Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Adherence type impacts completion rates of frequent mobile cognitive assessments among older adults with and without cognitive impairment

Background

Prior to a diagnosis of Alzheimer's disease, many individuals experience cognitive and behavioral fluctuations that are not detected during a single session of traditional neuropsychological assessment. Mobile applications now enable high-frequency cognitive data to be collected remotely, introducing new opportunities and challenges. Emerging evidence suggests cognitively impaired older adults are capable of completing mobile assessments frequently, but no study has observed whether completion rates vary by assessment frequency or adherence type.

Methods

Thirty-three older adults were recruited from the Boston University Alzheimer's Disease Research Center (mean age = 73.5 years; 27.3% cognitively impaired; 57.6% female; 81.8% White, 18.2% Black). Participants remotely downloaded and completed the DANA Brain Vital application on their own mobile devices throughout the study. The study schedule included seventeen assessments to be completed over the course of a year. Specific periods during which assessments were expected to be completed were defined as subsegments, while segments consisted of multiple subsegments. The first segment included three subsegments to be completed within one week, the second segment included weekly subsegments and spanned three weeks, and the third and fourth segments included monthly subsegments spanning five and six months, respectively. Three distinct adherence types - subsegment adherence, segment adherence, and cumulative adherence - were examined to determine how completion rates varied depending on assessment frequency and adherence type.

Results

Adherence type significantly impacted whether the completion rates declined. When utilizing subsegment adherence, the completion rate significantly declined (p = 0.05) during the fourth segment. However, when considering completion rates from the perspective of segment adherence, a decline in completion rate was not observed. Overall adherence rates increased as adherence parameters were broadened from subsegment adherence (60.6%) to segment adherence (78.8%), to cumulative adherence (90.9%).

Conclusions

Older adults, including those with cognitive impairment, are able to complete remote cognitive assessments at a high-frequency, but may not necessarily adhere to prescribed schedules.

TB disease patterns by HIV and diabetes status

BACKGROUND: TB is commonly categorised as pulmonary (PTB) or extrapulmonary TB (EPTB). Knowledge of TB disease patterns (PTB and/or EPTB) and determining risk factors remains limited.METHODS: This was a prospective cohort study using point-of-care ultrasound (POCUS) in Indian patients with presumed TB. Clinical and imaging data were used to develop refined case definitions for PTB, concurrent PTB and EPTB (PTB + EPTB) and EPTB without PTB (EPTB). These groups were analysed by HIV (HIV+/-) and diabetes mellitus (DM+/-) status.RESULTS: Of 172 HIV-/DM- patients with TB, 48% had PTB, 23% PTB + EPTB and 29% had EPTB, totalling 52% with any EPTB (PTB + EPTB or EPTB). In HIV+/DM- patients with TB (n = 35), 6% had PTB, 40% had PTB + EPTB and 54% had EPTB, accounting for 94% with EPTB. In HIV-/DM+ patients with TB (n = 61), 61% had PTB, 28% had PTB + EPTB and 11% had EPTB, representing 39% with EPTB.CONCLUSION: Refined case definitions revealed high proportions of EPTB even without HIV or DM. HIV further altered the TB disease pattern towards EPTB and DM towards PTB. Therefore, the dichotomy between PTB or EPTB does not represent the actual spectrum of TB disease. EPTB should receive higher priority in research and clinical practice.

Changes in stroke volume variation and cardiac index during open major bowel surgery

Background

Stroke volume variation (SVV) is a dynamic indicator of preload, which is a determinant of cardiac output. Aims: Aim of this study was to evaluate the relationship between changes in SVV and cardiac index (CI) in patients with normal left ventricular function undergoing major open abdominal surgery.

Patients and Methods

Patients undergoing major open abdominal surgery were monitored continuously with FloTrac® to measure SVV and CI along with standard monitoring. Both SVV and CI were noted at baseline and every 10 min thereafter till the end of surgery and were observed for concurrence between the measurements.

Results

1800 pairs of measurement of SVV and CI were obtained from 60 patients. Mean SVV and CI (of all patients) measured at different time points of measurement showed that as SVV increased with time, the CI dropped correspondingly. When individual readings of CI and SVV were plotted against each other, the scatter was found to be wide, reiterating the lack of agreement between the two parameters (R² = 0.035). SVV >13% suggesting hypovolemia was found at 207 time points. Of these, 175 had a CI >2.5 L/min/m² and only 32 patients had a CI <2.5 L/min/m².

Conclusion

SVV, a dynamic index of fluid responsiveness can be used to monitor patients expected to have large fluid shifts during major abdominal surgery. It is very specific and has a high negative predictive value. When SVV increases, CI is usually maintained. Since many factors affect SVV and CI, any increase in SVV >13%, must be correlated with other parameters before administration of the fluid challenge.

Pregnancy and postpartum outcomes in a universally tested population for SARS-CoV-2 in New York City: a prospective cohort study

OBJECTIVE

To describe differences in outcomes between pregnant women with and without coronavirus dsease 2019 (COVID-19).

DESIGN

Prospective cohort study of pregnant women consecutively admitted for delivery, and universally tested via nasopharyngeal (NP) swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using reverse transcription-polymerase chain reaction. All infants of mothers with COVID-19 underwent SARS-CoV-2 testing.

SETTING

Three New York City hospitals.

POPULATION

Pregnant women >20 weeks of gestation admitted for delivery.

METHODS

Data were stratified by SARS-CoV-2 result and symptomatic status, and were summarised using parametric and nonparametric tests.

MAIN OUTCOME MEASURES

Prevalence and outcomes of maternal COVID-19, obstetric outcomes, neonatal SARS-CoV-2, placental pathology.

RESULTS

Of 675 women admitted for delivery, 10.4% were positive for SARS-CoV-2, of whom 78.6% were asymptomatic. We observed differences in sociodemographics and comorbidities among women with symptomatic COVID-10 versus asymptomatic COVID-19 versus no COVID-19. Caesarean delivery rates were 46.7% in symptomatic COVID-19, 45.5% in asymptomatic COVID-19 and 30.9% in women without COVID-19 (P = 0.044). Postpartum complications (fever, hypoxia, readmission) occurred in 12.9% of women with COVID-19 versus 4.5% of women without COVID-19 (P < 0.001). No woman required mechanical ventilation, and no maternal deaths occurred. Among 71 infants tested, none were positive for SARS-CoV-2. Placental pathology demonstrated increased frequency of fetal vascular malperfusion, indicative of thrombi in fetal vessels, in women with COVID-19 versus women without COVID-19 (48.3% versus 11.3%, P < 0.001).

CONCLUSION

Among pregnant women with COVID-19 at delivery, we observed increased caesarean delivery rates and increased frequency of maternal complications in the postpartum period. Additionally, intraplacental thrombi may have maternal and fetal implications for COVID-19 remote from delivery.

TWEETABLE ABSTRACT

COVID-19 at delivery: more caesarean deliveries, postpartum complications and intraplacental thrombi.

Segmenting the manufacturing industries and measuring the performance: using interval-valued triangular fuzzy TOPSIS method

In this globalized scenario, the overall performance of the manufacturing industries is the backbone of the development of the countries’ economies. In this research, the authors’ main objective of the study is to segment the manufacturing industries by using the triangular interval-valued fuzzy TOPSIS Method and find out the factors determining its performance. The researchers have collected the data from 350 manufacturing industries located in Puducherry, India. They applied a Simple Random sampling method by using a structured questionnaire from manufacturing industries. To analyze the data, the researchers used software packages like Excel, SPSS and LISREL 8.72. The researchers applied Confirmatory Factor Analysis, Triangular Interval-Valued Fuzzy TOPSIS Method, Chi square and Correspondent Analysis to conclude the result. Based on the factors loadings of the items, the contribution made by the items in respect of Performance may be ranked as Sales growth, Market share, Profit margin and Return on investment. With the help of Triangular Interval-Valued Fuzzy TOPSIS Method researchers segmented the manufacturing industries into three groups and by using the Chi square analysis the researchers found that the five demographics characteristics like Number of years in Business (Company), Scale of industry, Kind of manufacturing, Number of employees and location of the production plant of the respondents and these are significantly associated with segmenting the manufacturing industries and determine the performance of manufacturing industries.

A sensitive refining of in vitro and in vivo toxicological behavior of green synthesized ZnO nanoparticles from the shells of Jatropha curcas for multifunctional biomaterials development

ZnO nanoparticles (NPs) possess a wide range of biological functions in pharmaceutical and cosmetic applications due to their excellent antimicrobial, optical and UV protective properties. This study first reports the toxicological assessment of ZnO NPs green synthesized from Jatropha curcas shells for multifunctional biomedical applications. The hot water extract of J.curcas shells is utilized as a chelating agent for the reduction of zinc acetate and then, the prepared ZnO NPs are broadly characterized using X-ray spectroscopic and electron microscopic observations. The prepared ZnO NPs acquire high purity (100%) wurtzite crystal with hexagonal structure with the average particle size of 53 nm. In vitro and in vivo toxicity evaluation against human tumor cell lines and zebrafish embryos have ascertained the purpose of ZnO NPs in clinical research. Toxic effects of ZnO NPs were observed by a dose-dependent reduction of bacterial growth at ≥1   μg ml^-1, by teratogenicity and genotoxicity in zebrafish embryos (from 3 to 90 μg ml^-1) and by a significant nanoparticle uptake (0.5 ng μl^-1) by a fish serum. In contrast, ZnO NPs fail to reduce the proliferation of human bladder tumor cells (UC6) and cell viability of A549 cells in vitro up to 500 μg ml^-1. All these observations limit the unobstructed application of ZnO NPs at higher concentrations. Thus, abundantly used metal oxide nanoparticles like ZnO NPs examined in our present study in different animal models under in vitro and in vivo conditions will be the significant screening strategy to determine the nanotoxicity.

Comparative efficacy of chemical stabilizers on the thermostabilization of a novel live attenuated buffalopox vaccine

In the present investigation, the thermostability of a live attenuated buffalopox vaccine prepared with an indigenous baffalopox virus isolate (BPXV Vij/96) and freeze-dried under conventional lyophilizing conditions is described. Three different stabilizer combinations like LS (lactalbumin hydralysate + sucrose), LHT (lactalbumin hydralysate + Trehalose dihydrate) and TAA (Trehalose dihydrate + l- Alanine + l-Histidine) were used to prepare the vaccine. The study indicated that the LS stabilizer was found to be the stabilizer of choice followed by LHT and TAA for buffalopox vaccine at all temperatures studied. The presence of stabilizers has beneficial influence in preserving the keeping quality of the vaccine. Further, among the diluents used to reconstitute the freeze-dried buffalopox vaccine, double distilled water, 0.85% normal saline solution and phosphate buffer saline were the choice of diluents in that order. However, 1M MgSO₄ did not perform well at higher temperatures. Investigation suggests for using LS as a stabilizer for freeze-drying and any of the three diluents except 1MgSO₄ for reconstitution of buffalopox vaccine.

Mg-Doped Hydroxyapatite/Chitosan Composite Coated 316L Stainless Steel Implants for Biomedical Applications

In this investigation, ultrasonication process was used for the synthesis of magnesium doped nano-hydroxyapatite (MH) (0, 1, 2, and 3 mol% of Mg concentration) particles with controlled size and surface morphology. The size of the prepared MH particles was in the range of 20-100 nm with narrow distribution. Increase in the concentration of Mg reduced the particle size distribution from 60 to 40 nm. On incorporation of Mg in HAp lattice, an increase of 20-66 nm in specific surface area was observed in microporous HAp particles. XRF and XRD patterns reveal that the particles possess stoichiometric composition with reduced crystallinity with respect to the Mg concentration. Surface morphology of MH/chitosan (CTS) coated implant was found to be uniform without any defects. The corrosion rate of the implant decreased with increase in Mg concentration. The in vitro formation of bonelike apatite layer on the surface of the MH/CTS coated implant was observed from simulated body fluid studies. The antimicrobial activity of the MH/CTS composites against gram-positive and gram-negative bacterial strains indicated that increasing Mg concentration enhanced antimicrobial properties. Nanoindentation analysis of apatite coated implant surface reveals that the mechanical property depends on the concentration of magnesium in HAp. From the cytotoxicity analysis against NIH 3T3 fibroblast, it was observed that the Mg incorporated HAp/CTS composite was less toxic than the MHO/CTS composite. From this result, it was concluded that the MH/CTS nanocomposites coated implant is the excellent material for implants.

Epidemiology, Clinico-Haematological Profile and Management of Aplastic Anaemia: AIIMS Experience

BACKGROUND

The incidence of aplastic anaemia (AA) is higher in Asia than in the West. The precise incidence of AA in India is not known due to lack of epidemiological study. 20-40% of pancytopenic patients in referral centres are of aplastic anaemia.

PATIENTS AND METHODS

This was an analysis of 1501 patients diagnosed with aplastic anaemia over a period of seven and half years (January 2007- June 2014) attending the Aplastic clinic of department of haematology of All India Institute of Medical Sciences, New Delhi. The details regarding medical history, physical examination, complete blood count, bone marrow aspirate and biopsy, treatment received, were retrieved. Inherited bone marrow failure was screened in patients below 35 years. Treatment response was analysed for various treatment modalities.

RESULTS

1501 patients of AA from 20 different states of India were analysed. The bulk of patients were from Uttar Pradesh (28.7%), Bihar (23.6%), Delhi/NCR (20%) and Haryana (7%).The average number of new aplastic anaemia patients enrolled per year 214 (range: 101 -263). The median age at presentation was 25 years (range 2-83),with M;F - 2.3:1. Severity of AA revealed: severe (SAA): 75%, very severe (VSAA): 15%, non-severe (NSAA): 10%. Inherited bone marrow failure syndromes constituted 5% (75 patients) of all aplastic anaemia patients. The most common clinical presentations were pallor (97%), bleeding manifestations (69.6%) and fever (54%). The haematological parameters showed: median level of haemoglobin level: 5.9 gm/dL, WBC: 2700/mm3, ANC: 380/mm3, platelet: 1 0000/mm3. PNH clone was present in 13.5% of patients. 107 patients (7%) were lost to follow up or expired before any treatment was initiated. Only 69 patients (4.5%) received treatment with HLA-matched sibling stem cell transplantation and another 232 (15.5%) patients received ATG plus cyclosporine as immunosuppressive therapy. Seven hundred thirteenpatients (47.5%) received cyclosporine. The overall response to various treatment modalities was: HLA matched sibling haematopoietic stem cell transplant: 75.3%, Anti-thymocyte globulin plus cyclosporine: 58.7%, cyclosporine plus androgen: 45.6%, cyclosporine alone: 32.2%.

CONCLUSION

Management of AA is a real challenge in developing countries.This is one of the largest case series from a single centre from India. It is our endeavour to reduce the detrimental outcome by increasing awareness among patients and referring physicians to reduce the delay between diagnosis and treatment.

Synthesis, characterization, structural analysis of metal(II) complexes of N'-[(E)-3-Bromo-5-Chloro-2-hydroxybenzidene]-4-hydroxybenzohydrazide-Multisubstituted Schiff base as a F(-) and Cu(2+) ions selective chemosensor

New colorimetric chemosensor, N'-[(E)-3-Bromo-5-Chloro-2-hydroxybenzidene]-4-hydroxybenzohydrazide, containing OH and NH groups as binding sites have been synthesized and characterized by spectral UV, IR, NMR and ESR. The molecular structure of ligand is determined by X-ray crystallography and it has the monoclinic space group P21/c with cell parameters a=15.1058(6), b=14.3433(6), c=17.5800(8)Å and Z=8. The electronic spectral measurements show that Co(2+), Ni(2+) and Zn(2+) complexes have tetrahedral geometry, while Cu(2+) complex has square planar geometry. Magnetic measurements show that Cu(2+), Co(2+) and Ni(2+) complexes have paramagnetic behavior and Zn(2+) complex has diamagnetic behavior. Anion binding studies carried out using (1)H NMR and UV-visible spectrophotometric titrations revealed that these receptors exhibit selective recognition towards F(-) over other halide anions. The selectivity for F(-) among the halides is attributed mainly to the hydrogen-bond interaction of the receptor with F(-). Receptor (5 × 10(-5)M) shows color change from colorless to yellow in the presence of tetrabutylammonium fluoride (TBAF, 1.5 × 10(-3)M). Moreover, F(-)-induced color changes remain the same even in the presence of large excess of Cl(-), Br(-) and I(-). The binding constant is found to be higher towards F(-) ion and this may be due to presence of OH group, which offers extra binding site. Chromogenic receptor undergoes distinct color changes from colorless to green on gradual addition of Cu(2+) can be used as colorimetric probes for spectrophotometric and visual analysis of Cu(2+) in the presence of other transition metal ions such as Co(2+), Ni(2+) and Zn(2+).

In vivo cytotoxicity of MgO-doped nanobioactive glass particles and their anticorrosive coating on Ti–6Al–4V and SS304 implants for high load-bearing applications

Magnesium-doped NBG composites (SiO₂–CaO–P₂O₅–MgO) coated implant is found to be a potential nanocomposite for high load-bearing applications with better anticorrosive property and long-term stability.

Comparative efficacy of live replicating sheeppox vaccine strains in Ovines

In the present study, two sheeppox vaccines made from strains [sheeppox virus-Srinagar (SPPV-Srin) and Ranipet (SPPV-R)] indigenous to India and adapted to Vero cells were compared in terms of their safety, potency, efficacy and antigenic value with the commercial in-use Roumanian Fanar (SPPV-RF) vaccine, a foreign strain adapted in primary lamb testes cells. The safety test indicated that the SPPV (Sri and RF) vaccines were safe while SPPV-R was not completely attenuated and caused excessive adverse reactions at the passage level tested. The immunized animals showed DTH reaction and resisted virulent SPPV challenge, while control animals developed disease. Specific virus could be detected in the controls and animals immunized with lower dilutions of vaccines after challenge but not in any of the sheep immunized with 1 and 100 doses of each vaccine. All vaccines were found potent and the PD(50) was highest for SPPV (Srin and R) followed by RF. The immunized animals were seroconverted following vaccination with sustained antibody responses after challenge. In conclusion, indigenous SPPV-Srin vaccine was found to be as efficacious as SPPV-R and SPPV-RF vaccines. Thus, there is potential benefit in replacing the currently used commercial vaccine SPPV-RF with indigenous SPPV-Srin vaccine for use in India.

(E)-N'-(3-Bromo-5-chloro-2-hy-droxy-benzyl-idene)nicotinohydrazide

There are two independent mol-ecules in the asymmetric unit of the title compound, C(13)H(9)BrClN(3)O(2), in which the dihedral angles between the benzene and pyridine rings are 8.23 (9)° and 52.84 (12)°. Both the mol-ecules exist in an E configuration with respect to the C=N double bond. The two mol-ecules in the asymmetric unit are linked via weak C-H⋯O hydrogen bonds. In both the mol-ecules, an intra-molecular O-H⋯N hydrogen bond generate an S(6) graph-set motif. In the crystal, inter-molecular N-H⋯O and C-H⋯O hydrogen bonds generate bifurcated R(1) (2)(7) ring motifs. The crystal packing is further stabilized by weak inter-molecular N-H⋯O, N-H⋯N, C-H⋯O and π-π [centroid-centroid distance 3.615 (2) Å] inter-actions.

N'-[(1E)-4-Diethyl-amino-2-hy-droxy-benz-idene]benzohydrazide

In the title compound, C₁₈H₂₁N₃O₂, the dihedral angle between the phenyl and benzene rings is 36.85 (10)°. The methyl C atom of one of the ethyl groups is disordered over two positions with site occupancies of 0.810 (8) and 0.190 (8). The mol­ecular structure is stabilized by a classical intra­molecular O—H⋯N hydrogen bond. The crystal structure exhibits weak inter­molecular N—H⋯O, C—H⋯O and C—H⋯π inter­actions.

A randomized controlled study of whether the partner's presence in the operating room during neuraxial anesthesia for cesarean delivery reduces patient anxiety

BACKGROUND

This study compared anxiety in two groups of women undergoing elective cesarean delivery to ascertain if their partner's presence during neuraxial anesthesia placement affected patients' overall anxiety levels.

METHODS

Three hundred fifteen patient-partner dyads were randomized to two groups: group 1 partners were present in the operating room during neuraxial anesthesia placement while group 2 partners remained outside the operating room during placement. Before surgery, all patient-partner dyads completed a survey of demographics, anesthetic experiences and baseline anxiety. Anxiety levels were rated using a visual analogue scale (VAS) and the state portion of the Spielberger State-Trait Anxiety Inventory.

RESULTS

The mean change in anxiety as measured by VAS among patients whose partners were present in the operating room for neuraxial anesthetic placement decreased from before to after the procedure (-4.5+/-25.8; P=0.03; 95% CI -8.55, -0.45); the mean change in anxiety in patients whose partners were not present did not alter significantly (+1.9 +/- 25.3; P=0.34; 95% CI 6.68, 12.12). Anxiety was increased among partners who were not present (+9.4, P<0.001).

CONCLUSION

Although patients whose partners were present in the operating room at the time of neuraxial anesthesia placement reported less anxiety over the time of the study than did patients whose partners were not present, these differences were small and are not considered to be clinically important. Increased anxiety among partners who were not present at neuraxial placements warrants further study.

Why treat? Better prevent: adult immunization

Immunization is a safe, effective and simple way to prevent life threatening illnesses not only in children but also in adults. Vaccines are some of the safest medicines available which can relieve suffering costs related to these preventable diseases. The reason for underutilization of vaccines in adults are 1) Low prioritization of the importance of vaccines preventable diseases among adults 2) Uncertainty or lack of knowledge about the safety and efficacy 3) Lack of universal recommendations for all adults and 4) Financial constraints, especially in developing countries. Adult immunizations are administered in primary series like previously immunized, booster doses and periodic doses. Agents include Toxoids (Diphtheria and Tetanus), Live Virus Vaccines (Measles, Mumps and Rubella), and inactivated virus vaccines (Influenza), Inactive viral particles (Hepatitis B), inactivated bacterial polysaccharide vaccine (Pneumococcal) and Conjugate / Polysaccharide vaccine (Meningococcal). And also vaccines like Hepatitis A, Polio and Varicella may be recommended in some. Since the economy and literacy rate has shown a steady rise in the South Asia and people are being aware of different health problems through the recently advanced global communication, the education and awareness for immunization not only in children but also in adults need a special consideration. Keeping in view the statistical data of suffering costs related to the non-utilization of immunization in adults, the need of hour has come for utilization of immunization to emphasize its importance.

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.

A study on rational drug prescribing and dispensing in outpatients in a tertiary care teaching hospital of Western Nepal

OBJECTIVES

To analyze the prescriptions of out-patients for rational prescribing and dispensing and to evaluate the patient's knowledge regarding use of drugs, using INRUD indicators.

METHODS

A cross-sectional, descriptive study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal during the time period from June 10th to August 19th 2004.

RESULTS

Totally 247 prescriptions were randomly selected for analysis, wherein 720 drugs were prescribed. Only 15% of drugs were prescribed by generic name, 21.67% of the total drugs consisted of fixed-dose combinations, only 40% of drugs were from the Essential drug list of Nepal and 29.44% (n=212) were from the WHO Essential drug list. It was found that more than half (54.17%) of the drugs were from Nepalese National Formulary and 35.69% were from WHO model formulary. Dermatological products were most commonly prescribed followed by drugs acting on central nervous system, antimicrobials and drugs acting on cardiovascular system. Among the drugs dispensed, 79.16% were oral followed by topical (18.19%) and parenteral forms (2.98%). Diagnosis was mentioned only in 3.23% (n=8) of the prescriptions and the average cost per prescription was found to be 241.11 Nepalese rupees (US$ 3.26). It was found out that pharmacist labelled only 0.4% of the medication envelopes with the name of the patient. However, 82.6% of the medication envelopes were labelled with name of the drug and 87.0% with drug strength. Only 53.8% (n=133) of the patient knew both the duration of the therapy and administration time of drugs.

CONCLUSION

There is a need for educational intervention for prescribers and both managerial and educational intervention for the hospital pharmacists to improve prescribing and dispensing.

Probable cutaneous allergic response to subcutaneous heparin--a case report

Heparin is a heterogeneous mixture of sulfated mucopolysaccharides, commonly used injectable anticoagulant. It is known to cause cutaneous adverse reactions like eczema, erythematous plaques, exfoliative dermatitis and tissue necrosis. We report a case of probable cutaneous allergic response caused by injection of heparin with an established causality and severity. The reaction developed after stopping the drug therapy and after the patient had already been discharged. Since heparin is a widely used drug and this reaction can manifest even after the drug therapy has ceased, thorough counseling of the patient is mandatory.

Therapeutic dimensions of ACE inhibitors--a review of literature and clinical trials

In the 1970s, pharmacological therapy interrupting the renin-angiotensin system was considered beneficial for patients with high-renin hypertension. This gave rise to the development of ACE inhibitors. Surprisingly, the ACE inhibitors proved to be effective not only in patients with high renin hypertension, but also in many patients with normal levels of plasma renin activity. At present ACE inhibitors have a significant position in a wide range of chronic illnesses such as atherosclerosis, hypertension, myocardial infarction, diabetic complications, stroke etc. They are combined safely with drugs like angiotensin receptor blockers, calcium channel blockers and thiazides with varying degree of benefits. Though they are safe drugs, patients need monitoring for renal insufficiency, hypotension, hyperkalemia etc. The safety of these drugs in paediatrics patients is not established. It is better to avoid these drugs during pregnancy.

Blink duration as a measure of low-level anaesthetic sedation

BACKGROUND AND OBJECTIVE

Variability in blink duration was examined to see whether it was sensitive to sevoflurane sedation at 0.05 and 0.1 minimum alveolar concentration (MAC).

METHODS

Blinks were measured with an infrared transducer in eight subjects. Sedation was scored using a visual analogue scale (VAS).

RESULTS

At baseline, 0.05 and 0.1 MAC sevoflurane, respectively, the overall median value of blink duration and its interquartile range were 95 (80-110) ms, 198 (163-245) ms and 210 (130-980) ms. The median percentage of blinks exceeding 500 ms was 0% (0-0.7%), 33.3% (25.5-34.7%) and 25% (15.7-63.3%) respectively. Values during 0.05 and 0.1 MAC sevoflurane were significantly different from baseline (P < 0.035) but not from each other. Baseline visual analogue scales showed large intersubject variability. Compared with baseline, VAS scores were higher at 0.05 MAC (P < 0.035) but not at 0.1 MAC. After discontinuing sevoflurane, median blink duration returned to baseline with a recovery half-life of 2.6 min (R2 = 0.95). Conclusion Blink duration is a sensitive measure of sevoflurane sedation even at 0.05 MAC.

Efficient double-clad thulium-doped fiber laser with a ring cavity

We have constructed a novel ring cavity for a double-clad thulium-doped fiber laser, by placing the fiber's 45 degrees angle-polished output end before the input end and relaunching the pump and the laser power into the fiber. This design can reduce reabsorption by using short fibers without loss of pump efficiency. The dependence of the laser's performance on the fiber's length and the output coupler's reflectivity is investigated experimentally and theoretically. With an 80-cm-long fiber, 2.7-W single-mode continuous-wave output is generated for 11.5 W of launched pump power.

An unusual cause of rhabdomyolysis following surgery in the prone position

Rhabdomyolysis, as a complication of prone positioning of patients during surgery, is rare. Previous case reports have suggested that the common cause of rhabdomyolysis during the postoperative period is ischemic muscle injury resulting from the use of a tourniquet, occlusion of pelvic blood vessels, or prolonged severe hypotension. We present two cases of this occurrence resulting from compression of the thighs by gel pads of the Jackson frame used to position these patients.