XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

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European Position Paper on Rhinosinusitis and Nasal Polyps 2020

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The United Nations Children's Fund, or UNICEF, was originally created to provide relief for children in countries devastated by the destruction of World War II. After 1950, UNICEF turned to focus on general programs for the improvement of children's welfare worldwide, and in 1965, it was awarded the Nobel Prize for Peace for its humanitarian efforts. The organization concentrates on areas in which relatively small expenditures can have a significant impact on the lives of the most disadvantaged children in developing countries, such as the prevention and treatment of disease, child healthcare, malnutrition, illiteracy, and other welfare services.

The United Nations Children's Fund

Pharmacovigilance can be helpful in protecting consumers from harmful effects of medicines. Healthcare professionals should consider Adverse Drug Reaction (ADR) reporting as their professional obligation and should be aware of the existing pharmacovigilance mechanisms in their countries. In Nepal, pharmacovigilance activities were initiated in 2004.Objectives: The present study evaluated the knowledge, attitude and practices (KAP) of the healthcare professionals towards ADRs and pharmacovigilance in Manipal Teaching Hospital (MTH), a tertiary care teaching hospital attached to the regional pharmacovigilance center in western Nepal.Methods: A cross-sectional study was carried out in 2007 using a pretested (Cronbach alpha=0.72) questionnaire having 25 questions (15 questions on knowledge, 5 on attitude and 5 on practice). The correct/positive responses were given a score of ‘2’ and the wrong/negative responses ‘1’, maximum possible score of ‘50’.Results: A total of 131 responses were obtained among which 42 were incomplete and remaining 89 [females 49 (55.1%)] were analyzed. Of the 89 professionals, 29 (32.6%) were doctors, 46 (51.8) nurses and 14 (15.7%) pharmacists. The mean age was 28.32 (SD=8.46) years and the median (interquartile range) of duration of the service 14.5 (6-36) months. The total KAP scores was 40.06 (SD=3.51) for doctors, 38.92 (SD=4.83) for pharmacists, and 35.82 (SD=3.75) for nurses. Among the 89 professionals, 59 (62.3%) had not reported even a single ADR to the pharmacovigilance center.Conclusion: The healthcare professionals at the MTH had a poor KAP towards ADRs and pharmacovigilance and there is a need for educational and awareness intervention for these professionals. Keywords: Adverse Drug Reaction Reporting Systems. Attitude of Health Personnel. Nepal.

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Health professionals' knowledge, attitude and practices towards pharmacovigilance in Nepal

Objectives: To analyze the prescriptions of out-patients for rational prescribing and dispensing and to evaluate the patient’s knowledge regarding use of drugs, using INRUD indicators. Methods: A cross-sectional, descriptive study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal during the time period from June 10 th to August 19 th 2004. Results: Totally 247 prescriptions were randomly selected for analysis, wherein 720 drugs were prescribed. Only 15% of drugs were prescribed by generic name, 21.67% of the total drugs consisted of fixed-dose combinations, only 40% of drugs were from the Essential drug list of Nepal and 29.44% (n=212) were from the WHO Essential drug list. It was found that more than half (54.17 %) of the drugs were from Nepalese National Formulary and 35.69% were from WHO model formulary. Dermatological products were most commonly prescribed followed by drugs acting on central nervous system, antimicrobials and drugs acting on cardiovascular system. Among the drugs dispensed, 79.16% were oral followed by topical (18.19%) and parenteral forms (2.98%). Diagnosis was mentioned only in 3.23% (n=8) of the prescriptions and the average cost per prescription was found to be 241.11 Nepalese rupees (US$ 3.26). It was found out that pharmacist labelled only 0.4% of the medication envelopes with the name of the patient. However, 82.6% of the medication envelopes were labelled with name of the drug and 87.0 % with drug strength. Only 53.8% (n=133) of the patient knew both the duration of the therapy and administration time of drugs. Conclusion: There is a need for educational intervention for prescribers and both managerial and educational intervention for the hospital pharmacists to improve prescribing and dispensing.

A study on rational drug prescribing and dispensing in outpatients in a tertiary care teaching hospital of Western Nepal.

Objectives: To study the demographic details of diabetes patients and their knowledge,
attitude and practices (KAP) regarding diabetes in Nepal.
Methods: The KAP of the diabetes patients visiting the Manipal Teaching hospital
(MTH) during the period from 22nd August to 7th December 2006 were studied by using
the KAP questionnaire developed by the researchers.
Results: Altogether 182 patients were enrolled in the study. There were 103 (56.59%)
males and 79 (43.41%) females. The greatest number of patients were in the age group of
51-60 years. A total of 685 drugs were prescribed to these patients. Antidiabetics were
the commonest class of drugs prescribed accounting for 314 (45.84%) of the total drugs.
The overall mean ( SD) scores of the patients was 7.78  3.8. Knowledge score was
4.90  3.34; attitude 2.03  0.95 and practice 0.840.76, with maximum possible scores
for knowledge, attitude and practice patient being 18, 4 and 3 respectively.
Conclusion: The KAP scores of the patients were low. This suggests the need for
educational interventions to improve the knowledge, attitude and practices of the diabetes
patients. (Rawal Med J 2008;33:8-11).

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Knowledge, Attitude and Practice about Diabetes among DiabetesPatients in Western Nepal -

Objective: To evaluate the drug dispensing practices and patients' knowledge on drug use among the outpatients and to identify and analyze the problems in drug prescribing and dispensing. Methods: A prospective cross-sectional descriptive study was conducted using World Health Organization (WHO) core drug use indicators from July 13, 2008 to August 15, 2008 in Manipal Teaching Hospital, Pokhara, Nepal. Results: A total of 4231 prescriptions were encountered with the total of 10591 drugs prescribed. The average number of drug per prescription was 2.5. Only 13% (n= 10591) of drugs were prescribed by generic name. Percentage of drug prescribed from WHO model list of Essential drugs, Essential drug list of Nepal and Nepalese National Formulary was 21.7%, 32.8% and 42.3% respectively. Antibiotics and injections encountered were 28.3% and 3.1% respectively. Average cost per prescription was found to be Nepalese Rupees (NRs) 285.99 (US $ 3.73). Patient knowledge on correct use of drugs and appropriate labeling was found to be 81% and 1.4% respectively. Average dispensing time per prescription was 52 seconds. Conclusion: The finding from current study shows a trend towards irrational prescribing and dispensing. Hence, there is a need for effective intervention programme to encourage the physicians and dispensing pharmacists in promoting more rational drug use (JPMA 59:726; 2009).

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A prospective surveillance of drug prescribing and dispensing in a teaching hospital in western Nepal.

The management of chronic illness needs lifestyle modifications and drug therapy for a long period. Patient understanding regarding the illness plays a very important role in management of chronic illness. Effective patient counseling makes the patient understand his/her illness, necessary lifestyle modifications and pharmacotherapy in a better way and thus enhance patient compliance. The pharmacist has immense responsibility in counseling the patients with chronic illness. The counseling pharmacist should possess adequate knowledge and should be an effective communicator, making use of the verbal and non-verbal communication skills.

Subish Palaian

Papers

Health professionals' knowledge, attitude and practices towards pharmacovigilance in Nepal

A study on rational drug prescribing and dispensing in outpatients in a tertiary care teaching hospital of Western Nepal.

Knowledge, Attitude and Practice about Diabetes among DiabetesPatients in Western Nepal -

A prospective surveillance of drug prescribing and dispensing in a teaching hospital in western Nepal.

Patient counseling by pharmacist - a focus on chronic illness.