Orofacial Dyskinesia in Uremia in Polycystic Kidney Disease.

Uremic encephalopathy presenting as involuntary movements of the orofacial region is important to recognize because of reversibility seen with resolution of azotaemia though residual neurological dysfunction might persist. Neuroimaging is important part of diagnosis with typical lesions involving basal ganglia seen mostly in diabetic patients. Our case highlights a patient with non-diabetic uremic encephalopathy with facial dyskinesia which is rare with a lesion in unilateral lentiform nucleus and small white matter hyperintensities. Resolution following dialysis pointed to uraemia as aetiology.

Spectrum of Anemia in Indian children with Nephrotic Syndrome: a prospective observational study.

We aimed to estimate the prevalence of anemia in children with nephrotic syndrome (NS), determine its etiology, and correlate severity with disease duration and response to steroids. This was a prospective cohort study carried from 15th July 2019-14th July 2021 at the pediatric nephrology clinic, of a teaching hospital in India. We screened children aged 3 months-18 years with NS for eligibility. We excluded those suffering from chronic kidney disease and, on haematinics. All children underwent investigations for evaluation of nephrotic syndrome and anemia. To define the clinical phenotype of nephrotic syndrome, the patients were classified as infrequent relapsers, frequent relapsers, steroid dependent and steroid resistant NS as per ISPN guidelines. Children were followed up at least for a period of one year to define their response to steroids. A total of 125 children were finally analysed for all treatment outcomes. Of 125, 37 (30%) children presented with the first episode of NS. Remaining 88 were follow up cases of NS. Of 125 children, 41 (33%) were found to be anemic as per the WHO criteria. Iron deficiency anemia was found in 21 (51%) children. Steroid resistance was twice more prevalent in the anemic group compared to the non-anemic group, 7.3% vs 4.8% respectively, however this difference was not statistically significant, p = 0.65. Anemic group had a trend of higher no. of children receiving antihypertensives compared to non-anemics (38 (93%) vs. 67 (80%), p = 0.07. CONCLUSION: Iron deficiency anemia was the commonest cause of anemia and, anemia and need for anti-hypertensives to attain BP control and adequate proteinuria often coexisted in children suffering from nephrotic syndrome. WHAT IS KNOWN: • Anemia is a significant complication in children suffering from nephrotic syndrome. • Cause of anemia in nephrotic syndrome is multifactorial. WHAT IS NEW: • Iron deficiency anemia was the most common cause of anemia in Indian children with nephrotic syndrome. • Anemia and need for anti-hypertensives to attain adequate BP control and proteinuria often coexisted in children with nephrotic syndrome.

Nutritional status, symptom burden, and predictive validity of the Pt-Global web tool/PG-SGA in CKD patients: A hospital based cross sectional study.

BACKGROUND: Despite not being frequently recognized, malnutrition, a consequence of chronic kidney disease, negatively affects morbidity, mortality, functional activity, and patient's quality of life. Management of this condition is made more difficult by the dearth of knowledge regarding the symptom burden brought on by inadequate nutritional status. Additionally, there are multiple tools to evaluate nutritional status in CKD; but, Pt-Global web tool/PG-SGA used in oncology, has not been investigated in chronic kidney disease patients. This study aimed to explore the nutritional status, symptom burden and also investigate the predictive validity of Pt-Global web tool/PG-SGA among pre-dialysis diabetic and non-diabetic chronic kidney disease patients. METHODOLOGY: This cross-sectional study was carried out at a renal clinic of a tertiary care public teaching hospital. Nutritional status and symptom burden was evaluated by employing a 'Pt-Global web tool/PG-SGA' which is considered as a preeminent interdisciplinary tool in oncology and other chronic catabolic conditions. The predictive validity of the Pt-Global web tool/PG-SGA, referred as overall score for malnutrition was ascertained using Receiver Operating Curves (ROC). The conclusions were drawn using descriptive statistics, correlation, and regression analysis. RESULTS: In a sample of 450 pre-dialysis CKD patients, the malnutrition was present in 292(64.9%) patients. Diabetic CKD patients exhibit higher proportion of malnutrition 159(35.3%). The prevalence of malnutrition was exacerbated by eGFR reduction. The overall Pt-Global web tool/PGA-SGA score was significantly influenced by the symptoms of fatigue (81.5%), appetite loss (54.8%), physical pain (45.3%), constipation (31.78%), dry mouth (26.2%), and feeling full quickly (25.8%). The ROC analysis showed that the AUC for the total PG-SGA score was 0.988 (95% CI: 0.976-1.000), indicating that it is a reliable indicator of malnutrition. The sensitivity (84.2%) for identifying malnutrition was low when using the conventional tool cut off score of ≥9. Instead, it was discovered that a score of ≥3 had a greater sensitivity (99.3%) and specificity (44.3%) and was therefore recommended. CONCLUSIONS: This study not only presents empirical evidence of poor nutritional status in CKD patients but also reveals that it is worse in patients with diabetes, hypoalbuminemia, and poorer kidney function (well recognized risk factors for cardiovascular disease). Early diagnosis and management of symptoms contributing malnutrition will reduce mortality and CKD progression. The Pt-Global web tool/PG-SGA total score of 3 or more appears to be the ideal cut off score for identifying malnutrition, which can be utilized by dietician for improving malnutrition.

Diminished PD-L1 regulation along with dysregulated T lymphocyte subsets and chemokine in ANCA-associated vasculitis.

ANCA-associated vasculitis (AAV) is a life-threatening disease characterized by small vessel inflammation and pathogenic self-directed antibodies. Programmed death-ligand 1 receptor (PD-1) and programmed cell death ligand-1 (PD-L1) are immune checkpoint molecules crucial for maintaining tolerance and immune homeostasis. After checkpoint inhibition therapy, development of various autoimmune diseases and immune-related adverse events (irAEs) have been observed. Here, we investigated the immunomodulatory roles of neutrophils through the expression of immune checkpoint molecule (PD-L1), migratory molecules (CXCR2), chemotactic chemokines (CXCL5) and other important molecules (BAFF and HMGB1) in development of AAV. We also scrutinized the immune mechanism responsible for development of pauci-immune crescentic GN (PICGN). We demonstrate for the first time that the frequency of PD-L1 expressing neutrophils was significantly reduced in AAV patients compared to healthy controls and correlated negatively with disease severity (BVASv3). Further, in renal biopsy, reduced PD-L1 immune checkpoint expression provides a microenvironment that unleashes uncontrolled activated CD4 + T cells, B cells, neutrophils and macrophages and ultimately causes engulfment of immune complexes leading to PICGN. Furthermore, during remission, reduced neutrophils PD-L1 and CXCR2 expression, increased neutrophils CXCL5 expression and increased peripheral effector memory T cells and increased HMGB1 and BAFF levels in serum, demonstrate the propensity for the persistence of sub-clinical inflammation, which could explain relapse, in this group of diseases.

Acute Kidney Injury in Acute Myocardial Infarction and Its Outcome at 3 and 6 Months.

Epidemiological data on the prevalence of acute kidney injury (AKI) in acute coronary syndrome are sparse, with most studies having been conducted retrospectively. This study prospectively analyzed the incidence of AKI in patients with acute myocardial infarction (AMI) and to identify the risk factors for AKI and their renal outcome at 3 and 6 months. This was a prospective and observational study, which enrolled 120 patients presenting with their first episode of AMI to our hospital and consented to the study. Renal function tests were performed at admission, at 48 h, and at follow-up at 3 and 6 months. The majority of the patients underwent a percutaneous coronary intervention (59.2%), 21.7% received thrombolytic therapy, and 19.2% were managed conservatively. At 48 h, 11 patients had AKI. At 3 months, 8 patients had died, and renal dysfunctions were seen in 9 out of 112 patients. At 6 months, 12 patients out of 112 had renal dysfunction. There was no difference in the incidence of AKI in patients with an estimated glomerular filtration rate above and below 60 mL/min/1.73 m2. Killip Class 4 and diabetes mellitus were associated with an increased incidence of renal dysfunction in AMI patients. The type of treatment and the use of a contrast agent in the coronary intervention did not affect the development of AKI. According to this study, if indicated, a percutaneous coronary intervention should not be denied to patients for fear of developing AKI. This needs to be examined in larger randomized trials.

Angiotensin receptor blockers for the treatment of covid-19: pragmatic, adaptive, multicentre, phase 3, randomised controlled trial.

OBJECTIVE: To determine whether disrupting the renin angiotensin system with angiotensin receptor blockers will improve clinical outcomes in people with covid-19. DESIGN: CLARITY was a pragmatic, adaptive, multicentre, phase 3, randomised controlled trial. SETTING: 17 hospital sites in India and Australia. PARTICIPANTS: Participants were at least 18 years old, previously untreated with angiotensin receptor blockers, with a laboratory confirmed diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection who had been admitted to hospital for management of covid-19. INTERVENTION: Oral angiotensin receptor blockers (telmisartan in India) or placebo (1:1) for 28 days. MAIN OUTCOME MEASURES: The primary endpoint was covid-19 disease severity using a modified World Health Organization Clinical Progression Scale (WHO scale) at day 14. Secondary outcomes were WHO scale scores at day 28, mortality, intensive care unit admission, and respiratory failure. Analyses were evaluated on an ordinal scale in the intention-to-treat population. RESULTS: Between 3 May 2020 and 13 November 2021, 2930 people were screened for eligibility, with 393 randomly assigned to angiotensin receptor blockers (of which 388 (98.7%) to telmisartan 40 mg/day) and 394 to the control group. 787 participants were randomised: 778 (98.9%) from India and nine (1.1%) from Australia. The median WHO scale score at day 14 was 1 (interquartile range 1-1) in 384 participants assigned angiotensin receptor blockers and 1 (1-1) in 382 participants assigned placebo (adjusted odds ratio 1.51 (95% credible interval 1.02 to 2.23), probability of an odds ratio of >1 (Pr(OR>1)=0.98). WHO scale scores at day 28 showed little evidence of difference between groups (1.02 (0.55 to 1.87), Pr(OR>1)=0.53). The trial was stopped when a prespecified futility rule was met. CONCLUSIONS: In patients admitted to hospital for covid-19, mostly with mild disease, not requiring oxygen, no evidence of benefit, based on disease severity score, was found for treatment with angiotensin receptor blockers, using predominantly 40 mg/day of telmisartan. TRIAL REGISTRATION: ClinicalTrials.gov NCT04394117.

Adenine phosphoribosyl transferase deficiency leads to renal allograft dysfunction in kidney transplant recipients: a systematic review.

BACKGROUND: Adenine phosphoribosyl transferase (APRT) deficiency has great implications on graft survival in kidney transplant patients. This systematic review investigated the diagnostic pattern, treatment approach, and kidney transplant outcomes among kidney transplant patients with adenine phosphoribosyl transferase deficiency. MATERIAL AND METHODS: Articles reporting the APRT enzyme deficiency and kidney allograft dysfunction were retrieved from PubMed/Medline, ScienceDirect, Cochrane library and Google scholar databases. Descriptive analysis was used to draw inferences. RESULTS: The results from 20 selected studies covering 30 patients receiving 39 grafts had an average age of 46.37 years are presented. Graft survival time of more than 6 months was reported in 23 (76.7%) patients, while other 7 (23.3%) patients had graft survival time of less than 6 months. Only 4 (13.3%) patients had APRT deficiency before transplantation. After follow-up, one-third of the patients 10 (33.3%) had stable graft function, 1 patient had allograft loss, 8 (26.6%) patients had delayed graft function while the remaining 11 (36.6%) patients had chronic kidney graft dysfunction. CONCLUSIONS: APRT deficiency is an under-recognized, treatable condition that causes reversible crystalline nephropathy, leading to loss of allograft or allograft dysfunction. The study results showed that inclusion of genetic determination of APRT deficiency in the differential diagnosis of crystalline nephropathy, even in the absence of a history of nephrolithiasis, can improve renal outcomes and may improve allograft survival.

Early diagnosis of kidney injury in a paediatric population: a prospective cohort study (E-DRIP STUDY).

BACKGROUND: Renal Angina Index (RAI) is a bedside tool for risk stratification of patients to predict acute kidney injury (AKI). Kidney biomarkers are better indicators of real-time injury and give us lead time for diagnosing impending AKI. METHODS: We enrolled consecutive children aged 2 months-14 years admitted to a tertiary hospital in northern India over 2 years. RAI was calculated on day 0 (D0) and urinary (u) and plasma (p) neutrophil gelatinase-associated lipocalin (NGAL) were measured within 6 h of admission. Children were followed for the development of severe AKI on day 3 (D3) using Kidney Disease Improving Global Outcomes criteria to define and stage AKI. RESULTS: Of the 253 children enrolled and analysed, 44 (17.4%) developed D3-AKI (stage 1 in 52.2%, stage 2 in 20.5% and stage 3 in 27.3%). Renal angina (RAI ≥ 8) on D0 was present in 66.7% children who developed stage 2/3 D3-AKI vs. 43.5% in children who did not develop D3-AKI /stage 1 AKI (p = 0.065). Area under ROC (AUROC) curve for D0-RAI to predict D3-severe-AKI was 0.66 (95% CI, 0.55-0.77). AUROC curve for uNGAL and pNGAL to predict D3-severe-AKI was 0.62 (95% CI, 0.50-0.74) and 0.48 (95% CI, 0.35-0.61), respectively. The severe AKI group had greater requirement of ventilation and inotropic support with mortality being thrice higher compared to the non-AKI group. CONCLUSION: RAI ≥ 8 and uNGAL had a high negative predictive value but low sensitivity for predicting D3-severe-AKI. pNGAL had a poor predictive value for D3-severe-AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.

Enhanced learning strategies of undergraduate medical students with a structured case presentation format.

BACKGROUND: Improvement of the learning in undergraduate bedside teaching needs to be promoted through innovative interventions. Changes in the structured format (SF) for bedside case discussion may help students improve their learning experience and gain insights into collaborative self-directed learning. The aim of the present study was to encourage collaborative and self-directed learning strategies by MBBS undergraduate students through a new case presentation format structured for this purpose. MATERIALS AND METHODS: This was an interventional study carried out in the year 2010-2011. A new SF for bedside cases presentation was developed. A comparison with the traditional format was done by holding one session in each format. Uniformity of topic and teaching style was ensured by having the sessions on pulmonary medicine cases with the same teacher. The student perspective of the educational process was analyzed using evaluation pro forma, Likert scale, and narratives. RESULTS: Ninety final year and prefinal year MBBS students participated in this study. There was significantly higher participation in history taking (50.7%) and clinical examination (60%) in the SF. A higher statistically significant number of clinical possibilities were considered in the SF (85.3% vs. 66.6%). Similarly, significantly higher number of students indulged in self-directed learning and referred to learning resources in the SF. The SF provided students an active role (96.9%), encouraged access to resources (93.9%), and control of learning (75.7%). The additional interactive session was productive (90.9%), discussions were streamlined (66.6%), and the role of a teacher was considered important (75.7%). CONCLUSION: The SF generated higher participation in the aspects of history taking, clinical examination, and consideration of differential diagnoses. It led to a perceived improvement in self-directed and collaborative learning among students.

Sea Blue Histiocytosis Concordant With Immune Thrombocytopenic Purpura.

Sea blue histiocytosis is an unusual bone marrow finding in many haematological conditions or lipid metabolic diseases that by itself may not carry any prognostic value. It may occur rarely as a primary genetic clinical syndrome characterized by splenomegaly, hypertriglyceridemia and thrombocytopenia. More commonly, the presence of these lipid-laden blue-stained macrophages indicates an underlying condition characterized by increased bone marrow precursor cell turnover due to myeloproliferative conditions or ineffective erythropoiesis. Rarely may they be observed in cases of immune thrombocytopenic purpura (ITP) incidentally due to rapid megakaryocytic turnover. Sea blue histiocytosis should prompt the clinician to evaluate the patient for more sinister conditions such as myelodysplastic syndrome or infiltrative disorders.

Acute paraparesis in HIV-infected patient after initiation of highly active antiretroviral therapy.

Neurological syndromes occur in around 40-70% of HIV-infected people. Direct central nervous system involvement by the virus usually manifests as HIV encephalitis, HIV leucoencephalopathy, vacuolar leucoencephalopathy or vacuolar myelopathy. Indirect involvement is usually associated with neurotropic opportunistic infections which include tuberculosis, toxoplasmosis, cryptococcosis and viral encephalitis such as herpes simplex, varicella-zoster, cytomegalovirus and Human polyomavirus 2. We report a case of transverse myelitis in a recently diagnosed HIV patient who was otherwise asymptomatic initially and developed paraparesis after 1 month of initiation of antiretroviral therapy. After ruling out opportunistic infections and other causes of compressive and non-compressive myelopathy, development of transverse myelitis was attributed to immune reconstitution inflammatory syndrome in view of baseline low CD4 count and their improvement after HAART initiation. Prompt treatment with corticosteroids successfully reversed the symptoms.

The spectrum of renal diseases observed in native renal biopsies in a single North Indian tertiary care center.

We analyzed the spectrum of biopsy-proven renal disease in a single tertiary care center in North India from 2007 to 2016. A total of 420 biopsies were analyzed. Patients were excluded if clinical details were unavailable or if either the histopathology core or the IF core was inadequate. In the final analysis, 359 biopsies were included. All clinical, laboratory, histopathological, and immunofluorescence (IF) findings were recorded in each case. The usefulness of IF in reaching a definitive diagnosis was also analyzed. The patients were in the age range of 2-94 years; 23.1% were children and 76.9% were adults. Males (60.4%) outnumbered females (39.6%) in all the disease categories except lupus nephritis (LN). Primary glomerular diseases (PGDs) (n = 297, 82.7%) were more common than secondary glomerular diseases (SGDs) (n = 46, 12.8%) and tubulointerstitial diseases (n = 16, 4.5%). The most common PGD was focal segmental glomerulosclerosis (FSGS) (23.4%), followed by minimal change disease (17%) and membranous nephropathy (12.5%), whereas the most common SGD was LN, seen in 9.2%. In the present study, IF helped in reaching the final diagnosis in 44.3%. The entities in which IF was most useful in reaching the final diagnoses were FSGS (31.5%) and IgA nephropathy (14.5%). The final pathological diagnosis correlated with the first clinical possibility in 207 of 359 (57.7%) cases. This 10-year study provides descriptive data and highlights the changing pattern of renal disease possibly due to an increased awareness and referral to higher centers.

An uncommon presentation of hyperhomocysteinemia and vitamin B12 deficiency: a case report.

INTRODUCTION: Cerebral venous thrombosis is relatively rare and characterized by a wide spectrum of clinical features. It is more common in young adults with women affected more than men. The diagnosis of cerebral venous thrombosis is easier nowadays due to easy access to advanced neuroimaging techniques. Abnormalities in thrombophilic profile are associated with enhanced risk of cerebral venous thrombosis. It has varied etiologies such as hypercoagulable states, infection, dehydration, pregnancy, and substance abuse. Hyperhomocysteinemia is found to be closely associated with an enhanced risk of cerebral venous thrombosis. CASE PRESENTATION: Here we report a case of cerebral venous thrombosis secondary to hyperhomocysteinemia caused by vitamin B12 deficiency in a 32-year-old Indo-Aryan man. A detailed coagulation workup led us to find the etiology of cerebral venous thrombosis in this patient who followed a strict vegetarian diet and had vitamin B12 deficiency leading to hyperhomocysteinemia. CONCLUSION: There are conflicting reports in the literature about the association of hyperhomocysteinemia, B12 deficiency, and cerebral venous thrombosis but some reports point to a significant association. We conclude that further studies with a large sample size are required to analyze the effect of hyperhomocysteinemia and low vitamin B12 on the risk of cerebral venous thrombosis.

Prevalence of depression and its associated factors among patients of chronic kidney disease in a public tertiary care hospital in India: A cross-sectional study.

Chronic kidney disease (CKD) patients are at high risk of depressive disorders because of considerable psychological stress due to physical and social changes brought on by disease. The aim of this study is to assess the prevalence of depression in patients with CKD and the factors affecting it at a public tertiary care hospital. This cross-sectional study was carried out at the renal clinic of a tertiary care hospital. Data on 612 patients diagnosed with CKD from September 2014 to April 2016 was obtained. Nine-item Patient Health Questionnaire from PRIME-MD was used to assess the depression. Of all the patients, 55.9% had no depression. Mild depression was found to affect 28.4% of the patients followed by moderate depression, moderately severe, and severe depression (11.8%, 3.8%, and 0.8%, respectively). According to multiple logistic regression, the occurrence of depression was significantly higher with age below 60 years [odds ratio (OR) 1.6, 0.8-2.7; P<0.05], male gender (OR 1.3, 0.9-3.1; P<0.05), no treatment funding (OR 2.6, 1.2-4.5; P<0.05), education less than grade 12 (OR1.3, 1.3-3.2; P<0.05), monthly income ≤INR 20,000 (OR 1.6, 1.1-3.6; P<0.05), CKD stage V (OR 1.3, 1.02.9; P <0.05), Patients on hemodialysis (hD) (OR 2.6, 1.2-4.5; P<0.05), comorbidities ≥3 (OR 1.7, 1.1-2.9; P<0.05), overweight (OR 2.5, 1.3-2.9; P<0.05), and duration of CKD >2 (OR 2.2, 1.3-4.3; P<0.05). About 44% of the patients were found to have depression. Patients' age, gender, body mass index, treatment funding, education status, income, CKD duration and stage, HD status, and comorbidities were found to be significant factors affecting depression.

Successful Use of Entecavir in Hepatitis B-associated Membranous Nephropathy.

We report the case of a 7-year-old unimmunized boy who presented with generalized anasarca for the first time, along with nephrotic-range proteinuria, hypoalbuminemia, microscopic hematuria and hypertension. Special investigations revealed ELISA test to be positive for hepatitis B surface antigen (HBsAg) and hepatitis B envelope antigen (HBeAg); hepatitis B viral DNA load (HBV DNA) level (real-time polymerase chain reaction) was 54 360 903 IU/ml. For hepatitis B virus (HBV)-related glomerulopathy, he was started on enalapril and lasilactone, and percutaneous renal biopsy was performed, which revealed membranous nephropathy (MN). A diagnosis of MN secondary to HBV infection contracted via horizontal transmission was made. The patient was started on peginterferon alfa-2b (50 µg/week) for 24 weeks. He failed to attain remission and seroconversion after interferon (IFN) therapy. Then, oral therapy with entecavir was started, and he attained remission as well as seroconversion after 3 months of therapy. He maintained his seroconversion status at his 6-month and the recent 12-month (quantitative HBV DNA level was 373 IU/ml) follow-up visit. Entecavir seems a promising drug for HBV-related glomerulopathy, especially in IFN-resistant cases.

Direct Cost for Treating Chronic Kidney Disease at an Outpatient Setting of a Tertiary Hospital: Evidence from a Cross-Sectional Study.

BACKGROUND: Chronic kidney disease (CKD) has a high morbidity and mortality in developing countries. And this burden is also increasing rapidly in India. Unaffordability due to high cost of medication and hemodialysis remains one of the major barriers in the successful treatment of CKD. OBJECTIVES: To determine the direct cost involved in treating CKD at an outpatient department of a public tertiary care hospital. METHODS: This cross-sectional study was carried out at a public tertiary care hospital. Patients diagnosed with CKD by a physician were included in the study after obtaining a written informed consent. All the relevant data were collected on a predesigned case record form. RESULTS: The results are based on data obtained from 150 patients. The average age of the patients was 55.7 ± 10.1 years. The average number of drugs per prescription was found to be 6.5 ± 1.7. The annual average costs of treatment for patients on medication only and for patients on hemodialysis plus medication were Rs 25,836 (US $386) and Rs 2,13,144 (US $3181), respectively (Rs = Indian rupee). Treatment cost was found to be statistically significantly higher in patients on hemodialysis, treatment support by employer, patients with a smoking habit, patients with comorbidities, and patients with end-stage renal disease. Calcium tablets, vitamin D sachets, iron supplements, torsemide, and amlodipine were the top five medications prescribed. CONCLUSIONS: Reimbursement, patient's dialysis status, habits, and comorbidities were found to have a significant effect on the direct cost of treatment.

Evidence-based information leads to reduction in inappropriate drug prescribing: Results from Indian older inpatients.

BACKGROUND: Although several guidelines for appropriate prescribing are available, inappropriate drug prescription remains noteworthy problem among older adults. Indian older patients are also not spare from this issue and existing literature indicates a fair level of inappropriate drug use (IDU). OBJECTIVES: Identified potentially IDU and documented their reduction based on provided evidence-based information and also identified possible predictors of IDU in older inpatients. SETTING: Three years prospective study included 1510 inpatients aged 60 years or over, of both sexes. IDU identified using the Modified Updated AGS Beers Criteria 2012. RESULTS: The patients had an average age of 67.10 ± 0.23 years and on an average were prescribed 9.29 ± 0.11 medications. Using AGS Beers Criteria 2012, total IDU was found to be 21% (n = 325). Of total 287 patients received only one inappropriate drug whereas 38 patients received two or more inappropriate drug(s). According to first list of criteria long acting benzodiazepines, anticholinergics, nitrofurantoin and digoxin were most common IDU. Prescription of theophylline in insomnia followed by aspirin in gastric ulcer and calcium channel blocker in constipation were listed from second list of criteria. 31% reductions in IDU were observed based on evidence-based information regarding each identified inappropriate drugs. CONCLUSIONS: The findings of this study provide evidence that provision of unbiased evidenced based information is the best possible means for improvement of pharmacotherapy in older patients.