Does Unidirectional Polyglycolide Caprolactone Barbed Suture Have Improved Outcomes Over Non-barbed Suture When Applied for Intra-oral Incision Closure?

Purpose

The choice of wound closure material may influence the clinical outcomes of intra-oral incision closure. Studies evaluating the application of barbed suture in the oral cavity are scarce. Hence, the present study was carried out with the aim to monitor and compare the efficacy and ease of handling of monofilament polyglycolide caprolactone (PGCL) unidirectional barbed and non-barbed sutures used for intra-oral incision closure in patients undergoing transalveolar extraction of impacted mandibular third molar and mandible fracture open reduction internal fixation.

Methods

A prospective randomized open label study was carried out among subjects requiring intra-oral incision closure following mandibular third molar extraction and isolated mandible fracture fixation. The difficulty index of the impacted third molars was evaluated pre-operatively. Subjects were randomized to receive either 3-0 monofilament PGCL unidirectional barbed or non-barbed sutures. Incision closure time and ease of suture handling were recorded intra-operatively. Post-operatively, patients were monitored for incision healing using the Hollander wound evaluation scale (HWES) and intensity of pain using visual analog scale (VAS) on post-operative days 1, 3 and 7. Data analysis involved descriptive statistics, Chi-square, unpaired t test and multivariate analysis using the IBM SPSS-PC software (v.25.0).

Results

A total of 60 subjects completed the study protocol, who were randomized into two groups (n1 = n2 = 30), comparable in terms of age, gender and treatment (TAE = 51; ORIF = 9) received. The incision healing outcomes were significantly better (p = 0.016) with barbed suture using HWES on day 7. The mean closure time using barbed suture (142.50 ± 34.803 secs) was significantly (p = 0.001) shorter than that with non-barbed suture (204.56 ± 52.94 secs). The mean VAS for the barbed suture (0.97 ± 1.89) was less (p = 0.015, 95% CI) than the non-barbed suture (2.50 ± 2.91) on day 3. The suture handling ease was comparable between the two groups.

Conclusion

Monofilament unidirectional PGCL barbed suture has merits over the non-barbed suture with regards to superior post-operative incision healing, reduced incision closure time (43%), lower post-operative pain and comparable ease of suture handling. Hence, knotless PGCL suture is a promising alternative for intra-oral surgical incision closure in oral and maxillofacial surgery.

Correction: Self-reported Morisky Eight-item Medication Adherence Scale for Statins Concords with the Pill Count Method and Correlates with Serum Lipid Profile Parameters and Serum HMGCoA Reductase Levels

[This corrects the article DOI: 10.7759/cureus.6542.].

Comparative Efficacy of Topical Finasteride (0.25%) in Combination with Minoxidil (5%) Against 5% Minoxidil or 0.25% Finasteride Alone in Male Androgenetic Alopecia: A Pilot, Randomized Open-Label Study

Background

Androgenetic alopecia (AGA) is the most common cause of hair loss in males which remains a therapeutic challenge.

Objectives

To compare the efficacy of topical 5% minoxidil and 0.25% finasteride combination (MNF) over 5% minoxidil (MNX) or 0.25% finasteride (FNS) alone by assessing hair count, physician assessment score (PAS), and patient satisfaction score (PSS).

Materials and Methods

Pilot randomized open-label study where 60 male patients with AGA ≥ III grade were randomized into three treatment groups and evaluated over 24 weeks. Improvement in hair count was assessed manually using dermoscopy. Global photographs were used to assess PAS. Side effects were evaluated using relevant laboratory investigations.

Results

At the 12th and 24th week, all three groups showed significant improvement in total hair density as compared to baseline (P < 0.001). None of the groups was superior to the other (P > 0.05) at the 12th week but at 24th week, MNF was comparatively superior (P < 0.02). At the 12th week and 24th week, all three groups showed significant improvement in terminal hair density as compared to baseline (P < 0.001). In the 12th week, MNF was comparatively superior (P = 0.028) and at the 24th week, MNF was comparatively superior (P < 0.02). PAS and PSS were significantly better with MNF and MNX compared to FNS (P < 0.004). Side effects such as scaling and itching were reported with MNF and MNX.

Conclusion

Topical minoxidil 5% and finasteride 0.25% had an overall better efficacy compared to monotherapy without significant side effects.

Materiovigilance of unidirectional barbed and poliglecaprone 25 nonbarbed sutures used for intraoral incision closure: An open-label prospective study

INTRODUCTION

The adverse events of sutures used for the closure of surgical incisions influence clinical outcomes. Literature on the safety profile of the application of unidirectional barbed sutures in oral and maxillofacial surgery is scarce. Hence, focused materiovigilance was done to monitor and compare the adverse events of unidirectional barbed and poliglecaprone 25 nonbarbed sutures for intraoral incision closure.

METHODS

In a prospective randomized comparative study, 64 patients requiring intraoral incision closure were randomized to receive either unidirectional barbed or poliglecaprone 25 nonbarbed sutures. Postoperatively, patients were monitored for any adverse events for 15 days. Causality association of adverse events with sutures was done using the European Commission directives on safety reporting of medical devices.

RESULTS

Adverse events observed with unidirectional barbed suture were suture extrusion (n = 7; 21.875%) and suture discomfort (n = 3; 9.375%). While subjects who received poliglecaprone 25 suture experienced suture discomfort (n = 6; 18.75%) and knot unraveling (n = 2; 6.25%). The number of adverse events in both groups was statistically comparable (P = 0.78). Causality assessment of adverse events was probable for suture extrusion and discomfort with nonbarbed and barbed sutures, while it was possible for knot unraveling for nonbarbed sutures.

CONCLUSION

Both types of study sutures were associated with minor severity adverse events when used for the closure of intraoral surgical incisions. Suture extrusion had a probable causal association with barbed suture. Knot unraveling was possibly associated with the nonbarbed suture. Both types of suture materials were equally safe in oral and maxillofacial intraoral surgical incision closure.

Exploring the role of adipsin in statin-induced glucose intolerance: a prospective open label study

Background Evidence from the literature, highlights the increased risk of developing glucose intolerance and type 2 diabetes mellitus (T2DM) with statin therapy. In addition, few animal studies demonstrate that adipsin secreted from adipocytes plays a crucial role in insulin secretion and the development of T2DM. Methods To further explore the role of serum adipsin, in this prospective open label study, 55 newly diagnosed dyslipidemic patients were enrolled. Before starting statin therapy, liver function test (LFT), kidney function test (KFT), lipid profile, glycemic parameters [glycated hemoglobin A (HbA1c), fasting blood sugar (FBS), and postprandial blood sugar (PPBS)], serum insulin, and serum adipsin were estimated. Then these patients were prescribed statin (i.e. atorvastatin, rosuvastatin, or pitavastatin) and after 12 weeks of therapy, all the above investigations were repeated. Results After 12 weeks of statin therapy, the LFT and KFT values remained unchanged and lipid parameters showed significant improvement. But the glycemic parameters deranged significantly (p < 0.001), i.e. FBS, PPBS, and HbA1c increased by 12.49% (102.99 ± 20.76 mg/dL), 24.72% (147.71 ± 47.29 mg/dL), and 21.43% (6.38 ± 1.34%), respectively. On the other hand, the baseline adipsin (2.73 ± 1.99 ng/mL) and insulin (16.13 ± 12.50 mIU/L) levels reduced significantly (p < 0.0001) to 1.43 ±1.13 ng/mL and 6.91 ± 5.93 mIU/L, respectively. The reduction in serum adipsin also showed a positive correlation with reduction in serum insulin (r = 0.85; p < 0.0001). None of the patients experienced any significant adverse effect or reaction leading to discontinuation of therapy. Conclusions There might be an association between reduction in adipsin and development of glucose intolerance by statin therapy.

Self-reported Morisky Eight-item Medication Adherence Scale for Statins Concords with the Pill Count Method and Correlates with Serum Lipid Profile Parameters and Serum HMGCoA Reductase Levels

Background It is imperative that non-compliance with statins be identified and addressed to maximize their clinical benefits. Patient self-reporting methods are convenient to apply in clinical practice but need to be validated. Objective We studied the concordance of a patient self-report method, Morisky eight-item medication adherence scale (MMAS)), with the pill count method in measuring adherence with statins and their correlation with extended lipid profile parameters and serum hydroxyl-methylglutaryl coenzyme A reductase (HMGCoA-R) enzyme levels. Methods MMAS and the pill count method were used to measure the adherence with statins in patients on statins for any duration. Patients were subjected to an estimation of extended lipid profile and serum HMGCoA-R levels at the end of three months follow-up. Results Out of a total of 200 patients included in the study, 117 patients had a low adherence (score less than 6 on MMAS) whereas 65 and 18 patients had medium (score 6 or 7) and high adherence (score of 8), respectively. The majority of patients who had low adherence to statins by MMAS were nonadherent by the pill count method yielding a concordance of 96.5%. Medium or high adherence to statins by the MMAS method had a concordance of 89.1% with the pill count method. The levels of total cholesterol, low-density lipoprotein-cholesterol, apolipoprotein B, and HMGCoA-R were negatively correlated with compliance measured by pill count and MMAS in a statistically significant way and with similar correlation coefficients. HMGCoA-R levels demonstrated a plateau phenomenon, with levels being 9-10 ng/ml when compliance with statin therapy was greater than 60% by pill count and greater than 6 on the Morisky scale. Conclusion In conclusion, MMAS and the pill count method showed concordance in measuring adherence to statins. These methods need to be explored further for their interchangeability as surrogates for biomarker levels.

Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome Associated with Ethambutol use: A Case Report

Background:

Among the first line Anti-Tubercular Drugs (ATDs), ethambutol has been rarely associated to cause drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.

Case Report:

A 34-year-old woman presented in an out-patient department of Dermatology with fever, skin eruptions, eosino- philia, hyperinflated lung fields and deranged liver enzymes after 35 days of the initiation of ATDs. The patient recovered completely after stopping ethambutol and administration of topical and sys- temic corticosteroids.

Results and Conclusion:

Based on the available evidences of de-challenge and re-challenge of suspected drugs, ethambutol was certainly implicated to cause DRESS syndrome.

Antimicrobial Agents-induced Hypokalemia: A Possible Causality Association

Background

Drugs including some of the antimicrobial agents (AMAs) can cause mild to severe intensity of hypokalemia, which leads to cardiac, muscular, renal, gastrointestinal, and metabolic manifestations.

Objective

To explore the possible association of AMAs use and the development of hypokalemia as an adverse drug reaction (ADR).

Methodology

Retrospective analysis of spontaneously individual case safety reports (ICSRs) received during January 2015 to September 2017 for any reduction in serum potassium levels following the use of AMAs. Such ICSRs were further analyzed for age, gender, seriousness and severity of hypokalemia, outcome, concomitant drugs, management of hypokalemia, and causality assessment using WHO-UMC causality assessment scale.

Result

Out of total 2,880 spontaneous ICSR, 53 had report title of hypokalemia. In almost half of these (27) ICSRs, AMAs were suspected to induced hypokalemia. Ceftriaxone (24.5%) and azithromycin (10.5%) were most suspected AMAs. Females (74.19%) aged between 21 years and 40 years experienced more AMA induced hypokalemia. The mild, moderate, and severe hypokalemia was present in 53.8%, 40.7%, and 7.4% of ICSRs, respectively. Drug-drug interaction of AMA with either furosemide, hydrocortisone and/or deriphyllin was present in six ICSRs. Causal association of all the ICSRs with AMA induced hypokalemia was possible.

Conclusion

Antimicrobial agents (especially ceftriaxone and azithromycin)-induced hypokalemia alert needs to be investigated. Further, healthcare professionals are advocated to take caution by monitoring serum potassium levels routinely for such patients.

How to cite this article

Rehan HS, Hotha P, Antimicrobial Agentsinduced Hypokalemia: A Possible Causality Association. Indian J Crit Care Med 2019;23(4):175-177.

Randomized controlled trial comparing the efficacy of daily and every other day atorvastatin therapy and its correlation with serum hydroxymethylglutaryl-CoA reductase enzyme levels in naïve dyslipidemic patients

Objective

Data regarding efficacy comparison of daily regimen (DR) versus every other day regimen (EODR) atorvastatin therapy is not validated by estimation of serum hydroxymethylglutaryl-CoA reductase (HMGCR) levels and HMGCR correlation with lipid indices.

Methods

In this randomized controlled trial, we compared the efficacy of DR versus EODR by measuring lipid indices and serum HMGCR levels at baseline and after 12 weeks of 10 mg atorvastatin therapy. Primary endpoint was comparison of mean change in serum HMGCR levels and lipid indices of both groups and their correlation with each other. Secondary endpoints were assessed by estimating serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase MM (CK-MM) levels and adverse drug reactions (ADRs).

Results

A total of 61 patients were enrolled of which 46 completed the study (24 in DR vs 22 in EODR group). The mean reduction in total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C) and non-high density lipoprotein-cholesterol (HDL-C) was significantly higher in DR group, whereas mean reduction in triglycerides (TG) and increase in HDL-C was similar in both the groups. Reduction in serum HMGCR levels was comparable in both the groups (31.17% vs 28.19%). Change in serum HMGCR levels correlated more with change in lipid indices of DR group. Also, safety parameters were similar between the two groups.

Conclusion

Both the regimens achieved therapeutic goals, however DR was found to be superior as it achieved greater reduction in TC and LDL-C. Further, these findings are substantiated by correlation of lipid indices with serum HMGCR levels.

Vaping versus Smoking: A Quest for Efficacy and Safety of E-cigarette

BACKGROUND

Electronic Cigarettes (ECIGs) are devices with a heating element which produces aerosol for inhalation. They have been propagated as a healthier alternative to tobacco smoking and a potential device for smoking cessation, despite non-documentation of their long-term adverse health effects.

OBJECTIVES

With the glorification of ECIG, its use has increased even among non-tobacco users. This makes it critical to understand and discuss a true picture of safety and utility of ECIGs by reviewing the literature.

METHODS

Literature search for narrative review was done on PubMed, Scopus and Web of Science databases using the keywords viz electronic cigarette, e-cigarette, electronic nicotine delivery systems, NRT, vaping and electronic nicotine delivery device. The review was sub-categorized into four themes (potential role in smoking cessation, chemicals in the smoke of traditional cigarette and ECIGs, pharmacology of nicotine delivery via ECIG and current regulatory status across the globe).

RESULTS

Search revealed a total of 40 articles out of which 29 were included in the review. ECIGs achieved modest cessation rates with benefits of behavioral and sensory gratification. On the contrary, in many studies where ECIGs were introduced as an intervention, participants continued to use them to maintain their habit instead of quitting. A total of 22 toxic substances apart from nicotine were reported in liquid of ECIG cartridges and its emissions. Many compounds had lower concentrations in ECIG compared to tobacco smoke. There existed a wide variation in the content of ECIG cartridges and strengths of nicotine in refill solutions. It has been observed that the second generation ECIGs delivered nicotine with a similar kinetic profile as conventional cigarettes. In 2013, US FDA gave market authorization to ECIG as substitutes for quitting smoking and cigarette substitutes. The United Kingdom also advocates ECIGs as a medicinal quit aid but bans it from workplaces and other public spaces. India along with many other countries still need to come up with a formal regulatory stand regarding ECIGs.

CONCLUSION

There is a need to conduct large long-term global clinical trials in real life settings to ascertain the potential uses, adverse effects of ECIG and achieve harmonization of nicotine solution concentration.

Correlation of long-term glycemic control as measured by glycated hemoglobin with serum angiopoietin-like 6 protein levels in type 2 diabetes mellitus patients

AIMS

Angiopoietin-like growth factors (ANGPTLs) regulate glucose, lipid homeostasis, and insulin sensitivity. This study aimed to find whether long-term glycemic control (glycated hemoglobin [HbA_1c]) has any correlation with serum ANGPTL6 levels in patients of type 2 diabetes mellitus.

MATERIALS AND METHODS

It was an open-label, observational, prospective clinical study. Sixty-five participants (41 diabetic patients receiving daily dose of oral metformin for a minimum of 3 months and 24 matched controls) completed the study. A single venous blood sample was taken from each participant to determine serum HbA_1c and serum ANGPTL6 levels. Comparison of serum ANGPTL6 levels according to the HbA_1c levels, in groups A, B, and C ranging from 6.5%-8%, 8.1%-9.5%, and >9.5%, respectively, was done using Kruskal-Wallis H-test followed by pairwise comparisons.

RESULTS

Serum HbA_1c and serum ANGPTL6 levels were raised significantly (P < 0.05) in diabetic patients when compared with control participants. A positive correlation was observed between serum HbA_1c and serum ANGPTL6 levels (r = 0.88, 95% confidence interval 0.81, 0.92). Mean ANGPTL6 level for Group A (n = 20) was 394.3 pg/ml, for Group B (n = 8) 692.8 pg/ml, and for Group C (n = 13) 896.2 pg/ml.

CONCLUSIONS

Serum ANGPTL6 levels were significantly higher in type 2 diabetic patients in comparison with healthy controls. Poor glycemic control in diabetes mellitus as reflected by higher serum HbA_1c levels is associated with raised serum ANGPTL6 levels.

Comparison of the knowledge, attitude, and practices of doctors, nurses, and pharmacists regarding the use of expired and disposal of unused medicines in Delhi

Objectives:

The use of out-of-date medicines and improper disposal of pharmaceutical products harm consumers and environment. To limit pharmaceutical load on the environment, it is important that healthcare professionals (HCPs) are aware of and have good practices toward their disposal.

Materials and Methods:

A pretested instructor administered questionnaire containing 21 questions was used to assess knowledge, attitude, and practices (KAP) of 300 HCPs toward use and disposal of unwanted/expired medicines.

Results:

Nurses (76%) had significantly (P < 0.01) better knowledge over doctors regarding the methods of drug disposal, whereas both doctors (63%) and nurses (64%) knew significantly (P < 0.05) more than pharmacists about type of formulations not to be incinerated. The majority (88%) of overall respondents were unaware of validity of dispensing medicines before 15 days of mentioned expiry date. A large proportion of HCPs had a positive attitude toward checking the expiry date of medicines (96%), and a significant proportion of doctors and nurses believed that drug disposal is everyone's responsibility. Only 8% of the HCPs received unused/expired drugs back from the consumers. Nurses (59%) had better (P < 0.01) practice than pharmacists regarding the disposal of expired medicines. Nearly half (44%) of all HCPs agreed that there existed a system for removing expiry and unused medicines from the inventory.

Conclusions:

The KAP of HCPs toward use and disposal of out-of-date and unused medicines need upgrading. The existing guidelines should be implemented to ensure patients' safety and to preserve the ecosystem.

Tracheo-Esophageal Fistula (TEF) in a Newborn Following Maternal Antenatal Exposure to Olanzapine

There is a dearth of evidence on the safety of the use of antipsychotics during pregnancy. Olanzapine, a pregnancy category C drug, has no unequivocal evidence of harm to the fetus. Against this backdrop, we report the first case of a tracheo-esophageal fistula (TEF) in a newborn following maternal antenatal exposure to olanzapine. A 29-year-old woman with acute psychotic disorder had been treated with olanzapine for the last 7 years. Her first pregnancy, while taking olanzapine, resulted in a miscarriage at 4 months' gestation, following which she discontinued olanzapine. She reconceived after a few months and delivered a full-term normal child. However, due to the recurrence of psychiatric illness after her second pregnancy, she was prescribed olanzapine again, which was continued throughout her third pregnancy. The outcome of the third pregnancy was a full-term female baby with a TEF. The baby was managed surgically and discharged with satisfactory vital signs. Unfortunately, however, the baby did not survive beyond 11 months of age. Causality between antenatal maternal olanzapine exposure and TEF in the newborn was determined to be 'probable' (score +5) as per the Naranjo causality assessment scale. Greater knowledge of this potential teratogenicity caused by olanzapine is needed to reduce morbidity and mortality in newborns.

Correlation of compliance to statin therapy with lipid profile and serum HMGCoA reductase levels in dyslipidemic patients

BACKGROUND

The efficacy of statin therapy may be lost or vary with reduction in compliance and intensity of statin therapy.

OBJECTIVE

To study and correlate the quantitative effect of compliance on lipid profile and 3-hydroxyl-3-methylglutaryl coenzyme A reductase (HMGCoA-R) levels in dyslipidemic patients.

METHODS

Compliance to different intensity of statin therapy assessed by pill count was correlated with serum levels of total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), triglycerides (TG), apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB) and HMGCoA-R.

RESULTS

Out of 200 patients, 160 received moderate intensity statin therapy whereas 40 were on high intensity statin therapy. The overall mean compliance of patients was 56.7%. The compliance of patients on moderate intensity statin therapy was higher (56.8%) than those on high intensity (56.4%) (p=0.92). There was significant inverse correlation (p<0.05) between compliance and TC, TG, LDL-C and HMGCoA-R levels and positive correlation (p<0.05) with HDL-C levels. The mean serum HMGCoA-R levels did not fall below 9-10ng/mL when compliance to either moderate or high intensity statin therapy was increased above 60%.

CONCLUSIONS

It is appropriate to improve the compliance to existing statin therapy than switching over to higher intensity statin therapy. Estimation of HMGCoA-R levels may be explored as a surrogate marker to monitor and assess the compliance of patients to statin therapy.

Unstable Angina: A Serious Adverse Event following Gemcitabine-Cisplatin Based Chemotherapy

A 29 year male, with an inoperable adenocarcinoma of gall bladder was initiated on gemcitabine and a platinum compound based chemotherapy. During 4th cycle of chemotherapy, patient complained of chest pain following cisplatin and gemcitabine infusion. ECG was suggestive of acute coronary syndrome, which was successfully managed by antianginal therapy. Fifth cycle of chemotherapy was uneventful. Patient died of cardiovascular collapse before receiving the 6th cycle of chemotherapy. As per Naranjo adverse drug reaction probability scale, causal association of the event with cisplatin and gemcitabine was probable and possible respectively. It is advised to routinely assess the cardiovascular status of patients before and during cisplatin and/or gemcitabine based chemotherapy.

Bacteriological Profile in Chronic Suppurative Otitis Media in Eastern Nepal

Aural swabs were collected from 250 patients with chronic suppurative otitis media (CSOM) (tubotympanic disease). Duration of ear discharge was more than 6 months for culture and sensitivity test. The disease was unilateral in 178(71.2%)and bilateral in 72 (28.8%) patients. From a total of 322 aural swab cultures, 324 organisms were isolated with predominance of Pseudomonas aerugimosa (36.4%) followed by Staphylococcus aureus (30.2%). All the isolated Gram-negative organisms showed in vitro sensitivity to ciprofloxacin, amikacin, ofloxacin, and gentamycin whereas cloxacillin, ofloxacin, erythromycin, ciprofloxacin, gentamicin and tetracycline were more effective against Gram-positive isolates. Most isolates were resistant to amoxycillin. It is concluded that ciprofloxacin is preferred to aminoglycosides as an important tool in the treatment of CSOM because of its lower cost, lack of ototoxicity and availability astopical oral preparations.

Olanzapine vs. Risperidone in Schizophrenia: A Cross-sectional Comparison of Quality of Life of Caregivers

In schizophrenia, efficacy of antipsychotic therapy might be better measured by quality of life (QoL) of caregiver, due to less reliability of patient's account and greater burden of management on caregiver. Hence, we compared QoL of the primary caregiver of schizophrenics prescribed either olanzapine or risperidone. In a cross sectional analytical study, caregivers of 120 schizophrenic patients' on either olanzapine or risperidone filled the WHOQOL-BREF questionnaire containing physical, psychological, social and environmental domains. Scores of these domains in both the groups were compared. Majority (33.3%) of caregivers in both groups were parents. The mean transformed scores in all domains viz. physical (p=0.358), psychological (p=0.352), social relationships (p=0.332) and environmental (p=0.448) were statistically similar. More than 75% of the subjects in both groups showed the highest satisfaction in work capacity, personal relations, physical pain, requirement of medications, frequency of negative feelings, safety and body appearanc, whereas ≤ 50% of the caregivers in both groups expressed dissatisfaction with their financial situation. Thus, QoL of caregivers in both groups was comparable. On the basis of QoL of caregivers, olanzapine and risperidone were similarly effective therapeutic agents for schizophrenia.

Effect of Sucrose Analgesia, for Repeated Painful Procedures, on Short-term Neurobehavioral Outcome of Preterm Neonates: A Randomized Controlled Trial

BACKGROUND

Safety of oral sucrose, commonly used procedural analgesic in neonates, is questioned.

AIM

To evaluate the effect of sucrose analgesia, for repeated painful procedures, on short-term neurobehavioral outcome of preterm neonates.

METHODS

Stable preterm neonates were randomized to receive either sucrose or distilled water orally, for every potentially painful procedure during the first 7 days after enrollment. Neurodevelopmental status at 40 weeks postconceptional age (PCA) measured using the domains of Neurobehavioral Assessment of Preterm Infants scale.

RESULTS

A total of 93 newborns were analyzed. The baseline characteristics of the groups were comparable. No statistically significant difference was observed in the assessment at 40 weeks PCA, among the groups. Use of sucrose analgesia, for repeated painful procedures on newborns, does not lead to any significant difference in the short-term neurobehavioral outcome.

Comparison of Effect of Enalapril and Losartan Monotherapy on Quality of Life and Safety of Stage 1 Hypertensive Patients

An open label randomized controlled study was conducted to compare the quality of life (QoL) and safety of newly diagnosed stage I hypertensive patients randomized into two groups of 30 receiving either enalapril 5 mg or losartan 50 mg per-oral once daily for three months. QoL was assessed at the baseline and at the end of study using SF-36v2 health care questionnaire. Adverse drug reactions (ADRs) were monitored. Investigations at baseline were compared with those after intervention. Pre & post-intervention QoL transformed scores within each group and change in the same between two groups were analyzed using paired and unpaired t-test respectively. Transformed scores of role limitation due to energy/fatigue, emotional well being and general health domains improved significantly in both treatment groups. Scores of bodily pain improved significantly (p=0.0008) in losartan group only. Results were not significantly different between two groups (except for bodily pain). No serious ADR was reported.

Safety and efficacy of Qurse-e-istisqua in chronic hepatitis C infection: an exploratory study

Background:

Qurse-e-istisqua (Q-e-I), an Unani medicine commonly prescribed to treat liver disorders.

Objectives:

To study efficacy and safety of Q-e-I in hepatitis C virus (HCV) infection.

Methods:

In this randomized double-blind exploratory study, 60 naive patients of HCV infection were assigned to receive either interferonα2a (IFNα2a) (3 mIU, subcutaneous, thrice weekly), ribavirin (RBV) (1000 mg, orally, twice daily in divided doses) and placebo (n = 30) or IFNα2a, RBV and Q-e-I (5 g, orally, thrice daily in divided doses) (n = 30). HCV RNA levels, serum hyaluronic acid (SHA), ultrasound image scoring for fibrosis, liver and renal function test, prothrombin time, were done at the baseline and thereafter periodically.

Results:

Early virologic response (EVR), end of treatment response (ETR) and sustained virologic response (SVR) were 90%, 96.6% and 90% in the control group and 86.6%, 90.0% and 83.3% in the treatment group. SHA level was lower in the treatment group at the end of the treatment as compared to the control group. Mean end of follow-up ultrasound image scoring for fibrosis in the control and the treatment group was 1.37 ± 0.07 and 1.22 ± 0.06 respectively. Aspartate aminotransferase (AST) levels were significantly lower in the treatment group than the control group at 1-month. Commonly observed adverse drug reactions included fever, hair fall, fatigue, anemia, and diarrhea.

Conclusion:

Q-e-I was well tolerated and showed anti-fibrotic activity. EVR, ETR and SVR suggested that Q-e-I do not have any anti-HCV activity. Early recovery in AST and inhibition of progress of fibrosis in Q-e-I group was probably due to the anti-inflammatory and antioxidant activity of its ingredients.

Supervised conventional interferon α2a in combination with ribavirin therapy is the preferred alternative for treatment of chronic hepatitis C

Objective:

To document the significant sustained virological response with supervised conventional interferon α and ribavirin therapy in hepatitis C virus (HCV)-infected patients, this study was planned.

Materials and Methods:

Sixty chronic hepatitis C naive patients were included in this study. Complete blood counts, prothrombin time, ALT, AST, and qualitative HCV RNA were done. Conventional interferon (INF) α2a, 3MIU, S.C and ribavirin 1000 mg PO was given as supervised therapy for 24 weeks in genotype 3 and 48 weeks in genotype 1 and 4 HCV patients. Qualitative HCV RNA was repeated at 12 weeks, 24 weeks for HCV infections with genotype 1, 2, 3 and 4, at 48 weeks for genotype 1 and 4, and thereafter 6 months after completion of treatment. End virological and sustained virological responses were observed.

Results:

Out of 60 patients, 55 completed the study. Five patients were lost to follow-up. Overall SVR was seen in 47 patients (85.4%) and 4 patients had relapses.

Conclusion:

Significant sustained virological response rates were seen in patients with supervised conventional INF α2a and ribavirin therapy.

A perspective on role of calcium and vitamin D in cardiovascular outcomes and lipid profile

Recent concerns on increased incidence of myocardial infarction and stroke on administration of calcium and vitamin D supplements have alarmed the physicians about safety of these drugs. Although both calcium and vitamin D have been shown in the past to have beneficial effect on cardiovascular disease status through lowering of harmful lipids, these findings have been contradicted by some recent meta-analysis and randomized controlled trials that have shown no beneficial or in some cases a deteriorating effect of these supplements on lipid levels. In particular, calcium supplementation has been associated more with increased incidence of cardiovascular morbidity than vitamin D, but the convincing proof is still lacking. Here we have highlighted the results of some significant studies that might impact the prescription of these drugs.

Comparison of knowledge, attitude and practices of resident doctors and nurses on adverse drug reaction monitoring and reporting in a tertiary care hospital

Background:

Lack of knowledge of pharmacovigilance (PhV) and adverse event (AE) reporting culture among the healthcare providers have been identified as major factors for under reporting of AE in developing countries. Hence, this study was planned to assess and compare the knowledge, attitude, and practices (KAP) of resident doctors and nurses about PhV and AE reporting.

Material and Methods:

This cross-sectional, questionnaire-based study was conducted to compare KAP of 100 doctors and 100 nurses on PhV and AE reporting.

Results:

All the respondents felt that AE reporting is necessary and two-thirds were aware of the existing PhV Program of India. Significantly, higher proportion of doctors had correct understanding regarding PhV (P<0.05) and knew what should be reported (P<0.05) but nurses (75%) knew better about where to report (P<0.001). Significantly (P<0.001), more doctors (98%) felt that the patients are benefited by reporting AE. Nurses (96%) felt the need for information on drugs causing AE and their management strategy (P<0.001). Around 60% of all the respondents were in favor of mandatory PhV and feedback on the submitted AE. Doctors (67%) (P<0.05) had a practice of inquiring patients for any untoward outcome of therapy. Higher proportion (P<0.05) of nurses (55%) mentioned that observed AE are recorded in patient's case record, but random screening of 1000 patients’ record did not reveal it. Nurses mentioned that they never reported any AE (P<0.05) and witnessed discussions on ADRs during the ward rounds (P<0.001). All the respondents preferred phone as the convenient method for reporting AE followed by drop box kept in the ward/OPD and felt the need of frequent workshops and continuing medical education.

Conclusion:

Resident doctors and nurses had good knowledge and awareness on AE reporting and PhV but their practices need to be improved.

Analgesic activity and safety of ash of silver used in Indian system of medicine in mice: a reverse pharmacological study

OBJECTIVE

To study the analgesic activity of ash of silver used in Indian system of medicine and to explore its safety.

MATERIALS AND METHODS

Albino mice of either sex (20-30 gm) were used to investigate the role of ash of silver against noxious stimuli: thermal (Eddy's hot plate and analgesiometer), mechanical (tail clip), and chemical (0.6% acetic acid induced writhing). An effort was made to find nature and site of action of ash of silver following naloxone pre-treatment. Maximum tolerated dose (MTD) and lethal dosage 50 (LD50) were also studied along with toxicological aspects of ash of silver.

RESULTS

Test drug (ash of silver) at a dose of 50 mg/kg p.o exhibited analgesic activity against thermal, mechanical, and chemical stimuli. Analgesic effects were compared with the standard drug, morphine, in thermal and mechanical noxious stimuli and to aspirin in chemical stimulus. Analgesic activity of the test drug was reduced following naloxone pre-treatment. MTD was found out to be greater than 1.5 g/kg p.o. LD50 was 2 g/kg p.o. Fraction of mice showed symptoms of argyria as explained by autopsy reports.

CONCLUSION

Test drug exhibited moderate analgesic activity at 50 mg/kg p.o against all type of noxious stimuli, also suggesting a role of opioidergic system. The ash of silver was been found to be safe upto a dose of 1.5 g/kg p.o. in mice without any untoward toxicity. Further studies are required to explore the effect of ash of silver on pain mediators and excitatory neurotransmitters like glutamate, aspartate, or N-methyl-D-aspartic acid (NMDA).

IFN-α-2a (Interferon) and ribavirin induced suicidal attempt in a patient of chronic HCV: A rare case report

Interferons (IFNs) are proteins produced by cells, fibroblasts and macrophages, in response to viral invasion, and mediates immune response. IFN-α and ribavirin are the approved treatment for HCV infection, but also carries a risk of neuropsychiatric adverse effects, viz. insomnia, irritability, mood changes, and depression.

We present a case report of depression induced by IFN-α and ribavirin, leading to attempted suicide. Following the episode, antidepressant paroxetine (20 mg o.d.) and zolpidem (10 mg h.s) were added with psychotherapy. No significant improvement was observed. Patient was given a drug dechallenge (IFN-α and ribavirin). Dramatic improvement was seen over 1 month. Following rechallenge with combination, patient again experienced depressive symptoms with suicidal ideation. IFN-α and ribavirin were promptly stopped. Naranjo causality assessment scale revealed probable association with IFN-α and ribavirin. The report intends to improve awareness among clinicians to facilitate early diagnosis and intervention of similar cases.

Neo-regeneration of urinary bladder: a desired metaplasia of autologous membrane from rectosigmoid colon containing stem cells of intestinal crypts

The current management of diseases of urinary bladder requiring resection is by augmentation cystoplasty or transplantation of ureters. Transplantation of ureters is associated with morbidity and mortality. Ideal management will be by regenerating urinary bladder in vivo. Neo-regeneration of tissues and organs like abdominal wall, aponeurosis etc., has been attempted and patented. After neo-regeneration of mesoderm tissues and organs, regeneration of urinary bladder (developed from endoderm) was. In vivo surgical techniques were developed in dogs. It is known that the embryonic morphogenesis of urinary bladder is from uro-genital sinus of hind gut. A membrane, containing endoderm stem cells in crypts of recto-sigmoid colon, was surgically isolated and colonized with remnant of urinary bladder wall after extensive resection. Experimental study was performed in dogs, for 60 days to one and a half year. Regeneration of all the layers of tissues of the wall of urinary bladder was observed. The neo-regeneration phenomenon has been recognized as "desired metaplasia". The regenerated neo tissue/organ on histological examination and cystometry studies was found compatible with normal urinary bladder. The hypothesis, neo-regeneration and desired metaplasia, is discussed.

Topiramate for prevention of olanzapine associated weight gain and metabolic dysfunction in schizophrenia: a double-blind, placebo-controlled trial

BACKGROUND

Olanzapine associated weight gain (WG) is a major concern in patients with schizophrenia. The purpose of this study was to assess the efficacy of topiramate to prevent olanzapine induced WG in these cases. We also studied various metabolic parameters.

METHODS

In this 12-week, double-blind, parallel group study, seventy-two drug-naïve, first-episode schizophrenia patients were randomized to receive olanzapine+placebo (olanzapine group) or olanzapine+topiramate (100mg/day) (topiramate group). Weight, body mass index, fasting glucose, insulin, insulin resistance (IR), leptin, lipids and blood pressure were assessed at baseline and at 12 weeks. The patients were clinically evaluated using Positive and Negative Syndrome Scale (PANSS) and were monitored for adverse effects.

RESULTS

Topiramate resulted in a weight loss of 1.27+/-2.28 kg (p<0.01), decrease in leptin (p<0.001), glucose, cholesterol, triglyceride levels and systolic and diastolic blood pressure. In the olanzapine group, there was a significant WG, hyperglycemia, hyperinsulinemia, increased IR, hyperleptinemia, hypercholesterolemia and hypertriglyceridemia (p<0.001).There was a greater clinical improvement (PANSS scores) (p<0.001) in the topiramate group. The adverse effects were well tolerated.

CONCLUSIONS

Topiramate could prevent olanzapine induced weight gain and adverse metabolic effects. It also results in a greater clinical improvement when used with olanzapine in schizophrenia.

Changes in quality of life after surgical removal of impacted mandibular third molar teeth

BACKGROUND

The decision to get impacted teeth removed is not straightforward because of the concerns about its possible outcome. Assessment of quality of life is now regarded as an essential component for assessing outcomes of dental health care. The purpose of this paper is to assess the effect of impacted third molar teeth surgery on a number of health related outcomes.

PATIENTS AND METHODS

A total of 72 patients undergoing surgical removal of their unilateral impacted mandibular third molar teeth were recruited to participate in this study. Patients were asked to complete two questionnaires, 14-item Oral Health Impact Profile (OHIP-14) and the 16-item UK Oral Health related Quality of Life measure questionnaire (OHQOLUK-16) daily for one week following surgery.

RESULTS

There was significant decrease in the mean OHQOLUK-16 score and OHIP-14 scores for the first five postoperative days. There were no significant differences in changes in the mean OHIP-14 scores or OHQOLUK-16 scores on postoperative day 6 and 7.

CONCLUSION

There was a significant deterioration in oral health related quality of life in the immediate postoperative period, which slowly returned to preoperative level by day 6. This information may be useful in creating realistic expectation for patients who are considering third molar surgery.

Physician's guide to pharmacovigilance: terminology and causality assessment

Adverse drug events can range from mild to life threatening reactions resulting in inconvenience or serious morbidity and mortality besides being a financial burden on the society. However clinicians often do not recognize this drug related harm. The terms used to describe these events with medication use cause much confusion. Moreover manifestations of adverse drug reactions can be non-specific making it difficult to differentiate from current illness. To determine the likelihood of relationship between the drug and the event assessment of causality is done. The purpose of this article is to review and clarify the terms encompassing the discipline of pharmacovigilance and also to outline the steps in causality assessment with the help of an actual case report.

EVALUATION OF DRUG ADVERTISEMENTS IN A MEDICAL JOURNALThough ideally the scientific information provided by pharmaceutical companies in drug advertisements should be for promotion of rational use of drugs, this objective is rarely achieved, as often the d

Though ideally the scientific information provided by pharmaceutical companies indrug advertisements should be for promotion of rational use of drugs, this objective israrely achieved, as often the data is incomplete and biased. Analytical studies withthe help of standard indicators on this aspect of drug advertisements are very fewfrom developing countries. We analyzed all medical drug advertisements in elevenconsecutive issues of Journal of Nepal Medical Association published between 1993and 1996 with a special emphasis on their conformity with WHO guidelines andInternational Federation of Pharmaceutical Manufacturers Association (IFPMA) codefor drug advertisement.The 78 advertisements in the Journal of Nepal Medical Association constituted 7.7%pages of the eleven issues. Of the 38 products advertised, 30 (79%) were manufacturedoutside Nepal. Antimicrobial agents were the most frequently advertised group ofdrugs (47.4%). While generic name was not mentioned in 16.7% of the advertisements,the information on indications, adverse effects and contra-indications was lacking in37%, 88.4% and 87.1% of the advertisements respectively. Only 11.5% ofadvertisements provided information on generic name, indications, dosage, adverseeffects and contra indications. However, none of the advertisement was "complete"on the basis of the indicators of WHO guidelines and IFPMA codes.Key Words: Medical drug advertisement, drug information, WHO guidelines, IFPMA code.

Recent Trends in Chemotherapy in Malaria

Abstract

Pattern of drug utilization in acute tonsillitis in a teaching hospital in Nepal

OBJECTIVE

A prospective study was undertaken to find out the baseline data on prescribing patten of drugs in acute tonsillitis.

METHODS

Prescriptions far acute tonsillitis were collected outside the ENT-OPD over a period of 6 months and were analyzed.

RESULTS

The average number of drugs per prescription was 3.24. Ninety five percent of the prescriptions contained antimicrobial agents (AMA with an average of 1.03 AMAs per prescription. AMA was the most commonly prescribed (31.81%) group of drugs followed by analgesics and antipyretics (20.70%). Amoxicillin (38.80%) and azithromycin (20.63%) were the most commonly prescribed AMAs. Erythromyein was prescribed in 11(6.73) patients while penicillin was not at all prescribed. Culture and sensitivity test was advised only in 14.75% of cases. Cough expectorants were the most commonly used fixed dose combination. Of the total drugs used, 96.9% were prescribed by brand names. The duration of therapy was not mentioned for 35.60% of the drugs prescribed. the iatyprtyriate and over use off antimicrobil agents make treatment east effective.

Adverse drug reaction monitoring: knowledge, attitude and practices of medical students and prescribers

BACKGROUND

Adverse drug reactions (ADRs) contribute to excessive health care costs through increased patient morbidity and mortality. Thus, there is an urgent need to create awareness among physicians towards ADR monitoring. The present study was designed to assess the knowledge, attitude and practices of fifth semester undergraduate students and prescribers (interns, junior residents and senior residents) towards the recording and reporting of ADRs.

METHODS

The fifth semester MB,BS undergraduate students (n=107) and prescribers (n=l 17) working in different disciplines of Lady Hardinge Medical College and associated hospitals were given a questionnaire to answer. The responses of the undergraduate students were compared with those of prescribers.

RESULTS

Knowledge about definition, classification, objectives and methods of ADR monitoring was found to be comparable in both groups. Spontaneous and intensive methods of ADR monitoring were known to the majority of participants of both groups. Attitude and practices of the prescribers were significantly (p<0.01 ) better with regard to the status of ADR monitoring in the institute. A significantly higher (p<0.001) proportion of prescribers (82%) as compared to the undergraduate students (64.5%), felt that ADRs should be reported both when it causes inconvenience to the patient as well as death. ADRs were encountered by both undergraduates (46%) and prescribers (66%) during their clinical project exercises and patient care, respectively. Commonly encountered ADRs were allergic reactions, symptoms of upper gastrointestinal irritation, extrapyramidal symptoms and hepatitis. The common offending groups of drugs causing these ADRs were non-steroidal anti-inflammatory drugs, antidopaminergics and chemotherapeutic agents. A majority of ADRs were suspected and subsided on their own by either stopping the drug or reducing its dose.

CONCLUSIONS

The knowledge, attitude and practices of both undergraduates and prescribers were comparable but need further improvement. This suggests the need for suitable changes in the undergraduate teaching curriculum. Further, the prescribers also need periodic reinforcement regardingADR monitoring.

Drug prescribing pattern of interns at a government healthcare centre in northern India

Prescribing habits of interns posted at a primary health centre for a period of 2 months (January 1994 and February 1994) were studied. Among the 1457 prescriptions collected, the average number of drugs per prescription was 2.47. The commonest groups of drugs prescribed were antibiotics (33.9%), analgesics and anti-inflammatories (17.0%), vitamins (13.0%), cough syrups (10.5%) and antihistamines (8.6%). The use of injectables was uncommon (0.9%). Most of the drugs prescribed were from the local drugs list of the centre (84.2%) consisting of 36 drugs. The list contained 20 drugs with proprietary names of which six were fixed-dose combinations. The local drug list needs modification. The proportion of drugs prescribed by generic name was 49.5%. As per Kunin's criteria, 57.9% of the antibiotics used were appropriate. Interns often forget to write the diagnosis (43%), signs and symptoms (50.2%), dosages and frequency of treatment. The result of this baseline study may be useful in promoting the education necessary in order to achieve the objectives of good prescribing.

Study of drug utilization pattern in dental OPD at tertiary care teaching hospital

Irrational prescribing is a global phenomenon. The objective of the study was to find out the prescribing practices of dental prescribers in a tertiary care teaching hospital with special emphasis on the utilization of antimicrobial agents. A prospective study was conducted in the month of March 2000. A total of 491 prescriptions were collected randomly. Prescribing pattern was analyzed using WHO basic drug indicators. The average number of drugs for prescription was 2.4. 78.8% of all prescriptions contained antimicrobial agents. It was most commonly prescribed (40.37%) group of drugs followed by anti-inflammatory and analgesics (33.8%). Fixed dose combination of ampicillin and cloxacillin was most commonly prescribed antimicrobial agents. Prophylactic use of AMA (78%) was more than therapeutic purpose (21.9%). Prophylactic use of antimicrobial agents was irrational in all the cases as duration for the use of antimicrobial agents was 5.1 +/- 0.5 days. Fixed dose combinations (45%), drugs by brand name (98.5%) were frequently used. Drug prescribed from Essential Drug List was maximum when one drug was prescribed. Results indicate that there is a scope for improving prescribing habits and minimizing the use of antimicrobial agents. This could be facilitated by periodic education to the prescribers.

Pupils Need To Know More About Use of Medicines and self-care

Abstract