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Objective: There is no definitive pharmacological strategy for COVID-19; thus, medicinal herbs can be an appropriate option for COVID-19 management. We investigated the efficacy of a D-reglis® tablet (root extract of licorice) as adjuvant therapy in critically ill patients with COVID-19 at intensive care units (ICUs) of Alzahra Teaching Hospital affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. Methods: In the present double-blind, randomized, placebo-controlled clinical trial, critically ill cases with COVID-19 (n = 52) received a D-reglis® tablet (760 mg) or a placebo tablet for 5 days. The ICU stay length was the primary outcome. The secondary outcome included the changes in oxygen saturation, duration of mechanical ventilation, mortality rate, and Sequential Organ Failure Assessment (SOFA) Score during the study period. Findings: The ICU stay was significantly lower in the licorice group than in the placebo group (P = 0.015). No significant difference was detected between the groups regarding oxygen saturation, SOFA score, duration of mechanical ventilation, and mortality rate. Conclusion: The licorice tablet (D-reglis®) as an adjuvant treatment showed promising results regarding the ICU stay length in critically ill COVID-19 patients. However, further clinical trials with larger sample sizes, further duration of intervention, measurement of inflammatory markers, and further study about the molecular mechanism of the effect of licorice on COVID-19 should be done to obtain more conclusive findings.

Background: Migraine is the second most common cause of headache, various methods have been mentioned for the treatment of migraine, including herbal medicine. Iaraj Fiqra is a combination of Aloe, saffron, cinnamon, mustalci, balsam incense and asaroon and claim to be effective in migraine. The present study aims to compare the effect of Iaraj Fiqra and placebo tablets on migraine headache. Methods: In this randomized, controlled trial, patients with migraine (based on the International Headache Society definition) received Iaraj Fiqra (500mg/daily) or placebo tablets for two months. Headache characteristics were measured using the Migraine Disability Assessment (MIDAS) and Headache Impact Test-6 (HIT-6). Results: Iaraj Fiqra reduced significantly the frequency (P=0.007), the severity (P=0.000) and the duration (P=0.000) of attacks compared to placebo. MIDAS and HIT-6 scores were significantly reduced in the drug group other than the placebo group (P=0.014 and P=0.000 respectively). Analgesic use also reduced. No significant difference was observed between the two groups in term of side effects (P=0.23). Conclusion: This study showed that Iaraj Fiqra had significant effects on reducing headache characteristics and analgesic use and given its limited side effects, it is recommended for the treatment of migraine. J Pharm Care 2024; 12(1): ?.

Aim:This study was performed to evaluate the effectiveness of topical lidocaine-ibuprofen (LI) combination compared the lidocaine-prilocaine (LP) combination Xyla-P in the reduction of the pain during central venous catheter (CVC) insertion.Materials and Methods:In this randomized clinical trial, 100 adult patients requiring CVC insertion in the emergency department were enrolled. The patients were randomly divided into two groups. The site of CVC insertion was covered with topical Xyla-P cream (2 g) in the first group, and topical LI (2 g) cream in the second group. The primary outcome was the assessment of pain during CVC implantation. The secondary outcomes were physician’s satisfaction and the incidence of side effects.Results:The mean age was 41.67±9.66 years (range 18-61), and 36% of patients were female. The mean visual analog scale (VAS) pain score during CVC insertion was 4.61±2.05 in the LP group and 3.86±2.09 in the LI group, respectively [mean difference of 0.75 (95% confidence interval (CI): -0.80 to 1.56)]. The mean VAS pain score during lidocaine injection was 1.78±0.79 in the LP group and 1.52±0.79 in the LI group, respectively [mean difference of 0.26 (95% CI: -0.05 to 0.57)]. The physician’s satisfaction did not show statistically significant differences between two groups.Conclusion:This study showed that topical LI is as effective as Xyla-P in relieving acute pain during CVC insertion.

Purpose: Oxidative stress-induced mitochondrial damage is the main event in acquired brain injuries (ABI). This study aimed to evaluate the effects of melatonin, a mitochondria-targeted antioxidant, on mitochondrial and brain injury markers, and the clinical outcomes of patients with ABI. Methods: In this randomized controlled trial, intensive care unit (ICU) or neurology patients with ABI (n=60) received melatonin (21 mg/day) or placebo tablets, within the first 72 hours of injury onset for five days. As a primary endpoint, serum levels of malondialdehyde (MDA), S100B and C-reactive protein (CRP) were compared at baseline, and after five days’ intervention. Secondary endpoints included assessment of Glasgow Coma Scale and Sequential Organ Failure Assessment (at the end of day 5), Rancho Los Amigos Revised Scale and modified Rankin Scale (at the end of month 3), the duration of mechanical ventilation, the lengths of ICU and hospital stays, and in-hospital and three-month mortality. Results: There were no significant effects of melatonin on the primary and secondary outcomes. However, the subgroup analysis showed a significant reduction in S100B in patients with non-traumatic brain injuries, receiving melatonin versus placebo (p: 0.016). Conclusion: This study showed that melatonin supplementation in the early phase of brain injury had no significant effects on the injury markers and clinical outcomes of patients with ABI. However, it reduced the level of S100B in the non-traumatic subgroup. Further larger-scale studies are needed to determine the effects of melatonin on the ABI and its subgroups.

Background: Cisplatin (CP) is a potent antineoplastic agent in the treatment of wide a range of cancers, but it is accompanied with nephrotoxicity, a major limiting side effect. The aim of the present study was to evaluate the possible protective effect of vitamin E in the prevention of CP-induced nephrotoxicity. Method: In this randomized clinical trial, a total of 51 patients treated with CP chemotherapy were randomly assigned to receive vitamin E supplementation (400 Iu/ daily) (N=26) or placebo (N=25). Serum creatinine, glomerular filtration rate (GFR), and neutrophil gelatinase-associated lipocalin were measured prior to each chemotherapy cycle and one month after the cessation of the cycles. Result: Compared to the baseline, a significant decrease was observed in the blood levels of neutrophil gelatinase-associated lipocalin and serum creatinine in the vitamin E group (P=0.001). GFR was not reduced in the vitamin E group (P=0.001), and vitamin E was generally tolerated well. Conclusion: Our findings indicated that vitamin E exert protective effects against CP-induced nephrotoxicity, a finding which requires larger studies for confirmation.

Background. Since the beginning of the novel coronavirus (SARS-CoV-2) disease outbreak, there has been an increasing interest in discovering potential therapeutic agents for this disease. In this regard, we conducted a systematic review through an overview of drug development (in silico, in vitro, and in vivo) for treating COVID-19. Methods. A systematic search was carried out in major databases including PubMed, Web of Science, Scopus, EMBASE, and Google Scholar from December 2019 to March 2021. A combination of the following terms was used: coronavirus, COVID-19, SARS-CoV-2, drug design, drug development, In silico, In vitro, and In vivo. A narrative synthesis was performed as a qualitative method for the data synthesis of each outcome measure. Results. A total of 2168 articles were identified through searching databases. Finally, 315 studies (266 in silico, 34 in vitro, and 15 in vivo) were included. In studies with in silico approach, 98 article study repurposed drug and 91 studies evaluated herbal medicine on COVID-19. Among 260 drugs repurposed by the computational method, the best results were observed with saquinavir (n = 9), ritonavir (n = 8), and lopinavir (n = 6). Main protease (n = 154) following spike glycoprotein (n = 62) and other nonstructural protein of virus (n = 45) was among the most studied targets. Doxycycline, chlorpromazine, azithromycin, heparin, bepridil, and glycyrrhizic acid showed both in silico and in vitro inhibitory effects against SARS-CoV-2. Conclusion. The preclinical studies of novel drug design for COVID-19 focused on main protease and spike glycoprotein as targets for antiviral development. From evaluated structures, saquinavir, ritonavir, eucalyptus, Tinospora cordifolia, aloe, green tea, curcumin, pyrazole, and triazole derivatives in in silico studies and doxycycline, chlorpromazine, and heparin from in vitro and human monoclonal antibodies from in vivo studies showed promised results regarding efficacy. It seems that due to the nature of COVID-19 disease, finding some drugs with multitarget antiviral actions and anti-inflammatory potential is valuable and some herbal medicines have this potential.

Introduction: Various methods of analgesia can be used to reduce or prevent procedural pain in emergency department (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combination compared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter (CVC) insertion. Methods: In this randomized clinical trial, 100 adult patients requiring CVC insertion in the ED were enrolled. These patients were randomly divided into two groups. The site of CVC insertion was covered with 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the second group. The primary outcome was the pain during CVC implantation. The secondary outcomes were physician satisfaction and the incidence of side effects. Results: On the visual analog scale (VAS), the pain score during CVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in pain scores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant difference in the rate of side effects between the two groups (p = 1.0). The physician’s satisfaction with the first group was significantly lower than the second group (p = 0.042). Conclusion: Although the CVC insertion pain was significantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there was no clinically important difference between the two groups and both topical anesthetics were effective and safe in reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-P cream.

Objective: This study aims to evaluate current pain assessment and management in critically ill patients and to describe (1) pain management episode, according to the behavioral pain scale (BPS), and (2) the effectiveness of analgesics, according to the recommendation of guidelines. Methods: In this cross-sectional study, a sample of 60 intubated critically ill patients was selected from the intensive care units (ICUs). A researcher evaluated the patient' pain severity using the BPS tool in patients receiving analgesics according to nurses' note. At each time of analgesic administration, the BPS score was recorded, and this process was repeated 72 h later. The appropriateness of pharmacological interventions was assessed according to the American College of Critical Care Medicine guideline. Findings: The most prescribed analgesic was morphine sulfate (48.3%) followed by fentanyl (23.3%). 55% of analgesics on day 1 and 25% on day 3 were prescribed appropriately according to the guideline recommendation and BPS score. Morphine was the most effective drug (17 patients out of 29). Even though a BPS score was

Background: Drug Utilization Evaluation (DUE) studies are designed to assess drug usage appropriateness. This study aimed to evaluate the drug utilization of antibiotics in the intensive care units (ICUs) of a referral teaching hospital.Methods: Patients hospitalized in ICU who received antibiotics were enrolled in this cross-sectional study. Patients’ medical charts were reviewed and data including indication of antibiotics, dosing, dose adjustment, and culture sensitivity test were recorded in a predesigned data collection form. Related guidelines and references were used for judgement about the correctness of these parameters.Results: Among 182 evaluated antibiotic prescriptions, 75.8% of the cases were prescribed empirically that for 31.88% of them, microbial culture and sensitivity test were requested. Indication was appropriate in 51.6%. Fifteen patients needed antibiotic dose adjustment that was performed just for 4 patients. Doses of antibiotics were correct in 58.5% of cases. Meropenem (15.9%), Metronidazole (15.9%), and vancomycin (11.5%) were the most frequently prescribed antibiotics.Conclusion: Use of antibiotics in ICUs of our hospital is associated with high rate of errors especially in the aspects of medical indication and dosage.

Objective: Recent studies have shown that serum cystatin C (Cys C) is a better marker for measuring the glomerular filtration rate and may rise more quickly with acute kidney injury (AKI). The purpose of this study was to evaluate the clinical application of serum Cys C to predict colistin-induced nephrotoxicity in comparison with serum creatinine (SCr). Methods: Thirty-two adult patients with no history of acute or chronic kidney injury having been planned to receive intravenous colistin for an anticipated duration of at least 1 week for any indication were recruited. At baseline and 5 days after colistin treatment, serum Cys C as well as creatinine levels were measured. The incidence of colistin-induced acute renal failure was defined according to the AKIN criteria for SCr. Rise in concentration of Cys C by more than 10% from baseline considered as AKI. Findings: Colistin-induced nephrotoxicity (defined as SCr ≥0.3 mg/dl) occurred in 6 patients (18.8%). A Cys C increase concentration ≥10% after 5 days of colistin treatment was detected in 15 patients (46.9%). There was a poor agreement between the presence and absence of any SCr-AKI and Cys C-AKI (κ = 0.28, P = 0.04). Conclusion: Serum Cys C is a better marker of renal function in early stages of AKI and predictive of persistent AKI on colistin treatment.

Introduction: fluoroquinolones have many adverse effects include the gastrointestinal tract and the central nervous system, phototoxicity, and dermal toxicity. Levofloxacin has favorable adverse reaction profiles compared to other fluoroquinolones. Among the reported dermal toxicity, there are few reports of TEN in association with levofloxacin usage. However, there is no published study on levofloxacin induced stomatitis. Stomatitis is characterized by pain, inflammation, and ulceration in the oral cavity. It can affect patient ability to eat, talk or daily workout. Hence, caution is advised while administering drugs with this potential adverse effect. Case Presentation: A 36-year-old man was referred to the hospital for ‘painful oral swelling and ulceration’. Before the admission due to a fever and productive cough, 750 mg levofloxacin were prescribed for him. After 2 days of consumption, the patient experiences painful ulcerative and erythema lesions in the oral cavity that consistent with stomatitis. Upon hospitalization, the patient only had 38 degrees and all laboratory value was in normal ranges except ESR, that was 89. Due to the possibility of a drug reaction, levofloxacin was discontinued and no other antibiotic was used. Oral lesions were managed with mouthwash and after 5 to 7 days, lesions recovered. Conclusions: To the best of our knowledge, this is the first case of a patient who developed stomatitis adverse drug reaction after two doses of levofloxacin and recovered just with topical therapy and without any systemic treatment. Further fluoroquinolone use should be avoided in such patients.

Background: Drug-drug interactions (DDIs) may often lead to preventable adverse drug events and health damage. Particularly in hospitals, this might be an important factor as multiple drug therapies are common. The objective of this study was to identify the frequency and levels of potential DDIs in internal medicine wards in an Iranian university hospital. Methods: A cross-sectional study was conducted by reviewing charts of 448 hospitalized patients in internal medicine wards of a teaching hospital, from November 2014 to May 2015. “Lexicomp drug interaction software” and Micromedex Drug-Reax system were used for screening the potential DDIs. The identified DDIs were categorized by level of severity. Logistic regression was applied to determine the odds ratio for specific risk factors of potential DDIs e.g., age, gender, hospital stay and number of medications. Results: The mean age of patients was 61 years, the length of hospital stay for patients was 9 days and the number of drugs per patient was 9. Potential interactions were detected in 386 patients. The most common types of interactions were type C (78.6%), moderate (60.9%) and delayed onset (56.5%). There was a significant association of the occurrence of potential DDIs with seven or more numbers of prescribed medications (OR: 0.048, 95% CI:0.02-0.12, p

Objective: Antimicrobial prophylaxis has been demonstrated to lower the incidence of postoperative infection in nearly all types of surgery. The American Society of Health-System Pharmacists (ASHP) guideline summarizes current data on the appropriate use of antibiotic for surgical prophylaxis. The objective of this study was to assess and audit the use of antibiotics in a tertiary care center according to the recommendation of ASHP guideline. Methods: This cross-sectional study was performed using prospective data gathered from April to September 2015 in the surgical wards of Al Zahra Hospital, Isfahan, Iran. Antibiotic indication and choice, dose, dosing interval, route of administration, and timing of first administration and duration of prophylaxis were compared with the ASHP guideline recommendations. Findings: A total of 100 patients with the mean age of 49.8 ± 18.2 years were recruited for this study. About 22% of procedures had full compliance with all guideline recommendations. The most frequently encounter noncompliance type were the duration of prophylaxis (14%) and appropriate agent choice (35%). Timing of the initial dose was appropriate in most of the procedures (42%). Conclusion: This study revealed that most of the prescribed antibiotics for surgical prophylaxis are not in accordance with standard treatment guideline. The density of antimicrobial use for preoperative antimicrobial prophylaxis is very high. Furthermore, the hospital should develop a formal strategy, including a local guideline for antimicrobial prophylaxis in surgical procedures.

Objective: Dabigatran etexilate is a novel oral anticoagulant with several advantages over warfarin such as no need for routine monitoring and fewer drug interactions. This drug was added to our hospital's formulary in 2012. The objective of this study was to assess the rational drug use of dabigatran at a large teaching hospital. Methods: A prospective cross-sectional study was performed from November to June 2015 at Alzahra teaching hospital, Isfahan, Iran. All patients who received at least one dose of dabigatran were eligible for inclusion. Data were collected on patient demographics, indication, dosing regimen, adverse events, concurrent anticoagulant therapy, and laboratory data (including renal function). Findings: A total of sixty patients were included in our study. The majority of patients (n = 40, 66.7%) was prescribed dabigatran for deep vein thrombosis prophylaxis. Only one patient received dabigatran with appropriate indication, dose, and duration. Thirty-six (60%) of our patients had thrombocytopenia at the time of dabigatran initiation. We also detected that ten patients (16.7%) received this drug for heparin-induced thrombocytopenia (HIT). In 32 patients, platelet levels increased after dabigatran initiation. Only seven patients received the appropriate dose of dabigatran (regarding both indication and renal function). Conclusion: Unlabeled use and incorrect dosing of dabigatran in this study emphasize the need to develop a hospital protocol for dabigatran use within our facility. We suggest proper education of clinicians about novel drugs, pharmacist interventions, and further studies about the safety and efficacy of dabigatran for the new indication (such as HIT).

Objective: Self-medication is common among patients with gastrointestinal (GI) symptoms. This study was performed to evaluate self-medication among patients who fulfilled irritable bowel syndrome (IBS) and dyspepsia diagnostic criteria and to investigate the appropriateness of self-medication with chemical and herbal drugs. Methods: A prospective, descriptive cross-sectional study was conducted in outpatient′s GI clinics at Shiraz from November 2011 to May 2012. A GI specialist visited the patients and recruited those who had IBS (base on Rome III adapted criteria) or functional dyspepsia. We surveyed self-medication among these patients, using a questionnaire containing specific questions about self-medication. Findings: One thousand four hundred and forty-seven patients visited by the GI specialist during the study period. Seven hundred and forty-seven patients had the inclusion criteria, 337 of them fulfilled criteria for IBS, with IBS-mixed (52%) being the most prevalent subtype, and 410 patients had dyspepsia. Overall, 78.8% of the total participants had recently sought medical attention for their GI complaint. Twenty-eight percent of patients selected inappropriate medication for their GI complaints. The H2-blockers class were most common medicines reportedly used. We did not find any significant relationship between age, gender, level of education, marital status, and self-medication frequency. Conclusion: Patients who fulfilled criteria for IBS had a high tendency to self-treat their GI symptoms, use of acid-suppressive agents was common among patients. Around one-third of patients self-treated GI symptoms inappropriately. Consequently, the concept of self-medication among patients has to be revised. We recommend conduction of educational programs to improve self-medications selection and attitude among patients to reduce the burden on other health care resources.

Metronidazole is a main stay of modern multidrug therapies for Helicobacter pylori (H. pylori) infection. Metronidazole resistance reduces the effectiveness of these combinations. Various methods have been used for the determination of the sensitivity of H. pylori to metronidazole with conflicting results. The aims of this study were: 1) to compare the E-Test and disk diffusion methods for determining the susceptibility of H. pylori to metronidazole; and 2) Metronidazole resistance in H. pylori has been found to be associated with mutations in rdxA. The role of this gene in metronidazole resistance in H. pylori was examined in this study. A total of 46 H. pylori strains from 223 consecutive patients were examined. The E-Test was performed according to the manufacturer's guidelines, and the disk diffusion according to standard procedure using 5-μg metronidazole disks. DNA was extracted from all H. pylori isolates by boiling & phenol-chloroform methods and then Polymerase Chain Reaction (PCR) was performed. Metronidazole resistance as determined by E-test and disk diffusion methods was 64.3% and 47.6% respectively. None of the resistant or sensitive samples possessed rdxA gene deletion. Disk diffusion method is not reliable in determining metronidazole resistance in H. pylori. An intact rdxA gene has also been reported in metronidazole-resistant H. pylori, suggesting that additional metronidazole resistance mechanisms exist in H. pylori and even molecular methods are not reliable for the detection of resistance.

Background: Selenium (Se), mainly through its incorporation into selenoproteins, plays an important role in inflammation and immunity. Evidence has emerged regarding roles for individual selenoproteins in regulating inflammation and immunity. The aim of this study was to evaluate the response on the inflammatory biomarker C-reactive protein, and its possible impact on the incidence of delirium. Methods: This prospective, non-randomized, open-label, single-center clinical trial included 100 critically ill patients. Patients in the Selenium group (n = 50) received Se for 5 days (500 μg twice daily infused over 2 hours). Plasma levels of C-reactive protein (CRP), was determined on days 1-5. The incidence of delirium was assessed by the Confusion Assessment Method (CAM) on a daily basis. Results: CRP decreased in the selenium group from day 1 onwards. The mean of CRP was 11.1 ± 2.20 in the Se group compared to 16.7±1.6 in the control group, the difference was significant (P < 0.0001). 32% of patients in the selenium group and 52% in the control group had delirium (P = 0.07). Conclusions: Se administration in critically ill patients decreased CRP levels, but did not reduce the incidence of delirium

Background: This study aims to determine the prevalence of early (less than 4 days of hospitalization) –and late-onset (more than 4 days after hospitalization) ventilator-associated pneumonia in the intensive care units of Al-Zahra center in Isfahan. Methods: Through a prospective study, 100 patients with ventilator-associated pneumonia who were hospitalized in the intensive care units of Al-Zahra hospital during 2015 were investigated, and early and late onset pneumonia were determined. Moreover, the etiology of bacterial strains and other clinical and demographic characteristics were compared in two groups. Results: The patients, 23 and 77 suffered from late –and early-onset pneumonia, respectively. The mean score of pneumonia in the two groups (early –and late-onset pneumonia) was 7.3± 2.1 and 7.2±1.6, respectively, which showed no significant difference (P: 0.8). The most common types of bacteria that caused pneumonia were methicillin-resistant Staphylococcus aureus (MRSA) (43% of frequency) and Acinetobacter Baumannii (34% of frequency) in early –and late-onset pneumonia, respectively. However, the frequency distribution of the type of bacteria by the type of pneumonia was not significantly different (P:0.1). Conclusion: A significant percentage of pneumonia in intensive care units are of early-onset type, which can lead to patients’ prolonged hospitalization in intensive care units and it may be lead to increased mortality rate among them. Therefore, it is recommended that the patients hospitalized in intensive care units should be carefully examined in terms of the occurrence of pneumonia symptoms.

Objective: This study aim to evaluate and compare type and prevalence of drug-drug interactions (DDIs) in prescriptions dispensed in both community and hospital setting in Zabol, Iran. Methods: A total of 2796 prescriptions were collected from community and inpatient and outpatient pharmacy of Amir-al-momenin only current acting hospital in Zabol, Iran. The prescriptions were processed using Lexi-Comp drug interaction software. The identified DDIs were categorized into five classes (A, B, C, D, X). Findings: Overall 41.6% of prescriptions had at last one potential DDI. The most common type of interactions was type C (66%). The percentage of drug interactions in community pharmacies were significantly lower than hospital pharmacies (P < 0.0001). Conclusion: Our results indicate that patients in Zabol are at high risk of adverse drug reactions caused by medications due to potential DDIs. Appropriate education for physicians about potentially harmful DDIs, as well as active participation of pharmacists in detection and prevention of drug-related injuries, could considerably prevent the consequence of DDIs among patients.

Background: Granulocyte Colony Stimulating factors (GCSF) are high cost agents commonly recommended for primary and secondary prophylaxis of chemotherapy-induced neutropenia and febrile neutropenia. GCSFs have been shown to be beneficial in some patient subgroups, although they are probably overused in clinical settings. The American Society of Clinical Oncology (ASCO) guidelines summarize current data on the appropriate use of CSFs. The objective of this study was to assess and audit the use of GCSF in a tertiary care center according to recommendation of ASCO guideline. Methods: A Retrospective observational study from November 2014 to June 2015 was performed on all patients prescribed with filgrastim in the large teaching hospital (Isfahan, Iran). Data was collected on demographics, indication, dosing regimen, duration of treatment, the Absolute Neutrophil Count (ANC) and patient outcome. Results: 91 patients were recorded over the period of the study. 63.7% of prescription complied with the ASCO guideline. Febrile neutropenia post chemotherapy/radiotherapy was the most common appropriate indication (29.3%) followed by primary prophylaxis (25.8%). Fourteen (32 %) patients showed ANC recovery in 1-3 days, and 16 (37%) within 4-7 days. Ten patients (23 %) showed no recovery. The overall mortality was 8 (8.8%) patients. Conclusion: This study revealed that at least one-third of prescribed GCSF was not in accordance with ASCO guideline. Considering the high cost of GCSF in our country and limitation of our resources, we proposed cost-effectiveness studies on GCSF treatment and also development of national guideline for optimizing GCSF use.

Arginine vasopressin as a supplementary vasopressor in septic shock restores vascular tone and mean arterial pressure, meanwhile decreases dose and exposure time to catecholamines. The objective of this study was to evaluate the effect of vasopressin on lactate and lactate clearance as markers of tissue perfusion during septic shock. In this prospective, randomized, controlled trial, 30 patients with septic shock were enrolled in two groups. One group received norepinephrine infusion (titrated to reach the target MAP of ≥65 mm Hg) and the other group in addition to norepinephrine, received vasopressin at a constant rate of 0.03 u/min. Serum lactate levels were assessed at baseline, 24 and 48 hours after randomization. Lactate clearance was estimated for each patient at 24 and 48 hours. Venous lactate was measured in both groups. Despite a tendency toward higher venous lactate at 24 and 48 hours in the norepinephrine group (3.1 vs. 2.5, P=0.67 and 1.7 vs. 1.1, P=0.47), the conflict was not statistically significant among them. While lactate clearance after 24 hours was significantly higher in vasopressin treatment group (46% vs. 20%, respectively; P=0.048), the 48-hour lactate clearance did not differ from statistic viewpoints despite their clinical values (66% vs. 40%, P=0.17). Although lactate levels did not significantly differ between treatment groups, lactate clearance at 24 hours was significantly higher in vasopressin group. This may be the effect of vasopressin effect on microcirculation and tissue hypoperfusion or its catecholamine sparing effect.

Objective. The aim of our study was to assess and validate the effectiveness of early dose adjustment of vancomycin based on first dose monitoring in achieving target recommended goal in critically ill patients. Methods. Twenty critically ill patients with sepsis received loading dose of 25 mg/kg of vancomycin and then were randomly assigned to 2 groups. Group 1 received maximum empirical doses of vancomycin of 15 mg/kg every 8 hrs. In group 2, the doses were individualized based on serum concentrations of vancomycin. First dose nonsteady state sampling was used to calculate pharmacokinetic parameters of the patients within 24 hours. Results. Steady state trough serum concentrations were significantly higher in group 2 in comparison with group 1 (19.4 ± 4.4 mg/L versus 14.4 ± 4.3 mg/L) (P=0.03). Steady state AUCs were significantly higher in group 2 compared with group 1 (665.9 ± 136.5 mg·hr/L versus 490.7 ± 101.1 mg·hr/L) (P=0.008). Conclusions. With early individualized dosing regimen, significantly more patients achieved peak and trough steady state concentrations. In the context of pharmacokinetic/pharmacodynamic goal of area under the time concentration curve to minimum inhibitory concentration (AUC/MIC) ≥400 and also to obtain trough serum concentration of vancomycin of ≥15 mg/L, it is necessary to individualize doses of vancomycin in critically ill patients.

Septic shock continues to be one of the leading causes of death in the Intensive Care Units. When the shock state persists after adequate fluid resuscitation, vasopressor therapy is required to improve and maintain adequate tissue/organ perfusion in an attempt to improve survival and prevent the development of multiple organ dysfunction and failure. Various studies have suggested that exogenous administration of arginine vasopressin may be an effective adjunctive therapy to traditional catecholamines for the management of hypotension during septic shock. Vasopressin is both a vasopressor and an antidiuretic hormone. It also has hemostatic, gastrointestinal and thermoregulatory effects, and is an adrenocorticotropic hormone secretagogue. Vasopressin is released from the axonal terminals of magnocellular neurons in the hypothalamus. Vasopressin mediates vasoconstriction via V1-receptor activation on vascular smooth muscle and mediates its antidiuretic effect via V2-receptor activation in the renal collecting duct system. Vasopressin infusion of 0.01 to 0.04 U/min in patients with septic shock increases plasma vasopressin levels. Current guidelines from the Surviving Sepsis Campaign recommend arginine vasopressin 0.03 unit/minute may be added to norepinephrine with the anticipation of an effect equal to higher doses of norepinephrine alone. Clinicians must be knowledgeable about the use of vasopressin in septic shock, including controversial areas where guidelines do not always provide solid recommendations.

Background: Adverse Drug Reactions (ADRs) are one of the leading causes of morbidity and mortality and contribute to excessive health care costs. Detection and reporting of ADRs could decrease these consequences. The present study was designed to assess the Knowledge, Attitude and Practice (KAP) of pharmacy students towards ADRs monitoring and reporting. Methods: A questionnaire was prepared to investigate the Knowledge, Attitude and Practice (KAP) of pharmacy students regarding ADR reporting. The questionnaire consisting of 17 questions (7 questions on knowledge, 5 on attitudes and 5 on practice) were given to pharmacy students randomly. Results: A total of 71 respondents participated in the study. 70% of participants had favorable general knowledge about ADRs but more than 60% of their professional knowledge was not satisfying. 60% of respondent believed that educational intervention will improve participating of health care professional in ADRs reporting. 63% of respondent observed ADRs cases but about 95% of them had never reported an ADR. Conclusion: In overall, pharmacy students have poor knowledge, attitude and practice towards ADRs reporting and pharmacovigilance. This suggests the need of suitable changes in the undergraduate teaching curriculum and additional training among the students regarding ADRs.

Background: An increased oxidative stress in patients under treatment with high concentrations of oxygen (hyperoxia) is considered to be one of the major mechanisms of lung injury. Between different mediators, transition metal ions especially iron, by generation of very reactive free radicals play an important role in oxidative stress process. Disruption of normal iron hemostasis has been reported in hyperoxic conditions. So we hypothesized that chelation of iron can reduce hyperoxia- induced lung injury. Methods: Mechanically ventilated patients, who received oxygen with FiO > 0.5 for at least 3 days, underwent bronchoscopy at baseline and 72 hours thereafter. Data from external control cases were collected prospectively to provide a comparative reference group.Iron and Iron-related proteins were measured in lavage fluid and plasma. Results: In 24 patients and in comparison with the results of previous study, Iron concentration decreased significantly in lavage fluid (P

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Background: Inappropriate use of vancomycin not only increase health care costs but also contribute to the emergence of resistant organisms. Higher trough serum vancomycin concentrations (>10mg/L) has been recommended for avoidance of development of resistance. We aim to compare the administered dose with recommended doses based on guideline-recommended weight-based dosing. Methods: In a cross sectional study, all patients who received vancomycin between July and October 2013, in infectious disease, internal medicine wards and emergency department of a teaching hospital in Tehran, Iran were entered to the study. Indication of vancomycin and necessary data for dose calculation including height and serum creatinine were recorded. Prescribed doses were compared with recommended doses in guidelines and calculated Glomerular filtration rate (GFR) for each patient. Results: One hundred and four patients (45 females and 59 males) recruited in the study. Our results indicated that, from all administered doses of vancomycin, 64.4% and 88.8% differs significantly (more than 20%) based on American Pharmacist Association (AphA) vancomycin monograph and guideline-recommended, weight-based vancomycin dosing (for adults), respectively. Conclusion: Underdosing of vancomycin is a major risk factor for developing resistance of gram positive organisms to this glycopeptide. Our results showed that more than half of patients receiving vancomycin are in the risk of low drug levels based on guidelines. So, having a comprehensive plan for the proper use of this drug especially designing effective internal guidelines can prevent emergence of resistance to vancomycin in future.

Background: Drug utilization studies are helpful in understanding the current practice. We have conducted a retrospective study to evaluate the relevant use of a group of most commonly prescribed antibiotics in a teaching hospital in Iran. The results of this study may be of help for clinicians to improve the patient care. Methods: Patients who received parenteral ceftazidim, vancomycin and amikacin from December2010 to May 2011 were enrolled in this study. Patient’s data including demographic, length of Hospital stay, drug allergy, first and final diagnosis were recorded in a predesigned data collection form. American Hospital Formulary Services (AHFS) book were used as a reference for evaluation of study drug indication and dosing according to diagnosis and microbiological culture. Defined Daily Dose (DDD) of each drug extracted from Anatomic and Therapeutic Chemical classification system (ATC/DDD) and drug usage data evaluated by calculating the ratio of prescribed drug to its DDD.| Results: The ratio of prescribed daily dose to DDD was 0.78, 0.95 and 0.86 for amikacin, ceftazidime and vancomycin respectively. Between amikacin group, 43 patients (86%) received drug empirically, the number of empiric treatments for ceftazidim and vancomycin were 45(90%) and 44 patients (88%). The renal function tests (Blood Urea Nitrogen, Serum Creatinin) were evaluated in 56% of amikacin group, 64% in ceftazidime group and 78% in vancomycin group. Conclusion: The results of this study indicate the need to establish continuing medical education (CME) courses for physicians to familiarize them with standards required to use and monitor these agents.

Background: Drug-Drug Interactions (DDIs) are adverse reactions caused by a combination of drugs; they are often predictable and therefore avoidable or manageable. The objective of this study was to evaluate the nature, type and prevalence of potential DDIs in prescriptions dispensed in university-based community pharmacies in Tehran, Iran. Methods: From July 2012 to February 2014, sample of 1260 prescriptions were collected from community and outpatient hospital pharmacies affiliated to Tehran University of Medical Sciences (TUMS), Iran. The prescriptions were assessed using the reference text “drug interaction facts”. The identified DDIs were categorized according to their level of significance into three classes (minor, moderate, major). Results: At least one drug-drug interaction was present in 339 (26.9%) of prescriptions and a total of 751 cases of interactions were found in prescriptions. Major DDIs represented 7.3% of all DDIs detected, whereas moderate DDIs were 75% of all DDIs. The mean number of drugs per prescriptions was 3.2, with a median of 4 (range, 2-10).There was a positive association between number of prescribed drugs and occurrence of DDIs (OR: 2.14, 95% CI: 1.9-2.4). The prescriptions of medical specialist had greater risk of occurrence of moderate severity DDIs than general practitioners (OR: 1.52, 95%CI: 1.08-2.15). Conclusion: Despite the prescriptions were collected from university-based pharmacies, but the overall prevalence of potential DDIs were high among patients. Physicians should be aware of potentially harmful DDIs. Meanwhile Pharmacists can contribute to the detection and prevention of drug-related injuries. Appropriate education, collaborating drug selection and pharmaceutical care are strongly recommended for physicians and pharmacists.

Background. Heparin, used clinically as an anticoagulant, also has anti-inflammatory properties. The purpose of this systematic review was to provide a comprehensive review regarding the efficacy and safety of heparin and its derivatives as anti-inflammatory agents. Methods. We searched the following databases up to March 2012: Pub Med, Scopus, Web of Science, Ovid, Elsevier, and Google Scholar using combination of Mesh terms. Randomized Clinical Trials (RCTs) and trials with quasi-experimental design in clinical setting published in English were included. Quality assessments of RCTs were performed using Jadad score and Consolidated Standards of Reporting Trials (CONSORT) checklist. Results. A total of 280 relevant studies were reviewed and 57 studies met the inclusion criteria. Among them 48 studies were RCTs. About 65% of articles had score of 3 and higher according to Jadad score. Twelve studies had a quality score > 40% according to CONSORT items. Asthma (n=7), inflammatory bowel disease (n=5), cardiopulmonary bypass (n=8), and cataract surgery (n=6) were the most studied disease condition. Forty studies use unfractionated heparin (UFH) for intervention; the remaining studies use low molecular weight heparin (LMWH). Conclusion. Despite the conflicting results, heparin seems to be a safe and effective anti-inflammatory agent; although it is shown that heparin can decrease the level of inflammatory biomarkers and improves patient conditions, still more data from larger rigorously designed studies are needed to support use of heparin as an anti-inflammatory agent in clinical setting. However, because of the association between inflammation, atherogenesis, thrombogenesis, and cell proliferation, heparin and related compounds with pleiotropic effects may have greater therapeutic efficacy than compounds acting against a single target.

Inappropriate use of drugs is a widespread problem with serious consequences such as increased adverse drug reaction and antimicrobial resistance. Proper interventions would have important financial and public health benefits. Several studies have been performed about Rational Drug Use (RUD) in Iran. To provide a picture of researches were done about RUD and highlight the existing gaps in practice in Iran, a systematic search was conducted by reviewing all papers (English and Persian) found by searching keywords in Pubmed, Web of Science, Google Scholar, CINAHL, Proquest, International Pharmaceutical Abstract (IPA), SID, Iran Medex and MagIran. Retrieved articles were extracted in Access form and exported to Excel for further analysis. After excluding duplicate and irrelevant articles, 466 related articles were remained. Number of publications increased dramatically after 2001. About 73% of studies were cross-sectional. Evaluation of prescribing pattern (15%), self-medication (11.3%) and adverse drug reaction (9.1%) were among the top topics which were studied. Despite an increasing trend in RUD publications in Iran, still large gaps remain to be investigated. Knowing the existing gaps is crucial for policy makers to make investments to solve the problems.