[Cerebrolysin for acute ischemic stroke].

The review discusses existing evidence of benefits and risks of cerebrolysin--a mixture of low-molecular-weight peptides and amino acids derived from pigs' brain tissue with proposed neuroprotective and neurotrophic properties, for acute ischemic stroke. The review presents results of systematic search and analysis of randomised clinical trials comparing cerebrolysin with placebo in patients with acute ischemic stroke. Only one trial was selected as meeting quality criteria. No difference in death and adverse events between cerebrolysin and placebo was established. The authors conclude about insufficiency of evidence to evaluate the effect of cerebrolysin on survival and dependency in people with acute ischemic stroke.

Clinical conferences for physicians: Who sets the agenda?

BACKGROUND: Clinical conferences are generally defined as scheduled events at which practicing physicians themselves present to their colleagues interesting clinical cases, share their new experiences and learn about the latest achievements of medical science and practice. The value of a clinical conference is thought to be in direct communication between physicians, in analysis of topical issues in a given specialty with the aim to improve the quality of care. Speakers based on their own observations and studies reveal the most urgent problems, analyze results and offer potential decisions to their colleagues interested in the same questions. The event format may be different: workshops, highly specialized sections, round tables and seminars with participation of the leading specialists in a given field. These conferences are generally organised by the Ministries and Departments of Health, by leading research and/or educational institutions in the field, by recognised medical centres and other institutions. Recently pharmaceutical companies got actively involved in medical events, acting as sponsors of various scientific conferences and congresses, however threatening the mission of these events [1]. This brings up some uneasy questions: who are the medical conferences for? Who is in charge of setting the conference agenda? Do they contribute to evidence-based medicine; do they contribute to better health? Unfortunately, there is a trend to duplication or multiplication of conferences: various agencies and departments deliver the same conferences, presentations at which are often pre-arranged by pharmaceutical companies and do not have clear scientific novelty, while the conferences themselves have largely transformed into advertising of new pharmaceuticals or new technologies [2]. Pharmaceutical corporations sponsor invited speakers paying for their trips and paying honoraria, organising cocktail parties as part of medical activities. With the help of leading experts with impressive titles serving as speakers at the conferences, pharmaceutical companies are trying to be as close as possible to routine practice of prescribing of certain drugs, manipulating evidence, controlling scientific societies as well as the process of clinical guideline development and publication of research results [3]. The degree of expert involvement depends on their level of influence [4]. OBJECTIVE: We aimed to study how often regular medical practitioners attend these conferences; to analyse who were keynote speakers and where they were coming from; to identify which organizations were responsible for organisation of these conferences and for sending out invitations to these conferences and for disseminating information about them. METHODS: We summarized all the invitations (printed on paper) received by one regular medical practitioner employed with the outpatient clinical of the city of Kazan for the period of two years (2012-2013). RESULTS: During the study period (2012-2013), a regular medical practitioner received 47 printed paper invitations to scientific conferences: 22 in 2012 and 25 in 2013. The conferences were not distributed evenly over the months of the years. November appeared to be the month with the highest density/number of medical conferences: 7 conferences in 2012 and 10 in 2013. If the distribution was even, then we could calculate the number per month dividing the number per year by 9 active months (excluding July, August and September). This resulted in 2.4 and 2.8 conferences per month. Among these studied conferences 4 were organized by public health agencies: invitation tickets were accompanied by the corresponding official order to organise a conference, issued by the Health Department. Noteworthy, that 2 of these conferences were held in conference rooms of the largest hotels of the city. Forty-one out of 47 medical conferences were sponsored by big pharma: either jointly with the major medical higher educational institutions of the city or plainly by pharmaceutical companies. Seventeen conferences were held during official working hours, in the first half of the day. Not only the logo of the pharmaceutical companies was printed on invitation tickets, but there was also an advert of the promoted pharmaceutical brand.Nine conference invitations contained invitation to dinner. In one of the invitations to a conference on neuroscience it was written: "dinner under the unforgettable music". Two conference invitations contained invitation to a lunch. Programs of 20 conferences (which were included) listed guest lecturers, coming from the leading medical universities in Moscow and St. Petersburg. Opinion leaders' involvement: some of the leading experts acted as speakers from 4 to 7 conferences a month in this sample conference invitations package of a regular polyclinic physician. CONCLUSIONS: In 2012-2013 health practitioners were invited to attend medical conferences regularly, at least 2 times a month, with November being the busiest month. The keynote speakers were the opinion leaders from the local medical educational institutions and visitors from Moscow and St. Petersburg; their involvement with the conferences was repetitive. Governmental institutions jointly with big pharma were responsible for organisation of these conferences and attracting audience.Limitations of these observations:Unfortunately, the information on printed-paper conference invitations was not complete because not all tickets have survived. From the interview with the physician we know that in addition to these printed on paper invitations there were many invitations and alerts sent out by e-mail, SMS messages and personal phone calls, making the regularity of these conferences much higher. The physician, who kindly provided this information to us, asked not to be named or thanked in any public presentation of the results of these analyses.

Towards the rational use of medicines.

BACKGROUND: Rational use of medicines remains to be one of the most challenging problems in health systems worldwide [1, 2]. ABC/VEN-analysis has been recommended for use by the World Health Organization (WHO) and has been used in health care practice globally since 1981. It represents the simple and effective method of analysis of medicine expenditures, identifying priority groups of medicines, the use of which, when improved, may provide the greatest clinical and economic impact. ABC analysis provides an accurate and objective picture of budget expenditures on medicines. VEN-analysis helps to prioritize between various medicines in their selection for procurement and use within a drug supply system [3-5]. OBJECTIVE: To assess the impact of introduction of evidence-based principles in the practice of medicine procurement and use on budget expenditures on medicines of a multidisciplinary health facility for the period of four years (2011-2014). METHODS: ABC/VEN analysis was carried out in a multidisciplinary health facility with over 1000 beds (an average number of beds for three years), which is responsible for provision of care to the population of about 1.4 million people. The analysis was carried out on the basis of information on medicine expenditures for 4 years: 2011 (1st year), 2012 (2nd year), 2013 (3rd year) and 2014 (4th year). When assigning VEN categories of medicines we used expert method: assignment of categories was carried out by clinical pharmacologists after reviewing all available evidence on effectiveness, safety and cost-effectiveness compared to other drugs in this group. In 2013, we implemented educational intervention, including detailed discussion of the results of the ABC/VEN-analysis for the years 2011-2012 from the standpoint of evidence-based pharmacology and recommendations for medicine procurement. In 2014, we delivered training workshop for the heads of clinical departments on evidence-based principles in clinical pharmacology and rational use of medicines. RESULTS: Medicines expenditures of the studied health facility for the year 2014 were less than for the year 2013, which was the important decrease reversing the trend of increasing medicines expenditures of the last three years: 2011 - 59,868,963 roubles; 2012 - 85,324,084 roubles, 2013 - 107 303 390 roubles, and 2014 - 74,416,692 roubles. The number of International Non-proprietary Names (INN) of medicines used in 2014 was 519, which was the highest number for the four years of the study: 2011 - 429 INN, 2012 - 432 INN, 2013 - 513 INN, and 2014 - 519 INN. Nearly 40% of the funds spent in 2014 on medicines have been used for Vital medicines: 2011 - 26%, 2012 - 39%, 2013 - 25%. Expenditures on Non-essential medicines in 2014 were about the same as in previous years - 14% of total medicine expenditures: 2011 - 16%, 2012 - 13%, 2013 - 15%. However in absolute numbers (roubles) expenditures on non-essential medicines decreased compared to the years 2013 and 2012: 2011 - 9,428,135 roubles, 2012 - 11,129,388 roubles, 2013 - 15,578,325 roubles, 2014 - 10,616,023 roubles.Expenditures on solutions for infusion (sodium chloride, Ringer's solution, dextran, glucose, hydroxyethyl starch) decreased as compared to the year 2013, but still remained high, thus indicating on the abuse of parenteral methods of drug administration. The portion of expenditures on isotonic sodium chloride solution and hydroxyethyl starch in 2014 decreased compared to the year 2013. We found a positive trend in the structure of expenditures on antibacterial agents: in 2014 expenditures on fluoroquinolones decreased nearly fivefold compared to 2013, expenditures on cephalosporins also decreased, but not so dramatically. However, there was a significant increase in expenditures on carbapenems, more than twofold compared with the year 2013. In 2014 we noted a twofold decrease in expenditures on medicines affecting blood, including antithrombotic agents, hemostatics and antianemic medicines, as compared to the values of the year 2013. In 2014 there was also a decrease in expenditures of cardio-vascular medicines, medicines affecting nervous system, alimentary tract and metabolism. CONCLUSIONS: Introduction of evidence-based principles through educational interventions at a multidisciplinary health facility resulted in a number of changes towards more rational medicine use. Regular educational interventions for practicing physicians and heads of clinical departments of health facilities that promote rational prescribing are needed.