Impact of medical conditions and medications received during pregnancy on adverse birth outcomes: A hospital-based prospective case-control study

Purpose

In view of the raising rate of adverse birth outcomes (ABOs) across the globe, this study was conducted to assess the impact of medical conditions and medications received during pregnancy on ABOs.

Materials and Methods

A prospective case-control study was conducted at the Department of Obstetrics and Gynecology of a tertiary care hospital over a period of 3 years from July 2015 to June 2018. Liveborn and stillborn neonates included in the study were categorized into cases and controls based on the presence or absence of composite ABOs, respectively. Binary logistic regression analysis was used to identify the risk factors for ABOs among medical conditions and medications received by mothers during their current pregnancy.

Results

Among 1214 neonates included in the study, 556 (45.8%) were identified with composite ABOs, the majority were low birth weight (320 [26.4%]) and preterm birth 300 (24.7%). After adjusting for confounding factors, it was identified that hypertension (adjusted odds ratio [aOR] 7.3), oligohydramnios (aOR 3.9), anemia (aOR 3.2), nifedipine (aOR 10.0), nicardipine (aOR 5.3), and magnesium sulfate (aOR 5.3) were the risk factors for overall and specific ABOs like preterm birth and low birth weight. It was also identified that the early detection and management of hypertension with antihypertensives like labetalol and methyldopa can reduce the risk of preterm birth by 93% and 88%, respectively.

Conclusion

Medical conditions such as hypertension, oligohydramnios, and anemia and medications such as nifedipine, nicardipine, and magnesium sulfate during pregnancy were identified as the risk factors for overall and specific ABOs like preterm birth and low birth weight.

Safety and Tolerability of Ivermectin and Albendazole Mass Drug Administration in Lymphatic Filariasis Endemic Communities of Tanzania: A Cohort Event Monitoring Study

Ivermectin and albendazole (IA) combination preventive chemotherapy to all at-risk populations is deployed to eliminate lymphatic filariasis. Although safety monitoring is imperative, data from Sub-Saharan Africa is scarce. We conducted a large-scale active safety surveillance of adverse events (AEs) following IA mass drug administration (MDA) to identify the type, incidence, and associated risk factors in Tanzania. After recording sociodemographic, clinical, and medical histories, 9640 eligible residents received single-dose IA combination preventive chemotherapy. Treatment-associated AEs were actively monitored through house-to-house visits on day 1, day 2, and day 7 of MDA. Events reported before and after MDA were cross-checked and verified to identify MDA-associated AEs. 9288 participants (96.3%) completed the seven-day safety follow-up, of whom 442 reported 719 MDA-associated AEs. The incidence of experiencing one or more type of MDA-associated AE was 4.8% (95% CI = 4.3−5.2%); this being significantly higher among those with Pre-MDA clinical events than those without (8.5% versus 4.1%, p < 0.001). AEs were mild (83.8%), moderate (15.9%), and severe (0.3%), and most resolved within 72 h. The incidence of experiencing one, two, ≥ three types of AEs were 2.8%, 1.3%, and 0.6%, respectively. The most common AEs were headache (1.23%), drowsiness (1.15%), fever (1.12%), and dizziness (1.06%). A chronic illness, or clinical manifestation of lymphatic filariasis, or being female or pre-existing clinical symptoms were independent significant predictors of AEs. IA combination preventive chemotherapy is safe and tolerable, and associated AEs are mild-to-moderate and transient, with few severe AEs. Safety monitoring during MDA campaigns in individuals with underlying clinical conditions is recommended for timely detection and management of AEs.

Comparative Assessment of the Pharmacovigilance Systems within the Neglected Tropical Diseases Programs in East Africa-Ethiopia, Kenya, Rwanda, and Tanzania

Monitoring the safety of medicines used in public health programs (PHPs), including the neglected tropical diseases (NTD) program, is a WHO recommendation, and requires a well-established and robust pharmacovigilance system. The objective of this study was to assess the pharmacovigilance systems within the NTD programs in Ethiopia, Kenya, Rwanda, and Tanzania. The East African Community Harmonized Pharmacovigilance Indicators tool for PHPs was used to interview the staff of the national NTD programs. Data on four components, (i) systems, structures, and stakeholder coordination; (ii) data management and signal generation; (iii) risk assessment and evaluation; and (iv) risk management and communication, were collected and analyzed. The NTD programs in the four countries had a strategic master plan, with pharmacovigilance components and mechanisms to disseminate pharmacovigilance information. However, zero individual case safety reports were received in the last 12 months (2017/2018). There was either limited or no collaboration between the NTD programs and their respective national pharmacovigilance centers. None of the NTD programs had a specific budget for pharmacovigilance. The NTD program in all four countries had some safety monitoring elements. However, key elements, such as the reporting of adverse events, collaboration with national pharmacovigilance centers, and budget for pharmacovigilance activity, were limited/missing.

Impact of indirect education on knowledge and perception on cervical cancer and its prevention among the parents of adolescent girls: an interventional school-based study

BACKGROUND

India has almost 225 million adolescent girls and they seem to be at a disadvantage, both economically and by their lack of knowledge on human papilloma virus (HPV) vaccine, when compared to adolescent girls of other Asian countries.

AIM

To assess the prevalence of HPV vaccination and to identify the impact of education in improving the knowledge and perception about the HPV infection and vaccination among the parents of adolescent girls.

METHODOLOGY

The prospective interventional study was conducted in four schools within a South Indian City, Mysuru. The informed consent form and the questionnaire were sent home with the identified adolescent girls during the pre-interventional phase. Educational sessions were conducted for the students in their school and an education leaflet was distributed to their parents. Three weeks later, questionnaires were re-administered to the parents via the enrolled girls and their responses were collected.

RESULTS

The prevalence of HPV vaccination in the study population was 4.4%. There was a statistically significant improvement in knowledge in the post-interventional phase of the study (p = 0.001), but could not identify a significant change in their perception (p = 0.479). Parents belonging to the socioeconomic class of upper middle and upper lower showed better improvement at the end of the study, with a percentage improvement of 58.93% and 48.44%, respectively.

CONCLUSION

The study proved that the healt care professional can target school children to communicate effectively to their parents on the importance of HPV vaccine as the study clearly observed a positive behavioral change among the study population.

Prevalence, Intensity, and Correlates of Schistosomiasis and Soil-Transmitted Helminth Infections after Five Rounds of Preventive Chemotherapy among School Children in Southern Ethiopia

Preventive chemotherapy (PC) is a WHO-recommended strategy to control and eliminate schistosomiasis and soil-transmitted helminths (STHs). We assessed the prevalence, intensity, and correlates of schistosomiasis and STH infection after five rounds of PC in southern Ethiopia. A total of 3162 school children from four schools in Wondo Gennet and Hawella Tula districts were screened for Schistosoma mansoni and STHs infection. The overall prevalence of S. mansoni infection was 25.8% (range between schools 11.6% to 54.1%), with light (19.1%), moderate (5.3%), and heavy (1.4%) infection intensities. A total of 61.6% S. mansoni-infected children were STH co-infected. The overall prevalence of STHs infection was 54.7% (range between schools 30.6-71.0%), with moderate-to-heavy intensity infections being 16.3%. Ascaris lumbricoides was the most prevalent 45% (95% CI, 43.5-47) followed by Trichuris trichiura 25.3% (95% CI, 23.8-26.9) and hookworm 6.1% (95% CI, 5.3-7). A total of 33.7% of STHs-infected children had A. lumbricoides and T. trichiura co-infections. S. mansoni infection was significantly associated with school and STHs co-infection (p < 0.001). STH infection was correlated with school and younger age (p < 0.001). Despite repeated PC, S. mansoni and STH infection remain significant health problems, and the WHO target to control schistosomiasis and eliminate STH by 2020 may not be achieved. Intensified control and prevention measures, including drug efficacy surveillance, is recommended.

Knowledge, beliefs, and practice of pregnant women regarding medication use during pregnancy: a hospital-based cross-sectional study

The purpose of this study was to assess the knowledge, beliefs, and practice (KBP) of pregnant women on medication use during pregnancy, and to identify the factors influencing KBP. A cross-sectional study was conducted in the Department of Obstetrics & Gynaecology of a tertiary care hospital over a period of nine months. Pregnant women receiving at least one medication were included in the study. A 19-item questionnaire was developed, validated, and used for assessing the KBP of pregnant women. Logistic regression analysis was used to identify the factors influencing the KBP. A total of 422 pregnant women with a mean (SD) age of 24.6 (4.05) years were included in the study. Pregnant women were having less knowledge on 'unsafe medications' and 'important medications' during pregnancy, wrong belief on 'stopping all medications during pregnancy', and less practice of 'asking Pharmacist how to take medications'. It was identified hat the age, education, occupation, and area of living were the factors influencing the knowledge and practice of pregnant women on medication use. This study identified the need for improvement in knowledge and practice of pregnant women who are young, having nil or low level of education, no occupation, and living in rural areas.IMPACT STATEMENTWhat is already known on this subject? Knowledge and beliefs on medication use play a vital role in medication adherence among pregnant women. Crisis in rural healthcare along with socio-demographic conditions and literacy status of Indian women may have contributed to the lack of understanding about use of medications during pregnancy.What the results of this study add? The knowledge of pregnant women was found to be insufficient on 'unsafe medications' and 'important medications' during pregnancy. Majority of the pregnant women believe that it is better for the foetus if they 'stop taking all medications during pregnancy'. 'Not asking Pharmacist how to take medications' is one important practice in India contributes less knowledge on medication use.What the implications are of these findings for clinical practice and/or further research? There is a need for improvement in knowledge and practice of medication use among pregnant women who are young, having nil or low level of education, no occupation, and living in rural areas.

Active surveillance of adverse events following immunization (AEFI): a prospective 3-year vaccine safety study

BACKGROUND

Vaccines used in national immunization programs are considered safe and effective but immunization safety has become as important as the efficacy of vaccination programs. The objective of the study was to detect adverse events following immunization (AEFIs) to all vaccines administered to a pediatric population in India.

METHODS

The prospective active vaccine safety surveillance study enrolled eligible children in the age group 0-5 years receiving vaccination from the immunization center at JSS Hospital, Mysuru. Study participants were monitored at the site for 30 min following vaccination and a telephonic survey was made after 8 days to identify all AEFIs. Causality assessment of the AEFIs were done using a new algorithm developed by the safety and vigilance department of the World Health Organization.

RESULTS

The incidence of reported AEFIs was 13.7%. The most frequently reported AEFI was fever (n = 3095, 93.2%) with an incidence of 109.7 per 1000 doses of vaccine administered, followed by persistent crying (n = 69, 2.4 per 1000 doses of vaccine) and diarrhea (n = 57, 2.0 per 1000 doses of vaccine). The majorly implicated vaccine for AEFIs was Pentavac® followed by BCG. Consistent causal association to immunization was observed in 93.4% of cases.

CONCLUSIONS

A high incidence rate of AEFI was observed in our study population when compared with previous published studies. AEFI surveillance studies help to detect changes in the frequency of adverse events, which may be an alert to consider vaccine quality or identify a specific risk among the local population.

Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

Medication errors (MEs) often prelude guilt and fear in health care professionals (HCPs), thereby resulting in under-reporting and further compromising patient safety. To improve patient safety, we conducted a study on the implementation of a voluntary medication error-reporting and monitoring programme. The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous, and stand-alone surveillance in a tertiary care teaching hospital located in South India. A prospective observational study was carried out for three years and a voluntary Medication Error-reporting Form was developed to report medication errors MEs that had occurred in patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out and discussed with HCPs to minimise the recurrence. A total of 1310 medication errors were reported among 20,256 hospitalised patients and the incidence was 6.4%. Common aetiologies were administration errors [501 (38.2%)], followed by prescribing and transcribing errors [363 (28%)]. Root-cause of these MEs were distractions, workload, and communications. Analgesics/antipyretics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. A clinical pharmacist initiated non-punitive anonymous ME reporting system could improve patient safety.

Implementation and evaluation of medicine and therapeutic information service by clinical pharmacists in oncology care setting

Background

This study was conducted to explore the role of clinical pharmacists in providing medicine and therapeutic information service in oncology care setting.

Methods

It was a prospective study conducted for a period of three years after implementation of medicine and therapeutic information service as an integral part of oncology pharmacy services. The medicine and therapeutic information queries were received during ward rounds, at ambulatory care and via telephone by clinical pharmacists. All the medicine and therapeutic information requests were reviewed and answered to the concerned requester(s). Answered medicine and therapeutic information requests were electronically documented in the hospital drug information database and analyzed further.

Results

A total of 484 medicine and therapeutic information requests were received by clinical pharmacists during period of August 2013 to June 2016. Majority of medicine and therapeutic information queries were requested by radiation oncologists (27.2%) followed by medical oncologists (26.4%), general physicians (14.04%), resident medical officers (11.7%), ambulatory care nurses (8.6%), in-patient nurses (5.1%) and patients and care takers (6.6%). Majority of the medicine and therapeutic information queries were asked for the purpose of improving patient care (48.3%) followed by to update knowledge (30.9%) and training sessions to nurses (6.6%). The most common categories of medicine and therapeutic information were adverse drug reactions and its management (21.4%) followed by dosage adjustments of chemotherapy and biologicals (15.5%), supportive care related (14.6%), contraindications (14%), drug–drug interactions (11.9%), management of co-morbidities (7.8%), chemotherapy selection in special populations (4.5%).

Conclusion

The provision of medicine and therapeutic information was found to be useful in providing medicine information to improve patient care and to update knowledge of health care professionals at the study hospital.

Implementation of clinical pharmacy services in an academic oncology practice in India

Objective This study was conducted to investigate medication-related problems after implementation of clinical pharmacy services at a speciality oncology care setting. Methods It was a prospective interventional study conducted for a period of three years at a private academic oncology care setting. Paper-based medical records and medication orders were reviewed and patients and care givers were interviewed to understand the treatment plan. All the medication-related problems were identified by clinical pharmacists by performing drug therapy review. Patients were also followed up at ambulatory care and in-patient units to ensure appropriate administration of anti-cancer drugs by nurses. All the medication-related problems were discussed with the concerned clinicians and then were resolved with the interventions of clinical pharmacists. Clinical significance of these interventions were assessed and classified as "Major", "Moderate "and "Minor". Educational, clinical and system-based interventions were developed and implemented to minimize medication-related problems at the study site. Results A total of 1359 medication-related problems were identified from 2120 medication orders reviewed of 1362 patients followed during the study period. The most common medication-related problems were lack of suboptimal supportive care (17.95%), inappropriate administration of medications (14.56%), untreated indication (14.20%), wrong dosing calculations (12.21%), drug-drug interactions (11.62%) and sub-therapeutic dose (11.11%). Clinical pharmacy interventions were made to resolve all the medication-related problems. Clinical significance of majority (n = 504, 37.08%) of medication-related problems was "Moderate" followed by "Major" (n = 434, 31.93%) and "Minor" (n = 421, 30.97%). Conclusion The study has demonstrated the importance of clinical pharmacy services in improving quality and safe use of medicines in oncology practice. Positive feedback of clinicians on clinical pharmacy services was a reflection of acceptance of clinical pharmacy interventions by clinicians.

A prospective observational study to evaluate safety reporting of antidepressants at a tertiary care hospital in India

Objective:

This prospective observational study was carried out to identify the prevalence and Severity of ADRs of antidepressant in a tertiary care teaching hospital.

Materials and Methods:

Patients prescribed with at least one antidepressant were randomly selected and monitored for adverse drug reactions (ADRs), irrespective of their age and gender.

Results:

Of the 401 patients who received antidepressants, 170 patients (42.39%) experienced 204 ADRs. Selective serotonin receptor inhibitors (SSRIs) [110 (53.92)] was the most common therapeutic class of drugs associated with ADRs. Gastrointestinal system [54 (26.47)] was most commonly affected system organ class. Dry mouth (n = 30) and diaphoresis (n = 21) were the most frequently reported ADRs. As assessed by the World Health organization (WHO) probability scale, 61% of the ADRs were ‘probable’ causality. Among all the ADRs, 22.54% (46) were preventable. Majority of the ADRs [(n = 184) 90.17%] were ‘mild’ in their severity.

Conclusion:

In this study, incidence of adverse reaction to antidepressants was 42.3% were the most comman SSRI inplicated drug group for the ADRs.

Serum myeloperoxidase: a novel biomarker for evaluation of patients with acute coronary syndrome

OBJECTIVES

Myeloperoxidase, an abundant leucocyte enzyme, is elevated in culprit lesions that have ruptured in patients with sudden cardiac injury. Multiple lines of evidence suggest an association between myeloperoxidase and inflammation and acute coronary syndrome. Myeloperoxidase has been proposed as a potent risk marker and diagnostic tool in acute coronary syndrome (ACS). Recent studies have reported the potential use of myeloperoxidase in acute coronary syndrome, but limited reports are available on its utility in different groups of ACS in the emergency department. Therefore the circulating levels of serum myeloperoxidase in patients with acute coronary syndrome and control subjects were studied.

DESIGN AND SETTING

The levels of serum myeloperoxidase were measured by ELISA in 485 patients admitted to emergency care unit, of which 89 patients were diagnosed as non-cardiac chest pain (NCCP). The levels of myeloperoxidase were significantly increased in patients with ACS when compared with controls and NCCP. From the receiver operator characteristic (ROC) curve analysis, the optimum value above which myeloperoxidase can be considered positive was found to be 48.02 U/ml. The area under the curve was found to be 0.956 with 95% CI (0.934 to 0.973) (p<0.0001). A combination analysis of ROC curves of troponin, creatine kinase MB (CK-MB) and myeloperoxidase showed myeloperoxidase to be highly significant. Multivariate analysis revealed myeloperoxidase to be an independent diagnostic marker for early diagnosis of ACS.

CONCLUSION

Myeloperoxidase, in contrast to troponin and CK-MB, identified patients at risk of ischaemic events, even in the absence of myocardial necrosis, thus highlighting its potent usefulness for risk stratification among patients presenting with chest pain.

Process development for the synthesis of 5'-O-(4,4'-dimethoxytrityl)-N2-isobutyryl-2'-O-(2-methoxyethyl)-guanosine--a potential precursor for the second generation antisense oligonucleotides: an improved process for the preparation of 2'-O-alkyl-2,6-diaminopurine riboside

An efficient four step process for the preparation of 5'-O-(4,4'-dimethoxytrityl)-N2-isobutyryl-2'-O-(2-methoxyethyl)-guanosine 1 was developed. Direct 2'-O-alkylation of 2,6-diaminopurine riboside 2 was accomplished via inexpensive and commercially available reagents such as KOH, DMSO and alkyl halides at room temperature in 4-6 hrs. Pure 2'-O-(2-methoxyethyl)-DAPR 3 was isolated by crystallization from methanol. Enzymatic deamination of 3 followed by selective N2-isobutyrylation and 5'-O-dimethoxytritylation furnished desired 1 in high yield and purity. Fully optimized four step synthetic process has been scaled up to the pilot plant level.

Dose related pharmacokinetics of ofloxacin in healthy volunteers

OBJECTIVE

To evaluate the pharmacokinetic profile of ofloxacin in healthy volunteers after single oral doses of 600 and 800 mg.

DESIGN

Seven healthy volunteers were administered 600 and 800 mg of ofloxacin on two occasions with an interval of one week. Paired samples of blood and saliva were collected after 1, 2, 3, 6, 9, 12, 24, 32 and 48 hours post-dose. Urine samples were collected over a period of 0-6, 6-12 and 12-24 hours. Concentrations of ofloxacin in plasma, saliva and urine were assayed by high performance liquid chromatography.

RESULTS

Increases of 22% in peak plasma concentration (Cmax) and 40% in area under the concentration-time curve (AUC0-24) were observed with the 800 mg dose. The other parameters, namely time to attain Cmax, half-life, the apparent volume of distribution, plasma and renal clearance and percentage of dose excreted in urine over 24 hours were independent of doses. The mean ratios of the concentration in saliva to the concentration in plasma ranged from 0.4-0.6, and the correlation coefficient was 0.94.

CONCLUSIONS

Dose proportionality was observed in Cmax and AUC0-24 when 600 and 800 mg doses of ofloxacin were given. Ofloxacin determined in saliva seems to be suitable for therapeutic drug monitoring.

Bioavailability of rifampicin, isoniazid and pyrazinamide in a triple drug formulation: comparison of plasma and urine kinetics

SETTING

The present study assesses bioavailability indices for rifampicin, isoniazid and pyrazinamide when administered to healthy volunteers separately or in a fixed triple-drug formulation, Rifater 125 SCT.

OBJECTIVE

To compare the pharmacokinetics of rifampicin, isoniazid and pyrazinamide based on their blood concentrations up to 12 hours with the proportions of the doses of the drugs and their metabolites excreted in urine up to 12 hours, and to assess the bioavailability indices for the free and fixed triple drug formulations.

DESIGN

An open cross-over study was conducted in 18 healthy volunteers with normal hepatic and renal functions to whom the drug combinations were administered in free and fixed dose formulations a week apart, to the same subject.

RESULTS

Concentrations of the three drugs/metabolites were assessed in blood and urine. The results indicated the absence of negative pharmacokinetic interactions between the drugs when administered in both the free and the new fixed triple drug formulation.

CONCLUSION

Human bioavailability studies provide direct straightforward information, particularly when studying compounds such as rifampicin and other major anti-tuberculosis drugs. The results of the present study indicate that the pharmacokinetic properties of rifampicin, isoniazid and pyrazinamide as assessed after individual and combined administration do not change when combined in a single pharmaceutical preparation. The bioavailability indices calculated based on plasma concentrations and urinary levels for all three drugs compared well.

Salivary levels of isoniazid and rifampicin in tuberculous patients

Concentrations of isoniazid and rifampicin were determined in time-matched samples of saliva and serum from 30 tuberculous patients (18 with pulmonary tuberculosis and 12 with intestinal tuberculosis), comprising 18 slow and 12 rapid acetylators of isoniazid, following administration of isoniazid 300 mg and rifampicin 12 mg/kg. The diffusion of isoniazid into saliva was quite rapid and the salivary concentrations were similar to those in serum, suggesting that saliva could be used in place of serum for all pharmacokinetic studies with isoniazid. The salivary concentrations of rifampicin were much lower than those in serum, the mean peak concentrations being 0.9 and 8.5 microgram/ml, respectively. Further, there was evidence of a significant delay in the diffusion of rifampicin from serum to saliva.

Membrane bound cytochrome P-450 determines the optimal temperatures of NADPH-cytochrome P-450 reductase and cytochrome P-450-linked monooxygenase reactions in rat and trout hepatic microsomes

The hepatic monooxygenase systems largely responsible for the biotransformation of drugs and other xenobiotics are comprised of NADPH-cytochrome P-450 reductase and multiple forms of cytochrome P-450. Optimal temperatures for these systems in the trout and rat are 26 degrees and 37 degrees, respectively. Purified trout and rat reductases are optimally functional at 26 degrees and 37 degrees, respectively, when added to trout and rat microsomes. However, rat reductase was shown to function optimally at 26 degrees when added to trout microsomes and trout reductase functioned optimally at 37 degrees when added to rat microsomes. Corresponding shifts in optimal temperatures of cytochrome P-450-linked 0-deethylation of 7-ethoxycoumarin occurred when these reductases were added to rat or trout microsomes. It is proposed that the phospholipid annulus surrounding the active site of membrane-bound cytochrome P-450 determines the optimal temperature of cytochrome P-450 systems.

Lack of relationship between hepatic toxicity and acetylator phenotype in three thousand South Indian patients during treatment with isoniazid for tuberculosis

The results are presented of a retrospective analysis of the incidence of jaundice among 3,000 patients with pulmonary tuberculosis and of the activities of serum aspartate aminotransferase among 850 according to their isoniazid acetylator phenotype. The patients had been treated with a variety of isoniazid-containing regimens in a series of controlled clinical trials in South India. The results show that rapid acetylators are no more prone to develop isoniazid-induced hepatic toxicity than are slow acetylators.

Pyrazinamide deamidase activity in tuberculous disease

To investigate whether pyrazinamide deamidase activity is suppressed in tuberculosis, serial serum concentrations of pyrazinamide, following 40 mg of pyrazinamide per kg, were determined in 10 patients with sputum positive pulmonary tuberculosis and in 10 control subjects without disease. The concentrations and the half-lives of pyrazinamide were similar in the 2 groups, suggesting no suppression of the deamidase activity in tuberculous patients.