8th National Conference on Medical Sciences 8-9 May 2003 Universiti Sains Malaysia Introduction : Stroke is the third most common cause of death and disability throughout the world. It poses a major financial, physical and psychological burden to patients, families and society. The treatment option for stroke have generally consisted of supportive measures and prevention of complications. Ischemic stroke accounts for approximately 85% of all strokes and it is most commonly due to occlusion of a cerebral artery. Surrounding the area of infarct lies an area of tissue with loss of neuronal function that is still reversible. This so called ischemic penumbra which is potentially salvageable by early reperfusion. Thus, therapeutic measure to prevent neuronal damage is by using medication that dissolve the acute thrombotic lesion that is turn resulting in early reperfusion. Thrombolysis serves to recanalise the occluded artery involved in the infarct and restore brain parenchyma blood supply therefore limiting the potential infarct volume. The use of rt-PA was approved by the Food and Drug Administration FDA ; in United Stated of America in 1996 for thromvolytic agent in acute ischemic stroke. We reported two cases of acute stroke that were treated with rt-PA Case1 : Mr. CHA, a 59 year old farmer with no previous medical illness presented with acute onset right hemiplegia with slurred speech of two hours duration. On examination he was conscious, alert with blood pressure of 200 110mmHg with pulse of 80 min. Neurological examination revealed right upper motor neuron facial palsy and right hemiparesis grade 3 5 MRC scale ; . An urgent CT brain revealed recent infarct in the left Basal ganglia and Corona radiate. His blood pressure was controlled with IV Labetalll infusion to 175 99mmHg with pulse rate 68 min. He was given rt-PA at dose of 0.5mg kg, 3.0mg bolus followed by 27.0 mg over one hour infusion within six hours period from arrival. He was monitored in neuro intensive care unit for any complication. There was no immediate complication of rt-PA and the patient regained full power on day four admission. He was discharged with Aspirin, Perindopril and Metoprolol. Case 2 : Mrs CYS, a 77 year old lady with multiple risk factor for stroke and previous stroke Left Hemiplegia ; one year back presented with acute onset global aphasia. On examination her blood pressure was 160 100mmHg with pulse of 76 minute. Neurological examination revealed generalized hypertonia and hyperreflexia with power in the right upper and lower limb 4 5 whereas in left upper and lower limb were 3 5. An urgent CT brain revealed left Frontal Parietal infarct with old right Parietal infarct. Intravenous rt-PA was given with dose of 2.0mg bolus and 18mg over one infusion. Blood pressure was controlled with intravenous Labetalol. There was no immediate complication related to rt-PA. She was discharged one week later. There was no improvement of her neurological deficit. She was put on Clopidogrel at discharge. Discussion : The two patients discuss above were the first two patient at USM to receive rt-PA for thrombolysis in acute stroke. The time of injection was within 6 hrs and not 3 hrs as recommended by US FDA. Both patients had no immediate complication. One patient improved fully while the other patient remain status-quo at end one week. She is being followed up. Both our patients did not have clinical radiological evidence of Intracerebral bleeding. Conclusion : In our experience rt-PA is an effective and safe therapy for acute Ischemic stroke.

The Drug Interface Group DIG this comprises representatives from within the PCG and UBHT and addresses issues of common interest to both primary and secondary care The UBHT Medicines Advisory Group MAG a group responsible for medicines issues within UBHT in which we, as a PCG, participate Group PCG Prescribing Group September Comments Avon Traffic Light System For treatments under shared care agreements. See this newsletter. Practice Visits and Support Practice visits to discuss prescribing to be reintroduced together with the offer of support to address prescribing issues. Prescribing Budget A large element of growth is from growing prescription numbers. Areas of major growth across the PCG include: Drugs for hyperlipidaemia, hypertension, angina, Drugs for psychosis Drugs for diabetes Areas where spend has reduced across the PCG: Antibiotics and ulcer healing drugs. The group noted that this is to be welcomed and prescribers congratulated. Repeat Prescribing and Waste A project to look at how repeat prescribing systems and medication review can be improved. Part of the spin off might be to reduce the amount of waste unused medicines returned for destruction in Avon; 11 tonnes in 1999 00, 14 tonnes in 2000 01 ; Avon Traffic Light System, NICE Guidance on COX II inhibitors See above. Avon Traffic Light System See this newsletter. New medicines in secondary care NICE recommendations and lipoprotein 3a2b inhibitors Rasbicurase for hyperuricaemic crisis. COX II inhibitors Endorsement of DIG discussion about the appropriate use of the four COXII inhibitors that were the subject of NICE guidance; due to their equal effectiveness choice to be based on price and maxalt.

Prior authorization is required for selected brand-name drugs as determined by the department for which there is available an "A" rated bioequivalent generic product as determined by the federal Food and Drug Administration. For prior authorization to be considered, evidence of a treatment failure with the bioequivalent generic drug must be provided. A copy of a completed Med Watch form, FDA Form 3500, as submitted to the federal Food and Drug Administration shall be considered as evidence of a treatment failure. Brand-name drugs selected by the department shall be obtained from those recommended by the Iowa Medicaid drug utilization review commission after consultation with the state associations representing physicians. The list of selected brand-name drugs shall be published in the Medicaid Prescribed Drug Manual and the Physician Manual. Prior authorization is required for lipase inhibitor drugs for weight loss. Requests must include documentation showing failure of other weight loss programs, a body mass index BMI ; equal to or greater than 30, one or more comorbidity conditions, and a weight management plan including diet and exercise. Prior authorization may be given for up to six months. Additional prior authorizations may be given on an individual basis after review of medical necessity and documented significant weight loss at least 10 percent ; from the individual's weight at the beginning of the previous prior authorization period. Cross-reference 78.28 1 ; "d" 20 Prior authorization is required for therapy with palivizumab. Payment for palivizumab shall be authorized for patients who meet one of the following criteria: 1. Patient is less than 24 months of age at start of therapy and has chronic lung disease requiring medication or oxygen within the last six months. 2. Patient is less than 12 months of age at start of therapy with a gestational age of less than or equal to 28 weeks. 3. Patient is less than 6 months of age at start of therapy with a gestational age between 28 weeks and 31 weeks. 4. Patient is less than 6 months of age at start of therapy with a gestational age of 32 weeks to 35 weeks and has at least one additional risk factor. The fiscal agent will consider other conditions on an individual basis after review of submitted documentation. Cross-reference 78.28 1 ; "d" 21 b. Medical and sickroom supplies are payable when ordered by a legally qualified practitioner for a specific rather than incidental use. When a recipient is receiving care in a nursing facility or residential care facility, payment will be approved only for the following supplies when prescribed by a legally qualified practitioner: 1 ; Colostomy and ileostomy appliances. 2 ; Colostomy and ileostomy care dressings, liquid adhesive and adhesive tape. 3 ; Disposable irrigation trays or sets. 4 ; Disposable catheterization trays or sets. 5 ; Indwelling Foley catheter. 6 ; Disposable saline enemas. 7 ; Diabetic supplies including needles and syringes, blood glucose test strips, and diabetic urine test supplies. c. Prescription records are required for all drugs as specified in Iowa Code sections 155.33, 155.34 and 204.308. For the purposes of the medical assistance program, prescriptions for medical supplies are required and shall be subject to the same provisions.

Hormones that can contribute to sexual arousal disorder. The vaginal thinning and dryness which can contribute to this may develop in HIV-positive women at younger ages than is the norm due to the earlier than usual development of perimenopause or menopause that so often occurs. Inappropriate use of too-high doses of testosterone especially through injections ; can ultimately lead to a shutdown of the body's natural production of testosterone, resulting in impotence. Inappropriate use of other anabolic steroids can also cause impotence. Neuropathy. A form of neuropathy called autonomic neuropathy causes a number of serious symptoms in some HIV + people, including impotence in some men and possibly sexual arousal disorder in some women as well as digestive dysfunction, bladder problems, and orthostatic hypotension ; . Because autonomic neuropathy is more common than is generally recognized, it may be contributing to sexual dysfunction in far more HIV + people than has been reported to date. Researchers have found that HIV-positive men with neuropathy whether asymptomatic or symptomatic ; have nerve conduction problems that may explain their impotence. Normally, nerve signals propagate in pulses along nerves at a certain rate. Researchers have found that this rate is diminished in the dorsal back ; nerve of the penis in HIV + people with neuropathy. In contrast, the penile brachial index that measures blood pressure appears to be unimpaired. This indicates that the problem lies in the nerves, not in the blood supply to the penis. [For more information, see Neuropathy.] Medications. Many different medications can cause sexual problems. Included on the list of drugs that may be problematic are protease inhibitors, as well as a very long list of other medications. In a recent study of 254 HIV-positive men, the rate of sexual problems erectile dysfunction and or loss of libido ; was shown to be increased during any protease inhibitor therapy, with the rate most elevated in those using ritonavir, followed by indinavir, nelfinavir, and saquinavir. There was no apparent association of sexual dysfunction with the use of NNRTIs non-nucleoside reverse transcriptase inhibitors ; or NRTIs nucleoside analogue reverse transcriptase inhibitors or nukes ; . There are many other drugs that are known to have possible sexual side effects. In a compilation by Consumer Reports On Health March 2002 ; , common drugs that may cause sexual dysfunction were listed as the following note that this list does not include sexual dysfunction that may be caused by interactions between drugs ; : Drugs that may cause decreased sexual desire: Q Anti-anxiety drugs: alprazolam Xanax ; and diazepam Valium ; Q Anticonvulsants: carbamazepine Tegretol ; , phenytoin Dilantin ; , and primidone Myidone, Mysoline ; Q Antidepressants: amitriptyline Elavil ; , amoxapine Asendin ; , clomipramine Anafranil ; , desipramine Norpramin ; , fluoxetine Prozac ; , imipramine Norfranil, Tofranil ; , phenelzine Nardil ; , sertraline Zoloft ; , venlafaxine Effexor ; Q Antihypertensives blood pressure meds ; : atenolol Tenormin ; , chlorthalidone Hygroton, Thalitone ; , clonidine Catapres ; , hydrochlorothiazide Esidrix, HydroDIURIL ; , labetalol Normodyne, Trandate ; , methyldopa Aldomet ; , metoprolol Lopressor ; , propranolol Inderal ; , spironolactone Aldactone ; Q Enlarged-prostate drug: finasteride Proscar ; Q Hair loss male pattern baldness ; drug: finasteride Propecia ; Q Heartburn drugs: cimetidine Tagamet, Tagamet HB ; , famotidine Pepcid, Pepcid AC ; , nizatidine Axid, Axid AR ; , ranitidine Zantac, Zantac 75 ; Q Heart failure drug: amiodarone Cordarone ; Drugs that may cause erectile dysfunction or vaginal dryness: Q Anticonvulsants: carbamazepine Tegretol ; , phenytoin Dilantin ; , and primidone Myidone, Mysoline ; Q Antidepressants: amitriptyline Elavil ; , amoxapine Asendin ; , clomipramine Anafranil ; , desipramine Norpramin ; , fluoxetine Prozac ; , imipramine Norfranil, Tofranil ; , paroxetine Paxil ; , phenelzine Nardil ; , sertraline Zoloft ; , venlafaxine Effexor ; Q Antihypertensives blood pressure meds ; : atenolol Tenormin ; , chlorthalidone Hygroton, Thalitone ; , clonidine Catapres ; , hydrochlorothiazide Esidrix, HydroDIURIL ; , labetalol Normodyne, Trandate ; , methyldopa Aldomet ; , metoprolol Lopressor ; , propranolol Inderal ; , spironolactone Aldactone ; Q Enlarged-prostate drug: finasteride Proscar ; Q Hair loss male pattern baldness ; drug: finasteride Propecia ; Q Heartburn drugs: cimetidine Tagamet, Tagamet HB ; , famotidine Pepcid, Pepcid AC ; , nizatidine Axid, Axid AR ; , ranitidine Zantac, Zantac 75 ; Q Heart failure drug: amiodarone Cordarone ; Q Muscle relaxant: baclofen Lioresal.
Theytendtohaveahigherincidenceofbilateralectopic to examine the entire pelvis as bilateral ectopics can sometimesbemissed. Tomaintainfertility, theinterventionshouldbeas treatedby salpingotomy, it is believedthat results are was performed on one of the tubes, the other was In the other two cases bilateral salpingectomies were performed. This was appropriate in one patient who had completed her family. It was not known whether the remaining patient had desired any more beenbetter. DAyCAREOBSTETRICUNIT: AWORKABLEALTERNATIVEAT THEQUEENELIzABETHHOSPITAL Cummins B, Greaves M, Marshall A, Scantlebury J, Straker J, Ogunbiyi B. DepartmentsofNursingandObstetrics &Gynaecology, QueenElizabethHospital hypertension and diabetes. To this effect, the idea of a day care outcome. The misuse of healthcare resources results in increasing workload and high financial costs and produces negative effects on the physical, social, and oftheQEH.Thefindingssuggestthat, themajorityof and lercanidipine.

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