Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2008 | Month : April | Volume : 2 | Issue : 2 | Page : 720 - 725

Correct Use Of A Metered Dose Inhaler: A Prospective Interventional Study Among Healthcare Professionals In A Nepalese Teaching Hospital

KISHORE P.V., PALAIAN S, ALAM K, SHANKAR PR, BAJRACHARYA B, DEN ENDE J. V.

Manipal College of Medical Sciences, Pokhara, Nepal.

Correspondence Address :
Dr. P.V. Kishore MD (Pulmonology), Associate Professor Department of Medicine, Manipal Teaching Hospital/ Manipal College of Medical Sciences, Pokhara, Nepal.

Abstract

Background: Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common in Nepal. Inhaled medications form the cornerstone of the management of these diseases. Metered Dose Inhalers (MDIs) are a common mode of delivering inhaled medications, and hence knowledge of the healthcare professionals regarding MDIs is the cornerstone for educating the patients about the correct use of MDIs.
Objectives: To study the correct use of MDIs by the doctors, nurses, pharmacists and medical interns, and to evaluate the impact of an educational intervention on the use.
Methods: A prospective, interventional study was carried out at the Manipal Teaching Hospital, Pokhara, Nepal. The subjects were asked to demonstrate the technique using a placebo inhaler, and the steps were graded as per the National Asthma Education and Prevention Program (NAEPP) criteria. Intervention was done by demonstrating correct MDI use with the help of placebo inhalers and an information leaflet. The post intervention response was analyzed using appropriate statistical tests.
Results: Altogether 143 health professionals (male 53.8%, female 46.1%) were studied prior to intervention, and 101 (male 41.5%, female 58.4%) of them in the post interventional phase. The overall mean ± SD score obtained by the professionals was 4.44 ± 2.07 (pre intervention), and 7.68 ± 1.74 (post intervention). (P< 0.001, Z value - 10.020, Mann Whitney test). With regard to the individual scores of different categories of healthcare professionals, the scores for the nurses were 3.99 pre intervention and 8.14 post intervention, for doctors it was 5.96 and 7.18, for pharmacists it was 5.8 and 7.1, and for interns it was 4.72 and 7.12. None of the professionals could initially demonstrate all the ten steps involved in the correct use of MDI. Following the intervention one doctor, four medical interns, and eight nurses all demonstrated the steps correctly.
Conclusion: MDI use among healthcare professionals was poor before the intervention. The intervention was substantially effective in improving the technique.

Keywords

Doctors, Education, Intervention, Metered dose inhalers, Nurses, Pharmacists

Introduction
Respiratory diseases like asthma (1) and Chronic Obstructive Pulmonary Disease (COPD)(2) are a common cause of morbidity and mortality worldwide. In Nepal, a combination of asthma and bronchitis constitutes a major cause of mortality(3). Bronchodilators and anti-inflammatory agents are important for the treatment of these diseases. On systemic administration, these agents produce considerable side effects. In order to overcome this problem and to have a quicker onset of action and better efficacy, inhaled medications are preferred(4). However failure of treatment is still a common problem for these diseases(5). One of the reasons for this is incorrect use of Metered Dose Inhalers (MDIs), the commonest method of inhaled drug delivery(6). It has been demonstrated to occur approximately in 75% of the patients using MDIs. 1

In order to improve MDI use, healthcare professionals should teach the patients to correctly use MDIs. Two studies from Nepal have demonstrated the usefulness of counseling by pharmacists in using MDIs(7),(8). To correctly teach MDI use, healthcare professionals like doctors, pharmacists and nurses should have adequate knowledge about the use of MDIs(9). Studies from different countries have demonstrated poor knowledge among these professionals regarding MDI use(10),(11),(12). Poor knowledge among healthcare professionals can lead to an incomplete and improper information about the patients. Studies have recommended training programs for healthcare professionals in order to improve their knowledge about the correct use of inhalers(10),(13),(14). These type of studies are lacking in Nepal.

Moreover, in Nepal, a large proportion of the patient population is illiterate, and hence the role of healthcare professionals in the education of the patients is very important. The doctors at our hospital educate the patients regarding the correct use of MDIs while prescribing them to the ambulatory patients. The nurses teach the ambulatory as well as the hospitalized patients about MDI use. The pharmacists at our hospital counsel the patients about the proper use of inhalers at the Medication Counseling Center (MCC) located adjacent to our out-patient pharmacy(15). Before educating patients, healthcare professionals need to have an adequate knowledge about the correct use of inhalers.

Thus, at the Manipal Teaching Hospital, a 700 bedded tertiary care center, doctors, nurses and pharmacists are involved in teaching the patients about the correct use of inhalers. However, their knowledge level regarding the correct use of inhalers is not known. Hence, the present study was carried out.

Objectives:
The present study was conducted with the following objectives.

1. To study the proficiency of the proper use of MDI demonstrated by the doctors, nurses, pharmacists and medical interns
2. To evaluate the impact of an educational intervention on the improvement in MDI use, if any.

Material and Methods

Study site: Manipal Teaching Hospital, Pokhara, Nepal, a 700 bedded tertiary care teaching hospital.

Study type: Prospective, interventional study

Study period: The study was carried out in three phases, the pre interventional, interventional, and the post interventional phase, with a one week gap between the phases.

Inclusion criteria: Doctors (only who prescribe MDIs), nurses and pharmacists were included in the study.

Study tool:An ‘MDI use evaluation score chart’ was prepared as per the National Asthma Education and Prevention Program (NAEPP) criteria(16), and was used in the study. For every correctly carried out step, a score of ‘1’ was given, and for every incorrect step, a score of ‘0’ was given. The score chart used is listed in Appendix 1.

Operational modality: The study had three phases, the pre interventional, interventional, and post interventional phase. The healthcare professionals were asked, after obtaining verbal consent, to demonstrate the use of the placebo inhaler, and the steps were graded as per the NAEPP criteria. Following the evaluation, the healthcare professionals were educated about the proper use of MDI. The educational intervention was carried out for doctors, nurses and pharmacists separately. Doctors and medical interns were contacted individually, nurses were trained in small groups, and pharmacists were educated during the Continuing Pharmacy Education (CPE), which is carried out by the Drug Information Center (DIC) members of our hospital on a fortnightly basis. All the healthcare professionals were also given information leaflets which described the ten steps involved in the correct use of MDIs. Following the intervention, the technique of the use of MDI was studied after a period of one week.

Statistical methods: We used the Mann Whitney test to compare the overall improvement in the scores of the health care professionals if any, following the intervention (P< 0.05). For the analysis, we used the Microsoft excel spread sheet and the Statistical Package for Social Sciences (SPSS) version 9.5.

Results

Age distribution: The details regarding the demographic distribution of the healthcare professionals are listed in (Table/Fig 1).

The overall knowledge regarding correct use of MDIs: The percentage of the professionals demonstrating each step of the MDI use correctly was identified and the details are listed in (Table/Fig 2).

Evaluation of the impact of the intervention: The impact of the intervention program was evaluated and the scores obtained by the health professionals were compared. The overall mean  SD score obtained by the professionals was 4.44  2.07 (pre intervention) and 7.68  1.74 (post intervention).

Distribution of the score based on their profession: The mean score obtained by the professionals were calculated as per their profession. The scores pre intervention and post intervention amongst nurses were 3.99 and 8.14, for doctors it was 5.96 and 7.18, for pharmacists it was 5.8 and 7.1, and for interns it was 4.72 and 7.12 respectively.

Distribution of the score based on the age of the professionals: The scores obtained by the professionals were grouped, based on their age. The average score obtained during pre intervention and post intervention by the professionals in the age group of 11-20 years was 3.07 and 8.38, followed by 4.5 and 7.62 for the age group 21-30 years, 6.1 and 7.8 for the age group 31-40 years, and lastly, 2 and 0 for the age group 41 and above.

Distribution of the score based on the length of service: The average score obtained by the professionals was grouped, based on their length of service. The details are listed in (Table/Fig 3)

Number of professionals who demonstrated all the steps correctly: None of the professionals in our study could demonstrate all the ten steps involved in the correct use of MDI during the pre intervention period. Following the intervention, 1 doctor, 4 interns, and 8 nurses demonstrated all the steps correctly.

Discussion

The present study identified a substantial improvement in the technique of inhaler use by the health care professionals of the hospital following the intervention.

Non-compliance to pharmacotherapy is a common reason for therapeutic failure(17). Studies have identified that up to 10% of hospital admissions, and more than 20% of nursing home admissions can be attributed to non-compliance(18),(19). In Nepal, respiratory diseases like asthma and COPD are highly prevalent(8). Non-compliance and treatment failure in these diseases may arise due to improper use of MDIs. In Nepal, the local manufacturers do not manufacture MDIs, and hence Patient Information Leaflets (PILs) in the native language for the patients, are not available.

The present study identified that healthcare professionals had a poor knowledge about the correct use of MDIs. It was surprising to know that none of the healthcare professionals could demonstrate the proper use of MDIs. In a study from Iran, which included physicians and nurses, only 6.93% could demonstrate MDIs correctly(13). In another study from Oman, 15% of respondents performed all the steps correctly(14). Our study has thus recorded a very poor understanding of healthcare professionals regarding MDI use. We could not identify the reason behind such a finding. The burden of respiratory diseases is so high in our region, that the use of MDI is unavoidable. In such a circumstance, the poor understanding of the healthcare professionals regarding the use of MDI can be dangerous. However, a few of the healthcare professionals could demonstrate the correct steps of MDI use. A study from Turkey, conducted amongst nurses, had demonstrated a significant improvement in MDI use after a training program(20). The authors also suggested a training program for nurses, and recommended repeat programs for better outcomes. The findings of our study also recommend training programs for the professionals to improve their knowledge. This training needs to be linked with managerial interventions as well.

The most difficult step identified by the professionals was the ‘step 5’, which included ‘Start breathing in slowly and deeply’. This step is very essential so that the medication can reach the respiratory tract. If one fails to inhale, the medication can deposit in the oral cavity, and can lead to wastage of the drug. This step can also be difficult for the patient. The study from Turkey reported the most improperly performed step to be ‘hold breath for 10 seconds’(10). Thus the difficult steps observed by the population can vary from place to place. In general, the steps that require hand to mouth coordination (steps 5-7) can be challenging. In such cases, a spacer can be beneficial, and can solve the co-ordination problem to a greater extent(20). However, in a poor country like Nepal, one should communicate to the patients, the cost factor before prescribing a spacer.

In our study, we found that overall, nurses had a poor score prior to the intervention. The knowledge of the nurses in this regard is very vital, as they teach the patients regarding MDI use when the patients get admitted in the hospital. However, the overall improvement in the score was higher in nurses than all the other professionals.

For the ambulatory patients using MDIs, the role of Pharmacists is very essential. The Pharmacists at the MCC of our hospital provide counseling to the patients regarding appropriate MDI use. In a preliminary evaluation carried out at our MCC, asthma or COPD was the commonest presumed diagnosis among the patients visiting the center, and MDIs were the most commonly used counseling aids(19). Inadequate knowledge of t

Conclusion

The present study identified poor understanding among healthcare professionals, regarding the correct use of inhalers. It was also surprising to know that even pharmacists who provide counseling to the patients were not able to demonstrate the different steps of the use of MDI correctly. Though the intervention was successful in increasing the knowledge of the healthcare professionals, there is scope for further improvement. It would be beneficial to have a periodic educational program for the healthcare professionals regarding MDI use.

References

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1. Gibbs KP, Small M. Asthma In: Walker R, Edwards C ‘editors’. Clinical Pharmacy and Therapeutics. 3 rd edition. Philadelphia: Churchill Livingstone; 2003; 375- 95
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Gibbs KP, Small M. Chronic obstructive pulmonary disease. In: Walker R, Edwards C ‘editors’. Clinical Pharmacy and Therapeutics. 3 rd edition. Philadelphia: Churchill Livingstone; 2003; 397- 411.
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Sharma GK. Leading causes of mortality from diseases and injury in Nepal: a report from national census sample survey. J Inst Med 2006; 28:7-11.
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Pain MCF. Delivering inhaled asthma therapy. Aust prescr 2003; 25:5-7.
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Ellis ME, friend JA. How well do asthma clinic patients understand their asthma? Br J Dis Chest 1985; 79:43-8.
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Hilton S. An audit of inhaler technique among asthma patients of 34 general practitioners. Br J Gen Pract 1990 40: 505-6.
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Bista D, Subish P, Upadhyay D K, Setty M, Mishra P. Impact of educational intervention on Inhaler Techniques. 56th Indian Pharmaceutical Congress, 3-5 December 2004, Science City Convention Center, Kolkota, India.
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Ansar M, Rao BS, Koju R, Shakya R, Impact of pharmaceutical intervention on inhalation technique. KathmanduUniversity Journal of Science, Engineering and Technology 2005; 1: 1-10.
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Lee-Wong M, Maya PH. Results of a programme to improve house staff use of metered dose inhalers and spacers. Post Grad Med J 2003; 79: 221-5.
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Yilmaz A, Bayramgurler B, Akkaya E. Evaluation of the usage techniques of the inhalational devices and the effects of training on Nurses. Turkish Respiratory Journal 2001; 2: 16-9.
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Hanania NA, Wittman R, Kesten S,Chapman KR. Medical personnel’s knowledge of and ability to use inhaling devices. Metered dose inhalers, spacing chambers, and breath- actuated dry powder inhalers. Chest 1994; 105: 111-6.
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Kelling JS, Strohl KP, Smith RL, Altose MD. Physician knowledge in the use of canister nebulizers. Chest 1983; 83: 612-4.
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Tables and Figures
[Table / Fig - 1] [Table / Fig - 2] [Table / Fig - 3]

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