The relationship between body mass index and outcomes in leukemic patients undergoing allogeneic hematopoietic stem cell transplantation.

Hematopoietic stem cell transplantation (HSCT) is being used increasingly in an attempt to cure many hematological disorders. Obesity has become a world wide phenomenon and is a known risk factor for numerous medical conditions, but its role in transplant outcomes remained controversial. Total of 192 patients with acute leukemia who underwent sibling HLA matched HSCT were analyzed to find the effect of pre-transplant body mass index (BMI) on transplant outcomes such as time to engraftment, infections, graft vs. host disease (GvHD), and overall survival (OS) for the period of three yr (April 2006-March 2009). There was a significant correlation between higher pre-transplant BMI and shorter engraftment time (p = 0.010); but no relation between BMI and GvHD, infection, and OS was found. The results of this study showed that patients with higher BMI may have a shorter engraftment time; but lower, although not significant, survival rate compared to non-obese patients.

Randomized trial of the effect of intravenous paracetamol on inflammatory biomarkers and outcome in febrile critically ill adults.

BACKGROUND AND THE PURPOSE OF THE STUDY: The febrile reaction is a complex response involving immunologic and other physiologic systems. Antipyretics are commonly used in critically ill patients with fever. We investigated the inflammatory responses following application of antipyretic therapy in febrile critically ill patients with Systemic Inflammatory Response Syndrome (SIRS). PATIENTS AND METHODS: In a prospective, randomized controlled study, critically ill patients with fever (T ≥ 38.3°C), SIRS diagnosed within 24 hours of Intensive Care Unit (ICU) admission and Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥10 were randomized into two groups. Upon appearance of fever, one group received intravenous paracetamol 650 mg every 6 hours for 10 days and other group received no treatment unless temperature reached 40°C. Body temperature, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sepsis-related Organ Failure Assessment (SOFA) scores, length of ICU stay, ICU mortality and infectious complications were recorded. Levels of Interleukin-1 alpha (IL-1α), IL-6, IL-10, Tumour Necrosis Factor alpha (TNFα) and High-Sensitive C-Reactive Protein (HS-CRP) were assessed at baseline and 2, 6 and 24 hours after intervention. RESULTS AND DISCUSSION: During a period of 15-month screening, 20 patients met the criteria and randomized to the control or paracetamol group. Body temperature decreased significantly in the paracetamol group (p = 0.004) and control group (p = 0.001) after 24 hours, but there was no significant difference between two groups at this time point (p = 0.649). Levels of IL-6 and IL-10 decreased significantly (p = 0.025 and p = 0.047, respectively) in the paracetamol group at 24 hours but this was not of statistical significance in control group. No patterns over time in each group or differences across two groups were found for HS-CRP, TNFα, and IL-1α (p > 0.05). There were no differences regarding ICU length of stay, mortality and infectious complications between both groups. CONCLUSION: These results suggest that antipyretic therapy may not be indicated in all ICU patients. Allowing fever to take its natural course does not appear to have detrimental effects on critically ill patients with SIRS and may avoid unnecessary expenses.

Plasma vitamin C concentrations in patients on routine hemodialysis and its relationship to patients' morbidity and mortality.

BACKGROUND: Some studies have hypothesized the protective role of vitamin C against cardiovascular disorders (CVD) in patients with end-stage renal disease (ESRD). This study was designed to assess plasma vitamin C concentration and its relationship to hemodialysis (HD) patients' morbidity and mortality. METHODS: Plasma vitamin C concentrations were assessed in HD patients using spectrophotometry and subjects were prospectively followed for up eighteen months for all-cause mortality. Any association between vitamin C concentration and patients' demographic data, co-morbidities, or the cause of ESRD were investigated using the Chi-square test. RESULTS: Ninety-one patients with a mean age of 56.7 ± 15.7 years were included in this study. The most frequent cause of ESRD was simultaneous hypertension and diabetes in 30 % of patients, followed by hypertension in 25.6 %, and diabetes in 11.1 %, respectively. About 34 % of patients had CVD as the most prevalent co-morbidity. Forty-nine patients (53.8 %) had low levels of vitamin C concentration. There was a significant relationship between vitamin C insufficiency and presence of any co-morbidity in HD patients (p < 0.05). There was a significant difference in vitamin C concentrations between patients without co-morbidities and those with cardiovascular ones (F[2,88]=3.447, p = 0.036). Twenty-two (24.2 %) patients died over a median duration of 227 days. There was a significant difference in time to death of patients with and without low levels of vitamin C concentration (p = 0.04). CONCLUSIONS: The results showed lower plasma vitamin C levels in HD patients who suffered any co-morbidity and sooner time to death in these patients.

Descriptive analysis of a clinical pharmacy intervention to improve the appropriate use of stress ulcer prophylaxis in a hospital infectious disease ward.

BACKGROUND: Stress ulcers are acute superficial inflammatory lesions of the gastric mucosa induced when an individual is subjected to unusually high physiologic demands. In recent years, use of acid suppression therapy (AST) for stress ulcer prophylaxis (SUP) in inpatient settings other than intensive care has become increasingly common, leading to increased drug cost and an avoidable increased risk of adverse events such as hospitalacquired pneumonia. OBJECTIVE: To assess the effects of a clinical pharmacist intervention including AST prescribing and adherence to a SUP guideline that was developed by clinical pharmacists for use in the infectious disease ward of a teaching hospital based on the 1999 American Society of Health-System Pharmacists (ASHP) guidelines for use of SUP. METHODS: This was an exploratory, prospective pre- and post-intervention study of all patients admitted to the infectious disease ward of Imam Khomeini Hospital, the major referral hospital for infectious disease patients in Iran, which is affiliated with Tehran University of Medical Sciences. The study intervention consisted of the use of an internal guideline for SUP that was prepared by clinical pharmacists in accordance with ASHP guidelines, followed by education provided to the physicians who monitored and visited the hospitalized patients in the infectious disease ward. For the 4-month pre-intervention (August 1, 2008, to December 1, 2008) and post-intervention (February 1, 2009, to June 1, 2009) periods, the following data were collected: admitting diagnoses, number and type of SUP risk factors for AST, and type of AST medication used (omeprazole or ranitidine). Exclusions included (a) patients using AST for appropriate gastrointestinal diagnoses at admission (n = 4 in each period), and (b) patients who died during the hospital stay because of a cause other than a gastrointestinal disorder (n = 3 pre-intervention and n = 1 post-intervention). Rates of AST use were measured for the sample overall, and for patients with and without an indication for SUP. Appropriate use was defined as 1 primary (absolute) risk factor (i.e., coagulopathy, mechanical ventilation, or history of gastrointestinal bleed in the last 12 months) or 2 or more secondary (relative) risk factors (e.g., use of heparin). Pre- and post-intervention results were compared using the Pearson chi-square test. RESULTS: AST use declined from 80.9% (212 of 262) infectious disease ward patients in the pre-intervention period to 47.1% (113 of 240) patients in the post-intervention period (P < 0.001). Of 23 patients in the preintervention period with an indication for SUP according to our ASHP-based guideline, 78.3% (n = 18) received AST versus 85.7% (n = 12 of 14) in the post-intervention period (P = 0.575). Of the patients without an indication for SUP, 194 of 239 (81.2%) received AST in the pre-intervention period versus 101 of 226 (44.7%) in the post-intervention period (P < 0.001). Of the patients who received AST, 194 of 212 (91.5%) did not have an indication for SUP in the pre-intervention period versus 101 of 113 (89.4%) in the post-intervention period (P = 0.528). CONCLUSION: In this pre- and post-intervention study without a comparison group, the introduction by pharmacists of a treatment guideline for SUP in the infectious disease ward of Imam Khomeini Hospital was associated with reduction in use of AST overall and in patients without an absolute indication for SUP. However, there was no significant change in either the proportion of patients with an indication for SUP who received AST or in the proportion who received AST without an indication for SUP.

Is deep vein thrombosis prophylaxis appropriate in the medical wards? A clinical pharmacists' intervention study.

OBJECTIVE: Venous thromboembolism is a major cause of mortality and morbidity in hospitalized patients. To evaluate physicians' approach to patients' thrombosis risk assessment and practice of thromboembolism prophylaxis in a teaching hospital, we designed an interventional prospective study. SETTING: This pre and post interventional study was conducted in the infectious diseases ward of Imam Khomeini referral hospital, Tehran, Iran. METHOD: Patients' risk factors for thromboembolism during hospitalization course and physicians' thromboembolism prophylaxis approaches were evaluated in a pre and post clinical pharmacists' interventional study. MAIN OUTCOME MEASURE: An internal guideline for prescribing anticoagulants as deep vein thrombosis (DVT) prophylaxis was prepared by clinical pharmacists and the appropriateness of anticoagulants' prescription was evaluated and compared before and after the implementation of consensual guideline. RESULTS: In the pre-intervention phase 69.9% of patients had appropriate indication and received thromboembolism prophylaxis and in 31.1% of enrolled patients anticoagulants were prescribed inappropriately. Prescription of anticoagulants was appropriate in 88.4% of patients during the post interventional phase of the study while 11.6% of admitted patients received prophylaxis improperly. A decrease in the number of patients who had the criterion for DVT prophylaxis but anticoagulants were not administered after the implementation of internal guideline was statistically significant (P=0.001). CONCLUSION: The implementation of clinical pharmacists' prepared protocol helped to a great extent in the improvement of administrating DVT prophylaxis appropriately in patients.

Community pharmacists and chronic pain: A qualitative study of experience, perception, and challenges.

Background: Patients suffering from chronic pain frequently ask pharmacists for advice. Aims: This study was prompted by inadequacies in the available body of literature reporting on pharmacists' experiences with providing care for patients with chronic pain in the community setting. Methods: A qualitative investigation of Ontario community pharmacists' experiences was carried out. Participants were interviewed using a semistructured guide. Interviews were analyzed using thematic analysis, influenced by grounded theory. Results: This study revealed that pharmacists were knowledgeable and empathetic toward patient concerns. Challenges in their role included financial factors, patient access to multimodal treatment options, potential for harm associated with opioid use, inadequate monitoring, and gaps in training. Conclusions: This study reports community and Family Health Team pharmacists' experiences caring for patients with chronic pain and perceptions of their professional role, including strengths and limitations, and identifies perceived challenges in the health care system.

Contexte: Les patients souffrant de douleur chronique demandent fréquemment conseil aux pharmaciens.Objectifs: Cette étude a été motivée par les insuffisances observées dans la littérature disponible sur les expériences des pharmaciens en matière de soins aux patients souffrant de douleur chronique en milieu communautaire.Méthodes: Une enquête qualitative sur les expériences des pharmaciens communautaires de l'Ontario a été réalisée. Les participants ont été interrogés à l'aide d'un guide semi-structuré. Les entretiens ont été analysés à l'aide d'une analyse thématique, influencée par la théorie ancrée.Résultats : Cette étude a révélé que les pharmaciens étaient bien informés et faisaient preuve d'empathie à l'égard des préoccupations des patients. Les difficultés rencontrées dans leur rôle comprenaient des facteurs financiers, l'accès des patients à des options de traitement multimodales, les risques associés à l'utilisation d'opioïdes, un suivi inadéquat et des lacunes dans la formation.Conclusions : Cette étude rapporte les expériences de pharmaciens communautaires et de l'équipe de santé familiale dans la prise en charge des patients souffrant de douleurs chroniques, les perceptions de leur rôle professionnel, y compris leurs forces et leurs limites, et recense les défis perçus dans le système de santé.

Effects of Pantoprazole on Systemic and Gastric Pro- and Anti-inflammatory Cytokines in Critically Ill Patients.

Stress-related mucosal damage (SRMD) is a significant cause of morbidity and mortality in critically ill patients due to the gastrointestinal blood loss. Prophylaxis of SRMD with proton pump inhibitors or histamine-2 blockers has gained widespread use in intensive care units. Both demonstrated to be effective in reducing clinically significant bleedings, while PPIs has shown to exert some anti inflammatory effects including the inhibition of producing pro-inflammatory cytokines. As cytokines have role in developing SRMD, the aim of this study was to evaluate the effect of PPIs on the inhibition of cytokine release following the critical illness. A total of 27 critically ill patients with risk factors of developing stress ulcer and intragastric pH < 3.0 enrolled to this Randomized clinical trial study. Patients were randomly assigned in three treatment groups; group one received 40 mg of intravenous pantoprazole every 12 h for 48 h (four doses), group two received 80 mg of intravenous pantoprazole every 24 h continuous infusion for 48 h and the third group received 150 mg of ranitidine intravenously as 24 h continuous infusion for 48 h. Plasma and gastric juice samples were obtained at 0th, 12th, 24th and 48th h for the measurement of EGF, IL-1ß, IL-6, IL-10 and TNF-α. Pantoprazole infusion have decreased the plasma IL-1ß concentrations (p = 0.041). No other significant differences in concentrations of EGF, IL-6, IL-10 and TNF-α were detected. There were reverse correlations between the intragastric pH with gastric juice IL-1ß and TNF-α concentrations and a direct correlation between the intragastric pH and gastric juice EGF in pantoprazole groups. Our data suggest that pantoprazole may have some anti-inflammatory effects on patients. However, the exact impact of this effect on patients should be assessed by further studies.