DRUG UTILIZATION PATTERN AND PHARMACOECONOMIC ANALYSIS OF ANTIHYPERTENSIVE DRUGS PRESCRIBED IN SECONDARY CARE HOSPITAL IN GUJARAT, INDIA

ABSTRACTObjective: Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if notdetected early and treated appropriately. A large number of antihypertensive drugs alone or in various combinations are available, and physiciansneed to choose most appropriate drug for a particular patient. Pharmacoeconomic and drug utilization studies at regular intervals help physicians toprescribed rational drugs with high efficacy along with minimal cost.Methods: The prospective observational study was conducted at Seth H. J. Mahagujarat Hospital from July to December 2013. 250 hypertensivepatients, attending medicine outpatient department were included for drug utilization study and 100 hypertensive patients, attending in patientsdepartment were included for pharmacoeconomics analysis during the study period.Result: The most frequently prescribed antihypertensive drug as monotherapy, as combination therapy and in fixed dose combinations was calciumchannel blocker (Amlodipine). Generic drugs showed same efficacy as brand drug, but both drugs were significantly differed in the prize. Among 100inpatients admitted for the hypertensive condition in general ward total of direct medical cost was 65.19% and total of indirect medical cost was34.81%. β-blocker and diuretics were the most effective therapy which is followed by the clonidine, envas (Enalapril), and then, amlodipine.Conclusion: We concluded from this study that use of β-blockers and diuretics were most cost-effective for the hypertensive patients in this study.Keywords: Antihypertensive drugs, Drug utilization study, Pharmacoeconomics analysis.Â

Root cause analysis of medication errors at a multi-specialty hospital in Western India

Background: Medication use is a complex process in a medical setting, it starts with physician prescribing, followed by nurse transcribing, pharmacist dispensing, medication administration, and patient monitoring. There is a definite role of clinical pharmacists in reduction of Medication errors by examining and evaluating its causes and communicate the results to physicians and caregivers. The aim of the present study was study of medication errors for the safety & the health benefit of the patient visiting multi specialty hospital. Methods: The Observational study was carried out at in-patient appointments at multi specialty hospital during the period of June 2012 to April 2013 at Baroda. Results: Total of 300 patients were observed out of which medication error has occurred in 117 (39%) cases considering 62% were males & 38% female patients. Out of 117 cases 28% of transcription errors, 62% of prescription errors, 11% of dispensing errors & 16 % Administration errors. 51% of medication errors were occurring in the age group of 40-60. Root cause analysis showed that prescription error was due to Illegible handwriting, No dosage form prescribed, the Wrong Brand name prescribed; transcription error due to Wrong drug is transcribed; administrative error due to Wrong dose is administered, Drug administered through wrong route, Wrong drug is administered while dispensing error due to Urgent dispensation not done within 10 to 15 minutes, Wrong dose dispensed.Conclusion: Most common medication errors were Prescription error & Transcription error which accounts for almost 77% of the total error, which is according to Pareto 80:20 Principle

EFFECTIVENESS AND SAFETY ASSESSMENT OF FIXED DOSE COMBINATION OF NON-STEROIDAL ANTIINFLAMMATORY DRUGS PRESCRIBED FOR ORTHOPEDIC PATIENTS

Objective: Many Fix Dose Combinations (FDCs) being introduced in India are usually irrational. The most pressing concern with irrational FDCs is that they expose patients to unnecessary risk of adverse drug reactions, for instance, pediatric formulations of nimesulide+paracetamol. Despite their wide clinical use, their gastro-intestinal toxicity is a major limitation. The aim of the present work was to evaluate the efficacy and safety of FDCs in non-steroidal anti-inflammatory drugs in the orthopedic department at a tertiary care teaching hospital. To study the effectiveness and safety parameters of fixed-dose combinations of Non-Steroidal Anti-inflammatory Drugs. Methods: This prospective, observational study was conducted among 150 out-patients of the orthopedic ward over a period of July 2013 to December 2013(Each combination with 50 patients). Three fixed-dose combinations utilized were paracetamol+diclofenac, paracetamol+ibuprofen and paracetamol+nimesulide. The effectiveness was analyzed by using Visual Analogue Scale (VAS) and Disease Activity Scale (DAS) and the safety criteria were analyzed by using the WHO probability scale and Naranjo scale. 150 orthopedic patients attending Out Patient Department were included. 50 participants for each of the combinations of fixed-dose combination (FDCs) of NSAIDs. Results: Out of 150 patients 33 patients developed adverse effects, and 17(51.51%) adverse effects due to the combination of Paracetmol+Nimuselide, 11(33.34%) adverse effects due to the Paracetamol+Ibuprofen and 5 (15.15%) were due to the combination of Paracetamol+Diclofenac. The maximum effectiveness (3.55±0.208) showed in the combination of paracetamol+diclofenac compared to the other two combinations. Conclusion: It was concluded from this study that the effectiveness and safety profile of PCM+DICLO is better than the other two FDCs

ORAL BIOAVAILABILITY ENHANCEMEMENT OF BROMOCRYPTINE MESYLATE BY SELF-MICRO EMULSIFYING DRUG DELIVERY SYSTEM (SMEDDS)

Objective: The purpose of this work was to enhance oral bioavailability of Bromocryptine Mesylate by preparing SMEDDS (self-micro emulsifying drug delivery system)Methods: Screening of oils, surfactants and co-surfactants were done by solubility study & pseudo ternary diagram. The batches of Bromocryptine Mesylate (BM)–SMEDDS were prepared and evaluated for droplet size analysis, poly dispensability index (PDI), robustness to dilution, zeta potential, in vitro dissolution. The optimized batch was compared with commercially available quick release tablets of BM (Brainstar®, 0.8 mg/tablet) by in vivo study (Pharmacodynamic study in rats).Results: Based on the drug's solubility study, Akoline MCM, Tween80 and PEG400 were selected as oil, surfactant and co-surfactant, respectively. By pseudo ternary diagram, the components' ratios were screened. In vitro drug release of the optimized batch was lower than the commercial preparation but in in vivo study, optimized batch was similar with commercial tablets.Conclusion: From the study, it was concluded that the group treated with optimized BM-SMEDDS showed better and sustained reduction in blood sugar as compared to control group and the group treated with marketed formulation, indicated improvement in bioavailability of drug. Keywords: Bromocryptine Mesylate, Type–II Diabetes, Self micro emulsifying drug delivery system, Bioavailability, Pharmacodynamic stud

IN VITRO EVALUATION OF ANTI-CANCER POTENTIAL OF A3 ADENOSINE RECEPTOR AGONIST ON A549 HUMAN LUNG CANCER CELL LINE

Objective: The objective of this study was to evaluate the cytotoxic potential of A3AR agonist (ABMECA) against human lung cancer cell line A549 by using 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay. Methods: Adenocarcinoma cell line A549 was used to assess MTT based cells viability. In vitro cytotoxic activity was evaluated for 3 different concentration of doxorubicin and A3AR by MTT cytotoxicity assay. Cytotoxicity assay carried out for 3 consecutive days that involves culturing cells into Dulbecco’s MEM medium modified with 10% FBS for 24 h then treatment with different dose of standard and test drug with incubation period of 24 h followed by treatment with MTT for estimation of cytotoxicity and finally, optical density (OD) was measured at 570-630 nm. Results: Different concentration of doxorubicin (1, 5, 10 µM) and ABMECA (10-6M, 10-5M and 10-4M) shown dose-dependent cytotoxicity. There was a significant decrease (p<0.05) in cell viability in both doxorubicin and ABMECA concentration in a dose-dependent manner. This study may guide further for in vivo evaluation of test drug in the lung cancer model. Conclusion: A3 Adenosine Receptor agonist could be potential moiety for the treatment of lung cancer and it would require in vivo study for further research

Coronary artery disease prescribing pattern and risk factor assessment in the patients undergoing angioplasty

Background: Coronary artery disease is caused by an obstruction in vascular supply to the heart. Angioplasty is a frequently used intervention for the management of CAD patients. Supportive and preventive therapies are additionally provided to these patients. Objective of current study was to assess the associated risk factors as well as prescribing trends in CAD patients.Methods: A prospective study was conducted in 88 patients undergoing coronary angioplasty. Patients were assessed for risk factors of CAD. Medication history of patients was recorded in case record form for analysis of prescribing trend and its rationality. Data were statistically analyzed using prism software.Results: In present study most of the CAD patients were male (80.68%) and mean age of patient was 59.19 years. Majority of patients (39.77%) were in age range of 61-70 years. Most common associated conditions at admission were hypertension and diabetes. In this study, BMI, stress, lack of exercise, hypertension, diabetes, family history of CVD were risk factors of CAD and significant correlation observed with risk factors and coronary artery disease. (p<0.05) Frequently prescribed drugs were antiplatelet, antibiotics, antihypertensive, antiulcer, antihyperlipidemic, antidiabetic agents. In 19.31% cases, drug interaction was detected out of which two cases recorded severe. Medical stents coated with everolimus, sirolimus were also prescribed.Conclusions: It was concluded that history of cardiovascular disease, hypertension, diabetes are major risk factors of CAD. Certain level of irrationality in the prescribing trend was observed. Proper patient counselling and care can help in preventing CAD and reduces health burden

Molecular modeling and ADMET predictions of flavonoids as prospective aromatase inhibitors

192-200With the advent of a myriad of treatment possibilities for breast cancer, enzyme inhibition turns out to be the prevailing strategy for inhibiting estrogen biosynthesis. Aromatization of ring A of androstenedione, testosterone and 16-hydroxytestosterone results in increased estrogen level, which embraces the risk for breast cancer. In this present research, we have targeted human placental aromatase complexed with HDDG046 (PDB ID: 4GL7) for its inhibition by several inhibitors of flavonoid derivatives and further screening those molecules for ADMET properties for assessing its credibility for acceptance in successive steps of drug discovery. Novel flavonoid derivative molecules have been designed using Maestro 10.4, based on the literature review. Further, their molecular modeling studies have been performed against the imported target PDB ID: 4GL7 using the GLIDE platform and have been subjected to ADMET assessment using the QikProp and pkCSM program. From all the series exposed to molecular modeling; 2K, 4K, 6K, 8W and 10K molecules have been subjected to ADMET study based on their interaction profile. Successively screening of these molecules led to selection of 8W molecule for further validation by pkCSM. The results obtained have been compared with the reported molecule HDDG046 which presents substantially positive outcomes for 8W in terms of CaCo2 permeability, water solubility, P- glycoprotein; hERG I, II and CYP interactions, hepatotoxicity, LD50 value and so forth. Juxtaposing the results of all the designed molecules under study, we have established that these prospective molecules especially 8W of flavonoid derivatives have the potency to inhibit the target under study, which can be useful in the treatment of breast cancer. This has been estimated based on the in silico approaches performed using Molecular Modeling which utilizes the integral function of Molecular Mechanics and Quantum Mechanics. In addition, the ADMET predictions validate their integrity for being the lead molecules in drug discovery stages in the near future

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Molecular modeling and ADMET predictions of flavonoids as prospective aromatase inhibitors

With the advent of a myriad of treatment possibilities for breast cancer, enzyme inhibition turns out to be the prevailing strategy for inhibiting estrogen biosynthesis. Aromatization of ring A of androstenedione, testosterone and 16a-hydroxytestosterone results in increased estrogen level, which embraces the risk for breast cancer. In this present research, we have targeted human placental aromatase complexed with HDDG046 (PDB ID: 4GL7) for its inhibition by several inhibitors of flavonoid derivatives and further screening those molecules for ADMET properties for assessing its credibility for acceptance in successive steps of drug discovery. Novel flavonoid derivative molecules have been designed using Maestro 10.4, based on the literature review. Further, their molecular modeling studies have been performed against the imported target PDB ID: 4GL7 using the GLIDE platform and have been subjected to ADMET assessment using the QikProp and pkCSM program. From all the series exposed to molecular modeling; 2K, 4K, 6K, 8W and 10K molecules have been subjected to ADMET study based on their interaction profile. Successively screening of these molecules led to selection of 8W molecule for further validation by pkCSM. The results obtained have been compared with the reported molecule HDDG046 which presents substantially positive outcomes for 8W in terms of CaCo2 permeability, water solubility, P- glycoprotein; hERG I, II and CYP interactions, hepatotoxicity, LD50 value and so forth. Juxtaposing the results of all the designed molecules under study, we have established that these prospective molecules especially 8W of flavonoid derivatives have the potency to inhibit the target under study, which can be useful in the treatment of breast cancer. This has been estimated based on the in silico approaches performed using Molecular Modeling which utilizes the integral function of Molecular Mechanics and Quantum Mechanics. In addition, the ADMET predictions validate their integrity for being the lead molecules in drug discovery stages in the near future