Dementia care landscape in Nepal: Understanding the context, barriers, and opportunities for the development of a national dementia care plan.

OBJECTIVE: This study was conducted to comprehensively understand the context, barriers, and opportunities for improving dementia care, treatment, and support. The objective is to guide the development of a national dementia care plan. METHODOLOGY: This document review was conducted by analyzing literature available in the public domain, including scientific publications, project documents/reports, media reports, and hospital records. Additionally, annual reports published by the Department of Health Services, national census and demographic and health survey reports, Old Age Homes, and other relevant government reports were examined. Firsthand information was gathered from relevant stakeholders based on the World Health Organization's situational analysis framework for dementia plans. This framework encompasses four domains: Policy context (national ministries, legislation, policies, strategies, plans related to dementia, mental health, aging, and disability), service delivery assessment (health and social care workforces, services, support and treatment programmes, and promotion of awareness and understanding), and epidemiological indicators (prevalence and incidence rates of dementia, risk factors). Ethical clearance was obtained from the Institutional Review Committee (IRC) of B.P. Koirala Institute of Health Sciences (IRC no.2658/023). RESULTS: Existing policies in Nepal inadequately address the needs of people with dementia and their caregivers. Concerning health services, the Government of Nepal provides financial subsidies to individuals diagnosed with dementia; however, numerous hurdles impede access to care. These obstacles include geographical and structural barriers, an inefficient public healthcare system, weak governance, financial constraints, low awareness levels, stigma, and inadequate workforce. Furthermore, the absence of robust nationally representative epidemiological studies on dementia in Nepal hampers the development of evidence-based plans and policies. Similarly, there are no interventions targeted at caregivers of people with dementia, and no initiatives for dementia prevention are in place. CONCLUSIONS: This review underscores the urgent need to formulate a comprehensive national dementia care plan to address the growing challenges. Key priority action areas include the integration of dementia care into primary healthcare services, training workforce to provide the care, increasing awareness, mitigating stigma, developing caregiver support programs, and initiating high-quality research to inform evidence-based policymaking.

Annual consumption of parenteral antibiotics in a tertiary hospital of Nepal, 2017-2019: a cross-sectional study.

SETTING: Patan Hospital, a tertiary care hospital in Lalitpur District, Nepal. OBJECTIVES: To describe the annual parenteral antibiotic consumption in 1) defined daily dose (DDD) and DDD per 100 admissions; 2) calculate DDD per 100 admissions and proportions by pharmacological subgroup, chemical subgroup and AWaRe categories; and 3) describe patient expenditure on parenteral antibiotics as a proportion of the total patient expenditure on drugs and consumables between 2017 and 2019. DESIGN: This was a cross-sectional study. RESULTS: Total DDD of parenteral antibiotics increased by 23% from 39,639.7 in 2017 to 48,947.7 in 2019. DDD per 100 admissions increased by 10% from 172.1 in 2017 to 190.2 in 2019. Other beta-lactam antibacterials comprised the most frequently consumed pharmacological subgroup. The chemical substance most often consumed was ceftriaxone, with an increasing trend in the consumption of vancomycin and meropenem. Parenteral antibiotics in 'Watch' category were the most consumed over the study period, with a decreasing trend in 'Access' and increasing trend in 'Reserve' categories. CONCLUSION: We aimed to understand the consumption of parenteral antibiotics at a tertiary care hospital and found that Watch antibiotics comprised the bulk of antibiotic consumption. Overconsumption of antibiotics from the 'Watch' and 'Reserve' categories can promote antimicrobial resistance; recommendations were therefore made for their rational use.

CONTEXTE: Hôpital de Patan, un hôpital de soins tertiaires du District de Lalitpur, Népal. OBJECTIFS: Décrire la consommation annuelle d'antibiotiques parentéraux en 1) dose définie journalière (DDD) et DDD pour 100 admissions ; 2) calculer la DDD pour 100 admissions et les pourcentages par sous-groupe pharmacologique, sous-groupe chimique et catégories de la classification AWaRe ; et 3) décrire les dépenses des patients en antibiotiques parentéraux en tant que proportion du total des dépenses des patients en médicaments et consommables de 2017 à 2019. MÉTHODE: Il s'agissait d'une étude transversale. RÉSULTATS: La DDD totale d'antibiotiques parentéraux a augmenté de 23%, de 39 639,7 en 2017 à 48 947,7 en 2019. La DDD pour 100 admissions a augmenté de 10%, de 172,1 en 2017 à 190,2 en 2019. Les autres bêtalactamines étaient le sous-groupe pharmacologique le plus consommé. La substance chimique la plus consommée était la ceftriaxone, avec une tendance à la hausse de la consommation de vancomycine et de méropénème. Les antibiotiques parentéraux du groupe « antibiotiques à utiliser sélectivement ¼ étaient les plus consommés pendant la période d'étude, avec une tendance à la baisse de ceux du groupe « antibiotiques dont l'accessibilité est essentielle ¼ et une tendance à la hausse de ceux du groupe « antibiotiques de réserve ¼. CONCLUSION: Nous avons cherché à comprendre la consommation d'antibiotiques parentéraux dans un hôpital tertiaire et avons observé que les « antibiotiques à utiliser sélectivement ¼ représentaient la majorité de la consommation d'antibiotiques. La surconsommation d'« antibiotiques à utiliser sélectivement ¼ et d'« antibiotiques de réserve ¼ peut favoriser la résistance antimicrobienne. Des recommandations ont donc été émises pour un usage raisonné de ces antibiotiques.

Accuracy and speed of elongation in a minimal model of DNA replication.

Being a dual purpose enzyme, the DNA polymerase is responsible for elongation of the newly formed DNA strand as well as cleaving the erroneous growth in case of a misincorporation. The efficiency of replication depends on the coordination of the polymerization and exonuclease activity of DNA polymerase. Here, we propose and analyze a minimal kinetic model of DNA replication and determine exact expressions for the velocity of elongation and the accuracy of replication. We first analyze the case without exonuclease activity. In that case, accuracy is determined by a kinetic competition between stepping and unbinding, with discrimination between correct and incorrect nucleotides in both transitions. We then include exonuclease activity and ask how different modes of additional discrimination in the exonuclease pathway can improve the accuracy while limiting the detrimental effect of exonuclease on the speed of replication. In this way, we ask how the kinetic parameters of the model have to be set to coordinate the two activities of the enzyme for high accuracy and high speed. The analysis also shows that the design of a replication system does not universally have to follow the speed-accuracy trade-off rule, although it does in the biologically realized parameter range. The accuracy of the process is mainly controlled by the crucial role of stepping after erroneous incorporation, which has impact on both polymerase and exonuclease activities of DNA polymerase.

Extrinsic Measurement of Carbon Black Aggregate Distribution within a Fluoroelastomer Matrix from Nanoindentation Experiments.

A novel extrinsic method for the measurement of particle surface distribution in a carbon black-filled elastomer via nanoindentation is developed. This method is based on the measurement of the contact stiffness obtained from the continuous stiffness measurement mode. The proposed tip-particle model is held by two main hypotheses: the particles do not deform significantly during indentation so that only the elastomer matrix elastically deforms; particles are physically bounded with the surrounding matrix. Therefore, when the tip comes in contact with a particle, the latter becomes a hard extension of the tip, able to deform the elastomer matrix. Finally, the evolution of the measured contact stiffness is directly related to the increase of the contact area between the tip-particles set and the elastomer matrix. The proposed model is validated through a numerical and an experimental study. Moreover, an evaluation of the measurements bias allows to correct the particle surface distribution. A good agreement is found between the distribution measured from transmission electron microscopy observations and nanoindentation measurements.

Monitoring steady production of 1,3-propanediol during bioprospecting of glycerol-assimilating soil microbiome using dye-based pH-stat method.

AIM: In this investigation, a dye-based pH-stat method was devised for monitoring steady production of 1,3-propanediol (1,3-PDO) during bioprospecting of glycerol-assimilating soil microbiome. METHODS AND RESULTS: Soil samples were collected from two potential sites of CSIR-IIP, India. Selective enrichment of microbial consortia was done using the glycerol-based medium at initial stage, followed by purification to isolated colonies, after positive high-performance liquid chromatography detection of 1,3-PDO in the fermentation broth. When the purified isolated were re-tested for 1,3-PDO production, only two isolates namely Isolate 1 and Isolate 3 were capable of producing the targeted product preferably under anaerobic conditions. Based on better 1,3-PDO fermentation efficiency (Isolate 3, 22% vs Isolate 1, 4·48%) and acetic acid as the only major by-product, Isolate 3 was shortlisted for further studies. A dye-based technique was devised in which bromothymol blue was incorporated into the medium to monitor the pH drop due to acetic acid formation and hence change in colour. Visual change in colour helped in intermittent pH restoration. During fermentation, with pH stat being 8-8·5, Isolate 3 at 32°C yielded 0·67 mol mol-1 1,3-PDO within a short span of 12 h only with an initial concentration of glycerol being 20 g l-1 . Phylogenetic analysis revealed that Isolate 3 shared 95·8% homology with Citrobacter freundii CFNIH1 and hence designated as C. freundii IIP DR3. CONCLUSION: This study demonstrated that during bioprospecting glycerol-assimilating microbiome, dye-based technique can be successfully employed. This technique can further be exploited to monitor consistent production of all microbial secondary metabolites that accompanies acid production. SIGNIFICANCE AND IMPACT OF THE STUDY: Incorporation of 'Bromothymol blue' can visually help in the identification of pH drop in the medium, so that pH stat can be easily maintained during 1,3-PDO production from glycerol especially under shake flask conditions.

Dorsal Metacarpophalyngeal Dislocations of Thumb in Children-Clues to the Clinical Decision Making and a Dorsal Approach to Open Reduction.

Dorsal Metacarpophalyngeal joint dislocation of thumb in children is a rare occurrence. All the three different types, namely Simple Complete, Complex Complete and Incomplete dislocations have been described in this article with clinical and radiological clues to differentiate the closely reducible (simple) dislocations from irreducible ones (complex). A simple approach to treatment decision making has been adopted for all cases, starting with attempt of closed reduction which if fails, moving to open reduction. First case is a simple dorsal dislocation presenting after fall injury with hyperextension deformity of thumb Metacarpophalyngeal joint that was reducible by closed maneuver. Second case presented with pain and inability to move thumb Metacarpophalyngeal joint, with less marked deformity than the first case. Closed reduction failed and open reduction was done with dorsal approach to the metacarpophalyngeal joint joint after volar plate interposed in the metacarpophalyngeal joint was pushed anteriorly. Third case was an incomplete dorsal dislocation that was reduced closed. Dorsal metacarpophalyngeal dislocation of thumb in children is rare injury. Diagnosis needs a high index of suspicion ascomplex dislocation can be missed due to less obvious deformity. Dorsal approach to open reduction of complex dislocation is a direct and reliable approach.

Estimation of Stature from Nasal Length.

INTRODUCTION: Estimation of stature for the purpose of identification has a significant forensic importance. This technique is based on a principle that bones or human body parts correlate positively with the stature. Stature can be estimated from measurements of various body parts such as arm, leg, feet, finger, facial height, nasal height etc. The aim of study was to correlate Stature of Nepalese with Nasal height and estimate Stature from Nasal height. METHODS: A cross-sectional study of 214 healthy adults comprising 110 males and 104 females in the age group of 25 to 35 years were carried out. Study was carried out in central Nepal where people from various parts of Nepal are migrated. Total body height and Nasal height were recorded with stadiometer and sliding caliper respectively. RESULTS: The mean of total body height in the male and female was 160.4 (±6.80) cm and 151.8 (±4.88) cm respectively. The mean of nasal height in the male and female was 4.6 (±0.31) cm and 4.3 (±0.29) cm respectively. This study observed that in both male and female nasal height had positive partial correlation with stature; r = 0.18 for male and 0.19 for female. Stature in nepali population could be calculated as: Stature=148.22+3.02x nasal height in male where as Stature=133.01+3.12x nasal height in female. CONCLUSIONS: Both Nepali male and female nasal height had positive partial correlation with stature; r = 0.18 for male and 0.19 for female. Stature in Nepali population could be calculated as: Stature=148.22+3.02x nasal height in male where as Stature=133.01+3.12x nasal height in female.

Prevalence of Occlusal Traits in the Deciduous Dentition of Children of Kaski District, Nepal.

INTRODUCTION: The prevalence of occlusal traits varies among various populations. Ethnic, genetic and environmental factors are the major contributors, with a role in the specific cause of malocclusion. The aim of this epidemiological study was to assess the prevalence of occlusal traits in the deciduous dentition of children of Kaski District,Nepal. METHODS: A total of 506 children (251 girls, 255 boys), aged 3-5 years, were assessed. The occlusion examination was carried out by three examiners, in the school camps,community dental care centre and general health camps, utilizing a mouih mirror and probe. Intra investigator error was calculated using kappa statistics. The data were analyzed by the statistical program SPSS version 17 using the Chi-square test. RESULTS: The present study studied occlusal traits of 506 children (251 girls, 255 boys), aged 3-5 years. The study result showed that bilateral mesial step seen in 40.3%,bilateral flush terminal plane in 33.5%, bilateral distal steps in 8.5%,mesial step one side and flush terminal other side in 12.7%,mesial step one side and distal step other side in 2.6%,flush terminal one side and distal step other side in 2.4%,anterior crossbite in 3%,posterior crossbite in 0.4% and non-spaced dentition in 20% children. CONCLUSIONS: Mesial step was the most prevalent followed by straight terminal plane and the distal terminal plane showed least prevalence. There were diverse traits for malocclusion. There was no significant difference(p>0.05) in occlusal traits between male and female children.

Surgical Results of Non-small Cell Lung Cancer in Nepal.

INTRODUCTION: Surgery remains the only curative modality for early stage of Non small cell lung caner (NSCLC). We reviewed overall scenario of lung cancer and surgical results in Nepal. METHODS: 1000 patients with the pathological diagnosis of lung cancer were analyzed to summarize the overall scenario of lung cancer. 157 NSCLC patients underwent pulmonary resection. cIA, IB, IIA, IIB, IIIA (N1) underwent surgery as initial modality of treatment. cIIIA (N2) patients were taken for surgery after neoadjuvant chemo/ chemoradiation. RESULTS: Analysis of 1000 patients showed squamous cell carcinoma in 41.3%, incurable stage (IIIB/ IV) in 66.8% and rate of curative resection in 6.7% cases. Surgery as a single modality of treatment was used in 38%. Neoadjuvant Chemo/ chemoradiation/ radiation followed by surgery and surgery followed by chemo/ chemoradiation/ radiation was done in 12% and 50%, respectively. In-hospital mortality was 2% (post pneumonectomy: 5.5%; post lobectomy: 1.5%; post sublobar resection: 0%). R0 resction was achieved in 91% cases. Median survival and 5-year overall survival were 36 months and 18%, respectively. Better survival was achieved in pI-II vs pIII/ IV, pN0-1 vs pN2 and pR0 vs pR+ (p <0.05). CONCLUSIONS: Earlier stage (pI-II), R0 resection and pathological pNo-1 has the best five year overall survival in Nepalese patients with NSCLC as well.

An anthropometric study of facial height among four endogamous communities in the Sunsari district of Nepal.

INTRODUCTION: Facial anthropometry has well-known implications in health-related fields and has been utilised for forensic purposes in the past. It provides an indication of the variations in facial shape in a population. The facial anthropometric profile of a population can characterise the distinctive features of a likely face in that population. The present study aimed to examine the differences in facial height proportions and facial growth patterns in different communities in the Sunsari district of Nepal. METHODS: The upper facial height (UFH) and lower facial height (LFH) proportions of 857 subjects (429 male and 428 female) aged between three and 18 years old from four communities (Brahmin, Chhetri, Rai and Limbu) in the Sunsari district of Nepal were calculated, and comparisons were made. RESULTS: Significant differences (p is less than 0.05) in the UFH and LFH percentages were observed between the Brahmin and Rai, Brahmin and Limbu, Chhetri and Rai, and Chhetri and Limbu communities. CONCLUSION: The study concluded that there is evidence of statistically significant differences of the upper and lower face height proportions among the different racial groups. A change in the facial height proportions of the various age groups was evident. However, differences in facial height proportions between male and female were found to be insignificant.

Multiple arterial anomalies in upper limb.

An isolated neurovascular variation is common but multiple vascular anomalies on same upper limb is a very rare case. We observed an unusual variations in right upper limb during routine dissection of a Nepali cadaver. The variations were observed in Axilla, Forearm and Palm. In axilla, fi rst part of axillary artery did not give any branch, the second part of axillary artery gave off only two branches - (a) thoracoacromial artery and (b) a large common trunk which later gave off lateral thoracic, thoracodorsal, subscapular, posterior circumflex scapular and then continued as posterior circumflex humeral artery. The third part of axillary artery gave off only anterior circumflex humeral artery. In forearm, the ulnar artery runs downward superficial to flexor muscles. Here, radial artery gave off common interosseous artery. In palm radial artery did not give any contribution to superficial palmar arch which is solely formed by the continuation of ulnar artery. This type of anomalies are very rare and is not reported in Nepalese cadaver at all. These anomalies are described in detail and their clinical relevance is highlighted.

Congenital anomaly of left renal vein.

Double left renal vein is a rare venous anomaly. In 6.5% of cases double left renal vein, one in front (preaortic) and another behind the abdominal aorta (retroaortic) has been reported. The development of renal vessels is very complicated. There are extensive changes which occur in subcardinal, supracardinal and sacrocardinal veins during development that may lead to congenital venous anomalies. Here, we report a case of congenital venous anomaly of persisting retroaortic left renal vein.

Supernumerary head of Biceps brachii: a rare occurrence in the Nepalese population.

Unilateral three headed biceps brachii muscle was observed in the dissected cadaver of a 45-year-old Nepalese cadaver. The supernumerary head is taking origin from the tendon of deltoid and crossing in front of the long head of biceps and joining with short head of biceps brachii. The incidence of this variation is very rare and there was no available literature in Nepalese population. Presence of such variation should be kept in mind by surgeons and traumatologists.

Phylogenetic variation in flexor digitorum brevis: a Nepalese cadaveric study.

Understanding muscle architecture of the foot may assist in the design of surgical procedures such as tendon transfer, biomechanical modeling of the foot, prosthesis design, and analysis of foot function. Flexor digitorum brevis (FDB) is the most superficial intrinsic muscle of the sole of the foot. When compared to the little finger, the little toe has less function and opposition is absent in humans. Hence, the muscles acting on the little toe are undergoing evolutionary changes. The objective of this study was to review the phylogenetic variation occurring in FDB in the Nepalese cadavers. Sixty soles in 20 male and 10 female adult embalmed cadavers were dissected and attachments of FDB observed. It was noted that the tendon for the fifth toe was missing in all sixty soles. The action of FDB can be compensated by other long flexors of the foot. This could have resulted due to gradual reduction in the usage of the little toe as the bipedal posture evolved. Variations of FDB are clinically important because FDB musculocutanous flap is used in the reconstruction of the heel pad.

Ectopic partial intrahepatic gall bladder with cholelithiasis--a rare anomaly.

The study was aimed to view the developmental anomalies of gall bladder (GB) in Nepalese cadavers. Forty GBs were studied for any anomalies during routine cadaveric dissection at the Department of Anatomy, Manipal College of Medical Sciences, Nepal. The study found that the congenital anomalies of GB are very rare. Only one case of ectopic partial intrahepatic GB with cholelithiasis was observed, which to our knowledge is the first reported case in Nepal. Awareness of GB anomalies is important to surgeons, radiologists, and clinicians in general. An ectopic partial intrahepatic GB can make cholecystectomy hazardous, when indicated.

Breathing comfort associated with different modes of ventilation: a comparative study in non-intubated healthy Nepalese volunteers.

OBJECTIVE: To compare subjective experience of comfort associated with various commonly used supportive modes of mechanical ventilation for weaning in the intensive care unit (ICU). SUBJECTS AND METHODS: The study was carried out in general ICU of a community-based teaching hospital in 30 healthy adult Nepalese volunteers of either sex and 19-37 years of age. The subjects were randomly made to experience breathing via anatomical facemask through ventilator circuit with synchronized intermittent mandatory ventilation (SIMV), assisted spontaneous breathing (ASB), biphasic positive airway pressure (BiPAP), and continuous positive airway pressure (CPAP) modes of ventilation with parameters set at intermediate level of respiratory support. Subjective comfort of breathing was noted using a 10 cm visual analogue scale (VAS) with no discomfort at one end and maximum imaginable discomfort at the other. Inspiratory and expiratory experience of discomfort was also noted using a four point ranking scale (0-no discomfort, 1-mild discomfort, 2-moderate discomfort and 3-severe discomfort). In addition, presence or absence of feeling of breathlessness and inflation was also noted. RESULTS: BiPAP was the most comfortable mode of ventilation (p<0.01) on visual analogue scale. SIMV and CPAP modes were associated with higher discomfort than other modes during inspiratory and expiratory phases respectively. Breathlessness and inflation were least felt in BiPAP and SIMV modes respectively. CONCLUSION: Perception of breathing comfort can vary widely with various supportive modes of ventilation in the ICU. Hence, no single supportive mode should be used in all patients during weaning from mechanical ventilation. Key words: assisted spontaneous breathing; biphasic positive airway pressure; breathing comfort; continuous positive airway pressure; mechanical ventilation; supportive modes synchronized intermittent mandatory ventilation; weaning.

Brachial plexus block as a sole anaesthetic technique in upper extremity fracture/dislocation in children: subclavian perivascular vs parascalene approach.

OBJECTIVE: To compare parascalene approach of brachial plexus block with the classical subclavian perivascular approach as a sole anaesthetic technique in children undergoing closed manipulation for fracture/dislocation around the elbow. MATERIALS AND METHODS: Sixty children (age 6-13 years) undergoing closed manipulation for fracture/dislocation around the elbow were randomly assigned to two groups, Group I (n=30) receiving brachial plexus block using Winnie's classical subclavian perivascular approach and Group II (n=30) receiving brachial plexus block using parascalene approach described by Dalens. Time required for performing the block, onset of analgesia, sensory block to pin prick, adequacy of relaxation, complications and acceptance of the technique to the children, parents and the surgeons were compared. RESULTS: Time required for performing the block (6.3+/-2.2 min vs. 8.2+/-2.4 min), onset of subjective analgesia (4.1+/-1.6 min vs. 5.2+/-1.4 min) and onset of sensory block to pinprick (6.8+/-2.1 min vs. 8.6+/-1.7 min) were significantly shorter in Group I as compared to Group II (p<0.01). Acceptance of the techniques by the children, parents and the surgeons, and the overall success rates were high and comparable between the groups. Complications were minor and the incidence was low in both the groups except Horner's syndrome in 46.7% of patients in Group II. CONCLUSION: Parascalene approach to brachial plexus block is comparable to classical subclavian perivascular approach in safety, success rate and acceptance in children undergoing closed manipulation and reduction of fracture/dislocation around the elbow.

Analgesic use in dentistry in a tertiary hospital in western Nepal.

The present study had been planned to determine the pattern of drug utilization of analgesics (non-opioid and opioid analgesics) in dental outpatients in a referral hospital in western Nepal. A total of 1820 prescriptions of dental patients attending the dental outpatient at Manipal Teaching Hospital (MTH), Fulbari, Pokhara, Nepal were collected by a random once-weekly survey between March 2001 and February 2002. The analgesic-containing prescriptions (n = 1346) were separated from the total prescriptions collected. This information was compiled, scored and analyzed in consultation with dentists using WHO guidelines. There were more female patients (56%) than male patients (44%) in this study. The dental disorders most frequently reported in our study were diseases of pulp and periapical tissue (36.5%), gingivitis and periodontal diseases (28.5%) and dental caries (16%) etc. In total, 74% prescriptions contained analgesics which are the second-most commonly prescribed drugs after anti-microbials (44.9%) in dental OPD. The total analgesics prescribed were 1358 that account for 36.7% of total drugs prescribed. Only 5 and 37.8% of analgesics were prescribed generically and from the essential drug list of WHO respectively. All the analgesics were administered orally which included 89.7 and 10.3% of non-opioid analgesics and opioid analgesics (propoxyphene and dextropopoxyphene) respectively. The average duration of analgesic use was 3.5 +/- 0.3 days. The most commonly prescribed non-opioid analgesic was ibuprofen (41%) followed by nimesulide (22%). A total of 38.9% analgesics were fixed-dose combinations (FDCs) of two drugs and the most common analgesic combination used was ibuprofen + paracetamol and paracetamol + opioid analgesics. All opioid analgesics were prescribed in combination with paracetamol (10.3%) only. In total, 1.6% analgesics were prescribed concomitantly with gastroprotective agents. All gastroprotective agents (n = 22) were prescribed concomitantly with opioid analgesics only. No gastroprotective was used when NSAIDs were prescribed alone or in combination with paracetamol. Our present study indicate that all the analgesics were prescribed in oral dosage forms but analgesics prescribed in generic name (5%) and from essential drug lists (37.8%) were very less. There was an inclination to prescribe the older non-opioid analgesics. Selection of analgesics was quite rational in our study but some lacunae were observed. A total of 38.9% analgesics were FDCs and most common FDC analgesics were ibuprofen + paracetamol. Avoiding unnecessary FDCs may help in reducing prescribing costs because FDCs usually cost more than single ingredient preparations. It is best to avoid combination therapy with more than one non-opioid analgesic; there is little evidence of extra benefit to the patient and the incidence of side effects generally is additive. Prescribing generic names aids in avoiding confusion and minimizing the costs. In the present study, coprescription of gastroprotective agents with analgesic use was low compared to a previous study but when opioid analgesics were prescribed, concurrent use of gastroprotective agents were irrational as opioid analgesics usually decrease the secretion of hydrochloric acid. It is also surprizing that, no gastroprotective was used when NSAIDs were prescribed alone, irrespective of sex, age, dose or duration or type of NSAID treatment in our study. There is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of analgesics in dentistry.

An audit of drug prescribing practices of dentists.

OBJECTIVES: Data are scarce on the prescribing habits of dental practitioners. Drug use in dentistry and stomatology is undertaken to determine the pattern of drug use for patients seeking treatment. METHODS: 1820 prescriptions of dental patients attending the dental outpatient departments at Manipal Teaching Hospital, Nepal were collected by a random once weekly survey between March '01 to February '02. The information was compiled, scored and analyzed in consultation with dentists using WHO guidelines. RESULTS: Males numbered 801 (44%) and females 1019 (56%). Most of the patients were aged between 13-25 years. The dental disorders most frequently reported in our study were diseases of pulp and periapical tissue (36.5%), gingivitis and periodontal disease (28.5%), and dental caries (16%). The average number of drugs prescribed was 2.03 (3698 / 1820) and 66% prescriptions contained antimicrobials (1 or 2). 21% drugs were prescribed in generic names and 38% drugs were fixed dose combinations of 2 or more drugs. 4/5 of the prescribed drugs were systemic agents and 1/5 were local/topical agents. The most commonly prescribed systemic agents were analgesics (43.7%) followed by antimicrobials (39%). The most conmonly prescribed local / topical agents were anti-infectives (74%). In the present study, NSAID's (89.6%) were the preferred analgesics over narcotic analgesics (10.4%). The most frequently prescribed systemic analgesic and antimicrobials were ibuprofen and amoxycillin, respectively. CONCLUSIONS: This study may help in identifying the problems involved in therapeutic decision making. Also, there is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of drugs in dentistry.

Efficacy of methotrexate in rheumatoid arthritis.

Rheumatoid arthritis is a common inflammatory articular disorder in Bangladesh. Methotrexate has proved to be an effective and relatively safe disease modifying drug for this disease. A quasiexperimental trial of the efficacy of methotrexate in rheumatoid arthritis was carried out in the Rheumatology Clinic, Institute of Postgraduate Medicine & Research, Dhaka during the period between July 1992 and September 1993. Thirty eight patients fulfilling the revised ARA criteria were given methotrexate in a total weekly dose of 7.5 to 15 mg. They were followed up at weekly intervals for one month and then monthly for a total duration of six months. Twenty three subjects eventually completed the trial. The trial showed significant differences in the disease activity indices at the end of six months. The decline of activity was noted at the end of one month. As a whole the response was complete in 4(17%), marked in 14(61%), moderate in 4(17%) and nil in 1(4%). Adverse effects occurred in 27 subjects. They were mild and transient in 22. Methotrexate appeared to be an acceptable DMARD for our rheumatoid arthritis population.