Reginald P. Sequeira

Evaluation of the Knowledge, Attitude and Practice of Self-Medication among First-Year Medical Students

Objective: This study was undertaken to determine the knowledge, attitude and practice of self-medication among first-year medical students of the Arabian Gulf University, Bahrain. Subjects and Methods: This was an anonymous, questionnaire-based, descriptive study. A prevalidated questionnaire, containing open-ended and close-ended questions, was administered to the subjects. Data were analyzed using SPSS version 12 and the results expressed as counts and percentages. Results: Out of the 134 respondents, 43 (32.1%) were males and 91 (67.9%) were females; their mean age in years ± SD was 18.01 ± 0.78. The respondents’ knowledge about appropriate self-medication was poor, but knowledge of the benefits and risks of self-medication was adequate. The respondents found self-medication to be time-saving, economical, convenient and providing quick relief in common illnesses. Important disadvantages of self-medication mentioned were the risk of making a wrong diagnosis, inappropriate drug use and adverse effects. The majority (76.9%) of the respondents had a positive attitude favoring self-medication. Self-medication was practiced by 44.8% of the subjects. The most common indications for self-medication were to relieve the symptoms of headache (70.9%), cough, cold and sore throat (53.7%), stomachache (32.8%) and fever (29.9%). Analgesics (81.3%) were the most common drugs used for self-medication. The practice of self-medication was appropriate in only 14.2% of cases. Conclusion: Knowledge about appropriate self-medication was poor, attitude towards self-medication was positive, and the practice of self-medication was common and often inappropriate.

Influence of medical training on self-medication by students.

OBJECTIVE To examine the influence of medical training on the knowledge, attitude and practice of self-medication by medical students. SUBJECTS AND METHODS This was a cross-sectional, descriptive study. A self-developed, pre-validated questionnaire containing open-ended and close-ended items was used for data collection. Medical students in the 2nd and 4th year of the medical course at the Arabian Gulf University Bahrain filled in the questionnaire anonymously. Data were analyzed using SPSS and results expressed as counts and percentages. 2-tailed Chi2-test was applied and p < 0.05 was considered significant. RESULTS The respondents (n = 141) had a mean age of 19.94 A+/- 1.21 years. Overall, they had a fair knowledge about appropriate self-medication but knowledge of the benefits and risks of self-medication was adequate. Self-medication was perceived to be time-saving, providing quick relief in common illnesses, a learning experience, economical, and convenient. Among the perceived disadvantages were adverse drug reactions, inappropriate drug use, and the risk of making a wrong diagnosis. Majority of the respondents had a positive attitude favoring self-medication and read the package insert. The practice of self-medication was common and often inappropriate. The commonest indications for self-medication were cough, cold and sore throat (63.2% in Year 2) and headache (78.3% in Year 4). Mild illness, previous experience, and lack of time were the most frequent reasons for resorting to self-medication. Analgesics were the commonest drugs used, and drugs were mostly obtained from private pharmacies. Students of Year 4 had better knowledge about appropriate self-medication (58.7% versus 35.8%, p = 0.02), had greater awareness of the risks of self-medication and would discourage others from practicing self-medication (58.7% versus 40.4%, p = 0.04). They had a more confident attitude (54.3% versus 35.1%, p = 0.03) and a smaller number of them would seek a prescription (34.8% versus 54.3%, p = 0.03). They practiced self-medication more often (73.3% versus 52.6%, p = 0.02) and more appropriately (58.7% versus 35.8%, p = 0.02). CONCLUSION This cross-sectional study shows that senior medical students tend to have greater knowledge of appropriate self-medication, have a more confident as well as concerned attitude towards self-medication, and tend to practice self-medication more often and appropriately.

Drug treatment of hypertension in pregnancy: a critical review of adult guideline recommendations.

This review evaluates the guideline recommendations for the management of hypertension in pregnancy as presented by 25 national/international guidelines developed for the management of arterial hypertension in adults. There is a general consensus that oral &agr;-methyldopa and parenteral labetalol are the drugs of choice for nonsevere and severe hypertension in pregnancy, respectively. Long-acting nifedipine is recommended by various guidelines as an alternative for first-line and second-line therapy in nonsevere and severe hypertension. The safety of &bgr;-blockers, atenolol in particular, in early and late stages of pregnancy is unresolved; their use is contraindicated according to several guidelines. Diuretic-associated harmful effects on maternal and fetal outcomes are controversial: their use is discouraged in pregnancy. It is important to develop specific guidelines for treating hypertension in special groups such as adult females of childbearing age and sexually active female adolescents to minimize the risk of adverse effects of drugs on the fetus. In several guidelines, the antihypertensive classes, recommended drug(s), intended drug formulation, and route of administration are not explicit. These omissions should be addressed in future guideline revisions in order to enhance the guidelines’ utility and credibility in clinical practice.

Prescribing Patterns and Therapeutic Implications for Diabetic Hypertension in Bahrain

OBJECTIVE: To determine drug prescription patterns and the extent of conformity with World Health Organization/International Society of Hypertension (WHO/ISH) guidelines in diabetic hypertension. DESIGN: Retrospective prescription-based survey. SETTING: Seven primary-care health centers, comprising approximately one-third of primary-care health centers in Bahrain. PATIENTS: Patients with type 2 diabetes and hypertension. MAIN OUTCOME MEASURE: The prescribing pattern of antihypertensive and antidiabetic drugs. RESULTS: Among a study sample of 1463 patients with type 2 diabetes and hypertension, antidiabetic agents were prescribed as monotherapy in the following descending order: glyburide, gliclazide, insulin, and metformin. As combinations, sulfonylureas plus metformin was most popular, followed by metformin plus insulin, and sulfonylureas plus insulin. Sulfonylurea and metformin with insulin was rarely used. There was no significant difference in prescribing of glyburide and metformin between the elderly and young middle-aged diabetic patients; many patients older than 65 years were treated with a β-blocker along with a long-acting sulfonylurea. Both as monotherapy and in overall use, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium-channel blockers were most often prescribed. Among 35.5% patients treated with antihypertensive combinations, various two- and three-drug combinations of β-blockers, ACE inhibitors, calcium-channel blockers, and diuretics were often used. The proportion of patients taking atenolol 100 mg/d was higher with combination regimens. Hydrochlorothiazide 25 mg or equivalent thiazide diuretics were extensively used. CONCLUSIONS: The prescribing pattern of antihypertensives in diabetic hypertension differs in many instances from WHO/ISH guidelines, especially regarding the choice of antihypertensive drugs and their combinations. The appropriateness of antidiabetic drug choice is questionable in relation to the antihypertensive used.

Prescription writing skills of residents in a family practice residency programme in Bahrain

Purpose of the study: To evaluate the prescription writing skill of final year residents in a family practice residency programme (FPRP) in Bahrain, and to compare skill of residents who have graduated from medical schools with problem based learning (PBL) versus traditional (non-PBL) curricula. Study design: Prescriptions issued by the residents were prospectively collected for two consecutive cohorts in May 2004 and May 2005. Prescription errors were classified as errors of omission (minor and major), commission (incorrect information) and integration (drug–drug interactions). Results: In 69.6% of medications with major omission errors, dosage form (39.4%) and length of treatment (18.5%) were not specified. In 24.7% of medications with commission errors, dosing frequency (19.9%) and incorrect strength/dose (2.2%) were the most common errors. Integration errors comprised 5.7% of all prescribing errors. No significant differences were observed between PBL and non-PBL graduates with regard to the total number of prescriptions with errors, drugs per prescription, polypharmacy, and the total number of drugs with errors. The proportion of prescriptions with a potential for drug–drug interactions was comparable between PBL and non-PBL graduates. PBL graduates prescribed medications using brand names at a rate greater than non-PBL, whereas non-PBL graduates prescribed medications on inappropriate “as required” basis, and injections at a rate greater than PBL residents. Conclusions: Prescription writing skill of the final year residents in an FPRP programme was suboptimal for both PBL and non-PBL graduates. Integration of prescription writing skill and a rational pharmacotherapeutic programme into the FPRP curriculum is recommended.

Rational pharmacotherapy of hypertension in the elderly: analysis of the choice and dosage of drugs

Objectives: To determine in older people with uncomplicated hypertension: (a) the pattern of prescribing of antihypertensives; (b) the extent of physicians’ adherence to recommendations on dosage for antihypertensive combinations; (c) whether prescribing practice conforms with recommended therapeutic guidelines; and (d) the frequency of prescribing of other drugs which have the potential to alter the efficacy of antihypertensive agents.

Antihypertensive Drugs and Male Sexual Dysfunction: A Review of Adult Hypertension Guideline Recommendations.

Background: Published clinical practice guidelines have addressed antihypertensive therapy and sexual dysfunction (SD) in many different ways. Objective: In this systematic review, we evaluated guidelines that address antihypertensive drug-associated SD, guideline recommendations, and recent guideline trends. Methods: Thirty sets of guidelines for hypertension management in adults that had been published in the English language since 2000 were reviewed. The primary outcome measure was antihypertensive-associated SD potential, which was independently evaluated using specific questions by 2 authors in a nonblinded standardized manner. Results: Sexual dysfunctions associated with thiazide-class diuretics, β-blockers, and centrally acting sympathoplegics were addressed by half of the guidelines reviewed. There is no clarity on β-blockers and thiazide-class diuretics because one-third of the guidelines are vague about individual β-blockers and diuretics, and there is no statement on third-generation β-blockers and thiazide-like diuretics that can improve erectile function. The revised guidelines never use terms such as loss of libido, ejaculatory dysfunction, lack of orgasm, and priapism. Summary versions of guidelines are inadequate to reflect the key interpretation of the primary guidelines on SD associated with antihypertensives, even in the major guidelines that were updated recently. Therapeutic issues such as exploring SD in clinical history, assessing SD prior to and during treatment with antihypertensives, substituting the offending agents with alternatives that possess a better safety profile, intervening with phosphodiesterase-5 inhibitors, and avoiding the concomitant use of nitrovasodilators are superficially addressed by most guidelines, with the exception of 2013 European Society of Hypertension/European Society of Cardiology and Seventh Joint National Committee recommendations. Conclusion: Future guideline revisions, including both full and summary reports, should provide a balanced perspective on antihypertensive-related SD issues to improve the impact of hypertension treatment guidelines on patient care and quality of life.

Knowledge of management of epilepsy in young adults in Jordan

PURPOSE Nationwide studies on public knowledge of epilepsy have been undertaken in several countries, but not in Jordan. The purpose of this study was to evaluate knowledge of the management of epilepsy in Jordan. METHODS A cross-sectional study was performed during the period February-June 2005 on 16,044 individuals selected randomly to represent all regions of Jordan. Respondents were interviewed and asked to complete a five-item questionnaire testing their knowledge of the management of epilepsy. RESULTS Most of the individuals (77.9%) agreed that patients with epilepsy are best treated in a specialized hospital for neurological diseases. Although the largest percentage of the sample (86.7%) agreed that the best person to treat epilepsy is a neurologist, others believed that a hypnotherapist (25.4%) or a religious healer (22.6%) is. As an immediate measure during an attack of epilepsy, most respondents (82.6%) agreed that protecting the patients head is most important. During the postseizure period, 45.8% of respondents believed that offering the patient water or a cold or hot drink is appropriate. Two-thirds of the respondents (66.2%) agreed that epilepsy can be treated with drugs. Responses of the participants to the five items significantly differed with respect to age, gender, level of education, and occupation. CONCLUSION Jordanians are reasonably well informed about most aspects of the management of epilepsy, but there is still a need for public education about this disorder.

Treatment of Hypertension in Bahrain

Objective To evaluate the adequacy of blood pressure (BP) control and therapeutic appropriateness of antihypertensive drug(s) prescribed, taking into consideration laboratory parameters and the presence of comorbidities, in hypertensive patients. Methods Therapeutic audit of medical records of hypertensive patients from 9 primary care health centers in Bahrain using World Health Organization/International Society of Hypertension guidelines criteria. Results The recommended target BP <140/<90 mm Hg was achieved in 37 (16.5%) patients with a mean BP of 126 ± 6 / 80 ± 5 mm Hg. Groups with inadequate BP control were 15 (6.7%) with normal systolic BP (SBP) and high diastolic BP (DBP), 59 (26.3%) with high SBP and normal DBP, and 113 (50.4%) with high SBP and high DBP. Pulse pressure of the controlled group was 46.3 ± 5.9, whereas pulse pressures of the inadequately controlled groups with BP cutoffs <140/≥90, ≥140/<90, and ≥140/≥90 mm Hg were 37.4 ± 6.1, 72.7 ± 13.5, and 59.7 ± 13.6 mm Hg, respectively. Of the 281 treated hypertensive patients, 56.6% were on monotherapy; BP of patients on combination therapy versus monotherapy did not differ. The choice of antihypertensives in relation to comorbidities and laboratory findings revealed that many hypertensive patients with dyslipidemia were on β-blockers and diuretics, 39.3% of patients with ischemic heart disease were on β-blockers, approximately 20% of patients with hyperuricemia were on diuretics, and 27.6% and 10.4% of patients with isolated systolic hypertension were on diuretics and calcium-channel blockers, respectively. Conclusions BP control was achieved in 1 of 6 treated patients. In several instances, metabolic abnormalities and comorbidities were apparently not considered while prescribing antihypertensives. A rational drug therapy approach is needed in treating hypertension to achieve better control rates.

Medication prescribing errors pertaining to cardiovascular/antidiabetic medications: a prescription audit in primary care

This study was carried out to identify the medication prescribing errors (MPEs) pertaining to cardiovascular/antidiabetic medications in prescriptions issued to hypertensive and diabetic hypertensive patients. A retrospective, nationwide audit of prescriptions (n = 2773) issued by primary care physicians (n = 194) of 20 health centres in Bahrain was carried out. Approximately one‐quarter of prescriptions ordered by two‐thirds of primary care physicians had errors. No significant differences with respect to overall errors were evident in prescriptions ordered by the family physicians and general practitioners. The most common error (in 8.0% of prescriptions) was prescribing β‐blockers or diuretics (thiazide) or their combinations to patients on lipid‐lowering drugs. Prescribing multiple antihypertensives, often with a similar mechanism, accounted for 2.2% errors: approximately half of these (1.45%) were two angiotensin‐converting enzyme inhibitors (ACEIs) co‐prescribed and/or ACEIs plus angiotensin‐II receptor blockers. In 0.7% of prescriptions, β‐blockers were ordered to patients on salbutamol treatment. High‐dose metformin (3 g/day) was prescribed to approximately 4% diabetic hypertensives; of these, many were elderly patients. Prescribing high‐dose glibenclamide (median dose 15 mg) to the elderly accounted for 3.6% of the overall errors. Polypharmacy, such as aspirin along with an immediate‐release dipyridamole, was prescribed occasionally (0.25%), particularly by the general practitioners (P = 0.0139). MPEs are common in primary care, in Bahrain. Some of these prescribing errors have the potential to harm patients. Effective measures to detect and prevent such errors are needed to improve the quality of health care. Standard treatment guidelines and educational interventions are important strategies to achieve these goals.