Potential drug-drug interactions in internal medicine wards in hospital setting in Pakistan.

BACKGROUND: Multiple drugs therapies may be the potential source of drug-drug interactions that can result in alteration of therapeutic response and/or increase untoward effects of many drugs. OBJECTIVE: To identify the frequency and levels of potential drug-drug interactions (pDDIs) in internal medicine wards and their association with patients' age, gender, length of hospital stay and number of prescribed medications; and to describe management of frequently identified major or moderate pDDIs. SETTING: Internal medicine wards of two major tertiary care hospitals of Khyber Pakhtunkhwa, Pakistan. METHOD: Micromedex Drug-Reax system was used to screen patient's profiles for pDDIs. Logistic regression was applied to determine the odds ratio for specific risk factors of pDDIs i.e., age, gender, hospital-stay and number of medications. MAIN OUTCOME MEASURE: Overall prevalence and prevalence of contraindicated, major, moderate and minor pDDIs; levels of pDDIs; frequently identified major or moderate interactions; and odds ratios for risk factors. RESULTS: Total, 188 interacting drug-combinations were identified that contributed to 675 pDDIs. Of 400 patients, 52.8% patients were presented with at least one pDDI (overall prevalence), 21.3% with at least one major-pDDI, and 44.3% with at least one moderate-pDDI. Of 675 pDDIs, most were of moderate (63.6%) or major severity (23%); good (61.2%) or fair (25.5%) type of scientific evidence; and delayed onset (50.2%). Most frequently identified major or moderate interactions resulted in 45.3% of all pDDIs. Their potential adverse outcomes included hepatotoxicity, bleeding, ototoxicity, nephrotoxicity, hypoglycemia, hyperglycemia, risk of thrombosis, hypotension, cardiac arrhythmias and reduction in therapeutic-effectiveness. There was significant association of the occurrence of pDDIs with patients' age of 60 years or more (OR = 2.1; 95% CI = 1.3-3.3; p = 0.003), hospital stay of 6 days or longer (OR = 2.6; 95% CI = 1.5-4.5; p = 0.001), and seven or more number of prescribed medications (OR = 5.9; 95% CI = 3.6-9.6; p < 0.001). CONCLUSION: The present study has recorded a high prevalence of pDDIs in internal medicine wards. Patients with old age, longer hospital stay and increased number of prescribed medications were at higher risk.

Frequency and characterisation of pancytopenia in megaloblastic anaemia.

BACKGROUND: A wide variety of clinical conditions, that primarily or secondarily affect the bone-marrow may present with pancytopenia, one of such conditions is megaloblastic anaemia. The purpose of this study was to determine the frequency and nature of pancytopenia in megaloblastic anaemia. METHODS: This was a prospective, cross-sectional descriptive study conducted in Medical Units, Ayub Teaching Hospital, Abbottabad, Pakistan during July 2010-January 2011. Total 90 patients were included in this study. Data were collected including history, clinical examination, haemoglobin level, mean cell volume, bone marrow examination and peripheral smear examination. RESULTS: Of total 90 patients, 54 were male and 36 were female. Mean age was 28 +/- 15.84 years. Common presenting features were weakness, fever and bleeding manifestations. Pancytopenia was present in 63 (70%) patients. Most common presenting feature related to anaemia was weakness (80%). Bleeding manifestations, related to low platelet count were found in 35 (39%) patients. Physical Examination findings were: pallor (100%), splenomegaly (33%), bleeding manifestations (25%), hepatomegaly (17%), and hepatosplenomegaly (19%). Mean peripheral blood findings of the study population included haemoglobin level (6.25 g/dL), total leukocyte count (2818.7/microL), platelet count (44040/uL), and reticulocyte count (1.7%). Mean values for red cells indices included red blood cells count (2.6 million/uL), mean corpuscular volume (114.3 fL), mean corpuscular haemoglobin (27.3 pg) and mean corpuscular haemoglobin concentration (31.8 g/dL). CONCLUSIONS: In megaloblastic anaemia, pancytopenia is a common and important clinical and haematological problem. Patients should be properly investigated for pancytopenia and its causes because many of them are completely curable while others are manageable. This will help to reduce patients' suffering, improve quality of life and prolong survival.

Prognostic significance of serum bilirubin in stroke.

BACKGROUND: Oxidative injury is an important cause of the neurologic lesion in stroke. Serum bilirubin is considered a natural antioxidant that may affect the prognosis of stroke. The purpose of this study was to evaluate the prognostic significance of bilirubin in stroke patients. METHODS: A prospective cross-sectional study was conducted in Medical Units of Khyber Teaching Hospital, Peshawar. Inpatients admitted with acute attack of stroke were included in this study. Data regarding serum bilirubin and concurrent cerebrovascular risk factors were collected. National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to analyse stroke's severity and functional outcomes, respectively. RESULTS: Hypertension, diabetes mellitus and heart diseases were the most common risk factors. Patients were divided into 3 groups on the basis of serum bilirubin, i.e., < or = 0.6 mg/dl (Group-1), 0.7-0.9 mg/dl (Group-2), and > or = 1.0 mg/dl (Group-3). The mean pre-hospitalisation NIHSS score for Groups 1, 2 and 3 was 5.62, 11.66 and 25.33, respectively; and post-hospitalisation score was 0.875, 3.76 and 16.26, respectively. The pre-hospitalisation mRS score was 4 for Group-1, 4.52 for Group-2 and 4.93 for Group-3; while post-hospitalisation Mrs Score was 1.50, 2.38 and 4.26, respectively. Average serum bilirubin level was significantly higher in patients with poor outcomes as compared with good outcomes (p < 0.01). CONCLUSIONS: This study suggests that higher serum bilirubin levels were associated with increased stroke severity, longer hospitalisation and poor prognosis.