Rational prescribing in the Caribbean

Inappropriate, wasteful and, often, irrational drug use has long been recognised worldwide. Overuse of antibiotics, especially for influenza, overuse of injections in primary care, use of unproven remedies, use of multiple drugs for self-limiting illness and inappropriate dosing are but a few of the recognised problems. Wastefulness on the one hand and patient dissatisfaction with service and outcome on the other are some of the recognised consequences. In the Caribbean the relative availability of a fairly wide range of drugs has created a laissez faire approach to drug use in many countries. The private sector is dominated by influential drugs companies, whose representatives provide the majority of drug education updating for many primary care physicians. As a result newly marketed drugs feature strongly in the prescribing patterns of the private sector. In the public sector drugs supply systems vary considerably across the Caribbean, from highly sophisticated annual international tendering in some countries (e.g. Barbados) and common tendering by the Eastern Caribbean Drug Service for the eight countries of the Organisation of Eastern Caribbean States (OECS) to be more ad hoc, traditional patterns of purchasing of other countries. Only Barbados publishes an annually updated National Formulary; OECS does so every two or three years, and other countries at intervals of 5 to 10 years. Thus prescribers often lack up to date, locally relevant guidelines, and there is no mandatory, even minimum continuing education in therapeutics for doctors. Government expenditures on drugs vary from US$2.00 in Guyana to US$40.00 in Barbados (1996/97 figures). In spite of the emphasis of the World Health Organisation Drug Action Programme on essential drug list, rational prescribing and the formulary process, it can not be said that satisfactory progress has been made in the Caribbean. Cultural factors ("champagne tastes and mauby pockets"), politics, commercial interests and marketing pressures, and the lack of appropriately trained personnel to promote better therapeutic practices, may all play a part. An effective, participatory formulary process with an up-to-date, user-friendly formulary, treatment guidelines, interactive education and prescription audit are techniques shown to improve prescribing practices. Both medical education and medical services should be paying more attention to "better value for money".(AU)

Preoperative diclofenac suppository reduces post-herniorrhaphy hospitalization

This study compared the analgesic efficacy of the diclofenac as a 100mg suppository and 75mg intramuscular injection given at induction of anaesthesia. Forty-four ASA I and II patients scheduled for herniorrhaphy at the Same Day Surgery Department of the Adult Hospital, Eric Williams Medical Sciences Complex, were randomly assigned to receive diclofenac either as 100mg suppository or 75mg in injection after written informed consent. Visual analogue scale (VAS) assessments between the two groups were measured on admission to the recovery room (Level I), the postoperative recovery ward (Level II) or on discharge Student's test X2 test and ANOVA were used, where appropriate, to analyse the data for differences between treatment groups. There was no difference between the 2 groups with respect to age, weight or duration of surgery. Diclofenac given as a suppository or an intramuscular injection significantly reduced pain intensity. Time to analgesic requests and number of patients requesting further analgesia did not differ between groups. However, patients who received the suppository were discharged earlier (43 versus 61 minutes, p<0.05).(AU)

Intramyometrial vasopressin as a haemostatic agent during myomectomy

OBJECTIVE: To assess the efficacy of intramyometrical vasopressin for minimising bleeding and its sequelae at myomectomy. DESIGN: A randomised placebo controlled trial. SETTING: University Hospital of the West Indies, Kingston, Jamaica. SUBJECTS: Twenty women with symptomatic uterine fibroids scheduled for myomectomy who satisfied entry criteria: 10 randomised to the vasopressin group and 10 to the control group. INTERVENTION: Myomectomy was performed after the intramyometrial injection of either 20 units vasopressin diluted to 20 ml in normal saline or placebo (20 ml normal saline). MAIN OUTCOME MEASURES: The efficacy of vasopressin was measured by comparing pre- and post-operative haemoglobin levels and haematocrit, changes in intra-operative pulse and blood pressure, measured blood loss, need for blood transfusion post-operative febril morbidity in the treatment and control groups. RESULTS: The use of vasopressin resulted in median blood loss of 225 ml (range150-400ml) compared with 675 ml (range 500-800ml) in the placebo group (p<0.001). The vasopressin group had a correspondingly lower fall in haemoglobin level (median 1.7g/dl vs 5.3g/dl, P<0.001) and haematocrit (median 5 percent vs 13 percent, P<0.001) compared with the controls. Fifty percent of the placebo group had blood transfusions compared with none in the vasopressin group (P=0.03). There were no significant differences between the groups in intra-operative pulse and blood pressure or post-operative white blood cell counts or temperature. CONCLUSION: The results indicate that vasopressin is effective in preventing blood loss and reducing the need for blood transfusion during myomectomy (AU)

Caffeine inhibits the central hypotensive action of propranolol in rats

Rats anaesthetized with alpha-chloralose were used to investigate the effects of caffeine on the central hypotensive action of d, l-propranolol(=propranolol). In these rats, intracisternal injections of graded doses (1.7 pmol to 13.6 pmol) of propranolol produced dose-dependent falls in mean arterial blood pressure (7 ñ 0.6 mm Hg to 27 ñ 2 mm Hg) which were inhibit by pretreatment with caffeine at a dose (12.9 pmol, intracisternally) that did not alter basal mean arterial blood pressure. The inhibition was reversible and it had an onset and duration of action of about 10 and 50 minutes respectively. It is concluded that caffeine may reduce the hypotensive response of propranolol during antihypertensive therapy with this drug (AU)

Central retinal artery occlusion without retrobulbar hemorrhage after retrobulbar anaesthesia

Four patients had central retinal artery occlusions after retrobulbar anaesthesia with lidocaine HCl was administered before photocoagulation. One of these four had two separate episodes of closure. Only one had permanent visual loss and none had evidence of retrobulbar hemorrhage. Each patient had a severe hematologic or vascular disorder. We think that direct trauma to the central retinal artery behind the globe, the pharmacologic or compressive effects of the injected solution,or both caused the occlusions in these patients. (AU)

Treatment of the enlarged benign prostrate using local injections: a preliminary report

The treatment of benign prostatic hypertrophy with sclerosant injections is described. The results of a preliminary series of 8 patients are reported and the advantages of this treatment in the Caribbean are discussed (AU)

Intra-amniotic saline induction for termination of early pregnancy

Experience with a relatively new but safe and simple method for termination of early pregnancy is described. Opinions regarding its mode of action are also discussed (AU)