Effect of Weekly Text Messaging Reminders on Medication Adherence in Hypertension and Type 2 Diabetes Mellitus at a Tertiary Care Center in Eastern Nepal

Background The short-message service (SMS) reminder techniques are found to be important in increasing medication adherence in non-communicable diseases. Objective To assess the effect of SMS on medication adherence in hypertension and/or type 2 diabetes mellitus. Method An observational study was conducted in the outpatient department using a semistructured questionnaire. Patients having hypertension and/or type 2 diabetes mellitus and taking at least one medication and having low to medium adherence were enrolled and short-message service was sent to them twice a week for up to two months reminding them to take medications as prescribed. At the end of two months, medication adherence was assessed using SPSS at P-value less than 0.05. Result Out of 105 patients, 64 (60.95%) were females. The mean age (±SD) was 51.15 ± 11.01 years. After two months of the short-message service reminders, majority of the patients were graded as having high adherence (73.33%) followed by medium adherence (20.0%) and low adherence (6.67%). The mean medication adherence scores on day one and after two months were 5.50 ± 1.14 and 7.50 ± 0.93 respectively (P-value=0.000). A high medication adherence was seen in individuals aged above 45 years (75.7%), males (78.0%) and those using a basic mobile phone (76.7%) after two months of follow-up; however it was statistically not significant (P-value > 0.05). Conclusion The SMS reminders had significantly improved the medication adherence in patients with hypertension and/or type 2 diabetes mellitus. However, none of the baseline variables were significantly associated with improvement in the adherence.

Knowledge, Attitude and Practice of Disposal of Unused, Unwanted and Expired Medicines among Healthcare Professionals

Background Unused, unwanted and expired medicines stored at home pose threats to both health systems and environments. Healthcare professionals (HCPs) should be aware of the proper disposal methods of such medicines. Objective To assess the knowledge, attitude and practice of disposal of unused, unwanted and expired medicines among healthcare professionals. Method A web-based cross-sectional descriptive study was conducted among faculties and junior residents at B.P. Koirala Institute of Health Sciences, Dharan, Nepal using a semi-structured proforma. The data were collected through Google Form. Descriptive statistics were calculated. Chi-square test and Student's t test were used for analysis using statistical package for the social sciences at p value of 0.05. Result A total of 294 healthcare professionals with mean age 35.37± 6.630 years were participated out of which 231 (78.6%) were male and 151 (51.4%) were faculties. Mean knowledge score was higher in faculties (2.37±1.111) than the Junior residents (2.33±1.155) [F(1,293)=0.102, p=0.750]. Junior residents (140 out of 143, 97.9%) had a better attitude than faculties (141 out of 151, 93.3%) regarding the disposal of medicines [χ2 (1)=3.558, p=0.059]. Junior residents (36 out of 143, 25.1%) also had a better practice than faculties (24 out of 151, 15.8%) regarding the disposal of medicines [χ2 (1)=3.895, p=0.048]. Conclusion Majority of the Healthcare professionals had positive attitude but poor knowledge and practice regarding disposal of expired and unused medicines. There was a high practice of keeping medicines at home by healthcare professionals. The findings would be useful for planning strategies to minimize unused medicines and foster the appropriate disposal practice.

COVID-19: All Facts, No Myth

On December 31, 2019, the China Health Authority alerted WHO about 27 cases of pneumonia of unknown etiology in Wuhan City. It was subsequently named Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and the disease as Coronavirus Disease 2019 (COVID-19). The disease has now become pandemic. Current review was done to summarize information on COVID-19 published in various scientific works. Electronic databases containing medical articles viz., MEDLINE/PubMed, Google Scholar etc were searched using the Medical Subject Headings 'COVID-19', '2019- nCoV', 'coronavirus' and 'SARS-CoV-2' during antecedent one year. All study designs were incorporated to harvest clinical, laboratory, imaging, and hospital course data. The intermediate host of the virus is still unknown. Respiratory droplets produced by the patient is main source of transmission. SARS-CoV-2 invades the airway epithelium by binding to angiotensin-converting enzyme-2 (ACE2) receptor with Coronavirus spike (S) protein. Most common symptoms are fever (98%), dry cough (77%), and dyspnea (63.5%). Later, complications like acute respiratory distress syndrome, septic shock etc may occur. Advanced age and co-morbidities like Diabetes have higher mortality otherwise Case Fatality Rate is 2-3%. RTPCR is the diagnosis of choice. Since no universally accepted registered drug or FDA approved vaccine has come by now, prevention is the key. Hands should be regularly cleaned with soap or alcohol based sanitizer and in public, Nose and Mouth should be covered with face-mask and social distance of one meter should be maintained. While Vaccines are expected by early 2021, we should not forget to take comprehensive measures to prevent future outbreaks of zoonotic origin.

Effect of Honey on Healing Process of Extraction Socket in Rabbits

Background Honey is regarded as the oldest wound dressing. It accelerates wound healing in burn, infected and open wounds. Its effect on wound healing process in extraction socket is not fully established till today. Objective To evaluate the effect of honey on the healing process of socket after tooth extraction in New Zealand White rabbits. Method Extraction of first premolar tooth on both sides of lower jaw in six rabbits was done under general anesthesia produced by ketamine and Xylazine followed by local application of honey on one socket (honey group) and normal saline (control group) in the opposite socket. On 7th day, biopsy was taken from the extraction site and histopathological examination was done. Student's t-test was used for comparison between the groups and the differences were considered to be statistically significant at P-value less than 0.05. Result There was a significant difference between control group and honey group in terms of fibroblast proliferation (p = 0.0019) and bony trabeculae formation (p=0.0003). Inflammatory cells were also observed in both groups and it was statistically not significant (p=1.0000). Overlying epithelium was hyperplastic in the both groups. Conclusion Local application of honey promoted the healing process by increasing fibroblast proliferation and bony trabeculae formation. Further studies in larger animals and human should be conducted to confirm the efficacy of honey in extraction socket healing.

Therapeutic Drug Monitoring of Antiepileptic Drugs at a Tertiary Care Hospital of Eastern Nepal

Background Therapeutic drug monitoring (TDM) is the process of measuring drug level in body fluids. It is done to maintain plasma concentration of the drug under therapy within a specific target range for maximum therapeutic efficacy without unnecessary exposure to adverse effects. Objective This study aims to evaluate necessity of therapeutic drug monitoring in Phenytoin, Carbamazepine and Lamotrigine therapy among epileptic patients. Method A prospective, cross-sectional study was conducted for a period of one year at BP Koirala Institute of Health Sciences, Dharan, Nepal. After taking detailed history, blood samples were collected from epileptic patients on monotherapy with the selected drugs. Plasma levels of these drugs were analyzed using High Performance Liquid Chromatography technique (HPLC). Out of total 42 selected patients, 21 were tested for phenytoin, 17 for carbamazepine and four for lamotrigine. The result was categorized into therapeutic, sub-therapeutic and above-therapeutic groups based on reference range. Result Out of total 21 samples tested for phenytoin, 15(71.4%) had plasma drug level within therapeutic range, 5(23.8%) had within subtherapeutic range and 1(4.8%) had above therapeutic range. Analysis of carbamazepine plasma level showed 14(82.3%) at therapeutic level, 1(5.9%) at sub-therapeutic level and 2(11.8%) at above-therapeutic level. Lamotrigine testing in four samples showed 2(50% in) both within therapeutic range and above-therapeutic range. Conclusion Therapeutic drug monitoring of phenytoin, carbamazepine and lamotrigine showed variation in plasma level irrespective of the therapeutic dose. It is suggested that dose adjustment of antiepileptic drugs should be done after establishing 'individual therapeutic range' following regular plasma monitoring.

Adverse Drug Reaction (ADR) Monitoring at the Eastern Regional Pharmacovigilance Centre, Nepal

Background Adverse Drug Reaction is any unintended drug consequence. It is often preventable. In developed countries, it is among the top ten leading causes of morbidity and mortality. However, it's monitoring is largely unexplored in developing countries like Nepal. Objective To identify and characterize the pattern of Adverse Drug Reactions at BP Koirala Instittue of Health Science (BPKIHS), the Eastern Regional Pharmacovigilance Centre of Nepal. Method It was an observational study among the patients presented to different Clinical Departments of BPKIHS. Study duration was between July 2012 to July 2015. Adverse Drug Reactions were documented in a structured questionnaire and analysis done, in the department of Clinical Pharmacology and Therapeutics, using Microsoft 2013 Excel. Result There were total 150 Adverse Drug Reactions documented mostly in the age range of 19-40 years (61.4%) with female preponderance (56.7%). Maximum Adverse Drug Reactions were collected from Psychiatry (60.7%) followed by Dental surgery (17.3%) and Internal Medicine (10.7%). Most frequent Adverse Drug Reactions were seen with drugs primarily affecting CNS (64.7%), followed by steroids (18.0%) and Antimicrobial drugs (12.0%). Among CNS drugs, Antidepressants (93.6%) accounted for most documentation. Weight gain (20.1%), Fatigue (12.4%), Rash (8.1%), Acid peptic disorder (7.7%), Headache (7.2%) and Puffiness of face (7.2%) were the most frequently encountered Adverse Drug Reactions. Conclusion Most reported Adverse Drug Reactions were from young (18-40) female presented to the department of Psychiatry. Weight gain was the most common side effect.

Antibiotic Usage and its Culture Sensitivity Pattern in Urinary Tract Infections at Tertiary Hospital in Eastern Nepal

Background The presence of microbial pathogen in the urinary tract is Urinary Tract Infection (UTI). In BP Koirala Institute of Health Sciences (BPKIHS), each year there are around 1000 cases of UTIs. Antibiotic is empirically started after sending culture/sensitivity (c/s) with intention to change antibiotic if c/s demands. Objective To see the antimicrobial prescribing pattern and c/s pattern of UTI inpatients of BPKIHS together with their socio-demographic and laboratory profile. Method It was a Record-Based Retrospective Descriptive Study of past one-year. All available inpatient-records from Medical-Record Section were extensively searched for the keyword "UTI" diagnosis. The relevant data were entered in Microsoft Excel-sheet and analyzed with IBM SPSS 21. Ethical clearance was obtained from the IRC before study. Result There were 86 cases from four different wards. There was slight female preponderance (51.16%). Fifty-five (63.95%) cases were complicated. Fever (75.51%) was the most common symptom. Only 20% were tachycardic but 90% were tachypnic. Leucocytosis (59.26%), urine albumin within 30-100 mg/dl (33.85%) and >5 Urine WBC/hpf (80.26%) were seen. Ceftiaxone (53.16%) was the most commonly prescribed empirical antibiotic, followed by Cefixime (6.32%). Fourteen (16.27%) cases were culture positive. E. coli was the most (78.57%) common pathogen grown. In culture sensitivity study, Amikacin (42.85%) was the most sensitive antibiotic. Conclusion Eighty-six UTI inpatients were identified last year. Fever and Tachypnoea were very common. Leucocytosis, 1+ proteinuria and urine WBC>5/hpf were frequently seen. Ceftriaxone was the most common antibiotic prescribed. E. coli was the most common pathogen grown and Amikacin was the most sensitive antibiotic.

Pattern of Self-medication in Undergraduate Students at BP Koirala Institute of Health Sciences

Background Self-medication is a growing health problem. It may lead to wastage of resources, emergence of antimicrobial resistance, adverse drug reactions and prolonged suffering. Little has been reported on the extent of self-medication practiced in medical students in Nepal. Objective To study the pattern, reason and perception of self-medication among undergraduate students. Method A cross-sectional study was conducted among all undergraduate students at BP Koirala Institute of Health Sciences, Dharan, Nepal between April and May, 2015. After obtaining ethical clearance, pre-validated questionnaire was used to collect data. The date were analyzed and presented as frequency and percentage using SPSS version 11.5. Result Total of 520 students participated in the study with a mean age of 21.2±1.7 years. Prevalence of self-medication was found to be 48.3%. Most common cause for self-medication was common cold (53.3%). Nonsteroidal anti-inflammatory drugs (78.9%) were the most commonly used medicine for self-medication. The students commonly approached their seniors (50.2%) for the drug information. The most common adverse drug reaction experienced by the students was drowsiness (50.9%). Approximately one third of the students (33.2%) used to prescribe medicines to others. More than half of the students (53.8%) opined that self-medication is a part of self-care. Around one-fifth of the students (21.5%) students opined that self-medication is recommended by WHO. Conclusion Self-medication is commonly practiced by undergraduate students. Nearly one third of the students also prescribe medicines to others. Nonsteroidal anti-inflammatory drugs are the most commonly used medicine as self-medication. The students need to be educated regarding appropriate safe-medication.

Effect of root-extracts of Ficus benghalensis (Banyan) in memory, anxiety, muscle co-ordination and seizure in animal models

Background

Ficus benghalensis L. (Banyan) is a commonly found tree in Eastern Nepal. Its different plant parts are used for various neurological ailments. This study was performed in mice to see its effects in various neuropharmacological parameters.

Methods

Passive-avoidance (memory), Open-field (anxiety), Pentobarbital-induced Sleep potentiation (sleep), Rota-rod (muscle-co-ordination), Pentylenetetrazol-Induced and Maximal Electroshock Seizure Tests were performed. Sample size was calculated using G*Power 3.1.9.2. Aqueous root extracts (Soxhlet method) of Ficus benghalensis 100 mg/kg and 200 mg/kg with negative and positive controls were used. The experimental results were represented as Mean ± SD. P-value was set at <0.05. Oneway analysis of variance (ANOVA) or Mann-Whitney U test was appropriately used.

Results

Passive-avoidance test showed 200 mg/kg group spent significantly less. Time (0.00s + 0.00s) in shock-zone than Normal Saline-group (9.67 s + 14.36 s, P = 0.000) or Diazepam-group (41.07 s + 88.24 s, P = 0.000).

Open-field test showed 200 mg/kg group spent significantly longer Time (24.77 s + 12.23 s) in central-square than either Normal Saline group (15.08 s + 6.81 s, P = 0.000) or Diazepam-group (15.32 s + 5.12 s, P = 0.000).

In Rota-rod test, 200 mg/kg group fell off the rod significantly (P = 0.000) earlier (33.01 s + 43.61 s) than both Normal Saline (>120 s) and Diazepam (62.07 s + 43.83 s) PTZ model showed that 100 mg/kg significantly (P = 0.004) delayed seizure-onset (184.40s + 36.36 s) compared to Normal Saline (101.79 s + 22.81 s), however, in MES model 200 mg/kg significantly (P = 0.000) prolonged tonic hind-limb extension (17.57 s + 2.15 s) compared to Normal Saline (13.55 s + 2.75 s) or Phenytoin (00.00s + 00.00s).

Conclusion

Aerial roots of Ficus benghalensis have memory-enhancing, anxiolytic, musclerelaxant, and seizure-modifying effect.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-016-1413-5) contains supplementary material, which is available to authorized users.

Effectiveness of an Educational Feedback Intervention on Drug Prescribing in Dental Practice

Background Irrational use of drugs as well as inappropriate and over drug prescribing leads to unnecessary expenditures and emergence of resistant bacterial strains. Feedback intervention on drug prescribing habits and face to face educational intervention of prescription audit would be effective in rationalizing prescribing practices. Objective To measure the impact of educational feedback intervention on the prescribing behavior of dental surgeons. Methods Prospective audit of twelve hundred outpatients prescriptions in dental OPD at BPKIHS of those dental surgeon who attended the educational intervention session was collected randomly by trained persons on customized data collection sheet before and after educational intervention. Results A total 1200 prescription were collected, 300 before and 300 after intervention period at the internal of one month, three months and six months. Majority of the prescriptions (39.33%) contained four drugs but after intervention, prescriptions contained mostly one drug, 73% in first month, 78.67% in third month and 65.34% in six month. Mean number of drugs per prescription after intervention were decreased. There was increased number of generic names of drugs after intervention. Amoxicillin, Metronidazole, Chlorhexidine, Povidone iodine gargle, Nimesulide, Ibuprofen, Ibuprofen + paracetamol, and Paracetamol were most commonly prescribed by dental prescribers before and after intervention. Selection of antimicrobial was done on empirical basis which was correct because Amoxicillin concentration reaches effectively in gingival crevicular fluid and Metronidazole covered effectively against anaerobic bacteria were found in orodental infection. The uses of topical anti-infective preparation as irrigants of choice that can kill majority of micro-organisms found is root canal and dental tubules and minimize systemic use of antimicrobials. Nimesulide prescribing needs to be rationalized. Conclusion Feedback educational intervention of prescription audit is effective to improve their prescribing behaviors and rationalize drug utilization pattern for the benefit of the patients. DOI: http://dx.doi.org/10.3126/kumj.v10i4.10991 Kathmandu Univ Med J 2012;10(4):30-35

Effect of Ocimum sanctum, ascorbic acid, and verapamil on macrophage function and oxidative stress in mice exposed to cocaine

OBJECTIVE

To investigate the effect of Ocimum sanctum, ascorbic acid, and verapamil on macrophage function and oxidative stress in experimental animals exposed to cocaine.

MATERIALS AND METHODS

Mice were used in this study and were divided randomly into different groups of six animals each. They were either treated with intraperitoneal injection of saline or cocaine hydrochloride or an oral feeding of oil of Ocimum sanctum, ascorbic acid or verapamil, or both (ascorbic acid and verapamil), and were evaluated for a respiratory burst of macrophages, superoxide and nitric oxide (NO) production, estimation of TNF-alpha in the serum and supernatant of cultured macrophages, estimation of lipid peroxidation (malondialdehyde- MDA) in the serum, and superoxide dismutase activity in the erythrocytes.

RESULTS

Unstimulated respiratory burst as well as superoxide production was enhanced on treatment with cocaine and all the three drugs were found to attenuate this enhancement. The bactericidal capacity of macrophages decreased significantly on chronic cocaine exposure, as it was associated with decreased respiratory burst and superoxide production. There was a significant decrease in NO production by macrophages on chronic cocaine exposure and all the test drugs were found to restore nitrite formation to a normal level. There was an increase in the malonylodialdehyde (MDA) level and decrease in the superoxide dismutase level on chronic cocaine exposure, and all the three drugs effectively decreased the MDA level and increased superoxide dismutase level. There was an increase in serum TNF-alpha on chronic cocaine exposure, which was decreased significantly by ascorbic acid and verapamil.

CONCLUSION

O. sanctum, ascorbic acid, and verapamil were equally effective in improving the macrophage function and reducing oxidative stress. These findings suggested that O. sanctum, ascorbic acid, and verapamil attenuated acute and chronic cocaine-mediated effects.

Prescription writing skills of pre-clinical medical and dental undergraduate students

Objective of this prospective study was to assess the acquisition of prescribing skill of preclinical medical and dental undergraduate students. Prescription writing skills of 258 students of both first and second year of MBBS and BDS students were analyzed through an objective structured practical examination. MBBS student of second year scored 85.01% and 92.82% respectively in physician and drug related component whereas first year MBBS students scored 89.9% and 83.4%. BDS student of first year scored 91.96% and 86.33% in physician and drug related components which is better than second year that scored 83.33% and 77.94% respectively. This study revealed that the students of both courses acquire prescribing skills to a limited extent during preclinical phase. Prescribing errors were found both in physician and drug related components. To minimize the different form of prescribing errors vigorous training in the internship period will help to minimize prescribing errors and improve rational prescribing too.

Recent advancement in drug delivery system

Ease of drug administration, safety, affordability and efficacy are the major concerns in pharmacotherapy leading to exploration of better drug delivery systems. Liposomes are lyotropic liquid crystals composed mainly of amphiphilic bilayers and these are more frequently used as drug carriers. Liposomes help reduce the toxicity and deliver the drug to the target tissue. So far, liposomes have been the most intensively studied lipid-based delivery system. In liposomes, a hydrophilic drug can be trapped in aqueous interior or channels between successive phospholipids bilayers whereas a hydrophobic drug can reside with the bilayer itself. The non-toxic and nonimmunogenic bilayers dissipate allowing the diffusion of the drug into the tissues. Attachment of polyethyl glycol to the surface of liposome (known as stealth liposome) aids in the better targeting of the drug to the tissues. Pegylated proteins and polymers of lactic and glycolic acids have been well studied as drug carriers and found to be resistant to phagocytosis and complement activation. Newer DNA based strategies including DNA vaccination and antisense oligonucleotides and immunomodulation show good results for new therapeutic systems. Though the DNA based therapeutic systems have high selectivity and specificity with few adverse effects, these systems are so far restricted to animal models and clinical trials.

Relationship between plasma leptin and plasma insulin levels in type-2 diabetic patients before and after treatment with glibenclamide and glimepiride

Type 2 diabetes affects 100 million people throughout the world. Among the various factors implicated in the causation of this disease, the role of leptin, an obesity gene product, is increasingly being investigated. This especially assumes importance in the light of knowledge that obesity confers a minimum of 3-10 fold higher risk of diabetes. This study was planned to investigate the relationship between leptin and insulin levels in type 2 diabetic patients before and after treatment with glibenclamide or glimepiride. 60 type 2 diabetic patients were recruited for the study and were divided into 2 groups-one receiving glimepiride and the other group receiving glibenclamide for duration of 10 weeks. This study demonstrated a highly positive correlation of plasma leptin levels with BMI, plasma insulin and insulin resistance. No gender specific differences were observed in leptin concentrations. The study, however, failed to demonstrate any possible relationship between glycemic control as assessed by blood sugars/ glycosylated hemoglobin (HbAlc) and plasma leptin. The administration of glibenclamide or glimepiride significantly lowered blood glucose levels coupled with a decrease in (HbAlc). Both the drugs increased insulin concentrations. Glibenclamide increased leptin levels but they remained unaltered with glimepiride. Glibenclamide and glimepiride were found to be equally effective in their glucose lowering action. However, the patients receiving glibenclamide experienced higher episode of hypoglycaemic spells than those receiving glimepiride.

Antinociceptive effect of amitriptyline in mice of acute pain models

Tricyclic antidepressant drugs induce antinociceptive effect and suggest that their analgesic action could be related to the monoaminergic activity of the drugs. The analgesic activity of amitriptyline was observed in mouse models of acute pain. Mice were divided into different groups and were given amitriptyline in different doses alone and in combination with morphine. Reaction time in Hot-Plate and Tail-Flick tests was observed. Results showed that amitriptyline had antinociceptive effect in acute pain state in experimental models. Amitriptyline in combination with morphine had better analgesic effect than the morphine alone in Hot-Plate test.

Vagus nerve stimulation: a novel approach for prevention and control of refractory seizures

In order to understand the brain function and to treat various neuropsychiatric illnesses including epilepsy, continued search and discovery of newer antiepileptic drugs has failed to revolutionize the approach in the management of this complex disorder. Moreover, in close to 30% of epilepsy patients, the seizure control is either not satisfactory or it is intractable to pharmacotherapy. Amongst the non-pharmacological treatment options for refractory epilepsy, vagus nerve stimulation occupies a unique position as an adjunctive treatment in prevention and control of partial-onset seizures in adults and adolescents older than 12 years. Though the precise mode of action of VNS is still debatable an honest attempt has been mode here to review all possible literatures available on VNS to establish its role in the management of this complex disorder.

Evaluation of anxiolytic activity of tensarin in mice

INTRODUCTION

Anxiolytic drugs are amongst the most frequently prescribed drugs. Available anxiolytic agents are associated with several limitations. Several indigenous drugs are being evaluated but none has been proved to be effective.

OBJECTIVES

Aim of the present study is to evaluate the anxiolytic effect of Tensarin.

MATERIAL AND METHOD

The behavioural tests were conducted with single dose schedule and multiple seven-dose schedules of Tensarin 50mg/kg, 100mg/kg and 200mg/kg in comparison with Diazepam 1mg/kg in mice using open field test, activity-monitoring and passive avoidance test. There were eight treatment groups in each treatment schedule. Each group consisted of ten animals of either sex. The data obtained were analyzed using non- parametric test and P-value of less than 0.05 was considered to be statistically significant.

RESULTS

Multiple doses produced anxiolytic effect as indicated by an increase in rearing, number of crossing and the time spent by the animals in Central Square. It was also seen that there was significant decrease in step down latency, increase in step down error and time spent by animal in shock zone, these effects were not observed in single dose study.

CONCLUSION

Tensarin shows a dose dependent anxiolytic effect but further studies are needed to find out the exact mechanism of action of the formulation.

Medical errors challenges for the health professionals: need of Pharmacovigilance to prevent

The incidence of different aspects of iatrogenic problems due to drugs is Adverse Events (AEs) 3.7%, Adverse Drug Events (ADEs) 2.4-6.5%, Adverse Drug Reactions (ADRs) is 6.7%. Negligence in serious ADEs and death is 34% and 51% respectively, preventable ADEs is 25-50%. Medication Errors (MEs) occur most often in perscribing (29-56%). The most common cause of MEs is lack of knowledge about the drug (29%) and the patient about 18%. MEs result malpractice claims in 13-25% of cases which occur due to mistakes and slips of action & lapses of memory. The MEs can be prevented by establishing effective Pharmacovigilance control center, which frequently gives proper guidance to the prescribers. Use of computerized decision for prescription writing, effective communication with patient, families, pharmacists and nurses and continuing medical education on information of new drugs and new information on current drugs can be effective tolls to prevent the errors.

Knowledge, attitudes and practices (KAP) regarding the management of diarrhea by pharmacists and licensed drug sellers in eastern Nepal

Diarrhea constitutes a major cause of morbidity and mortality in developing countries. Inappropriate drug prescribing is common in diarrhea, resulting in an increase in cost and adverse drug reactions. In Nepal, drug sellers often act as the first contact persons for the underprivileged. No information has been available regarding their knowledge, attitudes and practices (KAP) regarding diarrhea management. Using a structured questionnaire, between the 1st of January and the 31st of December 2003, 109 drug sellers in eastern Nepal were interviewed about their educational status, patient/attendant presentation at the outlet and their advice to patients/attendants. Only 2.7% of drug sellers were qualified in health education. Eighty percent of the patients/attendants sought advice from the drug sellers, only 20% presented to the outlet with prescriptions. The data reveals that about half of them were taking note of the nature of the diarrhea. Although 62 (56.8%) of them were aware of dehydration, only 2 (1.8%) of them knew all three signs of dehydration (dry tongue, non-elastic skin and sunken eyes). Sixty-six (60.5%) of them knew about oral rehydration solution (ORS), its principle and the required period of administration. About 50 to 60% of them were aware of the implications resulting from dehydration from uncontrolled diarrhea and of the importance of ORS in its management. Only 20% of the drug sellers advised ORS alone, otherwise it was dispensed along with drugs, such as antimotility agents (AMA) or metronidazole. As a result of the above findings, it is important to educate the drug sellers by conferring knowledge about the ethical aspects of drugs in the management of diarrhea.

Antimicrobial utilization pattern in out patient services of ENT department of tertiary care hospital of Eastern Nepal

OBJECTIVE

The objective of this study was to monitor the antimicrobial utilization in ENT out patient services in a tertiary care hospital of Nepal.

MATERIALS & METHODS

A total of 191 prescriptions were randomly audited at varying time interval from the department of ENT in the year 2003. The data was collected in customized Performa in the form of antibacterial audit questionnaires. It also contained Patient particulars, diagnosis, investigations, drug details and information from the prescriber regarding the indication for prescribing antimicrobial agent, suspecting organism underlying infection, duration of therapy and details of any concomitant medications.

RESULTS

The incidence of use of antimicrobial agents (AMA) in 191 prescriptions was analyzed from the enrolled prescriptions, a total of 218 antimicrobials i.e.1.4 antimicrobial agent per patient were prescribed. . The AMAs were indicated therapeutically in 73.29% of patients & 19.37% patients for prophylaxis. The AMAs were advised for more than 72 hours for prophylaxis in 86.48%. In the concomitant medications antihistaminic were prescribed in 32.62% and NSAIDS in 21.98% cases. Most of patients reported with upper respiratory tract infections (URTI-32.56%), Chronic Suppurative otitis Media (CSOM-18.3%), sinusitis (6.28%), tonsillitis (5.75%),. Pharyngitis (3.66%), Acute Suppurative Otitis Media (ASOM-2.61%) and others. The diagnosis was established clinically in 42.40% and confirmative in 35.60%. In 21.46% the diagnosis was not disclosed. Out of 191 patients, culture sensitivity tests were performed for only 31 patients and 13 patients depicted a positive culture sensitivity tests. The common microbes isolated from the culture were staphylococcus aureus (69.2%). Streptococcus (7.7%), Enterobacteriacae (7.7%), Pseudomonas auroginosa (7.7%) & psendomanas mirabilis (7.7%). Clinically suspected organism were mentioned in only 32 prescriptions and most prescriber presumed the infections due to staphylococci & pseudomonas (43.75%), streptococci (21.8%),Gram negative organisms (12.5%) and H influenza (9.3%). The use of a single drug was abundant (89.52%), two drugs (9.94%), and three drugs (0.52% )prescriptions. Ciprofloxacin (23.85%) was preferred, followed by amoxycillin (20.06%), combination of ampicillin + cloxacillin( 9.17%), doxycyclin (5.96%). Erythromycin (4.58%) and cotimoxazole (4.58%). Expensive drugs i.e azithromycin (2.75%), roxithromycin (1.37%) and cephalosporins (3.21%) were also prescribed. The causative microbes were sensitive to amoxycillin (53.84%), cloxacillin (53.84%) ciprofloxacin (46.15%), gentamicin (46.15%), and cephalosporin (46.15%). But resistant to erythromycin, tetracycline, cotrimoxazole and norfloxacin)

CONCLUSIONS

Majority of patients were prescribed drugs irrationally with misleading indications without confirming the bacteriological culture and sensitivity.

Recent advances in the management of epilepsy: a review

Epilepsy is a complex disorder affecting brain function having a variety of contributing factors. The genetic predisposition plays a key role in the genesis of epilepsy. The already existing antiepileptic drugs (AEDs) provide effective control of majority of patents with different types of seizures. In some refractory cases and in those patients who can not tolerate the conventional AEDs, there is an urgent need to provide relief by controlling the seizures adequately. Various newer approaches in the rational management of seizures have been evolved during the recent years, based on different mechanisms of action and side effects profile. A brief account of these newer treatment modalities have been incorporated in this review in order to enlighten the readers about the possible beneficial effect of this regimen vis a vis the limitations of such use.

ANTIMICROBIAL UTILIZATION PATTERN IN A TEACHING DISTRICT HOSPITAL OF NEPAL

The objective of this study was to monitor the antimicrobial utilization in a teaching district hospital and tocompare it against the rational antimicrobial use guidelines.Total 106 data sheet of indoor patients admitted in year 2001 were randomly chosen and analyzed. Thenumber of antimicrobials prescribed in every prescription was taken into account to calculate the incidenceof use of more than one antimicrobial agent. The Patient sheet included patient information, drug information(name, indication, dose, frequency and duration of antimicrobial use), diagnosis or provisional diagnosisand investigations. Prescription auditing was done on the selected prescriptions.Male: female ratio was 40:65. In 90.57% diagnosis was established empirically and in only 4.7 % patientsconfirmatory diagnosis was made using relevant investigations. The antimicrobials were prescribed chieflyfor respiratory tract infections (RTI -26.41%), gastrointestinal infections (GIT -22.64%), genital tractinfection (13.20%), wound infections (8.48%), urinary tract infections (UTI-6.6%), bone & joint infections(4.71%) and miscellaneous (Typhoid, Malaria, meningitis etc-17.92%). The causative organism wasconfirmed using culture & sensitivity tests in only one patient (0.94%) out of 106 patients. In 77 (69.8%)patient prescriptions suspected pathogenic organisms were mentioned. These were streptococcus (29.58%),Chlamydia (11.27%), mycoplasma (18.30%), staphylococcus (23.94%), E. coli (32.39%) and S. typhi(15.49%). In 35 prescriptions (33.01) no causative organism was mentioned. It was further observed that atotal 452 drugs (i.e. 4.26 drugs per patient), out of this only 165 antimicrobials (1.55 antimicrobials perpatient) were prescribed in the 106 enrolled prescriptions. On further analysis of antimicrobials use, it wasobserved that most patients were prescribed a single antimicrobial agent (58.49%), two AMAs (24.52%),three AMAs (13.20%) and least was four AMAs (3.77%).The antimicrobials were given prophylacticallyin 14 (13.10%) and therapeutically in 85 (80.18%) prescriptions. The use of antimicrobials were not indicatedin 7(6.60%) prescriptions.. In 91 cases (85.85%) duration for which AMAs were considered was notmentioned. Ampicillin + cloxacillin (12.12%), ciprofloxacin (10.30%), metronidazole (10.30%), amoxycillin(10.30%) and cephalosporins (25.47%) were the most frequently prescribed AMAs. A fixed dose combinationof ampicillin & cloxacillin, ciprofloxacin and metronidazole were recurrently prescribed while gentamicin,cotrimoxazole and crystalline penicillin were relatively least prescribed antimicrobials agents.Inappropriate and irrationality in the Antimicrobial prescribing pattern was observed.Das B P*, Sethi A*, Rauniar G P*Key Words: Antimicrobial agent, Respiratory tract infection (RTI), urinary tract infection (UTI),gastrointestinal infection, prophylaxis, therapeutic.

ANALGESIC UTILIZATION IN POSTOPERATIVE CARE AT A TERTIARY CARE TEACHING HOSPITAL IN NEPAL

ABSTRACTA retrospective analysis of analgesics used in postoperative pain in abdominal surgery was done to developbase line data. Appendectomy and cholecystectomy each formed 38.63% while hernia repair constituted22.74% of all the abdominal surgeries (422). NSAIDs were the most commonly prescribed group of analgesicsboth during the hospital stay (99.52%) and at the time of discharge (86.01%). Opioid analgesics (4.73%)was used in the immediate postoperative period mainly to supplement the NSAIDs. Diclofenac (88.86%)was the most commonly prescribed analgesic to in-patients and either diclofenac (47.63) or a fixed dosecombination of ibuprofen and paracetamol (32.46%) was the most commonly prescribed at the time ofdischarge. The administered dose of diclofenac was higher than the recommended dose. Utilization ofanalgesics during postoperative period may be rationalised by pain assessment charts and regular feedbackto the precribers.Key Words: Analgesic utilization, post operative, abdominal surgery.

HOW COST EFFECTIVE IS THE TREATMENT? ARE PRESCRIBERS CONCERNED ?

ABSTRACTCost-effective treatment should be of primary concern to prescribers in poor countries like Nepal. Thepresent study was carried out at a tertiary care hospital in Nepal to find out the perception of prices ofcommonly prescribed drugs among prescribers. The participants selected randomly were directed to writein 10 minutes on a proforma, the generic name(s) and price of the brand preparation of 18 most commonlyused drugs listed under their brand name.The price of the drug was considered correct if the price mentioned was within a range of 20% above orbelow the brand price. Results indicated that the participants were aware of the composition of majority(80%) of the drugs, but were not aware of the prices of 81.80% of the drugs. No single participant mentionedthe correct prices of all the drugs. Among the drug groups studied, the most accurate data was providedabout composition (90.43%) and price (24.47%) of non steroidal anti-inflammatory drugs (NSAIDs). Onlyin 9.22% of brand preparations of antimicrobial agents (AMA), the prices were mentioned correctly. Hence,sensitisation of physicians about cost-effective treatment is of immense importance and to facilitate this,hospital authorities could provide prescribers with regularly updated price lists of commonly prescribeddrugs and competitive prices of various brand preparations. Pharmacoeconomics may be introduced in the undergraduate curriculum which can be reinforced by continuing medical education.Key Words: Cost-effective, Pharmacoeconomics.

Effect of hyoscine butylbromide and atropine on heart rate during nocturnal sleep

This is a single blind crossover study designed to test the effects of hyoscine butylbromide (HBB), an anticholinergic which does not cross the blood brain barrier (BBB), on the temporal changes in heart rate during nocturnal sleep. The effects were compared with atropine sulphate which is known to cross the BBB. Ten healthy male volunteers slept in the JIPMER sleep disorders laboratory for three nights and received either saline, atropine sulphate (0.4 mg, i.v.) or HBB (10 mg, i.v.) just prior to sleep onset. All night polysomnography recording was done to monitor heart rate during the specific stages of sleep. The normal physiological fall in heart rate is blunted by both drugs during slow wave sleep whereas only HBB prevented the fall in rapid eye movement sleep. Therefore, HBB may be a better choice as pre-anaesthetic medication for patients with cardiac abnormalities since it does not alter heart rate during both slow wave sleep and rapid eye movement sleep.

Comparative effects of hyoscine butylbromide and atropine sulphate on sleep architecture in healthy human volunteers

The changes in sleep architecture, heart rate and respiratory rate to hyoscine butylbromide (HBB), a peripherally acting anticholinergic was studied. These effects were compared with that of atropine sulphate, a drug known to cross the blood brain barrier. The study followed a single blind cross over design with a one week washout period. Atropine sulphate (0.4 mg) and HBB (10 mg) were given intravenously to ten adult healthy male volunteers before sleep onset. Normal saline was used as control. All night sleep polysomnography was done with the standard montage for sleep staging. Respiration and airflow were also monitored. Rapid eye movement (REM) latency was significantly increased with both the drugs whereas the duration of REM sleep was decreased only with atropine. Slow wave sleep (SWS) was also increased significantly by atropine. There was no change in heart rate, or respiratory rate during any of the sleep stages. HBB affects the initiation of REM sleep whereas atropine affects both its initiation and maintenance.

Utilization Pattern Of Nonsteroidal Anti-Inflammatory Drugs(NSAIDS) in Orthopedic Practise at a tertuary Care Hospital In Eastern Nepal

abstract