Medicine counseling services at Tertiary care Hospital in Nepal

Background and Objectives: Patient needs specific guidelines from their pharmacist in support of better compliance of their medicine used. Counseling of the patient and patient representative is important for improving the therapeutic out comes. Counseling patients can improve their understanding regarding medication, disease and life style modifications which in turn improves compliance. Material and Methods: Patients and/or patient party were counseled as per the Omnibus Budget Reconciliation Act-1990 guidelines. The data was collected as per OBRA-90 during the period of eighteen month and was analyzed using statistical software SPSS version 17. Results: Three hundred and fifty patients were counseled during the study period. Majority of the counseled patients were females [75.9%]. Mean counseling time taken by the pharmacist was 7.43 minute. Minimum time taken to counsel the patient was 6-10 minutes in 58.41% of the counseled, followed by less than 5 minutes in 19.68% and 11-15 minutes in 8.89%. About 10.47% were counseled for more than 15 minutes by the pharmacist. Greater numbers of the patients referred to the Medicine Counseling Center (MCC) were from Obstetrics and Gynecology departments and most of them were directed by doctors [50.47%]. Conclusion: This study highlights that role of doctor is important to encourage patient to attend counseling services. Counseling is the integral part that not only help patient to understand the use of their medicine but also to improve their therapeutic out comes. The effect of counseling on compliance should be studied in future.

Study of Mumps in Children attending a Tertiary Care Centre.

Introduction: Mumps is a self-limiting viral infection of the salivary glands with systemic manifestations and complications. It primarily affects young children, with increased incidence in winter and spring. Mumps infection is endemic in developing countries because of poor vaccination coverage. This study is intended to highlight the increased number of mumps cases in children attending tertiary care center in Nepal and thus to emphasize the importance of mumps vaccination, so as to decrease the disease occurrence and disease burden by vaccinating all children. Materials and Methods: This was a prospective study done in Civil Service Hospital of Nepal over a period of 2 years from November 2009 to October 2011. All children less than 14years of age with symptoms of fever and parotid swelling were included in the study group. A detailed history pertaining to the disease was taken, that included; history of exposure and prior vaccination against mumps. Children were asked to follow up either after 5 days or in case of noticing any signs and symptoms of complication. Results: There were total 113 cases diagnosed clinically as mumps of which there were 71 males (62.83%) and 42 females (37.16%) with the peak incidence of disease in the month of March and September with 22 cases (19.46%) in each month. The increase incidence was seen in 4-6 years of age with 58 cases (51.32%). There were 70 patients (61.94%) that had history of exposure to mumps infection. All the patients in this study had either unilateral or bilateral parotitis. None of the children were vaccinated against mumps. And all the school going children had to be off school for a period of 3-5 days. Conclusion: There were large number of children with mumps and none of them were vaccinated. Child can be prevented from the infection by vaccination and thus avoiding possible sufferings and complications. Thus we recommend the use of mumps vaccination in Routine immunization programme.

Therapeutic drug monitoring of antiepileptic drugs.

Commonly used conventional antiepileptic drugs for pharmacotherapy in epilepsy are phenytoin, carbamazepine and valproic acid. These drugs have complex pharmacokinetic properties leading to fluctuation in their plasma level at given same therapeutic dose. The present study was done to monitor their plasma levels. A prospective observational study was conducted at National Public Health Laboratory. After taking detail history, blood samples were taken from epileptic patients of all age groups and both gender who were on usual therapeutic dose of one or two combined antiepileptic drugs. Plasma level of these drugs were analyzed by using Fluorescence Polarization Immuno Assay (FPIA) technique. Out of total 417 testing, 81 were tested for phenytoin , 241 for carbamazepine and 95 for valproic acid. Their levels were further analyzed to find therapeutic, subtherapeutic and toxic levels. Out of total 81 blood samples tested for phenytoin, 38.8% had plasma drug at therapeutic level, 38.8% at subtherapeutic level and 28.4% had toxic level. Carbamazepine was tested in 241 samples and 79.3% cases had at therapeutic drug level, 15.8% had subtherapeutic drug level and 4.9% had toxic level. Out of 95 samples tested for valproic acid, 62% had therapeutic level and 20% had subtherapeutic and 18% had toxic level of drug. Therapeutic drug monitoring of phenytoin showed wide fluctuation in its plasma level. Its toxic and subtherapeutic levels were quite high. It is suggested that the dose of phenytoin should be adjusted after regular plasma level monitoring only. Monitoring of carbamazepine and valproic acid were also helpful when their toxicity and efficacy are doubtful.

Leiomyoma of breast: a report of rare case.

Leiomyoma is a benign smooth muscle neoplasm. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus. Leiomyoma of breast is a rare benign non epithelial tumor. Most leiomyomas in the breast are found in the subareolar region. There are few cases being reported in the literature. Here we report a case of 52 years old lady who presented to us with a painless right sided breast lump. There was no history of nipple discharge, trauma or use of oral contraceptive pills. Excisional biopsy revealed a growth pattern of interlacing fascicles of smooth-muscle cells consistent with leiomyoma of breast.

Causative agents of urinary tract infections in children and their antibiotic sensitivity pattern: a hospital based study.

A retrospective study was conducted to find out the causative agents of urinary tract infection (UTI) in children and their antibiotic sensitivity pattern among Nepalese children. This was done at Kanti Children's Hospital in Kathmandu (Nepal) by analyzing the records of urine samples collected for culture and sensitivity tests over a period of six months (April to November, 2007). Of the total 1878 mid-stream urine samples collected from suspected cases of UTI, 538 (28.6%) were positive for pathogenic organisms. There was no significant difference in growth positive rate in two genders (M: 51.7% and F: 48.3%). Of the various pathogenic organisms isolated, Escherichia coli constituted for 93.3% followed by Proteus sp, Klebsiella sp, Citrobacter sp, Staphylococcus aureus and others. E. coli was found to be most sensitive to amikacin, chloramphenicol, nitrofurantoin and ofloxacin and least sensitive to most commonly used drugs like cephalexin, nalidixic acid, cotrimoxazole and norfloxacin.

Cytological diagnosis of bancroftian filariasis in lesions clinically anticipated as neoplastic.

Filariasis is a common disabling parasitic disease in this region and cytological diagnosis is often not required. Cytology has important role in diagnosis of sub-clinical filariasis. Most cases of cytologically diagnosed filariasis are clinically unanticipated. Microfilaria, ova and fragments of adult worm of Wuchereria bancrofti, in exfoliative as well as aspiration cytology have been reported and are useful in cytological detection of bancroftian filariasis. Microfilaria is frequently detected in association with neoplasm, although the role in tumorogenesis is controversial. The objective of the study was to investigate importance of cytology in diagnosis of filariasis in lesions clinically anticipated to be of neoplastic and to review the cytomorphology of bancroftian filaria and its association with neoplasm. This is a retrospective study carried out in cytology department of Tribhuvan University Teaching Hospital. 14 cases of cytological specimen out of 4291 (0.3%) showed microfilaria; 12 cases were from FNAC from different sites and 2 cases were from pleural fluid. 2 cases showed ova in addition to microfilaria and one of them in addition showed fragment of adult worm. Microfilaria in 4 cases of FNAC and one case ofpleural fluid were associated with malignant cells.

Supernumerary head of Biceps brachii: a rare occurrence in the Nepalese population.

Unilateral three headed biceps brachii muscle was observed in the dissected cadaver of a 45-year-old Nepalese cadaver. The supernumerary head is taking origin from the tendon of deltoid and crossing in front of the long head of biceps and joining with short head of biceps brachii. The incidence of this variation is very rare and there was no available literature in Nepalese population. Presence of such variation should be kept in mind by surgeons and traumatologists.

Chronic kidney disease 5 on hemodialysis in Nepal Medical College Teaching Hospital.

Chronic Kidney Disease (CKD) 5 is defined when glomerular filtration rate (GFR) is <15.0 ml/min/1.73m2. Though nephrology service was started in Nepal as early as in 1970, we do not have data regarding CKD 5 patients till date. So this study is being undertaken to know the epidemiological profile and etiology of CKD 5 patients attending hemodialysis (HD) unit of Nepal Medical College Teaching Hospital. This is a prospective study which was carried out in HD unit over a period of one year. CKD 5 patients having GFR of <15 ml/min/1.73m2 under HD were included in the study. Among 100 patients included in the study 57 were male and mean age of the study population was 46.9+/-17.9 years. Most common cause of CKD 5 in the study was hypertension (54.0%); other causes included diabetic nephropathy (18.0%), idiopathic (13.0%) and glomerulonephritis (6.0%). Fifty percent of patients were from outside Kathmandu Valley. Around 20.0% of the study population is on regular follow up while 45.0% were lost to follow up. Twenty percent of the patient underwent transplantation and 15.0% of the study population died. Majority of patients were anemic (85.0%). Correction of anemia was done with blood transfusion in 88.0% and only 12.0% received erythropoietin. Hypertension was the leading cause of CKD 5; majority of patients (45.0%) discontinued hemodialysis most probably due to economical constrain; blood transfusion was the main modality of treatment of anemia.

Prevalence of refractive error in mentally retarded students of Kathmandu Valley.

Mental retardation also known as 'mentally handicap' means a delay or insufficient development of mental capacities. The prevalence of mental retardation in Nepal is 4.1%. Vision being the best sense for their education and daily activities, a cross-sectional and descriptive study was conducted to find out the refractive error among the students in the schools for mentally retarded people. A total of 134 clinically diagnosed cases of mentally retarded students from three different schools of Kathmandu Valley were examined. Distance visual acuity was taken with the help of Cat Ford Vision Drum, SG chart and Kay Picture Test method but first preference was given to SG chart. Cyclo-retinoscopy and fundus examination under mydriasis were done in all the cases. Examination revealed that more than half of the examined had one or more ocular disorders with refractive error being the most common type of ocular morbidity followed by ocular motility disorders. Refractive errors were found in 34.4% in which the most common type of refractive error was simple hypermetropia. In conclusion refractive error was seen commonly among mentally retarded people of Kathmandu Valley.

Histopathologic diagnosis of lymph node biopsies.

This is a retrospective study of biopsies of lymph nodes received in the department of pathology, Nepal Medical College (NMC), from January 2004 to December 2005. Total number of lymph node biopsies during the two year period was 55, out of which 56.0% cases were females and 44.0% were males with M:F 1:1.29. Most common cause of lymphadenopathy was tuberculosis and most common group of lymph node was cervical lymph nodes. Metastatic deposits were seen in only six cases. So, like other developing countries, in our country also, tuberculosis is the leading cause for lymphadenopathy.

Comparative study of epidural administration of 10 ml of 0.1% bupivacaine with 2 mg butorphanol and 10 ml of 0.25% plain bupivacaine for analgesia during labor.

Analgesia during labor provided by two epidural drug regimens was compared in a double blind, randomized, prospective study. Group A (n = 12) received 10 ml bolus doses of 0.1% bupivacaine with butorphanol 2 mg while Group B (n = 8) received 10 ml of 0.25% plain bupivacaine. The objectives of this study was to compare, between the quality of an epidural labor analgesia using initial loading dose of 0.1% bupivacaine and 2 mg butorphanol with a initial loading dose of 0.25% bupivacaine. In Group A, incidence of motor block was 8.3% and that of prolong 2nd stage of labor was 16.7%, both were decreased in comparison with Group B, although they were not statistically significant. Hemodynamic variables were stable and no adverse neonatal and maternal outcome was observed in both groups. Addition of butorphanol to bupivacaine may be safe alternative to reduce motor block and decrease prolong 2nd stage for epidural labor analgesia.

Can homemade alcohol (Raksi) be useful for preserving dead bodies? An experiment on wistar albino rats.

INTRODUCTION: Embalming is the through disinfection and art of preserving bodies after death using chemical substances. It keeps a body life like in appearance during the time it lies in a state prior to funeral. OBJECTIVE: This study was undertaken to investigate the effectiveness of Raksi in sacrificed rats in arresting postmortem changes and establishing scientific fact whether Raksi can be an alternative to standard embalming constituent if it is not available. MATERIAL AND METHODS: 50 albino rats were systematically randomized into control and experiment groups. Raksi and distilled water were injected for embalming purpose intraventricularly in experiment and control groups of rats respectively and kept for 48 to 96 hours for observation for postmortem changes. RESULT: Observations made at 48 and 72 hours of embalming revealed that Raksi can arrest postmortem changes in the rats up to 72 hours (3rd day) successfully in the experimental group whereas moderate to severe postmortem changes were seen in the control group. The experimental group showed mild degree of putrefactive changes, liberation of gases and liquefaction of tissues only at 96 hours (4th day) of embalming. DISCUSSION: The Raksi used in this experiment contained 34% of alcohol, which was determined by an alcohol hydrometer. Experiment clearly demonstrated from its result that raksi can be utilised temporarily for embalming since it contains alcohol and has preservative, bactericidal and disinfectant properties. CONCLUSION: It is concluded from the study that this knowledge if applied to dead human subjects, may preserve dead bodies temporarily allowing delayed funeral.

Hepatitis E virus infection in chronic liver disease causes rapid decompensation.

Hepatitis E previously known as enterically transmitted non-A, non-B hepatitis, is a self limiting infectious viral disease of developing countries. Various issues regarding the pathogenesis of liver injury and its natural history remain unanswered after two decades of its discovery. A small proportion of patients develop fulminant hepatic failure. Mortality is very high if it is associated with pregnancy, especially during third trimester. After establishment of hepatitis A virus as a cause of decompensation of chronic liver disease, now there are reports that hepatitis E viruses also does the same. Acute hepatitis E in these patients has a protracted course with high morbidity and mortality. Many patients develop hepatorenal syndrome, hepatic encephalopathy and even liver failure after co-infection with hepatitis E virus. Now time has come to institute hepatitis E virus superinfection as one of the cause of acute on chronic liver failure. Hepatitis E is a problem of developing countries and Nepal is in the endemic zone. Sudden decompensation in chronic liver disease patient, who were otherwise stable and under regular follow up, should be carefully dealt with. Patient statistics at our unit shows that 7 cases of chronic liver diseases with superinfection with hepatitis E virus were dealt from April 2004 to August 2005. Two patients (29%) died and 5 recovered. In patients with recovery, there was deterioration of Child-Pugh grading and the duration of hospital stay was longer. Thus, hepatitis E in diagnosed chronic liver disease case should be taken apprehensively. Similarly patients of chronic liver disease traveling to endemic zone should take precaution. If vaccine against hepatitis E virus is developed, chronic liver disease patient would be the eligible candidate for vaccination beside pregnant ladies.

Association of systemic diseases with retinal vein occlusive disease.

Retinal vein occlusion (RVO) is the second commonest vascular disease of the eye, second only to Diabetic Retinopathy. The association of the retinal vein occlusion with other systemic disease likes hypertension, diabetes mellitus and others has been well documented. With the increase in persons being affected from these disorders, patients with retinal vein obstruction are also increasing. Hence, a study was designed to evaluate all cases of RVO to find out its association with systemic disorders. A total of 100 patients (106 eyes) were enrolled in the study. Out of which, 66 cases reported to have Brach Retinal Vein Occlusion (BRVO) and rest 34 cases with Central Retinal Vein Occlusion (CRVO). Among the associated systemic diseases, hypertension and diabetes mellitus accounted for 84% cases. Isolated hypertension (54%) was most commonly seen followed by diabetes mellitus (8%). The prevalence of BRVO was almost twice as compared to CRVO. The high association of various systemic disorder especially Hypertension and diabetes further supports the need of early and periodic eye examination for those suffering from these disorders.

Removal of central venous catheter fragment embolus in a young male.

A 22 years male admitted with severe pancreatitis with central venous catheter implanted for central venous pressure monitoring and for providing total parental nutrition developed catheter fragment embolus due to accidental fracture of the same while manipulating it. Non surgical retrieval of the same was done by radiological intervention without any complication.

Epilepsy in children: an epidemiological study at Kathmandu Medical College Teaching Hospital Kathmandu.

OBJECTIVES: To analyze the relative frequencies of various epileptic seizures and to study the age at onset of different seizure types in Nepalese children. DESIGN: Prospective study. SETTING: Hospital outpatient based in Kathmandu, Nepal, between November 2001 to October 2002. PARTICIPANTS: 50 children diagnosed as epilepsy excluding neonatal and febrile seizures. Main outcome measure: Diagnosis and classification of cases according to the International Classification of Epilepsy of the International League Against Epilepsy [ILAE] and number of patients in each category with various ages at first seizure. RESULT: Generalized seizures (78%) were 3.54 times commoner than partial seizures (22%). Most frequent seizure types were generalized tonic clonic (36%), tonic (16%), complex partial (14%), atonic (12%) and absence (10%). Generalized clonic, simple partial and partial with secondary generalization, each had less than 5% frequencies. In 40% cases the first seizure occurred when aged between 2-5 years. In partial seizures the peak age at onset was observed below 6 years while primary generalized seizure was more frequently seen in age group 2-10 years. CONCLUSION: More paediatric patients with primary generalized seizures (78%) were observed than with partial seizures (22%). In this age group, the most frequent seizure type was generalized tonic clonic (36%) with the peak frequency of age at onset of seizures in 2-5 years.

Association between weight for age and mid-upper arm circumference measurement: findings from Malawi

Anthropometric methods involving measurement of weight-for-height; height-for-age; weight-for-age; and mid-upper arm circumference have been extensively researched to identify an appropriate method of monitoring infant and child growth. Many countries have adopted weight for age as the main practical method. The Malawi Ministry of Health introduced weight for age based upon WHO recommended standards as a growth indicator in 1973. There are; however; difficulties in making the practice widely used at community level. In the present study; confined to the four urban areas of Malawi; a comparison was made between the weight-for-age (W/A) and mid-upper arm circumference (MUAC) measurements. A very good correlation was observed between the two methods of screening for identification of undernourished children from 4 months of age onwards. Correct use of MUAC was found to be as effective as W/A in detecting undernutrition. Author.90.Z1-542-363-300901107