Evaluation of outpatient prescription patterns of COVID-19 drugs in Iran: comparison of real practice with local therapeutic recommendations.

BACKGROUND: A comprehensive guideline named "Diagnostic Therapeutic Flow Chart for Covid-19″ (DTFC) was released by the Scientific Committee of Covid-19 of Iran's Ministry of Health and Medical Education and regularly was updated. The aim of this study was to compare the prescription pattern of drug treatment in outpatient Covid-19 patients with the DTFC. METHODS: A cross-sectional study was conducted on the prescription pattern of drugs given to outpatients with a diagnosis of Covid-19, in Isfahan City from June to September 2021 (concurrent with the fifth peak of Covid-19 in Iran) taking into account the recommendations of the 9th version of DTFC (December 2020). A total of 8250 prescriptions were retrieved from the Public Health Department of Isfahan City. RESULTS: Famotidine 20, 40 mg tablets (N = 936 patients) was the most prescribed drug followed by dexamethasone ampule (N = 588), prednisolone 5, 50 mg tablets (N = 478), azithromycin 250, 500 mg capsules (N = 452), diphenhydramine syrup (N = 362), vitamin D3 soft gel 50,000 Iu (N = 526), naproxen 250, 500 mg tablets (N = 266) and favipiravir 200 mg tablet (N = 191). The following drugs were administered against the recommendation of the DTFC-9: azithromycin, favipiravir, remdesivir, cetirizine, corticosteroids, vitamin C, vitamin B12, multivitamins, proton pump inhibitors (e.g., omperazole, anticoagulants (rivaroxaban,….), aspirin and ivermectin. Administration of analgesics, famotidine, hydroxychloroquine, vitamin D3, diphenhydramine and statins were in concordance with the DTFC-9. CONCLUSION: In this study, we showed frequent use of drugs with unproven efficacy in outpatient cases of Covid-19 mostly attributed to corticosteroids and antibiotics use. Our research highlights the discrepancy between recommendations for care and clinical practice and the need for strategy to bridge gaps in evidence-based informed decision-making.

An investigation on patient attitudes toward package inserts and their accessibility in Iran.

BACKGROUND: Package inserts (PIs) can be a source of information for patients, especially when clinicians do not provide adequate consultations to the patients. Therefore, for the first time, we investigated the state of PIs in Iran and evaluated patients' attitude toward PI. MATERIALS AND METHODS: In this descriptive study, conducted in a major teaching pharmacy in Isfahan, Iran, in 2016, 100 patients who presented a prescription were interviewed randomly and all medications in their medication bags were examined. The main outcome measures were whether or not the dispensed medications were accompanied by a PI and the behavior of patients in reading these PIs. RESULTS: From the 237 medication items investigated, 129 (54.4%) were dispensed with a PI. Eighty-four percent of patients read the PIs and only 19% stated reading a non-Farsi PI. The level of education was the only significant factor related to reading the PI (P = 0.02). Reading the side effects was the main reason for reading the PI (64%). PIs were considered useful by 83% while 25% kept PIs as a source of drug information. Experience of fear to take the medication after reading the PI was reported by 47%. CONCLUSION: About half of medications were dispensed along with the PI. Although the majority of patients report reading the PIs and consider them useful, confidence in using the medicine may be diminished after reading the PI. Patients with higher education read the PIs the most.

Comprehensibility of selected USP pictograms by illiterate and literate Farsi speakers: The first experience in Iran - Part I.

BACKGROUND: Good understanding of medication instructions is paramount to a good pharmaceutical care. The aim of our study was to examine the understandability of the selected three most applicable pictograms by participants and their recall after educational mini sessions. MATERIALS AND METHODS: First, nine experienced pharmacists selected the three most potentially applicable pictograms. Pictograms A to C were determined, respectively, "A-take medication with food," "B-medication may cause drowsiness," and "C-take medication before sleep." In the second phase, we measured the comprehensibility of pictograms by three groups of participants (sample of 358): highly educated participants of two major universities of Isfahan (Groups 1 and 2), low-literate and illiterate individuals (Groups 3 and 4), and the rest were participants interviewed in three teaching pharmacies affiliated to the Isfahan School of Pharmacy (Group 5). The American National Standards Institute (ANSI) and International Organization for Standardization (ISO) were used to compare the comprehensibility of pictograms. Furthermore, five qualitative questions were asked about the impact of pictograms on several parameters. RESULTS: In the pre-follow-up period, only Group 1 (75%) understood pictogram A while pictogram B did not pass the ANSI and ISO thresholds for acceptability in none of the groups. In the pre-follow-up period, Groups 1 and 2 surpassed the ANSI threshold and Group 5 passed the ISO limit for C. In the post-follow-up period, C passed the ISO limit in Group 3. Regarding the qualitative questions, 84.1% believed that pictograms had positive impact on the correct use of medications and timing of administration. CONCLUSION: The groups with high level of literacy interpreted the pictograms better than those with lower levels of literacy.

Comprehensibility of selected United States Pharmacopeia pictograms by illiterate and literate Farsi speakers: The first experience in Iran - Part II.

BACKGROUND: Conveying information to patients on how to use medications at the dispensing sessions and retention of this information by the patients is essential to the good pharmaceutical care. The aim of our study was to examine the comprehensibility of the selected three potentially usable pictograms by five groups of subjects who had different levels of literacy in both before and after mini educational sessions. MATERIALS AND METHODS: Nine experienced pharmacists selected three potentially usable pictograms in Isfahan pharmacies: Pictograms D through F representing respectively: "do not take medication during pregnancy," "keep medication in the refrigerator," and "take medication with plenty of water." Then, graduate students of two major universities (Groups 1 and 2), low-literate and illiterate individuals (Groups 3 and 4), and walk - in patients in the pharmacies affiliated to the Isfahan School of Pharmacy (Group 5) were asked about the comprehensibility of these pictograms before and after mini-education sessions. The American National Standard Institute and International Organization for Standardization standards were used for comparisons. RESULTS: In the pre-follow-up period, D and E pictograms were most understandable (87.4%, 87.2%). In the post-follow-up, E and D pictograms were understood most (98.0%, 95.3%), followed by F (92.9%). Among the improvements measured in post-follow-up, pictogram F showed the biggest improvement (P = 0.0). CONCLUSION: Pictograms depicting the use of medications during pregnancy (D) and storing medication in the refrigerator (E) was easier to understand by our study population. The groups with the high level of literacy interpreted the pictograms better than those with lower levels of literacy.

Adherence to statin therapy in patients with type 2 diabetes: An important dilemma.

BACKGROUND: Despite the importance of patients' adherence to their drug treatments for achieving desired therapeutic goals and the proven role 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) for the health status of patients with cardiovascular diseases, there is not enough information regarding diabetic patients' adherence to statin therapy in developing countries. In this clinical study we aimed to assess the adherence of diabetes type 2 patients to statin therapy in a research based community clinic in Iran. MATERIALS AND METHODS: In this prospective clinical study which was done at Isfahan Endocrinology and Metabolism Research Center, 204 diabetic type 2 patients under treatment with statin were interviewed twice and their demographic data (age, gender, body mass index, education), statin information (type, dose) and their serum lipid profile were recorded. Three months after the initial visits, patients were assessed using pill counting method and according to patients' self-reporting and also assessed low-density lipoprotein (LDL) cholesterol goal attainment <100 mg/dl. RESULTS: Adherence rate was 79.7% and 69% according to pill counting and self-reporting among study population. Moreover, 68.4% of patients achieved their LDL cholesterol goal of <100 mg/dl and adherent patients reached therapeutic goal significantly more than those who were considered non-adherence to statin therapy (P < 0.01). CONCLUSION: Adherence to statin therapy, as reflected by pill count method, is significantly related to LDL cholesterol goal achievement in patients with diabetes and dyslipidemia. Pill count method can be used to identify patients who are nonadherent to statin therapy and at high risk for failure to attain LDL cholesterol goals.

Taking stock of medication wastage: Unused medications in US households.

BACKGROUND: Despite the potential deleterious impact on patient safety, environmental safety and health care expenditures, the extent of unused prescription medications in US households and reasons for nonuse remain unknown. OBJECTIVE: To estimate the extent, type and cost of unused medications and the reasons for their nonuse among US households. METHODS: A cross-sectional, observational two-phased study was conducted using a convenience sample in Southern California. A web-based survey (Phase I, n = 238) at one health sciences institution and paper-based survey (Phase II, n = 68) at planned drug take-back events at three community pharmacies were conducted. The extent, type, and cost of unused medications and the reasons for their nonuse were collected. RESULTS: Approximately 2 of 3 prescription medications were reported unused; disease/condition improved (42.4%), forgetfulness (5.8%) and side effects (6.5%) were reasons cited for their nonuse. "Throwing medications in the trash" was found being the common method of disposal (63%). In phase I, pain medications (23.3%) and antibiotics (18%) were most commonly reported as unused, whereas in Phase II, 17% of medications for chronic conditions (hypertension, diabetes, cholesterol, heart disease) and 8.3% for mental health problems were commonly reported as unused. Phase II participants indicated pharmacy as a preferred location for drug disposal. The total estimated cost for unused medications was approximately $59,264.20 (average retail Rx price) to $152,014.89 (AWP) from both phases, borne largely by private health insurance. When extrapolated to a national level, it was approximately $2.4B for elderly taking five prescription medications to $5.4B for the 52% of US adults who take one prescription medication daily. CONCLUSION: Two out of three dispensed medications were unused, with national projected costs ranging from $2.4B to $5.4B. This wastage raises concerns about adherence, cost and safety; additionally, it points to the need for public awareness and policy to reduce wastage. Pharmacists can play an important role by educating patients both on appropriate medication use and disposal.

Medication error detection in two major teaching hospitals: What are the types of errors?

BACKGROUND: Increasing number of reports on medication errors and relevant subsequent damages, especially in medical centers has become a growing concern for patient safety in recent decades. Patient safety and in particular, medication safety is a major concern and challenge for health care professionals around the world. Our prospective study was designed to detect prescribing, transcribing, dispensing, and administering medication errors in two major university hospitals. MATERIALS AND METHODS: After choosing 20 similar hospital wards in two large teaching hospitals in the city of Isfahan, Iran, the sequence was randomly selected. Diagrams for drug distribution were drawn by the help of pharmacy directors. Direct observation technique was chosen as the method for detecting the errors. A total of 50 doses were studied in each ward to detect prescribing, transcribing and administering errors in each ward. The dispensing error was studied on 1000 doses dispensed in each hospital pharmacy. RESULTS: A total of 8162 number of doses of medications were studied during the four stages, of which 8000 were complete data to be analyzed. 73% of prescribing orders were incomplete and did not have all six parameters (name, dosage form, dose and measuring unit, administration route, and intervals of administration). We found 15% transcribing errors. One-third of administration of medications on average was erroneous in both hospitals. Dispensing errors ranged between 1.4% and 2.2%. CONCLUSION: Although prescribing and administrating compromise most of the medication errors, improvements are needed in all four stages with regard to medication errors. Clear guidelines must be written and executed in both hospitals to reduce the incidence of medication errors.

The efficacy of a synbiotic containing Bacillus Coagulans in treatment of irritable bowel syndrome: a randomized placebo-controlled trial.

AIM: We aimed to evaluate the efficacy of a synbiotic containing Bacillus Coagulans in treatment of IBS. BACKGROUND: Some studies have shown the efficacy of probiotics in the treatment of irritable bowel syndrome (IBS). PATIENTS AND METHODS: Adult IBS patients (n=85) were randomized to receive a synbiotic containing Bacillus Coagulans or placebo for 12 weeks. Frequency of IBS symptoms including abdominal pain (scored 1 to 7), and diarrhea and constipation (scored 1 to 5) was evaluated before and after the intervention and then after nine months follow-up. RESULTS: Twenty-three patients in the synbiotic group and 33 patients in the placebo group completed the study (age = 39.8±12.7 years, 78.6% female). After treatment, more reduction in abdominal pain frequency was observed with synbiotic compared with placebo (score reduction 4.2±1.8 vs. 1.9±1.5, P<0.001). Diarrhea frequency was decreased in the synbiotic group, but not in the placebo group (score reduction 1.9±1.2 vs. 0.0±0.5, P<0.001). Decrease in constipation frequency was the same between the two groups (score reduction 0.9±1.2 vs. 0.8±1.1, P=0.561). After nine months follow-up, abdominal pain frequency was decreased (P=0.016), constipation frequency was increased (P<0.001), and diarrhea frequency remained unchanged in the synbiotic group (P=1.000). In the placebo group, abdominal pain frequency was increased (P<0.001), constipation frequency remained unchanged (P=0.553), and diarrhea frequency was increased (P<0.001). CONCLUSION: Bacillus Coagulans improves abdominal pain and diarrhea in IBS patients. Further studies on a larger sample of patients are warranted.

Clinical pharmacists and basic scientists: do patients and physicians need this collaboration?

The aim of this commentary is to highlight the vital and beneficial role that pharmacists and inter-professional collaborative practice play in patient care from the economic, humanistic, efficacy, and safety perspectives. Pharmacists, particularly those with an in-depth knowledge of the basic pharmaceutical sciences, recognize the need to collaborate with other healthcare professions and understand the importance of combining all of the components of their education into a well-rounded, comprehensive clinical practice. Indeed, there is ample evidence in the literature that pharmacists equipped with a solid foundation in basic pharmaceutical science, coupled with clinical knowledge and skills can, more effectively, contribute to pharmacotherapy and patient care, particularly in a collaborative practice setting. Consequently, the burden on pharmacy education is to maintain its emphasis on the basic sciences while promoting the application of these sciences in clinical practice, in the Pharm. D. curriculum. This is a goal that can also be achieved through inter-professional educational approaches.

Cost-effectiveness analysis of linezolid, daptomycin, and vancomycin in methicillin-resistant Staphylococcus aureus: complicated skin and skin structure infection using Bayesian methods for evidence synthesis.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) complicated skin and skin structure infection (cSSSI) is a prominent infection encountered in hospital and outpatient settings that is associated with high resource use for the health-care system. OBJECTIVE: A decision analytic (DA) model was developed to evaluate the cost-effectiveness analysis (CEA) of linezolid, daptomycin, and vancomycin in MRSA cSSSI. METHODS: Bayesian methods for evidence synthesis were used to generate efficacy and safety parameters for a DA model using published clinical trials. CEA was done from the US health-care perspective. Efficacy was defined as a successfully treated patient at the test of cure without any adverse reaction. Primary outcome was the incremental cost-effectiveness ratio between linezolid and vancomycin, daptomycin and vancomycin, and linezolid and daptomycin in MRSA cSSSI. Univariate and probabilistic sensitivity analyses were performed to test the robustness of the model. RESULTS: The total direct costs of linezolid, daptomycin, and vancomycin were $18,057, $20,698, and $23,671, respectively. The cost-effectiveness ratios for linezolid, daptomycin, and vancomycin were $37,604, $44,086, and $52,663 per successfully treated patient, respectively. Linezolid and daptomycin were dominant strategies compared to vancomycin. However, linezolid was dominant when compared to daptomycin. The model was sensitive to the duration of daptomycin and linezolid treatment. CONCLUSION: Linezolid and daptomycin are potentially cost-effective based on the assumptions of the DA model; however, linezolid appears to be more cost-effective compared to daptomycin and vancomycin for MRSA cSSSIs.

Antiepileptic drug use during pregnancy: perinatal outcomes.

PURPOSE: This study was undertaken to (1) measure the frequency of AED monotherapy or polytherapy during pregnancy and AED discontinuation prior to pregnancy in a cohort of women with treated epilepsy; and (2) describe the frequency of major congenital malformations according to maternal use of AED during pregnancy. METHODS: A cohort of epileptic pregnant women was identified within the Quebec Pregnancy Registry and was divided into three groups based on maternal AED use during pregnancy: AED monotherapy, AED polytherapy and no AED use. RESULTS: Of the 349 pregnancies meeting eligibility criteria, 79.6% were exposed to AED monotherapy and 5.8% to polytherapy during pregnancy; 14.6% discontinued AED prior to pregnancy. The most commonly used AEDs were carbamazepine (29.9%) and valproic acid (19.7%); the most common AED polytherapy combination was carbamazepine combined with clobazam (2.5%). Of 111 deliveries in the group of women on monotherapy during pregnancy, 9.9% (n=11) were born with major congenital malformations; in the group of women treated with polytherapy, 19.0% (n=8 over 42) of babies had major congenital malformations compared to 20.0% in women who discontinued AEDs prior to pregnancy. CONCLUSION: This study demonstrates that the majority of women suffering from epilepsy were treated with monotherapy rather than polytherapy during pregnancy. While most used other agents, an important number of women continued to use valproate in pregnancy despite the long standing evidence of its teratogenicity and increasing evidence of its neuro-toxicity to the fetus.

Effect of pharmacist-led patient education on glycemic control of type 2 diabetics: a randomized controlled trial.

BACKGROUND: This study was conducted to evaluate the effect of a clinical pharmacist-led patient education program for type 2 diabetic patients at Isfahan Endocrine & Metabolism Research Center (IEMRC) from April 2008 to January 2009. METHODS: In a randomized controlled clinical trial, a total of 172 patients with uncontrolled type 2 diabetes were selected and randomly allocated into control and intervention groups. After taking informed written consent, the intervention group received an educational program about oral anti-hyperglycemic medications, adherence, diabetes dairy log and pill box usage. Patient's glycemic control in the intervention group was followed for three months through either telephone or face to face interviews with the pharmacist. Fasting blood glucose and HbA1c were measured at the start and end of the pharmacistled drug education program for both intervention and control groups. RESULTS: After a three months follow-up, mean fasting blood glucose and HbA1c of the patients in the intervention group decreased significantly compared to control group (p < 0.001). CONCLUSIONS: This study demonstrates an improvement in diabetes management of type 2 diabetics by involving a pharmacist in the multidisciplinary teams in the outpatient clinics. The results suggest the benefits of adding adherence education to the diabetic education programs.

Design and test of preference for a new prescription medication label.

OBJECTIVE: This study measured preference for newly designed prescription labels in comparison with two existing labels from the perspective of patients, pharmacists and physicians, based on three parameters: content, convenience and cosmetic appearance. SETTING: Participants were interviewed at pharmacies (patients) and at professional meetings (physicians and pharmacists) regarding their preference for the labels. METHOD: Two new labels (A and B) were designed using Publisher® Software version 2007 based on literature and results from our previous study. New features focusing on content, convenience and cosmetic appearance (3Cs) included a time table for medication administration, indication of medication and warnings, on a redesigned label. These labels were initially tested on a small sample and then revised. A survey instrument was developed to compare currently used labels and modified labels A and B, on the 3Cs. MAIN OUTCOME MEASURE: The preference of three groups of stakeholders (patients, pharmacists and physicians) were measured for newly designed labels in comparison with two existing labels. RESULTS: Complete data obtained with 444 patients, 115 pharmacists and 69 physicians indicated that the median age range of participants was between 51 and 64 years. The patient and physician samples consisted of a higher percentage of women. Pharmacists working in chain pharmacies and family practitioners comprised majority of our sample in professional groups. Mean years of experience in pharmacy and physician groups was 18.2 and 26.8 years, respectively. Most patients (94.4%) in the sample had at least high school education. Majority of patients (82.8%) preferred new labels over existing ones and 55.2% preferred label B on all three parameters. Close to two thirds of pharmacists (76.4%) and physicians (75.3%) preferred new labels with 55.3 and 57.9% preferring label B, respectively. Participants cited all the added modifications as reasons for their preference. CONCLUSION: New prescription labels were favored over existing labels by all stakeholders, for content, convenience and cosmetic appearance. The results may help in making labels more user-friendly and addressing problem areas in labels.

Access to multilingual prescription labels and verbal translation services in California.

BACKGROUND: The number of patients with limited English proficiency is on the rise in the United States, and conveying medication information to these individuals in an effective manner is crucial to improve adherence and reduce medication errors. OBJECTIVES: To examine (1) self-reported capability for and actual provision of prescription labels or verbal medication information in languages other than English by California pharmacies and (2) characteristics of pharmacies that provide such services. METHODS: In this cross-sectional, observational study, pharmacists in charge at 552 randomly selected retail pharmacies throughout California (US) were interviewed by phone. The main outcome measures of the study were number of pharmacies that could and did provide multilingual labels (MLs) and/or offer medication information verbally in the patient's preferred language. Chi-square tests and multivariate logistic regression analysis were used to determine associations between availability of MLs and verbal translation services and the demographic characteristics of pharmacies. RESULTS: Approximately, 69% of the pharmacies surveyed could provide MLs, and 67.9% did provide MLs routinely on patient request. Verbal translation of labels or other medication information such as leaflets, pamphlets, and guides was offered to patients who requested it in 82.4% of pharmacies. Chain pharmacies reported a significantly higher capability to provide MLs than independent pharmacies (Adjusted odds ratio [AOR]=0.28; 95% confidence interval [CI]=0.19, 0.42; P<.0001). Pharmacies located in rural areas reported higher availability of MLs (AOR=5.02; 95% CI=2.00, 12.6; P<.001) than pharmacies in urban areas. Pharmacies with higher number of estimated limited English proficient (LEP) patients reported higher availability of MLs (AOR=1.03; 95% CI=1.02, 1.05; P<.0001) and verbal translations (AOR=1.07; 95% CI=1.03, 1.09; P<.0001). CONCLUSIONS: There exists an unfulfilled need for providing MLs and/or verbal translations to LEP patients. Pharmacists and health care providers can fill this need to ensure appropriate medication usage and adherence and consequently reduce medication errors in this population.

Adherence to glyburide and metformin and associated factors in type 2 diabetes in isfahan, iran.

The purpose of this study was to determine the adherence to oral hypoglycemic medications and associated factors in type 2 Diabetes Mellitus patients who were referred to the Isfahan Endocrinology and Metabolism Research Centre (IEMRC). Convenience sampling was used to enroll 248 patients with type 2 diabetes in a prospective study at IEMRC from January 2007 to January 2008. Patients had to be on a stable dose of oral hypoglycemic medications (glyburide and metformin) or for 3 months prior to the study and willing to participate in consultation sessions with a pharmacist. Pill count and self report methods were used to measure the adherence. Mean (SD) of patients studied was 56.6 (8.9) years and 62% were females. The mean (SD) duration of diabetes in the study patients was 10.8 (6.1) years and 81.9% of them were literate with basic education. Non-adherence rates to metformin and glyburide were recorded in 39.7% and 35.3% of the study population respectively. Lower HbA1C levels and higher education were associated with higher adherence rates. Forgetfulness, confusion, fasting, adverse effects, complexity of medication regimen and disruption of routines were most commonly reported causes of non adherence. Prevalence of adherence to these two medications did not differ significantly between pill count (62.3%) and self report (62.8%), (p >0.05). Adherence rates did not vary by pill count and self report significantly. It was concluded that good adherence to medications was associated with a lower HbA1C profile; so it seems that pill count is a useful method in the clinical practice to identify non-adherent patients. Further studies are needed to find out efficient interventions to improve the patient's adherence.

How do patients read, understand and use prescription labels? An exploratory study examining patient and pharmacist perspectives.

OBJECTIVES: The aim of the study was to investigate ease of reading, understanding and usefulness of prescription labels in a real-world setting from patients' and pharmacists' perspectives. METHODS: A prospective, cross-sectional, exploratory study was conducted by interviewing 179 patients and 40 pharmacists in selected community pharmacies. KEY FINDINGS: The average age of patients was 55 years, 65% were females, and 56.4% had a high-school education or more. Pharmacists' mean age was 40.4 years with 12.8 years of experience. Self-reported ease of reading and understanding was rated as very or somewhat easy by 97.8 and 97.2%, respectively. Most of the patients correctly read (91.6%) and interpreted (89.4%) the label. A majority (90.5%) of patients found the label somewhat or very useful. About half of the pharmacist sample believed patients had difficulty reading or understanding the labels. CONCLUSIONS: This study, conducted with a sample that approximated the US population in level of education, found that prescription labels were reported to be useful and easy to read and understand. These results deviated from previous studies that were conducted in specific populations. Current prescription labels are useful and easy to read and understand by those who have college or higher education but improvements may be needed for specific vulnerable populations.

Comparative evaluation of Glasgow Coma Score and gag reflex in predicting aspiration pneumonitis in acute poisoning.

PURPOSE: The purpose of the study was to assess the incidence of aspiration pneumonitis (AP) and its association with gag reflex and Glasgow Coma Score (GCS). MATERIALS AND METHODS: In a retrospective analysis study after prospective data collection, 155 poisoned patients with GCS less than or equal to 12 were evaluated. An assessment of GCS and the quality of gag reflex was made on arrival and recorded. Intubation status before gastrointestinal decontamination was noted. All patients were subsequently followed for developing of AP. RESULTS: The incidence of AP was 15.5%, with significant variance among patients with respect to the gag reflex, GCS, and the performance of intubation. A logistic regression model for predicting AP contained the following predictors: GCS (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.30-0.62), intubation (OR, 0.07; 95% CI, 0.01-0.49), organophosphate ingestion (OR, 1.39; 95% CI, 0.96-2.01), and gastric evacuation (OR, 4.29; 95% CI, 0.94-9.51). In patients with reduced gag reflex, variations in GCS were associated with AP (OR, 0.43; 95% CI, 0.20-0.90), whereas in patients with absent gag reflex, age was the most important predictor of AP (OR, 2.67; 95% CI, 0.99-7.22). CONCLUSIONS: A reduced GCS and a nonintubated trachea are associated with an increased incidence of AP.

Prescription and nonprescription drug use in isfahan, Iran: An observational, cross-sectional study.

BACKGROUND: In Iran, nonprescription (ie, over-the-counter [OTC]) and prescription- only drugs are available at pharmacies. Self-medication and self-prescription practices are widespread. OBJECTIVE: The aim of this study was to assess self-medication and self-prescription practices in Iran, with an emphasis on determining the extent to which prescription-only drugs are obtained without a prescription and dzaracterizing those who engage in this practice. METHODS: This observational, cross-sectional study was conducted at pharmacies in Isfahan, Iran, between August 2001 and March 2002. The pharmacies were randomly selected from clusters categorized by the number of prescriptions handled or claims submitted to a major insurance company. Drug requesters were categorized accordingly: those who requested drugs with a prescription and those who requested drugs without a prescription. Prescription-only and nonprescription drug items requested at pharmacies were identified and included in the analysis. Cluster sampling was used to determine sample size and also to ensure that the results were reflective of the population studied. In addition, questionnaires were completed by persons who were seeking drugs without a prescription. Observations were also carried out in each pharmacy. To ensure measurement reliability, we conducted a pilot study before the commencement of this study. We determined sample size based on a >90% power to detect change. RESULTS: Fifty pharmacies were selected for inclusion in the study. A total of 33,282 drug items were identified on prescriptions presented at the pharmacies. This number served as sample size for this study. Of this number, 10,101 items were requested without a prescription, of which 9653 items (95.6%) were available and dispensed. Of the items dispensed, 5504 (57.0%) were prescription items. The percentage of prescription-only drugs sold without prescription to total pharmacy sales was 21.9%, 22.8%, 19.5%, and 10.7% in pharmacies with the fewest to the largest (<500, 500-999, 1000-1499, ≥1500) number of prescriptions, respectively. Individuals requesting OTC and prescription-only drugs without presenting a prescription used 1 of 3 behaviors: (1) verbal request (85.0%); (2) presenting the empty box, blister pack, or a sample of the drug (12.1%); or (3) showing a piece of paper (which was not a prescription) bearing the name of the drug (2.9%). The percentage of those with medical insurance who sought a drug without a prescription was significantly greater than the percentage of those who did not have medical insurance (61.6% [663] vs 38.4% [413], respectively; P < 0.001). CONCLUSIONS: The common practice of requesting and obtaining prescription-only drugs without a prescription in Iran, especially among persons with medical insurance, warrants research to identify the motives for this behavior and to improve the enforcement of existing laws regarding the dispensing of prescription-only drugs.

Inappropriate medication prescribing in community-dwelling elderly people living in Iran.

OBJECTIVES: To determine the prevalence of inappropriate medication prescribing in Middle Eastern community-dwelling elderly persons, and to determine factors associated with inappropriate prescribing. METHODS: Prescriptions from 3,000 elderly-patient visits (> or =65 years) to physicians in Isfahan, Iran were collected between September and December 2002; only the first patient visit was considered in the study. Inappropriate prescriptions were defined according to Beers' explicit criteria (1997). The presence of at least one drug-drug interaction (DDI) and at least one drug-class duplication within each patient visit was also determined. Multivariate analyses were performed to determine factors associated with receiving at least one inappropriate medication. These factors included age, gender, number of prescribed medications per visit, DDIs, duplications, and physician's number of years of experience. Similar analyses were performed to determine whether these factors were associated with a composite index (defined as having at least one of the following: receiving at least one inappropriate prescription, DDI, or duplication). RESULTS: The mean age of our cohort was 72.6 (+/-5.7) years, and 1,735 (57.8%) were females. A total of 829 (27.6%) patients received at least one inappropriate prescription, 285 (9.5%) had at least one DDI during the visit, and 746 (24.9%) had at least one duplication during the visit. The three most inappropriately prescribed medication classes were antihistamines (29%), non-steroidal anti-inflammatory agents (23%) and benzodiazepines (16%). In multivariate analyses, the number of prescribed medications per visit was the only factor significantly associated with receiving at least one inappropriate prescription (OR 1.24; 95%CI: 1.16-1.32); analyses using the composite index as outcome gave similar results (OR: 1.70; 95%CI: 1.60-1.80). CONCLUSION: Our findings indicate a high prevalence of inappropriate prescribing in elderly patients. Given the potential severity of this problem, further steps need to be implemented to prevent this occurrence.