Rationale use of proton pump inhibitors: observational study of hospital based prescriptions and role of clinical pharmacist

The rationale of acid suppressant therapy with PPIs was assessed to measure the treatments conformity in PGHI under clinical guidelines. The irrational use of PPIs was found to induce side effects in patients and increased budgetary constraint. In a 4 phase study, 2 groups of patients [784 and 2804] were selected; Pre intervention retrospective review of the prescriptions was done in phase I. Insightful awareness in clinicians and patients was created in phase II a and II b respectively. The ongoing prescriptions were intervened in phase III. The post-intervention retrospective audit of prescription was completed in phase IV. The data was recorded for chronic disease patients in the hospital, revealed a marked reduction [85%] in the frequency of PPI's prescriptions [784 to 117], Cost of PPI's /year reduced to 19.3% , from US dollar: 24522/- to US dollar: 4718/-. The side effects reported in patients' feedback was also reduced such as hypocalcaemia [59%], hypomagnesaemia [52%], anemia [28%], reflux dyspepsia [82%], C. difficile associated diarrhea [15%], pneumonia [5%], and nephritis in patients with CKD [11%]. The intervention induced awareness in Clincians [85%], in patients [38%], reduction in PPIs prescription [45%], whereas cost of PPI's prescription in group 2 was reduced from US dollar 36481/- to USdollar:10325/- i.e. [28%]

Formulation of lyophilized single vial kit of N-N-Ethylene-L-Dicysteine 99m [EC] for labeling with Tc. II: Radiochemical and clinical evaluation 99mr as a renal tubular agent in comparison with Tc-MAG[3]

A Technetium[99m]Tc labeled lyophilized single component kit of N-N-ethylene-I-dicysteine [EC] is developed to replace multiple step kit developed by others. The aim of study is to formulate a radionuclide that is easy to prepare, has rapid plasma clearance, produce high quality images and is an affective alternative to radioiodine labeled orthoiodohippurate, which has been remained the physiological 'gold standard' since long time. To achieve this goal, the systematically varied key parameters such as pH, the use of reducing agents, stabilizers and additives are optimized to obtain maximum radiochemical purity and optimum bio distribution in non human and human primates. Various pH levels of EC showed equally good results in animal experiments but only pH 10 was suitable for human use. Dynamic and renal Scintigraphic studies are carried out with[99m]Tc-EC at pH 8 in 12 volunteers and at pH 10 in 18 volunteers and compared with[99m]Tc-MAG[3], Background ratios, renograms, relative renal function and semi quantitative parameters are available in all studies. The background ratios [mean +/- SD] at 30[th] minute are 0229+/-0.024 and 0.236+/-0.018 for[99m]Tc-EC at pH 10 and[99m]c-MAG[3] respectively. The mean +/- standard error of mean [SEM] values of T[M]X and time to half activity [T[12]] for[99m]Tc-EC [pHIO] are 3.7+/-0.6 and 7.3+/-1.0 respectively while for [99m]Tc-MAG[3], they are 4.0+/-0.8 and 7.9+/-1.4 with p values 0.001 and 0.049 respectively. The values of relative renal function [RRF] for[99m]Tc-EC and[99m]Tc-MAG[3] are 50.8+/-3.11 and 51.2+/-3.4 respectively with p value of 0.822. The residual activity at 25[th] minute [A[25] / A[MAX]] and renal uptake are 0. 209+/-12.67+/-2.80 for[99m]Tc-EC and 0.218+/-0.035 and 1053+/-2.98 for[99m]Tc-MAG[3] [p=0.031 an 0.0003] respectively. The correlation coefficient [R] for T[max], T1/2, A[2]5/A[Max] and renal uptake are 0.96, 0.69, 0.93 and 0.85 respectively

Immediate postpartum IUCD [PPIUCD] insertion: an opportunity not to be missed

The present study was planned to evaluate the safety and efficacy of immediate postpartum IUCD insertion in women delivering vaginally or by caesarean section. This prospective study was carried out at Sobhraj Maternity Hospital from 1[st] July 2012 to 30[th] June 2013. Women delivering in the hospital fulfilling inclusion criteria were included in the study. Women with prelabour rupture of membranes for >18 hours, chorioamnionitis, temperature >380 [degree]C during or after labour, continued excessive postpartum bleeding were excluded from the study. The women included in the study underwent immediate postpartum insertion of Copper T 380A after delivery of placenta in vaginal or caesarean delivery. These women were followed up at 6 weeks and 6 months after delivery. A total of 1238 women were included in the study who underwent immediate postpartum IUCD insertion. 56% of insertions were performed after vaginal delivery and 44% insertions were done at caesarean sections. The follow up rate at 6 weeks was 51% and 14% at 6 months. There were no serious complications associated with immediate postpartum IUCD insertion. The expulsion rate at 6 weeks and 6 months were 5% and 6%. The removal rate was 5% at 6 weeks and 10% at 6 months. The continuation rates were 90% at 6 weeks and 84% at 6 months respectively. This study indicates that immediate PPIUCD insertion is safe and effective. However, the expulsion rate for immediate postpartum IUCD insertions are higher than for interval insertions, but the benefits of providing highly effective contraception immediately after delivery outweigh this disadvantage, particularly in country like ours where women have limited access to healthcare

Fetal transverse cerebellar diameter measurement; a useful predictor of gestational age in growth restricted fetuses

To determine the accuracy of fetal transverse cerebellar diameter measurement in the prediction of gestational age in growth restricted fetuses. This controlled was conducted at Sobhraj Maternity Hospital, Karachi from July 2012 to June 2013. A total of 100 pregnant women in the third trimester of pregnancy satisfying the eligibility criteria were included. Among these 50 were fetuses with normal fetal growth and 50 growth restricted fetuses. The mean transverse cerebellar diameter in the fetuses showing normal growth was not statistically different from the mean transverse cerebellar diameter in the growth restricted fetuses [p-value = 0.219]. Transverse cerebellar diameter measurement can be used reliably for accurate estimation of gestational age in growth restricted fetuses

Successful management of postpartum hemorrhage using B-lynch suture

Background: Postpartum haemorrhage [PPH] is a life threatening obstetric emergency. In Pakistan 25% of maternal deaths are due to PPH and majority is due to uterine atony. B-Lynch suture is a simple and effective method for control of PPH due to uterine atony as an alternative to more complicated surgery including hysterectomy with loss of fertility and associated psychological morbidity

Objective: To demonstrate the effectiveness of B-Lynch compression suture in patients with massive postpartum haemorrhage due to uterine atony refractory to medical treatment

Methods: Prospective observational study conducted at Sobhraj Maternity Hospital, Karachi, from January 1, 2012 to December 31, 2012. Data was collected during the 12 month period for all women who had massive primary postpartum haemorrhage [> 1500ml] due to uterine atony refractory to uterotonic agents in whom surgical haemostasis was initiated by applying B-Lynch suture. Patients were followed up at 6 weeks, 6 months and 12 months. The main outcomes evaluated were reduction or cessation of bleeding, whether hysterectomy was needed to control haemorrhage and whether minor or major complications of the procedure arose

Results: During the 12 months study period 3.1% [152/4782] women had primary postpartum haemorrhage, while massive postpartum haemorrhage occurred in 0.62% [30/4782] cases. Majority of these cases were due to uterine atony [20/30]. B-Lynch suture was applied to 16 women who had massive primary postpartum haemorrhage due to uterine atony refractory to uterotonic agents. Effective haemostasis was achieved in all cases. None of the women required hysterectomy. All women later resumed normal menstrual flow without any abnormality. One patient had spontaneous pregnancy after eleven months of her delivery

Conclusion: B-Lynch suture is effective in the control of massive postpartum haemorrhage as an alternative to hysterectomy, a lifesaving procedure preserving the uterus and thus fertility

Formulation and evaluation of a single vial lyophilized preparation of technetium-99m labeled ethylene dicysteine as a renal scintigraphic agent

Tc labeled N-N-ethylene-L, L-dicysteine [EC] was introduced in form of multiple-step kit as an alternate renal imaging radiopharmaceutical for commonly used [99m] Tc-MAG3. We developed a single component lyophilized kit of EC ready to be labeled with [99m]Tc

We present the optimization of the components of our formulation, its evaluation in animal models, normal human volunteers and patients of various renal diseases, in comparison with[99m] Tc-MAG3. Efficient labeling of EC was achieved with our preparation at pH 7 to 12. The formulation at pH 8 was used further for bio distribution studies in organs of sacrificed Sprague Dawley rats and a live rhesus monkey using scintigraphy

After satisfactory bio-distribution results, the kit was then evaluated in normal human volunteers through renography. But the renogram parameters of [99m] Tc-EC[pH 8] were statistically inferior to[99m] Tc-MAG3. Surrogate kit at pH 10 was therefore developed and re-evaluated in rats for organ bio distribution. After favorable results the kit was then assessed further in normal volunteers and a group of patients with various renal disorders via scintigraphy

The EC kit developed at pH 10 gave images better than and scintigraphic parameters comparable to [99m] Tc-MAG3. It was concluded that single vial kit we formulated easy to prepare than three-vial kit and can be used as an alternate to[99m] Tc-MAG3

Oral health and oral health care practices in pregnant women - an urban perspective

The objective of this study was to describe the oral health status and oral health practices among pregnant women in the urban population of Karachi and to determine the need for oral health care education in this population. This study was a descriptive, cross sectional study conducted at department of Gynae and Obstetrics unit IV Sobhraj Maternity Hospital from 1st No-vember 2011 to 31st July2012. This study examined oral health status and oral health care practices by age, parity, ethnicity, education level by using a specifically designed questionnaire from a convenience sample of 507 pregnant women attending the antenatal clinic at Sobhraj Maternity Hospital. A total of 507 participants were recruited during the study period. Most participants were young multigravida, age ranging between 23 and 27 years .belonging to Urdu speaking and Sindhi ethnicity. It was seen that 24.9% were reported to be having good oral health. Multigravida, illiterate women had poor oral health status. 46.9% were advised to improve oral hygiene. 38.1% were referred to dentist. Dental caries and gingivitis were the common conditions for these dental referrals. 51.7% of women were advised proper dental cleansing. Urdu speaking and Sindhi ethnic group had better oral hygiene but they were more significant users of pan/ chalya/ gutka than others [P = 0.011]. This study highlights the poor oral health status of the older multigravidas and the alarmingly high consumption of pan/chalya/gutka among the young Urdu speaking and Sindhi pregnant population. The healthcare providers should include oral health screening and education of these women as part of antenatal care

Pregnancy complications and outcomes among ; overweight and obese women

The study aimed to understand the relationship between maternal BMI and pregnancy complications and outcomes. This is a cross sectional study that was carried out at Sobhraj Maternity Hospital, Karachi from 1st May 2010 to 30th April 2011. A total of 608 women with accurate information regarding BMI recorded at booking visit [before 14weeks] and singleton pregnancy with cephalic presentation at 37 weeks or more admitted for delivery were re-cruited. These women were studied in three groups according to their BMI at booking visit [before 14 weeks]. Group I included 202 normal weight women with BMI 20 -24.9, Group II included 202 overweight women with BMI 25 -29.9 and Group III included 204 obese women with BMI > 30. Maternal adverse outcomes assessed were gestational diabetes, gestational hypertension, postpartum haemorrhage and wound infection. Labour outcomes assessed were, risk of postdates, induction of labour, mode of delivery, meconium stained liquor. Fetal outcome was assessed by macrosomia, Apgar score <7 at 5 minutes and admission to NICU. Groups were compared using SPSS version 18 for statistical analysis. Pearson's chi-square test was used to detect the difference between the group proportions. A total of 608 women were studied including 202 normal weight women [BMI 20 - 24.9], 202 overweight women [BMI 25 - 29.9] and 204 obese women [BMI > 30]. Compared to women with normal BMI the following outcomes were significantly more common in not only obese women but the overweight women were also seen to be at significantly higher risk for: gestational diabetes, gestational hypertension, postdates, induction of labour, instrumental delivery and caesarean section, meconium stained liquor, postpartum haemorrhage, wound infection, macrosomia, fetal Apgar score <7 at 5 minutes and admission to NICU. In all cases increasing maternal BMI was associated with increased magnitude of risk. Maternal obesity carries significant risk for the mother and fetus. The risk increases with the degree of obesity and not only obese but overweight women are at a significantly increased risk for pregnancy complications and adverse fetomaternal outcome. Therefore these women should be considered at high risk and councelled and managed accordingly

Domestic violence during pregnancy and its effects on gestational age and birth weight

Objective: To estimate the prevalence and characteristics of domestic violence in pregnancy and to determine its relationship with gestational age and birth weight. Design: Cross-sectional prospective study. Place and Duration of study: Sobhraj Maternity Hospital, Karachi from December 2003 to May 2004

Patients and Methods: One thousand low-income, relatively low risk, recently delivered women participated in this study. Confidential interviews were conducted using a structured questionnaire. The main outcome measures were a history of domestic abuse in the antecedent pregnancy, its nature and severity, infant gestational age at delivery and birth weight

Results: In this study, the prevalence of domestic violence during pregnancy was 24.8%. Women who reported physical, sexual or emotional abuse during pregnancy were significantly more likely than non-abused women to give birth prematurely [23.8% versus 8.1%, p = 0.001] or to a baby with low birth weight [32.1% versus 7.4 %, p = 0.001]

Conclusion: The present data suggests that domestic violence during pregnancy can play a role in preterm birth and low birth weight. As healthcare professionals, we need to be aware of this issue and maintain a high index of suspicion for the possibility of abuse in our clinical work

Pelvic tuberculosis mimicking malignant ovarian tumour

Two cases of pelvic tuberculosis with markedly raised serum CA 125 levels and initially suspected of ovarian carcinoma are presented. Tuberculosis is highly prevalent in developing world and should be considered in the diagnosis of pelvic mass, ascites and elevated serum CA 125 levels