Journal of Research in Pharmacy Practice

Abstract
Evidences regarding the efficacy of different antibiotic regimens proposed for treatment of 
multidrug‑resistant (MDR) Gram‑negative pathogens have been reviewed. Available data in 
Scopus, Medline, EMBASE, the Cochrane central register of controlled trials, and Cochrane 
database of systematic reviews have been collected. Several antibiotic regimens are proposed 
for treatment of MDR Gram‑negative infections (defined as nonsusceptibility to at least 
one agent in three or more antimicrobial categories). The most challenging issue is the 
treatment of carbapenem‑resistant (CR) Gram‑negative pathogens. A carbapenem plus either 
colistin or tigecycline was the most effective regimen for treatment of CR Gram‑negative 
pathogens with low‑level resistance (minimal inhibitory concentration [MIC] ≤ 8 mg/L). 
However, in high‑level resistance (MIC > 8 mg/L), combination of colistin and tigecycline 
showed promising effect.

Abstract An economic crisis has been defined as a situation in which the scale of a country’s economy 
becomes smaller in a period of time. Economic crises happen for various reasons, including 
economic sanctions. Economic crises in a country may affect national priorities for investment 
and expenditure and reduce available resources, and hence may affect the health care sector 
including access to medicines. We reviewed the pharmaceutical policies that the countries 
adopted in order to mitigate the potential negative effects on access to medicines. We 
reviewed published reports and articles after conducting a comprehensive search of the 
PubMed and the Google Scholar. After extracting relevant data from the identified articles, 
we used the World Health Organization (WHO) access to medicines framework as a 
guide for the categorization of the policies. We identified a total of 40 studies, of which 10 
reported the national pharmaceutical policies adopted to reduce the negative impacts of 
economic crises on access to medicines in high‑income and middle‑income countries. We 
identified 89 policies adopted in the 11 countries and categorized them into 12 distinct policy 
directions. Most of the policies focused on financial aspects of the pharmaceutical sector. 
In some cases, countries adopted policies that potentially had negative effects on access to 
medicines. Only Italy had adopted policies encompassing all four accesses to medicine factors 
recommended by the WHO. While the countries have adopted many seemingly effective 
policies, little evidence exists on the effectiveness of these policies to improve access to 
medicines at a time of an economic crisis.

Abstract Objective: Overcoming language and cultural barriers is becoming ever challenging for 
pharmacists as the patient population grows more ethnically diverse. To evaluate the current 
practices used by the pharmacists for communicating with patients with limited English 
proficiency (LEP) and to assess pharmacists’ knowledge of, attitude toward, and satisfaction 
with accessing available services for supporting LEPs patients within their current practice 
settings.
Methods: Semi‑structured interviews were conducted with five pharmacists employed in 
pharmacies representing multiple practice settings Queensland, Australia. Thematic analysis 
was primarily informed by the general inductive approach. NVivo software (QSR International 
Pty Ltd.) was used to manage the data.
Findings: Three interlinked themes emerged from the analysis of interview data: (1) Barriers 
to the provision of pharmaceutical care,(2) Strategies employed in dealing with LEP patients, 
and (3) Lack of knowledge about existing services. Pharmacists recognized their lack of 
skills in communicating with LEP patients to have potential negative consequences for the 
patient and discussed these in terms of uncertainty around eliciting patient information 
and the patient’s understanding of their instructions and or advice. Current strategies were 
inconsistent and challenging for LEP patient care. While the use of informal interpreters 
was common, a significant degree of uncertainty surrounded their actual competency in 
conveying the core message.
Conclusion: The present study highlights a significant gap in the provision of pharmaceutical 
care in patients with LEP. Strategies are needed to facilitate quality use of medicines among 
this patient group.

Abstract Objective: Many hematopoietic stem cell transplantation (HSCT) patients receive 
vancomycin empirically during febrile neutropenia. There are several models for estimation of 
vancomycin pharmacokinetic parameters and calculation of initial dosing regimen accordingly. 
However, the performance of these methods in HSCT patients remained to be evaluated. 
The aim of the study was to determine which of the vancomycin population pharmacokinetic 
methods best fit Iranian HSCT patients.
Methods: In order to evaluate predicted performance of seven vancomycin population 
pharmacokinetic models, the pharmacokinetic parameters of patients were estimated using 
each model’s equations. Then the predicted steady‑state trough vancomycin concentration was 
calculated based on each model’s parameters and using a formula based on Sawchuk–Zaske 
method. The predicted steady‑state trough vancomycin concentration and the real measured 
concentrations were compared to see which method was the most precise and least biased 
using mean squared error (MSE) and mean prediction error (ME) respectively.
Findings: Forty‑six patients (65% men) were included in the study. Calculated metrics showed 
a range of 38% under‑prediction bias with Rodvold to 34% over‑prediction bias with Matzke and 
Burton models. Birt and revised Burton methods showed no significant bias(ME [95% confidence 
interval(CI)]: –0.067 [–0.235–0.101] and 0.066 [–0.105–0.238]). Birt and revised Burton were not 
different significantly considering MSE (95% CI) of 0.385 (0.227–0.544) and 0.401 (0.255–0.546), 
respectively. Comparisons of precision with naive predictors revealed a delta MSE (95% CI) 
of –0.128 (–1.379–1.890) for Birt and 0.026 (–0.596–0.940) for revised Burton models.
Conclusion: Although the Birt and Burton revised methods performed well, none of the 
studied models showed acceptable performance to be implemented as a routine method 
for initial dose calculation in HSCT patients. A vancomycin pharmacokinetic model specific 
for this high‑risk subpopulation of Iranian patients should be designed and validated.

Abstract Objective: Hypertension and hyperlipidemia are two major risk factors for cardiovascular disease 
in continuous ambulatory peritoneal dialysis (CAPD) patients. This study was designed to investigate 
the effect of omega-3 fatty acids on blood pressure (BP) and serum lipids in CAPD patients.
Methods: This study was a randomized double‑blind clinical trial in which 90 CAPD patients 
were randomly assigned to either the omega‑3 or the placebo group. Patients in omega‑3 
group received 3 g/day omega‑3 for 8 weeks, whereas patients in the control group received 
placebo. At baseline and at the end of 8 weeks, the patients’ BP was controlled, and serum 
biochemistry was measured.
Findings: Mean systolic BP decreased (–22.2 ± 14.2 mmHg) in the omega‑3 group at the end 
of the study while in the placebo group increased (+0.5 ± 30.2 mmHg) (P < 0.0001). Mean 
diastolic BP of the omega‑3 group decreased more (–11.95 ± 11.9 mmHg) comparing with 
the placebo group (–1.1 ± 17.3 mmHg) (P = 0.001). There were no significant differences 
between the two groups in mean changes in serum triglyceride, and total, high‑density 
lipoprotein, and low‑density lipoprotein cholesterol.
Conclusion: The results of this study indicate that omega‑3 reduced BP significantly but 
had no effect on lipid profile in our CAPD patients.

Abstract Objective: Laryngoscopy and intubation are associated with sympathetic stimulation which 
can prove deleterious in patients with cardiovascular compromise; so, various methods have 
been tried to obtund this pressor response. In this study, we have assessed the efficacy of 
pregabalin in attenuating the pressor response to laryngoscopy and intubation.
Methods: This prospective randomized study included 80 patients with American Society 
of Anesthesiologists physical status grades I‑II, in the age group of 18–60 years of age. 
The patients were randomized into two groups of 40 patients each. Group A received 
the placebo orally, 90 min prior to surgery. Group B received 150 mg of pregabalin orally, 
90 min prior to surgery. These patients were assessed in terms of sedation with Ramsay 
sedation scale (RSS). In the operation theatre, the heart rate (HR), systolic blood pressure, 
diastolic blood pressure, mean arterial pressure, and oxygen saturation recorded at baseline 
and 1, 3, 5, and 10 min after intubation. The rate pressure product (RPP) was calculated for 
these time intervals. In the postoperative period, patients were assessed for complications 
like dizziness, nausea, and blurred vision. Statistical analysis was performed using Chi‑square 
and ANOVA tests.
Findings: The group receiving 150 mg of pregabalin as premedication was found to be 
adequately sedated at 1 h post-premedication with 52% patients having a RSS score of 3 
compared to 4% with the same RSS score in the placebo group (P < 0.0001). Hemodynamics 
was more stable post-intubation with significant stability in the HR (P = 0.002) and 
RPP (P = 0.004) in the pregabalin group.
Conclusion: Pregabalin when given as a premedication provides adequate sedation and 
obtunds the pressor response seen with intubation.

Abstract Objective: Considering the inability of neonates to swallow oral drugs in the form of solid 
tablets, the lack of appropriate dosage forms for infants, and the necessity to prepare some 
pills for neonates, the current study investigated dosage accuracy in drugs for neonates 
prepared from tablets by analyzing the concentrations of final products.
Methods: Captopril and spironolactone, oral dosage forms that are not suitable for infants, 
were chosen as the drug model for this study. Demographic characteristics of nurses providing 
medications and tablet preparation methods were documented in a random observational 
method. To determine concentrations of final solutions, 120 drug samples (60 captopril 
and 60 spironolactone samples) prepared by Neonatal Intensive Care Unit nurses of the 
Children Cure and Health Hospital of Tabriz University of Medical Sciences were analyzed 
using high performance liquid chromatography (HPLC) and spectrophotometry.
Findings: There was a significant error rate in the concentration of captopril in prepared 
solutions compared with the ordered dosage. No differences were observed in the 
demographic characteristics of the nurses and the method of preparation between the 
two drugs. The only difference related to the preparation technique was that in most 
cases (70.8%), one whole spironolactone tablet was used, whereas in around 50% of samples 
in captopril group, half or a quarter of one captopril tablet was utilized for the intended 
dosage (P = 0.009).
Conclusion: This research suggests that the use of a whole tablet instead of a divided 
tablet in the manual preparation of medication dosage forms for neonates is the most 
appropriate approach.

Abstract Objective: There is an increased prevalence of extended‑spectrum beta‑lactamase producing 
Klebsiella pneumoniae (ESBL‑KP) worldwide including India, which is a major concern 
for the clinicians, especially in intensive care units and pediatric patients. This study aims to 
determine the prevalence of ESBL‑KP and antimicrobial sensitivity profile to plan a proper 
hospital infection control program to prevent the spread of resistant strains.
Methods: KP isolates obtained from various clinical samples were evaluated to detect the 
production of ESBL by phenotypic methods. Antimicrobial susceptibility profile was also 
determined of all the isolates.
Findings: Of 223 nonduplicate isolates of K. pneumoniae, 114 (51.1%) were ESBL producer 
and antimicrobial susceptibility profile showed the isolates were uniformly sensitive to 
imipenem and highly susceptible to beta‑lactamase inhibitor combination drugs(67–81%) and 
aminoglycosides (62–76%), but less susceptible to third generation cephalosporins (14–24%) 
and non‑β‑lactam antibiotics such as nitrofurantoin (57%), fluoroquinolones (29–57%), 
piperacillin (19–23%), and aztreonam (15–24%).
Conclusion: This study found that beta‑lactamase inhibitor combinations are effective 
in treatment of such infections due to ESBL‑KP thus these drugs should be a part of the 
empirical therapy and carbapenems should be used when the antimicrobial susceptibility 
tests report resistance against inhibitors combinations.

Abstract Objective: This study was designed to evaluate the effect of different doses of midazolam 
on anesthesia and analgesia quality when added to lidocaine during the intravenous regional 
anesthesia (IVRA).
Methods: One hundred and forty patients underwent hand surgery were randomly allocated 
into four groups to receive 3 mg/kg lidocaine 2% diluted with saline to a total volume of 
40 mL in the control Group L‑C (n = 35), 30 µg/kg midazolam plus 3 mg/kg lidocaine 2% 
diluted with saline to a total volume of 40 mL in the midazolam Group L‑M1 (n = 35), 40 µg/kg 
midazolam plus 3 mg/kg 2% lidocaine diluted with saline to a total volume of 40 mL in the 
midazolam Group L‑M2 (n = 35), and 50 µg/kg midazolam plus 3 mg/kg lidocaine 2% diluted 
with saline to a total volume of 40 mL in the midazolam Group L‑M3 (n = 35). Sensory and 
motor block and recovery times, tourniquet pain, intra‑operative analgesic requirement, and 
visual analog scale (VAS) scores were recorded.
Findings: Onset time of sensory and motor block in L‑M3
 Group was shorter than the 
L‑M2
 and L‑M1
 and L‑C Groups (P < 0.001). Furthermore, prolonged sensory (P = 0.005) and 
motor recovery time (P = 0.001) in L‑M3
 were longer than the other groups. Intra‑operative 
VAS score and intra‑operative fentanyl consumption in L‑M3
 were lower than the other 
groups (P < 0.001). The numbers of patients needed to pethidine in Group L‑M3
 were 
significantly less compared with the other groups (P = 0.035). VAS scores were significantly 
lower in Group L‑M3
 in different time intervals in the postoperative period compared with 
the other groups (P < 0.001).
Conclusion: Addition of 50 µg/kg midazolam for IVRA (Group L‑M3
) enhanced 
intra‑operative analgesia and improved anesthesia quality better than other groups receiving 
lower midazolam doses as well as a control group.

Abstract Objective: Methamphetamine is the second most widely abused drug worldwide. We 
performed a study on the treatment outcome of acute methamphetamine intoxication in 
a referral tertiary care University hospital in Iran.
Methods: In this hospital‑based, retrospective study which was carried out from 2012 to 
2013, medical records of all patients aged 18 to 65 years who were admitted with a reliable 
history and clinical diagnosis of acute methamphetamine intoxication were abstracted 
and analyzed. Patients’ data included gender, age, type and route of poisoning, clinical 
manifestations, duration of hospitalization, and the treatment outcome. ANOVA, Chi‑square, 
and binary logistic regression statistical tests were used for data analysis.
Findings: A total of 129 patients with a mean age of 30.70 ± 0.93 (mean ± standard error), 
including 111 (86%) males, had been fully evaluated. Most of the patients had intentional 
poisoning (93.7%). In 42.6% of patients, inhalation was the main route of exposure. Most of the 
patients had complete improvement without any complication (89.1%). Age (odds ratio [OR], 
1.05; 95% confidence interval [95% CI] 1.006–1.099), suicide history (OR, 30.33; 95% CI 
3.11–295.24), route of poisoning ([ingestion: OR, 0.21; 95% CI 0.05–0.87], [inhalation: OR, 0.19; 
95% CI 0.04–0.78]), and pulmonary system manifestations (OR 1.84; 95% CI 1.15–2.93) 
were predictive in patients outcome (P < 0.05).
Conclusion: Methamphetamine poisoning was more common in males with intentional 
poisoning. Age, past history of suicide, route of poisoning, and pulmonary manifestations 
on admission could be considered as important predictive factors in patients’ outcome.
Keywords: Methamphetamine; poisoning; treatment outcome