Directorate General of Pharmacy
Federal Ministry of Health
Sudan Journal of Rational Use of Medicine
September 2014 - Issue No.9
S J
Patients' Adherence
•
Publication teamEditor in chief RandaAlsadigAlsaddig BSC.MSc.ClinicalPhamacyEditors Prof.AliMohamedArabi MBBS.MD ElkhatimElyasMohamed MBBS.MCOMH.DiplomaThoracicMed. HababKhalidElKheir B.Pharm.,M.Pharm.,Ph.DNuhaMohamedA.Agabna B.Pharm,M.Pharm,Ph.D DuriaHassanMerghani B.Sc.N,M.Sc.N.,Ph.D SarahA.KareemHassan B.Pharm,M.Pharm,MBA GhadaOmarShouna B.Pharm.,MScClinicalPhamacy BadreldinSaidHagnour B.Pharm,FPSM YasirMirghaniAbdalrahman B.Pharm. SawsanEltaherAhmed B.Pharm.Graphic Design MahmoudGahallaAhmedAdvisory board Prof.SamiAhmedKhalid B.Pharm.,M.Pharm.,Ph.D Prof.AbdallaO.Elkhawad B.Pharm.,M.Pharm.,Ph.D MohamedA.Zeinelabdin B.Pharm.,M.Pharm.
SudanJournalforRationalUseofMedicine(SJRUM)isaquarterlypublicationproducedbytheNationalMedicineInformationCenterandReferenceLibrary(NMICRL);DirectorateGeneral
ofPharmacy;FederalMinistryofHealth;Sudan.SJRUMisfundedbyGlobalFundandtechnicallysupportedbytheWorldHealthOrganization.ThefirstissuewaspublishedinSeptember2012.SJRUMaimstopromoteRationalUseofMedicines(RUM)throughdisseminatingprinciples,views,news,andeducatinghealthprovidersaboutrationaluseofmedicines.SJRUMtargetshealthprofessionals;prescribers,pharmacists,andnurses.Eachissueiscenteredonatheme;whichusuallyisanimportantsubjectinRUM.SJRUMhighlightsineachissuethecurrentsituationinSudanrelevanttothetheme,presentedeitherbyevidencefromlocalresearchorwithreliableanecdotalevidence.SJRUMincludesresearchstudieswhichaimtoencourageyoungresearcherstopublishtheirworkatnationalandinternationallevels.SJRUMalsoincludesasectionforeducationalmaterialsrelevanttoRUMrelyingmostlyontheWHOeducationalmaterialsandotherreliablesources.ThesectionofnewsreflectssomeimportantpublishednewsthatmayaffectRUMpractice.SJRUMincludessomeselectedcasestudies,reflectingcurrentpracticeatdifferenthealthfacilitiesinSudan,soastohighlighttheirrationalaspectsinordertoovercomethem.AspartofNMICRLactivities,medicalstudentsandthepublicareendowedwithleafletsandfliersonselectedtopicsofSJRUM.Readershavethefreedomtouseandreproduceanypartofthisjournal.Forparticipationpleasecontact:[email protected]…YoucanaccessSJRUMonlineonwww.sjrum.sd
AcknowledgementTheDirectorateGeneralofPharmacygratefullyacknowledgesthefinancialsupportoftheGlobalFundtofightagainstHIV/AIDS,TuberculosisandMalaria.ThisworkwouldnothavebeenpossiblewithouttechnicalsupportofWorldHealthOrganization.
SudanJournalofRationalUseofMedicine
Contents1
•
Contents2Editorial
3Where Are We?
4Current Topic
6
• Compliance,AdherenceandConcordance…What’sinaName?
Practice Issues • AnEpilepticChildWithPoorMedicationAdherence• WhoistoBlame?• OralAnticoagulants• AdherenceisVitalinChronicDiseases
10
12
Standard Treatment Guidelines • RedEye
Research Articles• PatientwithDiabetesType2:AssessingComplianceand
BarrierstoAdherence,NyalaCity,SouthDarfurState,Sudan
• HIV/AIDSPatientFactorsAffectingAdherencetoAntiretroviralTherapy
1617
NewsFocus • Doctors’AdvancementProgramKeepingAbreastin
MedicineandPharmacy
18
19
20
22
30
31
Useful Tips• TipsonhowtoUseAccuhaler
Questions and AnswersSuccess Stories• SouthDarfurStateMedicinesInformationCenter
Continuous Medical Education • PatientMedicationAdherence• StrategiestoImprovePatientMedicationAdherence• GuidelinestoImproveMedicationOrdersAdherence• PharmaceuticalPictogramsCanAidPatients’Adherence
Pharmacovigilance Awareness• PartnersoftheNationalPharmacovigilanceProgram
Anti-Microbial Awareness• ModeofAntibioticResistance
SudanJournalofRationalUseofMedicine
Dear fellows and readers
Welcometothe9thissueofSJRUM.
On behalf of the team of editors, I would like to welcome you all our distinguished readers, and present to you the ninth issue of SJRUM about patients’ adherence.
Patients adherence to treatment describes the degree to which patient follows correctly the medical advice or prescribed regimen, weather it is pharmacological, exercise, dietary or physical therapeutic regimen. It is a major public health problem that has been reported with a very high rate in the literature.
Patients' adherence to treatment is a key mediator between the medical practice and the patients' outcomes. Serious
consequences may result from lack of adherence, like therapeutic failure, reduced patient's quality of life, reduced patients' life span and higher long-term health costs. Patients’ non adherence is a multidimensional situation involving many stakeholders who should have positive roles in a concerted effort to ensure the success of adherence improving strategic programs. Healthcare providers in our beloved country Sudan are looking forward to make the paradigm shift towards the patient centered approach, so all of us need to take substantial steps to fill the gap in our practice to satisfy the allocated role, to make this inevitable shift. For example for pharmacists, the clear message is to assess each patient individually to provide the targeted intervention responsive to the patient own unique risk factors and needs.
The current issue includes articles about patients non adherence; the situation in Sudan, teaching materials, relevant researches and case study reports about the topic, written by different authors and healthcare professionals, reflecting valuable experiences in their field of knowledge and expertise.
I take this opportunity as well to invite you once again to contribute your knowledge and experience to enrich our journal, as we also welcome your feedback on this issue and all other issues.
Randa AlSadig AlMahdi
Editorial2
SudanJournalofRationalUseofMedicine
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Where are we from:Types of Medication Non-adherence
Factors affecting medication adherence
1. Planning and Policies Directorate, Directorate General of Pharmacy-Federal Ministry of Health
Einas S. Elwali 1
Primary
Secondary
Tertiary
Non fulfillmentPrescriptionwasneverfilledorinitiated.
Non persistentPatientstoppedtakingmedicationonhisown.Unintentional;usuallyarisefrommiscommunicationorresource/capacitylimitationormisunderstanding.
Non conformingPatientstoppedtakingmedicationonhisown.Medicationwasnottakenasprescribed.Misseddoses,incorrectdoses,dosetakenatwrongtimes.
Reference1. Jimmy, Beena, Jimmy jose. Patient medication adherence: Measures in daily practice. Oman medical journal. 2011; 155-159.2. Jing jin, Grant ES , Vernon MS Oh, Shu chuen li. Factors affecting therapeutic compliance: A review from the patient's
perspective. Ther Clin Risk Manag. 2008; 4(1): 269-286.3. Donovan JL, Blake DR. Pateint non-compliance: Deviance or reasoned decision-making. Soc Sci Med. 1992; 34(5): 507-13.
Disease factorsSocial and economic
Therapy-relatedfactors
Health care system factorsPatient - centered factors
DiseasesymptomsInabilitytogotowork
Routeofadministration
Lackofaccessibility
Demographic factors:age,ethnicity,gender,educationallevel,maritalstatus
Severityofthedisease
Costsandincome
TreatmentcomplexityLongwaitingtimePsychosocial factors:beliefs,
motivation,attitude,patient-
InformationaboutdiseaseSocialsupportDurationofthe
treatmentperiodDifficultyingettingprescriptionsfilledHealthliteracy
DiseasesymptomsVsadverseeffects
MedicationadverseeffectUnhappyclinicvisitPatientknowledge
Degreeofbehavioralchangerequired
Physicaldifficulties
Unpalatabletasteofmedication
Tobaccosmokingoralcoholintake
Asymptomaticdiseases
Specialstoragerequirementsforgetfulness
SudanJournalofRationalUseofMedicine
Current Topic4
SudanJournalofRationalUseofMedicine
Itisavery commonknowledge thatfailure to takemedicines,adverselyaffects the outcome of treatment,andplacesahugeburdenofwastedresources on the society. Threeseeminglyrelatedterms;compliance,adherence and concordance havebeen used to describemedication-
takingbehaviour inchronicillnesses.Thisevolution in the terminology isnotmerelyachangeindefinitionsbutittendstobeaconstructivedevelopmentembracestheideaofapartnershipbetween thepatientandproviderswhich isneededtoaddress thepatient’sneedsbetter.
Compliance isdefinedas“the extent to which the patient’s behaviour matches the prescriber’s recommendations” 1.However,studiesoverthepastfewdecadeshavequestioned the validity of this termbecause it refers toaprocesswhere thecliniciandecidesona suitable treatmentand the patient is expected to complywith unquestioningly, without given anyconsiderationtothepatients’perspectivesintakingtheirmedications.
Asaresult the termadherencehasbeenintroducedasareplacementforcompliancein an effort to place the clinician-patientrelationshipinitsproperperspective;henceadherencerefers to a process, in which the appropriate treatment is decided after a proper counselling with the patient. Thetermcompliancealsoimpliesthatthepatientisundernocompulsiontoacceptaparticulartreatment,andisnot tobeheldsolelyresponsiblefortheoccurrenceofnon-adherence.Accordingly,adherencehasbeen
definedas “theextent towhichaperson’sbehaviour, in takingmedication, followingadiet, and/orexecuting lifestyle changes,correspondswithagreedrecommendationsfromahealthcareprovider”2.
Lately the concept of concordance hasevolvedfromanarrowerview,emphasizingan agreement between the clinician andthepatient,which takes intoaccounteachother’s perspective onmedication taking,toabroader process consisting of open discussions with the patient regarding medication-taking, imparting information and supporting patients on long-term medication.Itisaprocess,whichentertainspatients’ views onmedication taking, andacknowledgesthatpatients’viewshavetoberespectedeveniftheymakechoices,whichappear tobe inconflictwith theclinician’sviews.
Adherence to medications causes 125,000 deaths annually and accounts for 10% to 25% of hospital and nursing home admissions 3.
Pharmacistsencountersimilarpatientsintheirdailypractice,andmanymaystruggletofindeffectivestrategiestoaddressnon-adherence.Pharmacists are in a unique position toaddressnon-adherence.Theirdrugexpertise,alongwiththeiraccessibility,makesthemidealcandidatestoaddressthissignificantproblem.Peer-reviewedshortstoriessimilartothethreecasespresentedinthisissueofSJRUMmayaddressthemisperceptionsunderlyingnon-adherence.
Although none of these terms are idealsolutiontounderstandthecomplexprocess
Compliance, Adherence and Concordance… What’s in a Name?
Sami A. Khalid1
1. Dean Faculty of Pharmacy, University of Sciences and Technology
SudanJournalofRationalUseofMedicine
Current Topic5
ofmedication-takingbehaviourofpatients,themovefromcompliancetoadherenceandconcordancerepresentsgenuineprogressinthisfield,whichputsthepatient’sperceptionsatthecentreofthewholeprocess.
Anumberofstrategieshavebeensuggestedtoimproveadherenceincluding:thesimplificationofregimenbyadjustingtiming,frequencyanddosagetomatchpatients’activities;impartingknowledgebydiscussionwithphysician,nurseandpharmacistsmodifyingpatient’sbeliefs,involvingpatientsindecisionstailoringtheeducationtopatients’levelofunderstandingandevaluatingadherencebyself-reporting,billcounting4.
Perhaps,thebesttherapeuticoutcomescanberealized,atleastinpart,bytailoringthetreatmenttothepatient’slifestyle,nottheotherwayaround.
References
1. Tilson HH, Adherence or compliance? Changes in terminology. Ann Pharmacother. 2004, 38: 161-162.
2. Dunbar-Jacob J, Burke LE, Puczynski S. Clinical assessment and management of adherence to medical regimens. In: Nicassio M, Smith T, eds. Managing chronic illness: A Biological Perspectives. Washington DC: American Psychological Association, 1995, 313-341.
3. Smith DL. Compliance packaging: a patient education tool. Am Pharm. 1989, NS29 (2): 42-4, 49-53.
4. Atreja A, Bellam, Levy SR. Strategies to enhance patient adherence: making it simple
www.medscape.com/viewarticle/498339_print
SudanJournalofRationalUseofMedicine
An Epileptic Child With Poor Medication Adherence
Randa A. Almahdi1
Practice Issues6
Scenario
Mohammed Ali is an 11yearsoldboywholivesina small rural communitynear Khartoum.Hewasdiagnosed with toniccolonic seizures sincethe age of 8 when hisfamily took him to a
referralhospitalinKhartoum.
Since the age of 5 he started to fall downsuddenly, lose consciousness, collapse, andthenhisbodybecomesstiff.Hisfamilyandthelocal community there have amisconceptionabouthisillnessasasupernaturalphenomenonthat can be treated by going to the localtraditionalhealer(Sheikh)whothoughtitwasacurse.Thechildcontinuedexperiencingtheseepisodesandeach timehewas taken to theSheikhwhousedtogivehimsomeblessingsandherbstodrink.
MohammedAlididnotgo toschoolbecauseof his illness, when he was 8 years old, Headmittedtothehospitalandhewasdiagnosedwithepilepsyandprescribedaphenytoin300mgperdayandregularvisitsforfollowupwerescheduled.Thechildwastakinghismedicineregularly supervised by themother who hasbeen told by the doctor andpharmacist howimportant thedrug is tocontrolhiscondition.Hissymptomswerebroughtundercontrol,andhehadveryfewseizuressincethen.
As MohammedAli grew older into his earlyadolescence, he started to refuse taking hismedication, as he thought the drug causedhimsomebadeffects' like frequentpainandswellingofhisgum.Hisadherencetotreatmentwas lost gradually, he also refused to go forfollowupvisitstothehospitalandhestartedtoseizeagainfrequently.
Problems• Misconceptionandlackofcorrect
informationaboutepilepsy.
• Patientnonadherencewithprescription.
• Nomedicalfollowupforalongtime.
• Thechildwasnotinvolvedinhisowndiseaseanditstreatmenttobecomecommitted,andtheresponsibilitywasleftforthemotheralone.
• Lackofpatienteducationaboutthediseasehasdirectlyledtothenoncompliance.
Solutions • Patienteducationshouldbehighly
consideredandmonitoredtoinsurepatientcommitmenttothetreatmentplan.
• Patienteducationshouldinvolvethepatienttobecommittedtothetreatmentplan.
• Patientcounselingonmedicationandtheassociationbetweenadherencetotreatmentandcontrolofsymptoms.
.
1. Lecturer of pharmacy practice, Faculty of Pharmacy, University of Sciences and Technology
SudanJournalofRationalUseofMedicine
Who is to Blame?
Practice Issues7
Nuha M. Agabna1
SudanJournalofRationalUseofMedicine
Scenario
Farouq, isa63yearsold retiredsoldierwhosuffersfromdiabetesmellitus type II for ten years.He is covered by insuranceand receives medical servicesfrom Military health units. Hegoesmonthlyforavisit,usuallyseenbyhouseofficers,andhis
prescriptionsrefilled.Thespecialistisseenonlywhenthereisamedicalconditionthatimpliesto.
Hisdiabetesalmostnevercontrolled;hesuffershypoglycemia frequently, and his monthlycheck up shows high blood sugar. He eatswhathelikes,notcompliantwithhismedicine,and generally thinks that death comes whenit comes and taking care won’t delay it. Hebecomes confused over his medicationfrequently; he is confused with the differentpackages of medicines he gets. As resultsometimes he misses doses, or takes themmorethanoncefromadifferentpackage.Andothertimesmedicineswerenotavailableatthepharmaciesandmightstaydayswithouttakinghismedication.
Becauseofbadcareforhisfoothedevelopedgangrene/ulcers on both feet. He was givenappropriatemedicationsandadvised todressthewounddaily,alongwiththeregularmonthlyspecialist visit. Because the specializeddiabetescarecenterwastoofarhewenttoanearhealthclinicfordressing.Noimprovementwasseenovertwomonths,andonelegactuallygotworsewithspreadingwound.Hisspecialistdecidedtoadmithimforsurgeryandtoswitchtoinsulintoassisthealing.
During his hospital stay hiswife encountereda “Diabetes Patients Friends” group and oneof the members came to visit her husband.The member offered counseling and someinformation about diabetes and the currentpatient’s condition. Both husband and wife
wereastonishedbecausethisisthefirsttimetheyhearsuchatalk.Theyunderstoodalotof things and both felt that life would havebeen easier for both if they had knew thisinformationbefore.
Problems• Patient’snonadherencewith
medicationanddiet.
• Confusionovermedicationbecauseofthedifferentpackagesforthesamemedicine.
• Medicinesunavailability.
• Difficultiesaccessingspecializedhealthcare.
• Lackofcounselingandpatienteducation.
Solutions• Patienteducationandcounseling
isanimportantpartofsuccessfuldiseasemanagement.Theprocesshastoberepeatedmanytimestoensurefullunderstandingandhencecompliance.Writteninformationcouldbeuseful;theywouldbeavailableforthepatientaspeoplegenerallydon’tgetallwhatissaid.
• Whenswitchingbrandpharmaceuticals;thepharmacistmustexplaintothepatient/co-patientandensureunderstanding.
1. Lecturer of pharmacology, Faculty of Dentistry, University of Khartoum
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Oral Anticoagulants
SenarioNissreen E. Mohamed 1
Practice Issues
1. Clinical pharmacist, Ahmed Gasim Cardiac Surgery and Renal Transplantation Center (AGCSRTC)
MohamedAhmedis43yearsoldbusdriverdiagnosedwithdeepveinthrombosisontheleftlegonemonthagosooralanticoagulant;warfarinwasprescribedfor six months. Lastweekhewasadmittedto
hospitalwithischemicstorkmostprobablybecauseofanembolusfromhisthrombosedleg.Propermanagementwasprovidedforhimandstrokesignswereimproved.TheappropriatedoseofwarfarinwasgivenaccordingtohisinternationalNormalized
Ratio(INR)andaspirin.DuringcounselingsessiontheclinicalpharmacistknewthatMohamedwastoldbyhispreviousphysicianthatwarfarinmaycausesome(troubles),andthatwasthereasonhewasnotadheredtohismedication.Hecompletelystoppedwarfarinwhenhisgummildlybled.Theclinicalpharmacistexplainedtohimthatstoppingthemedicationwasthecauseofthestroke.Theproperinformationtousewarfarin;adherencewiththetreatment,drug–druganddrug–foodinteractionsandpropermonitoringofINR,weregiventoMohamedAhmed.
Problems• Misleadinginformationwasgiventothe
patientinsteadofpropercounselingatfirsttime.
• Thepatientdiscontinuedhistreatmentbyhimself.
• Failureoftreatmentduetonon-adherencetomedication.
• Informationgiventopatientsabouttheirmedicationsshouldbebalancedtoinvolvetheimportanceandbenefitsfromusingmedicinesaswellasserioussideeffectslikebleeding.
Solution• Patientcounselingshouldbean
essentialpartoftherapeuticplanbecauseimpropercounselingcanleadtofailureoftherapyespeciallyformedicationsuchaswarfarinwhichrequiresclosemonitoring.
• Medicalstaffshouldbetrainedtodeliverpropercounselingregardingimportantmedicineslikeoralanticoagulants,usingverbalandwrittenmaterials.
• Patienteducationisanimportantelementthatleadstosuccessoftherapeuticplan.
• Deficiencyofclinicalpharmacyservicesmightleadtoserioushealthproblem.
Adherence is Vital in Chronic Diseases
A37years old pregnantlady, of 167 cmheightand96kgbodyweight,arrived to her regularantenatal care clinic.Upon measuring herb l o od p r e s su r e , i twas 150/100 mm Hg,
whichwasconsideredanelevatedsystolicanddiastolic bloodpressure, accordingly,diagnosisof hypertensionwasmade.Thepatienthadnormalhepaticandrenalfunctions.Shestatedthatshehasnohistoryofelevatedbloodpressure,deniedanyhistoryofchronicmedicationuseexceptparacetamolperneed.Thepatienthasreportedaremarkablerecentweightgainoverthepasttwoyears,attributingthistohersedentarylifestyleandstressfulworkloadbecauseofhernewjob.
The treating physician prescribed to her oralmethyl dopa tablets 250mg twice daily andadvised her to reduce her weight and to dosomeexercise.Onemonthlater,shecametothedoctorforascheduledfollow-upvisit,shehadnochange inherbodyweight,whileherbloodpressurereadinghasshownareductionin systolic blood pressure and elevation inherdiastolicbloodpressure, thereadingwas140/110 mmHg. The patient also admittedthatshedidnotdoanyexercise,butshewastaking her prescribed medication exactly aswasprescribed.Thedoctorthencontactedthepharmacy to cross check that the pharmacydispensedthisprescriptiononthesamedate,which was true, so he asked the patient tobring her medication bottle in her next visitto the clinic, fixed in two weeks time.Whenthepatientbroughthermedicationbottle, thedoctor found some remaining tablets in the
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bottle, whichmust have been empty by thistime, if the patient was compliant with herprescribedregimen.Moreover,thepatienttoldthedoctorthattherearesometabletskeptinatissuepaperinhercabinetaswell.Thedoctorrealizedthathispatientwasnotadherentwithhermedicationorder.
Problems • Thepatientwasnotadherentwithher
prescribeddrugregimen,orwiththeexerciseandweightreductionaswasadvisedbyhertreatingdoctor.
• Thepatienthaskeptsomeofhertabletsoutsidetheiroriginalcontainer,withthepotentialofconfusingthemwithothermedications,ifavailable.
• Itwasobviousthatthispatienthasnotbeencounseledabouthermedicationandhowimportanttoadherewiththedoctor'sadvises.
Solutions• Thediagnosisofhypertensionshould
bemadeafterthreeconsistentlyhighmeasurementsofbloodpressure.
• Doctorsandpharmacistsarerequiredtodoanefforttomakesurethatpatientswilladheretotheirprescribedmedicationregimensasprescribed.
• Interventionsthatcontributetoimproveadherencelikepatienteducationandpatientcounselingareveryimportantwithspecialconsiderationtochronicdiseasesfornewlydiagnosedpatients.
Sawsan E. Ahmed1
Practice Issues
1. Medicines’ Information Center pharmacist, Omdurman Maternity Hospital
Senario
Non adherence with the prescribedtreatment regimen is a real problemthat results in treatment failure andconsequently,increasedmorbidityandmortality.
SudanJournalofRationalUseofMedicine
Red Eye10Standards Treatment Guidelines
Introduction Commoncausesofredeyeinclude:• Conjunctivitis(viral,bacterial,allergicor
chemical).• Foreignbody,conjunctival,cornealor
subtarsal(undertheuppereyelid).• Cornealulceration.• Burns(acid,alkaliorthermal).• Bluntinjury;byabluntobjectmaycause
hyphema(bloodintheanteriorchamber).• Penetratinginjury(typicallybyasharp
objecte.g.astickcausecornealorscleralpenetration).
• Lidlaceration(inlidorcanaliculus).• Subconjunctivalhemorrhage.
Otheruncommoncausesincludeiritis,scleritis,episcleritisandacutecongestiveglaucoma,whichrequirereferral.
Signs, Symptoms and History Obtainathroughhistorytoidentifyifthereisapossibilityofoculartrauma,contactlenswear,thetimeandcourseoftherednessandthepresenceofeyepain,itchanddischarge.Diagnostic signs:Patientsmaypresentwithanarrayofsymptomsdependingontheetiologyoftheredeye.Patientswhopresentwithpain,photophobiaandwaterydischargemayhaveaforeignbody,atraumaticcornealulcer,herpeticulceroracuteglaucoma.Dull,achingeyepainisthemainpresentationwithiritis,scleritisandepiscleritis.Subconjunctivalhemorrhagemaybecausedbytraumaoritcouldalsobecausedbyvigorouscoughingorvomiting.Traumatotheeyecanpresentwithfocalconjunctivalinjectionoririsinjury.1. Conjunctivitis: 1.1. Infective conjunctivitis:Causedbybacteriaandresultsinastickydischargeinbotheyeswithclearcornea,normalpupilandnormalvisionandredeyes.Infectiveconjunctivitisintheneonateusuallyoccursintheseconddayofbirthduetoeyeexposuretobacteriaduringbirth.Itisabacterialswellingoftheeyeandcanleadtopurulentdischargeandeyelidswelling.(Chlamydiaandgonorrhoeainfectionsrequireurgentreferral).• Viralconjunctivitis:waterydischarge,
redeyesanditch.• Allergicconjunctivitis:redeyes,
excessivelacrimationanditch.1.2. Corneal ulcer:whitespotormarkonthecorneawhichstainswithfluroscein.Therednessismostmarkedaroundthecornea,excessivewaterydischarge(lacrimation)+significantphotophobia.Thereareseveralcausesforcornealulcersmostimportantly vitaminA deficiency,malnutrition,longstandingconjunctivitisandherpessimplexandherpeszosteropthalmicus.2.Iritis:Thepupilissmallandbecomesirregularasitdilates.Therednessismostmarkedaroundthecornea,waterydischarge(lacrimation)+significantphoto phobia. Patients should be referred tosecondarycare.3.Acute glaucoma:rednessisgeneralizedandtheeyeisverypainfulwithpoorvision,dilatedpupil,raisedintraocularpressureandshallowanteriorchamber.Thecorneaishazyduetofluids.Patientsshouldbereferredtosecondarycare.
Investigations Theeyeshouldbeexaminedcarefullybyinspectingtheeyelidsandtheirundersurface.Aslitlampshouldbeusedtoexaminetheconjunctiva,pupil,irisandcornea.Ifsuspectingacornealabrasionorulcer,staintheeyeusingflurosceinbeforetheexamination.Ifsuspectingtrauma,examineforenophthalmos,diplopia,subconjunctivalhemorrhage,hyphemaandretinaldetachment.Visualacuityshouldalwaysbemeasuredinpatientspresentingwitheyecomplaintsusingageappropriate-visualacuitychart.
Criteria for same day referral:1. Moderatetosevereeyepainorphotophobia2. Markedrednessoftheeye3. Reducevisualacuity4. Suspectedpenetratingeyeinjury5. Irritantconjunctivitis6. Neonatalconjunctivitis7. Scleritis
(Patientswithsuspectedraisedintraocularpressureshouldbegivenintravenousacetazolamideandpilocarpineeyedropsbeforeurgent referral tosecondarycare)
SudanJournalofRationalUseofMedicineSudanJournalofRationalUseofMedicine
11Standards Treatment Guidelines
Non Pharmacological Management(Seeunderseparateconditionsbelow)PharmacologicalManagement(Seeunderseparateconditionsbelow)1. Eye Tear• Donotplaceanythingontheeyeincluding
eyeointmentoreyedrops.• Placeasteriledressingtocovertheeye.• Givesystemicantibiotics.• Referthepatienttotheophthalmologistfor
samedayassessment.2. Allergic Conjunctivitis• Maybeseasonalandoccurswithother
symptomssuchasrhinorrheaandsneezing.
• Administerantihistamineeyedrops– ketotifenorsodiumcromoglycate
• Advisepatienttoavoidsuspectedallergens.
• Inseveresymptoms,givesteroideyedropsinadditiontoamildsteroide.g.fluorometholone.Ifnoimprovementthengivesdexamethasoneeyedropswithsubsequenttaperinginadditiontoamastcellsstabilizere.g.sodiumcromoglycateeyedrops(2%forchildrenand4%foradults)
3. Infective Conjunctivitis (Adult)• Infectiveconjunctivitiscausedby
bacteria.• Washtheeyesdailywithcleanwater.• Administertetracyclineeyeointmentevery
8hoursfor7days,orchloramphenicol.• Referthepatienttothespecialistifno
improvementinthreedays.
4. Infective conjunctivitis (Neonate)• Removepusfromtheeyeusingsterile
gauzeeveryhour.• Administertetracyclineointmentthree
timesdaily.• Refertheinfanttothehospital.
5. Corneal Ulcer• Administertetracyclineointmenttotheeye
everyhour.• Administersystemicantibiotice.g.
Doxycycline100mgcapsulesevery12hours.• AdministervitaminA100,000I.U.for
children• Referthepatienttoophthalmologisturgently.• EyeLesions
6. Foreign Body• Carefullyremovetheforeignbodywitha
cottonswabifitislyingsuperficiallyintheeye.Iftheobjectisembedded,referthepatientforremoval.
• Administertetracyclineointmentoncea night.
• Referthepatientifnoimprovementoccursafter24hours.
7. Corneal scratch• Administertetracyclineointmentonceat
night.• Closetheeyewithsteriledressing.• Referthepatienttothespecialistifno
improvementoccursafter3days.8. Subconjunctival Hemorrhage• Bedrestfor5days• Referifnoimprovementoccursafter3days.
9. Eyelid tears• Checktheeyecarefullyforothernon-
immediatelyapparenteyelidtears.• Closetheeyewithsteriledressing.• Administersystemicantibioticse.g.
Doxycycline100mgcapsulesevery 12hours.
• Refertothespecialist.
10. Chemical and heat burns• Washtheeyewithcopiousamountsof
sterilewater.• Administertetracyclineointment.• Referurgentlytothespecialist.
Follow-upPatientsshouldbeseenevery24hoursandreferredifworseningofthesymptomsoccurs.Prevention Patientsshouldbeadvisedtokeepforeignobjectsandchemicalsawayfromtheeye.Ininstanceswhereaneyebandageshasbeenplace,nottoremoveitwithoutthedoctor’sadvice.
Reference Sudan National Standard Treatment Guidelines, Directorate General of Pharmacy, Federal Ministry of Health, Sudan, 2014
SudanJournalofRationalUseofMedicine
IntroductionInSudan,therearefewarticlespublishedaboutadherencetomedications.Thecurrentneedforassessingmedicationsadherenceprovidegoodopportunitytoimplementinterventionaladherencerelatedstudies. Inacross-sectionalstudyofpatientswithhypertension,factorsassociatedwithadherence,statusofbloodpressure(BP)controlandoccurrenceofcomplicationswereassessed.Despitethattheadherenceratewasreasonable,36.8%ofpatientswerenon-compliantbecausetheycouldnotafford tobuyantihypertensivedrugs.Thesepatientsexperienceduncontrolledbloodpressure(BP)andothercomplications1.
Theaimofthisstudywastoinvestigatethelevelofcomplianceand theassociationsbetweeneducationlevel,occupation,incomeandageusingtheBriefMedicationQuestionnaire(BMQ)2.
MethodsThiswasapartofamulti-centerdescriptivestudy,including10publichealthclinicsinNyalaSouthDarfur.Thestudyemployed300patientswithtypetwodiabetes,aged18-79yearsonoralhypoglycaemicdrugstakingfourormoreothermedicines(whethercardiovasculardrugsornot).Demographics,medicalinformationandlaboratory resultswerecollectedbeside theBMQwhichassessesfourbarrierstoadherence;namelyregiment,beliefs,recallandaccesstomedication.Datawasanalyzedstatisticallytodeterminesignificance.
Results and DiscussionRegardingregimenthescreeningindicatedanon-adherencewithcurrentdrugregimen,whereatotalscoreoffivewasobtainedoutoffive.
Patient with Diabetes Type 2: Assessing Compliance and Barriers to Adherence, Nyala City, South Darfur State, SudanAhmedD.Ahmed1,AsimA.Elnour2,MirghaniA.Yousif3
Thescreenwaspositivedenotingnon-adherencewithdiabetesandcardiovascularmedicationsasindicatedbythehighscore.
Screeningforbeliefbarrierindicatednegativebeliefsormotivationalbarriersregardingefficacy,adversesideeffectsandotherconcernsregardingagivendruganditseffects,wherethetotalscoreobtainedwastwo.
The twoquestions:whetherpatient’s receiveamultipledoseregimen(2ormoretimes/day)and/orreportanydifficultyrememberinghis/hermedications,wereusedtodetectrecallbarrier(totalscores=2.0).Thepopulationscoredtwoconfirmedthepresenceofrecallbarriers.
Resultsdisplayeddifficultypayingformedicationanddifficultygettingrefillsintimeindicatingaccessbarrierstocompliance(totalscores=2.0)Theresultsshowedthataccessrepresentedcertaindegreeofhindrancetomedicationadherence.
Todeterminecorrelationbetweenscreenanddemographic parameters, person correlationcoefficientwasusedat final followsup.ThefindingsrevealedthateducationhadasignificantnegativecorrelationwithRegimen,Belief,Recallandaccessscreenswhichwere(-0.54,-0.11,-0.16and-0.4)respectively.Thisindicatedthatpatientswithhigheducationlevelhadlowscreenscores, which entails that patient’s level ofmedicationadherencewasimproved.
TherewassignificantpositivecorrelationbetweentheoccupationandRegimen,Belief,Recall,andAccessscreenswithcorrelationcoefficients(0.38,0.16,0.008and0.14);respectively.However;theassociationwasnotsignificantinRecallscreen(P=0.154).Thishasalsoindicatedthatpatient
12Research Articles
1. Department of Pharmaceutics, Faculty of Pharmacy, Gezira University, Sudan, [email protected]. Consultant Clinical Pharmacist, Al Ain Hospital, United Arab Emirates 3. College of Pharmacy, Clinical Pharmacy, Taif University, Saudia Arabia
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References:1. Elzubier A G, Husain AA, Suleiman IA, Hamid ZA. Drug Compliance among Hypertensive Patients in Kassala, Eastern
Sudan. Eastern Mediterranean Health Journal, Vol. 6, 2000, pp. 100-105. 2. SvarstadBL, Chewning BA, SleathBL, Claesson C. The Brief Medication Questionnaire: A Tool for Screening Patient
Adherence and Barriers to Adherence. Patient Education and Counseling, Vol. 37, No. 2, 1999, pp. 113-124. 3. Adepu R and ARri SSM. Influence of Structured Patient Education on Therapeutic Outcomes in Diabetes and Hypertensive
Patients. Asian Journal of Pharmaceutical and Clinical Research, Vol. 3, No. 3, 2010.
with occupation had low screen scores,whichentailsthatpatient’slevelofmedicationadherencewasimproved.
Withrespecttoincome,significantnegativecorrelationswasobservedwithRegimenandBeliefscreens,(-0.32and-0.14);respectively.However;theassociationwasnotsignificantwiththerecallandaccessscreens(P=0.961;0.64)respectively.
When income increased the regimen and belief would have decreased, which means improvement of adherence.
Regardingpatients’agetherewassignificantcorrelationonlywith regimenscreen,withacorrelationcoefficientsof0.13(P=0.029).Thismeansthatolderparticipantshadlowadherence.
The impactofpooradherencegrowsas theburden of chronic diseases grows too. Theconsequencesofpooradherencetolong-termtherapiesarepoorhealthoutcomesandincreasedhealthcarecosts,henceimprovingadherenceenhancespatients’safety3.Acorrelationbetweenthe screen and demographic parameters isdisplayedintable1.
Table 1 Correlation between the screen and demographic parameters at final stage (N= 300)
Patient socio-demographic parameter(Final assessment, stage 3) Regimen Belief Recall Access Total
EducationPearsonCorrelation -0.54 -0.11 -0.06 -0.16 -0.4
Pvalue 0.001* 0.049* 0.329 0.004* 0.001*
OccupationPearsonCorrelation 0.38 0.16 0.08 0.14 0.32
Pvalue 0.001* 0.007* 0.154 0.017* 0.001*
IncomePearsonCorrelation -0.32 -0.14 0.00 -0.03 -0.2
Pvalue 0.001* 0.014* 0.961 0.64 0.001*
AgePearsonCorrelation 0.13 0.04 0.05 0.06 0.12
Pvalue 0.029* 0.521 0.391 0.267 0.036
Total number (at each sub row) 300 300 300 300 300
Key: *P<0.05.
Conclusion and RecommendationsAnegativeassociationwasobservedbetweeneducationallevel,incomeandoccupation;whilepositiveassociationwasobservedforageonvariousBMQscreenscores.
Thisfindingdictatestheimportanceofeducatingandtrainingthepatientstoremovebarrierstomedicationsadherence.
Research Articles
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Research Articles
Introduction
Humanimmunodeficiencyv i r u s / A c q u i r e di m m u n o d e f i c i e n c ysyndrome (HIV/AIDS)i s t he f ou r t h mos tcommoncauseofdeathin theworld1.Globally,3 4 m i l l i o n p e o p l e
were livingwithHIVat theendof 2011 1.
HighlyActiveAntiretroviralTreatment(HAART)has dramatically reduced mortality andmorbidityduetoHIVinfection1,2.
Introduction of antiretroviral therapyhavetransferredthediseasecoursefromafatalincurableintoachronicmanageableinfection.However,incompleteadherencetomedicationis themostcontributingfactor in treatmentfailureandthedevelopmentofresistance.
Adherence to antiretroviral therapy wasdefined as to take 95%of the prescribedAnti-retroviral(ARV)drugscorrectly intherightdose,frequencyandtime.Eventhough,anadherencelevelof70-90%toARTdrugsis found to be acceptable and effective.Factorsthatleadtonon-adherencefellintothreecategories; those related topatients(e.g. educational level and psychologicalstatus) , relatedto thepatient’s interactionwithhealthcareproviderandothersrelatedto clinical factors (e.g. pill's burden, dosefrequencyoftheprescribedregimenandthedrugsadversereactions).
Theobjectivesofthisstudyweretoexamine
the level of adherenceof patients to theirtherapyandtoexplorefactorsassociatedwithpatients'non-adherenceamongHIV/AIDSpatientsreceivingARTdrugs.
MethodsThisisacrosssectionalclinicalcenterbasedsurvey done on 310 adults HIV positivepatientsinagesofmorethan16yearsoldwhoaretakingHAARTdrugsforatleast6monthspriortothesurvey,whoareregisteredinOmdurmanteachinghospitalSudanNationalAIDSProgram (SNAP) center.Omdurmancenter is the largestonereceivingpatientsresidingbothinsideandoutsideKhartoumcity.
Thedatawerecollectedusinginterviewsandquestionnaireforms,fromtwosources;keyinformants (were the healthcareworkers)and patients' medical records to fill thepredeterminedstudyvariables.
The study variables were grouped intodemographics,sociocultural,socioeconomicalvariables,and treatment relatedvariables.Other factors such as; quality of care,confidentiality of information, educationalservicesandcounselingonusingdrugswerealsotakenintoconsideration3.
Results and DiscussionThe respondents were 191 males and119 females.Among the total number ofthe respondents (70%) have startedARTtreatmentregimensatstage3ofdisease,withtimeelapsedsincediagnosis ranged from6months to twoyears. Subjectsadherent
HIV/AIDS Patient Factors Affecting Adherence to Antiretroviral Therapy
In Omdurman Teaching Hospital 2012
EslamAbdelhameed1,MustfaKhidir2
1. Pharmacy Specialization Board, [email protected]. Faculty of medicine and health sciences, Elneelain University
Research Articles
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15to treatmentwere66.1%,while33.9%werenot.Amongmalestheadherentswere71.7%comparedto57.1%amongfemales(p=0.008).Otherfactorsfoundtoinfluenceadherencelevelbesidegender,weremaritalstatus;marriedwere 70.7%, divorcedwere 53.8%, singleswere67.3%adherentand50%widowed(p=0.051).ResearchfindingshaveemphasizedtheimportanceofsocialsupportinthetreatmentofHIVpatients,family,communitymembersandpeersinimprovingARTadherence4.
Theeducational levelwas found to slightlyaffectadherence,thosewhowereatprimaryeducationwere55.7%,77.4%atsecondaryschoollevel,80.5%wereuniversitygraduates(p=0.001).Employmentwasanotherfactorthatinfluenceadherence,70.6%of theoccupiedwereadherentversus29.4%non-adherent.Amongthosewhowereunemployed;48.1%wereadherent,while51.9%werenonadherent(p=0.002).
Asignificantnegativeassociationaswellexistedbetween travelling time to the center andincreasedcostsoftreatmentwithadherence,(p=0.005).
In-spiteofthenegativeassociation,patientsstillprefertoreceivetheirhealthcareservicesfromSNAPcenters thatare far located from theirresidencesbecauseofthestigmaandsocialfears.
References1. Marcellin F, Boyer S, Protopopescu C, Dia A, Ongolo-Zogo P, Koulla-Shiro S, Abega SC, Abe C, Moatti JP, Spire B, Carrieri
MP: Determinants of unplanned antiretroviral treatment interruptions among people living international Health 2008, 13(12):1470-8.
2. Byakika-Tusiime J, Oyugi JH, Tumwikirize WA, Katabira ET, Mugyenyi PN, Bangsberg DR: Adherence to HIV antiretroviral therapy in HIV+ Ugandan patients purchasing therapy. International Journal of STD AIDS 2005, 16:38-41.
3. Mills et al.,2006 Mills, EJ, Nachega, JB, Buchan, I, Orbinski, J, Attaran, A, Singh, S, Rachlis, B, Wu, P, Cooper, C, Thabane, L, Wilson, K, Guyatt, GH & Bangsberg, DR. 2006. Adherence to antiretroviral therapy in Sub-Saharan Africa and North America. A Meta-analysis. Journal of American Medical Association 296(6):679-690.).available at www.jama.ama-assn.org
4. Nakiyemba A., Aurugai D A, Kwasa R and Oyobba T (2005). Factors that facilitate or constrain adherence to ART among adults in Uganda: A pre- interventional study.
Other factors that havepositivelyaffectedpatients’ adherence to treatment were;knowledge about ART and counseling(p=0.002).Furtherquestioningpatientsaboutreasonsfornon-adherencehasshownthat:forgetfulness(48%),drugsoutofstock(32%),appearanceoftroublesomesideeffects(7.6%),andtoomanypills(3.4%).
Bycheckingpatients'medicalrecords,reportshaveshownthat53%didn’tmissanydose,18%missedonedose, 14.8%missed twodoses,and10.6%missedthreedoseswhilejust3.2%have.However,thesereportswerein contradictionwith the direct responsesfrompatientswhichhaverevealedpatients'adherencelevel lowerthanthatreported intheirmedicalrecords.
ConclusionThissurveyhaspointedclearlyanumberoffactorsthathaveinfluencedthelevelofpatients'adherenceto treatment;amongwhichage,gender,andlevelofeducation,travelingtime,travellingcost,maritalstatus,employment,stigmaandgoodcounselingaboutdrugs.ThestudyhasfinallyrecommendednewerpoliciestobeintroducedintheoverallcareplanforbestmanagementofHIV/AIDSpatients.
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16News
WHO says it is ethical to use experimental drug ZMapp in management of EBOLA
WHO, August 2014
TheWHOhasrecentlyissuedastatementtoallowtheuseoftheexperimentaldrugZMappinthemanagementofEbolainfection.TherecentoutbreakofEbola infectionisthelargesttodateandhasclaimedthelivesofmorethan1000patientssinceitbeganintheWestAfricancountry;GuineainMarch2014.It is highly contagious and spread withinhumansthroughcontactwithbodilyexcretionsfrominfectedindividualswhoshowsymptoms.Thediseasestartswithnon-specificsymptomssuchasfever,myalgiaandasorethroatbutprogresses rapidly tocauseahaemorrhagicfeverwithafatalityrateof90%.
ThereiscurrentlynoknowncureorvaccineforEbolabutanexperimentaldrugthatconsistsofacocktailofantibodieshasbeenrecentlyusedtosuccessfullytreattwoAmericanaidworkerswhowereevacuated to theUSAafterbeinginfectedwiththeviruswhiletreatingpatientsinWestAfrica.
Thedrughasbeenusedsofarinmonkeyswithgoodresultsbuttherearenostudiesinhumansintermsofefficacyandsafety.Inviewoftherecentoutbreak,theWHOconvenedapanelofMedicalethiciststodiscussthepossibilityofusinganexperimentaldrugknownasZMappforthetreatmentofEbolapatients.Theexpertsissuedastatementstatingthatunderthecurrentcircumstances,itmaybeconsideredethicaltousethisdruginEbolainfectedpatientandurgedhealthcareworkersusing thedrug to reportpatientoutcomesinordertosharetheresultswithinthemedicalcommunity.
News Clarithromycin associated with increased risk of cardiac events.Schembri et al, BMJ, 2014A study conducted in Scotland has shownan increased association between the useof clarithromycin and cardiac events. Theresearchers compared the outcomes of twogroupsof patients admittedwith communityacquiredpneumoniaandchronicobstructivepulmonary disease into NHS hospitals inScotland.Cardiovasculareventsweredefinedas hospital admissionswith acute coronarysyndrome, decompensated cardiac failure,seriousarrhythmia,orsuddencardiacdeathwithinoneyearofdischargefromhospital.
Asignificantassociationwas foundbetweenclarithromycinuseandcardiovasculareventsandmortality.Longerdurationsofclarithromycinusewereassociatedwithmorecardiovascularevents.Whiletheuseofβlactamantibioticsordoxycyclinewasnotassociatedwithincreasedcardiovascular events inpatientswithacuteexacerbationsofchronicobstructivepulmonarydisease,suggestinganeffectthatisspecifictoclarithromycin.
Thisstudyhighlightsthefactthatclarithromycinandotherantibioticsshouldonlybeusedwhenabsolutelynecessarytoreducerisksassociatedwithsuchseveresideeffects.
Global antibiotics consumptionVan Boeckel et al, The lancet Infectious Diseases, August 2014A study published in the Lancet infectiousDiseaseshasshownanincreaseof36%intheconsumptionofantibioticsbetweentheyears2000and2010.Thestudyanalyseddatafromhospitalandretailpharmaciesin71countriesfromacross theglobe.Brazil,Russia, India,China,andSouthAfricaaccountedfor76%ofthisincrease.Themostalarmingfindingwastheincreaseintheuseoflastresortdrugssuchascarbapenems(increasedby45%)andpolymixins(increasedby13%).
Alyaa F. AL-Mahdi 1
1. Head of clinical pharmacy services, Radiation and Isotope Centre Khartoum
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19SudanJornalofRationalUseofMedicine Focus
Doctors’ Advancement ProgramKeeping Abreast in Medicine and Pharmacy
Focus
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Ahmad Al Safi1
17
1. Member of SMC, and chairperson of SMC Doctors’ Advancement Committee, [email protected]
BackgroundSudanMedicalCouncil (SMC) isdedicatedtothepromotionofexcellenceinhealthcaredelivery,medical education, and research.It recognizes its responsibility to promotelifelong learning through the provision ofeducationalexperiencesforalldoctors(medicaldoctors,dentists,andpharmacists)andalliedhealthcare professionals. Awide range oflearningopportunitiesfordoctorsviaaccreditedContinuingMedical Education (CME) andContinuingProfessionalDevelopment(CPD)activitieshadbeenrecognized.Development of the Specialist RegisterBasedon this report,SMCpassedbylawsforSpecialistRegistration,andaSpecialistRegisterwasestablishedin1986.ThisRegister,however, recognizedone levelofspecialistwithnodifferentiationon levelsor typesofspecialization.Documentation of CPD/CME activitiesThe ladder of progression in the doctors’advancementpathwaystartswithspecialist,goesuptoseniorspecialistandendswithconsultant.Tomove fromspecialist toseniorspecialistadoctormustattain600creditpointsinthreeyears,andfromseniorspecialisttoconsultantmustattain1000creditpointsin5years.ThisiswhyalldoctorsregisteredinSMCarerequiredtomaintainarecordoftheirparticipationintheDoctorsAdvancementProgrammeactivitiesinaportfolio(Logbook).ThisportfoliowillenablethemtokeepallthedocumentationrelatedtotheCME/CPDactivitiesinwhichtheyengageintheiractivelife.SMC renamed the Continuing MedicalEducationCommitteeto“DoctorsAdvancementCommittee” and gave it the mandate tofinalize,fine-tuneandimplementthedoctors’advancementprogramme.
Advantages and impact of the Doctors’ Advancement ProgrammeInadditiontoplacingmedicaldoctors,dentistsandpharmacistintheirrightfulcareerpositions,TheProgrammeisstructuredsothathealthcareprofessionalsareappropriately trained tobecompetenttodealwiththehealthchallengesofthe21stcentury.Thisshouldreflectdirectlyandimmediatelyonthequalityofhealthcareservicesthataredeliveredtopatients.TheprogrammeprovidesUniformedForces,Universi t ies, and even private pract icecorporations with yardstick or template onwhichtheycanequatetheranksofthemedicalprofessionals in their roster.Whenmovingacrossborders,thesystemhopefullyequatesorcomparestocurrentinternationalsystems.Tocarryoutitsdutiesefficiently,theProgrammefirstrecognizesthecentresinwhichthetrainingactivitiesarecarriedoutandaccreditsthemasauthorizedproviders.Accreditation of CME/CPD activitiesBeforesubmittinganactivityforaccreditation,theactivityprovidersneed tomakesure thatthe activity aim atmaintaining professionalcompetence,notjustscoringpointsfortheirownsake.PostscriptTheProgramhasbeenannouncedthroughallofficialchannels.Thecutoffdate,however, inwhichcandidatesareexemptediftheysatisfytheyearslimit,isApril2012.ThisimpliesthatallyoungspecialistandseniorspecialistsshouldapplyforthisProgrammeandregisterassoonaspossible.
References1. Sudan Medical Council, Continuing Medical Education
Points Registration Logbook, Personal Data, 2011, 24 pages.
Useful Tips18
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Tips on How to Use Accuhaler
Accuhalerisadry-powderinhaler(DPI)availableinaneasy-to-useformat.Itisbreathactivated;thismeanswhen inhaled, theaccuhalerautomatically releasesthemedication.Whenusedproperly, theaccuhalercandelivermedicationdeepintothelungstocontrolsymptomsofasthma.Patients tousesuch typeofmedicationshouldbeselectedcarefullyandinformedaboutthedifferencesbetweenDPIandMeteredDoseInhalers(MDI).Thefollowingstepsshouldbeclearlyexplainedtothepatient.Makesurethatpatientsareabletodemonstratethefollowingstepsproperlybeforeleavingthepharmacyorclinic.Checkperformanceonthenextvisit.1. Holding your Accuhaler in one hand, place the
thumbofyourotherhandonthethumbgrip.2. Open your Accuhaler by pushing the thumb grip
right around until it clicks, themouthpiece shouldnowbefullyvisible(You’llalsoseethelever).
3. Hold the mouthpiece towards you and push theleverawayfromyouuntilitstops.
4. Breatheoutasmuchaspossible.5. Placemouthpiecebetweenteethwithoutbitingand
closelipstoformagoodseal.6. Breathe in steadily through your Accuhaler (not
throughyournose).7. Remove yourAccuhaler and hold your breath for
about10seconds.8. Breatheoutslowly.9. Rinse your mouth with water after using your
Accuhalerandspitit.10.CloseyourAccuhalerbyslidingthethumbgripback
to theoriginalposition, thismakesyourAccuhalerreadytouseagainforthenexttime.
Note: The dose counter on the top of the Accuhaler shows how many doses are left to use.Advice on how to clean the Accuhaler device 1. Mouthpieceshouldbecleanedbyadrytissueorcloth,
twoorthreetimesaweekorasneeded,andNEVERbewashed.Ifitgetswet,itwillnotworkproperly.
2. Ifpowdersticksinthehole,itshouldbebrushedout.
Sarra I. Rashid 1
1. Medicines’ Information Center and Reference Library, Directorate General of Pharmacy, Federal Ministry of Health
Holdyouraccuhalerawayfromyourlips,breathoutasfarasitiscomfort.
Placethemouthpiecebetweenyourlips,breathinquicklyanddeeply.
Closeyouraccuhalerbyslidingtheoutercasebacktowardyou.
Removetheaccuhaerfromyourmouth,holdyourbreathfor10seconds,breathoutslowly.
Holdtheoutercaseinonehand,placethethumpofotherhandinthethumpgrip,slideawaytillitclicks.
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Q. What is meant by Adherence to (or compliance with) a medication regimen?A. Adherence to (or compliance with) amedicationregimen isgenerallydefinedastheextenttowhichpatientstakemedicationsas prescribed/advised by their physician/pharmacist . The word “adherence” isPREFERREDbymanyphysicians/pharmacists,because“compliance”suggeststhatthepatientisnotpositivelyinvolvedinhisowntherapeuticplan.Q. Why patient adherence to a medication regimen is important?A.Becausethefullbenefitofthemedicationswill onlybeachieved if patients follow theprescribedtreatmentregimenscarefully.
Q. What are the major complications related to poor patient adherence? A. Pooradherencetomedicationregimenscontributestoincreasemorbidity,worseningofdisease,mortality,andincreasedhealthcarecosts.Q. How adherence rate is estimated?A. Ratesofadherenceforindividualpatientsareusuallyreportedasthepercentageoftheprescribeddosesofthemedicationactuallytakenbythepatientoveraspecifiedperiod.Q. What are the major predictors that increase potential for patients' poor adherence to medications?A. Patients may be non-compliant withtheirprescribed regimen,when theyhave;asymptomaticdisease (e.g.hypertension),reduced cognitive abilities (forgetfulness),annoyingmedications'adverse-effects,patientlack on believe of benefits of treatment,psychological problems, complexity oftreatment,inadequatefollow-upordischargeplanning,orcostofmedication.
Q&A Q. What are the system's barriers to patients' adherence to treatment?A. Thoserelatedtohealthcaresystem;poorhealthcaresystem,incompetentstaff,orhighmedicationcost.Barriersrelatedtohealthcareproviders;lowlevelofjobsatisfactionandtheirinteractionwiththehealthcaresystemse.g.poorknowledgeaboutdrugcostandinsurancecoverageofdrugs.Q. How can we improve patients' adherence to their treatment regimens?A. Methodstoimproveadherencemustinvolvecombinationsofbehavioralinterventions;• Reinforcingandincreasing
convenienceofcare.• Providingeducationtopatientsabout
healthconditionsandimportanceoftreatments.
Methodscanbegrouped into fourgeneralcategories:• Patienteducationinvolvingpatients
families.• Improvingdosingschedules.• Extendingclinicsworkinghoursto
reducewaitingtime.• Improvingcommunicationbetween
physiciansandpatients.
Q. What is the role of practitioners in enhancing patient non adherence?Practitionersarerequiredtopaymoreattentiontodetectpooradherence,informingpatientsabout importanceof treatment, simplifyingprescribedregimensasmuchaspossibleandcustomizingthergimentothepatients'lifestyle.A simple strategy is to ask patients howtheytaketheirmedicationsto identifypooradherence,ifany.Pooradherentpatientsmayneedmore intensivestrategies to improvetheircompliancewithtreatmentschedulebyadoptingoneoftheinnovativemeasuresformanagingchronicdiseases.
Questions and Answers19
Sawsan E. Ahmed1
1. Medicines’ Information Center pharmacist, Omdurman Maternity Hospital
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Success Stories20
South Darfur State Medicines Information Center (SDSMIC): A Success Story
Since2007agroupofpharmacistinSouthDarfurStatetriedtoestablishMedicinesInformationCenter(MIC)inNyalacity.TheyheldnumberofmeetingswiththegeneralmanagerofNyalaTeachingHospitalatthattime.
InOctober2012,aworkshopentitled:RationalUseofMedicineswasheldatSouthDarfurStateinNyalaCity,bythelecturers(Prof.AbdallaElkhawad,ProfElrasheidAhmed,Dr.KamalAlomda).ThemainworkshoprecommendationwastheestablishmentofthefirstMIConthestatelevel,undertheGeneralDirectorateofPharmacy-SouthDarfurState.In2012
pharmacistunioninSouthDarfurStateatNyalacitysetoneofthemostimportantgoalsoftheunionastheestablishmentoftheMIC.ThismeetingwasorganizedbytheGeneralStateMinisterofHealth,theGeneralManagerofNyalaTeachingHospitalandGeneralDirectorofPharmacywiththeresultofestablishmentoftheMICinemergencydepartmentofNyalaTeachingHospital.TheGeneralDirectoryofPharmacyprovidesthecenterwithtwodesktopcomputer,printerandtwopharmacistsweresenttobeattachedforamonthintheNationalMedicinesInformationCenterandReferenceLibrary(NMICRL).
PresentlytheMICisanintegralpartofthePharmacyDepartmentandrespondstorequestsfromallhospitalstaffbutmostcommonlyreceivequestionsfromphysicians,pharmacists,pharmacytechnicians,nursesandpublic.MICprovidesdrugsinformationandeducationalmaterials.
Asia M. Zareiba1, Ahmed D. Ahmed2
1. Medicine supply fund , South Darfur Ministry of Health , South Darfur State 2. Revolving Drug Fund (RDF), Ministry of Health, Nyala, South Darfur State
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Success Stories21
Pharmacistsinchargearetrainedininformationretrievalandanalysisandusearangeofinformationsourcesincludingspecialisttexts,informationdatabases,referencesandprimaryjournals.Publiceducationhasbeendemonstratedthroughthelocalmedia(radioandTV)whichwascoveringtheopeningceremonyofthecenter.
Onthe2ndofNovember2014thecentercommenceditsactivitiesasthefirstcenterintheregionbyprovidingservicestothepublic.
Thecenternowbroadcastaseriesofradioprogramsforthelocalpubliconweeklybases.AspartofthecentersactivitiesaworkshopwasconductedontherationaluseofmedicinesinNyalaUniversityonFebruarythisyear.
Acknowledgements ThecenterstaffwishestothankallmedicalagenciesandcommunitypharmaciesinNyala,southDarfurstate;fortheirgreatsupport.
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Patient Medication Adherence
DefinitionsAdherence has been defined as the active,voluntary, and collaborative involvement ofthe patient in a mutually acceptable courseofbehaviortoproduceatherapeuticresult.Itdenoteschoiceandmutuality ingoalsetting,treatmentplanning,andimplementationoftheregimen.Complianceis"theextenttowhichaperson'sbehavior coincides with medical advice".Noncompliance then essentially means thatpatients disobey the advice of their healthcareproviders.Theconceptofnoncompliancenotonlyassumesanegativeattitude towardpatients,butalsoplacespatientsinapassive,unequal role in relationship to their careproviders.Concordanceis"anagreementreachedafternegotiation between a patient and a healthcareprofessionalthatrespectsthebeliefsandwishesofthepatientindeterminingwhether,when and howmedicines are to be taken ".Recentlythefocusofconcordancehasshifted
22
tomeansimilaritybetweendoctorandpatientingender,race,andlanguage.Causes of non-adherenceTheWorldHealthOrganizationproposesthatadherenceisaffectedbythefollowingfactors(Figure1):
• Healthcaresystemorprovider-patientrelationshipfactors.
• Diseaseandtreatmentfactors.• Patientrelatedfactors.• Socio-economicfactors.
Health care system or provider-patient relationship factor:Thequalityofthepatient-doctorrelationshipinawellorganizedhealthcaresystemisaveryimportantdeterminantofregimenadherence.Researchhasdemonstratedthatpatientswhoaresatisfiedwiththeirrelationshipwiththeirhealthcareprovidershavebetteradherence.Socialsupportprovidedbynurseshasbeenshowntopromoteadherence.
Continuous Medical Education
Nuha M. Agabna 1
Figure 1: Causes of non-adherence
1. Lecturer of pharmacology, Faculty of Dentistry, University of Khartoum
Diseaseandtreatments
factors
Causeofnon
adherence
Healthcaresystem
factors
Patientrelatedfactors
Socio-economicfactors
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23 Continuous Medical Education
Disease and treatment related factors:Research has generally shown that lowerregimenadherencecanbeexpectedincaseswhenahealthconditionischronic,whenthecourseofsymptomsvariesorwhensymptomsarenotapparent,whena regimen ismorecomplex, and when a treatment regimenrequireslifestylechanges.
Patient related factors:Patientnoncomplianceisattributedtopersonalqualitiesofthepatients,suchasforgetfulness,lackofwillpowerormotivation,orlowlevelofeducation.Higherlevelsofstressandmal-adaptivecopinghavebeenassociatedwithmoreadherenceproblems.Psychologicalproblemssuchasanxiety,depression,andfearofgastrointestinaladverseeffectshavealsobeen linkedwithworsediseasemanagement.
The socioeconomic factors which thought to influence compliance are identified as:
• un-affordabilityandun-availabilityofmedications.
• Shortageofhealthinsurancecoverage.• Greaterlevelsofsocialsupport,
particularlydisease-relatedsupportfromspousesandotherfamilymembersareassociatedwithbetterregimenadherence.Studieshaveshownthatlowlevelsoffamilyconflict,highlevelsofcohesionandorganizationandgoodcommunicationpatternsareassociatedwithbetterregimenadherence.
• Healthbeliefs,misconceptionandattitudes:Appropriatehealthbeliefs,suchasperceivedseriousnessofdisease,vulnerabilitytocomplications,andtheefficacyoftreatment,canpredictbetteradherence.Generallypatientsadherewellwhenthetreatmentregimenmakessensetothem,whenitseemseffective.
InterventionsThecomplianceinterventionswereclassifiedbytheoreticalfocusintoeducation,behavior,and affect ive categories within which
specific interventionstrategieswerefurtherdistinguished.Nosinglestrategyorprogrammaticfocusshowedanyclearadvantagecomparedwithanother.Comprehensive interventionscombiningcognitive,behavioral,andaffectivecomponentsweremoreeffectivethansingle-focusinterventions.
Effective behavioral interventions: Severalspecificstrategiescanhelppatientswithbehaviorchange.
• Firstistheestablishmentofrapport,conveyinggenuineinterestinpatients.
• Buildingthepatientconfidenceinhealthcaresystem.
• Goodcommunicationisacriticalpartofthebehavior-changeprocess.However,knowledgewillnotguaranteethatbehaviorchangewilloccur.
Finally,effectivebehavioralconsultationwithprovidersencouragespatientstoexpresstheirconcernsanduseactivelisteningtechniques,suchasopen-endedquestions,clarifications,reflectivestatements,andsummarystatements.
ReferencesAronson. Time to abandon the term ‘patient concordance. British journal of clinical pharmacology. 2007, 64(5) 711-713.
Cameron C. Patient compliance: recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. Journal of Advanced Nursing. 24(2): 244–250,
Roter et al., Effectiveness of Interventions to Improve Patient Compliance: A Meta-Analysis Medical Care. 1998, 36(8) 1138-1161.
Sabate E. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization; 2003.
Seltzer et al,. Effect of patient education on medication compliance. The Canadian Journal of Psychiatry. 1980, 25(8): 638-645.
Strategies to Improve Patient Medication Adherence
Halfofthepatientswithchronicdiseaseswerefoundby theWorldHealthOrganization tobenon-adherentwiththeirprescribedmedications'regimensinthedevelopedworld,whilethoseinthedevelopingworldwere farworse than thispercentage1.A large number of patients don’t follow thetreatment recommendations given to them.Solving non-adherence problem requiresmaking patients more proactive in their ownhealth care and forming closer interpersonalrelationshipswithpatients.
Don’t forget:
►Patientsneedtobesupported,notblamed. ►Theconsequencesofpooradherencetolong-termtherapiesarepoorhealthoutcomesandincreasedhealthcarecosts. ►Improvingadherencealsoenhancespatientsafety. ►Adherenceisanimportantmodifierofhealthsystemeffectiveness. ►Improvingadherencemightbethebestinvestmentfortacklingchronicconditionseffectively.
24
Sarah A. Kareem1
1. Head of Medicines’ Information Center and Reference Library, Directorate General of Pharmacy, Federal Ministry of Health
Figure 1 Integration of IMS model components’ for better adherence
Continuous Medical Education
SudanJournalofRationalUseofMedicine
Health care providers can help their patientsfollowprescribedtreatmentsandachievebettertreatment outcomes - particularly in chronicdisease management - by working throughthree components model: the Information-Motivation-Strategy(IMS)Model2.Thismodelwasdevelopedaftersynthesizingfindingsfrommore than 100 large-scale studies andmeta-analysesconductedbetween1948and2009.Researcheshaveshownthatusingmultimodalinterventions is more promising and haveimproved both adherence and treatmentoutcomes3.
TheIMSmodeldemonstratesthat informationis a prerequisite for changing behavior, but
The IMS model can be modified to fit in thehealth care setting of Sudan, illustrating thethree model components with the appropriaterecommendations for healthcare providers toapplythemontheirpatients.1. Information: Allpatientsmustwell
understandtheprovidedhealthinformationtheyreceive.
• Recommendations: Communicateinformationeffectivelytopatients.Buildtrustandencouragepatientstoparticipateindecision-makingandtobepartnersintheirownhealthcare.Askpatientstosharewhyandhowtheywillcarryouttheirtreatmentrecommendations.Listentopatients'concernsandgivethemfullattention.
2. Motivation:Makingpeoplebelieveintheirtreatment,motivatethemtofollowthetreatmentrecommendations.
in itself is insufficient to achieve this change.Motivationisalsoacriticaldeterminantandisindependent of behavior change. Informationandmotivationworkbetterwhencombinedwithstrategy to affect behavior; especially whenthestrategyused is familiaroruncomplicated(Figure1).
Information
Strategy Behavioralchabge
Betteradherance
Motivation
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25
References1. Adherence to long-term therapies: evidence for action,
World Health Organization, 2003, ISBN 92 4 154599 2.
2. M. Robin DiMatteo, Kelly Haskard-Zolnierek, Leslie Martin. Improving patient adherence: a three-factor model to guide practice. Health Psychology Review, 2011; DOI: 10.1080/17437199.2010.537592
3. Piette JD, Kraemer FB, Weinberger M, McPhee SJ. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System. Diabetes Care. 2001;24:202–208.
4. Putting prevention into practice: the green book, The Royal Australian College of General Practitioners (RACGP), http://www.racgp.org.au/your-practice/guidelines/greenbook/applying-the-framework-strategies,-activities-and-resources/motivational-interviewing-strategies/issues-and-strategies-to-address-patient-adherence/, accessed April 2015.
Continuous Medical Educatio9
• Recommendations:Helppatientstobelieveintheefficacyofthetreatment.Elicit,listentoanddiscussanynegativeattitudestowardtreatment.Determinetheroleofthepatient'ssocialsysteminsupportingorcontradictingelementsoftheregimen.Helpthepatientscommittoadherenceandtobelievethattheyarecapableofdoingit.Beawareofandsensitivetopatient'sculturalbeliefsandpractices,andviewtreatmentthroughaculturallenstomakesurethatrecommendationsdonotconflictwithculturalnorms.
3. Strategy:Concretebarriersrepresentacommonsetofobstaclestoadherence,suchasthecostofmedications,unreliabletransportationtomakeappointments,mentalhealthissues,complicatedstoragerequirementsandcomplextreatmentregimens.Patientsneedapracticalstrategytofollowtreatmentrecommendations.
• Recommendations:Helpovercomepracticalbarriersthatmakeitdifficultforpatientstoeffectivelycarryoutacourseofaction.Identifyindividualswhocanprovideconcreteassistance.Identifyresourcestoprovidefinancialaidordiscounts.Providewritteninstructions/reminders.Offerlinkstosupportgroups.
Health care providers should check what the patient remembers and understands 4
Reinforcekeymessagesby:
►Repetitionandsummary(especiallyattheendoftheconsultation)
►Keepthemessagessimple
►Givehandouts,drawingsandleafletstoaidunderstanding(thesemaybepersonalized)
►Reinforcebehavior
►Linkadherencetoroutineactivities(e.g.meals,prayers,cleaningteeth)
The IMS Model emphasizes the importanceof patient-practitioner relationships throughinforming,motivatingpatientsand focusingonthedeterminedstrategiesintendingtoeliminatebarriers to adherence with the prescribedtreatment. It also is a useful tool for targetingpatientneeds,toindividualizepatientadherenceandultimatelyoptimizehealthoutcomes.
Guidelines to Improve Medication Orders Adherence26
Tohelphealthcareprovidersbecomemore familiarwithproveninterventionsthatcanenhancepatientadherence,the fol lowing mnemonic"SIMPLE"couldbeused.
Nuha M. Agabna1
Continuous Medical Education
SudanJournalofRationalUseofMedicine
Strategies Specific Interventions
Simplifyingregimen
characteristics
Adjustmentoftime,frequency,amount,anddosageMatchtherapytopatients'dailyactivitiesUsingadherenceaids,suchasmedicationboxesandalarms
ImpartingknowledgeDiscussionwithphysician,nurse,orpharmacist.DistributionofwritteninformationorpamphletsAccesstohealth-educationinformationontheWeb
Modifyingpatientbeliefs
Assessmentofperceivedsusceptibility,severity,benefit,andbarriers.Rewarding,tailoring,andcontingencycontracting
Patientandfamily
communication
Activelisteningandprovisionofclear,directmessagesInvolvementofpatientsindecisionsabouttheirowntreatmentsSendingremindersviamail,email,ortelephoneConvenienceofcare,scheduledappointmentHomevisits,familysupport,counseling
Leavingthebias Tailorofpatienteducationtothelevelofunderstanding
Evaluatingadherence Self-reports(mostcommonlyused)
Pillcounting,measuringserumorurinedruglevels
1. Simplifyingregimen characteristics.
2. Impartingknowledge.3. Modifyingpatientbeliefs.4. Patientcommunication.5. Leavingthebias.6. Evaluatingadherence.
1. Lecturer of pharmacology, Faculty of Dentistry, University of Khartoum
SudanJournalofRationalUseofMedicine
27 Continuous Medical Education
1. Simplifying regimen:Manyofthestrategiesusedtosimplifyaregimenhavealreadybecomewell-standardizedpractices.• Prescribemedicinesthatcanbetaken
onceaday.Thiscanbedonewithalongeractingdrug(whereverpossible)orcombinedmedicines.
• Matchadministrationtothepatient'sdailyactivities.Forexample,beforeamealorbeforegoingtosleep.
• Useadherenceaidse.g.medicationboxes,alarms.
2. Imparting Appropriate Knowledge:Patients' understandingabout their conditionsand t reatments is pos i t ive ly re la ted toadherence.Adherence,satisfaction,recall,andunderstandingareallrelatedtotheamountandtypeofinformationgiven.Patientsdonotalwaysunderstandprescription instructionsandoftenforgetconsiderableportionsofwhathealthcarepractitionerstellthem.Effectiveinformationgivingcouldbedoneby:• Limitinginstructionsto3or4majorpoints
duringeachdiscussion.• Usingsimple,everydaylanguage,(only36%
ofpatientscorrectlyinterpretthemeaningof"every6hours"Correctly)
• Strengtheningoraleducationwithwrittenmaterials.
• Involvingthepatient'sfamilymembersandfriends.
• Reinforcingtheconceptsdiscussed.
3. Modifying Beliefs and Human Behavior:For interventions thatarecomplexandrequirelifestylemodificationsitisworthwhiletoaddresspatients'beliefs, intentions,andself-efficacytooptimizechangesinbehaviorandbeliefs.
4. Patient Communication:Communication encompasses interventionsranging fromphysician-patientcommunication,sendingmailortelephonereminders,toinvolvepatients'familiesinthedialogue.Listentopatients.
Askthepatientabouthis/herfeelings,concernsandviewsaboutpsychologicalfactorsontheadherence,thenprovidethemwith informationaboutallareasthat the individual findspertinent,andencouragethemtoparticipateindecisionmakingwhenaplanformanagementisformulated.
5. Leaving the Bias:Noclearrelationshipbetweenadherenceandrace,sex,educationalexperience,intelligence,maritalstatus,occupationalstatus, income,andethnicorculturalbackground.Moreover,an individual'slevelofadherencemayvaryovertimeandbetweendifferentaspectsoftreatmentproves thatdemographic factorsplayaminor role in adherence behavior.Adherencecanbeeffectivelyenhancedbytailoringtheeducationtothepatient'slevelofunderstanding.
6. Evaluating Adherence:Thiscanbedonebyself-reports,pillcounting,andinsomecasesmeasuringserumorurinedrug levels.Of these,self-reportisthemostsimple,practicalandwidely used tool. If a healthcareprofessional is unable to detect nonadherence,itisimpossibleforhimorhertocorrecttheproblem.
Reference
Ashish Atreja, Naresh Bellam, Susan R. Levy. Strategies to Enhance Patient adherence: Making it Simple. MedGenMed. 2005; 7(1):4.
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28 Continuous Medical Education
Pharmaceutical Pictograms Can Aid Patients’ AdherenceKamal Addin M. Ahmad 1, Sarah A. Kareem 2
To use their prescribedand/or over-the-counter(O . T.C ) med i c a t i o n ssafely and appropriately,patients need accurate,comprehensive,balanced,clear,easilyunderstandableand pract ica l ly usefu l
medicationinformation.Medicationinformationhastobeconsideredasanintegralpartofthehealthcare.Patientsusuallygettheirneededmedicationinformation,fromtheirhealthcareproviders,inverbal,writtenand/orvisualforms.Failuretounderstandmedicationinformation,may lead topoorpatients' adherenceandmedicationerrors,whichmayincreasetheriskstopatients,andbequitecostlytotheindividualpatientsandthecommunityatlarge.The verbal medication information whichpatientsgetfromtheirhealthcareproviders,mainly thephysiciansandpharmacists, ismostly deficient, suboptimal, inadequate,difficult to understand, and is also easilyforgotten. To be able to adhere to theirmedications,patientsneedtounderstandandrecallthatinformationandbesatisfiedwithit.Highpatients’generalilliteracy,andlowhealthliteracy,asitisthecaseindevelopingcountries,consideredamongmanyother factors, asthemost frequentcausesforpoorpatients’understandingofmedicationinformationanditshighlypossibleensuingrisks.The difficulty of understanding the verbalmedicationinformationprovidedtopatientsbytheirhealthcareproviders,isalsoattributedtotheveryshortdurationoftheencounterwithhealthcareproviders,languagebarriers,typeofmessage,numberofmedicinesprescribed,psychologicalstatusofpatient,age,anxiety,andmedicalandpharmaceutical technicalterms(jargon)used,andthecommunicationskillsoftheprovider1.
AccordingtotheSudaneseCouncilofMinisters2004,Sudanhaveahighgeneralilliteracyrate(50%)2,alsoSudanisdistinguishedbyitsmultiethnic society. Moreover, small percent ofregisteredmedicinesarelocallyproduced,andthecastingmajorityoftheofficiallyregisteredmedicationsareimported(88.8%)3.Englishareused in the textsofwrittenmedicationinformation,mainlythepackageinserts,morethanArabicwhichistheofficialnativelanguage.This assumption is further backedby thefact that theSudaneseNationalMedicinesandPoisonsBoard(NMPB),whichcurrentlyregulatestheregistrationofpharmaceuticalproducts,mandates in itsarticle13.2, that''The package insert should be at least written in English and or / Arabic languages".Thisstatement,initself,makesitverydifficult,evenforliterateSudaneseindividuals,toreadandcomprehend those texts. Moreover,manystudiesreportedthatthereisquiteconsiderableirrationalprescribing,inSudan,whichmightleadtomedicationerrors.Accordingly, it becomes imperative to usethe visualmedication information form,asrepresentedbypharmaceuticalpictograms,sidebysidetotheverbalandwrittenmedicationinformationforms,tocomplementandreinforcebothofthem,butnottoreplacethem;inanattempt to secure better understanding ofpatientsfortheirmedications’useinstructions,to help them handle their medicationsmoreproperly; thus increasing theirsafety,effectivenessandusefulness.Pictogramsareintendedtoactasstimulustorecallinformationandkeepitforfuturereference.TheInternationalPharmaceuticalFederation(FIP) suggested various formats of themedication instructions to be printed inpictogramsformat.
1. Pharmacy practice and pharmaceutical promotion specialist, [email protected]. Head of Medicines’ Information Center and Reference Library, Directorate General of Pharmacy, Federal Ministry of Health
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29 Continuous Medical Education
AmedicationinformationsheetforonemedicationAlabelwithcustomizablesize
AstoryboardofamedicationAprescriptioncalendarthatcombinesallmedicines
Sudanesepeoplehavealonghistoryoffamiliaritywithpictograms;sinceancient,Meroeuseofhieroglyphicsymbolsandtherecentofpictographicsymbolssincethefirstelections1953.Moreover,eventheilliteratecardriversaresmoothlydealingwiththevarioustrafficsignals.Thismayhelppublictoacceptthepharmaceuticalpictograms,whichmayprovemoreconducivetoimprovetheirunderstandinganduseofmedications’information.Belowaresomeexamplesofthepictogramsusedinthestudy.
References1. Awad A I. Himad HA. Drug use practices in teaching hospital of
Khartoum State, Sudan. European Journal of Clinical Pharmacology 2006; 62(12):1087 – 1093.
2. Council of Ministers, Central Bureau of Statistics (2005). Statistical Year Book for the Year 2004. Sudan Currency Printing Press Lmtd. Khartoum: pp. 199 – 255.
3. Yahia AY. Shouna GO. Ali M M. (2009). Sudan Medicine Index: Sudan Currency Printing Press. Khartoum: pp. 272 – 360.
30 Pharmacovigilance Awareness
SudanJournalofRationalUseofMedicine
Partners of the National Pharmacovigilance Program
Pharmacovigilance havepa r tne rs a t d i f f e ren tl eve l s ; i n te rna t i ona l ,national or state leveland pharmacovigilancesentinelsitesatthebottomo f the organ iza t iona ln e two r k . I n v o l v emen t
of pharmacovigilance partners is crucialfor the success of its activities. Partnersshareresponsibilityforthepracticeofdrugsafetymonitoring; anticipate, understandand respond to the continually increasingdemandsandexpectationsofthepublichealthadministrators, policy officials, politiciansand health professionals.These partnersinclude;theUppsalamonitoringcenterattheinternationallevel,nationalpharmacovigilancecenter,and theadvisorycommitteeat thenational level,hospitalsandtheacademia,the pharmaceutical industry, healthcareprofessionalsandthepatientsatthesentinelsites.• Pharmacovigilanceadvisorycommitteeis
amultidisciplinarypanelofclinicalexpertswhodeterminethevalidityandclinicalimportanceofthegeneratedsignals.Membersshouldbecapableoftechnicalassistanceincausalityassessment,risk
Randa A. Almahdi 1
1. Lecturer of pharmacy practice, Faculty of Pharmacy, University of Sciences and Technology
management,caseinvestigationandcrisismanagement.
• Pharmaceuticalindustry:Theprimaryresponsibilityistosupportpost-approvalsurveillanceactivitiesforthesafetyofmedicines.
• Hospitals:Pharmacydepartmentsinhospitalsaroundtheworld,haveimportanteffortsinclinicalpharmacologyandreportingofadversedrugreactions.
• Academia:Expansionofscientificknowledgeindrugsafetyisattributabletogreaterawarenessandacademicinterestinthisfield.
• HealthcareProfessionals:Doctors,pharmacistsandnurseswhohavebeenthemajorprovidersofcasereportsonsuspectedADRs.
• Patients:Observationsandreportsmadebyahealthprofessionalwillbeaninterpretationofadescriptionoriginallyprovidedbythepatient.
• Otherpartnersinclude;FederalandstatesministriesofhealthinSudan,Sudancentralmedicalsupplies,Sudanmedicalcouncil,drugimportingcompanies,thepublichealthinstitutePHI,thesocietyoftheSudaneseclinicalpharmacists,medicalsocieties,privateclinicsandcommunitypharmacies.
SudanJournalofRationalUseofMedicine
Anti-Microbial Awareness
Part 2: Modes of Antibiotic Resistance Kamal M. Elhag1
The emergences of newmechanisms of antibioticres is tance cont inue toevolve for the last sevendecades and whenevera new ant imicrobia l isintroduced,microorganismsdevelopnewmechanisms
toevadeitsaction.Theexplosionofantibioticusageworldwidewasalwaysfollowedbytheappearanceofclinicalinfectionwithorganismsresistant tocommonlyusedantibiotics.Thishasledtoavastandwideningchasmdividingthenumberofantibiotic resistant infectionsandeffectivedrugstotreatthem.Thisarticledealswiththedifferentmodesofantimicrobialresistanceandtheproblemsoftherapy,focusingonthesituationinSudan.
Modesofantibioticresistancearedifferent,awholebacterialspeciesmaybenaturallyor
intrinsiclyresistanttoanantibioticforexamplePseudomonasaeruginosaisinvariablyresistanttoerythromycin.Amicrobewillbenaturallyresistanttoanantibioticifeitheritdoesnotpossessatargetforitsactionoritsouterstructureisimpermeableto the drug. However, naturally susceptiblemicroorganisms can acquire resistance to avarietyofantibioticsbyselectionof resistantmutants.Inthissituationtheantibioticsuppressessusceptible bacteria and allows resistantmutantsandothersnaturallyinsusceptibletotheantibiotictoovergrowandreplacethesusceptiblebacterialpopulation.Theothermechanism isresistancetransferwherebacteriaacquireextra-chromosomalDNAsegment(plasmid,episomeetc.),thatcontainsresistancegenestoseveralantibiotics.ThisDNAsegment is transferablebetweenbacteria;alsoknownasinfectiousdrugresistance1.Underantibioticpressurebacteriathatpossessresistancegenesmaytransferthem
1. Consultant Microbiologist, Soba University Hospital, Khartoum, [email protected]
31
SudanJournalofRationalUseofMedicine
References1. Denis O, Rodriguez-Villalobos H, Struelens MJ. The problem of resistance. In: Finchh RG, Greenwood D, Norrby SR,
Whitley RJ eds. Antibiotics and chemotherapy 9th ed. Edinburgh: Elsevier;2010:24-48.2. Pallares R, Pujol M, Pena C, Ariza J, Martin R, Gudiol F. Cephalosporins as risk factor for nosocomial Enterococcus
faecalis bacteremia. A matched case-control study. Arch Intern Med 1993; 153:1581–6.8. 3. Dahms RA, Johnson EM, Statz CL, Lee JT, Dunn DL, Beilman GJ. Third-generation cephalosporins and vancomycin as
risk factors for postoperative vancomycin-resistant enterococcus infection. Arch Surg 1998; 133:1343–6. 4. Washio M, Mizoue T, Kajioka T, et al. Risk factors for methicillinresistant Staphylococcus aureus (MRSA) infection in a
Japanese geriatric hospital. Public Health 1997; 111:187–90.5. Landman D, Quale JM, Mayorga D, et al. Citywide clonal outbreak of multiresistant Acinetobacter baumannii and
Pseudomonas aeruginosa in Brooklyn, NY: the preantibiotic era has returned. Arch Intern Med 2002; 162:1515–20.6. Lautenbach E, LaRosa LA, Marr AM, Nachamkin I, Bilker WB, Fishman NO. Changes in the prevalence of vancomycin-
resistant enterococci in response to antimicrobial formulary interventions: impact of progressive restrictions on use of vancomycin and third-generation cephalosporins. Clin Infect Dis 2003; 36:440–6.
7. Lautenbach E, Strom BL, Bilker WB, Patel JB, Edelstein PH, Fishman NO. Epidemiological investigation of fluoroquinolone resistance in infections due to extended-spectrum b-lactamase–producing Escherichia coli and Klebsiella pneumoniae. Clin Infect Dis 2001; 33:1288–94.
8. Paterson DL. “Collateral Damage” from cephalosporins or quinolone antibiotic therapy. Clin Infect Dis 2004;38 (suppl 4): S341-5.
tootherbacteria.Resistanceisexpressedasinactivationof theantibioticby inactivatingenzymes,reducedpermeabilityoftheantibioticintothecell;alterationofthebindingsite,effluxoftheantibioticorthemicroorganismsusesanalternativepathway inmetabolizing thesubstrate1.
Theselectionofdrugresistantorganismsandtheunwanteddevelopmentofcolonizationor infectionwithmulti-resistant organismsisknownascollateraldamage,which isaterm used to refer to ecological adverseeffectsofantibiotictherapy.Thirdgenerationcephalosporin as well as quinolone usehas been linked to subsequent infectionwithmulti-resistantGramnegativebacteria,methicillin-resistantStaphylococcusaureus(MRSA)andvancomycin-resistantenterococci(VRE)2-7.Therefore,neitherthirdgenerationcephalosporinsnorfluoroquinolonesappearsuitable for sustained use in hospitals asroutineantibiotictherapy8.
Microorganismsareseveralstepsaheadofus.Wemustvalueandconservewhateverantibioticswe have and should use themwiselyandjudiciously.
Inourhospitalssettings,themaincausefortherisingantibioticresistanceisthatantibiotics
thatcausecollateraldamageare routinelyusedfortreatmentofcommoninfections,whilestandard,moreeffectiveandsafeantibioticsare excluded. This will undoubtedly leadto treatment failure and increasepatientsmorbidityandmortality,infectionwithmulti-resistantorganisms isknownascollateraldamage,which is a termused to refer toecologicaladverseeffectsofantibiotictherapy.Thirdgenerationcephalosporinaswellasquinoloneusehasbeenlinkedtosubsequentinfectionwithmulti-resistantGramnegativebacteria,methicillin-resistantStaphylococcusaureus (MRSA)and vancomycin-resistantenterococci (VRE) 2-5. Therefore, neitherth i rd generat ion cephalospor ins norfluoroquinolonesappearsuitableforsustaineduseinhospitalsasroutineantibiotictherapy6.
Inourhospitalssettings,themaincausefortherisingantibioticresistanceisthatantibioticsthatcausecollateraldamageare routinelyusedfortreatmentofcommoninfections,whilestandard,moreeffectiveandsafeantibioticsare excluded. This will undoubtedly leadto treatment failure and increasepatientsmorbidityandmortality.
32Anti-Microbial Awareness
Guide for authorsScope of the journal:Rationaluseofmedicines(RUM)issuesdirectedtohealthcareprovidersandmedicalstudents.Suitability of publication:All topics related to thedifferentaspectsofRUMwillbeevaluatedbytheeditorialboard.Prospectiveauthorswithasubject(s)orquestionsaboutthesuitabilityoftheirpapersormaterialsareinvitedtorequestanopinionfromtheEditorialBoard.([email protected]).Avoid plagiarismHow to submit materials:ManuscriptscanbehandedoverdirectlytotheDirectorateGeneralofPharmacyassoftcopyorbye-mail([email protected]).Types of manuscripts:1.Researchpapers.2.Casereports.3.Thematictopics.4.Successstories.
Preparation of manuscripts AllmanuscriptsmustbetypedinArialfontsize12,with1.5linespacing.ManuscriptsmustbeinWord.Pagemarginsonallsidesmustbeatleast2.5cmwide.YoucanuseeitherEnglishorAmericanspellingbutnotbothonthesamemanuscript.1. Research papersOriginal research will have the priority ofpublications.Author(s)nameandaffiliationsshould be clearly written. Contact person,telephonenumberande-mailaddressshouldbeincluded.Totalwordscountshouldnotexceed800wordsincludingreferences,tables,tablecaptions,figurelegends,andfootnotes.Maximumofthreetablesandfiguresareaccepted.Themanuscriptshouldbedividedintosections.Eachsectionshouldhaveaseparateheading.Subheadingstaketheformofparagraphlead-ins(shouldbeboldcase),indentedandruninwith
thetext,separatedbyaperiod.Introduction:This sectionshouldprovide thereaderwithsufficientbackgroundinformationtoevaluatetheresultsoftheresearch.Anextensivereviewoftheliteratureisnotneededinthissection.Itshouldalsogivetherationaleforandobjectivesofthestudythatisbeingreported.Methods:Sufficientinformationmustbeprovidedsothatthereaderwillunderstandthemethodologyandbeabletorepeattheexperiment.Results:Theresultssectionshouldbewritteninsuchamannertoprovideinformationbymeansoftext,tablesandfigures.Resultsanddiscussionmaybecombinedortheremaybeaseparatediscussionsection. Ifadiscussionsection isincluded,placeextensiveinterpretationsofresultsinthissection.Donotrepeattheresults.Givenumberstofiguresandtablesintheorderinwhichtheyarementionedinthetext.Allfiguresandtablesmustbecitedinthetext.Conclusionsandrecommendations:Acknowledgepersonal,financialandinstitutionalassistanceattheendofthissection.References:UsetheVancouverreferencesystem.Cite6referencesmaximum.Ethicalclearanceisarequirementforallresearchesfrom2012onward.2. Case reportsAnycasethatisrelatedtoRUMwillbeconsidered.Themanuscriptshouldincludethefollowingsetting:completedescriptionofthecase,consequencesandoutcomeandfinallyfollowupifapplicable.Suggestionsforsolutionsshouldbe included.Wordscountshouldnotexceed400words.3. Thematic topicsAny topic related to rationalmedicineuse isconsidered.Themanuscriptshouldnotexceed400words.4. Success storiesAnystorythatreflectsrationaluseofmedicineandpositivechangestowardsrationalmedicinesuseiswelcomed.Themanuscriptshouldnotexceed400words.NOTE: Acceptedmanuscriptsmaybesubjectedtominor/appropriatechangespriortopublishing.Pleasecheckthewebsiteforpreviousissuesandupdateswww.sjrum.sd
S J
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RepublicofSudanFederalMinistryofHealthDirectorateGeneralofPharmacyNationalMedicinesInformationCentreandReferenceLibraryAlgamaStreetTel.0183749255,0183772843Fax:0183749256Website:www.nmicrl.sd www.sjrum.sdEmail:[email protected] B.Pharm,M.Pharm,MBABadreldinSaidHagnour B.Pharm,FPSMNuhaHajAli B.Pharm,MCPEslamA.Mohammed B.Pharm,FPSM
©AllRightReservedforGDoP2014
J
AspartofactivitiestargetedtoimprovetheRationalUseofMedicinesattheDirectorateGeneralofPharmacy-FederalMinistryofHealth-
Sudan,theSudanNationalStandardTreatmentGuidelines2014havebeenpublishedandarecurrentlyinthe
processofdissemination.
StandardTreatmentGuidelines areinvaluable in resource-constrained
environmentswith thehighburdenofdisease, toensureequitableaccess to
medicines.Theobjectivesare toprovidequality, safe, and efficacious essential
medicinesataffordablecosttotheSudanesepeople and also ensure the rational use of
thesemedicines.ForthegrowingNationalHealthInsuranceFund,astandardtreatmentguidelineis
s e en a s acostcontainmenttooltoensurethatinefficiencies,fraudandirresponsiblepoly-pharmacyareminimized.
Byapplyingtheseguidelines,wewillhaveastandardapproachtomanagethepriorityandcommonmedicalconditionsinSudan.Itisenvisionedthatthisdocumentwillalsobeusedinpre-servicetrainingofhealthcareworkersand,assuch,willbeofbenefittostudentsinmedicaltraininginstitutions.
Sudan Standard Treatment Guidelines