Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit.

BACKGROUND: World Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India. METHODS: After obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed. RESULTS: A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs. CONCLUSION: While we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

Monte Carlo-based dosimetric studies of a locally developed170Tm LDR brachytherapy seed source.

170Tm is being explored as a source for applications in brachytherapy. Although it has adequate physical properties, such as a short half-life (128.6 d), high specific activity and a mean photon energy of about 66 keV, it has a drawback of low photon yield (only about six photon emissions/100 beta emissions). The objective of this work is to study the dosimetric characteristics of a locally developed170Tm brachytherapy seed source using the Monte Carlo-based EGSnrc code system. In this study, we calculate the dose rate constant, air-kerma strength, radial dose function, anisotropic function and 2D dose-rate distributions in water. Separate simulations are carried out by considering the photon (gamma and characteristic x-ray) and beta spectra of the source. For regions close to the source (surface of the source

Quantification of biomaterial dispersion during otologic procedures and role of barrier drapes in Covid 2019 era - a laboratory model.

BACKGROUND: Aerosol generation during temporal bone surgery caries the risk of viral transmission. Steps to mitigate this problem are of particular importance during the coronavirus disease 2019 pandemic. OBJECTIVE: To quantify the effect of barrier draping on particulate material dispersion during temporal bone surgery. METHODS: The study involved a cadaveric model in a simulated operating theatre environment. Particle density and particle count for particles sized 1-10 µ were measured in a simulated operating theatre environment while drilling on a cadaveric temporal bone. The effect of barrier draping to decrease dispersion was recorded and analysed. RESULTS: Barrier draping decreased counts of particles smaller than 5 µ by a factor of 80 in the operating theatre environment. Both particle density and particle count showed a statistically significant reduction with barrier draping (p = 0.027). CONCLUSION: Simple barrier drapes were effective in decreasing particle density and particle count in the operating theatre model and can prevent infection in operating theatre personnel.

MEASUREMENT OF OPERATIONAL QUANTITIES Hp(0.07) AND Hp(3) FOR INDIGENOUSLY DEVELOPED 106Ru/106Rh SOURCE USING AN EXTRAPOLATION CHAMBER.

In the present study, a prototype 106Ru/106Rh source was fabricated using high level liquid waste from reactor fuel, fixed in a stainless steel housing with a window and backing made of silver. The study involves measurement of the operational quantities Hp(0.07), Hp(3) and the percentage depth dose (PDD) using an extrapolation chamber. It also involves determination of necessary correction factors to arrive at Hp(0.07) and Hp(3) following International Organisation for Standardisation (ISO) and methods suggested in literature. The study facilitates incorporation of the 106Ru/106Rh source as a beta reference source for quality assurance programme in TLD personnel monitoring as per the guidelines of ISO.

Dosimetry of indigenously developed 177Lu patch source for surface brachytherapy-Experimental and Monte Carlo methods.

This paper describes the evaluation of dosimetry characteristics of an in-house developed 177Lu skin patch source for treatment of non-melanoma skin cancer. A 177Lu skin patch source based on Nafion-115 membrane backbone containing 3.46 ± 0.01 mCi of activity was used. Activity measurement of the patch source was based on gamma ray spectrometry using a HPGe detector. The efficiencies of the HPGe detector were fitted using an orthogonal polynomial function. The absorbed dose rate to water at 5 µm depth in water was determined using an extrapolation chamber, EBT3 Gafchromic film and compared with Monte Carlo methods. The correction factors such as Bragg-Gray stopping power ratio of water-to-air and chamber wall material being different from water, needed to be applied on measurements for establishing the dose rate at 5 µm depth, were calculated using the Monte Carlo method. Absorbed dose rate at 5 µm depth in water (surface dose rate) measured using an extrapolation chamber and EBT3 Gafchromic film were 9.9 ± 0.7 and 8.2 ± 0.1 Gy h-1 mCi-1 respectively for the source activity of 3.46 ± 0.01 mCi. The surface dose rate calculated using the Monte Carlo method was 8.7 ± 0.2 Gy h-1 mCi-1, which agrees reasonably well with measurement. The measured dose rate per mCi offers scope for ascertaining treatment time required to deliver the dose for propitious therapeutic outcome. Additionally, on-axis depth dose and lateral dose profiles at 5 µm and 1 mm depth in water phantom were also calculated using the Monte Carlo method.

Monte Carlo-based dose calculation for (32)P patch source for superficial brachytherapy applications.

Skin cancer treatment involving (32)P source is an easy, less expensive method of treatment limited to small and superficial lesions of approximately 1 mm deep. Bhabha Atomic Research Centre (BARC) has indigenously developed (32)P nafion-based patch source (1 cm × 1 cm) for treating skin cancer. For this source, the values of dose per unit activity at different depths including dose profiles in water are calculated using the EGSnrc-based Monte Carlo code system. For an initial activity of 1 Bq distributed in 1 cm(2) surface area of the source, the calculated central axis depth dose values are 3.62 × 10(-10) GyBq(-1) and 8.41 × 10(-11) GyBq(-1)at 0.0125 and 1 mm depths in water, respectively. Hence, the treatment time calculated for delivering therapeutic dose of 30 Gy at 1 mm depth along the central axis of the source involving 37 MBq activity is about 2.7 hrs.

Brachytherapy of intra ocular tumors using 'BARC I-125 Ocu-Prosta seeds': an Indian experience.

AIM: To report our experience of brachytherapy using 'BARC I-125 Ocu-Prosta seeds' for the management of intraocular tumors with regard to tumor control, globe preservation visual outcome, and patient survival at Sankara Nethralaya, Chennai, India between September 2003 and May 2011. MATERIALS AND METHODS: We reviewed records of 35 eyes of 35 patients who underwent ophthalmic brachytherapy between September 2003 and May 2011. Twenty-one cases had choroidal melanoma, nine had childhood retinoblastoma, two had adult-onset retinoblastoma, and there were one case each of vasoproliferative tumor, retinal angioma, and ciliary body melanoma. Brachytherapy was administered using a 15- or 20-mm gold plaque with or without a notch. Brachytherapy was the primary treatment modality in all tumors other than retinoblastoma, wherein brachytherapy was done post chemoreduction for residual tumor. RESULTS: For choroidal melanomas, the mean radiation dose was 68.69 ± 15.07 (range, 47.72-94.2) Gy. The eye salvage rate was 13/20 (65%) and tumor control rate was 16/20 (80%) at an average follow-up of 24.43 ± 24.75 (range, 1.5-87.98) months. For retinoblastoma, the mean dose was 45.85 ± 3.90 (range, 39.51-50.92) Gy. The eye salvage rate and tumor control rate was 5/6 (83.3%) at an average follow-up of 38.36 ± 31.33 (range, 4.14-97.78) months. All eyes with retinoblastoma needed additional focal therapy for tumor control and eye salvage. CONCLUSION: The results of this retrospective study confirms that the use of 'BARC I-125 Ocu-Prosta seeds' in episcleral plaques to treat intraocular tumors offers a viable option for the management of intraocular cancers.

Congenital anomalies presenting as recurrent post-auricular abscesses: an institution based retrospective study.

OBJECTIVES: This report is intended to bring out the association of recurrent postauricular abscess in children with various underlying congenital anomalies. MATERIALS AND METHODS: A retrospective study was done in tertiary care setting from the year August 2005 to February 2012 using the medical record department database to retrieve the patient details. During this study period, a total of 215 children with an age range of 1-14 years were treated at the hospital with postauricular abscess. We analysed the data using appropriate statistical tests for parametric and nonparametric data and setting the p value at 0.05 for significance. For testing the association between the recurrence of abscess and the presence of underlying congenital anomalies, Fischer's t test was used. RESULTS: A total of 215 patients were studied, of which 41 patients presented with recurrence. 26 of the 41 patients (63.4%) had recurrent postauricular abscess with associated congenital anomalies. Among the 26 patients, in 16 patients (62%), the recurrent abscesses were due to postauricular sinuses. Other less common causes were infected post auricular dermoid cyst, first branchial cysts, collaural fistula and congenital aural atresia. There was a statistically significant association of the recurrence of abscess with presence of underlying congenital anomalies. CONCLUSION: Paediatric recurrent postauricular abscesses are rare in the post antibiotic era. Their presence should alert a treating physician of an underlying congenital anomaly.

Targeting strategies for Human immunodeficiency virus: a combinatorial approach.

The battle between human and the Human immunodeficiency virus (HIV) is on, with both of them rapidly improving their attacking and defense strategies. Many therapeutic agents for HIV infection have been designed and developed, However there are various aspects, like novel targets against HIV, which are yet to be unfolded with a goal of designing and developing novel drug molecules against HIV. This article reviews the current status and innovative new options for antiretroviral therapy for HIV and also discusses the various mechanisms of action for each class of drugs, and the problems yet to be solved with respect to HIV as a target for improvised treatment against AIDS.

Diagnostic accuracy of small intestine ultrasonography using an oral contrast agent in Crohn's disease: comparative study from the UK.

AIM: To evaluate the usefulness of small intestine contrast-enhanced ultrasonography (SICUS) using an oral contrast agent in routine clinical practice by assessing the level of agreement with the established techniques, small bowel follow-through (SBFT) and computed tomography (CT), and diagnostic accuracy compared with the final diagnosis in the detection of small bowel Crohn's disease (CD) and luminal complications in a regional centre. MATERIALS AND METHODS: All symptomatic known or suspected cases of CD who underwent SICUS were retrospectively reviewed. The level of agreement between SICUS and SBFT, CT, histological findings, and C-reactive protein (CRP) level was assessed using kappa (κ) coefficient. Sensitivity was demonstrated using the final diagnosis as the reference standard defined by the outcome of clinical assessment, follow-up, and results of investigations other than SICUS. RESULTS: One hundred and forty-three patients underwent SICUS of these 79 (55%) were female. Eighty-six (60%) were known to have CD and 57 (40%) had symptoms suggestive of intestinal disease with no previous diagnosis. Forty-six (55%) of the known CD patients had had at least one previous surgical resection. The sensitivity of SICUS in detecting active small bowel CD in known CD and undiagnosed cases was 93%. The kappa coefficient was 0.88 and 0.91 with SBFT and CT, respectively. SICUS detected nine patients who had one or more small bowel strictures and six patients with a fistula all detected by SBFT or CT. CONCLUSION: SICUS is not only comparable to SBFT and CT but avoids radiation exposure and should be more widely adopted in the UK as a primary diagnostic procedure and to monitor disease complications in patients with CD.

Recurrent neck infection with branchial arch fistula in children.

OBJECTIVE: Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side. METHODS: A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases. RESULTS: The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence. CONCLUSION: Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.

Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis.

OBJECTIVE: We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy. METHOD: A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented. RESULTS: A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence. CONCLUSION: To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Fabrication of cesium-137 brachytherapy sources using vitrification technology.

137Cs source in solid matrix encapsulated in stainless-steel at MBq (mCi) levels are widely used as brachytherapy sources for the treatment of carcinoma of cervix uteri. This article describes the large-scale preparation of such sources. The process of fabrication includes vitrification of 137Cs-sodium borosilicate glass, its transformation into spheres of 5-6 mm diameter, casting of glass spheres into a cylinder of 1.5 mm (varphi) x 80 mm (l) in a platinum mould, cutting of the moulds into 5-mm-long pieces, silver coating on the sources, and finally, encapsulation in stainless steel capsules. Development of safety precautions used to trap 137Cs escaping during borosilicate glass preparation is also described. The leach rates of the radioactive sources prepared by the above technology were within permissible limits, and the sources could be used for encapsulation in stainless steel capsules and supplied for brachytherapy applications. This development was aimed at promoting the potential utility of 137Cs-brachytherapy sources in the country and reducing the user's reliance on imported sources. Since its development, more than 1000 such sources have been made by using 4.66 TBq(126 Ci) of 137Cs.

Hypohidrotic ectodermal dysplasia with atrophic rhinitis and nasal myiasis.

Hypohidrotic/anhidrotic ectodermal dysplasia is a rare inherited disorder characterized by hypohidrosis/anhidrosis, hypotrichosis, dysodontia and heat intolerance. Most common mode of transmission is X-linked recessive, showing complete expression in males, and only partial manifestations in the female carrier heterozygotes. Features like atrophic rhinitis, nasal and aural myiasis, syndactyly, cleft lip and/or palate, mental retardation and immunodeficiency are uncommonly seen in this syndrome. We hereby report a case of hypohidrotic ectodermal dysplasia with unusual features of atrophic rhinitis and nasal myiasis.

Myiasis in different types of carcinoma cases in southern India.

Myiasis maggots were isolated from the cancerous wounds, when the patients reported to the Department of ENT-OPD, JIPMER, Pondicherry. Maggots were identified to Chrysomyia bezziana based on characteristic patterns of posterior and anterior spiracles. Although the categories of cancer wounds were different, invasions were due to C. bezziana, which is very common in suburban areas of Tamil Nadu and Pondicherry in southern parts of India. This observation showed the importance of hygiene and sanitation in tropical countries with high fly population and emphasised the need for correct diagnosis of this obligatory myiasis, which was destructive. Through proper health care, further destabilization due to myiasis was avoided.

Subthreshold depression and cognitive impairment but not demented in stroke patients during their rehabilitation.

BACKGROUND: Subthreshold depression (sD) and cognitive impairment but not demented (CIND) in stroke patients are associated with poorer rehabilitative outcomes. Their diagnosis can easily be operationalized using validated scales. AIM: The aim of the study was to ascertain the prevalence of depressive symptoms and cognitive impairment in stroke patients during three crucial stages of the rehabilitative process, viz. upon admission, upon planned discharges from rehabilitation hospitals and at 6 months post-stroke, using validated scales like the Geriatric Depression Scale and Abbreviated Mental Test (recommended by the British Geriatric Society). Their baseline risk factors were also ascertained. RESULTS: On admission, the prevalence of depressive symptoms and cognitive impairment was 60% and 54% respectively. The prevalence upon planned discharges and 6 months post-stroke, respectively, of depressive symptoms was 38% and 34% and that of impaired cognition was 33% and 40%. Baseline independent correlates at 6 months post-stroke depressive symptoms were: recurrent stroke (OR 3.34); on admission cognitive impairment (OR 4.78) and ADL dependence (OR 5.28). And that of cognitive impairment were: increasing age (OR 8.07); post-stroke dysphagia (OR 4.58); on admission cognitive impairment (OR 23.95) and on admission depressive symptoms (OR 3.50). CONCLUSIONS: Continuous screening and appropriate intervention, especially at baseline, would significantly decrease the burden posed by stroke patients with such psychological impairments in the community.

Is improvement in impaired cognition and depressive symptoms in post-stroke patients associated with recovery in activities of daily living?

BACKGROUND AND PURPOSE: Depression and cognitive impairment after stroke are associated with physical functional outcomes, but there are limited data on whether depressive symptoms and cognitive status and improvements independently influence functional status and recovery. METHODS: In a 6-month prospective cohort study of 141 post-acute stroke patients, demographic and clinical data on admission, and neurological, cognitive, depressive symptoms and functional variables on admission and at 6 months after stroke were measured using the National Institute of Health Stroke Scale (NIHSS), Abbreviated Mental Test (AMT), Geriatric Depression Scale (GDS) and Barthel Index (BI). RESULTS: On multivariate analysis, severe activities of daily living (ADL) dependence at 6 months was significantly less likely associated with higher baseline AMT score denoting better cognitive status (OR=0.68, 95% CI 0.48-0.97 per score point) and with greater AMT change score denoting greater cognitive improvement (OR=0.61, 95% CI 0.41-0.91 per change score point); it was also more likely with higher baseline NIHSS scores denoting severe neurological impairment, (OR=1.74, 95% CI 1.13-2.63 per point score), NIHSS change score [denoting lesser neurological improvement (OR = 1.83, 95% CI 1.13-2.93 per unit change score)], but was not associated with baseline or change scores of GDS. Greater magnitudes of functional recovery [BI change score (standardized beta)] were associated with better baseline depressive symptoms (-0.21) and improvement (-0.31), but not with cognitive status or improvement, in the presence of other significant variables, neurological status (-0.89) and improvement (-0.65), lower baseline physical functional status (-0.85) and younger age (-0.23). CONCLUSIONS: These data suggest that improving depressive symptoms in stroke patients may accelerate functional recovery, but the level of physical functioning achieved post-stroke is determined by neurological and cognitive factors, consistent with the evidence that improvement of depressive symptoms through therapeutic intervention is limited by cognitive impairment.

Determinants of length of stay during post-stroke rehabilitation in community hospitals.

INTRODUCTION: Length of stay (LOS) in hospitals is the largest contributor of direct stroke care cost. Rehabilitation accounts for 16 percent of healthcare cost in the six-month post-stroke period. It is important to determine factors extending LOS in rehabilitation hospitals to identify focus areas of cost-control strategies. The aim of the study was to ascertain the predictors of LOS of post-stroke patients admitted into two community hospitals offering rehabilitation. METHODS: An observational cohort study was conducted on 200 stroke patients admitted from acute hospitals into two community hospitals. Data collected included baseline sociodemographical variables, and the National Institute of Health Stroke Scale, Abbreviated Mental Test, Geriatric Depression Scale and Barthel Index were used to assess neurological impairment, cognitive impairment, depressive symptoms and functional disability, respectively. Medical complications (defined as new or exacerbated medical problems that generated additional physician evaluation, a change in medication or additional medical intervention), after patients were admitted to the community hospitals until discharged, were recorded. The outcome variables measured were length and cost of stay. RESULTS: The mean LOS in our study was 34.4 (standard deviation [SD] 18.4) days, and the mean cost of hospital stay was S$2,410.83 (SD S$2,167.26). Length and cost of hospital stay were significantly correlated (r equals 0.52; p-value is less than 0.01). On multiple linear regression analysis, the significant variables positively associated with LOS were medical complications and functional dependence on admission. Significant variables negatively associated with LOS were unplanned discharge and recurrent strokes. CONCLUSION: Medical complication is a key reversible determinant of increased LOS of post-stroke patients receiving rehabilitation in community hospitals. Strategies for prevention, early detection and treatment of medical complications during stroke rehabilitation are discussed.

Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients.

BACKGROUND: Length of hospital stay (LOHS) is the largest determinant of direct cost for stroke care. Institutional discharges (acute care and nursing homes) from rehabilitation settings add to the direct cost. It is important to identify potentially preventable medical and non-medical reasons determining LOHS and institutional discharges to reduce the direct cost of stroke care. AIM: The aim of the study was to ascertain the total direct cost, LOHS, frequency of institutional discharges and their determinants from rehabilitation settings. METHODOLOGY: Observational study was conducted on 200 stroke patients in two rehabilitation settings. The patients were examined for various socio-demographic, neurological and clinical variables upon admission to the rehabilitation hospitals. Information on total direct cost and medical complications during hospitalization were also recorded. The outcome variables measured were total direct cost, LOHS and discharges to institutions (acute care and nursing home facility) and their determinants. RESULTS: The mean and median LOHS in our study were 34 days (SD = 18) and 32 days respectively. LOHS and the cost of hospital stay were significantly correlated. The significant variables associated with LOHS on multiple linear regression analysis were: (i) severe functional impairment/functional dependence Barthel Index < or = 50, (ii) medical complications, (iii) first time stroke, (iv) unplanned discharges and (v) discharges to nursing homes. Of the stroke patients 19.5% had institutional discharges (22 to acute care and 17 to nursing homes). On multivariate analysis the significant predictors of discharges to institutions from rehabilitation hospitals were medical complications (OR = 4.37; 95% CI 1.01-12.53) and severe functional impairment/functional dependence. (OR = 5.90, 95% CI 2.32-14.98). CONCLUSION: Length of hospital stay and discharges to institutions from rehabilitation settings are significantly determined by medical complications. Importance of adhering to clinical pathway/protocol for stroke care is further discussed.