A Nasty Act?

In this article, Lord Patel considers the Mental Health Bill from the perspective of parliamentary procedure and misadventure

Recent advances in pharmacotherapy of acute coronary syndrome

Acute coronary syndrome (ACS) describes the range of myocardial ischemic states that includes unstable angina, non-ST elevated myocardial infarction (MI), or ST-elevated MI. ACS is associated with substantial morbidity and mortality and places a large financial burden on the health care system. The diagnosis of ACS begins with a thorough clinical assessment of a patient’s presenting symptoms, electrocardiogram and cardiac troponin levels as well as a review of past medical history. Early risk stratification can assist clinicians in determining whether an early invasive management strategy or an initial conservative strategy should be pursued and can help determine appropriate pharmacologic therapies. Key components in the management of ACS include coronary revascularization when indicated; prompt initiation of dual antiplatelet therapy and anticoagulation; and consideration of adjuvant agents including beta blockers, inhibitors of the renin angiotensin system, and HmG-coenzyme A reductase inhibitors. It is essential for clinicians to take an individualized approach to treatment and consider long-term safety and efficacy when managing patients with a history of ACS after hospital discharge. This review identifies promising new or emerging techniques, as well as established tools, and reviews their current or potential role in clinical practice

A study of drug utilization pattern in post-acute coronary syndrome (ACS) patients at tertiary care teaching hospital: a prospective unicentric study

Background: The main objective of drug utilization research is to assess the rationality of drug use for specific disease. Long term survival in post-ACS patients depends largely on how well post ACS period is managed. Our aim is to record drug utilization pattern in post ACS patients after discharge and during follow-up visits.Methods: Prospective unicentric study was conducted in 200 patients suffering from ACS at Cardiology OPD of GCS Medical College, Hospital and Research Centre, Ahmedabad. Prescriptions issued to study subjects at the time of discharge and during follow-up who had recently suffered from ACS were intercepted after consultation and data recorded as per WHO guidelines as how to investigate drug use. Data were collected in the structured proforma (Case Record Form-CRF) which includes patient’s demographic details, registration number, diagnosis and the drug prescribed. Each prescription was analyzed using WHO core prescribing indicators to evaluate the rationality of the prescriptions.Results: Out of 200, 104 (52%) suffered from unstable angina, 84(42%) suffered from STEMI and 12(6%) were suffered with NSTEMI. Male patients of 114(57%) were more prone to ACS than female patients of 86 (43%). Out of 200 patients, 193 (97%) received antiplatelet, 187 (94%) received antihypertensive, 184 (92%) received anticoagulants, 180 (90%) received lipid lowering drugs and 119 (60%) received Nitrates. As per WHO core prescribing indicators, the average number of drugs encountered per prescription was 7.96. The prescription showed a high usage of drugs from NLEM i.e. 72.20% in post-ACS patients. However the percentage of drugs prescribed by generic name was only 10.68%. The frequency of use of injectable preparations in post-ACS patients was found to be 17.84% which was in accordance with WHO reference value. Out of 17.84% injectable preparations, only 0.82% accounted for antibiotic injection.Conclusions: Although generic prescribing indicator shows a low range of usage, it is interesting to notice that prescription pattern has a high usage of drugs from NLEM (78.2%) in ACS. Thus present study provides valuable insight about the overall pattern of drugs used in post-Acute Coronary syndrome

Warfarin induced hematuria

Warfarin is an oral vitamin K antagonist prescribed to those patients for the treatment and prevention of thromboembolism. The major challenges to be faced during the therapy were a greater risk for both major as well as minor bleeding, which makes the regular monitoring of INR (international normalized ratio) mandatory. Herein, we reported a case of Warfarin induced hematuria which is serious and we concluded this causality as possible category according WHO-UMC causality category

Survey of use of over the counter drug and other than over the counter drugs among medical students, nursing and technician staff of a tertiary care teaching hospital

Background: To find out pattern and extent of use of OTC and other than OTC drugs among medical students, nursing and technician staff.Methods: Study began after taking permission and approval from Institutional Review Board (IRB). Medical student, nursing and technician staff of tertiary care teaching hospital was enrolled after written informed consent. Pre validated questionnaire regarding use of such use was administered to each participant.Results: A total of 200 participants responded to questionnaire, M:F ratio was 1:1.7. Majority of the participants had taken OTC drugs for cough/cold (72.6%) followed by headache/ body ache (71.1%). Paracetamol (81%) followed by Diclofenac (42.5%), ibuprofen (37.8%) were the most common drugs taken. About 85% participants had taken antimicrobial considering it as an OTC product. Most commonly used antimicrobials were metronidazole (19.4%) followed by levofloxacin (17.9%).Most common reason for self medication was the perception that the disease wasn’t serious (44.8%), favourable prior advertisement (34.3%). About 52% requested for drug by mentioning name of drug. Most (50.7%) felt that OTC drug improved their illness. 45.9% stopped when symptoms disappeared. Majority of the participants (57.2%) believed use of OTC drug is a good practice. Most of the participants (56.7%) believed they can treat symptoms with OTC drugs.64.7% participants believed use of OTC drug is beneficial for them. Most of the participants lack the knowledge for dose (73.6%) and frequency (68.2%) of drug. A substantial number of participants (58.61%) were taking drugs outside OTC list.Conclusions: Awareness and dangers of misuse of OTC medications among all the participants was less. Therefore it is suggested that proper education should be imparted regarding illness where self-administration of OTC drugs to be employed

A study of morbidity and drug utilization pattern in indoor patients of high risk pregnancy at tertiary care hospital

Background: Pregnancy represents a special physiological state during which the use of drug is of growing concern due to risk of teratogenicity. High risk pregnancy is common threat to mother and foetus. Therefore, our aim was to study the drug utilization and morbidity pattern in high risk pregnancy in hospitalized pregnant women. Methods:An observational, prospective study was carried out in 250 patients for 6 months in the tertiary care hospital. Protocol was approved by the Institutional Review Board (IRB). The data were collected in a pre-designed proforma. Data were analysed by using SPSS version 20.0 Software. Results: Among 250 patients, 19 (7.6%), 218 (87.2%) and 13 (5.2%) were of less than 20, 20 to 30 and more than 30 years of age respectively. About 68.8% women had complained of abdominal pain and 67.6% had weakness followed by headache / body ache (47.2%), oedema (26.4%) and vomiting (18.8%). Iron (91.2%) and calcium (84.5%) were the commonest drugs prescribed followed by folic acid (59.6%), protein powder (54.8%), vitamin C (46.8%) and isoxsuprine (26.6%). As per FDA Drug Risk Category, Category-A (82.21%) was most frequently prescribed followed by Category-B (15.64%) and Category-C (2.15%). Percentage of drugs prescribed by generic name and from essential drug list was 62.80% and 80.79%. Conclusion: Iron, Calcium and Folic acid were most commonly prescribed drugs. There is lesser number of drugs prescribed by generic name suggesting need for sincere efforts to improve situation

Newer approaches in the treatment of asthma

Asthma is a worldwide public health problem. The most effective anti-asthmatic drugs - inhaled β2-agonists and glucocorticoids controls asthma in about 90-95% of patients. However, severe glucocorticoid-dependent and resistant asthma presents a great clinical burden. Therefore, reducing glucocorticoids - related adverse effects using novel steroid-sparing agents is needed. Furthermore, the mechanisms involved in the persistence of inflammation are poorly understood and the reasons why some patients have severe life threatening asthma and others have very mild disease are still unknown. Although glucocorticoids effectively control the inflammatory process in asthma, they have little effect on the lower airway remodeling processes that appear to play a role in the pathophysiology of asthma. Several new drugs developed to target specific components of the inflammatory process in asthma [e.g. anti-IgE antibodies (omalizumab), cytokines and/or chemokines antagonists, immunomodulators, antagonists of adhesion molecules)], have not yet been proven to be particularly effective. Hence, considering the central role of T lymphocytes in the pathogenesis of asthma, drugs targeting disease-inducing Th2 cells are promising future therapeutic strategies. Some of these new anti-asthmatic treatment approaches may in the future not only control symptoms and modify the natural course of asthma, but also potentially prevent or cure the disease. Hence, the development of novel drugs may allow resolution of these changes

A metabolomics analysis and the development of a fluorescent assay for kynurenine for the diagnosis of sepsis in trauma patients

Traumatic injuries are a leading cause of death worldwide. Whilst the physical injuries can be treated patients are still at risk of developing an infection and becoming septic. It is hard to diagnose sepsis in patients of trauma as the inflammatory response to sepsis is masked by the inflammatory response to the traumatic injury. Current diagnostic techniques involve culturing blood samples or identifying a site of infection, neither of which are fast enough to allow for the best patient outcome. As such there is much need for a point of care diagnostic test. This work attempted to tackle this problem in two ways. First by analysing a metabolomics data set to identify biomarkers of sepsis in burns patients. Second, by developing a quantitative fluorescent assay for the detection of kynurenine, a biomarker of sepsis. The data analysis was performed on a metabolomics data set acquired from clinical samples from burns patients. Three different classifiers were used to create models on the data set, k-nearest neighbours, naive Bayes and logistic regression. Classifier performance was above average on the data set, with the k-NN technique providing an AUC value of 0.82 and sensitivity and specificity of 85 % and 70 % respectively on the early-sample class-balanced subset of the data. The t-test and minimum redundancy maximum relevancy (MRMR) feature selection techniques were performed on the data set along with lasso with logistic regression. The t-test and logistic regression identified glucose and lactate as being the most important features whereas MRMR identified glucose and not lactate. These are both already well known biomarkers used in controlling the outcome of sepsis patients. A literature search identified the metabolite kynurenine as being a positive biomarker for sepsis in patients of trauma. A fluorescent molecule was synthesised which upon binding to kynurenine causes a large bathochromic shift in the emission spectrum of the fluorescent sensor from 470 nm to 560 nm. A fluorescent assay was created using the standard addition technique to quantify the amount of kynurenine in a urine sample. The standard addition technique was chosen as it removes matrix affects which would be present when using biological samples. Tests performed on pure samples of kynurenine, gave results within 5 % of the actual concentration. Synthetic urine was then used, giving results within 10 % of the actual concentration. HPLC experiments were performed to quantify the amount of kynurenine in actual urine samples. The HPLC protocol was validated with kynurenine in solutions of water and synthetic urine, however complications arose when using urine which meant the clinical samples could not be accurately quantified. As such, a qualitative experiment showed linear fluorescence plots when performing the standard addition technique with actual urine samples. The results indicate the assay will work in urine. Being fluorescence based it has the potential to move into a point of care device. Future work would go towards quantifying the kynurenine concentration in clinical samples and then optimising the assay parameters once known concentrations can be determined

Iatrogenic phenytoin toxicity: a case report of medication error

Medication errors may produce severe toxicity resulting in hospitalization. This can be compounded if the physician obtains the wrong concentration from a reference manual and a pharmacy miscalculates the conversion. We present a case report of phenytoin toxicity related to overdose in 19 year girl which is related to prescribing error and dose related error. A 19 years old girl came to emergency department with convulsions, gum hypertrophy and ataxia. Patient had history of convulsion before 2 months at that time she was given Tab. Phenytoin (100mg) (Eptoin) 2 times a day prescribed for generalized tonic clonic seizures (GTCS). Then before seven days she presented with convulsion so physician increased the dose of drug from 2 times a day to 3 times a day. Then patient developed gum hyperplasia and ataxia after 7 days and she presented with convulsion. Serum Phenytoin level was >40mcg/ml. Phenytoin was withdrawn. Then patient then recovered eventually. Medication errors may produce severe toxicity resulting in hospitalization. It also increases morbidity and mortality. A prescribing fault is a failure in the prescribing process. It leads to, or has the potential to lead to, harm to the patient. Phenytoin metabolism is dose dependent. So very small increments in dosage may result in adverse effects. In our case sudden increase in the dose by 100mg led to blood level double than therapeutic blood level. So, medication error occurred at the prescription level and because of that patient developed toxicity and she needed to hospitalization. In this case instead of suddenly increasing the dose of phenytoin one should change the drug or add another drug to prevent toxicity or side effect

A real-world evidence study to evaluate the efficacy of software-driven digital therapeutics on major adverse cardiovascular events, vitals, adherence to medication and lifestyle changes among patients with coronary artery disease or post-coronary interventions

Background: Coronary artery disease (CAD), a leading cause of cardiovascular disease (CVD) mortality worldwide, is a major health concern in India due to the high rates of the disease. Acute coronary syndrome (ACS) is a prevalent form of CAD that requires prompt treatment. Digital therapeutics (DTx) is an emerging field that employs remote monitoring and behavioural changes to manage diseases, with promising outcomes in ACS and post-percutaneous coronary intervention (PCI) patients. This study evaluates the efficacy of a software-driven DTx intervention in enhancing outcomes for CAD patients. Methods: This pilot, single-centred, prospective and real-world evidence cohort study aims to evaluate the effectiveness of a software-driven therapeutic intervention (LYFE) in patients with ACS and/or post-PCI. The study enrolled 30 patients over a 3-month follow-up period from October to November 2022. The main outcomes measured were changes in blood pressure, heart rate, medication adherence, the incidence of major adverse cardiovascular events (MACE), all-cause readmission, and lifestyle adherence at 1 and 3 months. Results: The mean age of the patients was 53.2±12.1 years; 27 (93%) males and 2 (7%) were females. Mean BMI of the patients was 26.3±5.0. The mean difference for systolic blood pressure (SBP) and diastolic blood pressure (DBP) was 7.8±10.9 (p=0.001*), 3.7±5.7 (p=0.002*) respectively with statistically significant reduction, at 3 months. The 25 (83.3%) patients had controlled blood pressure at 3 months. 27 (90%) patients were adherent to the medication and physically active, while 3 (10%) inactive throughout the study period. No CVD death/major bleeding event was reported. Conclusions: DTx improved medication adherence and blood pressure control in CAD, ACS with post-PCI patients during the study period.