Drug utilization review of general anaesthetic agents in a tertiary care hospital

Background: Drug utilization review plays a key role in helping the healthcare system to understand, interpret and improve the prescribing, administration and use of medications. The principle aim of drug utilization review was to facilitate rational use of drugs, which implies the prescription of a well documented drug in an optimal dose on the right indication.Methods: An observational study of anaesthetic practice was carried out in the department of Anaesthesiology in tertiary care hospital, Varanasi after approval from institutional ethical committee. The data of patients who underwent surgery under general anaesthesia were collected in predesigned patient profile form and were analyzed for drug utilization review.Results: 110 patients were enrolled with mean age 35.30±17.99 years and mean weight 51.32±15.32kg. Laparoscopic cholecystectomy (43.63%), otorhinolaryngology surgeries (36.36%), cardiothoracic vascular surgery (4.54%), neurosurgery (4.54%) and other surgeries (10.93%) required general anaesthetic agents were reviewed. Propofol (93.63%) and etomidate (6.36%) were used for induction of anaesthesia. Propofol (45.45%), isoflurane (53.63%), sevoflurane (0.90%) were administered for maintenance of anaesthesia in various surgeries. Adverse outcomes observed were hypotension (7.27%), bradycardia (6.36%), hypertension (3.63%) and post operative nausea and vomiting (PONV) (2.72%).Conclusions: Propofol is most commonly prescribed drug for induction of anaesthesia. Isoflurane is most commonly prescribed inhalational anaesthetic agent for maintenance of anaesthesia followed by Propofol. Hypotension is most common adverse outcome observed.

An Evaluation of Antibiotic Therapy in Pediatric Dentistry Outpatients.

Background: Antibiotics are commonly used on presumptive basis in treating oro-dental infections in children .These are sparse studies on patients of antibiotics usage including information on choice, processed, outcome assessment. Present study was precisely an assessment of antimicrobial therapy in Pedodontics outpatients of our university hospital focusing on clinical and laboratory application in management .The practical difference in antibiotics usage is described and rationally aspect is discussed. Methods: The study was carried out in pediatric dentistry outdoor patients, faculty of Dental Science, B.H.U, from March 2015 to May 2016 under routine care of Pediatric Dentistry Department. Pediatric age group (3 to 14 years) patients with oral and dental problem requiring use of antimicrobial drug were selected for study. Results: It is clear from above that all three regimen significantly decrease salivary bacterial counts. Oro dental pain/toothache decrease after treatment with cefixime. Conclusion: Antimicrobial chemotherapy of pediatricoro-dental infection is by subjective decision not by definitive microbiological diagnosis.

Clinical Profile of Patients with Scorpion Sting.

Introduction: Scorpion sting is a major public health problem in developing countries, especially in villagers. Manifestations include vomiting, profuse sweating, piloerection, diarrhoea, loss of appetite, loss of sphincter control and priapism. Stimulation of Alpha receptor results in hypertension, tachycardia, myocardial dysfunction, pulmonary edema and cool extremities. Aims: The study is undertaken to know the clinical profile of the patients with scorpion sting. Methods and Materials: prospective study was conducted from October 2011 to September 2013 at Mamata General Hospital, khammam in adult patients 18yrs and above with history of scorpion sting. Detailed physical examination and grading of envenomation was done. Results: Eighty two patients fulfilled the inclusion criteria for the time period studied. Fifty two patients (62.25%) were male and thirty (37.50%) were female. Mean age of patients with scorpion sting was 31.23±7.23 years. Pain (87.50%),Sweating (81.25%) tingling & numbness (77.50%) were the most common presenting symptoms Conclusion: The present study shows that scorpion bite is more common in males. Local pain and signs of sympathetic over activity were the commonest features.

Current state of pharmacology and therapeutics in irritable bowel syndrome with special reference to brain-gut axis.

Irritable bowel syndrome (IBS), principal morbidity being visceral hypersensitivity, consumes significant speciality gastroenterologic and general practitioner’s care. The complex etiology perhaps varying among the patients makes therapeutic address very challenging. Continuous researches on neurophysiological aberrations in IBS have continued. The drugs and the neurophysiological understanding with regard to addressing visceral hypersensitivity are relevant to be appraised. The translation of research wisdom into clinical practice may be facilitated by gastroenterology experts. The issues of effectiveness of the options in general and in particular patients may thus be addressed.

Comparative effectiveness study of vinpocetine vs. nimodipine on functional recovery in patients of head injury.

Background: Head injuries are increasing cause of overall disability which needs aggressive researches on neuroprotective agents to prevent or rectify the sequelae of brain damage. The outcomes on functional recovery following add on therapies either nimodipine or vinpocetine was done to compare merits of either therapies. Methods: 90 head injury cases admitted to S.S. hospital were divided into standard treatment group given neither vinpocetine nor nimodipine & other two groups given either nimodipine or vinpocetine dependent entirely on clinician’s discretion. The patients data on initial severity on GCS scale and functional recovery on Barthel Index, head injury watch scale, Disability rating score were collected at discharge & at one month follow up thereafter to compare the recovery profiles. Results: Vinpocetine treatment proved superior to nimodipine or standard treatment on examining the outcomes. Significance of time since injury was emphasized for improved outcome to nimodipine but not so necessary for vinpocetine. Conclusions: Nimodipine delayed administration had no consequence while vinpocetine is useful treatment at any stage to enhance functional recovery in cases of head injury.

Relapse of kala-azar after use of multiple drugs: A case report and brief review of literature.

We present a case of kala-azar infection that recurred in a patient after completion of the standard treatment course of miltefosine, amphotericin B-deoxycholate (short course), and amphotericin B lipid formulations. The patient was cured after continuous amphotericin B-deoxycholate administration for 4 weeks. This is a unique case of relapse following the use of three important drugs. Although amphotericin B-deoxycholate is a second line drug in Nepal, it has shown a satisfactory clinical response with continuous treatment for 4 weeks. Therefore, an extended course of amphotericin B-deoxycholate may be beneficial in patients with resistance to the standard short course and other anti-leishmania drugs.

The analgesic and anti-inflammatory activities of the hydroalcholic extract of "Shirishadi compound" in animal model.

The main objective of the present investigation is to evaluate the anti-inflammatory & analgesic activity of ethanolic extract of Shirishadi polyherbal compound on rats. Shirishadi compound consist of three herbal drugs namely- Shirisha (Albizzia lebbeck), Nagarmotha (Cyprus rotandus) & Kantakari (Solanum xanthocarpum).In Ayurveda (ancient Indian system of medicine) all these herbs alone or in combination with other herbs are commonly used in the managmant of bronchial asthma. In the carrageenan-induced rat paw edema test for acute inflammation, the extract of Shirishadi compound in doses of 50mg, 200 mg and 500 mg/kg body weight showed 77% and 79% and 81% inhibition of edema, respectively, at the end of 4h which is comparable to that of standard ( endomethacin) i.e. 92%. In the acetic acid induced writhing test the extract of Shirishadi compound ( 200 and 500 mg/kg body weight) showed a significant (p<0.001) reduction in the number of writhes with 65.6% and 70.9% of inhibition, respectively. In radiant heat tail-flick test the crude extract produced 58.1% (p<0.001) and 61.1% (p<0.001) elongation of tail flicking time 30 minutes after oral doses of 200 and 500 mg/kg body weight respectively . After 60 minutes the extract showed 56.3% (p<0.001) and 59% (p<0.001) elongation of tail flicking time. Experimental results showed that Shirishadi compound has persuasive anti-inflammmatory property along with significant analgesic activity.

Rotavirus Disease Burden and Molecular Epidemiology in Children with Acute Diarrhoea Age Less than 5 Years in Nepal.

Introduction: Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide. The aim of the study was to determine rotavirus disease burden and distribution of rotavirus genotypes in children less than five years of age. Methodology: Stool samples were collected from 1768 hospital admitted children under 5 years of age with acute watery diarrhea during November 2005 to October 2008. Rotavirus in stool samples was detected by Enzyme Immuno Assay (EIA) and positive specimens for rotavirus positive was genotyped by reverse transcription-polymerase chain reaction (RTPCR) and sequencing methods. Results: The prevalence of rotavirus was 36.59% (647/1768). Detection was higher in male (33.3%) than female (26.9%). The prevalence was higher during the month of January (2005-06) and February in other periods. During 2005-06, high prevalence of rotavirus was noted in children of age between 6-11 months while in 2006-07 and 2007-08 high prevalence was seen in age group 12-23 months. The most common genotyping of rotavirus identified 5 G types and 3 P types. Genotypes G12 and P [8] were most common during both periods studied (G12; 50%, 29% 33.7% in 2005-06, 2006-07 and 2007-08 respectively and P[8]; 47%, 35% and 43.5% in 2005-06, 2006-07 and 2007-08 respectively). Among six combined genotypes, G12P [6] was most prevalent (34%, 24% and 47.5% in 2005-06, 2006-07 and 2007-08 respectively) where as G1P [6] (4%) was seen in year 2007- 08 only. Conclusions: The study demonstrates the burden of rotavirus diarrhea in Nepal. The data on rotavirus genotypes will help inform decisions as to whether rotavirus vaccine should be considered for inclusion in to Nepal’s National Immunization Program.

Sub-trochanteric fractures of the femur: results of ORIF at KMCTH.

Sub-trochanteric fractures of the femur are not commonly encountered as compared to trochanteric or neck of femur fractures. Relatively younger persons are injured more and a considerable violence is required for this fracture to occur. These fractures, treated conservatively by methods like traction, splints or casts, are often associated with complications like non-union, mal-union, shortening of the limb etc. Thus, we undertook this study of 10 consecutive cases of sub-trochanteric fractures of the femur treated by open reduction and internal fixation and bone grafting in Kathmandu Medical College Teaching Hospital, Sinamangal, from the year Nov. 2000 to April 2006. There were 4 females and 6 male patients. Their age on average was 46.8 years (range 15 to 86 years). Most of the patients were in Type II or III in Seinsheimer classification; Type II A, B, and C, one, two and one respectively, and in Type III A and B three patients each. Seven patients were treated with dynamic hip screw. Three patients with type III were managed with centro-medullary interlocking nail with one cerclage suture. They were followed for a period of minimum 6 months to 6 years (average 3.5 years). Union was achieved in all, on an average 4 months postoperatively. Results were excellent and complications like nonunion, malunion or breakage of the implants, were not encountered in any patient.

Reduction of acute anterior shoulder dislocations: comparing intraarticular lignocaine with intravenous anesthesia.

Anterior shoulder dislocation is the most common dislocation in the body. Various methods of anesthesia are available for reduction. The objective of this study was to compare the application of intra-articular anesthesia with intravenous anesthesia for reduction of acute anterior shoulder dislocation. This study was conducted at Kathmandu Medical College Teaching Hospital (KMCTH) and Kathmandu Hospital and comprised of patients coming with anterior dislocation of shoulder from July 2001 to June 2005. Forty-five patients aged 17-55 years with no associated fractures of adjoining bones were included in the study. In twenty-three patients, reduction was done using intra-articular anesthesia and in 22 patients intravenous anesthesia was given. In five patients (three in intra-articular group and two in intravenous group) the reduction technique had to be changed to the Hippocratic method. In these three patients intravenous anesthesia had to be given after intra-articular anesthesia failed to relieve pain and spasm. In the intravenous group two patients had to be admitted overnight while in the intra-articular group none had to be admitted to the hospital. However, in the intra-articular group the average time taken from injection to reduction was significantly longer (<.001). The use of intra-articular lignocaine for reduction of shoulder dislocation is safe and effective especially when patients present early. In patients presenting late (more than 5 hours) intravenous anesthesia should be primarily considered as the method for shoulder reduction.

Supracondylar extension type III fracture of the humerus in children: percutaneous cross-pinning.

OBJECTIVE: Supracondylar extension type III fractures in children are difficult to treat especially in maintaining reduction after closed manipulation, thereby increasing chances of complications. MATERIALS AND METHODS: Forty consecutive patients with supracondylar extension type III fracture of the humerus attending Kathmandu Medical College Teaching Hospital (KMCTH) between July 2004 to December 2005, treated by closed manipulative reduction and percutaneous cross-pinning under general anaesthesia, were the subject of this prospective study. RESULTS: There were 16 females and 24 males. The mean age of the patients was 6.5 years (2 to 12 years). Left side was injured in 27 patients and right side in 13. Patients were followed for a period of one year on average (6 to 18 months). Under general anaesthesia and C-arm image intensifier, closed manipulative reduction was performed. Two K-wires of size 1.6 to 2.0 mm were introduced from lateral and medial side in crossed fashion. Ulnar nerve was protected by pushing it posteriorly during medial pinning. Long arm plaster slab was applied post-operatively. Patients were discharged the next day of operation. Callus was visible in all patients on X-rays after 3 weeks. The long arm slab and K-wires were removed and active mobilization of the elbow joint was started. Fracture union was seen in all, 6 weeks post-operatively. At follow-up, range of motion of the elbow joint was 25 to 135 degrees after 6 weeks and 0 to 140 degrees after 3 months, which was similar to that of normal side. After 3 months of operation carrying angle was 8-10 degrees in all except in two cases (0 degrees). There were no neuro-vascular complications or cubitus varus deformity in any of the patients. CONCLUSION: Percutaneous crossed K-wire pinning after closed manipulation in supracondylar extension type III fracture of the humerus is a reliable and safe method of treatment and is recommended in all.

Pre-operative assessment of K-nail length in fracture shaft of femur.

INTRODUCTION: Internal fixation of diaphyseal fracture of shaft of femur in an adult by Kuntscher nail is the most common operative method of treatment in Nepal where operative facilities for the same exist. Since the complete range of K-nail sizes and length are not available in most operation theatres in Nepal, most orthopaedic surgeons assess the size and length of the K-nail pre-operatively by various methods and keep one size above and below the assessed length for the planned surgery. MATERIALS AND METHODS: The following measurements were taken in five hundred people involved in the study: Measurement No. 1: Tip of the greater trochanter to lateral knee joint line minus 2 cm. Measurement No. 2: Tip of the olecranon process to the tip of little finger, and Measurement No. 3: Tip of the greater trochanter to the upper pole of patella. An average of all three lengths were analysed to see if there were any differences in their mean lengths. RESULTS: Analysis showed that there were significant differences between the mean lengths measured by the three different methods. The average length of measurement no: 2 was 3 cm longer than the average length of measurement no: 1, which is the reference pre-operative length of K.nail. CONCLUSION: However, in practice since measurement no:2 is more convenient to perform and can also be used when the patient has sustained bilateral fractures of femur, an accurate pre-operative K-nail length assessment can be done by subtracting 3 cm from measurement no:2, i.e. the tip of the olecranon process to the tip of the little finger.

Results of autogenous trephine biopsy needle bone grafting in fractures of radius and ulna.

Cortico-Cancellous bone graft harvested from the anterior iliac crest by the conventional open method is associated with more morbidity and is more time consuming as compared to the percutaneous method using trephine biopsy needle. The aim of the study was to determine whether cancellous bone graft harvested from anterior iliac crest using trephine biopsy needle consistently achieved bone union in comminuted fractures and fractures of more than 3 weeks duration of radius and ulna and also to determine the morbidity at the donor site. Autogenous cancellous bone graft was harvested percutaneously from 28 iliac crests in 16 patients and applied at fracture sites of 30 forearm bones using a 4mm trephine biopsy needle after the fractures had been fixed with plate and screws. The patients were followed up regularly upto 6 to 9 months post - operatively in the OPD to determine the union status of the fractured bones and the morbidity at the donor site. 29 of the 30 fractures of the forearm bones united without any problems. The shaft of a trephine got bent during the harvesting procedure at the beginning of the study due to improper technique. Cancellous bone graft harvested from the anterior iliac crest results in predictable good union results in comminuted fractures of forearm bones and also fractures presenting after 3 weeks of injury. It is also an easier and quicker way of harvesting bone graft and is associated with lesser morbidity and earlier recovery as compared to conventional open method.

Acute sacrococcygeal dislocation (anterior type): a case report.

Sacrococcygeal dislocation is a rare injury. A twenty nine year old male presented to us with pain over the lowest part of spine of 5 days duration. He fell down on stairs with his buttock landing directly over the edge of the stairs. On examination, a step was felt in the continuity of sacrum and coccyx. The tip of the coccyx was not palpable. Per rectal examination revealed a small bump on running the finger along the sacrococcygeal curvature. On plain radiographs of sacro coccygeal region, lateral view revealed anterior dislocation of the coccyx over the sacrum. On antero posterior view, the injury could not be identified. Under general anaesthesia, an attempt to reduce the dislocation per rectally was tried, but failed. The patient was treated conservatively with analgesics. He refused surgery, as he was relieved of pain with analgesics.

Molecular evolution, distribution and genetic relationship among the dengue 2 viruses isolated from different clinical severity.

Twenty-two strains of dengue 2 virus, isolated in China, Latin America, New Guinea and Thailand were subjected to phylogenetic analysis. The UPGMA analysis was carried out on each gene region of dengue virus and demonstrated that outcome from most of the gene regions showed similar results except those from NS4B and YUTR with very short nucleotide length. Among ten regions examined, the results from E gene documented the geographical differences of the virus strains most clearly and all the American strains (Mara 4, IQT1797 and S1) were distantly related to the Asian isolates. As for the 16 Thai strains isolated in 1993, they were clustered into three groups and a strain from a DSS patient formed a distinct branch compared to the other two groups. This finding from phylogenetic analysis is consistent with earlier conclusion and support the severity related subtyping of dengue 2 virus based on amino acid changes.

Identification of a flavivirus isolated from mosquitos in Chiang Mai Thailand.

A virus isolate, ThCAr105/92, from a pool of mosquitos, Culex tritaeniorhynchus, collected in Chiang Mai, Thailand in 1992, appeared to be a member of the genus Flavivirus of the family Flaviviridae, based on the reverse transcription polymerase chain reaction (RT-PCR) using flavivirus cross-reacting primer pairs, electron microscopic examination, and serological tests. However, RT-PCR using Japanese encephalitis (JE) virus-specific primers showed that the isolate was different from JE virus. Sucrose density gradient sedimentation of the virus replicated in C6/36 cells indicated that the virus is relatively unstable in the infected culture fluids at 37 degrees C. Antibody prepared against this virus and a virus seed for the isolate were tested by cross neutralization against a panel of flaviviruses and the results showed that the new isolate was a distinct subtype of Tembusu virus.

Mapping of additional restriction enzyme cleavage sites on bacteriophage MB78 enzyme.

A physical map of bacteriophage MB78 DNA indicating the cleavage sites for the enzyme Bg/II, ClaI, EcoRI, Pvull, Sa/! and SmaI comprising of a total of 34 cleavage sites have been constructed earlier. The cleavage sites for a few more restriction endonucleasesli ke ApaI, AvaI, Bg/!, Hindlll, KpnI and XhoI have now been mapped. A total of 72 cleavage sites on MB78 DNA are known by now. Relative positions of EcoRI I and J fragments which could not be decided earlier has now been determined.

Anti-inflammatory activity of seed extracts of Pongamia pinnata in rat.

Pongamia pinnata is a marsh growing Indian tree. Its seeds are used in febrile and inflammatory diseases in Indian system of medicine. Previous preliminary studies with ethanolic seed extract of this plant had exhibited an anti-inflammatory effect in rat. Different solvent fractionated extracts were evaluated in the present study for anti-inflammatory effect in chemically induced paw inflammation in rats. Anti-inflammatory effects of P. pinnata were best seen against bradykinin and PGE1-induced inflammation. In contrast minimal effects were seen against histamine and 5-HT-induced inflammation. The predominant action of extracts of Pongamia pinnata appears to be a modulation of eicosanoid-events in inflammation.

Malignant insulinoma presenting with recurrent episodic loss of consciousness.

A 57 year old male presented with episodic behavioural abnormalities and loss of consciousness for 2 years. His fasting blood glucose was 20 mg/dl and corresponding insulin level 119 uU/ml. His EEG showed intermittent rhythmic delta activity. Abdominal CT scan revealed an enhancing mass in the tail of the pancreas and secondaries in the liver. After distal pancreatectomy, resection of the left lobe of the liver and chemotherapy, the hypoglycaemic spells subsided. Histopathology revealed an islet cell tumour with metastases in the liver. Episodic neurobehavioural dysfunction should alert towards the possibility of hypoglycaemia.