Albumin: a comprehensive review and practical guideline for clinical use

PURPOSE

Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration.

METHODS

Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication.

RESULTS

A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation.

CONCLUSION

Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.

The protective effects of protocatechuic acid against natural and chemical toxicants: cellular and molecular mechanisms

Protocatechuic acid (PCA) is a water-soluble polyphenol compound that is extracted from certain fruits and plants or obtained from glucose fermentation. Several in vivo and in vitro studies have determined that PCA has protective effects against the toxicity of natural and chemical toxicants. We searched these articles in PubMed, Google Scholar, and Scopus with appropriate keywords from inception up to August 2023. Forty-nine studies were found about protective effects of PCA against drug toxicity, metal toxicity, toxins, chemical toxicants, and some other miscellaneous toxicants. PCA indicates these protective effects by suppression of oxidative stress, inflammation, and apoptosis. PCA reduces reactive oxygen/nitrogen species (RONS) and enhances the level of antioxidant parameters mainly through the activation of the Nrf-2 signaling pathway. PCA also decreases the levels of inflammatory mediators via downregulating the TLR-4-mediated IKBKB/NF-κB and MAPK/Erk signaling pathways. In addition, PCA inhibits apoptosis by lowering the expression of Bax, caspase-3, and caspase-9 along with enhancing the level of the antiapoptotic protein Bcl-2. Further evaluation, especially in humans, is necessary to confirm PCA as a potential therapeutic approach to intervene in such toxicities.

Enhancing treatment strategies for small bowel cancer: a clinical review of targeted therapy and immunotherapy approaches

Small bowel cancer (SBC) is a rare and aggressive disease with a poor prognosis, necessitating the exploration of novel treatment approaches. This narrative review examines the current evidence on targeted therapy and immunotherapy for SBC, focusing on the two most common subtypes: adenocarcinoma and neuroendocrine tumor. A comprehensive search of PubMed, Scopus, and Google Scholar databases was conducted to identify relevant clinical trials and case reports published in English up to September 2023. The review includes 17 clinical trials and 10 case reports, indicating that targeted therapy and immunotherapy can have the potential to improve survival rates in patients with SBC. Notably, promising targeted medicines include bevacizumab, cetuximab, and trastuzumab, while pembrolizumab and nivolumab show potential as immunotherapies. However, it should be noted that the magnitude of the increase in survival rates with these interventions was small. Further research is needed to determine the optimal combination of targeted therapy and immunotherapy for individual patients with SBC.

Hydrogel-Based Skin Regeneration

The skin is subject to damage from the surrounding environment. The repair of skin wounds can be very challenging due to several factors such as severe injuries, concomitant infections, or comorbidities such as diabetes. Different drugs and wound dressings have been used to treat skin wounds. Tissue engineering, a novel therapeutic approach, revolutionized the treatment and regeneration of challenging tissue damage. This field includes the use of synthetic and natural biomaterials that support the growth of tissues or organs outside the body. Accordingly, the demand for polymer-based therapeutic strategies for skin tissue defects is significantly increasing. Among the various 3D scaffolds used in tissue engineering, hydrogel scaffolds have gained special significance due to their unique properties such as natural mimicry of the extracellular matrix (ECM), moisture retention, porosity, biocompatibility, biodegradability, and biocompatibility properties. First, this article delineates the process of wound healing and conventional methods of treating wounds. It then presents an examination of the structure and manufacturing methods of hydrogels, followed by an analysis of their crucial characteristics in healing skin wounds and the most recent advancements in using hydrogel dressings for this purpose. Finally, it discusses the potential future advancements in hydrogel materials within the realm of wound healing.

Mustard Gas-Induced Ocular Surface Disorders: An Update on the Pathogenesis, Clinical Manifestations, and Management

PURPOSE

Mustard gas (MG) is a potent blistering and alkylating agent that has been used for military and terrorism purposes. Ocular surface injuries are common after exposure to MG. This review provides an update on the pathophysiology, ocular surface complications, and treatment options for MG-related ocular injuries.

METHODS

Required information was obtained by reviewing various databases such as Cochrane Library, Google Scholar, and PubMed until March 2022. Data were collected by using keywords: "mustard gas" OR "sulfur mustard" AND "eye" OR "cornea" OR "ocular complication" OR "keratitis" OR "keratopathy" OR "limbal stem cell deficiency" OR "dry eye."

RESULTS

Chronic intracellular toxicity, inflammation, and ischemia have been shown to play an essential role in the pathogenesis of MG injury. Ocular surface injuries can have acute, chronic, and most distinctly a delayed-onset presentation leading to various degrees of limbal stem cell deficiency. To date, no treatment has been agreed on as the standard treatment for chronic/delayed-onset MG keratopathy. Based on the authors' experience, we propose a management algorithm for MG-related ocular surface injuries involving optimization of ocular health, anti-inflammatory therapy, and if needed surgical interventions. The management of chronic and delayed-onset presentation remains challenging.

CONCLUSIONS

MG keratopathy is a unique form of chemical injury which can lead to a range of ocular surface pathologies. Long-term anti-inflammatory therapy even in patients with seemingly mild disease may potentially reduce the likelihood of the development of more severe delayed-onset disease.

HDL-cholesterol concentration and its association with coronary artery calcification: a systematic review and meta-analysis

BACKGROUND

Coronary artery calcification (CAC) is a potential risk marker of coronary atherosclerosis that has high specificity and sensitivity. However, the association between high-density lipoprotein cholesterol (HDL-C) concentration and CAC incidence and progression is controversial.

METHODS

PubMed, Embase, Web of Science, and Scopus were systematically searched to identify relevant observational studies up to March 2023 and assessed the methodological quality using Newcastle-Ottawa Scale (NOS) scale. Random-effects meta-analysis was used to estimate pooled odds ratios (OR) and 95% confidence interval considering heterogeneity across studies.

RESULTS

Of the 2,411 records, 25 cross-sectional (n = 71,190) and 13 cohort (n = 25,442) studies were included in the systematic review. Ten cross-sectional and eight cohort studies were not eligible and were omitted from the meta-analysis. A total of 15 eligible cross-sectional studies (n = 33,913) were included in the meta-analysis and pooled results revealed no significant association between HDL-C and CAC > 0, CAC > 10, or CAC > 100 [pooled OR: 0.99 (0.97, 1.01)]. Meta-analysis of the 5 eligible prospective cohort studies (n = 10,721) revealed no significant protective effect of high HDL-C against CAC > 0 [pooled OR: 1.02 (0.93, 1.13)].

CONCLUSIONS

According to this analysis of observational studies, high HDL-C levels were not found to predict protection against CAC. These results suggest HDL quality rather than HDL quantity is important for certain aspects of atherogenesis and CAC.

REGISTRATION NUMBER

CRD42021292077.

The Therapeutic Role of Rho Kinase Inhibitor, Fasudil, on Pulmonary Hypertension; a Systematic Review and Meta-Analysis

BACKGROUND

Pulmonary hypertension (PH) is a pathophysiological disorder, which involves multiple clinical conditions such as the upregulation of the Rho/ROCK signaling pathway. On the other hand, fasudil as a Rho kinase inhibitor has been investigated in the treatment of PH in some clinical studies.

OBJECTIVES

The present systematic review and meta-analysis aimed to evaluate the human clinical trials regarding the efficacy of fasudil in the management of PH.

METHODS

Databases were searched with pre-defined search terms, up to December 2021. Efficacy measures were such as mean pulmonary arterial pressure (mPAP), systolic PAP (sPAP), pulmonary vascular resistance (PVR), systolic vascular resistance (SVR) and cardiac index (CI).

RESULTS

A total of 12 studies involving 575 PH patients were included in our research. Eight short-term trials and four mid-term trials were found (no clinical trials on the long-term effects). Short-term trials had a before-after study design and measuring pulmonary hemodynamic parameters' intervention revealed a statistically significant improvement of mPAP, sPAP, PVR, SVR, and CI in the meta-analysis of five eligible studies. Three mid-term trials also revealed improvement in some pulmonary hemodynamic parameters with fasudil and in another mid-term trial, fasudil significantly decreased rehospitalization and mortality in PH patients. No serious adverse effects with fasudil were reported in these trials.

CONCLUSION

Fasudil therapy is efficacious and probably safe in the improvement of some hemodynamics in PH patients along short and mid-term periods. However, long-term randomized controlled trials comparing fasudil with placebo and other treatments are warranted for confirmation of these benefits.

The Effect of Heparin and Its Preparations on Disseminated Intravascular Coagulation Mortality and Hospitalization: A Systematic Review

METHODS

The databases of PubMed, Scopus, Embase, and Web of Science were searched systematically up to November 2021. The quality of RCTs was assessed by Cochrane Collaboration's tool and the risk of bias was assessed for cohort studies through NOS score.

RESULTS

Out of 3288 articles, eight studies were eligible to be included in this study. Our review retrieved six RCTs and two retrospective cohort studies consisting of 950 participants diagnosed by DIC. A significant effect of heparin on DIC mortality was identified in four studies. Furthermore, heparin was used as a control group in three studies.

CONCLUSIONS

We concluded that administration of heparin and its preparations in DIC patients could reduce the mortality rate and duration of hospitalization, especially in the earlier stages of DIC.

Evaluation of the effect of crocin on prevention of atrial fibrillation after coronary artery bypass grafting or heart valve replacement: A double-blind, randomized, placebo-controlled trial

Objective

The aim of this study was to evaluate the effect of crocin on the prevention of atrial fibrillation after coronary artery bypass grafting (CABG) and heart valve replacement.

Materials and Methods

100 patients who were scheduled for CABG or heart valve replacement surgeries were randomly assigned into two groups of treatment and placebo. In the treatment group, patients received crocin tablets from three days prior to surgery and on the first three postoperative days (for a total of six days). During the first three days after surgery, postoperative atrial fibrillation (POAF) was assessed by electrocardiogram monitoring. Prooxidant-antioxidant balance (PAB) and c-reactive protein (CRP) levels were also assessed.

Results

POAF developed in 7 patients in the treatment group versus 18 patients in the control (p=0.02). PAB levels were significantly lower in the crocin group (p<0.001), while differences in CRP levels were insignificant (p=0.39).

Conclusion

It seems that prophylactic use of crocin is effective in reducing the incidence of POAF in patients undergoing heart surgeries.

Over 60 years of age as an independent prognostic factor of in-hospital mortality among COVID-19 patients: a cohort study in an Iranian high-incidence area

Objectives

COVID-19 continues to cause devastation throughout the world. Various factors influence the perioperative course and prognosis of COVID-19. This study aims to collate the independent prognostic factors among hospitalised COVID-19 patients in east Iran.

Study design

In this cohort study, all patients with a confirmed diagnosis of COVID-19 between 19 February 2020 and 1 August 2020 who were admitted to nine public hospitals of South Khorasan province, Iran, were enrolled.

Methods

Univariate analysis (chi-square [χ²], and Mann–Whitney U test) and multiple logistic regression were performed.

Results

This study included 1290 participants; 676 patients (52.4%) were male. A total of 1189 (92.2%) recovered, and 101 (7.8%) died. The results show that in-hospital mortality increases with advanced age (the optimal cut-off point = 62 years). The following three variables were shown to have the most significant role in in-hospital mortality: age >60 years (odds ratio [OR] = 8.01, 95% confidence interval [CI] 4.8–13.35), shortness of breath (OR = 2.65, 95% CI: 1.4–69.17) and atypical radiological manifestations in a chest X-ray on admission (OR = 2.16, 95% CI: 1.3–28.64). In the univariate analysis, associated comorbidities, such as cardiovascular diseases, influenced the in-hospital mortality rate, while the same could not be replicated in the multiple variable analysis.

Conclusions

This study revealed the potential predictors of COVID-19 and highlighted the need to be cautious with advanced age and heightened clinical symptoms at the time of admission.

Alterations in corneal nerves in different subtypes of dry eye disease: An in vivo confocal microscopy study

PURPOSE

To evaluate corneal subbasal nerve alterations in evaporative and aqueous-deficient dry eye disease (DED) as compared to controls.

METHODS

In this retrospective, cross-sectional, controlled study, eyes with a tear break-up time of less than 10 s were classified as DED. Those with an anesthetized Schirmer's strip of less than 5 mm were classified as aqueous-deficient DED. Three representative in vivo confocal microscopy images were graded for each subject for total, main, and branch nerve density and numbers.

RESULTS

Compared to 42 healthy subjects (42 eyes), the 70 patients with DED (139 eyes) showed lower total (18,579.0 ± 687.7 μm/mm² vs. 21,014.7 ± 706.5, p = 0.026) and main (7,718.9 ± 273.9 vs. 9,561.4 ± 369.8, p < 0.001) nerve density, as well as lower total (15.5 ± 0.7/frame vs. 20.5 ± 1.3, p = 0.001), main (3.0 ± 0.1 vs. 3.8 ± 0.2, p = 0.001) and branch (12.5 ± 0.7 vs. 16.5 ± 1.2, p = 0.004) nerve numbers. Compared to the evaporative DED group, the aqueous-deficient DED group showed reduced total nerve density (19,969.9 ± 830.7 vs. 15,942.2 ± 1,135.7, p = 0.006), branch nerve density (11,964.9 ± 749.8 vs. 8,765.9 ± 798.5, p = 0.006), total nerves number (16.9 ± 0.8/frame vs. 13.0 ± 1.2, p = 0.002), and branch nerve number (13.8 ± 0.8 vs. 10.2 ± 1.1, p = 0.002).

CONCLUSIONS

Patients with DED demonstrate compromised corneal subbasal nerves, which is more pronounced in aqueous-deficient DED. This suggests a role for neurosensory abnormalities in the pathophysiology of DED.

Nephroprotective activity of natural products against chemical toxicants: The role of Nrf2/ARE signaling pathway

Nephropathy can occur following exposure of the kidneys to oxidative stress. Oxidative stress is the result of reactive oxygen species (ROS) formation due to intracellular catabolism or exogenous toxicant exposure. Many natural products (NPs) with antioxidant properties have been used to demonstrate that oxidative damage-induced nephrotoxicity can be ameliorated or at least reduced through stimulation of the nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway. Nrf2 is a basic leucine zipper (bZip) transcription factor that regulates gene expression of the antioxidant response elements (ARE). Nrf2 is involved in the cellular antioxidant-detoxification machinery. Nrf2 activation is a major mechanism of nephroprotective activity for these NPs, which facilitates its entry into the nucleus, primarily by inhibiting Kelch like-ECH-associated protein 1 (Keap1). The purpose of this article was to review the peer-reviewed literature of NPs that have shown mitigating effects on renal disorder by stimulating Nrf2 and thereby suggesting potential new therapeutic or prophylactic strategies against kidney-damaging xenobiotics.

MicroRNAs and SARS-CoV-2 life cycle, pathogenesis, and mutations: biomarkers or therapeutic agents?

To date, proposed therapies and antiviral drugs have been failed to cure coronavirus disease 2019 (COVID-19) patients. However, at least two drug companies have applied for emergency use authorization with the United States Food and Drug Administration for their coronavirus vaccine candidates and several other vaccines are in various stages of development to determine safety and efficacy. Recently, some studies have shown the role of different human and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) microRNAs (miRNAs) in the pathophysiology of COVID-19. miRNAs are non-coding single-stranded RNAs, which are involved in several physiological and pathological conditions, such as cell proliferation, differentiation, and metabolism. They act as negative regulators of protein synthesis through binding to the 3' untranslated region (3' UTR) of the complementary target mRNA, leading to mRNA degradation or inhibition. The databases of Google Scholar, Scopus, PubMed, and Web of Science were searched for literature regarding the importance of miRNAs in the SARS-CoV-2 life cycle, pathogenesis, and genomic mutations. Furthermore, promising miRNAs as a biomarker or antiviral agent in COVID-19 therapy are reviewed.

Corneal Stiffness Parameters Are Predictive of Structural and Functional Progression in Glaucoma Suspect Eyes

PURPOSE

To investigate corneal stiffness parameters (SPs) as predictors of future progression risk in glaucoma suspect eyes.

DESIGN

Prospective, longitudinal study.

PARTICIPANTS

Three hundred seventy-one eyes from 228 primary open-angle glaucoma suspects, based on optic disc appearance, with normal baseline Humphrey Visual Field (HVF; Carl Zeiss Meditec) results.

METHODS

Baseline corneal SPs were measured using Corvis ST (Oculus Optikgeräte GmbH). Participants were followed up every 6 months with clinical examination, HVF testing, and OCT. The baseline SP at first applanation (SP-A1) and highest concavity predicted the prospective outcome measures.

MAIN OUTCOME MEASURES

Structural progression was measured by the OCT rate of thinning of the retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL). Functional progression was assessed by permutation analysis of pointwise linear regression criteria on HVF testing.

RESULTS

Stiffness parameters correlated positively with central corneal thickness (CCT), which was adjusted for in all analyses. A higher SP-A1, suggestive of a stiffer cornea, was associated with a faster rate of RNFL thinning (P < 0.001), synergistic with thinner CCT (P = 0.004) over a mean follow-up of 4.2 years. Eyes with higher SP-A1 and thinner CCT (thin and stiff corneas) showed accelerated RNFL thinning by 0.72 μm/year relative to eyes with lower SP-A1 and thicker CCT (95% confidence interval [CI], 0.17-1.28; P = 0.011) and were at 2.9-fold higher likelihood of fast RNFL progression of more than 1 μm/year (95% CI, 1.4-6.1; P = 0.006). Consistent results also were observed with GCIPL thinning. Furthermore, a higher SP-A1 was associated with a greater risk of visual field progression (P = 0.002), synergistic with thinner CCT (P = 0.010). Eyes with higher SP-A1 and thinner CCT were at 3.7-fold greater risk of visual field progression relative to eyes with thicker CCT and lower SP-A1 (95% CI, 1.3-10.5; P = 0.014).

CONCLUSIONS

Glaucoma suspect eyes with higher corneal SPs and lower CCT, suggestive of thin and stiff corneas, are at greater risk of progression. Corneal SPs seem to act synergistically with CCT as risk factors for glaucoma progression.

Acute lung injury: The therapeutic role of Rho kinase inhibitors

Acute lung injury (ALI) is a pulmonary illness with high rates of mortality and morbidity. Rho GTPase and its downstream effector, Rho kinase (ROCK), have been demonstrated to be involved in cell adhesion, motility, and contraction which can play a role in ALI. The electronic databases of Google Scholar, Scopus, PubMed, and Web of Science were searched to obtain relevant studies regarding the role of the Rho/ROCK signaling pathway in the pathophysiology of ALI and the effects of specific Rho kinase inhibitors in prevention and treatment of ALI. Upregulation of the RhoA/ROCK signaling pathway causes an increase of inflammation, immune cell migration, apoptosis, coagulation, contraction, and cell adhesion in pulmonary endothelial cells. These effects are involved in endothelium barrier dysfunction and edema, hallmarks of ALI. These effects were significantly reversed by Rho kinase inhibitors. Rho kinase inhibition offers a promising approach in ALI [ARDS] treatment.

A review on gentisic acid as a plant derived phenolic acid and metabolite of aspirin: Comprehensive pharmacology, toxicology, and some pharmaceutical aspects

Beneficial therapeutic effects of phenolic acids have been proven in various research projects including in vivo and in vitro studies. Gentisic acid (GA) is a phenolic acid that has been associated with useful effects on human health, such as antiinflammatory, antigenotoxic, hepatoprotective, neuroprotective, antimicrobial, and especially antioxidant activities. It is an important metabolite of aspirin and also widely distributed in plants as a secondary plant product such as Gentiana spp., Citrus spp., Vitis vinifera, Pterocarpus santalinus, Helianthus tuberosus, Hibiscus rosa-sinensis, Olea europaea, and Sesamum indicum and in fruits such as avocados, batoko plum, kiwi fruits, apple, bitter melon, black berries, pears, and some mushrooms. This study was undertaken to review the pharmacological effects, pharmacokinetic properties as well as toxicity and pharmaceutical applications of GA.

Degeneration and Regeneration of Subbasal Corneal Nerves after Infectious Keratitis: A Longitudinal In Vivo Confocal Microscopy Study

PURPOSE

To investigate the longitudinal alterations of subbasal corneal nerves in patients with infectious keratitis (IK) during the acute phase, cessation of treatment, and the recovery phase by in vivo confocal microscopy (IVCM).

DESIGN

Prospective, longitudinal, case-control, single-center study.

PARTICIPANTS

Fifty-six eyes of 56 patients with the diagnosis of bacterial (n=28), fungal (n=15), or Acanthamoeba (n=13) keratitis were included in the study. Thirty eyes of 30 normal volunteers constituted the control group.

METHODS

Corneal sensation and serial IVCM of the central cornea were performed prospectively using the Heidelberg Retina Tomograph 3/Rostock Cornea Module (Heidelberg Engineering, Heidelberg, Germany). The IVCM images were assessed at 3 time points: at the acute phase (first visit to the cornea service), at cessation of antimicrobial treatment, and up to 6 months after the resolution of infection.

MAIN OUTCOME MEASURES

Total nerve number and length, main nerve trunks, branching, and corneal sensation were assessed during the follow-up period.

RESULTS

Corneal nerves were reduced significantly during the acute phase in eyes with IK compared with controls across all subgroups, with total nerve length of 5.47±0.69 mm/mm2 versus 20.59±1.06 mm/mm2 (P<0.0001). At the cessation of treatment, corneal nerves in patients with IK had regenerated, including total nerve length (8.49±0.94 mm/mm2; P=0.02) and nerve branch length (4.80±0.37 mm/mm2; P=0.005). During the recovery phase, after resolution of infection, corneal nerves regenerated further, including total nerve length (12.13±1.97 mm/mm2; P=0.005), main nerve trunk length (5.80±1.00 mm/mm2; P=0.01), and nerve branch length (6.33±0.76 mm/mm2; P=0.003) as compared with the acute phase, but were still significantly lower when compared with controls (P<0.05 for all parameters). Corneal degeneration and regeneration correlated with corneal sensation (r=0.47; P=0.0009).

CONCLUSIONS

Patients with IK who sustain profound loss of corneal nerves during the acute phase of infection demonstrate increased corneal nerve density during the first 6 months after the resolution of infection. However, despite significant nerve regeneration, corneal nerve density does not recover fully and remains low compared to controls. By providing an objective methodology to monitor corneal re-innervation, IVCM adds potentially important findings that may have implications for clinical management and surgical planning.

Genetic influences on the outcome of anti-vascular endothelial growth factor treatment in neovascular age-related macular degeneration

PURPOSE

To determine the association of genetic variants in known age-related macular degeneration (AMD) risk-associated genes with outcome of anti-vascular endothelial growth factor (VEGF) treatment in neovascular AMD.

DESIGN

Prospective cohort study.

PARTICIPANTS

We enrolled 224 consecutive patients with neovascular AMD at the Royal Victorian Eye and Ear Hospital, Australia.

METHODS

Patients were treated with 3 initial monthly ranibizumab or bevacizumab injections followed by 9 months of "as required" injections based on clinician's decision at each follow-up visit according to retreatment criteria. Seventeen single nucleotide polymorphisms (SNPs) in known AMD risk-associated genes including CFH (rs800292, rs3766404, rs1061170, rs2274700 and rs393955), HTRA1 (rs11200638), CFHR1-5 (rs10922153, rs16840639, rs6667243, and rs1853883), LOC387715/ARMS2 (rs3793917 and rs10490924), C3 (rs2230199 and rs1047286), C2 (rs547154), CFB (rs641153) and F13B (rs6003) were examined. Multivariate analysis was used to determine the role of each SNP in treatment outcome.

MAIN OUTCOME MEASURES

The influence of selected SNPs on mean change in visual acuity (VA) at 12 months.

RESULTS

Mean baseline VA was 51 ± 16.8 Early Treatment Diabetic Retinopathy Study letters. Overall, the mean change in VA from baseline was +3.2 ± 14.9 letters at 12 months. The AA (homozygote risk) genotype at rs11200638 - HTRA1 promoter SNP (P = 0.001) and GG (homozygote risk) genotype at rs10490924 (A69S) in LOC387715/ARMS2 (P = 0.002) were each significantly associated with poorer VA outcome at 12 months after multiple correction. Mean ± standard deviation change in VA from baseline in patients with AA genotype at rs11200638 was -2.9 ± 15.2 letters after 12 months compared with +5.1 ± 14.1 letters in patients with AG or GG genotypes at this SNP. Patients with either of these genotypes were also significantly more likely to lose >15 letters after 12 months. SNPs rs11200638 and rs10490924 were in high linkage disequilibrium (r(2) = 0.92). None of the other examined SNPs was associated with outcome.

CONCLUSIONS

The HTRA1 promoter SNP (rs11200638) and A69S at LOC387715/ARMS2 were associated with a poorer visual outcome for ranibizumab or bevacizumab treatment in neovascular AMD, suggesting strong pharmacogenetic associations with anti-VEGF treatment. This finding could aid in applying more individualized treatment regimens based on patients' genotype to achieve optimal treatment response in AMD.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Hepatitis B virus surface protein mutations clustered mainly in CTL immune epitopes in chronic carriers: results of an Iranian nationwide study

Mutations within the coding region of hepatitis B surface antigen (HBsAg) have been found naturally in chronic carriers. To characterize the mutations of HBsAg from Iranian chronic carriers who were vaccine and/or medication naive. The surface genes from 360 patients were amplified and directly sequenced. The distribution of amino acid substitutions was classified according to different immune epitopes of the surface protein. All isolates belonged to genotype D. 222 (61.6%) of 360 patients contained at least one amino acid substitution. 404 (74.5%) of 542 amino acid changes occurred in different immune epitopes of HBsAg, of which 112 (27.7%) in 32 residues of B-cell epitopes (62 in the 'a' determinant); 111 (27.4%) in 32 residues of T helper; and 197 (48.7%) in 32 residues inside cytotoxic T lymphocyte (CTL) epitopes. One Th (186-197) and two CTL (28-51 and 206-215) epitopes were found to be hotspot motifs for the occurrence of 213 (52.7%) substitutions. 20 stop codons were identified in different epitopes. There was a significant association between amino acid substitutions and anti-HBe seropositivity; however, the correlation between such changes with viral load and ALT levels was not significant. In chronic hepatitis B virus(HBV) carriers, positive selection in particular outside the 'a' determinant appeared to exert influence on the surface proteins. These changes could be immune escape mutations naturally occurring due to the host immune surveillance especially at the T-cell level.

Vector ecology and susceptibility in a malaria-endemic focus in southern Islamic Republic of Iran

This study aimed to carry out a malaria situation analysis, species composition and susceptibility levels of the main malaria vector, Anopheles stephensi, to different insecticides in Bashagard. A longitudinal survey was conducted in 2 randomly selected villages in Bashagard. Malaria vectors were sampled by dipping method for the larvae and hand catch, night-biting catch, total catch, and shelter pit collection for the adults. Standard WHO susceptibility tests were used for a variety of insecticides on F1 progeny of An. stephensi reared from wild-caught females. In total, 693 adult anopheline mosquitoes and 839 third and fourth-instar larvae were collected and identified. They comprised 7 species; the most abundant adult and larvae anopheline mosquito was An. dthali (40.7% and 30.5% respectively). An. culicifacies (24.2%) and An. stephensi (16.7%) were the next most common species for adult mosquitoes. An. stephensi was fully susceptible to malathion and pyrethroid insecticides but resistant to DDT and tolerant to dieldrin.

Variants in the VEGFA gene and treatment outcome after anti-VEGF treatment for neovascular age-related macular degeneration

PURPOSE

To determine the association of genetic variants of the VEGFA gene with outcome of anti-vascular endothelial growth factor (VEGF) treatment in neovascular age-related macular degeneration (AMD).

DESIGN

A prospective cohort study.

PARTICIPANTS

We included 201 consecutive patients receiving anti-VEGF injections for neovascular AMD.

METHODS

Patients were followed over 12 months. They were treated with 3 initial monthly ranibizumab or bevacizumab injections. Thereafter, the decision to retreat was made by clinicians at each follow-up visit on the basis of retreatment criteria. Seven tagged single nucleotide polymorphisms (tSNPs) in the VEGFA gene were selected and examined. Multivariate data analysis was used to determine the role of each tSNP in treatment outcome.

MAIN OUTCOME MEASURES

The influence of selected VEGFA tSNPs on visual acuity (VA) outcome at 6 months.

RESULTS

Mean baseline VA was 51±17 Early Treatment Diabetic Retinopathy Study (ETDRS) letter scores. Overall, the mean change in VA from baseline was +6.5±12, +4.4±13.4, and +2.3±14.6 letters at 3, 6, and 12 months, respectively. The tSNP rs3025000 was the only SNP significantly associated (P<1 × 10(-4)) with visual outcome at 6 months with multiple correction. The presence of the T allele (TC or TT genotypes) at this tSNP predicted a better outcome of +7 letters at 6 months compared with the CC genotype. In a subgroup analysis, presence of the T allele predicted a significantly higher chance of the patients belonging to the responder group (gain of ≥5 letters from baseline) after 3, 6, and 12 months treatment (odds ratio, 2.7, 3.5, and 2.4; 95% confidence interval, 1.46-5.07, 1.82-6.71, and 1.27-4.57, respectively) than any other outcome group.

CONCLUSIONS

Pharmacogenetic association with anti-VEGF treatments may influence the visual outcomes in neovascular AMD. In patients with the T allele in tSNP rs3025000, there was a significantly better visual outcome at 6 months and a greater chance of the patients belonging to the responder group with anti-VEGF treatment at 3, 6, and 12 months. The VA outcomes of patients harboring the T allele at SNP rs3025000 were comparable with those of the pivotal clinical trials but with fewer injections, making the treatment perhaps more cost effective in certain subgroups of patients.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Field evaluation of permethrin long-lasting insecticide treated nets (Olyset(®)) for malaria control in an endemic area, southeast of Iran

Long lasting insecticide treated nets (LLINs) have been advocated as an effective tool for prevention and control of malaria. Olyset net was the first LLINs which became commercially available and obtained WHO approval. According to the national strategic plan on evaluation of Olyset net, a field trial was conducted to determine the efficacy of these nets against malaria vectors in an endemic area in the southeast of Iran. Fourteen villages with similar topographical and epidemiological situations were selected and randomly assigned to two clusters of the study: Olyset net and untreated net. Distribution of nets was carried out to cover 100% of the population in Olyset net and untreated net cluster. Anopheline mosquitoes were collected monthly using different WHO standard methods in both areas to determine their abundance, feeding pattern and resting behaviour. Human blood index was determined using ELISA test. Additionally, Olyset nets were evaluated for their biological activity using WHO cone bioassay test by susceptible colony of Anopheles stephensi (Beech strain) and then for insecticide residues by employing high performance thin layer chromatography. Malaria incidence was measured by passive and active case detection from all study population. In total 2115 adult anopheline mosquitoes were collected and identified using morphological characters. They comprised of seven species: Anopheles dthali (Liston), A. culicifacies (Giles), A. stephensi (Liston), A. superpictus (Grassi), A.fluviatilis (James), A. moghulensis (Christophers) and A. turkhudi (Liston). A. dthali, A. culicifacies and A. stephensi were most prevalent species in both areas. In the Olyset net study area, there was a significant reduction of 41.1%, 54.4%, 59.39% and 64.1% in the indoor-resting density of A. culicifacies, A. stephensi, A. dthali and A. superpictus, respectively, with an overall reduction of 39.3% in total mosquitoes in comparison with untreated net area. A significant reduction was also observed in human blood index of vector species in the Olyset net villages. Bioefficacy test results of Olyset nets showed that the median knockdown time was 1.48 and 3.25min, while the average mortality rate was 100% and 72.3%±7.07 in baseline and after 1 year of intervention, respectively. The average permethrin content reached to 68.31% (683.1mg/m(2)) of the initial insecticide dose of 937±21.69mg/m(2) (nearly 1000mg/m(2)) at the end of intervention. Malaria incidence was reduced by 96.6% and 64.8% in the village with Olyset nets and in the villages with untreated nets, respectively. During intervention period, there was a reduction of 93.2% in malaria incidence in Olyset net area as compared to the untreated area. This study indicated that Olyset nets have a major impact on malaria vectors and disease burden; therefore it could be recommended as an effective personal protection tool for malaria control in malarious areas.

Larval habitats and biodiversity of anopheline mosquitoes (Diptera: Culicidae) in a malarious area of southern Iran

BACKGROUND & OBJECTIVES

Malaria is the most important mosquito-borne disease in Iran. It is endemic in south to southeastern part of the country. Knowledge about bio-ecology of vectors will support authorities for appropriate management of the disease. Bashagard district is one of the main endemic areas for malaria in south of Iran. This study was conducted to determine anopheline fauna, diversity and affinity in the area, characterization of larval habitats, and mapping their potential distribution across the district.

METHODS

The potential aquatic habitats for Anopheles larvae were extracted from Indian Remote Sensing Satellite (IRS) image and digital elevation model of the area using GIS. Surface water bodies were sampled monthly during 2009–10 for anopheline larvae, while characteristics of their physical environment were recorded and water samples were analyzed.

RESULTS

A total of 4511 Anopheles larvae were found during the year with the lowest and highest frequencies in February and April, respectively. Dominant species was Anopheles culicifacies. The Shanon diversity index ranged from 0.570–0.829 at fixed collection sites, while the affinity index was significant among some vector species.

CONCLUSION

Riversides and riverbeds were the main breeding places which provided sandy, rocky, and clay beds for different species. The potential breeding places as well as distribution of collected species were mapped. Knowledge about ecology of malaria vectors provides information to health sector for effective control programs.

Identification of Hepatitis B Virus Surface Antigen (HBsAg) Genotypes and Variations in Chronic Carriers from Isfahan Province, Iran

BACKGROUND

Hepatitis B virus (HBV) gene and protein variations are frequently been seen in chronic patients. The aims of study were to determine the genotypes as well as the patterns of variations distribution in chronically-infected patients from the central part of Iran.

METHODS

The surface gene was amplified, sequenced and subsequently aligned using international and national Iranian database.

RESULTS

All strains belonged to genotype D, subgenotype D1 and subtype ayw2. Of all 62 mutations occurred at 39 nucleotide positions, 31 (50%) were missense (amino acid altering) and 31 (50%) were silent (no amino acid changing). At the amino acid level, 30 substitutions occurred, however, 3 were in positions 122 and 127, corresponded to subtypic determination. 22 (73%) out of 30 amino acid mutations occurred in different immune epitopes within surface protein, of which 12 (54.54%) in B cell epitopes in 10 residues; 5 (45.45%) in T helper epitopes in positions; 5 (22.73%) in inside CTL epitopes in 4 residues.

CONCLUSION

The distribution of amino acid mutations as well as the ratio between silent and missense nucleotide mutations showed a narrowly focused immune pressure had already been on the surface protein in these patients, led to the emergence of escape mutants in these patients.

Entomological and epidemiological attributes for malaria transmission and implementation of vector control in southern Iran

Bashagard is an important malaria endemic area in south of Iran. An epidemiological and entomological survey was performed during 2002-2010. The aim of study was to determine malaria situation, species composition of anopheline mosquitoes and susceptibility status of main vectors to insecticides/larvicides. A total of 13,490 malaria cases were recorded, Plasmodium vivax (99.64%), P. falciparum (0.35%) and mix cases (0.01%). The highest and lowest Annual Parasite Incidence (API) were observed in 2007 (145.72/1000) and 2009 (6.29/1000), respectively. Anopheles culicifacies, An. dthali, An. stephensi, An. superpictus, An. fluviatilis, An. moghulensis, An. turkhudi and An. apoci were collected from the area. Two peak activities occur in April and October. The first five species were confirmed as malaria vectors in Iran. No indication of sporozoite in mosquitoes using molecular method was performed. Susceptibility tests using diagnostic dose of insecticides and larvicides showed only resistance of An. stephensi to DDT. Tolerance in An. stephensi to deltamethrin and bendiocarb is reported. The same phenomenon was observed in An. culicifacies to DDT, propoxur and deltamethrin, and in An. dthali to malathion and deltamethrin. Larvae of vectors were susceptible to all larvicides, except for An. stephensi that exhibited tolerance to fenthion. In conclusion it should be emphasized that malaria transmission is a complex process in Bashagard. This event is attributed to five proven vectors with different behaviors which are active in the area. Regarding tolerance of vectors to deltamethrin, resistance management is suggested by using new insecticide with novel mode of action.

Knowledge, attitudes and practices regarding malaria control in an endemic area of southern Iran

Iran is in the malaria pre-elimination stage. In this situation community based strategies are important for malaria control. In order to intensify elimination activities we need to have a better understanding of the knowledge, attitudes and practices (KAP) of malaria prevention in the community. We carried out a KAP study in one malaria endemic district in southern Iran in 2009 using a structured questionnaire. Five villages with indigenous malaria cases during the previous year and a high potential for anopheline mosquito breeding were selected. All the households in each village were visited and the head of the household or other responsible adult was interviewed. Data were analyzed using SPSS 11.5. A total of 494 respondents from the five villages participated. More than 33% of people in the study area were living in sheds with poor facilities. The illiteracy level of the studied population was high (44.2%) and significantly affected the knowledge and practices of the respondents about malaria control (p<0.05). Descriptive analysis showed significant differences between sex, job and history of malaria infection of the respondents and their knowledge and practices about malaria control (p<0.05). Knowledge of the respondents about the route of transmission in malaria was good; 72.1% knew mosquitoes were the vector. Most people knew at least one symptom of the disease. The practices of respondents were 59.5% for bednet use and 9.3% for screening windows. The knowledge, attitudes and practices of respondents in this survey about malaria control were good in some cases, but in general needed to be improved with educational programs.

Association of the Co-stimulatory Molecules Polymorphisms with CMV Infection in Liver Transplant Recipients

BACKGROUND

Co-stimulatory molecules play a critical role in regulating T-cell function during CMV infection after liver transplantation.

OBJECTIVE

To investigate the relationship between the polymorphisms of the co-stimulatory genes and the susceptibility to CMV infection after liver transplantation.

METHODS

Single nucleotide polymorphisms (SNPs) in PD-1 gene (PD1.1 A/G, PD1.3 A/G, PD1.9 C/T) ICOS (-693 A/G, 1720 C/T), CTLA-4 gene (318 C/T, 1722 T/C, 1661 A/G, 49 A/G) and CD28 (+17 C/T) were analyzed by PCR-RFLP in 70 liver transplant patients. CMV infection was determined in these patients by antigenemia test.

RESULTS

CTLA-4 49G showed significant association with CMV infection (p=0.03, OR=3.82, 95% CI: 0-3.5; p=0.01, OR=004, 95% CI: 0-1.3). G and T alleles in CTLA-4 gene (318 C/T and 1661 A/G) (p=0.03, OR=0, 95% CI: 0-3.5; p=0.01, OR=0.04, 95% CI: 0-1.3) were significantly higher in CMV-infected rejector group.

CONCLUSION

CTLA-4 have significant role in CMV pathogenesis and rejection among CMV-positive liver transplant patients.

Molecular Monitoring of Plasmodium vivax Infection after Radical Treatment in Southeastern Iran

BACKGROUND

The aim was to evaluate the relapse risk of vivax malaria in patients who received radical treatment in Hormozgan Province, a malarious area located on southeast of Iran.

METHODS

A total of 95 symptomatic vivax malaria infected patients were enrolled in urban health centers of Bandar-Abbas, Minab, Bandar-Jask and Bashagard districts of Hormozgan Province, southeast of Iran from January 2008 to March 2009 for consideration as a case- series study. DNA was extracted from parasite infected whole blood samples. A polymorphic region of Plasmodium vivax merozoite surface protein 1 (pvMSP1) was selected and a PCR method was employed for all the samples to amplify the specific variable gene fragment. The obtained fragments in primary and secondary samples were sequenced. Both nucleotide and amino acid sequences of the samples were investigated for returned patients.

RESULTS

3.2% of the patients experienced a second attack between 83-199 days after the initial episode of infection. Alignment of nucleotide and their deduced amino acid sequences between pair sequences of primary and secondary isolates revealed 8 and 6 dissimilarities respectively for the first case, and 9 and 7 dissimilarities for the second case. Although microscopical examination of recurrent thick blood smear of the third patient confirmed new P. vivax infection, the venous blood sample was accidentally missed. Sequencing results of primary and returned isolates 1P, 1S, 2P, 2S and 3P in this study showed an identity with BP13, T117, BP13, TC28 and Chesson genotypes respectively.

CONCLUSION

The returned (secondary) isolates may account to be for the sake of reinfection.