Anti-tubercular therapy (ATT) induced thrombocytopenia: A systematic review

INTRODUCTION

Drug-induced thrombocytopenia is a known adverse event of several drugs. Antitubercular therapy (ATT) is rarely reported but important cause of thrombocytopenia. The present review aimed to understand the profile of thrombocytopenia caused by first-line ATT i.e. isoniazid, rifampicin, pyrazinamide, and ethambutol.

MATERIALS AND METHODS

We screened case reports, case series, and letter-to-editor from databases, like Pubmed/MEDLINE, Ovid, and EMBASE from 1970 to 2021. The PRISMA guidelines were followed in the present systematic review.

RESULTS

Categorical data were expressed as n (%) and quantitative data were expressed as median (IQR). After applying the inclusion/exclusion criteria, 17 case reports and 7 letters to the editor were selected for the present review. Rifampicin was most frequently associated with thrombocytopenia (65%). A median (IQR) drop to 20,000 (49,500) platelets/mm3 was observed. Anti-rifampicin associated antibodies and anti-dsDNA positivity were found in six studies. Except for two, all patients responded to symptomatic treatment.

DISCUSSION

ATT-induced thrombocytopenia can be life-threatening and require hospitalization. Clinicians should be aware of the association of ATT with thrombocytopenia and should take appropriate measures for patient management.

CONCLUSION

This review provides clinicians a comprehensive picture of adverse effects and their management in ATT induced thrombocytopenia.

Efficacy and safety of aspirin as an adjunctive therapy in tubercular meningitis: A systematic review and meta-analysis

BACKGROUND

Tubercular meningitis (TBM) is associated with high mortality and stroke with chronic neurological sequelae even with best of care and antitubercular therapy. Studies have shown that aspirin as an adjunctive therapy might play some role in management of TBM. This systematic review and meta-analysis has been planned to evaluate the efficacy and safety of aspirin as an adjunctive therapy in TBM patients.

METHODS

We conducted a systematic search of randomized controlled trials in patients with tubercular meningitis published till October 2019 in all major clinical journals. Study was registered with PROSPERO with registration number: CRD42019136689. Articles were tested for eligibility and assessed for quality and various bias. Data synthesis and analysis was done using Review manager 5.3. The primary end point for assessment of efficacy was mortality at three months. The secondary end point was stroke or composite outcome of stroke and mortality at three months. Adverse effects were also assessed as secondary safety end point.

FINDINGS

Overall, three eligible randomized controlled trials with 365 participants were included that provided quantitative data for this meta-analysis. The analysis of primary and secondary end points was done using fixed effect model. There was not significant reduction in mortality [hazard ratio 0.78 (95% CI 0.45-1.35, p = 0.37)] and composite outcome of mortality and new onset stroke [hazard ratio 0.86 (95% CI 0.60-1.24, p = 0.43)] in aspirin group as compared to placebo. However, aspirin as compared to placebo significantly reduced new onset stroke [hazard ratio of 0.51 (95% CI 0.29-0.87, p = 0.01)].

INTERPRETATION

We did not find significant reduction in mortality and composite outcome (mortality and new onset stroke) with aspirin as compared to placebo but there was significant reduction in new onset stroke in aspirin group as compared to placebo with Number Needed to Treat (NNT) = 10, which might be of clinical importance since stroke is responsible for high mortality and morbidity in these subset of patients. However, a large well conducted randomized controlled trial is required to put more light on the available evidence.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Fixed-dose combinations of antimicrobials: A need for special attention

OBJECTIVE

To highlight the issue of freely available fixed-dose combinations (FDCs) of antimicrobials.

METHODS

A critique of two such antimicrobial FDCs was undertaken wherein the following aspects were assessed - rational and regulatory issues and justification for clinical use. Available in vitro, in vivo (animals and humans) evidence from published literature was analysed.

CONCLUSIONS

There are several inadequately addressed aspects of the considered FDCs which are available in Indian market. In view of the growing problem of antimicrobial resistance, this issue must get the required attention.

Hydroxychloroquine's Efficacy as an Antiplatelet Agent Study in Healthy Volunteers: A Proof of Concept Study

BACKGROUND

With the inflammatory model of atherosclerosis taking center stage, anti-inflammatory drugs hold a promising place in the therapy of cardiovascular disease (CVD). Recent studies showed that hydroxychloroquine (HCQ) was protective against thrombovascular events in lupus erythematosus and traditional cardiovascular risk factors in patients with rheumatoid arthritis. Some preliminary experimental data have shown that it may prevent platelet activation too.

OBJECTIVE

To evaluate the antiplatelet activity of HCQ when given alone and in combination with aspirin (ASA) and compare it with ASA alone and ASA plus clopidogrel (CLOP) in healthy human volunteers.

METHODS

In part 1 of the study, 8 volunteers were given HCQ for 7 days. In part 2, 12 volunteers were randomly assigned in a 1:1:1 ratio to the 3 groups in which 2 of the 3 treatments, ASA, ASA plus CLOP, and ASA plus HCQ, were given in the 2 treatment periods separated by a 14-day washout period using the incomplete block design. Inhibition of platelet aggregation (IPA) was measured by light transmission aggregometry.

RESULTS

When arachidonic acid (AA) was used as agonist, HCQ given alone showed a significant reduction in platelet aggregation (11.0% ± 4.2%, P = .03). The IPA was significantly increased when ASA plus HCQ was compared with ASA alone (31.2% ± 8.1%, P = .002). This synergistic effect was not seen with adenosine diphosphate and collagen as agonists. Levels of serum 11-dehydrothromboxane B2, a stable marker of thromboxane A2 production, were not significantly different between the groups. There was also a significant decrease in fibrinogen and erythrocyte sedimentation rate values when HCQ was used alone or in combination with ASA.

CONCLUSION

This study suggests that HCQ has antiplatelet properties possibly through the AA pathway (downstream to thromboxane A2 production). With possible additional beneficial effects over the traditional CVD risk factors, larger studies in the future might explore HCQ's potential as an antiplatelet agent.

Development of tool for the assessment of comprehension of informed consent form in healthy volunteers participating in first-in-human studies

Informed consent is a process that involves providing all pertinent study information to the potential study participant. The information imparted in the form gives all such information as would enable a potential participant to come to a decision regarding his/her participation in the study. Various study related aspects are outlined in the participant information leaflet including the background of the study, the benefits and risks, treatment alternatives; the methodology of the study, follow up schedules, confidentiality of the data, compensations and remunerations and right to not participate or withdraw from the study. We have continued a similar exercise for a phase I, first-in-human study, conducted by our center. Here, the volunteers were asked certain questions pertaining to the trial background, design, patients' rights and miscellaneous categories. They were then assessed and the scores compared to come up with certain conclusions. The median (range) for the entire comprehension score was calculated and statistically analyzed on various aspects. Readability of the ease of reading of the consent form was also analyzed on a Flesch-Kinkaid reading scale. A total of 69 volunteers were screened out of which 50 were enrolled in the study. The median (range) score was 27 (19 to 33) and the mean (S.D.) score was 28.9 (3.1). The maximum correct responses were observed for the questions falling under the volunteers' rights category. The Flesch reading ease score was 54 and the Flesch-Kincaid Grade level score was 9.8. Investigators may be encouraged to incorporate such tools in their informed consent process.

Evaluation of the ability of clinical research participants to comprehend informed consent form

BACKGROUND

The comprehension of informed consent is an integral part of clinical trials. Though India is rapidly becoming a hub of clinical trials very few studies have dealt with the issue of comprehension of informed consent by the patients participating in these trials.

METHODS

Patients who were invited to participate in a phase 3 multicentric trial of a novel lipid lowering agent were evaluated for comprehension score. The participants were explained about the structured consent form which included the question on background details for the study, design of the study, rights of the patients and miscellaneous aspects pertinent to the clinical trial. The questionnaire comprised of 24 items and each correct answer was assigned a score of 1. Total comprehension score (CS) was obtained by summing all the scores.

RESULTS

Participants were from diverse socio economic and educational backgrounds. The mean +/- SD CS achieved by the participants was 13.4 +/- 2.9; median 14(6 to 20). The highest correct responses were obtained for questions on background details (38%). For most of the categories the mean CS was more than 50%. Aspects related to design were mostly difficult to comprehend. No significant difference in the CS was noted between participants from different educational and socioeconomic groups. 8 patients refused to give consent, fear of adverse drug reactions (n = 3) and inability to follow up (n = 5) were the reasons cited by the patients.

CONCLUSION

In conclusion, CS of patients in trials conducted in developing countries can be reasonably good if the investigators explain the consent form in simple language to the participants and CS is not related to the educational status of the participants. Moreover, though a larger majority of patients agree to participate after knowing study details, some patients exercise their right to refuse.

A meta-analysis of trials comparing Cypher and Taxus stents in patients with obstructive coronary artery disease

AIMS

Drug-eluting stents have been shown to be superior to bare metal stents in reducing restenosis rates. Recently head-to-head trials comparing sirolimus-eluting stents and paclitaxel-eluting stents have been reported. An early combined analysis of these comparative trials is needed. The present meta-analysis was carried out to compare the effects of sirolimus-eluting stents with paclitaxel-eluting stents on the restenosis rate, major adverse cardiac events and late loss of arterial lumen diameter in patients with obstructive coronary artery disease.

METHODS

Electronic (Medline, Cochrane and Embase) and manual search (Index Medicus and cross references of retrieved articles) were carried out for all the relevant articles up till March 2005. Only randomized trials with adequate data for calculation of odds ratio for restenosis rates and major adverse cardiac events using the method of DerSimonian & Laird and standardized mean difference for late loss of arterial lumen diameter were included.

RESULTS

Four studies were found to be eligible for inclusion in the meta-analysis. Restenosis rate and late loss of arterial lumen diameter were significantly reduced by sirolimus-eluting stents as compared with paclitaxel-eluting stents (OR 0.598, 95% CI 0.400, 0.893, pooled mean difference -0.414, 95% CI -0.492, 0.336, respectively). The incidence of major adverse cardiac events was less with sirolimus-eluting stents as compared with paclitaxel-eluting stents (OR 0.727, 95% CI 0.518-1.018) but the results were not statistically significant.

CONCLUSIONS

Sirolimus-eluting stents are superior to paclitaxel-eluting stents in decreasing restenosis rate and late loss of arterial lumen diameter. However, no statistically significant difference in major adverse cardiac events was noted between the two stents.

A randomized controlled clinical trial to evaluate the efficacy, safety, cost-effectiveness and effect on PAI-1 levels of the three low-molecular-weight heparins--enoxaparin, nadroparin and dalteparin. The ESCAPe-END study

BACKGROUND

Comparative data for efficacy and safety between various low-molecular-weight heparins (LMWHs) in patients with unstable angina is not available. The present study was conducted to compare the efficacy, safety, cost-effectiveness and effects on plasminogen activator inhibitor-1 (PAI-1) levels of three LMWHs--enoxaparin, nadroparin and dalteparin.

METHODS

The study was a prospective, randomized, comparative, open with blinded endpoints (PROBE design) assessment with a 30-day follow-up. The primary endpoint of efficacy was a composite of cardiovascular death, myocardial infarction, recurrent angina and need for intervention. Cost-effectiveness was calculated by calculating the incremental cost-effectiveness ratio. Plasma PAI-1 levels were estimated by ELISA.

RESULTS

A total of 150 patients were available for intention-to-treat analysis. There was no significant difference at 30 days in the primary endpoint or in any of the individual components in the three groups. The secondary endpoint of silent ischemia was also not significantly different. Adverse events were similar in the three groups. The PAI-1 levels were not significantly different in the three groups. The total cost of treatment in the three groups was similar.

CONCLUSION

Any of the three LMWHs evaluated in this study were similar with respect to efficacy, safety, PAI-1 levels and cost-effectiveness.

Gabapentin versus nortriptyline in post-herpetic neuralgia patients: a randomized, double-blind clinical trial – The GONIP Trial

BACKGROUND

Gabapentin and nortriptyline have not been compared in a randomized trial in post-herpetic neuralgia (PHN). The present study was, therefore, undertaken to determine their comparative efficacy and tolerability in the treatment of post-herpetic neuralgia.

PATIENTS AND METHODS

The study was a randomized, double-blind, parallel-group trial of 9 weeks duration. Adult PHN patients with history of > 8 weeks of PHN pain after healing of rash, a pain intensity of at least 40 mm on a 100 mm visual analog scale at screening and at randomization, and average pain score of at least 4 on the Likert scale during the baseline week were included in the study. Gabapentin and nortriptyline were given in incremental doses at 2-weekly intervals till a maximum tolerated dose was obtained. The primary efficacy parameter was change in pain score (11-point Likert scale) from baseline to the end of the study period.

RESULTS

70 patients were available for intention-to-treat analysis. The average pain scores on the Likert scale were significantly reduced at the end of study in both the treatment groups with 47.6% and 42.8% reduction in pain scores in nortriptyline and gabapentin groups, respectively. Patients showed significant improvement in sleep scores in both the treatment groups nortriptyline (46.0%) and gabapentin (52.0%). The VAS and the SF-MPQ scores for pain were significantly reduced in both the groups. Gabapentin was, however, better tolerated as compared to nortriptyline.

CONCLUSION

Gabapentin was shown to be equally efficacious but was better tolerated compared to nortriptyline and can be considered a suitable alternative for the treatment of PHN.

What clinical pharmacology means to us

Clinical Pharmacology is a specialty with many attributes and our association with the subject has allowed us to acquire, apply and disseminate myriad aspects of research and practice. Though clinical pharmacologists are conspicuous by virtue of their small number, recent years have shown a growing need for the course. In the review below we navigate through several aspects of the subject as we encountered them from time to time. From critical appraisal of literature, to application of knowledge of drugs, to clinical practice; moving on to clinical and basic research, to drug development process, to policy making - these are but a few of the many fields which constitute the scope of clinical pharmacology. The importance of the subject lies in allowing a trainee to develop a broad overview of the entire process, from drug generation to drug distribution to drug utilization, a process meant for the greater common goal of better health for all. We foresee a bright future for the subject though with a slight skepticism thrown in. In the present article, we make use of personal experiences and reference from literature to help you get a broad view of what clinical pharmacology means to us.

Study design and rationale of a mock phase I trial as an educational tool for clinical pharmacology residents

OBJECTIVE

To invite comments and suggestions from the phase I trialists, the world over, on the design and rationale provided by us for conducting a mock phase I trial for training clinical pharmacology residents.

METHODS

The trial will be conducted by clinical pharmacology residents of the Post Graduate Institute of Medical Education and Research. After a thorough evaluation of Preclinical toxicity data of a pharmaceutical product provided by a dummy pharmaceutical firm, a randomized, double-blind, placebo controlled, parallel group design with dose escalation of the product will be carried out. A single dose administration will be followed by monitoring the participants for 24 h and again at one week. After obtaining results of the previous group, the next higher dose will be administered. Evaluation of the learners will be done by two independent teachers who will mark them for actual conduct of the study and writing a report of the study. Subsequently, we will try to publish the results of the mock trial and invite further comments.

CONCLUSIONS

This trial designed primarily for training purposes will be instrumental in equipping the residents with the expertise for conducting phase I trials.

Comparative gastrointestinal toxicity of selective cyclooxygenase (COX-2) inhibitors

Cyclooxygenase (COX-2) inhibitors were developed with the hope that they will cause fewer gastrointestinal adverse effects. Ability of selective as well as nonselective COX inhibitors to alter ischemia-reperfusion induced damage of gastric mucosa and hapten-induced colitis in rats has been compared. Celecoxib (10, 20 and 40 mg/kg(-l)) was significantly more potent at aggravating ischemia-reperfusion injury as compared to nimesulide. Similarly, celecoxib was found to maximally potentiate TNBS-induced colitis, followed by nimesulide and indomethacin. Celecoxib at its highest dose produced maximum deep histological injury. This paradoxic ulcer and colitis aggravating effect of selective COX-2 inhibitors may be explained by suppression of protective prostaglandins generated as a consequence of COX-2 induction in inflammatory states.

A meta-analysis of clinical trials of paclitaxel- and sirolimus-eluting stents in patients with obstructive coronary artery disease

AIM

This meta-analysis was conducted to compare the effects of drug (paclitaxel and sirolimus)-eluting stents with bare metal stents on major adverse cardiac events, restenosis rates and late loss of arterial lumen diameter in patients with obstructive coronary artery disease.

METHODS

Randomized, controlled clinical trials comparing sirolimus- and paclitaxel-eluting stents with bare metal stents were identified through electronic and manual search. Fixed effects method of Mantel-Haenszel and random effects method of DerSimonian and Laird were used for computing the pooled odds ratio (OR) and 95% confidence intervals (CI) for major adverse cardiac events and restenosis rates. Standardized mean difference with 95% CI was calculated for late-loss of arterial lumen diameter.

RESULTS

A total of 13 studies were included in the meta-analysis. As compared with bare metal stents, the use of sirolimus- and paclitaxel-eluting stents significantly reduced the major adverse cardiac events (pooled OR 0.35; 95% CI 0.24-0.50), restenosis rates (pooled OR 0.27; 95% CI 0.15-0.47), and late loss of arterial lumen diameter (mean difference 0.57 mm, 95% CI 0.49-0.68).

CONCLUSION

Paclitaxel- and sirolimus-eluting stents significantly reduced the incidence of major adverse cardiac events, restenosis rates, and late loss of arterial lumen diameter as compared with bare metal stents.

A comparison of observational studies and controlled trials of heparin in ulcerative colitis

OBJECTIVES

To compare the efficacy of heparin in ulcerative colitis (UC) as demonstrated in observational studies and controlled clinical trials.

INTRODUCTION

Ulcerative colitis (UC) is a chronic condition with a relapsing and remitting course. Several studies have been conducted (observational and controlled clinical trials) to test the usefulness of heparin in this condition but the results of these studies are variable. Some studies demonstrate efficacy while others do not.

METHODS

We pooled the results of observational studies and clinical trials separately in order to compare the results of observational studies and clinical trials using meta-analysis. With the aid of Medline and a manual search in Index Medicus and cross-references of articles published up to July 2003, we identified studies designed to evaluate the effects of heparin on UC. The pooled cure rate in observational studies was calculated.

RESULTS

The results of controlled clinical trials evaluated using meta-analysis showed that the pooled cure rate for observational studies was 87.7% (range 80 - 100). The odds ratio for the controlled trial was 0.34 (95% CI 0.08 - 1.49) using a random effects model and 0.21 (95% CI 0.06 - 1.38) using a fixed effects model. The results of meta-analysis demonstrate a non-significant effect of heparin in controlled clinical trials.

CONCLUSION

The findings of the clinical trials differ markedly from observational studies and indicate a lack of efficacy of heparin in patients with ulcerative colitis.

COX-2 inhibitors: a CLASS act or Just VIGORously promoted

Abstract Selective cyclo-oxygenase (COX)-2 inhibitors were developed with the hope of producing lesser gastrointestinal (GI) side effects as compared with the conventional nonsteroidal anti-inflammatory drugs (NSAIDs). Soon after their introduction into the market, the sales of celecoxib and rofecoxib went up considerably. Most of this was attributed to the results of the Celecoxib Long-term Arthritis Safety Study (CLASS) and Vioxx Gastrointestinal Outcome Research (VIGOR) trials. However, several discrepancies were noted in the presentation of the actual trial results submitted to the US Food and Drug Administration (FDA) and those used for the purpose of publication in scientific journals. These issues were discussed subsequently by the way of scientific communications. Moreover, with increasing use of these agents, evidence of their adverse effects is coming to light. The present review aims at discussing the above issues, with emphasis on the results of the CLASS and VIGOR trials.

Comparison of nonselective cyclo-oxygenase (COX) inhibitor and selective COX-2 inhibitors on preimplantation loss, postimplantation loss and duration of gestation: an experimental study

Comparison of effect of three cyclo-oxygenase (COX) inhibitors, indomethacin, nimesulide and celecoxib, on the following were assessed: preimplantation loss, postimplantation loss and duration of gestation in Wistar rats. Indomethacin (2.5 and 10 mg/kg), nimesulide (10 and 40 mg/kg) and celecoxib (10 and 40 mg/kg) were administered by gavage daily from days 1-7 for preimplantation loss studies and from day 13 to completion of gestation for postimplantation and duration of gestation studies. Number of animals in each group was six. Preimplantation loss was calculated by subtracting number of implantation sites from number of luteal spots and postimplantation loss was calculated by noting the difference between implantation sites and pups delivered. The higher doses of the three drugs were shown to increase significantly the preimplantation loss, while all the doses of three drugs produced a significant increase in postimplantation loss. Number of animals crossing upper limit of 23-day normal gestation period in Wistar rats was increased in the higher doses. At comparable dose levels, there was no significant difference among the three drugs.

Prevalence and pattern of use of complementary and alternative medicine (CAM) in hypertensive patients of a tertiary care center in India

OBJECTIVE

To study the prevalence and pattern of use of complementary and alternative medicine (CAM) in patients with essential hypertension.

METHOD

521 consecutive patients visiting the Hypertension Clinic at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, over a 6-month period were interviewed. Information was gathered on the patients' demographics, type(s) of CAM used, sequence of seeking CAM and conventional medicine, sources of recommendation, reasons for opting for CAM and areas of satisfaction and dissatisfaction associated with the use of CAM. Patients were also asked if they had informed their doctor about CAM use.

RESULTS

It was observed that 63.9% of patients overall used CAM. Ayurveda was the most commonly used CAM (56.7%), followed by herbal medicines (14.4%). The most commonly cited reason by patients for using CAM was fear of adverse drug reactions of conventional medicines (59.0%). However, more than half of the patients eventually became dissatisfied using CAM. Only 5.4% of CAM users had informed their medical doctors about the use of CAM.

CONCLUSION

A significant proportion of patients receiving conventional treatment for hypertension also use CAM therapies. A better understanding of the pattern of CAM use amongst these patients will help dispel prevalent misconceptions concerning CAM and, at the same time, assist conventional practitioners to critically evaluate possible gaps or omissions in their own prescribing habits.

Anticonvulsant action of celecoxib (alone and in combination with sub-threshold dose of phenytoin) in electroshock induced convulsion

Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor, COX-2 has been shown to be upregulated by convulsive nerve activity. Various earlier studies have given conflicting reports on the effect of COX inhibitors on seizures. This study investigates the effect of pretreatment with celecoxib alone, or in combination with phenytoin, on electroshock-induced convulsions. Both percentage protection (i.e., the percentage of animals not showing Tonic Hind Limb Extension [THLE] when a fixed dose of current is administered) and CC50 (i.e., the threshold current inducing THLE in 50%) was determined using a technoconvulsometer. Celecoxib and phenytoin were administered 1 and 2 h, respectively, prior to the experiments. When administered alone, celecoxib showed an increase in percentage protection at increasing doses, with maximum percentage protection (66.6%) occurring at a 30 mg/kg-1 dose. The ED25 value of celecoxib was calculated to be 8.03 mg/kg-1. The CC50 values for the treatment groups were significantly increased compared with the control group (CC50 values for control, celecoxib 10 mg/kg-1, celecoxib 20 mg/kg-1 and celecoxib 30 mg/kg-1, respectively, were 36.3, 49.12, 100.3 and 125.02 mA). An increase in percentage protection was noted when celecoxib 8.03 mg/kg-1 was coadministered with phenytoin 6 mg/kg-1 (66.6% with the combination vs. 16.6% when administered individually). A significant increase was noted in the CC50 value in a combination regimen (CC50 = 79.06) compared with either drug administered alone (CC50 = 49.12 with celecoxib 8.03 mg/kg-1 and 62.06 with phenytoin 6 mg/kg-1). This study may stimulate further interest in the role of COX-2 inhibitors in the modulation of seizure activity.

Patterns and perceptions of complementary and alternative medicine (CAM) among leukaemia patients visiting haematology clinic of a north Indian tertiary care hospital

PURPOSE

The use of complementary and alternative medicine (CAM) in cancer treatments is widespread with substantial number of patients deserting conventional cancer therapies in favour of unproven methods. The present study aimed at discovering the prevalence of use of CAM cancer therapies in leukaemia patients visiting haematology clinic of a north Indian tertiary care hospital.

METHODS

533 consecutive leukaemia patients were interviewed. Information was gathered about patients' demographics, types of CAM taken, sequence of seeking CAM and conventional medicine, sources of recommendation, reasons of opting for CAM, and areas of satisfaction and dissatisfaction associated with the use of CAM. Patients were also asked if they had informed their doctor about CAM use.

RESULTS

Prevalence of CAM use in leukaemia patients was found to be 56.6%. Ayurveda was the most commonly used CAM (33%). Most of the patients sought conventional medicine first, followed by CAM therapies. Fifty-two percent of the patients opted for CAM hoping for a miracle cure and 51% were dissatisfied with these therapies. Family members and neighbours constituted major source of recommendation of CAM therapy. Only 3.8% of the patients had informed their doctors about CAM use.

CONCLUSION

A sizeable percentage of patients receiving conventional treatment for leukaemia also use CAM therapies. Clinicians should not underestimate the value of hopeful attitude in their management of leukaemia patients and ought to be conversant with popular forms of CAM cancer therapies.

Effect of cyclooxygenase inhibitors in postoperative ileus: an experimental study

The aim of our study was to investigate the effect of various cyclooxygenase (COX) inhibitors (namely, indomethacin [a nonselective COX inhibitor], nimesulide [a partially selective COX inhibitor] and celecoxib [a highly selective COX inhibitor]) on postoperative ileus in rats. Equianalgesic doses of the three drugs were determined previously by formalin-induced hyperalgesia. Three comparative doses of the drugs were taken. After overnight fasting, a standardized laparotomy was performed on the rats. Bowel motility was determined by the charcoal meal test. The distance traveled by the charcoal meal was expressed as a percentage of the total length of the small intestine. The animals were pretreated intraperitoneally with either indomethacin (2.5, 5.0 and 10 mg/kg), nimesulide (10.0, 20.0 and 40 mg/kg), celecoxib (10.0, 20.0 and 40 mg/kg) or vehicle 1 h prior to the experiment. The lowest doses at which an increase in postoperative bowel motility occurred were 10 mg/kg of indomethacin and 20 mg/kg for both nimesulide and celecoxib. For equianalgesic doses it was noted that celecoxib was more effective than nimesulide or indomethacin in increasing postoperative bowel motility (52.15 +/- 1.08, 55.11 +/- 0.87 and 60.65 +/- 1.22 at the highest doses of indomethacin, nimesulide and celecoxib, respectively).