Addition of carboplatin-gemcitabine as second-line neoadjuvant chemotherapy in non-responsive locally advanced breast cancer patients to standard neoadjuvant chemotherapy and evaluation of factors affecting response: a randomized controlled trial.

BACKGROUND: Neoadjuvant chemotherapy (NACT) is the prime approach to the management of locally advanced breast cancer (LABC). Influenced by different factors such as pathologic tumor characteristics, hormone receptor status, HER2 and proliferation marker expressions, response to therapy cannot be easily predicted. Pathologic complete response (pCR) has been considered as an endpoint to NACT; however, pCR rates have been unsatisfactory in such patients. In this randomized trial, we studied the efficacy of carboplatin/gemcitabine as second-line NACT while evaluating the impact of different factors affecting response. METHODS: In this randomized controlled trial, 52 clinically non-responsive (confirmed by palpation and/or ultrasonography) LABC patients to 4 cycles of doxorubicin/cyclophosphamide followed by 4 cycles of paclitaxel ± trastuzumab were randomly allocated to two groups. "Control" group underwent breast surgery and were further evaluated for pCR (ypT0/is ypN0). "Intervention" group received 2 cycles of carboplatin/gemcitabine and patients were further evaluated for pCR following surgery. RESULTS: In a total of 52 patients, pCR rate was 30.7%. pCR and response rate in lymph nodes were higher in carboplatin/gemcitabine recipients (32% vs 29.7 and 44% vs 40.7% respectively), however differences were insignificant. In both the "intervention" group and total study population, most pCR cases were of the hormone receptor (HR)+/HER2+ subtype (87.5% and 75% respectively). HER2 positivity, ki67 expression, lower extent of ER positivity, higher tumor grade and tumor-infiltrating lymphocyte (TIL) lead to higher pCR rates. Adverse events following addition of carboplatin/gemcitabine were mostly hematologic and none required hospitalization. Anemia was the most common grade 3 adverse event observed. No grade 4 toxicity was evident. CONCLUSION: Although the proposed carboplatin/gemcitabine combination could not improve pCR rates as expected, probability of immune activation following use of carboplatin in achieving response to NACT may be considered. Accounting for the highest number of pCR cases in the "intervention" group, the HR+/HER2+ subtype with high TILs may be considered as most responsive to the proposed regimen in this study. It is noteworthy that the proposed combination imposed minimal toxicity. TRIAL REGISTRATION: This trial was prospectively registered in IRCT.ir ( IRCT2017100136491N1 ). Date of registration: 19 November 2017.

A randomized double-blinded placebo-controlled clinical trial on protective effects of pentoxifylline on gentamicin nephrotoxicity in infectious patients.

BACKGROUND AND OBJECTIVE: Renal toxicity has limited gentamicin use in clinical practice. The aim of the present clinical trial was to assess the possible nephroprotective effects of pentoxifylline (PTX) against gentamicin nephrotoxicity. MATERIALS AND METHODS: A multicenter, randomized, double-blind, placebo-controlled clinical trial was conducted on patients who had the indication for systemic gentamicin for at least 7 days. Sixty people were selected and randomly assigned. For patients in the intervention and control groups, 400 mg PTX sustained release tablet and placebo were given orally three times daily, respectively. Demographic, clinical, laboratory, and therapeutic information of patients were recorded. malondialdehyde (MDA) and tumor necrosis factor-alpha (TNF-α) levels in serum were measured on days 0 and 7. RESULTS: The incidence of nephrotoxicity in the placebo group was 19.6 times higher than that in the PTX group (OR = 19.6, 95%CI = 3.08-114.32; P value = 0.001). The mean ± SD time onset of ATN was 4.00 ± 2.32 and 5.58 ± 1.59 days in PTX and placebo recipients, respectively (P value < 0.001). No significant differences were observed for hypokalemia, hypomagnesemia, potassium and magnesium wasting between the two groups. The mean ± SD levels of serum MDA and TNF-α at day 7 were significantly lower in the PTX compared to those in the placebo group (P value < 0.001 for both indexes). CONCLUSION: The co-administration of 400 mg PTX orally three times daily along with gentamicin was both well-tolerated and effective in preventing the nephrotoxicity of gentamicin in patients with different infectious diseases.

Three Living Fasciola Hepatica in the Biliary Tract of a Woman.

Fasciola hepatica (F. hepatica) as a foodborne trematode can occasionally cause hepatobiliary diseases. We report a 67-year-old woman who was referred to our center because of the diagnosis of cholangitis. She was a resident of mountainous area with the history of unsafe water and contaminated vegetables. Endoscopic retrograde cholangiopancreatography (ERCP) was performed as a diagnostic and therapeutic modality for her. Three living F. hepatica was removed from biliary tract with a basket via ERCP. Clinical and laboratory condition of the patient improved after therapy of antibiotics and triclabendazole.

Thyroid diseases in children and adults with celiac disease: A cross-sectional study.

Background: There are few reports evaluating different factors, including the severity of duodenal histopathological findings and serological levels of celiac disease (CD), in increasing the probability of thyroid diseases (TD) in adults and children with CD, so, we designed this research. Methods: CD was defined as Marsh type 2 or higher in duodenal histopathology and serological levels of anti-transglutaminase antibodies (anti-tTG) equal to or greater than 18 IU/ml. To assess the likelihood of TD in CD patients, logistic regression analysis was employed. Results: 538 patients were included in this study. Of these, 354 (65.8%) were females and 184 (34.2%) were males. 370 (68.8%) patients were children. Overall, 57 (10.6%) patients had TD, of which 49 (9.1%) had hypothyroidism and 8 (1.5%) had hyperthyroidism. Adults had a significantly higher probability of developing TD than children (OR 1.9; 95% CI 1.1-3.4; P = 0.03). The odds of developing TD were also significantly higher in patients with family marriage in parents (OR 2.3; 95% CI 1.1-4.7; P = 0.03). Other variables such as gastrointestinal symptoms, anti-tTG levels, and severity of Marsh classification did not exhibit a substantial rise in the likelihood of TD development. Conclusion: The study findings indicated that the likelihood of developing TD in CD patients can be linked to advancing age and having family marriage in parents, while there was no significant association observed with anti-tTG levels, severity of histological damage, and gastrointestinal symptoms.

Pulmonary drug delivery: an effective and convenient delivery route to combat COVID-19.

The recent outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China has spread rapidly around the world, leading to a widespread and urgent effort to develop and use comprehensive approaches in the treatment of COVID-19. While oral therapy is accepted as an effective and simple method, since the primary site of infection and disease progression of COVID-19 is mainly through the lungs, inhaled drug delivery directly to the lungs may be the most appropriate route of administration. To prevent or treat primary SARS-CoV-2 infections, it is essential to target the virus port of entry in the respiratory tract and airway epithelium, which requires rapid and high-intensity inhibition or control of viral entry or replication. To achieve success in this field, inhalation therapy is the most attractive treatment approach due to efficacy/safety profiles. In this review article, pulmonary drug delivery as a unique treatment option in lung diseases will be briefly reviewed. Then, possible inhalation therapies for the treatment of symptoms of COVID-19 will be discussed and the results of clinical trials will be presented. By pulmonary delivery of the currently approved drugs for COVID-19, efficacy of the treatment would be improved along with reducing systemic side effects.

Extensive arm skin necrosis following administration of unfractionated heparin.

Unfractionated heparin (UH), a commonly used anticoagulant, can rarely cause skin necrosis following heparin-induced thrombocytopenia (HIT). A 38-year-old female, a case of chronic inflammatory demyelinating polyneuropathy (CIDP) admitted to the neurology ward, developed extensive skin necrosis following a change in UH dose at the exact site of UH injection. A sudden fall in the platelet count was observed within 48 h of increasing the UH dose. Necrosis of the outer layer of the skin along with clot formation and inflammation in the inner layers was detected after histopathological evaluation. UH was discontinued, and rivaroxaban was started for the patient as soon as the complication was detected. The patient was discharged in good condition after completing treatment for CIDP without any need for surgical removal of the necrotic tissue. Extensive skin necrosis, as a result of HIT, requires immediate discontinuation of UH and substitution of a nonheparin-based anticoagulation treatment.

Randomized trial of the effect of intravenous paracetamol on inflammatory biomarkers and outcome in febrile critically ill adults.

BACKGROUND AND THE PURPOSE OF THE STUDY: The febrile reaction is a complex response involving immunologic and other physiologic systems. Antipyretics are commonly used in critically ill patients with fever. We investigated the inflammatory responses following application of antipyretic therapy in febrile critically ill patients with Systemic Inflammatory Response Syndrome (SIRS). PATIENTS AND METHODS: In a prospective, randomized controlled study, critically ill patients with fever (T ≥ 38.3°C), SIRS diagnosed within 24 hours of Intensive Care Unit (ICU) admission and Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥10 were randomized into two groups. Upon appearance of fever, one group received intravenous paracetamol 650 mg every 6 hours for 10 days and other group received no treatment unless temperature reached 40°C. Body temperature, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sepsis-related Organ Failure Assessment (SOFA) scores, length of ICU stay, ICU mortality and infectious complications were recorded. Levels of Interleukin-1 alpha (IL-1α), IL-6, IL-10, Tumour Necrosis Factor alpha (TNFα) and High-Sensitive C-Reactive Protein (HS-CRP) were assessed at baseline and 2, 6 and 24 hours after intervention. RESULTS AND DISCUSSION: During a period of 15-month screening, 20 patients met the criteria and randomized to the control or paracetamol group. Body temperature decreased significantly in the paracetamol group (p = 0.004) and control group (p = 0.001) after 24 hours, but there was no significant difference between two groups at this time point (p = 0.649). Levels of IL-6 and IL-10 decreased significantly (p = 0.025 and p = 0.047, respectively) in the paracetamol group at 24 hours but this was not of statistical significance in control group. No patterns over time in each group or differences across two groups were found for HS-CRP, TNFα, and IL-1α (p > 0.05). There were no differences regarding ICU length of stay, mortality and infectious complications between both groups. CONCLUSION: These results suggest that antipyretic therapy may not be indicated in all ICU patients. Allowing fever to take its natural course does not appear to have detrimental effects on critically ill patients with SIRS and may avoid unnecessary expenses.

A Survey of Medical Residents' Knowledge, Attitude, and Practice about Drug-Drug Interactions, Shiraz, Iran.

Rationale, aims and objectives: Medical residents are among the most important and influential members of the medical team and the level of their knowledge regarding potential drug-drug interactions (DDIs) is a good predictor of the ability to prevent the occurrence of DDIs, as well as safe and rational prescribing in inpatient settings. This survey was designed to evaluate internal medicine and cardiology residents' knowledge and opinion toward DDIs and to determine different sources of DDI information used by this population. Method: This cross-sectional knowledge attitude practice (KAP) questionnaire study was conducted in Shiraz, Iran. A 25-question questionnaire was designed and completed by 86 internal medicine and cardiology residents. The questions were related to the participants' demographic information, their practice characteristics, the information sources used by the participants, the residents' opinion regarding DDIs, and their knowledge regarding the interaction between 8 drug pairs. Results: The results showed that when the participants wanted to learn more about DDIs, most of them used software on mobile or tablet (59.3%). Nearly three-fourths of the participants (73.82%) reported that when a patient was about to be exposed to a potential DDI, they were informed by software on mobile or tablet that the interaction may be present. On average, residents answered 44.03% ± 23.79 of drug pair questions correctly.Conclusion: Our results show insufficient practice skills, as well as relatively poor knowledge concerning the participants' answers to questions. It seems that further practical training and education are required to enable prescribers to prevent potential DDIs.

Case of possible encephalopathy following receiving the first dose of Iranian COVID-19Vaccine; COVIran Barakat.

We report a case of possible encephalopathy after receiving the first dose of Iran's COVIran Barekat vaccine. The patient had no history of neurological or mental illness. Clinical examinations and radiology reports were performed and differential diagnoses were analyzed by the treatment team. Finally, the possible association between vaccination and encephalopathy was concluded.

A randomized controlled clinical trial comparing calcitriol versus cholecalciferol supplementation to reduce insulin resistance in patients with non-alcoholic fatty liver disease.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the world with no definite treatment. Insulin resistance (IR) and low serum vitamin D are closely linked to NAFLD. Since there is no comparative study on the effect of calcitriol with cholecalciferol on NAFLD based on homeostasis model of insulin resistance (HOMA-IR) as an IR indicator, so we designed this research. METHODS: A double blind randomized clinical trial was conducted on patients with NAFLD with concomitant vitamin D deficiency/insufficiency at two referral tertiary teaching medical centers, from July 2017 to January 2019. Patients were randomly divided into two groups: calcitriol (1 mcg/day) and cholecalciferol (50,000 IU/week) for 8 weeks. Before and after the intervention, anthropometric and laboratory data were measured and HOMA-IR was calculated for each patient. RESULTS: 54 patients completed the trial. In total, calcitriol supplementation improved serum insulin levels as well as IR based on the HOMA-IR index, significantly compared to the cholecalciferol group. HOMA-IR decreased 1.8 times more in patients receiving calcitriol than in those receiving cholecalciferol, which was clinically meaningful. The observed changes were more pronounced in patients with higher baseline body mass index. Moreover, calcitriol was more associated with a significant decrease in liver enzymes and cholesterol levels comparing to cholecalciferol. CONCLUSION: Based on the findings of this study, the use of calcitriol supplementation significantly reduced HOMA-IR as an IR indicator in NAFLD patients, compared to cholecalciferol. To confirm this findings, further studies with larger sample sizes are recommended.

Impact of Serological and Histological Factors on Neurological Manifestations in Children and Adults with Celiac Disease.

PURPOSE: Celiac disease (CD) is a common autoimmune disease with extra-intestinal manifestations, including neurological disorders. There are few reports to assess various factors in increasing the chances of developing neurological disorders in CD, so we designed this study. METHODS: All patients with CD at any age who had been referred to the Celiac Clinic were evaluated for neurological problems. CD was defined as IgA anti-transglutaminase antibodies (anti-tTG) of 18 IU/mL or higher in serology and Marsh type I or more severe in histopathological evaluation. Logistic regression analysis was used to evaluate the impact of various independent variables on the neurological manifestations. RESULTS: A total of 540 patients enrolled in this study. A 360 (66.7%) of patients were children. A 64.8% and 35.2% were female and male, respectively. Overall, 34.1% of patients had neurological manifestation, including headache, neuropathy, epilepsy, and ataxia. The odds of developing neurological manifestations in children were significantly lower than in adults (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.45-0.96; p=0.03) and in patients with gastrointestinal (GI) symptoms significantly higher than in the group without GI manifestations (OR, 1.77; 95% CI, 1.18-2.63; p=0.005). Other variables, including Marsh classification (OR, 0.44; 95% CI, 0.18-1.11; p=0.08) and anti-tTG levels (OR, 1.00; 95% CI, 0.999-1.001; p=0.59) did not significantly increase the chances of developing neurological disorders. CONCLUSION: Our study showed that increasing age and the presence of GI symptoms, but not serological and histological findings, could increase the chances of developing neurological diseases in CD patients.

Psychiatric Adverse Drug Reactions and Potential Anti-COVID-19 Drug Interactions with Psychotropic Medications.

Coronavirus disease 2019 (COVID-19) management in patients with predisposing psychiatric disorders would be challenging due to potential drug-drug interactions (PDDIs) and precipitation of their disease severity. Furthermore, COVID-19 itself might precipitate or induce unpredicted psychiatry and neuropsychiatry complications in these patients. In this literature review study, the psychological impacts of COVID-19 and major psychiatric adverse drug reactions (ADRs) of COVID-19 treatment options have been discussed. A detailed Table has been provided to assess potential drug-drug interactions of COVID-19 treatment options with psychotropic medications to avoid unwanted major drug-drug interactions. Finally, potential mechanisms of these major drug-drug interactions and possible management of them have been summarized. The most common type of major PDDIs is pharmacokinetics. Hydroxychloroquine/chloroquine and lopinavir/ritonavir were the most involved anti-COVID-19 agents in these major PDDIs.

Is deep vein thrombosis prophylaxis appropriate in the medical wards? A clinical pharmacists' intervention study.

OBJECTIVE: Venous thromboembolism is a major cause of mortality and morbidity in hospitalized patients. To evaluate physicians' approach to patients' thrombosis risk assessment and practice of thromboembolism prophylaxis in a teaching hospital, we designed an interventional prospective study. SETTING: This pre and post interventional study was conducted in the infectious diseases ward of Imam Khomeini referral hospital, Tehran, Iran. METHOD: Patients' risk factors for thromboembolism during hospitalization course and physicians' thromboembolism prophylaxis approaches were evaluated in a pre and post clinical pharmacists' interventional study. MAIN OUTCOME MEASURE: An internal guideline for prescribing anticoagulants as deep vein thrombosis (DVT) prophylaxis was prepared by clinical pharmacists and the appropriateness of anticoagulants' prescription was evaluated and compared before and after the implementation of consensual guideline. RESULTS: In the pre-intervention phase 69.9% of patients had appropriate indication and received thromboembolism prophylaxis and in 31.1% of enrolled patients anticoagulants were prescribed inappropriately. Prescription of anticoagulants was appropriate in 88.4% of patients during the post interventional phase of the study while 11.6% of admitted patients received prophylaxis improperly. A decrease in the number of patients who had the criterion for DVT prophylaxis but anticoagulants were not administered after the implementation of internal guideline was statistically significant (P=0.001). CONCLUSION: The implementation of clinical pharmacists' prepared protocol helped to a great extent in the improvement of administrating DVT prophylaxis appropriately in patients.

Knowledge, attitude, and practice of health care workers towards antibiotic resistance and antimicrobial stewardship programmes: A cross-sectional study.

RATIONALE AND AIMS: Antibiotic development was a major breakthrough in defeating infections; however, their vast use has led to antimicrobial resistance (AMR) causing mortality, morbidity, and financial burden worldwide. Considering the limited introduction of newer antimicrobials to overcome resistance patterns, sufficient knowledge of their use can help manage this issue. Antimicrobial stewardship programmes (ASPs) with the mainstay of education can be a good resolution. The aim of this study was to seek aspects in which knowledge regarding antibiotics is lacking at our institutions. MATERIALS AND METHODS: This cross-sectional study performed in Shiraz, South of Iran, was designed as a knowledge, attitude, and practice (KAP) study. A self-administered questionnaire consisting of 15 questions was designed and handed out to health care workers including infectious disease practitioners, surgeons, internal medicine specialists and residents, general practitioners, medical students, and microbiology lab technicians and PhD graduates. Difference in response to questions was evaluated between the practitioner and nonpractitioner groups. RESULTS: Completed questionnaires were collected (n = 126). According to the results, most participants (88.1%) agreed on establishment of local guidelines. Majority (94.4%) also believed that education regarding antibiotics can help reduce AMR. Good patient care was not believed to be impaired by limiting use of antibiotics (72.2%). A significant difference in the practitioner and nonpractitioner groups' practice score was observed. CONCLUSION: In our study, knowledge deficit was observed in some aspects of AMR. We can conclude that more practice and education are needed in ASP for the better performance in reducing resistant patterns.

The Impact of an Antibiotic Stewardship Program on the Consumption of Specific Antimicrobials and Their Cost Burden: A Hospital-wide Intervention.

BACKGROUND: Inappropriate use of antimicrobials (AM) is a major concern worldwide that leads to the propagation of antimicrobial resistance (AMR). In addition to its clinical implications, AMR imposes an economic burden on communities, especially developing countries with more infectious diseases and less available resources. Antimicrobial stewardship programs (ASPs) have been found to be effective in reducing AMR. This study was designed to evaluate the effect of implementing an ASP in reducing AM consumption, its economic burden, and AMR as a consecutive result. MATERIALS AND METHODS: Consumption of caspofungin, amphotericin B, voriconazole, colistin, linezolid, vancomycin, and carbapenems was compared in a prospective cross-sectional study between two time periods introduced as pre- and post-ASP. Drug use density presented as anatomical therapeutic chemical (ATC)/defined daily doses (DDD) and normalized per 1000 bed days, cost savings, and AMR patterns were evaluated. RESULTS: A total of 9400 AM prescriptions were analyzed during a 2-year period. Consumption measured in DDD/1000 bed days dropped by 24.8, 25.0, 35.3, 47.0, 39.2, 10.5, and 23.2 percent for amphotericin B, caspofungin, colistin, voriconazole, meropenem, imipenem, and vancomycin, respectively. Linezolid consumption increased by 26.8% after implementing ASP. The expenditure of target AMs in the average value of USD decreased by 41.3% after the intervention compared to the time before using ASP (P-value=0.001). Implementing ASP also increased AM susceptibility of Pseudomonas aeruginosa, while the susceptibility of methicillin-resistant Staphylococcus aureus did not change significantly. CONCLUSION: The results of this study suggest that establishment of ASP can lead to a reduction in improper administration of AMs and their expenditure resulting in economic benefit and lowering AMR at hospitals with minimum resources. Clinical pharmacists' role was critical to the success of this ASP and was uniquely empowered at our center.

Association Between Metabolic Syndrome and Its Components with Severity of Acute Pancreatitis.

BACKGROUND: Acute pancreatitis (AP) and metabolic syndrome (MetS) are common clinical problems with serious complications and high cost of treatment. The relationship between MetS and severity of AP is unknown, and because there are very few published articles, further studies had been recommended. Therefore, we designed this study to estimate the association between MetS and its components with AP severity. PATIENTS AND METHODS: In this prospective analytical cross-sectional study, all AP patients who referred to two referral hospitals affiliated with Shiraz University of Medical Sciences between 2016 and 2019 were evaluated. The diagnosis of MetS syndrome as well as follow-up of patients for evaluation of severity and outcome of AP was performed in all enrolled patients. National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP-III) was used for diagnosis of MetS. Bedside Index for Severity in Acute Pancreatitis (BISAP) and revised Atlanta classification (RAC) were used to estimate the severity of AP. Finally, the association between MetS syndrome and its components at different AP severities was compared. RESULTS: Of the 214 patients referred to our center, a total of 76 patients with AP were included in this study. Of the included patients, 40 (52.6%) were male and 36 (47.4%) were female. Frequency of patients in Mets and non-MetS groups was 34 (44.74%) and 42 (55.26%), respectively. The gender and mean age difference between Mets and non-MetS groups were not statistically significant. According to Mets groups, 25 (73.5%) and 9 (26.5%) AP patients with MetS had BISAP score of 0-2 and 3-5, respectively. BISAP score in MetS group was significantly higher than non-MetS group (P = 0.022). Overall, 20 (58.8%), 11 (32.4%), and 3 (8.8%) of AP patients with MetS had mild, moderately severe, and severe AP based on RAC, respectively. Severe RAC was significantly higher in the MetS group than in the non-MetS group (P = 0.029). The frequency of complications in MetS group was significantly higher than in non-MetS group (P= 0.008). The length of hospital stay was also significantly higher in the MetS group than in the non-MetS group (P = 0.001). Overall, three patients died, two of whom had MetS and all had severe RAC and BISAP 3-5. Waist circumference, fasting blood sugar, and triglyceride were significantly higher in the severe and moderately severe types of AP group than in the mild AP group, according to RAC. Although, mean of all components of MetS except HDL-cholesterol were higher in BISAP of 3-5 group than BISAP of 0-2 group, the difference was only significant in waist circumference. CONCLUSION: The present study showed that there was a significant association between the rate of MetS and its components including waist circumference, hyperglycemia and hypertriglyceridemia with increasing AP severity. This study showed that the incidence of more severe AP in patients with MetS is much higher than in patients without MetS. We recommend that the new studies with larger sample sizes are conducted with careful consideration of confounding factors to investigate the relationship between the severity of MetS and AP as well as the effect of MetS treatment on the nature of AP.

Helicobacter pylori, Endoscopic, And Histologic Features Among Kidney Transplant Candidates In Southern Iran.

BACKGROUND: The risks of gastrointestinal disorders and cancer are higher in chronic kidney disease (CKD) patients than the general population. There are only a few published reports on the association of helicobacter pylori (H. pylori) infection, endoscopic findings, and histology in these patients. This study was designed to address these controversial topics among kidney transplant candidates as the first study in southern Iran. PATIENTS AND METHODS: In this cross-sectional study, patients undergoing renal transplantation in the largest center of southern Iran during 2016-2017 were evaluated for the frequency of H. pylori infection, endoscopic findings, and histology. Gastric endoscopic findings (normal, abnormal non-ulcerative, ulcerative) and histological findings of gastric biopsy (normal/non-significant, inflammation, premalignant lesions (PMLs), malignant lesions) were studied. RESULTS: In total, 293 patients underwent endoscopy for transplant work up. The mean age (SD) was 47.37 (13.14) years. The most common endoscopic finding was abnormal gastric lesions. Overall, 78.8% patients had abnormal gastric histologic findings, of which 6.1% had PMLs. There was no significant association between laboratory data of patients with H. pylori infection. Of these, 147 (50.2%) patients were positive and the others were H. Pylori negative. Positive H. pylori infection was significantly associated with gastric ulcerative lesions. Positive H. pylori infection was also strongly associated with inflammation (P<0.01), but not significantly associated with PMLs (P=0.99) in gastric histology. CONCLUSION: The present study showed that abnormal endoscopic and histologic findings as well as positive H. pylori infection were observed in a large number of kidney transplant candidates, so upper endoscopy with biopsy is an acceptable procedure for these patients. However, further studies are recommended to determine the relationship of H. pylori with abnormal endoscopic and histologic findings considering other confounding factors in kidney transplant candidates as well as the efficacy of H. pylori eradication therapy to improve these abnormal findings.

Economic impact of pharmacist interventions on correction of stress-related mucosal damage prophylaxis practice.

INTRODUCTION: Stress-related mucosal damage (SRMD) is described as the damage of gastric mucosa due to physiological stress that is a very common complication in critically ill patients. SRMD prophylactic medications are widely prescribed all over the world, while numerous studies have revealed that a large percentage of patients admitted to non-intensive care unit (ICU) services do not need to receive these medications. The aim of this study was to determine the frequency and type of medication errors and the economic impact of clinical pharmacist intervention on stress ulcer prophylaxis (SUP). METHODS: This prospective interventional study was conducted on adult patients admitted to internal, surgical, and critical care units at two large academic medical centers over 6 months. Risk factors of stress ulcer were recorded daily during hospital stay, and appropriateness of SUP administration was assessed according to the American Society of Health-System Pharmacists (ASHP) criteria. An intervention was performed by a clinical pharmacist in the case of contradictions. The rate of inappropriate SUP and the economic impact of a pharmacist intervention were recorded. RESULTS: In this study, 178 out of 219 (81.2%) patients received prophylactic treatments. Averagely, prophylactic therapy was compatible with standard treatment guidelines in 67.1% of cases. The implementation of ASHP guideline by a clinical pharmacist resulted in a cost saving of >18,000 USD monthly in this study, which would result in an estimated cost saving of >216,000 USD annually. CONCLUSION: Although treatment guidelines are available for the prophylaxis of SRMD, failure to observe these guidelines could increase the cost of treatment and adverse effects. The clinical pharmacists' intervention in order to implement standard protocols has a significant impact on the reduction of unintended mistakes in prescribing prophylaxis, as well as significant cost savings.

Community pharmacists' knowledge, attitude, and practice of Irritable Bowel Syndrome (IBS): the impact of training courses.

Introduction: Irritable Bowel Syndrome (IBS) is a common chronic functional gastrointestinal disorder. Pharmacists have a vital role in patient education and in drug-therapy management for IBS. This survey is the first study in Iran, to evaluate knowledge, attitude, and practice (KAP) of community pharmacists on IBS, and the impact of training courses on the improvement of their skills. Objective and setting: This pre- and post-cross-sectional study was conducted to evaluate IBS-KAP amongst Community pharmacists in Shiraz, Iran. Methods: Pretested questionnaires were designed to assess professional characteristics and KAP components of the community pharmacists regarding IBS. All pharmacists from Shiraz were invited to participate in a 3-day training course on IBS. The participants were requested to complete the questionnaire before commencing the training course (pre-test), at the end of the 3-days course (post-test), and also 3 months after the course (follow-up test). Results: Correct answers to all parts increased after the training course, as well as in the follow-up stage, which was statistically significant in all three parts (P<0.05). The increases in correct answers were seen in the fields of attitude, practice, and knowledge. Conclusion: It seems that continuing IBS training courses are essential for pharmacists, regarding the fact that they can play an important role in assisting patients with IBS, as they are easily accessible healthcare professionals.

Association of ki67 and tumor marker p53 in locally advanced breast cancer patients and evaluation of response to neoadjuvant chemotherapy: a survey in South Iran.

PURPOSE: Heterogeneity of breast cancer, the most common cancer in women, complicates approach to its treatment. Neoadjuvant chemotherapy (NAC) in the treatment of locally advanced breast cancer (LABC) with the endpoint of achieving pathologic complete response (pCR) is not always successful. The purpose of this study was to evaluate the clinicopathologic characteristics, biomarker status and response of LABCs to NAC. PATIENTS AND METHODS: Core biopsies and post-surgical specimens of LABC patients were evaluated after receiving NAC. Their lymph node involvement, tumor staging, grading, size, tumoral and stromal lymphocytic infiltration (TLI, SLI), hormonal status, ki67, p53 and HER2 expression were evaluated. Response to NAC was assessed using pCR, Miller-Payne grading and residual cancer burden. RESULTS: In a total of 71 patients, pCR rate was 5.6%. Strong association was observed between ki67 positivity and p53 expression (P-value˂0.001). Also ki67, TLI and SLI showed association with triple negative tumor subtype (P-value 0.011, 0.002 and 0.014). Good response to NAC was associated with p53 expression. Nodal metastatic residue was also associated with primary tumor's nuclear grade. CONCLUSION: Strong correlation of ki67 and p53 can suggest probable interchangeability of both markers in the prognosis of LABC. In this study p53 even showed superiority to ki67 having association with good response. Strong association of ki67, TLI and SLI with triple negative tumor subtype can be parallel to an overall better response rate of this subtype. We can also propose the effectiveness of defining nuclear grade as a prognostic factor towards residual lymph node involvement post NAC.