Role of vitamin C and rectal indomethacin in preventing and alleviating post-endoscopic retrograde cholangiopancreatography pancreatitis: a clinical study

Background/Aims@#This study aimed to determine whether vitamin C in addition to indomethacin decreases the occurrence and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) occurrence and severity. @*Methods@#This randomized clinical trial included patients undergoing ERCP. The participants were administered either rectal indomethacin (100 mg) plus an injection of vitamin C (500 mg) or rectal indomethacin (100 mg) alone just before ERCP. The primary outcomes were PEP occurrence and severity. The secondary amylase and lipase levels were determined after 24 hours. @*Results@#A total of 344 patients completed the study. Based on intention-to-treat analysis, the PEP rates were 9.9% for indomethacin plus vitamin C plus indomethacin and 15.7% for indomethacin alone. Regarding the per-protocol analysis, the PEP rates were 9.7% and 15.7% in the combination and indomethacin arms, respectively. There was a remarkable difference between the two arms in PEP occurrence and severity on intention-to-treat and per-protocol analyses (p=0.034 and p=0.031, respectively). The post-ERCP lipase and amylase concentrations were lower in the combination arm than in the indomethacin alone arm (p=0.034 and p=0.029, respectively). @*Conclusions@#Vitamin C injection in addition to rectal indomethacin reduced PEP occurrence and severity.

Does twice-weekly cabergoline improve anthropometrical and biochemical profiles in prediabetes? a randomized double-blind clinical trial pilot study

Dopaminergic signaling is one of the regulatory pathways being investigated for its implication in glucose metabolism. The aim of this study was to determine the effect of cabergoline on biochemical and anthropometric parameters in prediabetes stage [impaired fasting glucose and impaired glucose tolerance]. In this double blind, placebo-controlled, pilot study, 27 prediabetic adults were randomized to receive 0.25-mg cabergoline twice weekly for two weeks, followed by 0.5 mg twice weekly for next 14 weeks [n = 13] or placebo [n = 14]. All subjects were advised to follow a 500 kcal-deficit energy diet. Fasting plasma glucose [FPG], oral glucose tolerance, glycated hemoglobin [A1c], fasting, and 2-h insulin were measured at baseline and at 16-week follow-up. Homeostasis model assessment [HOMA] 2 was calculated to estimate steady-state beta-cell function, insulin sensitivity, and insulin resistance. Our results showed significant reductions in fasting [P = 0.004] and 2-h plasma glucose [P = 0.01] after treatment, and significant improvements in beta-cell function [P = 0.03] and insulin resistance [P = 0.04] in the cabergoline group. The trend of non-significant A1c changes was decreasing in the cabergoline group versus an increasing trend in the placebo group. All anthropometric parameters were similar between the two groups. Our results revealed that twice-weekly cabergoline could improve glucose metabolism in prediabetes stage. Larger studies of longer duration are warranted to investigate the effect of cabergoline in preventing progression of prediabetes to type 2 diabetes mellitus

Effect of a combination of omeprazole plus sustained release baclofen versus omeprazole alone on symptoms of patients with gastroesophageal reflux disease [GERD]

Previous studies have reported the efficacy of baclofen in the treatment of Gastroesophageal Reflux Diseases [GERD]. The objective of present study is to evaluate the effect of co-administration of omeprazole 20 mg/d plus sustained Release baclofen [SR baclofen] vs. omeprazole 20 mg/d plus placebo on alleviation of symptoms in patients with a diagnosis of GERD. A prospective, double blind, placebo controlled trial included 60 patients with diagnosis of GERD have been done. Patients were randomly selected to receive either SR baclofen or a placebo in addition to omeprazole 20 mg/d for a period of 2 weeks. Patients were questioned regarding heartburn, regurgitation, chest pain and hoarseness at the base line and after 2 weeks. All patients tolerated the medications and no patients failed to complete the study due to adverse drug reactions. A total of 53 patients completed the study, 25 in SR baclofen and 28 in placebo group. After 2 weeks, 1 patient [4%] in SR baclofen group reported heartburn and regurgitation. However 13[46.4%] and 15 [53.6%] of patients in the placebo group had heartburn and regurgitation respectively. The analysis of the data shows that there is a significant difference between the two groups in heartburn and regurgitation [p < 0.0001, p < 0.0001 respectively]. Statistical analysis revealed a significant difference in two groups regarding total GERD score [p <0.0001]. The results of the present study suggest that a combination of SR baclofen and omeprazole may be a more effective treatment for heartburn and regurgitation than omeprazole alone

[Prescription of ceftriaxone before and after implementation of physician's guidelines in a teaching hospital: a brief report]

Background: Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care

Ceftriaxone is a third-generation cephalosporin used widely for the treatment of various infections in outpatient and in-patient. The purpose of this study was to evaluate the ceftriaxone utilization before and after implementation of guidelines and physicians education

Methods: A descriptive cross-sectional, before-after intervention study was performed in 6 wards of a teaching hospital in Tehran, Iran

The study was conducted in three phases: pre-guideline, educational interventions and post guideline implementation

The pre intervention phase included chart analysis of current ceftriaxone use in 200 consecutive patients from the representative wards included in the study

The educational interventions included preparation and distribution of ceftriaxone guidelines as pamphlets among physicians working in the studied wards

Also the clinical pharmacist returned to each ward and trained physicians regarding the correct use of ceftriaxone. In the post intervention phase immediately after the instruction, and in the follow up phase, one month later, a prospective analysis of ceftriaxone utilization was performed by chart review of 200 patients to detect changes in ceftriaxone utilization pattern

Results: Four hundred cases were evaluated during study [200 before and 200 after physician's education]

The correct indication of ceftriaxone was 93% and 96% before and after the educational interventions respectively. Analysis showed that correct indication of ceftriaxone did not change significantly before and after education [P= 0.188]

Regarding to proper administration [dose, interval and duration] ceftriaxone utilization significantly changed after education [P< 0.001]

Conclusion: Adoption of the guidelines with associated training resulted in significant improvement in ceftriaxone administration pattern in the hospitals

Evaluating the frequency of errors in preparation and administration of intravenous medications in orthopedic, general surgery and gastroenterology wards of a teaching hospital in Tehran

The aim of this study was to determine the frequency of medication errors happened during the preparation and administration of intravenous [IV] drugs. This study was designed as prospective cross-sectional evaluations by direct unconcealed observation in a setting consisted of orthopedic, general surgery and gastroenterology wards of a teaching hospital. Participants were those patients hospitalized in these wards along with nurses responsible for preparation and administration of IV medications. Medication errors occurred in the process of preparation and administration of IV drugs, were recorded by a pharmacist. The frequency of medication errors with suggesting a solution to overcome was the main outcome of this study. Details of the preparation and administration stages of the observed drugs were compared to an instructed checklist prepared by an expert clinical pharmacist. From a total of 357 preparation and administration episodes, the most common type of error [%20.6] was the injection of bolus doses and infusion faster than the recommended rate. Metronidazole had the highest rate of error [%24.3]. IV rounds conducted at 12 p.m. had the most rate of error [%26.3]. Errors happened in the administration process were more prevalent than those in the preparation. No significant correlation was found between the frequency of errors and nurses' demographic data. This study revealed that the errors happened in the preparation and administration of IV drugs is prevalent. Improving the medication safety by the implementation of clinical pharmacists' prepared protocols at the point of care is an important concern

Potential drug-drug interactions in post-CCU of a teaching hospital

Drug-drug interactions [DDIs] can lead to increased toxicity or reduction in therapeutic efficacy. This study was designed to assess the incidence of potential drug interactions [PDI] and rank their clinical value in post coronary care unit [Post-CCU] of a teaching hospital in Tehran, Iran

In this prospective study, three pharmacists with supervision of a clinical pharmacist actively gathered necessary information for detection of DDIs. Data were tabulated according to the combinations of drugs in treatment chart. Verification of potential drug interactions was carried out using the online Lexi-Interact[TM] 2011

A total of 203 patients [113 males and 90 females] were enrolled in the study. The mean age of patients was 61 +/- 12.55 years [range = 26-93]. A total of 90 drugs were prescribed to 203 patients and most prescribed drugs were atorvastatin, clopidogrel and metoprolol. Mean of drugs was 11.22 per patient. A total of 3166 potential drug interactions have been identified by Lexi- Interact[TM], 149 [4.71%] and 55 [1.73%] of which were categorized as D and X, respectively. The most serious interactions were clopidogrel+omeprazole and metoprolol+salbutamol

Drug interactions leading to serious adverse effects are to be cautiously watched for when multiple drugs are used simultaneously. In settings with multiple drug use attendance of a pharmacist or clinical pharmacist, taking the responsibility for monitoring drug interactions and notifying the physician about potential problems could decrease the harm in patient and increase the patient safety

Detection and management of medication errors in internal wards of a teaching hospital by clinical pharmacists

Any suboptimum treatment in the management of patients can lead to medication errors [MEs] that may increase morbidity and mortality in hospitalized individuals. By establishing well-designed patient care activities within the managed care setting, clinical pharmacists can cooperate with other health care professionals to provide quality care and maximize safety. The aim of this study was to evaluate the frequency and prevention of MEs by clinical pharmacists. This was a cross-sectional interventional study conducted in internal wards of a teaching hospital during a two-month period. During this period, patient records, and physician orders were reviewed by clinical pharmacists. Any prescription error identified was documented. Incorrect drug selection, dose, dosage form, frequency, or route of administration all were considered as medication errors. Then, the clinical pharmacist discuss about findings with the clinical fellows to change faulty orders. The frequency and types of MEs in different wards that were detected and prevented by clinical pharmacists was documented. During the study period, in 132 patients, 262 errors were detected [1.98 per each]. Wrong frequency 71 [27%], forget to order 37 [14.1%], wrong selection 33 [12.5%], drug interactions 26 [9.9%], forget to discontinue 25 [9.5%] and inappropriate dose adjustment in renal impairment 25 [9.5%] were the most types of errors. Cardiovascular medications were the class with the highest detected errors [31.6%] followed by gastrointestinal agents [15.6%]. Medication errors are common problems in medical wards that their frequency can be restricted by the intervention of clinical pharmacists

effect of information provision on reduction of errors in intravenous drug preparation and administration by nurses in ICU and surgical wards

Malpractice in preparation and administration of intravenous [IV] medications has been reported frequently. Inadequate knowledge of nurses has been reported as a cause of such errors. We aimed to evaluate the role of nurses' education via installation of wall posters and giving informative pamphlets in reducing the errors in preparation and administration of intravenous drugs in 2 wards [ICU and surgery] of a teaching hospital in Tehran, Iran. A trained observer stationed in 2 wards in different work shifts. He recorded the nurses' practice regarding the preparation and administration of IV drugs and scored them before and after the education process. 400 observations were evaluated. Of them, 200 were related to before education and 200 were related to after education. On a 0-10 quality scale, mean +/- SD scores of before and after education were determined. Mean +/- SD scores of before and after education at the 2 wards were 4.51 [ +/- 1.24] and 6.15 [ +/- 1.23] respectively. There was a significant difference between the scores before and after intervention in ICU [P<0.001], surgery [P<0.001], and total two wards [P<0.001]. Nurses' education by using wall poster and informative pamphlets regarding the correct preparation and administration of IV drugs can reduce the number of errors

Does allopurinol prevent post endoscopic retrograde cholangio pancreatography pancreatitis? a randomized double blind trial

Post endoscopic retrograde cholangiopancreatography [ERCP] pancreatitis is a frequent complication either for diagnosis or treatment of pancreatobiliary diseases. A number of pharmacological agents have been tried for prevention or alleviation of the complication. Allopurinol with free radical scavenger property has been considered as an effective prophylactic agent in some clinical trials. Administration of allopurinol in these trials was done in a long period before doing ERCP. Hence allopurinol converts to oxupurinol in the liver rapidly; it seems that clinical judgment about the net effect of allopurinol on prevention of post ERCP pancreatitis is doubtful. In this randomized double blind clinical trial, effect of allopurinol on prevention or alleviation of clinical and laboratory signs of pancreatitis has been evaluated in 74 patients undergoing ERCP. Results showed that there is not any difference between allopurinol and placebo in occurrence and severity of post ERCP pancreatitis [P=0.97]. Also there is not any significant difference in amylase rises between 2 groups in 8 and 16 hours after ERCP [P=0.947, 0.287 respectively]. Beneficial effects of allopurinol in some of the previous studies may be attributed to its active metabolite [oxypurinol]. Further studies recommended about the net effect of allopurinol and oxypurinol in the complication

efficacy of a single dose of pethidine, fentanyl and morphine in treating postanesthesia shivering

Postanesthesia shivering is an undesirable event that may induce a variety of adverse consequences including patient discomfort, increased oxygen consumption and wound pain. Thus, its pharmacological treatment should be regarded. The purpose of this study was to compare the efficacy of morphine, fentanyl and pethidine for the treatment of postanesthesia shivering. Fifty patients who developed shivering were treated in a randomized double blinded manner with an intravenous bolus dose of 2 or 4 mg morphine, 25 or 50 mg pethidine, and 50 microg fentanyl. Then, they were monitored for 30 minutes and the shivering suppression grade, the time taken to stop shivering, the shivering cessation time, recurrence of shivering and opioid side effects were evaluated. Core body temperature was measured immediately before, and at 15 and 30 minute after administering the drug. The groups did not differ significantly regarding shivering suppression grade, shivering cessation time, and recurrence of shivering. There was a significant difference in the time taken to stop shivering between groups. Following injection of the drugs, the core temperatures increased in the five groups with statistical difference. All opioids were effective in treating postanesthesia shivering in a similar extent

effects of simvastatin on the serum concentrations of thyroid stimulating hormone and free thyroxine in hypothyroid patients treated with levothyroxine

Statins, such as simvastatin, are the drugs of choice for the treatment of hypercholesterolemia. On the other hand hypercholesterolmia can occur in hypothyroid patients, who receive levothyroxine. There are few clinical case reports in regards to drug interaction between levothyroxine and lovastatin or simvastatin, indicating decreased levothyroxine effects. This study aimed at determining possible interaction between simvastatin and levothyroxine in hypothyroid patients by assessing serum levels of thyroid stimulating hormone [TSH] and free thyroxine [FT4], the two important laboratory indices for levothyroxine therapy. In a cross sectional study, 41 eligible hypothyroid patients receiving levothyroxine [50-150 micro g/d] were selected. Blood samples were taken before and after three months of simultaneous treatment with simvastatin [20 mg/d] and levothyroxine to determine the serum levels of TSH and FT4. There was no significant difference between the serum levels of TSH [P=0.77] or FT4 [P=0.76] before and after three months of simultaneous treatment. Also, there was no aggravation or initiation of any sign or symptom of hypothyroidism in the patients during the study period. Considering that FT4 and TSH are the most reliable indicators for the levothyroxine treatment, the findings of the present study suggest that there may not be any significant interaction between simvastatin and levothyroxine