Indicator Based Assessment of Medicines Procurement Practices in Various Public Sector Hospitals of District Srinagar

Introduction: An organized and systematic drug procurement process based on well-established scientific principles effectively ensures the availability of right medicines in the right quantities, at reasonable prices, and at recognized standards of quality. It ensures ‘value for money’ and ‘economies of scale’ to the best possible extent. Methods: This study was carried out to evaluate various drug procurement and tendering practices prevalent at three tertiary care public health facilities of District Srinagar, the summer capital of J&K state. One children’s tertiary care hospital (CH), one Govt. Medical College Hospital (MCH), one district hospital (DH) was selected for the study. Two different pharmaceutical supply chains were involved in procurement of medicines for the study hospitals. A set of 149 qualitative and 15 quantitative indicators were developed to evaluate drug procurement practices in these healthcare settings. Results: Qualitative indicator based assessment revealed that a centralised procurement and decentralised distribution practice was being followed by both the supply chains studied. Procurement funds were found to be grossly inadequate whereas pre-qualification of suppliers was undertaken. Competitive e-tendering method was followed using double envelope system. However, rate contracts were not regularly updated and there were no means available to check and determine the quality of drugs effectively. Available pool of human resource was found to be inadequate and there were no standard procedures in place to monitor the performance of procurement and supply system on regular basis. Conclusion: Appropriate measures need to be taken for proper selection, quantification, forecasting and procurement of medicines in accordance with well established guidelines to make the supply chain more efficient. Allocation and disbursement of funds for procurement should also be sufficient and timely to cater to the needs of individual hospitals across all levels of care.

Indicator Based Assessment of Medicine Storage and Inventory Management Practices in various Public Sector Hospitals of District Srinagar

Introduction: The role and relevance of medicines, vaccines and other health supplies are critical, as they are considered important building blocks of the health care system. Well-located, well-built and secured storage facilities are an essential component of a pharmaceutical supply system. Methodology: This study was carried out at various public sector hospitals of District Srinagar using a set of 138 assessment indicators to study the drug storage and inventory management practices in terms of storage facilities and procedures, inventory and stock management practices and daily, monthly, yearly storage and inventory related activities. Results: Indicator based assessment for drug storage and inventory management practices revealed highest percentage adherence of 80% in managing expired drugs followed by 55.4% in daily, monthly, yearly storage and inventory control activities, 48% adherence in storage procedures, 46.1% in receiving supplies, 42.5% in stock positioning, 40.9% in storage space, 38% in stock management, 26% in stock-outs and the lowest percentage adherence of 22.9% was observed in inventory management. Facility-wise assessment revealed highest overall percentage adherence of 64.1% at Children’s Hospital (CH) followed by 54.3% at District Hospital (DH), 49.3% at Medical College (MC), 29.6 % at Sub-District Hospital (SDH) and 24.4% at Primary Health Centre (PHC). Overall percentage availability of indicator medicines was found to be 32.5% (CH=56.2% & DH=18.6%). Stock cards were not found in any of the health care facility and no expired products were found stocked in CH, MC and DH. Average indenting frequency was found to be 31 days (PHC=60; MC=10) whereas average numbers of medicines indented in one go were found to be 24. Average lead time was found to be 15 days (CH=15; MC=60) whereas average no of stock out days was found to be 66.6 days (CH=10 & PHC=115). Conclusion: Overall adherence towards various storage conditions was found to be less than 50% and lack of adherence to the basic inventory management principles was found to be common

Preload Versus Coload and Vasopressor requirement for the prevention of spinal anesthesia induced hypotension in non-obstetric patients

Objective: To compare the effectiveness of preload and coload for the prevention of Spinal Induced Hypotension [SIH] and vasopressor requirements

Study Design: Randomized trial

Place and Duration of Study: Department of Anesthesia, The Aga Khan University Hospital, Karachi, Pakistan, from June 2007 - June 2010

Methodology: Sixty patients were randomly divided into preload and coload group of 30 each. Patients with ASA 1 - 3, aged 20 - 60 years were included. Patients with history of IHD, COPD, BMI > 30 and surgical procedure TURP were excluded. All patients received crystalloid 10 ml/kg before induction of spinal anesthesia in preload group and at the time of spinal anesthesia in coload group. Blood pressure and heart rate were recorded at different time intervals till 45 minutes. Patients received ephedrine 5 mg when systolic blood pressure dropped below 90 mmHg and heart rate was less than 60 beats/minute and/or phenylephrine 50 micrograms when systolic blood pressure dropped below 90 mmHg and heart rate was more than 60 beats/minute

Results: There was no statistically significant difference at different time intervals in heart rate, systolic and mean arterial pressure between the groups. Diastolic blood pressure was significantly different in both groups at 6 - 15 minutes after spinal anesthesia. SIH occurred [21] 70% and [15] 50% in preload and coload groups, respectively [p=0.187]. Ephedrine requirement for SIH was significantly high in preload group [p=0.017]. Phenylephrine requirement for SIH was high in preload group which was statistically non-significant [p=0.285]

Conclusion: Coload group has lower incidence of spinal induced hypotension and significantly less vasopressor requirement than the preload group

Suicidal behavior among teenagers: a review

After every 16 minutes one individual die not merely from a disease or an accident but intentionally through suicide. Literature reveals that it is a long process usually stretches over years from suicidal ideation to planning and finally an attempt. The causes of suicidal behavior are immense which captivate these poor and innocent creatures in great troubles. In teenagers the suicidal ideations are related to multiple internal and external factors. They consume different lethal liquids and adopt different methods for performing this violent act. Further on its impact is not only on her individual and family life but has a great impact on the society as well. It is not an essay task to eradicate this violent act but as we a responsible member of the society we can assess their suffering and agony and help them identifying different social groups. Along with it we can also prevent the suicide at three different levels that's primary secondary and tertiary. We can also do the counseling. In conclusion, I would say that it is a rising issue of today's world and we all must give our efforts to show a reduction in its prevalence

Neurological improvement after cervical traction in patients with cervical spine injury

To estimate frequency of neurological improvement after cervical traction in patients with cervical spine injury. This observational study was conducted at Department of Neurosurgery, Lady Reading Hospital, Peshawar - Pakistan from December 2010 to November 2011. The medical record of all cases, in which cervical traction was applied for cervical spine injury, was checked from record room. Documentation was done according to proforma designed, indicating age, sex, neurological status before and after cervical traction and investigations with findings on X-rays, CT and MRI. The data was analyzed from different angles in SPSS software. A total of 30 patients were included in this study. There were 20 males and 10 females. The age of the patients ranged from 13 to 80 years [mean= 31.07 +/- 15.45]. Majority of the patients [83.3%] were young, in the age range of 13- 40 years. Neurological improvement was noted in 14 [46.7%] patients. It was more in age group of 13-20 years [66.7%] and in those who presented with weakness of Frankle grade "B" and "C" [66.7% each]. The improvement was more in patients in whom anatomical alignment of spine was achieved. Skeletal cervical traction is safe and effective means of early decompression of spinal cord with neurological improvement. It is more effective in young individuals and those presenting with Frankle grade B and C weakness

Immediate symptomatic relief after microvascular decompression for hemifacial spasm: a case series

Hemifacial spasmis a movement disorder characterized by intermittent, involuntary clonic or tonic clonic contractions of muscles innervated by the ipsilateral facial nerve. It is commonly caused by vascular compression of the facial nerve at its Root Exit Zone [REZ] from the brainstem. Anterior inferior cerebellor artery, posterior inferior cerebellor artery, vertebral artery commonly compress the facial nerve. Usual symptoms are progressive involuntary facial twitching. MRI brain and MRA are advised to know about neurovascular compression. Four case of hemifacial spasm are reported diagnosed on clinical grounds, and MRI brain and MRA are advised. Our objective is to assess the surgical outcome of microvascular decompression [MVD] for Hemifacial spasm [HFS]

Unilateral approach for bilateral decompression of lumbar spinal stenosis: a minimal invasive surgery

To assess the feasibility and efficacy of a novel, minimally invasive spinal surgery technique for the correction of lumbar spinal stenosis involving unilateral approach for bilateral decompression. Cross-sectional observational study. Neurosurgery Department of PGMI, Lady Reading Hospital, Peshawar, from January to December 2010. A total of 60 patients with lumbar stenosis were randomly assigned to undergo either a conventional laminectomy [30 patients, Group A], or a unilateral approach [30 patients, Group B]. Clinical outcomes was measured using the scale of Finneson and Cooper. All the data was collected by using a proforma and different parameters were assessed for a minimum follow-up period of three months. Data was analyzed by descriptive statistics using SPSS software version 17. Adequate decompression was achieved in all patients. Compared with patients in the conventional laminectomy group, patients who received the novel procedure [unilateral approach] had a reduced mean duration of hospital stay, a faster recovery rate and majority of the patients [88.33%] had an excellent to fair operative result according to the Finneson and Cooper scale. Five major complications occurred in all patient groups, 2 patients had unintended dural rent and 2 wound dehiscence each and fifth patient had worsening of symptoms. There was no mortality in the series. The ultimate goal of the unilateral approach to treat lumbar spinal stenosis is to achieve adequate decompression of the neural elements. An additional benefit of a minimally invasive approach is adequate preservation of vertebral stability, as it requires only minimal muscle trauma, preservation of supraspinous/intraspinous ligament complex and spinous process, therefore, allows early mobilization. This also shortens the hospital stay, reduces postoperative back pain, and leads to satisfactory outcome.

unusual cause of traumatic brain injury in Khyber Pakhtunkhwa: a case report

Penetrating head injuries can be the result of numerous intentional or unintentional events, including missile wounds, stab wounds, motor vehicle and occupational accidents [nails, iron rods] or assaults [screw-drivers]. Penetrating head injuries caused by screw-drivers constitute only a small part of the total number of traumatic head injuries seen in casualty. We report a case of neuro-trauma who was operated in our institution. A 25 years gentleman presented in casualty on with a screw-driver penetrating into the skull, as an unusual case of violence

Retinitis pigmentosa; clinical presentations and associations

To review clinical presentations and associations in patients suffering from Retinitis Pigmentosa. Descriptive study. January 2005 to December 2009. KTH Peshawar, DHQ Hospital Karak and Group of Teaching Hospital Bannu. A proper performa was made for documentation of patients. After informed consent, history was taken properly. Ocular examination regarding visual status, anterior and posterior segment examination with direct, indirect ophthalmoscope and slit lamp bimicroscopy was done. IOP was checked with applanation tonometer. For systemic examination and associations opinion of physician was asked if needed. Total 83 patients were examined out of which 49[59.03%] were male and 34[40.96%] were female. Regarding age factor 1[1.20%] patients were in age group up to 10 years, 3[3.61%] in age group 11 to 20 years, 12[14.45%] in age group 21 to 30 years, 21[25.30%] in age group 31 to 40 years, 27 [32.53%] in age group 41 to 50 years, 12[14.45%] in age group 51 to 60 years, and 7[8.43%] patients were in age group 61 to 70 years. In 79[95.18%] patients there was family history of R.P while in 4 [4.81%] patients no family history was present. All the patients have involvement of both eyes. 61[73.49%] patients presented with complaints of night blindness, 56[67.46%] patients with defect in visual acuity with range from 6/9 to perception of light, out of which 24 patients had refractive error and 32 patients had no refractive error. 21[25.30%] patients presented with field defect. Fundoscopy revealed, bone spicule pigments configuration in 83[100%] patients, attenuated blood vessels in 23[27.71%] patients and, waxy pallor disc in 12[14.45%] patients. Regarding associations, in systemic association group 82[98.79%] patients had no association while 1[1.20%] patients had bardet biedle syndrome. In ocular association group 24[28.91%] patients had myopia, 14[16.86%] patients had cataract. Primary open angle glaucoma was present in 3[3.61%] patients while 2[2.40%] had cystoid macular oedema. Keratoconus was present in 1[1.20%] patients. Retinitis Pigmentosa is a grave disease with irreversible loss of visual functions. Mostly it is bilateral. Severity increases with age. Familial onset is more

Risk factors and complications of hepatitis "C" in Peshawar. [A hospital based study]

To determine the risk factors and complications of hepatitis C in a tertiary care hospital in Peshawar. Prospective observational study. Medicine department, Khyber Teaching Hospital Peshawar. From April 2004 to June 2005. A total of 252 HCV positive patients were selected, 165 were males and 87 were females. Relevant information was obtained from the patients with the help of a predesignd questionnaire prepared in accordance with the objectives of the study. The age range of patients was from 11 years to 84 years with mean age of47.5 years. Out of total sampling 137[54.36%] patients had positive family history of hepatitis C virus [HCV]. Risk factors distribution was: intravenous drug users 73, HCV positive sexual partners 58 [23.01%], blood or blood product transfusion 34[13.49%] and occupational acquired HCV 18[7.14%]. Unknown source of HCV transmission was recorded in 69[27.38%]. Clinical presentation of HCV positive patient was: Chronic persistent hepatitis 87[34.52%], liver cirrhosis 41[16.26%], hepatocellular carcinoma 2[0.79%] and fulminant hepatitis 2[0.79%]. One hundred and twenty patients [47.61%] were asymptomatic or subclinical symptomatic. Intravenous drug abuse and HCV positive sexual partners [wife or husband] were found as major risk factors of HCV transmission and chronic persistent hepatitis and liver cirrhosis were recorded as major clinical presentations of HCV in our patients

frequency and age presentation of G6PD deficiency in 200 patients of hemolytic anaemia

To determine the frequency of G6PD deficiency in the etiology of anaemia and jaundice and to determine the most common age of presentation with anaemia and jaundice due to G6PD deficiency in adults. We did a hospital based study in the department of Medicine Khyber Teaching Hospital Peshawar from June 2003 to December 2003. The data of adult patients with signs and symptoms of anaemia and jaundice was collected on structured proforma. The clinical presentation and laboratory investigation results were documented. Out of 200 patients studied, 24 [12%] patients were found to be deficient in G6PD enzyme. The male to female ratio was 21:3 [87.5% and 12.5%] respectively. The age of appearance of jaundice in adults varied [most common age from 13 to 17 years]. The most common signs and symptoms were jaundice, anaemia and haemoglobinuria. All G6PD deficient patients except one recovered spontaneously when the offending precipltating factor were stopped or treated. One [0.5%] died because of rapid fall of haemoglobin and delayed recognition of the condition and subsequent blood transfusion. G6PD deficiency is not an uncommon cause of jaundice and anaemia in our patients. The jaundice due to G6PD mainly affects the adults in 2nd or 3rd decade. Therefore all the children and adults with jaundice and anaemia should be screened for G6PD status

Association study of the angiotensin-converting enzyme (ACE) gene G2350A dimorphism with myocardial infarction

The angiotensin converting enzyme (ACE) is a strong candidate gene for myocardial infarction (MI). Insertion-deletion dimorphism in intron 16 of this gene has been inconclusively found to be associated with it. Several new polymorphisms in the ACE gene have been identified and among these, a dimorphism in exon 17, ACE G2350A, has a significant effect on plasma ACE concentrations. To assess the value of genotyping the ACE G2350A dimorphism in a genetically homogeneous population, we carried out a case-control study of dimorphism G2350A for a putative association with MI among Pakistani nationals. We investigated a sample population of 370 Pakistanis, comprising 163 controls, and 207 patients with clinical diagnosis of acute MI (AMI). ACE G2350A alleles were visualized by assays based on polymerase chain reaction and restriction endonuclease analysis. Frequencies of G alleles were 0.68 among controls and 0.72 among AMI patients. The ACE G2350A dimorphism showed no significant association with MI (c2=0.90, 2 df, P=0.64), plasma levels of homocysteine (P=0.52) or with serum levels of folate (P=0.299). The results indicate that ACE G2350A polymorphism is not associated with risk of myocardial infarction in the Pakistani population investigated here.

Dilemma of myocardial infarction with angiographically normal coronary arteries: a review

In a small number of patients, Myocardial Infarction [MI] is not associated with Coronary Artery Disease [CAD] and normal coronary arteries are documented on angiography. The reasons for this paradox are varied. Thrombosis, embolism and vasospasm are believed to be the mechanisms of ischemia and infarction in these cases. Intravascular thrombosis can result from hematological disturbances as in protein S deficiency and progestational states in females. Coronary embolism has been reported with prosthetic and abnormal valves, endocarditis and cardiac arrythmias. Vasospasm is an important mechanism in cocaine and amphetamine induced infarction. Clinically, these patients are younger and have minimal of the classical risk factors for CAD except cigarette smoking, which has been hypothesized to play a role in pathogenesis. In addition, they do not have any angina before or after the infarct. They have a relatively better prognosis and tend to fare better than similar MI patients with CAD. Management should not differ in the acute phase but calcium channel blockers may have a role

Use of aspirin in acute coronary syndrome in a tertiary care hospital in Karachi

Large body of scientific evidence exists that use of Aspirin in acute myocardial infarction and other subsets of coronary heart disease significantly reduces morbidity and mortality. Aspirin has proved a life saving medication if taken in the early hours of myocardial infarction. This study was conducted to find out the aware- ness and actual use of Aspirin in patients with acute chest pain due to AMI and other acute coronary syndromes. Randomized prospective study. National Institute of Cardiovascular Diseases [NICVD] Karachi, Pakistan. Two hundred consecutive patients admitted to NICVD with the history of recent onset acute chest pain suggestive of myocardial ischemia/infarction. A questionnaire regarding the time of onset of chest pain, time interval of chest pain and use of Aspirin [chewed or swallowed], cause of chest pain, first consultation, use of any other remedy, risk factors, financial status, use of different types of fat, profession, family members and counseling about use of Aspirin were asked by the first author. The study included 200 patients, 150 males [75%] and 50 females [25%]. 25 [12.5%] of patients, 21 [10.5%] males and 4 [2%] females were between the age of 31-40 years, 59 [29.5%], males 41 [20.5%], females 18 [9%] were in 41-50 years, while 65 [32.5%], males 50 [25%] and females 15 [7.5%] were between the age of 51-60 years. 75 [37.5%] were labourers. 191 [95.5%] belonged to lower socio-economic group with income of < Rs.10,000/- per month. Majority 129 [64.5%] were illiterate or had primary education. 141 [70.5%] of patients took Aspirin within 6 hours. 21 [10.5%] used Aspirin at home. Although 47 [23.5%] patients first consulted a GP only 11 [23.4%] were given Aspirin. 15 [7.5%] got Aspirin at local hospital and 153 [76.5%] in NICVD. 102 [51%] patients came to NICVD directly. 77 [38.5%] got thrombolytic therapy. Pepsi [or cold drink], analgesics, syrup mucain, other digestives and Bam were the other drugs and substances first used after chest pain. Stress, Hypertension, smoking, hyperlipidemia, family history, obesity and diabetes mellitus were the important risk factors. 39 [19.5%] received counseling regarding benefits of Aspirin therapy. Despite compelling evidence regarding the known benefits, awareness about use of Aspirin among general physicians and community hospitals is highly unsatisfactory. Health Care Professionals need to be educated besides creating awareness among the public about the benefits of Aspirin therapy, using all available resources including the mass media

Risk stratification in patients with cardiac disease undergoing non cardiac surgery

Combination of clinical evaluation and non- invasive cardiac testing is the most efficient and appropriate method of identifying the patients at high risk of perioperative cardiac complications. This is a review article

Efficacy and safety of doxazosin in the treatment of mild to moderate essential hypertension

This was an open, non-comparative study on the efficacy and tolerability of doxazosin in the treatment of mild to moderate essential hypertension. 40 patients of both sexes were treated with doxazosin once daily for 10 weeks. The mean reduction in systolic and diastolic blood pressure from baseline to the end of the study was 20 mmHg and 22 mmHg respectively. These reductions were found to be statistically significant [p<0.05]. The mean reduction in the heart rate from baseline to the end of the study was 5 beats/min. These reductions were thought statistically significant [p<0.05] had no clinical relevance. At baseline the mean values for total cholesterol was 175mg/dl, for HDL 36.1mg/dl, for HDL 111.8mg/dl, and for triglycerides was 153.8mg/dl. At the end of the study the mean values for total cholesterol was 166.0mg/dl, for HDL was 34.2mg/dl, for LDL was 99.6mg/dl, and for triglycerides was 138.7mg/dl. The effect of doxazosin on the serum lipids of the patients was noted and some reduction was found in the total cholesterol, HDL, LDL and triglycerides. However, these reduction were not statistically significant. None of the patients experienced any adverse effects of doxazosin and no patient was withdrawn from the study due to any adverse events. These findings indicate that doxazosin is an effective and well tolerated antihypertensive agent for mild to moderate essential hypertension

Purification and characterization of lactate dehydrogenase from Varanus liver

Lactate dehydrogenase was purified 21-fold from liver of Varanus bengalensis using colchicine-sepharose column chromatography. The crude enzyme showed two isoenzymes (LDH-5 and LDH-4) by agarose gel electrophoresis (AGE). The purified enzyme showed a single band after SDS-PAGE corresponding to molecular mass of 35 kDa. The molecular mass of native enzyme was about 140 kDa. The optimum pH for the forward reaction was 7.5 while that for the reverse reaction was pH 9.5. The K-m values for pyruvate, NADH, lactate and NAD(+) were 0.17 +/- 0.037, 0.02 +/- 0.004, 12.4 +/- 3.05 and 0.38 +/- 0.032 mM, respectively. Pre-heating of enzyme showed that its t(50) was 40-50 degrees C. Oxalate and n-hexanediol were inhibitors for both forward and reverse reactions. Among divalent ions, Cu++ was shown to be more effective inhibitor for the forward reaction.