Browsing by Author "Shankar, PR"
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Publication Publication A Point Prevalence Study of the Use of Antibiotics in Six Tertiary Care Hospitals in the Kathmandu Valley, Nepal(Kathmandu University, 2022) Jha, N; Thapa, B; Pathak, SB; Pandey, A; Pokhrel, S; Shankar, PR; Bhandary, S; Mudvari, A; Dangal, GABSTRACT Background Point prevalence survey (PPS) on antibiotic use developed by the WHO has already been used in many hospitals globally. Objective To obtain information on antibiotic prescribtion using point prevalence survey methodology in six private hospitals in the Kathmandu valley. Method This descriptive cross-sectional study was completed during 20th July to 28th July 2021 using point prevalence survey methodology. The study was conducted among inpatients admitted at or before 8:00 AM on the day of survey in various wards. Data was presented as frequencies and percentages. Result Maximum number of patients were above 60 years [34 (18.7%)]. Number of male and female participants were equal [91 (50%)]. Only one antibiotic was used in 81 patients (44.5%) followed by two antibiotics in 71 (39%) patients. Duration of prophylactic antibiotic use was one day in 66 (63.7%) patients. Blood, urine, sputum, and wound swabs were the common samples for culture. Cultures were positive for 17 (24.7%) samples. The common organisms isolated were E. Coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Ceftriaxone was the most used antibiotic. Drug and therapeutics, infection control committee and pharmacovigilance activities were present in 3/6 (50%) study sites. Antimicrobial stewardship was present in 3/6 (50%) and microbiological services was present in all hospitals. Antibiotic formulary and antibiotic guideline were present in 4/6 sites and facilities to audit or review surgical antibiotic prophylaxis choice in 2/6 (33.3%) sites, facility to monitor antibiotic use in 4/6 (66.6%) and cumulative antibiotic susceptibility reports in 2/6 (33.3%) study sites. Conclusion Ceftriaxone was the most used antibiotic. E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia were the commonly isolated organisms. Not all parameters for infrastructure, policy and practice and monitoring and feedback were present at the study sites. KEY WORDS Antibiotics, Point prevalence survey, Private hospitals, Tertiary care centersPublication A study on rational drug prescribing and dispensing in outpatients in a tertiary care teaching hospital of Western Nepal(kathmandu University, 2006) Alam, K; Mishra, P; Prabhu, M; Shankar, PR; Palaian, S; Bhandari, RB; Bista, DObjectives: To analyze the prescriptions of out-patients for rational prescribing and dispensing and to evaluate the patient’s knowledge regarding use of drugs, using INRUD indicators. Methods: A cross-sectional, descriptive study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal during the time period from June 10 th to August 19 th 2004. Results: Totally 247 prescriptions were randomly selected for analysis, wherein 720 drugs were prescribed. Only 15% of drugs were prescribed by generic name, 21.67% of the total drugs consisted of fixed-dose combinations, only 40% of drugs were from the Essential drug list of Nepal and 29.44% (n=212) were from the WHO Essential drug list. It was found that more than half (54.17 %) of the drugs were from Nepalese National Formulary and 35.69% were from WHO model formulary. Dermatological products were most commonly prescribed followed by drugs acting on central nervous system, antimicrobials and drugs acting on cardiovascular system. Among the drugs dispensed, 79.16% were oral followed by topical (18.19%) and parenteral forms (2.98%). Diagnosis was mentioned only in 3.23% (n=8) of the prescriptions and the average cost per prescription was found to be 241.11 Nepalese rupees (US$ 3.26). It was found out that pharmacist labelled only 0.4% of the medication envelopes with the name of the patient. However, 82.6% of the medication envelopes were labelled with name of the drug and 87.0 % with drug strength. Only 53.8% (n=133) of the patient knew both the duration of the therapy and administration time of drugs. Conclusion: There is a need for educational intervention for prescribers and both managerial and educational intervention for the hospital pharmacists to improve prescribing and dispensing. Key words: Rational use of drugs, Dispensing, Pharmacist, PrescribingPublication Academic detailing(Kathmandu University, 2010) Shankar, PR; Jha, N; Piryani, RM; Bajracharya, O; Shrestha, R; Thapa, HSAbstract There are a number of sources available to prescribers to stay up to date about medicines. Prescribers in rural areas in developing countries however, may not able to access some of them. Interventions to improve prescribing can be educational, managerial, and regulatory or use a mix of strategies. Detailing by the pharmaceutical industry is widespread. Academic detailing (AD) has been classically seen as a form of continuing medical education in which a trained health professional such as a physician or pharmacist visits physicians in their offices to provide evidence-based information. Face-to-face sessions, preferably on an individual basis, clear educational and behavioural objectives, establishing credibility with respect to objectivity, stimulating physician interaction, use of concise graphic educational materials, highlighting key messages, and when possible, providing positive reinforcement of improved practices in follow-up visits can increase success of AD initiatives. AD is common in developed countries and certain examples have been cited in this review. In developing countries the authors have come across reports of AD in Pakistan, Sudan, Argentina and Uruguay, Bihar state in India, Zambia, Cuba, Indonesia and Mexico. AD had a consistent, small but potentially significant impact on prescribing practices. AD has much less resources at its command compared to the efforts by the industry. Steps have to be taken to formally start AD in Nepal and there may be specific hindering factors similar to those in other developing nations. Key words: Academic detailing, pharmaceutical industry, evidence-based informationPublication All drugs are poisons at a higher dose - acute paracetamol poisoning(Institute of Medicine, 2006) Palaian, S; Shankar, PR; Poudel, R; Mishra, PAbstract Paracetamol is considered to be a safe and effective drug and is available over the counter in many countries including Nepal. Though it is considered safe at its therapeutic dose, it may be toxic at higher dose. It is recognized as a major drug leading to poisoning in the United States of America, United Kingdom and even in Nepal. Several factors such as age of the patients, sex, alcohol intake, disease conditions, concomitant drug intake etc are known to be important factors affecting the severity and outcome of the poisoning. The signs and symptoms are exhibited in a sequential manner and may start with mild nausea and may end with fulminant hepatic failure. Though paracetamol poisoning is associated with many complications and may affect the cardiovascular, respiratory and renal systems, hepatotoxicity is the major complication leading to death. Since paracetamol may be available in combination with other drugs, on many occasions the patient may not present with classical symptoms of paracetamol poisoning. Several laboratory investigations along with the patients’ signs and symptoms help in diagnosis. The management involves symptomatic treatment and a specific antidote mainly N-acetyl cysteine. The estimation of plasma paracetamol concentration is beneficial in diagnosing as well as monitoring the poisoned patient. The pattern and management of paracetamol poisoning varies with the patient populations such as pregnant women, pediatric patients etc. Several strategies including restriction of pack size have been implemented worldwide to prevent the occurrence of paracetamol poisoning. Availability of unbiased drug information is very much essential in management.Publication Ambiguous pricing of Nepalese medicines(Institute of Medicine, 2006) Shankar, PR; Subish, P; Mishra, P; Lalit, MAbstract Background: The National Drug Policy of Nepal aims to make the country self-reliant in drug production. Nepal follows a competitive market system where both domestic and foreign manufacturers compete. Previous studies had shown ambiguities in drug pricing. Recent studies are lacking. Hence the present study was carried out to obtain information on the price variation between Nepalese brands for different drugs. Methods:The prices of drugs listed in the December 2005 issue of Nepal Drug Review were analysed. The following formula was used for calculation. Percentage price variation = Price of most expensive brand – Price of least expensive brand x 100 Price of least expensive brand The drugs were grouped together into various therapeuticcategories and for each category, the mean number of brands and the mean percentage price variation was calculated. Results: A total of 79 drugs and 537 brands were analysed. Thirty-five drugs which were being manufactured by a single manufacturer were listed but were not analysed. The maximum price variation was shown by the group of anthelminthics followed by antihistamines and antiemetics. Among the individual drugs, fexofenadine and albendazole showed the maximum variation. Three of the drug groups showed more than 50% variation. However, ten individual drugs showed more than 50% variation. Conclusion: Variations were observed in the prices of different brands of the same drug being manufactured by different Nepalese companies. Prescribers and patients should be educated about drug prices. Further studies are required. Keywords: National Drug Policy, Nepal Drug Review, Ambiguous pricingPublication Anomalous branching of the axillary artery: A case report(Kathmandu University, 2006) VijayaBhaskar, P; Ritesh, R; Shankar, PRWe present a case regarding the anomalous branching in the third part of the axillary artery on the left side in a 35- year-old male Nepalese cadaver. In the third part the axillary artery divided into superficial brachial and deep brachial arteries. The superficial brachial artery continued in the arm without giving any branches and ended in the cubital fossa dividing into radial and ulnar arteries. The deep brachial artery gave rise to subscapular, profunda brachii, articular branch to the shoulder joint, anterior circumflex humeral artery and posterior circumflex humeral artery. This variation is very rare and incidence is around 0.12-3.2% in the available literature. The normal and abnormal anatomy of the axillary region is having practical importance for the vascular radiologist and surgeon and it should be known for accurate diagnostic interpretation. Key words: Axillary artery, brachial arteryPublication Assessing Drug Utilization in the Emergency Medicine Department at a Tertiary Care Teaching Hospital Using WHO Drug Use Indicators(Kathmandu University, 2024) Jha, N; Manandhar, T; Oli, E; KC, P; Jha, AK; Karki, PS; Hada Batajoo, K; Shankar, PRABSTRACT Background Patients might need urgent care in critical cases. Limited resources and limited manpower are limitations seen in developing countries. Very few studies have been conducted on drug utilization in the emergency department in Nepal. Objective To find out the drug utilization pattern and the cost of medicines in emergency medicine department as per WHO drug use indicators. Method The study design was a hospital based retrospective cross-sectional study done at the emergency department of KIST Medical College and Teaching Hospital, Lalitpur, Nepal. The study population were patients visiting the emergency department. The data was collected during the period from April to June 2023. Data was collected for one month from each quarter for the year 2023 from the medical records of the patients from the medical records section. A structured proforma was used for the data collection process. Census sampling method was used. Result Maximum patients, 257 (25.1%) were from age group 21-30 years. Females were slightly more than males, 537 (50.5%). The top three diagnosis among the admitted patients were soft tissue injury, 148 (13.9%), dengue fever, 138 (12.9%) and viral fever, 51 (4.7%). Maximum patients, 346 (32.5%) were given two therapeutic classes of drugs, followed by only one therapeutic class of drug for 251 (23.6%) patients. The common classes of drugs prescribed for the patients were analgesics, 639 (60.1%) followed by intravenous fluids, 410 (38.5%) and antiulcer drugs, 377 (35.4%). The total cost of drugs used was calculated as Rs. 305126.4 (2280.99 USD) and the average cost per patient was Rs. 297.97 NPR; 2.23 USD. The WHO drug prescribing indicators showed maximum percentage, (85.4%) of encounters with injection prescribed followed by the percentage of drugs prescribed from the Nepalese National List of Essential Medicines 81.71%. Conclusion On the basis of the findings from this study injection prescribing, and the number of drugs prescribed per encounter showed considerable deviation from the standards recommended by the WHO. Hence, it is important for the hospital to design and implement a system to promote judicious prescribing and injection medication administration. KEY WORDS Drug utilization, Emergency department, WHO core drug use indicators, NepalPublication Cephalosporin utilization in the inpatient wards of a teaching hospital in western Nepal(Institute of Medicine, 2005) Shankar, PR; Subish, P; Dubey, AK; Deshpande, VYAbstract Objective and rationale: Information on the utilization of cephalosporins is lacking in hospitals in western Nepal. The present study was carried out to obtain information on the demographic characteristics, cephalosporin prescribing patterns, sensitivity patterns of commonly isolated microorganisms, mean ± SD cost of drugs per patient and the cephalosporin utilization in defined daily dose (DDD)/100 bed-days. Methods: A retrospective analysis of the case records of patients admitted to the inpatient wards of the Manipal Teaching Hospital (a tertiary care hospital in Pokhara, Nepal) and prescribed a cephalosporin during the study period (1.11.2003 to 29.02.2004) was carried out. The median length of stay and cost of the drugs prescribed during the stay was calculated. The frequency of prescribing of other antibiotics coprescribed with cephalosporins was noted. Results: 252 patients (2.56% of total patients) were prescribed cephalosporin. The median length of stay was 9 days. One hundred eighteen patients (46.8%) were prescribed cephalosporin for prophylaxis and 30 patients (11.9%) for bacteriologically proven infections. E.coli, Klebsiella spp., S.aureus, Acinetobacter spp., P.aeruginosa, P.vulgaris and Enterococcus spp. were the common organisms isolated and were generally sensitive to the prescribed cephalosporins. Mean ± SD cost of drugs per hospital admission was 34.78 ± 26.06 US$ and cephalosporins contributed to 51.56% of the total drug costs. Cephalosporin utilization was 4.6 DDDs/100 bed days. Metronidazole was the most commonly coprescribed. Conclusions: The use of cephalosporins was lower than that reported in the literature. Antibiotic use policies for postoperative prophylaxis and infection control policies for the wards are required.Publication Publication Publication Drug induced hepatitis with anti-tubercular chemotherapy: Challenges and difficulties in treatment(Kathmandu University, 2007) Kishore, PV; Palaian, S; Paudel, R; Mishra, P; Prabhu, M; Shankar, PRTuberculosis is a major health burden worldwide. In Nepal, it is a significant cause of morbidity and mortality. Although better drugs are available for managing tuberculosis, treatment failure is one of the common problems encountered. Among the various causes which can cause treatment interruption, drug induced hepatotoxicity is a common cause. Isoniazid and Pyrazinamide are the common drugs causing hepatotoxicity. Upon occurrence of hepatotoxicity, the hepatotoxic drugs should be stopped and reintroduced as per the available guidelines. The healthcare professional should also counsel the patients for recognizing the early symptoms due to hepatotoxicity which could prevent morbidity. Key words: Adverse effects, Hepatotoxicity, Tuberculosis.Publication Emotional impact of cadaver dissection: a survey in a medical college in western Nepal(Kathmandu University, 2005) Vijayabhaskar, P; Shankar, PR; Dubey, AKObjectives: Adverse physical and psychological effects to human dissection have been reported in many studies. In Nepal, the basic science subjects are taught in an integrated manner in the first four semesters of the MBBS course. Studies on the attitudes of medical students towards anatomy dissection are lacking in Nepal. The present study was carried out to obtain information on the present and initial perception of medical students on exposure to anatomy dissection and the association, if any, of the perception with demographic factors. Methods: The study was carried out among the first, second and third semester students at the Manipal College of Medical Sciences, Pokhara using the appraisal of life events (ALE) scale in February 2005. Sixty-three first semester, 57 second and 65 third semester students successfully completed the questionnaire and their responses were taken up for analysis. Information on sex, age, nationality, religion, food habits, occupation of parents and selection procedures of respondents was collected. The parameters loss, challenge and threat were measured on first exposure to dissection and at the time of the study. The scores were compared among different categories of students (p< 0.05). Results: 185 of the 225 students (82.2%) successfully completed the questionnaire. The median initial loss, challenge and threat scores were 2, 19 and 4 respectively. The median present loss, challenge and threat scores were 1, 20 and 0 respectively. The present threat score was higher among second semester students. The initial loss was higher among Indians and the present challenge score was higher among vegetarians. Conclusions: The loss and threat score were low compared to that reported in a previous study. The challenge scores were higher than those reported previously. Majority of students considered anatomy dissection as a significant life experience and one which was largely positive. Further studies with a larger student population and in other medical colleges are required. Key words: Anatomy dissection, emotional impact, medical studentsPublication Publication Familial Erythrocytosis(Institute of Medicine, 2008) Piryani, RM; Osti, B; Shankar, PRAbstract Erythrocytosis is a rare red cell disorder characterized by an elevated haematocrit (Hct) and haemoglobin (Hb) level and red blood cells (RBC) with normal white cells and platelets. Both sporadic and familial forms exist. A 49 years old gentleman presented with lightheadedness, tinnitus, dizziness and uncontrolled hypertension of 5 days duration KIST Medical College Hospital Lalitpur Nepal. His Hb was 17.0 g/dl, Hct 69%, red blood cell (RBC) count 5.8Million, white blood cell (WBC) 10500 and platelets 255000. His oxygen saturation was 98% and serum erythropoietin level was 11.3 m IU/milt (normal range 3.7-29.7m IU/ml). Hb and Hct of his elder brother was 16.5 g/dl and 54% respectively and of elder sister 14.5 g/dl and 50% respectively. Our patient was having erythrocytosis most likely familial. Family didn’t agree for genetic workup; this is the limitation of our case report. Keywords: Erythrocytosis, Familial, NepalPublication Ginkgo biloba- an appraisal(Kathmandu University, 2004) Dubey, AK; Shankar, PR; Upadhyaya, D; Deshpande, VYGinkgo biloba has been used in traditional Chinese medicine for about 5000 years. A standardized preparation, EGb 761 has been recently prepared. The pharmacologically active constituents, flavonol glycosides and the terpene lactones are standardized. The terpene lactones comprise of ginkgolides A, B, C and bilobalides. The extract scavenges excess free radicals and pretreatment with EGb 761 reduces damage by free radicals in patients undergoing coronary bypass surgery. The action of platelet activating factor is antagonized and platelet aggregation is reduced. Blood flow is increased. Release of prostacyclines and nitric oxide was shown to be stimulated. Ginkgo biloba has been found to be useful in the treatment of Alzheimer’s disease and cognitive impairment. EGB 761 has shown beneficial effect in aging and mild cognitive impairment. Bilobalide has been shown to be protective against glutamate-induced excitotoxic neuronal death. Early studies indicate a potential role in age-related macular degeneration and some types of glaucoma. Anticancer action is related to antioxidant, anti-angiogenic and gene regulatory actions. Ginkgo biloba has shown overall improvement in about 65% of patients with cerebral impairment and a similar percentage suffering from peripheral vascular diseases. A recent study suggested that phytoestrogens in Ginkgo biloba may have a role as alternative hormone replacement therapy. Recent trials have not shown a beneficial effect of Ginkgo biloba in tinnitus and acute mountain sickness. Ginkgo biloba increased the bioavailability of diltiazem. The extract has been shown to protect against doxorubicin-induced cardiotoxicity and gentamicin-induced nephrotoxicity in animals. Ginkgo biloba inhibits microsomal enzymes and has a potential for drug interactions. Further studies to establish the efficacy of Ginkgo biloba are required. Key words: Dementia, Drug interactions, Ginkgo biloba extract, Neuroprotection, Peripheral vascular diseasePublication Publication In the Foothills of Medicine: A Young Doctor’s Journey from the Inner City of Chicago to the Mountains of Nepal(Institute of Medicine, 2006) Shankar, PRNA.Publication Initiating and strengthening medical student research: Time to take up the gauntlet(Kathmandu University, 2006) Shankar, PR; Chandrasekhar, TS; Mishra, P; Subish, PSelf-directed learning and evidence-based medicine are becoming increasingly important in medical education. Medical student research projects can enable students to learn research methodologies and critical analysis skills. Medical schools in developed countries have introduced research programmes for medical students. A few medical colleges in developing countries have initiated student research programmes. South Asia has a huge population and massive health problems and research may be helpful in finding solutions. Student research can contribute to the published output of institutions. Research projects can help students to develop critical analysis skills, teach them to write for peer-reviewed publications and can foster student-faculty interaction. In Nepal, opportunities and funding for research are limited. Principles of scientific research should be taught to students. A community research project should be made compulsory. Funding for research should be boosted and infrastructure strengthened. Faculty members actively involved in research can serve as powerful ‘role models’. Marks should be allotted for research projects and students must be encouraged to publish their findings. Publications and projects should be considered during admission to postgraduate courses. Student research should be initiated, actively pursued and strengthened.Publication Intensive care unit drug utilization in a teaching hospital in Nepal(Kathmandu University, 2005) Shankar, PR; Partha, P; Dubey, AK; Mishra, P; Deshpande, VYObjectives: The intensive care unit (ICU) is a setting where a large number of drugs are administered to patients and the costs of hospitalization and drug treatment are high. Information on drug utilization in intensive care units (ICUs) are lacking in western Nepal. The present study was carried out to obtain information on the basic demographic pattern of the respondents , drug utilization during the study period, the antibiotic sensitivity patterns of isolated microorganisms and measure drug consumption in defined daily dose (DDD)/ 100 bed-days. Methods: A retrospective analysis of patients admitted to the ICU of the Manipal Teaching hospital, Pokhara, Nepal during the time period from 01/02/2002 to 31/05/2002 was carried out. The ICU mortality rate, length of stay greater than 7 days and median length of stay were calculated. Results: A total of 259 individuals were admitted. The ICU mortality rate was 15.4%; median length of stay was 4 days. E.coli, H.influenzae, K.pneumoniae, S.aureus and P.aeruginosa were the common organisms isolated and were found to be resistant to some of the commonly used antibiotics. Mean ± SD number of drugs and cost of drugs were 5.1 ± 2.7 and 1958.5 ± 1267.8 Nepalese rupees (25.1 ± 16.2 US$). Total drug consumption was 356.4 DDD/100 bed-days. Consumption of intravenous fluids was 25.8 litres/100 bed-days. Conclusions: An antibiotic use policy should be framed. Formation of a multidisciplinary team to oversee drug use and periodically review microbial sensitivity patterns will be helpful. Longitudinal surveillance of ICU drug use should be carried out. Key words: Antibiotic sensitivity patterns, Defined daily dose, Drug utilization, Intensive care unit