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   2015| April-June  | Volume 4 | Issue 2  
    Online since April 24, 2015

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Polypharmacy in the elderly
Negar Golchin, Scott H Frank, April Vince, Lisa Isham, Sharon B Meropol
April-June 2015, 4(2):85-88
DOI:10.4103/2279-042X.155755  PMID:25984546
Objective: The objective was to assess the frequency of polypharmacy and potential complications among local seniors. Methods: A cross-sectional convenience sample of 59 adults aged above 65 years was interviewed at Cuyahoga county (U.S. state of Ohio) senior programs. Polypharmacy was defined as more than five prescribed medications. Primary outcomes were frequent missed doses, one or more duplicate drug/s, and equal or more than one contraindicated drug combinations. Findings: Among seniors with the mean age of 76.9 years (25.4% male), 40.6% used multiple pharmacies and 35.6% had polypharmacy. Of all seniors with polypharmacy, about 57% had contraindicated drug combinations. Polypharmacy was associated with duplication (P = 0.02), but not frequent missed doses (P = 0.20). Conclusion: As shown by this study, polypharmacy was associated with duplicated therapy and contraindicated drug combinations. Improved communications among seniors, physicians, and pharmacists is necessary to minimize adverse consequences of polypharmacy.
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Midazolam premedication for Ketamine-induced emergence phenomenon: A prospective observational study
Deepa Kameswari Perumal, Mangaiarkkarasi Adhimoolam, Nitya Selvaraj, Suneeth Pullikotil Lazarus, Meher Ali Raja Mohammed
April-June 2015, 4(2):89-93
DOI:10.4103/2279-042X.155758  PMID:25984547
Objective: Ketamine administration is known to induce hemodynamic pressor response and psychomimetic effects which could be attenuated by appropriate premedication. The present study was designed to evaluate the effect of midazolam on hemodynamic stability and postoperative emergence phenomenon following ketamine anesthesia. Methods: This was a prospective observational study including 30 adult patients with American Society of Anesthesiologists physical grades I and II scheduled for elective short surgeries under ketamine anesthesia. Patients were premedicated with midazolam (0.02 mg/kg intravenously) before the ketamine induction (1 mg/kg intravenously). Demographic data and hemodynamic variables were observed during the perioperative period. Pain score by visual analog scale score and psychomimetic effects were recorded postoperatively. Findings: The mean ± standard deviation of heart rate, systolic blood pressure, diastolic blood pressure, and respiratory rate were decreased postoperatively (85.3 ± 11.4, 120.7 ± 8.2, 79.2 ± 5.5, 13.5 ± 1.8, respectively) compared to intraoperative period (88.53 ± 14.1, 123.83 ± 13.8, 83 ± 9.1, 14.13 ± 2.0, respectively). There was statistically significant decrease in systolic (P = 0.03) and diastolic (P = 0.002) blood pressure, but not with heart rate and respiratory rate. Eighty percent of patients had no pain at ½ hour and 1 hour, while this increased to 90% at 2 hours postoperatively. Mild emergence delirium was noted in 13.3% and 16.7% at ½ hour and 1 hour, respectively, which decreased to 13.3% at 2 hours. Dreams were noticed in 20%, 27% and 10% of patients at ½ hour, 1 and 2 hours after surgery, respectively. Conclusion: Midazolam premedication in ketamine anesthesia effectively attenuated the hemodynamic pressor response and postoperative emergence phenomenon. Hence, the combination of midazolam with ketamine can be safely used for short surgical painful procedures in adults.
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Different doses of intravenous Magnesium sulfate on cardiovascular changes following the laryngoscopy and tracheal intubation: A double-blind randomized controlled trial
Azim Honarmand, Mohammadreza Safavi, Sajad Badiei, Neda Daftari-Fard
April-June 2015, 4(2):79-84
DOI:10.4103/2279-042X.154365  PMID:25984545
Objective: Laryngoscopy and intratracheal intubation may cause acute hemodynamic instabilities due to catecholamine release. Magnesium sulfate (MgSO 4 ) prevents catecholamine release and results in bradycardia and vasodilatation, so can be used to diminish complications of laryngoscopy and intubation in doses > 50 mg/kg. The aim of this study was to compare the different doses of MgSO 4 used to improve cardiovascular instabilities due to laryngoscopy and intratracheal intubation. Methods: In this double-blind randomized controlled trial, 120 patients undergoing elective surgery were divided equally into four groups (n = 30) and received different doses of MgSO 4 as case groups (Group I: 30 mg/kg, Group II: 40 mg/kg, Group III: 50 mg/kg) or the equal volume of normal saline as a control group. The patients' hemodynamic status was recorded at baseline, before laryngoscopy and in 1, 3, 5, and 10 minutes after laryngoscopy. Bradycardia, tachycardia, hypertension, hypotension, ST-T changes, arrhythmias, and duration of extubation and laryngoscopy were also recorded. Findings: There was no significant difference in heart rate between four groups (P baseline = 0.46, P preoperation = 0.55, P 1 min = 0.86, P 3 min = 0.30, P 5 min = 0.63, P 10 min = 0.74). Systolic, diastolic and mean arterial pressures were statistically significant less at 1, 3, and 5 minutes after intubation in comparison with other times of following-up in the three groups received MgSO 4 than the control group. Conclusion: The use of MgSO 4 in doses less than 50 mg/kg can be effective to reduce cardiovascular instability related to laryngoscopy and tracheal intubation.
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Identification of possible adverse drug reactions in clinical notes: The case of glucose-lowering medicines
Pernille Warrer, Peter Bjødstrup Jensen, Lise Aagaard, Lars Juhl Jensen, Søren Brunak, Malene Hammer Krag, Peter Rossing, Thomas Almdal, Henrik Ullits Andersen, Ebba Holme Hansen
April-June 2015, 4(2):64-72
DOI:10.4103/2279-042X.155753  PMID:25984543
Objective: Through manual review of clinical notes for patients with type 2 diabetes mellitus attending a Danish diabetes center, the aim of the study was to identify adverse drug reactions (ADRs) associated with three classes of glucose-lowering medicines: "Combinations of oral blood-glucose lowering medicines" (A10BD), "dipeptidyl peptidase-4 (DDP-4) inhibitors" (A10BH), and "other blood glucose lowering medicines" (A10BX). Specifically, we aimed to describe the potential of clinical notes to identify new ADRs and to evaluate if sufficient information can be obtained for causality assessment. Methods: For observed adverse events (AEs) we extracted time to onset, outcome, and suspected medicine(s). AEs were assessed according to World Health Organization-Uppsala Monitoring Centre causality criteria and analyzed with respect to suspected medicines, type of ADR (system organ class), seriousness and labeling status. Findings: A total of 207 patients were included in the study leading to the identification of 163 AEs. 14% were categorized as certain, 60% as probable/likely, and 26% as possible. 15 (9%) ADRs were unlabeled of which two were serious: peripheral edema associated with sitagliptin and stomach ulcer associated with liraglutide. Of the unlabeled ADRs, 13 (87%) were associated with "other blood glucose lowering medications," the remaining 2 (13%) with "DDP-4 inhibitors." Conclusion: Clinical notes could potentially reveal unlabeled ADRs associated with prescribed medicines and sufficient information is generally available for causality assessment. However, manual review of clinical notes is too time-consuming for routine use and hence there is a need for developing information technology (IT) tools for automatic screening of patient records with the purpose to detect information about potentially serious and unlabeled ADRs.
  4 3,009 505
Evaluation of productivity in Iranian pharmaceutical companies: A DEA-based Malmquist approach and panel data analysis
Mehdi Varmaghani, Amir Hashemi Meshkini, Farshad Farzadfar, Mehdi Yousefi, Saeed Yaghoubifard, Vida Varahrami, Ehsan Rezaei Darzi, Majid Anabi, Abbas Kebriaeezadeh, Hedieh-Sadat Zekri
April-June 2015, 4(2):51-56
DOI:10.4103/2279-042X.155750  PMID:25984541
Objective: In this study, we aimed to assess comparative productivity of 21 pharmaceutical companies in Iran during 2000-2013. Methods: To evaluate the productivity trend of pharmaceutical companies in Iran, we used data envelopment analysis-based Malmquist index. "Total assets" and "capital stock" as inputs and "net sales" and "net profit" as outputs extracted from Tehran stock exchange, were selected to be included in the analysis. This method provides the possibility for analyzing the performance of each company in term of productivity changes over time. We also used an estimation generalized least square panel data model to identify the factors that might affect productivity of pharmaceutical companies in Iran using  EViews 7 and Deep 2.1 software. Findings: The mean total productivity during all years of the study was 0.9829, which indicates the improvement in their overall productivity. The results, over the 13-year period, indicated that the range of productivity changes in pharmaceutical companies, that were included in this study, was between 0.884 and 1.098. Panel data model indicated that age of company could positively (t = 4.765978, P < 0.001) and being located in cities other than Tehran (the capital) could negatively (t = −5.369549, P < 0.001) affect the productivity of pharmaceutical companies. The analysis showed the new policy (brand-generic scheme) and also the type of ownership did not have a significant effect on the productivity of pharmaceutical companies. Conclusion: In this study, pharmaceutical productivity trends were fluctuated that could be due to the sub-optimal attention of policy makers and managers of pharmaceutical companies toward long-term strategic planning, focusing on productivity improvement.
  3 2,576 401
Knowledge, awareness, and perception of contraception among senior pharmacy students in Malaysia: A pilot study
Ramadan M Elkalmi, Muhammad Umair Khan, Akram Ahmad, Akshaya B Srikanth, Norny Syafinase Abdurhaman, Shazia Q Jamshed, Ammar Ihsan Awad, Hazrina Binti Ab Hadi
April-June 2015, 4(2):94-98
DOI:10.4103/2279-042X.155760  PMID:25984548
Objective: This study aimed to assess the knowledge, awareness, and perception of contraception among senior pharmacy students of a public sector university in Malaysia. Methods: A cross-sectional, questionnaire-based study was conducted among senior pharmacy students. The pretested questionnaire was used to collect data from the participants over the period of 1-month. The questionnaire was divided into four sections, for gathering the information about students' demographic data, and their knowledge, attitudes, and perception toward contraception. Data were statistically analyzed using SPSS version 20. Findings: The response rate was 68.6%. The results showed that the contraceptive knowledge was comparatively higher in year four students (P < 0.001), married respondents (P < 0.001) and those taking elective courses (P = 0.022) as compared to their respective counterparts. Majority of the students were well aware and had a positive perception about contraception. Conclusion: Overall findings reflect that the majority of the students had good knowledge, perception, and awareness about contraception. The study recommends future studies to be conducted covering different pharmacy schools across the country to further establish the results.
  2 4,186 451
Multiple cutaneous necrotic lesions associated with Interferon beta-1b injection for multiple sclerosis treatment: A case report and literature review
Gita Faghihi, Akram Basiri, Mohsen Pourazizi, Bahareh Abtahi-Naeini, Ali Saffaei
April-June 2015, 4(2):99-103
DOI:10.4103/2279-042X.155762  PMID:25984549
Multiple sclerosis (MS) is a chronic and debilitating inflammatory autoimmune disorder of the central nervous system. MS patients may experience severe local inflammatory skin reactions during disease-modifying therapy with subcutaneously injected interferon-beta-1b (IFN-β). We report the case of a 49-year-old woman with relapsing-remitting MS, who developed multiple cutaneous necrotic ulcers on both arms and thighs after 3 months of treatment with subcutaneous IFN-β-1b. The biopsy specimens showed skin and subcutaneous tissue necrosis. We diagnosed the skin lesions as cutaneous necrotic ulcerations associated with IFN-β-1b injection. The treatment included ending the use of subcutaneously injected IFN-β-1b and switching to intramuscularly injected IFN-β-1a because of the multiple cutaneous necrotic ulcers. The injection of IFN-β-1b in the areas with lesions was stopped, and the patient's clinical condition improved with the addition of routine wound care, surgical debridement, and skin grafting. This report is intended to raise awareness about severe adverse skin reactions which may rarely occur with subcutaneous IFN-β-1b injection. Early recognition and correction of the injection technique and switching to other forms of interferon can help to prevent these complications.
  2 2,810 298
The comparative study of intravenous Ondansetron and sub-hypnotic Propofol dose in control and treatment of intrathecal Sufentanil-induced pruritus in elective caesarean surgery
Anahita Hirmanpour, Mohammadreza Safavi, Azim Honarmand, Akram Zavaran Hosseini, Maryam Sepehrian
April-June 2015, 4(2):57-63
DOI:10.4103/2279-042X.155751  PMID:25984542
Objective: Pruritus is a common and disturbing side effect of neuraxial opioids after cesarean section. The purpose of this study was to compare the efficacy of intravenous ondansetron and sub-hypnotic dose of propofol in control and treatment of intrathecal sufentanil induced pruritus in cesarean surgery. Methods: Totally, 90 parturient with American Society of Anesthesiology physical status grade I-II, undergoing spinal anesthesia with 2.5 μg sufentanil and 10 mg bupivacaine 0.5% were enrolled to this randomized, prospective, double-blind study. The women were randomly assigned to two groups who received 8 mg ondansetron or 10 mg propofol to treat pruritus grade ≥3. The patient was evaluated after 5 min and in the lack of successful treatment, the doses of two drugs repeated and if the pruritus is on-going, the exact treatment with naloxone was done. Findings: The incidence of pruritus was 69.3%. Both groups were well-matched. The peak time pruritus was 30-75 min after injection. The percentage of individuals consumed naloxone were 6.8% and 15.9% in ondansetron and propofol groups, respectively (P = 0.18). The mean score of satisfaction (according to visual analog scale criteria) was 9.09 ± 1.1 in ondansetron group and 9.3 ± 1.07 in the propofol group (P = 0.39). Conclusion: Ondansetrone and sub-hypnotic dose of propofol are both safe and well-tolerated. Due to their same efficacy in the treatment of intrathecal sufentanil-induced pruritus, they can be widely used in clinical practice.
  2 2,462 820
Comparison of prescribing indicators of academic versus non-academic specialist physicians in Urmia, Iran
Laya Sadigh-Rad, Leila Majdi, Mehrnush Javaezi, Mohammad Delirrad
April-June 2015, 4(2):45-50
DOI:10.4103/2279-042X.155749  PMID:25984540
Objective: As chief prescribers, physicians could have a key role in rational drug use. Core prescribing indicators of all physicians have been evaluated in the Islamic Republic of Iran for several years, but no study has assessed the effects of academic status of doctors on their prescribing behaviors. We aimed to compare prescribing indicators of two groups of academic and non-academic specialist physicians working in Urmia, Iran. Methods: In this cross-sectional study, prescribing indicators of the total number of 37 academic and 104 non-academic specialist physicians in six medical specialties (infectious diseases, psychiatry, otorhinolaryngology, gynecology, pediatrics and general surgery) were studied during 2012 using Rx-analyzer, a dedicated computer application. A set of five quality indicators was used based on the World Health Organization and International Network for Rational Use of Drugs recommendations. Findings: Totally, 709,771 medications in 269,660 prescriptions were studied. For academic and non-academic specialist physicians, the average number of medications per prescription was 2.26 and 2.65, respectively. Similarly, patients' encounters with injectable pharmaceuticals were 17.37% and 26.76%, respectively. The corresponding figures for antimicrobial agents were 33.12% and 45.46%, respectively. The average costs of every prescription were 6.53 and 3.30 United States Dollar for academic and non-academic specialist physicians, respectively. All the above-mentioned differences were statistically significant. Conclusion: Better prescribing patterns were observed in academic specialist physicians. However, they prescribed medications that were more expensive, while the reason was not investigated in this study. Further studies may reveal the exact causes of these differences.
  1 2,349 343
Usefulness of Danaparoid sodium in patients with Heparin-induced thrombocytopenia after cardiac surgery
Farzaneh Foroughinia, Fariborz Farsad, Kheirollah Gholami, Somayeh Ahmadi
April-June 2015, 4(2):73-78
DOI:10.4103/2279-042X.155754  PMID:25984544
Objective: Thrombocytopenia is a common problem in cardiovascular surgery patients. However, heparin-induced thrombocytopenia (HIT) is a rare but life-threatening complication of prophylaxis or treatment with heparin. Prompt management of HIT with an alternative anticoagulant is necessary due to the extreme risk of thrombotic complications. Therefore, we evaluated the effects of danaparoid in the treatment of HIT in patients with cardiac surgery who are at moderate to high risk of HIT. Methods: A prospective observational study involving 418 postcardiac surgery patients who received unfractionated heparin and low-molecular weight heparin was conducted in an educational tertiary cardiac care hospital in Iran. All patients were assessed for HIT type II based on thrombocytopenia and pretest clinical scoring system, the "4T's" score. HIT patients were treated with 1500-2500 units intravenous bolus danaparoid sodium followed by 200-400 units/h for a mean of 5 days. Successful response to danaparoid therapy, defined as augmentation in platelet count and improvement of thrombotic events was assessed in all patients treated with danaparoid. Findings: According to pretest clinical score (4T's), the probability of HIT was high in 14 (3.3%) patients and intermediate in three ones (0.7%). 15 patients with HIT were treated with danaparoid. One death occurred in danaparoid-treated group due to persistent thrombocytopenia. The rest of patients were treated successfully with danaparoid without any major thrombotic complication. Conclusion: According to our data and the previous studies', HIT can be managed prosperously with danaparoid in postcardiac surgery patients. However, with the absence of any increase in platelet count after 3-5 days of danaparoid therapy and/or the occurrence of a new thrombotic event, danaparoid cross-reactivity with heparin should be suspected.
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