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Govoni S, Fantucci P, Marchesi N, Vertemara J, Pascale A, Allegri M, Calvillo L, Vanoli E. N-Acetylcysteine Antagonizes NGF Activation of TrkA through Disulfide Bridge Interaction, an Effect Which May Contribute to Its Analgesic Activity. Int J Mol Sci 2023; 25:206. [PMID: 38203377 PMCID: PMC10778962 DOI: 10.3390/ijms25010206] [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: 11/20/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
N-acetylcysteine (NAC), a mucolytic agent and an antidote to acetaminophen intoxication, has been studied in experimental conditions and trials exploring its analgesic activity based on its antioxidant and anti-inflammatory properties. The purpose of this study is to investigate additional mechanisms, namely, the inhibition of nerve growth factor (NGF) and the activation of the Tropomyosin receptor kinase A (TrkA) receptor, which is responsible for nociception. In silico studies were conducted to evaluate dithiothreitol and NAC's interaction with TrkA. We also measured the autophosphorylation of TrkA in SH-SY5Y cells via ELISA to assess NAC's in vitro activity against NGF-induced TrkA activation. The in silico and in vitro tests show that NAC interferes with NGF-induced TrkA activation. In particular, NAC breaks the disulfide-bound Cys 300-345 of TrkA, perturbing the NGF-TrkA interaction and producing a rearrangement of the binding site, inducing a consequent loss of their molecular recognition and spatial reorganization, which are necessary for the induction of the autophosphorylation process. The latter was inhibited by 40% using 20 mM NAC. These findings suggest that NAC could have a role as a TrkA antagonist, an action that may contribute to the activity and use of NAC in various pain states (acute, chronic, nociplastic) sustained by NGF hyperactivity and/or accompanied by spinal cord sensitization.
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Affiliation(s)
- Stefano Govoni
- Department of Drug Sciences, Pharmacology Section, University of Pavia, 27100 Pavia, Italy; (S.G.); (N.M.)
| | - Piercarlo Fantucci
- Department of Biotechnology and Biosciences, University of Milan-Bicocca, 20126 Milan, Italy; (P.F.); (J.V.)
| | - Nicoletta Marchesi
- Department of Drug Sciences, Pharmacology Section, University of Pavia, 27100 Pavia, Italy; (S.G.); (N.M.)
| | - Jacopo Vertemara
- Department of Biotechnology and Biosciences, University of Milan-Bicocca, 20126 Milan, Italy; (P.F.); (J.V.)
| | - Alessia Pascale
- Department of Drug Sciences, Pharmacology Section, University of Pavia, 27100 Pavia, Italy; (S.G.); (N.M.)
| | - Massimo Allegri
- Centre Lémanique de Neuromodulation et Thérapie de la Douleur, Hôpital de Morges, Ensemble Hospitalier de la Côte (EHC), 1110 Morges, Switzerland;
| | - Laura Calvillo
- Department of Cardiology, Cardiology Research Laboratory, Istituto Auxologico Italiano IRCCS, 28824 Milan, Italy;
| | - Emilio Vanoli
- School of Nursing, University of Pavia, 27100 Pavia, Italy;
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Wilson SH, Sirianni JM, Bridges KH, Wolf BJ, Valente IE, Scofield MD. The impact of intraoperative N-acetylcysteine on opioid consumption following spine surgery: a randomized pilot trial. Pain Manag 2023; 13:593-602. [PMID: 37877260 PMCID: PMC10694787 DOI: 10.2217/pmt-2023-0061] [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: 04/02/2023] [Accepted: 08/22/2023] [Indexed: 10/26/2023] Open
Abstract
Aim: N-acetylcysteine (NAC) decreases inflammation and could augment perioperative analgesia. Materials & methods: This prospective pilot trial examined postoperative opioid consumption at 12 h following intraoperative NAC. In phase I, 20 adults scheduled for posterior spine surgery were randomized to NAC (0, 50, 100 and 150 mg/kg) to determine the optimal dose. In phase II, 30 patients were randomized to placebo or NAC (150 mg/kg). Opioid consumption, pain ratings and time to opioid rescue were recorded. Results: Postoperative opioid consumption was reduced in the NAC group 19.3% at 12 h and 20% at 18 and 36 h. Opioid consumption was reduced 22-24% in the NAC group at all times after adjusting for intraoperative opioid administration. NAC subjects reported lower pain scores relative to placebo. Conclusion: Subjects randomized to NAC consumed less postoperative opioids and reported less pain versus placebo. Larger randomized controlled trials are needed to further evaluate NAC for analgesia. Clinical Trial Registration: NCT04562597 (ClinicalTrials.gov).
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Affiliation(s)
- Sylvia H Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Joel M Sirianni
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kathryn H Bridges
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Bethany J Wolf
- Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Isabella E Valente
- College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Michael D Scofield
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
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Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [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] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies. RECENT FINDINGS CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.
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Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
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Bernatoniene J, Sciupokas A, Kopustinskiene DM, Petrikonis K. Novel Drug Targets and Emerging Pharmacotherapies in Neuropathic Pain. Pharmaceutics 2023; 15:1799. [PMID: 37513986 PMCID: PMC10384314 DOI: 10.3390/pharmaceutics15071799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
Neuropathic pain is a debilitating condition characterized by abnormal signaling within the nervous system, resulting in persistent and often intense sensations of pain. It can arise from various causes, including traumatic nerve injury, neuropathy, and certain diseases. We present an overview of current and emerging pharmacotherapies for neuropathic pain, focusing on novel drug targets and potential therapeutic agents. Current pharmacotherapies, including tricyclic antidepressants, gabapentinoids, and serotonin norepinephrine re-uptake inhibitors, are discussed, as are emerging treatments, such as ambroxol, cannabidiol, and N-acetyl-L-cysteine. Additionally, the article highlights the need for further research in this field to identify new targets and develop more effective and targeted therapies for neuropathic pain management.
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Affiliation(s)
- Jurga Bernatoniene
- Department of Drug Technology and Social Pharmacy, Faculty of Pharmacy, Medical Academy, Lithuanian University of Health Sciences, Sukileliu pr. 13, LT-50161 Kaunas, Lithuania
- Institute of Pharmaceutical Technologies, Faculty of Pharmacy, Medical Academy, Lithuanian University of Health Sciences, Sukileliu pr. 13, LT-50161 Kaunas, Lithuania
| | - Arunas Sciupokas
- Pain Clinic, Lithuanian University of Health Sciences Hospital Kauno Klinikos, Eivenių Str. 2, LT-50009 Kaunas, Lithuania
- Department of Neurology, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50009 Kaunas, Lithuania
| | - Dalia Marija Kopustinskiene
- Institute of Pharmaceutical Technologies, Faculty of Pharmacy, Medical Academy, Lithuanian University of Health Sciences, Sukileliu pr. 13, LT-50161 Kaunas, Lithuania
| | - Kestutis Petrikonis
- Department of Neurology, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50009 Kaunas, Lithuania
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Ferraro MC, Cashin AG, Wand BM, Smart KM, Berryman C, Marston L, Moseley GL, McAuley JH, O'Connell NE. Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD009416. [PMID: 37306570 PMCID: PMC10259367 DOI: 10.1002/14651858.cd009416.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013. OBJECTIVES To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS. METHODS We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria. Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment. MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison. There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181). There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids. AUTHORS' CONCLUSIONS Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.
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Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- The School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Keith M Smart
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- Physiotherapy Department, St Vincent's University Hospital, Dublin, Ireland
| | - Carolyn Berryman
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
- School of Biomedicine, The University of Adelaide, Kaurna Country, Adelaide, Australia
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
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6
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Anastasi E, Scaramuzzino S, Viscardi MF, Viggiani V, Piccioni MG, Cacciamani L, Merlino L, Angeloni A, Muzii L, Porpora MG. Efficacy of N-Acetylcysteine on Endometriosis-Related Pain, Size Reduction of Ovarian Endometriomas, and Fertility Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4686. [PMID: 36981595 PMCID: PMC10048621 DOI: 10.3390/ijerph20064686] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Endometriosis is a chronic, estrogen-dependent, inflammatory disease, whose pivotal symptoms are dysmenorrhea, dyspareunia, and chronic pelvic pain (CPP). Besides the usual medical treatments, recent evidence suggests there are potential benefits of oral N-acetylcysteine (NAC) on endometriotic lesions and pain. The primary objective of this prospective single-cohort study was to confirm the effectiveness of NAC in reducing endometriosis-related pain and the size of ovarian endometriomas. The secondary objective was to assess if NAC may play a role in improving fertility and reducing the Ca125 serum levels. METHODS Patients aged between 18-45 years old with a clinical/histological diagnosis of endometriosis and no current hormonal treatment or pregnancy were included in the study. All patients received quarterly oral NAC 600 mg, 3 tablets/day for 3 consecutive days of the week for 3 months. At baseline and after 3 months, dysmenorrhea, dyspareunia and CPP were assessed using the Visual Analog Scale score (VAS), while the size of the endometriomas was estimated through a transvaginal ultrasound. Analgesics (NSAIDs) intake, the serum levels of Ca125 and the desire for pregnancy were also investigated. Finally, the pregnancy rate of patients with reproductive desire was evaluated. RESULTS One hundred and twenty patients were recruited. The intensity of dysmenorrhea, dyspareunia and CPP significantly improved (p < 0.0001). The use of NSAIDs (p = 0.001), the size of the endometriomas (p < 0.0001) and the serum levels of Ca125 (p < 0.0001) significantly decreased. Among the 52 patients with reproductive desire, 39 successfully achieved pregnancy within 6 months of starting therapy (p = 0.001). CONCLUSIONS Oral NAC improves endometriosis-related pain and the size of endometriomas. Furthermore, it decreases Ca125 serum levels and may improve fertility in patients with endometriosis.
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Affiliation(s)
- Emanuela Anastasi
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Sara Scaramuzzino
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Maria Federica Viscardi
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Valentina Viggiani
- Department of Molecular Medicine, “Sapienza” University of Rome, 00161 Rome, Italy
| | - Maria Grazia Piccioni
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Laura Cacciamani
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Lucia Merlino
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Antonio Angeloni
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
| | - Maria Grazia Porpora
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, 00161 Rome, Italy
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Yaryari AM, Mousavibahar SH, Amirhassani S, Bagheri M, Mohammadi Y, Mehrpooya M. Men suffering from category III chronic prostatitis may benefit from N-acetylcysteine as an adjunct to alpha-blockers. Low Urin Tract Symptoms 2022; 14:199-207. [PMID: 35068061 DOI: 10.1111/luts.12425] [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: 10/22/2021] [Revised: 12/17/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We designed this study to investigate the potential use of N-acetylcysteine (NAC) as an adjunct to alpha-blockers in the treatment of category III chronic prostatitis (CP). METHODS Sixty-three men with category III CP with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score of 15 or more were randomized to either the NAC treatment group or the placebo treatment group. Besides tamsulosin at a dose of 0.4 mg once daily, participants based on their allocation group received NAC or placebo at a dose of 600 mg twice daily for 12 weeks. The efficacy of the medications was assessed by measuring changes in the NIH-CPSI total score and its subscales, including pain, urinary symptoms, and quality of life. RESULTS Based on the general linear model analysis of the data, over the 12-week treatment, NAC+tamsulosin was statistically superior to placebo+tamsulosin in reducing the total NIH-CPSI score, pain subscore, and quality-of-life subscore (P value <.001). Further, after 12 weeks, more patients in the NAC+tamsulosin group than in the placebo+tamsulosin group met the responder criterion, defined as a decrease of at least 6 points in the NIH-CPSI total score (65.6% vs 29.0%). A more favorable outcome was also noted in the NAC+tamsulosin group regarding the number of patients reporting moderate or marked improvement in symptoms (62.5% vs 25.80%). No significant difference was seen between the groups concerning changes in urinary symptoms. CONCLUSIONS Our study provided clinical evidence that men with category III CP might benefit from NAC treatment. Further studies are needed for the validation of these findings.
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Affiliation(s)
- Amir-Mohammad Yaryari
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Shahriar Amirhassani
- Urology and Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Bagheri
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Younes Mohammadi
- Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Mehrpooya
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.,Urology and Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
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