Objectives To update a 2004 systematic review of health care service use and health outcomes related to differences in health literacy level and interventions designed to improve these outcomes for individuals with low health literacy. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. Data sources We searched MEDLINE®, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, PsychINFO, and the Educational Resources Information Center. For health literacy, we searched using a variety of terms, limited to English and studies published from 2003 to May 25, 2010. For numeracy, we searched from 1966 to May 25, 2010. Review methods We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grading. We resolved disagreements by consensus. We evaluated whether newer literature was available for answering key questions, so we broadened our definition of health literacy to include numeracy and oral (spoken) health literacy. We excluded intervention studies that did not measure health literacy directly and updated our approach to evaluate individual study risk of bias and to grade strength of evidence. Results We included good- and fair-quality studies: 81 studies addressing health outcomes (reported in 95 articles including 86 measuring health literacy and 16 measuring numeracy, of which 7 measure both) and 42 studies (reported in 45 articles) addressing interventions. Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. Health literacy level potentially mediates disparities between blacks and whites. The strength of evidence of numeracy studies was insufficient to low, limiting conclusions about the influence of numeracy on health care service use or health outcomes. Two studies suggested numeracy may mediate the effect of disparities on health outcomes. We found no evidence concerning oral health literacy and outcomes. Among intervention studies (27 randomized controlled trials [RCTs], 2 cluster RCTs, and 13 quasi-experimental designs), the strength of evidence for specific design features was low or insufficient. However, several specific features seemed to improve comprehension in one or a few studies. The strength of evidence was moderate for the effect of mixed interventions on health care service use; the effect of intensive self-management inventions on behavior; and the effect of disease-management interventions on disease prevalence/severity. The effects of other mixed interventions on other health outcomes, including knowledge, self-efficacy, adherence, and quality of life, and costs were mixed; thus, the strength of evidence was insufficient. Conclusions The field of health literacy has advanced since the 2004 report. Future research priorities include justifying appropriate cutoffs for health literacy levels prior to conducting studies; developing tools that measure additional related skills, particularly oral (spoken) health literacy; and examining mediators and moderators of the effect of health literacy. Priorities in advancing the design features of interventions include testing novel approaches to increase motivation, techniques for delivering information orally or numerically, "work around" interventions such as patient advocates; determining the effective components of already-tested interventions; determining the cost-effectiveness of programs; and determining the effect of policy and practice interventions.

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Health literacy interventions and outcomes: an updated systematic review.

The world's most widely used comprehensive reference book of medicine has been updated 16 times since 1899. It took 5 years of work to bring out this 16th edition. The 12 physicians on the editorial board enlisted the aid of 29 distinguished consultants with outstanding qualifications to complete the volume. The manual has been expanded by 120 pages and includes 154 figures and 382 tables. New subjects include sports medicine, hospice medicine, human immunodeficiency virus infection in children, cardiopulmonary resuscitation in infants and children, genetic evaluation and counseling, anabolic steroid abuse, cultural issues in medicine, and cocaine withdrawal in newborns. A table of generic drugs with their trade names has been included and will be useful for the ophthalmologist as a reference. As in past editions, the contents are arranged by organ system on the basis of the origins of each disease. The pathologicand physiologic features of each disease are

https://jamanetwork.com/journals/jamaophthalmology/articlepdf/640584/archopht_112_3_018.pdf

The Merck Manual of Diagnosis and Therapy

Purpose 
Access to critical care is a crucial component of healthcare systems. In low-income countries, the burden of critical illness is substantial, but the capacity to provide care for critically ill patients in intensive care units (ICUs) is unknown. Our aim was to systematically review the published literature to estimate the current ICU capacity in low-income countries.


Methods 
We searched 11 databases and included studies of any design, published 2004-August 2014, with data on ICU capacity for pediatric and adult patients in 36 low-income countries (as defined by World Bank criteria; population 850 million). Neonatal, temporary, and military ICUs were excluded. We extracted data on ICU bed numbers, capacity for mechanical ventilation, and information about the hospital, including referral population size, public accessibility, and the source of funding. Analyses were descriptive.


Results 
Of 1,759 citations, 43 studies from 15 low-income countries met inclusion criteria. They described 36 individual ICUs in 31 cities, of which 16 had population greater than 500,000, and 14 were capital cities. The median annual ICU admission rate was 401 (IQR 234-711; 24 ICUs with data) and median ICU size was 8 beds (IQR 5-10; 32 ICUs with data). The mean ratio of adult and pediatric ICU beds to hospital beds was 1.5% (SD 0.9%; 15 hospitals with data). Nepal and Uganda, the only countries with national ICU bed data, had 16.7 and 1.0 ICU beds per million population, respectively. National data from other countries were not available.


Conclusions 
Low-income countries lack ICU beds, and more than 50% of these countries lack any published data on ICU capacity. Most ICUs in low-income countries are located in large referral hospitals in cities. A central database of ICU resources is required to evaluate health system performance, both within and between countries, and may help to develop related health policy.

/pdf/intensive-care-unit-capacity-in-low-income-countries-a-1qsi8o48ug.pdf

Intensive Care Unit Capacity in Low-Income Countries: A Systematic Review

Part 1 Principles of poison management: the clinical approach diagnostic procedures gut decontamination elimination enhancement antidotes supportive care toxicokinetics the pregnant patient. Part 3 Drugs: analgesics - newer analgesics, nonsteroidal anti-inflammatory drugs, phenazopyridrine salicylate update anti-infectivedrugs - AIDS drugs, antifungal drugs, antiparasitic drugs, antiviral drugs drugs of abuse - amphetamines and designer drugs, cocaine, hallucinogenic drugs, marijuana and other cannabinoids, phencyclidine, opiates systems toxicology - bone drug toxicology, blood and blood forming products, anticoagulants, antifibrinolytics, thrombolytics, blood transfusions and citrate intoxication, cytokines, plasma volume expanders, ticlopidine, cardiovascular toxicology, antiarrhthmic drugs, antihypersensitive agents, vasodilators, lipid lowering drugs, central nervous system drugs, anticonvulsants, the psychotropic agents, antidepressant agents, cyclic antidepressants, monoamine oxidase inhibitors, the neuroleptics, sedative hypnotics, endocrine drugs, gastrointestinal tract drugs, immunotoxicology, respiratory tract drugs receptor toxicology - antimuscarines, dopamine receptor drugs, H1 receptor drugs, serotonin receptor agents, muscle relaxants unclassified drugs. Part 3 The home: over-the-counter products, food poisonings, household poisonings. Part 4 Chemicals: the alcohols, anaesthetics, antiseptics and disinfectants, chemical disasters, chemical warfare, contrast media, cancer chemotherapeutic agents (cytoxic drugs), disulfiram, explosives, hobbies, arts and crafts, the hydrocarbon products, respiratory toxicology, metals and related compounds, pesticides, plastics and plasticizers and epoxy resins, radiation poisoning, veterinary product poisonings in man. Part 5 Natural toxins: envenomations - bites and stings, indigenous toxicology, folk medicine, plants - mycotoxins - mushrooms.

Ellenhorn's medical toxicology : diagnosis and treatment of human poisoning/ Matthew J. Ellenhorn ; consulting editors, Donald G. Barceloux, Seth Schonwald, Jonathan Wasserberger ; technical associate, Sylvia Syma Ellenhorn

Caplan's Stroke: A Clinical Approach

Background: Cutaneous tuberculosis (TB) is essentially an invasion of the skin by Mycobacterium tuberculosis, the same bacteria that causes pulmonary tuberculosis. Aim: This study was conducted to study the common types of cutaneous TB and to find the management pattern in a tertiary teaching hospital in Pokhara, Nepal. Materials and Methods: All the cases of cutaneous TB were biopsied and furthermore investigated by performing Mantoux test, sputum examination, fine needle aspiration cytology, chest X-ray and ELISA. Results: In this study, we found that tuberculosis verrucous cutis (48%) had a higher incidence than other types of cutaneous TB. More males were affected than were females (1.2:1). Commonly affected sites were the limb and the buttock (48%). The most commonly affected age group was 16-25 years (40%). All cases (except two) were more than 15 mm in size in the Mantoux test. The histopathological picture was typical in all except three cases. All patients were treated with antitubercular treatment as per the national guidelines. Conclusion: The most common type of cutaneous TB was tuberculosis verrucous cutis and the most commonly affected sites were the limb and the buttock. As cutaneous TB sometimes reflects the presence of pulmonary tuberculosis, its incidence should not be ignored.

A clinicoepidemiological study of 50 cases of cutaneous tuberculosis in a tertiary care teaching hospital in pokhara, Nepal.

Tuberculosis is a major health burden worldwide. In Nepal, it is a significant cause of morbidity and mortality. Although better drugs are available for managing tuberculosis, treatment failure is one of the common problems encountered. Among the various causes which can cause treatment interruption, drug induced hepatotoxicity is a common cause. Isoniazid and Pyrazinamide are the common drugs causing hepatotoxicity. Upon occurrence of hepatotoxicity, the hepatotoxic drugs should be stopped and reintroduced as per the available guidelines. The healthcare professional should also counsel the patients for recognizing the early symptoms due to hepatotoxicity which could prevent morbidity.

Drug induced hepatitis with anti-tubercular chemotherapy: challenges and difficulties in treatment.

Drug interactions (DIs) represent an important and widely under recognized source of medication errors. An interaction is said to occur when the effects of one drug are changed by the presence of another drug(s), food, drink or an environmental chemical. When a therapeutic combination could lead to an unexpected change in the condition of the patient, this would be described as an interaction of potential clinical significance. DIs can arise in numerous ways; such as pharmacodynamic interaction, in which receptor effects of different agents interacts to produce synergy or antagonism of drug effects. In pharmacokinetic interaction, the blood levels of given agents may be raised or lowered based on the type of interaction. Special attention and thorough monitoring is needed for the patients who are predisposed to develop DIs and those on drugs with narrow therapeutic index. DIs can be a very important contributory factor for the occurrence of adverse drug reactions and adverse drug events. DIs monitoring programs should be initiated and strengthened in order to minimize their occurrence. Herbal drug interactions and DIs comprising over the counter medicines should also be considered seriously.

Understanding the essentials of drug interactions: a potential need for safe and effective use of drugs.

Background/Aim: Alcohol is the most common substance abused in Nepal. Liver disease caused by alcohol abuse, including its end stage, cirrhosis, is a major health care problem, which is difficult to treat. Objectives: To study the demographic profile, laboratory parameters, complications and their prognostic implications among patients of alcoholic liver disease (ALD). Materials and Methods: Records of all patients of ALD admitted from January1 , 2005 to December 31 , 2006 were studied and followed up to December 31, 2007. A total of 181 patients were analyzed. Their clinical profile and laboratory parameters were noted and analyzed using SPSS-10.0 software. Results: Among the 181 patients, 80.7% were male, 30.9% were army/ex-army and 65.2% were documented smokers. The mean age of presentation was 52.08 years. Jaundice (57.5%) was the most common presentation followed by hepatomegaly (51.4%). Hypoalbuminemia (50.3) followed by ascites (48.1) were common complications. Death occurred in 19.1% of the patients, the most common cause being hepatic encephalopathy (72.2%) followed by variceal bleeding and hepatorenal syndrome. Jaundice, ascites and hepatic encephalopathy at presentation and female sex were significantly associated with increased mortality along with discriminant score >32, aspartate aminotransferase (AST): Alanine aminotranferase (ALT) ≥ 2, ultrasonography (USG)-proven cirrhosis, rise in prothrombin time ≥5 s, total bilirubin ≥ 4 mg/dL and ESR ≥34. Conclusion: ALD was predominantly seen among the productive age group with a high morbidity and mortality. Jaundice, ascites, hepatic encephalopathy at presentation and female sex are poor prognostic indicators along with discriminant score > 32, AST:ALT ≥ 2, USG-proven cirrhosis, coagulopathy, hyperbilirubenemia and high ESR.

Retrospective Study of the Clinical Profile and Prognostic Indicators in Patients of Alcoholic Liver Disease Admitted to a Tertiary Care Teaching Hospital in Western Nepal

Introduction: Acute coronary syndrome (ACS), one of the commonest causes of intensive care unit (ICU) admission, casts a large burden of cost on the health care system, along with a huge mortality in the elderly population. Objectives: This study determined the difference in presentation, complication, management and outcome in elderly patients with acute coronary syndrome, as compared to the young patients. Material And Methods: Records of all patients who were diagnosed to have acute coronary syndrome, admitted to the ICU in the Manipal Teaching Hospital in the month of March 2006 to June 2007, was entered in a designated Proforma. Demographic details, clinical findings, treatment and complications were recorded. A total of 153 patients were analyzed and elderly patients (≥ 65 yrs) were compared with young patients (< 65yrs) using SPSS-10.0 software. Results: Elderly patients constituted 51% (78) of the study population, among which 46.2% (36) were females. 7.7% (6) elderly patients presented with atypical symptoms, among which syncope was the commonest. Young patients were more likely to be hypertensive as compared to the elderly patients (70.7% vs. 39.7%; p<0.001). The median time of presentation to the hospital after chest pain was comparable in the two groups: 16 hours overall, but in cases of STEMI, elderly patients were brought to the hospital comparatively late, with a median time of 15 hours (IQ 5.5 – 72 as compared to young individuals in which median time was 7.25 hours (IQ 2.87 – 39 hours), which was statistically significant (p=0.000). Non ST elevated myocardial infarction (NSTEMI) and ST elevated myocardial infarction (STEMI) were similar in distribution among the elderly and young patients. Complication was seen predominantly among the elderly, with 62.8 %( 49) Vs38.7% (29); p =0.03. Overall, heart failure was the commonest complication (28.2%), followed closely by arrhythmias (26.9%). Cardiogenic shock complicating STEMI resulted in high patient mortality in both the age groups. Thrombolysed patients were similar in distribution in both groups. But the success rate of thrombolysis was lower in elderly patients (50%) as compared to young patients (76.9%). Beta blockers were less commonly used in the elderly- 47.4% (34) than in young patients- 61.3% (46). A combination of aspirin and clopidogrel was also less commonly used in the elderly patients {60.3% (47) Vs 76% (57); p=0.03}. Mortality was higher in the elderly patients (24.4% Vs 10.7%; p =0.03) Conclusion: Elderly patients are more prone to complications, have less success rate for thrombolysis and have a higher mortality rate as compared to young patients of ACS.

R Paudel

Papers

A clinicoepidemiological study of 50 cases of cutaneous tuberculosis in a tertiary care teaching hospital in pokhara, Nepal.

Drug induced hepatitis with anti-tubercular chemotherapy: challenges and difficulties in treatment.

Understanding the essentials of drug interactions: a potential need for safe and effective use of drugs.

Retrospective Study of the Clinical Profile and Prognostic Indicators in Patients of Alcoholic Liver Disease Admitted to a Tertiary Care Teaching Hospital in Western Nepal

Acute Coronary Syndrome In Elderly - The Difference Compared With Young In Intensive Care Unit Of A Tertiary Hospital In Western Nepal