Pheochromocytoma: A Rare Cause of Secondary Hypertension

  Introduction: Pheochromocytoma is a rare tumor, originating from the chromaffin tissue. Its frequency is approximately 1/100,000. The clinical manifestation is due to catecholamine excess, which includes high blood pressure, palpitation, headache, sweating, nausea, vomiting, trembling, weakness, irritation, abdominal and chest pain, dyspnea, red warm face, constipation, polyuria, and polydipsia.   Case Report: We present a case of 53 years old male, hospitalized for hypertensive crisis following the manipulation of left sided frozen shoulder. He had labile blood pressure ranging from 220/120 systolic- 90/60 diastolic, profuse sweating and tachycardia. Findings of Contrast enhanced CT of abdomen was consistent with right adrenal pheochromocytoma and 24 hours urinary VMA was 17 mg /24 hr (Normal <13.6 mg /24hr). After the clinical, paraclinical investigations and radiological tests, it was proved to be a pheochromocytoma. The surgical intervention was planned. But due to unavailability of required antihypertensive drugs in Nepal (alpha-blockers like phentolamine and phenoxybenzamine), surgeons were reluctant to operate, although blood pressure was well controlled with use of sodium nitroprusside during hypertensive crisis and prazosin, a selective alpha blocker as maintainance therapy. The use of prazosin to control hypertension secondary to pheochromocytoma is limited to case report and case series.   Conclusion: Although rare, pheochromocytoma is a treatable surgical cause of secondary hypertension

Loss of beta-catenin triggers oxidative stress and impairs hematopoietic regeneration

Accidental or deliberate ionizing radiation exposure can be fatal due to widespread hematopoietic destruction. However, little is known about either the course of injury or the molecular pathways that regulate the subsequent regenerative response. Here we show that the Wnt signaling pathway is critically important for regeneration after radiation-induced injury. Using Wnt reporter mice, we show that radiation triggers activation of Wnt signaling in hematopoietic stem and progenitor cells. β-Catenin-deficient mice, which lack the ability to activate canonical Wnt signaling, exhibited impaired hematopoietic stem cell regeneration and bone marrow recovery after radiation. We found that, as part of the mechanism, hematopoietic stem cells lacking β-catenin fail to suppress the generation of reactive oxygen species and cannot resolve DNA double-strand breaks after radiation. Consistent with the impaired response to radiation, β-catenin-deficient mice are also unable to recover effectively after chemotherapy. Collectively, these data indicate that regenerative responses to distinct hematopoietic injuries share a genetic dependence on β-catenin and raise the possibility that modulation of Wnt signaling may be a path to improving bone marrow recovery after damage

The state of indoor air quality in Pakistan—a review

Background and purpose: In Pakistan, almost 70% of the population lives in rural areas. Ninety-four percent of households in rural areas and 58% in urban areas depend on biomass fuels (wood, dung, and agricultural waste). These solid fuels have poor combustion efficiency. Due to incomplete combustion of the biomass fuels, the resulting smoke contains a range of health-deteriorating substances that, at varying concentrations, can pose a serious threat to human health. Indoor air pollution accounts for 28,000 deaths a year and 40 million cases of acute respiratory illness. It places a significant economic burden on Pakistan with an annual cost of 1% of GDP. Despite the mounting evidence of an association between indoor air pollution and ill health, policy makers have paid little attention to it. This review analyzes the existing information on levels of indoor air pollution in Pakistan and suggests suitable intervention methods. Methods: This review is focused on studies of indoor air pollution, due to biomass fuels, in Pakistan published in both scientific journals and by the Government and international organizations. In addition, the importance of environmental tobacco smoke as an indoor pollutant is highlighted. Results: Unlike many other developing countries, there are no long-term studies on the levels of indoor air pollution. The limited studies that have been undertaken indicate that indoor air pollution should be a public health concern. High levels of particulate matter and carbon monoxide have been reported, and generally, women and children are subject to the maximum exposure. There have been a few interventions, with improved stoves, in some areas since 1990. However, the effectiveness of these interventions has not been fully evaluated. Conclusion: Indoor air pollution has a significant impact on the health of the population in Pakistan. The use of biomass fuel as an energy source is the biggest contributor to poor indoor air quality followed by smoking. In order to arrest the increasing levels of indoor pollution, there is a dire need to recognize it as a major health hazard and formulate a national policy to combat it. An integrated effort, with involvement of all stakeholders, could yield promising results. A countrywide public awareness campaign, on the association of indoor air pollution with ill health, followed by practical intervention would be an appropriate approach. Due to the current socioeconomic conditions in the country, development and adoption of improved cooking stoves for the population at large would be the most suitable choice. However, the potential of biogas as a fuel should be explored further, and modern fuels (natural gas and LPG) need to be accessible and economical. Smoking in closed public spaces should be banned, and knowledge of the effect of smoking on indoor air quality needs to be quantified. © 2010 Springer-Verlag

Evaluation of teachers training workshop at Kirkpatrick level 1 using retro–pre questionnaire

Rano Mal Piryani,1 Govinda Prasad Dhungana,2 Suneel Piryani,2 Mamata Sharma Neupane3 1Department of Internal Medicine, Health Professionals Education & Research Centre, Chitwan Medical College, Bharatpur, Chitwan, Nepal; 2School of Public Health and Community Medicine, Chitwan Medical College, Bharatpur, Chitwan, Nepal; 3School of Nursing, Chitwan Medical College, Bharatpur, Chitwan, Nepal Background: Teacher training focusing on teaching learning methodologies, assessment tools, and approaches that motivate the teachers and enhance their confidence is one of the fundamental programs of faculty development. The objective of this study was to assess the self-reported perceived confidence of faculty members after participating in a basic teachers training workshop. Methodology: The retrospective post-then-pre design questionnaire was used for evaluating the faculty members’ self-reported perceived confidence at Kirkpatrick level 1 (evaluation of reaction) after completing basic teachers training workshops. The self-reported perceived confidence on 30 statements were analyzed by 3 categories (not confident, confident, and highly confident) on a Likert scale. Results: Out of 60 participants (18 in the 3rd and 21 each in the 4th and 5th teachers training workshops), 58 (96.67%) responded to all statements. The mean age of the participants was 34.14±5.15 years; 70.7% were male and 29.3% female. Overall, the self-reported perceived confidence level of the participants of the 3rd (pre-training median 57, post-training median 70, p<0.001), 4th (pre-training median 51, post-training median 67, p<0.001) and 5th (pre-training median 51, post-training median 68, p<0.001) training workshops was significantly increased after training. There was a noticeable change in the level of confidence of the participants after training. The observed percentage change in self-reported perceived confidence was 29.63% in those who received no training prior to joining college (n=51, 87.9%); this was 2 times more than those who received some sort of training prior to teachers training (n=7, 12.1%). Conclusion: Overall, the self-reported perceived confidence level of the participants was significantly increased after teachers training workshop. Keywords: assessment, confidence, Kirkpatrick level 1, Nepal, retro–pre, teachers’ trainin

Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal.

Background: The majority of patients with asthma and chronic obstructive pulmonary disease (COPD) have been known to perform inhaler technique inadequately. We aimed to evaluate the benefit of hospital pharmacy intervention on the current status of dry powder inhaler (Rotahaler®) technique in such patients and the factors associated with the correct use. Methods: A pre-post interventional study was conducted at the outpatient pharmacy in a teaching hospital of the Central Development Region, Nepal, in patients with asthma and COPD currently using a Rotahaler device. Patients' demographics and Rotahaler technique were assessed before intervention. Those who failed to demonstrate the correct technique were educated and trained by the pharmacist, and their technique was reassessed after 2 weeks of intervention. Descriptive statistics, including Wilcoxon signed rank test, Mann-Whitney U test, Spearman's correlations and Kruskal-Wallis test, were performed for statistical analysis. Results: Before intervention, only 5.7% (10 of 174) of the patients demonstrated the correct Rotahaler technique and the most common errors observed were failure to breathe out gently before inhalation (98.8%) and failure to hold breath for about 10 seconds after inhalation (84.8%). After the intervention (n=164), 67.1% of the patients showed their technique correctly (p≤0.001) and failure to breathe out gently before inhalation was the most common error (27.44%). Age (p=0.003), previous instruction (p=0.007), patient's education level (p=0.013) and source of instruction (p<0.001) were associated with an appropriate technique before intervention, while age (p=0.024), duration of therapy (p=0.010) and gender (p=0.008) were the factors correlated with correct usage after intervention. Conclusion: The current status of Rotahaler technique is inadequate in patients with asthma and COPD attending the Chitwan Medical College Teaching Hospital in the Central Development Region, Nepal. However, a single hospital pharmacy intervention can significantly improve the correct use of the technique, highlighting the role of hospital pharmacies in the improvement of inhaler technique

Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal

Ramesh Sharma Poudel,1 Rano Mal Piryani,2 Shakti Shrestha,3 Aastha Prajapati1 1Hospital Pharmacy, 2Department of Internal Medicine, Chitwan Medical College Teaching Hospital, 3Department of Pharmacy, Shree Medical and Technical College, Chitwan, Nepal Background: The majority of patients with asthma and chronic obstructive pulmonary disease (COPD) have been known to perform inhaler technique inadequately. We aimed to evaluate the benefit of hospital pharmacy intervention on the current status of dry powder inhaler (Rotahaler&reg;) technique in such patients and the factors associated with the correct use. Methods: A pre&ndash;post interventional study was conducted at the outpatient pharmacy in a teaching hospital of the Central Development Region, Nepal, in patients with asthma and COPD currently using a Rotahaler device. Patients&rsquo; demographics and Rotahaler technique were assessed before intervention. Those who failed to demonstrate the correct technique were educated and trained by the pharmacist, and their technique was reassessed after 2&nbsp;weeks of intervention. Descriptive statistics, including Wilcoxon signed rank test, Mann&ndash;Whitney U test, Spearman&rsquo;s correlations and Kruskal&ndash;Wallis test, were performed for statistical analysis. Results: Before intervention, only 5.7% (10 of 174) of the patients demonstrated the correct Rotahaler technique and the most common errors observed were failure to breathe out gently before inhalation (98.8%) and failure to hold breath for about 10&nbsp;seconds after inhalation (84.8%). After the intervention (n=164), 67.1% of the patients showed their technique correctly (p&le;0.001) and failure to breathe out gently before inhalation was the most common error (27.44%). Age (p=0.003), previous instruction (p=0.007), patient&rsquo;s education level (p=0.013) and source of instruction (p&lt;0.001) were associated with an appropriate technique before intervention, while age (p=0.024), duration of therapy (p=0.010) and gender (p=0.008) were the factors correlated with correct usage after intervention. Conclusion: The current status of Rotahaler technique is inadequate in patients with asthma and COPD attending the Chitwan Medical College Teaching Hospital in the Central Development Region, Nepal. However, a single hospital pharmacy intervention can significantly improve the correct use of the technique, highlighting the role of hospital pharmacies in the improvement of inhaler technique. Keywords: asthma, COPD, intervention, Nepal, pharmacy, pharmacist, Rotahale

Diabetes Mellitus with Poor Glycemic Control as a Consequence of Inappropriate Injection Technique.

Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control

Opinion of hospital pharmacy practitioners toward the Continuing Pharmacy Education program: a study from a tertiary care hospital in central Nepal

Ramesh Sharma Poudel,1 Rano Mal Piryani,2 Shakti Shrestha,3 Roshan Chaurasiya,1 Bed Prakash Niure1 1Hospital Pharmacy, Chitwan Medical College Teaching Hospital, Chitwan, Nepal, 2Health Professionals Education and Research Centre, Chitwan Medical College Teaching Hospital, Chitwan, Nepal, 3Department of Pharmacy, Shree Medical and Technical College, Chitwan, Nepal Background: Meeting participants&rsquo; needs and matching their preferences are important prerequisites for an effective Continuing Pharmacy Education (CPE) program. The objective of this pilot study was to assess the opinion of hospital pharmacy practitioners with respect to the CPE program.Methods: The pretested questionnaires were distributed to 20 pharmacy practitioners working in a pharmacy at a tertiary care hospital in Nepal which asked for their opinions and suggestions with respect to the CPE program. Descriptive statistics were performed using IBM SPSS version 20.Results: Topics related to skills development (75%) and recent innovations in pharmacy practice (65%) were mostly preferred. Live (in-person) presentations (80%) and small group discussion (60%) were the most suitable methods for delivery. Improving knowledge (75%), improving skills (60%) and keeping up-to-date in the latest information (60%) were major motivating factors to participate, while lack of time (75%) was a major barrier. Approximately 55% of the participants believed that face-to-face interview was a suitable method for evaluating the effectiveness. Allocation of separate time for the program, assessing baseline knowledge and skills of the participants along with delivery of quality materials in an understandable way were the top common suggestions for improving the CPE program.Conclusion: Hospital pharmacy practitioners&rsquo; opinions and suggestions were assessed with respect to the CPE program and this was upgraded accordingly to meet their expectations. Keywords: continuing education, opinion, pharmacy, pharmacy practitioner, Nepa

Opinion of hospital pharmacy practitioners toward the Continuing Pharmacy Education program: a study from a tertiary care hospital in central Nepal.

Background: Meeting participants' needs and matching their preferences are important prerequisites for an effective Continuing Pharmacy Education (CPE) program. The objective of this pilot study was to assess the opinion of hospital pharmacy practitioners with respect to the CPE program. Methods: The pretested questionnaires were distributed to 20 pharmacy practitioners working in a pharmacy at a tertiary care hospital in Nepal which asked for their opinions and suggestions with respect to the CPE program. Descriptive statistics were performed using IBM SPSS version 20. Results: Topics related to skills development (75%) and recent innovations in pharmacy practice (65%) were mostly preferred. Live (in-person) presentations (80%) and small group discussion (60%) were the most suitable methods for delivery. Improving knowledge (75%), improving skills (60%) and keeping up-to-date in the latest information (60%) were major motivating factors to participate, while lack of time (75%) was a major barrier. Approximately 55% of the participants believed that face-to-face interview was a suitable method for evaluating the effectiveness. Allocation of separate time for the program, assessing baseline knowledge and skills of the participants along with delivery of quality materials in an understandable way were the top common suggestions for improving the CPE program. Conclusion: Hospital pharmacy practitioners' opinions and suggestions were assessed with respect to the CPE program and this was upgraded accordingly to meet their expectations