Thrombocytopenia has been reported as an adverse reaction of numerous drugs. Vancomycin is often overlooked as a culprit but has been associated with several cases of thrombocytopenia that were not well described in the literature. A literature search was conducted to find reports of thrombocytopenia induced by vancomycin. Biomedical databases including 'PubMed', 'Scopus', and 'Web of Science' were searched using terms 'vancomycin', 'platelet', 'pancytopenia', 'thrombocytopenia', and 'bleeding'. English language articles published before July 2015 were included. Thirty-nine papers including 29 case reports (30 cases), five observational studies, two clinical trials, two letters, and one case series remained for final analysis. The main route of administration was intravenous infusion. This adverse reaction seems to be duration dependent with the mean time to platelet nadir count of 8 days in reported cases. The interval may be significantly shorter in re-exposure to the drug. Platelet nadir counts ranged from 2000 to 100,000/mL in patients who experienced bleeding. Vancomycin-specific antibodies were detected in 13 of 17 patients who were tested in the case reports. Based on the Naranjo Adverse Drug Reaction Probability Scale, reaction was 'definite', 'probable', and 'possible' in 1, 15, and 14 patients, respectively. Among 30 cases, vancomycin was discontinued in 29 patients and platelets returned to normal counts within 5-6 days in 17 of them; in one patient, vancomycin was not discontinued, but platelet count recovered 11 days after the nadir time. Transfusion might be recommended if severe thrombocytopenia and bleeding occurs. Intravenous immunoglobulins, corticosteroids, rituximab, and plasma exchange should be reserved for patients with resistant thrombocytopenia and severe bleeding as mentioned in a number of reports.

Oral mucositis (OM) is a complication of high-dose chemotherapy (HDC) which is frequently observed in hematopoietic SCT settings. Antioxidant agents have been proposed to prevent OM and therefore N-acetyl cysteine (NAC) could have an important role. In the present study, we conducted a double-blind, randomized, placebo-controlled study to evaluate the NAC effect on OM incidence and severity, and also glutathione peroxidase-1 activity. Leukemia patients undergoing allogeneic hematopoietic SCT preceded by HDC were recruited into the study and received either NAC (100 mg/kg/day) (n = 38) or placebo (n = 42) from the starting day of HDC until day +15 after transplantation. OM was evaluated daily for 21 days after transplantation according to World Health Organization oral toxicity scale. The incidence of severe OM (grades 3-4) was significantly lower in the NAC group (23.7% vs 45.3%, P = 0.04). Moreover, the mean duration of OM was significantly shorter in the intervention group (6.24(2.96) vs 8.12(3.97) days, P = 0.02). The glutathione peroxidase-1 activity was also significantly higher in the NAC group seven days after transplantation (3.38(2.19) vs 2.41(1.70) ng/mL, P = 0.003). It is concluded that parenteral NAC is effective in reducing the incidence of severe cases and the total duration of OM.

(2015) Urine neutrophil gelatinase associated lipocalin as an early marker of acute kidney injury in hematopoietic stem cell transplantation patients, Renal Failure, 37:6,[994][995][996][997][998] DOI: 10.3109 AbstractAcute kidney injury (AKI) is common in hematopoietic stem cell transplantation (HSCT) patients with an incidence of 21-73%. Prevention and early diagnosis reduces the frequency and severity of this complication. Predictive biomarkers are of major importance to timely diagnosis. Neutrophil gelatinase associated lipocalin (NGAL) is a widely investigated novel biomarker for early diagnosis of AKI. However, no study assessed NGAL for AKI diagnosis in HSCT patients. We performed further analyses on gathered data from our recent trial to evaluate the performance of urine NGAL (uNGAL) as an indicator of AKI in 72 allogeneic HSCT patients. AKI diagnosis and severity were assessed using Risk-Injury-Failure-Loss-End-stage renal disease and AKI Network criteria. We assessed uNGAL on days À6, À3, +3, +9 and +15. Time-dependant Cox regression analysis revealed a statistically significant relationship between uNGAL and AKI occurrence.(HR ¼ 1.04 (1.008-1.07), p ¼ 0.01). There was a relation between uNGAL day + 9 to baseline ratio and incidence of AKI (unadjusted HR ¼ 1.047 (1.012-1.083), p50.01). The area under the receiver-operating characteristic curve for day + 9 to baseline ratio was 0.86 (0.74-0.99, p50.01) and a cut-off value of 2.62 was 85% sensitive and 83% specific in predicting AKI. Our results indicated that increase in uNGAL augmented the risk of AKI and the changes of day +9 uNGAL concentrations from baseline could be of value for predicting AKI in HSCT patients. Additionally uNGAL changes preceded serum Cr raises by nearly 2 days.

Acute kidney injury (AKI) is one of the complications of hematopoietic stem cell transplantation and is associated with increased mortality. N-acetylcysteine (NAC) is a thiol compound with antioxidant and vasodilatory properties that has been investigated for the prevention of AKI in several clinical settings. In the present study, we evaluated the effects of intravenous NAC on the prevention of AKI in allogeneic hematopoietic stem cell transplantation patients. A double-blind randomized placebo-controlled trial was conducted, and 80 patients were recruited to receive 100 mg/kg/day NAC or placebo as intermittent intravenous infusion from day -6 to day +15. AKI was determined on the basis of the Risk-Injury-Failure-Loss-End-stage renal disease and AKI Network criteria as the primary outcome. We assessed urine neutrophil gelatinase-associated lipocalin (uNGAL) on days -6, -3, +3, +9 and +15 as the secondary outcome. Moreover, transplant-related outcomes and NAC adverse reactions were evaluated during the study period. Statistical analysis was performed using appropriate parametric and non-parametric methods including Kaplan-Meier for AKI and generalized estimating equation for uNGAL. At the end of the trial, data from 72 patients were analysed (NAC: 33 patients and placebo: 39 patients). Participants of each group were not different considering baseline characteristics. AKI was observed in 18% of NAC recipients and 15% of placebo group patients, and the occurrence pattern was not significantly different (p = 0.73). Moreover, no significant difference was observed between groups for uNGAL measures (p = 0.10). Transplant-related outcomes were similar for both groups, and all patients had successful engraftment. Three patients did not tolerate NAC because of abdominal pain, shortness of breath and rash with pruritus and were dropped from the intervention group before transplantation. However, the frequency of adverse reactions was not significantly different between groups. In conclusion, our findings could not show any clinical benefits from high-dose NAC particularly for AKI prevention in allogeneic hematopoietic stem cell transplantation patients.

Background Appropriate pharmacotherapy, self-care and adherence to medications are crucial to diabetes control. We aimed to study the diabetes care and glycemic control in patients with type two diabetes living in an urban area of Iran. Methods In this cross-sectional study, patients with type 2 diabetes who attended a referral university affiliated community pharmacy and an accredited pathobiology laboratory in the 17th district of Tehran were evaluated. Data including demographics, medical and drug history were collected. Self-care activity (Diabetes Self-care Activity Measurement Scale) and medication adherence (8-item Morisky Medication Adherence scale) were also assessed. After completing the questionnaires, the patients were referred to the laboratory for Hemoglobin A1c test. Results Three hundred forty-eight patients (60.3% females) were recruited. The mean (SD) of patients' age was 55.82 (12.72) and 75.3%of them were Illiterate or had primary education. Mean (SD) of Hemoglobin A1c levels was 8.39 (2.03) and 33% of patients had levels higher than 9%. Among study patients, 186 (53.4%) patients received monotherapy for diabetes type 2 and 200 (57.5%) patients had low adherence to medications. Physical activity, blood glucose selfmonitoring and foot care were domains of self-care with the fewest practice. Re-using a pen or syringe needle more than once was reported by 83% of patients and mean (SD) time of re-using a pen needle was 9.11 (8.74). Conclusion Poor glycemic control, low medication adherence, inadequate self-care activities, signals of inappropriate pharmacotherapy and inadequate medical visits and monitoring in the study patients highlight the importance of providing accessible and affordable health care services in the region. Moreover, educational needs of the patients should be considered especially in an area in which the majority of patients are old and illiterate and have low socioeconomic status.