Assessing medical student learning in assessing the quality of health information on the internet and communicating the skill to patients

BACKGROUND

Patients increasingly turn to the internet for health information. However, seeking valid information can be difficult because of the speed of accumulation of information and lack of control. HealthInSite, the Canadian Health Network, the Health On the Net Foundation and the QUality Information ChecKlist have created criteria to assess internet health information. The fourth semester students at the Manipal College of Medical Sciences, Pokhara, Nepal, were taught to assess health information online and to communicate the same to simulated patients. Student feedback regarding the exercise was collected using a questionnaire.

METHODS

The exercise was carried out during the pharmacology practical sessions in small groups of seven or eight students each. The students developed their own checklist using information from the organisation websites mentioned above. Each group analysed a particular health website. During the second session the groups communicated the critical appraisal criteria to a simulated patient. Then the patient chose websites for a particular disease condition. Formative assessment of the sessions was carried out. A questionnaire was used to collect student feedback about the sessions. Basic demographic information was collected. Student attitude was studied by noting their degree of agreement with a set of seven statements using a Likert-type scale. The median score was calculated.

RESULTS

A total of 56 of the 73 fourth semester students participated. The gender ratio was equal. The common nationalities were Indians, Nepalese and Sri Lankans. The median score was 27 (maximum score 35) and the interquartile range was 4. There were no significant differences in the total scores among different subgroups of respondents. The students wanted similar sessions to be frequently incorporated during the course. Formative assessment revealed that the groups worked cohesively. They were able to analyse the given website appropriately and were successful in communicating the assessment criteria to the simulated patient.

CONCLUSIONS

The sessions should be continued and strengthened and could be expanded to other semesters and especially to students during the clinical years of study. Preliminary feedback was positive but more detailed studies are required.

Surgical site infection and antibiotics use pattern in a tertiary care hospital in Nepal

OBJECTIVE

To obtain information on surgical site infection (SSI) and the regimens used for surgical prophylaxis.

METHODS

The study was carried out at Manipal Teaching Hospital, Pokhara, Nepal from 1st January to 30th June 2004. Inpatients and outpatients undergoing surgical procedures in General Surgery department were included. Data was collected on a specially designed proforma. Demographic details, details of SSI, results of culture/sensitivity testing and antibiotics used for prophylaxis were noted. Associations of SSI with different variables were studied.

RESULTS

A total of 507 patients were included. SSI was noted in 37 patients (7.3%), of which 21 (56.8%) were superficial SSI. Total duration of antibiotic use, type of anaesthesia and post-operative fever showed significant statistical association with SSI. Organisms were isolated in 12 out of 37 SSI cases (32.4%). E. coli was the most organism isolated. Combination of ampicillin and cloxacillin was the most commonly used antibiotic regimen (138 patients) followed by combination of ampicillin, cloxacillin and metronidazole (26 patients).

CONCLUSIONS

The incidence of SSI was higher compared to developed countries. Surveillance systems for SSI and hospital guidelines for antibiotic prophylaxis are required.

Pretreatment with sarafotoxin 6c prior to coronary occlusion protects against infarction and arrhythmias via cardiomyocyte mitochondrial K(ATP) channel activation in the intact rabbit heart during ischemia/reperfusion

BACKGROUND

Endothelial ET(B) receptor activation by exogenously administered sarafotoxin 6c(a snake venom peptide with a sequence homology to ET-1 prior to ischemia activates release of nitric oxide(NO) and previous studies have shown that NO facilitates mitochondrial K(ATP) activation in cardiac cells and cardioprotection.

OBJECTIVES AND METHODS

The aim of this investigation was to test whether the administration of sarafotoxin 6c(a selective ET(B) receptor agonist) has cardioprotective and antiarrhythmic effects against ischemia and reperfusion injury in a well-standardized model of reperfusion arrhythmias in anesthetized adult male rabbits (n = 53) subjected to 30 min occlusion of the left coronary artery followed by 120 min of reperfusion.

RESULTS

Pretreatment with sarafotoxin 6c (0.24 nmol/kg, i.v.) prior to the period of coronary occlusion offers significant infarct size reduction (19.1 +/- 2.0% versus 39.7 +/- 3.7% in the saline control group; P < 0.01) and antiarrhythmic effects. Sarafotoxin 6c treatment significantly attenuated the incidence of life-threatening arrhythmias like sustained VT (13 versus 100% in the saline control group; P < 0.005) and other arrhythmias (25 versus 100% in the saline control group; P < 0.005), and increased the number of surviving animals without arrhythmias. Pretreatment with 5-HD but not HMR 1883 abolished the beneficial effects of sarafotoxin 6c on reperfusion induced arrhythmias and cardioprotection suggesting that benefits have been achieved via the selective activation of cardiomyocyte mitochondrial K(ATP) channels. Sarafotoxin 6c evoked NO release and selective activation of mitoK(ATP) channels in cardiomyocytes contributes to cardioprotection and antiarrhythmic activity during ischemia-reperfusion in the anesthetized rabbit.

CONCLUSIONS

We conclude that the selective activation of ET(B) receptors by sarafotoxin 6c prior to coronary occlusion contributes to cardioprotective and antiarrhythmic properties.

Drug utilization pattern in dental outpatients in tertiary care teaching hospital in western Nepal

A high incidence of dental disease has been reported in Nepal. Previous studies, both in the Manipal Teaching Hospital, Pokhara, Nepal, and other centers revealed problems in the use of medicines in dentistry. A number of initiatives to improve prescribing have been carried out. The study presented here was undertaken to assess the impact of these initiatives on drug utilization among dental outpatients. The study was conducted among patients attending the dental outpatient department of the hospital over a six-month period. Demographic details were studied. The drug classes and individual drugs prescribed were recorded. The cost of drugs was calculateS using the outpatient pharmacy price list. The prescriptions were analyzed using the WHO/INRUD prescribing indicators. Anomalies were noted in prescribing. Improvement was noted in certain parameters compared to previous studies. The educational initiatives should be strengthened. Managerial interventions can be considered. Further studies are required.

Pattern of potential drug-drug interactions in diabetic out-patients in a tertiary care teaching hospital in Nepal

A prospective study was conducted at Manipal Teaching Hospital, Pokhara, Nepal to identify and analyze the pattern of the potential DDIs (drug-drug interaction) in diabetes patients. A total of 182 patients who were prescribed 685 drugs (average, 3.76 drugs per prescription) were enrolled. Patients 51 to 60 years of age had a higher risk [43 patients, or (23.6%)] of developing DDIs. It was found that 174 (92.1%) of the potential DDIs were of "moderate" severity. Cardiovascular drugs carried a risk of DDIs (187 drugs, or 49.5%). The most common potential DDI observed was between metformin and enalapril (n = 64).

Science attitudes and knowledge among preclinical medical students in Pokhara, Nepal

Knowledge of science and the scientific method are important in learning about and using evidence-based medicine in practice. Courses in research methodology have been introduced for both medical students and practicing doctors. In Pokhara, the basic science subjects are taught in an integrated manner during the first four semesters of the undergraduate medical course. Studies on students' attitudes towards and knowledge of science are lacking in medical colleges in Nepal. Hence the study was carried out to obtain information on students' attitude towards and knowledge of science and scientific methodology among preclinical medical students and note the association, if any, of students' attitudes and their demographic characteristics. The study was carried out in March 2005 among the students of the first four semesters at the Manipal College of Medical Sciences, Pokhara, Nepal using a questionnaire developed by Hren and coworkers. Two hundred and twenty students (overall response rate 73.3%) successfully completed the questionnaire. Seventy-five respondents were Nepalese, 115 were Indians, 27 were Sri Lankans and 3 belonged to other nationalities. The X +/- SD total attitude score was 147.4 +/- 10.8 (neutral score 135). The X +/- SD scores on the subscales, value of science to humanity, value of scientific methodology and value of science to medicine were 51.3 +/- 5.4, 39.6 +/- 3.7 and 58.5 +/- 5.9 (neutral scores were 36, 51 and 48 respectively). The knowledge score measured using a set of 8 multiple choice questions was 3.3 +/- 1.4. The attitude scores were lower and the knowledge score was comparable to that reported previously in a study in Croatia but higher than that reported from Southeast Europe.

Can drug utilization help in promoting the more rational use of medicine? Experiences from Western Nepal

Drug utilization research describes the extent, nature and determinants of drug use in populations and aims to facilitate the more rational use of medicines. The departments of Pharmacology and Clinical Pharmacy at the Manipal College of Medical Sciences, Pokhara, Nepal are committed to promoting the more rational use of medicines. The departments run a Drug Information Center and a Pharmacovigilance Center in the teaching hospital. Over the last eight years, the departments have conducted drug utilization studies in the teaching hospital and the community. A few of these were of the intervention type and drug use was studied before and after the intervention. Members of the departments are on the hospital Drug and Therapeutics Committee. Educational initiatives to improve prescribing have been carried out in a few instances. Restricting the number of brands in the hospital pharmacy and creation of a hospital drug list has been carried out. The impact of these initiatives has been studied only in a few cases. Generic prescribing was found to be low. The educational initiatives to improve prescribing had only limited success. The hospital is in the process of framing antimicrobial use guidelines for various departments. A hospital formulary is under preparation. The influence of drug utilization studies on the prescribing patterns has been low to moderate. The department of Clinical Pharmacy runs a Medication Counseling Center in the hospital and teaches appropriate use of medicines to patients. The studies and initiatives to promote the more rational use of medicines should be continued and strengthened.

Understanding the essentials of drug interactions: a potential need for safe and effective use of drugs

Drug interactions (DIs) represent an important and widely under recognized source of medication errors. An interaction is said to occur when the effects of one drug are changed by the presence of another drug(s), food, drink or an environmental chemical. When a therapeutic combination could lead to an unexpected change in the condition of the patient, this would be described as an interaction of potential clinical significance. DIs can arise in numerous ways; such as pharmacodynamic interaction, in which receptor effects of different agents interacts to produce synergy or antagonism of drug effects. In pharmacokinetic interaction, the blood levels of given agents may be raised or lowered based on the type of interaction. Special attention and thorough monitoring is needed for the patients who are predisposed to develop DIs and those on drugs with narrow therapeutic index. DIs can be a very important contributory factor for the occurrence of adverse drug reactions and adverse drug events. DIs monitoring programs should be initiated and strengthened in order to minimize their occurrence. Herbal drug interactions and DIs comprising over the counter medicines should also be considered seriously.

Personal drug selection: problem-based learning in pharmacology: experience from a medical school in Nepal

Background

At the Manipal College of Medical Sciences, Pokhara, Nepal, Pharmacology is taught during the first four semesters of the undergraduate medical course. Personal or P-drug selection is an important exercise. The present study was carried out to obtain student opinion about the P-drug learning sessions, the assessment examinations, and on the small group dynamics.

Method

The practical sessions on P-drug selection are carried out in small groups. Student feedback about the session was obtained using focus group discussions. The focus groups were selected to represent both genders and the three main nationalities, Nepalese, Indians, and Sri Lankans. There were four Nepalese, five Indians, and three Sri Lankans. Within each nationality and gender category the students were randomly selected. The respondents were explained the objectives of the study and were invited to participate. Written informed consent was obtained. The discussion lasted around two hours and was conducted in the afternoon in two groups of six students each. The first author (PRS) acted as a facilitator. The responses were recorded and analyzed qualitatively.

Results

The overall student opinion was positive. Around 25% (3 respondents) of respondents were confused about whether P-drugs were for a disease or a patient. Group consensus was commonly used to give numerical values for the different criteria. The large number of brands created problems in calculating cost. The students wanted more time for the exercise in the examination. Formative assessment during the learning sessions may be considered. The group members usually got along well. Absenteeism was a problem and not all members put in their full effort. The physical working environment should be improved.

Conclusions

Based on what the students say, the sessions on P-drugs should be continued and strengthened. Modifications in the sessions are required. Sessions during the clinical years and internship training can be considered.

Knowledge about heart attack and hypertension among individuals attending a cardiac camp in Pokhara city

OBJECTIVES

Previous studies in other countries had shown lacunae in patients' and general publics' understanding of cardiovascular diseases. Such studies are lacking in Nepal. Hence the present study was carried out to: a) note the respondent's knowledge regarding myocardial infarction and hypertension and b) note the association, if any, of the knowledge with demographic and personal characteristics.

MATERIALS AND METHODS

Respondents attending a cardiac camp organized in the Manipal Teaching hospital during September 2002 were interviewed by previously briefed seventh semester students using a structured questionnaire. Basic demographic information and knowledge about myocardial infarction and hypertension was collected. The median score was calculated. Differences in scores among different subgroups of respondents were noted using appropriate statistical tests (p<0.05).

RESULTS

Sixty-six respondents were interviewed; 44 were male. The knowledge scores for heart attack and hypertension were 6 (maximum score 8) and 11 (maximum score 14) respectively. The scores were significantly lower among respondents with a monthly family income below 2000 rupees and was higher among respondents/family members suffering from cardiovascular disease.

CONCLUSION

The respondents were aware of the basic facts regarding myocardial infarction and hypertension. However, lacunae in knowledge were noted. Further studies are required.

Disease mongering

Convincing healthy people that they are sick and require medicines can enormously expand the market. Disease mongering can turn ordinary ailments like baldness into medical problems, consider risk factors such as hypertension and osteoporosis as diseases and frame prevalence estimates to increase potential markets. In Asia, conditions like erectile dysfunction, male pattern baldness, attention deficit hyperactivity disorder and irritable bowel syndrome, and the drugs to treat them, are widely promoted. Fairness creams and traditional medicines are also widely used. The cost of disease mongering to the individual and the community is expected to be high. Some authors have argued that medicalisation of illnesses may not be a problem and the real problem may be the lack of medicines. Doctors will play a key role in combating disease mongering. Disentanglement from the pharmaceutical industry and development of a capacity for critical analysis are required. Educating patients and empowering them to make decisions are important. Several initiatives have been undertaken to combat disease mongering. Initiatives at the level of the patient and the physician are especially important. Studies on the extent and knowledge of disease mongering among doctors and medical students, and their economic and social consequences are urgently required.

Drug induced hepatitis with anti-tubercular chemotherapy: challenges and difficulties in treatment

Tuberculosis is a major health burden worldwide. In Nepal, it is a significant cause of morbidity and mortality. Although better drugs are available for managing tuberculosis, treatment failure is one of the common problems encountered. Among the various causes which can cause treatment interruption, drug induced hepatotoxicity is a common cause. Isoniazid and Pyrazinamide are the common drugs causing hepatotoxicity. Upon occurrence of hepatotoxicity, the hepatotoxic drugs should be stopped and reintroduced as per the available guidelines. The healthcare professional should also counsel the patients for recognizing the early symptoms due to hepatotoxicity which could prevent morbidity.

Breast-feeding initiation and determinants of exclusive breast-feeding - a questionnaire survey in an urban population of western Nepal

OBJECTIVE

To assess rates of initiation of breast-feeding and exclusive breast-feeding within 2 months after delivery and to determine the factors influencing exclusive breast-feeding.

DESIGN

A health worker-administered questionnaire survey was carried out during the time period 1 August-30 September 2005.

SETTING

Immunisation clinics of Pokhara, a submetropolitan city in western Nepal.

SUBJECTS

Three hundred and eighty-five mothers who had delivered a child within the previous 2 months.

RESULTS

The rates of initiation within 1 h and within 24 h of delivery were 72.7 and 84.4%, respectively. Within 2 months after delivery, exclusive breast-feeding was practised by 82.3% of the mothers. Breast milk/colostrum was given as the first feed to 332 (86.2%) babies but 17.2% of them were either given expressed breast milk or were put to the breast of another lactating mother. Pre-lacteal feeds were given to 14% of the babies. The common pre-lacteal feeds given were formula feeds (6.2%), sugar water (5.9%) and cow's milk (2.8%). Complementary feeds were introduced by 12.7% of the mothers. By logistic regression analysis, friends' feeding practices, type of delivery and baby's first feed were the factors influencing exclusive breast-feeding practice of the mothers.

CONCLUSIONS

Despite the higher rates of initiation and exclusive breast-feeding, practices such as pre-lacteal feeds and premature introduction of complementary feeds are of great concern in this urban population. There is a need for promotion of good breast-feeding practices among expectant mothers and also the community, especially the families, taking into account the local traditions and customs.