Global research production in glyphosate intoxication from 1978 to 2015: A bibliometric analysis.

BACKGROUND: Glyphosate (N-phosphonomethylglycine) has been used as a broad-spectrum herbicide that has been widely used in the agricultural industry and also available for home use. The main aim of this study is to present a general overview of glyphosate intoxication-related publications from its introducing since the early 1970s using bibliometric technique. METHODS: On June 23, 2016, a literature search of the Scopus database was performed. We then extracted and analyzed the data using well-established qualitative and quantitative bibliometric indices: Publication year, affiliation, document type, country name, subject category, journal name, publishing language, and collaboration and citation patterns. RESULTS: We recognized a total of 3735 publications on glyphosate published between 1973 and 2015. There were 875 publications related to glyphosate intoxication in the Scopus database published between 1978 and 2015. Articles (757) comprised 86.5% of the total publications, followed by reviews (41; 4.7%). Most publications were published in English (87.9%), followed by Portuguese (6.6%). The number of publications related to glyphosate intoxication increased from 44 in 1978-1987 up to 152 in 1996-2005 and then quadrupled in 2006-2015. The United States was the leading country with 180 documents representing 20.6%, followed by Brazil (120; 13.7%), Canada (78; 8.9%), Argentina (61; 7.0%), and France (57; 6.5%). The 85.6% of the publications was cited, and the average of citation per document was 17.13 with h-index of 55. Furthermore, the United States achieved the highest h-index of 33. Most of the global international collaborations are made with researchers from the United States, who collaborated with 23 countries/territories in 44 publications. CONCLUSIONS: The trends in global glyphosate-related research between 1978 and 2015 were evaluated by a bibliometric technique. Results showed that English was the leading publishing language, and the major publication type was original article. Findings showed that number of research publications related to glyphosate intoxication increased significantly in the last decade. The United States and Brazil are the two most productive countries in research on glyphosate intoxication. This study will be beneficial to policy makers by identifying areas that need greater investment and research funding to target appropriate agriculture sectors so as to improve glyphosate safety in a global setting.

Public Knowledge and Attitudes Regarding the Use of Antibiotics and Resistance: Findings from a Cross-Sectional Study Among Palestinian Adults.

Antibiotics are considered to be among the most commonly sold drug classes in Palestine. Resistance to antibiotics has increased for reasons relating to the use and misuse of antibiotics. The aim of this study was to evaluate the knowledge, and attitudes regarding antibiotic use and awareness about resistance among adults visiting the emergency departments at hospitals in North Palestine. A self-administered cross-sectional questionnaire survey involving participants aged 18 or over was conducted from June 2012 to February 2013. Adults who visited the emergency departments at hospitals in North Palestine were included. Demographic characteristics, knowledge and attitudes towards antibiotic use were included in the questionnaire. Poor and good knowledge were defined as a total knowledge score of 0-7 and 8-15 of 15 questions, respectively. Attitude scores of 0-3 and 4-7 of 7 questions were considered poor and good, respectively. A total of 375 questionnaires were included in the study. A response rate of 83.3% was attained. About 55.0% of the participants had a good knowledge and 56.5% had a good attitude towards rational antibiotic use. A significant positive correlation was shown between participants' knowledge scores and participants' attitude scores towards antibiotic use (R = 0.344, P = 0.001. Participants with a high family income were more likely to be aware of appropriate antibiotic use than participants with a low family income (P-value <0.001). Participants with a higher educational level (university) had a good attitude towards rational antibiotic use than those with a lower education level (P-value <0.001). This study has documented important knowledge and attitude gaps in antibiotic use. These findings will help health policymakers in Palestine to implement intervention programmes to rationalize antibiotic use. Continuing medical education, professional development and training workshops for healthcare professionals regarding rational use of antibiotics and health risks associated with the spread of antibiotic resistance are needed. In addition, minimizing non-prescription use of antibiotics and increasing the public awareness about the health and economic hazards of antibiotic resistance are also required.

Global research productivity of N-acetylcysteine use in paracetamol overdose: A bibliometric analysis (1976-2012).

PURPOSE: The main objective of this study was to examine the publication pattern of N-acetylcysteine (NAC) research output for paracetamol overdose at the global level. METHODS: Data were searched for documents that contained specific words regarding NAC and paracetamol as keywords in the title and/or abstract and/or keywords. Scientific output was evaluated based on a methodology developed and used in other bibliometric studies. Research productivity was adjusted to the national population and nominal gross domestic product per capita. RESULTS: The criteria were met by 367 publications from 33 countries. The highest number of articles associated with the use of NAC in paracetamol overdose was from the United States of America (USA; 39.78%), followed by the United Kingdom (UK; 11.99%). After adjusting for economy and population power, USA (2.822), Iran (1.784) and UK (1.125) had the highest research productivity. The total number of citations at the time of data analysis (14 March 2014) was 8785 with an average of 23.9 citations per document and a median (interquartile range) of 6 (1-22). The h-index of the retrieved documents was 48. The highest h-index was 32 for USA, followed by 20 for UK. Furthermore, the highest number of collaborations with international authors for each country was held by USA with 11 countries, followed by Canada with 7 countries. CONCLUSION: The amount of NAC-based research activity was low in some countries, and more effort is needed to bridge this gap and to promote better evaluation of NAC use worldwide. Our findings demonstrate that NAC use for paracetamol overdose remains a hot issue in scientific research and may have a larger audience compared with other toxicological aspects. Editors and authors in the field of toxicology might usefully promote the submission of work on NAC in future to improve their journal's impact.

Scientific research related to calcium channel blockers poisoning: Bibliometric analysis in Scopus, 1968-2012.

PURPOSE: Calcium channel blockers (CCBs) were the most common agents associated with a significant morbidity and mortality rate. The main objective of this study was to examine the publication pattern related to CCBs poisoning at the global level using bibliometric analysis of articles published in SciVerse Scopus online database. METHODS: Data were searched for documents that contained specific words regarding CCB poisoning as keywords in the title. No time period limitations were specified in the search regarding the starting year. The ending date of the search was 31 December 2012. RESULTS: The criteria were met by 713 publications from 53 countries. The largest number of articles associated with CCBs was from the United States (30%), followed by the United Kingdom (7.4%), Japan (6%), and Germany (5.6%). No data related to CCBs were published from 159 (75%) of 212 countries registered in World Bank online database. There was no correlation between the number of published articles in the country and its population size (r = 0.03, p > 0.926). United Kingdom and Australia were the leading countries in terms of number of CCBs publications per million inhabitants (0.83 and 0.82 articles per million inhabitants, respectively), followed by the United States (0.68). Countries with a large population, such as India, tended to rank relatively low (0.01 articles per million inhabitants). The total number of citations at the time of data analysis (23 October 2014) was 6462, with an average of 9.1 citations per document. The highest median (interquartile range) number of citations was 8 (8-18) for the United States, followed by 6 (1-21) for Australia, 5 (1-15) for the United Kingdom, and 5 (1-24) for Canada. The h-index of the retrieved documents was 37. CONCLUSIONS: Scientific production on CCBs poisoning is increasing; nonetheless, the international collaboration is still rare. The amount of CCBs-based research activity was low or not available in most countries. More regional epidemiological studies are required to bridge the gap in CCBs-based research and to promote better evaluation of CCBs poisoning worldwide.

Worldwide research productivity of paracetamol (acetaminophen) poisoning: a bibliometric analysis (2003-2012).

PURPOSE: There is a lack of data concerning the evaluation of scientific research productivity in paracetamol poisoning from the world. The purposes of this study were to analyse the worldwide research output related to paracetamol poisoning and to examine the authorship pattern and the citations retrieved from the Scopus database for over a decade. METHODS: Data were searched for documents with specific words regarding paracetamol poisoning as 'keywords' in the title or/and abstract. Scientific output was evaluated based on a methodology developed and used in other bibliometric studies. Research productivity was adjusted to the national population and nominal gross domestic product (GDP) per capita. RESULTS: There were 1721 publications that met the criteria during study period from the world. All retrieved documents were published from 72 countries. The largest number of articles related to paracetamol poisoning was from the United States (US; 30.39%), followed by India (10.75%) and the United Kingdom (UK; 9.36%). The total number of citations at the time of data analysis was 21,109, with an average of 12.3 citations per each documents and median (interquartile range) of 4 (1-14). The h-index of the retrieved documents was 57. After adjusting for economy and population power, India (124.2), Nigeria (18.6) and the US (10.5) had the highest research productivity. Countries with large economies, such as the UK, Australia, Japan, China and France, tended to rank relatively low after adjustment for GDP over the entire study period. CONCLUSION: Our study demonstrates evidence that research productivity related to paracetamol poisoning has increased rapidly during the recent years. The US obviously dominated in research productivity. However, certain smaller country such as Nigeria has high scientific output relative to their population size and GDP. A highly noticeable increase in the contributions of Asia-Pacific and Middle East regions to scientific literature related to paracetamol poisoning was also observed.

Blood lead level among Palestinian schoolchildren: a pilot study.

In Palestine, chronic exposure to lead has not been adequately addressed as a problem for children. To assess the exposure of Palestinian schoolchildren, we surveyed blood lead levels in 3 schools in Nablus city and collected demographic and clinical data. Blood samples were collected from 178 children (140 boys, 38 girls), age range 6-8 years. The overall mean blood lead level was 3.2 (SD 2.4) microg/dL, and 4.5% of children had levels above 10 microg/dL. Blood lead levels were significantly higher among children living in refugee camps near industrial/high traffic regions than among children living in residential areas of the city. Blood lead levels were positively correlated with family size (r = 0.15) and negatively correlated with household area (r = -0.18). Blood lead levels among these Palestinian schoolchildren were higher than those of other countries where leaded gasoline has been banned and seemed to be higher in more economically deprived children.

Blood lead level among Palestinian schoolchildren: a pilot study

In Palestine, chronic exposure to lead has not been adequately addressed as a problem for children. To assess the exposure of Palestinian school children, we surveyed blood lead levels in 3 schools in Nablus city and collected demographic and clinical data. Blood samples were collected from 173 children [140 boys/38 girls], age range 6-8 years. The overall mean blood lead level was 3.2 [SD 2.4] microg/dL, and 4.5% of children had levels above 10 microg/dL Blood lead levels were significantly higher among children living in refugee camps near industrial high traffic regions than among children living in residential areas of the city. Blood lead levels were positively correlated with family size [r = 0.15] and negatively correlated with household area [r =0.18]. Blood lead levels among these Palestinian schoolchildren were higher than those of other countries where leaded gasoline has been banned and seemed to be higher in more economically deprived children

Utilization and cost of antibacterial drugs in 2 general surgery units in Palestine measured using anatomical therapeutic chemical classification and defined daily dose methodology.

This study compared the utilization and cost of antibacterial agents in surgical units of 2 government hospitals in Palestine. The consumption and cost of drugs was estimated in the units over a 1-month period in 2010 using the anatomical therapeutic chemical classification and defined daily doses (DDD) per 100 bed-days. The total consumption of antibacterial agents was 414.1 DDD and 591.5 DDD at Thabet and Rafidia hospitals respectively. These corresponded to 133.6 DDD/100 bed-days and 162.2 DDD/100 bed-days respectively, figures that were higher than those reported in surgical units in many other countries. Total cost of antibacterial agents during the study period was 24 800 and 23481 NIS for Rafidia and Thabet hospitals respectively. Approximately 11.2% and 18.0% of the total antibiotic DDD in Rafidia and Thabet hospitals were given to patients with clean surgeries in which antibiotic prophylaxis is not indicated.

Utilization and cost of antibacterial drugs in 2 general surgery units in Palestine measured using anatomical therapeutic chemical classification and defined daily dose methodology

This study compared the utilization and cost of antibacterial agents in surgical units of 2 government hospitals in Palestine. The consumption and cost of drugs was estimated in the units over a 1-month period in 2010 using the anatomical therapeutic chemical classification and defined daily doses [DDD] per 100 bed-days. The total consumption of antibacterial agents was 414.1 DDD and 591.5 DDD at Thabet and Rafidia hospitals respectively. These corresponded to 133.6 DDD/100 bed-days and 162.2 DDD/100 bed-days respectively, figures that were higher than those reported in surgical units in many other countries. Total cost of antibacterial agents during the study period was 24 800 and 23 481 NIS for Rafidia and Thabet hospitals respectively. Approximately 11.2% and 18.0% of the total antibiotic DDD in Rafidia and Thabet hospitals were given to patients with clean surgeries in which antibiotic prophylaxis is not indicated

Antibiotic resistance of bacterial strains isolated from patients with community-acquired urinary tract infections: an exploratory study in Palestine.

BACKGROUND AND OBJECTIVES: No studies about resistance of bacteria isolated from patients with community-acquired urinary tract infections (CA-UTI) or local guidelines for antibiotic use in these infections have been published or established in the West Bank, Palestine. The objectives of this study were to determine the (1) type and frequency of isolated bacteria and (2) their resistance to commonly used antibiotics. METHODS: A cross sectional study on community urinary isolates was carried out in Nablus, Palestine between November 2009 and April 2010. A convenience sampling method was used for collection of specimens. RESULTS: A total of 375 specimens were collected from 306 (81.6%) females and 69 (18.4%) males. Three hundred and thirty nine (90.4%) of isolated uropathogens were Gram-negative bacteria, of which 243 (71.7%) were Escherichia coli. Thirty six (9.6 %) of the total isolates were Gram-positive bacteria, of which 21 (58.3%) were Staphylococcus saprophyticus. High resistance rates were recorded for E. coli against trimethoprim/sulfamethoxazole (37%), nitrofurantoin (29%), ampicillin (65%), and nalidixic acid (37%). E. coli showed low resistance to amoxicillin/clavulanic acid, ciprofloxacin, cefotaxime and ceftriaxone with rates of 12.2, 17.2, 11.1, and 11.1% respectively. CONCLUSION: E. coli was the most frequent bacterium in the studied sample and showed high resistance to first-line antibiotics. Our results highlight the need for developing local guidelines where elevated resistance to antibiotics should influence prescribing decisions.

Analysis of prescriptions dispensed at community pharmacies in Nablus, Palestine.

We investigated the prescription quality and prescribing trends of private clinicians in Nablus governorate, Palestine. A total of 363 prescriptions were collected from a random sample of 36 community pharmacies over a study period of 288 working hours. Data regarding elements in the prescription and the types of drugs prescribed were analysed. Physician-related variables were mostly noted, however, patient's address and weight were absent in all prescriptions and less than half included age and sex. Information regarding strength of the medications prescribed was missing in over 70% of prescriptions. Other drug-related variables like frequency and instruction of use were present in over 80% of prescriptions. Antimicrobial agents were the most commonly prescribed followed by NSAIDs/analgesics. Amoxicillin alone or in combination was the most commonly prescribed antimicrobial agents followed by cefuroxime. Prescription writing quality in Nablus is deficient in certain aspects and improvement is required.

Epidemiological, clinical and pharmacological aspects of headache in a university undergraduate population in Palestine.

Headache is one of the most common complaints in clinical practice. Few studies regarding headache in university students have been conducted in the Middle East. The objective of this study was to explore the prevalence, clinical characteristics, triggering factors and treatment options of headaches in university undergraduate students in Palestine/Middle East. Data were collected by interviewing a sample of 1900 students. The Headache Assessment Quiz was used to measure quality and severity of headache and to collect data on triggering factors and symptom management. A total of 1808 (95.2%) reported having at least one headache episode in the previous year. A positive family history of headache was found in 40% of students. The prevalence rate of frequent headache (tow or more episodes/month) was found in 1096 (60.9%) students; 613 women (55.9%). Of those having frequent headaches, 228 (20.8%) experienced moderate to severe episodes, 341 (31.2%) had pulsating, throbbing and pounding pain, and 274 (25%) had unilateral pain. The most common triggering factors among students with frequent headaches were: tension/stress (78.2%) and sleep deprivation (75.4%). Less than 5% of students sought medical assistance during headache episodes. Most students (79.1%) reported self-therapy with a single analgesic (53.4%), herbs (10.2%) or combination (15.5%), while 20.9% reported using no medication of any type to decrease pain. Paracetamol (48.5%) followed by ibuprofen (4.9%) were the most commonly used non-prescription analgesic drugs. Headache is a prevalent symptom in the college age population. Further research is needed to determine the prevalence of specific types of headaches. Healthcare providers are required to educate this population as well as to assist students in properly diagnosing and treating headache types.

Storage, utilization and cost of drug products in Palestinian households.

BACKGROUND AND OBJECTIVE: Appropriate storage and use of medications in households may decrease drug wastage and unnecessary hazard. The objective of this study was to investigate storage, utilization habits and cost of medications in households in Palestine. METHODS: This is a cross sectional, anonymous, questionnaire-based study of 465 households in northern Palestine. The drug product inventory in the surveyed households was investigated and family members were interviewed. RESULTS: A total of 465 households were assessed, 50 were excluded. The total number of drug products in the 415 households was 5,505; the mean + or - SD was 13.3 + or - 7.8. Level of father's education, presence of chronic disease and insurance coverage were the variables that showed a significant relationship with the amount of drug products found in the households. Most of the drug products (43.4%) were stored in relatively unsafe places in the house within the reach of children. Approximately one third (32.5%) of the drug products were not in their original container. The percentages of unused drug products, expired, or those with no clear expiry date were 32.7%, 17.7% and 11% respectively. Estimated drug wastage in the 415 households and nationwide would be 16,100 and 19 million USD respectively. The most common drug categories encountered in households were alimentary, musculoskeletal and anti-infective agents. The most common individual drugs encountered were: paracetamol (8.5%), ibuprofen (4.9%) and diclofenac (3.7%). CONCLUSION: Medications were stored in large quantities in Palestinian households, and a large percentage was being wasted. Drug-use assessments and a comprehensive evaluation of the current national drug policies are warranted to curtail this problem.

Analysis of prescriptions dispensed at community pharmacies in Nablus, Palestine

We investigated the prescription quality and prescribing trends of private clinicians in Nablus governorate, Palestine. A total of 363 prescriptions were collected from a random sample of 36 community pharmacies over a study period of 288 working hours. Data regarding elements in the prescription and the types of drugs prescribed were analysed. Physician-related variables were mostly noted, however, patient's address and weight were absent in all prescriptions and less than half included age and sex. Information regarding strength of the medications prescribed was missing in over 70% of prescriptions. Other drug-related variables like frequency and instruction of use were present in over 80% of prescriptions. Antimicrobial agents were the most commonly prescribed followed by NSAIDs/analgesics. Amoxicillin alone or in combination was the most commonly prescribed antimicrobial agents followed by cefuroxime. Prescription writing quality in Nablus is deficient in certain aspects and improvement is required

Target blood pressure attainment in diabetic hypertensive patients: need for more diuretics?

OBJECTIVE: To determine target blood pressure attainment and to evaluate blood pressure control relative to type of therapy among diabetic hypertensive patients. METHODOLOGY: An observational retrospective study of all diabetic hypertensive patients visiting Al-Watani governmental medical center from August 01, 2006 until August 01, 2007. The blood pressure (BP) measurement made during the patient's recent visit and documented in the medical files was used in the study. Controlled BP values for hypertensive patients with diabetes mellitus were defined per JNC 7 guidelines: 130/80 mmHg or lower. Proportions of use of 5 different antihypertensive drug classes were compared between patients with controlled and uncontrolled BP. RESULTS: Of the 311 patients, 79 (25.4%) had their BP controlled. No significant differences in age, gender, body weight, duration of hypertension or diabetes, renal function, average number of anti-hypertensive medications and doses of most commonly reported antihypertensive medications were found between controlled and uncontrolled BP groups. ACE-I/ARB was the most commonly used drug class in both groups. Overall, the use of ACE-I/ARB, beta-blockers, calcium channel blockers, alpha-blockers and multi drug regimens were also not significantly different between the controlled and uncontrolled groups. However, overall use of diuretics was significantly higher in controlled group than uncontrolled group (59.5% versus 45.7%, p < 0.001). CONCLUSION: Despite the common use of ACE-I/ ARB as recommended per JNC 7th report, the majority of the patients had uncontrolled BP. Diuretics is an important drug class in attaining target BP. Use of diuretics in combination with ACE-I as well as drug compliance needs to be emphasized and encouraged.

Predictors of in-hospital mortality after acute stroke: impact of renal dysfunction.

OBJECTIVE: The objective of this 1-year, hospital-based study was to identify the impact of renal dysfunction on in-hospital mortality after acute stroke. METHODOLOGY: All patients admitted to Al-Watani governmental hospital and diagnosed with acute stroke from September 2006 to August 2007 were included in the study. Data were obtained from patients' medical files. Creatinine clearance (CrCl) was calculated using Cockcroft-Gault equation. Patients with CrCl < 60 ml/min were designated as Group 1 while those with CrCl > or = 60 ml/min were designated as Group 2. The main outcome measure in this study was vital status at discharge. Pearson chi2 and independent Student's t test were used in the univariate analysis while multiple logistic regression analysis was used to identify independent predictors of in-hospital mortality. Statistical testing and graphics were carried out using SPSS 15. RESULTS: A total of 186 acute stroke cases were included. Hypertension (HTN) (69.9%) and diabetes mellitus (DM) (45.2%) were the most prevalent risk factors. Patients in Group 1 were significantly older than those in Group 2 (74.11 +/- 9.46 versus 66.53 +/- 10.74 years). Thirty nine (21%) of the stroke patients died during their hospital stay. In the total stroke patients, three predictors of in-hospital mortality were identified: CrCl (p = 0.004), number of post-stroke complications (p = 0.001), and type of stroke (p = 0.034). In Group 1, CrCl (p = 0.012) was the only independent predictor of mortality, with patients who died having significantly lower CrCl than those who survived. However, in Group 2, CrCl level was not a predictor of mortality and was not significantly different (p = 0.26) between those who died and those who survived. In Group 2, no predictors of mortality were identified. CONCLUSION: Screening and better control of renal dysfunction is required to decrease the risk of in-hospital mortality among patients after acute stroke. Our study also shows that the lower the CrCl, the greater is the risk of in-hospital mortality after acute attack. This finding needs to be considered in preventive and therapeutic strategies of acute stroke.

Potential adverse effects of a low-dose aspirin-diuretic combination on kidney function.

OBJECTIVE: Low-dose aspirin and diuretics are commonly co-utilized in patients with cardiovascular diseases. The objective of this study was to investigate the effects of a low-dose aspirin-diuretic drug combination on renal function. METHODS: In this cross-sectional retrospective study, all patients, excluding those on renal dialysis, admitted to the Internal Medicine Department of the Al-Watani Hospital, Nablus, Palestine, were included in the study. Medical data were obtained from patients' medical files. Estimation of creatinine clearance was carried out using the Cockcroft-Gault equation. Patients on the target drug combination were compared with patients who were not receiving the target drug combination. An independent paired t-test and 1-way ANOVA were used to test for significance between groups. Statistics were carried out using the Statistical Package for Social Sciences (SPSS), version 13. RESULTS: A total of 340 subjects (54.4% men) were included in the study. There were 90 patients on the target drug combination and designated as the study group. Of the remaining 250 patients comprising the control group, 114 received none of the target drugs and 136 received only one target medication. There was a significant (p < 0.001) difference in the levels of creatinine clearance between the two groups. Patients on the target drug combination had significantly lower creatinine clearance levels than those in the control group. Men in the study group had lower creatinine clearances than men in the control group and similar results were found for women. Patients in the study group with > or = 2 chronic diseases, had lower creatinine clearances than patients in the control group with > or = 2 chronic diseases. Similar results were found in patients with < 2 chronic diseases. CONCLUSION: Administration of a low-dose aspirin-diuretic drug combination was associated with significantly lower creatinine clearance levels. This finding was independent of gender and the number of chronic diseases present. Monitoring kidney function in patients receiving this drug combination is recommended.

Audit of prescribing practices of topical corticosteroids in outpatient dermatology clinics in north Palestine.

To analyse the prescribing pattern of topical corticosteroids, 802 outpatient dermatology prescriptions were randomly collected during June 2003-September 2003 from all the 12 nongovernmental dermatological clinics in north Palestine. Of the 2458 medications prescribed, 616 were topical corticosteroids. In most prescriptions, information about strength, duration of treatment and quantity to be used was inadequate, while information regarding frequency, route and area of application was adequate. High efficacy and highest efficacy corticosteroids were prescribed for approximately 18% of patients; intermediate efficacy preparations were prescribed for approximately 50%.

Audit of prescribing practices of topical corticosteroids in outpatient dermatology clinics in north Palestine

To analyse the prescribing pattern of topical corticosteroids, 802 outpatient dermatology prescriptions were randomly collected during June 2003-September 2003 from all the 12 nongovernmental dermatological clinics in north Palestine. Of the 2458 medications prescribed, 616 were topical corticosteroids. In most prescriptions, information about strength, duration of treatment and quantity to be used was inadequate, while information regarding frequency, route and area of application was adequate. High efficacy and highest efficacy corticosteroids were prescribed for approximately 18% of patients; intermediate efficacy preparations were prescribed for approximately 50%