Sarcoidosis--three clinical vignettes with a short review.

Sarcoidosis is a multi system disorder of unknown cause most commonly affecting the young and middle age adults and frequently presents bilateral hilar lymph-adenopathy. The diagnosis of sarcoidosis is often delayed following the onset of symptoms. The reason being first, the disease is often sub clinical; second as the disease affects any system, the diagnosis of sarcoidosis may not be considered; third, the symptoms are not disease specific hence often treated as other chronic pulmonary diseases; finally economic issues or barriers to access for further workup may affect the timeliness of the diagnosis. No laboratory diagnosis is specific for diagnosing sarcoidosis but histological confirmation from the lymph nodes accessible for biopsy either direct or by intervention may be more specific.

Parkisonism with Shy-Drager syndrome--a case report.

A previously healthy 60 years old female patient presented with bradykinesia, postural instability and increased rigidity of both upper and lower limbs for 2 years and was diagnosed as Parkinsonism for last years. Later on she developed features of autonomic dysfunction including postural hypotension, hyperhydrosis and urinary incontinence so was diagnosed as Shy-Drager Syndrome. She was treated with fludrocortisone and nefidipine for the management of postural hypotension. Patient developed aspiration pneumonia during oral feeding, despite of ICU management for the same cause patient died of respiratory arrest.

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.

When left ventricular failure complicates chronic obstructive pulmonary disease: hypoxia plays the major role.

INTRODUCTION: As the chronic obstructive pulmonary disease (COPD) progress, is usually accompanied by involvement of the both left ventricle (LV) and right ventricle (RV), and their systolic and diastolic function. Signs and symptoms of LV failure can be difficult to distinguish from those of COPD. OBJECTIVE: The study was carried out to determine the prevalence of LV systolic dysfunction in the COPD patients and to assess the possible risk factor behind such development. MATERIAL AND METHODS: It is a prospective study of 60 cases of COPD patients with or without cor-pulmonale attending Manipal Teaching Hospital. RESULTS: The prevalence of LV systolic dysfunction was found to be 26.7%, and the findings directly correlate with the severity of COPD i.e., the more the severity of the lung disease more the probability for the incidence of LV systolic dysfunction. These data are in support of the hypothesis that hypoxia and the excess accumulation of toxic metabolic products like lactic acid, significant right-to-left shunting through the bronchial circulation explains the diminished LV ejection fraction in severe COPD patients. CONCLUSION: Routine echocardiography investigation of the severe COPD patients is required for assessing the status of LV function and to rule out the possible association of LV systolic dysfunction.

Understanding the essentials of drug interactions: a potential need for safe and effective use of drugs.

Drug interactions (DIs) represent an important and widely under recognized source of medication errors. An interaction is said to occur when the effects of one drug are changed by the presence of another drug(s), food, drink or an environmental chemical. When a therapeutic combination could lead to an unexpected change in the condition of the patient, this would be described as an interaction of potential clinical significance. DIs can arise in numerous ways; such as pharmacodynamic interaction, in which receptor effects of different agents interacts to produce synergy or antagonism of drug effects. In pharmacokinetic interaction, the blood levels of given agents may be raised or lowered based on the type of interaction. Special attention and thorough monitoring is needed for the patients who are predisposed to develop DIs and those on drugs with narrow therapeutic index. DIs can be a very important contributory factor for the occurrence of adverse drug reactions and adverse drug events. DIs monitoring programs should be initiated and strengthened in order to minimize their occurrence. Herbal drug interactions and DIs comprising over the counter medicines should also be considered seriously.

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.

Interaction between warfarin and tamoxifen: a case report.

Warfarin is a commonly used anticoagulant with documented reports of drug interactions. Tamoxifen is used in the adjuvant hormonal treatment of women with oestrogen-receptor- positive breast cancer. Warfarin and tamoxifen are known to interact with each other with a resultant increase in the bleeding tendency. These reports are mainly from the white population. We report a case of drug interaction between warfarin and tamoxifen with an acute onset. This report suggests that when these drugs are co administered, careful monitoring of the coagulation profile is needed.

Effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health.

INTRODUCTION: Development of knowledge and attitude takes place during the adolescent period, which can have lifelong effects on the individual, family and society. Proper education in this age group is important for prevention of untoward social and health related problems. OBJECTIVE: To find out the effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health. MATERIALS AND METHODS: An experimental study with pretest - posttest control group design was carried out in four selected schools with similar settings in Dharan town of Nepal. All the subjects were divided into two groups: experimental and control, each comprising of two subgroups of 50 boys and 50 girls. Structured teaching program consisting of information on human reproductive system was used as a tool of investigation for the experimental group, whereas conventional teaching method was used for the control group. RESULTS: A total of 200 Adolescent school students were included in this study. The mean (+/-SD) pretest score of the experimental group on knowledge of reproductive health was 39.83 (+/- 16.89) and of the control group was 39.47(+/- 0.08). The same of experimental group after administration of the structured teaching program (84.60+/-10.60) and of the control group with conventional teaching method (43.93+/-10.08) was statistically significant (p<0.001). Similarly, the post-test scores of knowledge of the groups on responsible sexual behaviour and their attitude towards reproductive health were better in the experimental group than in the control group (p<0.001). CONCLUSION: The knowledge of adolescent school students on reproductive health is inadequate. The use of structured teaching program is effective in improving knowledge and attitude of the adolescents on reproductive health.