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Safari F, Bardania H, Dehshahri A, Hallaj-Nezhadi S, Asfaram A, Mohammadi V, Baneshi M, Bahramianpour S, Akrami N, Khalvati B, Mirzaei A. Targeted delivery of interleukin-12 plasmid into HepG2 cells through folic acid conjugated graphene oxide nanocarrier. Biotechnol Prog 2024; 40:e3473. [PMID: 38757348 DOI: 10.1002/btpr.3473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/31/2024] [Accepted: 04/09/2024] [Indexed: 05/18/2024]
Abstract
Successful gene therapy relies on carriers to transfer genetic materials with high efficiency and low toxicity in a targeted manner. To enhance targeted cell binding and uptake, we developed and synthesized a new gene delivery vector based on graphene oxide (GO) modified by branched polyethyleneimine (BPEI) and folic acid (FA). The GO-PEI-FA nanocarriers exhibit lower toxicity compared to unmodified PEI, as well as having the potential to efficiently condense and protect pDNA. Interestingly, increasing the polymer content in the polyplex formulation improved plasmid transfer ability. Substituting graphene oxide for PEI at an N/P ratio of 10 in the HepG2 and THP1 cell lines improved hIL-12 expression by up to approximately eightfold compared to simple PEI, which is twice as high as GO-PEI-FA in Hek293 at the same N/P ratio. Therefore, the GO-PEI-FA described in this study may serve as a targeting nanocarrier for the delivery of the hIL-12 plasmid into cells overexpressing folic acid receptors, such as those found in hepatocellular carcinoma.
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Affiliation(s)
- Farshad Safari
- Student Research Committee, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Hassan Bardania
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Ali Dehshahri
- Pharmaceutical Sciences Research Center, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Somayeh Hallaj-Nezhadi
- Pharmaceutical and Food Control Department, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arash Asfaram
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Vahid Mohammadi
- Student Research Committee, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Marzieh Baneshi
- Department of Chemistry, Cape Breton University, Sydney, Nova Scotia, Canada
| | - Sima Bahramianpour
- Student Research Committee, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Negar Akrami
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Bahman Khalvati
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
- Biological Mass Spectrometry Center, Stony Brook Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Ali Mirzaei
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
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Ye J, Yi Y, Wang H, Wang G, Sun Y, Liu E, Tao X, He C. A Study of Glutathione-Responsive Dual-Drug-Loaded Nanoparticles in Anti-Osteosarcoma Treatment. J Biomed Nanotechnol 2022. [DOI: 10.1166/jbn.2022.3411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We connected polyglutamic acid and methotrexate (MTX) through disulfide bonds to prepare glutathione-responsive nanoparticles (MTX NPs) and encapsulated doxorubicin (DOX) to obtain dual drug-loaded NPs (DOX/MTX NPs) (Fig. 1). The appearance of the carbonyl stretching vibration peak
at approximately 1640 cm−1 in the results of the infrared spectrum proved the successful synthesis of three kinds of nanoparticles (NPs) with different feeding ratios. The particle sizes of NPs with different feeding ratios were 100–200 nm, and the encapsulation of DOX
slightly increased the size, while the surface charge was always negative. The release of MTX at 10 mM glutathione (GSH) was as high as 91.45%, and that of DOX was 89.44%, suggesting that the breakage of disulfide bonds leads to the disintegration of NPs. The results of the cell experiment
showed that the encapsulation of DOX effectively increased toxicity and side effects in 143B cells and significantly induced cell apoptosis, and the inhibition of the migration rate increased as the feeding ratio increased. In animal experiments, DOX/MTX NPs significantly induced tumor cell
apoptosis and inhibited cell proliferation and tumor growth. The nanoparticles had excellent tumor-targeting properties. Tumor-targeted NPs with the combined action of the two drugs provided a good strategy for the efficient and precise treatment of osteosarcoma.
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Affiliation(s)
- Jia Ye
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Yangfei Yi
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Hongyi Wang
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Guowei Wang
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Yuting Sun
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Enze Liu
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Xiaojun Tao
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
| | - Chunlian He
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province and Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, 410013, China
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Mu QG, Lin G, Jeon M, Wang H, Chang FC, Revia RA, Yu J, Zhang M. Iron oxide nanoparticle targeted chemo-immunotherapy for triple negative breast cancer. MATERIALS TODAY (KIDLINGTON, ENGLAND) 2021; 50:149-169. [PMID: 34987308 PMCID: PMC8722574 DOI: 10.1016/j.mattod.2021.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Triple negative breast cancer is difficult to treat effectively, due to its aggressiveness, drug resistance, and lack of the receptors required for hormonal therapy, particularly at the metastatic stage. Here, we report the development and evaluation of a multifunctional nanoparticle formulation containing an iron oxide core that can deliver doxorubicin, a cytotoxic agent, and polyinosinic:polycytidylic acid (Poly IC), a TLR3 agonist, in a targeted and simultaneous fashion to both breast cancer and dendritic cells. Endoglin-binding peptide (EBP) is used to target both TNBC cells and vasculature epithelia. The nanoparticle demonstrates favorable physicochemical properties and a tumor-specific targeting profile. The nanoparticle induces tumor apoptosis through multiple mechanisms including direct tumor cell killing, dendritic cell-initiated innate and T cell-mediated adaptive immune responses. The nanoparticle markedly inhibits tumor growth and metastasis and substantially extends survival in an aggressive and drug-resistant metastatic mouse model of triple negative breast cancer (TNBC). This study points to a promising platform that may substantially improve the therapeutic efficacy for treating metastatic TNBC.
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Affiliation(s)
- Qin gxin Mu
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Guanyou Lin
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Mike Jeon
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Hui Wang
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Fei-Chien Chang
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Richard A Revia
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - John Yu
- Department of Neurosurgery, Maxine-Dunitz Neurosurgical Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Miqin Zhang
- Department of Materials Science and Engineering, University of Washington, Seattle, WA 98195, USA
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Ramezani S, Javadi I, Kokhdan EP, Omidifar N, Nikbakht J, Sadeghi H, Doustimotlagh AH, Danaei N, Abbasi R, Sadeghi H. Protective and therapeutic effects of ethanolic extract of Nasturtium officinale (watercress) and vitamin E against bleomycin-induced pulmonary fibrosis in rats. Res Pharm Sci 2020; 16:94-102. [PMID: 33953778 PMCID: PMC8074801 DOI: 10.4103/1735-5362.305192] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/15/2020] [Accepted: 12/13/2020] [Indexed: 12/11/2022] Open
Abstract
Background and purpose Pulmonary fibrosis is a chronic disease of the lungs caused by inflammation, species of reactive oxygen, and immune defects. Antioxidant properties of Nasturtium officinale has been reported in some studies. Therefore, the objective of the current study was to evaluate the effect of ethanolic extract of Nasturtium officinale (EENO) on bleomycin (BLM)-induced lung fibrosis in rats. Experimental approach Forty adult male Wistar rats (180-220 g) were randomly divided into 5 experimental groups. Normal control, BLM control received a single dose of BLM (6 IU/kg) intratracheally only on the first day, EENO + BLM group received EENO (500 mg/kg) one week before intratracheal BLM instillation and two weeks afterward, BLM + EENO group and BML + vitamin E group received EENO (500 mg/kg) and vitamin E (500 mg/kg) half-hour after BLM installation, respectively. The animals were sacrificed on day 22. Change in body weight, lung index, serum level of malondialdehyde (MDA) and nitric oxide (NO) metabolite, lung tissue hydroxyproline content and lung pathology were assessed. Findings/Results Pre- or post-treatment with EENO attenuated pulmonary fibrosis as evidenced by normalized lung index, improved histological changes and inhibited collagen deposition (hydroxyproline) in the animal lung. EENO also decreased MDA and NO metabolite release in comparison to the BLM control. vitamin E (500 mg/ kg) also significantly inhibited the BLM-induced lung toxicity. Conclusions and implications EENO can prevent BLM-induced lung fibrosis in rats via antioxidant activities. However, more studies are needed to elicit the exact mechanism of this effect.
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Affiliation(s)
- Sanaz Ramezani
- Department of Toxicology, Shahreza Branch, Islamic Azad University, Shahreza, I.R. Iran
| | - Iraj Javadi
- Department of Toxicology, Shahreza Branch, Islamic Azad University, Shahreza, I.R. Iran
| | - Esmaeel Panahi Kokhdan
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, I.R. Iran
| | - Navid Omidifar
- Clinical Education Research Center, Department of Pathology, Medical School, Shiraz University of Medical Sciences, Shiraz, I.R. Iran
| | - Jafar Nikbakht
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, I.R. Iran
| | - Heibatollah Sadeghi
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, I.R. Iran
| | | | - Nazanin Danaei
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, I.R. Iran
| | - Reza Abbasi
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, I.R. Iran
| | - Hossein Sadeghi
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, I.R. Iran
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Nguyen KG, Vrabel MR, Mantooth SM, Hopkins JJ, Wagner ES, Gabaldon TA, Zaharoff DA. Localized Interleukin-12 for Cancer Immunotherapy. Front Immunol 2020; 11:575597. [PMID: 33178203 PMCID: PMC7593768 DOI: 10.3389/fimmu.2020.575597] [Citation(s) in RCA: 228] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/08/2020] [Indexed: 12/30/2022] Open
Abstract
Interleukin-12 (IL-12) is a potent, pro-inflammatory type 1 cytokine that has long been studied as a potential immunotherapy for cancer. Unfortunately, IL-12's remarkable antitumor efficacy in preclinical models has yet to be replicated in humans. Early clinical trials in the mid-1990's showed that systemic delivery of IL-12 incurred dose-limiting toxicities. Nevertheless, IL-12's pleiotropic activity, i.e., its ability to engage multiple effector mechanisms and reverse tumor-induced immunosuppression, continues to entice cancer researchers. The development of strategies which maximize IL-12 delivery to the tumor microenvironment while minimizing systemic exposure are of increasing interest. Diverse IL-12 delivery systems, from immunocytokine fusions to polymeric nanoparticles, have demonstrated robust antitumor immunity with reduced adverse events in preclinical studies. Several localized IL-12 delivery approaches have recently reached the clinical stage with several more at the precipice of translation. Taken together, localized delivery systems are supporting an IL-12 renaissance which may finally allow this potent cytokine to fulfill its considerable clinical potential. This review begins with a brief historical account of cytokine monotherapies and describes how IL-12 went from promising new cure to ostracized black sheep following multiple on-study deaths. The bulk of this comprehensive review focuses on developments in diverse localized delivery strategies for IL-12-based cancer immunotherapies. Advantages and limitations of different delivery technologies are highlighted. Finally, perspectives on how IL-12-based immunotherapies may be utilized for widespread clinical application in the very near future are offered.
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Affiliation(s)
- Khue G Nguyen
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
| | - Maura R Vrabel
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
| | - Siena M Mantooth
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
| | - Jared J Hopkins
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
| | - Ethan S Wagner
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
| | - Taylor A Gabaldon
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
| | - David A Zaharoff
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill and North Carolina State University, Raleigh, NC, United States
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6
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Yuan C, Liu Y, Wang T, Sun M, Chen X. Nanomaterials as Smart Immunomodulator Delivery System for Enhanced Cancer Therapy. ACS Biomater Sci Eng 2020; 6:4774-4798. [DOI: 10.1021/acsbiomaterials.0c00804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Congshan Yuan
- College of Marine Life Science, Ocean University of China, Qingdao 266003, P.R. China
| | - Ya Liu
- College of Marine Life Science, Ocean University of China, Qingdao 266003, P.R. China
| | - Ting Wang
- College of Marine Life Science, Ocean University of China, Qingdao 266003, P.R. China
| | - Mengjie Sun
- College of Marine Life Science, Ocean University of China, Qingdao 266003, P.R. China
| | - Xiguang Chen
- College of Marine Life Science, Ocean University of China, Qingdao 266003, P.R. China
- Qingdao National Laboratory for Marine Science and Technology, Qingdao 266000, P.R. China
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7
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Dehshahri A, Sadeghpour H, Mohazzabieh E, Saatchi Avval S, Mohammadinejad R. Targeted double domain nanoplex based on galactosylated polyethylenimine enhanced the delivery ofIL‐12 plasmid. Biotechnol Prog 2020; 36:e3002. [DOI: 10.1002/btpr.3002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/08/2020] [Accepted: 04/08/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Ali Dehshahri
- Department of Pharmaceutical Biotechnology, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
- Pharmaceutical Sciences Research Center, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
| | - Hossein Sadeghpour
- Pharmaceutical Sciences Research Center, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
- Department of Medicinal Chemistry, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
| | - Erfaneh Mohazzabieh
- Department of Pharmaceutical Biotechnology, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
- Pharmaceutical Sciences Research Center, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
| | - Sara Saatchi Avval
- Department of Pharmaceutical Biotechnology, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
- Pharmaceutical Sciences Research Center, Shiraz School of Pharmacy Shiraz University of Medical Sciences Shiraz Iran
| | - Reza Mohammadinejad
- Pharmaceutics Research Center, Institute of Neuropharmacology Kerman University of Medical Sciences Kerman Iran
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Pishavar E, Oroojalian F, Ramezani M, Hashemi M. Cholesterol-conjugated PEGylated PAMAM as an efficient nanocarrier for plasmid encoding interleukin-12 immunogene delivery toward colon cancer cells. Biotechnol Prog 2019; 36:e2952. [PMID: 31846226 DOI: 10.1002/btpr.2952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/12/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
IL-12 is a pleiotropic cytokine, which shows an ideal applicant for tumor immunotherapy, because of its features of creating an interconnection between innate (NK cells) and adaptive (cytotoxic T lymphocyte) immunity. IL-12 gene therapy is a useful technique to deliver an immune-modulatory gene directly into tumor site thereby limiting the adverse effects of systemic administration of IL-12 proteins. One of the most largely investigated non-viral gene carriers is polyamidoamine (PAMAM). In the current research, 5 and 3% of PAMAM primary amines were substituted to transmit the plasmid encoding IL-12 gene to cells by cholesteryl chloroformate and alkyl-PEG, respectively. The features of modified PAMAMs containing size and surface charge density, cytotoxicity, and transfection efficiency were investigated in colon cancer cells. in vitro experiment showed that this modified carrier with average size of about 160 nm and zeta potential of 30 mV was able to increase the level of IL-12 production up to two folds as compared to that of the unmodified PAMAM. Improvement of the polymer hydrophobic balance along with of the modulation of the surface positive charge could provide an efficient and safe non-viral IL-12 gene for colon cancer immunogene therapy.
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Affiliation(s)
- Elham Pishavar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina.,Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Oroojalian
- Department of Advanced Sciences and Technologies, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran.,Natural Products and Medicinal Plants Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Mohammad Ramezani
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Hashemi
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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Nouri F, Sadeghpour H, Heidari R, Dehshahri A. Preparation, characterization, and transfection efficiency of low molecular weight polyethylenimine-based nanoparticles for delivery of the plasmid encoding CD200 gene. Int J Nanomedicine 2017; 12:5557-5569. [PMID: 28831252 PMCID: PMC5548269 DOI: 10.2147/ijn.s140734] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Various strategies have been utilized to improve both gene transfer efficiency and cell-induced toxicity of polyethylenimine (PEI), the most extensively investigated cationic polymeric vector. In this study, we sought to enhance transfection efficiency of low molecular weight PEI (LMW PEI) while maintaining its low toxicity by cross-linking LMW PEI via succinic acid linker. These modifications were designed to improve the hydrophilic–hydrophobic balance of the polymer, by enhancing the buffering capacity and maintaining low cytotoxic effects of the final conjugate. Decreased expression of CD200 in the central nervous system has been considered as one of the proposed mechanisms associated with neuroinflammation in multiple sclerosis; therefore, we selected plasmid-encoding CD200 gene for transfection using the modified PEI derivatives. Dynamic light scattering experiments demonstrated that the modified PEIs were able to condense plasmid DNA and form polyplexes with a size of approximately 130 nm. The highest level of CD200 expression was achieved at a carrier to plasmid ratio of 8, where the expression level was increased by 1.5 fold in the SH-SY5Y cell line, an in vitro model of neurodegenerative disorders. Furthermore, the results of in vivo imaging of the LMW PEI-based nanoparticles in the mouse model of multiple sclerosis revealed that fluorescently labeled plasmid encoding CD200 was distributed from the injection site to various tissues and organs including lymph nodes, liver, brain, and finally, kidneys. The nanoparticles also showed the ability to cross the blood–brain barrier and enter the periventricular area.
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Affiliation(s)
| | | | - Reza Heidari
- Department of Pharmacology and Toxicology, School of Pharmacy
| | - Ali Dehshahri
- Department of Pharmaceutical Biotechnology.,Center for Nanotechnology in Drug Delivery, School of Pharmacy.,Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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