Clinical characteristics, management, outcome, and cost of stings and bites in patients admitted to a tertiary care teaching hospital

AIM

The objective of this study was to identify the clinical epidemiology and medical cost of stings and bites at a tertiary care hospital in South India.

SUBJECTS AND METHODS

The medical records of hospitalized patients in the tertiary care unit between 2016 and 2020 with the history of either being stung or bitten by insects were reviewed retrospectively. The patient's demographic details, clinical symptoms, treatment chart, expenditure details, and outcomes were collected in pre-structured case report forms. The data were analyzed using SPSS Version 20.0.

RESULTS

A total of 66 patients were enrolled, with a mean age of 45.86 ± 23.37 years. The majority of the incidence was due to bee stings (61%). Anaphylaxis was reported in 38% of the cases, followed by acute kidney injury (10.6%). The cost of hospitalization was found to be higher for spider bites at 896.73 ± 1414.95 USD, followed by wasp stings at 989.81 ± 1185.57 USD. In patients with complications, the average cost of stings and bites was 438.81 ± 685.81 USD. Most of the patients received antibiotics (75.8%), followed by steroids (62.1%).

CONCLUSION

Stings and bite injuries may appear harmless initially, but they can cause severe complications in unidentified cases and for those who do not seek urgent medical attention. Antibiotics and corticosteroids can help in the management of envenomation.

Economic Burden of Mosquito-Borne Diseases in Low- and Middle-Income Countries: Protocol for a Systematic Review

BACKGROUND

Globally, among all the vector-borne diseases, mosquito-borne diseases are responsible for a substantial number of cases and deaths and amount to an economic cost of US $12 billion per year. However, there is a dearth of systematic research conducted on the economic burden of mosquito-borne diseases. To address the lack of comprehensive information on this topic, a systematic review will be conducted to synthesize evidence for informing targeted policies and strategies addressing this growing burden and for better financial protection of households.

OBJECTIVE

The systematic review aims to review the economic burden of mosquito-borne diseases in low- and middle-income countries (LMICs). The review estimates the total cost, which is the compilation of both the direct costs and indirect costs. Additionally, it reports cost estimates per disease, country, and patient. The review outcome will also discuss the impact of the economic burden in terms of out-of-pocket expenditure, catastrophic health expenditure, impoverishment, and gross domestic product impact due to mosquito-borne diseases in LMICs.

METHODS

Systematic searches will be conducted in PubMed (MEDLINE), Ovid Embase, Scopus, the cumulative index of nursing and allied health literacy, and Cochrane CENTRAL. Additionally, websites of the World Bank, World Health Organization, and Asian Development Bank as well as grey literature (eg, Malaria No More and the Ministry of Health websites) will be searched to gather comprehensive information on the topic and identify studies published in the English language. The titles and abstracts will be independently screened by 2 reviewers, followed by a full-text review against the inclusion criteria. Disagreements will be resolved through discussion with a third author. The methodological reporting quality of the studies will be evaluated using the Larg and Moss checklist, Cochrane risk-of-bias tool for randomized trials, and the Consensus on Health Economic Criteria. Data will be extracted using a standardized data extraction form.

RESULTS

The protocol was registered in PROSPERO (CRD42023427111) prior to the initiation of the search strategy. The review is currently ongoing and will synthesize information from the identified studies through a process involving structured screening, data extraction, and critical appraisal in the form of tables and a narrative summary of studies reporting the economic burden incurred due to mosquito-borne diseases in LMICs.

CONCLUSIONS

This review seeks to report the economic burden of mosquito-borne diseases. It will act as evidence for policymakers to prioritize their decisions regarding containing the prevalence of mosquito-borne diseases and the means to lowering the incidence of diseases spread by mosquitoes.

TRIAL REGISTRATION

PROSPERO CRD42023427111; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=427111.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50985.

Determinants of Medication Non-Adherence Among the Elderly with Co-Existing Hypertension and Type 2 Diabetes Mellitus in Rural Areas of Udupi District in Karnataka, India

Purpose

Medication adherence is a crucial component in the management of elderly with co-morbid chronic conditions. Hence, this study aimed to investigate the determinants of medication non-adherence among rural elderly with co-morbid chronic conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) in India.

Patients and Methods

This cross-sectional study adopted the probability proportional to size (PPS) sampling technique to find the determinants of medication non-adherence among elderly residing in rural coverage areas of five randomly selected primary health centres (PHC) in Udupi district, Karnataka, India. A total of 360 elderly (72 samples from each cluster) who met the inclusion criteria and consented were interviewed using predesigned prevalidated and standardized or reliable tools. The data were coded and entered in SPSS version 16.0 and analyzed using both descriptive and inferential statistics.

Results

The study found that 55.6% (n=200) of rural elderly with co-morbid conditions HTN and T2DM were non-adherent to their medications and established Spearman correlation coefficient rank (r) value between undesirable person-related factors (r=-0.444); good family support (including financial support) (r=0.185); poor accessibility to healthcare facility (r=-0.209); detrimental medication-related factors including high cost of medication (r=-0.237) were found to be significant at 0.05 level of confidence (p < 0.05). Further, the study depicted that the chi-square test (χ²) was identified to be significantly associated (p<0.05) with a variable such as education, knowledge, number of illnesses and impairments, vision, memory, and physical impairments.

Conclusion

Medication adherence could be improved among rural elderly with co-morbid conditions by identifying and addressing the determinants at the earliest. Further, it is vital to identify the suitable intervention program to address these avoidable problems.

The significance of APACHE II as a predictor of mortality in paraquat poisoning: A systematic review and meta-analysis

The Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is utilised as a prognostic method in paraquat poisoning; however, current evidence shows ambiguity. Although some studies have shown APACHE II to be a superior tool, others have reported it inferior to other prognostic markers, such as lactate, severity index of paraquat poisoning and urine paraquat concentration. Hence, to address this ambiguity, we conducted a systematic review and meta-analysis to analyse prognostic accuracy of APACHE II score in predicting mortality in paraquat poisoning. We included twenty studies with 2524 paraquat poisoned patients in the systematic review, after a comprehensive literature search in databases PubMed, Embase, Web of Science, Scopus and Cochrane Library, from which 16 studies were included in the meta-analysis. The survivors of paraquat poisoning were found to have significantly lower APACHE II scores (Mean Difference (MD): -5.76; 95% CI: -7.93 to -3.60 p < 0.0001; n = 16 studies) compared to non-survivors. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) for APACHE II score <9 was found to be 74%, 68%, 2.58, 0.38 and 7.10, respectively (n = 5 studies). The area under the curve (AUC) of the bivariate summary receiver operating characteristic (SROC) curve was found to be 0.80. The pooled sensitivity, specificity, PLR, NLR and DOR for APACHE II score ≥9 was found to be 73%, 86%, 4.69, 0.33 and 16.42, respectively (n = 9 studies). The AUC of the SROC curve was found to be 0.89. Pairwise AUC comparison of APACHE II with other prognostic markers showed serum presepsin to have a significantly better discriminatory ability than APACHE II. Through the findings of this study, we conclude that APACHE II was found to be a good indicator of death in paraquat poisoning patients. However, higher APACHE II scores (≥9) depicted greater specificity in predicting mortality in paraquat poisoning. Thus, APACHE II can be used as a practical tool in the hand of physicians to prognose patients with paraquat poisoning to aid clinical decisions.

Factors contributing to the adverse drug reactions associated with the dipeptidyl peptidase-4 (DPP-4) inhibitors: A scoping review

BACKGROUND AND AIM

Adverse drug reactions are one of the contributors to increased hospital admission and length of hospital stay. Among the various antidiabetic agents prescribed, dipeptidyl peptidase-4 (DPP-4) inhibitors have gained wide recognition and shown more persistence than other novel hypoglycemic agents. We performed a scoping review to identify the risk factors contributing to the adverse drug reactions with DPP-4 inhibitors.

METHODOLOGY

We followed Preferred Reporting Items for Scoping Review (PRISMA-ScR) Guidelines for reporting the findings. Data sources such as PubMed/MEDLINE, Scopus, Embase, and Cochrane were assessed. We included studies that reported the risk factors contributing to the DPP-4 inhibitor-associated adverse drug reactions. The Joanna Briggs Institute (JBI) critical appraisal checklist was used to assess the methodological quality of the studies.

RESULTS

Of the 6406 studies retrieved, 11 studies met our inclusion criteria. Of these 11 studies, seven were post-marketing surveillance studies, one nested case-control study, one comparator cohort study, one food and drug administration (FDA) adverse event reporting system (FAERS)-based observational study, and one questionnaire-based cross-sectional survey study. A total of eight factors were identified that contributed to the DPP-4 inhibitor-associated adverse drug reactions.

CONCLUSION

The included studies suggested age >65 years, females, grade 4 and 5 renal impairment, concomitant drugs, disease and drug therapy duration, liver disease, non-smokers, and non-hypertension as risk factors. Further studies should be conducted to provide insight into these risk factors so that the appropriate use of DPP-4 inhibitors in the diabetic population can be encouraged to improve the health-related quality of life.

PROSPERO REGISTRATION

CRD42022308764.

Impact of COVID-19 pandemic on medicine supply chain for patients with chronic diseases: Experiences of the community pharmacists

Problem considered

Coronavirus disease(COVID-19) outbroke towards the end of December 2019 in China, soon it started spreading rapidly to various countries leading to an outburst of pandemic. Due to the restrictions imposed to control the spread of the infection, globally the manufacturing, import and export of medicine and the healthcare services to patients with chronic illness had been affected. This study aimed to explore the perspectives of the pharmacists on the medicine supply chain for patients with chronic diseases during COVID-19 pandemic in India.

Methods

This study is a prospective, qualitative research involving telephonic, semi-structured in-depth interviews. An interview guide for pharmacists was prepared and validated using "Interview Protocol Refinement" method. Purposive sampling method was used to recruit the pharmacists; a telephonic oral consent was obtained. The interview session was audio recorded and the recordings were transcribed verbatim. Further, transcripts were validated and later analysed using NVivo software.

Results

A total of 8 participants were interviewed during our study. Thematic analysis of the transcripts resulted in seven main themes. The study showed that there was deficiency in medicine supply during the COVID-19 pandemic and the pharmacists faced several challenges in procuring and storing the medication, arranging for unavailable medicines, medication dispensing and provision of the services such as medicine delivery, patient counselling. There was also scarcity of manpower leading to extra workload and working overtime.

Conclusion

Uninterrupted supply of essential medicine is the backbone of health care system. An effective plan and appropriate strategies are vital to combat such future emergencies.

Perspectives of patients and healthcare professionals on metabolic monitoring of adult prescribed second-generation antipsychotics for severe mental illness: A meta-synthesis

OBJECTIVES

We conducted a meta-synthesis of qualitative studies to synthesize the views of psychiatric patients on second-generation antipsychotics (SGAs) and the healthcare providers about the metabolic monitoring of adult-prescribed SGAs.

METHODS

A systematic search was conducted in four databases through SCOPUS, PubMed, EMBASE, and CINAHL to identify qualitative studies of patients' and healthcare professionals' perspectives on the metabolic monitoring of SGAs. Initially, titles and abstracts were screened to exclude articles that were not relevant followed by full-text reading. Study quality was assessed by using Critical Appraisal Skills Program (CASP) criteria. Themes were synthesized and presented as per the Interpretive data synthesis process (Evans D, 2002).

RESULTS

A total of 15 studies met the inclusion criteria and were analyzed in meta-synthesis. Four themes were identified: 1. Barriers to metabolic monitoring; 2. Patient related concerns to metabolic monitoring; 3. Support system by mental health services to promote metabolic monitoring; and 4. Integrating physical health with mental health services. From the participants' perspectives, barriers to metabolic monitoring were accessibility of services, lack of education and awareness, time/resource constraints, financial hardship, lack of interest on metabolic monitoring, patient capacity and motivation to maintain physical health and role confusion and impact on communication. Education and training on monitoring practices as well as integrated mental health services for metabolic monitoring to promote quality and safe use of SGAs are the most likely approaches to promote adherence to best practices and minimize treatment-related metabolic syndrome in this highly vulnerable cohort.

CONCLUSION

This meta-synthesis highlights key barriers from the perspectives of patients and healthcare professionals regarding the metabolic monitoring of SGAs. These barriers and suggested remedial strategies are important to pilot in the clinical setting and to assess the impact of the implementation of such strategies as a component of pharmacovigilance to promote the quality use of SGAs as well as to prevent and/or manage SGAs-induced metabolic syndrome in severe and complex mental health disorders.

Relationship between antibiotic consumption pattern and antibiotic resistance in neonatal sepsis

Background and aim

Inappropriate use of antibiotics may increase antimicrobial resistance (AMR) among different microorganisms and may lead to treatment failure in neonatal septicemia. The aim of this study was to recognize the most common microorganisms responsible for neonatal sepsis and to evaluate the trend of change of resistance pattern among microorganisms.

Methods

This study was done retrospectively on 344 cases diagnosed with neonatal sepsis, including both early and late onset cases, admitted to the tertiary care teaching hospital of southern India from January 2012 to July 2017. Accordingly, 231 culture positive neonatal sepsis cases were collected from hospital data base and analyzed. Culture positive cases within 72 hours of life were termed as early onset while after 72 hours were late onset. Antibiotics utilization during the period was calculated using WHO AMC tool and reported as (DDD)/100 bed days.

Results

Klebsiella pneumoniae with 56 (21.8%) and Coagulase negative Staphylococcus with 52 (20.2%) cases were the most frequent isolated organisms which were responsible for 55.8% and 14.6% of deaths among the study subjects respectively. Amikacin (86.7%), vancomycin (52.3%) and ampicillin (40.6%) were the most used antibiotics in terms of DDD/100 bed days.

Conclusion

The results obtained from our study have brought substantial information on the antibiotic resistance pattern among microorganisms causing neonatal sepsis. Moreover, results obtained from this study can be used for designing antibiotic stewardship policies to prevent the emergence of resistance and to improve the treatment outcome.

Impact of Diabetes in COVID-19 Associated Mucormycosis and its Management: A Non-Systematic Literature Review

BACKGROUND

COVID-19 has become extremely dangerous manifesting itself in a variety of forms ranging from a simple flu-like illness to death. COVID-19 associated mucormycosis (CAM) is a global threat with diabetes being a major contributor.

OBJECTIVE

This review aims to give a clear picture of the impact of hyperglycemia in CAM along with its management.

METHODS

Google and Google Scholar were searched and studies that addressed the impact of diabetes in CAM were considered for this review. We also performed a bibliographic search of the specific article to find additional studies.

RESULTS

A series of events such as unregulated activation of innate immune system modification, pro-inflammatory M1 macrophages activation, and the depletion of natural killer cell activity is very common in patients with COVID-19. In addition, the exacerbated cytokine syndrome and hyperinflammatory response may elevate the severity of this condition, which further leads to higher mortality. The impaired immune phase which follows provide the niche for increased infection among diabetic patients making them more prone towards developing mucormycosis and associated infections. Early detection, surgical debridement, and appropriate medical treatment with antifungals and hypoglycaemic agents may help control the infection and associated morbidity and mortality. COVID-19 drugs, hypoglycaemic agents, antifungals, and comorbidities have all been associated with adverse side effects and drug interactions.

CONCLUSION

Clinicians should be well aware of this deadly disease and manage COVID-19, diabetes, and mucormycosis through individualized treatment regimens to improve patient outcomes.

Systematic review and meta-analysis of global prevalence of neurotoxic and hemotoxic snakebite envenomation

Background

The World Health Organization estimates that there are approximately 5.4 million snakebites and 1.8-2.7 million cases of envenomation, with 81 410-137 880 deaths each year worldwide.

Aims

To estimate the prevalence of neurotoxic and haemotoxic snakebite envenomation through a comprehensive systematic review and meta-analysis.

Methods

We searched Medline/PubMed, Scopus and Cochrane Library up to January 2021 using keywords such as snakebite and snake envenomation. Bibliographic and random searches were also performed. Prospective or retrospective observational studies and randomized controlled trials were included for the review.

Results

We included 271 of 9711 studies published between 1963 and 2020. The pooled prevalence of snakebite from 188 studies with a total of 207 235 participants showed the highest prevalence in North America (69.20%; 95% confidence interval, CI: 57.06-81.34%) and lowest in Africa (28.10%; 95% CI: 22.22-33.98%). There was a pooled prevalence of 24.94% (95% CI: 22.84-27.03%) for haemotoxicity, with a highest prevalence of coagulopathy (43.76%; 95% CI: 33.15-54.37%). The overall prevalence of neurotoxicity was 38.20% (95% CI: 31.88-44.53%), with a highest prevalence of ptosis (53.57%; 95% CI: 38.51-68.62%).

Conclusion

There was a higher prevalence of snakebites in North America. The most prevalent haemotoxicity and neurotoxicity were coagulopathy and ptosis, respectively. The overall quality of evidence was good with a non-significant publication bias.

Global prevalence of neurotoxic and hemotoxic snakebite envenomation: a systematic review and meta-analysis

Background: According to the World Health Organization, globally, there are ~5.4 million snake bites and 1.8–2.7 million cases of envenomation, with 81 410–137 880 deaths annually. Aims: To estimate using a comprehensive systematic review and meta-analysis the prevalence of neurotoxic and haemotoxic snake bite envenomation. Methods: Medline/PubMed, Scopus and Cochrane Library were searched up to January 2021 using keywords such as snake bite and snake envenomation. A bibliographic search and random search were also performed. Prospective or retrospective observational studies and randomized controlled trials were included in the review. Results: We included 271 of 9711 studies published between 1963 and 2020. The pooled prevalence of snakebite from 188 studies with a total of 207 235 participants showed the highest prevalence in North America [69.20%; 95% confidence interval (CI): 57.06–81.34%] and lowest in Africa (28.10%; 95% CI: 22.22–33.98%). There was a pooled prevalence of 24.94% (95% CI: 22.84–27.03%) of haemotoxicity, with a highest prevalence of coagulopathy (43.76%; 95% CI: 33.15–54.37%). The overall prevalence of neurotoxicity was 38.20% (95% CI: 31.88–44.53%), with a highest prevalence of ptosis (53.57%; 95% CI: 38.51–68.62%). Conclusion: There was a higher prevalence of snakebite in North America. The most prevalent haemotoxicity and neurotoxicity were coagulopathy and ptosis, respectively. The overall quality of evidence was good with a nonsignificant publication bias.

Identification of risk factors associated with hyponatremia in psychiatric patients: a case-control study

Background and aims

Prompt recognition and optimal management of hyponatremia helps the physician devise a better treatment plan to prevent future complications in patients. Hence this study aims to identify the risk factors associated with hyponatremia in psychiatric patients.

Methods

A case-control study was conducted among psychiatric inpatients in a tertiary care teaching hospital. Patients admitted from January 2013 to December 2017 were identified using ICD-10 code F01-F99. Patients with serum sodium levels < 135 mmol/L were considered to have hyponatremia and between 135-145 mmol/L as controls. Factors associated with hyponatremia were identified by multiple logistic regression, and the odds ratio (OR) was calculated.

Results

Based on the inclusion and exclusion criteria, 264 cases of hyponatremia and 253 matching controls were included in the study. The mean age of patients with hyponatremia was 56.4 ± 16.8 years compared to 39.6 ± 13.9 years in controls, and 65.7% of them were males. Seizure disorder (OR = 3.14, p = 0.047), bipolar disorder (OR = 6.03, p = 0.001), depression (OR = 4.78, p = 0.0005), use of quetiapine (OR = 2.11, p = 0.007) and insulin (OR = 3.53, p = 0.038) were independent risk factors associated with development of hyponatremia.

Conclusions

The chances of developing hyponatremia are increased in psychiatric patients with a seizure disorder, bipolar disorder, depression and using quetiapine or insulin. And they should be monitored carefully.

Identification of factors affecting outcomes in patients with Guillain Barre syndrome

Background

Guillain Barre syndrome (GBS) is a rare autoimmune neurological disorder resulting in variable clinical course and outcome. Various factors such as age, symptoms and disease form that influence the outcome of GBS have been previously studied.

Aim

This study aimed at identifying factors affecting the outcomes in patients with GBS.

Methods

A retrospective observational study was conducted on GBS (ICD-G61.0) patients admitted to the hospital between 2014 and 2019. Patient information on demographics, medical and medication history, laboratory parameters, electrophysiological data, type of GBS and therapy received were retrieved from medical records. Univariate and multivariate analysis were conducted to identify factors associated with outcome (improved and not improved) and calculate odds ratio (OR).

Results

A total of 212 GBS patients were included in the study, of which 67% were males and the mean age was 39.9±20.1 years. 168 (79%) patients showed improvement whereas the remaining 44(21%) did not show improvement. Patients with hypertension (OR=4.512; CI=1.309-15.556, p=0.017), alcoholics (OR=5.148; CI=1.234-21.472, p=0.025), sepsis (OR= 9.139; CI=1.102-75.760, p=0.040) and cardiac arrest (OR=17.495; CI=1.249-245.027, p=0.034) were associated with risk of no improvement. Whereas those treated with IVIgG plus Physiotherapy/Occupational therapy (OR=0.062; CI=0.016-0.242, p=0.001) and Plasmapheresis plus Physiotherapy/Occupational therapy (OR=0.007; CI=0.000-0.147, p=0.001) were associated with improvement.

Conclusion

Understanding these factors help to further give a more directed and focused management to improve the condition in patients who are at risk of poor outcome. Further follow-up studies could be done to determine and manage the residual disabilities associated with GBS to improve patient's quality of life.

Proton pump inhibitors use and risk of inflammatory bowel diseases: a meta-analysis of observational studies

Background and objective

Proton Pump Inhibitors (PPIs) reduce gastric acid production and they are indicated for myriad gastrointestinal conditions. Prolonged use of PPI has been linked to the risk of inflammatory bowel disease (IBD) though this fact is not well established. We aimed to conduct a systematic review and meta-analysis to estimate the risk of IBD occurrence with PPI use.

Methodology

The databases such as PubMed, Scopus, and Cochrane Library were accessed from inception to December 2020. Additionally, the bibliographic search and a random search in Google, Google Scholar, and ResearchGate were performed to find additional sources. The observational studies estimating the risk of IBD following the use of PPI, published in the English language were considered for this review. The methodological quality of included studies was assessed using the Modified Downs and Black checklist.

Results

Eight out of 2038 studies with 157,758 participants were included in this meta-analysis. A significantly higher risk of IBD (adjusted odds ratio [aOR] 2.43; 95% Confidence Interval [CI] 1.18-5.02; P=0.02; n=6) was observed in participants taking PPIs for any indication. Moreover, a significant association was observed between PPI exposure on the different types of IBD such as ulcerative colitis and Crohn's disease together (aOR: 3.60; 95% CI: 1.10-11.74), collagenous colitis (OR: 4.73; 95% CI: 1.99-11.22) and lymphocytic Colitis (OR: 3.77; 95% CI: 2.91-4.87), but not with ulcerative colitis (P=0.47) and microscopic colitis (P=0.07) alone. Similarly, a significant association was observed among Europeans (aOR: 3.98; 95% CI: 2.36-6.71), but not with North American (aOR: 0.48; 95% CI: 0.01-26.71) studies. Overall the study quality was good.

Conclusion

The current evidence indicates that exposure to PPI is significantly associated with increased risk of IBD. Further, adequately powered studies from various parts of the world are needed for better quantification and generalizability of our findings.

PROSPERO Protocol Registration Number

CRD42020209674.

Role of human leukocyte antigen in anti-epileptic drugs-induced Stevens-Johnson Syndrome/toxic epidermal necrolysis: A meta-analysis

PURPOSE

Antiepileptic drugs (AEDs) are extensively used to manage epilepsy and other comorbidities associated with seizures. Human Leukocyte Antigen (HLA) has a strong association with AED-induced severe cutaneous adverse drug reactions.

OBJECTIVE

We aimed to perform a systematic review and meta-analysis to identify, critically evaluate, and synthesize the best possible evidence on HLA-associated AED-induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN).

METHODS

MEDLINE/PubMed, Scopus, and the Cochrane Library were searched for literature from inception up to July 2022. We included case control studies analyzing association between HLA and AED-induced SJS/TEN. We assessed the studies' risk of bias in using Quality of genetic studies (Q-genie) tool. Outcomes focused on association (risk) between HLA and AED-induced SJS/TEN. The estimated risk was presented in the form of odds ratio (OR).

RESULTS

We included 37 studies (51,422 participants; 7027 cases and 44,395 controls). There was a significantly higher risk of Carbamazepine-induced SJS/TEN with HLA-A (OR: 1.50; 95% CI: 1.03 to 2.17), HLA-B (OR: 1.94; 95% CI: 1.45 to 2.58), HLA-C (OR: 7.83; 95% CI: 4.72 to 12.98), and HLA-DRB1 (OR: 2.82; 95% CI: 1.94 to 4.12). Lamotrigine-induced SJS/TEN posed a higher risk with HLA-A (OR: 2.38; 95% CI: 1.26 to 4.46) and HLA-B (OR: 2.79; 95% CI: 1.75 to 4.46). Phenytoin-induced SJS/TEN showed a higher risk with HLA-A (OR: 3.47; 95% CI: 2.17 to 5.56), HLA-B (OR: 1.72; 95% CI: 1.38 to 2.15), and HLA-C (OR: 2.92; 95% CI: 1.77 to 4.83). Phenobarbital-induced SJS/TEN had a higher risk with HLA-A (OR: 6.98; 95% CI: 1.81 to 26.84), HLA-B (OR: 2.40; 95% CI: 1.39 to 4.17), and HLA-C (OR: 3.37; 95% CI: 1.03 to 11.01). Zonisamide-induced SJS/TEN was significantly associated with HLA-A*02:07 (OR: 9.77; 95% CI: 3.07 to 31.1), HLA-B*46:01 (OR: 6.73; 95% CI: 2.12 to 21.36), and HLA-DRB1×08:03 (OR: 3.78; 95% CI: 1.20 to 11.97). All other alleles of HLA were observed to have a non-significant association with AED-induced SJS/TEN. All included studies were of good quality, with a score of >50 and a mean score of 54.96 out of 77.

CONCLUSION

Our study showed a significant association between few variants of HLA alleles and AED-induced SJS/TEN. Evidences from our study could help in population-based studies and in implementation of individualized treatment regimens. These findings could be part of translational research helping in precision therapy.

Identification of potential risk factors for the poor prognosis of neonatal sepsis

Background and aim. Risk factor-based approach is one of the best approaches employed by middle income countries which are not well facility driven for any disease management. Thus, through this approach, we aim to identify the potential risk factors responsible for the poor outcome in neonatal sepsis. Methods. A case control was conducted retrospectively with neonates admitted to Neonatal Intensive Care Unit during January 2012 to December 2016. Cases were identified using ICD-10 Code from inpatient medical records and demographic, maternal and neonatal details were collected from the medical files. Logistic regression was performed to identify the risk factors associated with mortality in neonatal sepsis. Results. A total of 613 neonates were found to have culture positive sepsis from the 4690 neonates admitted in the Neonatal Intensive Care Unit (NICU). There was a total of 831 episodes in the 613 neonates. The mortality rate in neonates with sepsis was found to be 25.4%. Extremely low birth weight (OR 6.171, CI 3.475-10.957), extreme preterm (OR 5.761, CI 2.612-12.708), very preterm (OR 2.548, CI 1.607-4.042), preeclampsia (OR 1.671, CI 1.091-2.562), acute renal failure (OR 4.939, CI-2.588-9.426), coagulopathy (OR 2.211, CI-1.486-3.289), septic shock (OR 173.522, CI-23.642-1273.59), thrombocytopenia (OR 5.231, CI-3.310-8.268), leukopenia (OR 2.422, CI- 1.473-3.984), CRP > 24 (OR 2.099, CI-1.263-3.487) and abnormal absolute neutrophil count (OR 2.108, CI-1.451-3.062) were some of the significant predictors, identified through risk-based approach, in assessing mortality in neonatal sepsis. Conclusion. Risk-based approach applied was successful in determining plausible important predictors such like extreme low birth weight, extreme preterm, resistance against gram negative infections, preeclampsia, septic shock, hypotension, leukopenia, neutropenia, thrombocytopenia in predicting mortality in neonatal sepsis. These potential risk factors, identified through risk- based approach, can play a pivotal role in assisting clinician to make appropriate and judicious decision.

COVID-19 Vaccine Hesitancy: The Perils of Peddling Science by Social Media and the Lay Press

Introduction: Vaccines are the best tools to end the pandemic, and their public acceptance is crucial in achieving herd immunity. Despite global efforts to increase access to vaccination, the World Health Organization explicitly lists vaccination hesitancy (VH) as a significant threat. Despite robust safety reports from regulatory authorities and public health advisories, a substantial proportion of the community remains obsessed with the hazards of vaccination. This calls for identifying and eliminating possible causative elements, among which this study investigates the inappropriate dissemination of medical literature concerning COVID-19 and adverse events following immunization (AEFI), its influence on promoting VH, and proposals for overcoming this problem in the future. Methods: We searched PubMed, Embase, and Scopus databases, using the keywords “adverse events following immunization (AEFI)”, “COVID-19”, “vaccines” and “hesitancy” and related medical and subjective headings (MeSH) up to 31 March 2022, and extracted studies relevant to the COVID-19 AEFI and associated VH. Finally, 47 articles were chosen to generate a narrative synthesis. Results: The databases depicted a steep rise in publications on COVID-19 AEFI and COVID-19 VH from January 2021 onwards. The articles depicted multiple events of mild AEFIs without fatal events in recipients. While documenting AEFIs is praiseworthy, publishing such reports without prior expert surveillance can exaggerate public apprehension and inappropriately fuel VH. VH is a deep-rooted phenomenon, but it is difficult to zero in on the exact reason for it. Spreading rumors/misinformation on COVID-19 vaccines might be an important provocation for VH, which includes indiscriminately reporting AEFI on a massive scale. While a number of reported AEFIs fall within the acceptable limits in the course of extensive COVID-19 vaccinations, it is important to critically evaluate and moderate the reporting and dissemination of AEFI in order to allay panic. Conclusions: Vaccination programs are necessary to end any pandemic, and VH may be attributed to multiple reasons. VH may be assuaged by initiating educational programs on the importance of vaccination, raising public awareness and monitoring the inappropriate dissemination of misleading information. Government-initiated strategies can potentially restrict random AEFI reports from lay epidemiologists and healthcare practitioners.

Artificial intelligence in differentiating tropical infections: A step ahead

Background and objective

Differentiating tropical infections are difficult due to its homogenous nature of clinical and laboratorial presentations among them. Sophisticated differential tests and prediction tools are better ways to tackle this issue. Here, we aimed to develop a clinician assisted decision making tool to differentiate the common tropical infections.

Methodology

A cross sectional study through 9 item self-administered questionnaire were performed to understand the need of developing a decision making tool and its parameters. The most significant differential parameters among the identified infections were measured through a retrospective study and decision tree was developed. Based on the parameters identified, a multinomial logistic regression model and a machine learning model were developed which could better differentiate the infection.

Results

A total of 40 physicians involved in the management of tropical infections were included for need analysis. Dengue, malaria, leptospirosis and scrub typhus were the common tropical infections in our settings. Sodium, total bilirubin, albumin, lymphocytes and platelets were the laboratory parameters; and abdominal pain, arthralgia, myalgia and urine output were the clinical presentation identified as better predictors. In multinomial logistic regression analysis with dengue as a reference revealed a predictability of 60.7%, 62.5% and 66% for dengue, malaria and leptospirosis, respectively, whereas, scrub typhus showed only 38% of predictability. The multi classification machine learning model observed to have an overall predictability of 55–60%, whereas a binary classification machine learning algorithms showed an average of 79–84% for one vs other and 69–88% for one vs one disease category.

Conclusion

This is a first of its kind study where both statistical and machine learning approaches were explored simultaneously for differentiating tropical infections. Machine learning techniques in healthcare sectors will aid in early detection and better patient care.

Distinguishing tropical infections is difficult due to its homogeneous nature from clinical and laboratory presentations among them. This is a first of its kind study where both statistical and machine learning approaches were explored simultaneously for differentiating tropical infections. Dengue, malaria, leptospirosis and scrub typhus were the common tropical infections in our settings as per the need analysis. Better predictors in terms of laboratory parameters and clinical presentations were identified from retrospective analysis and used for the regression and machine learning models. The parameters such as accuracy, true positive rate/sensitivity/recall, false positive rate, precision/positive predictive value, F-measure and ROC area for both the training and validation sets (10-fold cross validation) for all modelling approaches and diseases (One vs One and One vs others) were calculated. All the models observed to have an acceptable range of model performance in differentiating tropical infections. Albumin can be considered as the main parameter in differentiating these tropical infections. These models should be implemented in daily clinical routine practice via mobile or desktop assisted applications or tools.

Mobile applications in medical education: A systematic review and meta-analysis

Objective

This review evaluates the effectiveness of smartphone applications in improving academic performance and clinical practice among healthcare professionals and students.

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were retrieved from PubMed, Scopus, and Cochrane library through a comprehensive search strategy. Studies that included medical, dental, nursing, allied healthcare professional, undergraduates, postgraduates, and interns from the same disciplines who used mobile applications for their academic learning and/or daily clinical practice were considered.

Results

52 studies with a total of 4057 learner participants were included in this review. 33 studies (15 RCTs, 1 cluster RCT, 7 quasi-experimental studies, 9 interventional cohort studies and 1 cross-sectional study) reported that mobile applications were an effective tool that contributed to a significant improvement in the knowledge level of the participants. The pooled effect of 15 studies with 962 participants showed that the knowledge score improved significantly in the group using mobile applications when compared to the group who did not use mobile applications (SMD = 0.94, 95% CI = 0.57 to1.31, P<0.00001). 19 studies (11 RCTs, 3 quasi-experimental studies and 5 interventional cohort studies) reported that mobile applications were effective in significantly improving skills among the participants.

Conclusion

Mobile applications are effective tools in enhancing knowledge and skills. They can be considered as effective adjunct tools in medical education by considering their low expense, high versatility, reduced dependency on regional or site boundaries, online and offline, simulation, and flexible learning features of mobile apps.

MO471: Adverse Drug Reactions and Drug–Drug Interaction in Chronic Kidney Disease With Tuberculosis

BACKGROUND AND AIMS

The risk of developing tuberculosis (TB) is 10–25% in chronic kidney disease (CKD) patients. TB in CKD patients may have a mortality of 16–37%. Standard treatment with four drugs (Isoniazid, Rifampin, Pyrazinamide and Ethambutol) predisposes to side effects, drug interactions and incomplete adherence in this population. We studied adverse drug reactions and potential drug–drug interactions in CKD patients with TB.

METHOD

Consecutive patients with CKD and TB attending tertiary care hospitals in South India were included over a period of 12 months. CKD was diagnosed based on estimated GFR using CKD EPI and TB using standard methodology. Data on demographic details and adverse drug reactions were collected from case records. Potential drug–drug interactions were checked using Micromedex Drug-Reax® (Truven Health Analytics, Greenwood Village, Colorado, USA). Statistical analysis was done using SPSS version 20.

RESULTS

Of 1300 TB patients, 59 had CKD. The demographic details are as per Table 1.

CONCLUSION

In CKD with TB, adverse drug reactions were seen in 45.5% and potential drug–drug interactions were seen mostly with rifampin (28.81% in CKD).

Adverse drug reactions of GLP-1 agonists: A systematic review of case reports

BACKGROUND AND AIM

The importance of glucagon-like peptide-1 (GLP-1) agonists is increasing because of its blood sugar controlling and weight loss properties. The data regarding safety of GLP-1 agonists are limited. This study aims to review case reports and case series on adverse drug reactions (ADRs) of GLP-1 agonist.

METHODOLOGY

A comprehensive search was performed in PubMed/Medline, Scopus and Embase to identify literatures. Bibliographic search and open search in Google, Google Scholar, SpringerLink and ResearchGate was performed to identify additional studies. Case reports and case series published the ADRs by the use of GLP-1 agonists in type 2 diabetes patients were included in the study. Reviews, experimental studies, observational studies, grey literature and non English studies were excluded.

RESULTS

The study identified 120 cases of GLP-1 agonists associated ADRs (liraglutide - 46, exenatide - 46, dulaglutide - 20, semaglutide - 4, albiglutide - 2, lixisenatide - 2). The major ADRs reported was gastrointestinal disorders (n = 40) followed by renal (n = 23), dermatologic (n = 14), hepatic (n = 10), immunologic (n = 13), endocrine/metabolic (n = 7), hematologic (n = 3), angioedema (n = 3), neurologic (n = 2), cardiovascular (n = 2) and 1 from each of psychiatric, reproductive, generalized edema problems.

CONCLUSION

Gastrointestinal problems, particularly pancreatitis was the more frequently reported adverse drug reaction associated with GLP-1 agonist. The most adverse drug reactions were observed with liraglutide and exenatide.

Factors affecting the outcomes in patients with acute respiratory distress syndrome in a tertiary care setting

Purpose

The clinical profile and factors affecting outcomes in acute respiratory distress syndrome (ARDS) from adequately sample-sized Indian studies are still lacking. We aimed to investigate the clinical profile, treatment pattern, outcomes; and to assess factors affecting non-recovery in ARDS patients.

Patients and methods

A retrospective observational study was conducted among adult ARDS patients admitted during five year period (January 2014-December 2018) in a South Indian tertiary care setting. The relevant data were collected from the medical records to the data collection form. The univariate and multivariate logistic regression analyses were conducted to identify the predictors of outcomes using SPSS v20.

Results

A total of 857 participants including 496 males and 361 females with a mean age of 46.86 ± 15.81 years were included in this study. Fever (70.9%), crepitation (58.3%), breathlessness (56.9%), and cough (45%) were the major clinical presentation. Hypertension (25.2%), kidney disease (23.8%), and diabetes (22.3%) were the major comorbidities; and sepsis (37.6%), pneumonia (33.3%), and septic shock (27.5%) were the major etiological factors observed. Antibiotics and steroids were administered to 97.9% and 52.3% of the population, respectively. The recovery rate was 47.49%. The patients with scrub typhus, dengue, pancreatitis, and oxygen supplementation had significantly lower mortality. The factors such as advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were observed to be the independent predictors of non-recovery in ARDS patients.

Conclusion

A comparable recovery rate was observed in our population. Advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were the independent predictors of non-recovery.

Efficacy and safety of corticosteroids in acute respiratory distress syndrome: An overview of meta-analyses

BACKGROUND

Evidence-based recommendations on the efficacy and safety of corticosteroids in acute respiratory distress syndrome (ARDS) remain a therapeutic challenge. Findings from several systematic reviews and meta-analyses are inconsistent. We aimed to assess the published meta-analyses through a systematic review approach and provide further insight into the current uncertainty and also to perform an updated meta-analysis from all the available primary studies.

METHODOLOGY

We followed the Preferred Reporting Items for Systematic Review (PRISMA) guidelines to establish the patients, intervention, control and outcome (PICO) for reviewing published meta-analyses. Data sources such as PubMed/MEDLINE, SCOPUS, Cochrane and Google Scholar from inception to February 2021 were accessed. Prevention of ARDS, mortality, ventilator-free days, ICU stay and safety in terms of occurrence of adverse effects were the patient-related outcomes. The review also assessed meta-analysis design-related outcomes which includes the quality of meta-analysis, factors contributing to the risk of bias, extent and sources of heterogeneity, publication bias and robustness of findings. AMSTAR-2 checklist assessed the quality of published meta-analyses.

RESULTS

A total of 18 meta-analyses were reviewed comprising a total of 38 primary studies and 3760 patients. Fourteen studies were in ARDS, three in community-acquired pneumonia and one in critical care. The overall quality of meta-analyses was observed to be critically low to high. A non-significant risk of publication bias and non-significant level of heterogeneity was observed in the reviewed meta-analysis. Corticosteroid was significantly effective in preventing ARDS among CAP patients. The effect of corticosteroids on mortality was observed to be still inconsistent, whereas significant improvement was observed with ICU and ventilator outcomes compared with the control group. Our meta-analysis observed a significant reduction of mortality in RCTs (RR: 0.78; 95% CI: 0.61 to 0.99) and the duration of mechanical ventilation (MD: -4.75; 95% CI: -7.63 to -1.88); and a significant increase in ventilator-free days (MD: 6.03; 95% CI: 3.59 to 8.47) and ICU-free days (MD: 8.04; 95% CI: 2.70 to 13.38) in ARDS patients treated with corticosteroids compared with the control group.

CONCLUSION

The quality of included studies ranged from critically low to high demonstrating inconsistency in risk of bias. While older studies found no significant effect, recent meta-analyses of RCTs found a significant mortality reduction in the corticosteroid group with considerable levels of heterogeneity. The updated meta-analysis by our team found a significant reduction in mortality in the pooled estimation of RCTs but not in cohort studies. Corticosteroid therapy was effective in terms of ICU and ventilator outcomes with minimal safety concerns. Future meta-analyses should be well executed with specific research questions and well performed with minimal risk of bias to produce good quality evidence.

N-Acetyl cysteine in rodenticide poisoning: A systematic review and meta-analysis

BACKGROUND

Treatment with N-Acetyl cysteine (NAC) in rodenticide poisoning has not been well established due to mixed study results and insufficient evidence. This review aimed to summarize the clinical benefits of NAC in the management of rodenticide poisoning.

METHOD

This review follows the PICOS framework and the PRISMA guidelines. PubMed/MEDLINE, Scopus, and the Cochrane library were searched to identify the published literature from inception to September 2020, and a reference search was performed for additional relevant studies. The English language studies addressing the use of NAC in rodenticide poisoning were considered for the review. We considered all experimental and observational studies due to the insufficient number of interventional studies.

RESULTS

Ten studies (two RCTs, four observational, and four descriptive) out of 2,178 studies with 492 participants were considered for the review. Only six studies (two RCTs, one prospective, and three retrospective studies) reported recovery and mortality rates. Pooled results of RCTs (n=2) showed a significant recovery rate (Odds Ratio [OR]:3.97; 95% Confidence Interval [CI]:1.69-9.30), whereas summary estimates of prospective and retrospective studies recorded a non-significant effect. Meta-analysis of RCTs (OR: 0.25; 95% CI: 0.11-0.59; n=2) and retrospective studies (OR: 0.34; 95% CI: 0.15-0.78; n=3) showed a significant reduction in mortality, whereas pooled analysis of prospective studies recorded a non-significant effect. A significant reduction in intubation or ventilation (OR: 0.25; 95% CI: 0.11-0.60; 2 RCTs) and a non-significant (P=0.41) difference in duration of hospitalization was observed with NAC when compared to the non-NAC treated group. The quality of the included studies appeared to be moderate to high.

CONCLUSION

Our findings indicate that NAC showed better survival and lower mortality rate when compared to a non-NAC treated group; hence NAC can be considered for the management of rodenticide poisoning.

Survival Benefits of N-Acetylcysteine in Rodenticide Poisoning: Retrospective Evidence from an Indian Tertiary Care Setting

RATIONALE & OBJECTIVE

Rodenticide poisoning, either accidental or intentional, is very common in rural India. The absence of a definite antidote made it a major concern with a high mortality rate. Therefore, this study aimed to assess the effectiveness of N-Acetyl Cysteine (NAC) in rodenticide poisoning as there are recent positive shreds of evidence on it.

METHODOLOGY

A retrospective study was conducted in a tertiary care teaching hospital on patients admitted with rodenticide poisoning during a period of 2012-2017. The Fischer's exact test and relative risk were measured to analyze the outcome of treatment and risk factors, respectively.

RESULTS

A total of 229 patients were enrolled in the study with a mean age of 30.04 ± 15.67 years. The suicidal attack was the major (86.0%) reason for poison consumption. The survival rate was significantly (p ≤ 0.03) higher in the NAC treatment group compared to the non-NAC group. Moreover, the majority (93.4%) of participants did not experience any adverse effects. The mean oral loading dose and maintenance dose was 7580.95 ± 2204.29 mg and 3694.53 ± 2322.58 mg, respectively. Yellow Phosphorus poisoning (Relative Risk [RR] 2.888 (1.179-7.079); p=0.020) and Time lag of ≥ 24 hours (RR 3.479 (1.137-10.645); p=0.029) were the significant risk factors for mortality.

CONCLUSION

NAC is shown to have a significant survival benefit with a good safety profile among rodenticide poisoners. Further adequately powered prospective researches with more emphasis on dosing parameters are warranted for better quantification in different settings and for clinical implementation.

Prevalence And Predictors Of Potentially Inappropriate Medication Use Among Elderly Patients Using Updated Beers Criteria 2019: A Single Centered Retrospective Analysis

BACKGROUND

Inappropriate medication use poses a sizable health safety hazard in the elderly owing to aging-associated physiological and anatomic changes. Inappropriate drug prescribing and polypharmacy in this population elevates the risk of adverse drug reactions (ADR). To assess the prevalence and predictors of Potentially Inappropriate Medication (PIM) use in elderly patients according to updated Beers Criteria 2019.

METHOD

Medical Records of 402 patients aged ≥65 years admitted a tertiary care hospital from June 2018 to May 2019 were analyzed. The patients who experienced at least one PIM based on the 2019 Updated Beers Criteria were considered as cases and others as control. Data were presented as descriptive statistics and logistic regression was performed to assess the factors affecting the outcomes.

RESULT

The mean age was found to be 73.7 ±6.4 years in the test and 70.5±5.5 years in the control group. The prevalence of PIMs to be used with caution was found to be 54%. Whereas the prevalence of PIMs to be avoided and to be used with reduced dose was found to be 45% and 1% respectively. The most prescribed PIMs were aspirin, diuretics, long-acting sulfonylureas, and proton pump inhibitors (PPIs). Increasing age, polypharmacy, and the number of drugs in medication history were significantly (P<0.05) correlated with a substantial risk of PIM use. The risk of developing serious and moderate drug-drug interactions (DDIs) was significantly high in the test group (P<0.05) when compared to the control group.

CONCLUSION

A high prevalence of PIMs was observed in this study. Age, polypharmacy and ≥3 drugs in medication history were identified as risk factors for PIM use and were at a higher risk of developing DDIs. Continuous medication review by clinical pharmacists can aid in reducing the occurrence of PIMs amongst geriatrics.

Identification of risk factors and metabolic monitoring practices in patients on antipsychotic drugs in South India

The objectives of this study were to identify the risk factors for metabolic syndrome in patients on antipsychotics and to compare the frequency of metabolic monitoring with evidence-based guidelines. We conducted a retrospective cohort study in a tertiary care health institution of South India. The study included patients with schizophrenia, bipolar disorder, and schizoaffective disorders prescribed with antipsychotic drugs. Data was collected from the medical records department. American Diabetic Association/American Psychiatric Association (ADA/APA) guidelines were used as a reference standard to assess the monitoring for metabolic parameters. Diagnosis of metabolic syndrome was done according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) guidelines. Risk factors for metabolic syndrome and frequency of metabolic monitoring were analyzed. A total of 668 patients were included for clinical audit. About 16.5 % of the patients were diagnosed with metabolic syndrome. Age >50 years (Odds Ratio (OR) 2.00; p value <0.001) and duration of antipsychotic treatment>5 years (OR 1.55; p value< 0.05) were recognized as the independent risk factors for metabolic syndrome using multiple logistic regression. Blood pressure (BP) and fasting blood sugar (FBS) levels were documented in 99.7 % and 47 % of cases at baseline respectively, however, subsequent annual data on BP and FBS monitoring was reduced to 72.7 % and 46 % respectively. Weight was documented in 60 % of the cases at baseline, whereas the subsequent data on four times the annual assessment of weight was reduced to 9.8 %. The extent of documentation of metabolic monitoring parameters was inadequate.

The trade-off dilemma in pharmacotherapy of COVID-19: systematic review, meta-analysis, and implications

INTRODUCTION

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worldwide and has contributed to over 650,000 deaths. This review synthesizes the literature on COVID-19 pharmacotherapy to inform practice and policymaking.

AREAS COVERED

The authors systematically review the published literature on COVID-19 therapeutics, grouping candidate treatments into repurposed, adjunct, and experimental agents. They conducted meta-analysis where appropriate and provide recommendations based on compilation from real-time/interim therapeutic guidelines. They then advise on how to navigate and advance the evidence in the current context of uncertainty and urgency and provide expert opinion on suggested framework.

EXPERT OPINION

Current evidence does not support a clear role for pharmacotherapy in COVID-19. While promising signals have been found through limited number of RCTs, these must be interpreted with caution. Without proper protection from bias and confounding we risk exposing patients to treatments where the potential for benefit is at best unclear, yet the potential for harm from adverse effects is high leading to a trade-off dilemma in decision making. Advancing the evidence requires a coordinated effort to design and conduct robust trials and to systematically synthesize and critically evaluate findings. Therapies should be reserved for use in clinical trials, emergency or compassionate access until we gain more confidence in the balance of benefit and harm.

Factors associated with outcomes in organophosphate and carbamate poisoning: a retrospective study

Organophosphate and carbamate (OPC) poisoning is a major global health hazard requiring immediate medical intervention. Atropine (ATR) is an essential antidote in organophosphate and carbamate poisoning, with the inclusion of cholinesterase reactivators and other anticholinergics, namely pralidoxime (PAM) and glycopyrrolate (GPR). This study aimed to compare the efficacy of various treatment regimens and identify the factors affecting mortality. The data of patients presented at the emergency unit with the consumption of OPC compounds between the years 2013 and 2017 were retrospectively reviewed. The study population was then categorized into four treatment patterns (1) ATR alone, (2) ATR and PAM, (3) ATR and GPR, (4) ATR, PAM and GPR. The outcome of the patients was assessed in terms of survival, intubation, ICU days, and days of ventilation and hospitalization. Univariate and multivariate analyses were performed to investigate the risk factors associated with mortality and odds ratio (OR). A total of 441 patients were included in the study, of which 69.16% were males, and 375 patients survived. Consumption of poison with a suicidal intention was reported in 98.19% of the patients, and the treatment with ATR and PAM (42.86%) was observed to have lower days of ventilation in comparison to the treatment with ATR and GPR (p = 0.003). Patients requiring intubation were also lowest in the group treated with ATR and PAM (27.51%). The age group of > 50 years (OR 4.275 [CI 2.179-8.387]), male gender (OR 2.608 [CI 1.258-5.406]), and the treatment pattern with ATR, PAM and GPR (OR 2.233 [CI 1.002-4.040]) were independently associated with mortality. In summary, male gender, elderly population, and treatment patterns followed adversely affected the outcome in patients with OPC poisoning.

Training Needs Assessment for Employability in Pharmaceutical Industries

OBJECTIVE: The aim of the study was to assess the perception of final year pharma students, faculties from various Pharmacy Council of India/All India Council for Technical Education approved pharmacy colleges and industrial experts toward skill gaps, employability, and job-oriented training programs. METHODS: Cross-sectional survey conducted using validated piloted questionnaire in both educational and industry sector. Mann–Whitney test was used to analyze difference in opinions of industry professionals and academicians. NVIVO 12(trial version) used to analyze qualitative data from open-ended question. RESULTS: Both faculty (65%) and industrial expert (31.5%) surveyed opined that graduates are lack of skills. It was also observed that basic knowledge and technical skills are the gaps that affect graduates’ performance. Most of the students (94%), academicians (92%), and industry professionals (93%) unanimously agreed that there is a strong need of training programs. CONCLUSION: Revival of pharmacy education incorporating training programs is the need of the hour.

Evidence based medicine and pharmacy curriculum: an insight into Indian perspective

World Health Organization recommends doctor population ratio as 1: 1000 and in India the ratio is 0.62: 1000. With the ever growing population and tremendous patient pool in India the significant challenge faced by clinicians is lack of skilled allied health professionals who can assist in providing timely, unbiased, critically appraised health information. Pharmacists are the most accessible health professionals and thereby crucial in facilitating rational medication usage and working closely with the public and multidisciplinary health care team. The goal of patient care can be achieved through the focused skill development programs embedded in health students’ curriculum. Indian pharmacy curriculum should be fostered with inclusion of evidence based medicine focused training programs, workshops, case studies, digital stories, e - pocket cards and simulations. This article represents current status of evidence based medicine learning and teaching in Indian pharmacy curriculum. Bangladesh Journal of Medical Science Vol.19(4) 2020 p.603-608

Assessment of association between antihypertensive drug use and occurrence of new-onset diabetes in south Indian patients

Objective:

The objective of this study was to determine the association between antihypertensive drug use and new-onset diabetes (NOD) in patients with hypertension (HTN).

Materials and Methods:

A retrospective observational study was conducted in a tertiary care hospital located in south India. Patients diagnosed with HTN and HTN with diabetes between January 2012 and December 2016, were identified and studied. Medical records of these patients from Medical Record Department were evaluated by medical record review method, and relevant data were recorded in a case record form. Statistical evaluation by chi-square method and odds ratio (OR) was carried out to appraise the incidence of NOD in patients taking antihypertensive medications.

Results:

A total of 1250 patients with HTN were screened, and based on inclusion and exclusion criteria, 952 patients were enrolled in the study; among which, 537 were patients with HTN and 415 were patients with diabetic HTN. The majority of the patients with HTN and patients with diabetic HTN were from the age-group of above 60 years. The most commonly prescribed drugs observed in our study population were amlodipine in 94 (22.7%) patients. OR was calculated and it was observed that the combination therapy has a fivefold risk for the development of NOD in patients with HTN, followed by Angiotensin II receptor blockers (2.06) (confidence interval [CI]: 1.56–2.73), diuretics (1.33) (CI: 0.95–1.85), non-Dihydropyridine calcium channel blockers (DHP CCBs) (1.3) (CI: 0.51–3.30), vasodilators (1.13) (CI: 0.40–3.15), and Angiotensin converting enzyme inhibitors (1.06) (0.68–1.64).

Conclusion:

Patients on non-DHP CCBs, diuretics, and combination antihypertensives showed more chances of developing NOD.

A Global Overview of Poison Treatment Apps and Databases

Acute poisoning is a serious health problem that is associated with high mortality. Management of acute poisoning cases in the critical care settings is the biggest challenge due to the difficulty in identification of poison involved. Immediate information about the poisoning and its management is crucial in the early diagnosis, treatment, and in the prevention of poisoning complications. Poison information resources, such as various poison apps and databases, are essential for the retrieval of updated and quick information on poisoning. Through provision of information to the public and to health care professionals, apps and databases play a significant role in the management of poisoning cases.

Identification of factors affecting treatment outcome in bipolar disorder

BACKGROUND AND AIM

Treatment outcomes in bipolar disorder are highly variable, and several sociodemographic, clinical characteristics, and comorbidities play an important role. Early recognition of these factors will help the physicians to implement individualized treatment and a better clinical outcome. The present study was aimed at identifying the factors affecting treatment outcomes in bipolar disorder.

MATERIALS AND METHODS

All patients diagnosed with bipolar disorder as per diagnostic and statistical manual-IV criteria were included in the study. Patients were followed for 6 months from the day of enrollment. Patient demography, age at bipolar disorder was diagnosed, age at treatment was started, social habits, signs and symptoms, comorbidities, symptoms, treatment pattern, and compliance to treatment were recorded in case record form. Based on the changes in young mania rating scale and Hamilton Depression Rating Scale (HAM-D) score from baseline to last follow-up, the patients were classified as remission and non-remission. Multiple logistic regression was used to identify risk factors associated nonremission in bipolar disorder patients and calculation of odds ratio (OR).

RESULTS

The mean age of the study population was 37.6 ± 14.1 years. Out of the 121 patients, 68 (56.2%) were female. At the end of the follow-up period, 41 (33.9%) had remission, and 80 (66.1%) had nonremission. Early onset (OR: 9.77; confidence intervals [CI]: 1.77-86.01), treatment delay (OR: 6.48; CI: 1.27-32.92), treatment noncompliance (OR: 4.64; CI: 1.37-15.64), and single living (OR: 4.26; CI: 1.56-11.66) were independently associated with nonremission in bipolar disorder patients.

CONCLUSIONS

Early-onset bipolar disorder, delay in treatment, treatment non-compliance, and single living adversely affect remission in bipolar disorder.

Comparison of Various Severity Assessment Scoring Systems in Patients with Sepsis in a Tertiary Care Teaching Hospital

BACKGROUND

Sepsis is a complex condition defined by the systemic response to infection. Severity assessment scoring systems are used to aid the physician in deciding whether aggressive treatment is needed or not. In this study, various severity assessment scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score (MODS), Predisposition, Infection, Response, and Organ Dysfunction (PIRO), and Mortality in Emergency Department Sepsis (MEDS), were compared to assess their sensitivity and specificity.

MATERIALS AND METHODS

A prospective cohort study was conducted over 6 months. The study was conducted in the intensive care unit (ICU) of a tertiary care teaching hospital. All patients above 18 years of age with confirmed sepsis diagnosis and a well-defined outcome were included in the study.

RESULTS

A total of 193 patients were included in the study. The mean age was 57.2 ± 15.3 (mean ± standard deviation) years. Majority of the patients were male, 125 (64.76%). Overall mortality was 108 (55.9%). The calculated area under the receiver operating characteristic curve was 0.86 (95% confidence interval [CI]: 0.80-0.90) for APACHE II, 0.81 (95% CI: 0.75-0.87) for REMS, 0.80 (95% CI: 0.74-0.86) for SOFA, 0.74 (95% CI: 0.67-0.80) for MODS, 0.78 (95% CI: 0.71-0.84) for PIRO, and 0.77 (95% CI: 0.71-0.83) for MEDS. Sensitivity and specificity for APACHE II were 81.5 and 75.3, respectively.

CONCLUSIONS

In our study, APACHE II score was found to be the most sensitive and specific in predicting the severity of sepsis compared to other scores.

Factors that Correlate with Poor Glycemic Control in Type 2 Diabetes Mellitus Patients with Complications

Objectives

Inadequate glycemic control amongst patients with Type 2 diabetes mellitus (T2DM) indicates a major public health problem and a significant risk factor for the progression and complications caused by diabetes. Glycemic control is the main therapeutic objective for the prevention of organ damage and other complications arising from diabetes.

Methods

This was a retrospective observational study of T2DM patients with complications, who were aged 40 years and older. The study was conducted retrospectively on medical records (in-patient and out-patient) obtained from a South Indian teaching hospital, Manipal, India. The patients included in the study had fasting blood sugar, postprandial blood sugar and HbA1c measured at least twice during follow-ups the previous year. Patients' HbA1c levels were categorized into good control ≤7% (≤53mmol/mol), and poor control >7% (>53mmol/mol), and patients' characteristics were analyzed.

Results

A total of 657 patients were included in the study. The mean age was 59.67 (SD = 9.617) years, with 152 (23.1%) females and 505 (76.9%) males, and 514 (78.2%) patients had poor glycemic control. Most of the patients were on insulin mono-therapy [n = 271 (42.1%)], about a third of the patients were on combination therapy that included an oral hypoglycemic agent and insulin [n = 236 (36.6%)]. Patients with a history of more than 10 years of diabetes [n = 293 (44.6%)], had a family history of diabetes [n = 256 (39%)] and obesity [n = 95 (14.5%)], all had poor glycemic control.

Conclusion

This present study indicated a significant association of gender (female), age, high-density lipoprotein level, duration of diabetes and type of medication, with poor glycemic control in T2DM patients that had secondary medical complications.

Descriptive Analysis of Mortality Predictors in H1n1 Influenza in South Indian Patients

BACKGROUND

H1N1 (hemagglutinin-H-neuroaminidase-N) influenza infection is associated with high morbidity and mortality because of associated complications and related factors. Predictors of mortality in H1N1 patients are studied with very few without seasonal/pandemic declaration. This study was carried out to describe the clinical features, complications and different risk factors that affect the outcome in the patients with confirmed H1N1influenza infection.

METHODS

A retrospective study was done in Kasturba Medical College Hospital, Manipal, India by analyzing the medical records of 141 patients admitted from January, 2011 to June, 2015.

RESULTS

Of the 141 patients in the study, 51.1% of the patients were female with a mean age of 32±16.2 years. Fever with headache was observed in 92.9% patients while cough in 78.7% patients and breathlessness in 54.6% patients. On the basis of disease severity, 53.2% of the patients were put on mechanical ventilation. For all the patients, treatment for influenza management began with oseltemivir. Diuretics, antianxiety and corticosteroids were given as supportive and symptomatic care which contributed to high mortality in hospitalized patients. Mean hospitalization period was 8.5 days. During the hospitalization, patients developed different complications i.e. 31.20% patients developed respiratory tract infections, while 17.7% patients developed ARDS and 14.4% patients developed sepsis. The mortality rate of this study population was found to be 29.1 %.

CONCLUSION

It was observed that low oxygen saturation during admission, high blood urea level, use of diuretics, corticosteroids, anti-anxiety drugs and complications like ARDS, sepsis influence the mortality rate of patients with H1N1 infection.

Evaluation of supportive care management outcomes in cancer chemotherapy: A prospective observational study in a tertiary care teaching hospital in South India

Aims:

Settings and Design:

Subjects and Methods:

Statistical Analysis Used:

Results:

Conclusions:

Comparison of the Nosocomial Pneumonia Mortality Prediction (NPMP) model with standard mortality prediction tools

BACKGROUND

Severity or mortality prediction of nosocomial pneumonia could aid in the effective triage of patients and assisting physicians.

AIM

To compare various severity assessment scoring systems for predicting intensive care unit (ICU) mortality in nosocomial pneumonia patients.

METHODS

A prospective cohort study was conducted in a tertiary care university-affiliated hospital in Manipal, India. One hundred patients with nosocomial pneumonia, admitted in the ICUs who developed pneumonia after >48h of admission, were included. The Nosocomial Pneumonia Mortality Prediction (NPMP) model, developed in our hospital, was compared with Acute Physiology and Chronic Health Evaluation II (APACHE II), Mortality Probability Model II (MPM₇₂ II), Simplified Acute Physiology Score II (SAPS II), Multiple Organ Dysfunction Score (MODS), Sequential Organ Failure Assessment (SOFA), Clinical Pulmonary Infection Score (CPIS), Ventilator-Associated Pneumonia Predisposition, Insult, Response, Organ dysfunction (VAP-PIRO). Data and clinical variables were collected on the day of pneumonia diagnosis. The outcome for the study was ICU mortality. The sensitivity and specificity of the various scoring systems was analysed by plotting receiver operating characteristic (ROC) curves and computing the area under the curve for each of the mortality predicting tools.

FINDINGS

NPMP, APACHE II, SAPS II, MPM₇₂ II, SOFA, and VAP-PIRO were found to have similar and acceptable discrimination power as assessed by the area under the ROC curve. The AUC values for the above scores ranged from 0.735 to 0.762. CPIS and MODS showed least discrimination.

CONCLUSION

NPMP is a specific tool to predict mortality in nosocomial pneumonia and is comparable to other standard scores.

Pharmacokinetic Potentiation of Mixed Organophosphate and Pyrethroid Poison Leading to Prolonged Delayed Neuropathy

Organophosphate (OP) and mixed pesticide poisoning remains an important cause of hospital admission. Therefore, physician must be aware of atypical presentations of delayed neurological complications of poisoning by taking proper patient history. We report a case of a 23-year-old female who presented with high stepping gait and muscle wasting in hands. Patient history revealed consumption of approximately 4ml of mixed pesticide, consisting of 50% chlorpyrifos with synthetic pyrethroid, 5% cypermethrin. The prolonged and severe nature of delayed peripheral neuropathy, persisting at two years of follow-up, suggests that even small quantities of OP taken in combination with a pyrethroid can result in significant morbidity and is irreversible.