Resource Limited Setup Research Articles

Potential drug-drug interactions among elderly patients admitted to medical ward of Ayder Referral Hospital, Northern Ethiopia: a cross sectional study.

BackgroundThe elderly are considered as special population, as they differ from younger adults in terms of comorbidity, polypharmacy, pharmacokinetics, vulnerability to drug–drug interactions and adverse drug reactions. Despite the fact that the elderly patients are at high risk of having drug interaction and potential adverse outcomes, studies in this regard are scarce in resource limited settings like Ethiopia. The aim of this study was to assess the prevalence and determinants of potential drug–drug interaction in elderly patients admitted to medical ward of Ayder Referral Hospital in Northern Ethiopia.MethodsA cross sectional study was conducted among elderly inpatients aged 60 years and above. The study was conducted from February to May 2014. Prescribed drugs being taken concurrently for at least 24 h were included and checked for drug–drug interaction using Micromedex® 2.0 online drug reference. Data were analyzed using statistical software, statistical package for social sciences for windows version 20. Logistic regression model was used to analyze factors associated with occurrence of drug interaction. P value of <0.05 was considered statistically significant.ResultsA total of 140 patients were participated in the study. The mean age (±standard deviation) of participants was 68 (±7) years. Majority (61.4 %) of patients were diagnosed with cardiovascular and/or renal diseases. A total of 814 drugs were prescribed with a mean of 6 (±4) medications per patient during a 13 (±9) days of hospital stay. About two-third (62.2 %) of the respondents were exposed to at least one potential drug–drug interaction. Among these 3.6, 32.9 and 25.7 % of patients had taken contraindicated drug combination, at least one major and at least one moderate drug–drug interaction, respectively. Patients with five or more prescribed medications were four times at risk of having drug–drug interaction (P = 0.00; adjusted odds ratio 4.047; 95 % confidence interval 1.867–8.775).ConclusionDrug–drug interaction in elderly patients was common in this resource limited set-up. Awareness creation and clinical pharmacist involvement in minimizing the risk associated with potentially harmful drug combinations are needed.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-016-2238-5) contains supplementary material, which is available to authorized users.

Assessment of patients presenting in shock at emergency department in a tertiary care teaching hospital

Introductions: Clinical profile of patient presenting with shock is important in early recognition and intervention to improve outcome especially in resource limited setup. This study is designed with an objective to evaluate history, clinical findings, laboratory findings and provisional diagnosis of patient presenting with shock.Methods: This was a cross sectional observational study conducted at Patan Hospital emergency department from September to November 2014. All consecutive patients presenting with shock were included. Patient’s demography (age, sex), provisional diagnosis, major findings (blood pressure, lactate, total count, fluid given, stay in emergency), requirement of inotropes and improvement were analyzed.Results: In three months period, 38 patients presented with shock to the emergency. Out of them 21 (55.3 %) were female and 17 (44.7%) were male. Commonest presenting complain was fever and shortness of breath 12 (31.6%), diarrhea 6 (13.4%) and shortness of breath 5 (13.2%). Septic shock was seen in 17 (44.7%), hypovolemic in 10 (26.3%), cardiogenic 7 (18.4%) and unclassified 4 (10.5%). Mean duration of stay in emergency was 100.6 minutes. Mean fluid given in emergency was 2328.9 milliliters.Conclusions: Sepsis was an important cause of shock in the emergency department. Pneumonia was common cause of sepsis and chronic obstructive pulmonary disease was common underlying condition.Journal of Patan Academy of Health Sciences, Vol. 3, No. 1, 2016, Page: 18-22

BMI is a Better Indicator of Cardiac Risk Factors, as against Elevated Blood Pressure in Apparently Healthy Female Adolescents and Young Adult Students: Results From a Cross-Sectional Study in Tripura.

Background:Anthropometric measures are used as indicators of elevated blood pressure, but reported to have variable sensitivity among populations. This study was undertaken to identify the better indicator of Cardiac-risk factors by statistical comparison of BMI, Waist circumference, and Waist to Height (WtHr) ratio in apparently healthy adolescents and young adult female students of Tripura.Materials and Methods:A cross-sectional study was conducted in a resource limited setup on 210 apparently healthy female adolescents and young adult students in Tripura. Mean (±SD) of all parameters were compared (ANOVA) to recognize significant independent (anthropometric measures) and dependent factors (blood pressure indices and so on). Correlation (r) analysis was used to identify the better (p) indicator of blood pressure indices (dependent variable) and its impact was assessed by Multiple Regression analysis.Results:blood pressure indices are comparatively higher in obese and overweight participants with statistically significant (95.5% confidence) mean differences. Significant correlation with dependent factors is observed with BMI followed by WtHr and Waist Circumference. Impact of anthropometric measures with blood pressure Indices is most significant for BMI (P ≤ 0.020) followed by WtHr (P ≤ 0.500) and waist circumference (P ≤ 0.520).Conclusion:BMI is a superior indicator of blood pressure indices and can identify participants at risk even in apparently healthy adolescent and young adult females.

Can use of low-cost white reflecting curtains increase the efficacy of phototherapy?

Context: In the face of a steep rise in the rate of bilirubin in neonates, we often seek improvisations to increase the efficacy of phototherapy machines. In addition, in resource-limited setup, a need is felt for the methods of reducing the duration of phototherapy so that the same machine can be used for more number of neonates. Aim: To study the effect of using white reflecting curtains around phototherapy machines on the efficacy of phototherapy for the treatment of neonatal jaundice. Settings and Design: Double-blind, parallel, randomized controlled trial. Level 2 Neonatal Intensive Care Unit and Neonatal Ward of a tertiary care hospital between June 2011 and May 2012. Subjects and Methods: About 102 term neonates with jaundice were randomized into two groups of 51 neonates each. Group A (the study group) received curtains and Group B (the control group) did not receive curtains during phototherapy. Two phototherapy units were designed so that the white curtains could be hung or removed as required. Along with baseline variables including blood count, reticulocyte count, and G6PD, total serum bilirubin (TSB) was measured for each neonate at 4, 12, and 24 h from the initiation of phototherapy. The primary outcome measure was the mean difference in TSB measured at baseline and after 4, 12, and 24 h of phototherapy. The secondary outcome was the duration of phototherapy in hours and also the mean difference in bilirubin between 12 and 24 h. Results: The mean bilirubin concentration of Group A was significantly less (17.42 ± 1.04 mg/dL at 4 h, 14.52 ± 1.05 mg/dL at 12 h, and 11.33 ± 1.11 mg/dL at 24 h of phototherapy) than Group B (18.02 ± 1.13 mg/dL at 4 h, 17.6 ± 1.09 mg/dL at 12 h, and 16.65 ± 1.11 mg/dL at 24 h) with similar bilirubin concentrations initially. The mean duration of phototherapy in Group A (28.87 ± 4.11 h) was significantly less than Group B (51.14 ± 18.62 h) (P < 0.01). Conclusions : Using white reflecting curtains significantly reduces the mean bilirubin concentration and the duration of phototherapy in jaundiced neonates.

Case Report: A case report of unstable Hangman fracture in a eighty year old male.

Herein we discuss a rare variant of hangman's fracture in an eighty year old male with good Karnofsky performance score. We performed X-ray and magnetic resonance imaging (MRI) of the cervical spine to confirm the diagnosis. The patient was placed on a gentle cervical traction which showed good reduction. Despite being on a resource limited setup, we performed posterior occipitocervical fusion with bone graft fusion followed by early mobilization. A postoperative scan showed good reduction and purchase of the screws. This case highlights the importance of choosing the correct therapeutic attitude for the management of the geriatric population especially in those who do not have any significant co-morbid conditions.

Acute fulminant myocarditis complicated by complete atrioventricular block with favourable outcome in a resource-limited setting

Complete heart block in paediatric acute fulminant myocarditis (AFM) is rare and carries a grave prognosis. Aggressive haemodynamic support, especially mechanical support, i.e. with an extracorporeal membrane oxygenator during the initial presentation, improves the outcome in such patients. Unavailability of mechanical support in developing countries warrants aggressive rhythm management to achieve haemodynamic stability. We report a case of a 5-month-old who presented with AFM complicated with complete heart block. Quick recognition, aggressive cardiopulmonary management and transcatheter placement of a temporary pacemaker as soon as possible resulted in complete recovery in this patient. Aggressive management with rhythm control can lead to a favourable outcome in paediatric patients with AFM complicated by complete heart block, even in a resource-limited set-up.

Preliminary screening for in vitro anti-enteritic properties of a traditional herb Dillenia pentagyna Roxb. fruit extracts

ObjectiveTo explore anti-enteric properties of Dillenia pentagyna Roxb. (D. pentagyna) fruit extract fractions of different polarities by comparative antimicrobial activity against municipal sewage microflora and to assess its urease inhibition potential. MethodsDifferent polar fractions of D. pentagyna fruit extracts were studied by antimicrobial susceptibility test with several adjustments in this resource limited setup. Tests were done against municipal sewage microbes at various bacterial load (initially with 1.0 McFarland followed by 1.5 McFarland) using basal (nutrient agar) and selective medium (MacConkey's agar with and without supplementation of 5% NaCl). All assays statistically scaled with a gradient for uniformity and comparison with ciprofloxacin standard. Fraction with highest activity was studied for urease inhibition potential by kinetic method. ResultsDP-47 separated by 30% ethyl acetate (EtOAc) in CHCl3 from CHCl3 extract had slightly higher antimicrobial potency (y=0.758x+7.571) as dissolved in methanol than in dimethylsulfoxide (y=0.300x+6.000). EtOAc extract fractioned by 10% methanol in EtOAc (DP-43) was more potent antimicrobial (y=1.428x+8.392) and soluble in water. Butanol extract fractioned by water (DP-50) showed highest antimicrobial potency (y=3.384x+2.000) than both DP-47 and DP-43 in disk diffusion assays. In higher microbial load DP-50 was potent antimicrobial (y=1.538x+3.000) and completely inhibited any vegetative growth at lower load of 0.5 McFarland. In selective environment DP-50 was effective (y=1.076x+7.500 in MacConkey's, y=1.307x+6.000 in 5% NaCl supplemented). It was evident that enteric pathogens may not easily develop resistance against DP-50 and at high concentration it inhibited urease activity by 94.87%. The standard inhibition by thiourea (1%) is 33.914%. ConclusionsHighly polar fraction of D. pentagyna Roxb. fruit extract DP-50 have potential antimicrobial activity against sewage microflora in basal and selective culture indicating its potential against non-fastidious, coliforms and Vibrio pathogens. Urease inhibition indicates efficacy against Helicobactor pylory.

Interobserver variation is a significant limitation in the diagnosis of Burkitt lymphoma.

Context:The pathology of classic Burkitt lymphoma (BL) remains a challenge despite being a well-defined entity, in view of the significant overlap with atypical BL and B-cell lymphoma intermediate between DLBL (diffuse large B cell lymphoma) and BL. They are difficult to be segregated in resource-limited setups which lack molecular testing facilities. This is further affected by interobserver variability and experience of the reporting pathologist.Aims:The aim of our study was to quantitate variability among a group of pathologists with an interest in lymphomas (albeit with variable levels of experience) and quantitate the benefit of joint discussions as a tool to increase accuracy and reduce interobserver variability of pathologists, in the diagnosis of BL in a resource-limited setup.Materials and Methods:A set of 25 non-Hodgkin lymphoma cases in which a diagnosis of BL was entertained were circulated to 14 participating pathologist within the Mumbai lymphoma study group. A proforma recorded the morphologic and immunohistochemical features perceived during the initial independent diagnosis followed by a consensus meeting for discussion on morphology and additional information pertinent to the case.Statistical analysis and Results:The concordance was poor for independent diagnosis among all the pathologists with kappa statistics (±SE) of 0.168 (±0.018). Expert lymphoma pathologists had the highest (albeit only fair) concordance (kappa = 0.373 ± 0.071) and general pathologists the lowest concordance (kappa = 0.138 ± 0.035). Concordance for morphological diagnosis was highest among expert lymphoma pathologists (kappa = 0.356 ± 0.127). Revision of diagnoses after consensus meeting was highest for B-cell lymphoma intermediate between DLB and BL. To conclude, interobserver variation is a significant problem in BL in the post WHO 2008 classification era. Experience with a larger number of cases and joint discussion exercises such as the one we conducted are needed as they represent a simple and effective way of improving diagnostic accuracy of pathologists working in a resource-limited setup.

Usefulness of Downe Score as Clinical Assessment Tool and Bubble CPAP as Primary Respiratory Support in Neonatal Respiratory Distress Syndrome

Background: In preterm neonates respiratory distress syndrome (RDS) is one of the common causes of morbidity and mortality. Application of Bubble CPAP has been shown to be beneficial in terms of reduced need of invasive ventilation and prolonged hospital stay in newborns with RDS. Objective: Present study was conducted to assess the outcome of Bubble CPAP in newborns and usefulness of Downe score in predicting outcome and use as an assessment tool by medical/ nursing staff in resource limited setup. Method: We conducted this prospective study to evaluate effectiveness of Bubble CPAP as primary mode of respiratory support in resource limited setup of periphery with Downe score used as one of the tool to assess response to treatment. The study was conducted from November 2010 to February 2012 and based on inclusion criteria a total of 75 newborns were enrolled. Results: CPAP failure was observed in37.3% of preterm babies with RDS. Chest X ray suggestive of severe RDS, Downe score > 6 at 15-20 minutes of starting CPAP and sepsis/pneumonia was significantly associated with CPAP failure and also were independent predictors of outcome. Area under curve (AUC) for Downe score at 15-20 minutes of starting CPAP was 78.5% (95% CI = 67.9 to 89.1) Conclusion: Bubble CPAP was found to be effective and safe mode of treating mild to moderate RDS and Downe score can be used at periphery to monitor response and to decide about referral in absence of sophisticated test. Keywords: Bubble CPAP, Downe score, Predictors of CPAP failure

Bronchiectasis: Experience of Surgical Management at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Bronchiectasis is one of the major health problems in Ethiopia. We analyzed the outcome of surgery done for bronchiectasis in a resource-limited setup. A retrospective cross-sectional analysis of 22 patients who underwent surgery for bronchiectasis in Tikur Anbessa specialized hospital (TASH) during the period 2012 - 2017 were done. There were 13(59%) female and 9(41%) male patients with a mean age of 34.1 +/-16.9 years. The mean duration of symptoms was 2.2 years. Blood streak sputum, 13(59%), dyspnea, 9(49.9%), fetid sputum, 8(36.4%), dry cough, 6(27.3%), chest pain, 6(27.3%) and massive hemoptysis 3(13.6%) were the main presenting symptoms. In 20(91%) of the patients, previous history of TB treatment was identified. Recurrent childhood infection, 1(4.5%), and tumor obstruction, 1(4.5%), were also seen. Bronchiectasis was left sided in 12(54.5%), right-sided in 7(31.8%) and bilateral in 3(13.6%) patients. The disease affected multiple lung lobes in 9(40.9%), left lower lobe in 6(27.3%) and left upper lobe in 3(13.6%) cases. Indications for surgery were the failure of medical management in 10(45.5%), destroyed lung in 9(40.9%), and massive hemoptysis in 3(13.6%) cases. The procedures performed were lobectomy in 14(63.6%) and pneumonectomy in 8(36.4%) cases. Postoperative complications occurred in 5(22.7%) patients with one (4.5%) death. On the other hand, 77.3% of operated patients had significant improvement compared to their preoperative symptoms. In a resource-limited setup like TASH, localized bronchiectasis can be treated surgically with an acceptable result. Proper selection and preparation with complete resection of the involved segments are needed for maximum control of symptoms and better outcomes.