Randomised trial of IV metoclopramide vs IV ketorolac in treatment of acute primary headaches.

INTRODUCTION: Headache is one of the most common neurological conditions among emergency department visits (ED), although the best therapy has not been identified yet. Therefore, in the current study, we aimed to compare the pain-relieving effect of metoclopramide and ketorolac in acute primary headaches patients. METHODS: This double-blind, randomised clinical trial was conducted at Golestan Hospital, Ahvaz, Iran. This research involved all adult patients with acute primary (migraine or tension-type) headaches presented to the ED. Pain intensity was assessed with 0 to 10 verbal Numeric Rating Scales (NRS). The subjects were randomised into 10 mg intravenous (IV) metoclopramide or 30 mg IV ketorolac groups. Pain score and drug adverse reactions were compared between the two groups at baseline, 15, 30, and 60 min after baseline. RESULTS: 108 patients completed this trial and were equally divided into two groups (mean age of 34 ± 8.54 years; 57.4% female). Before treatment, the mean pain score was 6.9 and 6.8 in metoclopramide and ketorolac groups, respectively (p > 0.05). Metoclopramide failed to provide more improvement in pain score at 30 min (p = 0.55) and 60 min (p = 0.15) from baseline. There were no serious adverse events in this study. Only five patients required rescue medication which four of them were in ketorolac group. CONCLUSION: We were unable to reject the null hypothesis that there would be no difference in pain outcomes between metoclopramide and ketorolac.

Identifying medication errors in neonatal intensive care units: a two-center study.

BACKGROUND: This study aimed to assess the types and frequency of medication errors in our NICUs (neonatal intensive care units). METHODS: This descriptive cross-sectional study was conducted on two neonatal intensive care units of two hospitals over 3 months. Demographic information, drug information and total number of prescriptions for each neonate were extracted from medical records and assessed. RESULTS: A total of 688 prescriptions for 44 types of drugs were checked for the assessment of medical records of 155 neonates. There were 509 medication errors, averaging (SD) 3.38 (+/- 5.49) errors per patient. Collectively, 116 neonates (74.8%) experienced at least one medication error. Term neonates and preterm neonates experienced 125 and 384 medication errors, respectively. The most frequent medication errors were wrong dosage by physicians in prescription phase [WU1] (142 errors; 28%) and not administering medication by nurse in administration phase (146 errors; 29%). Of total 688 prescriptions, 127 errors were recorded. In this regard, lack of time and/or date of order were the most common errors. CONCLUSIONS: The most frequent medication errors were wrong dosage and not administering the medication to patient, and on the quality of prescribing, lack of time and/or date of order was the most frequent one. Medication errors happened more frequently in preterm neonates (P < 0.001). We think that using computerized physician order entry (CPOE) system and increasing the nurse-to-patient ratio can reduce the possibility of medication errors.

Pattern and extent of off-label and unlicensed drug use in neonatal intensive care units in Iran.

BACKGROUND: Many newborns may need to be hospitalized and receive drugs during the first days of their lives. These drugs are fundamentally prescribed as off-label and unlicensed. This study aimed to investigate the amount of these kinds of drugs administered in the Neonatal Intensive Care Units (NICUs) of Abuzar and Imam Khomeini Teaching Hospitals in Ahvaz, Iran. METHODS: This was a 3-month descriptive, cross-sectional study with retrospective nature in which 193 hospitalized newborns were studied. Demographic data were extracted from the patients' files. The drugs were classified as off-label, unlicensed or licensed according to the Pediatric & Neonatal Dosage Handbook (Lexicomp®, 22nd Edition). RESULTS: In total, 1049 prescriptions were registered for the 193 hospitalized newborns (term and preterm). For each newborn, the mean numbers of prescriptions and drugs received were 5.4 and 4.5, respectively. The mean numbers of prescriptions and drugs were greater for preterm newborns. Of the total 1049 prescriptions, 38.1% were off-label and 1.9% were unlicensed. Of the 193 newborns, 85% received at least one off-label or unlicensed prescription. Off-label prescriptions were mostly related to dose (44.8%) and dosing interval (36.5%). Most off-label drugs were antibiotics (mainly Gentamicin). Albuterol was used off-label in 100% of the cases. CONCLUSIONS: The results of the present study show that the prescription of off-label and unlicensed drugs in NICUs is as high in Iran as in other countries. This suggests that it is necessary to provide information to neonatologists to decrease the prescription of off-label and unlicensed drugs.

Memantine Augmentation Improves Symptoms in Serotonin Reuptake Inhibitor-Refractory Obsessive-Compulsive Disorder: A Randomized Controlled Trial.

INTRODUCTION: There is a large body of evidence on the clinical benefits of augmentation therapy with glutamate-modulating agents, such as memantine in reducing OCD symptoms. METHODS: A double-blind, placebo-controlled trial was conducted on SRIrefractory OCD patients. Thirty-two patients were randomized to receive either 20 mg/day memantine or placebo augmentation and were visited at baseline and every 4 weeks for 12 weeks. Results were measured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). RESULTS: The Y-BOCS total score was significantly reduced in the memantine group at the end of weeks 8 and 12, while no improvement was observed in the placebo group throughout the trial. A reduction of 40.9% in the mean Y-BOCS total score by week 12 in the memantine group resulted in 73.3% of patients achieving treatment response. The findings showed that a time to effect of 8 weeks was necessary to observe significant improvement in OCD symptoms, while treatment response was only seen after 12 weeks of memantine augmentation. DISCUSSION: Memantine is an effective and well-tolerated augmentation in severe OCD patients refractory to SRI monotherapy.

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.

Positive effect of septimeb™ on mortality rate in severe sepsis: a novel non antibiotic strategy.

BACKGROUND: Septimeb is a new herbal-derived remedy, recently approved for its potential immunomodulatory effects. Regarding the key role of immune system in the pathogenesis of severe sepsis and lack of any standard treatment for improving survival of these patients; we evaluated the effect of Septimeb -as an adjutant to standard treatment-on inflammatory biomarkers and mortality rates in patients with severe sepsis. METHODS: In this multicenter, randomized, single-blind trial, we assigned patients with severe sepsis and Acute Physiology and Chronic Health Evaluation (APACHE II) score of more than 20 to receive standard treatment of severe sepsis (control group) or standard treatment plus Septimeb. This group was treated with Septimeb for 14 days then followed up for another14 days. APACHE score, Sequential Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score (SAPS) were calculated daily. Blood samples were analyzed for interleukin 2 tumor necrosis factor-α, total antioxidant power, platelet growth factor and matrix metalloproteinase 2. RESULTS: A total of 29 patients underwent randomization (13 in control group and 16 in Septimeb group). There was significant difference between the Septimeb and control group in the 14 days mortality rate (18.8% vs. 53.85 respectively, P=0.048). Compared to control group, Septimeb was significantly effective in improving SAPS (P= 0.029), SOFA (P=0.003) and APACHE II (P=0.008) scores. Inflammatory biomarkers didn't change significantly between the two groups (P>0.05). CONCLUSION: Septimeb reduces mortality rates among patients with severe sepsis and it could be added as a safe adjutant to standard treatment of sepsis.

The university students' viewpoints on e-learning system during COVID-19 pandemic: the case of Iran.

The outbreak of COVID-19 closed educational institutions and universities. The aim of this study was to explain the strengths and weaknesses of the e-learning system in Iranian universities of medical sciences in the COVID-19 pandemic. This is a qualitative study that was conducted with students enrolled in Iranian medical universities. Data was collected through an open-ended electronic questionnaire based on the interview guide and was analyzed through content analysis. 122 students from 46 medical universities participated in this study. 122 questionnaires from 46 universities of medical sciences were completed. From a total of 54 codes extracted from the results, seven (strengths/positive experiences) and six (weaknesses/challenges) themes were extracted, each of which had several subsets. E-learning has both visible and hidden layers in terms of advantages and disadvantages. The e-learning system is an essential tool to continue education during the COVID-19 pandemic. Most students believe that e-learning was a great complement to prevent academic failure, but it cannot replicate the same efficiency of face-to-face training.

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.

Validating a Drug-Related Problems Classification System in Outpatient Setting in Iran.

OBJECTIVE: Medication Therapy Management service (MTMs) has been introduced to improve cooperation among pharmacists and other healthcare professionals in the management of chronic diseases, drug therapy, and patients on polypharmacy. One part of MTMs is detection and resolution of possible drug-related problems (DRPs). Nowadays, numerous DRPs classification systems are available, but due to some defects none of them are currently accepted and implemented universally. The purpose of this study is to design and validate a comprehensive system for classification and documentation of possible DRPs for the Iranian patients. METHODS: In this methodological study, four classification systems were studied, and their differences were reviewed, compared. Ultimately, a comprehensive documentation system was developed and tested for validity using experts' opinions. FINDINGS: A comprehensive list of 53 DRPs under eight categories was developed and examined for validity. After collecting the data and validity assessment, questions with content validity ratio of <0.4 and content validity index of <70% were excluded and modified. Finally, with the exclusion and modification of eight DRPs, a modified DRPs list was created. CONCLUSION: According to the universality and validity assessment and based on consensus of 20 experts, this DRPs list can be used to regulate the standard operation procedure of outpatient clinics in Iran, and could act toward standardization of this service.

An Interprofessional Collaboration between Medicine and Pharmacy Schools: Designing and Evaluating a Teaching Program on Practical Prescribing.

OBJECTIVE: Medical students need proper education in drug prescription. The aim of the present study is to introduce a course that improves the students' prescribing skills and also promotes an interprofessional collaboration between medicine and pharmacy schools. METHODS: This study was done in a skill laboratory at the pharmacotherapy department of Tehran University of Medical Sciences, Tehran, Iran. The course was an 18-h interactive workshop in 3 days under the supervision of clinical pharmacists. A total of 18 medical students participated in these classes before their internship. Before and after each class, they were given tests and paired t-test was done to compare the marks. FINDINGS: A total of 18 medical students participated in this study. The results showed that the knowledge of the students on pharmacotherapy, drug information, and prescribing skills has been significantly improved at the end of the course. CONCLUSION: Using clinical pharmacists to the present pharmacotherapy course could be an effective model for medical students to obtain better prescribing skills.

Cognitive Function before and during Treatment with Selective Serotonin Reuptake Inhibitors in Patients with Depression or Obsessive-Compulsive Disorder.

Objectives. Identification of adverse effects of selective serotonin reuptake inhibitors (SSRIs) is of great importance due to their extensive use in medicine. Some studies have reported the effects of SSRIs on cognitive functions, but the results are conflicting. This study was designed to assess the effect of these drugs on cognition of patients with depression or obsessive-compulsive disorder (OCD). Methods. Patients with depression or OCD, naïve to therapy, and candidates of receiving one drug from SSRI class, voluntarily, entered this study. Mini-Mental State Examination (MMSE) test was the tool to assess their cognitive functions. MMSE scores of each patient were recorded prior to taking SSRIs and at weeks 3, 5, and 8 of drug therapy. Results. 50 patients met our inclusion criteria, with a baseline mean MMSE score of 23.94. At 3, 5, and 8 weeks of treatment, the mean scores were 22.1, 21.4, and 20.66, respectively. With a p value of <0.0001, the gradual decline was statistically significant. Conclusion. The MMSE scores of our patients showed a gradual decline over the consecutive weeks after taking SSRI drugs. It seems that the use of SSRIs in patients with depression or OCD, can cause cognitive dysfunction in the acute phase of treatment.

Changes of Nitric Oxide and Peroxynitrite Serum Levels during Drug Therapy in Patients with Obsessive-Compulsive Disorder.

Objectives. Some studies have shown that increased nitric oxide (NO) concentrations may be associated with obsessive-compulsive disorder (OCD). In a few animal researches, enhanced synthesis of NO had reversed the effect of selective serotonin reuptake inhibitors (SSRIs). The present study tries to find the effect of treatment with SSRIs on NO serum levels and its product peroxynitrite. Patients and Methods. Patients diagnosed with OCD who are candidates of receiving SSRIs entered this study. Two blood samples were taken from subjects, prior to drug therapy and after the patients had shown some improvements due to their regimen. Serum NO and peroxynitrite levels were measured and their correlation with SSRI use was assessed. Results. 31 patients completed this study. Mean concentrations of NO and peroxynitrite prior to drug therapy were 28.63 ± 16.9 and 5.73 ± 2.5 µmol/L, respectively. These values were 18.87 ± 7.55 and 2.15 ± 0.94 µmol/L at the second blood test. With p values < 0.05, these differences were considered significant. Conclusion. Patients, who showed improvement of OCD symptoms after a mean duration of SSRI monotherapy of 3.531 ± 0.64 months, had lower values of NO and peroxynitrite in their sera compared to their levels prior to therapy. Such results can be helpful in finding a predictive factor of response to therapy and augmentation therapy with future drugs that target NO synthesis.

A two-year utilization of the pharmacist-operated drug information center in Iran.

OBJECTIVE: To assess and describe the call services delivered by drug and poison information call center (DPIC) of 13-Aban pharmacy, which is closely operated by the Department of Clinical Pharmacy, College of Pharmacy affiliated to Tehran University of Medical Sciences. METHODS: All calls services including counseled and follow-up calls provided by 13-Aban DPIC to health care professionals and public were collected, documented, and evaluated in a 2 years period from July 2010 to June 2012 using the designed software. Data analysis was done by SPSS version 16.0. FINDINGS: Totally 110,310 calls services delivered during a 2 years period. Among healthcare professionals, pharmacists, general physicians, and nurses requested more call services respectively (P = 0.001). DPIC could detect 585 potential cases of adverse drug reactions (ADRs) and 420 cases of major drug-drug interactions (DDIs). CONCLUSION: This study by analyzing and reporting the two-years activities of one of the major DPICs in Iran, showed that DPICs can offer drug consultation for healthcare professional and public as well as detect and prevent ADRs and DDIs, and therefore can promote patients' health regarding drug therapy.