Effect of combination of thalidomide and sulfasalazine in experimentally induced inflammatory bowel disease in rats

Thalidomide provided significant protection against tri nitro benzene sulfonic acid induced colitis. Combination therapy also reduced colonic inflammation and all the biochemical parameters (myeloperoxidase assay, malondialdehyde assay and tumor necrosis factor-alpha, estimation) were significant as compared to control as well as thalidomide alone treated group. Combination therapy showed additive effect of thalidomide which restored lipid peroxidation as well as reduced myeloperoxidase and TNF-a towards the normal levels. Morphological and histological scores were significantly reduced in combination groups. In experimental model of colitis, oral administration of thalidomide (150 mg/kg) alone as well as its combination with sulfasalazine (360 mg/kg) significantly reduced the colonic inflammation. The results indicate the additive effect of thalidomide with sulfasalazine in rat colitis model which requires further confirmation in human studies.

Comparison between acetylator phenotype and genotype polymorphism of n-acetyltransferase-2 in tuberculosis patients

BACKGROUND

Isoniazid (INH) is one of the most important drugs of antitubercular treatment regime, and in some cases it causes hepatotoxicity. It is metabolized by hepatic N-acetyltransferase-2 (NAT2).

AIM

To compare whether both methods, i.e., genotype NAT2 and phenotype test of measuring serum INH levels, are useful to identify acetylator status of patients on antitubercular treatment (ATT).

METHODS

A total of 251 tuberculosis (TB) patients on standard treatment were followed up to 6 months for this study. NAT2 genotype was assessed by PCR with restriction fragment length polymorphism (RFLP) whereas serum INH levels were measured by fluorometry.

RESULTS

Of the 251 patients, 50 (19.9%) developed ATT-induced hepatotoxicity. By phenotypic estimation, in the hepatotoxicity group, 17/50 (34%) were slow acetylators whereas 33/50 (66%) were fast acetylators. Genotypically, 19/50 (38%) were slow acetylators and 31/50 (62%) fast acetylators. By phenotypic analysis, in non-hepatotoxicity group, 46/201 (22.9%) were slow acetylators and 155/201 (77.1%) fast acetylators. By genotypic analysis, 30/201 (14.9%) were slow acetylators and 171/201 (85%) fast acetylators. Overall, slow acetylators (25.1%) measured phenotypically were not significantly different from slow acetylators (19.5%) measured genotypically.

CONCLUSION

This study suggests that the acetylator status of TB patients can be detected by phenotypic method as efficaciously as by genotypic method. Therefore, phenotypic method can replace genotypic method to determine acetylating status as phenotypic method is simple and inexpensive.

Development of tool for the assessment of comprehension of informed consent form in healthy volunteers participating in first-in-human studies

Informed consent is a process that involves providing all pertinent study information to the potential study participant. The information imparted in the form gives all such information as would enable a potential participant to come to a decision regarding his/her participation in the study. Various study related aspects are outlined in the participant information leaflet including the background of the study, the benefits and risks, treatment alternatives; the methodology of the study, follow up schedules, confidentiality of the data, compensations and remunerations and right to not participate or withdraw from the study. We have continued a similar exercise for a phase I, first-in-human study, conducted by our center. Here, the volunteers were asked certain questions pertaining to the trial background, design, patients' rights and miscellaneous categories. They were then assessed and the scores compared to come up with certain conclusions. The median (range) for the entire comprehension score was calculated and statistically analyzed on various aspects. Readability of the ease of reading of the consent form was also analyzed on a Flesch-Kinkaid reading scale. A total of 69 volunteers were screened out of which 50 were enrolled in the study. The median (range) score was 27 (19 to 33) and the mean (S.D.) score was 28.9 (3.1). The maximum correct responses were observed for the questions falling under the volunteers' rights category. The Flesch reading ease score was 54 and the Flesch-Kincaid Grade level score was 9.8. Investigators may be encouraged to incorporate such tools in their informed consent process.

A drug utilization study to provide background data for bringing amendments in the drug dispensing policy of a pediatric referral center

OBJECTIVES

The purpose of this study was to generate data regarding the drug utilization pattern in pediatric population of our tertiary care hospital so that we could generate an essential medicine list (EML).

BACKGROUND

Drug therapy accounts for a major portion of expenditure toward health care. Reduction in health care cost for an individual can be achieved by lowering the cost of drug treatment.

METHODS

This was an observational study conducted in the Advanced Pediatric Centre of our hospital, during which prescriptions and case records were reviewed.

RESULTS

During the study a total of 891 prescriptions were reviewed. Antibiotics and nutritional supplements were the major drugs prescribed. A large percentage of drugs were prescribed as trade names. Eighty three per cent of the drugs were prescribed from the National List Of Essential Medicine 2003 (India). Antibiotics accounted for the major bulk of cost of drugs, most of which were purchased by the patients.

CONCLUSIONS

Restricted use of newer antibiotics, branded drugs and prescribing from the EML could be considered as targets for reduction of cost of therapy.

Evaluation of the ability of clinical research participants to comprehend informed consent form

BACKGROUND

The comprehension of informed consent is an integral part of clinical trials. Though India is rapidly becoming a hub of clinical trials very few studies have dealt with the issue of comprehension of informed consent by the patients participating in these trials.

METHODS

Patients who were invited to participate in a phase 3 multicentric trial of a novel lipid lowering agent were evaluated for comprehension score. The participants were explained about the structured consent form which included the question on background details for the study, design of the study, rights of the patients and miscellaneous aspects pertinent to the clinical trial. The questionnaire comprised of 24 items and each correct answer was assigned a score of 1. Total comprehension score (CS) was obtained by summing all the scores.

RESULTS

Participants were from diverse socio economic and educational backgrounds. The mean +/- SD CS achieved by the participants was 13.4 +/- 2.9; median 14(6 to 20). The highest correct responses were obtained for questions on background details (38%). For most of the categories the mean CS was more than 50%. Aspects related to design were mostly difficult to comprehend. No significant difference in the CS was noted between participants from different educational and socioeconomic groups. 8 patients refused to give consent, fear of adverse drug reactions (n = 3) and inability to follow up (n = 5) were the reasons cited by the patients.

CONCLUSION

In conclusion, CS of patients in trials conducted in developing countries can be reasonably good if the investigators explain the consent form in simple language to the participants and CS is not related to the educational status of the participants. Moreover, though a larger majority of patients agree to participate after knowing study details, some patients exercise their right to refuse.

Efficacy of Biologicals in the Treatment of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic multisystem disease. A characteristic feature of RA is persistent inflammatory synovitis, usually involving the peripheral joints in a symmetric distribution. The prevalence of RA is approximately 0.8% of the population (range: 0.3–2.1%); women are affected approximately 3 times more often than men. The current therapeutic approach is to start a disease-modifying agent early in the illness to prevent eventual joint damage. Older disease-modifying anti-rheumatic drugs include methotrexate, sulphasalazine and hydroxychloroquine. Newer ones such as leflunomide and cyclosporin are also used. A recent advance in the management of rheumatoid arthritis is the use of biological agents, which block certain key molecules involved in the pathogenesis of the illness. They include tumour-necrosis-factor-α-blocking agents such as infliximab, etanercept and adalimumab, the anti-CD-20 agent, rituximab, and CTLA-4 Ig abatacept. The present study was planned with the aim of evaluating the efficacy of such newer biological therapies in refractory RA at various time points. Databases including Medline, Embase and the Cochrane Library were searched for all relevant studies up to January 2007. A total of 26 studies were included in present meta-analysis. The method of DerSimonian and Laird [Control Clin Trials 1986;7:177–188] was used to calculated a pooled odds ratio (OR) for the American College of Rheumatology (ACR) criteria 20, 50 and 70, at 24, 54 and 96 weeks. The overall pooled OR were found to be significantly more than the placebo at all 3 time points for all 3 criteria (ACR 20, 50 70). In conclusion, biologicals as a group are highly effective in the treatment of RA. Biologicals were efficacious both in treatment naïve and methotrexate-refractory patients.

Experimentally induced various inflammatory models and seizure: understanding the role of cytokine in rat

BACKGROUND

The mechanism of epileptogenesis is not well established. There is higher incidence of seizures among patients with chronic inflammatory disease. Cytokines are rapidly induced in the brain after a variety of stimuli including inflammation. Aim of this study was to produce various inflammatory models and seizure to understand the role of TNFalpha in above mentioned models.

MATERIALS AND METHODS

A total of 54 male rats were included in the study. Animals were divided into 3 groups of colitis, arthritis, and cotton wool granuloma. Each group had 3 subgroups of control, model and treatment. At the end of 3 days in colitis, 17 days in arthritis and 7 days in cotton wool granuloma groups a subconvulsive dose of PTZ (40 mg/kg i.p) was injected to note seizure onset and seizure score. Brain samples were subjected to DNA fragmentation testing. Presence of inflammation was confirmed by morphology and histology. Plasma and brain TNFalpha levels were measured.

RESULTS

The models of colitis, arthritis and CWG were effectively produced as evidenced by morphology and histology scores (p<0.001). Seizure onset was reduced and grade was increased (p<0.001). Thalidomide reduced the morphological, histological (p<0.002), DNA fragmentation and seizure grade (p<0.001) while increased seizure onset (p<0.001) in the arthritis group. TNFalpha levels in both plasma and brain were reduced following thalidomide treatment (p<0.002) in arthritis group. There were no significant findings in colitis or cotton wool granuloma groups.

CONCLUSION

Inflammation was associated with decreased threshold to PTZ induced seizure. Thalidomide is effective in reducing the extent of arthritis as well as reducing the seizure scoring and increasing seizure onset in the adjuvant arthritis group. Thalidomide was also effective in reducing TNFalpha levels thus contributing to its antiepileptic activity.

Seasonal variation in plasma levels of lithium in the Indian population: is there a need to modify the dose?

INTRODUCTION

Lithium still remains an important choice in the therapy of manic-depressive psychosis (MDP), and though there are reports of seasonal variation in lithium levels from a few countries, such studies have not been conducted in India. Variability in the lithium level can lead to lack of efficacy or toxicity, making seasonal variation clinically relevant.

METHODS

A retrospective case sheet audit was performed for 101 MDP patients for recording plasma lithium level, oral lithium dose, age and gender for one year. The overall average oral lithium dose and level were recorded; the monthly average to which it most closely matched was noted as the control month, and values of other months were compared with this control month by Friedman's test followed by Dunn's test.

RESULTS

The mean age of patients was 38.22 (standard deviation 12.07) years, and 72 out of 101 patients were male. The mean lithium dose in November (938.61 +/- 243.40 mg/day), which was the closest to the overall mean dose (938.24 +/- 241.78 mg/day) was taken as the control month, which when compared with other monthly values, did not show any significant difference. The June (0.54 +/- 0.23 meq/L), July (0.55 +/- 0.24 meq/L) and August (0.55 +/- 0.24 meq/L) mean plasma lithium values were significantly high when compared to the October value (0.45 +/- 0.22 meq/L) as control. High-low variability between the plasma lithium values of different months was found to be 25 percent.

CONCLUSION

The present study showed a significant high variability of lithium levels in different months of the year, therefore frequent plasma level monitoring and oral lithium dose adjustment to prevent situations of toxicity and lack of efficacy in MDP.

Effect of Manuka honey and sulfasalazine in combination to promote antioxidant defense system in experimentally induced ulcerative colitis model in rats

Manuka honey (MH, 5g/kg) provided protection against trinitro-benzo-sulphonic acid induced colonic damage. Combination therapy (MH+sulfasalazine) also reduced colonic inflammation and all the biochemical parameters were significant compared to control and MH alone treated group. Combination therapy showed additive effect of the MH which restored lipid peroxidation and improvement of antioxidant parameters. Morphological and histological scores were significantly reduced in combination groups. In inflammatory model of colitis, oral administration of MH (5g/kg) and combination with sulfasalazine (360 mg/kg) with MH (5g/kg) significantly reduced the colonic inflammation. The results indicate the additive effect of Manuka honey with sulfasalazine in colitis.

Association of anticardiolipin antibodies levels with instent restenosis in patients with coronary artery disease

Present study was conducted to evaluate the association of IgG anticardiolipin antibodies with instent restenosis in patients having undergone percutaneous intervention with bare metal or drug eluting stents. Coronary artery disease patients with stent placement at least 6 months prior were screened for eligibility. 26 satisfied the inclusion/exclusion criteria. 10 patients with symptoms of restenosis, confirmed on check angiography served as cases and 16 without symptoms of restenosis served as control. Unpaired t- test was applied to ascertain the significance of any difference between control and study groups. Antibody levels were estimated on ELISA reader. The mean (+/- SD) anticardiolipin antibodies levels in cases and controls were 11.8 +/- 5.1 GPL/U/ml and 14.3 +/- 10.2 GPL/U/ml, respectively. The difference was not statistically significant (P > 0.05). In conclusion, we did not observe any significant correlation between the level of IgG aCL and instent restenosis.

Bacopa monniera ameliorates amnesic effects of diazepam qualifying behavioral-molecular partitioning

Benzodiazepines are known to produce amnesia by involvement of GABAergic system and by interference of long term potentiation (LTP). In this study, we examined effect of Bacopa monniera on downstream molecules of LTP after diazepam-induced amnesia in mice. We used a Morris water maze scale for evaluating the effect of Bacopa monniera after screening for muscle coordination by rota rod. The index of acquisition and retrieval was recorded as escape latency time (ELT). Behavioral results showed that Bacopa monniera (120 mg kg(-1) oral) significantly reversed diazepam- (1.75 mg kg(-1) i.p.) induced amnesia in Morris water maze task. The molecular studies revealed that diazepam upregulated mitogen activated protein kinase (MAP kinase), phosphorylated CREB (pCREB) and inducible nitric oxide synthase (iNOS), while it downregulated nitrite, nitrate, total nitrite, cAMP response element binding protein (CREB) expression, phosphodiesterase, cyclic adenosine monophosphate (cAMP) without affecting calmodulin levels. Bacopa monniera suppressed the diazepam induced upregulation of MAP kinase, pCREB and iNOS and attenuated the downregulation of nitrite. It did not affect the cAMP, PDE, nitrate, total nitrite, total CREB level. These behavioral findings displayed the reversal of diazepam-induced amnesia by Bacopa monniera without qualifying the molecular details although some downstream molecules of LTP may be involved.

Study of association between use of complementary and alternative medicine and non-compliance with modern medicine in patients presenting to the emergency department

CONTEXT

Complementary and alternative medicines (CAMs) are extensively used by the public. Noncompliance is an important cause of therapy failure.

AIM

This study was done to determine prevalence of emergency admission due to noncompliance with modern medicine following switching over to CAM and to identify any significant association for CAM use among noncompliers.

SETTING AND DESIGN

This cross-sectional study was conducted in the emergency unit of a tertiary healthcare institute.

MATERIALS AND METHODS

Demographic factors and system affected were compared between compliers and noncompliers. Prevalence, reasons and nature of noncompliance were determined. Age, gender, outcome, relation strength and potential preventability of noncompliance, precipitating and previous disease and noncompliant drugs were compared for significant association between CAM using and other noncompliers.

STATISTICAL ANALYSIS

Student's 't' test, Chi square test and odds ratio were used.

RESULTS

Of the 506 patients interviewed 168 (33%) were noncompliant. In 160 (95%) patients noncompliance was due to under-dosing. Lack of knowledge and CAM use constituted 144 (86%) noncompliance-related admissions. Thirty-three (7%) admissions were strongly related to noncompliance and CAM use. Age, gender, outcome, drug use and diseases except chronic obstructive pulmonary disease (COPD) and asthma showed no association while relation strength and potential preventability of emergency admission was less with CAM-using noncompliers. Noncompliance was observed for hypertension, diabetes, COPD and asthma, seizure disorder, tuberculosis and hemophilia besides hepatic and renal failure. The CAM noncompliers used CAM more for modern medicine incurable or unaffordable than curable diseases.

CONCLUSION

Advice for regular treatment and frequent monitoring can decrease CAM use-related noncompliance admissions.

Randomized double-blind study comparing the efficacy and safety of lamotrigine and amitriptyline in painful diabetic neuropathy

AIMS

To compare the efficacy and safety of lamotrigine and amitriptyline in controlling chronic painful peripheral neuropathy in diabetic patients.

METHODS

A randomized, double-blind, crossover, active-control, clinical trial with variable dose titration was carried out (n = 53). Amitriptyline orally, at doses of 10, 25 and 50 mg at night-time, each dose for 2 weeks, and lamotrigine orally, at doses of 25, 50 and 100 mg twice daily, each dose for 2 weeks, by optional titration were used. There was a placebo washout period for 2 weeks between the two drugs. Assessment for pain relief, overall improvement and adverse events were carried out.

RESULTS

Good, moderate and mild pain relief were noted in 19 (41%), six (13%) and seven (15%) patients on lamotrigine and 13 (28%), five (11%) and 15 (33%) patients on amitriptyline, respectively, by patient's global assessment of efficacy and safety. Patient and physicians global assessment, McGill pain questionnaire and Likert pain scale showed no significant difference between the treatments, although improvement with both treatments was seen from 2 weeks. Of the 44 adverse events reported, 33 (75%) were with amitriptyline, sedation being the commonest [in 19 (43%) patients]. Lamotrigine caused adverse events in 11 (25%), of which rash in three (7%) and elevations of creatinine in four (9%) were the most common. The preferred lamotrigine dose was 25 mg twice daily.

CONCLUSIONS

As there are few differences between the two treatments in efficacy, lamotrigine 25 mg twice daily might be the first choice as it is associated with fewer adverse effects in our population.

A meta-analysis of trials comparing Cypher and Taxus stents in patients with obstructive coronary artery disease

AIMS

Drug-eluting stents have been shown to be superior to bare metal stents in reducing restenosis rates. Recently head-to-head trials comparing sirolimus-eluting stents and paclitaxel-eluting stents have been reported. An early combined analysis of these comparative trials is needed. The present meta-analysis was carried out to compare the effects of sirolimus-eluting stents with paclitaxel-eluting stents on the restenosis rate, major adverse cardiac events and late loss of arterial lumen diameter in patients with obstructive coronary artery disease.

METHODS

Electronic (Medline, Cochrane and Embase) and manual search (Index Medicus and cross references of retrieved articles) were carried out for all the relevant articles up till March 2005. Only randomized trials with adequate data for calculation of odds ratio for restenosis rates and major adverse cardiac events using the method of DerSimonian & Laird and standardized mean difference for late loss of arterial lumen diameter were included.

RESULTS

Four studies were found to be eligible for inclusion in the meta-analysis. Restenosis rate and late loss of arterial lumen diameter were significantly reduced by sirolimus-eluting stents as compared with paclitaxel-eluting stents (OR 0.598, 95% CI 0.400, 0.893, pooled mean difference -0.414, 95% CI -0.492, 0.336, respectively). The incidence of major adverse cardiac events was less with sirolimus-eluting stents as compared with paclitaxel-eluting stents (OR 0.727, 95% CI 0.518-1.018) but the results were not statistically significant.

CONCLUSIONS

Sirolimus-eluting stents are superior to paclitaxel-eluting stents in decreasing restenosis rate and late loss of arterial lumen diameter. However, no statistically significant difference in major adverse cardiac events was noted between the two stents.

Effect of inhaled corticosteroids on risk of development of cataract: a meta-analysis

The objective of this study was to quantify the risk of cataract among users of inhaled corticosteroids (ICS). Studies that examined the association of ICS use with risk of cataract were identified through computerized (MEDLINE, EMBASE), manual searches using Index Medicus, and checking cross-references to recover all published articles and scientific session abstracts. Pooled odds ratio (OR) with 95% confidence intervals (CI) were estimated using two methods, fixed effects Mantel-Haenszel model and random effects DerSimonian-Laird model. Four studies satisfied all the inclusion/exclusion criteria and were included in the analysis. The pooled OR (95% CI) by the Mantel-Haenszel method was 1.48 (1.39-1.57) and by the DerSimonian-Laird method was 1.48 (1.30-1.68). The test for heterogeneity was not significant. A total number of nine negative studies would be required to make the results of our meta-analysis non-significant. Number needed to harm is 16 with 95% CI of 13-19. Contrary to popular belief, inhaled ICS may be associated with systemic side effects like cataract as shown by this meta-analysis. The risk of increased cataract shown in our analysis needs to be weighted against the benefits of ICS. Further evaluations are required to clarify the causal association between the dosage and duration of drug use.

Drug utilization pattern in the intensive care unit of a tertiary care hospital

The authors studied the factors affecting drug use pattern, cost of therapy, and the association between the pattern of drug use and survival as well as the duration of stay in a prospective, observational study in an intensive care unit between February and May 2005. Data were collected regarding drugs used, severity of the disease, and their outcome. The mean +/- SD of the Acute Physiology and Chronic Health Evaluation (APACHE III) and Glasgow Coma Scale (GCS) scores of 84 patients were 52.2 +/- 19.4 and 7.5 +/- 2.4, respectively. Although the mean number of drugs at the time of admission to the intensive care unit was 5.3, it increased to 12.9 on the first day and 22.2 during the entire stay. More than 50% of the average expenditure on drugs and nutrition was accounted by antibiotics. Requirement of insulin or inotropes signified an adverse outcome on mortality (odds ratios of 3.43 and 8.44, respectively). In conclusion, there is a tremendous impact of antibiotic use on the cost of therapy in the intensive care unit. The requirement of certain drugs such as insulin and inotropes is of prognostic significance.

A randomized controlled clinical trial to evaluate the efficacy, safety, cost-effectiveness and effect on PAI-1 levels of the three low-molecular-weight heparins--enoxaparin, nadroparin and dalteparin. The ESCAPe-END study

BACKGROUND

Comparative data for efficacy and safety between various low-molecular-weight heparins (LMWHs) in patients with unstable angina is not available. The present study was conducted to compare the efficacy, safety, cost-effectiveness and effects on plasminogen activator inhibitor-1 (PAI-1) levels of three LMWHs--enoxaparin, nadroparin and dalteparin.

METHODS

The study was a prospective, randomized, comparative, open with blinded endpoints (PROBE design) assessment with a 30-day follow-up. The primary endpoint of efficacy was a composite of cardiovascular death, myocardial infarction, recurrent angina and need for intervention. Cost-effectiveness was calculated by calculating the incremental cost-effectiveness ratio. Plasma PAI-1 levels were estimated by ELISA.

RESULTS

A total of 150 patients were available for intention-to-treat analysis. There was no significant difference at 30 days in the primary endpoint or in any of the individual components in the three groups. The secondary endpoint of silent ischemia was also not significantly different. Adverse events were similar in the three groups. The PAI-1 levels were not significantly different in the three groups. The total cost of treatment in the three groups was similar.

CONCLUSION

Any of the three LMWHs evaluated in this study were similar with respect to efficacy, safety, PAI-1 levels and cost-effectiveness.

Gabapentin versus nortriptyline in post-herpetic neuralgia patients: a randomized, double-blind clinical trial – The GONIP Trial

BACKGROUND

Gabapentin and nortriptyline have not been compared in a randomized trial in post-herpetic neuralgia (PHN). The present study was, therefore, undertaken to determine their comparative efficacy and tolerability in the treatment of post-herpetic neuralgia.

PATIENTS AND METHODS

The study was a randomized, double-blind, parallel-group trial of 9 weeks duration. Adult PHN patients with history of > 8 weeks of PHN pain after healing of rash, a pain intensity of at least 40 mm on a 100 mm visual analog scale at screening and at randomization, and average pain score of at least 4 on the Likert scale during the baseline week were included in the study. Gabapentin and nortriptyline were given in incremental doses at 2-weekly intervals till a maximum tolerated dose was obtained. The primary efficacy parameter was change in pain score (11-point Likert scale) from baseline to the end of the study period.

RESULTS

70 patients were available for intention-to-treat analysis. The average pain scores on the Likert scale were significantly reduced at the end of study in both the treatment groups with 47.6% and 42.8% reduction in pain scores in nortriptyline and gabapentin groups, respectively. Patients showed significant improvement in sleep scores in both the treatment groups nortriptyline (46.0%) and gabapentin (52.0%). The VAS and the SF-MPQ scores for pain were significantly reduced in both the groups. Gabapentin was, however, better tolerated as compared to nortriptyline.

CONCLUSION

Gabapentin was shown to be equally efficacious but was better tolerated compared to nortriptyline and can be considered a suitable alternative for the treatment of PHN.

Effect of Oral Administration of Crude Aqueous Extract of Garlic on Pharmacokinetic Parameters of Isoniazid and Rifampicin in Rabbits

AIM

To study the effect of oral administration of crude aqueous extract of garlic for 14 days on pharmacokinetic parameters of isoniazid and rifampicin.

MATERIALS AND METHODS

Crude extract was prepared according to the method described by Fromtling and Bulmer. The study was done on 16 New Zealand white rabbits, divided into two groups of 8 animals each for two drugs. Baseline pharmacokinetic parameters for single-dose isoniazid and rifampicin were calculated from plasma drug concentrations obtained at various time intervals after dosing. The animals were given garlic extract orally for 14 days. Pharmacokinetic parameters were calculated again as done previously.

OBSERVATIONS

Administration of crude aqueous extract of garlic significantly altered the pharmacokinetic parameters for isoniazid. C(max) was reduced from 15.4 +/- 5.6 to 5.4 +/- 3.3 microg/ml. AUC((0-24)) was reduced from 76.7 +/- 25.0 to 34.3 +/- 19.2 microg/ml.h. No significant change in T(max), k(el) and AUC((0-)(alpha)) was seen. Pharmacokinetic parameters of rifampicin were not significantly altered by administration of garlic extract.

CONCLUSIONS

Oral administration of garlic extract decreased the bioavailability of isoniazid significantly with no change in rate of elimination. Bioavailability of rifampicin is not significantly altered by garlic extract.

Effects of artemisinin, artemether, and arteether on the pharmacokinetics of phenytoin

The aim of the study was to determine the effect of artemisinin, artemether, and arteether on the pharmacokinetics of phenytoin in rabbits. In a cross-over study, phenytoin (30 mg/kg/day, o.s.) was given daily for 7 days. On day 7, blood samples were taken at various time intervals between 0 and 24 h. In the artemisinin group, phenytoin was administered for 7 days. On day 8, artemisinin alone (82 mg/kg) was administered, followed by artemisinin (41 mg/kg) along with phenytoin (30 mg/kg/day) for the next 2 days, and blood samples were drawn at various time intervals. For the artemether group, artemether (10 mg/kg, i.m.) was given on day 8, followed by artemether (5 mg/kg, i.m.) for 2 days. For the arteether group, arteether (10 mg/kg, i.m.) was given from day 8 for 3 days. Plasma phenytoin levels were assayed by HPLC, and pharmacokinetic parameters were calculated. In the artemisinin group, there was a significant decrease in t(1/2) a of phenytoin. In the artemether group, t(1/2) el decreased compared to that of controls. In the arteether group, no significant change was observed in the pharmacokinetic parameters. These results suggest that artemisinin compounds alter the pharmacokinetics of phenytoin. Confirmation of these results in human studies will warrant changes in phenytoin dose or frequency, when either of these antimalarials is coadministered with it.

Effects of Artemisinin, Artemether, Arteether on the Pharmacokinetics of Carbamazepine

The effect of artemisinin, artemether and arteether on the pharmacokinetics of carbamazepine in rabbits was studied. In a cross-over study, carbamazepine 40 mg/kg/day orally was given daily for 7 days. On day 7, blood samples were taken at various time intervals between 0 and 24 h. In the artemisinin group, carbamazepine was administered for 7 days as above. On day 8, artemisinin 82 mg/kg followed by 41 mg/kg on the 9th and 10th day along with carbamazepine 40 mg/kg/day was administered and blood samples drawn as above. Artemether 10 mg/kg i.m. was given on day 8 followed by 5 mg/kg i.m. for 2 days. Arteether 10 mg/kg i.m. was given from day 8 for 3 days. Plasma carbamazepine levels were assayed by high-performance liquid chromatography and pharmacokinetic parameters calculated. In all the groups there was an increase in the AUC(0-infinity) when carbamazepine was co-administered with artemisinin, artemether or arteether. The increase in AUC(0-infinity) (22.78 +/- 4.71 to 63.10 +/- 12.29), Cmax (2.76 +/- 0.77 to 7.02 +/- 1.08), Tmax (2.83 +/- 0.17 to 4.16 +/- 0.40) was statistically significant when artemether was given along with carbamazepine (p < 0.05). In the other groups the increase was not significant. These results suggest artemisinin compounds alter the pharmacokinetics of carbamazepine with significant change in the bioavailability. Confirmation of these results in human studies will warrant changes in carbamazepine dose or frequency when either of these antimalarials is co-administered with it.

Study design and rationale of a mock phase I trial as an educational tool for clinical pharmacology residents

OBJECTIVE

To invite comments and suggestions from the phase I trialists, the world over, on the design and rationale provided by us for conducting a mock phase I trial for training clinical pharmacology residents.

METHODS

The trial will be conducted by clinical pharmacology residents of the Post Graduate Institute of Medical Education and Research. After a thorough evaluation of Preclinical toxicity data of a pharmaceutical product provided by a dummy pharmaceutical firm, a randomized, double-blind, placebo controlled, parallel group design with dose escalation of the product will be carried out. A single dose administration will be followed by monitoring the participants for 24 h and again at one week. After obtaining results of the previous group, the next higher dose will be administered. Evaluation of the learners will be done by two independent teachers who will mark them for actual conduct of the study and writing a report of the study. Subsequently, we will try to publish the results of the mock trial and invite further comments.

CONCLUSIONS

This trial designed primarily for training purposes will be instrumental in equipping the residents with the expertise for conducting phase I trials.

Honey--a remedy rediscovered and its therapeutic utility

Honey is a common household product with many medicinal uses described in traditional medicine. Modern system of medicine is also finding the honey efficacious in various medical and surgical conditions. Antimicrobial, antioxidant and wound healing properties of honey are being evaluated with successful outcome. Prevention and treatment of various infections due to a wide variety of organisms and promoting surgical wound healing are some of the areas where honey is making its mark.

Comparative gastrointestinal toxicity of selective cyclooxygenase (COX-2) inhibitors

Cyclooxygenase (COX-2) inhibitors were developed with the hope that they will cause fewer gastrointestinal adverse effects. Ability of selective as well as nonselective COX inhibitors to alter ischemia-reperfusion induced damage of gastric mucosa and hapten-induced colitis in rats has been compared. Celecoxib (10, 20 and 40 mg/kg(-l)) was significantly more potent at aggravating ischemia-reperfusion injury as compared to nimesulide. Similarly, celecoxib was found to maximally potentiate TNBS-induced colitis, followed by nimesulide and indomethacin. Celecoxib at its highest dose produced maximum deep histological injury. This paradoxic ulcer and colitis aggravating effect of selective COX-2 inhibitors may be explained by suppression of protective prostaglandins generated as a consequence of COX-2 induction in inflammatory states.

A meta-analysis of clinical trials of paclitaxel- and sirolimus-eluting stents in patients with obstructive coronary artery disease

AIM

This meta-analysis was conducted to compare the effects of drug (paclitaxel and sirolimus)-eluting stents with bare metal stents on major adverse cardiac events, restenosis rates and late loss of arterial lumen diameter in patients with obstructive coronary artery disease.

METHODS

Randomized, controlled clinical trials comparing sirolimus- and paclitaxel-eluting stents with bare metal stents were identified through electronic and manual search. Fixed effects method of Mantel-Haenszel and random effects method of DerSimonian and Laird were used for computing the pooled odds ratio (OR) and 95% confidence intervals (CI) for major adverse cardiac events and restenosis rates. Standardized mean difference with 95% CI was calculated for late-loss of arterial lumen diameter.

RESULTS

A total of 13 studies were included in the meta-analysis. As compared with bare metal stents, the use of sirolimus- and paclitaxel-eluting stents significantly reduced the major adverse cardiac events (pooled OR 0.35; 95% CI 0.24-0.50), restenosis rates (pooled OR 0.27; 95% CI 0.15-0.47), and late loss of arterial lumen diameter (mean difference 0.57 mm, 95% CI 0.49-0.68).

CONCLUSION

Paclitaxel- and sirolimus-eluting stents significantly reduced the incidence of major adverse cardiac events, restenosis rates, and late loss of arterial lumen diameter as compared with bare metal stents.

Effect of rofecoxib on antihypertensive effects of candesartan in experimental models of hypertension

Given the high prevalence of hypertension, concomitant use of nonsteroidal anti-inflammatory drugs and antihypertensive medications is commonly encountered in clinical practice. The present study was designed to study the effect of indomethacin, nimesulide, and rofecoxib on blood pressure (BP) in normotensive and hypertensive rats and also to investigate the effect of rofecoxib on BP control in candesartan-treated hypertensive rats. Male Wistar rats weighing 150-200 g were divided into three groups: control, DOCA-hypertensive, and L-NAME-hypertensive rats. All the rats were given indomethacin (15 mg/kg body weight), nimesulide (20 mg/kg body weight), rofecoxib (10 mg/kg body weight), or vehicle orally and daily for 6 weeks. Hypertensive rats in separate groups were treated with either candesartan (1 mg/kg body weight) alone or a combination of candesartan (1 mg/kg body weight) and rofecoxib (10 mg/kg body weight) orally and daily for 6 weeks. BP measurements were performed using tail cuff method at baseline and 1-week intervals throughout the treatment period. All the three COX inhibitors resulted in increase in BP, but mean change in BP was the highest with rofecoxib. Rofecoxib-treated L-NAME-hypertensive rats exhibited a significant increase in mean arterial pressure at 6 weeks (168.3+/-5.7 mmHg) as compared with DOCA-hypertensive rats (128.818+/-7.2 mmHg). Administration of Rofecoxib L-NAME-hypertensive rats treated with candesartan resulted in a significant increase in BP. Systolic BP at 0 week (107.0+/-4.2 mmHg) rose to 141.6+/-2.0 mmHg at 6 weeks. Systolic BP at 2, 4, and 6 weeks was significantly higher as compared with (L-NAME+candesartan)- and (rofecoxib+candesartan)-treated group. In conclusion, concomitant use of rofecoxib resulted in poor BP control by candesartan in L-NAME-hypertensive rats.

Effect of nimesulide co-administration on pharmacokinetics of lithium

In a crossover study, lithium was given orally at a dose of 56 mg/kg, prepared as suspension (0.5%) in carboxymethyl cellulose (CMC) and blood samples (1 ml) collected after 0-24 hr after drug administration. After a washout period of two weeks, nimesulide (10 mg/kg) was administered alongwith lithium (56 mg/kg) and blood samples were drawn at the same time intervals (0-24 hr) after drug administration. Plasma was separated and assayed for lithium by M 654 Na+/K+/Li+ analyzer and various pharmacokinetic parameters were calculated. C(max), K(el), t(1/2el) and AUC(0-alpha) of lithium were significantly increased when nimesulide was administered along with lithium as compared to control group.

A comparison of observational studies and controlled trials of heparin in ulcerative colitis

OBJECTIVES

To compare the efficacy of heparin in ulcerative colitis (UC) as demonstrated in observational studies and controlled clinical trials.

INTRODUCTION

Ulcerative colitis (UC) is a chronic condition with a relapsing and remitting course. Several studies have been conducted (observational and controlled clinical trials) to test the usefulness of heparin in this condition but the results of these studies are variable. Some studies demonstrate efficacy while others do not.

METHODS

We pooled the results of observational studies and clinical trials separately in order to compare the results of observational studies and clinical trials using meta-analysis. With the aid of Medline and a manual search in Index Medicus and cross-references of articles published up to July 2003, we identified studies designed to evaluate the effects of heparin on UC. The pooled cure rate in observational studies was calculated.

RESULTS

The results of controlled clinical trials evaluated using meta-analysis showed that the pooled cure rate for observational studies was 87.7% (range 80 - 100). The odds ratio for the controlled trial was 0.34 (95% CI 0.08 - 1.49) using a random effects model and 0.21 (95% CI 0.06 - 1.38) using a fixed effects model. The results of meta-analysis demonstrate a non-significant effect of heparin in controlled clinical trials.

CONCLUSION

The findings of the clinical trials differ markedly from observational studies and indicate a lack of efficacy of heparin in patients with ulcerative colitis.

Serum albumin-adjusted phenytoin levels: an approach for predicting drug efficacy in patients with epilepsy, suitable for developing countries

INTRODUCTION

The antiepileptic drug phenytoin has a high degree of plasma protein binding. Therefore, total phenytoin levels in plasma are misleading indicators of clinical efficacy. This study was designed to investigate whether serum albumin-adjusted phenytoin levels in Indian patients with epilepsy predict clinical outcome better than total phenytoin levels.

PATIENTS AND METHODS

Fifty patients with epilepsy were included in the study and were followed-up for a period of 6 months. Serum albumin levels were estimated spectrophotometrically using the bromocresol green dye method, and serum phenytoin levels were estimated using high pressure liquid chromatography. Values were expressed as mean +/- SEM. Corrected phenytoin levels were calculated using the Sheiner-Tozer equation. Corrected phenytoin levels = Measured total phenytoin(micromol/l) [(albumin g/1 x 0.9)+ 0.1] 40.

RESULTS

At Visit 1, mean serum albumin levels were 44.1 +/- 1.1 micromol/l and mean serum phenytoin levels were 33.9 +/- 2.8 g/l. After correction of the total phenytoin levels using the Sheiner-Tozer equation, 30% of the patients shifted to a different category. The follow-up visits showed similar results. Throughout the study, the corrected phenytoin levels were better indicators of clinical outcome than the total levels. In 23% of patients there was a significant difference between total and corrected phenytoin levels.

CONCLUSION

In patients with serum albumin levels in the hyper- and hypoalbuminemic range, corrected phenytoin levels were better indicators of clinical outcome. In developing countries like India, where estimation of free drug levels is expensive and suitable equipment is not available in most centers, serum albumin-adjusted levels can be used by pharmacologists to predict response and thus assist in clinical decision-making.

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.

Potentiation of antihyperalgesic activity of diclofenac by nimodipine in a formalin model of facial pain in rats

The present study evaluates the possible role of dihydropyridine calcium channel antagonist nimodipine on diclofenac analgesia in formalin-induced facial pain model in rats. Adult Wistar rats of either sex received an injection of 50 microl of 5% v/v subcutaneous formalin into one vibrissal pad and consequent facial grooming behaviour was monitored. Animals exhibited two distinct periods of nocifensive grooming: i) an acute phase lasting 0-6 min; and ii) a tonic phase lasting 6-45 min. The individual analgesic response of nimodipine and diclofenac was noted at doses of 5, 10 and 20 mg/kg i.p. and 1, 2 and 4 mg/kg i.p., respectively, administered 5 min prior to formalin injection. Diclofenac 1, 2 and 4 mg/kg i.p. produced dose-dependent inhibition of facial grooming in both acute and tonic phases. Nimodipine per se had antihyperalgesic effect, but to a very small extent. Nimodipine 10 and 20 mg/kg significantly potentiated the subanalgesic dose of diclofenac, i.e., 0.2 mg/kg. Results of the study showed that low dose nimodipine per se has insignificant antihyperalgesic effect. However, it potentiated the subanalgesic dose of diclofenac showing a synergistic response. These results imply that nimodipine can be used as an adjunct to the treatment of various neuropathic pains, postherpetic and diabetic neuropathies but the clinical efficacy needs to be evaluated in patients.

Investigation of central mechanism of insulin induced hypoglycemic convulsions in mice

Insulin produces seizures in healthy and diabetic animals. Amongst suggested mechanisms, the role of neuromodulators and neurotransmitters is not clear. The present study explores the mechanisms involved in insulin-induced convulsions. Convulsions were induced in Swiss male albino mice with graded doses of insulin. Blood sugar levels were measured prior to and after the first convulsion. Drugs like 5-HTP (5-HT precursor), pCPA (5-HT depletor), ondansetron (5-HT3 antagonist), ketanserin (5-HT, antagonist), ketamine (NMDA antagonist), 1-dopa (dopamine precursor) and reserpine (amine depletor) were studied for interaction with convulsive behaviour induced by insulin. Insulin in 2 IU/kg dose did not produce convulsions while 4 and 8 IU/kg doses produced convulsions in 50% and 100% of animals respectively. 5-HTP, ondansetron, ketanserin, ketamine and l-dopa significantly protected/inhibited animals from convulsions at all studied doses of insulin. On the contrary, pCPA and reserpine potentiated insulin induced convulsions. Insulin caused mortality in 40 and 100% animals with 4 and 8 IU/kg doses respectively. pCPA and reserpine treatments caused mortality at all doses of insulin, while other drugs did not influence insulin induced mortality. Blood sugar levels were reduced in all groups irrespective of the presence or absence of convulsions. A definitive link of serotonergic, dopaminergic and excitatory amino acid pathways in mediating insulin-induced hypoglycemic convulsions is suggested.

COX-2 inhibitors: a CLASS act or Just VIGORously promoted

Abstract Selective cyclo-oxygenase (COX)-2 inhibitors were developed with the hope of producing lesser gastrointestinal (GI) side effects as compared with the conventional nonsteroidal anti-inflammatory drugs (NSAIDs). Soon after their introduction into the market, the sales of celecoxib and rofecoxib went up considerably. Most of this was attributed to the results of the Celecoxib Long-term Arthritis Safety Study (CLASS) and Vioxx Gastrointestinal Outcome Research (VIGOR) trials. However, several discrepancies were noted in the presentation of the actual trial results submitted to the US Food and Drug Administration (FDA) and those used for the purpose of publication in scientific journals. These issues were discussed subsequently by the way of scientific communications. Moreover, with increasing use of these agents, evidence of their adverse effects is coming to light. The present review aims at discussing the above issues, with emphasis on the results of the CLASS and VIGOR trials.

Biologics in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic progressive disease of the joints associated with significant morbidity, deformity, and impaired quality of life. A satisfactory remission of disease is seldom achieved, so therapy is aimed at controlling joint damage and pain with preservation of joint mobility. Until recently, NSAIDs, followed by DMARDs, was considered the treatment of choice. However, many patients fail to gain a satisfactory response to DMARDs or response declines over time. Biologics such as IL-1 receptor antagonist (anakinra), and anti TNF-alpha agents (Etanercept, Infliximab, and Adalimumab) are now available. The anti TNF and IL-1 therapies exert their anti-inflammatory action by neutralizing the activities of TNF-alpha and IL-1 respectively. In contrast to older DMARDs, these agents have rapid onset of action with fewer side effects and have pronounced disease reducing activity in patients who have previously been treated with other DMARDs, when administered as monotherapy or in combination with methotrexate. They have been shown to be at least as effective as methotrexate in reducing clinical disease activity and reducing radiographic progression. Biological agents are generally well tolerated, although their long-term safety needs to be determined. Some concerns have been raised that anti TNF-alpha therapy can increase the risk of serious infections, since TNF-alpha plays an important role in host defense. In light of limitations of cost and lack of long-term safety and efficacy data, newer agents for the time being are used as second- or third-line agents in patients with active RA. The dilemma is that which patients with RA are most suitable for such therapy, since it is still not possible to accurately predict which patient with RA will develop severe disease. One alternative approach may be to limit the use in patients who can afford it, and who are at high risk of radiographic progression and disability.

Possible mechanisms of insulin antinociception

The antinociceptive mechanisms of insulin are not clearly understood. It has been postulated that insulin may act as a neuromodulator. The present study investigates the possible mechanisms of insulin antinociception in mice using the tail flick test. Healthy Swiss male albino mice were treated with insulin and the antinociceptive effect of modulators of 5-HT, NMDA, dopamine, opioids, potassium and calcium channels was tested, followed by blood sugar estimation. All drug doses were given as milligrams per kilogram of body weight 30 min prior to insulin administration, except for para-chlorophenylanine (pCPA), which was given for three consecutive days per orally. Pretreatment with morphine (opioid agonist), 5-Hydroxytryptophan (5-HTP; 5-HT precursor), nicorandil (K(+) channel opener) and nimodipine (Ca(+) channel antagonist) significantly (p < 0.001) potentiated insulin antinociception, whereas naloxone (opioid antagonist), ketanserin (5-HT(2) receptor antagonist), pCPA (5-HT depleter), ondansetron (5-HT(3) receptor antagonist), L-dopa (dopamine precursor), reserpine (dopamine depleter), ketamine (NMDA receptor antagonist) and glibenclamide (K(+) channel blocker) significantly antagonized insulin antinociception (p < 0.001). Results suggest that 5-HT, dopamine, NMDA, opioidergic receptors and potassium and calcium channels play a significant role in insulin analgesia. However, detailed studies on individual mechanisms are necessary.

Comparison of nonselective cyclo-oxygenase (COX) inhibitor and selective COX-2 inhibitors on preimplantation loss, postimplantation loss and duration of gestation: an experimental study

Comparison of effect of three cyclo-oxygenase (COX) inhibitors, indomethacin, nimesulide and celecoxib, on the following were assessed: preimplantation loss, postimplantation loss and duration of gestation in Wistar rats. Indomethacin (2.5 and 10 mg/kg), nimesulide (10 and 40 mg/kg) and celecoxib (10 and 40 mg/kg) were administered by gavage daily from days 1-7 for preimplantation loss studies and from day 13 to completion of gestation for postimplantation and duration of gestation studies. Number of animals in each group was six. Preimplantation loss was calculated by subtracting number of implantation sites from number of luteal spots and postimplantation loss was calculated by noting the difference between implantation sites and pups delivered. The higher doses of the three drugs were shown to increase significantly the preimplantation loss, while all the doses of three drugs produced a significant increase in postimplantation loss. Number of animals crossing upper limit of 23-day normal gestation period in Wistar rats was increased in the higher doses. At comparable dose levels, there was no significant difference among the three drugs.

Effect of different aspirin doses on platelet aggregation in patients with stable coronary artery disease

BACKGROUND

Aspirin is widely used as an antiplatelet agent in the primary and secondary prevention of cardiovascular disease. In order to spare prostacyclin formation and reduce gastrointestinal side-effects, very low doses of aspirin have been introduced. However, it remains unclear whether these low doses are equally effective with respect to inhibition of platelet aggregation.

AIMS

In a randomized, controlled study in 60 patients with stable coronary artery disease, the effects on platelet aggregation of five doses (50, 80, 100, 162.5 and 325 mg) of aspirin, which are widely used in clinical practice, given for 70 days, were investigated. Two reagents, adenosine diphosphate (ADP) and epinephrine, were used to induce platelet aggregation in platelet-rich plasma. An age- and sex-matched group of people without coronary artery disease served as the control.

RESULTS

ADP- and epinephrine-induced platelet aggregation was 78.2 +/- 12.8% and 76.7 +/- 15.5% of maximum aggregation in the control group. Aspirin inhibited platelet aggregation in a dose-dependent manner. Minimum platelet aggregation was observed at a dose of 325 mg aspirin (27.5 +/- 17.4% with ADP). Doses of 50 and 80 mg aspirin were much less effective in inhibiting platelet aggregation (59.1 +/- 11.4% and 50.3 +/- 12.1% with ADP, respectively). Doses of 100 and 162.5 mg aspirin produced significantly greater inhibition of platelet aggregation than lower doses (36.2 +/- 11.7% and 38.5 +/- 19.8% platelet aggregation with ADP, respectively).

CONCLUSION

Our results demonstrate that doses of aspirin less than 100 mg are not as effective at inhibiting platelet aggregation as doses greater than 100 mg.

Prevalence and pattern of use of complementary and alternative medicine (CAM) in hypertensive patients of a tertiary care center in India

OBJECTIVE

To study the prevalence and pattern of use of complementary and alternative medicine (CAM) in patients with essential hypertension.

METHOD

521 consecutive patients visiting the Hypertension Clinic at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, over a 6-month period were interviewed. Information was gathered on the patients' demographics, type(s) of CAM used, sequence of seeking CAM and conventional medicine, sources of recommendation, reasons for opting for CAM and areas of satisfaction and dissatisfaction associated with the use of CAM. Patients were also asked if they had informed their doctor about CAM use.

RESULTS

It was observed that 63.9% of patients overall used CAM. Ayurveda was the most commonly used CAM (56.7%), followed by herbal medicines (14.4%). The most commonly cited reason by patients for using CAM was fear of adverse drug reactions of conventional medicines (59.0%). However, more than half of the patients eventually became dissatisfied using CAM. Only 5.4% of CAM users had informed their medical doctors about the use of CAM.

CONCLUSION

A significant proportion of patients receiving conventional treatment for hypertension also use CAM therapies. A better understanding of the pattern of CAM use amongst these patients will help dispel prevalent misconceptions concerning CAM and, at the same time, assist conventional practitioners to critically evaluate possible gaps or omissions in their own prescribing habits.

Prehospital delay in patients hospitalized with acute myocardial infarction in the emergency unit of a North Indian tertiary care hospital

BACKGROUND

Prompt treatment of patients presenting with acute myocardial infarction decreases the incidence of death from early arrhythmia, and maximizes the potential benefit of thrombolytic therapy. Prehospital delay has been identified as a major obstacle to the widespread use of thrombolytic therapy. The aim of the present study was to examine the extent of, and factors associated with, delay in seeking medical care (usually thrombolytic therapy) in patients with acute myocardial infarction.

METHODS AND RESULTS

The study was conducted in patients visiting the medical emergency unit of the Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh. A total of 104 patients diagnosed with acute myocardial infarction were interviewed using a pre-designed proforma. Pain-to-door, and door-to-drug times, were the main outcome measures. The corrected mean (SEM) and median (range) pain-to-door times were 8.5 (0.8) hours and 5.2 (0.5-24) hours, respectively. Out of 104 patients, 38 did not receive thrombolytic therapy. In those who did not receive thrombolytic therapy, prior therapy at local health centers, lack of knowledge of symptoms, and transportation problems were the main reasons for hospital delay. The mean (SEM) and median (range) of door-to-drug times were 1.2 (0.1) hours and 1 (0.2-3.5) hours, respectively.

Anticonvulsant action of celecoxib (alone and in combination with sub-threshold dose of phenytoin) in electroshock induced convulsion

Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor, COX-2 has been shown to be upregulated by convulsive nerve activity. Various earlier studies have given conflicting reports on the effect of COX inhibitors on seizures. This study investigates the effect of pretreatment with celecoxib alone, or in combination with phenytoin, on electroshock-induced convulsions. Both percentage protection (i.e., the percentage of animals not showing Tonic Hind Limb Extension [THLE] when a fixed dose of current is administered) and CC50 (i.e., the threshold current inducing THLE in 50%) was determined using a technoconvulsometer. Celecoxib and phenytoin were administered 1 and 2 h, respectively, prior to the experiments. When administered alone, celecoxib showed an increase in percentage protection at increasing doses, with maximum percentage protection (66.6%) occurring at a 30 mg/kg-1 dose. The ED25 value of celecoxib was calculated to be 8.03 mg/kg-1. The CC50 values for the treatment groups were significantly increased compared with the control group (CC50 values for control, celecoxib 10 mg/kg-1, celecoxib 20 mg/kg-1 and celecoxib 30 mg/kg-1, respectively, were 36.3, 49.12, 100.3 and 125.02 mA). An increase in percentage protection was noted when celecoxib 8.03 mg/kg-1 was coadministered with phenytoin 6 mg/kg-1 (66.6% with the combination vs. 16.6% when administered individually). A significant increase was noted in the CC50 value in a combination regimen (CC50 = 79.06) compared with either drug administered alone (CC50 = 49.12 with celecoxib 8.03 mg/kg-1 and 62.06 with phenytoin 6 mg/kg-1). This study may stimulate further interest in the role of COX-2 inhibitors in the modulation of seizure activity.

Evaluation of antiepileptic activity of aspirin in combination with newer antiepileptic lamotrigine in mice

Neurotransmitters such as GABA, glutamate and prostaglandins mediate synaptic transmission and their modulation may play a role in the generation of seizures. Numerous studies implicate prostaglandins as potential modulators of seizure activity. This study was designed to assess the antiepileptic activity of aspirin and to investigate the potentiation of its activity in combination with a subconvulsive dose of lamotrigine. Graded doses of aspirin and lamotrigine were used in pentylenetetrazole (PTZ) and maximal electroshock (MES) seizure models in mice. To study the interaction of aspirin and lamotrigine, ED(25) doses of aspirin (250 mg/kg) and lamotrigine (1.5 mg/kg) were used in the two seizure models. Aspirin dose-dependently decreased the incidence of seizures in the PTZ-model mice but did not show any effect in MES-model mice. ED(25) doses of aspirin and lamotrigine showed 100% protection of the PTZ seizure model. Aspirin alone in doses of 400 and 800 mg/kg and in combination decreased mortality in the PTZ model. Aspirin showed a significant anticonvulsant effect in PTZ seizure mode. Potentiation of the anticonvulsant effect of lamotrigine with aspirin was shown in the PTZ model, indicating that prostaglandins could play an important role in this seizure model.

Patterns and perceptions of complementary and alternative medicine (CAM) among leukaemia patients visiting haematology clinic of a north Indian tertiary care hospital

PURPOSE

The use of complementary and alternative medicine (CAM) in cancer treatments is widespread with substantial number of patients deserting conventional cancer therapies in favour of unproven methods. The present study aimed at discovering the prevalence of use of CAM cancer therapies in leukaemia patients visiting haematology clinic of a north Indian tertiary care hospital.

METHODS

533 consecutive leukaemia patients were interviewed. Information was gathered about patients' demographics, types of CAM taken, sequence of seeking CAM and conventional medicine, sources of recommendation, reasons of opting for CAM, and areas of satisfaction and dissatisfaction associated with the use of CAM. Patients were also asked if they had informed their doctor about CAM use.

RESULTS

Prevalence of CAM use in leukaemia patients was found to be 56.6%. Ayurveda was the most commonly used CAM (33%). Most of the patients sought conventional medicine first, followed by CAM therapies. Fifty-two percent of the patients opted for CAM hoping for a miracle cure and 51% were dissatisfied with these therapies. Family members and neighbours constituted major source of recommendation of CAM therapy. Only 3.8% of the patients had informed their doctors about CAM use.

CONCLUSION

A sizeable percentage of patients receiving conventional treatment for leukaemia also use CAM therapies. Clinicians should not underestimate the value of hopeful attitude in their management of leukaemia patients and ought to be conversant with popular forms of CAM cancer therapies.

Pattern of use of complementary/alternative medicine (CAM) in epileptic patients in a tertiary care hospital in India

PURPOSE

Many patients use complementary/alternative medicine (CAM) for their health problems especially where long-term treatment is required. Epilepsy is the most prevalent neurological disorder requiring long-term treatment and compliance. The purpose of the study was to establish the pattern of use of CAM in epileptic patients.

METHODS

1000 patients with seizure disorder visiting the Neurology outpatient department were interviewed regarding use of complementary/alternative medicine (CAM) in the past. The pattern of use, persons who recommended CAM and the reasons for trying these therapies and sequence of seeking them was noted in these patients.

RESULTS

Overall 32% of patients had used CAM. Ayurvedic medicine was used most frequently, either alone (43%) or in combination (38%) with other CAM therapies followed by homeopathy (12.5%). Use of CAM was seen among all age groups and at all levels of education and was most frequent in the rural population (67%). Influence of family and friends (50%) was the most common reason for trying these therapies. Most patients (57%) sought CAM providers first before seeking the services of a medical doctor in our study.

CONCLUSION

As more and more patients use CAM, physicians should ask their patients whether they use these therapies and should discuss these practices with their patients in order to safeguard their health.

Eradication of Helicobacter pylori: current perspectives

Helicobacter pylori appears to be a necessary cofactor for the majority of non-drug-associated duodenal and gastric ulcers. H. pylori infection is a chronic and transmissible infectious disease whose eradication has proved difficult. The last decade has seen > 1000 clinical trials using different eradication regimens. Many of these trials had severe limitations, some of which will be discussed here. The current review also focuses on the regimens that were used in the past, the present regimens and possibilities for the future. Also highlighted are some other aspects of H. pylori management, such as eradication failures and drug resistance.