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Sunil Shrestha,1 Simit Sapkota,2,3 Vibhu Paudyal,4,5 Zoe Moon,6 Rob Horne,6 Siew Hua Gan1 1School of Pharmacy, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia; 2Department of Clinical Oncology, Kathmandu Cancer Center, Tathali, Bhaktapur, Bagmati Province, Nepal; 3Department of Clinical Oncology, Civil Service Hospital, Minbhawan, Kathmandu, Bagmati Province, Nepal; 4Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College, London, UK; 5School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham Edgbaston, Birmingham, UK; 6Centre for Behavioural Medicine, Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UKCorrespondence: Sunil Shrestha, Email sunilcresta@gmail.comBackground: Adherence to pain medication is crucial for cancer patients, since non-adherence can lead to increased suffering, reduced quality of life and increased healthcare costs. Although the five‐item Medication Adherence Report Scale (MARS-5) is a validated tool for assessing medication adherence, but it has not been translated and validated into the Nepalese language. This study aimed to translate, culturally adapt and validate the MARS-5 in Nepalese language for Nepalese cancer patients who were experiencing pain.Materials and Methods: The cross-sectional validation study utilized a convenience sampling method. Initially, a pre-test was conducted with 25 patients. The MARS-5 was then forward and backward translated following the EORTC QLG translation procedure. The final translated version was reviewed by experts and subjected to a second pre-test. Construct validity was assessed through principal component analysis, and internal consistency was measured using Cronbach’s alpha coefficient. Inter-rater reliability was evaluated using the Intra-Class Correlation coefficient (ICC).Results: The study included 204 cancer patients (ages 18– 86, 55% female). The Nepalese version of the MARS-5 was translated without significant issues and underwent pre-testing with participants. Participants discussed the scale during these pre-tests, providing feedback on its clarity and comprehensibility. While formal assessment tools were not employed, the iterative nature of the pre-testing process allowed for the refinement of the translation based on participant feedback, indicating a robust understanding of the scale among participants. The ICC of test-retest reliability was found to be 0.860. The Kaiser Meyer Olkin’s value was 0.690, and Cronbach’s alpha was 0.72, indicating good construct validity and high internal consistency. The medication non-adherence rate was 11.3%.Conclusion: The MARS-5 was successfully translated, culturally adapted, and validated in Nepalese for use among Nepalese cancer patients experiencing pain. The Nepalese version of MARS-5 is a reliable tool for evaluating medication adherence in this population.Keywords: cancer pain, cultural adaptation, MARS-5, medication adherence, Nepalese patients, validation

Kiran Shahbaz,1 Alamgeer,1 Vibhu Paudyal,2 Maryam Zubair,3 Maryam Zahra Safdar,4 Momina Tahir,4 Laraib Akram,4 Salamat Ali4 1Department of Pharmacology, University College of Pharmacy, University of the Punjab Lahore, Pakistan; 2Institute of Clinical Sciences, University of Birmingham, Edgbaston Birmingham, UK; 3Faculty of Experimental Medicine Orebro University, Sweden; 4Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, GC University Faisalabad, Faisalabad, PakistanCorrespondence: Salamat Ali, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, GC University Faisalabad, Faisalabad, Pakistan, Tel +00-92-3004189052; +00-92-041-9201036, Email drsalamatali@gcuf.edu.pkBackground: Prevalence of psychological disorders among individuals with diabetes is significantly higher as compared to the general population.Aim: This study aimed to assess the prevalence and impact of psychological disorders on pharmacotherapy of diabetes patients.Methodology: This cross-sectional study was conducted at two primary care hospitals in Pakistan from April to June 2023. The nine-item Patient Health Care Questionnaire (PHQ-9) scale was used to assess depression in the study’s population, and its effects on pharmacotherapy of diabetes. Chi-square test was used to evaluate relationship between ordinal variables/categorical variables and depression whereas; Student’s t-test was used to assess the relationship between numerical variables with depression.Results: A total of 320 patients were assessed, comprising 120 (37.5%) males and 200 (62.5%) females, with a mean age of 52.5 (SD± 11.8) years. The average duration of diabetes is 7.0 (SD± 5.4). The average PHQ-9 score was 8.3 (SD± 5.5). Depression was found to be prevalent in 43.7% of the study population. Gender (female) (p-value 0.002), advanced age (p-value 0.002), lower income (p-value 0.001), education levels (p-value 0.001), longer duration of diabetes (p-value 0.001), poor diabetes control according to BSR value (p-value 0.001), usage of injectable insulin (p-value 0.005), and concomitant diseases (p-value 0.001) were found to be independently linked with depression. Significant association was observed between depression and treatment adherence (p-value 0.0025), number of missed doses (p-value 0.045), and difficulty in diabetes management (p-value 0.0015).Conclusion: Our study highlights significant prevalence of depression in study population and the prevalent depression negatively impacts on treatment adherence. It also revealed that depression complicates diabetes management resulting in poor medication adherence, poor diabetes control and diabetes related complications, making diabetes control more challenging and difficult.Keywords: psychological disorders, diabetes, pharmacotherapy, PHQ-9

Introduction: The early and late pregnancy both can be hazardous for mother and child. The study aims to explore the maternal age group among Nepalese women who delivered in Tribhuvan University Teaching Hospital and its effects on perinatal outcomes. Methods: An observational cross-section study was carried out from February to September, 2023 with the records of maternity cases at a tertiary care hospital after receiving ethical approval from the Institutional Review Committee [Reference number: 130(6-11) E2-2 079/080]. The records of maternity cases of four years duration from April, 2018 onwards were included. Data was entered in Microsoft Excel 2016 and descriptive analysis was done. Results: Out of 13062 maternity cases, the prevalence of pregnancy in normal reproductive age was 12035 (92.13%). A total of 882 (6.67%) maternity cases were in advanced age and 145 (1.11%) were in teen age. The alive newborns which were more in normal reproductive age was 12008 (99.77%) and stillbirth which was more in teen age pregnancy was 4 (2.75%). The low-birth-weight newborns distributed more in teen age pregnancy was 44 (30.34%) and high birth weight newborns distributed more in advanced age pregnancy was 18 (2.04%). Conclusions: The abnormal birth weight and stillbirths were common in teen age and advanced age pregnancy.

ABSTRACT Introduction There is a paucity of research on and a limited understanding of patient and public involvement (PPI) in the context of research in homelessness and, in particular, direct involvement of people with lived and living experience of homelessness (PEH) as expert advisors. We aim to report on outcomes and reflections from lived experience advisory panel (LEAP) meetings and PPI activities, held throughout the study lifecycle of a pilot randomised‐controlled trial (RCT) focused on evaluating integrated health and practical support for PEH. Methods Community Pharmacy Homeless Outreach Engagement Non‐medical Independent prescribing Rx (PHOENIx Community Pharmacy RCT) is an integrated health and social care intervention for people experiencing homelessness who present to community pharmacy. Intervention includes weekly support from a pharmacist prescriber and a third sector support worker for up to 6 months. PPI activities undertaken throughout the study were documented, including outcomes of LEAP meetings. Outcome reporting followed Guidance for Reporting Involvement of Patients and the Public 2 Short Form (GRIPP2‐SF). Results In total, 17 members were recruited into the LEAP; six meetings (three in two study sites) were held. PPI input was also received through representation from homelessness third sector organisation staff as study co‐applicants and core membership in the trial steering committee. Together, the PPI activities helped shape the study proposal, design of study materials, data analysis and dissemination materials. LEAP panel members offered valuable input via their experience and expertise into the delivery and refinement of interventions. Although longitudinal input was received from some LEAP members, ensuring repeat attendance in the pre‐planned meetings was challenging. Conclusion People who face social exclusion and marginalisation can provide highly valuable input as equal partners in co‐design and delivery of interventions seeking to improve their health and well‐being. Fluid membership and flexible methods of seeking and incorporating advice can offer pragmatic approaches to minimising barriers to continued involvement in research. Patient or Public Contribution This study reports findings and learning relevant to involvement of people with lived and living experience of homelessness as advisors in a research study. It is important for researchers to offer fluid memberships and use diverse methods to receive input from lived experience members, as traditional PPI methodology may be insufficient to ensure inclusivity. Staff and volunteers from third sector organisations were important PPI partners who bring their experience based on frontline service provision, often as the first port of call for people experiencing severe and multiple disadvantage. Trial Registration ISRCTN88146807.

Key Clinical Message Early recognition and treatment of Multisystem Inflammatory Syndrome in Children (MIS‐C) within the context of COVID‐19 infection is crucial for improved outcomes. Prompt intervention with IVIG and steroids leads to significant improvement in a severe case of MIS‐C. Clinicians should be vigilant for MIS‐C symptoms and initiate timely management. Abstract We report a case involving a fourteen‐year‐old male with COVID‐19 infection who developed multisystem inflammatory disease. A previously healthy child presented with a history of 10 days of fever and cough, along with diarrhea, and vomiting for 3 days. His COVID‐19 infection was confirmed through Polymerase Chain Reaction (PCR), and the laboratory values were remarkable for high levels of C‐reactive protein, D‐dimers, B‐type natriuretic peptide (BNP), and troponin I. He developed circulatory shock on the second day of the presentation and needed inotropic support. Steroids and intravenous immunoglobulin (IVIG) were started in light of Multisystem Inflammatory Syndrome in Children (MIS‐C), which improved his condition. Thus, during the management of COVID‐19 infection, early detection and a careful clinical characterization for MIS‐C are essential.

Abstract Background Chronic migraine (CM) is a significant neurological condition affecting a substantial portion of the global population. The economic burden of CM includes both direct healthcare costs and indirect costs resulting from productivity losses and intangible impacts on patients’ quality of life. However, there is limited research that comprehensively evaluates all cost components associated with CM, highlighting the need for a systematic review. Methods We conducted a systematic literature search in databases including MEDLINE, Embase, and CINAHL to identify studies estimating the cost of illness of chronic migraines. The search was restricted to English language articles published from inception to October 2021, and only findings from Organisation for Economic Co-operation and Development (OECD) countries were included. Methodology features and key findings were extracted from the studies, and reported costs were converted to GBP for cross-country comparisons. Results Thirteen cost-of-illness studies on CM from various OECD countries were included in this review. The studies demonstrated substantial variations in monetary estimates, but consistently highlighted the considerable economic burden of CM. Direct costs, particularly hospitalisation and medication expenses, were identified as the highest contributors. However, indirect costs, such as productivity losses due to absenteeism and presenteeism, were often underexplored in the reviewed studies. Additionally, intangible costs related to emotional and social impacts on patients were largely overlooked. Conclusion Chronic migraine imposes a significant economic burden on individuals, healthcare systems, and society. Policymakers and healthcare stakeholders should consider both direct and indirect cost components, as well as intangible costs, in developing targeted strategies for effective CM management and resource allocation. Further research focusing on comprehensive cost assessments and sensitivity analyses is needed to enhance the understanding of CM’s economic implications and inform evidence-based healthcare policy decisions. Addressing these research gaps can alleviate the economic burden of CM and improve patient outcomes.

Introduction: Hearing loss is defined as the partial or total reduction in auditory acuity. Hearing loss can cause detrimental effects on speech, language, developmental, educational, and cognitive outcomes in children. This study aimed to find out the prevalence of hearing loss among children visiting the Department of Otolaryngology and HNS of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among children visiting the Department of Otolaryngology and HNS between 1 January 2022 and 31 December 2022 after obtaining ethical approval. All the patients who underwent pure tone evaluation were included in the study. A convenience sampling technique was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 3051 children, 328 (10.75%) (9.65-11.85, 95% Confidence Interval) had hearing loss. Among children with hearing loss, 170 (51.83%) of children were female. The mean age of children with hearing loss was 13.31±3.39 years. The mean pure tone average among 452 ears with hearing loss was 44.60±17.71 dB. The commonest degree of hearing loss was mild hearing loss 266 (58.85%), and the commonest type was conductive hearing loss 310 (68.58%). Among children with hearing loss, 124 (37.80%) had bilateral hearing loss. Conclusions: The prevalence of hearing loss among children visiting the Department of Otolaryngology and HNS was found to be lower than similar studies done in similar settings.

Abstract Background People experiencing homelessness (PEH) have complex health and social care needs and most die in their early 40 s. PEH frequently use community pharmacies; however, evaluation of the delivery of structured, integrated, holistic health and social care intervention has not been previously undertaken in community pharmacies for PEH. PHOENIx (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) has been delivered and tested in Glasgow, Scotland, by NHS pharmacist independent prescribers and third sector homelessness support workers offering health and social care intervention in low threshold homeless drop-in venues, emergency accommodation and emergency departments, to PEH. Building on this work, this study aims to test recruitment, retention, intervention adherence and fidelity of community pharmacy-based PHOENIx intervention. Methods Randomised, multi-centre, open, parallel-group external pilot trial. A total of 100 PEH aged 18 years and over will be recruited from community pharmacies in Glasgow and Birmingham. PHOENIx intervention includes structured assessment in the community pharmacy of health, housing, benefits and activities, in addition to usual care, through weekly visits lasting up to six months. A primary outcome is whether to proceed to a definitive trial based on pre-specified progression criteria. Secondary outcomes include drug/alcohol treatment uptake and treatment retention; overdose rates; mortality and time to death; prison/criminal justice encounters; healthcare utilisation; housing tenure; patient-reported measures and intervention acceptability. Analysis will include descriptive statistics of recruitment and retention rates. Process evaluation will be conducted using Normalisation Process Theory. Health, social care and personal resource use data will be identified, measured and valued. Discussion If the findings of this pilot study suggest progression to a definitive trial, and if the definitive trial offers positive outcomes, it is intended that PHOENIx will be a publicly funded free-to-access service in community pharmacy for PEH. The study results will be shared with wider stakeholders and patients in addition to dissemination through medical journals and scientific conferences. Trial registration International Clinical Trial Registration ISRCTN88146807. Approved protocol version 2.0 dated July 19, 2022.

Sunil Shrestha,1 Asmita Priyadarshini Khatiwada,2 Binaya Sapkota,3 Simit Sapkota,4,5 Prabhat Poudel,6 Bhuvan KC,7,8 Siew Li Teoh,1 Ali Qais Blebil,1 Vibhu Paudyal9 1School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, 47500, Malaysia; 2Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA; 3Department of Pharmaceutical Sciences, Nobel College, Kathmandu, Nepal; 4Department of Clinical Oncology, Civil Service Hospital, Minbhawan, Kathmandu, Bagmati Province, Nepal; 5Department of Clinical Oncology, Kathmandu Cancer Center, Tathali, Bagmati Province, Nepal; 6Nepal Medical College Hospital, Kathmandu, Province Bagmati, Nepal; 7College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, QLD, Australia; 8Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Campus Parkville, Melbourne, VIC 3052, Australia; 9School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UKCorrespondence: Sunil Shrestha; Vibhu Paudyal, Tel +60 102874113, Email Sunil.shrestha@monash.edu; sunilcresta@gmail.com; v.paudyal@bham.ac.ukIntroduction: Opioid stewardship has been widely used to promote rational use, monitoring and discontinuation of opioid therapy; however, its definition and scope of practice remain unclear.Objective: To synthesize definitions of opioid stewardship proposed by clinical practice guidelines and professional societies, and to offer a proposal for a universally acceptable definition.Methods: Systematic literature searches were performed (earliest records to May 2022) in six databases (MEDLINE, EMBASE, APA PsycINFO, Scopus, and CENTRAL) and grey sources guidelines development bodies and professional societies through Google. The conventional but widely applied content analysis and word frequencies were used to analyze the definitions and scope of practice.Results: After removing duplicates, 449 articles were retrieved (439 databases and registers and 11 from other sources), 19 of which included a definition of “opioids stewardship”. A total of 12 themes was identified in the definitions, including 1) improvement or appropriateness of prescribing opioids use, 2) mitigation of risk from opioids, 3) monitoring opioid use, 4) evaluation of opioid use, 5) judicious opioid use, 6) appropriateness of opioid disposal, 7) identification and treatment of opioid use disorder, 8) reduction in mortality associated with opioid overdoses, 9) appropriate procurement practices, 10) appropriate storage, 11) promoting better communications between patients and prescribers including education provision and 12) patient-centered decision-making.Conclusion: Opioid stewardship is inconsistently defined across professional and research literature. While there is a greater focus on appropriateness and need for improvement of prescribing and monitoring of opioid use, the importance of communications between patients and prescribers, and patient involvement in both prescribing and deprescribing decision-making remains sparse. A comprehensive definition has been proposed as part of the work. There is a need to develop and validate the proposed definition and scope of practice to promote rationale for opioid prescribing, use and attainment of favourable outcomes through international consensus involving practitioners, researchers, and patients.Keywords: opioid, opioid stewardship, opioid stewardship definition, stewardship

Introduction: Children play vital role to the nation’s present and its future. The healthy and educated child of today is the intelligent and active citizen of tomorrow. Hence, the objective of our study was to assess the level of knowledge regarding child rights among teachers, compare the knowledge about child rights in context of private and government school, measure the association between knowledge regarding child rights with selected demographic variables. Methods: This is a cross-sectional comparative study conducted among 200 school teachers 100 each from four government and three private schools of Pokhara using purposive sampling method. Data was collected from November 1 to December 1, 2021. Structured self-administered questionnaire tool on knowledge regarding child rights was prepared by the researcher herself. The data were collected by self-administered tool by researcher herself within 30 minutes. The quantitative data was analyzed using statistical package for social sciences version 20.0 descriptive statistics and non-parametric test were used for analyzing knowledge and association. P-value of

Key Clinical Message Clinicians should consider central venous thrombosis (CVT) as a differential diagnosis in young adolescents with persistent headaches. It is essential to assess for concurrent CVT and dural arteriovenous fistula (DAVF), particularly in those with a history of CVT. Abstract Cerebral venous thrombosis (CVT) and dural arteriovenous fistula (DAVF) are uncommon vascular disorders with diverse clinical presentations. The coexistence of CVT and DAVF is a rare but important association that may impact the management and prognosis of affected patients. Prothrombotic conditions generally ranging from acquired to genetic, oral contraceptives, malignancy, puerperium, infection, and head injury are the common risk factors for cerebral venous thrombosis. Here, we present a case of 18 years males who developed recurrent cerebral thrombosis on the background of the presence of an arteriovenous fistula.

Introduction: Stress is the response of body to any change. The end stage of renal disease and the process of haemodialysis treatment are long-term stressors that alter patients’ well-being and everyday lifestyle. The aim of this study was to find out the prevalence of moderate stress levels among patients undergoing hemodialysis in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients undergoing hemodialysis from 1 October 2021 to 30 September 2022. Ethical clearance from the Institutional Review Committee. Patients undergoing maintenance haemodialysis for at least 3 months were included in the study. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 118 patients, 82 (69.49%) (61.18-77.80, 95% Confidence Interval) had moderate stress levels, out of which 51 (62.20%) were male and 31 (37.80%) were female. Conclusions: The prevalence of moderate stess level was found to be higher than other studies done in similar settings.

Abstract Background Medication use assessment has a critical role in promoting the effective and rational use of pharmaceutical medications. There are no studies that have explored the utilization of all medications in England and Wales in the past 15 years without restrictions in the age group being studied or class of medications. Aim To explore the medication utilization pattern of dispensed medications in England and Wales in the past 15 years. Method A secular trend analysis study using publically available dispensing data on the population level in England and Wales for the duration between 2004 and 2019. Medication dispensing data was extracted from the Prescription Cost Analysis database. Results Medication prescriptions rate increased by 42.6% [from 1,345,095.75 (95% CI 1,345,004.25 – 1,345,187.26) in 2004 to 1,918,138.48 (95% CI 1,918,038.38 – 1,918,238.57) in 2019 per 100,000 persons, trend test, p

Introduction: More than 700, 000 people die due to suicide every year. Suicide is the fourth leading cause of death among 15-29 year-olds. A total of 77% of global suicides occur in low- and middle-income countries. There is an increasing number of suicide all over the world. There is limited data regarding this issue. The available data are based on police reports or on specific populations. The aim of this study was to find out the prevalence of suicidal attempts among psychiatry patients presented to the Department of Emergency of a tertiary care centre. Methods: A Descriptive cross-sectional study was done in a tertiary care centre from January 2019 to July 2020 after taking Ethical approval from the same institute. Beck Suicide Intent Scale, MINI-7, IPDE and PLESS were used to assess suicidal intent, psychiatric comorbidities, personality disorder and life stress event scores respectively. Bronfenbrenner’s Social Ecological Model was used to access various stressors. Point estimate and 95% Confidence Interval were calculated. Results: The Prevalence of suicidal attempts among psychiatry patients in the emergency department was 265 (24.50%), (21.66-26.74, 95% Confidence Interval). The majority were females 135 (51%). The majority attempted at home 238 (89.81%). Poisoning was the most common mode of attempting suicide. Conclusions: The Prevalence of suicidal attempts among psychiatry patients was higher than in the other studies done in similar settings.

Aziza Alenezi, Asma Yahyouche, Vibhu Paudyal University of Birmingham, School of Pharmacy, Institute of Clinical Sciences, Birmingham, B15 2TT, UKCorrespondence: Asma Yahyouche, School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK, Tel/Fax + 44121 415 8798, Email A.Yahyouche@bham.ac.ukPurpose: In view of concerns about the harmful effects of long-term use and patient misuse of opioids in chronic non-malignant pain, this study provides insight into patients’ perspectives on their experience of living with chronic non-malignant pain (CNMP), prescribed opioid use, and optimisation.Patients and Methods: Data were collected from active UK-based CNMP specific or general health forums that do not require registration, with more than 100 members. English written thread posts between 2016 and 2020 were systematically searched from the forum search bar using different keywords and then analysed using the Theoretical Domains Framework (TDF).Results: Findings showed that chronic pain is a dominant, life-altering experience with physical, psychological and social impact. Findings highlighted that opioid optimisation is facilitated by patients’ knowledge and understanding, practical coping strategies and supportive relationships with healthcare providers and others in their surroundings. The study found that barriers to opioid optimisation included lack of availability of alternatives, difficulties accessing health services and broken relationships with clinicians.Conclusion: Analysis of CNMP patients’ posts on online forums highlighted the devastating impact of pain on social functioning, relationships and mental health. Patients emerged as knowledge seekers prepared to engage in opioid optimisation.Keywords: chronic non-malignant pain, medication optimisation, patient perspective, prescribed opioids, theoretical domains framework, qualitative study

Rajina Shakya,1,* Rajeev Shrestha,2,* Sunil Shrestha,3,* Priti Sapkota,1 Roshani Gautam,4 Lalita Rai,4 Asmita Priyadarshini Khatiwada,5 Kamal Ranabhat,6,7 Bhuvan KC,3 Binaya Sapkota,8 Saval Khanal,9 Vibhu Paudyal10 1Department of Nursing, Nobel College, Kathmandu, Province Bagmati, Nepal; 2Department of Pharmacy, District Hospital Lamjung, Lamjung, Province Gandaki, Nepal; 3School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia; 4Department of Nursing, Tribhuvan University, Maharajgunj Nursing Campus, Kathmandu, Nepal; 5Department of Pharmaceutical and Health Service Research, Nepal Health Research and Innovation Foundation, Lalitpur, Province Bagmati, Nepal; 6Center Department of Public Health, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal; 7Ministry of Health and Population, Kathmandu, Nepal; 8Department of Pharmaceutical Sciences, Nobel College, Affiliated to Pokhara University, Kathmandu, Province Bagmati, Nepal; 9Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK; 10School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK*These authors contributed equally to this workCorrespondence: Rajeev Shrestha, Department of Pharmacy, District Hospital Lamjung, Besisahar, Province Gandaki, Nepal, Tel +977 9845445205, Email rajiv2stha@gmail.com Sunil Shrestha, School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Subang Jaya, Selangor, Malaysia, Tel +60 102874113, Email sunil.shrestha@Monash.eduBackground: Control of high blood pressure and prevention of cardiovascular complications among hypertensive patients depends on patients’ adherence to therapy. The Hill–Bone Compliance to High Blood Pressure Therapy Scale (HBCTS) is one of the most popular scale to assess hypertensive patients’ adherence behaviour. Unfortunately, no questionnaire in the Nepalese language is available to date to assess adherence to anti-hypertensive therapy.Aim: To translate, culturally adapt and validate the English original version of the HBCTS into Nepalese language to measure treatment adherence of Nepalese hypertensive patients.Methods: The cross-sectional study was conducted to translate, culturally adapt and validate the HBCTS into Nepalese version. The standard translation process was followed and was evaluated among 282 hypertensive patients visiting selected primary healthcare centers (PHCCs) of Kathmandu district, Nepal. Cronbach’s alpha was measured to assess the reliability of the tool. Exploratory factor analysis using principal component analysis with varimax rotation was used to evaluate structural validity.Results: The mean±SD age of 282 participants was 58.49± 12.44 years. Majority of participants were literate (75.2%), and consumed at least one anti-hypertensive medication per day (85.5%). Nearly half (42.2%) of the participants had a family history of hypertension, and almost half (48%) of them had comorbid conditions. Mean ±SD score for overall adherence was 17.85± 3.87 while those of medication taking, reduced salt taking, and appointment keeping subscales were 10.63± 2.55, 4.16± 1.12 and 3.06± 1.07, respectively. Kaiser Meyer Olkin (KMO) was found to be 0.877. Exploratory factor analysis revealed a three-component structure; however, the loading of components into medication adherence, reduced salt intake and appointment keeping constructs were not identical to the original tool. Cronbach’s alpha score for the entire HBCTS scale was 0.846.Conclusion: The translated Nepali version of the HBCTS demonstrated acceptable reliability and validity to measure adherence to antihypertensive therapy among hypertensive patients in clinical and community settings in Nepal.Keywords: cultural adaptation, Hill–Bone scale, hypertension, Nepal, treatment adherence, translation

Hamzeh Mohammad Alrawashdeh,1,&ast; Abdallah Y Naser,2,&ast; Hassan Alwafi,3,4 Amal Khaleel AbuAlhommos,5 Zahra Jalal,6 Vibhu Paudyal,6 Dina M Abdulmannan,3 Fadi Fouad Hassanin,7 Sara Ibrahim Hemmo,2 Fawaz Al Sarireh8 1Department of Ophthalmology, Sharif Eye Centers, Irbid, Jordan; 2Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan; 3Faculty of Medicine, Umm Alqura University, Mecca, Saudi Arabia; 4Alnoor Specialist Hospital, Ministry of Health, Mecca, Saudi Arabia; 5Pharmacy Practice Department, Clinical Pharmacy College, King Faisal University, Alhasa, Saudi Arabia; 6School of Pharmacy, University of Birmingham, Birmingham, UK; 7Department of Medicine, University of Jeddah, Jeddah, Saudi Arabia; 8Department of Ophthalmology, College of Medicine, University of Mutah, Karak, Jordan&ast;These authors contributed equally to this workCorrespondence: Abdallah Y Naser; Hamzeh Mohammad Alrawashdeh, Email abdallah.naser@iu.edu.jo; dr_hmsr@yahoo.comPurpose: To investigate the trends of hospital admissions concerning diseases of the eye and adnexa in the United Kingdom in the past 20 years.Materials and Methods: An ecological study was conducted using hospital admission data taken from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales. Hospital admissions data for diseases of the eye and adnexa were extracted for the period between April 1999 and March 2019. The trend in hospital admissions was assessed using a Poisson model.Results: Hospital admission rate for diseases of the eye and adnexa increased by 73.8% [from 7.48 (95% CI 7.45– 7.50) in 1999 to 13.00 (95% CI 12.97– 13.02) in 2019 per 1000 persons, trend test, p < 0.001]. The most common cause of hospitalisation for diseases of the eye and adnexa was disorders of the lens (62.3%), followed by disorders of the choroid and retina (14.2%), followed by disorders of the eyelid, lacrimal system and orbit (11.5%). Hospital admission rate among males increased by 91.2% [from 6.19 (95% CI 6.16– 6.22) in 1999 to 11.83 (95% CI 11.80– 11.87) in 2019 per 1000 persons]. Hospital admission rate among females increased less sharply by 63.2% [from 8.71 (95% CI 8.68– 8.75) in 1999 to 14.22 (95% CI 14.18– 14.26) in 2019 per 1000 persons].Conclusion: There are clear gender and age trends in the epidemiology of hospital admissions related to eye and adnexa disorders. Further observational studies are warranted to identify other risk factors for these important causes of hospitalisation and understanding of differential trends.Keywords: admission rate, adnexa, ecological study, England, eye, hospitalisation, United Kingdom, Wales

Introduction: Rupture of the corpus luteum, though generally self-limiting in women with normal coagulation, could lead to life-threatening bleeding in patients with prosthetic valves on anticoagulant therapy and described in only a few case reports in the literature. The aim of this study was to find out the prevalence of ruptured corpus luteum among women undergoing laparotomy for hemoperitoneum in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among women undergoing laparotomy for hemoperitoneum in a tertiary centre from 7 April 2017 to 31 March 2021 after obtaining ethical approval from the Institutional Review Committee [Reference number: 328(6-11-E)2/73/74]. All women who underwent laparotomy for hemoperitoneum during the study period were enrolled. Convenience sampling technique was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of 447 women who underwent laparotomy for hemoperitoneum, ruptured corpus luteum was seen in 48 (10.74%) (7.87-13.61, 95% Confidence Interval). Out of which 36 (75%) had prosthetic valves. There was 1 (2.77%) mortality and 3 (8.33%) recurrences. Conclusions: The prevalence of rupture of the corpus luteum among women undergoing laparotomy for hemoperitoneum was similar to other studies done in similar settings. Early diagnosis, emergent reversal of coagulopathy and surgery if needed are the mainstay of management.

Introduction: Rupture of the corpus luteum, though generally self-limiting in women with normal coagulation, could lead to life-threatening bleeding in patients with prosthetic valves on anticoagulant therapy and described in only a few case reports in the literature. The aim of this study was to find out the prevalence of ruptured corpus luteum among women undergoing laparotomy for hemoperitoneum in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among women undergoing laparotomy for hemoperitoneum in a tertiary centre from 7 April 2017 to 31 March 2021 after obtaining ethical approval from the Institutional Review Committee [Reference number: 328(6-11-E)2/73/74]. All women who underwent laparotomy for hemoperitoneum during the study period were enrolled. Convenience sampling technique was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of 447 women who underwent laparotomy for hemoperitoneum, ruptured corpus luteum was seen in 48 (10.74%) (7.87-13.61, 95% Confidence Interval). Out of which 36 (75%) had prosthetic valves. There was 1 (2.77%) mortality and 3 (8.33%) recurrences. Conclusions: The prevalence of rupture of the corpus luteum among women undergoing laparotomy for hemoperitoneum was similar to other studies done in similar settings. Early diagnosis, emergent reversal of coagulopathy and surgery if needed are the mainstay of management.

Introduction: Anaemia is one of the common health problems of pregnant women and children in developing countries. Anaemia in pregnancy is related to poor foetal and maternal outcomes contributing to significant morbidity and mortality. Anaemia is a treatable and preventable condition. The objective of this study was to find out the prevalence of anaemia in pregnant women visiting the Obstetric Department of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among the pregnant women visiting the Department of Obstetrics and Gynecology of a tertiary care centre for their antenatal checkup. The study was conducted from 2 November 2022 to 11 November 2022 after obtaining ethical approval from the Institutional Review Committee (Reference number: 11(6-11)E2/079/080). Pregnant women with a history of blood transfusion, anaemia of chronic disease like chronic kidney disease, history of recurrent bleeding, and referral cases from other centres were excluded from the study. Serum haemoglobin was used for diagnosing anaemia according to criteria given by the World Health Organization. Convenience sampling was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 442 pregnant women, the prevalence of anaemia was 24 (5.43%) (3.32-7.54, 95% Confidence Interval). Conclusions: The prevalence of anaemia among pregnant women was lower in comparison to other studies done in similar settings.

Umaani Rauf,1 Majid Ali,2 Inderpal Dehele,1 Vibhu Paudyal,1 Mohamed Hassan Elnaem,3,4 Ejaz Cheema1 1School of Pharmacy, University of Birmingham, Birmingham, B15 2TT, UK; 2Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; 3Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 4Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, MalaysiaCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UKTel +44 121-4146845Email E.Cheema@bham.ac.ukObjective: Mortalities due to fentanyl derivatives are on the rise with novel fentanyl analogues and still emerging on the global illicit drug market. They are highly potent and very fatal in low doses, yet there has been a lack of systematic research surrounding this subject. This review aims to assess the causes, nature, and toxicology of fatalities associated with fentanyl analogues.Methods: Five databases: Scopus, Embase, Medline, PubMed and Google Scholar were searched from inception to October 2020 to identify case studies and case series reporting fentanyl analogue-related fatalities. Two independent reviewers screened and selected the articles followed by the data extraction from each article, which included demography, route of administration, causes and nature of death, and the fentanyl analogue implicated. All articles were then subject to quality assessment tools developed by the Joanna Briggs Institute (JBI). A narrative synthesis was undertaken.Results: The initial data search yielded 834 articles, only 14 of which met the inclusion criteria – this included nine case reports and five case series. Of the 1079 fentanyl-analogue related deaths reported, the majority of them occurred in the US (n=1044, 96.8%). The majority of fatalities were male (n=766, 71%), white (n=884, 87%) and in the age ranges 25– 34 and 35– 44 years (30.5% and 29.6%, respectively). The most common route of administration was intravenous (n=319, 66%) and the manner of death was almost exclusively accidental (99.7%). The predominant cause of death was fentanyl-analogue toxicity (n=292, 85.4%) and involved mixed drug toxicity (n=47, 13.7%). The mean post-mortem fentanyl analogue concentration was 31.6 ng/mL.Conclusion: Most fatalities were reported in the US involving young white males. Overdose through intravenous administration and by mixed drug toxicities with other opioids were the major causes of death. Deaths reported in peer-reviewed literature were relatively less than those reported by real-world data.Keywords: fentanyl-analogues, fatalities, systematic review, case series, case reports

Rajeev Shrestha,1,&ast; Binaya Sapkota,2,&ast; Asmita Priyadarshini Khatiwada,3 Sunil Shrestha,4,&ast; Saval Khanal,5 Bhuvan KC,4 Vibhu Paudyal6 1Department of Pharmacy, District Hospital Lamjung, Besisahar, Province Gandaki, Nepal; 2Department of Pharmaceutical Sciences, Nobel College, Affiliated to Pokhara University, Kathmandu, Province Bagmati, Nepal; 3Department of Pharmaceutical and Health Service Research, Nepal Health Research and Innovation Foundation, Lalitpur, Province Bagmati, Nepal; 4School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, 47500, Malaysia; 5Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK; 6Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK&ast;These authors contributed equally to this workCorrespondence: Rajeev ShresthaDepartment of Pharmacy, District Hospital Lamjung, Besisahar, Province Gandaki, NepalTel +977-9845445205Email rajiv2stha@gmail.comBinaya SapkotaDepartment of Pharmaceutical Sciences, Nobel College, Affiliated to Pokhara University, Kathmandu, Province Bagmati, NepalTel +977-9851134925Email sapkota.binaya@gmail.comBackground: The General Medication Adherence Scale (GMAS) evaluates intentional and unintentional behaviour of patients, disease and medication burden and cost-related burden associated with non-adherence. GMAS was developed and validated among Urdu-speaking patients with chronic diseases. However, validated tool in Nepalese language to measure medication adherence among chronic illness patients currently does not exist.Aim: To translate, culturally adapt, and validate the English version of GMAS into the Nepalese language to measure medication adherence among chronic illness patients.Methods: The study was conducted among patients with chronic diseases in both hospital and community pharmacies of Nepal. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Good Practice Guideline for linguistic translation and cultural adaptation was used to translate and culturally adapt the English version of GMAS into the Nepalese version. The translated version was validated amongst patients with chronic diseases in Nepal. Exploratory factor analysis was carried out using principal component analysis with varimax rotation. Test–retest reliability and internal consistency were analysed.Results: A total of 220 (53.6% females, and 51.4% of 51 to 70 aged patients) patients with chronic diseases participated in the study. The majority of patients took two medications (27.3%) from six months to five and half years (68.2%). Kaiser Meyer Olkin was found to be 0.83. A principal axis factor analysis was conducted on the 3 items of GMAS without and with orthogonal rotation (varimax). The scree plot showed an inflexion on the third item that meant three components were present. The overall Cronbach’s alpha value of the full-phase study was 0.82.Conclusion: The General Medication Adherence Scale was successfully translated into the Nepalese language, culturally adapted, and validated amongst chronic diseases patients of Nepal. Therefore, the GMAS-Nepalese version can be used to evaluate medication adherence among Nepalese-speaking patients with chronic disease.Keywords: adherence, chronic disease, general medication adherence scale, GMAS, Nepal, psychometric validation

Penile fracture is a rare condition with an incidence of 1 case per 175000 United States male population. It can be caused by vigorous sexual intercourse and masturbation. Patients usually present with pain and swelling of the penis and can be diagnosed clinically. It mostly occur as a result of rupture of tunica albuginea of corpora cavernosa. Ultrasound is the most reliable investigation to detect penile fractures. Patients need prompt treatment with exploration and repair of defects to prevent long-term sequelae. Here we present a case of 44 years male who developed a penile fracture following sexual intercourse and underwent surgical exploration and repair.

Introduction: Poisoning is one of the major public health problems worldwide. The World Health Organization has estimated 0.3 million deaths a year due to various poisoning agents; pesticides being the leading one. Poisoning is one of the leading causes of emergency room visits. It has become a significant public health issue in Nepal. This study aimed to find out the prevalence of poisoning among patients presenting to the Department of Emergency Medicine of a tertiary care centre. Methods: A descriptive cross-sectional study was done in the Department of Emergency Medicine of a tertiary care centre from 24 June 2022 to 6 July 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: 11/2022). Data from 765 patients were collected from the hospital records. The patient's history and clinical examination were used to make the diagnosis of poisoning. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 765 patients visiting the emergency department, 8 (1.04%) (0.99-1.09, 95% Confidence Interval) patients were of poisoning. The most common poison used was organophosphates which was consumed by 2 (25%) patients and benzodiazepines by 2 (25%) patients. Conclusions: The prevalence of poisoning among patients presenting to the Department of Emergency Medicine was similar when compared to other studies conducted in similar settings. Although agricultural poisons were commonly used, cases of drug poisoning seems to be on the rise nowadays.

Stump appendicitis is a rare, delayed complication of appendectomy. It is seen following both open and laparoscopic appendectomy and may occur weeks to years following the initial appendectomy. We report two cases of stump appendicitis seen at our hospital. Both cases were diagnosed based on radiological findings and successfully managed conservatively with antibiotics. Although the usually recommended treatment for stump appendicitis is completion appendectomy, conservative management may be suitable for some patients. This report highlights the possibility of utilizing a conservative approach in the management of stump appendicitis compared to the recommended operative intervention. Awareness of the possibility of stump appendicitis is crucial for early diagnosis and treatment, to prevent potentially catastrophic complications.

Abstract Hansen's disease, a chronic granulomatous disease, classically has cutaneous and neurological manifestations. Musculoskeletal manifestation of the disease is underappreciated. This case report conveys that musculoskeletal manifestation of the disease should not be missed, as sometimes it is the only presenting symptom, to avoid delay in correct diagnosis and treatment.

Abstract Pure Sertoli cell tumors are an uncommon variant of rare ovarian Sertoli‐Leydig cell tumors. Due to nonspecific clinical and imaging features, diagnosis is often made after histopathological examination. The prognosis is excellent as most are detected in the early stages and surgical resection is often curative in most cases.

Abstract Pyoderma Gangrenosum and Palmoplantar Pustular Psoriasis share the common pathogenesis, histological features, age group, and female preponderance that suggests a common etiological link.

Ejaz Cheema,1 Khalil McGuinness,1 Muhammad Abdul Hadi,1 Vibhu Paudyal,1 Mohammed Hassan Elnaem,2 Abdullah A Alhifany,3 Mahmoud E Elrggal,3 Abdullah Al Hamid1 1School of Pharmacy, University of Birmingham, Birmingham, UK; 2Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University, Kuantan, Malaysia; 3Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi ArabiaCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Room 356, Robert Aitken Building, Edgbaston, Birmingham B15 2TT, UKEmail e.cheema@bham.ac.ukPurpose: Fentanyl poisoning has been widely reported, yet there is a lack of systematic evaluation of the nature and toxicology of associated deaths in the published literature. This article aims to systematically review the nature, causes, routes of administration and toxicology of fentanyl-associated deaths using case studies and case series in peer-reviewed published literature.Methods: Four electronic databases including Embase, Medline (via Ovid), Scopus and Google Scholar were searched from inception until October 2019 to identify the studies reporting fentanyl related deaths. Two independent reviewers screened and selected the titles and then evaluated the full texts. Only case studies and case series were included. A structured data extraction tool was used to extract data on the number of deaths, routes of administration, concomitant drug use and toxicological data. The Joanna Briggs Institute quality assessment tool was used to evaluate the quality of included studies. Data were synthesized narratively.Results: Of 1251 articles identified during initial search, 8 case reports and 9 case series met the inclusion criteria. A total of 1969 deaths were reported in the included studies. Deaths were concentrated in the north American region (n = 1946) and the Nordic region (n = 22). Reported causes of death included fentanyl overdose (n = 321, 56.4%), mixed drug toxicity (n = 196, 34.5%), natural (n = 28, 4.9%), other drug toxicity (n = 10, 1.8%), fentanyl and ethanol intoxication (n = 8, 1.4%), incidental (n = 5, < 1%) and aspiration (n = 1). Most common routes of use were intravenous (70.5%) and transdermal routes (23.0%). Deaths came swiftly via the intravenous route. Mean level of blood fentanyl amongst all reported deaths was 0.024 μg/mL.Conclusion: Literature related to fentanyl-associated deaths predominantly come from North America. Deaths are comparatively lower or not reported in peer-reviewed publications from the rest of the world. Abuse through intravenous administration, mixed drug toxicities and self-treatment of breakthrough pain are mainly responsible for majority of the reported deaths.Keywords: fentanyl, death, nature, cause, toxicology

Abstract High index of suspicion of ectopic (much likely ovarian) pregnancy should be considered if a woman with IUD in situ presents with abdominal pain, vaginal bleeding, and positive urine pregnancy test.

Introduction: Coronavirus Disease 2019 pandemic is raging across the world and has affected pregnant women as well. There is limited information regarding COVID-19 in pregnant women. The study aimed to find the prevalence of COVID-19 among all pregnant women who delivered during the study period in a tertiary care center. Methods: This was a descriptive cross-sectional study conducted in a tertiary care center from 16th August to 15th November 2020 after obtaining ethical clearance from the Institutional Review Committee of a tertiary care center. All the women who delivered in the hospital during the study period were enrolled and they were subjected to COVID-19 Reverse Transcriptase Polymerase Chain Reaction test. A total of 667 samples were taken using convenience sampling technique. Data were analyzed using the Statistical Package for the Social Sciences version 24 software. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: Among 667 pregnant women, the prevalence of COVID-19 was 47 (7.05%) (5.10-8.99 at 95% Confidence Interval). Though the majority of women were asymptomatic 40 (85.1%), 5 (10.64%) developed mild disease, 1 (2.12%) each had severe and critical COVID-19 pneumonia. Conclusions: The prevalence of COVID-19 among pregnant women delivering in our center is similar to other studies done in similar settings. In our study, we found that the majority of women had been asymptomatic and were diagnosed on routine testing. Hence, it is important to test all pregnant women before delivery for Coronavirus Disease 2019 irrespective of the presence or absence of symptoms.

Documented re-infection of COVID-19 is uncommon and doing a major spinal surgery in an elderly patient right after the recovery from the first event is itself a major undertaking. Re-infection after successful surgery points to the possibility of COVID-19 infection being a post-surgical complication. Here, we report a case of a 72-years-old elderly female who had presented to us with features of COVID-19 infection confirmed by reverse transcription polymerase chain reaction assay and unstable spinal fracture who underwent a pedicle screw fixation for the fracture of the third and fourth thoracic vertebrae after two consecutive negative serology assays. A month after discharge from the hospital, she presented with severe symptoms of COVID-19 again confirmed by two consecutive polymerase chain reaction assays. She was managed conservatively and was discharged without significant respiratory and neurological complications. We described this case in detail in addition to reviewing the pertinent literature.

Nepal started the COVID-19 vaccination on 27 January 2021 with AstraZeneca/Oxford Coronavirus Disease-19 AZD1222 (Covishield) vaccine to control the Coronavirus disease pandemic. The vaccine has a good safety profile, with cardiovascular complications being rare. Herein we report a rare case of cardiovascular complication following Covishield vaccination in a 33 years old female who had dizziness and elevated blood pressure immediately following vaccination and abnormal electrocardiogram showing T wave inversions followed by left bundle branch block. The patient was kept on observation, following which the blood pressure and electrocardiogram changes were normal by seven days. This cardiovascular complication following the vaccination demands further investigation into the adverse event of the vaccine. However, since the benefit of the vaccine outweighs the risk, World Health Organization has recommended the continuity of the vaccine as of now.

Background: Epidemiological studies focused on primary healthcare needs of persons experiencing homelessness (PEH) are often based on data from specialist homeless healthcare services. Aim: To explore the presentation of PEH, coding of homelessness, and associated health conditions in mainstream primary care general practices in England. Design & setting: EMIS electronic database search of medical records was conducted across 48 general practices in a clinical commissioning group (CCG), representing one of the most socioeconomically deprived regions in England, which also lacks a specialist primary healthcare service for PEH. Method: Key terms and codes were used to identify PEH, their respective diagnoses across 22 health conditions, and prescribed medications over the past 4 years. Results: From a population of approximately 321 000, 43 (0.013%) people were coded as PEH, compared with a homelessness prevalence of 0.5% in the English general population. Mental health conditions were the most prevalent diagnoses among the PEH registrants (56.6%); the recorded prevalence of other common long-term conditions in PEH was lower than the levels observed in PEH registered with specialist homelessness health services. Conclusion: In a population with approximately four times higher rate of statutory homelessness, PEH representation in mainstream general practices was under-represented by several folds. As homelessness overlaps with mental health, substance misuse, and long-term health conditions, consistent coding of homelessness in medical records is imperative in order to offer tailored support and prevention actions when patients present for services.

Salamat Ali,1,2 Mashhood Ali,3 Vibhu Paudyal,4 Faisal Rasheed,5 Shahan Ullah,1 Sayeed Haque,6 Tofeeq Ur-Rehman1 1Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan; 2Services Institute of Medical Sciences, Lahore, Pakistan; 3Department of Gastroenterology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan; 4School of Pharmacy, University of Birmingham, Birmingham, UK; 5Pakistan Institute of Nuclear Sciences and Technology, Islamabad, Pakistan; 6Institute of Applied Health Research Medical Statistics, University of Birmingham, Birmingham, UKCorrespondence: Tofeeq Ur-RehmanDepartment of Pharmacy, Quaid-I-Azam University, Islamabad, PakistanTel +92 51 9064 4135Email tofeeq.urrehman@qau.edu.pkPurpose: The role of specialized pharmacy services remains unexplored in clinical practice for hepatitis C patients in Pakistan. This study aimed to evaluate the impact of clinical pharmacy interventions on treatment outcomes, health-related quality of life (HRQoL), and medication adherence among hepatitis C patients.Methods: A randomized control trial was conducted at two tertiary-care teaching hospitals in Pakistan. Hepatitis C patients who attended the outpatient clinics between October 2015 and September 2018 were randomized to two groups [usual care (UC) and pharmaceutical care (PC)] in a 1:1 ratio, applying simple envelope method. The PC group received pharmaceutical care led by a clinical pharmacist. The care that patients received included education and counseling on medication compliance, labeling of medication packs, and monitoring of adverse drug events, led by a qualified clinical pharmacist during the 15- to 20-minute monthly sessions, while the UC group received standard care at hospital, which did not involve clinical pharmacist input. Outcome measures, such as sustained virological response, HRQoL, and adherence rate (pharmacy data) were assessed at enrolment and distinct time intervals: 4 weeks, 8 weeks, and end of treatment.Results: A total of 931 patients were included in the study (UC 466 and PC 465), with mean age 42.35±1.9 years. Sustained virological response at 12 weeks was achieved in 86.0% patients in the PC group, significantly (p

Abstract Cyclopia with a proboscis, a rare congenital anomaly, and a severe form of holoprosencephaly occur as a result of incomplete separation of prosencephalon into two halves of hemispheres during organogenesis. A prenatal anomaly scan can help in the early detection of the condition and timely termination of the pregnancy.

Abstract Type 1 reaction in pure neuritic leprosy usually occurs in the form of neuritis. The development of new skin lesion during reaction is rare. Clinicians should be aware about occurrence of type 1 reaction in pure neuritic leprosy.

Introduction: Human Immunodeficiency Virus is a lentivirus that causes human immunodeficiency virus infection and over time, acquired immunodeficiency syndrome. Cluster of Differentiation 4+ T cell count of people living with this infection play a vital role to determine infection progression and necessary treatment changes. This study was conducted to find out the prevalence of low Cluster of Differentiation 4+ T Cell Count in the People Living with human immunodeficiency virus/ acquired immunodeficiency syndrome. Methods: A descriptive cross-sectional study was conducted between June to August 2018 in the Human Immunodeficiency virus and Hepatitis Reference Unit of National Public Health Laboratory, Ministry of Health and Population Teku. Ethical approval was taken (Reference Number 2912) and a total of 550 seropositive cases of Human Immunodeficiency Virus-1 undergoing antiretroviral therapy were studied. Convenient sampling technique was used. Data was analysed by Statistical Package for the Social Sciences. Results: Seventeen (3.1%) of patients had Cluster of Differentiation 4+ T cell counts below 100 cells/mm3 of blood. The mean Cluster of Differentiation 4+ T cell count was 509.3 cells/mm3 of blood. Of the total samples, 280 (50.9%) were males, 268 (48.7%) were females, and the rest 2 (0.4%) were of other gender. Conclusions: Majority of people living with human immunodeficiency virus/ acquired immunodeficiency syndrome were found immune-competent.

Background: Sildenafil and tadalafil are recommended firstline treatments for erectile dysfunction (ED). Sildenafil was legally reclassified to a ‘pharmacy’ medicine in the UK in 2018. Aim: To assess the prescribing patterns and costs associated with prescribing of ED drugs in England, and to investigate the link between prescribing and deprivation, regional demography, and legal reclassification. Design & setting: Analyses were conducted of publicly available government data from various sources pertaining to primary care prescribing and demographics in England. Method: Prescribing and cost data from January 2009 to November 2019 were extracted and adjusted for inflation, male populations, and regional deprivation. Results: Between 2009 and 2019 the rate of prescribing, measured as the number of items per 1000 men, increased by 110%. In 2019, the rate of prescribing of ED medicines in the most deprived areas was 21.0% higher than the rate observed in least deprived areas. The northern regions of England approximately had a 50% higher rate of prescribing compared with London. A 1.3% annual increase in the number of prescription items was observed between 2018 and 2019 for Sildenafil, with a 5.8% increase observed from 2017–2018. Conclusion: The two-fold increase in the rate of primary care prescriptions in the past 10 years suggests that more men are being screened for, or seeking help for, ED. The higher rate of prescribing offers opportunity for monitoring of linked risk factors, such as diabetes mellitus, dyslipidaemia, and vascular disorders, in deprived populations. Reclassification of sildenafil had a modest impact on prescribing practices.

Sertoli-Leydig cell tumor of the ovary is an unusual neoplasm that belongs to a group of sex cord-stromal tumors of the ovary and accounts for less than 0.5% of all primary ovarian neoplasms. They are often characterized by the presence of mass with androgen production and signs of virilization. Due to the substantially low incidence of Sertoli-Leydig cell tumors, information on clinical behavior, prognostic factors, and optimal management arelimited. Here in, we report a case of aprimary ovarian Sertoli-Leydig cell tumor in a 21-year-old student, previously diagnosed to have polycystic ovarian syndrome and subsequently congenital adrenal hyperplasia, who presented with a large abdominal mass and features of virilization along with elevated serum testosterone levels. Fertility sparing unilateral salpingo-oophorectomy was done and adjuvant chemotherapy was given after histopathology showed moderate to poorly differentiated Sertoli-Leydig cell tumor. Following surgery, her features of hyperandrogenism resolved and serum testosterone levels returned to normal.

Background: Skin appendageal tumors (SAT) are a large and diverse group of tumors that are commonly classified according to their state of appendageal differentiation: Follicular, sebaceous, eccrine and apocrine. Most adnexal neoplasms are uncommonly encountered in routine practice, and pathologists can easily recognise frequently encountered tumours. In this study, the histological features of important benign and malignant tumors of pilosebaceous origin were reviewed considering its morphologic types, subtypes, age, sex and anatomic site. Methods: This is a hospital based retrospective study which includes all cases of tumors with pilosebaceous differentiation diagnosed histologically during the period of five years (1st January, 2008 to 31st December, 2012). Tumors were analyzed considering the anatomic location and type of the tumor, along with age and sex of the patient. The Histological characterization was done according to the WHO classification system for SAT. Collected data were entered in Microsoft Excel 2000 and converted it into SPSS PC+ 11.5 Version for statistical analysis. Results: A total of 53 neoplasms of pilosebaceous differentiation included, 52 (98.1%) were benign and one (1.8%) was malignant. The mean age was 39.23 years. Females comprised of 35 (66%) and 18 (34%) were males. Most common location was in head and neck area. Of all, 51 (96.2%) tumors were follicular, and two (3.7%) were with sebaceous differentiation. Among all follicular tumors, Pilomatricoma (33.9%), Keratoacanthoma (26.4%) and Trichoepithelioma (22.6%) were the commonest tumors observed. Conclusion: The study findings reveal majority of the tumors origin were of follicular differentiation and all were benign. J-GMC-N | Volume 11 | Issue 01 | January-June 2018, Page: 33-39

The thoracic kidney is the rarest form of an ectopic kidney that usually present on the left thorax and twice more common in males. No case has been reported from Nepal and very few cases are reported worldwide. We report a 24 years-old female with right thoracic kidney with Bochdalek hernia diagnosed incidentally. We have included clinico-radiological and surgical findings of the case with a review of the literature.

Introduction: Perimenopause is an unavoidable stage of a woman's reproductive life that starts several years before menopause. Due to declining estrogen level, women experience physiological and psychological changes during perimenopausal period and sometimes symptoms are very distressing that affect the women’s quality of life negatively. This study was done to assess the knowledge of women about perimenopausal symptoms. Methods: A cross-sectional analytical study was done at Lumbini Medical college (LMC) throughout the months of November and December, 2013. Women of age 40-60 years, attending various clinics in LMC and ready to take part in the study were included. A total of 142 women were selected purposefully. The data was collected using the semi structured interview schedule. Results: The study revealed that half of respondents were between age group 40-44 years, 141 (99.3%) were married and 82 (57.7%) were literate. Three quarter of respondents (74.6%) were menstruating women. The main source of information on perimenopausal symptoms was friends and relatives (81.2%). Majority of respondents (n=90, 63.4%) had poor, 52 (33.8%) had fair and only 2.8% had good level of knowledge on perimenopausal symptoms. The respondents’ level of knowledge on perimenopausal symptoms was statistically significant with educational status (p

Introduction: Endophthalmitis is a potentially devastating ocular complication of perforating eye injury where prompt intervention can save some vision. This study aims to explore the clinico-microbiologic profile and visual outcome following pars plana vitrectomy (PPV) in traumatic endophthalmitis. Methods: This is a retrospective interventional case series study conducted at a tertiary eye care centre of Nepal. A total of 49 consecutive cases (49 eyes) of endophthalmitis following PEI, who underwent PPV from January 2007 to June 2010 were included in the study. Results: Mean age was 14.7 years (S.D. 14.27). Twenty seven patients (55%) were of age group below 10 years. Male to female ratio was 2.75:1. Mean duration of presentation was 8.9 days. Nineteen eyes (36.73%) had injuries with wooden sticks, followed by injury with metallic objects in 16 patients (32.56%). PEI involving zone I was found in 31 eyes (63.25%). The retained intraocular foreign body was found in seven patients (14.2%). The post operative vision improved in almost 24 cases (49%) with visual recovery of 20/200 and better in six cases (12.24%). The vitreous culture was positive in five cases (12.8%) with predominant streptococcus pneumonia in four cases (10.25%). Conclusions: Children were the mostly affected group with males outnumbering females. Wooden sticks and metallic objects were the commonest insulting agents. Despite the late presentation and predominant zone I injury, eye could be salvaged in majority with visual recovery of 20/200 and better in six cases (12.24%). Keywords: endophthalmitis; intra-ocular foreign body; perforating eye injury; vitrectomy .

Introduction: We are increasingly noticing isolated left axis deviation (LAD) in electrocardiogram in younger people with diabetes without obvious heart disease and association of LAD with glucose intolerance has not been explicitly raised before. We planned a study of ambulatory adults with borderline (0o to –30o) and moderate-to-marked (

Introduction: We are increasingly noticing isolated left axis deviation (LAD) in electrocardiogram in younger people with diabetes without obvious heart disease and association of LAD with glucose intolerance has not been explicitly raised before. We planned a study of ambulatory adults with borderline (0o to –30o) and moderate-to-marked (

Epiretinal membrane is avascular fibrous tissue which is adhered to the internal layers of retina in the macular area. Patient may be asymptomatic or present with blurring of vision and metamorphopsia. The idiopathic Epiretinal Membrane is more often seen in elderly but it could be present in young patients in association with other vitreo-retinal diseases and following intraocular surgery. The idiopathic Eperetinal Membrane in young patients are rare. Here we present a thirty one year healthy women presented with idiopathic Epiretinal Membrane who gained full visual recovery following the pars plana vitrectomy, membrane peeling and gas for its rarity. _______________________________________________________________________________________ Keywords: epiretinal membrane; idiopathic; young women.

Epiretinal membrane is avascular fibrous tissue which is adhered to the internal layers of retina in the macular area. Patient may be asymptomatic or present with blurring of vision and metamorphopsia. The idiopathic Epiretinal Membrane is more often seen in elderly but it could be present in young patients in association with other vitreo-retinal diseases and following intraocular surgery. The idiopathic Eperetinal Membrane in young patients are rare. Here we present a thirty one year healthy women presented with idiopathic Epiretinal Membrane who gained full visual recovery following the pars plana vitrectomy, membrane peeling and gas for its rarity. _______________________________________________________________________________________ Keywords: epiretinal membrane; idiopathic; young women.

Introduction: Clinical features of Systemic lupus erythematosus vary between different parts of the World; however, this information on Nepalese Sytemic lupus erythematosus does not exist. Methods: Patients with Systemic lupus erythematosus fulfilling the American College of Rheumatology criteria treated in Patan Hospital were studied by means of retrospective review of their case records. The results were compared with various regional and international studies. Results: The female to male ratio was 36:1 with a mean age at diagnosis 28.67 years. Cutaneous manifestations were the most common 72 (96%) presentations followed by musculoskeletal involvement 70 (93%). Haematological and renal involvements each were present in 33 (44%) of patients. Pulmonary and neuropsychiatric involvements were present in 15 (20%) and 8 (11%) patients respectively. Antinuclear antibody and anti-double stranded deoxyribonucleic acid antibodies were positive in 70 (93%) and 66 (88%) of patients respectively. A quarter of patients had some form of co-morbid conditions. At the time of last follow up, 70 (93%), 66 (90%), and 6 (9%) of patients were taking antimalarials, steroids and immunosuppressive agents respectively, mostly in combinations. Eighty seven percent of patients had their disease activity under control at the time of last follow up whereas four percent still had an active disease. In another four percent died during the course of therapy and the outcome was unknown in another four percent of patients who lost to follow up. Conclusions: Clinical characteristics and antinuclear antibody pattern of Nepalese lupus patients is more or less similar to those with patients from other countries in the region and in the World. Keywords: clinical profile; Nepal; systemic lupus erythematosus.