Efficacy of Oral, Topical, and Intradermal Tranexamic Acid in Patients with Melasma - A Meta-Analysis.

Background and Objective: Tranexamic acid (TXA) has recently shown promising results in the treatment of melasma. The objective of this study was to generate statistical evidence on the efficacy of TXA with different routes. Materials and Methods: We searched studies in PubMed, Cochrane, ClinicalTrials.gov, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A change in melasma area and severity index (MASI)/modified MASI score from the baseline at the end of 8 and 12 weeks was seen. Inverse variance method was used for continuous data to measure standard mean difference (SMD) at a 95% confidence interval (CI). RevMan version 5.4 was used for analysis, and statistical heterogeneity across studies was reported using I2 statistics. P < 0.05 was considered significant. Results: Totally, 28 randomized control trials were included. At 8 weeks, oral TXA showed a significant change in SMD of 1.61, 95% CI 0.44-2.79, P = 0.007; at 12 weeks, oral TXA showed SMD of 2.39, 95% CI 1.42-3.35, P < 0.00001 compared to adjuvant treatment. At 8 weeks, topical TXA did not show a significant change with SMD of -0.05, 95% CI -1.08-0.97, P = 0.92; at 12 weeks, topical TXA did not show a significant change with SMD of 0.66, 95% CI -0.10-1.42, P = 0.09 compared to adjuvant treatment. Similarly, for intradermal TXA at 8 weeks, results were not significant with SMD of 1.21, 95% CI -0.41-2.83, P = 0.14, and at 12 weeks, SMD was -0.55, 95% CI -2.27-1.18, P = 0.54 compared to adjuvant treatment. Conclusion: Tranexamic acid in an oral formulation can be used along with adjuvant treatment for the management of melasma. Data are still required for topical and intradermal routes. Owing to the fact that our included studies had a lot of heterogeneity, more research is needed along with addressing the adverse effects of tranexamic acid as well as its variation in different skin colors.

Modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome: A prospective observational study from a tertiary care teaching hospital, India.

Introduction: Acute pancreatitis (AP) is one of the most common yet, the most complex and challenging abdominal emergencies encountered by clinicians globally. It runs an unpredictable course. One-fifth of all AP patients develop complications. Many prognostic predictive scoring systems are used for AP. The aim of our study was to evaluate the usefulness of modified computed tomography severity index (MCTSI) scores to predict the need for intensive care unit (ICU) stay, complications, and mortality in patients of AP. Methodology: An observational, prospective study was conducted for 1 year. Fifty cases diagnosed as AP were included in this study. Contrast-enhanced computed tomography of the abdomen and pelvis was carried out in all patients. MCTSI was calculated according to CT findings. Patients' demographic details, clinical findings, duration of hospital stay, complications, and interventions were recorded. SPSS version 26.0 was used for statistical analysis. Results: A.total of 50 patients were enrolled in the study. The mean age was 43.34 years. Total hospital stay was 9.02 ± 6.47 days, mean ward stay was 6.08 ± 2.73, and mean ICU stay was 2.94 ± 4.7 days. Five deaths were reported. There was a significant correlation between the necessity of ICU admission and grade of pancreatitis. There is significant correlation with age and ICU stay (r = 0.344, P = 0.014), age and ward stay (r = -0.340, P = 0.016), total duration of hospital stay and MCTSI score (r = 0.742, P = 0.000), duration of ward stay and MCTSI score (r = -0.442, P = 0.001), and strong correlation with duration of ICU stay and MCTSI score (r = 0.869, P = 0.000). A higher MCTSI score was significantly associated with the presence of local as well as systemic complications and with death (P = 0.0001). Conclusion: Grading by modified CT severity index has a significant direct correlation with the necessity of ICU admission, duration of ICU stay, and total duration of hospital stay. A modified CT severity index can be used to predict the possibility of developing local and systemic complications as well as the need for interventions. Modified CTSI is a reliable predictor of clinical course and outcome in cases of acute pancreatitis.

Résumé Introduction: La pancréatite aiguë (PA) est l'une des urgences abdominales les plus courantes, les plus complexes et les plus difficiles rencontrées par les cliniciens du monde entier. Il suit un cours imprévisible. Un cinquième de tous les patients AP développent des complications. De nombreux scores pronostiques prédictifs systèmes sont utilisés pour AP. Le but de notre étude était d'évaluer l'utilité de l'indice de gravité de la tomodensitométrie modifiée (MCTSI) scores pour prédire le besoin de séjour en unité de soins intensifs (USI), les complications et la mortalité chez les patients atteints de PA. Méthodologie: Une observation, Une étude prospective a été menée pendant 1 an. Cinquante cas diagnostiqués comme AP ont été inclus dans cette étude. Tomodensitométrie à contraste amélioré de l'abdomen et du bassin a été réalisée chez tous les patients. Le MCTSI a été calculé en fonction des résultats de la TDM. Données démographiques des patients, les résultats cliniques, la durée du séjour à l'hôpital, les complications et les interventions ont été enregistrés. La version SPSS 26.0 a été utilisée pour l'analyse statistique. Résultats: Au total, 50 patients ont participé à l'étude. L'âge moyen était de 43,34 ans. Le séjour total à l'hôpital était de 9,02 ± 6,47 jours, en moyenne le séjour était de 6,08 ± 2,73 et le séjour moyen en USI était de 2,94 ± 4,7 jours. Cinq décès ont été signalés. Il y avait une corrélation significative entre la nécessité d'admission en USI et grade de pancréatite. Il existe une corrélation significative avec l'âge et le séjour en USI (r = 0,344, P = 0,014), l'âge et séjour en salle (r = −0,340, P = 0,016), durée totale du séjour à l'hôpital et score MCTSI (r = 0,742, P = 0,000), durée du séjour en salle et MCTSI score (r = -0,442, P = 0,001) et forte corrélation avec la durée du séjour en USI et le score MCTSI (r = 0,869, P = 0,000). Un score MCTSI plus élevé était significativement associée à la présence de complications locales et systémiques et au décès (P = 0,0001). Conclusion: classement par l'indice de gravité CT modifié a une corrélation directe significative avec la nécessité d'une admission en USI, la durée du séjour en USI et la durée totale de séjour à l'hôpital. Un indice de gravité CT modifié peut être utilisé pour prédire la possibilité de développer des complications locales et systémiques ainsi que le besoin d'interventions. Le CTSI modifié est un prédicteur fiable de l'évolution clinique et des résultats dans les cas de pancréatite aiguë. Mots-clés: pancréatite aiguë, admission en unité de soins intensifs, complications locales et systémiques, gravité de la tomodensitométrie modifiée indice, pronostic.

Impact of newer direct-acting antiviral drugs based on quality-adjusted life years: A prospective pharmacoeconomic study in hepatitis C patients.

CONTEXT: The Indian government is dispensing newer direct-acting antiviral (DAA) drugs, which may have impact on hepatitis C virus (HCV) patients' quality of life (QoL). AIMS: To evaluate different DAA regimens and impact on QoL in terms of quality-adjusted life year (QALY) in HCV patients and to measure cost-effectiveness. METHODS: This prospective, observational study was carried out on patients who were diagnosed with HCV. Recruited patients were followed up until 12-24 weeks. Patients were recruited following the selection criteria. Along with demographic and drug details, the regimens used were analyzed and evaluated for cost minimization, cost-effectiveness, and cost-utility analysis. For health quality check, the Chronic Liver Disease questionnaire (CLDQ) was used which was also used for QALY assessment. Data were entered into MS Excel 2016. Difference in between the regimens for total cost was done using unpaired t-test and ANOVA test using SPSS 25.0. Overall cost-effectiveness, cost minimization, cost utility and cost of illness analysis was also calculated. P < 0.05 was considered statistically significant. RESULTS: A total of 31 patients were enrolled. A total of five drugs, namely, sofosbuvir, daclatasvir, ribavirin, velpatasvir, and ledipasvir were widely used. Sofosbuvir was most common (46.25%)component of drug combination in our study. A total of five types of regimen were used according to the genotype of patients. With 44,260.13 ± 15,884.92 INR of the total drug cost, 70.97% of patients spent around 30,000-40,000 INR for the whole pharmacotherapy. The total indirect cost was 2768.39 ± 3916.13 INR with the total direct cost of 48,660.90 ± 15,356.39 INR. The total cost including direct as well as indirect cost spent during 6-month therapy by 61.29% of patients was 40,000-50,000 INR. Based on the CLDQ score, QoL was 64.1 ± 25. Regimen 2 (sofosbuvir + velpatasavir) stood out with the lowest cost. Regimen 5 (ribavirin [200 mg] + sofosbuvir [400 mg] + velpatasvir [100 mg]) was found to be the most cost-effective. Considering 1 life year with good health after treatment, QALY was 0.31. CONCLUSIONS: Ribavirin (200 mg) + sofosbuvir (400 mg) + velpatasvir (100 mg) was found to be the cost-effective and cost-saving regimen among DAAs.

Global Trigger Tool: Proficient Adverse Drug Reaction Autodetection Method in Critical Care Patient Units.

BACKGROUND: Emergency department (ED) being the most crucial part of hospital, where adverse drug reactions (ADRs) often go undetected. Trigger tools are proficient ADR detection methods, which have only been applied for retrospective surveillance. We did a prospective analysis to further refine the trigger tool application in healthcare settings. OBJECTIVE: To estimate the prevalence of ADRs and prospectively evaluate the importance of using trigger tools for their detection. MATERIALS AND METHODS: A prospective study was conducted in the ED for the presence of triggers in patient records to monitor and report ADRs by applying the Institute for Healthcare Improvement (IHI) trigger tool methodology. RESULTS: Four hundred sixty-three medical records were analyzed randomly using 51 trigger tools, where triggers were found in 181 (39.09%) and ADRs in 62 (13.39%) patients. The prevalence of ADR was 13.39%. According to the World Health Organization (WHO)-Uppsala Monitoring Centre (UMC) causality scale, 47 (75.8%) were classified as probable and 15 (24.2%) as possible, wherein 39 (62.9%) were predictable and 8 (12.9%) were definitely preventable. Most common triggers were abrupt medication stoppage (34.98%), antiemetic use (25.91%), and time in ED >6 hours (17.49%). The positive predictive values (PPVs) of triggers such as international normalized ratio (INR) > 4 (p = 0.0384), vitamin K administration (p = 0.002), steroid use (p = 0.0001), abrupt medication stoppage (p = 0.0077), transfusion of blood or blood products (p = 0.004), and rash (p = 0.0042) showed statistically significant results, which make the event detection process more structured when these triggers are positive. Presence of five or more triggers has statistically significant chances of developing an ADR (p < 0.05). CONCLUSION: Trigger tool could be a viable method to identify ADRs when compared to the traditional ADR identification methods, but there is insufficient data on IHI tool and its use to identify ADRs in the general outpatient setting. Healthcare providers may benefit from better trigger tools to help them detect ADRs. HOW TO CITE THIS ARTICLE: Pandya AD, Patel K, Rana D, Gupta SD, Malhotra SD, Patel P. Global Trigger Tool: Proficient Adverse Drug Reaction Autodetection Method in Critical Care Patient Units. Indian J Crit Care Med 2020;24(3):172-178.

Off-label drugs use in neurology outpatient department: A prospective study at a tertiary care teaching hospital.

BACKGROUND: Off-label drug use refers to any use of an approved or cleared drug that is not included in that product's approved labeling or cleared indications for use. It may be in terms of indication, age group, dosage, or route of administration. Off-label drug prescriptions are common neurology practice. AIM: The aim of the study is to evaluate the prevalence pattern of off-label drug use in neurology. SUBJECTS AND METHODS: A prospective, observational, cross-sectional study was carried out in the neurology outpatient department of tertiary care teaching hospital. Data of patients above 18 years were recorded after obtaining their informed consent. The National Formulary of India (NFI) and British National Formulary (BNF) guidelines were used as tools for evaluation of the prevalence of off-label drug use. RESULTS: A total of 709 drugs were recorded from the prescription data of 205 patients collected in the duration of 2 months. The results reported 145 (20.45%) and 317 (44.71%) drugs as off-label as per the NFI and BNF, respectively. Prescriptions with minimum 1 off-label drug use were 78.05% - BNF and 46.83% - NFI. The indication was one of the most common causes of drugs being off-label. Out of the total 317 off-label drug uses reported, 84 were unlicensed drug use as per the BNF. There is strong and positive correlation established between the age of the patients, number of drugs prescribed, and total off-label drugs prescribed per patient in the given study. The most common off-label drug use noted was with clonazepam and amitriptyline. CONCLUSION: Off-label prescriptions practice is common in the field of neurology.

Comparison of the extent and prevalence of prescription of potentially inappropriate medications prescribed to geriatric age group residing in old-age homes versus those receiving care from tertiary care hospital using Beers criteria.

CONTEXT: Certain medications have higher chances of causing adverse effects in geriatric age group. Evidence is against prescribing these medications to the elderly. A list of such medications is called Beers criteria, which was revised by the American Geriatrics Society in 2015. AIMS: Using the Beer's list as reference, the researchers intend to find the extent and prevalence of potentially inappropriate medication (PIM) in geriatric population residing in different settings. SETTINGS AND DESIGN: The researchers analyzed prescription pattern of 200 individuals with age ≥65 years, 100 individuals from old-age homes (OAHs) and 100 individuals from a tertiary care hospital. After collecting data, the researchers tallied each prescription with list of drugs in Beers criteria to find all the possible PIMs in both the groups. RESULTS: It was found that the average age of residents of OAHs was significantly higher (P < 0.002) than the corresponding group from a tertiary care hospital. The residents of OAHs were also a receiving significantly higher (P < 0.0001) number of PIM than their counterparts from the tertiary care hospital. The average number of PIMs prescribed to females in OAHs was also significantly higher than those in the other group. About 55% of residents of OAHs received at least one PIM, compared to just 26% in the other group. At least 27% of individuals of OAHs received two or more PIMs, compared to just 2% in a tertiary care hospital. Lorazepam was the most commonly prescribed PIM in OAHs, whereas ranitidine was the most common PIM in a tertiary care hospital. Ibuprofen was the second most common PIM, with 15% of OAHs residents receiving this drug, while none of the patients from a tertiary care hospital received ibuprofen. CONCLUSION: All the results point toward a poor prescription pattern in the residents of OAHs compared to those receiving care from a tertiary care hospital.

Students' perceptions on feedback module in pharmacology.

CONTEXT: Feedback is an integral part of formative assessment though underutilized in medical education. The objective of this study was to review our feedback module through students' perceptions. METHODOLOGY: We have developed a feedback module which is practiced by us for last 10 years for term ending examination that gives collective feedback to the whole class, followed by individual student-teacher interactions. Students were also exposed to 6-7 multiple choice questions (MCQs) based assessment during the course of pharmacology. Immediately after each MCQ test the answer keys is displayed along with an explanation. Two classes of students were requested to give their perceptions about the feedback by responding on Likert scale for the statements in the questionnaire. All the 206 students who volunteered for the study were enrolled in the study. Mann-Whitney test was used to calculate the difference in perceptions. RESULTS: Of 278 students of two classes, 206 responded (74%). Students' agreement varied from 93% to 98% for 5 items in the questionnaire for the feedback after term ending examinations. Perception of students attending one or more than one feedback session did not differ significantly. For MCQs, tests agreement was 91% to 98% for the 4 items. There was no significant difference between two classes in their perceptions regarding feedback practices (P < 0.05). CONCLUSION: Students gave a favorable opinion for our feedback module. In the medical colleges with a large number of students, this module is feasible for feedback in formative assessment in the form of written tests.

Off-label drug use in Psychiatry Outpatient Department: A prospective study at a Tertiary Care Teaching Hospital.

INTRODUCTION: Off-label drug prescribing is very common in Psychiatry. US-Food and Drug Administration has defined off-label drug as "use of drugs for the indication, dosage form, regimen, patient or other use constraint not mentioned in the approved labeling." OBJECTIVE: The objective was to evaluate off-label drug use in patients attending Outpatient Department of Psychiatry. MATERIALS AND METHODS: One year prospective, cross sectional study was conducted on patients attending Psychiatry Outpatient Department. Demographic data, clinical history, and complete prescription were noted in the predesigned proforma and prescriptions were analyzed for off-label drug use as per British National Formulary-2011. RESULT: A total of 250 patients were enrolled with mean age 40.36 ± 12.3 years. Most common diagnosis was major depressive disorder 101 (40.4%). A total of 980 drugs (mean 3.68 ± 1.42) were prescribed out of which 387 (39.5%) were off-label. Of 250 patients, 198 (79.2%) received at least one off-label drug. Psychopharmacological agents most frequently used in off-label manner were clonazepam 31 (12.4%), lorazepam 30 (12%), and trihexyphenidyl HCl 25 (10%). Prevalence of off-label use of these three drugs was significantly higher than other off-label drugs (P < 0.0001, P < 0.0001 and P < 0.0001 respectively). Inappropriate indication was the most common category of off-label use. There was positive and significant correlation between off-label prescribing and number of drugs (r = 0.722, P ≤ 0.000). Off-label prescribing was statistically significantly higher in 21-40 year age group, but no difference was seen in any co-morbid condition or in between any psychiatric disorder. CONCLUSION: Off-label drugs use is common in psychiatric OPD in our setup. Clonazepam, lorazepam, and trihexyphenidyl HCl were the most frequently used drugs in off-label manner.

Is off-label use a risk factor for adverse drug reactions in pediatric patients? A prospective study in an Indian tertiary care hospital.

BACKGROUND: The lack of specific medicines and labeling recommendations for the pediatric population is a long-standing problem. Using data from an observational study of adverse drug reactions (ADRs) among pediatric inpatients, we aimed to test the hypothesis that off-label status is a risk factor for ADRs. METHODS: A prospective intensive surveillance was conducted at a pediatric ward of a public teaching hospital. Adverse events to labeled and off-label use were assessed for incidence, severity and predictors. A multivariate Cox proportional hazards regression model used to assess off-label use is a risk factor for ADR occurring. RESULTS: Off-label and labeled use were responsible for 34 (67%) and 17 (33%) ADRs respectively. Medicines which lacked complete pediatric labeling had the greatest odds for ADRs (9.21% of medicines in this category were implicated, OR 2.84 (95% CI 1.37-7.09). Number of off-label medicines given to patient significantly increased the hazard of an ADR (hazard ratio (HR) 1.28, 95% CI 0.43-3.78, P = 0.002). Number of medicines given also significantly increased the hazard (HR 1.2, 95% CI 0.80-1.71, P < 0.001). CONCLUSIONS: Use of off-label medicines were more likely to be implicated in an ADR than labeled medicines. This off-label use would be acceptable if evidence of potential benefits outweighs ADRs risk.

Off-label medicine use in pediatric inpatients: a prospective observational study at a tertiary care hospital in India.

Background. In the absence of standard pediatric prescribing information, clinicians often use medicines in an off-label way. Many studies have been published across the globe reporting different rates of off-label use. There is currently no study based on Indian drug formulary. Methods. The prospective observational study included pediatric patients in ages between 0 and 12 years admitted in a tertiary care hospital. Off-label use was assessed using the National Formulary of India (NFI). Predictors of off-label use were determined by logistic regression. Results. Of the 1645 medications prescribed, 1152 (70%) were off-label based on 14 possible off-label categories. Off-label medicines were mainly due to dose difference and use in restricted age limits as indicated in NFI. Respiratory medicines (82%), anti-infectives (73%), and nervous system medicines (53%) had higher off-label use. Important predictors of off-label prescribing were pediatric patients in age of 0 to 2 years (OR 1.68, 95% CI; P < 0.001) and hospital stay of six to 10 days (OR 1.91, 95% CI; P < 0.001). Conclusion. Off-label prescribing is common among pediatric patients. There is need to generate more quality data on the safety and efficacy of off-label medicines to rationalize pediatric pharmacotherapy.

A study of potential adverse drug-drug interactions among prescribed drugs in medicine outpatient department of a tertiary care teaching hospital.

OBJECTIVE: To evaluate prevalence, types, and severity of potential adverse drug-drug interaction in medicine out-patient department. MATERIALS AND METHODS: A single-point, prospective, and observational study was carried out in medicine OPD. Study began after obtaining approval Institutional Ethics Committee. Data were collected and potential drug-drug interactions (pDDIs) were identified using medscape drug interaction checker and were analyzed. RESULT: A total of 350 prescriptions with mean age 52.45 ± 14.49 years were collected over a period of 5 months. A total of 2066 pDDIs were recorded with mean of 5.90 ± 6.0. The prevalence of pDDI was 83.42%. Aspirin was most frequently prescribed drug in 185 (10.15%) out of total of 1821 drugs It was also the most frequent drug implicated in pDDI i.e. in 48.16%. The most common pDDI identified was metoprolol with aspirin in 126 (6.09%). Mechanism of interactions was pharmacokinetic in 553 (26.76%), pharmacodynamic in 1424 (68.92%) and 89 (4.30%) having an unknown mechanism. Out of all interactions, 76 (3.67%) were serious, 1516 (73.37%) significant, and 474 (22.94%) were minor interaction. Age of the patients (r = 0.327, P = 0.0001) and number of drugs prescribed (r = 0.714, P = 0.0001) are significantly correlated with drug interactions. CONCLUSION: Aspirin being the most common drug interacting. The use of electronic decision support tools, continuing education and vigilance on the part of prescribers toward drug selection may decrease the problem of pDDIs.

Evaluation of rationality in prescribing, adherence to treatment guidelines, and direct cost of treatment in intensive cardiac care unit: A prospective observational study.

BACKGROUND: Cardiovascular diseases (CVDs) remain the most common cause of sudden death. Hence, appropriate drug therapy in intensive cardiac care unit (ICCU) is crucial in managing cardiovascular emergencies and to decrease morbidity and mortality. OBJECTIVE: To evaluate prescribing pattern of drugs and direct cost of therapy in patients admitted in ICCU. MATERIALS AND METHODS: Patients admitted in ICCU of a tertiary care teaching hospital were enrolled. Demographic data, clinical history, and complete drug therapy received during their stay in ICCU were noted. Data were analyzed for drug utilization pattern and direct cost of treatment calculated using patient's hospital and pharmacy bills. Rationality of therapy was evaluated based on American College of Cardiology/American Heart Association (ACC/AHA) guidelines. RESULT: Data of 170 patients were collected over 2 months. Mean age of patients was 54.67 ± 13.42 years. Male to female ratio was 2.33:1. Most common comorbid condition was hypertension 76 (44.7%). Most common diagnosis was acute coronary syndrome (ACS) 49.4%. Mean stay in ICCU was 4.42 ± 1.9 days. Mean number of drugs prescribed per patient was 11.43 ± 2.85. Antiplatelet drugs were the most frequently prescribed drug group (86.5%). Mean cost of pharmacotherapy per patient was '2701.24 ± 3111.94. Mean direct cost of treatment per patient was '10564.74 ± 14968.70. Parenteral drugs constituted 42% of total drugs and 90% of total cost of pharmacotherapy. Cost of pharmacotherapy was positively correlated with number of drugs (P = 0.000) and duration of stay (P = 0.027). CONCLUSION: Antiplatelet drugs were the most frequently prescribed drug group. Mean number of drugs per encounter were high, which contributed to the higher cost of pharmacotherapy. ACC/AHA guidelines were followed in majority of the cases.

Randomized comparative trial of efficacy of paracetamol, ibuprofen and paracetamol-ibuprofen combination for treatment of febrile children.

OBJECTIVE: Paracetamol and ibuprofen are widely used for fever in children as monotherapy and as combined therapy. None of the treatments is proven clearly superior to others. Hence, the study was planned to compare the efficacy of paracetamol, ibuprofen and paracetamol-ibuprofen combination for treatment of febrile children. MATERIALS AND METHODS: This was an investigator blind, randomized, comparative, parallel clinical trial conducted in 99 febrile children, 6 months to 12 years of age, allocated to three groups. First group received paracetamol 15 mg/kg, second group received ibuprofen 10 mg/kg and third group received both paracetamol and ibuprofen, all as a single dose by the oral route. Patients were followed-up at intervals of 1, 2, 3 and 4 h post dose by tympanic thermometry. RESULTS: Mean tympanic temperature after 4 h of drug administration was significantly lower in the combination group compared with paracetamol group (P < 0.05); however, the difference was not clinically significant (<1°C). The rate of fall of temperature was highest in the combination group. Number of afebrile children any time post dose until 4 h was highest in the combination group. Difference between combination and paracetamol was significant for the 1(st) h (P = 0.04). Highest fall of temperature was noted in the 1(st) h of drug administration in all the groups. No serious adverse events were observed in any of the groups. CONCLUSION: Paracetamol and ibuprofen combination caused quicker temperature reduction than either paracetamol or ibuprofen alone. If quicker reduction of body temperature is the desired goal of therapy, the use of combination of paracetamol + ibuprofen may be advocated.

Use of potentially inappropriate medications in hospitalized elderly at a teaching hospital: a comparison between Beers 2003 and 2012 criteria.

OBJECTIVES: To detect the prevalence and pattern of use of Potentially inappropriate medications (PIMs) in hospitalized elderly patients of a tertiary care teaching hospital using Beers 2012 criteria and to compare the same with Beers 2003 criteria. MATERIALS AND METHODS: Prescriptions of the elderly patients aged 65 years and above were collected from the medicine ward and analyzed. PIMs were identified with help of Beers 2003 and Beers 2012 criteria and comparison was made between the two criteria. Predictors associated with use of PIM were identified using bivariate and multivariate logistic regression analysis. RESULTS: A total of 210 patients received 2,267 drugs. According to Beers 2003 criteria, 60 (28.57%) elderly patients received at least one PIM and 2.9% drugs were prescribed inappropriately. According to Beers 2012 criteria, 84 (40%) elderly received at least one PIM while 22 (10.47%) received multiple PIMs and about 5% drugs were prescribed inappropriately. The most commonly prescribed PIM was mineral oil-liquid paraffin (30, 14.3%) followed by spironolactone (25, 11.9%), digoxin (19, 9%), and benzodiazepines (14, 6.7%). There was a significant association between the number of patients receiving more than six drugs and the use of PIMs (P < 0.01). Use of more than 10 drugs was a significant predictor for use of PIMs in the elderly. CONCLUSION: The study shows high prevalence of prescribing PIMs in hospitalized elderly patients. Beers 2012 criteria are more effective in identifying PIMs than Beers 2003 criteria.

Inappropriate surgical chemoprophylaxis and surgical site infection rate at a tertiary care teaching hospital

OBJECTIVES: This study aimed to analyze the pattern of surgical chemoprophylaxis, surgical site infection rate, and to check rationality of surgical chemoprophylaxis based on Kunin's criteria. MATERIALS AND METHODS: A prospective, observational study was performed on patients undergoing surgery, in a tertiary care teaching hospital. Data were collected in a pro-forma which included the patients' details, prescriptions from date of admission to discharge or any other outcome and operative notes. Surgical site infection as defined by Centre for Disease Control criteria was recorded. Rationality was assessed based on Kunin's criteria. RESULTS: Total 220 patients were enrolled over a period of one year. Mean hospital stay was 8.67 ± 5.17 days. A total of 2294 drugs were prescribed out of which 840 (36.61%) were antimicrobials. Mean duration for pre-operative intravenous antimicrobial therapy was 0.75 ± 0.45 day and for post-operative intravenous antimicrobial therapy was 3.33 ± 2.24 days while post-operative oral antimicrobial therapy was 4.58 ± 3.34 days. Third generation cephalosporins were prescribed most frequently 64.74% and 64.40% pre-operatively and post-operatively respectively. Antimicrobial prescribing was inappropriate in 52.28%. Total of 19 patients developed surgical site infection. Surgical site infection rate was significantly higher (13.04%) in patients receiving inappropriate chemoprophylaxis (p < 0.01). Surgical site infection adds 9.98 days of hospital stay (p < 0.0001) and 3.57 extra drugs (p < 0.0001) compared to group without surgical site infection. CONCLUSION: Inappropriate use of antimicrobials is highly prevalent in surgical chemoprophylaxis leading to higher surgical site infection rate. Adoption of international standard and formulation of locally feasible guidelines can help overcome this situation.

Inappropriate surgical chemoprophylaxis and surgical site infection rate at a tertiary care teaching hospital.

OBJECTIVES: This study aimed to analyze the pattern of surgical chemoprophylaxis, surgical site infection rate, and to check rationality of surgical chemoprophylaxis based on Kunin's criteria. MATERIALS AND METHODS: A prospective, observational study was performed on patients undergoing surgery, in a tertiary care teaching hospital. Data were collected in a pro-forma which included the patients' details, prescriptions from date of admission to discharge or any other outcome and operative notes. Surgical site infection as defined by Centre for Disease Control criteria was recorded. Rationality was assessed based on Kunin's criteria. RESULTS: Total 220 patients were enrolled over a period of one year. Mean hospital stay was 8.67±5.17 days. A total of 2294 drugs were prescribed out of which 840 (36.61%) were antimicrobials. Mean duration for pre-operative intravenous antimicrobial therapy was 0.75±0.45 day and for post-operative intravenous antimicrobial therapy was 3.33±2.24 days while post-operative oral antimicrobial therapy was 4.58±3.34 days. Third generation cephalosporins were prescribed most frequently 64.74% and 64.40% pre-operatively and post-operatively respectively. Antimicrobial prescribing was inappropriate in 52.28%. Total of 19 patients developed surgical site infection. Surgical site infection rate was significantly higher (13.04%) in patients receiving inappropriate chemoprophylaxis (p<0.01). Surgical site infection adds 9.98 days of hospital stay (p<0.0001) and 3.57 extra drugs (p<0.0001) compared to group without surgical site infection. CONCLUSION: Inappropriate use of antimicrobials is highly prevalent in surgical chemoprophylaxis leading to higher surgical site infection rate. Adoption of international standard and formulation of locally feasible guidelines can help overcome this situation.

Drug utilization in emergency medicine department at a tertiary care teaching hospital: A prospective study.

BACKGROUND AND OBJECTIVES: The practice of emergency medicine has the primary mission of evaluating, managing and providing treatment to those patients with unexpected injury or illness. Instituting appropriate therapy is necessary for safety of the patients and to decrease mortality and morbidity. The objectives were to study the drug utilization pattern and direct cost of therapy in emergency medicine department of a tertiary care teaching hospital. MATERIALS AND METHODS: Data of the patients admitted to emergency medicine department was collected prospectively for 48 h from the time of admission over 2 months. The prescriptions were analyzed for drug use pattern and direct cost of therapy was calculated. RESULTS: A total of 156 patients received 1635 drugs with the mean of 9.99 ± 2.55 drugs/patient. Most common diagnosis was acute coronary syndrome 35 (21.79%). Ondansetron 135 (86.53%) was most frequently prescribed drug followed by pantoprazole 133 (85.25%) and furosemide 68 (43.58%). Amongst antimicrobials ceftriaxone 51 (32.69%) was the most commonly prescribed drug. Direct cost of treatment per patient for the first 48 h was र 4051 ± 1641. CONCLUSION: Ondansetron and pantoprazole were the most commonly prescribed drugs in the emergency department. However, their use in all patients was not justified. Polypharmacy was prevalent. A closer look at the rationality of therapy would help in highlighting issues involved and would be helpful to authorities in deciding prescribing policies.

Evaluation of antidiabetic prescriptions, cost and adherence to treatment guidelines: A prospective, cross-sectional study at a tertiary care teaching hospital.

INTRODUCTION: Diabetes mellitus is on alarming rise in India. Drug utilization studies help to identify the adherence to standard treatment guidelines and to evaluate the rational drug usage. OBJECTIVE: To study prescription pattern, calculate the cost of antidiabetic drugs and to evaluate the adherence to treatment guidelines in diabetic patients attending the medicine outpatient department in a tertiary care teaching hospital. MATERIALS AND METHODS: A prospective observational study was carried out for a period of 5 months. The diabetic patients who visited the medicine outdoor department were included. Demographic data and complete prescription details were recorded in the structured case record form. Cost of the drug therapy was calculated from the patient's bills. Indian Council for Medical research guidelines-2005 for diabetes management was used to evaluate the adherence. RESULTS: A total of 250 patients were enrolled in the study with mean age 57.91 ± 9.37. Out of 250 patients 126 (50.4%) were male and rest were female. A total of 1,391 drugs were prescribed, with mean of 5.56 ± 2.52 drugs and out of which 539 drugs were antidiabetics with mean of 2.18 ± 0.96. In monotherapy, metformin was frequently 218 (40.45%) prescribed. Glimepiride and metformin was the most frequently prescribed in 119 (76.28%) out of 156 antidiabetic drug combinations. Most commonly used drugs other than antidiabetics were aspirin 146 (18.9%) and atorvastatin 119 (15.41%). Mean cost of therapy for a month for a diabetic patient was 354.60 ± 305.72 INR. Majority 209 (83.6%) of prescriptions was in accordance to guidelines. CONCLUSION: Metformin was the most frequently prescribed drug in the diabetes patient. Metformin and glimeperide being the most frequent combination used. Majority of the prescriptions followed standard guidelines.