Changing trends in the hospital management of unstable angina: a drug utilization analysis

OBJECTIVE

The current study was designed to investigate drug utilization in the management of unstable angina in India and to examine the changing trends in the management of unstable angina over the past 4 years.

METHODS

We conducted a prescription survey to examine the use of antianginal drugs in patients with unstable angina in a tertiary care Indian hospital. The use of concurrent medications such as antidiabetic, antihypertensive and lipid-lowering agents was also examined. This study results were compared with a similar study done in this institute 4 years earlier.

RESULTS

A total of 159 consecutive prescriptions were evaluated. Aspirin (86%), nitroglycerin infusion (77%) and low-molecular weight heparins (93%) were the most frequently prescribed drugs. Enoxaparin accounted for 76% of the total LMWH use. One of the heparins was used by 92% of all patients, angiotensin-converting enzyme inhibitors (ACEIs) and beta-blockers by 70% and 67%, respectively. Lipid-lowering agents (57%), antidiabetic agents (16%) and antianxiety agents (33%), in addition to antianginals, were also frequently co-administered. Time trend analysis showed that the use of unfractionated heparin fell from 35% to 10% and the use of ACEIs and enoxaparin increased from 17% to 70% and from 51% to 71%, respectively.

CONCLUSIONS

The study showed that unfractionated heparin is less frequently used in the treatment of unstable angina than in the past and that ACEIs are preferred to calcium channel blockers. Enoxaparin remains the most commonly used low-molecular weight heparin for this indication. A variety of low-molecular weight heparins are available for therapy but comparative clinical trials of efficacy and pharmacoeconomic studies comparing the various LMWHs still need to be carried out.

Utilization of parenteral anti-infective agents in the medical emergency unit of a tertiary care hospital: an observational study

A pharmacy based prescription audit was undertaken in the medical emergency unit of a tertiary care hospital to determine the frequency of prescribing of parenteral anti-infective agents. During the study period, 885 patients were screened. The analysis was done for the number of parenteral anti-microbials in each prescription frequency of individual drug prescribe number and dose unit (DDD), frequency of age and sex, site of infection and daily cost incurred by the patient. It was found that 400 patients (45.2%) received parenteral anti-infective agents. Cephalosporins, aminoglycosides and metronidazole accounted for about 70% of total antimicrobial use. More than 50% of patients had culture sensitivity reports available. The mean (standard deviation, SD) daily cost of antibiotic was USD 3.8 (7.7), median; range 2 (0.1-85.7). Two anti-microbials per prescription were indicated in most of the patients (43.88). In conclusion we have provided an overview of parenteral anti-infective use in medical emergency, which may serve as a basis for intervention and improvement in prescribing pattern of parenteral anti-microbials.

Seizure evolution and amino acid imbalances in murine succinate semialdehyde dehydrogenase (SSADH) deficiency

Mice with targeted deletion of the GABA catabolic enzyme succinic semialdehyde dehydrogenase (SSADH) manifest lethal tonic-clonic seizures, amenable to pharmacologic rescue, at 3-4 weeks of life. In the current report, we characterized amino acid profiles in SSADH(-/-) brain utilizing whole brain and regional extracts (frontal and parietal cortex, hippocampus, and cerebellum) to develop hypotheses concerning epileptogenesis. Of 35 amino acids quantified, we found significant dysregulation in SSADH(-/-) mice for 11 (GABA, glutamate, glutamine, alanine, aspartate, serine, taurine, cystathionine, methionine, homocarnosine, and arginine) as compared to age-matched littermates both before, and following, the period of generalized convulsive seizures and status epilepticus. Our results reveal imbalanced amino acid levels potentially involved in the transition from absence seizures to generalized convulsive seizures resulting in SSADH(-/-) mice. We conclude that the SSADH(-/-) mouse represents a unique epileptic model with the potential to reveal novel aspects of excitatory/inhibitory interactions in the genesis of seizures.

Endoscopic biopsies from normal-appearing terminal ileum and cecum in patients with suspected colonic tuberculosis

BACKGROUND AND STUDY AIMS

Colonic tuberculosis is generally diagnosed by colonoscopy and targeted biopsy of lesions. However, the diagnostic yield of colonic biopsies is not very good. So far as we are aware, there have been no studies investigating the role of biopsies from endoscopically normal-appearing cecum and terminal ileum in diagnosing colonic or ileal tuberculosis, or both.

PATIENTS AND METHODS

Patients with a clinical suspicion of colonic tuberculosis, in whom no endoscopic abnormalities were found on colonoscopy or ileoscopy, were included in the study. Multiple biopsies were obtained from the cecum and ileum.

RESULTS

Fifty patients were studied. Intubation of the terminal ileum was possible in 43 patients (86 %). Histological examination of biopsies obtained from the cecum and terminal ileum showed noncaseating granuloma in two patients. Both of these biopsies were from the terminal ileum. In two other patients, collections of loosely arranged epithelioid cells were observed. This established the diagnosis in these four patients (8 %). In the remaining 46 patients, histology showed nonspecific inflammation in 18 patients (in the cecum in 15 and in the terminal ileum in seven). The other biopsies did not show any abnormalities (33 from the cecum, 34 from the terminal ileum).

CONCLUSIONS

Histological examination of biopsies from the normal-appearing cecum and terminal ileum is useful in a small but significant number of patients with colonic tuberculosis.

Screening for visual impairment in elderly patients with hip fracture: validating a simple bedside test

AIMS

1. To assess the prevalence of visual impairment in those patients who sustain proximal hip fracture after a simple fall. 2. To test the validity of a simple screening test to identify patients with visual impairment.

METHODS

Patients on the orthopaedic rehabilitation ward recuperating from proximal hip fracture were recruited. The nurse screener and examining Ophthalmologist independently assessed the patients' distance visual acuity and visual field to confrontation. In addition, the nurse screener assessed for the presence of cataract in the red reflex and the examining Ophthalmologist performed a dilated slit-lamp examination. On completion of the examination, the Ophthalmologist documented the cause(s) of any visual impairment found.

RESULTS

A total of 89 patients were assessed. In all, 29 patients (33%) could be classified as visually impaired using the United States criteria and 52 patients (58%) had a distance visual acuity of 6/18 or worse in at least one eye. The test reliably identified those patients with visual impairment (sensitivity 94% (+/-5%), specificity 92% (+/-6%)), but was less reliable at identifying those patients with potentially remedial visual impairment (sensitivity 70% (+/-10%), specificity 92% (+/-6%)).

CONCLUSION

The level of visual impairment in this group of patients is high and screening for visual impairment in the elderly with a history of falls is justified. We have demonstrated that a suitably trained member of the rehabilitation team can identify over 94% of those patients with impaired vision. We believe this simple test should now be incorporated into the assessment of all patients requiring rehabilitation after a proximal hip fracture.

Inhibition of skin sphingosine synthesis: enhanced percutaneous permeation of 5-fluorouracil

The present study was designed to investigate the role of skin sphingosine inhibition in enhancing the transcutaneous permeation of 5-fluorouracil (5-FU), a hydrophilic drug, across rat skin. Ethanol-perturbation significantly reduced the sphingosine content as compared to that in normal skin until 24 h of perturbation (p < 0.05). To maintain the low content of sphingosine for a longer time, beta-chloroalanine (beta-CA), a selective inhibitor of serine palmitoyl transferase, was used for inhibiting the sphingosine synthesis in viable skin. Application of beta-CA (600 microg or 1200 microg/7 cm2) to viable skin perturbed with ethanol significantly reduced the sphingosine content until 48 h as compared to that in perturbed viable skin (p < 0.05). However, the sphingosine content in viable skin perturbed with ethanol and treated with lower doses (200 or 400 microg/7 cm2) of beta-CA, returned significantly close to that in ethanol-perturbed viable skin at 36 h (p < 0.05). Skin sphingosine synthesis inhibition efficacy of 1200 microg beta-CA was insignificantly different to that of 600 microg dose of beta-CA at 36 h or 48 h (p < 0.05). The systemic delivery of percutaneously applied 5-FU across ethanol-perturbed rat skin treated with either 600 microg or 1200 microg beta-CA was significantly greater as compared to that obtained after oral administration or after application of lower percutaneous doses of beta-CA (p < 0.05). Higher Cmax, MRT, AUC and maintenance of effective plasma concentration of 5-FU for 46 h was achieved by a single topical application of a formulation containing 5-FU and 600 microg beta-CA to ethanol-perturbed skin.

Efficacy of photodynamic therapy in circumscribed choroidal haemangioma

PURPOSE

To report efficacy of photodynamic therapy (PDT) in the treatment of three cases of juxtafoveal circumscribed choroidal haemangioma.

METHODS

Data on three patients (two primary, and one failed TTT) treated with verteporfin, 6 mg/m2 given as i.v. infusion over 10 min. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 s (50 mJ/cm2) was applied 5 min after completion of infusion. Overlapping multiple spots (2500 microm) were applied to cover the entire surface of the tumour. The mean pretreatment tumour size was 7 mm (base) x 2.2 (thickness) mm. Periodic follow-up with ophthalmoscopy, ultrasonography, and angiographic studies was performed.

RESULTS

All three cases showed complete regression of the tumour with resolution of subretinal fluid, flattening of tumour, and absence of choroidal vasculature on ICG. The visual acuity either improved or remained stable in all three cases. The overlying retinal vessels remained unaffected. There were no ocular or systemic complications.

CONCLUSIONS

PDT is an effective treatment for management of juxtafoveal circumscribed choroidal haemangioma.

Cutaneous reactions in patients with solitary cysticercus granuloma on phenytoin sodium

Several medical conditions are believed to be associated with an increased risk of cutaneous adverse reactions to anti-epileptic drugs. The aim of this study was to study the frequency and nature of cutaneous reactions in a cohort of patients being treated with phenytoin sodium for seizures, who were divided into those with a solitary cysticercus granuloma (SCG) and those with a condition other than SCG, to determine if the presence of SCG increases the risk of cutaneous adverse reaction to phenytoin. A cohort of 117, consecutively begun on treatment with phenytoin for seizure control, were followed up prospectively for the development of cutaneous reactions. There were 63 patients with SCG upon imaging and 54 patients to whom phenytoin was administered for seizures due to causes other than SCG or multiple neurocysticercosis. Cutaneous reactions were significantly more common (p = 0.02) in patients with SCG (9/63 patients; 14.3%) than in controls (2/54 patients; 3.7%). The spectrum of skin reactions in patients with SCG included benign skin rash (n = 3), anticonvulsant hypersensitivity syndrome (n = 4), Stevens-Johnson syndrome (n = 1), and urticaria (n = 1). Individuals with seizures due to SCG have a high incidence of cutaneous adverse reactions to phenytoin. This fact should be kept in mind when initiating them on treatment with this anti-epileptic drug.

Anti-steroidogenic activity of the two Indian medicinal plants in mice

The chloroform extract of Croton roxburghii bark (CECR, Euphorbiaceae) and ethyl acetate extract of Zizyphus jujuba bark (EAZJ, Rhamnaceae) were evaluated for anti-steroidogenic activity in the adult female mouse. This study was designed to assess the effects of CECR and EAZJ on ovarian steroidogenisis. Antifertility activity was evaluated by observing the estrus cycle, body weight, wet weight of ovaries, steroidogenic enzymes, and substrates. Blood profiles were estimated to find out the toxic manifestations of the extracts. CECR and EAZJ each arrested the normal estrus cycle of adult female mouse at diestrus stage and reduced the wet weight of ovaries significantly. Cholesterol and ascorbic acid content in ovaries of crude extract-treated mice were significantly elevated. The significant inhibition of delta(5)-3beta-hydroxysteroid dehydrogenase (delta(5)-3beta-HSD) and glucose-6-phosphate dehydrogenase (G-6-PDH), the two key enzymes involved in ovarian steroidogenisis, were also observed in mouse after 18 days of treatment. Hematological profiles, biochemical estimations of whole blood and serum remains unaltered in extract-treated mouse. Normal estrus cycle and ovarian steroidogenisis were restored after withdrawal of treatment with CECR and EAZJ on average 27 and 32 days, respectively. Antifertility activities of crude extracts were found to be reversible.

Delayed renal allograft dysfunction and cystitis associated with human polyomavirus (BK) infection in a renal transplant recipient: a case report and review of literature

Human polyomavirus type BK (BKV) associated nephritis (BKVAN) has recently emerged as an important cause of renal allograft dysfunction and failure. Early recognition of this entity as a cause of allograft dysfunction is extremely important since misdiagnosis can accelerate graft loss. We report a case of BKVAN that presented with symptoms related to cystitis, and review the risk factors, the diagnostic tools and the approach to treatment of BK virus associated allograft nephropathy.

Tissue HHV6 and 7 determination in pediatric solid organ recipients--a pilot study

Herpes virus infections remain a major challenge in solid organ transplantation. HHV6 and 7 blood viral load was associated with pathology after renal transplantation. Little is known about the significance of tissue HHV6 and 7 infections. A total of 18 tissue biopsies (13 kidney, three GI and two BAL) from nine pediatric transplant patients (five kidney, two liver, one combined liver and kidney and one bone marrow transplant) were subjected to blood HHV6 IgG and IgM testing. In addition, tissue HHV6 and 7 semi-quantitative PCR analysis with subsequent detection by ELISA and quantitative methods were applied to the same samples. We also studied four native kidney biopsies of children with other kidney disease. The results of the biopsies were correlated with clinical data. Of the transplant patients, 78% were HHV6 IgG positive. Six of nine had a positive IgM on at least one occasion, however, only two of nine transplant patients were symptomatic with a mixed CMV/EBV septic picture of multi-organ failure. Only these two patients had a significant tissue viral load for HHV6. Additionally, a very significant tissue viral load for HHV6 was detected in an immunocompromised patient 3 wk after a roseola-like febrile illness. The HHV6 copies were 31, 88 and 206 per 10 microL of DNA, respectively. In the patient who also had the fourth positive ELISA for HHV6 PCR product, the Multiplex PCR and restriction enzyme assay on its PCR product revealed a significant contribution by HHV7, while the HHV6-B signal was rather weak. Significant tissue HHV6 loads can be found in tissue biopsies from organ recipients with significant illness and also in native kidneys after primary infection. This may explain the high prevalence of HHV6 in transplanted kidneys. Further studies on HHV6 and 7 using molecular techniques should be supported.

Early postnatal behavior deficits after maternal carbon dioxide pneumoperitoneum during pregnancy

BACKGROUND

In this study, we tested the hypothesis that maternal pneumoperitoneum produces early postnatal behavior deficits in the offspring.

METHODS

Time-dated pregnant guinea pigs were exposed to 45 min of carbon dioxide (CO2) pneumoperitoneum at a pressure of 7 mmHg. There was no manipulation of the control animals. On postnatal days (PND) 10 and 20, the behavior of their offspring was assessed by monitoring the locomotor activity of each of the pups in a 1 x 1 m chamber demarcated into 100 squares. Locomotor data was log-transformed and expressed as mean values (SD).

RESULTS

At PND 10, pneumoperitoneum offspring exhibited significantly higher levels of locomotor activity than the offspring of controls (1.81 +/- 0.48 vs 1.33 +/- 0.78). The pneumoperitoneum pups continued to exhibit hyperactive behavior at PND 20 (1.83 +/- 0.72 vs 1.20 +/- 0.72).

CONCLUSIONS

Maternal pneumoperitoneum produces postnatal hyperactivity in guinea pig offspring, suggesting that there may be long-term consequences associated with the physiologic changes produced in the fetus during CO2 insufflation.