Treatment of vincristine-induced ileus with metoclopramide: A case report.

INTRODUCTION: Acute lymphoblastic leukemia is an invasive malignancy which ought to be treated with several cytotoxic medications. Vincristine-based regimen is among the most commonly used regimens for the treatment of adult acute lymphoblastic leukemia. Peripheral neuropathy caused by vincristine provides a limitation in dose administration and can influence the treatment outcome and patient's quality of life. CASE PRESENTATION: Ileus and constipation occurred as a result of autonomic neuropathy in a 58-year-old man who underwent vincristine-based regimen for acute lymphoblastic leukemia treatment. Despite the administration of several laxative agents for constipation, the complication did not improve. So metoclopramide as a prokinetic agent was administered intravenously, and patient bowel movement and defecation started after 24 h. CONCLUSIONS: There is no approved protocol for vincristine-induced autonomic neuropathy treatment; thus, prokinetic agents such as metoclopramide can be considered as an option for ileus treatment after ruling out the possibility of bowel obstruction. Prophylactic stool softeners should be administrated in all patients undergoing chemotherapy with vincristine to prevent gastrointestinal motility disorders.

Significant drug interaction between voriconazole and dexamethasone: A case report.

BACKGROUND: Voriconazole is extensively metabolized by the CYP450 isoenzymes 2C19 and 3A4 and to a lesser extent by CYP2C9; therefore, any medication that affects this pathway can alter its plasma concentration. Treatment failure can probably occur if subtherapeutic levels are achieved. CASE DESCRIPTION: A 32-year-old woman who suffered from acute lymphoblastic leukemia was admitted and received treatment with vincristine and dexamethasone. After several days, to control her fever, based on two consecutive positive serum galactomannan test results, voriconazole as an antifungal agent was added to Aspergillus infection treatment. Through the first week after voriconazole initiation, its plasma concentrations were subtherapeutic. The most suspicious medication for interaction was dexamethasone, which can induce CYP450 isoenzymes and reduce plasma concentration. CONCLUSION: As a result of the narrow therapeutic window of voriconazole and the relationship between efficacy and plasma concentration of azoles, therapeutic drug monitoring of voriconazole in patients receiving a high dose of glucocorticoids is recommended, in order to achieve optimal response to treatment and toxicity reduction. Further studies regarding the interaction between voriconazole and dexamethasone to prevent clinically relevant interactions should be considered.

Using Modern Learning Method to Teach Pharmacy Students Psychopharmacotherapy.

Background: Applying modern educational methods for digital native students seems necessary. Active learning strategies promote students' skills and knowledge. This study was conducted to design and evaluate active learning methods by teaching psychopharmacotherapy to pharmacy students. Methods: This was a quasi-experimental study with three randomized study groups (control, game, and multimedia), using a pre-and post-test design, conducted on 155 students of 5-year pharmacy in 2022 at the Faculty of Pharmacy of Tehran University of Medical Sciences, Iran. Overall, 18 clinical cases were designed for the basic structure of interventions. After teaching psychopharmacotherapy contents through lecturing, the pre-test was held. The next steps were playing the educational game, studying the multimedia case-based learning files, and then completing questionnaires, respectively. Then, a post-test was held. Results: 65.33% of participants were female and 34.66% were male. The pre-test and post-test scores comparison showed no difference in control group (P=0.409). However, in the serious game and multimedia groups, the average score of pre-test and post-test had a statistically significant difference (P<0.001, P=0.002 respectively), this difference was higher in the serious game group. Questionnaire evaluation showed substantial differences between game and multimedia groups. Conclusion: The educational interventions were able to improve student's knowledge and skills so they can better help patients and promote public health. In the sections of Confidence, Social Interactions, Fun, Focused attention, Learnability, Relevance, and Perceived Learning, the serious game far outweighed the multimedia case-based learning.

Association of Voriconazole Trough Plasma Concentration with Efficacy and Incidence of Hepatotoxicity in Iranian Patients with Hematological Malignancies.

There are conflicting data regarding the association between plasma concentration of voriconazole (VCZ) and both efficacy and safety. This study investigates the association of VCZ trough plasma level with clinical efficacy and hepatotoxicity in the Iranian population suffering hematological malignancies. This cross-sectional study was performed on adult Iranian patients (age ≥ 18 years) with hematological malignancies undergoing treatment with oral or intravenous VCZ for proven or probable invasive aspergillosis. Plasma concentrations of VCZ were measured at two time points on day 4 and 14 during the study period. A total of 60 VCZ trough concentrations of 30 patients were drawn on days 4 and 14 after the initiation of treatment. There was no definite correlation between the mean plasma concentration of VCZ and VCZ dosage (p = 0.134, r = 0.280). In multivariable model, only plasma concentration of VCZ on day 14 was associated with the incidence of hepatotoxicity (p = 0.013; OR = 1.42, 95% CI = 1.07-3.24). Plasma trough concentration neither on day 4 nor on day 14 was related to the treatment response. No significant association was observed between the mean plasma concentration of VCZ and 3-month patients' survival (p = 0.696). To conclude, VCZ trough concentration may not be a predictor of treatment response or 3-month patients' survival. However, the wide inter- and intra-patient variability of VCZ plasma concentration coupled with the observed association between VCZ trough level and the incidence of hepatotoxicity would pose the question regarding the potential benefit of VCZ concentration monitoring.

Clinical Role of Silymarin in Oxidative Stress and Infertility: A Short Review for Pharmacy Practitioners.

Silymarin (SMN) as an ancient plant has various therapeutic usage in many diseases. Almost all of its properties attributed to antioxidant and anti-inflammatory properties. Currently, infertility problems impose a heavy burden on many developing countries. As a result, effective infertility treatment is indicated. The role of oxidative stress in both male and female infertility has been revealed. Many studies have shown protective and antioxidative properties of SMN against adverse effects of chemotherapy medications and environmental toxins in sperms and oocytes. The antioxidative and clinical role of SMN in infertility has been reviewed. The use of antioxidants such as SMN can help to improve fertility rate by scavenging free radicals and inhibiting nuclear factor kappa B transcription factor. Animal studies in both male and female have indicated a beneficial effect of SMN on fertility recovery. Further clinical studies are needed considering the phytoestrogenic property of SMN, to determine the right dose and duration of treatment.

Evaluation of Medication Package Inserts in Iran.

OBJECTIVE: Package inserts (PIs) provide information for the safe and effective use of medication. There is no study on the evaluation of PIs in Iran. The purpose of this study was to evaluate the completeness of PIs supplied with the 100 top-selling medications in Iran. METHODS: This cross-sectional observational study was conducted during 3 weeks in January 2017. One hundred medications were chosen from a list supplied by the Iran Food and Drug Administration (IFDA). The PIs were assessed for the presentation and completeness of quality criteria, which was consisted of two parts. The first part was the criteria required by the IFDA, mentioned in Chapter 16 of the Pharmaceutical Regulations and Instructions provided by the IFDA. The second part of the criteria was defined according to the critical comments of clinical and industrial pharmacists. FINDINGS: Thirty-seven out of 100 medications included no PIs. None of the PIs met all the criteria required by the IFDA. The highest score for completeness was 18 out of 21 (85.7%). Medication name, description, and adverse reaction were mentioned in all PIs. Other items such as patient counseling information (98%), warnings (95.2%), precautions (95.2%), pregnancy/lactation (95%), and storage condition (90.5%) have been mentioned in a high percentage of PIs. CONCLUSION: PIs have improved in recent years in Iran, but there is an absolute need for more accurate and up-to-date information. The IFDA should supervise pharmaceutical companies more strictly in this regard and should revise its regulations requiring PIs to conform to the FDA regulations.

Out of Pocket Payment and Affordability of Medication for Geriatric Patients in Tehran, Iran.

BACKGROUND: Considering the importance of high out-of-pocket (OOP) payment (OOPP), as a marker of health system performance, and affordability of medications in the elderly, this study was conducted to determine these issues. METHODS: In this cross-sectional study, prescriptions of patients aged 65 yr or older from 5 university-affiliated pharmacies in Tehran, Iran were evaluated from Jan to Mar 2014. Prescriptions were selected from four insurance organizations. We used the prescriptions data regarding patients' demographics and the prescribers as well as the sales data for OOP. Affordability was calculated by considering the daily salary of an unskilled worker. RESULTS: Totally, 1467 prescriptions were analyzed. Mean age of patients was 73.89(6.66) yr. Mean (SE) of reimbursable and OOPP of the prescriptions were 203820 (10831) and 230252 (10634) IRR (Iranian Rials) respectively (equivalent to 81.6 (4.33) and 92.17 (4.33) US$ respectively). Subspecialists imposed higher expenditures for patients and insurance organizations. Patients referred to the ophthalmologists paid less OOP. Nearly 50% of the total prescription costs was paid as OOP. The mean OOPP was averagely equal to 1.41(0.065) daily salary. These prescriptions were unaffordable for 36.2% of patients. CONCLUSION: The OOPP was higher than the insurance goal of 30% for outpatients in Iran. More than one-third of elderly patients could not afford their single prescription. Due to the health consequences of the unaffordability of medications, corrective actions are needed by the insurance organizations and the health system.

Risk factors of fatal occupational accidents in Iran.

BACKGROUND: Occupational accidents are of most important consequences of globalization in developing countries. Therefore, investigating the causes of occupational accidents for improving the job situation and making operational policy is necessary. So the aim of this study was to investigate factors affecting the fatal occupational accidents and also calculate the years of life lost for dead workers. METHODS: This cross-sectional study was conducted on data related to the 6052 injured workers that was registered in the 2013 registry system of the Ministry of Health and Medical Education of Iran. Variables including sex, education, age, job tenure, injury cause, referred location of injured workers, occupation, shift work, season, accident day, damaged part of the body were chosen as independent variables. The Chi-squared and Fisher exact tests were used for univariate analysis and then exact multiple logistic regression was carried out to identify independent risk factors of fatal occupational accidents. Finally, for dead workers, years of life lost, according to the injury causes was calculated. RESULTS: Among the 6052 accidents reported, 33 deaths were recorded. Chi-square and Fisher exact tests showed that factors including: current job tenure (p = 0.01), damaged parts of the body (p < 0.001) and injury cause (p < 0.001) are associated with the fatal accidents. Also exact multiple logistic regression analysis showed a significant association between electric shocks as a cause of injury (OR = 7.04; 95% CI: 1.01-43.74; p = 0.02) and current job tenure more than 1 year (OR = 0.21; 95% CI: 0.05-0.70; p = 0.005) with the fatal accidents. The total amount of years of life lost based on causes of injuries was estimated 1289.12 years. CONCLUSIONS: In Iran, fatal accident odds in workers with job tenure more than 1 year was less in comparing to the workers with job tenure less and equal to 1 year. Also odd of death for electrical shock was more than other causes of injuries. So it seems that employing of workers who have more than one-year work experience in a specific job and using of appropriate safeguards will be useful for the reducing of fatal occupational accidents.

Incidence of Medication Discrepancies and Its Predicting Factors in Emergency Department.

BACKGROUND: This study was conducted to evaluate the incidence of medication discrepancies and its related factors using medication reconciliation method in patients admitted to the emergency department of Tehran University of Medical Sciences hospitals. METHODS: In this cross-sectional study, 200 adult patients with at least one chronic disease that used two regular prescription medications were included in 2015. After 24 h of admission, demographic data and patient's home medications were collected. Medication discrepancies were assessed through comparison of a best possible medication history list with the physician's orders. RESULTS: Out of 200 patients (mean age, 61.5 yr; 86 males, 114 women), 77.5% of patients had one or more medication discrepancies. The most common discrepancies were medication omission (35.49%), change (14.22%) and substitution (10.97%), respectively. The relationship between number of comorbid conditions (P=0.025), regular home medications (P=<0.001), high-risk medications (P=0.032), medications pharmacological classes (P=<0.001) and medication discrepancies were statistically significant. Cardiovascular drugs compared to other medications classes showed the highest discrepancies (36.2%). Multiple logistic regression showed that the drug groups, including anti-infective for systemic use (OR=8.43; 95%CI 2.5-28.2; P=0.001), Antineoplastic and Immuno-modulator Agents (OR=0.49; 95%CI 0.27-0.87; P=0.016), Blood and Blood-Forming Organs (OR=0.33; 95%CI 0.21-0.52; P<0.001), Muscular-Skeletal System (OR=2.4; 95%CI 1.13-5.1; P=0.022), Nervous-System (OR=2.75; 95%CI 1.7-4.4; P<0.001), Respiratory-System (OR=0.38; 95%CI 0.22-0.67; P=0.001) were associated with the drug discrepancy. CONCLUSION: A medication discrepancy occurs commonly at hospital emergency department. Understanding the type and frequency of discrepancies with using structured medication reconciliation process can help clinicians to prevent them.