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Introduction Nephrotoxicity remains a major long-standing concern for colistin, and it is critical to find agents that can prevent it. The present study aims to investigate the effect of vitamin E on the prevention of colistin-induced nephrotoxicity based on its antioxidant and free radical scavenging properties. Methods A randomized clinical trial was designed for 52 patients taking colistin. These patients were categorized into two groups of equal size, receiving colistin or colistin plus vitamin E (α-Tocopherol). Vitamin E with doses of 400 units was administrated daily either orally or by a nasogastric tube if needed. The incidence of Acute Kidney Injury (AKI) and its duration was recorded based on RIFLE criteria. Results The Incidence of AKI based on RIFLE criteria was 42.3% and 46.2% in intervention and control groups, respectively. The analysis showed no significant difference in the prevalence of AKI for the two groups (P = 0.78). There was no significant difference in the duration of AKI neither (P = 0.83). Conclusion Although vitamin E is a powerful biological antioxidant, the effects of Vitamin E prophylaxis on colistin-induced nephrotoxicity was not taken into consideration in this study.

Objectives It remains unclear which formulation of corticosteroid regimen has the optimum efficacies on COVID-19 pneumonia. Herein we evaluated two regimens including methylprednisolone at a dose of 1 mg/kg every 12 hours (low-dose group) and 1000 mg/day pulse-therapy for 3 days following 1 mg/kg every 12 hours (high-dose group) methylprednisolone to assess the clinical outcomes in acute respiratory distress syndrome (ARDS) due to COVID-19. Methods This randomized clinical trial was performed on patients with mild to moderate ARDS following COVID-19 randomly assigned to receive low-dose (n = 47) or high-dose (n = 48) intravenous methylprednisolone. Two groups were matched for age, gender, BMI, comorbidities, leukocytes, lymphocytes, neutrophil/lymphocyte, platelet, hemoglobin, and inflammatory markers (ESR, CRP, Ferritin). both regimens were initiated upon admission and continued for 10-days. the clinical outcome and secondary complications were evaluated. Results and discussion Evaluating in-hospital outcomes, no difference was revealed in the duration of ICU-stays (5.4 ± 4.6 vs 4.5 ± 4.9, p-value = 0.35), total hospital-stays (8 ± 3.1 vs 6.9 ± 3.4, p-value = 0.1), requirement rate for invasive ventilation (29.2% vs 36.2%, p-value = 0.4) or none-invasive ventilation (16.6% vs 23.4%, p-value = 0.4), and hemoperfusion (16.6% vs 11.3%, p-value = 0.3) between the groups. Fatality due to ARDS (29.2% vs 38.3, p-value = 0.3), and septic shock (4.2%, 6.4%, p-value = 0.3) was respectively reported in low-dose and high-dose groups, with no significant difference. Patients who received pulse-therapy had significantly higher bacterial pneumonia co-infection events (18.7% versus 10.6% (p-value = 0.01). What is new and conclusion: adjuvant pulse-therapy for intravenous methylprednisolone does not improve the in-hospital clinical outcomes among mild to moderate ARDS COVID-19 patients. Higher risk of Bacterial pneumonia should be considered in such cases receiving the higher dose of steroids.

Augmented renal clearance (ARC) defined as creatinine clearance (Clcr) above 130 mL/min/1.73mIn this randomized clinical trial, patients with VAP and high risk for ARC were recruited. An 8-h urine collection was performed on the 1st, 3rd, and 5th days of study to measure Clcr. Included patients were divided into three groups: (1) 1 g meropenem, 3-h infusion, (2) 2 g meropenem, 3-h infusion, (3) 1 g meropenem, 6-h infusion. On the 2nd, 3rd, and 5th days of treatment, peak and trough blood samples were collected to undergo HPLC assay. MICs were assessed using microdilution method. Patients were also clinically monitored for 14 days.Forty-five patients were included. Group 3 showed significanty higher rate of patients achieving fT MIC 50% (100% for group 3 versus 40% for group 2 and 13% for group 1; p = 0.0001). Mean fT MIC% was significantly higher in group 3 (78.77 ± 5.87 for group 3 versus 49.6 ± 7.38 for group 2 and 43.2 ± 7.98 for group 1; p = 0.0001). Statistical analysis showed no significant differences among groups regarding clinical improvement.According to the findings of this trial, prolonged meropenem infusion is an appropriate strategy compared to dose elevation among ARC patients.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has caused significant mortality worldwide. The disease attacks the lung tissue and may lead to acute respiratory distress syndrome . An in vitro study showed that hydroxychloroquine (HCQ) has a prophylactic effect against COVID-19 due to its anti-inflammatory effects. The present study aimed to evaluate the prophylactic effect of HCQ on individuals in close contact with patients with COVID-19. Method In this quasi-trial study, we prescribed HCQ for 7 days to all people who had close contact with a patient with COVID-19. All contacts underwent a nasal swab in two steps, and those positive for COVID-19 were excluded from the study. After 14 days of follow-up, the clinical and laboratory manifestations of COVID-19 were evaluated. Results A total of 113 participants completed the study. The HCQ group comprised 51 (45.13%) contacts, and 62 (54.86%) contacts were allocated to the control group. According to the results of clinical examination and real-time polymerase chain reaction test, 8 (12.90%) contacts in the control group were reported to have contracted COVID-19. In the HCQ group, 7 (13.72%) contacts were confirmed to have contracted COVID-19. There was no relationship between HCQ use and age, sex, underlying disorders, and laboratory data (all p > 0.05). In terms of HCQ side effects, five participants experienced gastrointestinal and cutaneous side effects that subsided on discontinuation of HCQ. Conclusion The current study showed that HCQ had no prophylactic effect with regard to COVID-19 prevention.

Background For decades, child labor has been an important global issue associated with inadequate educational opportunities, poverty and gender inequality. In order to make effective policies to reduce child labor it is important to understand the specific factors that affect it. We aimed to investigate the main factors affecting child labor n Iran. Materials and Methods There are authoritative websites on the topic of working children in Iran, including the WHO, UNFPA, UNDP, Web of Science, ProQuest, Medline, Scopus, and CINAHL databases for reviewing studies conducted in Iran. Articles from internal dissertations and Google's databases, SID, Magiran, and Iran Doc during the period 1985 to June 2019 were included. Quality of studies was reviewed by the STROBE checklist. Information was extracted by two blind researchers. Results A total of 9 studies were identified (including 17, 219 on child labor), the majority of which were cross-sectional. Affecting factors on child labor and Street children were grouped into four categories such as "Family problems", "Urbanization", "Social and Cultural", and "Personality". Conclusion In the contemporary Iranian society, many children, for some reasons including personal, family, social and cultural, and urbanization problems, are involved with important social damages such a child labor. These factors make children vulnerable and endanger the health of the community.

Rheumatoid arthritis (RA) is considered as an autoimmune-related condition in which the overproduction of pro-inflammatory cytokines leads to an inflammatory cascade. N-acetylcysteine (NAC) is a potent anti-inflammatory and anti-oxidant agent. We aimed to explore the impact of oral NAC on cytokines activities and clinical indicators in RA patients. In this placebo-controlled randomized double-blind clinical trial, 41 active RA patients were allocated in either NAC (600 mg, twice a day) or placebo group, as add-on therapy to the routine regimen, for 8 weeks. Disease activity score with an erythrocyte sedimentation rate (DAS28-ESR), and serum concentrations of interleukin (IL)-1β and IL-17 were assessed at baseline and end of the trial for all participants in the test and control groups. The reduction of the DAS28-ESR was higher considerably in the NAC group compared to that of the control group. No statistically significant differences were seen in the reduction of IL- 1β and IL-17 cytokines between the NAC and control groups. In addition, improvements in the patient global assessment, number of tender joints, number of swollen joints, and the ESR rates were in favor of the NAC group. Our findings reveal that NAC may have a beneficial effect on all of the clinical features of RA. However, non-significant variations in the IL-1β and IL-17 levels suggest an alternative way of NAC effectiveness without influencing the measured cytokines. Nevertheless, these results need to be confirmed by further investigations.

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Reduced graft function (RGF) in donor renal transplant recipients is caused by oxidative damage due to extensive ischemia-reperfusion (I/R) injury during transplantation. Neutrophil gelatinase-associated lipocalin (NGAL) is a promising biomarker to detect tubular injury early after renal transplantation. N-acetylcysteine (NAC) is a potent antioxidant that can reduce I/R injury by improving oxidative damage. The aim of the present study is to assess the efficacy of NAC in improving graft function and reducing renal tubular injury in deceased donor renal transplant recipients. A double-blind, randomized clinical trial was conducted on 50 deceased donor renal transplant recipients. The patients were randomized into two groups, receiving either 600 mg NAC twice daily, or placebo (days 0 to 5). Results were assessed based on the rate of RGF, levels of plasma NGAL (p-NGAL) and the estimated glomerular filtration rate (eGFR). The rate of RGF was significantly lower in the patients receiving NAC vs. placebo (21.4% vs. 50%). The measurement of p-NGAL levels showed that the patients in the NAC group had significantly greater reduction of p-NGAL by both days 1 and 5 post-transplantation than those in the placebo group. A near steady-state eGFR level was reached by week 1 in the NAC group, however, the improvement of eGFR was significantly slower in the placebo group and a near steady-state was only achieved by week 4. NAC has promising potential in reducing tubular injury and improving graft function, evidenced by significant reduction in the rate of RGF and levels of p-NGAL.

Background: Albumin is a colloidal protein medication in which has a limited availability in market and it has a high cost. Albumin must be used in such approved indications as, large volume paracentesis, plasmapheresis, spontaneous bacterial peritonitis and hepato-renal syndrome. Objectives: The aim of this study was to evaluate the appropriateness of albumin utilization in a teaching hospital in Iran before and after guideline implementation. Methods: In this prospective study, a total of 100 patients were enrolled into the study in Loghman Hakim Teaching Hospital. The medical records of patients were reviewed and some information such as demographic parameters, albumin indication, albumin therapy duration, appropriateness of indication, nutrition type were recorded in pre-intervention phase. Then in post-intervention phase, albumin was administered after clinical pharmacist teaching and guideline implementation. After post-intervention period, demographic parameters, albumin indication, albumin therapy duration, appropriateness of indication were recorded again. Results: In phase 1, albumin was mostly prescribed in inappropriate indications and internist physicians were the most physicians who ordered albumin and wound healing also was the most frequent indication for albumin therapy. This improvement also was significant (P < 0.05). Data showed that albumin indication in post-intervention was different from that in the pre-intervention phase. After clinical pharmacist intervention most of indications were appropriately. Conclusions: This study demonstrated that in this hospital, albumin was prescribed inappropriately in most cases based on hospital guideline. This rate improved after clinical pharmacist intervention and resulted in significant reduction in albumin irrational utilization. It is advisable that albumin prescription must be monitored carefully by clinical pharmacists.

Backgrounds and aims: Clinical studies demonstrated that the efficacy of Coenzyme Q10 (CoQ10) as an adjuvant therapeutic agent in several neurological diseases such as Parkinson disease (PD), Hunti...

Background and objectives The association between preoperative Urine Neutrophil Gelatinase-associated Lipocalin (uNGAL) and interleukin-18 (uIL-18) with poor 1-year allograft function has been shown in deceased-donor kidney transplant recipients previously, and also these markers could predict 3-month allograft function. However, it is unknown whether there is an association between these postoperative biomarkers with important recipient outcomes beyond this time in livedonor transplants. Methods NGAL and IL-18 four and 24 hours were measured in live-donor kidney transplant recipients after transplantation. The relationships between changes in these markers with clinical outcomes as well as kidney function were examined at 1 month and 2 years. Moreover, the association between delayed graft function with clinical outcome and Serum Creatinine (SrCr) was evaluated during this period. Results The Mean age for kidney recipients was 23.9 years. Significant interaction was observed between uNGAL 24 hr (pvalue=0.01) and uIL-18 four and 24 hr after transplantation (pvalue=0.04, 0.03; respectively) with patients' outcome after 1 month and changes in uNGAL with outcomes after 2 years (pvalue= 0.04). Conclusion Changes in urine NGAL postoperative are associated with worst outcomes, 2 years after kidney transplantation, suggesting its potential role in identifying patients that are at high risk for diminished allograft function, outcome and survival.

CONTEXT Acute kidney injury (AKI) is a common complication after kidney transplantation (KT), especially in recipients from deceased donors. Urinary neutrophil gelatinase-associated lipocalin (u-NGAL) is an early and sensitive marker of AKI after transplantation. OBJECTIVES We assessed the renoprotective effect of N-acetylcysteine (NAC) on u-NGAL levels as an early prognostic marker of graft function immediately after transplantation. MATERIALS AND METHODS A double-blind, randomized, placebo-controlled trial was conducted on 70 deceased-donor KT recipients ( www.irct.ir , trial registration number: IRCT2014090214693N4). Patients received 600 mg oral NAC or placebo twice daily from day 0 to 5 and urine samples were taken before, and on the first and fifth days after transplantation. U-NGAL and early graft function were compared between the two groups. RESULTS NAC significantly reduced u-NGAL levels compared to placebo (p value = 0.02), while improvement in early graft function with NAC did not reach statistical significance. CONCLUSIONS This study showed that NAC administration in deceased-donor KT recipients can reduce tubular kidney injury, evidenced by u-NGAL measurements. Improvement in early graft function needs a larger sample size to reach a statistical conclusion.

In regard with the effect of immune-stimulants in the treatment of infectious diseases, the effect of vitamin D administration on the outcome of patients with Ventilator-Associated Pneumonia (VAP) with a high rate of mortality, was studied.In this trial, 46 adult patients suffering from VAP and vitamin D deficiency were enrolled. The first group of patients received single intramuscular injection of vitamin D (300000Unit), while the other group were given the placebo.Administration of vitamin D significantly enhanced its levels (P0.0001) in the treated patients (12.28±8.26) in comparison with placebo group (1.15±1.50). Serum Interleukin-6 levels were significantly reduced in the treated group compared to placebo (P=0.01). Although C-Reactive protein (CRP) levels showed an improving trend in the vitamin D group, no significant difference between groups (P=0.12) was found. Interestingly, the mortality rate of patients that treated with vitamin D (5/24) was significantly lower (p=0.04) than that of the placebo group (11/22).Our results indicate that vitamin D administration can significantly reduce the IL-6 as prognostic marker in VAP patients, and must be considered as adjunct option in the treatment of VAP patients.

Since late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, better known as COVID-19) has rapidly spread worldwide. The primary pathophysiology by which COVID-19 leads to severe lung damage is cytokine releasing syndrome (CRS), which can cause death. Therefore, removing cytokines via therapeutic plasma exchange or hemoperfusion could be a therapeutic approach to treat CRS. However, hemoperfusion or therapeutic plasma exchange could alter the effectiveness of concomitant medications. Thus, concomitant medication doses might need to be adjusted to prevent their elimination via therapeutic plasma exchange or hemoperfusion, thus ensuring that these medications remain effective. This narrative review investigates the elimination status of current medications used to manage COVID-19 during hemoperfusion and therapeutic plasma exchange, with a focus on their pharmacokinetic profiles.

Renal transplantation is the treatment of choice for many patients with end-stage renal disease. Because there is little information about depression after kidney transplantation, we investigated frequency and determinant factors of depression and also its association with interleukin (IL)-18. Kidney transplant recipients were investigated between January 2011 and February 2013. Depression was assessed using the Beck Depression Inventory (BDI, BDI-II). We investigated the relationship between 1-year posttransplantation depression and all-cause mortality, acute kidney injury, and serum creatinine 1, 3, and 12 months after transplantation. Furthermore, the association of depression with IL-18 biomarker was recorded 1 year after transplantation. A total of 74 patients (age: 37.06 ± 16.2 years; 59.5% male) were enrolled in this study 1 year after transplantation. Nineteen (25.6%), 2 (2.7%), and 1 (1.3%) of them experienced mild, moderate, and severe depression, respectively. IL-18 biomarker (independent variable) was significantly associated with depression 1 year after transplantation. Our data suggested that IL-18 level increased significantly in renal transplant patients with depression.

Background: Ventilator associated pneumonia is one of the most important nosocomial infections with often poor outcomes and heavy economic burdens on health care systems. Objectives: Several studies have been done for evaluating the effect of different types of stress related mucosal disease (SRMD) prophylaxis on nosocomial pneumonia, as among factors participating in its establishment, gastrointestinal tract is believed to play an important role especially in ventilator-associated pneumonia. Methods: In this cross-sectional study, 150 patients who were admitted to intensive care unit (ICU) and developed documented culture positive VAP, were evaluated for the study inclusion criteria. The patients with clinical pulmonary infection score (CPIS) ≥ 6 were included and some others with conditions affecting comparability excluded. The patients with Acute Physiology and chronic health evaluation II (APACHEII) scores between 10 and 24, within the first 24 hours of ICU stay, were included. Finally, 100 patients who fulfilled all criteria were evaluated for the responsible organisms and type of SRMD prophylaxis they had received. The patients included were either on intravenous pantoprazole (49 patients) or intravenous ranitidine (51 patients). The goal of this study was to evaluate the organisms, which have been isolated from the sputum of ICU patients with ventilator-associated pneumonia, according to their SRMD prophylaxis regimen. Results: There were 59 men (59) and 41 women (41) ranging from 19 to 82 years old. The mean ages were not significantly different between the two groups (P = 0.586). APACHEII score was ranging between 15 and 21 with the mean of 17.57 in pantoprazole and 16.80 in ranitidine group (P = 0.006), there was a statistical but not clinical difference. With P-value of 0.001, there was significant difference in ICU stay days. The mean mortality rates were 18.4 and 1.8 for pantoprazole and ranitidine group, respectively. The difference was statistically significant (P < 0.001). Multi-drug resistant pathogens were significantly higher in the pantoprazole group (0.001). The organisms, which have been obtained from each group were different. Acinetobacter and Pseudomonas aeruginosa were highly cultivated in the pantoprazole group, while Staphylococcus aureus and Proteus were more in patients who had received ranitidine. Conclusions: It can be suggested that each bacterium has a unique propensity to grow in specific gastric pH and other systemic changes made by various agents used for SRMD prophylaxis. More studies are needed to evaluate large number of patients receiving SRMD prophylaxis, with perspective of VAP incidence, the responsible organisms, hospital and ICU stay days, and mortality rate in order to prevent poor outcomes caused by specific organisms. © 2018, Archives of Clinical Infectious Diseases.

Disruption of prooxidant-antioxidant balance may lead to oxidative stress which is known as a mechanism contributing to ischemic stroke. Coenzyme Q10 (CoQ10) is an endogenous antioxidant that could be effective in preventing oxidative stress. However, the contribution of serum levels of CoQ10 in clinical neurological outcomes following ischemic stroke has not been clearly established. This study aims at measuring serum concentration of CoQ10 along with major indicators of antioxidant and oxidant among patients within 24 h after onset of the stroke symptoms, and investigating their relation with the clinical status of patients. Serum levels of CoQ10, superoxide dismutase (SOD), and malondialdehyde (MDA) were measured in 76 patients and 34 healthy individuals. Severity of the neurological deficit, functional disability, and cognitive status in ischemic subjects were respectively studied with the National Institutes of Health stroke scale (NIHSS), modified Rankin Scale (MRS), and Mini-Mental State Examination (MMSE). Stroke patients had significantly lower serum level of CoQ10 and SOD as compared to controls (27.34 ± 35.40 ng/ml, 18.58 ± 0.76 μ/ml, respectively; p

N-acetylcysteine (NAC) is a potent antioxidant that acts through regenerating glutathione stores and scavenging oxygen-free radicals. This study assesses the short-term effects of NAC in cadaveric kidney transplant (KT) recipients. A double blind, randomized, placebo controlled trial was designed and patients were randomly assigned to receive either NAC or placebo. Glutathione peroxidase (GPX) activity in erythrocytes and serum malondialdehyde (MDA) levels were measured and serum creatinine levels and estimated glomerular filtration rate (eGFR) determined in the early phase after transplantation, were also compared between two study groups. Thirty-seven males and 20 females, with mean ± SD age of 44.6 ± 12.4 years completed the study. Significant difference (P = 0.02) was seen between GPX activity reduction in the placebo group, and that of the NAC group and on the levels of MDA there was no significant difference between two study groups (P = 0.53). Significant improvement in immediate graft function (IGF), (68% versus 40%, P = 0.05) and the first week eGFR were observed in the NAC group compared to the placebo group (52.46 ± 2.77 versus 38.75 ± 19.67 mL/min/1.73 m2, P = 0.02). It seems that the protective mechanisms of NAC, other than its antioxidant properties, can be favorable in KT patients.

Colistin is an antibiotic that was introduced many years ago and was withdrawn because of its nephrotoxicity. Nowadays, reemergence of this antibiotic for multi-drug resistant Gram-negative infections, and a new high dosing regimen recommendation increases concern about its nephrotoxicity. This review attempts to give a view on colistin nephrotoxicity, its prevalence especially in high doses, the mechanism of injury, risk factors, and prevention of this kidney injury. The data collection was done in PubMed, Scopus and Cochrane databases. The keywords for search terms were “colistin”, “nephrotoxicity”, “toxicity”, “renal failure”, “high dose”, and “risk factor”. Randomized clinical trials and prospective or retrospective observational animal and human studies were included. In all, 60 articles have been reviewed. Colistin is a nephrotoxic antibiotic; a worldwide increase in nosocomial infections has led to an increase in its usage. Nephrotoxicity is the concerning adverse effect of this drug. The mechanism of nephrotoxicity is via an increase in tubular epithelial cell membrane permeability, which results in cation, anion and water influx leading to cell swelling and cell lysis. There are also some oxidative and inflammatory pathways that seem to be involved in colistin nephrotoxicity. Risk factors of colistin nephrotoxicity can be categorized as dose and duration of colistin therapy, co-administration of other nephrotoxic drugs, and patient-related factors such as age, sex, hypoalbuminemia, hyperbilirubinemia, underlying disease and severity of patient illness.

The effects of vinegar and oxymel solutions (used in Iranian traditional medicine) and processing temperatures (75, 85 and 100°C) on the milk coagulation was studied to identify and determine the protein indicators of resulting whey. The HPLC (high performance liquid chromatography) analysis showed that the α-lactalbumin (ALA) and β-lactoglobulin (BLG) contents of resulting whey reduced significantly, when the coagulation temperature increased from 75 to 100°C. In both solutions and at 75°C processing temperature, the BLG of final whey protein was significantly more (∼ 60-70 %) than ALA content. The reverse process happened at 85°C, and the ALA content became much higher than BLG. A significantly higher content of ALA was recovered once the combination of oxymel and vinegar solutions with milk reached to respectively ∼ 10 and 0.3 % and milk protein was coagulated at 85°C. Overall, there is a good possibility to make a milk whey with high content of desirable ALA and negligible concentrations of BL...

Ventilator-associated pneumonia (VAP) is a common and serious problem that develops after more than 48 h of mechanical ventilation. Improving the activity of immune system with vitamin D, and its consequent impact on prognostic biomarkers of VAP was studied in the current study. A randomized double blind placebo controlled clinical trial was designed. A total of 46 patients with VAP, who were suffering from vitamin D deficiency, were randomly allocated into the study groups of placebo (n=22) and treatment (n=24) The treatment group received 300,000 units of intramuscular vitamin D. Serum levels of procalcitonin and vitamin D along with SOFA and CPIS scores were determined at baseline and on day 7 after intervention. The mortality rate of patients was also monitored for the succeeding 28 days after the injection. The administration of vitamin D significantly enhanced its levels (P

Nephrotoxicity has been a major long-standing concern about colistin.This study was designed to compare nephrotoxicity of high dose and conventional dose of colistin. A randomized open-labeled clinical trial on 40 patients with multi-drug resistant gram negative infections was designed. Patients were allocated into two equal-size groups receiving high (a loading dose of 9 million international units (MIU) and maintenance doses of 4.5 MIU every 12 h) and conventional dose (2 MIU every 8 h) of colistin. Blood samples were taken on day 1, 3, 5, 7 and 10 of treatment for measuring serum cystatin C (Cys C) levels. Incidence of acute kidney injury (AKI) was also evaluated based on RIFLE criteria. Mean ± sd of the difference between baseline and day 10 Cys C levels in high dose and conventional dose groups were 1.61 ± 0.90 and 1.32 ± 0.48, respectively (P = 0.30). Within group analysis showed increase in Cys C levels in both groups (P = 0.001),however, no significant difference in Cys C levels was seen in between groups analysis (P = 0.13). Prevalence of AKI based on RIFLE criteria was 60% and 15% in high dose and conventional dose groups, respectively (P = 0.003). Comparison of Cys C between AKI (mean ± sd) and non-AKI (mean ± sd) patients, irrespective of colistin dosage regimens, confirmed a significant difference (P < 0.0001). Although, colistin-induced nephrotoxicity, determined by Cys C levels, was not confirmed by our findings, however, higher incidence of AKI in high-dose group, defined by RIFLE criteria, along with higher levels of Cys C in AKI patients are supportive of the higher risk of renal toxicity associated with high-dose regimen of colistin. More RCTs with a larger sample size are recommended.

After brain injuries, concentrations of some brain markers such as S100B protein in serum and cerebrospinal fluid (CSF) are correlated with the severity and outcome of brain damage. To perform an updated review of S100B roles in human neurocritical care domain, an electronic literature search was carried among articles published in English prior to March 2017. They were retrieved from PubMed, Scopus, EMBSCO, CINAHL, ISC and the Cochrane Library using keywords including “brain”, “neurobiochemical marker”, “neurocritical care”, and “S100B protein”. The integrative review included 48 studies until March 2017. S100B protein can be considered as a marker for blood brain barrier damage. The marker has an important role in the development and recovery of normal central nervous system (CNS) after injury. In addition to extra cerebral sources of S100B, the marker is principally built in the astroglial and Schwann cells. The neurobiochemical marker, S100B, has a pathognomonic role in the diagnosis of a broad spectrum of brain damage including traumatic brain injury (TBI), brain tumor, and stroke. Moreover, a potential predicting role for the neurobiochemical marker has been presumed in the efficiency of brain damage treatment and prognosis. However further animal and human studies are required before widespread routine clinical introduction of S100 protein.

Nephrotoxicity has been a concern with new dosing regimens of colistin. This study was designed to compare nephrotoxicity of high dose and conventional dose of colistin and the ability of detecting it using neutrophil gelatinase-associated lipocalin (NGAL).A randomized clinical trial was carried out on 40 patients with multidrug-resistant gram-negative infections assigned into 2 groups to receive high and conventional doses of colistin. Blood samples were taken 4 times for measuring serum NGAL. The incidence of acute kidney injury was also evaluated based on the risk, injury, failure, loss, end-stage renal disease (RIFLE) criteria.Baseline levels of NGAL were not significantly different between the patients on the high dose and conventional dose of colistin. The mean NGAL levels on day 10 were 762.14 ± 415.44 pg/mL and 623.67 ± 272.61 pg/mL, respectively. However, between-group analysis did not show a significant difference in the NGAL levels. The prevalence of acute kidney injury was 60% and 15% based on the RIFLE criteria, in the high-dose and conventional-dose groups, respectively (P = .003).Although colistin-induced nephrotoxicity was not confirmed with NGAL levels, our findings, however, showed a higher incidence of acute kidney injury associated with high-dose colistin, defined by the RIFLE criteria. Higher levels of NGAL in the acute kidney injury patients were associated with high-dose regimen of colistin.

Background: Vancomycin is a glycopeptide antibiotic used to treat infections caused by Gram-positive bacteria. Irrational administration of this antibiotic may result in increased morbidity or mortality due to toxicity and the emergence of resistant organisms and also impose additional costs. Objectives: The current study aimed at evaluating the effect of pharmacist intervention on vancomycin administration, and discussing appropriate and inappropriate applications of this drug. Methods: The current study was performed on all patients receiving vancomycin intravenously in the intensive care unit (ICU) of Loghman educational Hospital in Tehran, Iran, from May to September 2015. Relevant data were collected by a pharmacist from each patient and their datasheets such as medical records, patient’s history, medical orders, nursing reports, and the experimental results available in the patient’s records, duration of vancomycin use, history of drug allergy, first diagnoses, type of administration, monitoring necessity, dosing regimen, and occurrence of adverse drug reaction. Patients then were followed until discharge from ICU. Results: About 82% of patients had received vancomycin without noticing their body mass index (BMI) or calcium-induced calcium release (CICR). In addition, 2.63% had inappropriate indication, and in general, the duration of therapy was somehow correct in 44.73% of patients, and 55.26% received vancomycin for more than the appropriate period. Most of the wrong administration was for postoperative prophylaxis. The appropriate duration is maximum 48 hours. But in 63.33% of the patients, it continued for more than 2 - 3 days. And this inappropriate usage could increase vancomycin resistance. Conclusions: Due to the increasing resistance rate to antibiotics, indication and duration of administration and dosing should be more accurate, and for each patient must be according to his/her ideal body weight (IBW).

Background: One of the main causes of morbidity in hospitalized patients, and especially in the intensive care unit (ICU), is venous thromboembolism (VTE). The best way to deal with VTE is prophylaxis. Rational prophylaxis should be provided after risk factor anal- ysis. Dierent prophylaxis regimens are pharmacological and physical. Pharmacological prophylaxis regimens consist of heparin and enoxaparin that are given subcutaneously. Objectives: The current study aimed to investigate appropriate administration of deep vein thrombosis (DVT) prophylaxis in ICU in an educational hospital. Methods: Caprini risk assessment model was employed to evaluate patients' risk factors. Immobile patients (for three days) with at least one thrombotic risk factor were selected. The Caprini scores were identified from patients' medical record. Three groups were identified after obtaining the scores: patients at low, medium and high risks. For each group, appropriate prophylaxis regimen was recommended. Results: A total of 52 patients were evaluated, about 88.46% of the subjects had DVT prophylaxis indication; 10.71% received physical prophylaxis and 89.29% of them received pharmacological prophylaxis. For two-thirds of the patients with pharmacological pro- phylaxis enoxaparin was administered and for the other part heparin. Totally, 32.61% of the subjects received correct prophylaxis, 17.39% received inadequate prophylactic doses and 6.52% received higher doses. Totally, 67.39% of the subjects did not receive correct prophylaxis. Conclusions: According to the collected data, appropriate DVT prophylaxis was not prescribed. It is required to pay serious atten- tion to this medication error. It is suggested to invest on educating medical teams about DVT prophylaxis, which is highly demanded.

A 33-year-old healthy woman at 6 weeks of gestation without any underlying disease developed erythema multiforme (EM) after misoprostol. She had no history of herpes simplex virus infection and drug allergy to nonsteroidal anti-inflammatory drugs and antibiotic agents. Medical abortion was performed at 6 weeks' gestation. Later day, the patient developed oral lesions as several white bullae lesions in her buccal mucosa and hyperkeratotic lip plaques with mild pain. Then, lesions resolved within approximately 3 weeks. Microscopic finding of oral biopsy from beneath the tongue and lesions was performed. The result was consistent with erosive mucosa with granulation tissue formation and acute inflammation in favor of EM. This is the case report of probable misoprostol-induced EM. Because EM may produce in skin as a Stevens-Johnson syndrome in subsequent attack, monitoring of this adverse drug reaction should be considered for proper management and follow-up.

Patients with chronic kidney disease (CKD) have high incidence rates of cardiovascular disease and malignancy. Several factors contribute to these conditions. Structural characteristics in CKD, loss of renal energy, and uremia result in an imbalance between free radical production and antioxidant defenses. Also, CKD patients usually have multiple cardiovascular risk factors like diabetes mellitus, dyslipidemia, and hypertension. These conditions are associated with oxidative stress, which can trigger the inflammatory process and accelerate renal injury progression. There are some clinical biomarkers to detect oxidative stress and antioxidant status in CKD patients. Antioxidant therapies may be beneficial in reducing oxidative stress, lowering uremic cardiovascular toxicity, and improving survival. Therefore, their roles in CKD patients have been evaluated in several studies as a new target for therapeutic intervention. This review provides an overview of oxidative stress mechanisms, clinical squeals, biomarkers, and possible antioxidant therapies in CKD patients.

Delayed graft function (DGF) is a consequence of ischemia-reperfusion injuries in kidney allografts, for which no definite treatment is available. The neutrophil gelatinase-associated lipocalin (NGAL) and interleukin-18 (IL-18) are introduced as the most promising urine biomarkers to detect DGF. N-acetylcysteine (NAC) and vitamin C, well-known potent antioxidants that scavenge free radicals, may alleviate kidney injury. This study investigated the protective effects of NAC alone and in combination with vitamin C on DGF, by measuring IL-18 and NGAL in living donor kidney transplantations.Patients transplanted between January 2011 and February 2013 were randomly divided into 3 groups to receive routine anti-rejection medication only (n = 32), NAC plus routine immunosuppressive regimen (NAC group; n = 33), and NAC and vitamin C plus routine regimen (NAC and vitamin C group; n = 19). Urine samples were taken 4 hours and 24 hours after transplantation. Enzyme-linked immunosorbent assay kits were utilized for measuring urine NGAL and IL-18.There were no significant differences in the DGF prevalence and its duration between the study arms. Although the levels of NGAL and IL-18 decreased in the NAC and NAC and vitamin C groups, these reductions were not significant. Glomerular filtration rate at 30 and 60 days after transplantation were not significantly different between study groups, either.Our results showed that NAC is a safe drug without significant adverse effects in kidney transplant recipients; however, its potential useful effects on urinary biomarkers of DGF were not illustrated in the present study.

Oxidative stress is a major mediator of adverse outcomes throughout the course of transplantation. Transplanted kidneys are prone to oxidative stress-mediated injury by pre-transplant and post-transplant conditions that cause reperfusion injury or imbalance between oxidants and antioxidants. Besides adversely affecting the allograft, oxidative stress and its constant companion, inflammation, cause cardiovascular disease, cancer, metabolic syndrome, and other disorders in transplant recipients. Presence and severity of oxidative stress can be assessed by various biomarkers produced from interaction of reactive oxygen species with lipids, proteins, nucleic acids, nitric oxide, glutathione, etc. In addition, expression and activities of redox-sensitive molecules such as antioxidant enzymes can serve as biomarkers of oxidative stress. Via activation of nuclear factor kappa B, oxidative stress promotes inflammation which, in turn, amplifies oxidative stress through reactive oxygen species generation by activated immune cells. Therefore, inflammation markers are indirect indicators of oxidative stress. Many treatment options have been evaluated in studies conducted at different stages of transplantation in humans and animals. These studies have provided useful strategies for use in donors or in organ preservation solutions. However, strategies tested for use in post-transplant phase have been largely inconclusive and controversial. A number of therapeutic options have been exclusively examined in animal models and only a few have been tested in humans. Most of the clinical investigations have been of short duration and have provided no insight into their impact on the long-term survival of transplant patients. Effective treatment of oxidative stress in transplant population remains elusive and awaits future explorations.