Assessing Drug Utilization in the Emergency Medicine Department at a Tertiary Care Teaching Hospital Using WHO Drug Use Indicators.

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.

Joint EANM/SNMMI guideline on radiomics in nuclear medicine : Jointly supported by the EANM Physics Committee and the SNMMI Physics, Instrumentation and Data Sciences Council.

PURPOSE: The purpose of this guideline is to provide comprehensive information on best practices for robust radiomics analyses for both hand-crafted and deep learning-based approaches. METHODS: In a cooperative effort between the EANM and SNMMI, we agreed upon current best practices and recommendations for relevant aspects of radiomics analyses, including study design, quality assurance, data collection, impact of acquisition and reconstruction, detection and segmentation, feature standardization and implementation, as well as appropriate modelling schemes, model evaluation, and interpretation. We also offer an outlook for future perspectives. CONCLUSION: Radiomics is a very quickly evolving field of research. The present guideline focused on established findings as well as recommendations based on the state of the art. Though this guideline recognizes both hand-crafted and deep learning-based radiomics approaches, it primarily focuses on the former as this field is more mature. This guideline will be updated once more studies and results have contributed to improved consensus regarding the application of deep learning methods for radiomics. Although methodological recommendations in the present document are valid for most medical image modalities, we focus here on nuclear medicine, and specific recommendations when necessary are made for PET/CT, PET/MR, and quantitative SPECT.

Analgesic Efficacy of Fascia Iliaca Compartment Block for Positioning During Spinal Anesthesia in Patients with Femur Fractures.

Background Positioning patients with femur fractures for spinal anesthesia is associated with excruciating pain. Fascia iliaca compartment block has the potential to block all nerves supplying the femur and therefore may provide effective analgesia during positioning these patients for spinal anesthesia. Objective To assess the analgesic efficacy of Fascia iliaca compartment block, during positioning patients with femur fracture for spinal anesthesia. We also assessed the duration of analgesia and the requirement for rescue analgesics in the postoperative period. Method Seventy adult patients with fracture femurs were randomly divided into two equal groups (A and B). Patients in both groups received fentanyl one mcg/kg intravenously, 20 minutes before positioning them for spinal anesthesia. Patients of group B additionally, received ultrasound-guided Fascia iliaca compartment block with 40 ml of 0.25% Ropivacaine, immediately after intravenous fentanyl. Numerical rating score (0-10) was used for the assessment of pain at five, 10, and 20 minutes after the block and immediately after positioning patients for spinal anesthesia. Result Immediately after positioning patients for spinal anesthesia, the numerical rating score of pain was 5.06±1.5 in group A and 2.49±1.2 in group B (p<0.001). The duration of analgesia was 799.7±62.1 minutes in group B and 314.65±118.9 minutes in group A (p<0.001). One (2.8%) patient of group B and 18(51.4%) patients of group A required rescue analgesics within four to twelve hours in the postoperative period (p=0.001). In group A, seven patients were satisfied with the analgesia technique while in group B, 17 were satisfied and eight patients were strongly satisfied (p<0.001). Conclusion Ultrasound-guided Fascia iliaca compartment block is effective in reducing pain during positioning patients with femur fractures for spinal anesthesia. Patients receiving this block had a prolonged duration of analgesia, required lesser analgesics, and were more satisfied in the postoperative period as compared to patients not receiving the block.

AN EVALUATION OF ANTIBIOTIC PRESCRIPTION PRACTICES: PERSPECTIVES OF VETERINARY TRAINEES AND PRACTICING VETERINARIANS.

Antibiotic resistance is a major worldwide problem that has an impact on the well-being of humans as well as animals. Antibiotic resistance is caused by the misuse and excessive use of antibiotics. The key to reducing this issue lies in educating veterinary medical learners on the proper and accountable utilization of antibiotics for the care of animals. Objective - using awareness-raising and instruction as the foundation, this research of Indian veterinary learners can help resolve the issue of antibiotic resistance throughout the care of animals. The questionnaire survey was taken between June and July 2022 and it was aimed at learners registered in veterinary medical studies at academic and research institutions in India. The study included 500 pupils overall. The purpose of the survey was to gather information about students' knowledge of antibiotics, including antibiotic resistance, as well as their feelings on the consequences of antibiotic resistance on the globe at large and their acquaintance with the one health ideology. According to this study's findings, 83.3 percent of respondents thought antibiotic resistance was a serious problem. 57.92 percent of respondents understood the issue's worldwide consequences and its one health ideology. The study emphasizes the significance of expanding the veterinary educational program to include thorough instruction on prudent antibiotic usage and the concepts of one health.

Nevus Lipomatosus Cutaneous Superficialis of Hoffmann and Zurhelle: a rare cutaneous hamartoma.

Nevus lipomatosus cutaneous superficialis (NLCS) is a rare idiopathic cutaneous hamartoma characterized by ectopic clusters of mature adipose tissues in dermis. It is classified into two types. Classical type presenting as multiple lesions with onset at birth or within third decade of life and solitary type with onset between third to sixth decade of life. Here we present a case of 45 years female with adult onset, asymptomatic, grouped, skin colored, soft sessile growth in zosteriform pattern on left buttock. We here intend to report rare case of classical Nevus Lipomatosus Cutaneous Superficialis.

Comparison of Outcome of Borderline and Normal Amniotic Fluid Index in Term Pregnancy.

Background Determination of Amniotic Fluid Index (AFI) is an important component of antepartum assessment of all normal pregnancies. Objective To compare the obstetric interventions and neonatal outcomes in term pregnancies with borderline Amniotic Fluid Index versus normal Amniotic Fluid Index. Method This hospital based prospective study was conducted at Tribhuwan University Teaching Hospital over 1 year between 2017 and 2018 in 128 women having uncomplicated term pregnancy admitted in labor ward. Of the 128 women, 64 women had borderline Amniotic Fluid Index (5.1-8 cm) and 64 normal AFI (8.1 - 24 cm). Parameters studied were induction of labor, cesarean section, instrumental delivery, intrapartum abnormal fetal heart rate, meconium staining of liquor, APGAR score at 5 and 7 minutes, birth weight, neonatal intensive care unit (NICU) admission and neonatal death. Data was analyzed using software OpenEpi. Result Statistically significant difference in result was obtained in the two groups in terms of rate of induction of labor (73.4% vs 35.9%, p = 0.0001, OR = 4.9), rate of cesarean section (42.1% vs 28 .1%, p = 0.04, OR = 1.8), tachypnea (50% vs 11.1%, p = 0.01) and low birth weight (9.1% vs 4.5%, p = 0.04). No statistical significance was found in meconium staining of liquor (33% vs 38.3%, p = 0.3) and APGAR score of <7 at 5 minutes (3.1% vs 1.5%, p = 0.06). There were no neonatal intensive care unit admissions and neonatal mortality in any of the babies. Conclusion Detection of amniotic fluid volume at term is important for timely maternal interventions to improve the overall fetal outcome.

Dynamic adjustments in working memory in the face of affective interference.

Cognitive control, which allows for the selection and monitoring of goal-relevant behavior, is dynamically upregulated on the basis of moment-to-moment cognitive demands. One route by which these demands are registered by cognitive control systems is via the detection of response conflict. Yet working memory (WM) demands may similarly signal dynamic adjustments in cognitive control. In a delayed-recognition WM task, Jha and Kiyonaga (Journal of Experimental Psychology: Learning, Memory, & Cognition, 36(4), 1036-1042, 2010) demonstrated dynamic adjustments in cognitive control via manipulations of mnemonic load and delay-spanning cognitive interference. In the present study, we aimed to extend prior work by investigating whether affective interference may similarly upregulate cognitive control. In Experiment 1, participants (N = 89) completed a delayed-recognition WM task in which mnemonic load (memory load of one vs. two items) and delay-spanning affective interference (neutral vs. negative distractors) were manipulated in a factorial design. Consistent with Jha and Kiyonaga, the present results revealed that mnemonic load led to dynamic adjustments in cognitive control, as reflected by greater performance on trials preceded by high than by low load. In addition, we observed that affective interference could trigger dynamic adjustments in cognitive control, as evinced by higher performance on trials preceded by negative than by neutral distractors. These findings were subsequently confirmed in Experiment 2, which was a pre-registered replication study (N = 100). Thus, these results suggest that in addition to dynamic adjustments as a function of mnemonic load, affective interference, similar to cognitive interference (Jha & Kiyonaga Journal of Experimental Psychology: Learning, Memory, & Cognition, 36(4), 1036-1042, 2010), may trigger dynamic adjustments in cognitive control during a WM task.

Sonographic Quantification of Ovarian Volume in Adults Attending General Health Checkup and General Out Patient Department in Tribhuvan University Teaching Hospital.

Background Ultrasonography is the easily available, cheap and reliable method for evaluation of ovaries. Ovarian volume is the major factor in the diagnosis of various ovarian pathologies and confusing discrepancies are found in the literature. Objective To determine the ovarian volume among individuals attending outpatient department in tertiary level hospital. Method Descriptive cross sectional study design was used; 305 patients of 16-60 years attending general outpatient department in the Tribhuvan University Teaching Hospital, Kathmandu, Nepal were included. Ovarian volume was calculated by using transabdominal ultrasonography. Data was collected in the predesigned proforma and analyzed using statistical package for the social sciences software. Result The study showed mean total ovarian volume 5.95 ± 2.44 cc (centimeter cube) with mean right ovarian volume 5.94 ± 2.70 cc and mean left ovarian volume 6.05 ± 2.79 cc. Significant decrease in ovarian volume with age was observed. Height and weight did not show significant correlation with ovarian volumes and no significant variation seen in the volumes of right and left ovaries. Periovulatory ovaries show significantly higher volumes on right side than luteal phase. Similarly, significantly higher volume of left ovary seen in mixed ethnic group than mongoloid group. Conclusion Measurement of ovarian volume is important for evaluation and management of ovarian disorders. Ultrasonography which is readily available, simple and cost effective is better suited for our environment than other imaging modality. Values of ovarian volume from this study may provide a baseline of normal ovarian volume in our community.

Mycetoma: reviewing a neglected disease.

Mycetoma caused by either filamentous fungi (eumycotic) or bacteria (actinomycotic) has recently been recognized by the World Health Organization as a neglected tropical disease. Although mycetoma is preventable and treatable, especially in the early stages, it carries high morbidity and a huge socioeconomic burden. Skin and subcutaneous tissue is affected, with a classic presentation of hard woody swellings, discharging sinuses and presence of grains (containing the causative organism). Variants with swelling without sinuses have also been described. Left untreated it may involve underlying bone and muscle, leading to permanent disability. Common actinomycotic species include Streptomyces somaliensis, Actinomadura madurae, Actinomadura pelletieri, Nocardia brasiliensis and Nocardia asteroides, while Madurella mycetomatis, Madurella grisea, Pseudoallescheria boydii and Leptosphaeria senegalensis are common eumycotic agents. Men are more commonly affected than women, and the leg is the most frequently affected site. Diagnosis in suspected lesions is made with the help of grain examination, microscopy, imaging (radiography, ultrasonography, magnetic resonance imaging) and culture, and more recently by molecular methods such as PCR and molecular sequencing. Molecular sequencing for both fungi and bacteria is important for rapid and correct diagnosis, especially in culture-negative cases. Treatment is long, more successful in actinomycetoma than eumycetoma, and may require a holistic approach comprising antimicrobials, surgery and rehabilitation. Mycetoma can be prevented by simple measures such as wearing protective garments and shoes, especially in rural areas and during outdoor activities.

Influenza burden, prevention, and treatment in asthma-A scoping review by the EAACI Influenza in asthma task force.

To address uncertainties in the prevention and management of influenza in people with asthma, we performed a scoping review of the published literature on influenza burden; current vaccine recommendations; vaccination coverage; immunogenicity, efficacy, effectiveness, and safety of influenza vaccines; and the benefits of antiviral drugs in people with asthma. We found significant variation in the reported rates of influenza detection in individuals with acute asthma exacerbations making it unclear to what degree influenza causes exacerbations of underlying asthma. The strongest evidence of an association was seen in studies of children. Countries in the European Union currently recommend influenza vaccination of adults with asthma; however, coverage varied between regions. Coverage was lower among children with asthma. Limited data suggest that good seroprotection and seroconversion can be achieved in both children and adults with asthma and that vaccination confers a degree of protection against influenza illness and asthma-related morbidity to children with asthma. There were insufficient data to determine efficacy in adults. Overall, influenza vaccines appeared to be safe for people with asthma. We identify knowledge gaps and make recommendations on future research needs in relation to influenza in patients with asthma.

Tuberculosis of the Sternoclavicular Joint: Report of Three cases.

Ebstein's anomaly accounts for 0.3% to 0.7% of all cases of congenital heart disease. The condition is characterized by abnormal tricuspid valve and right ventricle with apical displacement of tricuspid valve leading to atrialization of right ventricle. There have been case reports of patients surviving up to ninth decade. It is unusual for these patients to be asymptomatic in adulthood for long duration. We describe a patient with Ebstein's anomaly in the ninth decade with coronary artery disease.

Patient quality of life and short-term surgical outcomes between robotic and laparoscopic anterior resection for adenocarcinoma of the rectum.

PURPOSE: To compare patient quality of life (QoL) and short-term surgical outcomes between robotic anterior resection (r-AR) and laparoscopic (l-AR) approach. METHODS: Consecutive patients having undergone either robotic or laparoscopic AR for adenocarcinoma were studied. All operations were performed by two surgeons experienced in laparoscopic and recently introduced robotic surgery. Surgical outcomes were determined by post-operative histology and short-term complications. QoL was prospectively assessed using the EORTC QLC-CR30 and QLC-CR29 questionnaires. RESULTS: In total, 36 patients (18 r-AR) with a median follow-up of 12 months following surgery (9-month robotic and 20-month laparoscopic) were studied. The two groups were similarly matched for age and gender. Laparoscopic patients had a lower ASA grade (p = 0.02). There was no significant difference in surgical outcomes between groups. r-AR patients reported lower pain scales (2 ± 6 vs. 11 ± 13) (p = 0.04), lower levels of insomnia 0 vs. 8 ± 15 (p = 0.04) and a lower abdominal pain scale (2 ± 9 vs. 17 ± 27) (p = 0.04). Male impotence scores were higher in l-AR 33 ± 35 compared to r-AR 7 ± 21 (p = 0.03). CONCLUSION: Despite its recent introduction to our centre, the quality of oncological resection using the robotic surgery is comparable to laparoscopy. Lower impotence and QoL scores in patients after robotic procedure may be explained on the basis of better visualisation and precise tissue handling.

A Phase 3, Double-Blind, Randomized Study of Arterolane Maleate-Piperaquine Phosphate vs Artemether-Lumefantrine for Falciparum Malaria in Adolescent and Adult Patients in Asia and Africa.

BACKGROUND: Artemisinins, which are derived from plants, are subject to risk of supply interruption due to climatic changes. Consequently, an effort to identify a new synthetic antimalarial was initiated. A fixed-dose combination of arterolane maleate (AM), a new synthetic trioxolane, with piperaquine phosphate (PQP), a long half-life bisquinoline, was evaluated in patients with uncomplicatedPlasmodium falciparummalaria. METHODS: In this multicenter, randomized, double-blind, comparative, parallel-group trial, 1072 patients aged 12-65 years withP. falciparummonoinfection received either AM-PQP (714 patients) once daily or artemether-lumefantrine (A-L; 358 patients) twice daily for 3 days. All patients were followed up until day 42. RESULTS: Of the 714 patients in the AM-PQP group, 638 (89.4%) completed the study; of the 358 patients in the A-L group, 301(84.1%) completed the study. In both groups, the polymerase chain reaction corrected adequate clinical and parasitological response (PCR-corrected ACPR) on day 28 in intent-to-treat (ITT) and per-protocol (PP) populations was 92.86% and 92.46% and 99.25% and 99.07%, respectively. The corresponding figures on day 42 in the ITT and PP populations were 90.48% and 91.34%, respectively. After adjusting for survival ITT, the PCR-corrected ACPR on day 42 was >98% in both groups. The overall incidence of adverse events was comparable. CONCLUSIONS: AM-PQP showed comparable efficacy and safety to A-L in the treatment of uncomplicatedP. falciparummalaria in adolescent and adult patients. AM-PQP demonstrated high clinical and parasitological response rates as well as rapid parasite clearance. CLINICAL TRIALS REGISTRATION: India. CTRI/2009/091/000101.

Spiradenoma causing longitudinal splitting of the nail.

Longitudinal splitting of the nails can occur as a result of any growth arising in the nail matrix. We present a case of a 50-year-old woman who presented with an 18-month history of longitudinal splitting of the nail on her right little finger, along with pain in the proximal nail fold region, which was extremely tender to touch. Magnetic resonance imaging revealed an intensely enhancing lesion, while colour Doppler imaging revealed hypervascularity within the mass. A provisional diagnosis of glomus tumour was considered. Histopathology demonstrated presence of a well-circumscribed tumour comprising a dual population of cells, which stained negatively with periodic-acid-Schiff. The histopathological features were consistent with those of eccrine spiradenoma (ES). In this case, glomus tumour was considered as the first differential diagnosis, but histopathology confirmed it as an ES.

Linear trichilemmoma following a blaschkoid pattern: a clinical dilemma.

BACKGROUND: Trichilemmoma are benign adnexal neoplasm with follicular outer sheath differentiation. It usually appears as single or multiple papules that resembles colour of the surrounding skin. They are most commonly seen on the face particularly on the nose and cheek. OBJECTIVES: We report a case of linear trichilemmoma following blaschkoid pattern. METHODS: A 13 year old boy presenting with asymptomatic plaque on the right side of the nose was fully evaluated for possible cause. RESULTS: On histopathology, a diagnosis of trichilemmoma was made. CONCLUSION: This is the first case report where linear trichilemmoma following a blaschkoid pattern is seen.

Land-use and land-cover change in Western Ghats of India.

The Western Ghats (WG) of India, one of the hottest biodiversity hotspots in the world, has witnessed major land-use and land-cover (LULC) change in recent times. The present research was aimed at studying the patterns of LULC change in WG during 1985-1995-2005, understanding the major drivers that caused such change, and projecting the future (2025) spatial distribution of forest using coupled logistic regression and Markov model. The International Geosphere Biosphere Program (IGBP) classification scheme was mainly followed in LULC characterization and change analysis. The single-step Markov model was used to project the forest demand. The spatial allocation of such forest demand was based on the predicted probabilities derived through logistic regression model. The R statistical package was used to set the allocation rules. The projection model was selected based on Akaike information criterion (AIC) and area under receiver operating characteristic (ROC) curve. The actual and projected areas of forest in 2005 were compared before making projection for 2025. It was observed that forest degradation has reduced from 1985-1995 to 1995-2005. The study obtained important insights about the drivers and their impacts on LULC simulations. To the best of our knowledge, this is the first attempt where projection of future state of forest in entire WG is made based on decadal LULC and socio-economic datasets at the Taluka (sub-district) level.