Prescription Analysis And Prevalence Of Potentially Inappropriate Medication Use In Older Adults; An Observational Study

Objective: The objectives of the present study were to determine the prevalence of Potentially Inappropriate Medications and Adverse Drug Reactions in older adults and to collect doctors’ responses regarding the PIM list or any other criteria to treat older adults in India. Methods: This was an observational study conducted in different tertiary care hospitals of two districts, Erode and Salem after obtaining approval of the Institutional Ethics Committee. A sample of 250 older adults (60 y and above) and 97 doctors were included during the study period of 6 mo from February 2019 to July 2019. Inappropriate medications were identified by using 2019 updated Beer’s criteria. The causality of the adverse events was assessed by Naranjo Adverse Drug Reaction Probability Scale. Results: Out of the 250 prescriptions, only 86(34.4%) of the prescriptions were appropriate and 164(65.6%) were inappropriate. The most commonly inappropriate prescribed medications were diuretics, ranitidine, and tramadol. A total of 74 ADRs was observed in 74 patients. Of these, 57(22.8%) ADRs were due to inappropriate medications listed in Beers criteria. There was a significant association between the occurrence of ADRs and the use of PIMs listed in 2019 updated Beer’s criteria [χ2 = 6.08, P = 0.013 (df = 1)]. Conclusion: The study shows that there is a high prevalence of inappropriate medications and adverse drug reactions in hospitalized older adults. Beer’s criteria can be used as a guideline by the physicians while prescribing the drugs to the geriatric population.

A Short Study on Change in BP with BMI in Obese and Nonobese Young Girl Students.

Title: Short study on change in BP and BMI in obese and non obese young girl students. Introduction: High blood pressure (BP) is a major determinant of cardiovascular events in obesity. This study was undertaken to analyze the differences in certain well-defined cardiovascular parameters in obese and non-obese young girl students between age 17 to 21 with respect to their BMI. Aims and Objectives: To compare change in BP and BMI in obese and non obese young girls. Materials and methods: This study was conducted on 50 girl students of our medical college. The parameters studied were change in BP and BMI. They were divided in to 2 groups, obese and non obese. Their baseline BP, SBP after moderate exercise and their body mass index were noted. The values obtained were analyzed by unpaired t test and p value <0.05 considered as significant. Results: The mean and std dev of SBP after moderate exercise in obese and non obese young girls were 143.64±18.4184 and 132.08±12.6948 respectively and their p value is 0.0129. The mean and std dev of BMI in obese and non obese young girls were 25.7048±0.0578 and 20.8316±0.5185 respectively and their p value is 0.0001. The mean and std dev of change in BP in obese and non obese young girls were 32.6±18.5539 and 22.24±12.2925 respectively and their p value is 0.0242. Conclusion: There is a significant rise in SBP in obese girls with moderate exercise limiting their physical abilities.

Diagnostic value of C-reactive protein in suspected acute appendicitis - A prospective case control study.

Aim: To find out the Sensitivity, Specificity and Predictive value of C-reactive protein in the diagnosis of acute appendicitis. Materials and Methods: Hundred patients undergoing emergency appendicectomy were cases and thirty patients undergoing interval appendicectomy during the same period were controls. Creactive protein was measured pre-operatively. Results: CRP was reactive in 89% of cases and 3 of 30 controls (P = 0). Among the thirteen complicated cases, two had a CRP reactivity of 1.2 mg/dl, eight had 2.4 mg/dl and three had 3.6 mg/dl. In the uncomplicated cases, forty nine were reactive at 1.2 mg/dl, twenty six at 2.4 mg/dl and one at 3.6 mg/dl ( P = 0.0009). In histopathologically inflamed appendix, reactivity was 94.4% and in normal appendix reactivity was 40% ( P = 0.00007). CRP positivity had a sensitivity of 94.4% (CI 89.9-98.9) and a positive predictive value of 95.5% (CI 91.4-99.6). CRP reactivity and leucocytosis if combined, the sensitivity, specificity, PPV and NPV were 85%, 100%, 100% and 81% respectively. Threshold for CRP reactivity if raised to 2.4 mg/dl, the sensitivity, specificity, PPV and NPV are 42%, 100%, 100% and 16% respectively. Conclusion: CRP estimation is a good 'rule-in' test and not-so-good 'rule-out' test to diagnose acute appendicitis.

Comparative study of angiotensin converting enzyme inhibitor and calcium channel blocker in the treatment of steroid-resistant idiopathic nephrotic syndrome.

BACKGROUND: The aim of this study was to evaluate and compare the anti-proteinuric effect of ramipril and verapamil in patients with steroid-resistant idiopathic nephrotic syndrome. Twenty one (21) cases of steroid-resistant idiopathic nephrotic syndrome were randomized to receive ramipril (11) and verapamil (10) and were followed up for 12 months; monthly for the 1st 3 months and then every 3 months for the remaining study period. The degree of reduction of proteinuria, blood pressure, serum creatinine, serum albumin and side effects were noted between the two groups. The comparison within the groups over different time periods was made using paired 't' test and between the groups for specific time period by unpaired 't' test. The level of significance was taken as 5% or below. RESULTS: Seventeen patients (nine in the ramipril group and eight in the verapamil group) completed the study. The mean age of the patients, duration of illness, 24 hours urinary excretion of protein, mean arterial pressure, serum creatinine, cholesterol and albumin were similar in both the groups at time of randomization. The 24 hours urinary protein excretion decreased from 6319.44 +/- 1971.70 mg/day to 1852.44 +/- 1813.74 mg/day in patients receiving ramipril and from 5332.87 +/- 1947.47 mg /day to 2759.37 +/- 1929.6 mg/day in patients treated with verapamil after 12 months. There was no statistically significant difference in the reduction of proteinuria between the two groups. However, reduction in proteinuria was statistically significant from 2nd month onwards in Ramipril group and reduction was sustained throughout the study period. Reduction in mean arterial pressure was better achieved in Ramipril groups. The change in the serum potassium, creatinine, cholesterol and albumin were similar in either group of patients. Cough (2), hypotension (1) and reversible rise in serum creatinine (1) were observed with ramipril and no side effect was noted with verapamil. CONCLUSION: Both ramipril and verapamil can reduce proteinuria in patients suffering from steroid-resistant idiopathic nephrotic syndrome. However, ramipril had a better and sustained reduction in proteinuria with well-controlled mean arterial pressure. Verapamil can be considered as an alternative to ramipril when the use of the latter is not tolerated because of side effects and/or worsening of renal function in patients with chronic renal insufficiency.

Acute renal failure in Plasmodium vivax malaria.

OBJECTIVES: To analyze incidence, clinical feature and outcome of acute renal failure due to Plasmodium vivax malaria. MATERIAL & METHOD: This is retrospective analysis of smear positive Plasmodium vivax patients with acute renal failure between Jan 1995 to Dec 2000. RESULT: Out of 577 cases of ARF, 93 [falciparum 74 (79.61%); vivax 19 (20.4%)] were related to complicated malaria. 3.2% (19/577) patients, 16 males and three females with age range 17-72, mean 43.3 +/- 13.4 years were due to vivax malaria. Thirteen had only vivax and six had mixed falciparum and vivax infection. The presenting features were fever (100%), jaundice (36.8%), hypotension--eight (42%), encephalopathy--11 (57.9%), sepsis--five (26.3%) and DIC--four (21%). The probable contributory factors for ARF were heavy parasitemia--11 (57.9%), hypotension--six (31.5%), hyperbilirubinemia--seven (36.8%), hemolysis--eight (42%) and DIC--four (21%). Oliguria was present in 47.3%, 13 (68.4%) patients required dialysis. Mortality was noted in 15.7% (3/19) patients. CONCLUSIONS: P. vivax malaria can cause ARF, which occurs more commonly in P. falciparum malaria. Renal ischemia is the dominant pathogenic mechanism that results in acute tubular necrosis. The prognosis of ARF in P. vivax malaria is favorable.

Large thrombus in the pulmonary arteries in a case of atrial septal defect-Eisenmenger syndrome.

A 41-year-old man with atrial septal defect-Eisenmenger syndrome presented with progressively worsening breathlessness. The echocardiogram, computerized tomographic scan and magnetic resonance imaging of the thorax showed dilated pulmonary arteries and large thrombi in the right and left pulmonary arteries. Contrast-enhanced computerized tomographic scan was better than magnetic resonance imaging in picking up the thrombus. The possibility of in situ thrombus formation was considered more likely than thromboembolism, as there were none of the acute symptoms expected with the embolization of such large thrombi.

Acute renal failure complicating rifampicin therapy.

BACKGROUND : Since 1971, 55 case-reports of rifampicin-induced acute renal failure (ARF) have been published. Covic et al described 60 consecutive cases of rifampicin-induced ARF during a period of eight years (1987-1995) from Iasi Dialysis Centre, Romania. The systenic data on this condition are not available, in view of the anecdotal nature of the observation from our country. OBJECTIVE: The aims of study were to analyze clinical features, course and outcome of ARF complicating rifampicin therapy at our centre. METHODS: We retrospectively studied prevalence, clinical presentations and renal histology and outcome of 11 cases (eight males, three females, aged 42-72 years) who were referred to Nephrology Unit of University Hospital, Varanasi for acute renal failure following retreatment with rifampicin between period of 1994-1999. RESULTS: The gastrointestinal symptoms (abdominal pain, nausea and vomiting) and 'flu like' (fever, weakness and body ache) syndrome were the most frequent presenting features. The clinical signs of intravascular hemolysis were observed in four cases. The commonest laboratory findings included: Anaemia (7), leukocytosis (5), thrombocytopenia (3) and toxic hepatitis in (2) patients. Toxic hepatitis, hemolysis and ARF was seen in one patient in combination. The typical clinical features of allergic interstitial nephritis and acute tubular necrosis were seen in six and two patients respectively. Renal biopsy in three cases revealed; crescentic GN (1) and ATN in (2) patients. Acute renal failure complicating rifampicin accounted for 1.8% (11/607) of all ARF cases hospitalized in our centre during the study period. Renal function returned to normal in nine cases and one patient died on account of hepatic failure (toxic hepatitis). The patients with crescentic GN remained anuric and became dialysis dependent. Thus, clinical course of rifampicin induced ARF was favourable; with only one mortality, compared to a 18% mortality rate among all ARF patients. CONCLUSION: Acute renal failure complicating rifampicin therapy is not an uncommon condition, and typically occurs after reintroduction of rifampicin. The renal prognosis is usually favourable. Intermittent or interrupted therapy appears to be a significant risk factor for the development of acute renal failure.

Non-diabetic renal disease in patients with type 2 diabetes mellitus.

OBJECTIVES: A wide spectrum of non-diabetic renal diseases (NDRD) are reported to occur in patients with type 2 diabetes mellitus. However, the prevalence and nature of NDRD in type 2 diabetics is not widely documented in our country. Therefore, the objectives of this study were to analyse prevalence and spectrum of non-diabetic renal disease in type 2 diabetic patients. METHODS: Two hundred sixty type 2 diabetic with clinical renal diseases were screened for evidence of NDRD, between April 1997 to March 1999. Renal disease other than diabetic nephropathy was found in 32 (12.3%) patients. Their (male 23; female 9) age ranged between 35-72 (mean 54.15+/-10.3) years. The duration of diabetes was < 5 years in 14 (43.7%), between 5-9 years in 8 (25%) and > 10 years in 10 (31.2%) patients. RESULTS: The presenting clinical syndromes were : chronic renal failure 15 (47%), acute nephritic syndrome 6 (18.7%), nephrotic syndrome 5 (15.6%), acute renal failure 4 (12.5%) and rapidly progressive glomerulonephritis (RPGN) in 2 (6.2%) cases. Overall, incidence of glomerular (46.8%) and tubulo-interstitial lesions (53.2%) were almost equal in type 2 diabetes patients. The spectrum of non-diabetic renal diseases includes : primary isolated glomerulopathy 12 (37.5%); mesangioproliferative GN superimposed on diabetic glomerulosclerosis (DGS) in 3 (9.3%); acute tubulo-interstitial nephropathy (TIN) 4 (12.5%); chronic TIN 10 (31.25%) and three patients had chronic pyelonephritis. Diabetic retinopathy was absent in 22 (69%) cases where 10 (31%) patients had background diabetic retinopathy. None of the patients with non-diabetic glomerular disease had diabetic retinopathy, except two who had DGS in addition to mesangioproliferative GN on renal biopsy. The background diabetic retinopathy was seen in 47% of patients with TIN without clinical evidence of diabetic nephropathy. The recovery of renal function or clinical improvement was observed in 47% of patients with NDRD with institution of appropriate treatment. CONCLUSION: The prevalence of NDRD was 12.3% in our type 2 diabetic patients. Both non-diabetic glomerulopathy (47%) and tubulo-interstitial nephropathy (53%) can occur with nearly equal frequency in such patients. It is also gratifying to diagnose and treat NDRD in type 2 diabetics in selected cases.

Anemia and nutritional status of pre-school children in Kerala.

A study on the pattern of anemia and its relation to nutritional status and dietary habits was conducted among 3633 pre-school children of 108 selected anganwadi centers in rural areas of Kerala State during the period 1996 to 1998. Children were invited with their parent or guardian. Capillary blood was collected from each child and hemoglobin was estimated by cyanomethemoglobin method. Weight and height of children were taken for assessing their nutritional status. The information regarding their age, sex, clinical condition and dietary habits was collected in a performa through an interview. Chi-square test was used to assess the relationship of anemia to sex, dietary habits, and nutritional status. For multivariate analysis logistic regression model was employed. The prevalence of anemia was 11.4%. The percentage of anemic children among male and female children was 10.25 and 12.55 respectively and statistical analysis showed that female children were more susceptible to anemia. Normal nutritional status was seen among 46.7% of the children. When 187 (11.78%) of the mild undernourished children were anemic, the percentage anemic among the moderate undernourished children was 57 (16.37%). Moderate under nutrition and anemia showed a significant association. Anemia was reported among both vegetarians and non-vegetarians. Among 927 vegetarians, 86 (9.27%) were anemic and among 2,706 non-vegetarians, 328 (12.1%) were anemic. Dietary survey revealed that, consumption of iron sources, whether haem or non-haem, was below the recommended level. Undernutrition can be attributed as the major reason for nutritional anemia. Changes in eating behaviour could have potentially affected the iron bio-availability.

Influence of host plant on growth and reproduction of Aphis nerii and feeding and prey utilization of its predator Menochilus sexmaculatus.

Influence of different physiological stages (young, mature and senescent) of Calotropis gigantea leaves on growth and reproductive ability of A. nerii and feeding, prey utilization, fecundity and lipid content of its predator M. sexmaculatus were investigated. Increased reproductive period, total life span and reproduction of nymphs per female of A. nerii were observed when reared on mature leaves. This relative preference of A. nerii and maximum utilization of mature leaves as compared to other physiological aged leaves are mainly due to changes in the chemical composition such as protein, carbohydrate, lipid, amino acid, nitrogen and phenolic of C. gigantea. Further, aphids reared on mature leaves influenced its predator's (M. sexmaculatus) growth, prey utilization and reproductive performances. Fecundity and longevity were high, while developmental time of predator was shorter on mature leaves fed aphid. Maximum prey utilization and increased efficiency of ingested and digested food of predator was observed on mature leaves reared aphid. The results are interpreted and discussed in relation to plant aphid and predator interaction (tritrophic).

Anthropometric indices, cord length and placental weight in newborns.

A study on the anthropometric indices of 3835 singleton newborn babies was conducted over a four months period at Sree Avittom Thirunal Hospital, Trivandrum. Of these, 1921 (50.1%) were male babies and 1914 (49.9%) were female babies. The majority of infants (43%) were born to the middle socio-economic groups and the mean birth weight of babies was high among the high-income groups. Five hundred and ninety six (15.5%) babies weighed less than 2500 g; of these 121 (20.2%) were preterm and 477 (79.8%) were full term. The prevalence of low birth weight (LBW) was high (22.0%) among the mothers aged between 15 and 19 years. There was a significant difference (p < 0.001) in the mean birth weight (BW) of term male and female babies but there was no significant differences in their body length, head circumference and cord length. The mean ponderal index of term newborn babies was 2.3 g/cm3. The mean placental weight of LBW term and preterm babies was less than that of the corresponding normal weight babies. The birth weight of babies was directly proportional to their placental weight.

A study on the health status of twin babies.

A study on twin births was conducted from May 1993 to April 1994 at S.A.T. Hospital, Thiruvananthapuram. The twinning rate in this period was found as 17.33 per 1000 births. 79.6% babies in the twin pairs were of like sex and 20.4% were of unlike sex. The incidence of low birth weight twin babies in this study was 68.9%. There was no significant difference in the physical parameters (birth weight, body length and head circumference) of twin babies in relation to sex. The incidence of twin birth was higher among primipara mothers and in the mothers of age group 21 to 25 years. The first born baby (twin A) was found to be heavier than the second born baby (twin B) in 44.78% twin pairs and their mean birth weight difference was 438 g, while the second born baby (twin B) was found to be heavier than the first born (twin A) in 38.31% twin pairs and their mean birth weight difference was 291 g. Statistical analysis showed that the difference between the mean birth weight difference in the case of twin A > B was significantly greater when compared to that of twin A < B.

Synthesis and secretion of lipoproteins by primary cultures of rat hepatocytes.

Synthesis and secretion of VLDL and LDL by primary cultures of rat hepatocytes maintained in serum free medium have been studied. A time-dependent increase found in the [3H]leucine labelled lipoproteins which floated at a density of 1.006 g/ml indicate the secretion of VLDL into the medium. That the hepatocytes also secrete. LDL is shown by floatation of [3H]leucine labelled lipoproteins by sequential centrifugation at a density range of 1.006-1.06 g/ml. Electrophoretic and immunoprecipitation analysis show that about 60% and 65% respectively of 3H-radioactivity is associated with apoB in the two fraction of lipoproteins. At about 12hr 70-75% lipoproteins in the culture medium is in the VLDL density range and 25-30% is in the LDL density range. Conversion of secreted VLDL to LDL has also been shown by incubating hepatocytes with pre-labelled lipoproteins when there is a decrease in the fraction of VLDL range with a corresponding increase in the fraction of the LDL density range. Addition of glycosaminoglycans such as hyaluronic acid, chondroitin sulphate, and heparin into the medium cause significant increase in the synthesis and secretion of [3H]apoB into the medium indicating a possible secretory control of apoB by local reuptake.

Synthesis and secretion of VLDL by rat hepatocytes--modulation by cholesterol and phospholipids.

The synthesis and secretion of apoB, the major protein component of very low density lipoprotein (VLDL) and low density lipoprotein (LDL), were studied using rat hepatocytes maintained in primary culture. Supplementation of hepatocytes with rat serum VLDL and LDL increased the production of apoB while delipidated lipoproteins had no significant effect, suggesting a role for lipids in the production of apoB. Addition of cholesterol to the culture medium also increased the production of apoB in a concentration-dependent manner. Pulse labelling followed by chase in presence of cholesterol indicated enhancement in apoB secretion. Mevinolin which inhibits cholesterol synthesis significantly reduced the secretion of apoB. The presence of phosphatidylcholine and phosphatidylethanolamine in the culture medium also increased the secretion of apoB into the medium. These data suggest that availability of lipids, particularly cholesterol, is an important determinant of apoB synthesis and secretion as VLDL.

Bedside urinalysis in untreated leprosy patients.

The study included 53 patients of untreated leprosy attending University Hospital, Banaras Hindu University during study period of 1 1/2 years. The various types of leprosy included 9,14,16 and 14 cases of tuberculoid, borderline, lepromatous and leprosy with type II reaction respectively. Majority of the patients were below the age of 49 years with male preponderance. 66.04% of patients came from the rural area. Painful micturation (dysuria) (13.20%) was the commonest urinary complaint recorded on enquiry. Specific gravity of urine did not show any change. Abnormal proteinuria was noted in 16.98%, 11.32%, 7.54% and 3.77% of patients of leprosy with reaction, lepromatous, borderline and tuberculoid group respectively. Significant haematuria, pyuria and epithelial cells were noted in all the groups. Haematuria was recorded in focal segmental Glomerulonephritis (GN), mesangioproliferative and diffuse endocapillary Glomerulonephritis (GN) incidence of which was 7.89%, 7.89% and 5.26% respectively in the biopsy tissue. Significant pyuria was noticed in all the groups except minimal change GN.