The Use of Analgesic Drugs in Patients with Sickle Cell Painful Crisis.

OBJECTIVE: To determine the drug options used for pain in patients with acute sickle cell painful crisis at the University Hospital of the West Indies (UHWI), Jamaica. METHOD: This retrospective study assessed all patients admitted to the UHWI between January 1, 2006 and December 31, 2010 with acute sickle cell anaemia painful crisis and the data obtained regarding site, severity, outcome and drug options selected for pain. RESULTS: There were 101 patients with a mean age (± SD) of 18.6 (± 14.3) years; there was no difference in gender (42 females, 59 males). Eight sites of pain were reported, with the most common site being the lower limbs (44.6%) and 60.3% experienced pain in more than one site. Most of the patients (75.2%) were diagnosed with severe pain. Drug options included opioid, non-opioid or a combination, with pethidine (76) and paracetamol (79) being the most common chosen opioid and non-opioid drugs selected for therapy. There was low correlation between pain severity and appropriate first-line treatment (Spearman's rho = 0.344; p < 0.000). All patients with "mild" and "mild to moderate" pain were initially treated and obtained resolution of pain with non-opioid based therapy. However, most of the patients with severe pain (55.3%) required a second-line and some third-line (14.5%) of therapy for resolution at the time of discharge from the hospital. CONCLUSION: Painful crisis in patients with sickle cell anaemia is associated with severe pain in 75% and most will require second-line therapy for adequate resolution. Physicians need to provide adequate pain relief to decrease morbidity in these patients.

Monoclonal Antibodies in Cancer Therapy: Mechanisms, Successes and Limitations.

Rituximab was the first chemotherapeutic monoclonal antibody (CmAb) approved for clinical use in cancer therapeutics in 1997 and has significantly improved the clinical outcomes in non-Hodgkin's lymphoma. Since then, numerous CmAbs have been developed and approved for the treatment of various haematologic and solid human cancers. In this review, the classification, efficacy and significantly reduced toxicity of CmAbs available for use in the United States of America are presented. Finally, the limitations of CmAbs and future considerations are explored.

A Review of Pharmacovigilance.

Pharmacovigilance supports safe and appropriate use of drugs. Spontaneous reporting of adverse drug reactions (ADRs) is an essential component of pharmacovigilance. However, there is significant underreporting of ADRs. Adverse drug reactions have become a major problem in developing countries. Knowledge of pharmacovigilance could form the basis for interventions aimed at improving reporting rates and decreasing ADRs.

A Case for a Holistic Approach to the Improvement of Compliance among Hypertensive Patients: A Hospital Review.

The second Jamaica Health and Lifestyle Survey completed in 2007-2008 provided evidence that the prevalence of hypertension has increased significantly since 2000-2001. With more of the population living with hypertension, greater will be the need to ensure the best quality of life. A recent survey conducted in the ambulatory section of the Emergency Medicine Division at the University Hospital of the West Indies, identified a 36.5% non-compliance rate among the 52 patients prescribed with antihypertensive drugs. The reasons given for non-compliance with their antihypertensive medications are not new and included adverse effects, inconvenience and fear of dependence. However, in the same survey, it was also found that blood pressure was poorly controlled in 69.7% of the self-reported compliant subjects. Together, these points suggest that simply providing access to drugs is inadequate and a more holistic approach will be required to reduce blood pressure at the population level.

The antimicrobial screening of a Barbadian medicinal plant with indications for use in the treatment of diabetic wound infections.

OBJECTIVE: Diabetes mellitus is a chronic non-communicable disease with high prevalence in the North American and Caribbean region. Diabetic Foot Syndrome which is an associated complication can lead to the development of wounds and ulcers which can become infected. Justicia secunda, a plant known locally in Barbados as Bloodroot used in folklore for wound healing, was selected to test its ability to aid diabetic wound healing by antimicrobial activity. It was therefore tested against the bacteria Staphylococcus aureus ATCC 25923, Pseudomonas aeruginosa ATCC 27853, and Enterococcus feacalis (clincal strain) which are commonly found in diabetic wounds. METHODS: The plant was collected by local users. Methanol and acetone extracts of the plant were prepared with use of soxhlet extraction. The antimicrobial activity was assessed with the use of a modified Kirby-Baurer method. Concentrations of 200 mg/ml, 100 mg/ml, 10 mg/ml, and 1 mg/ml of the extract were used, with a standard ciprofloxacin 5 microg positive control, and a 5% dimethyl sulfoxide (DMSO) solution negative control. RESULTS: The J secunda methanol and acetone extracts with an extraction yield of 15.3% and 0.75%, respectively yielded no activity within the concentration range against the three strains of bacteria tested. In comparison with the positive control, relative inhibition zone diameter (RIZD) values of 0% resulted for both the negative control and the extracts, with the positive control having a value of 100%. CONCLUSION: The in vitro screen of the extracts prepared from J secunda, yielded no antimicrobial activity against the three strains of bacteria tested and therefore does not support the folklore claims by this mechanism of action.

Preference of patient information leaflets over standard drug monographs by patients prescribed hydrochlorothiazide, nifedipine and enalapril.

Standard drug monographs (SDMs) have been described as deficient in providing information in a manner simplified enough for patient reading. The aim of this study was to design patient information leaflets for hydrochlorothiazide, nifedipine and enalapril with content indicated by patients as relevant and to evaluate them against the SDM. Patient information leaflet (PIL) for each drug was designed to contain information on name, use of drug, how it works, how it is to be taken, common side effects, storage, missed dose action, things to avoid and when to contact the physician. Appropriateness was assessed by 10 practising pharmacists. For each drug, 40 patients were recruited, of which 20 were given SDM and 20 PIL. The knowledge of each participant was examined before and after exposure to SDM or PIL, as well as opinion on ease of reading and attractiveness using Pearson s Chi-square analysis. The results showed that both SDM and PIL improved knowledge of common side effects when compared with responses before exposure (chi2 = 24.26 for SDM and 27.64 for PIL, p < 0.001) with no difference between the groups. Respondents receiving PILs were better able to recall "things to avoid" after exposure to PIL (chi2 =10.85, p < 0.001). After exposure to SDM or PIL, the respondents who received PIL were more aware of when to contact the physician, compared to the SDM group (chi2 = 8.41, p < 0.01). When compared with SDM, respondents receiving PIL were more likely to indicate that PIL was easy to read (chi2 = 20.00, p < 0.001), attractive (chi2 = 12.45, p < 0.001) and they were more likely to recommend distribution of their reading material to other patients (chi2 = 22.11, p < 0.001). We conclude that there is benefit in designing information leaflets that simplify language and medication information contained in SDMs, including better understanding of precautions to take while on medication and when to consult physicians.

Prevalence of the metabolic syndrome in patients presenting to the university hospital of the West Indies: a need to adopt proactive screening and specific management policy.

Studies have shown that the metabolic syndrome (MetS), a major risk factor for the development of Type 2 diabetes mellitus and cardiovascular disease, is higher among psychiatric patients on antipsychotic medications than the general population. While studies on the prevalence of MetS in the Jamaican adult population have been undertaken, no such study has been done on the corresponding psychiatric population. The purpose of this study was to determine the prevalence of MetS in a Jamaican adult psychiatric inpatient population. The study group comprised thirty-eight patients with a primary DSM-IV-TR Axis 1 diagnosis. Criteria for the diagnosis of MetS were the presence of any three or more of five factors as defined by using the International Diabetes Federation (IDF) and American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) consensus agreement. The prevalence of MetS in this cohort was 28.9% and was associated with significantly higher abdominal obesity (p = 0.010), elevated blood pressure (p = 0.000), elevated triglycerides (p = 0.019) and low high density lipoprotein-cholesterol (p = 0.016) when compared with patients not diagnosed with MetS. Metabolic syndrome was common in this group of psychiatric patients and likely represents a pathway to the future development of Type 2 diabetes mellitus and cardiovascular disease. Screening and continuous monitoring will allow for early intervention and possibly prevention of increased morbidity and mortality in this vulnerable population.

Suicide attempt by self-poisoning: characteristics of suicide attempters seen at the Emergency Room at the University Hospital of the West Indies.

OBJECTIVE: To document the characteristics of self-poisoning suicide attempters who were brought to the University Hospital of the West Indies (UHWI) Emergency Room and to outline the type of drug used in the attempt. METHOD: This was a retrospective study conducted over the period 2005-2009. Data were gathered from patients' case records, log books and the hospital records using a questionnaire developed for this study. The questionnaire examined demographics, parameters of the drug ingested, patient's disposition, and reasons for attempt, final outcome and the type of discharge of patients who reported to the UHWI Emergency Room due to a suicide attempt by self-poisoning. RESULTS: Over the five-year period, 127 cases of suicide attempt by self-poisoning were reported. Significantly more females than males presented to the hospital due to self-poisoning (3:1, chi2 = 33.37; p < 0.001). Of this amount, 96 cases (75.6%) were females and 31 (24.4%) were males. The age group most recorded was 16-30 years (70.8%). The most common reason for the suicide attempt was an interpersonal conflict (52%). The drug category most often used in self-poisoning was analgesics (52%) with acetaminophens being the most common (26.2%). CONCLUSION: These findings are consistent with global suicide trends and indicate an urgent need to develop and implement national preventative and treatment measures for groups known to be at risk of suicidal attempts.

Improvement in HDL cholesterol in postmenopausal women supplemented with pumpkin seed oil: pilot study.

OBJECTIVE: Pumpkin seed oil is rich in phytoestrogens and animal studies suggest that there is some benefit to supplementation in low estrogen conditions. This study is the first to evaluate the benefit of pumpkin seed oil in postmenopausal women. METHODS: This pilot study was randomized, double-blinded and placebo-controlled. Study participants included 35 women who had undergone natural menopause or had iatrogenically entered the climacteric due to surgery for benign pathology. Wheat germ oil (placebo; n = 14) and pumpkin seed oil (n = 21) were administered to eligible participants over a 12-week period at a dose of 2 g per day. Serum lipids, fasting plasma glucose and blood pressure were measured and an 18-point questionnaire regarding menopausal symptoms was administered; the atherogenic index was also calculated. Differences between groups, as well as before and after the period of supplementation, were evaluated with Student's t-test, Wilcoxon matched-pair signed-ranked test and Mann-Whitney test, as appropriate (Stata version 10.1). RESULTS: Women receiving pumpkin seed oil showed a significant increase in high density lipoprotein cholesterol concentrations (0.92 ± 0.23 mmol/l vs. 1.07 ± 0.27 mmol/l; p = 0.029) and decrease in diastolic blood pressure (81.1 ± 7.94 mmHg vs. 75.67 ± 11.93 mmHg; p < 0.046). There was also a significant improvement in the menopausal symptom scores (18.1 ± 9.0 vs. 13.2 ± 6.7; p < 0.030), with a decrease in severity of hot flushes, less headaches and less joint pains being the main contributors. Women in the group receiving wheat germ oil reported being more depressed and having more unloved feeling. CONCLUSION: This pilot study showed pumpkin seed oil had some benefits for postmenopausal women and provided strong evidence to support further studies.

Pharmacovigilance: healthcare professionals' role in benefits versus harm analysis of drugs use.

Monitoring the negative effect of drugs is a concept that all healthcare professionals would be aware of as part of their professional responsibility. However since 1968, it has evolved into a structured science called 'Pharmacovigilance'. This review aims to sensitize Caribbean healthcare professionals to the global pharmacovigilance network of the World Health Organization and how their active involvement at the national level is imperative to the benefit versus harm evaluation of drugs.

Hypoglycaemic complications with diabetes mellitus management: the predominant adverse drug reaction presenting to the Accident and Emergency Department of The University Hospital of the West Indies.

Evaluation of adverse drug reactions (ADRs) is important to the assessment of risk factors in an aim to ensure maximum benefits of drug therapy. This study was done to assess the types of ADRs presenting to the Accident and Emergency department (A&E) of the University Hospital of the West Indies. Admissions to the A&E associated with drugs were followed on a weekly basis for 19 weeks from October 2007 to February 2008 using the patient logbook. Medical records of patients with suspected ADRs were collected and evaluated by an Emergency Medicine Consultant of A & E to confirm the occurrence of ADRs and the suspected drug. Of the 8170 admissions to A&E, 48 (0.6%) were related to ADRs, with most occurring in females and the mean age (+/- standard error) was 58.9 (+/- 3.4) years. Drug induced hypoglycaemia accounted for 28 (56.3%) cases of ADRs and included mainly patients on insulin, with or without a sulphonylurea therapy. Most of these diabetic patients also had co-morbidities and were on multi-drug therapy (18). Allergic reactions accounted for 10 (21%) of the ADR outcomes. Other drugs accounting for ADRs included cardiovascular drugs (10.4%), analgesic/anti-inflammatory medications (8.3%), drugs acting on the central nervous system (8.3%) and anti-infectives (8.3%). It is concluded that drug-induced hypoglycaemia is the major ADR presenting to the A&E of the University Hospital of the West Indies; it is a preventable ADR and therefore further investigation should evaluate possible factors attributed to the occurrences.

Supplementation with pumpkin seed oil improves plasma lipid profile and cardiovascular outcomes of female non-ovariectomized and ovariectomized Sprague-Dawley rats.

Pumpkin (Cucurbita species) seed oil (PSO) is a rich source of phytoestrogens and the aim of this study was to examine the effect of PSO supplementation on the total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides, high density lipoprotein cholesterol (HDL-C), systolic and diastolic blood pressure in non-ovariectomized and ovariectomized Sprague-Dawley rats. Female rats weighing 220-300 g were divided into non-ovariectomized rats for supplementation with corn oil (control CO; n = 6) or PSO (control PSO; n = 5) and ovariectomized rats for supplementation with corn oil (OVX/CO; n = 6) or PSO (OVX/PSO; n = 5) for 5 days per week for 12 weeks (corn oil 40 mg/kg or PSO 40 mg/kg given orally). Systolic and diastolic blood pressures were measured weekly. Blood was collected at the end of the period for plasma lipid assays. Control PSO had lower TC, LDL-C, triglycerides and higher HDL-C than the control CO. The OVX/CO had higher TC, LDL-C, triglycerides and lower HDL-C than the control CO and these changes were prevented in the OVX/PSO rats. PSO supplementation also resulted in lower systolic and diastolic blood pressures in both non-ovariectomized and ovariectomized rats. It is concluded that PSO supplementation can prevent changes in plasma lipids and blood pressure associated with inadequate oestrogen availability.

Generic substitutions: a 2005 survey of the acceptance and perceptions of physicians in Jamaica.

In Jamaica, the 1993 amendment to the Pharmacy Act allows pharmacists to offer patients generic substitutions for innovator brands; however, there were reservations among physicians about this policy implementation. The success of the amendment may be influenced by the confidence of physicians in the therapeutic equivalence of generics, especially since the act also allows physicians to indicate "no substitution" on prescriptions. The aim of this investigation was to examine the current attitudes of physicians towards the use of generic substitutions. One hundred questionnaires were distributed island-wide among physicians of varying specialities, with items to characterize their demographics and specific statements to determine their perception of generics. Sixty questionnaires were returned completed (60% response). Most of the responding physicians were males (2:1 male:female ratio); the majority were general/family medicine physicians in private practice. Forty-nine per cent of the responding physicians were mostly prescribing generic brands willingly, indicating that the cheaper cost of generic substitutes was a significant factor for this trend. There were doubts about whether bioequivalence of a generic was equitable to therapeutic equivalence to innovator drug. Additionally, 33% of the physicians were able to identify at least one case in the past year of clinical problems with generic substitutes that they perceived would not have occurred with the innovator. It is concluded that while the amendment to the Pharmacy Act encourages the substitution of generics in preference to innovator brands, more emphasis should be placed on improving physician confidence in the therapeutic equivalence of generics.

Inhibition of testosterone-induced hyperplasia of the prostate of sprague-dawley rats by pumpkin seed oil.

The oil from the pumpkin (Cucurbita pepo) seed is claimed to be useful in the management of benign prostatic hyperplasia. This investigation seeks to examine the effect of pumpkin seed oil on testosterone-induced hyperplasia of the prostate of rats. Hyperplasia was induced by subcutaneous administration of testosterone (0.3 mg/100 g of body weight) for 20 days. Simultaneous oral administration of either pumpkin seed oil (2.0 and 4.0 mg/100 g of body weight) or corn oil (vehicle) was also given for 20 days. The weights of the rats were recorded weekly, and the influence of testosterone and pumpkin seed oil on the weight gain of the rats was examined. On day 21, rats were sacrificed, and the prostate was removed, cleaned, and weighed. The prostate size ratio (prostate weight/rat body weight) was then calculated. Neither testosterone nor pumpkin seed oil had any significant influence on the weight gain of the rats. Testosterone significantly increased prostate size ratio (P < .05), and this induced increase was inhibited in rats fed with pumpkin seed oil at 2.0 mg/100 g of body weight. The protective effect of pumpkin seed oil was significant at the higher pumpkin seed oil dose (P < .02). We conclude pumpkin seed oil can inhibit testosterone-induced hyperplasia of the prostate and therefore may be beneficial in the management of benign prostatic hyperplasia.

Choline: are our university students eating enough?

Choline is an essential nutrient; dietary deficiency of choline is associated with impaired liver function, elevated blood concentrations of alanine aminotransferase, creatinine phosphokinase and homocysteine. There is also depletion of acetylcholine concentration in the brain, leading to deficit in memory function. The authors examined the dietary intake of choline in groups of students at the Mona Campus of the University of the West Indies. Sixty-two medical students (first and second years) and biochemistry students (final year) were recruited They were asked to (including amounts) record all foods and drinks consumed for three days (two weekdays and one weekend day). The sheets were collected and the amount of choline and betaine (a metabolite of choline) consumed were calculated Dietary intake of folate was also evaluated. The analysis revealed that 86.2% of the females and 90.9% of the males reported diets that delivered less daily choline than the adequate intake quoted by the Institute of Medicine of the National Academy of Sciences, USA (425-550 mg/day). The betaine consumption ranged between 25 to 620 mg/day (no adequate intake documented) and the folate consumed was more than the recommended daily allowance of folate (180-200 microg/day). The dietary intake of choline in the majority of students is below adequate intake. Although folate also serves similar functions to choline, it is unlikely that it can substitute for choline in all physiological aspects and therefore the implications of low dietary choline need further investigation.

Choline supplementation facilitates short-term memory consolidation into intermediate long-term memory of young Sprague-Dawley rats.

Choline is important for the synthesis of acetylcholine, an integral neurotransmitter involved in memory formation. In order to investigate the effect of choline supplementation on memory consolidation, the study utilized a T-maze to facilitate passive avoidance learning and memory in young female Sprague-Dawley rats. Rats were placed in two groups; choline-supplemented that received choline chloride daily for two weeks, and control that received vehicle daily for two weeks. Rats were evaluated to determine their ability to avoid an aversive electric foot-shock (0.1 mA at 60V) when they characteristically entered the preferred dark area (DA) of the T-maze. Both groups of rats showed preference, without significant difference, for entry into DA of the T-maze. However, fifteen minutes after passive avoidance both choline supplemented and control rats avoided entry into DA. This display of DA avoidance 15 minutes after training, suggests that both groups of rats had acquired short-term memory of the aversive stimulus. However, when the test was repeated 24 hours after training, the control group did not avoid entry into DA, whereas the choline-supplemented group either avoided entry or entered after a significantly longer latency period (p < 0.01). These results suggest that supplementation with choline facilitated the consolidation of short-term memory of the avoidance learning into intermediate long-term memory in young rats.

Dietary intake of choline and plasma choline concentrations in pregnant women in Jamaica.

Choline is an essential nutrient for humans and its availability during pregnancy is important for optimal fetal development. The Food and Nutrition Board of the Institute of Medicine in the United States of America has set the adequate choline intake during pregnancy at 450 mg/day. There is limited data available on normal plasma choline concentrations in pregnancy. Moreover, there are neither documented studies of choline intake among pregnant women in the Jamaican population nor of free plasma choline concentrations during pregnancy. Sixteen women presenting to the antenatal clinic of the University Hospital of the West Indies (UHWI) at 10-15 weeks of gestation were selected for this pilot study. A food frequency questionnaire was administered to estimate frequency of consumption of foods rich in choline. Fasting blood samples were collected by venepuncture and plasma assayed for choline using liquid chromatography electrospray ionization isotopic dilution mass spectrometry. Most of the women reported consumption of diets that delivered less than the recommended choline intake (mean +/- SEM, 278.5 +/- 28.9 mg). Mean plasma choline concentration was 8.4 +/- 0.4 micromol/L. This falls below the normal concentration (10 micromol/L) reported for individuals that are not pregnant and pregnant (14.5 micromol/L). The results of this study may be an indication that the choline included in the diet of pregnant women in Jamaica may not be adequate to meet both the needs of the mother and fetus and that further studies are warranted to determine clinical implications.

The effect of Bromelia pinguin extract on the pregnant rat uterus.

A non proteinaceous extract of Bromelia pinguin fruit was examined for activity on the rat uterus in vivo and in vitro. The in vivo experiments involved pregnant rats given the extract intraperitoneally. These rats did not abort nor were any foetal deformities observed. The extract inhibited spontaneous activity of the pregnant rat uterus in vitro. These results do not support the claimed folklore use of the plant as an abortifacient. The extract of Bromelia pinguin fruit may have some utero-active compound which inhibits uterine motility.