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Ren F, Ma Y, Zhang K, Luo Y, Pan R, Zhang J, Kan C, Hou N, Han F, Sun X. Exploring the multi-targeting phytoestrogen potential of Calycosin for cancer treatment: A review. Medicine (Baltimore) 2024; 103:e38023. [PMID: 38701310 PMCID: PMC11062656 DOI: 10.1097/md.0000000000038023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 04/05/2024] [Indexed: 05/05/2024] Open
Abstract
Cancer remains a significant challenge in the field of oncology, with the search for novel and effective treatments ongoing. Calycosin (CA), a phytoestrogen derived from traditional Chinese medicine, has garnered attention as a promising candidate. With its high targeting and low toxicity profile, CA has demonstrated medicinal potential across various diseases, including cancers, inflammation, and cardiovascular disease. Studies have revealed that CA possesses inhibitory effects against a diverse array of cancers. The underlying mechanism of action involves a reduction in tumor cell proliferation, induction of tumor cell apoptosis, and suppression of tumor cell migration and invasion. Furthermore, CA has been shown to enhance the efficacy of certain chemotherapeutic drugs, making it a potential component in treating malignant tumors. Given its high efficacy, low toxicity, and multi-targeting characteristics, CA holds considerable promise as a therapeutic agent for cancer treatment. The objective of this review is to present a synthesis of the current understanding of the antitumor mechanism of CA and its research progress.
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Affiliation(s)
- Fangbing Ren
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yanhui Ma
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Kexin Zhang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Youhong Luo
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Ruiyan Pan
- School of Pharmacy, Weifang Medical University, Weifang, China
| | - Jingwen Zhang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Chengxia Kan
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Ningning Hou
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Fang Han
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xiaodong Sun
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
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Zheng X, Chen D, Li M, Liao J, He L, Chen L, Xu R, Zhang M. Calycosin (CA) inhibits proliferation, migration and invasion by suppression of CXCL10 signaling pathway in glioma. Aging (Albany NY) 2024; 16:4191-4203. [PMID: 38461458 PMCID: PMC10968673 DOI: 10.18632/aging.205572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/13/2023] [Indexed: 03/12/2024]
Abstract
Glioblastoma is the most common malignant tumor in the central nervous system and its occurrence and development is involved in various molecular abnormalities. C-X-C chemokine ligand 10 (CXCL10), an inflammatory chemokine, has been reported to be related to the pathogenesis of cancer while it has not yet been linked to glioma. Calycosin, a bioactive compound derived from Radix astragali, has demonstrated anticancer properties in several malignancies, including glioma. Nonetheless, its underlying mechanisms are not fully understood. This study explores CXCL10 as a potential therapeutic target for calycosin in the suppression of glioblastoma. We observed that CXCL10 expression correlates positively with glioma malignancy and inversely with patient prognosis, highlighting its potential as a glioblastoma treatment target. Furthermore, we found that calycosin inhibited proliferation, migration, and invasion in U87 and U251 glioma cells, and decreased CXCL10 expression in a dose-dependent manner, along with its downstream effectors such as NLRP3, NF-κB, and IL-1β. Additionally, molecular docking experiments demonstrated that calycosin exhibits a notable binding affinity to CXCL10. Overexpression of CXCL10 counteracted the inhibitory effects of calycosin on cell proliferation, migration, and invasion, while CXCL10 knockdown enhanced these effects. Finally, we verified that calycosin inhibited glioma growth in a xenograft mouse model and downregulated CXCL10 and its downstream molecules. These findings suggest that targeting CXCL10 may be an effective strategy in glioblastoma treatment, and calycosin emerges as a potential therapeutic agent.
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Affiliation(s)
- Xiaoyu Zheng
- Department of Intensive-Care Unit, Affiliated First Hospital, Jinan University, Guangzhou 510630, China
- Department of Neurosurgery, Affiliated Shunde Hospital, Jinan University, Shunde, Foshan 528000, China
| | - Danmin Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Menghui Li
- Department of Neurosurgery, Affiliated First Hospital, Jinan University, Guangzhou 510630, China
| | - Jianchen Liao
- Department of Neurosurgery, Affiliated First Hospital, Jinan University, Guangzhou 510630, China
| | - Liqun He
- Department of Neurosurgery, Affiliated First Hospital, Jinan University, Guangzhou 510630, China
| | - Lu Chen
- Department of Neurosurgery, Affiliated First Hospital, Jinan University, Guangzhou 510630, China
| | - Rong Xu
- Department of Operating Room, Guangzhou Tianhe Longdong Hospital, Guangzhou 510520, China
| | - Maoying Zhang
- Department of Neurosurgery, Affiliated Shunde Hospital, Jinan University, Shunde, Foshan 528000, China
- Department of Neurosurgery, Affiliated First Hospital, Jinan University, Guangzhou 510630, China
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Sohel M, Zahra Shova FT, shuvo S, Mahjabin T, Mojnu Mia M, Halder D, Islam H, Roman Mogal M, Biswas P, Saha HR, Sarkar BC, Mamun AA. Unveiling the potential anti-cancer activity of calycosin against multivarious cancers with molecular insights: A promising frontier in cancer research. Cancer Med 2024; 13:e6924. [PMID: 38230908 PMCID: PMC10905684 DOI: 10.1002/cam4.6924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/11/2023] [Accepted: 12/30/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Calycosin may be a potential candidate regarding chemotherapeutic agent, because already some studies against multivarious cancer have been made with this natural compound. AIM This review elucidated a brief overview of previous studies on calycosin potential effects on various cancers and its potential mechanism of action. METHODOLOGY Data retrieved by systematic searches of Google Scholar, PubMed, Science Direct, Web of Science, and Scopus by using keywords including calycosin, cancer types, anti-cancer mechanism, synergistic, and pharmacokinetic and commonly used tools are BioRender, ChemDraw Professional 16.0, and ADMETlab 2.0. RESULTS Based on our review, calycosin is available in nature and effective against around 15 different types of cancer. Generally, the anti-cancer mechanism of this compound is mediated through a variety of processes, including regulation of apoptotic pathways, cell cycle, angiogenesis and metastasis, oncogenes, enzymatic pathways, and signal transduction process. These study conducted in various study models, including in silico, in vitro, preclinical and clinical models. The molecular framework behind the anti-cancer effect is targeting some oncogenic and therapeutic proteins and multiple signaling cascades. Therapies based on nano-formulated calycosin may make excellent nanocarriers for the delivery of this compound to targeted tissue as well as particular organ. This natural compound becomes very effective when combined with other natural compounds and some standard drugs. Moreover, proper use of this compound can reverse resistance to existing anti-cancer drugs through a variety of strategies. Calycosin showed better pharmacokinetic properties with less toxicity in human bodies. CONCLUSION Calycosin exhibits excellent potential as a therapeutic drug against several cancer types and should be consumed until standard chemotherapeutics are available in pharma markets.
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Affiliation(s)
- Md Sohel
- Biochemistry and Molecular BiologyPrimeasia UniversityDhakaBangladesh
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Fatema Tuj Zahra Shova
- Biotechnology and Genetic EngineeringMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Shahporan shuvo
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Taiyara Mahjabin
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Md. Mojnu Mia
- Biotechnology and Genetic EngineeringMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Dibyendu Halder
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Hafizul Islam
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Md Roman Mogal
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
| | - Partha Biswas
- Department of Genetic Engineering and Biotechnology, Faculty of Biological Science and TechnologyJashore University of Science and Technology (JUST)JashoreBangladesh
| | - Hasi Rani Saha
- Biochemistry and Molecular BiologyPrimeasia UniversityDhakaBangladesh
| | | | - Abdullah Al Mamun
- Biochemistry and Molecular BiologyMawlana Bhashani Science and Technology UniversityTangailBangladesh
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Song Y, Li X, Liu X, Yu Z, Zhang G. Calycosin Alleviates Oxidative Injury in Spinal Astrocytes by Regulating the GP130/JAK/STAT Pathway. J Oleo Sci 2022; 71:881-887. [PMID: 35584953 DOI: 10.5650/jos.ess21174] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Spinal injury is a complicated disease and is reported to be associated with damages on spinal astrocytes induced by oxidative injury. Astragali Radi, a famous traditional Chinese medicine, is reported to have promising efficacy in protecting injuries in the central nervous system. This study aims to investigate the effect of calycosin, an isoflavone phytoestrogens isolated from Astragali Radi, on oxidative injury in spinal astrocytes induced by H2O2 and the underlying mechanism. Primary rat spinal astrocytes were pretreated with 5, 10, and 20 μM calycosin and subjected to H2O2 treatment for 24 h to establish an oxidative injury model. Cell viability was detected using the CCK-8 assay to screen the optimized concentration of calycosin. Flow cytometry was used to evaluate the apoptotic rate and cell cycle. The expression level of Brdu was visualized using the immunofluorescence assay. Western blotting was used to measure the expression levels of p-JAK2, p-STAT3, p-AKT, GP130, and IL-6 in spinal astrocytes. We found that proliferation was inhibited and that apoptosis was induced by the stimulation of H2O2. The expression levels of p-JAK2, p-STAT3, p-AKT, GP130, and IL-6 were significantly elevated in H2O2-treated astrocytes. After the treatment of calycosin, proliferation was facilitated, and apoptosis was suppressed. These phenomena were accompanied by the downregulation of p-JAK2, p-STAT3, p-AKT, GP130, and IL-6, which were abolished by the co-administration of PI3K (ly294002) or STAT3 (stattic) inhibitor. Overall, calycosin alleviated oxidative injury in spinal astrocytes by mediating the GP130/JAK/STAT pathway.
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Affiliation(s)
- Yingjun Song
- Department of traumatic orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine
| | - Xu Li
- Department of traumatic orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine
| | - Xiaozhou Liu
- Jiangxi University of Traditional Chinese Medicine
| | - Zhaozhong Yu
- Department of traumatic orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine
| | - Guofu Zhang
- Department of traumatic orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine
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The Mechanism Study of Common Flavonoids on Antiglioma Based on Network Pharmacology and Molecular Docking. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2198722. [PMID: 35140796 PMCID: PMC8820855 DOI: 10.1155/2022/2198722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/30/2021] [Accepted: 12/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Glioma is the most common primary intracranial tumor in adult patients. Among them, glioblastoma is a highly malignant one with a poor prognosis. Flavonoids are a class of phenolic compounds widely distributed in plants and have many biological functions, such as anti-inflammatory, antioxidant, antiaging, and anticancer. Nowadays, flavonoids have been applied to the therapy of glioma; however, the molecular mechanism underlying the therapeutic effects has not been fully elaborated. This study was carried out to explore the mechanism of selected active flavonoid compounds in treating glioma using network pharmacology and molecular docking approaches. METHODS Active ingredients and associated targets of flavonoids were acquired by using the Traditional Chinese Medicine Database and Analysis Platform (TCMSP) and Swiss TargetPrediction platform. Genes related to glioma were obtained from the GeneCards and DisGeNET databases. The intersection targets between flavonoid targets and glioma-related genes were used to construct protein-protein interaction (PPI) network via the STRING database, and the results were analyzed by Cytoscape software. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed and displayed by utilizing the Metascape portal and clusterProfiler R package. Molecular docking was carried out by iGEMDOCK and SwissDock, and the results were visually displayed by UCSF Chimera software. RESULTS Eighty-four active flavonoid compounds and 258 targets overlapped between flavonoid targets and glioma-related genes were achieved. PPI network revealed potential therapeutic targets, such as AKT1, EGFR, VEGFA, MAPK3, and CASP3, based on their node degree. GO and KEGG analyses showed that core targets were mainly enriched in the PI3K-Akt signaling pathway. Molecular docking simulation indicated that potential glioma-related targets-MAPK1 and HSP90AA1 were bounded more firmly with epigallocatechin-3-gallate (EGCG) than with quercetin. CONCLUSIONS The findings of this study indicated that selected active flavonoid compounds might play therapeutic roles in glioma mainly through the PI3K-Akt signaling pathway. Moreover, EGCG had the potential antiglioma activity by targeting MAPK1 and HSP90AA1.
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Wu L, Chen Y, Chen M, Yang Y, Che Z, Li Q, You X, Fu W. Application of network pharmacology and molecular docking to elucidate the potential mechanism of Astragalus-Scorpion against prostate cancer. Andrologia 2021; 53:e14165. [PMID: 34185887 DOI: 10.1111/and.14165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/29/2021] [Accepted: 06/05/2021] [Indexed: 12/24/2022] Open
Abstract
The present study aimed to investigate the molecular mechanism of the Astragalus-Scorpion drug pair in the treatment of prostate cancer (PCa). We employed network pharmacology and molecular docking technology to retrieving the active ingredients and corresponding targets of Astragalus-Scorpion by using TCMSP, BATMAN-TCM, TCMID and Swiss Target Prediction Databases. The targets related to PCa were retrieved through GeneCards. Cytoscape software was used to construct the 'active ingredient-target disease' network, and GO and KEGG enrichment analyses were performed on the common targets. Autodock software was used for molecular docking verification. In total, 26 active ingredients, 340 potential targets related to active ingredients and 122 common targets were screened from Astragalus-Scorpion drug pair. The core targets of the protein-protein interaction (PPI) network were JUN, AKT1, IL6, MAPK1 and RELA, whereas the core active ingredients were quercetin, kaempferol, formononetin, 7-o-methylisomucronulatol and calycosin. Nearly 762 GO entries and 154 pathways were obtained by using the pathway enrichment analysis. Molecular docking results revealed that quercetin and kaempferol bind to AKT1 and formononetin binds to RELA, all of which were found to be stable bounds.
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Affiliation(s)
- Litong Wu
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China.,School of Graduate, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ying Chen
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China.,School of Graduate, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Minjing Chen
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China.,School of Graduate, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yueqin Yang
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China.,School of Graduate, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zuzhao Che
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China.,School of Graduate, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qixin Li
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Xujun You
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Wei Fu
- Shenzhen Bao'an Traditional Chinese Medicine Hospital Group, Guangzhou University of Chinese Medicine, Shenzhen, China
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Deng M, Chen H, Long J, Song J, Xie L, Li X. Calycosin: a Review of its Pharmacological Effects and Application Prospects. Expert Rev Anti Infect Ther 2020; 19:911-925. [PMID: 33346681 DOI: 10.1080/14787210.2021.1863145] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Calycosin (CA), a typical phytoestrogen extracted from root of Astragalus membranaceus. On the basis of summarizing the pharmacological and pharmacokinetic studies of CA in recent years, we hope to provide useful information for CA about treating different diseases and to make suggestions for future research.Areas covered: We collected relevant information (January 2014 to March 2020) on CA via the Internet database. Keywords searched includ pharmacology, pharmacokinetics and toxicology, and the number of effective references was 118. CA is a phytoestrogen with wide range of pharmacological activities. By affecting PI3K/Akt/mTOR, WDR7-7-GPR30, Rab27B-β-catenin-VEGF, etc. signaling pathway, CA showed the effect of anticancer, anti-inflammatory, anti-osteoporosis, neuroprotection, hepatoprotection, etc. Therefore, CA is prospective to be used in the treatment of many diseases.Expert opinion: Research shows that CA has a therapeutic effect on a variety of diseases. We think CA is a promising natural medicine. Therefore, we propose that the research directions of CA in the future include the following. Carrying out clinical research trials in order to find the most suitable medicinal concentration for different diseases; Exploring the synergistic mechanism of CA in combination with other drugs; Exploring ways to increase the blood circulation concentration of CA.
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Affiliation(s)
- Mao Deng
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Huijuan Chen
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Jiaying Long
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Jiawen Song
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Long Xie
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Xiaofang Li
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
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Yarmohammadi F, Hayes AW, Karimi G. Natural compounds against cytotoxic drug-induced cardiotoxicity: A review on the involvement of PI3K/Akt signaling pathway. J Biochem Mol Toxicol 2020; 35:e22683. [PMID: 33325091 DOI: 10.1002/jbt.22683] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/09/2020] [Accepted: 11/25/2020] [Indexed: 12/17/2022]
Abstract
Cardiotoxicity is a critical concern in the use of several cytotoxic drugs. Induction of apoptosis, inflammation, and autophagy following dysregulation of the PI3K/Akt signaling pathway contributes to the cardiac damage induced by these drugs. Several natural compounds (NCs), including ferulic acid, gingerol, salvianolic acid B, paeonol, apigenin, calycosin, rutin, neferine, higenamine, vincristine, micheliolide, astragaloside IV, and astragalus polysaccharide, have been reported to suppress cytotoxic drug-induced cardiac injury. This article reviews these NCs that have been reported to have a protective effect against cytotoxic drug-induced cardiotoxicity through regulation of the PI3K/Akt signaling pathway.
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Affiliation(s)
- Fatemeh Yarmohammadi
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - A Wallace Hayes
- College of Public Health, University of South Florida, Tampa, Florida, USA.,Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA
| | - Gholamreza Karimi
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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