edu/staff/saedzyoud/article/Effect-of-Prestroke-Use-of-Angiotensin-Converting-Enzyme-Inhibitors-Alone-Versus-Combination-With-Antiplatelets-and-Statin-on-Ischemic-Stroke-OutcomePublished Articles Yahaya Hassan Samah W Al-Jabi Faculty of Pharmacy An-Najah National University Nablus Palestine Noorizan A Aziz Irene Looi Sa\ed H Zyoud Poison Control and Drug Information Centre An-Najah National University Nablus Palestine saedzyoud@najahedu Abstract: Background: Angiotensin-converting enzyme inhibitors ACEIs antiplatelets APs and statin are increasingly being prescribed for ischemic stroke prevention Objectives: The objective of the study was to examine whether previous combination therapy of ACEI with AP andor statin has additive effect compared with ACEI alone on functional outcome after ischemic stroke Furthermore factors associated with improving functional outcome were investigated Methods: Ischemic stroke patients attending a Malaysian hospital in 2008 were categorized according to Barthel Index at discharge Favorable outcome was defined as Barthel Index of 75 or greater Data included demographic information clinical characteristics and previous medications with particular attention to ACEI AP and statin Results: Overall 505 patients were included Variables associated with good functional outcome were younger age P = 0002 first-ever attack P = 0016 lacunar P = 0015 or posterior circulation infarct stroke subtype P = 0034 minor Glasgow Coma Scale P 0001 and previous use of ACEI alone or combined with AP andor statin P = 0002 Using ACEI alone as the reference for ACEI AP ACEI statin or ACEI AP statin combinations there was no significant difference among combinations on improving functional outcome P = 0852 Conclusions: Prestroke use of ACEI either alone or combined with AP andor statin was associated with better functional outcome Previous use of ACEI in combination with AP andor statin did not significantly differ from ACEI alone in their effect on outcome Our study provides a potential rationale for optimizing the use of ACEI among individuals at risk of developing ischemic stroke Impact of the Additive Effect of Angiotensin-Converting Enzyme Inhibitors and /or Statins with Antiplatelet Medication on Mortality After Acute Ischaemic Strokehttp://blogs.najah.edu/staff/saedzyoud/article/Impact-of-the-Additive-Effect-of-Angiotensin-Converting-Enzyme-Inhibitors-andor-Statins-with-Antiplatelet-Medication-on-Mortality-After-Acute-Ischaemic-StrokePublished Articles Yahaya Hassan Samah W Al-Jabi Faculty of Pharmacy An-Najah National University Nablus Palestine Noorizan A Aziz Irene Looi Sa\ed H Zyoud Poison Control and Drug Information Centre An-Najah National University Nablus Palestine saedzyoud@najahedu Abstract: There has been recent interest in combining antiplatelets angiotensin-converting enzyme inhibitors ACEIs and statins in primary and secondary ischaemic stroke prevention This observational study was performed to evaluate the impact of adding ACEIs andor statins to antiplatelets on post-stroke in-hospital mortality Ischaemic stroke patients attending a hospital in Malaysia over an 18-month period were evaluated Patients were categorized according to their vital status at discharge Data included demographic information risk factors clinical characteristics and previous medications with particular attention on antiplatelets ACEIs and statins In-hospital mortality was compared among patients who were not taking antiplatelets ACEIs or statins before stroke onset versus those who were taking antiplatelets alone or in combination with either ACEIs statins or both Data analysis was performed using spss version 15 Overall 637 patients met the study inclusion criteria After controlling for the effects of confounders adding ACEIs or statins to antiplatelets significantly decreased the incidence of death after stroke attack by 68 p = 0036 and 81 p = 0010 respectively compared to patients on antiplatelets alone or none of these medications Additionally the addition of both ACEIs and statins to antiplatelet medication resulted in the highest reduction by 94 of the occurrence of death after stroke attack p 0001 Our results suggest that adding ACEIs andor statins to antiplatelets for patients at risk of developing stroke either as a primary or as a secondary preventive regimen was associated with a significant reduction in the incidence of mortality after ischaemic stroke than antiplatelets alone These results might help reduce the rate of ischaemic stroke morbidity and mortality by enhancing the application of specific therapeutic and management strategies for patients at a high risk of acute stroke N-Acetylcysteine-Induced Headache In Hospitalized Patients With Acute Acetaminophen Overdosehttp://blogs.najah.edu/staff/saedzyoud/article/N-Acetylcysteine-Induced-Headache-In-Hospitalized-Patients-With-Acute-Acetaminophen-OverdosePublished Articles Saed H Zyoud Poison Control and Drug Information Center PCDIC College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program College of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi Clinical Pharmacy Program College of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Abstract: 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 231 16; 839 of them were women and 149 had a headache during hospitalization Headache among patients was significantly associated with IV-NAC administration P = 0001 intentional ingestion of drug P = 004 acetaminophen concentration above possible toxicity treatment line P = 004 a high acetaminophen concentration P = 004 and a long hospital stay P = 003 Multiple logistic regression showed a significant risk factor for headache in patients administered IV-NAC P = 004 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 Availability Of Decontamination, Elimination Enhancement, And Stabilization Resources For The Management Of Acute Toxic Exposures And Poisonings In Emergency Departments In Malaysiahttp://blogs.najah.edu/staff/saedzyoud/article/Availability-Of-Decontamination-Elimination-Enhancement-And-Stabilization-Resources-For-The-Management-Of-Acute-Toxic-Exposures-And-Poisonings-In-Emergency-Departments-In-MalaysiaPublished Articles Sa\ed H Zyoud Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Abstract: Acute poisoning is a common medical emergency in Malaysia Life can be saved if the patient is diagnosed properly and receives the appropriate treatment such as gastrointestinal decontamination techniques and resources to increase poison elimination according to clinical guidelines at a reasonable time The aims of this study were to determine the availability of decontamination elimination enhancement and stabilization resources for the management of acute toxic exposures and poisonings in accident and emergency departments in Malaysia and to compare the availability of such facilities among various types of hospitals A comparative descriptive cross-sectional study was conducted using a structured questionnaire Seventy-four 583 out of the targeted 127 hospitals replied and completed the questionnaire The availabilities of most items related to stabilization resources were far better in general hospitals compared to district hospitals with specialists and district hospitals without specialists These items were mechanical ventilators p = 0011 non-invasive positive pressure ventilators 0024 pacemakers p = 0019 and transcutaneous cardiac pacing p 0001 The availability of decontamination resources varied substantially with hospital type Nevertheless these differences did not reach statistical significance in any of the cases whereas sodium sulphate sorbitol and polyethylene glycol were almost never available The availabilities of most items related to elimination enhancement resources were far better in general hospitals and district hospitals with specialists compared to district hospitals without specialists These items were haemodialysis p = 0046 haemoperfusion p = 0002 haemofiltration p = 0002 acid diuresis p = 004 peritoneal dialysis p 0001 and exchange transfusion p 0001 Most Malaysian hospitals have certain important immediate interventions such as gastrointestinal decontamination techniques and resources to increase poison elimination The availabilities of most facilities were far better in the general hospitals Coordination between the National Poison Centre in Malaysia and hospitals should be established regarding the emergency facilities for effective management of poisoning cases in each hospital in order to direct the poisoned patients to the hospital where the appropriate management resources is available Adherence and satisfaction with oral hypoglycemic medications: a pilot study in Palestinehttp://blogs.najah.edu/staff/saedzyoud/article/Adherence-and-satisfaction-with-oral-hypoglycemic-medications-a-pilot-study-in-PalestinePublished Articles Objectives Diabetes mellitus is a chronic progressive disease characterized by numerous health complications Medication adherence is an important determinant of therapeutic outcome Few studies on medication adherence have been published from the Arab countries Therefore the objective of this pilot study was to assess hypoglycemic medication adherence and its association with treatment satisfaction Setting Military Medical Services clinic in Nablus Palestine Methods This is a cross sectional descriptive study A convenience sample of 131 diabetic patients was studied The 8-item Morisky Medication Adherence Scale MMAS-8 and Treatment Satisfaction Questionnaire for Medication were used to assess adherence and treatment satisfaction respectively Statistical Package for Social Sciences was used for statistical analysis Main outcome measure Level of adherence treatment satisfaction and association between adherence and treatment satisfaction among diabetic patients Results According to MMAS-8 50 patients 385 had a high adherence 58 446 had a medium adherence and 22 169 had a low adherence rate The mean scores of satisfaction domains were 71176 and 95164 for effectiveness EFF and side effects SE respectively Adherence score was a positively and significantly correlated with EFF satisfaction domain P001 and age P=001 Similar significant correlation was found between adherence level and duration of illness P=0047 However adherence was not significantly associated with gender P=02 number of hypoglycemic medications P=05 or SE satisfaction domain P=02 Discussion and conclusion The majority of diabetic patients in this pilot study were non-adherent Improving patients\ treatment satisfaction will improve treatment adherence Reliability of the Reported Ingested Dose of Acetaminophen for Predicting the Risk of Toxicity in Acetaminophen Overdose Patientshttp://blogs.najah.edu/staff/saedzyoud/article/Reliability-of-the-Reported-Ingested-Dose-of-Acetaminophen-for-Predicting-the-Risk-of-Toxicity-in-Acetaminophen-Overdose-PatientsPublished Articles Sa\ed H Zyoud WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia;College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program School of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Abstract: Objectives: 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 g 10 g and 12 g was determined Methods: This retrospective cohort study included patients admitted to the emergency department or hospital within 24 hours of acetaminophen ingestion Serum acetaminophen concentrations were considered to be the gold standard and specificity sensitivity and positivenegative predictive values were calculated from the reported ingested dose to predict toxicity using the RumackMatthew nomogram ie the possible toxicity treatment line and standard equations[12] Results: Of 305 patients identified 291 met the study inclusion criteria and 121 416 had serum acetaminophen concentrations above the possible toxicity treatment line The range of patient-reported acetaminophen ingested was 175 g with 185 patients 636 reporting 8 g 118 patients 975 who reported ingesting 8 g had serum acetaminophen concentrations above the 150-line compared with only 3 patients 25 who reported ingesting 8g p 0001 The positive predictive value of a patient-reported dose 8 g for predicting serum acetaminophen concentrations above the possible toxicity treatment line was 6378 with a negative predictive value of 9717 The sensitivity of patient-reported doses 8g was high 9752 but with low specificity 6059 The sensitivity of patient-reported doses 10 g was also high 8926 with low specificity 6529 while the sensitivity of 12 g dose was low 6116 with high specificity 8647 Conclusions: Patient-reported doses of acetaminophen are good risk indicators for acetaminophen overdose patients in Malaysia Patientreported ingestion of 8 g as a cutoff dose had a higher sensitivity than 10 g or 12 g The results of this study have important implications for toxicity risk evaluations in areas with poor serum acetaminophen assay availability References 1 Rumack BH Matthew H Acetaminophen poisoning and toxicity Pediatrics 1975; 55: 871-6 2 Rumack BH Peterson RC Koch GG et al Acetaminophen overdose 662 cases with evaluation of oral acetylcysteine treatment Arch Intern Med 1981; 141: 380-5 Pharmaco-Epidemiologic Study Of The Prescription Of Contraindicated Drugs In A Primary Care Setting Of A University: A Retrospective Review Of Drug Prescriptionhttp://blogs.najah.edu/staff/saedzyoud/article/Pharmaco-Epidemiologic-Study-Of-The-Prescription-Of-Contraindicated-Drugs-In-A-Primary-Care-Setting-Of-A-University-A-Retrospective-Review-Of-Drug-PrescriptionPublished Articles AAH Dhabali WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia R Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia SH Zyoud Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory saedzyoud@najahedu Abstract: 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 USMs primary care Descriptive and comparative statistics were used to characterize DCIs Results: There were 1317 DCIs during the study period These were observed in a cohort of 923 patients out of a total of 17288 patients representing 5339 DCIs per 100000 patients or 53 of all patients over a 1-year period Of the 923 exposed patients 745 807 were exposed to 1 DCI event 92 10 to 2 DCI events 35 38 to 3 DCI events 18 2 to 4 DCI events and 33 patients 36 were exposed to 5 or more DCI events The average age of the exposed patients was 307 15 y and 515 were male Multivariate logistic regression analysis revealed that being male OR = 13; 95 CI = 11 15; p 0001 being a member of the staff OR = 3; 95 CI = 25 37; p 0001 having 4 or more prescribers OR = 28; 95 CI = 22 36; p 0001 and having 4 or more longterm therapeutic groups OR = 23; 95CI = 17 31; p 0001 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 Adverse Drug Events in Hospitalized Patients with Acetaminophen Overdose Treated with Intravenous N-Acetylcysteinehttp://blogs.najah.edu/staff/saedzyoud/article/Adverse-Drug-Events-in-Hospitalized-Patients-with-Acetaminophen-Overdose-Treated-with-Intravenous-N-AcetylcysteinePublished Articles Authors: Sa\ed H Zyoud WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia;College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program School of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia saedzyoud@najahedu Abstract: Background and objectives: Intravenous N-acetylcysteine IV-NAC is widely recognized as the antidote of choice for acetaminophen overdose [1] However its use is not without adverse drug reactions ADR which might affect therapeutic outcome or lead to treatment delay [2 3] The aims of this study were to investigate the type and incidence of ADR induced by IV-NAC in patients treated for acetaminophen overdose and to assess the causality of individual ADR to IV-NACusing Naranjo\s algorithm [4] Methods: This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years January 1 2004 to December 31 2008 The primary outcome of interest in this study was the occurrence of ADR during NAC administration The probability of an ADR was assessed using the Naranjo algorithm which consists of 10 questions and has been used to determine the likelihood that an ADR was related to a specific medication [4] Results: During the study period 305 patients with a diagnosis of overdose of paracetamol-containing compounds were admitted to the hospital for monitoring and treatment Different types of ADR occurred in 137 patients 137305; 449 Of those patients who had an ADR 98 98137; 715 had been treated with IV-NAC and 39 39137; 285 had notp 0001 Comparison of different ADR in all patients showed that the following ADR were significantly associated with IV-NAC administration: nausea p = 0004 vomiting p 0001 flushing p 0001 rash P 0001 pruritus p 0001 chest pain p = 0001 bronchospasm p = 0015 coughing p = 0017 headache p 0001 dizziness p 0001 convulsion p = 0035 and hypotension p = 0001 Based on Naranjos algorithm 226 events were judged to be NAC-related 311 probably and 679 possibly drug-related None of the events were definitely drug-related Conclusion: Adverse drug reactions to IV-NAC were common among patients with acetaminophen overdose but mostly minor and that all reported adverse reactions were easily managed Key Words: Acetaminophen; Adverse drug reaction; N-acetylcysteine; Naranjo\s algorithm; Overdose Self-Reported Medication Adherence And Treatment Satisfaction In Patients With Epilepsyhttp://blogs.najah.edu/staff/saedzyoud/article/Self-Reported-Medication-Adherence-And-Treatment-Satisfaction-In-Patients-With-EpilepsyPublished Articles Authors: Waleed M Sweileh Faculty of Pharmacy An-Najah National University Nablus Palestine waleedsweileh@najahedu Manal S Ihbesheh Faculty of Pharmacy An-Najah National University Nablus Palestine Ikhlas S Jarar Faculty of Pharmacy Clinical Pharmacy Graduate Program Nablus Palestine Adham S Abu Taha Faculty of Pharmacy Clinical Pharmacy Graduate Program Nablus Palestine Ansam F Sawalha Poison Control and Drug Information Centre An-Najah National University Nablus Palestine ansam@najahedu Sa\ed H Zyoud Poison Control and Drug Information Centre An-Najah National University Nablus Palestine saedzyoud@najahedu Raniah M Jamous Faculty of Pharmacy An-Najah National University Nablus Palestine Donald E Morisky Department of Community Health Sciences UCLA School of Public Health Los Angeles CA USA Abstract: Objective Reports about medication adherence and satisfaction in patients with epilepsy in Arab countries are lacking The objective of this study was to assess medication adherence and its relationship with treatment satisfaction number of antiepileptic drugs AEDs taken and epilepsy control in a sample of Palestinian patients Methods This cross-sectional descriptive study was carried out at Al-Makhfya Governmental Outpatient Center in Nablus Palestine during the summer of 2010 A convenience sampling method was used to select patients over the study period Medication adherence was measured using the eight-item Morisky Medication Adherence Scale MMAS; treatment satisfaction was measured using the Treatment Satisfaction Questionnaire for Medication TSQM 14 Epilepsy was arbitrarily defined as well controlled if the patient had had no seizures in the last 3 months and was defined as poorly controlled if he or she had had at least one seizure in the last 3 months Results A convenience sample of 75 patients was studied On the basis of the MMAS 11 patients 147 had a low rate 37 493 had a medium rate and 27 36 had a high rate of adherence Adherence was positively and significantly correlated with age P = 002 and duration of illness P = 001 No significant difference in adherence was found between patients with well-controlled and those with poorly controlled epilepsy Similarly there was no significant difference in adherence between patients on monotherapy and those on polytherapy Mean satisfaction with respect to effectiveness side effects convenience and global satisfaction were 736 207 824 298 695 155 and 684 183 respectively There were significant differences in mean values in the effectiveness P 001 and convenience P 001 domains but not the side effect P = 01 and global satisfaction P = 008 domains among patients with different levels of adherence Patients on monotherapy had significantly higher satisfaction in the effectiveness domain P = 004 than patients on polytherapy Similarly patients with well-controlled epilepsy scored significantly higher in the Effectiveness P = 001 and Global Satisfaction P = 001 domains than those with poorly controlled epilepsy Conclusion In our convenience sample we found that adherence to and satisfaction with AEDs were moderate and were not associated with seizure control or number of AEDs Sleep Habits And Sleep Problems Among Palestinian Studentshttp://blogs.najah.edu/staff/saedzyoud/article/Sleep-Habits-And-Sleep-Problems-Among-Palestinian-StudentsPublished Articles Authors: Waleed M Sweileh Faculty of Pharmacy An-Najah National University Nablus Palestine waleedsweileh@najahedu Iyad A Ali Faculty Of Human Medicine An-Najah N University Nablus Palestine Ansam F Sawalha Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory ansam@najahedu Adham S Abu-Taha Faculty of Pharmacy An-Najah National University Nablus Palestine Sa\ed H Zyoud Poison Control and Drug Information Centre An-Najah National University Nablus Palestine saedzyoud@najahedu Samah W Al-Jabi Faculty of Pharmacy An-Najah National University Nablus Palestine Abstract: Aim The aim of this study was to describe sleep habits and sleep problems in a population of undergraduates in Palestine Association between self-reported sleep quality and self-reported academic achievement was also investigated Methods Sleep habits and problems were investigated using a convenience sample of students from An-Najah National University Palestine The study was carried out during spring semester 2009 A self-administered questionnaire developed based on The Diagnostic and Statistical Manual of Mental Disorders IV criteria and Pittsburgh Sleep Quality Index was used Results 400 students with a mean age of 202 13 were studied Reported mean duration of night sleep in the study sample was 64 11 hours The majority 583 of students went to bed before midnight and 18 of the total sample woke up before 6 am Sleep latency of more than one hour was present in 193 of the students Two thirds 648 of the students reported having at least one nocturnal awakening per night Nightmares were the most common parasomnia reported by students Daytime naps were common and reported in 745 of the study sample Sleep quality was reported as poor in only 98 and was significantly associated with sleep latency frequency of nocturnal awakenings time of going to bed nightmares but not with academic achievement Conclusion Sleep habits among Palestinian undergraduates were comparable to those reported in European studies Sleep problems were common and there was no significant association between sleep quality and academic achievement Clinical Characteristics, Sex Differences And Inhospital Mortality Among Stroke Patients With And Without Diabetes Mellitushttp://blogs.najah.edu/staff/saedzyoud/article/Clinical-Characteristics-Sex-Differences-And-Inhospital-Mortality-Among-Stroke-Patients-With-And-Without-Diabetes-MellitusPublished Articles Authors: Waleed M Sweileh Faculty of Pharmacy An-Najah National University Nablus Palestine waleedsweileh@najahedu Saed H Zyoud Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory saedzyoud@najahedu Ansam F Sawalha Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory ansam@najahedu Samah W Al-Jabi Faculty of Pharmacy An-Najah National University Nablus Palestine Adham S Abu-Taha Faculty of Pharmacy An-Najah National University Nablus Palestine Abstract: The aim of the study was to investigate and compare clinical characteristics sex differences and in-hospital mortality between stroke patients with and without diabetes mellitus DM All patients admitted to Al- Watani Governmental Hospital for 12 consecutive months and diagnosed with acute stroke were included in the study Demographic data clinical characteristics and in-hospital mortality were compared between diabetic and nondiabetic stroke patients Pearson 2-test and Students t-test were used on univariate analysis Data were analyzed using SPSS 16 There were 186 stroke patients mean age 690909 years with positive DM history recorded in 489 of male and 452 of female patients Diabetic stroke patients were significantly younger 6681099 vs 711052 years; P=0009 and had a higher proportion of ischemic heart disease 119 vs 39; P=004 compared to nondiabetic stroke patients Inhospitalmortality accounted for 39 21 patients including 23 274 diabetic and 16 157 nondiabetic stroke patients P=0051 Univariate analysis of diabetic stroke patients based on sex showed male patients to have significantly more hemorrhagic strokes P=004 recurrent strokes P=0003 and in-hospital mortality P=0034 compared to female patients There was no sex difference in nondiabetic stroke patients Analysis of diabetic stroke patients based on vital status indicated that in-hospital mortality was significantly associated with sex P=0034 type of stroke P=0006 and recurrent stroke P=001 None of the variables was significantly associated with mortality in nondiabetic stroke patients In conclusion diabetic patients have different clinical characteristics show sex differences and in-hospital mortality differences compared to nondiabetic patients after acute stroke Reliability Of The Reported Ingested Dose Of Acetaminophen For Predicting The Risk Of Toxicity In Acetaminophen Overdose Patientshttp://blogs.najah.edu/staff/saedzyoud/article/Reliability-Of-The-Reported-Ingested-Dose-Of-Acetaminophen-For-Predicting-The-Risk-Of-Toxicity-In-Acetaminophen-Overdose-PatientsPublished Articles Authors: Sa\ed H Zyoud Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia Penang Malaysia Abstract: PURPOSE: 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 12g was determined METHODS: This retrospective cohort study included patients admitted to the emergency department or hospital within 24 hours of acetaminophen ingestion Serum acetaminophen concentrations were considered to be the gold standard and specificity sensitivity and positivenegative predictive values were calculated from the reported ingested dose to predict toxicity using the Rumack-Matthew nomogram ie the \possible toxicity\ treatment line and standard equations RESULTS: Of 305 patients identified 291 met the study inclusion criteria and 121 416 had serum acetaminophen concentrations above the \possible toxicity\ treatment line The range of patient-reported acetaminophen ingested was 1-75g with 185 patients 636 reporting 8g One hundred eighteen patients 975 who reported ingesting 8g had serum acetaminophen concentrations above the \150-line\ compared with only three patients 25 who reported ingesting 8g p0001 The positive predictive value of a patient-reported dose 8g for predicting serum acetaminophen concentrations above the \possible toxicity\ treatment line was 6378 with a negative predictive value of 9717 The sensitivity of patient-reported doses 8g was high 9752 but with low specificity 6059 The sensitivity of patient-reported doses 10g also was high 8926 with low specificity 6529 whereas the sensitivity of 12g dose was low 6116 with high specificity 8647 CONCLUSIONS: Patient-reported doses of acetaminophen are good risk indicators for acetaminophen overdose patients in Malaysia Patient-reported ingestion of 8g as a cut-off dose had a higher sensitivity than 10g or 12g The results of this study have important implications for toxicity risk evaluations in areas with poor serum acetaminophen assay availability Evaluate The Impact Of Hospital Types On The Availability Of Antidotes For The Management Of Acute Toxic Exposures And Poisonings In Malaysiahttp://blogs.najah.edu/staff/saedzyoud/article/Evaluate-The-Impact-Of-Hospital-Types-On-The-Availability-Of-Antidotes-For-The-Management-Of-Acute-Toxic-Exposures-And-Poisonings-In-MalaysiaPublished Articles Authors: Sulaiman I Al-Sohaim WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Sa\ed H Zyoud Poison Control and Drug Information Center PCDIC An-Najah National University Nablus Occupied Palestinian Territory saedzyoud@najahedu Sazaroni Md Rashid WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Sirajuddin Hashim Disease Control Division Ministry of Health Kuala Lumpur Malaysia Abstract: The availability of antidotes may be considered essential and lifesaving in the management of certain poisonings Surveys carried out in a number of countries have demonstrated inadequate availability of a variety of poisoning antidotes Objectives: The purpose of this study was to determine the availability of antidote stocking at hospitals based on published guidelines for antidote stocking and to evaluate the impact of hospital types on the availability of antidotes for the management of acute toxic exposures and poisonings in Malaysia Methods: A questionnaire on the availability of antidotes was sent to all government accident and emergency departments in Malaysia The list of commonly required antidotes and essential drugs was compiled from published guidelines Collected data were analysed in SPSS version 16 using descriptive and comparative analysis Results: The response rate was 5906 None of the responding hospitals stocked all of the antidotes on the lists In relation to hospital type there was great variability in the availability of antidotes there were significant differences between hospitals for 13 antidotes The availabilities of most antidotes were far better in the General Hospitals and the District Hospitals with specialists compared to District Hospitals without specialists Calcium gluconate sodium bicarbonate atropine sulphate naloxone flumazenil vitamin K and pyridoxine were available at all general hospitals Atropine sulphate and naloxone were available at all district hospitals with specialists Conclusion: Most Malaysian government hospitals stocked some important antidotes Raising awareness of the importance of antidotes by education regular review of antidote storage distribution plans and appropriate legislation might provide solutions Coordination between Malaysian hospitals and the National Poison Centre at Universiti Sains Malaysia is also important Statin Use Prior To Ischemic Stroke Onset Is Associated With Decreased In-Hospital Mortalityhttp://blogs.najah.edu/staff/saedzyoud/article/Statin-Use-Prior-To-Ischemic-Stroke-Onset-Is-Associated-With-Decreased-In-Hospital-MortalityPublished Articles Authors: Hassan Y Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia yahaya@usmmy Samah W Al-Jabi College Of PharmacyAn-Najah National UniversityNablus Palestine Aziz NA Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Looi I Clinical Pharmacy Program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Sa\ed H Zyoud Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine saedzyoud@najahedu Abstract: Statins can reduce the risk of stroke in at-risk populations and improve survival after acute ischemic stroke AIS among patients with previous statin use This study aimed to investigate the impact of statin use before AIS onset on in-hospital mortality and identify the factors related to in-hospital mortality among patients with and without previous statin use A retrospective cohort study of all patients with AIS attending hospital from June 1 2008 to December 31 2008 Data were collected from medical records including demographic information diagnostic information risk factors previous statin use and vital discharge status Chi-square Fisher\s exact tests student\s t-test and Mann-Whitney U test whatever appropriate were used to test the significance between the variables and multiple logistic regression was used to identify factors associated with in-hospital mortality Altogether 386 patients with AIS were studied of which 113 293 had a documented previous statin use A total of 62 161 patients with AIS died in hospital In-hospital mortality was significantly lower among previous statin users P = 0013 The presence of atrial fibrillation AF increased in-hospital mortality among patients with or without previous statin use The independent predictors for in-hospital mortality among AIS patients without previous statin use were the presence of diabetes mellitus P = 0047 AF P = 0045 and renal impairment P 0001 The prophylactic administration of statins significantly reduces post-AIS in-hospital mortality Furthermore the identification of predictors of in-hospital mortality might reduce death rates and enhance the application of specific therapeutic and management strategies to patients at a high risk of dying Impact Of Serum Acetaminophen Concentration On Changes In Serum Potassium, Creatinine And Urea Concentrations Among Patients With Acetaminophen Overdosehttp://blogs.najah.edu/staff/saedzyoud/article/Impact-Of-Serum-Acetaminophen-Concentration-On-Changes-In-Serum-Potassium-Creatinine-And-Urea-Concentrations-Among-Patients-With-Acetaminophen-OverdosePublished Articles Authors: Sa\ed H Zyoud Poison Control and Drug Information Center PCDIC and College of Pharmacy An-Najah National University Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy Program College of Pharmaceutical Science Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi Poison Control and Drug Information Center PCDIC and College of Pharmacy An-Najah National University Nablus Palestine Abstract: Background : Acetaminophen overdose may be accompanied by electrolyte disturbances The basis for electrolyte change appears to be due to increased fractional urinary electrolyte excretion Purpose : This study investigated the impact of serum acetaminophen concentration on changes in serum potassium creatinine and urea concentrations in patients with acetaminophen overdose Methods : This was a retrospective cohort study which included patients admitted to the emergency department and hospital within 24h of acetaminophen ingestion The study was conducted over a period of 5 years from 1 January 2004 to 31 December 2008 Data are presented as meanSD and as medians interquartile range and groups were compared using independent two-tailed Student t-test Statistical Package for Social Sciences SPSS 15 was used for data analysis Results : Two hundred and eighty-three patients were studied 44 males and 239 females mean age 2375 years Patients who had a serum acetaminophen concentration above a possible toxicity treatment line were associated with an elevation in serum creatinine concentration p=0044 and a reduction in the serum potassium concentration p0001 but were not associated with a reduction in serum urea concentration p099 During the study period 633 179 patients had serum potassium concentrations less than the normal concentration 35mmoll and 314 89 patients had serum urea concentrations less than the normal concentration 25mmoll The serum creatinine concentration in all patients was within the normal range Conclusions: Acetaminophen appears to cause a concentration-dependent reduction of potassium concentrations and an elevation of creatinine concentrations of short duration 24h after overdose An Analysis Of The Length Of Hospital Stay After Acetaminophen Overdosehttp://blogs.najah.edu/staff/saedzyoud/article/An-Analysis-Of-The-Length-Of-Hospital-Stay-After-Acetaminophen-OverdosePublished Articles Sa\ed H Zyoud Poison Control And Drug Information Center PCDIC An-Najah National University PO Box 7 Nablus Palestine saedzyoud@najahedu Rahmat Awang WHO Collaborating Centre for Drug Information National Poison Centre Universiti Sains Malaysia USM Penang Malaysia Syed Azhar Syed Sulaiman Clinical Pharmacy program School of Pharmaceutical Sciences Universiti Sains Malaysia USM Penang Malaysia Samah W Al-Jabi Poison Control and Drug Information Center PCDIC College of Pharmacy An-Najah National University Nablus Palestine Abstract: Background : 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 Objectives : This study aims to identify the clinical and demographic factors associated with the length of in-hospital stay LOS and to evaluate the effect of early treatment of acetaminophen overdose patients 8 hours by intravenous N-acetylcysteine IV-NAC on hospital stay Methods : This is a retrospective cohort study of hospital admissions for acetaminophen overdose conducted over a period of 5 years from 1 January 2004 to 31 December 2008 Patients were divided into two groups: LS group patients had a long hospital stay median hours stay in hospital and SS group patients had a short hospital stay median hours stay in hospital Variables were abstracted from medical records for comparison between the two groups A total of 20 variables were identified for comparison 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 Results : Of the 305 patients 11 factors were identified in the univariate analysis as associated with LS Three independent factors were found to be significant predictors of LS in the multivariate analysis The factors associated with LS were seen among patients with a history of abdominal pain after ingestion of acetaminophen p = 004 who were on IV-NAC administration p 0001 and had an acutely depressed mood p = 0003 Late time to NAC infusion of more than 8 hours was associated with LS rather than SS 96 patients [57] and 6 [24] respectively; p = 0003 Conclusion : Patients with long hospital stay have different clinical characteristics compared to patients with short hospital stay We identified time to IV-NAC administration is a potentially modifiable factor that may lead to prolonged hospital stay When risk assessment indicates that NAC is required it is highly recommended that NAC be started in the first hours of admission to reduce the LOS Antipsychotic medication adherence and satisfaction among Palestinian people with schizophrenia.http://blogs.najah.edu/staff/saedzyoud/article/Antipsychotic-medication-adherence-and-satisfaction-among-Palestinian-people-with-schizophreniaPublished ArticlesSweileh WM Ihbesheh MS Jarar IS Sawalha AF Abu Taha AS Zyoud SH Morisky DE Source Department of Pharmacology and Toxicology School of Pharmacy An-Najah National University Nablus Palestine Abstract BaCKGROUND: In Arab and Muslim-dominated countries spirituality and religiosity shape the belief and practices toward chronic illnesses No previous studies were published to assess adherence to and satisfaction with antipsychotic medications in persons with schizophrenia in the Arab world OBJECTIVE: To assess medication adherence and treatment satisfaction with antipsychotics in a sample of Palestinian people with schizophrenia METHODOLOGY: Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale MMAS-8 Treatment satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication TSQM 14 Psychiatric symptoms were assessed using the expanded Brief Psychiatric Rating Scale BPRS-E Data were entered and statistically analyzed using SPSS 16 for windows RESULTS: A convenience sample of 131 persons with schizophrenia was studied Based on MMAS-8 44 persons 336 had a low rate 58 443 had a medium rate and 29 221 had a high rate of adherence Age was significantly correlated P=0028 with adherence score However variables like use of monotherapy or atypical or depot antipsychotics were not significantly associated with higher adherence The means of satisfaction with regard to effectiveness side effects convenience and global satisfaction were 726 205 679 3147 632 143 and 631 188 respectively There was a significant difference in the means of effectiveness P 001 convenience P 001 global satisfaction P 001 but not side effects domains P=01 among persons with different levels of adherence Furthermore there was a significant difference in the means of positive symptom score P 001 manic P 001 and depression P 001 but not negative symptom score P=04 among persons with different levels of adherence ConcluSIONS: Medication nonadherence was common and was associated with low treatment satisfaction scores and poor psychiatric scores Medication related factors had insignificant effects on adherence scoresGender differences in sleep habits and sleep-related problems in Arab Palestinian university studentshttp://blogs.najah.edu/staff/saedzyoud/article/Gender-differences-in-sleep-habits-and-sleep-related-problems-in-Arab-Palestinian-university-studentsPublished ArticlesAbstract: Sweileh Waleed M 1 Ali Iyad 1 Sawalha Ansam F 1 Abu-Tah Adham S 1 Zyoud Saed H 1 Al-Jabi Samah W 1 1College of Medicine and Health Sciences An-Najah National University Nablus Palestinian Authority Corresponding author: Adham S Abu-Taha Assistant Professor Clinical Pharmacology Department of Pharmacology and Toxicology School of Pharmacy An-Najah National University PO Box 7 Nablus Palestinian Authority email A convenience sample of 400 students were recruited to investigate gender differences in sleep habits and sleep-related problems using a self-administered questionnaire Univaraiate analysis showed that females went to bed earlier p001 and rose earlier p001 had longer sleep duration p001 more nightmares p001 lesser snoring p001 lesser nocturnal awakening caused by eating p001 and had poorer sleep quality than males on the night of examination p001 Gender differences in sleep habits and sleep problems were found and were different than those reported from other cultures Keywords: gender differences; sleep habits; undergraduatesThe Poison Control and Drug Information Center (PCDIC) provides up-to-date guidelines for the treatment of white phosphorus poisoning http://blogs.najah.edu/staff/saedzyoud/article/The-Poison-Control-and-Drug-Information-Center-PCDIC-provides-up-to-date-guidelines-for-the-treatment-of-white-phosphorus-poisoning-General PostsThe Poison Control and Drug Information Center PCDIC provides up-to-date guidelines for the treatment of white phosphorus poisoningBy:Dr Ansam Sawalha; Director PCDICDr Saed Zyoud; Poison Information SpecialistPhosphorus comes in many forms including toxic and non-toxic and is used in many venues currently There is red white yellow and black phosphorus White and yellow phosphorus has emerged since their use in fireworks ammunition rodenticides and others White phosphorus has received increased attention lately due to its use in war It is considered a toxic and dangerous chemical with a garlic-like odor It burns immediately upon contact with oxygen producing fire and a dense white smoke This can further produce phosphine gas that is also toxic If a populated area gets exposed to white phosphorus residents can get poisoning by inhalation ingestion or skin contact This article will focus on the signs and symptoms and treatment of white phosphorus after inhalation or skin contactAdverse health affects that result from contact with white phosphorus:Eye and nose: conjunctivitis irritation lacrimation and corneal damageHeart: tachycardia arrhythmia heartblock and shockRespiratory system: upper respiratory tract irritation cough difficulty breathing tachypnea pulmonary edema and bronchitisSkin: sever pain necrosis second or third degree burns that are yellowish and smell like garlicCentral nervous system: headache seizures delusions fatigue nervousness dizziness general weakness and comaGastrointestinal system: nausea vomiting could be bloody abdominal pain diarrhea and smoke-smell being produced from vomitus and stoolGenitourinary system: blood in urine and renal failureCirculatory system: abnormal lab results for blood analysisTREATMENT:Inhalation Exposure: Move patient from the toxic environment to fresh air If cough or difficulty in breathing develops evaluate for hypoxia respiratory tract irritation bronchitis or pneumonitis Administer 100 humidified supplemental oxygen perform endotracheal intubation and provide assisted ventilation as required Administer inhaled beta adrenergic agonists if bronchospasm develops Exposed skin and eyes should be flushed with copious amounts of waterEye Exposure: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 09 saline or water for at least 15 minutes If irritation pain swelling lacrimation or photophobia persists after 15 minutes of irrigation an ophthalmologic examination should be performed Keep exposed eyes covered with wet dressings until definitive surgical removal of phosphorus can be accomplishedDermal Exposure: Brush all non-adherent phosphorus from the skin Avoid application of any lipid based ointments as these may increase the skin penetration of phosphorus Remove clothing and promptly begin continuous water irrigation of the affected site Water or saline-soaked dressings applied to the affected area will allow the patient to be transported without re-ignition of the remaining particles Keep dressing moist until debridement is accomplished Phosphorus will fluoresce under ultraviolet light With the exposed areas immersed in water loose or imbedded phosphorous particles that are visualized under UV light can be mechanically but delicately removed safely under water Traditionally copper sulfate solution has been topically applied to skin burns caused by yellow phosphorus The rationale for the use of copper sulfate is based on a chemical reaction that binds up the phosphorus thereby preventing further burning due to phosphorus oxidation The granules of Cu3P2 are black and decompose easily CAUTION - Acute renal failure and massive hemolysis may occur if significant copper sulfate is absorbed from the burn site A solution of 5 percent sodium bicarbonate 1 percent hydroxyethyl cellulose 3 percent copper sulfate and 1 percent lauryl sulfate has been proposed as a decontaminating agent For deep and extensive injury consult a burn specialist Partial skin thickness burns from a phosphorus pentachloride splash were treated with 1 silver sulfadiazine cream twice daily Healing was slow 8 weeks and painful and no signs of hypertrophic scarring were evident at follow-up Fluid and electrolytes should be replenished when indicated Prophylactic topical antibiotic therapy with silver sulfadiazine is recommended for all burns except superficial partial thickness first-degree burns For first-degree burns bacitracin may be used but effectiveness is not documented Systemic antibiotics are generally not indicated unless infection is present or the burn involves the hands feet or perineum Depending on the site and area the burn may be treated open face ears or perineum or covered with sterile nonstick porous gauze The gauze dressing should be fluffy and thick enough to absorb all drainage Alternatively a petrolatum fine-mesh gauze dressing may be used alone on partial-thickness burns Other signs and symptoms are treated based on the used protocols toxicology