An observational study of root-cause analysis of medication errors in elderly with methotrexate toxicity.

INTRODUCTION: Medication errors are inherent in a healthcare system. This results in both time and cost burdens for both the patient and the health system. The aim of this study was to conduct a root-cause analysis of medication errors in elderly patients with methotrexate toxicity, analyze associated factors, and propose solutions. METHODS: This single-center prospective study was designed to identify medication errors in cases of methotrexate toxicity between November 2022 to May 2023. Categorical data and free-text data are used to describe incidents. Harm assessment, factors related to medication errors, and preventability were evaluated for each case. Possible strategies to prevent similar occurrences are discussed. RESULTS: Out of a total of 15 patients who presented during the study period, nine suffered from methotrexate toxicity due to medication errors. Most medication errors occurred during prescribing or dispensing (seven cases). Inadequate knowledge about medication and dosage, inadequate communication was identified as a contributing factor for all medication errors. Patients on long-term methotrexate treatment are at high risk of methotrexate toxicity. CONCLUSION: This study highlights the challenges of health literacy and lacking communication between healthcare providers and patients that can be met through community pharmacy programs for the elderly in lower-middle-income countries.

An Urticarial and Acral Manifestation of Bullous Pemphigoid After Vildagliptin Therapy: A Case Report.

Drug-induced bullous pemphigoid (DBP) may present identical to an idiopathic type of illness. Thus, DBP should be considered as a differential diagnosis when evaluating the cause of bullous pemphigoid (BP) in elderly individuals with diabetes. We present the case of a 65-year-old "young-elderly" female who developed bullous lesions after initiation of medication. This case report casts light on a commonly prescribed antidiabetic drug, a dipeptidyl peptidase-4 inhibitor, vildagliptin, and its unforeseen complication in the elderly. The long-term complication is BP. With long-term use, there is an increased likelihood of encountering such cases among the elderly. Thus, we recommend that DBP be considered an important early differential diagnosis among elderly diabetics presenting with initial signs and symptoms of BP.

Arglabin: A mediator of inflammasome modulated and independent myocardial injury (PARA-AMI study).

BACKGROUND: Arglabin is a plant alkaloid (sesquiterpene lactone) that is used as an anticancer drug. It has potential anti-diabetic and anti-atherogenic effects. PURPOSE: Arglabin has drawn particular attention because of its therapeutic effects as an anti-inflammatory agent in multiple diseases. Since arglabin inhibits Epidermal Growth Factor Receptor (EGFR) tyrosine kinase, concerns for cardiotoxic effects are valid. The present study was designed to investigate the protective effects of arglabin on the myocardium. STUDY DESIGN: This study was designed to evaluate the effect of arglabin on the myocardium in an experimental model of myocardial necrosis in rats. Different doses of arglabin (2.5, 5, and 10 µg/kg) were investigated as pre-treatment for 21 days in the isoproterenol (ISO) model of myocardial necrosis groups and per se groups. METHODS: On the 22nd day, hemodynamic, histopathological, electron microscopy, oxidative stress markers, inflammatory mediators, apoptotic markers, inflammasome mediators, and Western blot analysis were performed to evaluate the effects of arglabin. RESULTS: Arglabin pre-treatment showed improvement in hemodynamic parameters and histopathological findings at low doses in isoproterenol-induced myocardial necrosis model of rats. Arglabin administration altered myocardial structure and modulated myocardial function via activation of NFκB/MAPK pathway that led to myocardial injury with an increase in dose. CONCLUSION: Arglabin imparted partial cardio-protection via an inflammasome-dependent pathway and mediated injury through the inflammasome-independent pathway.

Effect of adjuvant yoga therapy for asthma control: A randomized controlled trial.

BACKGROUND: Asthma is a chronic respiratory disease with symptoms of attacks of wheezing, shortness of breath, & tightness in the chest. Even with pre-existing treatment exacerbations go uncontrolled. OBJECTIVE: This study compared asthma control in yoga intervention versus non-yoga intervention group using Asthma Control Test. METHODS: In this randomized controlled trial, participants were allocated into two groups in 1:1 ratio - yoga intervention versus non-yoga intervention. Only outcome assessor was blinded. Sample size of 200 was calculated. Individuals between 18 and 60 years of age, diagnosed with mild to moderate asthma with no exacerbation in past one month were screened and enrolled. Per-protocol analysis was done to assess the outcomes of Asthma Control Test and expenditure.(CTRI/2020/02/023534) RESULTS: A total of 192 participants enrolled, 165 completed this study who were considered for final analysis. A significant difference (p < 0.001) was found between yoga and non-yoga exercise group at 13 weeks. Expenses were more in non-yoga exercise group. CONCLUSION: Our findings confirm that yoga exercise with routine medical care reduces exacerbations and improves asthma control.

Yoga therapy on elderly patients with fear of fall: an open-label randomised controlled trial (YOFEAR trial).

INTRODUCTION: Fear of fall is experienced by the elderly irrespective of the presence or absence of history of fall. Falls contribute to injuries that culminate in hospitalisation that incur unwarranted medical expenses. Yoga is unique to Indian cultural practices, with a potential to enhance proprioception. It increases self-body awareness, ultimately improving the balancing capacity of older adults. Thus, the objective of this study is to compare the effect of yoga therapy in the study and control groups at 12 weeks from the baseline. METHODS AND ANALYSIS: This study is designed as an open-label, randomised controlled trial (1:1) with a sample size of 62 elderly patients more than or equal to 60 years of age. Participation of either sex, male or female with a fear of fall will be considered. Two randomised groups of 31 participants each will receive standard therapy for their primary diseases as per the local, national or international guidelines. However, participants in the intervention arm will receive additional structured yoga therapy sessions. The primary objective of this study is to assess and compare the change in fear of fall score of participants in each group using Falls Efficacy Scale (FES) and Berg Balance Scale (BBS) at 12 weeks versus baseline. The secondary endpoint will assess the change in the quality of life of participants at 3 months compared with the baseline.Data will be gathered, entered into Microsoft Excel and further analysed by R software (V.4.3.0). Changes in FES-Intervention and BBS of two groups will be compared either by Student's t-test for parametric data or Mann-Whitney U test for non-parametric data. Statistical significance will be considered if p<0.05 at 95% confidence level. ETHICS AND DISSEMINATION: Ethical approval for this study protocol (version 1.0, 22 April 2022) was obtained from the institute ethics committee (AIIMS/IEC/22/195). TRIAL REGISTRATION NUMBER: CTRI/2022/06/043287.

Atorvastatin-induced Myositis and Drug-induced Liver Injury.

Statins are drugs for preventing cardiac events in the elderly population. Statins are well tolerated with a lower reported incidence of serious side effects (<0.15%) like myopathy and elevated transaminases [>3× upper limit of normal (ULN)]. Serious adverse effects of statins like statin-associated myopathy range from mild muscle pain to rhabdomyolysis. Drug-induced liver injury (DILI) is another adverse effect of statin use, typically presenting with an acute hepatocellular liver injury pattern as mixed or cholestatic injury. Symptoms usually disappear after 3 months of discontinuation of statins. Some patients require immunosuppression with steroids, intravenous immunoglobulin, or rituximab for management of rhabdomyolysis. DILI can be rapidly reversed by the stoppage of the statins if the enzyme elevation is more than twice the normal. Elderly patients are particularly at increased risk of such adverse effects, emphasizing a need for rational prescription of statins in older adults and close monitoring. We report a case of an elderly presenting with paraparesis and later diagnosed to be a case of statin-induced myositis that significantly improved with prompt management. How to cite this article: Kashyap K, Bisht K, Dhar M, et al. Atorvastatin-induced Myositis and Drug-induced Liver Injury. J Assoc Physicians India 2023;71(10):96-98.

24-Hour Holter Monitoring for Identification of Arrhythmias in Elderly Heart Failure Patients: A Single-Centre Study.

Introduction Chronic heart failure (CHF) is a common condition seen in the elderly, and unlike coronary artery disease (CAD), its prevalence increases with age. Electrocardiography (ECG) at rest is a simple, non-invasive investigation that is recommended in the initial evaluation of patients with heart failure. The purpose of this study was to identify various ECG abnormalities in elderly patients with heart failure and to find out whether Holter monitoring increases the chances of identifying arrhythmia in them. Materials and methods The current study was a single-centre, cross-sectional observational study. The study was conducted by collecting data from patients with heart failure attending the medicine and cardiology departments of All India Institute of Medical Sciences, Rishikesh, a tertiary care facility, from May 1st, 2020, to October 31st, 2021. The goal of this study was to look for electrocardiographic abnormalities in elderly heart failure patients who had a reduced (<50%) or preserved (>=50%) left ventricular ejection fraction (LVEF). All consecutively admitted patients who fulfilled the inclusion criteria were enrolled in the study after taking informed consent. All patients underwent echocardiography, electrocardiography and Holter monitoring. Demographic parameters were collected on a pre-formed proforma, and data was entered into an Excel sheet. Results A total of 101 patients were analyzed, and abnormal ECG results were found in 98% of them. Out of 101 patients, 80 (79.2%) patients had heart failure with reduced ejection fraction (HFrEF), with LVEF < 50%, and 21 (20.8%) patients had heart failure with preserved ejection fraction (HFpEF), with LVEF >=50%. Hypertensive heart disease was the most common etiological factor attributing to heart failure in 37 (36.6%) patients and more among heart failure with reduced EF (p=0.01) followed by ischemic heart disease. Old ischemic changes were the commonest ECG abnormality, found in 48 (47.53%) patients with heart failure and among 45 patients (56.25%) with HFrEF (p=<0.001 ). Atrial fibrillation was the most common arrhythmia, occurring in 25 (24.75%) patients with heart failure. The detection rate of arrhythmia by Holter was better than surface ECG in patients with HErEF (p=0.007). Conclusion Electrocardiogram (ECG) in elderly heart failure patients is almost always abnormal. The majority of the patients in our study had more than two ECG abnormalities. ECG is a simple non-invasive tool that can detect underlying etiological factors attributing to heart failure. Holter monitoring can be done as an additional modality to detect arrhythmias in heart patients with reduced ejection fraction for risk stratification.

The dietary isoflavone daidzein mitigates oxidative stress, apoptosis, and inflammation in CDDP-induced kidney injury in rats: Impact of the MAPK signaling pathway.

Cisplatin-induced nephrotoxicity persists as a clinical problem despite several supportive measures to alleviate renal damage. Daidzein (DZ), a dietary isoflavone having antioxidant and anti-inflammatory activity, is investigated in this study for protective effects against cisplatin-induced renal injury in rats. DZ (25, 50, or 100 mg/kg; intraperitoneally; 10 days) was administered along with Cisplatin, single dose, on the 7th day of the experiment. On the 11th day, the rats were euthanized, and different samples were collected for analysis. Biochemical, histopathological, and molecular parameters were assessed to evaluate the effect of daidzein. Cisplatin injection resulted in renal dysfunction, lipid peroxidation that led to consumption of antioxidants, exaggerated apoptosis, and inflammation. These changes were associated with increase in the signaling proteins. DZ attenuated the toxic effects of cisplatin on the kidney at 100 mg/kg dose. The study concludes with the finding that daidzein imparts protection against the nephrotoxic effect of Cisplatin and can be considered as a novel, potential therapy.