Relationship between medication safety-related processes and medication use in residential aged care facilities.

OBJECTIVE: To explore the association between the implementation of medication safety-related processes measured with the Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) tool and medication use in residential aged care facilities (RACFs). METHODS: A descriptive cross-sectional study was conducted in Australian RACFs. Data on facility characteristics, aggregated medication use at the facility level for selected medications commonly associated with a high risk of harm and the MSSA-LTC were completed by clinical pharmacists providing clinical pharmacy services. The Spearman's correlation test was used to evaluate the association between the MSSA-LTC score and medication use. A scatter plot between the MSSA-LTC score and medication use data was generated, and a linear trend line was plotted using the least squares method. RESULTS: Data were collected from 31 RACFs servicing 2986 residents. Most medication safety-related processes were implemented in Australian RACFs. A higher facility MSSA-LTC score was associated with a lower proportion of residents with polypharmacy (r = -.48, p = .01) and one or more benzodiazepines (r = -.41, p = .03). In addition, a negative linear trend was observed between the MSSA-LTC score and the average number of medications per resident, the proportion of residents with one or more anticonvulsants and the proportion of residents using one or more opioid analgesics. CONCLUSIONS: This study indicates that implementing medication safety-related processes may improve medication use in RACFs.

Psychosocial Well-Being of People Living with HIV/AIDS in Chitwan District, Nepal: a Mixed Method Study.

BACKGROUND: Along with many physical issues associated with the HIV/AIDS there are socio-psychological ill-effects including depression, anxiety and stress. The antiretroviral therapy has been successful in prolonging the life but not much information is available on the psychosocial issues and social support from Nepal. METHODS: Sequential explanatory mixed method study design was followed. All the patients undergoing antiretroviral therapy in Bharatpur Hospital above 18 years of age and giving consent to participate were conveniently selected. Validated Nepalese version of Becks Depression Inventory and Becks Anxiety Inventory tool while translated and validated Multidimensional Scale of Perceived Social Support scale was used Purposive In-depth Interview was conducted with open ended questionnaire to obtain qualitative data. Chi-square and logistic regression were used for quantitative analysis while manual content analysis was used to analyze the qualitative data. RESULTS: The totals of 288 participants were included in the study About 43% had some level of depression, 98% had very low level of anxiety and almost half of the people had high support. In binary logistic regression model, the significant variables were sex, marital status and occupation. Females had 2.622 times more odds of depression than males, the risk of having depression in occupation group- agriculture and household was 3.661 and 2.508 time more as compared to jobholder respectively. Similarly, single individuals had 2.815 higher odds of depression than couples. Emotional disturbances and fear of vulnerability, stigmatization, dealing with difficulties were the major problems in these groups with good familial and organization support. CONCLUSIONS: Clinicians, health and AIDS professionals should routinely screen for depression among other interventions to promote psychological health in HIV/AIDS-positive individuals.

Price variation among different brands of anticancer medicines available in hospital pharmacies of Nepal.

OBJECTIVE: To assess the variation in price among different brands of anticancer medicines available in hospital pharmacies at Nepalese cancer hospitals. METHODS: The price of different brands of the same anticancer medicines available in the hospital pharmacies of two cancer hospitals was assessed. Prices of different dosage forms such as a single tablet, capsule and vial were calculated. The difference in the maximum and minimum price of the same drug manufactured by different pharmaceutical industries was determined, and the percentage variation in price was calculated. The prices of medicines (brands) were also compared with the price determined by the government where available. RESULTS: Price variation was assessed for 31 anticancer medicines belonging to six broad categories. Prices were found to vary maximally among the following medicines, each belonging to separate categories: among alkylating agents, the price of temozolomide 100 mg capsule varied 308%; among antimetabolite agents, the price of pemetrexed 500 mg injection varied 134%; among hormonal drugs, the price of letrozole 2.5 mg tablet varied 200%; among antibody class, the price of trastuzumab 440 mg injection varied 73%; among natural products, the price of irinotecan 100 mg injection varied 590%; and among miscellaneous agents, the price of bortezomib 2 mg injection varied 241%. There was a significant difference in the mean MRP of the alkylating agents with the antimetabolites (p-value 0.006) and the monoclonal antibody (p-value <.001). Antimetabolites, natural products, hormonal therapy all had significant mean differences in their MRPs with the monoclonal antibodies. (p-value <.001) and the monoclonal antibodies had a significant mean difference in the MRP with the miscellaneous agents. (p-value <.001). CONCLUSIONS: There was a considerable variation in the price of different brands of anticancer medicines available in the Nepalese market. The Government of Nepal has regulated the prices of some medicines, including anticancer medicine. However, it is not enough as prices of the majority of anticancer medicines are still not regulated. Therefore, further strategies are needed to address the variation in the prices of anticancer medicines available in the Nepalese market.

Outcome Predictors in Scrub Typhus Requiring Ventilator and Vasopressor Support.

BACKGROUND: Age and serum creatinine are known to be predictors of mortality in scrub typhus patients admitted in intensive care unit. This study aimed to explore the factors predicting mortality in patients with scrub typhus requiring both ventilator and vasopressor support in our set up. METHODS: A retrospective analysis of 43 patients with scrub typhus (ELISA IgM positive, optical density ?0.5) admitted in Medical Intensive Care unit of Chitwan Medical College Teaching Hospital between April 2016 to September 2017 was performed considering recovery or death (poor outcome) as outcome measurement. Potential variables (p<0.25) from bivariate analysis were used to perform a multivariate logistic regression analysis (p<0.10) to predict mortality. RESULTS: The mortality rate was 56% (24/43). Acute respiratory distress syndrome and shock were observed in all 43 patients. The median (IQR) duration of ventilation use and vasopressor use was 53(101) hours and 48(79.5) hours, respectively. On bivariate analysis, an independent and statistically significant association of mortality with age in years (p=0.039), number of vasopressor use (p<0.001) and serum creatinine more than 1.4 mg/dl (p=0.012) was observed and on multivariate regression analysis, these variables were also the predictors of mortality (age in years: p=0.011, ?=0.115, OR=1.211, 95% CI=1.027-1.225; number of vasopressor use: p=0.009, ?=3.705, OR=40.647, 95% CI=2.532-652.425; serum creatinine more than 1.4 mg/dl: p=0.046, ?=-2.205, OR=0.110, 95% CI=0.013-0.961) Conclusions: In scrub typhus with ARDS and septic shock, increasing age and serum creatinine, and requiring more than one vasopressor to maintain blood pressure are at increased risk of mortality.

Factors predicting home medication management practices among chronically ill older population of selected districts of Nepal.

BACKGROUND: Older population often have multiple and complex needs that are consequently challenged by the presence of polypharmacy, adverse drug reactions and drug-drug interaction. We aimed to determine home medication management practices (MMP) and its associated factors among chronically ill older population of selected districts of Nepal. METHODS: A community based cross-sectional survey was conducted among 386 chronically ill older individuals from selected areas of Nepal between April to September 2016. Appropriateness of MMP was assessed through scores of questions using interview method. Multivariate logistic regression analysis using potential variables from bivariate analysis were used to determine factors affecting MMP. RESULTS: The overall home MMP was mostly inappropriate (80.1%). Most participants had multiple prescribers for single disease (202, 52.3%) and inappropriate medication storage (188, 48.7%). Though the majority of them had drug administration schedule (378, 97.9%), expired medicines were also used (2, 0.5%). Regression analysis showed less than one year duration of disease (odds ratio [OR] = 3.901, 95% confidence interval [CI] = 1.528 to 9.959, P = 0.004), 1-2 years duration of disease (OR = 2.415, 95% CI = 1.210 to 4.821, P = 0.012) and smokers (OR = 2.025, 95% CI = 1.036 to 3.956, P = 0.039) as the major factors affecting appropriate home MMP. CONCLUSIONS: The home MMP was associated with duration of disease and smoking status among chronically ill older patients living in selected districts of Nepal. Proper counselling and monitoring of such patients might be necessary to improve the practice.

Assessment of Insulin Injection Practice of Nurses Working in a Tertiary Healthcare Center of Nepal.

INTRODUCTION: Sound knowledge and good practice on insulin injection technique are essential for nurses in order to administer insulin correctly and to educate patients or their relatives adequately. This study aimed to assess the insulin injection practice through the use of insulin pen among nurses working in a tertiary healthcare center of Nepal. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted among 67 nurses working in one of the tertiary healthcare centers of Nepal. Demographic information and insulin injection practice of nurses through the use of insulin pen were assessed using self-administered questionnaire. Each correct practice was scored "1" and incorrect practice was scored "0." Results. The median (IQR) insulin injection practice score of nurses was 11 (9-12) out of 16. Thirty-seven (55.2%) nurses store insulin pen filled with insulin cartridge at room temperature while 57 (85.1%) nurses store unopened cartridge at refrigerator (2-8°C). The practice of hand washing and injection site cleaning was mentioned by 92.5% and 82.1% of the nurses, respectively. However, just over half of the nurses mix the premix (cloudy) insulin and prime insulin pen before each injection. Thirty-four (50.7%) nurses do not lift skin during injection and more than half of the nurses keep needle beneath the skin for less than 5 seconds after completely injecting the required dose of insulin. One out of ten nurses massage injection site after injecting insulin. Most of the nurses (86.6%) use single needle more than once and the median (IQR) frequency of needle reuse was 6 (3-12). Similarly, systematic site rotation was performed by 59 (88.1%) nurses and twenty (29.9%) nurses claim that they use single insulin pen for two different cartridges. CONCLUSION: The insulin injection practice of nurses assessed through the use of insulin pen was suboptimal and highlights the need for urgent educational intervention.

Predictors of Mortality in Scrub Typhus Infection Requiring Intensive Care Admission in Tertiary Healthcare Centre of Nepal.

INTRODUCTION: This study aimed to explore the predictors of mortality from scrub typhus infection in patients requiring intensive care unit (ICU) admission. MATERIALS AND METHODS: A retrospective study was conducted on 120 patients with serum ELISA IgM positive for scrub typhus (optical density ≥ 0.5) admitted at the medical ICU of Chitwan Medical College Teaching Hospital between April 2016 and September 2017. Data was extracted from patient medical records and electronic database of the hospital. The outcome measurement was mortality (Yes/No) due to the infection. A multivariate binary logistic regression analysis (p < 0.10) using potential variables from bivariate analysis (p < 0.25) was adjusted to predict the mortality. RESULTS: The mortality rate was 20% (24/120). Factors associated with mortality, as found using bivariate analysis, were heart rate > 100/minute (p < 0.001), systolic blood pressure < 90 mmHg (p = 0.025), diastolic blood pressure < 60 mmHg (p = 0.032), serum creatinine > 1.4 mg/dl (p < 0.001), acute kidney injury requiring dialysis (p = 0.029), acute respiratory distress syndrome (p < 0.001), and shock requiring vasopressor (p < 0.001). Regression analysis showed age (odds ratio [OR] = 1.063; 95% CI = 1.010-1.118; p = 0.019) and serum creatinine (OR = 1.063; 95% CI = 1.010-1.118; p = 0.019) as significant predictors of poor outcome. CONCLUSION: Older age and high serum creatinine were found to be independent predictors of poor outcome in patients with scrub typhus admitted in medical ICU.

Assessment of primary labeling of medicines manufactured by Nepalese pharmaceutical industries.

BACKGROUND: Appropriate labeling of marketed medicines is necessary to fulfill the regulatory provisions and ensure patient medication safety. This study aimed to assess the primary labeling of medicines manufactured and marketed by Nepalese pharmaceutical industries. METHODS: We assessed the primary labeling of all medicines available at the pharmacy of Chitwan Medical College Teaching Hospital (CMCTH), Chitwan, Nepal, between November 2017 to December 2017. Medicines were assessed as required by Drug Standard Regulation, 2043 (1986 AD) of Nepal. Appropriate classification of all the medicines and content of over-the-counter (OTC) medicines (where certain information should be in Nepali language) was also assessed. Descriptive statistics was performed. RESULTS: Seven hundred fifty-nine medicines manufactured by 37 Nepalese pharmaceutical industries were assessed. While all pharmaceutical products had the name of the drug (brand), only76.8% of them stated drug quantity. Almost all products were found to declare category of the drug, with only a few (4.1%) mentioning the sub-category. The system of medicine was stated in 9.9% of the products. Active ingredients and their quantity, manufacturer's information, serial number for the production of drug and the date of production, storing methods, and information on the quantity used were mentioned in almost all the products. Similarly, all the products had batch number and the date of expiry. But, 11% of the products lacked the name of pharmacopoeia to which the drug belongs and all the products lacked the serial number for establishment of pharmaceutical industry. Similarly, 5.3% of the products did not list their price, and 2.4% of prescription medicines lacked caution labeling. Unfortunately, the majority of the products (84.4%) did not provide the directions of use. Appropriate drug classification was found in 89.6% of products. None of the over-the-counter medicines totally adhered to the requirements for writing certain information in Nepali language. CONCLUSIONS: Majority of the products did not meet the regulatory standards of primary labeling of Nepalese pharmaceutical products. This study highlights the necessities for improvement from all stakeholders.

Diabetes Mellitus with Poor Glycemic Control as a Consequence of Inappropriate Injection Technique.

Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control.

Do Face-to-Face Training and Telephonic Reminder Improve Dry Powder Inhaler Technique in Patients with COPD?

Introduction. Current modes of instruction on inhaler technique are inadequate. We aimed to evaluate the value of face-to-face training and telephonic reminder (FFTTR) for improving Rotahaler technique in experienced patients with COPD. Materials and Methods. A single group pre-/postinterventional study was conducted at Chitwan Medical College Teaching Hospital, Nepal. We assessed the Rotahaler technique of thirty consecutive patients using Rotahaler device for more than one year. Patients with incorrect technique (n = 20) were instructed and trained by a pharmacist. Telephonic reminder was used to reinstruct patients on the correct technique on weekly basis for two weeks and technique was reassessed after 4 weeks of their first training. Descriptive statistics including Wilcoxon Signed Rank test were applied. Results. The mean age was 66.06 ± 10.6. Of 30 patients, 10 (33.3%) performed Rotahaler technique correctly at baseline and were excluded from FFTTR intervention. FFTTR corrected the technique in 18 (90%) patients and the median (IQR) score increased from 6 (5-6) to 8 (8-8) (p < 0.001). The most incorrect steps were "breathe out gently but not towards the inhaler mouthpiece" (16, 80%) and "hold breath for about 10 seconds" (18, 90%) at baseline which improved after intervention. Conclusion. FFTTR approach markedly improved Rotahaler technique in patients with COPD.

Knowledge, Beliefs, and Practices on Epilepsy among High School Students of Central Nepal.

Introduction. Epilepsy continues to increase worldwide but, unfortunately, many high school students have inadequate knowledge of and negative beliefs towards the disease. We aimed to assess the knowledge, beliefs, and practices of epilepsy among high school students of Central Nepal. Materials and Methods. A cross-sectional study was performed involving 1360 high school students from 33 private schools across Bharatpur, from June 2013 to July 2013, to assess their knowledge, beliefs, and practices (KBP) on epilepsy using a standardized questionnaire. The differences in mean KBP scores between different sexes, religions, and those personally knowing versus not knowing someone with epilepsy were assessed using independent t-tests; a Pearson correlation was calculated to assess the relationship between KBP scores and age. Results. Of 1360 participants, 79 (5.8%) students had never heard or read about epilepsy and were consequently excluded from statistical analysis. Only 261 out of 1360 (19.2%) had personally known someone with epilepsy. The mean KBP scores were 5.0/8, 7.4/12, and 1.7/3, respectively. Statistically significant differences were only observed in the knowledge component of the KBP score; female scored higher than males (p < 0.001) and, interestingly, students who had personally known a person with epilepsy actually knew less than those who had not known one (p = 0.018). We also found a significant negative correlation between knowledge and age (p = 0.003). Conclusions. The overall knowledge, beliefs, and practices appear to be inadequate, emphasizing the need for further educational intervention.

Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal.

BACKGROUND: The majority of patients with asthma and chronic obstructive pulmonary disease (COPD) have been known to perform inhaler technique inadequately. We aimed to evaluate the benefit of hospital pharmacy intervention on the current status of dry powder inhaler (Rotahaler®) technique in such patients and the factors associated with the correct use. METHODS: A pre-post interventional study was conducted at the outpatient pharmacy in a teaching hospital of the Central Development Region, Nepal, in patients with asthma and COPD currently using a Rotahaler device. Patients' demographics and Rotahaler technique were assessed before intervention. Those who failed to demonstrate the correct technique were educated and trained by the pharmacist, and their technique was reassessed after 2 weeks of intervention. Descriptive statistics, including Wilcoxon signed rank test, Mann-Whitney U test, Spearman's correlations and Kruskal-Wallis test, were performed for statistical analysis. RESULTS: Before intervention, only 5.7% (10 of 174) of the patients demonstrated the correct Rotahaler technique and the most common errors observed were failure to breathe out gently before inhalation (98.8%) and failure to hold breath for about 10 seconds after inhalation (84.8%). After the intervention (n=164), 67.1% of the patients showed their technique correctly (p≤0.001) and failure to breathe out gently before inhalation was the most common error (27.44%). Age (p=0.003), previous instruction (p=0.007), patient's education level (p=0.013) and source of instruction (p<0.001) were associated with an appropriate technique before intervention, while age (p=0.024), duration of therapy (p=0.010) and gender (p=0.008) were the factors correlated with correct usage after intervention. CONCLUSION: The current status of Rotahaler technique is inadequate in patients with asthma and COPD attending the Chitwan Medical College Teaching Hospital in the Central Development Region, Nepal. However, a single hospital pharmacy intervention can significantly improve the correct use of the technique, highlighting the role of hospital pharmacies in the improvement of inhaler technique.

Opinion of hospital pharmacy practitioners toward the Continuing Pharmacy Education program: a study from a tertiary care hospital in central Nepal.

BACKGROUND: Meeting participants' needs and matching their preferences are important prerequisites for an effective Continuing Pharmacy Education (CPE) program. The objective of this pilot study was to assess the opinion of hospital pharmacy practitioners with respect to the CPE program. METHODS: The pretested questionnaires were distributed to 20 pharmacy practitioners working in a pharmacy at a tertiary care hospital in Nepal which asked for their opinions and suggestions with respect to the CPE program. Descriptive statistics were performed using IBM SPSS version 20. RESULTS: Topics related to skills development (75%) and recent innovations in pharmacy practice (65%) were mostly preferred. Live (in-person) presentations (80%) and small group discussion (60%) were the most suitable methods for delivery. Improving knowledge (75%), improving skills (60%) and keeping up-to-date in the latest information (60%) were major motivating factors to participate, while lack of time (75%) was a major barrier. Approximately 55% of the participants believed that face-to-face interview was a suitable method for evaluating the effectiveness. Allocation of separate time for the program, assessing baseline knowledge and skills of the participants along with delivery of quality materials in an understandable way were the top common suggestions for improving the CPE program. CONCLUSION: Hospital pharmacy practitioners' opinions and suggestions were assessed with respect to the CPE program and this was upgraded accordingly to meet their expectations.

Assessment of Insulin Injection Practice among Diabetes Patients in a Tertiary Healthcare Centre in Nepal: A Preliminary Study.

INTRODUCTION: Proper insulin injection practice is essential for better diabetic control. This study aims to assess the insulin injection practice of patients with diabetes. MATERIALS AND METHODS: A cross-sectional study was conducted at Chitwan Medical College Teaching Hospital, Bharatpur, Nepal, from February 2017 to May 2017. Patients injecting insulin through insulin pens (n = 43) for a minimum of 4 weeks were consecutively recruited. Patients' baseline characteristics, current insulin injection technique, insulin transportation practice, complications of insulin injection, disposal practice of used needle, and acceptability of insulin were recorded. Descriptive statistics were performed using IBM-SPSS 20.0. RESULTS: The insulin injection technique of patients and their relatives was inadequate. The majority of patients and their relatives (25, 58.1%) mentioned that they transport their insulin cartridge without maintaining cold chain. Thirteen patients (30.2%, n = 43) reported complications of insulin injection and the most common complication among those patients was bruising (10, 76.9%, n = 13). Almost all patients disposed the used needle improperly, and the common method was disposing the needle in a dustbin and then transferring to municipal waste disposal vehicle. Insulin was accepted by just 16 (37.2%) patients. CONCLUSION: There was a significant gap between the insulin delivery recommendation through insulin pen and current insulin injection practice.

Knowledge, attitude, and practice of stroke among high school students in Nepal.

BACKGROUND: Baseline stroke knowledge in a targeted population is indispensable to promote the effective stroke education. We report the baseline knowledge, attitude, and practice (KAP) of high school students with respect to stroke from Nepal. MATERIALS AND METHODS: A self-structured questionnaire survey regarding KAP about stroke was conducted in high school students of 33 schools of Bharatpur, Nepal. Descriptive statistics including Chi-square test was used, and the significant variables were subjected to binary logistic regression. RESULTS: Among 1360 participants, 71.1% had heard or read about stroke; 30.2% knew someone with stroke. 39.3% identified brain as the organ affected. Sudden onset limb/s weakness/numbness (72%) and hypertension (74%) were common warning symptom and risk factor identified. 88.9% would take stroke patients to a hospital. Almost half participants (55.5%) felt ayurvedic treatment be effective. 44.8% felt stroke as a hindrance to a happy life and 86.3% believed that family care was helpful for early recovery. Students who identified at least one risk factor were 3.924 times (P < 0.001, confidence interval [CI] = 1.867-8.247) or those who identified at least one warning symptom were 2.833 times (P ≤ 0.023, CI = 1.156-6.944) more likely to take stroke patients to a hospital. CONCLUSION: KAP of high school Nepalese students regarding stroke was satisfactory, and the students having knowledge about the risk factors and warning symptoms were more likely to take stroke patients to a hospital. However, a few misconceptions persisted.

Stroke subtype, age, and baseline NIHSS score predict ischemic stroke outcomes at 3 months: a preliminary study from Central Nepal.

BACKGROUND: The combined medications practice of using antithrombotic agents and statins with or without antihypertensive agents is common in the treatment of acute ischemic stroke in Nepal. Short-term outcomes of the current practice have been studied. We aim to explore the predictors of ischemic stroke outcomes at 3 months, with the current combined medications practice. METHODS: The study population (N=56) included acute ischemic stroke patients treated at the Neurology Department of the College of Medical Sciences-Teaching Hospital, Chitwan, Nepal, from May 2014 to August 2014 and followed up at 3 months. Death or disability (modified Rankin scale >2) was defined as poor outcomes. Multivariate logistic regression analysis (P<0.10) using potential variables from bivariate analysis (P≤0.20) was adjusted to predict outcomes at 3 months. RESULTS: At 3 months, 29 (51.8%) patients were independent, eleven (19.6%) were dependent, while 16 (28.6%) died. Stroke subtype and baseline National Institute of Health Stroke Scale (NIHSS) scores were associated with death/disability (27, 48.2%) at 3 months. Regression analysis showed that large-artery stroke (odds ratio [OR] =284.145, 95% confidence interval [CI] =5.221-15,465.136, P=0.006), age (OR =1.113, 95% CI =1.002-1.236, P=0.045), and baseline NIHSS score (OR =1.557, 95% CI =1.194-2.032, P=0.001) were significant predictors of poor outcome at 3 months. CONCLUSION: Stroke subtype, age, and baseline NIHSS score are predictors of ischemic stroke outcomes in Nepalese population treated with the current practice of using combined antithrombotic and statins with or without antihypertensive agents, and these predictors can be used for the improvement of selection of patients for the appropriate treatment.