The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study.
A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas.
Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care.
The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities.
Multimorbidity; care plans; collaborative care; diabetes; heart disease; depression
Our study retrospectively reviewed the presentation, neuro-radiological findings, and outcomes of eight adult patients presenting at our institution with subarachnoid haemorrhage (SAH), which was subsequently proven to be due to cortical venous thrombosis (CVT).
We reviewed the case records and neuroimaging findings of eight patients diagnosed with SAH and CVT over a span of two years at our institution, a tertiary care centre in Western India. All details pertaining to their presentation, clinical findings, neuroimaging, management, and outcome following therapy with anticoagulants were collected until patient discharge.
There were a total of eight patients, with the average age being 34 years (range 25–42). Only one patient was female. Six patients had a history of recent binge drinking. None of the patients had a past or family history of common risk factors for thrombosis. All patients presented acutely, with headache (n=6) and seizures (n=6) being the most common presenting features, occurring in three-quarters of the patients examined. Non-contrast computed tomography (NCCT) was the initial imaging study for all but one of the patients and showed cortical SAH (cSAH) without basilar haemorrhage. Magnetic resonance imaging/magnetic resonance venography (MRI/MRV) confirmed the underlying CVT. Unfractionated heparin was used in all cases. Seven patients improved and were discharged on oral anticoagulation. The eighth patient died.
Localised cSAH with sparing of basal cisterns can be a presentation for CVT. In patients with cSAH, MRI/MRV can be useful to make a diagnosis of CVT. Anticoagulation for CVT, even in the presence of SAH was related to seven out of eight patients being discharged.
Cortical venous thrombosis; subarachnoid haemorrhage; non-contrast CT
Although medicines shortages are a persistent and challenging problem for all health systems, the reasons for such shortages vary considerably between settings. Understanding the range of problems encountered, and the specific reasons for each medicines shortage event, may help to identify the most appropriate systems-wide responses.
South Africa’s health system is, at this point, still clearly divided between a better-resourced private sector and an overwhelmed public sector. Medicines selection and procurement processes in the two sectors are markedly different. However, in both sectors there is a dearth of publicly accessible information about the incidence and consequences of medicines shortages.
This brief report describes the medicines selection and procurement processes currently applied in South Africa’s public health sector, and then describes the nature of the medicines shortages that have been experienced in the KwaZulu-Natal provincial health services between July 2012 and June 2013. The degree to which these shortages might have been managed differently, had the recommendations developed by the International Pharmaceutical Federation Summit on Medicines Shortages been implemented, is then explored.
Medicines shortages; South Africa; public sector selection and procurement; systems-wide responses
Supernumerary kidney is the rarest of all renal anomalies; fewer than 80 cases have been reported in the literature over the years. Supernumerary kidneys are most commonly located on the left side of the abdomen. Different pathologic conditions are reported to affect supernumerary kidneys and they may be associated with malformations of the upper urinary tract and genital tract. Because of their infrequent occurrence and reporting, they frequently cause diagnostic challenges. Here we report a case in a 14-year-old male patient of unilateral supernumerary kidney on the right side of the abdomen with multiple calculi, mal-rotation and a gross hydronephrotic left kidney.
Hydronephrosis; renal anomalies; Supernumerary kidney
Mycobacterium tuberculosis remains one of the most significant causes of death from an infectious agent. Rapid and accurate diagnosis of pulmonary and extra-pulmonary tuberculosis (TB) is still a great challenge. The GeneXpert MTB/RIF assay is a novel integrated diagnostic system for the diagnosis of tuberculosis and rapid detection of Rifampin (RIF) resistance in clinical specimens. In 2012, the Arkansas Tuberculosis Control Program introduced GeneXpert MTB/RIF assay to replace the labour-intensive Mycobacterium Tuberculosis Direct (MTD) assay.
To rapidly diagnose TB within two hours and to simultaneously detect RIF resistance.
Describe the procedure used to introduce GeneXpert MTB/RIF assay in the Arkansas Tuberculosis Control Program.
Characterise the current gap in rapid M. tuberculosis diagnosis in Arkansas.
Assess factors that predict acid fast bacilli (AFB) smearnegative but culture-positive cases in Arkansas.
Illustrate, with two case reports, the role of GeneXpert MTB/RIF assay in reduction of time to confirmation of M. tuberculosis diagnosis in the first year of implementation.
Between June 2012 and June 2013, all AFB sputum smearpositive cases and any others, on request by the physician, had GeneXpert MTB/RIF assay performed as well as traditional M. tuberculosis culture and susceptibilities using Mycobacteria Growth Indicator Tube (MGIT) 960 and Löwenstein-Jensen (LJ) slants. Surveillance data for January 2009–June 2013 was analysed to characterise sputum smear-negative but culture-positive cases.
Seventy-one TB cases were reported from June 2012– June 2013. GeneXpert MTB/RIF assay identified all culture-positive cases as well as three cases that were negative on culture. Also, this rapid assay identified all six smear-negative but M. tuberculosis culture-positive cases; two of these cases are described as case reports.
GeneXpert MTB/RIF assay has made rapid TB diagnosis possible, with tremendous potential in determining isolation of TB suspects on one hand, and quickly ruling out TB whenever suspected.
Tuberculosis; GeneXpert MTB/RIF assay; AFB
In Nepal, reporting of adverse drug reactions (ADRs) occurs on a voluntary basis by doctors, pharmacists, nurses, health assistants, and other healthcare professionals. The country’s pharmacovigilance program is still in its infancy; it has limited coverage and underreporting is common. This major limitation could be reduced with consumer involvement. This report examines the necessity and benefits of consumer involvement in Nepal’s existing pharmacovigilance program, reflecting on existing examples of consumer pharmacovigilance in different countries to highlight the necessity for such a framework in Nepal.
Consumers; Nepal; pharmacovigilance
Despite best efforts by healthcare providers to sterilise their hands through hand washing prior to touching medical equipment and patients, bacteria are still present and can be spread through physical contact. We aimed to reduce the spread of touch-induced and airborne bacteria and virus spreading by using a touch-free glove-dispensing system that minimally exposes gloves in the box to air.
The team met multiple times to undertake early prototyping and present ideas for the design. We experimented with folding gloves in varying patterns, similar to facial tissuedispensing boxes, and tried several methods of opening/closing the glove box to determine the most effective way to access gloves with the least amount of physical contact. We considered the user experience and obtained user feedback after each design iteration.
Ultimately, we decided on a vertically oriented box with optional holes for dispensing a glove on the side of the box or on the bottom by means of the pull-down drawer mechanism. This system will dispense a single glove at a time to the user with the option of using a pull-down drawer trigger to decrease the likelihood of physical contact with unused gloves. Both methods dispense a single glove.
By reducing physical contact between the healthcare practitioner and the gloves, we are potentially reducing the spread of bacteria. This glove box design ensures that gloves are not exposed to the air in the clinic or hospital setting, thereby further reducing spread of airborne germs. This could assist in decreasing the risk of nosocomial infections in healthcare settings.
Disposable gloves; contamination; pathogens; clinic
With more people being exposed to antibiotics, intestinal microflora faces constant pressure of antibiotic selection, which has resulted in the emergence of multidrug resistant strains. This may pose a severe problem as intestinal Enterobacteriaceae members are commonly implicated in human infections.
This surveillance study was undertaken to investigate the carriage of carbapenem-resistant Enterobacteriaceae (CRE) in the gastrointestinal tract among patients attending the outpatient clinic in a tertiary care center of East Delhi, India.
We performed a prospective surveillance study to screen 242 Enterobacteriaceae isolates for carbapenemase production from the stool samples of 123 outpatients attending a tertiary care hospital in East Delhi over a four-month period.
Twenty-four (9.9 per cent) isolates demonstrated carbapenemase activity among 242 screened Enterobacteriaceae isolates. Four stool samples had two isolates of different species, both eliciting this feature and therefore indicating presence of multiple carbapenem-resistant Enterobacteriaceae (CRE) isolates in a single sample.
Screening for carriage of CRE in stools of patients undergoing elective or emergency gastrointestinal surgical procedures, with haematological malignancies taking chemotherapy, or those planned for bone marrow transplantation can guide clinicians about gut colonisation of multidrug-resistant Enterobacteriaceae as these groups of patients are at risk of possible endogenous infection.
Carbapenem resistant Enterobacteriaceae; gut colonisation; prophylactic antibiotic
Driving is a complex task. Many older drivers are unaware of their obligation to inform authorities of conditions which may impact upon their driving safety.
This study sought to establish the adequacy of driving advice in electronic discharge summaries from an Australian stroke unit.
One month of in-patient electronic discharge summaries were reviewed. A predetermined list of items was used to assess each electronic discharge summary: age; gender; diagnosis; relevant co-morbidities; deficit at time of discharge; driving advice; length of stay; and discharge destination.
Of 41 participants, the mean age was 72 years. Twenty patients had a discharge diagnosis of stroke, nine of transient ischaemic attack, four of seizure and one of encephalitis. Of these, only eight discharge summaries included driving advice.
The documentation of driving advice in electronic discharge summaries is poor. This has important public health, ethical and medico-legal implications. Avenues for future research are explored.
Aged; automobile driving; patient discharge; seizure; stroke
Drug-related problems such as overuse of injectable drug products and antimicrobials, increased cost of drug therapy, polypharmacy, and adverse drug reactions (ADRs) are prevalent in the healthcare settings of Nepal. To date, no new drug development processes or clinical trials have been conducted in Nepal, despite the fact that studies of real life situations are an essential tool for monitoring medicine use. Pharmacoepidemiology (PE) is an important area that evaluates the effects of drug use in large populations.
Data obtained from pharmacoepidemiological studies may highlight ways to reduce certain drug-related problems and provide reliable information on the safety profile of a drug. Moreover, clinicians and regulatory authorities may also use the data to make drug therapy decisions, drug regulation and policy development. Therefore, there is a great need to conduct appropriate pharmacoepidemiological studies that involve multiple regions and in various groups of the population of Nepal, to collect unbiased and reliable information on drug use.
Clinical decisions; drug regulation; Nepal; pharmacoepidemiology
Community pharmacies in Nepal serve both rural and urban populations and are an integral part of the Nepalese healthcare system. These community pharmacies are run by non-pharmacist professionals with orientation training on pharmacology and drug dispensing. Graduate pharmacists’ involvement in community pharmacy will help with patient counselling, dispensing of medication and promotion of safe and appropriate medicine use. Nepal has an organised pharmacovigilance system which incorporates adverse drug reaction (ADRs) from hospitals and tertiary care centres but not from the community. Involvement of pharmacists in community pharmacy will help in ADR reporting and, monitoring at community level and will help in promoting medication safety in the community. This article describes the community pharmacovigilance program in Nepal and the prospects for community pharmacists.
Community Pharmacy; Adverse Drug Reaction; Pharmacist; Nepal
In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.
The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two ‘plain English’ booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.
The resources are intended to facilitate home care that acknowledges and plans for the client’s deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and clinically futile interventions are also minimised.
Evidence-based health care; guidelines; palliative care; aged care; community care
Globally, it is estimated that 170 million people are living with hepatitis C and between three and four million are newly infected annually. In Australia, around 1% of people are living with chronic hepatitis C, with two-thirds of these being men.
This research aimed to determine the impact of hepatitis C treatment on partners of patients using in-depth exploratory techniques.
Four infected men and their partners (n= 8 participants) and three service providers were recruited and interviewed separately to identify the needs of female partners supporting patients with Hepatitis C. Discussion was based on the experiences of female partners during the treatment phase of male hepatitis C patients.
All participants recognised a need for greater assistance for partners of hepatitis C treatment patients. It was also recognised that strong social support improved treatment outcomes and helped to maintain the survival of family relationships during the intensive treatment phase.
Although this research was limited by size, it provides valuable insights into ways to enhance hepatitis C management outcomes beyond traditional medical treatment regimes, for example through formal partner support.
Caregivers/caring; coping and adaptation; partners; hepatitis C.
Frail older people who are considering movement into residential aged care or returning home following a hospital admission often face complex and difficult decisions.Despite research interest in this area, a recent Cochrane review was unable to identify any studies of interventions to support decision-making in this group that met the experimental or quasi-experimental study design criteria.
This study tests the impact of a multi-component coaching intervention on the quality of preparation for care transitions, targeted to older adults and informal carers. In addition, the study assesses the impact of investing specialist geriatric resources into consultations with families in an intermediate care setting where decisions about future care needs are being made.
This study was a randomised controlled trial of 230 older adults admitted to intermediate care in Australia. Masked assessment at 3 and 12 months examined physical functioning, health–related quality of life and utilisation of health and aged care resources. A geriatrician and specialist nurse delivered a coaching intervention to both the older person and their carer/family. Components of the intervention included provision of a Question Prompt List prior to meeting with a geriatrician (to clarify medical conditions and treatments, medications, ‘red flags’, end of life decisions and options for future health care) and a follow-up meeting with a nurse who remained in telephone contact. Participants received a printed summary and an audio recording of the meeting with the geriatrician.
The costs and outcomes of the intervention are compared with usual care. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000638437).
Caregivers; continuity of patient care; cost-benefit analysis; health care costs; intermediate care facilities; patient-centred care; quality of life; randomised controlled trial
Medical education is associated with various pressures and stresses which can lead to depression. This study was undertaken to discover the prevalence of depression in medical students and various factors contributing to depression.
This is a cross-sectional, questionnaire-based study. Using stratified random sampling, 237 students were selected according to year of study. Patient Health Questionnaire (PHQ-9), based on PRIME-MD Today, was used to make a provisional diagnosis of depression.
The overall prevalence of provisionally diagnosed depressive and major depressive disorder using PHQ-9 was 21.5% and 7.6%, respectively. Year of study and academic performance of students had a statistically significant association with depression. Other factors, including gender, self-reported past history of depression, family history of psychiatric disorders, type of social support, family structure, number of siblings and education of parents were not found to have any significant association with prevalence of depression in the study. It was also observed that students were reluctant to seek help for depressive symptoms.
Medical students; depression; academic performance
The use of electronic resources in education, including i- applications used on portable handheld devices, is increasing. Apple® handheld devices are popular, with free applications the most prevalent download form. Many gross anatomy i- applications are available, however no information on the quality of free anatomy products is available. Rating such products could therefore guide product recommendations.
To evaluate the quality and range of free iPod® applications that are applicable for tertiary level gross anatomy education.
A search of the iTunes® Application Store with keywords anatomy, free, medical, functional, clinical, gross, and human was performed, with inclusion based on free applications containing human gross anatomy usable for tertiary education purposes. Application specification was noted; each was trialled independently and rated for usability, specification, academic level, and quality (image and programme).
Sixty-three applications were identified and eleven met inclusion criteria. Two provided gross anatomy of the entire body, nine examined specific regions or systems. Five were judged introductory in academic level, five intermediate, and one advanced. One application was rated low quality, and four excellent. None were considered difficult to use (six easy, five medium). Application size ranged between 1.2MB and 229MB (mean 27MB).
There are few free i-applications for learning gross anatomy and most concentrate on individual body systems, with the academic level and usability of all products well rated. Results suggest some free I- applications could be suitable adjuncts for gross anatomy education at both an undergraduate and graduate level.
Gross anatomy; i-applications; education
Medical schools have a major challenge in teaching students to choose and prescribe medicines safely and effectively. Problem-based learning based on national essential medicine lists and standard treatment guidelines has been strongly recommended to improve prescribing. In Nepal, pharmacology is taught during the first two years of the undergraduate medical course. At KIST Medical College, Lalitpur the Department of Clinical Pharmacology teaches students to use essential medicines rationally. Small group, activity-based learning is used during practical sessions. In this article the author lists the 10 basic competencies which students should have developed by the end of the pharmacology practical module and also describes a selection of activities with regard to a particular competency used during the practical module and an exercise used to assess these competencies during the practical examination.
Competencies; Nepal; Pharmacology; Small groups
There is good evidence that regular fish consumption can lead to a range of health benefits, and that there is high public awareness of this fact. In spite of this, Australians do not, on average, consume fish to recommended levels. An intervention is proposed, leveraging social media and mobile technology. This approach is justified on the basis of a precedence of similar initiatives and the calculation of a potential target group size of 2.8 million adult Australians.
Brief health interventions; chronic disease; fish; seafood; social media; mobile technology
This multimedia project was as a beer commercial, a lad’s night in, an environment that can be used to target the relevant audience. The goal was to deploy a familiar atmosphere and recognisable characters whilst delivering a serious message with humour in a very short space of time.
Video; technology; condoms; advertisement; youth
Personal or P-drug selection teaches students to use impartial, objective information to make prescribing decisions. It is an important exercise recommended to reduce irrational prescribing and improve the prescribing behaviour of healthcare professionals. The exercise of P-drug selection has not been widely implemented in health professions schools in South Asia. This article describes the author’s personal experiences of P-drug selection teaching, learning and assessment in two Nepalese medical schools, Manipal College of Medical Sciences, Pokhara and KIST Medical College, Lalitpur.
Healthcare professionals; Nepal; Personal drugs; Pharmacology
This report outlines the content of a one-day workshop on Generic Medicines that was held at KIST Medical College, Lalitpur, Nepal on 13th December 2010, which was attended by 32 delegates from different institutions in Nepal, including pharmacists, pharmacologists and medical doctors. Right medicine, right patient, right dose, right frequency and duration, right information and right monitoring are conditions to be fulfilled for the rational use of medicine (RUM). The World Health Organization (WHO) defines generic medicine as ‘a pharmaceutical product, usually intended to be interchangeable with the innovator product, marketed after the expiry of patent or other exclusivity rights’. Economic factors, supportive legislation and regulation, public and professional acceptance and quality assurance are key enabling factors promoting use of generics. Increased patent protection for medicines and removing process patents is a key feature of new trade agreements and newer medicines for diseases like HIV/AIDS, tuberculosis and infectious diseases are likely to be more expensive. The Medicine and Therapeutics Committee (MTC) can play a key role in promoting generic medicine use in institutions.
Nepal being among the Least Developed Countries (LDCs) need not provide patent protection for medicines until 31st December 2015. Only a few ‘true’ generics are available in Nepal and there is huge cost variation in the price of different branded generics. Clinicians have concerns about the quality of medicines in general, substitution of poor quality brands by pharmacists and about therapeutic substitution. Generics have to meet the same regulatory requirements and be bioequivalent to reference preparations assuring their quality.
Generic medicines; Nepal; Patents; Rational use of medicines