Opioid-Induced Hyperalgesia (OIH): Case Study of a Woman with Metastatic Colon Cancer

Pain is an unpleasant experience and a subjective term that is associated with tissue damage. Cancer patients experience pain for a myriad of reasons, from disease related to treatment causes and unrelated to both of these categories. Opioids are the mainstay in the treatment of moderate to severe cancer pain. Progressive opioid dose increases can cause opioid-induced hyperalgesia (OIH). OIH has no definite management, here we present a 47-year-old cancer patient with OIH and her management

Is Albumin-based Resuscitation in Severe Sepsis and Septic Shock Justifiable? An Evidence from a Cost-effectiveness Evaluation

BACKGROUND: Fluid and antimicrobial therapy are the essential parts of sepsis management. The type of fluid to resuscitate with is an unsettled issue in the treatment of severe sepsis and septic shock. The objective of this study was to evaluate the cost effectiveness of albumin-based resuscitation over crystalloids.METHODS: A cost-effectiveness analysis was conducted by extracting data from a database of Sina Hospital, Islamic Republic of Iran. A decision tree was constructed by using Tree Age Pro2011. The patients were grouped based on the types of fluids used for resuscitation into crystalloid alone or crystalloid + albumin groups at the initial decision node. The patients were followed from the onset of severe sepsis and septic shock upto 28 days. The healthcare payers’ perspective was considered in constructing the model. The cost was measured in US dollars and the effectiveness was measured by life years gained.RESULTS: The addition of albumin during resuscitation of patients with severe sepsis and septic shock has an effectiveness gain of 0.09 life years and cost increment of 495.00 USD. The estimated ICER for this analysis was 5500.00 USD per life year gained. The probability that albumin is cost-effective at one GDP per capita is 49.5%.CONCLUSION: Albumin-based resuscitation is not cost-effective in Iran when a GDP per capita was considered for a life year gain. The cost-effectiveness was insensitive to the cost of standard care. We recomend the caustious use albumin as per the Surviving Sepsis Campaign guideline.

The Evaluation of Albumin Utilization in a Teaching University Hospital in Iran

Abstract The goal of this study was to evaluate the pattern and the suitability of the human Albumin usage according to the available and reliable guidelines. A concurrent, cross-sectional study was performed in Shariati Hospital (associated with Tehran University of Medical Sciences, Tehran, Iran). All inpatient adults that were prescribed albumin during the study period were evaluated to register the indications for albumin usage patients during the study period. The most common reasons to prescribe albumin were volume expansion after the heart surgery (53.3%), nutrition source in malnourished patients (19.3%), paracentesis (12.9%), plasmapheresis (9.6%), hypoalbuminemia (3%) and the others (2.1%). Only 411 vials (32.1%) prescribed with 34 prescriptions (25.2%) were utilized appropriately based on the guidelines. The results showed that based on the guidelines, the most prescriptions of albumin in this hospital have not been written appropriately. Therefore, educational programs on using guidelines may help reduce albumin usage and treatment costs

Using hydrogen peroxide as a bladder irrigation solution for clot evacuation

Gross hematuria or macroscopic hematuria is a high risk urologic condition that might occur in different settings. In the case of continued gross hematuria, blood clot size may grow and lead to complete obstruction of urinary outflow. Placement of three-way catheter, continuous bladder irrigation with normal saline, and cystoscopy are conventional treatments. Here we introduce a case with urinary obstruction who did not respond to conventional therapies. A subject of Hodgkin lymphoma with urinary obstruction caused by heavy gross hematuria was presented to emergency department. Three-way catheter was inserted to facilitate urination. However, there was no urinary drainage and bladder was distended. Consequently, 100 ml solution of hydrogen peroxide 0.15% was prepared and administered into the bladder to irrigate and evacuate the clots. A single intravesical infusion of hydrogen peroxide rapidly resolved urinary obstruction and improved patient distress. After administration of hydrogen peroxide solution, blood clots and bloody urine were evacuated successfully. These findings suggest that an intravesical injection of hydrogen peroxide can induce dissolution of blood clots and may be a simple and efficient therapy for urinary obstruction due to gross hematuria

A Case of Ciprofloxacin-Induced QT Prolongation and Torsade de Pointes

Prolongation of the QT interval is a recognized adverse effect of fluoroquinolone antibiotics. This effect on ventricular repolarization can potentially lead to life-threatening arrhythmias such as Torsade de pointes. Torsade de pointes is a polymorphic form of ventricular tachycardia identified by twisting of the QRS axis around an isoelectric point. We report a case of torsade de pointes induced by ciprofloxacin treatment. The patient experienced an acquired QT interval prolongation followed by Torsade de pointes arrhythmia with ciprofloxacin administration for ileostomy closure surgery and unfortunately expired

Bibliographic Search of Publication Patterns in Rational Use of Drugs in Iran: A Systematic Approach

Inappropriate use of drugs is a widespread problem with serious consequences such as increased adverse drug reaction and antimicrobial resistance. Proper interventions would have important financial and public health benefits. Several studies have been performed about Rational Drug Use (RUD) in Iran. To provide a picture of researches were done about RUD and highlight the existing gaps in practice in Iran, a systematic search was conducted by reviewing all papers (English and Persian) found by searching keywords in Pubmed, Web of Science, Google Scholar, CINAHL, Proquest, International Pharmaceutical Abstract (IPA), SID, Iran Medex and MagIran. Retrieved articles were extracted in Access form and exported to Excel for further analysis. After excluding duplicate and irrelevant articles, 466 related articles were remained. Number of publications increased dramatically after 2001. About 73% of studies were cross-sectional. Evaluation of prescribing pattern (15%), self-medication (11.3%) and adverse drug reaction (9.1%) were among the top topics which were studied. Despite an increasing trend in RUD publications in Iran, still large gaps remain to be investigated. Knowing the existing gaps is crucial for policy makers to make investments to solve the problems

A Survey of Linezolid Prescription Before and After Protocol Implementation in a Teaching Hospital

Background: Linezolid has been recognized as a safe and effective medicine against a wide variety of Gram-positive pathogens. Purpose: The primary objective of this study was to assess utilization appropriateness of linezolid and explore the efficiency of protocol intervention to proceed to rational drug usage. Method: The project was conducted in a referral teaching hospital from September 2015 to January 2017 in two phases. In the first step, a six-month survey was performed to evaluate the prescribing appropriateness of linezolid. Patients receiving linezolid were identified using hospital IT system and the medical charts were analyzed based on accurate indications and duration of linezolid prescription. Subsequently, a restrictive protocol was developed and communicated after a consensus by Drug and Therapeutics Committee in May 2016. After introduction of the protocol, an active daily surveillance of patients was done by hospital pharmacists. The appropriateness of linezolid utilization and infectious consultations were compared before and after protocol implementation. Results: In the first phase of the study, the indication of linezolid was appropriate in 56.2% of cases and improved considerably to 68.6% (P value: 0.04) after protocol enforcement. Furthermore the duration of the linezolid consumption was correct in 66.6% of patients, increasing to 88.5% after protocol introduction (P value 0.07). In the first step, 56.9% of linezolid prescriptions were based on infectious disease consultation which enhanced remarkably to 87.5% in the second step (P value 0.001), while, 65.5% and 73.8% of these consultations were appropriate in the study surveys respectively. Conclusion: The protocol intervention could improve appropriate prescribing of linezolid in the hospital setting. However, ongoing audit studies are recommended to maintain the rational prescription of linezolid

Evaluation of Febrile Neutropenia in Patients Undergoing Hematopoietic Stem Cell Transplantation

The aim of this study was to determine the incidence and causes of fever as a major problem contributing to transplantation related mortality among patients undergoing hematopoietic stem cell transplantation (HSCT) and evaluation of antibiotic use, according to reliable guidelines.We retrospectively reviewed hospital records of 195 adult patients who underwent HSCT between 2009-2011 at hematology-oncology and bone marrow transplantation research center. Baseline information and also data related to fever and neutropenia, patient's outcomes, duration of hospitalization and antibiotic use pattern were documented.A total of 195 patients were analyzed and a total of 268 febrile episodes in 180 patients were recorded (mean 1.5 episodes per patient). About 222 episodes (82%) were associated with neutropenia which one-fourth of them were without any documented infection sources. Microbiologic documents showed that the relative frequencies of gram positive and gram negative bacteria were 62.5% and 37.5%, respectively. The hospital stay duration was directly related to the numbers of fever episodes (P<0.0001).The rate of febrile episodes in autologous stem cell transplantation was significantly higher compared to allogeneic type (P<0.05).It is necessary to determine not only the local profile of microbiologic pattern, but also antibiotic sensitivities in febrile neutropenic patients following hematopoietic stem cell transplantation, and reassess response to antibiotic treatment to establish any necessity for modifications to treatment guidelines in order to prevent any fatal complications from infection

A comprehensive review of adherence to diabetes and cardiovascular medications in Iran; implications for practice and research

Treatment of diseases such as diabetes mellitus and cardiovascular disorders are highly dependent on medications and particularly adherence to medications to achieve optimal pharmacotherapy outcomes. Several factors can affect a patient's adherence including: knowledge and beliefs about their illness and medications, concomitant psychological disorders, type of therapeutic regimen, and lack of access to medicines. In Iran, a middle income country, essential medicines are highly available and affordable. However, adherence to medications has not been emphasized especially for patients with diabetes and cardiovascular diseases. In the present study, we reviewed the available literature on adherence to medications used to treat diabetes and cardiovascular disorders in Iran. We systematically searched Scopus, Web of Science, PubMed, CINAHL, Google Scholar, Scientific Information Database, and IranMedex using a highly sensitive protocol on July 2012. We retrieved 1003 citations; and two independent researchers screened them for relevant publications. Studies were included if they reported rate or determinants of adherence to diabetes mellitus and cardiovascular medications. Trials on improving interventions were also included. The quality of studies was assessed using appropriate guidelines. Fourteen studies were eligible for data extraction and review. The definition of adherence and the measurement tools used were unclear among studies. Methodological caveats including inappropriate sample size, sampling methods, inclusion/exclusion criteria, and high rate of loss to follow-up were also observed. Nevertheless, adherence rate was reported to be 62.8-86.3% for oral hypoglycemic medications and 38.8-60.0% for cardiovascular medicines. Forgetfulness, lack of knowledge about medical condition and prescribed medications, and concerns about medications efficacy and side effects were consistently reported as barriers to adherence. Patient education plus telephone or short message service follow-ups were reported to improve adherence to oral hypo-glycemic medications. We did not find any high quality trials on adherence to cardiovascular medicines. In conclusion, adherence to cardiovascular and diabetes medications is not assured in Iranian patients. Based on the available literature, patient education and reinforcement interventions are required to address this issue. Future studies should employ careful designs and standard tools for assessment of adherence to medications

Evaluation of Risk Factors for Hepatic Complications after Allogeneic Hematopoietic Stem Cell Transplantation

Background:  Hepatic dysfunction in patients who have undergone allogeneic haematopoietic stem cell transplantation (HSCT) is a major cause of morbidity and mortality. The aim of this study is to evaluate the incidence of post-transplantation hepatic complications in these patients. Methods: A total of 121 patients (age above 15 with no abnormality in their hepatic tests) participated in the study. The influence of a variety of risk factors on the incidence, type, and pattern of hepatic dysfunction as well as the length of hospital stay related to these complications were studied. Results:  As a whole, 76 patients (62%)—44 males and 32 females—were diagnosed with hepatic dysfunction after transplantation. As many as 31(25%) of the patients showed increased measures in their hepatic enzyme, while 45(37%) of them ended up with both abnormal enzyme measure and clinical symptoms including diarrhoea, skin rash, jaundice, and anorexia. The hepatic dysfunction rates owing to drug toxicity and GVHD (21.5% and 16.5%, respectively) proved to be the highest in our study. Analysing risk factors, the immunosuppressive regimen could affect the type of hepatic dysfunction—i.e., less patients with GVHD were found in the group who received ATG in their regimen (p-value =0.034). Conclusion: According to these findings, the immunosuppressive regimen can play a role in preventing the incidence of GVHD. Less occurrence of hepatic complications, especially GVHD, may lead to less clinical symptoms and time of hospital stay