Methotrexate induced ventricular arrhythmia as a medication error: a case report

Methotrexate (MTX) is the most widely used drug in clinical practice for long term treatment of connective tissue disorders. As this drug has narrow therapeutic index, if it goes unmonitored can lead to life threatening complications. Herein we are describing the case of a patient who presented with ventricular arrhythmia, due to failure to execute MTX therapy in the prescribed frequency and took daily dose of MTX which was meant to be taken as a weekly dose pointing to failure of patient education or patient comprehension regarding MTX and finally succumbed due to cardiogenic shock. We concluded this causality as probable/likely category according to WHO-UMC causality categories.

Warfarin induced hematuria

Warfarin is an oral vitamin K antagonist prescribed to those patients for the treatment and prevention of thromboembolism. The major challenges to be faced during the therapy were a greater risk for both major as well as minor bleeding, which makes the regular monitoring of INR (international normalized ratio) mandatory. Herein, we reported a case of Warfarin induced hematuria which is serious and we concluded this causality as possible category according WHO-UMC causality category.

Piperacillin-tazobactam induced hypokalaemia

Electrolytes imbalance has been reported with the use of several antimicrobials in clinical scenarios. Piperacillin/tazobactam is a commonly used antibiotic with tolerable side effects and broad antimicrobial activity in general practice. Herein we report a case of a 27 year old male presented with Road Traffic Accident with depressed frontal bone fracture, fracture humerus and fracture of great toe complicated with Ventilator associated Pneumonia (VAP) who developed hypokalemia secondary to intravenous piperacillin-tazobactam. Upon withdrawal of the drug, serum potassium normalized in 2 days. There were no other underlying renal or hepatic illness and other causes of hypokalemia. Hypokalemia is a serious adverse effect of piperacillin-tazobactam and should be suspected while treating patients with this drug in clinical practice especially in Intensive Care Units (ICU). We concluded this causality as probable/likely category according to WHO-UMC Causality Categories.

Primary dysmenorrhea: evaluation and treatment pattern among female medical students

Background: Dysmenorrhea is a very common condition in females in fertile age group and its affective and somatic features often limit female mobility which results in loss of work hours. The aim of the study was to evaluate prevalence, severity, drug usage and loss of work days among young female medical students.Methods: The current questionnaire based study was done in Department of pharmacology, GMC Jammu over a period of 3 months. Female students aged between 17-24 years who consented for participation were included. The demographic profile and detailed history of dysmenorrhea was recorded.Results: Out of 342 participants, 218 females (63.7%) had history of dysmenorrhea. Most of the dysmenorrhic females had menarche between 13-14 yrs of age (73.3%) and menstrual cycle of 21-34 days (82.5%), duration of bleeding less than 6 days (91.6%) and had a positive family history of dysmenorrhea (58.7%). Majority of females had mild to moderate features of dysmenorrhea (93.4%). Most common medication was Mefenemic acid alone and in combination (90.5%). Most of the females took self-medication (69.8%) and only 30.2% took medicines on advice of doctor. 71.5% students missed their classes due to symptoms of dysmennorhea.Conclusions: Dysmenorrhea is quite prevalent among college going medical students. Most of them had positive family history. Mefenemic acid and its combination was frequently used to treat symptoms. On an average 1-2days were lost due to dysmenorrhea.

Analysis of drug related electrolyte disturbances in emergency medicine department

Background: Electrolytes play an important role in various physiological functions of the body. Electrolyte disturbances are one of the most common problems encountered in critically ill patients. Drugs are also known to cause adverse electrolyte consequences. These drugs could be anti-hypertensive agents, hormones, antipsychotics or steroids. There is paucity of published literature on electrolyte disturbances caused by drugs. The purpose of our study was to evaluate the electrolyte disturbances caused by various drugs in critically ill patients.Methods: Following approval of the Institutional Ethics Committee, data collection was started. Adverse Drug Reactions (ADRs) presenting as an electrolyte disturbance in emergency medicine department or occurring in hospitalized patients in the Intensive care unit (ICU) of our hospital was be collected. ADRs resulting into electrolyte disturbances were identified and analysed in detail for demographic details, types of electrolyte disturbances, seriousness, severity, causality and preventability of ADRs. Fisher's exact test was done to find out the statistical difference between the electrolyte disturbances and different drugs.Results: Total 58 ADRs were reported as an electrolyte disturbance. Mean age of the patients affected was 52.48 years. Highest number of ADRs were observed in the age group of 61 to 70 years. Hypokalemia constituted 32 cases (55.2%) followed by hyponatremia (25.9%), hyperkalemia (6.9%), hypernatremia (6.9%), hypocalcemia (1.7%), hypomagnesemia (1.7%) and hypophosphatemia (1.7%). Insulin was associated with maximum cases of ADRs (27.6%).Conclusions: Electrolyte disturbances constitutes a major chunk of ADRs especially in critically ill patients. The physicians must be well-versed with the dynamics of fluid-electrolyte balance.

Analysis of adverse drug reactions in a tertiary care emergency medicine department: prevalence, preventability and reporting

Background: Adverse drug reactions (ADRs) are negative consequences of drug therapy. ADR results in diminished quality of life, increased physician visits, hospitalizations, and even death. Hence a study was planned to detect and analyze ADR encountered in emergency medicine department.Methods: Data was collected over a period of 1 year after taking approval from IRB (Institutional Review Board) and written informed consent from patients. ADRs presenting as a cause of hospital admission or developed during hospitalization were analyzed.Results: A total of 229 ADRs were analyzed. Majority of ADRs were found in the age group of 40-60 Years. The M: F Ratio was 1.10:1. According to Wills and Brown Classification, majority of the ADRs belonged to Type A. According to Hartwig and Siegel classification of severity of ADRs, 18.78% of the ADRs were severe in nature. According to Schumock and Thornton preventability score, majority (64.19%) of the ADRs were not preventable, whereas 17.03% were definitely preventable. 120 (52.40%) of the ADRs were serious in nature Anti-infective were the most common drug class (30.13%) followed by CVS (24.03%) group of drugs. About (57.64%) ADRs fall in the category of probable/likely. Regarding their Outcome, 44.10% of the ADRs were recovered and 43.23% were recovering.Conclusions: Anti-infective were the most reported drug class to cause ADRs in a tertiary care emergency medicine department. Causality assessment according to WHO-UMC and Naranjo’s causality assessment criteria reported to be Probable. Whereas modified Schumock and Thornton scale preventability scale showed that majority were not preventable.

A case series on drug induced hyponatremia: uncommon adverse effect of commonly used drugs

Older patients suffering from depression and psychosis have markedly increased since last decade. So, has the use of antidepressants and antipsychotics. The prevalence of hyponatremia due to these drugs is common in general as well as psychiatric practice. It may also lead to life threatening morbidity and mortality. Loss of renal function, polypharmacy, dementia and other conditions of advanced age can either exacerbate the severity of hyponatremia or mask its onset. In this case series, total four cases were reported of hyponatremia and drugs causing it were escitalopram, quetiapine, tianeptine and oxcarbazepine. Due to polypharmacy, a chance of hyponatremia was more in these patients. Patients received infusion of hypertonic saline with salt added diet to treat hyponatremia. Symptoms of hyponatremia were improved after the treatment. In all four cases, WHO and Naranjo’s causality assessment revealed ‘possible’ causal relationship with the prescribed drug. Prescribers should be aware of such adverse effect due to these drugs.

Sirenomelia: A Rare Entity

Sirenomelia also called as Mermaid Syndrome, is a rare congenital malformation of uncertain aetiology. It is characterised by fusion of the lower limbs and commonly associated with severe urogenital and gastrointestinal malformation. It should be suspected in antenatal period in cases presenting with severe oligohydramnios and intra-uterine growth retardation. Here, we report a case of sirenomelia in a 26th weeks foetus.

Sirenomelia: A Rare Entity.

Sirenomelia also called as Mermaid Syndrome, is a rare congenital malformation of uncertain aetiology. It is characterised by fusion of the lower limbs and commonly associated with severe urogenital and gastrointestinal malformation. It should be suspected in antenatal period in cases presenting with severe oligohydramnios and intra-uterine growth retardation. Here, we report a case of sirenomelia in a 26th weeks foetus.

Extended spectrum β--lactamases in Escherichia coli & Klebsiella pneumoniae & associated risk factors.

Background & objectives: Extended spectrum β-lactamases (ESBLs) have emerged as a major threat worldwide with limited treatment options. The genotypes of ESBL producing strains largely remain unknown in India; hence the present study was aimed to determine the occurrence of ESBLs in Escherichia coli and Klebsiella pneumoniae, their molecular types and associated risk factors in a tertiary care hospital. Methods: Total 200 consecutive clinical isolates of E. coli (n=143) and K. pneumoniae (n=57) collected between February and July 2006 at Sanjay Gandhi Postgraduate Institute of Medical Sciences, a tertiary care hospital in north India, were examined phenotypically for ESBL production. ESBL strains were further typed for the blaTEM/SHV/CTX-M genes by PCR using specifi c primers. The blaCTX-M cluster was identifi ed by restriction analysis and genotype by sequencing of PCR product. Resistance to other antimicrobial agents was also studied. Various risk factors associated with ESBL infections were analyzed by logistic regressions. Results: ESBLs were found in 63.6 per cent E. coli and 66.7 per cent K. pneumoniae isolates. Majority of the typeable isolates harboured two or more ESBL genes (57.3%). Overall blaCTX-M was the commonest genotype (85.4%) followed by blaTEM (54.9%) and blaSHV (32.9%) either alone or in combination. All CTX-M enzymes in E. coli and 87.5 per cent in K. pneumoniae belonged to the CTX-M-1 cluster. Sequencing was done for randomly selected 20 blaCTX-M PCR products and all were identifi ed as CTXM- 3. Resistance of ESBL isolates to other antibiotics was amikacin 14.7 per cent, gentamicin 66.7 per cent, trimethoprim/sulphamethoxazole 79.1 per cent and ciprofl oxacin 93.8 per cent. Prior antibiotic exposure, use of intravenous device and urinary catheter, renal insuffi ciency and ICU admission were associated with ESBL infection on univariate analysis. On multivariate, antibiotic exposure (P=0.001) and use of urinary catheter (P<0.001) were identififi ed as risk for ESBL infection. Interpretation & conclusions: Our study showed high ESBL occurrence with CTX-M as the emerging type in our hospital and CTX-M-3 being reported for the fi rst time in India. High co-resistance to other non-β-lactam antibiotics is a major challenge for management of ESBL infections.

Effects of tamoxifen therapy on plasma lipid profile in patients of breast cancer.

AIM: To evaluate the effects of tamoxifen therapy on plasma lipid profile in patients of breast cancer. METHOD: A total of 55 postoperative patients of breast cancer were given tablet tamoxifen 20mg orally daily for 6 months. Estimation of plasma lipid by standard method was carried out in both pre-menopausal and postmenopausal new patients of early stage breast cancer at 0 day, 3rd month and 6th months of therapy. RESULTS: Suggested that in pre-menopausal and postmenopausal patient's TC and LDL-c levels were reduced significantly, whereas, TG, VLDL-c and HDL-c were not altered. Comparison of the effects of tamoxifen in pre-menopausal and postmenopausal patients on lipid profile revealed that fall in TC and LDL-c was significantly higher at both 3 and 6 months in postmenopausal patients. CONCLUSION: The study demonstrates that tamoxifen to favorably alter the markers of cardiovascular risk in both pre-menopausal and postmenopausal patients of breast cancer.