The Effect of Dextrose Hypotonic vs Saline Hydration on Methotrexate-Induced Nephrotoxicity in Male and Female Rats

Background

High-dose methotrexate (HDMTX) as a cytotoxic agent might cause various side effects. Hyperhydration has been implemented as the major strategy to decrease the potential risk of toxicities induced by HDMTX. This study aims to assess the renoprotective effect of hydration with dextrose water (DW) 5% versus normal saline (N/S) 0.9% against methotrexate (MTX) induced nephrotoxicity.

Materials and Methods

This experimental animal study has been conducted on 36 Wistar rats (200-250 g) categorized into six groups, including male (n = 6) and female (n = 6) rats receiving sodium chloride 0.9% saline plus MTX, DW 5% plus MTX, or MTX alone. By the fifth day after the MTX injection, biochemical indexes were measured. The rats were also sacrificed and renal specimens were evaluated microscopically to determine kidney tissue damage (KTD).

Results

The groups were not significantly different with regard to blood urea nitrogen (BUN) (P = 0.5), creatinine (Cr) (P = 0.24), kidney weight (P = 0.34), and urine flow (UF) (P = 0.5), while KTD score was remarkably less in the hydrated groups (P < 0.001). Weight loss in DW-treated rats was significantly more than N/S-treated ones, and creatinine clearance (CrCl) and urine load (UL) of Cr were statistically similar between males and females in the control group, but significantly lower among the DW5% treated males.

Conclusion

Based on the findings of this study, hydration with N/S was superior to DW5% for the prevention from HDMTX-induced nephrotoxicity. Besides, we found insignificant differences between male versus female rats in response to the hydration for HDMTX-induced renoprotection; however, females probably benefit more.

Evaluation of Central Nervous System Relapse in Adults with Acute Lymphoblastic Leukemia (ALL) Receiving Hyper-CVAD Treatment in Seyyed Al-Shohada Hospital: Isfahan, 2014-2019

Background: Recurrence of ALL in the central nervous system, CNS Relapse, is known as a poor prognostic factor. Few studies have been performed on the CNS Relapse in adults with ALL. This study aimed to evaluate the recurrence of acute lymphoblastic leukemia in the central nervous system, CNS relapse, in adults with ALL. Materials and Methods: Seventy newly diagnosed patients with acute lymphoblastic leukemia aged 15 years and older referred to Seyyed Al-Shohada Hospital in Isfahan between 2014 and 2019 were included in this study. All patients treated with the Hyper-CVAD regimen underwent prophylaxis for the central nervous system based on the risk of CNS relapse. All study participants with CNS relapse underwent intrathecal chemotherapy. Results: The median age of patients was 34 years. Four patients (5.7%) had primary central nervous system involvement. Out of 70 patients receiving the Hyper-CVAD regimen, 59 (84.2%) achieved complete remission. Of the 59 patients achieving CR, ten (16.94%) developed CNS relapse. The median duration of CR before CNS relapse was 21 weeks. Out of 10 patients with CNS relapse, seven (70%) achieved complete remission. Of seven patients achieving CR in the central nervous system, one had a second recurrence in the central nervous system, but finally achieved CNS complete remission. The median survival of patients after CNS relapse was four months. The results also showed that out of 10 patients with CNS relapse, four (40%) survived one year. Conclusion: This study shows that the prognosis of CNS relapse in adults with ALL has not improved much. Limited studies have been conducted on the recurrence of the central nervous system in adults with acute lymphoblastic leukemia. Therefore, further studies on CNS relapse after complete remission of ALL are required to clarify more details.

Prognostic Factors and Outcome of Patients with Adult Acute Lymphoblastic Leukemia Treated with the Hyper-CVAD Regimen: A Retrospective Study

Aim

The Hyper-CVAD regimen has shown promising results for adult patients with acute lymphoblastic leukemia (ALL), as designed by the MD Anderson Cancer Center (MDACC). This treatment has resulted in a complete remission rate of 92% and a 5-year overall survival of 38%. However, given the diversity of patient demographics and institutional methods, outcomes may differ between various institutions. This study will compare the outcome of adult ALL patients treated with the Hyper-CVAD regimen in Iran with those obtained in the original series presented at the MDACC. Patients and Method. In this retrospective study, we evaluated the 2-year leukemia-free survival (LFS) and the 2-year overall survival (OS) of 70 ALL patients treated between 2014 and 2019 in the Seyed Al-Shohada Hospital in Isfahan, Iran.

Results

In total, 59 ALL patients (84.28%) achieved complete remission (CR). The CR rate had statistical differences by bone marrow transplantation (BMT) and WBC count. The 2-year LFS and OS were 40% and 42%, respectively. There were significant differences in LFS and OS by BMT, myeloid marker, and WBC count.

Conclusion

The outcome of the traditional Hyper-CVAD regimen in treating adult ALL was not satisfying. More efficient therapies should be applied for the treatment of adult ALL.

Patient and Physician Perspectives in the Management of Immune Thrombocytopenia in Iran: Responses from the ITP World Impact Survey (I-WISh)

Data describing physicians' and patients' perspectives towards immune thrombocytopenia (ITP) management and impact of disease in Iran are limited. This ITP World Impact Survey was conducted between October 2019 and October 2020. Of the 114 patients included in the survey, 17 were aged ≤18 years. Forty-seven physicians, including 22 pediatric hematologists, participated in the survey. Fatigue and anxiety around stable platelet counts were frequent patient-reported symptoms at diagnosis and at survey completion. According to physicians, "watch-and-wait" was the preferred treatment option for mean (standard deviation) proportion of 50.1 (24.1) and 48.6 (21.8) of their adult and pediatric patients, respectively, following first diagnosis. Per adult and pediatric hematologists, the most prescribed treatments for newly diagnosed patients based on available answers were steroids (100%, n = 20/20; 89%, n = 16/18), respectively. Forty percent of adult (n = 10/25) and 38% of pediatric hematologists (n = 8/21) reported that ITP reduced patients' quality of life. Energy levels (46%, n = 52/112) and ability to concentrate on everyday activities (42%, n = 47/113) were the most affected aspects of patients' lives. This I-WISh study in Iran underlined the negative impact of ITP on patients.

The feasibility of PETHEMA ALL-96 regimen on treatment of patients with acute lymphoid leukemia

Background

Asparaginase-based treatment regimen for acute lymphocytic leukemia (ALL) is considered as feasible, but there is still a lack of data. In this study, considering the results of other regimen that were not optimum in previous studies. Here, we aimed to investigate the feasibility of PETHEMA ALL-96 treatment regimen.

Materials and Methods

This is a retrospective feasibility study that was performed in 2019-2021 on 13 patients diagnosed with B-cell ALL. Patients were treated by PETHEMA ALL-96 regimen during induction, consolidation, reinduction, and maintenance phases. Patients were followed for 2 years after initiation of PETHEMA ALL-96 regimen for disease-free survival (DFS) and overall survival (OS) of all patients were evaluated after 2 years.

Results

Data of 11 patients were analyzed. Within 28 days after treatments, all patients (100%) had no blasts in the bone marrow that was considered as complete remission (CR). The CR rate was 100% within 6 months and 12 months and 81.8% within 2 years after the treatments. Evaluation of OS, CR, and DFS regarding 6, 12, and 24 months showed 100% for all items after 6 and 12 months. After 24 months, the CR was 90.9%, the OS was 81.8% and the DFS was 90.9%. None of the patients died during the induction phase and during the 12 months study. No side effects were observed.

Conclusion

The PETHEMA ALL-96 had high feasibility and survival rates with no side effects during the study course. It is believed that PETHEMA ALL-96 regimen has beneficial outcomes in young patients with ALL.

Bacterial spectrum and antimicrobial resistance pattern in cancer patients with febrile neutropenia

BACKGROUND

Bloodstream infections are serious complications in neutropenic cancer patients. There has been a universal pickup in multidrug resistant (MDR) strains. For individuals who are at high risk for infections caused by MDR bacteria, a novel de-escalation strategy has been developed. Determine the bacterial spectrum and antibiotic resistance pattern in febrile neutropenic cancer patients was the goal of this investigation.

MATERIALS AND METHODS

From 2019 to 2020, 60 cancer patients with febrile neutropenia who were sent to Isfahan's Omid Hospital were included in this retrospective analysis. Experiments were done on the antimicrobial susceptibility of isolated bacterial infections.

RESULTS

The patients' average age was 43.35±15.59 years. Ninety-one percent (55/61) of the 60 patients had hematologic malignancies, and 8.3 percent (5/61) had solid tumors. The majority of the germs were gram-negative bacteria (66.7 percent). E. coli was the pathogen that was isolated the most frequently (26.7%), followed by Klebsiella (16.7 percent). In addition, the most prevalent identified Gram-positive bacteria was Staphylococcus epidermidis (21.7 percent). Third-generation cephalosporin (ESBL-E) resistance was present in 50% of E. coli, along with 50% resistance to cotrimoxazole, ciprofloxacin, and piperacillin, 31% resistance to amikacin, and 20% resistance to meropenem (CRE). They had an 80% sensitivity to amikacin and a 70% sensitivity to ciprofloxacin. Ten percent of our patients had antibiotic resistance in the antibiogram (XDR).

CONCLUSION

In summary, most bacterial infections were resistant to different medications. The emergence and spread of Gram-negative bacteria that are resistant to antibiotics can be stopped by prudent antibiotic use.

Thalidomide for the Treatment of COVID-19 Pneumonia: A Randomized Controlled Clinical Trial

Background

Coronavirus disease 2019 has become a public health concern with a high number of fatalities. Thalidomide can target inflammatory mediators and decrease inflammation in SARS-CoV-2.

Materials and Methods

An open-label, randomized controlled trial was conducted on patients with compatible lung high-resolution computed tomography scan for COVID-19 pneumonia and moderate involvement. Childbearing-age women were excluded. A total of 20 patients in the control group receiving usual treatment were compared with 26 patients in the case group who in addition to the same regimen also received thalidomide. The primary outcome was time for clinical recovery (TTCR) and intensive-care unit (ICU) admission.

Results

From April 25 to August 8, 2020, based on the inclusion criteria, 47 patients were assigned to the study. Patients receiving thalidomide had a mean TTCR of days 5.5 (95% confidence interval [CI], 0.7-10.3), as compared with days 5.3 (95% CI, 1.7-8.9) with control (odds ratio 0.01; 95% CI, -1.58-1.59, P = 0.807). The incidence of ICU admission was 27% in the thalidomide group compared with 20% in the control group (odds ratio 3.89; 95% CI, 0.55-27.4, P = 0.425). The mean length of stay in hospital in both groups was 10 days. Progressive improvement in respiratory rate, fever, and O₂ saturation during the study was seen in both groups without a significant difference between the thalidomide and control group (P > 0.05).

Conclusion

This study investigated the effects of thalidomide to treat moderate COVID-19 clinical outcomes. The results established that this drug regimen did not add more effect to usual treatment for moderate COVID-19 pneumonia.

A comparative study of the effects of multimedia training materials on mini CEX scores of internal medicine residents in Isfahan University of Medical Sciences

BACKGROUND

Role of multimedia training materials on Mini-CEX scores of internal medicine residents. We aimed to assess the effect of multi multimedia training materials on Mini-CEX scores of internal medicine residents of Isfahan University of Medical Sciences.

SETTINGS AND DESIGN

A quasi-experimental action research study on 1^st, 2^nd, and 3^rd-year internal medicine residents were implemented.

MATERIALS AND METHODS

The Mini-CEX test measures students' performance in six core skills necessary for medical practice. Mini-CEX scores of 135 internal medicine residents in 2017-2018 were compared before and after the training with prepared multimedia materials. We used repeated measured ANOVA and Mann-Whitney U test to compare the distribution of Mini-CEX scores across corresponding groups. Analysis was done using the SPSS software version 23 (IBM SPSS Statistics for Windows. Armonk, NY, USA: IBM Corp).

RESULTS

The median Mini-CEX score (IQR) of students in preintervention and postintervention groups were 16.14 (5.19) and 19.62 (3.13), respectively. Findings of this study showed a significant increase in mini-CEX scores of the groups who used the multimedia learning material compared to those who did not use it (P < 0.001).

CONCLUSIONS

Multimedia learning resources demonstrated a promising influence on internal residents' mini-CEX scores in this study. They demonstrate significantly greater performance after using multimedia learning materials compared to their same-year residents who did not benefit from it. This demonstrates the favorable effect of multimedia on the acquisition of practical skills such as obtaining a history or performing a physical examination.

The Prevention of Cisplatin-Induced Nephrotoxicity: A General Consensus Statement of a Group of Oncologist-Hematologists, Adult and Pediatric Nephrologists, Radiation Oncologists, Clinical Pathologists, Clinical Pharmacologists, and Renal Physiologists on Cisplatin Therapy in Cancer Patients

Backgrounds

Most of the cancer patients with solid tumor are subjected to chemotherapy with cisplatin (CP) in clinic. However, the most side effect of CP is nephrotoxicity, which limits the treatment. The aim of study was to develop a general consensus statement for CP therapy in clinic to limit the drug-induced nephrotoxicity.

Methods

A total of 30 oncologist-hematologists, adult and pediatric nephrologists, radiation oncologists, clinical pathologist clinical pharmacologist, and renal physiologist participated in a workshop, and in order to reduce the incidence of CP-induced nephrotoxicity, a general consensus was developed.

Results

The developed general consensus was focused on some items such as age, sex, female hormone, nonsteroidal anti-inflammatory drugs (NSAID), renin-angiotensin system inhibitor drugs, glomerular filtration rate, hydration methods, contrasts, antioxidants, dextrose, and magnesium.

Conclusion

The agreement between participants for CP therapy in clinic was achieved, and this general consensus was announced to be implemented in the hospitals.

Validation of a newly developed questionnaire regarding clinical history in patients with breast and colorectal cancers

BACKGROUND

Understanding the close interaction between the specialties of cardiology and oncology is necessary for early detection of cardiovascular disease (CVD) events in cancer patients. For the risk assessment of CVD in Breast and Colorectal Cancers (CIBC) study, in the current study we aimed to validate a questionnaire for the assessment of clinical history in patients with breast cancer and colorectal cancer (CRC).

METHODS

We determined the content validity of the questionnaire using the 2 indexes of content validity ratio (CVR) and content validity index (CVI) to examine the specificity, simplicity, clarity, and transparency of the items. Content validity assessment was performed through a panel of experts including 2 oncologists, 5 cardiologists, 2 general practitioners, and 1 epidemiologist. The reliability of the questionnaire was estimated using Cronbach's alpha coefficient in 50 patients. Intraclass correlation coefficient (ICC) was used to examine the reproducibility of the questionnaire during 1 week.

RESULTS

The CRC and breast cancer questionnaire were designed with 16 and 32 questions, respectively. To obtain acceptable CVR, 5 and 11 questions were removed from the CRC and breast cancer questionnaires, respectively. Cronbach's alpha was 0.70 in the breast cancer questionnaire and 0.94 in the CRC questionnaire. All questions had a CVI of higher than 80%. The ICC in the breast cancer questionnaire ranged between 0.71 and 0.96 and in CRC questionnaire ranged between 0.78 and 0.98.

CONCLUSION

The validity and reliability of our newly developed questionnaire was desirable. The reliability of the breast cancer questions was acceptable and that of the CRC questions was excellent. Thus, thus questionnaire can be used in this group of patients regardless of whether the goal is cardiac care or not.

Association of lymphocyte subsets with mortality in severe COVID-19 pneumonia patients

Background

Few studies have investigated the alterations in the T and B cell counts and related subgroups in pulmonary infections especially COVID‐19. Here, we aimed to evaluate total T and B lymphocytes and T cell subgroup counts to find the possible correlation between number of these cells and severity and mortality in COVID‐19 patients.

Methods

This study was performed on 40 patients with severe COVID‐19 infection confirmed by reverse transcription‐polymerase chain reaction (RT‐PCR) and chest HRCT in August 2020. By the time of admission, T lymphocytes profile in peripheral blood was investigated using multicolor flow cytometry. The total number of T lymphocytes, CD4+ T cells, CD8+ T cells, and B lymphocytes were calculated. Expression of CD2, CD3, CD5, and CD7 as pan T cell surface markers and expression of CD38 and HLA‐DR as activated markers on T lymphocytes were also evaluated.

Results

Nine patients (22.5%) died during the study and 16 patients (40%) were admitted to ICU. Deceased patients demonstrated lower amounts of T cell count and CD4+ T cell count (with a marginal difference (p = 0.07)) compared with survived patients at the time of admission. The chance of mortality was significantly higher for patients with CD7 loss (OR = 14.89). A marginally significant relationship was also indicated between CD4<200/ml and mortality (OR = 8.65), but no other significant relationships were observed between variables and ICU admission.

Conclusion

Altogether, CD7 loss on T lymphocytes and CD4+ T cell count below 200/ml revealed a significant relationship with mortality. Considering T lymphocytes and T cell subgroup count could have a predictive value for patients suffering from COVID‐19.

Survival of Post-Transplant Lymphoproliferative Disorder after Kidney Transplantation in Patients under Rapamycin Treatment

Background: One of the important causes of mortality and morbidity in kidney transplanted patients is Post Transplant Lymphoproliferative Disease (PTLD), which is due to immunosuppression therapy and viral activity. It seems that Rapamycin, with dual antineoplastic and immunosuppressive effects, may have a pivotal role in the treatment of PTLD patients and preserving transplanted kidneys.

Methods and Materials: Twenty patients with PTLD were enrolled. Immunosuppressive therapy was reduced or ceased, and Rapamycin was initiated at the time of PTLD diagnosis. We evaluated the effects of switching immunosuppressive drugs to Rapamycin on graft status, the response of tumor, and 6, 12 months, and 5-year survival in patients.

Results: PTLD remission was achieved in 14 patients, while six patients died; no relapse was detected in recovered patients. The median of PTLD free time was 25 months, and the mean overall survival in patients with PTLD treated by Rapamycin was 84.8 (95% CI=61.3-108.23).The five-year survival rate was 67%, 12 months survival was 73.8%, and six months' survival was 80%. The response rate to Rapamycin and immunosuppression reduction alone was 46.6%. Four out of 13 Diffuse Large B-Cell Lymphoma patients achieved a complete response just only after the reduction of immunosuppressive drugs and the consumption of Rapamycin.

Conclusion: The present study demonstrated the effectiveness of conversion from immunosuppressive medication, particularly of Calcineurin inhibitors to Rapamycin in PTLD patients. However, more research is needed to confirm the Rapamycin effect on patients with PTLD.

T-cell immunophenotyping in COVID-19 pneumonia

The COVID-19 epidemic is currently a global threat that has affected many parts of the world. Some patients require intensive care unit admission due to severe symptoms in the course of the disease. The severity of symptoms in this disease varies from person to person. The effectiveness of the immune response against viral infections depends on the number and activity of T-cells, which play an important role in eliminating virus-infected cells. In this study, we report two patients with COVID-19 pneumonia, one with moderate symptoms and the other with severe symptoms. Although a decrease of absolute lymphocyte count was seen in both patients, a more significant decline reported in the ICU-admitted patient. Expression of activated markers, HLA-DR, CD38, on CD8-positive T-cells was shown in a patient with more severe disease. On the other hand, partial loss of CD7 in the severe case was also observed. Hence, besides of the above parameters that already mentioned in other studies, loss of pan T-markers could be considered as a potentially valuable test for predicting disease severity. We suggest evaluating the predictability of these tests in COVID-19 in larger studies. This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.MED.REC.1399.238).

Rational, design and preliminary results of a cohort study on breast and colorectal cancer to develop a risk assessment model to predict future cardiovascular events. "Cardio vascular events In Breast and Colorectal cancers (CIBC) study"

AIM

Breast cancer (BC) and colorectal cancer (CRC) are among the most common cancers in Iran. We aimed to develop a risk assessment model to predict the development of cardiovascular events in these patients by performing a 5-year prospective cohort study on a newly diagnosed patients with BC or CRC before they receive any treatment.

METHODS

A multi-center prospective cohort study of 2700 newly diagnosed BC and CRC patients has been started in Iran since 2019 and will be continued until 2024. Demographics, socioeconomic status, life style behaviors, psychological characteristics and type of cancer treatments will be collected by standard questionnaires and blood pressure, obesity indices will be measured. Blood sampling, ECG, and echocardiography will be done in all patients at base line, 6 and 12 months, then at annual basis for five years. Incidence of heart failure, acute coronary syndrome, stroke and CVD related death are the primary outcome of this study.

RESULTS

In this preliminary analysis, 70 patients with BC and 30 patients with CRC were enrolled in this study from April 2019 to November 2019. Mean age of BC and CRC patients was 48±10.5 and 61±13.2 respectively. 98.6% of patients in BC group and 60% of CRC groups were female.

CONCLUSION

This study will be a platform for other cancers to develop CVD risk assessment charts that can cover other cancers. Patients who lie in the high risk category according to the newly developed risk assessment chart, should receive special management and preventive interventions.

Pentoxifylline in Prevention of Amphotericin B-induced Nephrotoxicity and Electrolyte Abnormalities

Objective:

Amphotericin B is an antifungal agent used to treat serious fungal infections mainly in critically ill patients. Despite its adverse effects including renal toxicity and electrolyte imbalances, amphotericin B remains one of the best choices for antifungal treatment. Information from animal studies has provided a strong scientific basis for the use of pentoxifylline as lowering nephroprotective agent. The present study was designed to evaluate the efficacy of pentoxifylline in preventing renal toxicity and electrolytes imbalances induced by amphotericin B.

Methods:

This study was conducted as a randomized controlled trial on 44 patients admitted to Sayyedoshohada Hospital, Isfahan, Iran, from October 2016 to August 2018. Patients were assigned to one of the two groups: Pentoxifylline, 400 mg twice a day, or matching placebo, from the 1^st day of amphotericin B therapy till minimum of 7 days. All patients' information including lab data (serum and urine levels of Mg, Na, and K, serum creatinine level, blood urea nitrogen [BUN] and urinary creatinine excretion) were gathered at the time of drug initiation and during the study period. The results were analyzed by SPSS v. 20 software and Repeated measures test was used to assess the differences between groups

Findings:

This study did not show any significant differences between the two groups in terms of all the assessed variables, including serum and urinary levels of electrolytes, and creatinine, as well as the number of cases presented acute kidney injury during the study period.

Conclusion:

Despite the positive effects of pentoxifylline in preventing renal complications in previous studies, this study could not show a definitive result in salt wasting or renal damage induced by amphotericin B. So, Designing robust studies with more included samples would be valuable.

COVID19 Prevention & Care; A Cancer Specific Guideline

On March 11th 2020, the coronavirus outbreak was declared a pandemic by the WHO. One of the groups that is considered high risk in this pandemic are cancer patients as they are treated with a variety of immune system suppressor treatment modalities and this puts them in a great risk for infectious disease (including COVID-19). Therefore, cancer patients require higher level measures for preventing and treating infectious diseases. furthermore, cancer patients may bear additional risk due to the restriction of access to the routine diagnostic and therapeutic services during such epidemic. Since most of the attention of health systems is towards patients affected with COVID-19, the need for structured and unified approaches to COVID-19 prevention and care specific to cancer patients and cancer centers is felt more than ever. This article provides the recommendations and possible actions that should be considered by patients, their caregivers and families, physician, nurses, managers and staff of medical centers involved in cancer diagnosis and treatment. We pursued two major goals in our recommendations: first, limiting the exposure of cancer patients to medical environments and second, modifying the treatment modalities in a manner that reduces the probability of myelosuppression such as delaying elective diagnostic and therapeutic services, shortening the treatment course, or prolonging the interval between treatment courses.

Reduced Weekly Subcutaneous Doses of Bortezomib in Combination with Cyclophosphamide and Dexamethasone for Newly Diagnosed Multiple Myeloma

Objective:

A combination of bortezomib, cyclophosphamide, and dexamethasone is highly effective in the treatment of newly diagnosed multiple myeloma. Neuropathy is a dose-limiting adverse effect of this regimen. Subcutaneous and weekly injection instead of biweekly intravenous administration are used to reduce neuropathy. In this study, patients treated with subcutaneous weekly reduced the dose of bortezomib to reduce neuropathy and cost of treatment.

Methods:

This is an interventional study, including 16 patients. Enrolled patients received bortezomib 1 mg/m² subcutaneously, cyclophosphamide 300 mg/m² intravenously, and dexamethasone 40 mg intravenously days 1, 8, 15, and 22 of a 28 cycle.

Findings:

The overall response rate (≥partial response [PR]) was 93.8%. Thirteen of 16 patients (81.3%) were in an acceptable PR and complete response. Two patients (12.5%) achieving a PR. Meantime to achievement, the best response was 71 (55–87) days. Median progression-free survival was 33 (2–56) months, and autologous stem cell transplantation was performed for 68.8% of patients. Five patients (31.25%) experienced Grade I and one patient (6.25%) Grade III (no Grade 2 or 4) of peripheral neuropathy. Dose reduction and drug discontinuation was required in one patient (6.25%).

Conclusion:

A reduced subcutaneous, weekly dose of bortezomib in combination with cyclophosphamide and dexamethasone is effective with manageable profile toxicity and acceptable cost.

A case report of sinusoidal diffuse large B-cell lymphoma in a STK4 deficient patient

INTRODUCTION

Primary immunodeficiency diseases (PIDs), a rare group of gene defects with different manifestations, are at great risk of malignancy. The incidence of diffuse large B-cell lymphoma in the sinusoidal tract is quite rare with nasal congestion, stuffiness, and pain in maxillary sinus manifestation. Human serine-threonine kinase 4 (STK4) deficiency affects the immune system with recurrent bacterial and viral infections, mucocutaneous candidiasis, cutaneous warts, skin abscesses, T- and B-cell lymphopenia, and neutropenia.

PATIENT CONCERN

In this study we describe the infrequent incidence and successful treatment of sinusoidal diffuse large B-cell lymphoma in a STK4 deficient patient with clinical manifestation of severe intractable headaches, unilateral swelling of her face, nasal congestion, stuffiness, and pain in maxillary.

DIAGNOSIS

Clinical data including headaches, unilateral swelling of face, nasal congestion, stuffiness and pain in maxillary sinus with confirmed histopathology and magnetic resonance imaging finding confirmed sinusoidal diffuse large B cell lymphoma in a STK4 deficient patient.

INTERVENTION

Six cycles of R-CHOP (rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisolone) were administered and after each cycle, G-CSF support was used. Chemotherapeutic drugs were administered with standard dose and no dose reduction was done during the treatment. IVIG treatment continued during the courses of chemotherapy.

OUTCOME

The index patient achieved complete response at the end of chemotherapy courses and was in remission for about 8 months afterward, prior to the date of the present report.

CONCLUSION

PID patient are often at increased risk of malignancies. Sinusoidal diffuse large B-cell lymphoma is quite rare and prognosis is variable. Early attention to patient's manifestation, suitable treatment, and monitoring manifestations caused by PID are critical.

Optimization of In Vitro Expansion and Activation of Human Natural Killer Cells against Breast Cancer Cell Line

BACKGROUND

Regarding to the increase of cancer deaths in recent years and disability of common therapies to eradicate cancers, as well as expansion of Natural Killer (NK) cell therapy, it seems so vital to find new useful therapies against cancers. Breast cancer is the second main cause of cancer death among women. As it is impossible for a majority of patients to receive NK cell therapy, an attempt was made to establish a low-cost and efficient method for expanding and activating NK cells against breast cancer cell line (MCF7).

METHODS

NK cells were isolated from Peripheral Blood Mononuclear Cells (PBMCs) applying either MACS based NK cell enrichment kit or antibodies and complement as cytotoxic method. Then, the NK cells were cultured in Stem Cell Growth Medium (SCGM) with feeder layer (irradiated PBMCs) along with PHA or OKT3. IL-2, IL-15 and IL-21 were used to expand NK cells and finally their cytotoxic activity was investigated by flow cytometry.

RESULTS

Highly pure NK cells were obtained and no significant difference between the two isolation methods was found. Using IL-2 plus IL-15, the number of NK cells increased up to100 fold after 16 days. No significant effect was observed after IL-21 treatment.

CONCLUSION

Our data indicated that cytotoxicity method can be considered a low-cost alternative for NK cell isolation kits. It seems that culturing NK cells for 14 days in either PHA or OKT3 supplemented SCGM medium would be more effective than culturing for 16 days in the presence of IL-21.

Comparison of the effects of pegylated granulocyte-colony stimulating factor and granulocyte-colony stimulating factor on cytopenia induced by dose-dense chemotherapy in breast cancer patients

Background:

Myelosuppression is one of the frequent side effects of chemotherapy in breast cancer patients. Granulocyte-colony stimulating factor (G-CSF) and pegylated G-CSF are used for the prevention of neutropenia after chemotherapy. Pegylated G-CSF has longer half-life of action and can be used as a single dose in comparison to G-CSF. The aim of this study is to compare the grade of cytopenia and side effects between G-CSF and biosimilar pegylated G-CSF in breast cancer patients treated with dose-dense chemotherapy.

Materials and Methods:

In the cross-over clinical trial study, 24 women with breast cancer were randomly divided into two groups and treated with dose-dense chemotherapy. The first group was treated with single dose of 6 mg biosimilar pegylated G-CSF 24 h after the first course of chemotherapy and the second course was followed by 300 μg daily injection of G-CSF for 6 days. The chemotherapy regimen was combination of doxorubicin 60 mg/m² and cyclophosphamide 600 mg/m². The second group was treated with G-CSF after the first course and pegylated G-CSF after the second course. Cell blood count (CBC) and side effects were evaluated 1 and 2 weeks after both courses of chemotherapy.

Results:

In this study, no significant carryover effect and treatment effect about the CBC parameters was found between pegylated G-CSF and G-CSF. Patients who were treated with biosimilar pegylated G-CSF had significantly higher side effects such as bone pain (P = 0.09) and gastrointestinal effects (P = 0.005) in comparison to G-CSF.

Conclusion:

G-CSF and biosimilar pegylated G-CSF are effective in reducing cytopenia in breast cancer patients treated with dose-dense chemotherapy, but side effects induced by pegylated G-CSF (Pegagen) are higher.

Potential Role of Bupropion Sustained Release for Cancer-Related Fatigue: a Double-Blind, Placebo-Controlled Study

Background:

Cancer-related fatigue (CRF) is very common and can be experienced at all stages of disease and in survivors. CRF causes patients more distress than pain or nausea and vomiting. Different pharmacologic interventions have been evaluated for the management of CRF. The purpose of this study was to determine the efficacy of bupropion sustained release (SR) as a treatment for fatigue in patients with cancer.

Methods:

In this randomized, double-blind, placebo-controlled trial, patients with fatigue due to cancer were randomly assigned to either 150mg daily of bupropion SR or matching placebo. The primary endpoint was the changes in average daily fatigue from baseline to week 4 using the Functional Assessment of Chronic Illness-therapy- Fatigue (FACIT-F) questionnaire.

Results:

40 patients were randomly assigned to treatment with bupropion SR or placebo (20 in each group). Analysis of covariance (ANCOVA) showed a significant improvement in fatigue and quality of life in the bupropion group compared to baseline (P=0.000). Secondary outcome, including depression, severity of fatigue and performance status didn’t show significant difference between groups. Generally, bupropion SR was tolerated well.

Conclusion:

Four weeks of 150 mg bupropion SR improve fatigue significantly in cancer patients. Bupropion has potential as an effective and safe pharmaceutical agent for treating CRF.

Management of Febrile Neutropenia: A Description of Clinical and Microbiological Findings by Focusing on Risk Factors and Pitfalls

Objective

Febrile neutropenia (FN) is one of the most serious clinical problems in patients with hematologic malignancies and patients receiving chemotherapy. The present study was implemented to determine precisely how FN is managed in most referral hospitals in Isfahan (Iran) and what are the characteristics of FN patients as well as risk factors associated with FN development.

Methods

This study was a cross-sectional study performed over a period of 6 months on patients hospitalized in the Hematology-Oncology Center of Omid Hospital, Isfahan, Iran. The information was collected by filling the designed data abstraction form.

Findings

A total of 115 oncology patients were admitted with or encountered to FN. This equates to a cumulative incidence of 1.26% of FN cases per 1000 oncology admissions. The average age was 49.5 ± 18.02 years (range 18-85 years), with 42.6% of patients being female. The most frequently prescribed antibiotic agents were meropenem (91.3%) and vancomycin (47.82%) alone or in combination. Empiric antifungal agents initiated in 20.86% of cases, and we could not find any patients who needed to receive antiviral treatment. From all positive cultures, Gram-positive microorganisms were the most found pathogen. Among them, female sex (42.6%) and lymphopenia (26.5%) were the most noted predictors. Neutropenia (81.7%) was the most reported risk factors for serious complications.

Conclusion

Although our center is university-affiliated, there are still several points, and pitfalls must be considered and revised in the management of FN patients. Obtaining and assessing the samples microbiologically and antibiotic therapy accordingly were the most troublesome complications.

Effect of Short Hydration on Cisplatin-Induced Nephrotoxicity in Cancer Patients: A Retrospective Study

Background: The aim of this study was to evaluate the protective role of short hydration against nephrotoxicity induced by cisplatin (CDDP). Materials and Methods: Twenty-two patients (13 men and 9 women) under CDDP therapy were enrolled in this retrospective study between 2009 and 2014. The CDDP was given in 500 ml of isotonic solution, and before and after CDDP administration, the patients received 10mEq potassium chloride15% and 1gr magnesium sulfate in 1000 ml isotonic saline. Renal parameters were evaluated on the first day of each cycle of CDDP therapy. Results: Median cumulative CDDP dose was 465 mg/m². Based on renal parameters, the prevalence of CDDP-induced nephrotoxicity (CIN) was 22.7%, while no hypokalemia and hypomagnesemia were observed. Conclusion: Short hydration accompanied with potassium chloride and magnesium sulfate may decrease the risk of CIN.

The Immune Response of Vaccination Against Hepatitis B virus in Iranian Patients Undergoing Chemotherapy

Introduction:

Hepatitis B virus (HBV) infection and its complications are major public health problems. As it is hard to treat and control the chronic state, control of disease depends on the prevention especially by vaccination. There is an impaired immune response to vaccinations including HBV in patients with some malignancies. The aim of this study is to assess the response rate of patients undergoing chemotherapy to HBV vaccination.

Materials and Methods:

All patients from two hematology/oncology clinics in Isfahan, Iran with the history of at least 1 month chemotherapy who had the inclusion criteria were enrolled in a case control study. Also a sex- and age-matched control group from healthy population was selected. They were vaccinated in a schedule of 0, 1, and 6 months and were examined for antibody titers 1 month after the last dose. The titers more than 10 mIU/ml were determined as positive response to vaccination.

Results:

In this study, 50 patients and 50 healthy subjects were enrolled. The two groups were age and sex matched (P > 0.05). Frequency of negative responses to HBV vaccination in case and control groups were 9 (18%) and 1 (2%), respectively (OR = 10.75, CI = 1.30–88.47, P = 0.027). Of 50 patients, 54%, 12%, 22%, and 12% had breast cancer, lymphoma, gastrointestinal, and genitourinary cancers, respectively, and frequency of negative responses were 3 (11%), 1 (16%), 4 (36.4%), and 1 (16%), respectively (P = 0.167).

Conclusion:

According to our results, malignancy and chemotherapy will have an important effect on the immune system and cause negative response to HBV vaccination. Our results revealed the importance of passive immunity and screening for HBV infection in patients undergoing chemotherapy. Also more studies for better vaccination schedules in this group of patients are recommended.

Pseudohypercalcemia in Multiple Myeloma: A Case Report

Hypercalcemia is a common finding in patients with multiple myeloma. Clinical manifestations of hypercalcemia correlate with the level of serum calcium. Ionized serum calcium (Ca (I)) will be increased in true hypercalcemia. In pseudohypercalcemia the Ionized Ca is normal, although binding of calcium to abnormal immunoglobulin causes increased serum calcium level. In the asymptomatic multiple myeloma patients with moderate to severe hypercalcemia, measurement of ionized calcium is critical to exclude pseudohypercalcemia. Here, we describe an asymptomatic 44-year-old man with multiple myeloma who had severe hypercalcemia, but normal serum Ionized Ca level.

Comparison of Ifosfamide, Carboplatin and Etoposide versus Etoposide, Steroid, and Cytarabine Cisplatin as Salvage Chemotherapy in Patients with Refractory or Relapsed Hodgkin's lymphoma

BACKGROUND

Refractory or relapsed Hodgkin's disease (HD) occurs in 10-50% of patients. The treatment of choice for these patients is high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT). Response to salvage chemotherapy (SCT) partial remission (PR) is necessary before HDCT with ASCT. However, its applicability is restricted mostly to patients responding to salvage chemotherapy. Optimal salvage regimen for these patients is unclear. In this study, our aim was to compare the efficacy profiles of ifosfamide, carboplatin, and etoposide (ICE) and etoposide-steroid-cytarabine-cisplatin (ESHAP) (cytosine arabinoside, cisplatin, and dexamethasone) regimens in the salvage treatment of relapsed or refractory HD.

MATERIALS AND METHODS

In this retrospective analysis, 114 patients with primary refractory or relapsed HD who received ICE or ESHAP salvage regimen were included.

RESULTS

Of 114 patients, 47 (41.2%) were females and the median age was 31.5 years. Response could be evaluated in 114 patients. Of 114 patients, 38 (33%) achieved complete remission (CR) and 21 (18.4%) achieved PR, leading to an overall response rate (ORR: CR + PR) of 51.4%. In the evaluable ICE group (n = 41), rates of CR, PR, and ORR were 21.9%, 17.1%, and 39% and in the ESHAP group (n = 73), rates of CR, PR, and ORR were 39.7%, 19.2%, and 58.9% (for ORR, P = 0.04), respectively.

CONCLUSION

In patients with relapsed or refractory HD, treatment with ESHAP seems to have higher rates of response than ICE regimen does.

Cisplatin-Induced Nephrotoxicity; Protective Supplements and Gender Differences

Cisplatin (CDDP) has been widely used as a chemotherapeutic agent for solid tumors. The most common side effect of CDDP is nephrotoxicity, and many efforts have been made in the laboratory and the clinic to employ candidate adjuvants to CDDP to minimize this adverse influence. Many synthetic and herbal antioxidants as well as trace elements have been investigated for this purpose in recent years and a variety of positive and negative results have been yielded. However, no definitive supplement has so far been proposed to prevent CDDP-induced nephrotoxicity; however, this condition is gender related and the sex hormone estrogen may protect the kidney against CDDP damage. In this review, the results of research related to the effect of different synthetic and herbal antioxidants supplements are presented and discussed with suggestions included for future work.

New Indications for Dabigatran: A Suggestion from a Drug Use Evaluation Study

Objective:

Dabigatran etexilate is a novel oral anticoagulant with several advantages over warfarin such as no need for routine monitoring and fewer drug interactions. This drug was added to our hospital's formulary in 2012. The objective of this study was to assess the rational drug use of dabigatran at a large teaching hospital.

Methods:

A prospective cross-sectional study was performed from November to June 2015 at Alzahra teaching hospital, Isfahan, Iran. All patients who received at least one dose of dabigatran were eligible for inclusion. Data were collected on patient demographics, indication, dosing regimen, adverse events, concurrent anticoagulant therapy, and laboratory data (including renal function).

Findings:

A total of sixty patients were included in our study. The majority of patients (n = 40, 66.7%) was prescribed dabigatran for deep vein thrombosis prophylaxis. Only one patient received dabigatran with appropriate indication, dose, and duration. Thirty-six (60%) of our patients had thrombocytopenia at the time of dabigatran initiation. We also detected that ten patients (16.7%) received this drug for heparin-induced thrombocytopenia (HIT). In 32 patients, platelet levels increased after dabigatran initiation. Only seven patients received the appropriate dose of dabigatran (regarding both indication and renal function).

Conclusion:

Unlabeled use and incorrect dosing of dabigatran in this study emphasize the need to develop a hospital protocol for dabigatran use within our facility. We suggest proper education of clinicians about novel drugs, pharmacist interventions, and further studies about the safety and efficacy of dabigatran for the new indication (such as HIT).

Osteonecrosis of the Jaws in Patient Received Bisphosphonates and Sunitinib Separately: A Case Report

Recently published reports have suggested that antiangiogenic drugs such as sunitinib could potentiate the osteonecrosis of the jaw (ONJ) induced by bisphosphonates (BPs) and even induce this adverse effect per se. We reported a case of ONJ with renal cell carcinoma under sunitinib medication and history of BPs therapy. A 53-year-old man was referred to the oral surgery clinic complaining of painful exposed oral lesion and bone extraction from right lower jaw in the mouth. He underwent nephrectomy followed by 5 months treatment with cycles of 50 mg sunitinib (Sutent^®) once a day for 4 weeks followed by 2 weeks drug free before lesion exposure in October 2016. However, the patient has encounter to intermittent mucositis and gingivitis in oral cavity several times. Our patient had a history of zoledronic acid (4 mg intravenously two times) administration due to primary cancer misdiagnosis. In our case, no dental procedure contributed to the occurrence of ONJ. The lesion was improved by sunitinib cessation and administration of antibiotics through 2 weeks. Mucosal injury induction as well as inhibition of angiogenic signaling pathways by sunitinib administration may have precipitated the occurrence of ONJ. In addition, a possible synergistic effect by previously BP treatment is another accused.

Screening and evaluation of chronic and occult Hepatitis B in chemo - radiotherapy patients with cancer

Background:

Hepatitis B virus infection (HBV) and its complications is one of the most serious problems of the health system in many parts of the world. In the present study, we will assess chronic and occult HBV and isolated anti-Hepatitis B core antigen whose screening and evaluation is not routine in different populations.

Materials and Methods:

This descriptive analytical study was conducted on 213 patients undergoing chemotherapy - radiotherapy referred to the hematology - oncology clinics of Isfahan, Iran in 2012. In order to determine the serum levels of hepatitis B surface antigen (HbSAg), Hepatitis B Antigen and Antibody (HBCAb), aspartate aminotransferase (AST), alanine transaminase (ALT) and Alkaline phosphatase (ALK.P), venous blood samples were obtained. If the HBCAb sample was positive, another sample of the serum was sent to the laboratory to perform polymerase chain reaction and to determine viral load.

Results:

The mean age of the patients was 47.7 ± 9 years, with an age range of 27 -73 years; 98 (46%) and 115 (54%) cases were male and female, respectively, with mean age of 51.9 ± 8.3 and 44.1 ± 8.1 years, and there was no significant difference (P < 0.001). The mean level of liver enzymes including AST, ALT and ALK.P were 34.2 ± 36.02, 38.9 ± 47.1 and 252.1 ± 234.7, respectively. Two cases were HbSAg positive (0.9%) and six cases were HBCAb positive (2.8%) and HbSAg negative. Three cases had a high viral load at the rate of starting treatment among positive anti-HBC patients.

Conclusion:

Because occult hepatitis is investigated less commonly in routine studies, it seems that screening and evaluating its prevalence is useful in the management of patients.

Granulocyte Colony-Stimulating Factor Use in a Large Iranian Hospital: Comparison with American Society of Clinical Oncology (ASCO) Clinical Practice Guideline

BACKGROUND

Granulocyte Colony Stimulating Factors (GCSF) is high-cost agents commonly recommended for primary and secondary prophylaxis of chemotherapy-induced neutropenia and febrile neutropenia. GCSFs have been shown to be beneficial in some patient subgroups, although they are probably overused in clinical settings. The American Society of Clinical Oncology (ASCO) guidelines summarize current data on the appropriate use of CSFs. The aim of this study was to assess and audit the use of GCSF in a tertiary care center according to the recommendation of ASCO guideline.

SUBJECTS AND METHODS

A prospective observational study from November 2014 to June 2015 was performed on all patients prescribed with filgrastim in the large teaching hospital (Isfahan, Iran). Data was collected on demographics, indication, dosing regimen and duration of treatment, the Absolute Neutrophil Count (ANC) and patient outcome.

RESULTS

91 patients were recorded over the period of the study. 63.7% of prescription complied with the ASCO guideline. Febrile neutropenia post chemotherapy/radiotherapy was the most common appropriate indication (29.3%) followed by primary prophylaxis (25.8%). Fourteen (32%) patients showed ANC recovery in 1-3 days and 16 (37%) within 4-7 days. Ten patients (23%) showed no recovery. The overall mortality was 8 (8.8%) patients.

CONCLUSION

This study revealed that at least one-third of prescribed GCSF was not in accordance with ASCO guideline. Considering the high cost of GCSF in our country and limitation of our resources, we proposed cost-effectiveness studies on GCSF treatment and also the development of a national guideline for optimizing GCSF use.

Effect of enalapril in cisplatin-induced nephrotoxicity in rats; gender-related difference

Background:

The function of renin angiotensin system (RAS) is gender-related, and this system affects cisplatin (CP)-induced nephrotoxicity. In this study, we compared the effect of enalapril as an angiotensin-converting enzyme (ACE) inhibitor on CP-induced nephrotoxicity between male and female rats.

Materials and Methods:

Sixty-two adult male and female Wistar rats were divided into eight groups. Both genders received CP (2.5 mg/kg, i.p.) and enalapril (30 mg/kg, i.p.) for 7 days in compared with CP alone or enalapril alone or vehicle alone treated groups. At the end of the experiment, blood samples were obtained, and the kidney tissue was investigated for histopathological changes.

Results:

CP increased the serum levels of blood urea nitrogen and creatinine as well as kidney weight and kidney tissue damage score in both genders (P < 0.05). However, not only enalapril failed to ameliorate the aforementioned parameters in both genders, but also it intensified nephrotoxicity in females (P < 0.05). In addition, enalapril enhanced body weight loss induced by CP in females (P < 0.05). CP alone decreased kidney level of nitrite in both genders (P < 0.05) and enalapril could not reverse this decreasing. The combination of enalapril and CP significantly increased serum level of nitrite in females, but this was not observed in males (P < 0.05).

Conclusion:

Enalapril as an ACE inhibitor failed to ameliorate nephrotoxicity induced by CP in both male and female rats. In addition, enalapril aggravated CP-induced nephrotoxicity in female possibly due to gender-dependent RAS response.

Molecular structure, spectroscopic assignments and other quantum chemical calculations of anticancer drugs - A review

In many texts, both theoretical and experimental studies on molecular structure and spectroscopic assignments of anticancer medicines have been reported. Molecular geometry parameters have been experimentally obtained by x-ray structure determination method and optimized using computational chemistry method like density functional theory. In this review, we consider calculations based on density function theory at B3LYP/6-31G (d,p) and B3LYP/6-311++G (d,p) levels of theory. Based on optimized geometric parameters of the molecules, molecular structures (length of bonds, bond angles and torsion angles) and vibrational assignments have been obtained. Molecular stability and bond strength have been investigated by applying natural bond orbital (NBO) analysis. Other molecular properties such as mulliken population analysis, thermodynamic properties and polarizabitities of these drugs have been reported. Calculated energies of HOMO and LUMO show that charge transfer occurs in the molecular. Information about the size, shape, charge density distribution and site of molecular chemical reactivity has been obtained by mapping electron density isosurface of electrostatic and compared with experiment data.

Medical oncology, history and its future in Iran

Systemic therapy is one of the cornerstones of cancer treatment. In 1972, following representations by American Society of Clinical Oncology (ASCO), the American Board of Internal Medicine (ABIM) recognized medical oncology as a new subspecialty of internal medicine. Subspecialty of Hematology and Medical Oncology was emerged in Iran in 1983. In the past, modern medical treatments and education were started in Dar Al-fonun school and then in Tehran University; now six universities in Iran are training in Subspecialty of Hematology and Medical Oncology. There are also ten active hematopoietic stem cell transplantation centers, thirty-one provincial medical schools use their specialized services. Future goals for Hematology and Medical Oncology in Iran include expansion and reinforcement of multidisciplinary teams across the country, early detection and prevention of cancer, providing educational program and conducting cancer researches. To achieve these goals, it is necessary to establish Cancer Hospitals in each province that link together through a network.

Cost-effectiveness Analysis of Cetuximab in Treatment of Metastatic Colorectal Cancer in Iranian Pharmaceutical Market

BACKGROUND

Cetuximab is a monoclonal antibody which acts against the epidermal growth-factor receptor. Randomized controlled trials show that the addition of cetuximab to folinic acid, 5-flourouracil, irinotecan (FOLFIRI), folinic acid, 5-flourouracil, oxaliplatin (FOLFOX) and capecitabin + oxaliplatin (CAPOX) regimens, as the first-line treatment for metastatic colorectal cancer (CRC), increases the overall survival (OS) and progression-free survival (PFS) compared to FOLFIRI, FOLFOX and CAPOX regimens alone. The aim of this study was to analyze the cost-effectiveness of different treatment programs for managing metastatic CRC with and without cetuximab in the first-line treatment of unresectable metastatic CRC in Iran.

METHODS

A systematic search of the literature was performed in PubMed, Centre for Reviews and Dissemination Databases and Cochrane Library to assess the effectiveness of the drug in the context of PFS, OS and the adverse events. The incremental cost-effectiveness ratio of each treatment program was calculated. An extensive sensitivity analysis was conducted on the results regarding the effectiveness.

RESULTS

The addition of cetuximab to FOLFIRI, FOLFOX and CAPOX programs increased PFS by 0.1, 0.042 and 0.042 years, respectively. Similarly, the addition of cetuximab to FOLFIRI, FOLFOX and CAPOX increased OS by 0.325, 0.442 and 0.442 years and also cost $212825, $202484 and $204198 individually. Whereas, based on the World Health Organisation (WHO) suggested threshold for cost-effectiveness analysis, even FOLFOX + cetuximab was very higher than the threshold in Iran (37.4 times higher).

CONCLUSIONS

The FOLFOX regimen + cetuximab provides lower costs per additional life years gained (more cost-effective) compared with its alternatives in the treatment of patients with unresectable metastatic CRC. However, according to the WHO indicator, none of the cetuximab regimens could be considered as cost effective for the Iranian health care market.

Protective effect of pomegranate flower extract against gentamicin-induced renal toxicity in male rats

Introduction: Gentamicin (GM) as an antibiotic is used in clinic. However, its administration is limited by side effects such as nephrotoxicity. Herbal extracts could be used in therapeutic approaches.

Objectives: The present study was planned to investigate whether pomegranate flower extract (PFE) could ameliorate GM-induced renal toxicity in male rats.

Materials and Methods: Twenty eight male Wistar rats were divided into 5 groups. Groups 1 and 2 respectively received PFE 25 and 50 mg/kg for 9 days. Groups 3, 4 and 5 received saline, PFE 25 mg/kg, and PFE 50 mg/kg for 9 days, respectively, and GM (100 mg/kg/day) was administered from day 3 on. Blood samples were obtained, and after sacrificing the animals, the kidneys were removed for histopathology investigations.

Results: GM alone increased the serum levels of creatinine (Cr) and blood urea nitrogen (BUN), and tissue damage and kidney weight (P < 0.05). However, administration of low dose of PFE accompanied with GM decreased these markers significantly (P < 0.05). Low dose of PFE also ameliorated weight loss induced by GM (P < 0.05).

Conclusion: It is concluded that PFE 25 mg/kg is the effective dose to ameliorate nephrotoxicity induced by GM.

Outcome of rapamycin therapy for post-transplant-lymphoproliferative disorder after kidney transplantation: case series

BACKGROUND

Post-transplant lymphoproliferative disorders (PTLD) are a complication of chronic immunosuppressive therapy in solid organ transplantation with a high mortality rate. Alternative treatments such as rapamycin have been explored.

METHODS

A detailed retrospective analysis was performed according to data collected from 13 patients with PTLD. At the time of PTLD diagnosis, immunosuppressive therapy was decreased and rapamycin administered. Overall survival, disease-free survival of patients and graft survival were determined.

RESULTS

Among 590 kidney transplant recipients, 13 adult patients with PTLD were included in this study. The mean age of the patients was 42.15 (range: 25-58) years at the time of PTLD diagnosis, and 9 patients were male. Histology was distributed in 9 diffuse large B cell, 1 Malt lymphoma, 1 Burkitt lymphoma, 2 Hodgkin-like PTLD. The response rate to rapamycin alone was 30.8%. The mean overall survival period was 23.38 months and 11 patients are still alive. In total, 10 patients (76.9%) achieved a complete remission with functioning graft in 11 (84.6%) patients.

CONCLUSION

Despite the retrospective focus and limited number of patients, this study provides promising results regarding the effectiveness of stopping calcineurin inhibitors and switching to rapamycin for patients with PTLD.

Low-dose pamidronate for treatment of early bone loss following kidney transplantation: a randomized controlled trial

INTRODUCTION

Kidney transplantation is associated with rapid loss of bone mineral density (BMD) in the first months after transplantation. The effect of pamidronate on bone loss after transplantation was evaluated in a randomized controlled trial.

MATERIALS AND METHODS

Forty patients were enrolled in this study (16 in the pamidronate group and 24 in the control group). Pamidrinate was administered as 30-mg intravenous infusion within 2 days after transplantation and 3 months later. All of the patients received calcium and vitamin D supplementation. Laboratory parameters and BMD (lumbar spine and femoral neck) were measured at baseline and 6 months after kidney transplantation.

RESULTS

Bone mineral density at the initiation of study had no significant differences between the two groups. In each group, BMD of femoral neck and lumbar spine had no significant differences 6 months after transplantation in comparison to pretransplantation values. There was no significant difference in BMD changes after intervention between two groups. Parathyroid hormone level normalized in both of the pamidronate and control groups 6 months after kidney transplantation. Glomerular filtration rate at the end of study was not significantly different between the two groups.

CONCLUSIONS

Our study suggests that administration of calcium and vitamin D following transplantation may be beneficial to counterbalance the substantial bone loss occurring within 6 months after transplantation, and addition of pamidronate has no beneficial effect in BMD in this short interval after kidney transplantation.

Composite lymphoma in a patient with ulcerative colitis: a case report

A 45-year-old female patient with a diagnosis of ulcerative colitis complicated with composite lymphoma in the spleen and para-aortic lymph node presented with a one-month history of malaise, weakness and fatigue. Only mesalamine kept ulcerative colitis under control. In physical examination, splenomegaly was revealed and pancytopenia was obtained from laboratory data. Computed tomography scan revealed para-aortic mediastinal lymphadenopathy with splenomegaly. Splenectomy and excisional biopsy of abdominal lymph node were performed and disease was diagnosed as composite lymphoma, consisting of diffuse large B-cell lymphoma and nodular sclerosing Hodgkin lymphoma.

Effect of pomegranate flower extract on cisplatin-induced nephrotoxicity in rats

Background: Chemotherapy with cisplatin (CP) is accompanied with nephrotoxicity.

Objectives: In the current study, pomegranate flower extract (PFE) has been evaluated as an antioxidant agent against CP-induced-renal toxicity.

Materials and Methods: Thirty two male Wistar rats were divided into five groups (6-8 in each group). The animals in groups 1 to 3 received PFE (25 mg/kg), PFE (50 mg/kg), and placebo (saline), respectively for 9 days, and onset of the day 3, they also received CP (2.5 mg/kg/day). Groups 4 and 5 were treated with PFE (25 and 50 mg/kg/day) for 9 days. Finally, the animals were sacrificed at day 9 after collecting blood samples. Kidneys were removed, weighted, and underwent histopathological investigation.

Results: The mean serum level of creatinine in group 3 (treated with CP and placebo) increased significantly (p<0.05), but the value decreased significantly (p<0.05) in group 1. Kidney weight in group 1 was lower than KW in groups 2 and 3, however it was significant when compared with group 2 (p<0.05). The serum nitrite level in group 2 was non-significantly lower than that in other groups, and no significant changes were observed in serum levels of malondialdehyde (MDA). Tissue level of nitrite was significantly decreased in the positive control and high dose of PFE plus CP-treated groups (p<0.05). Among CP-treated groups, low dose of PFE significantly improved kidney nitrite level (p<0.05). The results from histopathological staining indicated less tissue damage in group 1 when compared with group 3.

Conclusions: It seems that low dose of PFE plays a protective role against CP-induced renal toxicity in rats.

Effect of testosterone on Cisplatin-induced nephrotoxicity in surgically castrated rats

BACKGROUND

Cisplatin (CP) is an important antitumor drug with serious side effects such as nephrotoxicity. Estrogens can affect CP-induced nephrotoxicity; however, the role of testosterone (TS), the main male sex hormone, is not clear.

OBJECTIVES

This study aimed to investigate the effect of TS on CP-induced nephrotoxicity in castrated male rats.

MATERIALS AND METHODS

A total of 54 male Wistar rats were castrated and allocated into eight groups. Groups 1 through 3 respectively received 10, 50, and 100 mg/kg/wk of TS and group 4 received sesame oil for four weeks; then all four groups received 2.5 mg/kg/d CP for one week. Groups 5 through 8 received the same treatment regimen as groups 1 through 4 during first four weeks but instead of CP, they received saline for one week. Then the animals were sacrificed for biochemical and histopathologic studies.

RESULTS

CP increased the serum levels of blood urea nitrogen (BUN), creatinine (Cr), and malondialdehyde (SMDA) as well as kidney weight (KW), bodyweight (BW) loss, and kidney tissue damage score (KTDS). It significantly decreased the serum and kidney levels of nitrite and serum level of TS in comparison with the control group (P < 0.05). However, coadministration of CP and low dose of TS significantly decreased the serum levels of BUN as well as Cr and KTDS (P < 0.05). Administration of high-dose TS alone increased the SMDA level, KTDS, and KW while decreased the BW significantly (P < 0.05).

CONCLUSIONS

It seems that testosterone in low dose, i.e. physiologic dose, protects kidneys against CP-induced nephrotoxicity; however, special care is needed in CP therapy of patients with high levels of TS.

Complete heart block in a patient with POEMS syndrome: A case report

BACKGROUND

Polyneuropathy, organomegaly, endocrinopathy, monoclonal syndrome (POEMS) is a rare paraneoplastic syndrome associated with plasma cell dyscrasia.

CASE REPORT

A 48-year-old man presented with a 1-year history of paresthesia and progressive weakness of extremities. Diagnosis of POEMS syndrome was made for him on the basis of clinical presentation, additional physical findings, typical sclerotic bone lesion, and bone marrow findings. In last admission, he explained episodes of dyspnea and chest pain that associated with frequent premature ventricular contraction in his electrocardiograph. Patient heart monitoring showed some episodes of complete heart block. Infra-His atrioventricular block in electro-physiologic study was detected. He had no history of ischemic heart disease. His cardiopulmonary findings on examination were normal. All results of cardiac biomarkers and serum electrolytes and repeated echocardiography were within normal range. Cong red staining of rectal fat pad biopsy was negative. After pacemaker insertion radiation of sclerotic bone, lesion started for him, but radiotherapy was ineffective, and he expired with respiratory failure. Complete heart block in POEMS syndrome has not been reported previously, and it is the first POEMS case with complete heart block.

CONCLUSION

Complete heart block is a cardiac manifestation of POEMS syndrome.

Electrical stimulation of acupuncture points for analgesia during bone marrow aspiration and biopsy: A randomized double-blind placebo-controlled trial

Background:

Bone marrow aspiration and biopsy (BMA/BMB) is a painful procedure mostly used in diagnosing and staging of a broad spectrum of hematological diseases. In spite of local anesthesia, the prevalence and intensity of the pain and patient discomfort caused by this procedure are considerable. The effect of acupuncture and electrical stimulation of acupoints (acupuncture points) in the treatment of many medical conditions, including pain, have been approved. The study is designed to evaluate the effect of electrical stimulation of acupoints to decrease the pain during BMA/BMB in adults.

Materials and Methods:

In a double-blind controlled clinical trial, 50 patients undergoing BMA/BMB were randomly allocated into two groups, to receive either true or placebo electrical stimulation of acupoints LI-4 (large intestine 4, Hegu) and LI-11 (large intestine 11, Quchi), bilaterally. Both groups received infiltrative local anesthesia. The pain level caused by BMA/BMB was measured using the Visual Analog Scale (VAS).

Results:

The means of the VAS in the case and control groups were 41.84 ± 20.54 and 69.40 ± 20.06 respectively (P < 0.001). The systolic and diastolic blood pressure and pulse rate rose significantly in both the groups compared to the basal values. The rise was lower in the acupuncture group compared to the placebo group regarding systolic blood pressure and pulse rate (P = 0.018 and P < 0.001, respectively).

Conclusions:

The results of this study show that the electrical stimulation of acupoints significantly decreases the pain caused by BMA/BMB and some of the complications of the pain.