Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity.

OBJECTIVE: The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates. METHODS: Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees. RESULTS: Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation. CONCLUSION: Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Patient engagement in the Continuing Professional Development programs within the department of radiation oncology at the University of Toronto (UTDRO): A qualitative study.

INTRODUCTION: There is little research regarding patient engagement (PE) in Continuing Professional Development (CPD) programs in radiation oncology. This study aims to understand the barriers and enablers to PE in the design and implementation process of CPD programs, and advance PE in these programs moving forward. METHODS: This qualitative study involved 17 semi-structured interviews, with 5 cancer patients and 12 educators, conducted from June 2019 to April 2020. Interview data identified common themes, such as: the current state of PE in CPD programming, and key barriers and recommendations on how to engage patients in meaningful and practical ways. RESULTS: Six themes were identified related to PE: the concept of PE, ethical considerations, barriers, key considerations in planning resources, and the anticipated impact of PE on curriculum planning. CONCLUSION: Both patients and educators emphasized that creating and sustaining meaningful educator-patient relationships and giving patients an active and effective role in CPD planning would improve curriculum content. The University of Toronto Department of Radiation Oncology (UTDRO) should consider building this initiative into its strategic CPD priorities and ensure the appropriate infrastructure is in place.

Molecularly targeted therapies in non-small cell lung cancer: The evolving role of tyrosine kinase inhibitors.

Non-small cell lung cancer (NSCLC) is a major subtype of lung cancer. Patients with NSCLC are diagnosed at a locally advanced or metastatic stage where prognosis with palliative chemotherapy is poor. The discovery of epidermal growth factor receptor (EGFR) mutations has revolutionized cancer treatment for NSCLC by promoting the development of molecularly targeted therapies like tyrosine kinase inhibitors (TKIs). This review summarizes the clinical efficacy and tolerability of EGFR-TKIs, including osimertinib, in EGFR-mutated advanced NSCLC. EGFR-TKIs have demonstrated superior response and overall survival rates compared with chemotherapy in EGFR-mutated NSCLC. However, despite the initial rapid and durable clinical responses, acquired resistance to first- and second-generation TKIs eventually develops in most cases, with disease progression observed mostly within 12 months of treatment initiation. Osimertinib, a potent third-generation TKI, irreversibly inhibits mutated EGFR alleles, including T790M. In addition to longer survival and higher response rate, osimertinib has a favorable safety profile with a lower incidence of grade ≥3 treatment-related adverse events compared with other TKIs. Based on the efficacy and safety results, recently the National Comprehensive Cancer Network (NCCN) has included osimertinib as the "preferred first-line of treatment" in patients with metastatic EGFR mutationpositive NSCLC. Thus, osimertinib as first-line therapy for EGFRpositive patients irrespective of the T790M mutation status could be an ideal choice in the Indian setting where only 50% of patients opt for any second-line therapy after first-line failure.

Surgical interventions for pulmonary tuberculosis in Mumbai, India: surgical outcomes and programmatic challenges.

Setting: While surgery for pulmonary tuberculosis (PTB) is considered an important adjunct for specific cases, including drug-resistant tuberculosis, operational evidence on its feasibility and effectiveness is limited. Objective: To describe surgical outcomes and programmatic challenges of providing surgery for PTB in Mumbai, India. Design: A descriptive study of routinely collected data of surgical interventions for PTB from 2010 to 2014 in two Mumbai hospitals, one public, one private. Results: Of 85 patients, 5 (6%) died and 17 (20%) had complications, with wound infection being the most frequent. Repeat operation was required in 12 (14%) patients. Most procedures were performed on an emergency basis, and eligibility was established late in the course of treatment. Median time from admission to surgery was 51 days. Drug susceptibility test (DST) patterns and final treatment outcomes were not systematically collected. Conclusion: In a high-burden setting such as Mumbai, important data on surgery for PTB were surprisingly limited in both the private and public sectors. Eligibility for surgery was established late, culture and DST were not systematically offered, the interval between admission and surgery was long and TB outcomes were not known. Systematic data collection would allow for proper evaluation of surgery as adjunctive therapy for all forms of TB under programmatic conditions.

Contexte : La chirurgie de la tuberculose pulmonaire (TBP) est considérée comme un adjuvant important dans des cas spécifiques, notamment celui de la TB pharmacorésistante ; les preuves opérationnelles de sa faisabilité et de son efficacité sont cependant limitées.Objectif : Décrire les résultats de la chirurgie et les défis programmatiques liés à l'offre de chirurgie à Mumbai, Inde.Schéma : Une étude descriptive de données recueillies en routine relatives aux interventions chirurgicales de TBP de 2010 à 2014 dans deux hôpitaux de Mumbai (un public, un privé).Résultats : Sur 85 patients, 5 (6%) sont décédés, 17 (20%) ont eu des complications, dont la plus fréquente était une infection de la plaie. Une deuxième intervention a été nécessaire dans 12 cas (14%). La majorité des procédures a été réalisée en urgence et l'éligibilité a été établie tardivement au cours du traitement. Le délai médian de l'admission à la chirurgie a été de 51 jours. Les profils de résistance de la TB et le résultat final du traitement n'ont pas été recueillis de façon systématique.Conclusion : Dans un contexte lourdement touché comme Mumbai, des données importantes relatives à la chirurgie de la TBP ont été étonnamment limitées à la fois dans le secteur privé et public. L'éligibilité à la chirurgie a été établie tardivement, la culture et le test de pharmacosensibilité n'ont pas été systématiquement proposés, l'intervalle entre l'admission et la chirurgie a été long et les résultats en matière de TB n'ont pas été notés. Un recueil systématique des données permettrait une évaluation correcte de la chirurgie comme traitement adjuvant de toutes les formes de TB dans des conditions de programme.

Marco de referencia: El tratamiento quirúrgico se considera un complemento importante en el manejo de casos específicos de tuberculosis pulmonar (TBP), como la TB farmacorresistente; sin embargo, las pruebas operativas de su factibilidad y eficacia son escasas.Objetivo: Describir los desenlaces quirúrgicos y las dificultades programáticas de la prestación de opciones quirúrgicas a los casos de TBP en Bombay, en la India.Método: Fue este un estudio descriptivo de los datos recogidos de manera sistemática sobre las intervenciones quirúrgicas por TBP, realizadas del 2010 al 2014 en dos hospitales de Bombay (uno del sector público y otro del sector privado).Resultados: De los 85 pacientes tratados, cinco fallecieron (6%), 17 presentaron complicaciones (20%), de las cuales la infección de la herida fue la más frecuente. Fue necesaria una segunda intervención en 12 pacientes (14%). La mayoría de los procedimientos tuvieron lugar en un contexto de urgencia y los criterios de selección se analizaron tarde en el curso del tratamiento. La mediana del tiempo entre la hospitalización y la cirugía fue 51 días. El tipo de resistencia de la TB y los desenlaces terapéuticos no se registraron de manera sistemática.Conclusión: En un entorno con alta carga de morbilidad por TB como Bombay, los datos importantes sobre la cirugía por TBP son sorprendentemente escasos en el sector público y también en el sector privado de atención. Los criterios de selección para la cirugía se analizan tarde, no se ofrece de manera sistemática el cultivo y las pruebas de sensibilidad a los medicamentos, el intervalo entre la hospitalización y el procedimiento es prolongado y se desconocen los desenlaces clínicos de la tuberculosis. La recogida sistemática de datos facilitaría una evaluación adecuada de la cirugía como tratamiento complementario en todas las formas de TB en un contexto programático.

Developing trends in the intestinal transplant waitlist.

The United Network for Organ Sharing database was examined for trends in the intestinal transplant (ITx) waitlist from 1993 to 2012, dividing into listings for isolated ITx versus liver-intestine transplant (L-ITx). Registrants added to the waitlist increased from 59/year in 1993 to 317/year in 2006, then declined to 124/year in 2012; Spline modeling showed a significant change in the trend in 2006, p < 0.001. The largest group of registrants, <1 year of age, determined the trend for the entire population; other pediatric age groups remained stable, adult registrants increased until 2012. The largest proportion of new registrants were for L-ITx, compared to isolated ITx; the change in the trend in 2006 for L-ITx was highly significant, p < 0.001, but not isolated ITx, p = 0.270. New registrants for L-ITx, <1 year of age, had the greatest increase and decrease. New registrants for isolated ITx remained constant in all pediatric age groups. Waitlist mortality increased to a peak around 2002, highest for L-ITx, in patients <1 year of age and adults. Deaths among all pediatric age groups awaiting L-ITx have decreased; adult L-ITx deaths have dropped less dramatically. Improved care of infants with intestinal failure has led to reduced referrals for L-ITx.

ICON 2013: practical consensus recommendations for hormone receptor-positive Her2-negative advanced or metastatic breastcancer.

The management of hormone receptor-positive Her2-negative breast cancer patients with advanced or metastatic disease is a common problem in India and other countries in this region. This expert group used data from published literature, practical experience, and opinion of a large group of academic oncologists, to arrive at practical consensus recommendations for use by the community oncologists.

Isolated peritoneal donor-related plasmacytoma 3 years after liver transplantation: a case report.

Organ transplantation carries a risk of disease transmission from donor to recipient, primarily infection or malignancy. Although donors are thoroughly screened, donor-related malignancies are reported to occur in 0.01% of solid organ transplants. Plasma cell neoplasm, to the best of our knowledge, has not been reported as a donor-transmitted malignancy in liver transplantation. We describe a liver transplant from a donor with unrecognized plasmacytoma requiring retransplantation. Three years after the first transplant a single peritoneal mass was detected on surveillance imaging and radically excised; HLA phenotyping confirmed the mass to be an isolated extra-medullary plasmacytoma of chimeric donor and recipient origin.

A phase 3, randomized, double-blind study of single-dose fosaprepitant for prevention of cisplatin-induced nausea and vomiting: results of an Indian population subanalysis.

CONTEXT: Currently, there is limited data on the prevention of chemotherapy-induced nausea and vomiting (CINV) in Indian patients. AIMS: This post hoc study assessed the efficacy and safety of fosaprepitant compared with aprepitant for prevention of CINV in the Indian population. A subgroup analysis was performed from data collected in a phase 3 study of intravenous (IV) fosaprepitant or oral aprepitant, plus the 5-HT 3 antagonist ondansetron and the corticosteroid dexamethasone, in cisplatin-naοve patients with solid malignancies. MATERIALS AND METHODS: Patients scheduled to receive cisplatin (≥70 mg/m 2 ) were administered a single IV dose of fosaprepitant dimeglumine (150 mg) on day 1 or a 3-day dosing regimen of oral aprepitant (day 1:125 mg, days 2 and 3:80 mg) with standard doses of ondansetron and dexamethasone. Patients recorded nausea and/or vomiting episodes and their use of rescue medication and were monitored for adverse events (AEs) and tolerability. STATISTICAL ANALYSIS USED: Differences in response rates between fosaprepitant and aprepitant were calculated using the Miettinen and Nurminen method. RESULTS: In the Indian subpopulation (n = 372), efficacy was similar for patients in both the fosaprepitant or aprepitant groups; complete response in the overall, acute, and delayed phases and no vomiting in all phases were approximately 4 percentage points higher in the fosaprepitant group compared with the aprepitant group. Fosaprepitant was generally well-tolerated; common AEs were similar to oral aprepitant. CONCLUSIONS: IV fosaprepitant is as safe and effective as oral aprepitant in the Indian subpopulation and offers an alternative to the oral formulation.

Survival of cystic fibrosis patients undergoing liver and liver-lung transplantations.

BACKGROUND: We evaluated the outcome of combined liver-lung transplantation (L-LTx) in cystic fibrosis (CF) patients with liver transplantation (LTx) for CF liver disease. METHODS: The United Network for Organ Sharing (UNOS) data were analyzed from October 1987 to August 2009. RESULTS: Of 294 patients (210 children), 265 (90.1%) received an LTx and 29, an L-LTx. Patient survival was: adult LTx, 80%, 74%, and 67% at 1, 3, and 5 years, and L-LTx, 72%, 61.4%, and 61.4% (P = .7); pediatric LTx, 85%, 82%, and 74% at 1, 3, and 5 years, and L-LTx, 83%, 83%, and 83% (P = .4). Pediatric patients had a slight survival advantage over adults for LTx (P = .08). Graft survival, not affected by immunosuppression regimens, was similar to patient survival. CONCLUSIONS: The outcome of L-LTx appears similar to LTx in CF providing support for the prospect of a combined transplant.

Outcome of intestinal transplants for patients with Crohn's disease.

BACKGROUND: The pathophysiology of Crohn's disease (CD) is related to immune dysregulation making it unique among indications for intestinal transplants (ITx). We examined whether outcomes of ITx for CD are any worse than the overall ITx population. METHODS: United Network for Organ Sharing Standard Transplant Analysis and Research files were analyzed. Adult ITx recipients from 1987 to 2009 were included. RESULTS: Of 86 primary ITx for CD, 61 (70%) had isolated ITx and 25 (30%) had liver-ITx (L-ITx). The 1-, 3-, and 5-year patient survival for isolated ITx was 85%, 67%, and 54%; for L-ITx, 63%, 47%, and 41% (P = .04). The graft survival at 1, 3, and 5 years was 85%, 55%, and 45% for isolated ITx recipients and 63%, 47%, and 41% for L-ITx recipients (Wilcoxon's test, P = .04). Patient and graft survival was better in era 2 (January 2001 through August 2009) than in era 1 (October 1987 through December 2000). In the regression analysis of long-term outcome of adults undergoing ITx, recipient age > 40 years and hospitalization prior to transplantation were negative predictors of outcome. CONCLUSION: Patient and graft survival for CD patients is not inferior to other indications for ITx.

Temperature diagnostics of ECR plasma by measurement of electron bremsstrahlung.

The x-ray bremsstrahlung spectrum emitted by the electron population in a 14.5 GHz ECR plasma source has been measured using a NaI(Tl) detector, and hence the electron temperature of the higher energy electron population in the plasma has been determined. The x-ray spectra for Ne and Ar gases have been systematically studied as a function of inlet gas pressure from 7 × 10(-7) mbar to 7 × 10(-5) mbar and for input microwave power ∼1 W to ∼300 W. At the highest input power and optimum pressure conditions, the end point bremsstrahlung energies are seen to reach ∼700 keV. The estimated electron temperatures (T(e)) were found to be in the range 20 keV-80 keV. The T(e) is found to be peaking at a pressure of 1 × 10(-5) mbar for both gases. The T(e) is seen to increase with increasing input power in the intermediate power region, i.e., between 100 and 200 W, but shows different behaviour for different gases in the low and high power regions. Both gases show very weak dependence of electron temperature on inlet gas pressure, but the trends in each gas are different.

Age-based disparity in outcomes of intestinal transplants in pediatric patients.

Outcomes of intestinal transplants (ITx; n = 977) for pediatric patients are examined using the United Network for Organ Sharing data from 1987 to 2009. Recipients were divided into four age groups: (1) <2 years of age (n = 569), (2) 2-6 years (n = 219), (3) 6-12 years (n = 121) and (4) 12-18 years (n = 68). Of 977 ITx, 287 (29.4%) were isolated ITx and 690 (70.6%) were liver and ITx (L-ITx). Patient survival for isolated ITx at 1, 3 and 5 years, 85.3%, 71.3% and 65.0%, respectively, was significantly better than L-ITx, 68.4%, 57.0% and 51.4%, respectively, (p = 0.0001); this was true for all age groups, except for patients <2 years of age. The difference in graft survival between isolated ITx and L-ITx was significant at 1 and 3 years (Wilcoxon test, p = 0.0012). After attrition analysis of graft survival of patients who survived past first year, 3 and 5 years, graft survival for L-ITx patient was significantly better than those for isolated ITx. Isolated ITx should be considered early before the onset of liver disease in children >2 with intestinal failure but is not advantageous in patients <2 years.

An evaluation of the effect of atorvastatin on memory and psychomotor functions in hypertensive patients.

BACKGROUND: The effect of statins on memory and psychomotor function has been controversial and needs further evaluation. AIMS: To evaluate the effect of atorvastatin on memory and psychomotor functions in hypertensive patients treated with enalapril or amlodipine. SETTINGS AND DESIGN: Prospective, comparative, non-randomized, before-after, open-label clinical study conducted at a tertiary care hospital in Western India. MATERIALS AND METHODS: Memory was evaluated with PGI (Post Graduate Institute, Chandigarh) Memory Scale, while psychomotor functions were evaluated with Digit Letter Substitution test, Six Letter Cancellation test, and Finger Tapping test at baseline, 1 week, 1 month, and 3 months of starting atorvastatin in 74 hypertensive patients who were prescribed either enalapril or amlodipine with or without atorvastatin 10 mg/day. Scores obtained in patients receiving enalapril or amlodipine were compared with those receiving these drugs along with atorvastatin. Memory and psychomotor functions of 12 healthy volunteers were also evaluated and compared with those of the patients at respective time periods. STATISTICAL ANALYSIS: Student's t test, Wilcoxon Signed Rank test, and Mann Whitney U test were used to compare the pre- and post-treatment scores of memory and psychomotor functions in various groups. Statistical significance was considered at P<0.05. RESULTS: A statistically significant improvement in scores of memory and psychomotor functions was observed in both healthy volunteers (P=0.009 and P=0.016) and hypertensive patients (P=0.008 and P=0.031) throughout the study period. Memory and psychomotor function in hypertensive patients remained significantly inferior to those of healthy volunteers (P=0.01 and P=0.018). There was no significant difference in the scores of memory and psychomotor functions between patients receiving atorvastatin and those not receiving this drug. CONCLUSION: Atorvastatin, at 10 mg/day dose, does not have any significant effect on memory and psychomotor functions in hypertensive patients treated with enalapril or amlodipine.

Autotransplantation of solitary kidney with renal artery aneurysm treated with laparoscopic nephrectomy and ex vivo repair: a case report.

INTRODUCTION: Renal artery aneurysms (RAA) are extremely rare clinical entities with associated morbidities including hypertension and rupture. Although most RAA can be treated with in vivo repair or endovascular techniques, these may not be possible in patients with complex RAA beyond the renal artery bifurcation. We report a case of RAA in a patient with a solitary kidney that we treated successfully by extracorporeal repair and autotransplantation and the 2-years follow-up. CASE REPORT: A 64-year-old woman with a history of right nephrectomy for renal cell carcinoma presented with RAA found on routine computed tomography (CT). Preoperative workup demonstrated a 2.2 × 2.1 × 3-cm aneurysm in the distal left renal artery that was not amendable to in vivo or endovascular repair. The patient underwent a laparoscopic-assisted left nephrectomy, ex vivo renal artery aneurysm repair, and autotransplantation. She did well postoperatively and in clinic follow-up was found to have a creatinine of 1.2 mg/dL at the end of 2 years and stable blood pressure control. DISCUSSION: This patient with RAA in her solitary kidney was successfully treated with laparoscopic-assisted nephrectomy, ex vivo repair, and autotransplantation. Her creatinine was stable postoperatively despite absence of a second kidney.

DNA interactions and promotion in antibacterial activities of ciprofloxacin drug due to formation of mixed-ligand complexes of oxovanadium(IV).

Mixed-ligand complexes of oxovanadium(IV) of the type [VOAL]*2H(2)O [where A = ciprofloxacin and L = uninegative bidentate ligands] have been synthesized and characterized using infrared spectra, electronic spectra, magnetic measurements, elemental analyses, thermal investigation, and mass spectroscopy. Here, we tried to increase an antibacterial activity of ciprofloxacin drug due to formation of mixed-ligand complexes. The complexes were found to be more potent compare to some standard drugs, ligands and metal salt against selective gram(+ve) and gram(-ve) organisms. Binding of the complexes with DNA have been investigated by spectroscopic absorption titration and viscometric techniques. The mixed-ligand complexes show good binding ability. The cleavage efficacy has been determined using gel electrophoresis method and complexes were found to be more active compared to parental ligands and metal salt.

Complex arterial reconstruction in multivisceral transplantation.

We report the case of a successful multivisceral transplant in which both donor and recipient presented aberrant anatomy of the celiac-mesenteric axis requiring five separate arterial anastomoses to reconstruct the blood inflow to the graft.

Granular cell tumour of the bile duct mimicking distal cholangiocarcinoma: one case report and review of the literature.

Granular cell tumours (Gcts) are rare and most commonly located in the oral cavity, skin or subcutaneous tissue. The occurrence of this tumour in the biliary tract is rare. A 26 year old African man presented with abdominal pain and obstructive jaundice was found to have a localised distal bile stricture suggestive of cholangiocarcinoma which was resected by pylorus preserving partial pancreaticoduodenectomy. Histology revealed a gct of the intrapancreatic portion of the distal bile duct. GCT of the biliary tract are important as they are benign and can mimic bile duct cancers. A review of the 77 reported cases of Gcts of the biliary tract showed that the common bile duct is the most common site of occurrence (n=35). Only 2 cases in literature have been reported to be diagnosed preoperatively. Since there are no characteristic radiological features, the GCTs are difficult to differentiate from cholangiocarcinoma, sclerosing cholangitis or other benign tumors.