Journal of Research in Pharmacy Practice

Abstract  Tricyclic antidepressants poisoning (TCA) is associated with cardiovascular complications, electrocardiographic abnormalities, and central nervous system toxicity. This study aimed to compare the clinical manifestations of poisoned patients with tricyclic antidepressants alone or with benzodiazepine (BZD) intoxication according to the dose of BZDs. Methods: In this case–control study, 120 patients with TCA poisoning were divided into four groups: the first group of TCA poisoning alone, the second group of TCA and BZD poisoning of <7.75 mg, the third group of TCA and B poisoning of 7.75 to 80 mg, and the fourth group of more than 80 mg of TCA and BZD poisoning. Patients' demographic, clinical, and cardiac information was extracted from their records at admission and 6 h after admission. Findings: Cardiac complications 6 h after referral and total cardiac complications between TCA and TCA low-dose BZD groups were significantly reduced in the low-dose BZD poisoning group. Comparison of TCA and TCA groups with a moderate dose of BZD showed a significant reduction in time six and total cardiac complications. However, due to the significant difference in TCA values between the two groups, the results are not significant. Comparing the two groups of TCA and TCA with a high dose of BZD, both 6-hour cardiac complications and total cardiac complications in the high-dose BZD group, it was significantly reduced. However, the loss of consciousness was also considerably greater in the high-dose BZD group than in the TCA group. Conclusion: Concomitant BZDs with TCA can reduce cardiovascular complications from TCA poisoning. However, with high doses of BZDs, there is a greater loss of consciousness.

Abstract  This study aimed to measure patient satisfaction with community pharmacy in Isfahan, Iran, in 2019. Methods: In this cross-sectional study (2019), we selected 104 pharmacies located in the second largest city of Iran (Isfahan) based on systematic random sampling and at least five clients at different times of a day who finished the process of obtaining medications from the pharmacies were randomly selected for a short and structured interview using the Persian version of the MacKeigan and Larson questionnaire for measuring patients' satisfaction with pharmacy services. Findings: The reliability of the questionnaire was confirmed after distributing 520 among the patients (r = 0.958). No significant difference was observed between sex, marital status, housing status, and total satisfaction score based on the results. In addition, there was a significant difference between educational levels, location, job status, insurance status, real income, and total score of satisfaction (P < 0.05). Our results revealed acceptable satisfaction in some aspects, such as paying attention to pharmacists, the general condition of the pharmacy, and their technical competence. On the other hand, the patients were not satisfied enough in different aspects, for example, counseling, accessibility to their needed drugs, and expenses. Conclusion: Patient satisfaction needs to be improved and enhanced in the case of counseling the patients on their medications, and drug accessibility and expenses remain the primary source of dissatisfaction in the studied population, which should be noted by the Iranian Food and Drug Organization and other related authorities.

Abstract  In this study, we evaluated the predictive factors for the occurrence of metabolic acidosis in patients with multi-drug poisoning, including antidepressants (Ad)/antipsychotics (Ap). Methods: This cross-sectional study was carried out in the referral poisoning center, Khorshid University Hospital, affiliated with Isfahan University of Medical Sciences. All patients with multi-drug ingestion, including Ad/Ap, were included in the study. Patients were divided into two groups with and without metabolic acidosis. Demographic factors, time from ingestion to admission, clinical manifestations, length of hospital stay, and outcome were compared in two groups. Binary logistic regression was used to identify factors associated with the risk of metabolic acidosis occurrence. Findings: Among the 206 evaluated patients, 45 patients (21.8%) had metabolic acidosis whom the majority were female (73.3%) with intentional purposes (77.8%). 31.1% of the patients with metabolic acidosis had tachycardia on admission (P = 0.03). Among all variables, time from ingestion to admission (P = 0.02) and lengths of hospital stay (P = 0.002) were significantly different between patients with and without metabolic acidosis. Tachycardia on admission (adjusted odds ratio [OR], 2.24; 95% confidence interval [CI]: 1.05–4.76; P = 0.036) and time from ingestion to admission (adjusted OR, 1.06; 95% CI: 1.00–1.13; P = 0.04) were also the predictive factors in occurrence of metabolic acidosis. Most of the patients survived without any complications (94.6%), of whom 72.3% had no previous underlying somatic diseases (P = 0.05). Conclusion: Admission tachycardia and the time elapsed from ingestion to admission may be considered important factors for predicting metabolic acidosis in multi-drug poisoning, including Ad/Ap.

Abstract  The purpose of this study was to document the demographic data, to assess the proportion of consumed medicines and the amounts and types of drugs available to households, and to to estimate the probable prevalence of certain diseases in the southern region of Iran. Methods: In this cross-sectional population-based study carried out in Shiraz (the central city in the Southern part of Iran), we documented and evaluated the drug usage details in a random sample of 1000 households during 2018–2020. We analyzed the usage of drug categories based on the anatomical therapeutic chemical classification, which the World Health Organization recommends. Findings: In the studied population, the average age (± standard deviation) was 45.54 ± 15.82, ranged 18–91 years. More than 90% had medical insurance coverage. About 81.8% of the participants had individual family medicine practitioners, and most of them (93.8%) received medications with a physician's prescription. The most frequently used medications were cough and cold preparations (12.9%), nervous system drugs (12.6%), and cardiovascular system drugs (11.6%). Conclusion: Despite the easy access to medications for most participants, few individuals (about 6%) received their medications without a prescription. The most frequently prescribed medicines were the common cold, acetaminophen, and metformin. Common cold, gastrointestinal (GI) disorder, and diabetes were the most commonly used medication classes. Furthermore, we have found a probably higher than average prevalence of cardiovascular, GI, and endocrine disorders. This information could be used by the local policymakers as a basis for the estimation and allotment of health-care resources.

Abstract Acute low back pain is a common ailment and causes pain and disability. Physicians often prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to treat acute low back pain; however, due attention has recently been drawn to muscle relaxants to reduce the severity of patients' daily physical dysfunction. Therefore, this study aimed to evaluate the therapeutic effect of the administration of indomethacin alone compared with methocarbamolas a muscle relaxant and indomethacin as an NSAID on the treatment of acute low back pain. Methods: The present double-blind clinical trial was performed on 64 patients with acute low back pain. The patients were categorized into two groups and received the treatments as follows. Indomethacin capsules of 25 mg every 8 h and placebo tablets every 8 h were administered in the first group (Group I). Indomethacin capsules of 25 mg every 8 h and methocarbamol tablets of 500 mg every 8 h were administered in the second group (Group I + M). Patient pain intensity and physical function based on Back Pain Function Scale (BPFS) were recorded before and 1 week after the intervention. Findings: The present study results revealed that the mean pain reduction of patients in Group I + M was significantly higher than that of Group I (3.66 ± 3.17 vs. 1.84 ± 1.53; P < 0.001). Moreover, the mean BPFS increase in Group I + M was significantly higher than that of Group I (19.44 ± 8.66 vs. 4.75 ± 4.35; P < 0.001). Conclusion: According to the results of the present study, concomitant administration of indomethacin and methocarbamol can be more effective in reducing pain intensity and improving the patient's physical function (or performance).

Abstract Opioid abuse is widespread throughout the world. Aspiration pneumonia is a serious problem following opioid overdose and poisoning. This study aimed to evaluate the safety and effectiveness of antimicrobial management of opioid-overdose induced aspiration pneumonia in a referral poisoning management university hospital in Iran. Methods: In an observational cross-sectional study (September–March 2019), opioid poisoned patients diagnosed with aspiration pneumonia within a maximum of 48 h of their overdose were evaluated regarding several variables, including the level of consciousness on admission, drug regimen used for the treatment of aspiration pneumonia, and its appropriateness, and the correctness of the used antibiotics dose and the therapeutic outcome. Findings: During the study, 53 eligible patients were identified and included in the study. The most frequently abused opioids were methadone (60.4%) and opium (17%). “Ceftriaxone + Clindamycin” (54.7%) and “Meropenem + Vancomycin” (9.5%) were the most frequently administered regimens. Regarding treatment outcome, most cases (n = 36, 67.9%) were discharged with a stable and satisfying medical status, while 3.8% of the cases (n = 2) died. Conclusion: The use of antibiotics in the treatment of aspiration pneumonia in hospitalized patients with opioid overdose in our referral university hospital is associated with notable antibiotic regimen choice issues. The implementation of strategies for improving the pattern of antibiotic prescribing for these patients is necessary.

Abstract Coronavirus 19 (COVID-19) is an extremely transmittable microbial infection that has emerged in Wuhan (China) in late 2019, leading to severe acute respiratory syndrome coronavirus 2 syndrome, and caused a pandemic all over the globe. This study is a systematic review of all 927 clinical trial studies performed worldwide from the beginning of the COVID-19 mysterious pandemic in China. These researches have registered in different databases. According to the best of our knowledge, China (74.82%), the United States (4.49%), and France (2.72%) have the most significant number of clinical trials, respectively. Clinical trials can be randomized or nonrandomized. Due to our results, 32.58% of studies were randomized, and 7.12% were not randomized. Most of the studies were open-labeled studies (22.44%), and double-blinded (4.42%) and quadruple blinded (2.48%) studies stand in second and third place regarding the number of trials, respectively. The direction and quantity of clinical trials attempted to identify a possible cure for COVID-19 demonstrates the depth of this crisis. As we are writing this article, a significant international endeavor will find a cure or vaccine for containing this devastating and mysterious disease.

Abstract  Opioids poisoning is of the most important cause of mortality. The objective of the study was to compare the demographic factors, clinical manifestations, and outcomes of the most common opioids involved in drug overdose presenting to the Emergency Department. Methods: This cross-sectional study was conducted from October 2016 to March 2017 in the Clinical Toxicology Department of the main referral center of the university. All poisoning cases with common opioids were included in the study. Demographic factors, clinical manifestations, and outcome were recorded in a check list. ANOVA, Chi-square or Fisher's exact test, and binary logistic regression analysis were used for outcome prediction. Findings: Two hundred and thirty six patients with opioids poisoning were evaluated during the study period. The most common opioids involved in poisoning were methadone (47.9%), tramadol (24.2%), and opium (21.6%). Patients with opium poisoning were older than others (P < 0.0001). The rate of suicide was more in the tramadol group, while the past history of psychological problems was more observed in the methadone group (P < 0.0001). Increasing age (odds ratio [OR], 1.05; 95% confidence interval [CI]: 1.02–1.09; P = 0.05) and addiction (P = 0.01; OR, 7; 95% CI: 1.55–31.52) was associated with an increased complications or death. Also patients with somatic disease had more chance of complications/death (P = 0.04; OR, 3.71; 95% CI: 1.06–12.97). Kind of opioids was not a predictive factor in the outcome of the patients with acute poisoning. Conclusion: Age, addiction, and somatic disease should be considered as more important factors in outcome prediction with opioids poisoning, including opium, tramadol, and methadone.

Abstract  Patients' complain regarding pharmaceutical services at community pharmacies is a fundamental issue as it can directly affect people's service utilization. For the first time in Iran, this survey aimed to investigate the experience of people regarding declare a complaint against the pharmacy sectors as a community-based study. Methods: In this cross-sectional study, over 100 samples based on postal codes were randomly selected from the city of Shiraz in 2017–2018. The data collection instrument was designed in two parts (demographic and social profile which record the complaint experiences against pharmacists, pharmacy services, etc.). The data were analyzed by SPSS. Findings: All 1035 eligible participants had a mean age of 45.54 ± 15.82 years (ranged from 14 to 91). Nearly 70% of the participants were female. Around 81.8% had a family physician coverage, whereas 7.4% of them had no medical insurance coverage. The frequency of complaints from the pharmacies was 35.6%. Nearly 55% of the complaints were related to governmental pharmacies. Homemakers were 1.36 times more likely to have experienced complaints in comparison with their employed female counterparts. Health status had an inverse association with complaints. Those participants who had received prescription medication were about two times more likely to have filed a complaint in comparison with those who received medication without a prescription. In addition, females aged 40–59 and above 60 and unemployed participants were more satisfied with respect to complaint follow-up process. Conclusion: Low level of satisfaction with respect to the complaint process is a concerning issue; hence, strategies are warranted to improve the quality of services provided in the pharmacies.

Abstract  We aimed to find the toxicoepidemiological indicators of tramadol poisoning in children and also the relationship of these indicators (such as demographic characteristics, and referral time) with the final therapeutic outcome. Methods: In this cross-sectional study with retrospective data collection, we included the records for all the patients under 18 that have been admitted due to tramadol poisoning between 2010 and 2015 to Noor and Ali-Asghar (PBUH) University hospital which serves as the referral medical center for acute poisonings management in the central part of Iran and is located in Isfahan. Demographic characteristics, ingested dose, dosage forms, clinical manifestations, coingested drugs, and the outcome of treatment for all pediatric patients were documented and descriptively analyzed. Findings: Demographic and clinical data of a total of 189 patients including 101 male (53.4%) with a mean age of 16.66 ± 2.64 years were abstracted and included in this study. The average time between tramadol ingestion and hospital admission was 3.39 ± 3.23 h. Mean duration of hospitalization was 12.3 ± 10.7 h. In all cases, the route of drug exposure was oral, and the most common form of drug dosage form was 100 mg tablets (n = 122) proceeded by 200 mg tablets (n = 32). The mean estimated dose of ingested tramadol was 1126 ± 1061 mg (median, 900 range, 50–7000 mg). 43.9% of the poisoned patients were high school students, and 23.3% had a high school diploma. Intentional intoxications were reported in 93.1% cases and 42.9% had coingestions. Activated charcoal (87.3%), gastric lavage (59.3%), oxygen therapy with mask (46.6%), naloxone (11.6%), anticonvulsants (13.2%), and intubation and ventilation (5.3%) were done as first-line therapeutic measures. Conclusion: Our results suggest that the trend of acute tramadol poisoning among children is decreasing, mostly accidental in adolescents and commonly intentional among young children. Proper education to improve emotional intelligence for young adults and to keep drugs out of reach of the children and safer packaging is recommended to reduce tramadol poisoning incidence in the pediatric population

Abstract  We aimed to detect and report the frequency of occurrence of drug-related problems (DRPs) in a Middle Eastern University Children's Hospital (Isfahan, Iran) and classify them in terms of their nature and cause to clarify the responsibility of clinical pharmacists for the safe utilization of medications in hospitalized children. Methods: In this cross-sectional study which was carried out in Imam Hossein Children's University Hospital affiliated with Isfahan University of Medical Sciences (Isfahan, Iran) from September 2017 to May 2018, DRPs during the hospitalization of pediatric patients in three medical wards, the pediatric intensive care unit, and two neonatal intensive care units were detected and identified concurrently with the treatment process using Pharmaceutical Care Network of Europe data gathering form for DRPs v. 8.01. All cases were verified and validated in a professional focus group before documentation. Findings: We detected 427 DRPs in 201 out of 250 randomly included hospitalized children in which 86% of them were directly reported by the hospital's clinical pharmacist. The highest frequency of DRPs (47.3%) was observed in the age range of 1 month–2 years. Safety of treatment was the most frequently reported as the nature of the problem (43.5%), followed by effectiveness issues (36.8%). The most frequent cause of DRPs was dose selection issues (34.2%), followed by drug-type selection (25.5%), and unavailability of appropriate dosage forms (13.6%). Ninety-eight interventions were proposed by the clinical pharmacist, in which 59.2% of them were accepted. Conclusion: This study confirms the necessity for the active role of clinical pharmacists before, during, and after drug therapy in hospitalized pediatric patients for the safety and proper utilization of drugs in this vulnerable population.

Abstract The dramatic increase in the consumption of intravenous immunoglobulin (IVIG) products in nonapproved indications, its high cost, and the severe shortage has developed the concerns of its irrational utilization, especially in the Middle East countries. Therefore, this clinical study attempts to describe the pattern of IVIG administration in one of the largest hospitals in Iran and find the variables associated with inappropriate IVIG utilization. Methods: This cross-sectional medication utilization study was conducted in one of the largest referral hospitals in Iran. Random IVIG administrations were assessed from different wards for 9 months. Different data were collected to evaluate the pattern of IVIG administration and find variables, which could predict this behavior. Findings: IVIG was prescribed for approved indications in 72% of 201 patients recruited in our study. Although, the rate of drug administration was appropriate in most of the study population, hydration and pre-medication were unsuitable in more than one-third of the patients. Among the variables analyzed to find the factors affecting the misuse of IVIG, female gender, older age of patients, and longer time to start IVIG administration due to hospital admission were statistically significant in the multivariate model. Conclusion: Despite the fact that inappropriate use of IVIG was confirmed in less than 30 % of its utilization for the studied patients, it caused a potential risk of treatment complications and a notable and unjustifiable burden of unnecessary costs for this University hospital.

Abstract The trend of methadone toxicity in children and adolescents seems to be increasing in Iran since it is used as a legal measure of the treatment for opioids addiction in methadone maintenance therapy clinics. In the present study, we describe the clinical and demographical characteristics of acute methadone toxicity in a cohort of pediatric poisoned patients in Isfahan, Iran and discussed the predictive factors for their treatment outcomes. Methods: In this 4-year cross-sectional study which was performed from 2013 to 2016 in a referral university hospital (Isfahan, Iran), medical records of the demographic and admission time clinical characteristics of all in-patients aged <18 years with acute methadone poisoning were abstracted and analyzed. According to the outcomes of hospital care and treatment, patients were divided as survived without medical complication and patients survived with at least one medical complication or death. Findings: A total number of 157 (79 male) children and adolescents with a mean age of 105.4 ± 6.1 months were hospitalized and included in the study. A total of 145 (92.4%) patients survived and discharged from the hospital without any medical complication. Pupil size, respiratory rate, and level of consciousness were predictive factors for the outcome of death or medical complications. Conclusion: It seems that methadone poisoning in children and adolescents is more commonly accidental in school-aged boys (6–12 years old) and it occurs mostly with the syrup dosage form, especially when one of the parents or people who live with the child has an addiction history and if the patients' house located in lower socioeconomic class area of Isfahan city (Iran).

Abstract Suicide is a social health problem worldwide. Anemia has been associated with depression. Since it remains debated whether anemia is associated with suicide independently of depression, we evaluate this probable association in women who attempted suicide through acute poisoning. Methods: The study design was cross-sectional and performed on women who attempted suicide through intentional poisoning with age more than 18 years old. Different variables were evaluated and compared in patients with respect to anemia, depression, other psychiatric diseases and history of suicide. Independent t-tests and binary logistic regression were used for statistical analysis. Findings: Nearly 26.2% of the women had anemia (n = 55). Most women with anemia were in the age group of 20–40 years (68.8%). 52.2% of the women were married. Mixed-drug poisoning was the most common (60.1%) followed by pesticide (8.9%), and antipsychiatric medications (8.4%). There was a significant difference in duration of hospitalization between anemic and nonanemic patients. Nearly 72.7% of the patients survived without complications. Anemia and depression were not significant predictive factors for depression and suicide. However, in our patients, the presence of other underlaying psychiatric disorders was a risk factor for suicidal attempt through acute poisoning. Conclusion: In women who attempted suicide through acute poisoning, anemia and depression were not predicting factors for suicide. However, the presence of other underlying psychiatric psychiatric disorders had a predictive value for the outcome of treatment. Length of hospital stay was also correlated with anemia.

Abstract

Abstract Bispectral index (BIS) is one of the several methods used to monitor the depth of anesthesia. Poisoning with ingestion of different drugs is one of the most common poisonings that have different clinical signs from drowsiness to coma. This study was performed to compare the BIS index number in poisoned patients with multi drugs ingestion with or without the need for endotracheal intubation. Methods: This cross-sectional study was performed on poisoned patients with ingestion of different drugs referring to Clinical Toxicology Department of Noor University Hospital, Isfahan, Iran. The clinical signs and symptoms and the vital signs at the admission time were measured, and the required therapies were given. The endotracheal intubation was done for patients who had the indication of intubation. BIS was monitored and compared for all patients with or without a need for intubation on the admission time and time of endotracheal intubation. Obtained data were analyzed by SPSS software. Findings: At the admission time, the mean (standard error [SE]) BIS index value for poisoned patients who needed endotracheal intubation was 66.47 ± 2.57 in comparison with 85.21 ± 1.47 for patients who did not need intubation (P < 0.001). The results of receiver operating characteristic curve (mean ± SE) showed the discrimination was excellent for BIS (0.899 ± 0.04; 95% confidence interval: 0.81–0.98) (P < 0.0001). BIS <79.5 had the sensitivity 88% and specificity 87% for endotracheal intubation. Conclusion: BIS is an appropriate index for prediction of the need to intubation in poisoned patients with ingestion of different drugs.

Abstract This study was designed to compare the severity of gastrointestinal (GI) side effects in Type 2 diabetes mellitus (DM) patients receiving tablet or capsule forms of metformin. Methods: In this prospective interventional study, patients were evaluated from June to November 2016 at DM clinics affiliated to Isfahan University of Medical Sciences, Isfahan, Iran. Adult patients with Type 2 DM who were eligible for inclusion criteria switched from metformin tablet to metformin capsule. Hemoglobin A1c (HbA1c), GI side effects, and patient satisfaction based on visual analog scale (VAS) were assessed during a 6-week follow-up of receiving metformin capsule. Findings: One hundred and three patients were evaluated, and 75 patients participated in this study. At the baseline, 40 patients (53.3%) had GI side effects due to metformin tablet which was reduced to 16 patients (21.3%) after switching to metformin capsule (P = 0.001). There was also an improvement in HbA1c (from 7 to 6.8,P < 0.0001). The results of patients' satisfaction based on VAS and numeric rating scale indicated that in 59 patients (78.67%), GI side effects were reduced after switching to metformin capsule (mean score: 7.2 with the range of 6–9) while 16 patients stated no treatment preference. Conclusion: Switching to metformin capsule may result in less GI side effects, with no further side effect complications.

Abstract  Methadone poisoning is common in our society, mainly in drug addicts. One of its lethal complications is pulmonary edema. Therefore, we evaluated the prevalence of pulmonary edema in the deceased cases with methadone poisoning and its possible relationship with some medical variables.
Methods: In this cross-sectional study which was done in 2014, we have investigated the deceased patients with methadone toxicity who underwent autopsy at Isfahan Forensic Medicine Department (Iran). All variables including age, gender, and autopsy findings were recorded and analyzed. Demographic characteristics and medical complications of the patients were compared between the patients with or without pulmonary edema in the autopsy findings.
Findings: There were 64 cases who died with methadone poisoning during the 1-year study period. The average age of cases (±standard deviation) was 32.1 ± 10.29 years, among which 92.2% were male. Based on the autopsy findings, 64.1% were diagnosed with pulmonary edema. There was no statistically significant relationship between pulmonary edema and age, gender, history of addiction, and hepatic or cardiovascular complications.
Conclusion: Pulmonary edema is a common finding in deceased methadone poisoning cases and must be considered and ruled out in patients with acute methadone toxicity.