Drug Utilization Study in Outpatient Department of Ophthalmology in Tertiary Care Hospital.

Background The advancement in drug development and availability of newer drugs has improved overall health services including decrease in mortality and hospital stay. Along, it has brought negative impacts such as polypharmacy and associated adverse drug reactions and antimicrobial resistance. Drug utilization research is an essential approach to understand the drug use pattern, identify the early signs of such irrational drug use and to improve quality of drug use. Objective To study the drug utilization pattern in the Ophthalmology Outpatient department (OPD) of Dhulikhel Hospital, Kathmandu University Hospital (DH-KUH). Method A descriptive, cross sectional study was conducted from March 2019 to August 2019 in patients attending OPD of Ophthalmology in Dhulikhel Hospital, Kathmandu University Hospital. Prescriptions of 311 patients were analyzed using World Health Organization (WHO) International Network of Rational Use of Drug (INRUD) and additional other indices. The descriptive data was presented in mean and standard deviation. Result The average number of drugs per prescription was 2.10±1.35. Out of total 311 prescriptions, drugs prescribed in generic name were 152 (23.30%). Total antibiotics encountered were 247 (37.90%) and total drugs prescribed from National Essential Medicine List (NEML) were 371 (56.90%). Antibiotics 247 (37.90%) were the most commonly prescribed drugs followed by lubricants 146 (22.40%). Conclusion Practice of polypharmacy was very high. Most of the drugs were prescribed in brand names and antibiotics were the most frequently used drugs.

Study on Patient's Perception on Medication Counseling at Community Pharmacy in Sub-urban Area of Nepal.

Background Community pharmacists are the primary contact point in a healthcare system who provide medication information to the patients and enable them to make appropriate decision regarding their therapy. Hence, this study explored patients' perception of community pharmacist based on medication counseling. Objective To study patient's perception on medication counseling by community pharmacist at Manohara Municipality, Kathmandu, Nepal Method A cross sectional study was conducted from November 2020 to April 2021 in population visiting pharmacies of Kageshwori Manohara Municipality of Kathmandu valley. A total of 384 participants included in the study were surveyed using a structured questionnaire exploring the content of medication counseling, level of satisfaction on counseling and use of various means of counseling. Descriptive data were presented in frequencies and percentages using EXCEL 2016. Result This study enrolled 384 participants out of which 354, 92.19% received medication counseling. The main reason of pharmacy visit was to obtain over the counter medicines, 262, 68.23%. Majority of the participants rated satisfied with informations provided on use of medication 218, 56.77%, duration of therapy 261, 67.97%, about side effects 211, 54.95% and on action to be taken following side effects 246, 64.06%. Most of the participants rated satisfied with counseling on storage 189, 49.22% and for referral 250, 65.10% while 201, 52.34% participants rated highly satisfied with advice on lifestyle and dietary changes required. Conclusion This study concludes that the patients' perception regarding the medication counseling by community pharmacist was acceptable. Thus pharmacists should be encouraged to support patients with their medication to promote patient care.

Ultrasound Guided Stellate Ganglion Block with Dexmedetomidine as an Adjuvant in Complex Regional Pain Syndrome (CRPS).

This is a case report of successful use of ultrasound for stellate ganglion (SG) blocks in CRPS I in 11 patients using local anesthetic bupivacaine with injection dexmedetomidine as an adjunct. Ultrasound helped us to deposit Local anesthetics in target area without any noticeable side effects and trauma to adjacent structures.

Ultrasonographic Assessment of the Distance of Sciatic Nerve Bifurcation from the Popliteal Crease and its Depth from Skin in Volunteers.

Background Sciatic nerve block used for various surgeries below knee and for maintenance of analgesia demonstrates wide variability regarding its bifurcation into tibial and common peroneal nerves, frequently accounting for incomplete nerve blocks. Objective To determine the variation of sciatic nerve bifurcation among Nepalese volunteers. Method This cross sectional study was conducted in the Department of Anesthesiology of Kathmandu Medical College Teaching Hospital from March to May 2019, where 110 healthy volunteers underwent ultrasonography of sciatic nerve starting from popliteal fossa to its bifurcation. The distance between the bifurcation of sciatic nerve from popliteal crease and depth of the nerve at that point from the skin were measured. Result The mean distance at which sciatic nerve bifurcated from the popliteal crease was 5.42 ± 1.37 cm. Most commonly, the sciatic nerve bifurcated at a distance of 5-7 cm from the popliteal crease in 110 limbs (50.45%). However, in 80 limbs (36.69%), the bifurcation was found at less than 5 cm from the popliteal crease. The depth of the nerve from the skin at the point of bifurcation was 1.72 ± 0.54 cm, with results showing it was deeper in females compared to males (p value < 0.001). Conclusion This study showed that though the distance of sciatic nerve bifurcation from the popliteal crease in our study group was coherent with the published literature of 5-12 cm; many volunteers also had this bifurcation at distances less than 5 cm. Females showed nerves to be deeper at the point of bifurcation than males.

Water dynamics in rigid ionomer networks.

The dynamics of water within ionic polymer networks formed by sulfonated poly(phenylene) (SPP), as revealed by quasi-elastic neutron scattering (QENS), is presented. These polymers are distinguished from other ionic macromolecules by their rigidity and therefore in their network structure. QENS measurements as a function of temperature as the fraction of ionic groups and humidity were varied have shown that the polymer molecules are immobile while absorbed water molecules remain dynamic. The water molecules occupy multiple sites, either bound or loosely constrained, and bounce between the two. With increasing temperature and hydration levels, the system becomes more dynamic. Water molecules remain mobile even at subzero temperatures, illustrating the applicability of the SPP membrane for selective transport over a broad temperature range.

Craniofacial Microsomia: Goldenhar Syndrome in Association with Bilateral Congenital Cataract.

Craniofacial microsomia (CFM) includes a spectrum of malformations primarily involving structures derived from the first and second branchial arches. Patients with hemifacial microsomia and epibulbar dermoids are said to have Goldenhar syndrome (GHS). Four-month-old boy with whitish pupillary reflex presented with the features of GHS in pediatric ophthalmology clinic. The child had ocular and auricular manifestations. There were no vertebral anomalies, but he had bilateral congenital cataract. The peculiarity of this case is the presence of the bilateral total congenital cataract, in association with CFM. There is absence of epibulbar dermoid or lipodermoid in the eyes, although the child had features of GHS. In addition to it, anesthetic intubation was smooth in this case. Any case diagnosed with CFM and/or GHS needs treatment through multidisciplinary approach, consultation in ophthalmology department is one of them.

Perceptions and Attitudes towards Evidence Based Practice among Nurses and Nursing Students in Nepal.

Background As the evidence based practice (EBP) movement expands, there is a need for health leaders and educators in each country to assess the extent to which health professional students and practitioners are prepared to locate, evaluate, and apply evidence to guide their practice. Objective The study objective was to explore nurses' and nursing students' perceptions and attitudes towards EBP. Method This was a descriptive cross-sectional survey administered to all 273 nurses and nursing students from Nepal who attended an EBP conference. The survey instrument that was used by Majid in Singapore was adapted for use in this study with permission from the author. Result In total, 121 nurses participated in the study. The majority (93%) of respondents reported that they had no previous training in EBP. The respondents' perceptions of their EBP knowledge and skills were variable, but most of them demonstrated positive attitudes toward EBP. Respondents identified a number of barriers that limit the implementation of EBP in Nepal. The greatest barriers were lack of time and resources, difficulty understanding research articles and translating the findings to practice, and limited autonomy to change practice based on evidence. Conclusion Although respondents had positive attitudes towards EBP, their knowledge and skills were limited and barriers to implementation existed. Nursing faculty can use the findings to guide implementation of EBP into curricula, and nursing administrators and clinicians can use the findings to guide practice to promote EBP.

Growing Resistance to Vancomycin among Methicillin Resistant Staphylococcus Aureus Isolates from Different Clinical Samples.

INTRODUCTION: Methicillin resistant Staphylococcus aureus (MRSA), majorly associated with nosocomial and community infections worldwide, are emerging as resistant strains to many antibiotics narrowing down the efficacy of antimicrobial therapy. In order to investigate the changing resistant pattern of MRSA to empirical drugs, the study was carried out at KIST Medical College and Hospital, Nepal. It also aims to determine the minimum inhibitory concentration (MIC) of vancomycin among MRSA. METHODS: Altogether 3500 clinical samples including 1303 blood, 1489 urine and 708 body fluids were collected and processed. Isolated S. aureus were further screened for methicillin resistance by Kirby-Bauer disk diffusion technique using cefoxitin (30µg) disk. All MRSA were subjected to in vitro determination of MIC of vancomycin by agar dilution method as recommended by CLSI guidelines. RESULTS: Total 287 S. aureus were isolated from the different clinical samples. Altogether 248 (86.41%) were found to be multidrug resistance (MDR) while 42 (14.63%) of the isolates were methicillin resistance with the highest prevalence in the age group of 16-30. All 42 (100%) MRSA isolates were resistant to ampicillin and penicillin followed by 41 (97.62%), 32 (76.19%), 31(73.81%), 29 (69.05%), 9 (21.43%) and seven (16.67%) to cefotaxime, gentamycin, cotrimoxazole, erythromycin, tetracycline and ciprofloxacin respectively. Although all MRSA strains were sensitive to vancomycin on disc diffusion, four isolates were intermediates in vitro determination of MIC of vancomycin. The break point for vancomycin was found to be 15mm. CONCLUSIONS: The increment in vancomycin MIC among MRSA is alarming. Strict control measures to prevent MRSA spread and a routine surveillance for VRSA must be incorporated in hospitals.

Visual Axis Opacification in Children Following Paediatric Cataract Surgery.

Visual axis opacification (VAO) occurs in up to 40% of pediatric patients after cataract surgery withintraocular lens implantation(IOL) even with a primary posterior capsulotomy (PPC). In both children and adult group, opacification does obscure the visual axis. However, in children after PPC, there is no capsule. Hence, the terminology VAO is used in children rather than posterior capsular opacification. This opacification is caused by a proliferation of epithelial cells on the posterior capsule or anterior vitreous face and can hinder the optical image quality needed for normal visual development. The rate of epithelial mitotic activity is higher in children compared to adult. It can be managed by Yag laser or surgical membranectomy, the latter is preferable. International and national published articles were systematically reviewed on aetio-pathogenesis, surgical techniques and equipment, type and material of IOL, and management of VAO in children operated for cataract. Author's experience was also included to write manuscript. VAO is frequent complication following cataract surgery in pediatric patients. Age of cataract patients, surgical technique and type and materials of IOL are most common influencing factor for VAO. Immediate management with advance equipment of VAO reduces the incidence for development of irreversible stimulation deprivation amblyopia.

Retinoblastoma: geographic distribution and presentation at a tertiary eye care centre in Kathmandu, Nepal.

INTRODUCTION: Several aspects of retinoblastoma in Nepal remain enigmatic. OBJECTIVE: To assess the demographic and geographic distribution, clinical presentation, and treatment methods of retinoblastoma at a tertiary level ophthalmic institution in Kathmandu, Nepal. MATERIALS AND METHODS: A retrospective analysis of all the patients diagnosed with retinoblastoma at Tilganga Institute of Ophthalmology from July 2004 to June 2008 was performed. The main outcome measures included region of residence, treatment options and histopathological findings. The histopathological analysis was performed on enucleated and exenterated specimens. STATISTICS: The statistical analysis was performed with SPSS Version 11.5. Descriptive statistics are represented as mean ± standard deviation. All tests were two-sided and the P-values of less than 0.05 were considered statistically significant. RESULTS: Thirty patients presented with retinoblastoma during the study period. The mean age at presentation was 2.5 ± 1.6 years (range five months to seven years). Ten of the 12 patients who presented with bilateral retinoblastoma (83 %) were from the Terai region of Nepal. The ratio of unilateral to bilateral cases in the Terai region was 1:2. This differed significantly with the ratio in the hilly region (Fisher's Exact Test, p = 0.0012). The mean duration of symptoms before presentation was 2.5 3.2 months (range three days to 12 months). Twenty-four patients (80 %) presented with leukocoria. Eleven patients (36.6 %) presented with leukocoria as their only symptom. Ninety-seven percent of the patients underwent either enucleation (90 %) or exenteration (6.7 %) of at least one eye. CONCLUSION: Bilateral retinoblastoma is more prevalent in the Terai region of Nepal. The majority of the patients present with leucokoria and are treated with enucleation.

Bruckner red light reflex test in a hospital setting.

BACKGROUND: Childhood blindness is a major problem in developing world including Nepal that needs to be addressed. OBJECTIVE: The objective of study was to measure the effectiveness of the Bruckner red reflex test for screening of posterior segment opacities in children. METHODS: Patients aged less than five years who came to the Tilganga Institute of Ophthalmology, Kathmandu from March to August, 2009 were recruited in this cross-sectional descriptive study. Children were screened with the Bruckner red light reflex test in a dark room. Patients with abnormal Bruckner tests had their eyes dilated for further investigations. Abnormalities were recorded. The number of patients with an abnormal Bruckner test was recorded and correlated with their potential pathology. RESULTS: A total of 172 patients with 97 boys and 75 girls were included. Twenty-three had abnormal Bruckner test results in either one or both eyes. Four of these twentythree patients had no pathology diagnosed; hence the sensitivity of the Bruckner screen to diagnose significant pathology was calculated at 82.6%. Of the 153 patients with normal results, two patients were found to have pathology detected, which included cataract and strabismus. Hence, the specificity of this test was 98.7%. The screening test had a positive predictive value of 90.5% and a negative predictive value of 97.4%. CONCLUSION: Bruckner test screening is a sensitive and specific marker for detecting the posterior segment opacities in children. We recommend utilizing the test to evaluate these problems where other technologies are rare.

Cataract surgery in children: controversies and practices.

Pediatric cataract is totally different from adult cataract. The objective of this review article is to describe the peculiarities of pediatric cataract and the controversies and practices in pediatric cataract surgery. The differences in the surgical technique are discussed in the article. There are lots of controversies regarding IOL implantation in children. The result of the review is that the pediatric cataract surgery should be performed in between 6-8 weeks of age. There is no contra-indication for IOL implantation. Surgeons can implant either polymethylmethacrylate (PMMA) or Acrysoft foldable IOL.

Aberrant regeneration of the third cranial nerve.

BACKGROUND: Aberrant regeneration of the third cranial nerve is most commonly due to its damage by trauma. CASE: A ten-month old child presented with the history of a fall from a four-storey building. She developed traumatic third nerve palsy and eventually the clinical features of aberrant regeneration of the third cranial nerve. The adduction of the eye improved over time. She was advised for patching for the strabismic amblyopia as well. CONCLUSION: Traumatic third nerve palsy may result in aberrant regeneration of the third cranial nerve. In younger patients, motility of the eye in different gazes may improve over time.

Goldenhar syndrome in association with Duane syndrome.

Goldenhar syndrome (GHS) is also known as Oculo-Auriculo-Vertebral (OAV) syndrome or Branchial arch syndrome. Duane retraction syndrome (DRS) is a congenital disorder of ocular motility characterized by limited abduction, adduction or both. It is unilateral in 80% of cases. The important and interesting part of this eight months old child is presence of GHS with DRS. She has bilateral invol-vement, which is seen in only 5-8% of GHS, as compared to high incidence of unilateral involve-ment. This child also had refractive error of + 6.00/ - 1.5 * 180. At four year of age her vision with glass was 6/9. Children with GHS and DRS should have early eye examination done to treat the problem of refractive error.

Axial length in eyes with bilateral pediatric cataract at tertiary eye care center in Nepal: a preliminary report.

The aim of the study was to determine the average axial length reading of the bilateral pediatric cataract undergoing cataract surgery. Pre-operative axial length measurement was done in 80 children below 15 years who had bilateral pediatric cataract. Axial length measurement was done in 56 fellow eyes. The axial length was measured under general anesthesia with the Accutome A-scan. The mean age was 69.7 months (SD=52.6), range from one month to 168 months. The mean axial length reading was 21.3 mm in operated eyes and 21.1 mm in fellow eyes. The range of axial length reading was 16.2 -31.5 mm in operated eyes and it was 16.5 -31.5 mm in fellow eyes. This short observation found that in bilateral pediatric cataract, the axial length value is similar in both operated and fellow eyes. Based on the axial length value of the operated eye, the patients with bilateral congenital cataract can undergo surgery in those eye hospitals where facilities of measurement of axial length is not available.

Validation of performance of certified medical assistants in preschool vision screening examination.

INTRODUCTION: Preschool vision screening examination is still a new concept in Nepal. There is a need for developing cost-effective tools for detecting amblyogenic factors in Nepalese children. Certified medical assistants (CMA) are health personnel who work in village health posts. OBJECTIVE: To find out the effectiveness of vision screening by certified medical assistants using simple tools like an HOTV chart and the Red Reflex test. MATERIALS AND METHODS: A cross sectional and validation study was carried out in two phases. In the first phase, 20 CMAs from each Village Development Centre (VDC) of the Bhaktapur District were given training on visual acuity test by using an HOTV chart, Bruckner test by using a retinoscope and the test for ocular alignment by a torch light. In the second phase, children aged 3 - 7 years were examined by trained certified medical assistants in five remote VDCs of Bhaktapur District. These children underwent the gold standard examination by two pediatric ophthalmologists blind to the CMAs± findings. RESULTS: The mean age of children was 5.26 ± 376 years. The overall sensitivity of certified medical assistants examination was 58 % and the specificity was 98 %. While comparing the test characteristics of different examination tools, the HOTV test was found to be the most effective one with the sensitivity of 80 % and the specificity of 98 %. CONCLUSION: Vision screening by certified medical assistants can help in detection and early referral of children having amblyogenic risk factors with high sensitivity. The HOTV test is the most effective one with high sensitivity and specificity. In developing countries like Nepal,where access to regular eye examination is a rare possibility, preschool vision screening using the HOTV test can be effective.

Tertiary eye care centre model for development of paediatric cataract surgery services in developing countries.

It is estimated that every minute a child becomes bilaterally blind in developing nations. Paediatric cataract blindness presents an enormous problem to developing countries in terms of the human social burden, economic loss, and morbidity. The management of the paediatric cataract is lens aspiration with intra ocular lens implantation with anterior vitrectomy. The surgery should be performed by paediatric ophthalmologist in tertiary eye care centres. Facilities of general anaesthesia should be available in these centres and the operating theatres should be well-equipped with vitrectomy machine, biometry and portable keratometer.

Impalement injury to the heart.

Cardiac impalement injury is rare and one of the most severe penetrating chest injuries, often fatal. The management of penetrating cardiac injuries is a challenging one. The success in management of impaling cardiac trauma requires stabilization of the impaling object, expeditious transfer to a facility for open heart surgery, rapid imaging, access to blood and blood products and a ready surgical team. We report a case of impalement injury to the heart by a stick, transfixing the right ventricle and its successful treatment.

Ocular morbidity among orphanages.

INTRODUCTION: The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley. METHODS: A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression. RESULTS: A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbidity was 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall). CONCLUSIONS: Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal.