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Kaya K, Ciftci O, Basak Turkmen N, Taşlıdere A, Gül CC. β-Glucan ameliorates cisplatin-induced oxidative and histological damage in kidney and liver of rats. Biotech Histochem 2024; 99:92-100. [PMID: 38444353 DOI: 10.1080/10520295.2024.2320626] [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] [Indexed: 03/07/2024] Open
Abstract
We investigated the effects of β-glucan (βg) on kidney and liver damage caused by cisplatin (CP), an antineoplastic agent widely used to treat many types of cancer, in a rat model. The side effects of CP in many tissues and organs limit its usage. βg is a natural polysaccharide that is an effective free radical scavenger. A total of 28 rats were randomly divided into four groups. Group 1 was a non-intervention control, only feed and water were given. Group 2 was administered 7 mg/kg CP in a single dose. Group 3 was administered 50 mg/kg βg orally for 14 days. Group 4 was administered βg for 14 days, following a single dose of CP. At the end of the experiment, kidney and liver tissues were evaluated biochemically and histopathologically. Increased thiobarbituric acid-reactive substances (TBARS) levels, as well as decreased catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx) activities, and reduced glutathione (GSH) levels, as well as histological damage, were noted in both the kidney and liver tissues of the CP group. However, βg treatment prevented the oxidative and histopathological effects of CP. The study demonstrates the protective efficacy of βg against CP-induced kidney and liver damage through the effect of its antioxidant properties.
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Affiliation(s)
- Kürşat Kaya
- Department of Medicinal Biochemistry, Faculty of Medicine, Pamukkale University, Denizli, Türkiye
| | - O Ciftci
- Department of Pharmacology, Faculty of Medicine, Pamukkale University, Denizli, Türkiye
| | - N Basak Turkmen
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, İnönü University, Malatya, Türkiye
| | - A Taşlıdere
- Department of Histology and Embryology, Faculty of Medicine, İnönü University, Malatya, Türkiye
| | - C C Gül
- Department of Histology and Embryology, Faculty of Medicine, İnönü University, Malatya, Türkiye
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Pharmacological treatment with annexin A1-derived peptide protects against cisplatin-induced hearing loss. Toxicol Lett 2022; 363:27-35. [PMID: 35561849 DOI: 10.1016/j.toxlet.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022]
Abstract
Cisplatin is an antineoplastic agent widely used, and no effective treatments capable of preventing cisplatin-induced ototoxicity and neurotoxicity in humans have yet been identified. This study evaluated the effect of the anti-inflammatory annexin A1 (AnxA1)-derived peptide Ac2-26 in a cisplatin-induced ototoxicity model. Wistar rats received intraperitoneal injections of cisplatin (10mg/kg/day) for 3 days to induce hearing loss, and Ac2-26 (1mg/kg) was administered 15minutes before cisplatin administration. Control animals received an equal volume of saline. Hearing thresholds were measured by distortion product otoacoustic emissions (DPOAE) before and after treatments. Pharmacological treatment with Ac2-26 protected against cisplatin-induced hearing loss, as evidenced by DPOAE results showing similar signal-noise ratios between the control and Ac2-26-treated groups. These otoprotective effects of Ac2-26 were associated with an increased number of ganglion neurons compared with the untreated cisplatin group. Additionally, Ac2-26 treatment produced reduced immunoreactivity on cleaved caspase 3 and phosphorylated ERK levels in the ganglion neurons, compared to the untreated group, supporting the neuroprotective effects of the Ac2-26. Our results suggest that Ac2-26 has a substantial otoprotective effect in this cisplatin-induced ototoxicity model mediated by neuroprotection and the regulation of the ERK pathway.
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Ikewaki N, Dedeepiya VD, Raghavan K, Rao KS, Vaddi S, Osawa H, Kisaka T, Kurosawa G, Srinivasan S, Kumar SRB, Senthilkumar R, Iwasaki M, Preethy S, Abraham SJK. β‑glucan vaccine adjuvant approach for cancer treatment through immune enhancement (B‑VACCIEN) in specific immunocompromised populations (Review). Oncol Rep 2021; 47:14. [PMID: 34779494 DOI: 10.3892/or.2021.8225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/07/2021] [Indexed: 11/06/2022] Open
Abstract
The incidence of cancer, which is the second leading cause of mortality globally, continues to increase, although continued efforts are being made to identify effective treatments with fewer side‑effects. Previous studies have reported that chronic microinflammation, which occurs in diseases, including diabetes, along with weakened immune systems, may ultimately lead to cancer development. Chemotherapy, radiotherapy and surgery are the mainstream approaches to treatment; however, they all lead to immune system weakness, which in turn increases the metastatic spread. The aim of the present review was to provide evidence of a biological response modifier β‑glucan [β‑glucan vaccine adjuvant approach to treating cancer via immune enhancement (B‑VACCIEN)] and its beneficial effects, including vaccine‑adjuvant potential, balancing metabolic parameters (including blood glucose and lipid levels), increasing peripheral blood cell cytotoxicity against cancer and alleviating chemotherapy side effects in animal models. This suggests its value as a potential strategy to provide long‑term prophylaxis in immunocompromised individuals or genetically prone to cancer.
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Affiliation(s)
- Nobunao Ikewaki
- Department of Medical Life Science, Kyushu University of Health and Welfare, Nobeoka, Miyazaki 882‑8508, Japan
| | | | - Kadalraja Raghavan
- Department of Paediatric Neurology, Kenmax Medical Service Private Limited, Tallakulam, Madurai 625002, India
| | - Kosagi-Sharaf Rao
- Institute of Scientific Research and High Technology Services of Panama (INDICASAT‑AIP), Clayton 88888, Republic of Panama
| | - Suryaprakash Vaddi
- Department of Urology, Yashoda Hospitals, Hyderabad, Telangana 50008, India
| | - Hiroshi Osawa
- Clinical Services Department, Omote Medical Clinic, Chiba 296‑8602, Japan
| | - Tomohiko Kisaka
- Division of Biodesign, Office of Research and Academic‑Government‑Community Collaboration, Hiroshima University, Higashihiroshima, Hiroshima 739‑8511, Japan
| | - Gene Kurosawa
- Department of Academic Research Support Promotion Facility, Center for Research Promotion and Support, Fujita Health University, Toyoake, Aichi 470‑1192, Japan
| | - Subramaniam Srinivasan
- The Mary‑Yoshio Translational Hexagon (MYTH), Nichi‑In Centre for Regenerative Medicine (NCRM), Chennai 600034, India
| | | | - Rajappa Senthilkumar
- The Fujio‑Eiji Academic Terrain (FEAT), Nichi‑In Centre for Regenerative Medicine (NCRM), Chennai 600034, India
| | - Masaru Iwasaki
- Centre for Advancing Clinical Research (CACR), University of Yamanashi‑ School of Medicine, Chuo, Yamanashi 409‑3898, Japan
| | - Senthilkumar Preethy
- The Fujio‑Eiji Academic Terrain (FEAT), Nichi‑In Centre for Regenerative Medicine (NCRM), Chennai 600034, India
| | - Samuel J K Abraham
- The Mary‑Yoshio Translational Hexagon (MYTH), Nichi‑In Centre for Regenerative Medicine (NCRM), Chennai 600034, India
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Kaya K, Ciftci O, Aydın M, Cetin A, Basak N. Favourable effect of β-glucan treatment against cisplatin-induced reproductive system damage in male rats. Andrologia 2019; 51:e13342. [PMID: 31274209 DOI: 10.1111/and.13342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/27/2019] [Accepted: 05/08/2019] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to investigate the potential beneficial effects of β-glucan treatment against oxidative, histological and spermatological damage caused by cisplatin on the male reproductive system. Twenty-eight Sprague Dawley male rats were used in the study. The rats were randomly divided into four equal-sized groups: a control group, cisplatin group (7 mg/kg in a single-dose cisplatin administered intraperitoneally), β-glucan group (β-glucan given at a dose of 50 mg kg-1 d-1 for 14 day) and a cisplatin plus β-glucan group (cisplatin and β-glucan administered together at the same dose). Cisplatin administration induced an increase in the level of thiobarbituric acid-reactive substances, a lipid peroxidation indicator. It induced a decrease in enzymatic (superoxide dismutase, catalase and glutathione peroxidase) activities and nonenzymatic (reduced glutathione) antioxidant levels. In addition, cisplatin caused both histological and spermatological damage, as shown by a decrease in sperm motility and epididymal sperm concentrations and an increase in abnormal sperm rates. The β-glucan treatment improved cisplatin-induced oxidative, histological and spermatological damage. This study revealed that β-glucan treatment provided prevention against male reproductive system damage caused by cisplatin. These preventative effects were likely due to its antioxidant properties.
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Affiliation(s)
- Kürşat Kaya
- Department of Biochemistry, Faculty of Pharmacy, Adiyaman University, Adiyaman, Turkey
| | - Osman Ciftci
- Department of Medicinal Pharmacology, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Muhterem Aydın
- Department of Obstetrics and Gynecology, Faculty of Veterinary Medicine, Firat University, Elazig, Turkey
| | - Aslı Cetin
- Department of Histology and Embryology, Faculty of Medicine, Inönü University, Malatya, Turkey
| | - Neşe Basak
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Inönü University, Malatya, Turkey
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Cobanoglu HB, Vuralkan E, Arslan A, Mirasoglu B, Toklu AS. Is Hyperbaric Oxygen Therapy Effective in Cisplatin-Induced Ototoxicity in Rats? Clin Exp Otorhinolaryngol 2018; 12:66-71. [PMID: 30189717 PMCID: PMC6315209 DOI: 10.21053/ceo.2017.01704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/31/2018] [Indexed: 11/22/2022] Open
Abstract
Objectives Cisplatin is an antineoplastic agent, used in the treatment of different types of malignant neoplasms. Side effects such as ototoxicity, nephrotoxicity, and bone marrow toxicity are the main limitations of its clinical use. The aim of the present study was to evaluate the possible effects of hyperbaric oxygen (HBO) therapy as a protective agent in cisplatin-induced ototoxicity in rats. Methods A total of 30 adult Wistar rats (60 ears) were divided into five equal groups. Group 1 is a control group; group 2 is HBO therapy group; group 3 received 15 mg/kg cisplatin intraperitoneally; group 4 received 15 mg/kg cisplatin intraperitoneally and HBO treatment on the same day; group 5 received 15 mg/kg cisplatin intraperitoneally and HBO treatment 72 hours later. The effect of ototoxicity was measured with distortion product otoacoustic emission testing performed on the days 1, 3, and 7. Results Groups 4 and 5 that received HBO treatment after cisplatin had better signal-to-noise ratio (SNR) values compared with group 3 that received only cisplatin (P<0.05). Compared with group 5, group 4 (same day HBO treatment) had better SNR values (P<0.05). Conclusion HBO was found effective for prevention of cisplatin-induced ototoxicity in rats. Our study differs from other studies regarding using a promising treatment, which does not expose subjects to extra stress.
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Affiliation(s)
- H Bengu Cobanoglu
- Department of Otorhinolaryngology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Erkan Vuralkan
- Department of Otorhinolaryngology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Abdullah Arslan
- Department of Underwater and Hyperbaric Medicine, Meram University, Faculty of Medicine, Konya, Turkey
| | - Bengusu Mirasoglu
- Department of Underwater and Hyperbaric Medicine, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - A Savas Toklu
- Department of Underwater and Hyperbaric Medicine, Istanbul University, Faculty of Medicine, Istanbul, Turkey
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The protective effects of whortleberry extract against cisplatin-induced ototoxicity in rats. Braz J Otorhinolaryngol 2017; 85:55-62. [PMID: 29174583 PMCID: PMC9442816 DOI: 10.1016/j.bjorl.2017.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/20/2017] [Accepted: 10/20/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Cisplatin is one of the main chemotherapeutic agents used for the treatment of many types of cancer. However, ototoxicity, one of the most serious side effects of cisplatin, restricts its usage. OBJECTIVE We aimed to investigate the protective effects of whortleberry extract against cisplatin-induced ototoxicity by evaluating hearing and histopathological cochlear damage and by measuring the biochemical parameters affected byoxidative stress. METHODS Forty-eight male rats were included in the study after performing Distortion Product Otoacoustic Emission test to confirm that their hearing levels were normal. The rats were randomly divided into six groups: the control group, the sham group, and, which received only whortleberry extract, only cisplatin, cisplatin+100mg whortleberry extract, cisplatin+200mg whortleberry extract, respectively. Audiologic investigation was performed by performing the Distortion Product Otoacoustic Emission test at the beginning and at the eighth day of the study. Cardiac blood samples were collected for biochemical analysis, and the rats were sacrificed to obtain cochlear histopathological specimens on the eighth day. RESULTS The results revealed that whortleberry protects hearing against cisplatin-induced ototoxicity independent of the dose. However, high doses of whortleberry extract are needed to prevent histopathological degeneration and oxidative stress. CONCLUSION The results obtained in this study show that whortleberry extract has a protective effect against cisplatin-induced ototoxicity.
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Kaya K, Ciftci O, Cetin A, Tecellioğlu M, Başak N. Beneficial effects of β-glucan against cisplatin side effects on the nervous system in rats 1. Acta Cir Bras 2016; 31:198-205. [PMID: 27050791 DOI: 10.1590/s0102-865020160030000008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 02/11/2016] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To investigate the protective effect of Bg on cisplatin (CP)-induced neurotoxicity in rats. METHODS Twenty eight rats were randomly distributed into four groups. The first group was kept as a control. In the second group, CP was given at the single dose of 7 mg/kg intraperitoneally. In the third group, βg was orally administered at the dose of 50 mg/kg/day for 14 days. In the fourth group, CP and βg were given together at the same doses. RESULTS CP treatment caused significant oxidative damage via induction of lipid peroxidation and reductions antioxidant defense system potency in the brain tissue. In addition, histopathological damage increased with CP treatment. On the other hand, βg treatment largely prevented oxidative and histopathological negative effects of CP. CONCLUSIONS Cisplatin has severe neurotoxic effects in rats and βg supplementation has significant beneficial effects against CP toxicity depending on its antioxidant properties. Thus, it appears that βg might be useful against CP toxicity in patients with cancer in terms of nervous system.
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Affiliation(s)
- Kürşat Kaya
- Department of Biochemistry, Faculty of Pharmacy, Adıyaman University, Adıyaman, Turkey
| | - Osman Ciftci
- Department of Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Aslı Cetin
- Department of Histology and Embryology, Faculty of Medicine, Inönü University, Malatya, Turkey
| | - Mehmet Tecellioğlu
- Department of Neurology, Faculty of Medicine, Inönü University, Malatya, Turkey
| | - Neşe Başak
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Inönü University, Malatya, Turkey
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Kara M, Türkön H, Karaca T, Güçlü O, Uysal S, Türkyılmaz M, Demirtaş S, Dereköy FS. Evaluation of the protective effects of hesperetin against cisplatin-induced ototoxicity in a rat animal model. Int J Pediatr Otorhinolaryngol 2016; 85:12-8. [PMID: 27240489 DOI: 10.1016/j.ijporl.2016.03.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/13/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We aimed to investigate the effects of hesperetin as a flavanon both histopathologically and immunohistochemically on cochlear apoptosis in a rat model of cisplatin-induced ototoxicity (CIO). The evaluation of the effects of hesperetin on cisplatin-induced hearing loss was performed using distortion product otoacoustic emission (DPOAE). METHODS Twenty-eight wistar albino rats were used in the current study. The rats were randomly divided into four groups with seven rats in each group. Group C was exposed to a single dose of cisplatin (12mg/kg) by intraperitoneal injection. Group CH received intraperitoneally cisplatin (12mg/kg) and hesperetin (20mg/kg). Group H was exposed to hesperetin (20mg/kg) intraperitoneally. The sham group (group S) received normal saline (6cc) intraperitoneally. The measurements of DPOAE and signal-noise ratios (SNR) were performed before the treatment and again on the first and 6 days after administration of the drugs. Rats were sacrificed and cochleae were dissected 10 days after drug administration. The cochlear tissue was assessed in all groups by histopathologic, immunohistochemical and TUNEL assay. In addition, serum oxidative stress markers and antioxidant parameters were analyzed. RESULTS There was a significant difference between the basal value and the sixth day at frequencies 8.4, 9.6 and 9.96 for group C. We also found a significant difference between the first and sixth day at frequencies 7.2, 8.4, 9.6 and 9.96. On the 6th day, there were significant differences between C and S groups at all frequencies except 2.4. We showed a significant difference between C and H groups at frequencies 4.8, 6.0, 8.4, 9.6 and 9.96. There was also a significant difference between C and CH groups at frequencies 2.4, and 3.6. We found lower levels of oxidants and higher levels of antioxidants in CH group as compared to C group. C group had a significantly greater number of TUNEL-positive cells than did S, H and CH groups. The number of TUNEL-positive cells in CH group was higher than in S and H groups. There was a significant difference between the positive PCNA cells of CH group compared to S and H groups in spiral ganglion and stria vascularis. In addition, there were no positive PCNA cells in C group. CONCLUSIONS Hesperetin may prevent ototoxicity by increased antioxidant enzymes and reduced oxidant parameters and protected against apoptosis resulting from a proliferation of cochlear cells in CIO.
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Affiliation(s)
- Medine Kara
- Department of Otorhinolaryngology, Canakkale Onsekiz Mart University, Faculty of Medicine, 17060 Canakkale, Turkey.
| | - Hakan Türkön
- Department of Biochemistry, Medical Faculty of Canakkale Onsekiz Mart University, 17060 Canakkale, Turkey.
| | - Turan Karaca
- Department of Histology and Embryology, TrakyaUniversity, Faculty of Medicine, 22030 Edirne, Turkey.
| | - Oğuz Güçlü
- Department of Otorhinolaryngology, Canakkale Onsekiz Mart University, Faculty of Medicine, 17060 Canakkale, Turkey.
| | - Sema Uysal
- Department of Biochemistry, Medical Faculty of Canakkale Onsekiz Mart University, 17060 Canakkale, Turkey.
| | - Mehmet Türkyılmaz
- Department of Otorhinolaryngology, Canakkale Onsekiz Mart University, Faculty of Medicine, 17060 Canakkale, Turkey.
| | - Selim Demirtaş
- Department of Histology and Embryology, TrakyaUniversity, Faculty of Medicine, 22030 Edirne, Turkey.
| | - Fevzi Sefa Dereköy
- Department of Otorhinolaryngology, Canakkale Onsekiz Mart University, Faculty of Medicine, 17060 Canakkale, Turkey.
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Doğan M, Polat H, Yaşar M, Kaya A, Bayram A, Şenel F, Özcan İ. Protective role of misoprostol against cisplatin-induced ototoxicity. Eur Arch Otorhinolaryngol 2016; 273:3685-3692. [DOI: 10.1007/s00405-016-4031-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/01/2016] [Indexed: 12/01/2022]
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Kelles M, Tan M, Kalcioglu MT, Toplu Y, Bulam N. The Protective Effect of Chrysin Against Cisplatin İnduced Ototoxicity in Rats. Indian J Otolaryngol Head Neck Surg 2013; 66:369-74. [PMID: 26396946 DOI: 10.1007/s12070-013-0695-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 11/21/2013] [Indexed: 11/25/2022] Open
Abstract
Ototoxicity is a common side effect of cisplatin chemotherapy. The aim of this study was to investigate the potential protective effect of chrysin against cisplatin-induced ototoxicity. Thirty-four adult female Wistar albino rats were separated into four groups: a cisplatin group (Group A), with cisplatin administered to ten rats once daily for three consecutive days at doses of 8 mg/kg body weight intraperitoneally (i.p.); a cisplatin plus chrysin group (Group B), with 8 mg/kg of cisplatin administered i.p. daily to ten rats for three consecutive days and 25 mg/kg of chrysin administered via oral gavage in a corn oil for 5 days: a chrysin group (Group C), with 25 mg/kg of chrysin administered via oral gavage in corn oil for 5 days to seven rats; and a control group (Group D), with 5 ml/kg of corn oil administered to seven rats via oral gavage for 5 days. Distortion product otoacoustic emission measurements were performed in the same ear of the rats under general anesthesia at baseline and on the first and fifth days after drug administration. No significant differences were noted between the measurements either in the chrysin group or in the control group. In the cisplatin group, there was a significant worsening of hearing compared to baseline and the measurements on the fifth day at all frequencies. In the statistical analysis, a statistically significant difference was observed at 5039, 6351, 8003, and 10078 Hz frequencies between the measurements on the first and fifth days. In the cisplatin plus chrysin group, there were statistically significant differences at frequencies of 2,003 and 5,039 Hz between the measurements at baseline and on the fifth day, at 3,175 and 5,039 Hz between the measurements on the first and fifth days, and at 8,003 and 100,078 Hz between the measurements at baseline and on the first day. According to these results, this study demonstrates that cisplatin-related ototoxicity can be prevented in rats by the administration of chrysin.
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Affiliation(s)
- Mehmet Kelles
- Department of Otorhinolaryngology, Sutcu Imam University, Kahramanmaras, Turkey
| | - Mehmet Tan
- Department of Otorhinolaryngology, Inonu University, Malatya, Turkey
| | - M Tayyar Kalcioglu
- Department of Otorhinolarngology, Istanbul Medeniyet University Medical Faculty, Istanbul, Turkey
| | - Yuksel Toplu
- Department of Otorhinolaryngology, Inonu University, Malatya, Turkey
| | - Nazire Bulam
- Turgut Ozal Medical Center, Inonu University, Malatya, Turkey
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