This study assessed the appropriateness of acid suppression therapy (AST) prescribed to patients admitted to the internal medicine ward of a tertiary care teaching hospital in Pakistan. The study reviewed 300 patient records and found that AST was prescribed inappropriately in 65.3% of cases. Only 17.6% of AST prescriptions had an approved FDA indication, while 17% were prescribed for stress ulcer prophylaxis but did not meet ASHP guidelines. The most common AST prescribed was omeprazole. The study concluded that AST is often inappropriately prescribed in internal medicine wards and implementation of evidence-based guidelines could help optimize appropriate AST use.
This randomized controlled trial compared the effectiveness and safety of minimal stimulation IVF (mini-IVF) to conventional IVF. 564 women were randomly assigned to either mini-IVF using oral clomiphene and gonadotropins followed by a freeze-all policy, or conventional IVF using high dose gonadotropins and fresh double embryo transfer. The primary outcome was cumulative live birth rate within 6 months, and secondary outcomes included pregnancy rates, ovarian hyperstimulation syndrome, and multiple pregnancy rates. Results showed mini-IVF resulted in comparable live birth rates but significantly lower risks of ovarian hyperstimulation syndrome and multiple pregnancies compared to conventional IVF.
This study investigated the effects of omega-3 fatty acids, vitamin C, and zinc supplementation individually and combined on asthma control in children. 76 children with moderate persistent asthma were randomly assigned to receive normal diet plus placebo, omega-3, zinc, vitamin C, or a combination of all three supplements over 5 phases. Asthma control was assessed using ACT scores, pulmonary function tests, and sputum inflammation markers. The combination phase showed the greatest improvement in ACT scores, lung function, and reduction of inflammatory markers compared to placebo or single supplements. This study suggests children with asthma may benefit from dietary supplementation with omega-3s, vitamin C, and zinc.
This study evaluated the efficacy and safety of lacosamide in treating diabetic neuropathic pain through an 18-week double-blind trial of 370 patients with doses of 200 mg/day, 400 mg/day, and 600 mg/day compared to a placebo. The 400 mg/day dose was found to significantly improve pain scores over the placebo and had the optimal balance of efficacy and side effects. Common side effects included dizziness, tremor and headache. While lacosamide showed potential for treating diabetic neuropathic pain, the study period was short and the 600 mg/day group had a high withdrawal rate due to adverse events.
This document summarizes a randomized controlled trial that investigated whether stable patients with infective endocarditis could be safely treated with oral antibiotics rather than continued intravenous antibiotics. The trial involved 400 patients across multiple centers in Denmark who had infective endocarditis of the left heart caused by common bacterial species. Patients received either continued intravenous antibiotics according to guidelines or a partial oral antibiotic treatment regimen. The primary outcome was to show non-inferiority of oral treatment. Results showed that oral antibiotic treatment was found to be non-inferior to continued intravenous treatment for stable patients.
Context—Proton pump inhibitors (PPIs) are among the most commonly used drugs worldwide, and have been linked to acute interstitial nephritis. Less is known about the relationship between PPI use and chronic kidney disease (CKD).
Objective—To quantify the association between PPI use and incident CKD in a population based cohort.
In total, 144,032 participants in Communities study with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2 were followed from a baseline visit between February 1, 1996, and January 30, 1999, to December 31, 2011. The data was analysed from May 2015 to October 2015.
This document summarizes several research studies that have investigated the physiological effects and potential therapeutic applications of wet cupping therapy. Specifically, the studies found that wet cupping therapy can reduce oxidative stress biomarkers, restore autonomic nervous system balance, reduce pain and improve function for neck pain patients, and may have benefits for over 120 medical conditions according to traditional Persian medicine texts. However, the document also notes that many cupping studies to date have been of low methodological quality.
Proton Pump Inhibitors and Risk of Acute and Chronic Kidney Disease: A Retros...KhalafAlGhamdi
This document summarizes a study presented at a nephrology journal club that examined the association between proton pump inhibitor (PPI) use and the risk of acute kidney injury (AKI) and chronic kidney disease (CKD) using a large health insurance database. The study found that PPI use was associated with a 4-fold higher risk of AKI and a 20% higher risk of CKD compared to non-users. While the results strengthen evidence of this association, limitations include potential residual confounding and inability to account for over-the-counter medication use. The conclusion calls for provider education and deprescribing initiatives to reduce PPI overuse and potential kidney risks.
This randomized controlled trial compared the effectiveness and safety of minimal stimulation IVF (mini-IVF) to conventional IVF. 564 women were randomly assigned to either mini-IVF using oral clomiphene and gonadotropins followed by a freeze-all policy, or conventional IVF using high dose gonadotropins and fresh double embryo transfer. The primary outcome was cumulative live birth rate within 6 months, and secondary outcomes included pregnancy rates, ovarian hyperstimulation syndrome, and multiple pregnancy rates. Results showed mini-IVF resulted in comparable live birth rates but significantly lower risks of ovarian hyperstimulation syndrome and multiple pregnancies compared to conventional IVF.
This study investigated the effects of omega-3 fatty acids, vitamin C, and zinc supplementation individually and combined on asthma control in children. 76 children with moderate persistent asthma were randomly assigned to receive normal diet plus placebo, omega-3, zinc, vitamin C, or a combination of all three supplements over 5 phases. Asthma control was assessed using ACT scores, pulmonary function tests, and sputum inflammation markers. The combination phase showed the greatest improvement in ACT scores, lung function, and reduction of inflammatory markers compared to placebo or single supplements. This study suggests children with asthma may benefit from dietary supplementation with omega-3s, vitamin C, and zinc.
This study evaluated the efficacy and safety of lacosamide in treating diabetic neuropathic pain through an 18-week double-blind trial of 370 patients with doses of 200 mg/day, 400 mg/day, and 600 mg/day compared to a placebo. The 400 mg/day dose was found to significantly improve pain scores over the placebo and had the optimal balance of efficacy and side effects. Common side effects included dizziness, tremor and headache. While lacosamide showed potential for treating diabetic neuropathic pain, the study period was short and the 600 mg/day group had a high withdrawal rate due to adverse events.
This document summarizes a randomized controlled trial that investigated whether stable patients with infective endocarditis could be safely treated with oral antibiotics rather than continued intravenous antibiotics. The trial involved 400 patients across multiple centers in Denmark who had infective endocarditis of the left heart caused by common bacterial species. Patients received either continued intravenous antibiotics according to guidelines or a partial oral antibiotic treatment regimen. The primary outcome was to show non-inferiority of oral treatment. Results showed that oral antibiotic treatment was found to be non-inferior to continued intravenous treatment for stable patients.
Context—Proton pump inhibitors (PPIs) are among the most commonly used drugs worldwide, and have been linked to acute interstitial nephritis. Less is known about the relationship between PPI use and chronic kidney disease (CKD).
Objective—To quantify the association between PPI use and incident CKD in a population based cohort.
In total, 144,032 participants in Communities study with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2 were followed from a baseline visit between February 1, 1996, and January 30, 1999, to December 31, 2011. The data was analysed from May 2015 to October 2015.
This document summarizes several research studies that have investigated the physiological effects and potential therapeutic applications of wet cupping therapy. Specifically, the studies found that wet cupping therapy can reduce oxidative stress biomarkers, restore autonomic nervous system balance, reduce pain and improve function for neck pain patients, and may have benefits for over 120 medical conditions according to traditional Persian medicine texts. However, the document also notes that many cupping studies to date have been of low methodological quality.
Proton Pump Inhibitors and Risk of Acute and Chronic Kidney Disease: A Retros...KhalafAlGhamdi
This document summarizes a study presented at a nephrology journal club that examined the association between proton pump inhibitor (PPI) use and the risk of acute kidney injury (AKI) and chronic kidney disease (CKD) using a large health insurance database. The study found that PPI use was associated with a 4-fold higher risk of AKI and a 20% higher risk of CKD compared to non-users. While the results strengthen evidence of this association, limitations include potential residual confounding and inability to account for over-the-counter medication use. The conclusion calls for provider education and deprescribing initiatives to reduce PPI overuse and potential kidney risks.
This document summarizes the current best practices for the management of incidental gallbladder cancer discovered after cholecystectomy. It reviews the available literature on pathology and staging, timing and type of re-resection, and the role of adjuvant therapies. The key findings are that early stage T1a cancers often do not require additional surgery and have a very low risk of recurrence. For T1b or higher cancers, preoperative imaging and restaging is recommended followed by extended resection with lymphadenectomy. While the optimal approach remains controversial, re-resection within 4-8 weeks of initial surgery tends to have the best outcomes. Adjuvant chemotherapy may provide a benefit for higher stage or node-positive cancers but requires
Effects of acupuncture on point pericardium 6 on hydromorphone induced nausea...Amanda Maijer
This research paper evaluated the effects of acupuncture at point Pericardium 6 (PC6) on nausea and vomiting induced by hydromorphone administration in healthy dogs. 81 dogs were randomly assigned to receive acupuncture at PC6, alternative acupuncture at Lung 5, or no acupuncture. After hydromorphone injection, dogs that received acupuncture at PC6 had a significantly lower incidence of vomiting compared to the other groups. Acupuncture at PC6 reduced vomiting in dogs but did not affect other signs of nausea like hypersalivation or licking. The study suggests acupuncture at PC6 can decrease opioid-induced vomiting in dogs during the perioperative period.
- This randomized controlled trial studied the effect of erythropoietin treatment in 941 extremely preterm infants between 24 and 27 weeks gestation. Infants received either erythropoietin or placebo intravenously for 6 doses then subcutaneously until 32 weeks postmenstrual age.
- The primary outcome of death or severe neurodevelopmental impairment at 2 years was not significantly different between the erythropoietin and placebo groups. No meaningful differences in serious adverse events were found.
- Unlike previous studies, this larger trial found that high-dose erythropoietin treatment did not reduce the risk of death or improve neurodevelopmental outcomes in extremely preterm infants compared to placebo.
PEPTIC (Holden Young - Roseman University College of Pharmacy)HoldenYoung3
PEPTIC (Holden Young - Roseman University College of Pharmacy)
Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital
mortality among ICU patients receiving invasive mechanical ventilation (PEPTIC).
JAMA . 2020; 323(7):616-626
The study assessed adherence to cardiovascular medications in rural patients attending a tertiary hospital in India. It found that adherence was lowest in hypertension patients at 20.83% and highest in ischemic heart disease patients at 32%. The most common reason for non-adherence was carelessness. The study concluded that rural Indians adhere poorly to cardiovascular medications and that more efforts are needed to address this issue.
Ppi for bleeding ulcers intermittent vs continuousHassan Al tomy
in last few years there is emergent data on use of intermittent PPI in bleeding ulcers compared to continous infusion
in this meta-analysis the invistigator select 13 randomized controlled trial
Intermittent PPI regimens are comparable to continuous PPIinfusion regimens in patients with bleeding ulcers and high risk endoscopic findings
Because of ease of use and lower cost and resource utilization, intermittent PPI therapy may be the regimen of choice after endoscopic therapy in such patients
"Long-term kidney outcomes among users of proton pump inhibitors without intervening acute kidney injury, Proton Pump Inhibitors and Risk of Incident CKD and Progression to ESRD"
This document summarizes a journal club presentation on a study assessing the knowledge and practices of intensive care nurses regarding the prevention of ventilator-associated pneumonia. The study found that the nurses had average knowledge but unsatisfactory practices in preventing VAP. It concluded that additional in-service education and training programs are needed to improve nurses' knowledge and practices and reduce infections among patients. The presentation reviewed the objectives, methods, findings and conclusions of the descriptive study conducted with 50 nurses in India. It also discussed relevant literature supporting the average knowledge levels found and the need for preventative protocols and guidelines.
The study evaluated the effects of low-dose aspirin versus placebo in 10,010 patients undergoing noncardiac surgery who were at risk of vascular complications. Patients were stratified based on whether they had not been taking aspirin before the study or were already on an aspirin regimen. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days. The study found that aspirin did not significantly reduce the primary outcome but did increase the risk of major bleeding.
Corticosteroids for sore throat sr ma bmj 2018Mayra Serrano
This systematic review and meta-analysis found that a single low dose of corticosteroids, such as oral dexamethasone up to 10 mg, provides moderate to high quality evidence of pain relief for patients with sore throat. Patients who received corticosteroids were twice as likely to experience pain relief after 24 hours and 1.5 times more likely to have no pain at 48 hours, with no increase in serious adverse effects. The mean time to complete pain resolution was about 11 hours shorter with corticosteroids. Included trials enrolled over 1400 individuals and assessed outcomes up to 48 hours, but did not evaluate risks of repeated corticosteroid use for recurrent sore throats.
This study examined the association between herpes zoster infection and risk of peripheral arterial disease using a nationwide cohort in Taiwan. The study found that patients with herpes zoster had a 13% higher risk of developing peripheral arterial disease compared to those without herpes zoster, after adjusting for risk factors. Female sex and older age were also associated with small increases in risk. While antiviral treatment for herpes zoster did not affect risk of peripheral arterial disease, larger prospective studies are still needed to determine if treatment can reduce risk.
The study aimed to assess the effectiveness of intradialytic exercises in reducing muscle cramps and improving quality of life among patients undergoing hemodialysis. 80 patients were randomly assigned to experimental and control groups. The experimental group performed intradialytic exercises for 2 weeks, while the control group received usual care. Results found significant reductions in muscle cramps and improvements in quality of life in the experimental group compared to the control group. The study demonstrated that intradialytic exercises are an effective non-pharmacological approach for reducing muscle cramps and improving quality of life in hemodialysis patients.
This study investigated calcium and vitamin D intake in healthy children. 184 children with intake below recommendations were randomly assigned to receive dietary counseling plus calcium/vitamin D supplements (Group 1) or counseling alone (Group 2). After 4 months, Group 1 showed improved intake of both nutrients and optimal vitamin D levels, while Group 2 only improved calcium intake and had lower vitamin D levels. The study concludes that counseling alone is not sufficient to achieve adequate vitamin D intake.
PEPTIC (Holden Young - Roseman University College of Pharmacy)HoldenYoung3
PEPTIC (Holden Young - Roseman University College of Pharmacy)
Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital
mortality among ICU patients receiving invasive mechanical ventilation (PEPTIC).
JAMA . 2020; 323(7):616-626
This systematic review and meta-analysis evaluated the efficacy of oral corticosteroids for acute wheezing episodes in asthmatic preschoolers. The analysis included 11 randomized controlled trials involving oral corticosteroid treatment compared to placebo. The results showed no significant differences overall between corticosteroids and placebo for hospital admissions, need for additional corticosteroid treatment, or unscheduled visits. However, corticosteroids may reduce hospital admissions and additional corticosteroid need for more severe cases presenting to the emergency department or requiring hospitalization. The evidence was deemed inadequate to form clinical recommendations due to limitations in the studies.
This study assessed the safety and efficacy of the herbal cough syrup Mykoff in 50 patients with coughs of various causes. 84% of patients experienced excellent or good relief of cough symptoms. Cough severity, frequency, chest discomfort and sputum quantity all significantly decreased over the course of treatment. Most patients found the remedy acceptable. Only one adverse event occurred, deemed unlikely related to the medication. The study concluded that Mykoff is an effective and safe treatment for coughs of short duration from various etiologies.
Efficiency of Use of Dietary Supplement Arteroprotect® In Prevention of Cardi...inventionjournals
Cardiovascular diseases are the leading cause of death in most developed countries and in many developing countries. The main cause of cardiovascular disease in 95% cases is supposed to be atherosclerosis, and the symptoms occur when the process is already at an advanced stage of disease. Present study was conducted to examine an efficiency of ARTEROprotect® (by Abela Pharm, Serbia) in prevention of cardiovascular diseases. The study was conducted by 76 doctors in primary health centers throughout the Republic of Serbia as a prospective clinical study of two groups of subjects. The study group included 4031 subjects (1785 males and 2246 females) who were taking ARTEROprotect® , while the control group consisted of 2564 subjects (1135 males and 1428 females) who were not taking it. Based on the results, dietary supplement ARTEROprotect® , used alone, could contribute to lowering levels of cholesterol, triglycerides, LDL-cholesterol; in combination with a statin it can achieve the target value of LDL- and HDL-cholesterol.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
The document describes a multiprogramming system with a hierarchical structure implemented on a Dutch computer. The system divides all activities across sequential processes at different hierarchical levels, with independent abstractions at each level. This hierarchical structure proved vital for verifying the system's logical soundness and implementation correctness. The primary goal of the system is to smoothly process a continuous flow of user programs as a service to the university.
The Epidemiology of Deliberate Self-Poisoning Presenting at a Tertiary Care ...Faizan Qaisar
Faizan Qaisar1*, Mohsin Shafi1, Ayesha Majeed1, DileepKumar1, Awais Memon1and Umer Memon1
1Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro,
Sindh, Pakistan
The document appears to contain the results of a survey about students' daily habits:
- Most students (33%) eat 3 meals per day, with breakfast being mostly sandwiches (37%) or milk and toast (26%). Dinner is commonly soup (52%) or fried food (35%).
- The majority of students (54%) drink 1-2 glasses of milk or dairy per day. 41% eat 1-2 pieces of fruit daily.
- When spending money on sweets, most students (44%) spend less than 1 euro.
- Students commonly practice sports for enjoyment (39%) or to stay fit (24%) during physical education classes (51%) or in after school activities (23%). Popular sports include football
This document summarizes the current best practices for the management of incidental gallbladder cancer discovered after cholecystectomy. It reviews the available literature on pathology and staging, timing and type of re-resection, and the role of adjuvant therapies. The key findings are that early stage T1a cancers often do not require additional surgery and have a very low risk of recurrence. For T1b or higher cancers, preoperative imaging and restaging is recommended followed by extended resection with lymphadenectomy. While the optimal approach remains controversial, re-resection within 4-8 weeks of initial surgery tends to have the best outcomes. Adjuvant chemotherapy may provide a benefit for higher stage or node-positive cancers but requires
Effects of acupuncture on point pericardium 6 on hydromorphone induced nausea...Amanda Maijer
This research paper evaluated the effects of acupuncture at point Pericardium 6 (PC6) on nausea and vomiting induced by hydromorphone administration in healthy dogs. 81 dogs were randomly assigned to receive acupuncture at PC6, alternative acupuncture at Lung 5, or no acupuncture. After hydromorphone injection, dogs that received acupuncture at PC6 had a significantly lower incidence of vomiting compared to the other groups. Acupuncture at PC6 reduced vomiting in dogs but did not affect other signs of nausea like hypersalivation or licking. The study suggests acupuncture at PC6 can decrease opioid-induced vomiting in dogs during the perioperative period.
- This randomized controlled trial studied the effect of erythropoietin treatment in 941 extremely preterm infants between 24 and 27 weeks gestation. Infants received either erythropoietin or placebo intravenously for 6 doses then subcutaneously until 32 weeks postmenstrual age.
- The primary outcome of death or severe neurodevelopmental impairment at 2 years was not significantly different between the erythropoietin and placebo groups. No meaningful differences in serious adverse events were found.
- Unlike previous studies, this larger trial found that high-dose erythropoietin treatment did not reduce the risk of death or improve neurodevelopmental outcomes in extremely preterm infants compared to placebo.
PEPTIC (Holden Young - Roseman University College of Pharmacy)HoldenYoung3
PEPTIC (Holden Young - Roseman University College of Pharmacy)
Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital
mortality among ICU patients receiving invasive mechanical ventilation (PEPTIC).
JAMA . 2020; 323(7):616-626
The study assessed adherence to cardiovascular medications in rural patients attending a tertiary hospital in India. It found that adherence was lowest in hypertension patients at 20.83% and highest in ischemic heart disease patients at 32%. The most common reason for non-adherence was carelessness. The study concluded that rural Indians adhere poorly to cardiovascular medications and that more efforts are needed to address this issue.
Ppi for bleeding ulcers intermittent vs continuousHassan Al tomy
in last few years there is emergent data on use of intermittent PPI in bleeding ulcers compared to continous infusion
in this meta-analysis the invistigator select 13 randomized controlled trial
Intermittent PPI regimens are comparable to continuous PPIinfusion regimens in patients with bleeding ulcers and high risk endoscopic findings
Because of ease of use and lower cost and resource utilization, intermittent PPI therapy may be the regimen of choice after endoscopic therapy in such patients
"Long-term kidney outcomes among users of proton pump inhibitors without intervening acute kidney injury, Proton Pump Inhibitors and Risk of Incident CKD and Progression to ESRD"
This document summarizes a journal club presentation on a study assessing the knowledge and practices of intensive care nurses regarding the prevention of ventilator-associated pneumonia. The study found that the nurses had average knowledge but unsatisfactory practices in preventing VAP. It concluded that additional in-service education and training programs are needed to improve nurses' knowledge and practices and reduce infections among patients. The presentation reviewed the objectives, methods, findings and conclusions of the descriptive study conducted with 50 nurses in India. It also discussed relevant literature supporting the average knowledge levels found and the need for preventative protocols and guidelines.
The study evaluated the effects of low-dose aspirin versus placebo in 10,010 patients undergoing noncardiac surgery who were at risk of vascular complications. Patients were stratified based on whether they had not been taking aspirin before the study or were already on an aspirin regimen. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days. The study found that aspirin did not significantly reduce the primary outcome but did increase the risk of major bleeding.
Corticosteroids for sore throat sr ma bmj 2018Mayra Serrano
This systematic review and meta-analysis found that a single low dose of corticosteroids, such as oral dexamethasone up to 10 mg, provides moderate to high quality evidence of pain relief for patients with sore throat. Patients who received corticosteroids were twice as likely to experience pain relief after 24 hours and 1.5 times more likely to have no pain at 48 hours, with no increase in serious adverse effects. The mean time to complete pain resolution was about 11 hours shorter with corticosteroids. Included trials enrolled over 1400 individuals and assessed outcomes up to 48 hours, but did not evaluate risks of repeated corticosteroid use for recurrent sore throats.
This study examined the association between herpes zoster infection and risk of peripheral arterial disease using a nationwide cohort in Taiwan. The study found that patients with herpes zoster had a 13% higher risk of developing peripheral arterial disease compared to those without herpes zoster, after adjusting for risk factors. Female sex and older age were also associated with small increases in risk. While antiviral treatment for herpes zoster did not affect risk of peripheral arterial disease, larger prospective studies are still needed to determine if treatment can reduce risk.
The study aimed to assess the effectiveness of intradialytic exercises in reducing muscle cramps and improving quality of life among patients undergoing hemodialysis. 80 patients were randomly assigned to experimental and control groups. The experimental group performed intradialytic exercises for 2 weeks, while the control group received usual care. Results found significant reductions in muscle cramps and improvements in quality of life in the experimental group compared to the control group. The study demonstrated that intradialytic exercises are an effective non-pharmacological approach for reducing muscle cramps and improving quality of life in hemodialysis patients.
This study investigated calcium and vitamin D intake in healthy children. 184 children with intake below recommendations were randomly assigned to receive dietary counseling plus calcium/vitamin D supplements (Group 1) or counseling alone (Group 2). After 4 months, Group 1 showed improved intake of both nutrients and optimal vitamin D levels, while Group 2 only improved calcium intake and had lower vitamin D levels. The study concludes that counseling alone is not sufficient to achieve adequate vitamin D intake.
PEPTIC (Holden Young - Roseman University College of Pharmacy)HoldenYoung3
PEPTIC (Holden Young - Roseman University College of Pharmacy)
Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital
mortality among ICU patients receiving invasive mechanical ventilation (PEPTIC).
JAMA . 2020; 323(7):616-626
This systematic review and meta-analysis evaluated the efficacy of oral corticosteroids for acute wheezing episodes in asthmatic preschoolers. The analysis included 11 randomized controlled trials involving oral corticosteroid treatment compared to placebo. The results showed no significant differences overall between corticosteroids and placebo for hospital admissions, need for additional corticosteroid treatment, or unscheduled visits. However, corticosteroids may reduce hospital admissions and additional corticosteroid need for more severe cases presenting to the emergency department or requiring hospitalization. The evidence was deemed inadequate to form clinical recommendations due to limitations in the studies.
This study assessed the safety and efficacy of the herbal cough syrup Mykoff in 50 patients with coughs of various causes. 84% of patients experienced excellent or good relief of cough symptoms. Cough severity, frequency, chest discomfort and sputum quantity all significantly decreased over the course of treatment. Most patients found the remedy acceptable. Only one adverse event occurred, deemed unlikely related to the medication. The study concluded that Mykoff is an effective and safe treatment for coughs of short duration from various etiologies.
Efficiency of Use of Dietary Supplement Arteroprotect® In Prevention of Cardi...inventionjournals
Cardiovascular diseases are the leading cause of death in most developed countries and in many developing countries. The main cause of cardiovascular disease in 95% cases is supposed to be atherosclerosis, and the symptoms occur when the process is already at an advanced stage of disease. Present study was conducted to examine an efficiency of ARTEROprotect® (by Abela Pharm, Serbia) in prevention of cardiovascular diseases. The study was conducted by 76 doctors in primary health centers throughout the Republic of Serbia as a prospective clinical study of two groups of subjects. The study group included 4031 subjects (1785 males and 2246 females) who were taking ARTEROprotect® , while the control group consisted of 2564 subjects (1135 males and 1428 females) who were not taking it. Based on the results, dietary supplement ARTEROprotect® , used alone, could contribute to lowering levels of cholesterol, triglycerides, LDL-cholesterol; in combination with a statin it can achieve the target value of LDL- and HDL-cholesterol.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
The document describes a multiprogramming system with a hierarchical structure implemented on a Dutch computer. The system divides all activities across sequential processes at different hierarchical levels, with independent abstractions at each level. This hierarchical structure proved vital for verifying the system's logical soundness and implementation correctness. The primary goal of the system is to smoothly process a continuous flow of user programs as a service to the university.
The Epidemiology of Deliberate Self-Poisoning Presenting at a Tertiary Care ...Faizan Qaisar
Faizan Qaisar1*, Mohsin Shafi1, Ayesha Majeed1, DileepKumar1, Awais Memon1and Umer Memon1
1Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro,
Sindh, Pakistan
The document appears to contain the results of a survey about students' daily habits:
- Most students (33%) eat 3 meals per day, with breakfast being mostly sandwiches (37%) or milk and toast (26%). Dinner is commonly soup (52%) or fried food (35%).
- The majority of students (54%) drink 1-2 glasses of milk or dairy per day. 41% eat 1-2 pieces of fruit daily.
- When spending money on sweets, most students (44%) spend less than 1 euro.
- Students commonly practice sports for enjoyment (39%) or to stay fit (24%) during physical education classes (51%) or in after school activities (23%). Popular sports include football
This study assessed the appropriateness of acid suppression therapy (AST) prescribed to patients admitted to the internal medicine ward of a tertiary care hospital in Pakistan. The study reviewed 300 patient records and found that AST was prescribed inappropriately in 65.3% of cases. Only 17.6% of AST prescriptions had a FDA-approved indication, while 17% were prescribed for stress ulcer prophylaxis but did not meet ASHP guidelines. Omeprazole was the most commonly prescribed AST. The study concluded that AST is often inappropriately prescribed in internal medicine wards and implementation of evidence-based guidelines could help optimize appropriate AST use.
The document summarizes the 2011/2012 school year calendar for Poland. It begins on September 1st and ends on June 29th, with summer holiday during July and August. There are two semesters separated by a two week winter holiday. Important dates include national holidays, religious observances, and the written Matura exam at the end of the school year.
This document discusses various programs and services provided by Lehigh Valley Health Network including their surgery education center, children's ER, heart disease risk identification and education program, telehealth services, regional burn center, community health and wellness center, hybrid operating rooms, rapid assessment unit, use of da Vinci surgical robot, distracted driver safety campaign, AIDET patient experience training, research and innovation programs, simulation center, educational lecture series, mini medical school, health network laboratories, partnership with University of South Florida, magnet status for nursing excellence, cancer prevention programs, neurosurgery services, and MedEvac emergency transport. The content covers their embrace of new technologies, focus on education, priority of excellent patient services, and efforts to
Jessenia Carolina Barrera Urrutia was born on April 24, 1993 in Pelileo, Ecuador. She graduated from the ABDON CALDERON school and is currently studying clinical psychology at the Technical University of Ambato. In her free time, she enjoys basketball, dancing, and romantic music.
This document provides information about Poland, including its capital Warsaw, other major cities like Krakow, Tricity, Poznan, and Wroclaw, and upcoming events like Euro 2012 and the Open'er Festival. It also shares details about prominent Polish figures like Chopin and Curie, athletes like Kubica and Malysz, political leaders like Walesa, scientists like Copernicus, cultural icons like cartoons Reksyo and Bolek i Lolek, foods like dumplings and cabbage rolls, and industries like Fiat and Wedel confectionery.
In Poland, education is compulsory until age 18 and free in public schools. Students attend primary school from ages 6-13, then take a test to determine placement in junior high school. After junior high, students can choose between technical school lasting 4 years, high school for 3 years, or basic vocational school for 2-3 years. All schools culminate in an exam, with technical and high schools requiring a Matura exam for university admission. Higher education includes bachelor's and master's degree programs.
Minsk Mazowiecki is a small city near Warsaw with over 38,000 citizens. It was granted municipal law in 1421. The city has several monuments and memorials of national importance, and was bombarded by Germans in 1939 and the USSR in 1945. The city owns several schools and has partnerships with cities in France, Lithuania, the Czech Republic, Greece, and the United States.
Effect of Jianpi-yangwei decoction on gut fungi in the patients with gastric ...LucyPi1
Abstract Background: Our previous study shows that the empirical formula of Chinese medicine Jianpi-yangwei decoction (JYD) can improve the quality of life in patients with gastric cancer undergoing chemotherapy by increasing beneficial gut bacteria and decreasing harmful bacteria. The present study aims to investigate the effect of JYD on gut fungi in patients with gastric cancer undergoing chemotherapy. Methods: A total of 73 patients with gastric cancer undergoing chemotherapy were recruited. Twenty-nine patients in the chemotherapy group were given standard chemotherapy and 44 patients in the observation group were given JYD plus standard chemotherapy. A control group (55 cases) was recruited from the healthy medical examiners. After 3 months of treatment, life-quality score was evaluated and fecal microbiota was tested by high-throughput sequencing based on the 18S rRNA gene. Results: After treatment, life-quality score in the observation group was significantly lower than that in the chemotherapy group (P < 0.05). There was no significant difference between the observation and control groups’ diversity and richness indices of intestinal fungi. The Chao index for intestinal fungi in the chemotherapy group was significantly lower than that in the observation group (P < 0.05). There was a significant difference between the control and chemotherapy groups in the intestinal fungi according to Shannon and Simpson indices (P < 0.05). Linear discriminant analysis effect size analysis showed no significant differences among the three groups, but significant difference in intestinal fungi was observed between the observation group and the chemotherapy group. At the genus level, the relative abundance of the Aspergillus genus in the observation and control groups was significantly lower (P < 0.05), the relative abundance of the Cutaneotrichosporon, Galactomyces, and Ganoderma genus taxa was significantly higher compared with those in the chemotherapy group (P < 0.05), and there was no significant difference between the observation group and control group. Conclusion: JYD can ameliorate chemotherapy-induced fungal dysbacteriosis in patients with gastric cancer undergoing chemotherapy and improve the quality of life of patients.
A SEEMINGLY BENIGN DRUG IN THE SPOTLIGHT: AN EDUCATIONAL INTERVENTION TO REDU...Khushboo Gandhi
INTRODUCTION
Overutilization of Proton pump inhibitors (PPI) in hospitalized patients is a well-recognized problem. In our previous study at St. Luke’s Hospital, we found that the lack of published guidelines for PPI use in non-critically ill patients results in overutilization of PPI in hospitalized patients. We conducted an educational intervention program to address this problem.
DISCUSSION
Overutilization of PPI in non-critically ill hospitalized patients is a known problem in medical practice. Use of PPI has been implicated in number of adverse consequences including but not limited to Clostridium difficile infection, pneumonia, and osteoporosis. In recent studies, PPI was found to be associated with increased in-hospital mortality, increased risk of cardiovascular events, dementia and chronic renal failure (CRF). We studied the magnitude of the problem in our hospital and employed an educational intervention program, which resulted in a significant reduction of inappropriate use of PPI in the hospital.
There were several limitations to our study. This was a retrospective study where we noted a lack of proper documentation for outpatient use of PPI. We also were unable to precisely determine for how long the patients were taking PPI as outpatients. Our intervention included only medical residents (a total of 41), so we excluded data from NPs, hospitalists or PCPs after intervention. As a result, we are unable to determine the effect of the educational intervention on their practice.
CONCLUSION
PPIs have long been considered as relatively harmless drugs. In recent years, it has been implicated in several adverse effects that increases patient morbidity and mortality along with increased healthcare expenditure. Our data shows that proper education and ongoing surveillance, especially during admission and discharge can significantly reduce overutilization of PPI.
This document summarizes a pilot study that evaluated the safety and effectiveness of an alternative therapy for polycystic ovary syndrome (PCOS) using natural minerals. 20 women with PCOS received weekly treatments involving wrapping the body in bandages soaked in a mineral solution for 1 hour. Hormone levels were measured before and after treatment. Results found that treatment significantly improved levels of luteinizing hormone, prolactin, anti-Mullerian hormone, fasting insulin, and liver enzymes. No adverse events occurred. The study suggests this natural mineral treatment may be a safe and effective approach for managing symptoms of PCOS.
Safety and efficacy of aflibercept in combination with fluorouracil, leucovor...Mary Ondinee Manalo Igot
This study evaluated the safety and efficacy of combining aflibercept with FOLFIRI chemotherapy (fluorouracil, leucovorin, irinotecan) in Asian patients with metastatic colorectal cancer who had progressed after prior oxaliplatin-based therapy. Nineteen patients received treatment with aflibercept and FOLFIRI. The combination showed a median progression-free survival of 4.1 months and median overall survival of 11.6 months. The majority of adverse events were grade 1-2 and included neutropenia, anemia, fatigue, and liver enzyme elevation. Grade 3 toxicities included neutropenia and neutropenic complications. All adverse events were managed with supportive care and
Antibiotics in the ICU - when, what and how?scanFOAM
A presentation by Fredrik Sjövall at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
A Prospective Study on Role of Water Soluble Contrast in Management of Small ...Kundan Singh
There is no definite protocol in management of small bowel obstruction in relation to duration and need of surgery. The aim is to study the role of gastrografin in management of small bowel obstruction.In this study patients who were diagnosed with intestinal obstruction were administered gastrografin. The patients were followed serially using x-ray at 4hrs interval for 24hrs; decision to operate was taken on non-progression of dye in two consecutive x-ray. Among 20 patients of this study 9 patients were operated on basis of gastrografin study. 11 were treated conservatively. 8 patients were of adhesive bowel obstruction. Out of which 1 was operated, 7 were treated conservatively. The sensitivity, specificity, positive and negative predictive value of gastrografin administration in this study was 100%, 89%, 92%, 100% respectively.Gas¬trografin helps in strengthening the clinical decision about the management of intestinal obstruction; it helps in early decision making regarding continuing the conservative or operative management and allows the introduction of oral intake earlier and earlier discharge from the hospital as well as reduction in operative rate.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Nejm journal watch practice changing articles 2014Jaime dehais
This document provides a compilation of summaries of the latest practice-changing articles from NEJM Journal Watch. It includes summaries of articles on topics such as delayed or no antibiotic prescriptions for respiratory infections, physical therapy being beneficial for knee osteoarthritis, low-dose steroids being better than high-dose for COPD exacerbations, a diagnostic algorithm for upper-extremity deep vein thrombosis, evidence that meniscal tears may not require surgery, improvements in mental health with smoking cessation, doubts cast on flu drugs by meta-analyses, the 2014 recommended childhood immunization schedule, sentinel lymph node biopsies for thin melanomas, age-specific d-dimer cutoffs for pulmonary embolism, evidence that FOD
Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking. We reviewed the charts of patients status post BMT on PN to determine whether institutional guidelines for PN initiation and continuous supervision of NSTs could be applied in this population. With the Institutional Review Board (IRB) approval, charts of adult BMT recipients on PN between June 14, 2006 and June 30, 2007 were examined. Sixty-nine charts were reviewed. Indications for initiation of PN included severe mucositis, graft versus host disease (GVHD), and other transplant related side effects resulting in poor oral intake. Among 69 patients, 37 (54%) had severe mucositis, 12 (17%) had GVHD, 2 (3%) had both mucositis and GVHD, and 18 (26%) had other side effects. It was determined that all patients met the criteria for initiation of PN support, as outlined in the guidelines form. Comprehensive guidelines for initiating PN support, developed by NSTs can also be used for BMT recipients in order to optimize their nutritional status.
This study compared the effectiveness and safety of silodosin versus tamsulosin in treating 57 men with benign prostatic hyperplasia (BPH) over 12 weeks. Both drugs significantly reduced International Prostate Symptom Score (IPSS) from baseline, though silodosin showed slightly greater reduction than tamsulosin initially. Silodosin had a greater impact on sexual function due to retrograde ejaculation. Adverse effects were seen in around 35% of silodosin patients and 27% of tamsulosin patients, with dyspepsia and retrograde ejaculation more common for silodosin and headaches and hypotension for tamsulosin. The study concluded that silodosin is comparable
Silodosin versus tamsulosin in symptomatic benign prostatic hyperplasia-Our e...iosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
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In this randomized controlled trial conducted across 51 centers, 792 patients with early septic shock who were randomized to receive early goal-directed therapy (EGDT) were compared to 796 patients receiving usual care. The primary outcome of all-cause mortality at 90 days was 18.6% in the EGDT group and 18.8% in the usual care group, showing no significant difference between the groups. Secondary and tertiary outcomes also showed no differences. The findings suggest that EGDT does not offer a survival advantage over usual care for patients presenting with early septic shock.
This document summarizes the results of a randomized, prospective, open-label clinical trial evaluating the efficacy and safety of Sulfad tablets for the management of non-alcoholic steatohepatitis (NASH) patients. The trial involved 100 patients taking Sulfad tablets for 3 months. Significant improvements were seen in liver enzymes and lipid profiles after 1, 2, and 3 months of treatment. No major safety issues were reported. The study concluded that Sulfad tablets were well-tolerated and effective for the management of NASH patients.
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Similar to Www.iosrjournals.org Inappropriate use of acid suppression therapy in Internal Medicine wards of a tertiary care teaching Hospital (20)
Www.iosrjournals.org Inappropriate use of acid suppression therapy in Internal Medicine wards of a tertiary care teaching Hospital
1. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 8, Issue 6 (Jul.- Aug. 2013), PP 66-69
www.iosrjournals.org
www.iosrjournals.org 66 | Page
Inappropriate use of acid suppression therapy in Internal
Medicine wards of a tertiary care teaching Hospital.
FaizanQaisar, *Ayesha Memon, Dileep Kumar, Muhammad AwaisMemon
1
R-4 Resident M.D(Internal Medicine)Liquat University of Medical and Health Sciences Jamshoro,Sindh,
Pakistan
2,3,4
FCPS Part II TraineeLiquate University Of Medical And Health Sciences Jamshoro,
Abstract: Objective: To assess appropriateness of prescription of acid suppressive therapy (AST) in Internal
Medicine ward in a tertiarycare hospital.
Methods: In this prospective observational study , weincluded all those patientswho were started on AST
after admission in the internal medicine ward in a tertiary care hospital in Hyderabad ,Sindh ,Pakistan from
May 1 to July 31, 2013 . All those patientswere excluded from the study who were alreadyon the AST therapy.
Details were taken regarding age, sex, primary diagnosis, other morbidity, drug used for AST and indication for
AST on a specifically designed proforma. The appropriatenessof AST was determined by widely accepted Food
and drug authority (FDA) indications and American society of health system pharmacist (ASHP) guidelines.
Results: We included300 Patients in our study. All patients, in our study, were given AST at the time of
admission tothe medicine ward. 133 (44.33%) Patients were male and 167 (55.66%) were female, their mean
age was 43.91±18.58 (mean ± SD). 53 (17.6%) Patients had a FDA approved indication.51 (17%) Patients
received AST therapy for SUP (stress ulcer prophylaxis) Out of that 7 (2.3%) had an absolute indication for
SUP, 44(14.8%) had 2 or more relative indications for SUP . 196 (65.3%)received AST without any
appropriate indication. Omeparzolewas themost frequently used AST (55%), followed byranitidine (45%)
Conclusion:Use of AST is mostly inappropriate inInternal medicinewards.Implementation of institutional
protocols, evidence based medicine teaching during residency training, and frequent review of therapy by the
attending consultant during ward rounds may be helpfulto promote appropriate use of AST in medicine wards.
Keywords: Acid suppressive therapy, Liquate UniversityHospital, lUMHSJamshoro,Sindh, Pakistan
I. Introduction:
There are many FDA approved indications for the use of AST (acid suppressiontherapy) such as
(Healing of erosive esophagitis Maintenance of healing of erosive esophagitis, Symptomatic gastro-esophageal
reflux disease, Helicobacter pylori eradication in combination with antibiotics, Short-term treatment of active
gastric, ulcer ,Short-term treatment of active duodenal ulcer,Maintenance of healed duodenal ulcer, Healing of
NSAID-Associated gastric ulcer, Risk reduction of NSAID-associated gastric Ulcer, Pathologicalhypersecretory
conditions including Zollinger-Ellison syndrome)(1-2)
In addition, American society of health system pharmacist
(ASHP) has also published,in 1983,the guidelines to administer AST for SUP (stress ulcer
prophylaxis).(3)
Nevertheless, Several studies from all over the world, have reported that AST is prescribed
inappropriately in hospitalized non-critically ill patients.In medical wards most prescriptions of AST are for
stress ulcer prophylaxis or they are prescribed without alicensed indication. Inappropriately prescribed AST has
potential for drug-drug interaction and agent specific side effects.Furthermore, AST can increase the risk of
hospital acquired pneumonia and clostridium difficile infection.(4-15)
In Pakistan where poverty is a bigger
problem, The cost of using drugs like PPIs,H2R blocker for an individual person, particularly for long-term is
of utmost concern.(16)
In Pakistan, data on the appropriateness of AST in Medicine wards is available scarcely.
Therefore,we conducted this study to see the appropriateness of acid suppressiontherapy inthe patientsadmitted
to medical ward of Liaquat University Hospital,Hyderabad, Sindh, Pakistans.
II. Material and Method:
LiaquatUniversity Hospital is a tertiary care teaching hospital in public sector in Hyderabad, Sindh,
Pakistan. There are 4 medicine wards in this hospital. Each ward has an assigned admission day. Cases from all
four medicine wards were collected on their respective admission day. All thePatients who were prescribedAST
after admission in the medical ward were included in the study. Patients, alreadyon AST, were excluded. Details
were takenregardingage, sex, primary diagnosis, other morbidity, drug used for AST and indications for AST on
a specifically designed Proforma. All the patients were categorized into 3 groups A, B, C respectively. Group A
included the patients who were prescribed AST for stress ulcer prophylaxis. Group B included those who were
started with AST for a FDA approved indications. Group C included the patients who were given AST without
2. USE Of Inappropriate Acid Suppression Therapy In Internal Medicine Wards Of A Tertiary Care
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any licensed indication. We followed ASHP Guidelines to judge the appropriateness of AST for
SUP.Prescription of AST for SUP was considered appropriate if the patient had 1 absolute indication i.e
Coagulopathy (defined as platelet count <50 000 mm or an international normalization ratio of > 1.5, or a
partial thromboplastin time > 2 times the control value, or requiring mechanical ventilation for> 48 h), or
2 or more relative indications (Respiratory Failure ,Renal Failure, Heart Failure ,Hepatic dysfunction
,Jaundice ,Sepsis, Stroke ,Hypotension ,Previous Gastrointestinal Disease, High-Dose Corticosteroids
(>250 Mg/Day Of Hydrocortisone),Thermal Injury To >35% , Heparin Or Warfarin, kidney or liver transplant,
head injury). Treatment for Non-SUP was considered appropriate if patient had any of the FDA approved
indications for AST that includes,(Healing of erosive esophagitis Maintenance of healing of erosive esophagitis,
Symptomatic gastro esophageal reflux disease,Helicobacter pylori eradication in combination with
antibiotics,Short-term treatment of active gastric, ulcerShort-term treatment of active duodenal ulcer,
Maintenance of healed duodenal ulcer,Healing of NSAID-Associated gastric ulcer, Risk reduction of NSAID-
associated gastric Ulcer,Pathologicalhypersecretory conditions including Zollinger-Ellison syndrome) . AST
was considered inappropriate in all those patients who had no FDA approved indications for AST as well as had
no indication mentioned in ASHP guidelines for SUP.
III. Results:
We included 300 patients in our study.All patients in our study were given AST at the time of
admission to Internal Medicine ward. 133 (44.33%) were male and 167 (55.66%) were female .Their mean age
was 43.91 ± 18.58 (mean ± SD). 53 (17.6%) patients had a FDA approved indication (Symptomatic
gastroesophageal reflux disease, Helicobacter pylori eradication in combination with antibiotics, Short-term
treatment of active gastric ulcer, Risk reduction of NSAID-associated gastric Ulcer).51 (17%) patient received
AST therapy for SUP (stress ulcer prophylaxis) Out of that 7 (2.3%) had an absolute indication for SUP,
44(14.8%) had 2 or more relative indications for SUP . 196 (65.3%) received AST without any appropriate
indication. Omeparzolewas the most frequently used AST (55%), followed by ranitidine (45%)
IV. Discussion:
Currently, Alittle information is available on the prescription of acid suppression therapy in Pakistan.
In our study we aimed to evaluate the appropriateness of prescription of AST in patients admitted to Internal
Medicine ward.
Our study suggests that AST is commonly prescribed inappropriately in Internal Medicine ward. We
included a total number of 300 patients in our study. All patients in our study were given AST at the time of
admission to Internal Medicine ward. 133 (44.33%) Patients were male and 167 (55.66%) were female. their
mean age was 43.91 ± 18.58 (mean ± SD). 53 (17.6%) patients had a FDAapproved indications(TableIII)
.51 (17%)
Patients received AST therapy for SUP (stress ulcer prophylaxis) Out of that 7 (2.3%) had an absolute
indication for SUP, 44(14.8%) had 2 or more relative indications for SUP (Table IV)
. 196 (65.3%) received
AST without any appropriate indication(Table V)
. Omeprazolewas themost frequently used AST (55%), followed
byRanitidine (45%).
Our study agrees with the previous studies carried out on the same topic with slight variations within
the results. In Italy gullotta et al carried out a single day survey of hospitalized patients at 20 centers and found
that 27% received AST of which 51% was inappropriate(5)
. A study conducted by Nardino et al in USA in a
large community hospital reported that 54% of the hospitalized patients received AST of which 65% were
inappropriate(4)
. In addition,Parente et al reported the hospitalized patient receivingAST, 65.3% of the
prescription wasinappropriate(7).
Furthermore Hwang et also conducted the similar study in non-
criticallyhospitalized patients in a teaching hospital reported that 54.9% received AST of which 58.5% were
inappropriate(10).
Treatment with AST in most of the patients who received AST unnecessarily was attributed to
SUP. Although guidelines of ASHP are available to select the patient to administer AST for SUP and available
medical literature also support indication of SUP only in ICU patientsNevertheless, practice of starting AST for
SUP in non-critically ill patient admitted to medical ward has been increasing day by day with no scientific
literature to support this practice. In our study we follow ASHPTable 1
to evaluate appropriateness of AST for
SUP(3)
.One more important thing which was noticed, that in our study, almost every patient was started on AST
by on-duty Postgraduate Fellow orResidentbut the next day after admission every treatment order was reviewed
by aconsultant physician during morning ward round but no modification was made in the prescription order nor
the AST was stopped.
The ASHP guidelinespublished, in 1989, do not include PPIs for SUP but in our study Omeprazole was
the most common AST used for this purpose. (55%).Othermedical sources also reported the PPIs are more
commonlyprescribed drugs for SUP despite limited data is available to support this practice(17)
.
AST is considered safe but current scientific data suggest that AST is associated with an increased risk
of nosocomial pneumonia. (12)
AST can also increase risk of clostridium difficile infection.(13-15)
Furthermore AST
3. USE Of Inappropriate Acid Suppression Therapy In Internal Medicine Wards Of A Tertiary Care
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has the potential for drug-drug interaction and agent specific side effects. (3)
Financial implication of AST cannot
be ignored in third world poverty-stricken country like Pakistan, Although ,in Pakistan, a little information is
available on financial burden of AST but the annual cost of inappropriate SUP in Non -ICU patients were found
to be nearly $111000 .(8)
V. Recommendations:
The practice of prescribing AST unnecessarily can increase cost, drug interactions., and adverse
events. It is of key importance in Pakistan where mostly patients are non-affording .Implementation of
institutional protocols, evidence based medicine practice during residency training, and frequent review of
therapy by the attending consultant during ward rounds may be helpful to promote appropriate use of AST in
medicine ward.
American society of health system pharmacist Guidelines.
Table I
Table II
FDA approved indication for PPIs use.
Healing of erosive esophagitis
Maintenance of healing of erosive esophagitis
Symptomatic gastroesophageal reflux disease
Helicobacter pylori eradication in combination with antibiotics
Short-term treatment of active gastric ulcer
Short-term treatment of active duodenal ulcer
Maintenance of healed duodenal ulcer
Healing of NSAID-Associated gastric ulcer
Risk reduction of NSAID-associated gastric Ulcer
Risk reduction of upper gastrointestinal bleeding in critically Ill patients
Pathological hypersecretory conditions including Zollinger-Ellison syndrome
TableIII
FDA approved indication for AST in Group B Patients
S.NO. INDICATION No.of patients %
1 Helicobacter pylori eradication in combination with antibiotics 03 1%
2 Short-term treatment of active gastric ulcer 6 2%
3 Risk reduction of NSAID-associated gastric Ulcer 09 3%
4 Symptomatic gastroesophageal reflux disease 35 11.66%
TableIV
AST used according to ASHP guidelines
Indications No. of patients Percentage
Absolute indication 7 2.33%
Relative indication 44 14.66%
Absolute Indication Relative indication 2 or more of the following
Intensive care unit (ICU) patient plus one of the following,
,Coagulopathy (i.e., platelet count of <50,000 mm3,
international normalized ratio (INR) >1.5, or an activated
partial thromboplastin time (aPTT) >2 times control)
OR
Mechanical ventilation for >48 hours
Respiratory Failure
Renal Failure
Heart Failure
Hepatic Dysfucntion
Jaundice
Sepsis
Stroke
Hypotension
Previous Gastrointestinal Disease
High-Dose Corticosteroids (>250 Mg/Day Of
Hydrocortisone)
Thermal Injury To >35%
Heparin Or Warfarin
Kidney Or Liver Transplant
Head Injury
Spinal Cord Injury
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Table V
Primary diagnosis of inappropriately prescribed AST Group.
S.No Primary diagnosis No. of patients %
1 Unexplained fever 3 1%
2 Typhoid fever 3 1%
3 Diabetic ketoacidosis 3 1%
4 COPD 3 1%
5 Hepatic encephalopathy 3 1%
6 Organophosphorous poisoning 5 1.66%
7 Chronic kidney disease 5 1.66%
8 Malaria 5 1.66%
9 Uncontrolled diabetes 8 2.66%
10 Pulmonary T.B 8 2.66%
11 Meningitis 8 2.66%
12 Cerebral malaria 13 4.33%
13 Chronic liver disease 13 4.33%
14 Stroke 33 11%
15 Acute gastroenteritis 37 12.33%
16 Miscellaneous 46 15.33%
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Acknowledgment:
Dr.AbdulMajeedMemon, Dr.Muhammad Ali Memon ,Dr.FaizaMemon , Dr.RabiaMemon, Muhammad UmerMemon , Muhammad
Hassan Memon.