Blogger Widgets

...

TRANSLATE AS YOU LIKE

January 21, 2012

Small Cell Lung Cancer (SCLC)

Small cell lung cancer (SCLC) occurs almost exclusively in smokers and represents 15 to 25% of all lung cancer histologies and in bronchogenic carcinomas.At the time of diagnosis, approximately 30% of patients with SCLC will have tumors confined to the hemithorax of origin, the mediastinum, or the supraclavicular lymph nodes. It is distinguished from non-small cell lung cancer (NSCLC) by its rapid tumor doubling time, high growth fraction, and early development of widespread metastases. While SCLC is considered highly responsive to chemotherapy and radiotherapy, relapse despite treatment commonly occurs within 2 years.
Overall, survival beyond 5 years occurs in 3 to 8% of patients with SCLC (7% with limited disease. 

Pathogensis 
SCLC is characterized by small "blue" malignant cells about twice the size of lymphocytes, with sparse cytoplasmic and nuclear features having finely dispersed chromatin without distinct nucleoli. Nuclear molding is considered characteristic in well-preserved specimens, although a nondiagnostic "crush" artifact is more frequently observed. The histologic subtypes recognized in the pathology literature, classic oat cell and intermediate cell types,do not appear to behave differently biologically or clinically. On the other hand, histologic findings with combined large cell/small cell or mixed small cell with squamous cell or adenocarcinoma impart a poorer prognosis and greater resistance to treatment. While these histologic results are rarely detected in untreated specimens, the observation that up to 30% of autopsies demonstrate areas of NSCLC differentiation has led to the proposal that pulmonary carcinogenesis occurs in a pluripotent stem cell capable of differentiation along several pathways. Eight to 15 SCLC antigen clusters have been identified
by segregation analysis and divided into the following three groups: neural, epithelial, and neuroendocrine.
Epithelial differentiation is demonstrated by keratin expression. Neuroendocrine and neural differentiation result in the expression of dopa-decarboxylase, calcitonin, neurofilament, neural cell adhesion molecule, gastrin-releasing peptide, and insulin-like growth factor. Occasional hosts can produce antibodies (anti-r7w) that cross-react with both SCLC cells and the central nervous system and are associated width cerebral and cerebellar degenerative syndromes. Moreover, SCLC cells also produce a number of polypeptide hormones, including adrenocorticotrophic hormone and vasopressin, resulting in various paraneoplastic and ectopic hormonal syndromes. Insulin-like growth factor-1 and gastrin-releasing peptide may participate in autocrine and paracrine loops to enhance growth of SCLC cells. In addition to these growth factors being overexpressed, neural endopeptidase (common acute lymphoblastic leukemia antigen), the enzyme that inactivates these small polypeptide hormones, is underexpressed in SCLC cells and in bronchoalveolar lavage fluid from smokers.
The development of lung cancer occurs through mutagenesis and proliferative stimuli caused by tobacco and
other carcinogens over years. Multiple genetic defects are detected, some characteristic and perhaps involved with the process, and some random or secondary events. Included in the characteristic lesions is a loss of heterozygosity on chromosome 9p and deletion of 3p, including 3p21-22, leading to inactivation of as many as three putative tumor-suppressor genes. The identity of these genes is unknown, but several candidate regulatory genes reside in the vicinity (protein-tyrosine phosphatase-7, c-raf-1, p-retinoic acid receptor), none of which are felt to be the actual genes responsible. Loss of the retinoblastoma gene function at 13ql4 is ubiquitous. Approximately 60% of SCLC cell lines have undetectable transcripts, and the remaining 40% have an abnormal gene product. These abnormalities are also detected in fresh tumor specimens. p53 mutations are detected in most SCLC cell lines and fresh tumors.

Clinical Features
Lung cancer may present with symptoms or be found incidentally on chest imaging. Symptoms and signs may result from the location of the primary local invasion or compression of adjacent thoracic structures, distant metastases, or paraneoplastic phenomena. The most common symptoms at presentation are worsening cough, shortness of breath, and dyspnea.
Other presenting symptoms include the following:
  • Chest pain.
  • Hoarseness.
  • Malaise.
  • Anorexia.
  • Weight loss.
  • Hemoptysis.
Symptoms may result from local invasion or compression of adjacent thoracic structures, such as compression involving the esophagus causing dysphagia, compression involving the laryngeal nerves causing hoarseness, or compression involving the superior vena cava causing facial edema and distension of the superficial veins of the head and neck. Symptoms from distant metastases may also be present and include neurological defect or personality change from brain metastases or pain from bone metastases.
Infrequently, patients with SCLC may present with symptoms and signs of one of the following paraneoplastic syndromes:
  • Inappropriate antidiuretic hormone secretion.
  • Cushing syndrome from secretion of adrenocorticotropic hormone.
  • Paraneoplastic cerebellar degeneration.
  • Lambert-Eaton myasthenic syndrome.
Physical examination may identify enlarged supraclavicular lymphadenopathy, pleural effusion or lobar collapse, unresolved pneumonia, or signs of associated disease such as chronic obstructive pulmonary disease.

Diagnosis
Treatment options for patients are determined by histology, stage, and general health and comorbidities of the patient. Investigations of patients with suspected SCLC focus on confirming the diagnosis and determining the extent of the disease.
The procedures used to determine the presence of cancer include the following:
  • History.
  • Physical examination.
  • Routine laboratory evaluations.
  • Chest x-ray.
  • Chest computed tomography scan with infusion of contrast material.
  • Biopsy.
Before a patient begins lung cancer treatment, an experienced lung cancer pathologist must review the pathologic material. This is critical because SCLC, which responds well to chemotherapy and is generally not treated surgically, can be confused on microscopic examination with NSCLC. Immunohistochemistry and electron microscopy are invaluable techniques for diagnosis and subclassification, but most lung tumors can be classified by light microscopic criteria.

Staging Evaluation
Staging procedures for SCLC are important in distinguishing patients with disease limited to their thorax from those with distant metastases. At the time of initial diagnosis, approximately two-thirds of patients with SCLC have clinical evidence of metastases; most of the remaining patients have clinical evidence of extensive nodal involvement in the hilar, mediastinal, and sometimes supraclavicular regions.

Determining the stage of cancer allows an assessment of prognosis and a determination of treatment, particularly when chest radiation therapy or surgical excision is added to chemotherapy for patients with LD. If ED is confirmed, further evaluation should be individualized according to the signs and symptoms unique to the individual patient.
Standard staging procedures include the following:
  • A thorough physical examination.
  • Routine blood counts and serum chemistries.
  • Chest and upper abdominal computed tomography (CT) scanning.
  • A radionuclide bone scan.
  • A brain magnetic resonance imaging scan or CT scan.
Bone marrow aspirate or biopsy in selected patients in which treatment would change based on the results.
The role of positron emission tomography (PET) is still under study. SCLC is fluorodeoxyglucose (FDG) avid at the primary site and at metastatic sites. PET may be used in staging patients with SCLC who are potential candidates for the addition of thoracic radiation therapy to chemotherapy, as PET may lead to upstaging or downstaging of patients and to alteration of radiation fields due to the identification of additional sites of nodal metastases.

Evidence (FDG-PET):
In a study of 120 patients with LD SCLC or ED SCLC, ten patients were upstaged and three patients were downstaged. PET was more sensitive and specific than CT scans for nonbrain distant metastases.
In a small series of 24 patients with LD by conventional staging, two patients were upstaged to ED. Unsuspected nodal metastases were documented in 25% of patients, which altered the radiation plan in these patients. At this time, sensitivity, specificity, and positive- or negative-predictive value of PET scanning and its enhancement of staging accuracy are uncertain.

Prognosis:  
Systemic therapy is required for all patients with SCLC, even those with radiographically staged LD. Thus, the major therapeutic role of staging is to guide the use of chest radiotherapy, which is indicated for LD but not necessarily for ED. In addition to obtaining tissue diagnosis, exhaustive staging would include chest radiograph;
physical examination, chest, liver, and adrenal CT scan,head MRI, bone scan and unilateral or bilateral bone marrow aspirates and biopsies. An alternate, abbreviated staging algorithm could be directed by symptoms and terminated with documentation of ED. This latter strategy, the rule for many European trials, is likely to become more prevalent in the United States in these times of health-care parsimony and need for economic justification. Specifically, many investigators argue that bone marrow examination, given the relative invasiveness of the procedure, has very low yield in patients with normal serum lactate dehydrogenase (LDH) levels. Arguments against sequential staging include the fact that bone scans
are positive in up to 30% of patients who do not have abnormal alkaline phosphatase levels or symptoms. A head CT scan is positive in about 15% of patients at diagnosis, one third of whom are asymptomatic, and early treatment of brain metastases yields a lower rate of chronic neurologic morbidity. Of greater importance is the swift progression of untreated SCLC. Most patients have developed their prediagnosis symptoms within the preceding weeks. Staging should not delay treatment more than 7 to10 days, or else many patients will become seriously ill.
The most important prognostic factors are performance status and body weight, as well as tumor-related factors involving extent of disease (LD vs ED). Within the LD subset, early stage disease (stage I) carries a favorable prognosis, whereas elevated LDH level indicates an unfavorable prognosis. Within the ED subset, the number of organ sites involved is inversely related to the prognosis.
Metastatic involvement of the central nervous system, bone marrow, or liver is unfavorable, compared with other sites, although these variables are confounded by the number of sites involved. The presence of paraneoplastic syndromes is also generally unfavorable.

Treatment:
Five types of standard treatment are used:
1) Surgery
Surgery may be used if the cancer is found in one lung and in nearby lymph nodes only. Because this type of lung cancer is usually found in both lungs, surgery alone is not often used. Occasionally, surgery may be used to help determine the patient’s exact type of lung cancer. During surgery, the doctor will also remove lymph nodes to see if they contain cancer.
Even after removes all the cancer that can be seen at the time of the operation, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

2) Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Drugs Approved for Small Cell Lung Cancer includes
  • Methotrexate
  • Etoposide
  • Etoposide Phosphate
  • Topotecan Hydrochloride
3) Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy X-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. Prophylactic cranial irradiation (radiation therapy to the brain to reduce the risk that cancer will spread to the brain) may also be given. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

4)Laser therapy
Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells. 

5) Endoscopic stent placement
An endoscope is a thin, tube-like instrument used to look at tissues inside the body. An endoscope has a light and a lens for viewing and may be used to place a stent in a body structure to keep the structure open. Endoscopic stent placement can be used to open an airway blocked by abnormal tissue.

Smoking cessation: 
The importance of quitting smoking cannot be overemphasized, particularly for patients with limited stage disease. Patients who continue to smoke do less well. One reason is that if they survive their first lung cancer, they have a substantial chance of developing a second lung cancer because of smoking. Furthermore, treatment with chemotherapy, radiation therapy, and surgery can cause lung damage. It is therefore important to have the best lung function possible prior to and after receiving treatment. Thus, if at all possible, patients should stop smoking.
This is also an important opportunity for family and friends to stop smoking. There are inherited genetic factors that increase the likelihood of getting lung cancer, especially if persons with these genetic factors smoke or are around those who do.

Thanking you
Akshaya Srikanth,
Pharm.D Internee



January 20, 2012

MRI IN CARDIAC PACEMAKERS

Magnetic resonance imaging (MRI) is a widely accepted tool for the diagnosis of a variety of diseases. However, due to safety reasons the presence of an implanted cardiac pacemaker or of an implantable cardioverter defibrillator (ICD) is considered to be a strict contraindication to MRI in most medical centers. Thus, a substantial number of patients are precluded from the diagnostic advantages of this imaging modality. Because of its high spatial and contrast resolution, it is now the primary diagnostic imaging test of choice for disorders of the central nervous and musculoskeletal systems. It is also important for oncological and certain cardiovascular disorders. In certain clinical instances, denying a patient an MRI procedure may have a significant effect on the patient’s care. Subsequently, this could prove to have a major impact on overall public health.

Cardiac MRI imaging is performed to:
  • evaluate the anatomy and function of the heart, valves, major vessels, and surrounding structures (such as the surrounding pericardial sac).
  • diagnose a variety of cardiovascular (heart and/or blood vessel) problems.
  • detect and evaluate the effects of coronary artery disease.
  • plan a patient's treatment for cardiovascular problems and monitor a patient's progress over time.
  • evaluate the anatomy of the heart and blood vessels in children with congenital cardiovascular disease.
Physicians can use use cardiac MRI: 
  • examine the size of the heart chambers and the thickness of the heart wall.
  • determine the extent of myocardial (heart muscle) damage caused by a heart attack or progressive heart disease.
  • detect the buildup of plaque and blockages in blood vessels.
  • assess a patient's recovery following treatment. 
  • assess the heart anatomy, muscle function, heart valve function and vascular blood flow both before and after surgical repair of congenital cardiovascular disease in children.
Benefits
  • MRI is a noninvasive imaging technique that does not involve exposure to ionizing radiation.
  • MRI images of the heart are generally clearer than with some other imaging methods for certain conditions. This advantage makes MRI an invaluable tool in early diagnosis and evaluation of certain cardiac abnormalities, especially those involving the heart muscle.
  • MRI has proven valuable in diagnosing a broad range of conditions, including cardiac anatomical anomalies (e.g., congenital defects), functional abnormalities (e.g., valve failure), tumors and conditions related to decreased blood flow.
  • MRI can help physicians evaluate both the structure of an organ and how it is working.
  • MRI enables the discovery of abnormalities that might be obscured by bone with other imaging methods.
  • The contrast material used in MRI exams is less likely to produce an allergic reaction than the iodine-based contrast materials used for conventional x-rays and CT scanning.
  • Cardiac MRI allows physicians to examine the structures and function of the heart and major vessels without risks like exposure to radiation typically associated with traditional, more invasive procedures.
Risks
  • The MRI examination poses almost no risk to the average patient when appropriate safety guidelines are followed.
  • If sedation is used there are risks of excessive sedation. The technologist or nurse monitors your vital signs to minimize this risk.
  • Although the strong magnetic field is not harmful in itself, implanted medical devices that contain metal may malfunction or cause problems during an MRI exam.
  • There is a very slight risk of an allergic reaction if contrast material is injected. Such reactions usually are mild and easily controlled by medication. If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance.
  • Nephrogenic systemic fibrosis is currently a recognized, but rare, complication of MRI believed to be caused by the injection of high doses of gadolinium contrast material in patients with very poor kidney function.
Although there is no reason to believe that magnetic resonance imaging harms the fetus, pregnant women usually are advised not to have an MRI exam unless medically necessary. Acquiring detailed images of the coronary arteries and their branches is more difficult with MRI than with cardiac CT or invasive coronary angiography.
MRI typically costs more and may take more time to perform than other imaging modalities.


Thanking for reading 
Akshaya Srikanth,
Pharm.D Internee
India

January 19, 2012

NUCLEAR MEDICINE


Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose and determine the severity of or treat a variety of diseases, including many types of cancers, heart disease, gastrointestinal, endocrine, neurological disorders and other abnormalities within the body. Because nuclear medicine procedures are able to pinpoint molecular activity within the body, they offer the potential to identify disease in its earliest stages as well as a patient’s immediate response to therapeutic interventions.

Diagnosis
Nuclear medicine, or radionuclide, diagnostic imaging procedures are noninvasive and, with the exception of intravenous injections, are usually painless medical tests that help physicians diagnose and evaluate medical conditions. These imaging scans use radioactive materials called radiopharmaceuticals or radiotracers.
Depending on the type of nuclear medicine exam, the radiotracer is either injected into the body, swallowed or inhaled as a gas and eventually accumulates in the organ or area of the body being examined. Radioactive emissions from the radiotracer are detected by a special camera or imaging device that produces pictures and detailed molecular information.
In many centers, nuclear medicine images can be superimposed with computed tomography (CT) or magnetic resonance imaging (MRI) to produce special views, a practice known as image fusion or co-registration. These views allow the information from two different exams to be correlated and interpreted on one image, leading to more precise information and accurate diagnoses. In addition, manufacturers are now making single photon emission computed tomography/computed tomography (SPECT/CT) and positron emission tomography/computed tomography (PET/CT) units that are able to perform both imaging exams at the same time. An emerging imaging technology, but not readily available at this time is PET/MRI.

Therapy
Nuclear medicine also offers therapeutic procedures, such as radioactive iodine (I-131) therapy that use small amounts of radioactive material to treat cancer and other medical conditions affecting the thyroid gland, as well as treatments for other cancers and medical conditions.
Non-Hodgkin's lymphoma patients who do not respond to chemotherapy may undergo radioimmunotherapy (RIT).
Radioimmunotherapy (RIT) is a personalized cancer treatment that combines radiation therapy with the targeting ability of immunotherapy, a treatment that mimics cellular activity in the body's immune system.

Use:
Clinicians use radionuclide imaging procedures to visualize the structure and function of an organ, tissue, bone or system within the body in order to:

Cancer
  • stage cancer by determining the presence or spread of cancer in various parts of the body localize sentinel lymph nodes before surgery in patients with breast cancer or melanoma 
  • plan treatment
  • evaluate response to therapy
  • detect the recurrence of cancer
  • detect rare tumors of the pancreas and adrenal glands

Renal
  • analyze native and transplant kidney function
  • detect urinary tract obstruction
  • evaluate for hypertension related to the kidney arteries
  • evaluate kidneys for infection versus scar
  • evaluate and follow-up urinary reflux in pediatric patients
Heart
  • visualize heart blood flow and function (such as a myocardial perfusion scan)
  • detect coronary artery disease and the extent of coronary stenosis
  • assess damage to the heart following a heart attack
  • evaluate treatment options such as bypass heart surgery and angioplasty
  • evaluate the results of revascularization procedures
  • detect heart transplant rejection
  • evaluate heart function before and after chemotherapy (MUGA)
Lungs
  • scan lungs for respiratory and blood flow problems
  • assess differential lung function for lung reduction or transplant surgery
  • detect lung transplant rejection
Bones
  • evaluate bones for fractures, infection and arthritis
  • evaluate for metastatic bone disease
  • evaluate painful prosthetic joints
  • evaluate bone tumors
  • identify sites for biopsy
Brain
  • investigate abnormalities in the brain, such as seizures, memory loss and abnormalities in blood flow
  • detect the early onset of neurological disorders such as Alzheimer disease
  • plan surgery and localize seizure foci
  • evaluate post-concussion syndrome
Other Systems
  • identify inflammation or abnormal function of the gallbladder
  • identify bleeding into the bowel
  • assess post operative complication of gallbladder surgery
  • evaluate lymphedema
  • evaluate fever of unknown origin
  • locate the presence of infection
  • measure thyroid function to detect an overactive or underactive thyroid
  • help diagnose hyperthyroidism and blood cell disorders
  • evaluate for hyperparathyroidism
  • evaluate stomach emptying
  • evaluate spinal fluid flow and potential spinal fluid leaks
Nuclear medicine therapies include:
  • Radioactive iodine (I-131) therapy used to treat some causes of hyperthyroidism (overactive thyroid gland, for example, Graves' disease) and thyroid cancer
  • Radioactive antibodies used to treat certain forms of lymphoma (cancer of the lymphatic system)
  • Radioactive phosphorus (P-32) used to treat certain blood disorders
  • Radioactive materials used to treat painful tumor metastases to the bones
  • I-131 MIBG (radioactive iodine laced with metaiodobenzylguanidine) used to treat adrenal gland tumors in adults and nerve tissue tumors in children.
Benefits
  • Nuclear medicine examinations offer information that is unique—including details on both function and structure—and often unattainable using other imaging procedures.
  • For many diseases, nuclear medicine scans yield the most useful information needed to make a diagnosis or to determine appropriate treatment, if any.
  • Nuclear medicine is less expensive and may yield more precise information than exploratory surgery.
  • Nuclear medicine offers the potential to identify disease in its earliest stage, often before symptoms occur or abnormalities can be detected with other diagnostic tests.
  • By detecting whether lesions are likely benign or malignant, PET scans may eliminate the need for surgical biopsy or identify the best biopsy location.
Risks
  • Because the doses of radiotracer administered are small, diagnostic nuclear medicine procedures result in low radiation exposure, acceptable for diagnostic exams. Thus, the radiation risk is very low compared with the potential benefits.
  • Nuclear medicine diagnostic procedures have been used for more than five decades, and there are no known long-term adverse effects from such low-dose exposure.
  • The risks of the treatment are always weighed against the potential benefits for nuclear medicine therapeutic procedures. You will be informed of all significant risks prior to the treatment and have an opportunity to ask questions.
  • Allergic reactions to radiopharmaceuticals may occur but are extremely rare and are usually mild. Nevertheless, you should inform the nuclear medicine personnel of any allergies you may have or other problems that may have occurred during a previous nuclear medicine exam.
  • Injection of the radiotracer may cause slight pain and redness which should rapidly resolve.
  • Women should always inform their physician or radiology technologist if there is any possibility that they are pregnant or if they are breastfeeding. See the Safety page for more information about pregnancy, breastfeeding and nuclear medicine exams.
Thanks for reading..
Please share your comments
Akshaya Srikanth Bhagavathula
Hyderabad, India


NEED OF PHARMACOVIGILANCE

Medicines safety is an important issue, Because of intense competition among pharmaceutical manufacturers, products may be registered and marketed in many countries simultaneously. As a result, adverse effects may not always be readily identified and so are not monitored systematically. Pharmacovigilance is a structured process for the monitoring and detection of adverse drug reactions (ADRs) in a given context. Data derived from sources such as Medicines Information, Toxicology and Pharmacovigilance Centres have great relevance and educational value in the management of the safety of medicines. Medicine related problems, once detected, need to be assessed, analysed, followed up and communicated to regulatory authorities, health professionals and the public. Pharmacovigilance includes the dissemination of such information. In some cases, medicines may need to be recalled and withdrawn from a market, a process that entails concerted action by all those involved at any point in the medicines supply chain. Pharmacists have an important contribution to make to post-marketing surveillance and pharmacovigilance. The value of professional pharmacist services. Through its impact on individual patients’ state of health, pharmaceutical care improves the quality and cost-effectiveness of health care systems. Improvements at the micro-level impinge on the overall situation at the macro-level, i.e., communities benefit when individuals within them enjoy better health. Ultimately the population at large will also benefit as system-wide improvements occur. Pharmacists’ services and involvement in patient centered care have been associated with improved health and economic outcomes, a reduction in medicine-related adverse events, improved quality of life, and reduced morbidity and mortality.These accomplishments have been achieved through gradual expansion of traditional roles and, in some cases, through the emergence of collaborative drug therapy management programmes. Nonetheless, the potential for pharmacists to effect dramatic improvements in public health remains largely untapped. 
A recent review investigated the effectiveness of professional pharmacist services in terms of consumer outcomes, and where possible, the economic benefits. Its key findings illustrate the value of a range of services, including continuity-of-care after hospital discharge and education to consumers and to health practitioners. Overall, this review demonstrates that there is considerable high quality evidence to support 
the value of professional pharmacy services in improving patient outcomes or medication use in the community setting. Elsewhere, an Australian study on the economic impact of increased clinical intervention rates in community pharmacy found that adequately trained and remunerated pharmacists generated savings (on health care, medicines and pharmacy practice costs) six times greater than those of a control group with 
no access to the same education or remuneration. It was estimated that adequately trained and remunerated pharmacists would save the health care system 15 million Australian dollars (approx. US$100 million) a year.23 Similar findings are reported from the USA.
by
Akshaya Srikanth
Pharm.D Internee

PHARMACY PRACTICE STILL A CHALLENGE IN INDIA

With a decade of introduction of pharmacy practice education in India, there has been a paradigm shift in 
the practice of pharmacy in the country. In spite of this, pharmacy practice education faces many 
challenges before it can transform the pharmaceutical care practice in India from a product-oriented 
approach to patient-oriented care. Pharmacy education in India is mainly industry oriented. The
curriculum at the undergraduate level is more or less designed for preparing students towards industry 
rather than for patient-oriented services like hospital, clinical, and community pharmacy. To train the 
graduate pharmacists to provide patient-oriented services, a pharmacy practice course was started at a postgraduate level. Pharmacy practice curriculum enters its tenth year in India since its beginning in 1997. 
The curriculum trains the postgraduates in rational therapeutics, patient counseling, pharmacovigilance, 
therapeutic drug monitoring, clinical research,and toxicology to name a few. With the efforts being on
introducing the advanced clinical-based courses of the Doctor of pharmacy (PharmD) degree in India, there is a need to contemplate where the profession stands at this juncture. As of today pharmacy practice is at a 
crossroads in India, facing numerous challenges that need to be addressed before marching further. This 
letter is an effort to identify deficiencies, regulatory requirements, and evaluate the current status of pharmacy practice education in India. 

Some key-Insights like:
  • The profession is restricted only to the hospitals linked to a pharmacy practice school
  • Regulatory framework does not recognize the need for clinical pharmacist at the national level
  • Trained clinical pharmacists toward industry as there is almost no opportunity in the hospital setting
  • The need for adding industry relevant topics in course curriculum – Dilemma of Dilution vs. Evolution.
Please add some of your comment relevant to this topic..

Thanking you
Akshaya Srikanth
Pharm.D Internee
Hyderabad, India

Pharmacy Scope Today & Tomorrow

“Some Say, pharmacy is a field.
 Some say, pharmacy is carrier.
 Some say, pharmacy is science.
But I say, ‘Pharmacy is the world of medicine’.”
Pharmacists are health professional who practice the science of pharmacy. In their traditional role, pharmacists typically take a request for medicine from a prescribing health care provider in the form of a medical prescription evaluate the appropriateness of the prescription, dispense the medication to the patient and counsel them on the proper use and adverse effects of that medication. In this role pharmacists act as a learned intermediary between physicians and patients and thus ensure the safe and effective use of medications. 
Pharmacists also participate in disease-state management, where they optimize and monitor drug therapy or interpret medical laboratory results - in collaboration with physicians and/or other health professionals. 
Advances into prescribing medication and in providing public health advice's and services are occurring in Britain as well as the United States. Pharmacists have many areas of expertise and are a critical source of medical knowledge in clinics, hospitals, medical laboratory and community pharmacies throughout the world. Pharmacists also hold positions in the pharmaceutical industry as well as in pharmaceutical education and institutions.
The development of pharmacy is not uniform in world wide. In U.K & U.S.A it is well developed while in India nobody knows about it. In current scenario of India Pharmacy do not have its own identity. It is recognized by ‘chemical stores’ or ‘drug stores’. It is the place where the drug is purchased in the form of medicine following prescription or sometimes non-prescribed drugs are also given. To ignorant people, they are giving the cheapest quality drug having no significant therapeutic activity. They are doing just for getting the profit. The pharmacist has lost his professional standing primarily because the patient cannot visualize as a “tradesman and professional simultaneously”, so pharmacist presently are embracing changing professional role. Several factors impair the adoption of new role including lack of consensus regarding the pharmacy professional goals. Number of steps need to be consider as pharmacy prepare to shift towards the profession wide, patient centered practice model.

Pharmacists are trained in pharmacology, pharmacognosy, pharmaceutical chemistry, microbiology, pharmacy practice (including drug interaction, medicine monitoring, medication management), pathophysiology, anatomy, biochemistry, pharmacokinetics, drug delivery, pharmaceutical care, and compounding medications. Additional curriculum covers diagnosis with emphasis on laboratory tests, disease state management, therapeutics and prescribing (selecting the most appropriate medication for a given patient).

One of the most important roles that pharmacists are currently taking on is one of pharmaceutical care. Pharmaceutical care involves taking direct responsibility for patients and their disease states, medications, and the management of each in order to improve the outcome for each individual patient. Pharmaceutical care has many benefits that include but are not limited to:
  •        Decreased medication errors
  •        Increased patient compliance in  medication regimen
  •        Better chronic disease state management
  •        Strong pharmacist-patient relationship
  •        Decreased long-term costs of medical care
Pharmacists are often the first point-of-contact for patients with health inquiries. This means that pharmacists have large roles in the assessing medication management in patients, and in referring patients to physicians. These roles may include, but are not limited to:
  1. Clinical medication management
  2. The assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical medication management required.
  3. Specialized monitoring of disease states
  4. Reviewing medication regimens
  5. Monitoring of treatment regimens
  6. Delegating work
  7. General health monitoring
  8. Compounding medicines
  9. General health advice
  10. Providing specific education to patients about disease states and medications
  11. Oversight of dispensing medicines on prescription
  12. Provision of non-prescription medicines
  13. Counseling and advice on optimal use of medicines
  14. Advice and treatment of common ailments
 In addition, it is also widely believed that pharmacists can make a great contribution to the provision of the primary health care, especially in developing countries. Their role varies in different parts of the world: some deal with the preparation and supply of medicines, while some focus on sharing pharmaceutical expertise with doctors and patients. Some of the major issues identified as barriers to effective pharmacy practice models in these countries include an acute shortage of qualified pharmacists and no implementation of dispensing separation practices - especially in countries where the pharmacist is not the sole dispenser and medical practitioners are allowed to dispense as well - and a lack of standard practice guidelines. Pharmaceutical services in developing countries face some specific challenges unlike those faced by pharmacists in the developed world. The current era of globalization has witnessed evolution in the professions of the health sector, especially in pharmacy. Whereas previously the pharmacist worldwide was seen as responsible primarily for manufacturing and supplying medicines, today the pharmacist's role has evolved towards a clinical orientation. The profession is still under continuous transition. With change in the health demands, pharmacists have a further role to play in patient care. The precise role of a pharmacist in the health setting is altering and varies significantly from country to country. In contrast to the developed world, pharmacists in developing countries are not fully executing their potential role. They are still struggling for the recognition of their role that can help improve the health care system. Along with lack of human resources, the profession seriously lacks government interest in many countries. Access to and appropriate use of medicine is among the major health sector problems in most of the developing countries. The health care system without pharmacists is unable to cope effectively with most medicine-related issues. Thus, involvement of skillful and authoritative pharmacists in therapeutic procedures is necessary to improve appropriate use of medicines, eliminate medication errors, make proper use of the medicine.
In future pharmacy will play key role in generating drug librarary for developing novel drug candidate during drug development process. In the coming decades, pharmacists will be become more integral within the health care system. 







Thanks for reading...
by
Akshaya Srikanth,
Pharm.D Internee,
FIP-YPG Project associate,
Hyd, India.

January 17, 2012

The drugs don't work - so what will?


Antibiotics have been one of the greatest success stories in medicine.
But there is growing concern that the drugs' usefulness is coming to an end.
It has been reported that antibiotic resistance has reached "unprecedented levels". Last year in Europe more than 25,000 people died of bacterial infections that were resistant to antibiotics.

source: http://www.bbc.co.uk/news/health-13005739
As the director general of the World Health Organisation, Dr Margaret Chan, put it: "The world is heading towards a post-antibiotic era in which many common infections will no longer have a cure and, once again, kill unabated."
During the last decade, MRSA became one of the most feared words in hospitals.
The latest concern is NDM-1. It is resistant to one of the more powerful groups of drugs, carbapenem antibiotics, and has been detected in UK patients.
Why not produce more antibiotics?
One solution to antibiotic resistance is to develop new drugs.
The eminent microbiologist Professor Hugh Pennington told the BBC: "There are no new antibiotics coming along and we've run out of easy targets.
"Pessimism is the order of the day, we're holding the line, but we're not gaining."
However, Professor Chris Thomas, molecular geneticist at the University of Birmingham, says that while a degree of complacency did set in: "There is a pipeline of new antibiotics from the evidence I've seen. There are new ways of developing drugs and new drugs have come through."
Drug manufacture almost inevitably depends on the pharmaceutical industry and unfortunately there are problems with the present business model.
To take a drug from discovery to market is estimated to cost £700m.
Colin McKay, from the European Federation of the Pharmaceutical Industries and Associations, said: "It is very difficult to make economically viable models for antibiotics."
"With heart medication or anti-depressants a lot of people take them for a long time so you can make money back. An antibiotic that works is unlikely to be used for more than a couple of weeks."
He added: "A new way to promote research is needed and there is an ongoing debate into how to do it."
Virus vs Bacteria
Viruses have long been touted as a solution to antibiotic resistance.
Bacteriophage are a group of viruses which infect and kill bacteria. They were discovered in 1915 in the former Soviet republic of Georgia and have remained part of medical practice there.
However, research on them was largely abandoned in the West due to the success of antibiotics.
Clinical trials on phage are taking place, but the subject area has attracted some critics who say the field has not delivered.
Dr Martha Clokie, a microbiologist at the University of Leicester working on phage for Clostridium difficile, said: "That criticism is fair, there has been a lot of talk and hyperbole about phage, but recently there is increasing evidence that they do work."
"It's an exciting time to be in this area, I hope the criticism won't be accurate soon. I'm very optimistic that phage have a future."
Vaccines
Vaccination has also attracted a lot of publicity.
Just like for seasonal flu, a vaccine would be developed for superbugs.
This could be taken before going into hospital for surgery.
In 2008, the then chief medical officer for England, Sir Liam Donaldson, said vaccines for MRSA and C. difficile should be ready within a decade.
Surveillance and hygiene
Monitoring antibiotic resistance in the UK is the responsibility of the Health Protection Agency.
Its executive director of microbiology services, Christine McCartney, said: "The emergence of antibiotic resistance, especially against carbapenems, is a major public health concern.
"Antibiotic resistance makes infections much harder to treat and its spread underscores the need for good infection control in hospitals."
Prof Pennington said: "We need to stop patients passing bugs on. It needs very strict rules with patients kept in isolation and barrier nursing. We need to sharpen infection control practices."
Prof Thomas argues that "hygiene appears to be responsible for the reduction in MRSA cases" and that "we need to get back to careful nursing."
He concluded: "We need to pursue every possible link, having one strategy is like having all your eggs in one basket."
Source: BBC News UK
by Akshaya Srikanth, Pharm.D Candidate

Paracetamol warning: 'Slightly too much can cause overdose'


Taking slightly too much paracetamol day after day can be fatal, experts have warned.
A dangerous dose might just be a few pills too many taken regularly over days, weeks or months, they said.
Researchers at Edinburgh University saw 161 cases of "staggered overdose" at its hospital over a 16-year period.
People taking tablets for chronic pain might not realise they were taking too many or recognise symptoms of overdose and liver injury, they said.

The researchers told the British Journal of Clinical Pharmacology that this life-threatening condition could be easily missed by doctors and patients.
Doctors may not initially spot the problem because blood tests will not show the staggeringly high levels of paracetamol seen with a conventional overdose, where someone may have swallowed several packets of the drug.

Start Quote

Over time the damage builds up and the effect can be fatal”
Lead researcher Dr Kenneth Simpson
Patients who have taken a staggered overdose tend to fare worse than those who have taken a large overdose, the study suggests.
Dr Kenneth Simpson and colleagues looked at the medical records of 663 patients who had been referred with paracetamol-induced liver injury to the Scottish Liver Transplantation Unit at the university hospital.
The 161 who had taken a staggered overdose were more likely to develop liver and brain problems and need kidney dialysis or help with their breathing. They were also more likely to die of their complications.
Dr Simpson said: "They haven't taken the sort of single-moment, one-off massive overdoses taken by people who try to commit suicide, but over time the damage builds up, and the effect can be fatal."
Professor Roger Knaggs of the Royal Pharmaceutical Society said patients should heed the warning.
"If people experience pain and paracetamol doesn't help, rather than thinking a 'top up' dose may work, they should consult their pharmacist for alternative pain control or referral to someone who can help with the cause of the pain.
"The message is clear: if you take more paracetamol than is recommended, you won't improve your pain control but you may seriously damage your health.
"At this time of year people should also take care with combination cold and flu products which may have paracetamol as one of the ingredients. It's easy to take more than intended, so if in doubt consult your pharmacist."
Recommended dose
  • Take paracetamol as directed on the packet or patient information leaflet that comes with the medicine
  • Each tablet usually contains 500mg
  • Adults can take 1-2 tablets of paracetamol 4-6 hourly, up to four times a day
  • This means you should not take more than 8 tablets (4g) in a 24-hour period
  • If you accidentally take an extra dose of paracetamol, you should miss out the next dose so that you do not take more than the recommended maximum dose for a 24-hour period.
Source: BBC News
by
Akshaya Srikanth
Pharm.D Internee


January 16, 2012

How To Find Your Dream Career

Before we begin let’s just agree on one thing. There are no quick answers to how to find your dream career. Finding your dream career is a process. How lengthy this process is depends on how sincere you are with yourself. It also depends on how much you are willing to sacrifice in pursuit of your dream career.
1. The Toughest Part - Know What You Want
The toughest part about finding your dream career isn’t about finding the dream career. It is about finding yourself. Do you know what you want? This is the first question you need to ask yourself. It is a seemingly easy question many answer by mentioning what they DON’T WANT instead of what they WANT. But that is not the answer that will ensure you to find your dream job.
Knowing what you don’t want does not mean you easily arrive at what you want.Unfortunately, the process of elimination does not work in finding your dream career. You can go through a thousand “don’t wants” and still not hit it. How to find your dream career? Start by knowing what you want!
2. Know Your Values
If you feel a little lost with finding what you want, start by knowing your values. Ask yourself, what do you really value? Time? That’s a common answer I get and a good one too. We all want more time for ourselves and family. So, if you value time then you know the dream career you are looking for must offer more time. Is that all? List a set of values you treasure. Then things will begin to fall in place. You have defined what it is that will fit in these criteria.
3. Know How Much You Are Willing To Sacrifice
Do you have the knowledge and skill set that fit the needs of your dream career? If you do not, how much are you willing to sacrifice in order to add those skill set in your repertoire? How to find your dream career is easy. How much you are willing to sacrifice in order to achieve it is tough to answer.
4. Do It For The Right Reasons
The trigger to how to find your dream career should never be money. It should not be because you are currently unhappy with your salary and hence you want a dream career that pays you an enormous amount of money. Money should never be the motivation. Make passion a motivation but never money.
5. The Easiest Part
If you know what you want, what you value and you do it for the right reasons – then this is the easy part. Here are your “3 Steps Guide to How To Find Your Dream Career” so to speak.
Do Your Research
Find out about the industry. Do you have friends in the industry? Find out what are the expectations, the knowledge and skills needed. The Internet is also the perfect place to start. You can read books focused on your dream career or check out sites offering career advice on certain industries. For example, the site - Job Application and Interview Advice is a compelling site written to help people Snag A Job every day. It covers all aspects of how to snag a job including job applications forms, resumes, cover letters and interview questions and answers.
Network With People In The Industry
Get to know people in the industry so you get a feel of what it is like upfront. This also sets you up for potential short-term work when the opportunity arises for some hands on experience before you make that leap. I have personally allowed friends based on recommendations to visit us after office hours. This allows them to see what it is like in our industry and to speak in depth with staff from various departments in order to understand our line.
Create A Plan To Pursue Your Dream Career
Now that you know how to find your dream career, create a plan to achieve it. How do you plan to add new skill sets? How do you plan to apply for the job? When would be able to get practical training, if that’s a requirement? Develop a plan and act upon it!
I hope it will motivate you all.
Thanks for reading
AKSHAYA SRIKANTH
Pharm.D aspirant

Pursuing Career Success the Right Tools are Important for Your Career Success


Life in the working world is very different from school or college. There are no clear rules so to speak. But there are guidelines and principles you can follow to increase your chances of career success.

Based on our real life experiences, we want to provide you with guidelines, advice and tips to help you ease into the working world. In the hope this will help you achieve career success.

This is our toolbox, tools we have used in the course of our own pursuit of a successful career. The tips, techniques and advice are geared for you to be a success with bosses, colleagues, clients and foes.

While we can share our experiences with you, YOU need to belief that you are in charge of your own destiny. Everything starts and ends with you. You are the one in control, no one else. We do not have magic formulas here you can learn in a night and be on your way to greatness. But what we know is this - the advice, tips and techniques here are used by ourselves. We aim to guide you towards a successful career, work and life.

We have collected them for you to freely use in pursuing career success. You are your own career builder; we are the supplier of the tools. You need to decide which tools to use, which suits you best and then put them into action.

There are three things we ask of you:

1. Bring Enthusiasm. Unless you are interested to improve yourself and attain success, no amount of reading can help you.

2. Take Action. Internalize the relevant materials. Then decide to take action. Nothing happens until you act upon that change you desire.

3. Be Patient. Nothing happens overnight. Success like many things in life takes time. Drop by drop an empty bucket is soon filled with water. Small steps at a time. Pursuing career success is a marathon. Not a sprint.

As you peek around you will see things in a different perspective, so you can enjoy and feel more satisfied pursuing career success. Well, come on in and let’s get started!

Hope you enjoy reading..

Thanking you
Akshaya Srikanth,
Pharm.D Internee