Analysis of Health Sector Budget of Nepal.

INTRODUCTION: Primarily, health sector connects two segments - medicine and public health, where medicine deals with individual patients and public health with the population health. Budget enables both the disciplines to function effectively. The Interim Constitution of Nepal, 2007 has adapted the inspiration of federalism and declared the provision of basic health care services free of cost as a fundamental right, which needs strengthening under foreseen federalism. METHODS: An observational retrospective cohort study, aiming at examining the health sector budget allocation and outcome, was done. Authors gathered health budget figures (2001 to 2013) and facts published from authentic sources. Googling was done for further information. The keywords for search used were: fiscal federalism, health care, public health, health budget, health financing, external development partner, bilateral and multilateral partners and healthcare accessibility. The search was limited to English and Nepali-language report, articles and news published. RESULTS: Budget required to meet the population's need is still limited in Nepal. The health sector budget could not achieve even gainful results due to mismatch in policy and policy implementation despite of political commitment. CONCLUSIONS: Since Nepal is transforming towards federalism, an increased complexity under federated system is foreseeable, particularly in the face of changed political scenario and its players. It should have clear goals, financing policy and strict implementation plans for budget execution, task performance and achieving results as per planning. Additionally, collection of revenue, risk pooling and purchasing of services should be better integrated between central government and federated states to horn effectiveness and efficiency.

Hyponatremia with venlafaxine.

OBJECTIVE: To describe a patient with hyponatremia associated with venlafaxine therapy. CASE SUMMARY: A 92-year old white woman who was receiving venlafaxine for management of depression was found to have hyponatremia. A detailed workup confirmed the diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). A temporal relationship between initiation of venlafaxine therapy and the onset of hyponatremia indicated it as the probable cause. Venlafaxine was discontinued, and hyponatremia resolved with a few weeks. DISCUSSION: Hyponatremia has been reported with selective serotonin-reuptake inhibitors (SSRIs). Serotonin has been reported to elevate concentrations of vasopressin in animal models. Venlafaxine is a potent inhibitor of serotonin reuptake and may have adverse effects similar to those of SSRIs. CONCLUSIONS: We report a case of hyponatremia probably caused by venlafaxine. Awareness of this potential problem would be helpful to clinicians and should be considered in the differential diagnosis of hyponatremia.

Lithium pharmacokinetics in the obese.

INTRODUCTION: The purpose of this study was to investigate the disposition of lithium in obese subjects compared with the disposition in normal weight volunteers. METHODS: Ten obese volunteers (weight, 110.2 +/- 28.6 kg) were compared with eight evaluable normal weight volunteers (weight, 63.1 +/- 6.6 kg). Oral lithium citrate (31.4 mEq) was administered and blood samples were obtained over a 48-hour period. Creatinine clearance (CLCR) was determined from a 12-hour urine collection. Total body water was determined by the deuterium oxide dilution method. RESULTS: The clearance of lithium (CLLi) for the obese group was significantly greater than that for the control group (33.9 +/- 7.0 ml/min versus 23.0 +/- 6.2 ml/min; p = 0.005). The steady-state volume of distribution (VSS) for the obese group was significantly less than that for the control group (0.42 +/- 0.09 L/kg versus 0.66 +/- 0.16 L/kg; p = 0.001). For the combined group, VSS was significantly correlated with ideal body weight and fat free mass but not with total body weight. The CLLi was significantly correlated with total body weight, but not with CLCR. CONCLUSIONS: The pharmacokinetic properties of lithium were significantly different for the obese subjects compared with those the normal weight control subjects. At steady state there is a direct proportionality between CLLi and the dose required to achieve a given serum lithium concentration, therefore the results of this study suggest that obese patients may require larger lithium maintenance doses than nonobese patients.

Disposition of intramuscular cefonicid in elderly patients.

OBJECTIVE: To examine the disposition of intramuscular (IM) cefonicid in elderly patients with bacterial pneumonia. DESIGN: Pharmacokinetic study. SETTING: A 620-bed university-affiliated long-term care institution with its own 39-bed acute care unit. PATIENTS: Nine consecutive elderly patients with bacterial pneumonia treated with IM cefonicid. MEASUREMENTS: Blood samples were collected on the seventh day of therapy over a 24-hour period and analyzed by high performance liquid chromatography. Pharmacokinetics parameters (volume of distribution, half-life, and clearance) and protein binding were calculated. Clinical outcome of IM cefonicid therapy was also noted. RESULTS: The estimated creatinine clearance (CIcr) ranged from 32 to 145 mL/min. Peak cefonicid serum concentrations occurred at 0.5-1.5 hours, with a mean value of 118 +/- 41 micrograms/mL. Cefonicid concentrations declined monoexponentially to 57 +/- 16 micrograms/mL at 12 hours and 28 +/- 14 micrograms/mL at 24 hours. The mean apparent distribution volume was 0.2 +/- 0.07 L/kg, and the mean apparent total clearance was 15 +/- 12 mL/min. The half-life ranged from 3.1 to 38 hours. A linear correlation was noted between Clcr and cefonicid clearance (r = 0.99). CONCLUSIONS: Cefonicid absorption was variable among these patients, and the serum half-life was longer than previous values noted in younger patients with similar degree of renal dysfunction. Pharmacokinetic and clinical outcome data from our study group indicate the potential role of IM cefonicid in treating elderly patients with bacterial pneumonia.

Seizure with ciprofloxacin and theophylline combined therapy.

Ciprofloxacin has been reported to cause theophylline toxicity by inhibiting theophylline metabolism. A 93-year-old woman without a known seizure history, while on ciprofloxacin and theophylline combined therapy, experienced a grand mal seizure. Her serum theophylline concentration at the time was 20 micrograms/mL. On previous occasion of theophylline toxicity, she had a serum theophylline concentration of 27 micrograms/ml but the patient did not experience any seizure. Several reports suggest that the combination of theophylline and ciprofloxacin has an additive inhibitory effect on gamma-aminobutyric acid (GABA) sites. Inhibition of the binding of GABA to its receptor sites has been related to the convulsant effects of other drugs. The seizure in our patient may have been caused by altered pharmacokinetics and pharmacodynamics brought about by combined therapy of theophylline and ciprofloxacin.

A team approach to reduce antibiotic costs.

After partial success in reducing antibiotic drug costs by traditional methods (i.e., closed formulary, use of generic drugs, retrospective drug usage review, continuing education), a study of a new "team approach" was implemented. The study involved a clinical pharmacist and physicians working together to select the most appropriate antibiotic therapy. The clinical pharmacist reviewed the culture and sensitivity data and the pattern of infectious disease over the six-month period prior to the initiation of the study and prepared a list of the most appropriate antibiotics based on clinical efficacy and cost effectiveness. He then joined the physicians on morning rounds to monitor therapy and help in the selection of the most appropriate drug regimen. At the end of the study period, antibiotic cost savings of 58.6 percent were achieved.

Effect of assay methodology on the prediction of lithium maintenance dosage.

Test dose methods have been used to predict the maintenance dosage of lithium carbonate tablets in bipolar patients. These methods require a lithium analytical method that is accurate to the second decimal place. Successful use of these test methods has employed the atomic absorption spectrophotometric method, yet many hospitals use a flame spectrophotometric method. We evaluated a two-point method to predict lithium maintenance dosages of slow-release lithium carbonate tablets in 20 bipolar patients using both assay methodologies. No clinically significant differences were found between the two sets of predictions, suggesting that either assay methodology has requisite sensitivity and accuracy for use in test dose predictions of lithium maintenance dosages.

Appropriateness of the use of serum lithium assays.

The performance of 222 lithium assays was studied in a psychiatric hospital to determine if their use was appropriate and therapeutically beneficial. Charts of all patients whose serum lithium levels were measured in a month were reviewed to determine whether the assays were indicated, whether they were performed correctly, and whether the dosage was adjusted appropriately. Of the assays reviewed, 16 percent were performed for inappropriate indications and 98 percent were drawn at correct times. Of 157 assays that should not have resulted in a dosage change, 8 changes were made; of 63 assays that should have resulted in a dosage change, only 23 changes were made. Inappropriate orders for assays cost the hospital +5016 per year. If routine serum lithium assay monitoring is changed to a three-month frequency, the total cost savings would be +16,632 per year. Clinical pharmacists with specialized knowledge of clinical pharmacokinetics should work with physicians and treatment teams in monitoring serum drug assays to ensure appropriateness of assay request, more complete interpretation of results, and proper follow up.

Evaluation of a two-point method for prediction of lithium maintenance dosage.

A lithium test dose method, based on the two-point method of Perry et al. (1982), was evaluated in 20 patients for the prediction of maintenance dosage of slow-release lithium carbonate tablets. These predictions were compared with the predictions obtained from the dosing chart of Cooper et al. (1973). The two-point method accurately predicted the maintenance dosage within clinically acceptable limits, but dosages predicted from the dosing chart would have yielded much higher serum lithium concentrations.