Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity.

OBJECTIVE: The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates. METHODS: Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees. RESULTS: Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation. CONCLUSION: Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

An evaluation of impact of educational interventions on the technique of use of metered-dose inhaler by patients.

OBJECTIVES: The objective of this study is to evaluate the impact of two educational interventions that are demonstration versus pictorial Leaflet in patients using metered-dose inhaler (MDI). MATERIALS AND METHODS: This interventional study was done in patients who were prescribed drugs through MDI at Tuberculosis and Chest Department. The patients were enrolled in Group A or Group B as per random number table method. The method of use of MDI was assessed using a checklist based on the technique described in the WHO Guide to good prescribing. Patients in Group A were taught the use of MDI by demonstration of the technique by the investigator. Patients in Group B were educated about the technique by a pictorial leaflet based on the technique. Patients were followed up after 15 days and assessed for correct technique for use of the MDI. RESULTS: A total 100 patients were included in the study and were allotted to Group A (47) and Group B (53). Ninety-five percent of the patients had been taught by the treating physician about the method of use of MDI. All the patients at the baseline placed the lips tightly around the mouthpiece and held the aerosol as indicated in the manufacturer's instructions while the step least followed was coughing up the sputum before inhalation. The average steps correctly followed by the patients in Group A and B at baseline were 5.17 ± 2.07 and 5.11 ± 2.04, respectively. These improved significantly to 9.19 ± 0.67 and 6.67 ± 0.63 in Group A and B, respectively, postintervention. The five essential steps of using MDI were followed by 25.53% and 26.41% patients preintervention. An improvement in the technique of use of MDI was observed in 85.11% and 49.06% patients (P = 0.003) postintervention. All the ten steps of the technique were followed by 34.04% patients from Group A and none from Group B at postintervention evaluation (P = 0.0001). CONCLUSION: The inhalation technique for the use of MDI used by the patients is inappropriate. Educational interventions such as demonstration or pictorial leaflet help ensure a better use of the MDI.

A study of the use of drugs in patients suffering from psoriasis and their impact on quality of life.

OBJECTIVE: To study the use of drugs in patients suffering from psoriasis and their effect on quality of life (QOL). MATERIALS AND METHODS: This was a prospective, observational study carried out in newly diagnosed patient of psoriasis at Department of Pharmacology and Outpatient Department of Skin and Venereal diseases at tertiary care teaching hospital, and patients were divided into three groups: Group A: topical therapy alone, Group B: methotrexate with topical therapy, and Group C: cyclosporine with topical therapy. The efficacy of drug was measured using Psoriasis Area Severity Index (PASI). QOL was measured using Psoriasis Disability Index. Patients were followed up at 1 month and 6 months of treatment. Statistical analysis was done using analysis of variance (ANOVA) test. RESULTS: A total 126 patients were enrolled, out of which 114 patients completed the study. PASI score was reduced significantly (P < 0.001) in each treatment group and QOL score was significantly (P < 0.001) decrease in Group B and C as compared to baseline at the end of 6 months. A significant (P < 0.001) reduction in PASI score and QOL was observed in patients of Group B and C as compared to Group A. Correlation between efficacy and QOL was not significant in all three treatment groups. CONCLUSION: Combination therapy (topical + systemic) is more efficacious and associated with significant improvement of QOL as compared to topical therapy alone. Methotrexate and cyclosporine are equally efficacious in treating and improving the QOL in patients suffering from psoriasis.

Self-medication for Acne among Undergraduate Medical Students.

AIMS: This study aims to evaluate the knowledge and pattern of self-medication for acne among undergraduate medical students at a tertiary care teaching hospital. MATERIALS AND METHODS: This cross-sectional study was conducted in II MBBS (Group A), III MBBS Part I (Group B), and III MBBS Part II (Group C) students. Prevalidated questionnaire about knowledge, attitude, and practice of self-medication were administered to participants. Data were analyzed using one-way analysis of variance and Chi-square test. RESULTS: Out of 582 students who responded to questionnaire, 518 suffered from acne. Self-medication practice was observed in 59.2% students. Significantly higher number of female students practiced self-medication (P < 0.0001). Most common source of information was seniors/friends/family members (34.2%). The mildness of illness (42.3%) was the most common reason of self-medication. A total mean score of knowledge was significantly higher in Group C as compared to Group A (P < 0.001) and Group B (P < 0.05). Allopathic medication was preferred by 69.8% students. Seventy-five percentage students read leaflet/package insert/label instruction and expiry date of the medicines. CONCLUSIONS: The participating students lack the knowledge about self-medication for acne. Adequate knowledge and awareness about the appropriate use of medication will reduce the practice of self-medication and improve rational prescribing.

Academic abilities and glycaemic control in children and young people with Type 1 diabetes mellitus.

AIMS: To determine if children and young people aged < 23 years with Type 1 diabetes differ in academic ability from age-matched control subjects without Type 1 diabetes and whether academic scores are related to glycaemic control. METHODS: Using a cross-sectional study design, we administered cognitive and academic tests (Woodcock-Johnson III Spatial Relations, General Information, Letter-Word Recognition, Calculation and Spelling tests) to young people with Type 1 diabetes (n=61) and control subjects (n=26) aged 9-22 years. The groups did not differ in age or gender. Participants with Type 1 diabetes had a disease duration of 5-17.7 years. History of glycaemic control (HbA1c , diabetic ketoacidosis and severe hypoglycaemic episodes) was obtained via medical records and interviews. RESULTS: The participants with Type 1 diabetes had a lower mean estimated verbal intelligence (IQ) level compared with those in the control group (P=0.04). Greater exposure to hyperglycaemia over time was associated with lower spelling abilities within the group with Type 1 diabetes (P=0.048), even after controlling for age, gender, socio-economic status, blood glucose level at time of testing and verbal IQ (P=0.01). History of severe hypoglycaemia or ketoacidosis was not associated with differences in academic abilities. CONCLUSIONS: In children and young people, Type 1 diabetes was associated with a lower verbal IQ. Moreover, increased exposure to hyperglycaemia was associated with lower spelling performance. These results imply that hyperglycaemia can affect cognitive function and/or learning processes that may affect academic achievement.

Practice variations in the conduct of hypothermic circulatory arrest for adult aortic arch repair: focus on an emerging European paradigm.

INTRODUCTION: Hypothermic circulatory arrest for adult aortic arch repair is still high-risk. Despite decades of clinical experience, significant practice variations exist around the world. These practice variations in hypothermic circulatory arrest may offer multiple opportunities to improve practice. The hypothesis of this study was that the current conduct of adult hypothermic circulatory arrest in Europe has significant variations that might suggest opportunities for risk reduction. METHODS: An adult hypothermic circulatory arrest questionnaire was developed and then administered at thoracic aortic sessions at international conferences during 2010 in Beijing and Milan. The data was collected, abstracted and analyzed. RESULTS: The majority of the 105 respondents were anesthesiologists based in Europe and China. The typical adult aortic arch repair in Europe was with hypothermic circulatory arrest at moderate hypothermia utilizing bilateral antegrade cerebral perfusion, typically monitored with radial arterial pressure and cerebral oximetry. Brain temperature was frequently measured at distal locations. The preferred neuroprotective agents were steroids, propofol and thiopental. CONCLUSIONS: The opportunities for outcome improvement in this emerging European paradigm of tepid adult aortic arch repair include nasal/tympanic temperature measurement and adoption of unilateral antegrade cerebral perfusion monitored with radial artery pressure and cerebral oximetry. The publication of an evidence-based consensus would enhance these practice-improvement opportunities.

Transitioning mental health & psychosocial support: from short-term emergency to sustainable post-disaster development. Humanitarian Action Summit 2011.

INTRODUCTION: The Working Group (WG) on Mental Health and Psychosocial Support participated in its second Humanitarian Action Summit in 2011. This year, the WG chose to focus on a new goal: reviewing practice related to transitioning mental health and psychosocial support programs from the emergency phase to long-term development. The Working Group's findings draw on a review of relevant literature as well as case examples. OBJECTIVES: The objective of the Working Group was to identify factors that promote or hinder the long term sustainability of emergency mental health and psychosocial interventions in crisis and conflict, and to provide recommendations for transitioning such programs from relief to development. METHODS: The Working Group (WG) conducted a review of relevant literature and collected case examples based on experiences and observations of working group members in implementing mental and psychosocial programming in the field. The WG focused on reviewing literature on mental health and psychosocial programs and interventions that were established in conflict, disaster, protracted crisis settings, or transition from acute phase to development phase. The WG utilized case examples from programs in Lebanon, the Gaza Strip, Sierra Leone, Aceh (Indonesia), Sri Lanka, and New Orleans (United States). RESULTS: The WG identified five key thematic areas that should be addressed in order to successfully transition lasting and effective mental health and psychosocial programs from emergency settings to the development phase. The five areas identified were as follows: Government and Policy, Human Resources and Training, Programming and Services, Research and Monitoring, and Finance. CONCLUSIONS: The group identified several recommendations for each thematic area, which were generated from key lessons learned by working group members through implementing mental health and psychosocial support programs in a variety of settings, some successfully sustained and some that were not.

Pediatric facial fractures: analysis of differences in subspecialty care.

At the University of Michigan, the pediatric facial fracture call schedule rotates through the plastic surgery, otolaryngology, and oral surgery services. This situation provides an opportunity to evaluate differences in the management of pediatric facial fractures between subspecialty groups. At this hospital, a retrospective review of all pediatric facial fracture cases within a 5-year period was undertaken. Sixty patients with 82 facial fractures were studied along subspecialty lines. Differences in patient groups, practice patterns, and treatment strategies based on subspecialty assignment were found. Overall treatment followed traditional lines, with plastic surgeons involved in all types of pediatric facial fractures, whereas otolaryngology and oral surgeons were more limited in their operative scope, despite equal call responsibilities. It is believed that the managed care arena is a competitive environment in which it will be important to know the strengths and weaknesses of the plastic surgery specialty, as well as those of competing specialties, as patient contracts are negotiated. The overlap of plastic surgery, otolaryngology, and oral surgery in the care of facial trauma could result in plastic surgeons being left off of managed care participant lists. This study highlights plastic surgeons as efficient deliverers of quality care for pediatric facial fractures. Although the treatment of these fractures has fallen into the duties shared by all three subspecialties, data such as those presented here should strengthen our ability to succeed in the evolving environment of managed care.

Pediatric facial fractures: a demographic analysis outside an urban environment.

This study reviews all pediatric facial fractures treated operatively at the C.S. Mott Children's Hospital of the University of Michigan over a 5-year period. Previous series of pediatric facial fractures have been collected at large urban centers and may not be representative of all practice environments. Our institution is a level 1 trauma center that serves a patient population primarily from suburban and rural regions throughout the state. Referral and practice patterns at our institution gave us an important opportunity to analyze differences in patient care and management secondary to venue, and challenge the assumptions made by studies collected at large urban centers. We reviewed 80 fractures in 62 patients. Patient age ranged from 2 to 18 years old with the majority of patients (58%) between 15 and 18 years old. Most fractures resulted from motor vehicle accidents (43%) and there were no firearm injuries. Fracture sites included the mandible (38%), the frontonasoethmoid region (35%), the midface (17%), and the orbit (10%). Only two operative complications were reported. There were no cervical spine injuries. Median patient age was higher and mechanism of injury differed in our study compared with urban studies. Rapid changes in the health care delivery system and the emergence of managed care demand accurate demographic updates for the efficient allocation of valuable resources. Our results showed important differences with previous studies and imply that assumptions and analysis of the care of pediatric facial fractures based solely on data collected at large urban centers may be too parochial, and therefore subsequent health care decisions of resource allocation arrived at without respect to practice environment could be erroneous.

Sensitivity and specificity of a DNA polymerase chain reaction nonisotopic-based detection method for the confirmation of infection with human T-lymphotropic virus types I and II.

BACKGROUND: A convenient, standard format for the detection of polymerase chain reaction (PCR) amplicons would increase the use of PCR for the confirmation of infection with human T-lymphotropic virus types I and II (HTLV-I and HTLV-II). OBJECTIVES: To determine the sensitivity and specificity of an enzyme oligonucleotide assay (EOA) for the confirmation of infection with HTLV-I or HTLV-II. STUDY DESIGN: The sensitivity of the EOA was determined by examining 88 specimens representing diverse geographic-associated genotypes and clinical manifestations. The specificity was determined by testing 40 HTLV-seroindeterminate (PCR-negative) specimens. RESULTS: Of the 52 HTLV-I-positive specimens tested, 46 (88%) were confirmed positive for HTLV-I by the EOA; these included 25 of 30 (83%) specimens from asymptomatic carriers, 14 of 15 (93%) specimens from patients with HTLV-I-associated myelopathy, and all 7 specimens from patients with adult T-cell leukemia. Similarly, 33 of 36 (92%) HTLV-II-positive specimens were confirmed positive for HTLV-II. None of the specimens were wrongly classified. All specimens tested with distinct geographic-associated genotypes for HTLV-I and -II were detected by EOA. Analysis of seroindeterminate specimens, all of which were previously shown to be negative by nested PCR, showed that none of 40 were detected by either the HTLV-I or HTLV-II EOA. CONCLUSIONS: The overall sensitivity of the EOA detection for confirmation of HTLV-I and HTLV-II was 79 of 88 (90%) and the overall specificity was 100%. These findings demonstrate that the EOA provides a simple, standardized assay system for reliable confirmation and typing of HTLV infection.

Isolation from rat kidney of a cytosolic high molecular weight cysteine-S-conjugate beta-lyase with activity toward leukotriene E4.

A cytosolic high M(r) cysteine-S-conjugate beta-lyase (apparent M(r) of approximately 330,000) has been partially purified from rat kidneys. The high M(r) lyase is also present in the mitochondria. The purified enzyme contains at least two proteins with apparent M(r) values of approximately 50,000 and approximately 70,000. Activity is stimulated by dithiothreitol, alpha-keto acids, and pyridoxal 5'-phosphate; aminooxyacetate is an inhibitor. The enzyme catalyzes a competing (half) transamination reaction between pyridoxal 5'-phosphate cofactor and cysteine-S-conjugate substrate; added alpha-keto acids promote conversion of active site pyridoxamine 5'-phosphate to pyridoxal 5'-phosphate. The enzyme also catalyzes a full (but weak) transamination between L-phenylalanine and alpha-keto-gamma-methiolbutyrate. The purified enzyme is not recognized by polyclonal rabbit antibodies to cytosolic rat kidney glutamine transaminase K (another cysteine-S-conjugate beta-lyase of rat kidney) and has no obvious similarities to other pyridoxal 5'-phosphate-containing enzymes. In addition to catalyzing elimination reactions with S-(1,2-dichlorovinyl)-L-cysteine and S-(1,1,2,2-tetrafluoroethyl)-L-cysteine, the enzyme reacts with leukotriene E4 and 5'-S-cysteinyldopamine. Finally, the cytosolic and mitochondrial enzymes are activated by alpha-ketoglutarate. Thus, the possibility must be considered that, in kidneys of animals exposed to various cysteine conjugates, the high M(r) lyase contributes to the generation of pyruvate, ammonia, and reactive fragments in vivo. Many cysteine conjugates are nephrotoxic, and the high M(r) lyase(s) may be involved.

Measurement of kinetic perfusion parameters of gadoteridol in intact myocardium: effects of ischemia/reperfusion and coronary vasodilation.

Quantitation of myocardial perfusion is feasible using contrast enhanced magnetic resonance imaging. A method to quantitate myocardial blood flow is provided by the Kety model modified to account for a diffusable tracer such as gadoteridol. In the present study, perfusion parameters of the modified Kety model (partition coefficient and extraction efficiency) were determined for gadoteridol in intact myocardium using a constant flow, isolated, perfused heart model. Perfusion conditions included hearts with normal perfusion, hearts made globally ischemic for 20 min then perfused normally, and hearts whose coronary flow was more than doubled with 9 microM adenosine. T1 relaxation times were rapidly measured at 0.5 T following step increases in perfusate gadoteridol concentration and at steady state. Both the partition coefficient and extraction efficiency were found to be significantly increased in ischemic/reperfused hearts compared to normal. While flow rates in adenosine hearts were too high for accurate extraction efficiency determination using this technique, the partition coefficient was no different between adenosine and normally perfused hearts. The method described in this article allowed the kinetic parameters of the modified Kety model to be determined in intact heart using NMR relaxation time measurements as the basis of the calculation.

Antidepressant treatment and chemical sympathectomy fail to modulate alpha 1-adrenoceptor sensitivity in mouse eye.

The mydriatic response to alpha 1-adrenergic agonists was used as a functional index of postsynaptic alpha 1-adrenoceptors in mouse iris dilator muscle. Topical ocular application of methoxamine or phenylephrine caused dose-related mydriasis which was inhibited by pretreatment with prazosin or phentolamine. Chemical sympathectomy with topical 6-hydroxydopamine (6-OHDA) produced supersensitivity to phenylephrine but not methoxamine. Daily antidepressant treatment for 14 days with desipramine (10 mg/kg, i.p.), amitriptyline (10 mg/kg, i.p.), fluoxetine (2 mg/kg, i.p.), or moclobemide (40 mg/kg, i.p.) did not alter the response to methoxamine. Central alpha 1-adrenoceptors labelled with [3H]prazosin were similarly unaffected except for a modest downregulation produced by fluoxetine. These results demonstrate that postsynaptic alpha 1-adrenoceptors in mouse CNS and iris dilator muscle are refractory to manipulations known to alter their sensitivity in other tissues.

Automated myocardial edge detection on MR images: accuracy in consecutive subjects.

The authors previously demonstrated the feasibility of graph-searching-based automated edge detection in cardiac magnetic resonance (MR) imaging. To further assess the clinical utility of this method, unselected images from 11 consecutive subjects undergoing clinically indicated (except for one healthy volunteer) short-axis spin-echo MR imaging were analyzed. A total of 142 images from the 11 subjects, encompassing the left ventricle from apex to outflow tract, were analyzed. The computer algorithm correctly identified complete endocardial and epicardial contours in 121 of 142 images (85%). Correlations between observer-traced and computer-derived epicardial areas for all images were good (r = .71 for epicardium, r = .83 for endocardium); they improved for a subset of higher-quality images (r = .82 for epicardium, r = .92 for endocardium). The authors conclude that the current data further support the usefulness of computer digital image processing in geometric analysis of cardiac MR image data.

Non-linkage of the islet amyloid polypeptide gene with type 2 (non-insulin-dependent) diabetes mellitus.

Type 2 (non-insulin-dependent) diabetes is associated with the deposition of islet amyloid. The major formative peptide, islet amyloid polypeptide, has recently been characterised and an abnormality of the structure or expression of this gene is a possible candidate for the inherited component of Type 2 diabetes. A restriction fragment length polymorphism of the gene has been identified with Pvu II. To study the relationship between the islet amyloid polypeptide gene and Type 2 diabetes, two distinct genetic approaches have been undertaken. Firstly, non-linkage has been demonstrated in four pedigrees, with four normoglycaemic first degree relatives having an allele associated with diabetes in other family members, and one affected relative not having the putatively associated allele. The LOD score taking age-related penetrance into account was -1.68, making linkage unlikely (p = 0.02). Secondly, in a population-based restriction fragment length polymorphism survey, no linkage disequilibrium of the alleles was found between a population of unrelated Caucasian subjects with Type 2 diabetes and a normal population. A mutation in or near the islet amyloid polypeptide gene is thus unlikely to be a common cause of Type 2 diabetes.