Epstein-Barr virus in Hodgkin`s lymphoma

Transcription

Annals of
the College
of Medicine
Mosul
Volume 35 Number 2 December 2009 Editorial Board Professor Hisham A. AL‐ATRAKCHI Professor Elham K. AL‐JAMMAS Professor Raad Y. AL‐HAMDANI Dr. Bedoor A. K. AL‐IRHAYIM Dr. Kahtan B. IBRAHEEM Dr. Rami M. A. AL‐HAYALI Dr. Mazin M. FAWZI Professor Taher Q. AL‐DABBAGH
Miss Faiza A. ABDULRAHMAN Editor Member Member Member Member Member Member & Manager External editor Administration A publication of the College of Medicine (since 1966), University of Mosul, Mosul, Iraq. Annals of
the College
of Medicine
Mosul
(Ann Coll Med Mosul)
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ISSN 0027-1446
CODE N: ACCMMIB
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Annals of
the College
of Medicine
Mosul
Volume 35 Number 2 December 2009 CONTENTS
Epstein-Barr virus in Hodgkin's lymphoma - immunohistochemical case series study
Mohammed S. Saeed ……………………………………………………………………….………...……93- 103
Antiemetic activity of ginger in children receiving cancer chemotherapy
Mazin M. Fawzi ………………………..……………………….……………………………………….….104- 110
P53 expression in colonic carcinoma – immunohistochemical study
Dena A. Jerjees, Bedoor A. AL- Irhayim…………………………………………………….….…………111-116
Bcl-2 oncoprotein expression in breast cancer, its relation to estrogen and progesterone
receptors and other prognostic factors
Banan B. Mohammed, Kassim S. Ibrahim…………………………………………………………….….117-123
Molecular characterization of beta-thalassemia mutations in Ninawa governorate
Waleed Abdelaziz Omer ……………………………………………………………………………..….....124-133
Prevalence of surgical inguino-genital conditions among male kindergartens and primary
school children in Mosul city
Abdul Salaam Al-Masri, Bassam A. Al-Ne`ema, Khalaf Rasheed………………………………...……134-139
Pulmonary embolism, seasonal variations in admission to hospital, and the association of
calf deep vein thrombosis with pulmonary embolism
Dhaher JS. Al-Habbo, Talal M. Al-Saegh, Mohammed K. Hammo, Rami M. Al-Hayali …………….140-146
Non-compliance to treatment among type 2 diabetic men in Mosul: A case-control study
Waleed G.A. Al-Taee……………………………………………………………………………..…..……..147-153
Assessing the effects of low dose aspirin on uric acid and renal function in healthy adults
Jonaya Sarsam, Yaser Adeep……….……………….…………………………………………………….154-159
The effect of nandrolone decanoate on liver of rabbits using histological and ultrasound
methods
Rand A. Hasso, Mohammed Taib Tahir, Sameer Abdullateef………………………………...….…..160-166
Printing of this issue was completed in October, 2010.
Annals of the College of Medicine
Vol. 35 No. 2, 2009
Epstein-Barr virus in Hodgkin's lymphoma immunohistochemical case series study
Mohammed S. Saeed
Department of Pathology, College of Medicine, University of Mosul.
(Ann. Coll. Med. Mosul 2009; 35(2): 93-103).
Received: 8th May 2009; Accepted: 4th Oct 2009.
ABSTRACT
Objectives: 1- To determine the association between Hodgkin's lymphoma and Epstein-Barr virus.
2- To determine if it is related to certain age groups or specific histologic subtypes. 3- To compare the
pattern with other developing or developed countries.
Methods: Biopsies of seventy cases with Hodgkin's lymphoma were collected from the pathology
laboratories. The clinical data, including the patient’s age, sex, site of lymph node affected and the
histological classification according to the REAL classification, were retrieved from the pathologic
reports. Immunoperoxidase stains for LMP-1 were performed on 40 cases.
Results: The mean age of all cases was 26.7 years, with a median of 25 years. There were 36 males
and 34 females. The largest age group was seen in 15 - 40 years accounting for 68.5%. The third
decade took the peak incidence (21/70, 30%). Nodular sclerosis Hodgkin's lymphoma was the most
common subtype representing 58.5% of all the cases, followed by mixed cellularity (37.2% of cases).
The lymphocyte depleted subtypes in 2.8%, whereas lymphocytic predominant seen in 1.4% of cases.
Latent membrane protein-1 was observed in 37.5% of Hodgkin's lymphoma. The most frequent
association was observed in lymphocytic depletion subtype (50%), followed by mixed cellularity
subtype (45%). The least frequent association was in nodular sclerosis type (27.7%). The highest rate
of EBV expression was seen in the pediatric age group (< 15 years; 66.6%) and the lowest rate was
among young adults (15-40 years; 26.9%). Older age group (> 40 years) has a rate of EBV
expression (50%) which is higher than the young adult patients, but lower than the pediatric age
group. Epstein-Barr virus positive cases were mostly males (73.3%) compared to females (26.7%).
Conclusion: Hodgkin's lymphoma in our locality, in comparison with earlier studies, shows changing
pattern with a gradual trend to those of developed countries including peak age group and subtypes.
Moreover, Epstein-Barr virus is seen in slightly more than one third of cases and mostly seen in
childhood, mixed cellularity and lymphocytic depletion subtypes with a male predominance.
Keywords: Hodgkin's lymphoma, Epstein-Barr virus, LMP1, developed and developing countries.
‫اﻟﺨﻼﺻﺔ‬
‫ ﺗﺤﺪﻳﺪ ﻋﻼﻗﺔ اﻟﻔﻴﺮوس ﻣﻊ اﻟﻔﺌﺎت‬:‫ ﺛﺎﻧﻴﺎ‬.‫ﺑﺎر‬-‫ ﻟﻜﺸﻒ اﻟﻌﻼﻗﺔ ﺑﻴﻦ ورم اﻟﻬﻮﺟﻜﻦ اﻟﻠﻤﻔﺎوي و ﻓﻴﺮوس اﺑﺸﺘﺎﻳﻦ‬:‫ أوﻻ‬:‫اﻷهﺪاف‬
.‫ ﻣﻘﺎرﻧﺔ اﻟﻨﺘﺎﺋﺞ ﻣﻊ اﻟﺪول اﻟﻤﺘﻄﻮرة واﻟﻨﺎﻣﻴﺔ‬:‫ ﺛﺎﻟﺜﺎ‬.‫اﻟﻌﻤﺮﻳﺔ أو اﻷﻧﻮاع اﻟﻤﺨﺘﻠﻔﺔ ﻣﻦ أورام اﻟﻬﻮﺟﻜﻦ اﻟﻠﻤﻔﺎوي‬
‫ ﻋﻴﻨﺎت ﺳﺒﻌﻴﻦ ﺣﺎﻟﺔ ﻣﻦ أورام اﻟﻬﻮﺟﻜﻦ اﻟﻠﻤﻔﺎوﻳﺔ ﺗﻢ ﺟﻤﻌﻬﺎ ﻣﻦ اﻟﻤﺨﺘﺒﺮات‬.‫ هﺬﻩ دراﺳﺔ رﺟﻌﻴﺔ وﺳﺎﺑﻘﺔ‬:‫اﻟﻄﺮق واﻷدوات‬
‫ ﻣﻮﻗﻊ اﻟﻌﻘﺪ اﻟﻠﻤﻔﺎوﻳﺔ اﻟﻤﺼﺎﺑﺔ واﻟﺘﺼﻨﻴﻒ‬،‫ اﻟﺠﻨﺲ‬،‫ اﻟﺒﻴﺎﻧﺎت اﻟﺴﺮﻳﺮﻳﺔ واﻟﻤﺘﻀﻤﻨﺔ ﻋﻤﺮ اﻟﻤﺮﻳﺾ‬.‫اﻟﻤﺮﺿﻴﺔ اﻟﻨﺴﻴﺠﻴﺔ‬
‫ ﺗﻢ دراﺳﺘﻪ ﻓﻲ أرﺑﻌﻴﻦ‬١-‫ ﺻﺒﻐﺔ اﻟﻤﻨﺎﻋﻴﺔ اﻟﻨﺴﻴﺠﻴﺔ ﻟﻠﺒﺮوﺗﻴﻦ أﻟﺠﺪاري اﻟﻤﺴﺘﺘﺮ‬.‫اﻟﻨﺴﻴﺠﻲ ﻟﻠﺤﺎﻟﺔ اﺧﺬ ﻣﻦ ﺗﻘﺎرﻳﺮ اﻟﻤﺮﻳﺾ‬
.‫ﺣﺎﻟﺔ‬
© 2009 Mosul College of Medicine
93
Vol. 35 No. 2, 2009
١:١.٠٦ ‫ أﻧﺜﻰ ﻣﻊ ﻧﺴﺒﺔ‬٣٤ ‫ ذآﺮ و‬٣٦ ‫ ﺗﻢ ﺟﻤﻊ‬.‫ ﺳﻨﺔ‬٢٥ ‫ ﺳﻨﺔ ﻣﻊ ﻣﺘﻮﺳﻂ ﻋﻤﺮ‬٢٦,٧ ‫ ﻣﻌﺪل أﻋﻤﺎر اﻟﻤﺮﺿﻰ آﺎن‬:‫اﻟﻨﺘﺎﺋﺞ‬
،%٣٠ ‫ اﻟﻌﻘﺪ اﻟﺜﺎﻟﺚ أﺧﺬ ﻧﺴﺒﺔ اﻟﺬروة ﻟﻺﺻﺎﺑﺔ وﺑﻤﻌﺪل‬.%٦٨,٥ ‫ ﺳﻨﺔ وﺑﻨﺴﺒﺔ‬٤٠ ‫ إﻟﻰ‬١٥ ‫أآﺒﺮ ﻓﺌﺔ ﻋﻤﺮﻳﺔ ﻟﻠﻮرم آﺎﻧﺖ ﺑﻴﻦ‬
‫ آﺎﻧﺖ ﺑﺄﻋﻤﺎر أآﺒﺮ ﻣﻦ‬%١٤,٣ ‫ ﺑﻴﻨﻤﺎ‬.%١٧,١ ‫ ﺳﻨﺔ آﺎﻧﺖ‬١٥ ‫ ﻧﺴﺒﺔ اﻟﻤﺮﺿﻰ اﻷﻗﻞ ﻣﻦ‬.%٢٤,٣ ‫أﺗﺒﻊ ﺑﺎﻟﻌﻘﺪ اﻟﺜﺎﻧﻲ وﺑﻨﺴﺒﺔ‬
‫ ﺛﻢ ﻣﺴﺘﻨﻔﺬ‬.%٣٧,٢ ‫ ﻳﻠﻴﻪ ﻣﺨﺘﻠﻒ اﻟﺨﻼﻳﺎ وﺑﻨﺴﺒﺔ‬.%٥٨,٥ ‫ اﻟﺘﺼﻠﺐ اﻟﻌﻘﺪي ﻟﻠﻮرم آﺎن أآﺜﺮ اﻷﻧﻮاع ﺷﻴﻮﻋﺎ وﺑﻨﺴﺒﺔ‬.‫ ﺳﻨﺔ‬٤٠
.%١,٤ ‫ وأﺧﻴﺮا ﺳﺎﺋﺪ اﻟﺨﻼﻳﺎ اﻟﻠﻤﻔﻴﺔ وﺑﻨﺴﺒﺔ‬.%٢,٨ ‫اﻟﺨﻼﻳﺎ اﻟﻠﻤﻔﻴﺔ وﺑﻨﺴﺒﺔ‬
‫ أآﺜﺮ اﻷﻧﻮاع ارﺗﺒﺎﻃﺎ ﻣﻊ اﻟﻔﻴﺮوس‬.‫ ﻣﻦ أورام اﻟﻬﻮﺟﻜﻦ اﻟﻠﻤﻔﺎوﻳﺔ‬%٣٧,٥ ‫ ﻟﻮﺣﻆ ﺑﻨﺴﺒﺔ‬١-‫اﻟﺒﺮوﺗﻴﻦ أﻟﺠﺪاري اﻟﻤﺴﺘﺘﺮ‬
‫ ﺑﻴﻨﻤﺎ أﻗﻞ اﻷﻧﻮاع ارﺗﺒﺎﻃﺎ ﻣﻊ اﻟﻔﻴﺮوس‬.%٤٥ ‫ ﻳﻠﻴﻪ ﻣﺨﺘﻠﻒ اﻟﺨﻼﻳﺎ وﺑﻨﺴﺒﺔ‬.%٥٠ ‫وﺟﺪت ﻣﻊ ﻣﺴﺘﻨﻔﺬ اﻟﺨﻼﻳﺎ اﻟﻠﻤﻔﻴﺔ وﺑﻨﺴﺒﺔ‬
‫ أﻋﻠﻰ ﻣﻌﺪﻻت إﺻﺎﺑﺎت ﻣﻦ اﻷورام اﻟﻬﻮﺟﻜﻦ ﻟﻠﻔﻴﺮوس آﺎﻧﺖ ﻷﻋﻤﺎر اﻷﻃﻔﺎل أﺻﻐﺮ‬.%٢٧,٧ ‫آﺎن اﻟﺘﺼﻠﺐ اﻟﻌﻘﺪي وﺑﻨﺴﺒﺔ‬
.%٢٦,٩ ‫ ﺳﻨﺔ وﺑﻨﺴﺒﺔ‬٤٠ ‫ إﻟﻰ‬١٥ ‫ ﺑﻴﻨﻤﺎ أدﻧﻰ اﻟﻤﻌﺪﻻت آﺎﻧﺖ ﻓﻲ اﻷﻋﻤﺎر اﻟﻤﺘﻮﺳﻄﺔ ﻣﺎﺑﻴﻦ‬%٦٦,٦ ‫ ﺳﻨﺔ وﺑﻨﺴﺒﺔ‬١٥ ‫ﻣﻦ‬
‫ﺑﺎر‬-‫ ﻟﻮﺣﻆ ﺗﺠﻠﻴﺔ اﻟﺬآﻮر ﻋﻠﻰ اﻹﻧﺎث ﺑﺎﻹﺻﺎﺑﺔ ﺑﻔﻴﺮوس اﺑﺸﺘﺎﻳﻦ‬.%٥٠ ‫ ﺳﻨﺔ آﺎﻧﺖ ﻧﺴﺒﺔ اﻻرﺗﺒﺎط‬٤٠ ‫اﻟﻌﻤﺎر أآﺒﺮ ﻣﻦ‬
.١:١.٧ ‫وﺑﻨﺴﺒﺔ‬
‫ أورام اﻟﻬﻮﺟﻜﻦ اﻟﻠﻤﻔﺎوﻳﺔ ﻓﻲ ﻣﻨﻄﻘﺘﻨﺎ وﻣﻊ ﻣﻘﺎرﻧﺘﻬﺎ ﺑﺪراﺳﺎت ﺳﺎﺑﻘﺔ ﻟﻮﺣﻆ ﺗﻐﻴﺮ ﺷﻜﻠﻲ ﻣﻊ ﻣﻴﻞ ﺗﺪرﺟﻲ ﺗﺠﺎﻩ‬:‫اﻻﺳﺘﻨﺘﺎج‬
‫ وإﺿﺎﻓﺔ ﻟﺬﻟﻚ ﻇﻬﻮر ارﺗﺒﺎط اﻟﻮرم‬.‫اﻟﺪول اﻟﻤﺘﻄﻮرة ﺧﺎﺻﺔ ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﺬروة اﻟﻔﺌﺔ اﻟﻌﻤﺮﻳﺔ اﻟﻤﺼﺎﺑﺔ و ﺑﺎﻟﻨﻮع اﻟﺨﺎص ﻟﻠﻮرم‬
.‫ﺑﺎﻟﻔﻴﺮوس وﺑﻨﺴﺒﺔ اﻟﺜﻠﺚ ﺗﻘﺮﻳﺒﺎ ﺧﺎﺻﺔ ﻓﻲ اﻷﻃﻔﺎل و ﻣﺘﻌﺪد اﻟﺨﻼﻳﺎ و ﺑﻐﺎﻟﺒﻴﺔ ذآﺮﻳﺔ‬
H
odgkin's
lymphoma
(HL)
is
a
heterogeneous condition that most
probably comprises more than one etiological
entity. As early as 1966 MacMahon proposed
that Hodgkin's lymphoma might be caused by
an infectious agent(1). Epidemiological studies
have indicated that many of the features of
Hodgkin's lymphoma mimic those of an
infectious process, including occurrence of
disease in more than one member of the
family of different ages, and clustering of
cases in winter months (1). EBV–associated
disease is more common in low socioeconomic class and in children with maternal
deprivation (2-4).
The first evidence that suggests the
relationship between Hodgkin's lymphoma and
Epstein-Barr virus (EBV) was provided by the
detection of raised antibody titres to EBV
antigens in patients with Hodgkin's lymphoma
when compared with patients with other
lymphomas and, further, that these raised
values preceded the development of Hodgkin's
disease by several years(1,5). In addition, there
is a specific association between EBVassociated HL in young adults and previous
infectious mononucleosis with a relative risk of
developing Hodgkin's lymphoma relative to
those with no previous history, was shown to
range between 2.0 to 5.0 (1,6).
Studies suggest that the EBV is associated
with approximately one third of cases in
developed countries, and this association is
believed to be casual(7,8). Whereas higher
rates of association was reported in
developing countries (9-14).
EBV is more often associated with mixed
cellularity HL than with nodular sclerosis type,
and in children and older adults than in young
adults (15-18). Also it is more in males than
females and more in Asians and Hispanics
than whites or blacks (19).
According to the age of the patients and EBV
association: 4-disease models have been
recognized, one EBV-negative group of cases,
which accounts for the young adult peak in
disease incidence as seen in developed
countries, and three EBV-positive subgroups.
The latter includes a childhood group,
accounting for almost all cases of HL in early
childhood; a young adult group, and an older
adult group, which results from loss of the
normal balance between latent EBV infection
and host immunity (figure 1) (6, 20,21).
EBV is an extremely efficient transforming
agent infecting the Hodgkin/Reed Stenberg's
(HRS) cells. The EBV genome is composed of
linear-double-stranded DNA which code for
different types of latent proteins. Six are
nuclear antigens (EBNA1, 2, 3A, 3B, 3C,
EBNA-LP), and three latent membrane
94
Vol. 35 No. 2, 2009
proteins (LMP1, LMP2A, LMP2B). LMP1 is the
major transforming protein of EBV and is the
only latent protein that can transform rodent
fibroblast(22). Expression of LMP1 appears to
mimic a constitutively active CD40 receptor(23).
Both CD40 and LMP1 bind tumor necrosis
factor (TNF) receptor-associated factors
(TRAFs), initiating a signaling cascade that
leads to activation of transcription factors NFkappa B, AP-1 and STAT (22, 24-29). By providing
these CD40-like signals, it is conceivable that
LMP1 allows EBV-infected HRS cells
upregulate various antiapoptotic genes
including bcl-2, mcl-1 & cytokine that bypass a
germinal center checkpoint and escape
apoptosis(27, 30- 33).
Older adults and children who are EBV
positive have a poor prognosis possibly
reflecting a poor immune status, which in turn
means that those patients may tolerate
disease and its treatment less well(3, 34).
The aims of this study were first, to determine
the association between Hodgkin's lymphoma
and Epstein-Barr virus. Second, to determine if
it is related to certain age groups or specific
histologic subtypes. Third, to compare the
pattern with other developing or developed
countries.
Figure (1): Four disease model of Hodgkin's
lymphoma. Solid
line is EBV–associated
cases (three groups first below 10 years,
second young adult between 14 and 34 years,
the third are more than 55 years of age).
Dashed line is non-EBV associated cases (one
peak at young adults mainly seen in
developed countries).
Methods
This is a retro- and prospective study,
conducted between 2007 - 2009. Seventy
cases of Hodgkin's lymphoma were collected
with their clinical data including age, sex, site
of lymph node affected and the histological
classification according to the REAL scheme).
To some of the cases immunohistochemical
stains including (CD15, CD30, CD43 and
CD20) have been also applied as
complementary tests.
Immunoperoxidase staining for LMP-1 was
performed on 40 cases in this study. Three
micron thick sections were cut from each
selected paraffin block onto silane-coated
slides; sections were then dewaxed,
rehydrated to distilled water. Antigen retrieval
was carried out by autoclaving at 95-99oC, for
20 minutes by a retrieval solution. The
sections were then allowed to cool for at least
20 minutes, followed by washing 3 times each
for 5-minutes in changes of phosphate
buffered
saline
(PBS).
Endogenous
peroxidase activity was blocked by placing
sections in 3% hydrogen peroxide for 5
minutes and washed in 3 changes of distilled
water. Sections were incubated with 1:100
diluted primary antibodies against LMP1
(Dako, Monoclonal Mouse Anti-Epstein-Barr
virus, LMP1, Clone C4.1-4) for 30 minutes,
followed by washing twice in 5-minutes
changes of PBS. The sections were incubated
for 30 minutes with secondary Dako envision
antibody. Sections were washed twice by PBS
and visualized using diaminobenzidine (DAB).
Finally,
the
sections
were
lightly
counterstained with hematoxylin, dehydrated
and mounted. Negative control sections were
treated in the same way except for the use of a
negative control (Dako Mouse IgG1) instead of
primary antibody. Positive control sections
were taken from a positive case and were
done in each run.
Results
Clinical findings: From the 70 collected
cases, the ages of the patients ranged from 280 years with a mean of 26.7 years, and a
median of 25 years. There were 12 patients
(17.1%) under 15 years of age. Ten cases
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Vol. 35 No. 2, 2009
(14.3%) were above 40 years of age. Whereas
the greatest group of Hodgkin's lymphoma
was seen in young adult group (15 - 40 years)
48 patients (68.5%). The third decade took the
peak incidence (21/70, 30%), followed by the
second decade (17/70, 24.3%). There were 36
males and 34 females with male to female
ratio of 1.06:1.
lymphocytic predominant is reported in 1.4%
(1/70), figure 2.
In patients <15 years old, the most frequent
subtype was mixed cellularity (66.6%),
followed by nodular sclerosis (25.0%). The
most common subtype in patients aged 15-40
years was nodular sclerosis (70.8%), followed
by mixed cellularity (27.1%), and then by
lymphocytic predominant (2.1%). Patients >40
years, the most common type was mixed
cellularity (50%), followed by nodular sclerosis
(40%), then lymphocytic depletion subtypes
(10%) (Table 1).
Histopathologic findings: Nodular sclerosis
Hodgkin's lymphoma was the most common
subtype in this series representing 58.5%
(41/70) of all the cases; mixed cellularity
represents
37.2%
(26/70),
lymphocyte
depleted subtype represents 2.8% (2/70), and
45
58.5%
40
35
30
41
37.2%
25
20
26
15
10
5
2.8%
1.4%
2
0
Nodular sclerosis
Mixed cellularity
1
Lymphocytic depletion
lymphocytic predominant
Figure (2): The percentage of various subtypes of Hodgkin's lymphoma.
Table (1): Distribution of Hodgkin's lymphoma subtypes according to the main age groups.
Age group
(years)
Mixed cellularity
No.
/
Nodular sclerosis
%
No.
/
%
Lymphocytic
depletion
No.
/
%
Lymphocytic
predominant
No.
/
%
Total
No. /
%
<15
15 - 40
8
13
(66.6)
(27.1)
3
34
(25.0)
(70.8)
1
0
(8.3)
(0.0)
0
1
(0.0)
(2.1)
12
48
17.1
68.5
>40
5
(50.0)
4
(40.0)
1
(10.0)
0
(0.0)
10
14.3
Total
26
(37.2)
41
(58.5)
2
(2.8)
1
(1.4)
70
100.0
96
Vol. 35 No. 2, 2009
Epstein-Barr virus status: Positive LMP-1
staining was seen in the cytoplasm and cell
membranes of Hodgkin's/Reed-Sternberg
cells. It was observed in 15 out of 40 cases
(37.5%) of Hodgkin's lymphoma (figure 3).
The most frequent association was in cases
of lymphocytic depletion subtype (1/2; 50%),
followed by mixed cellularity subtype (9/20;
45%). The least frequent association was
observed in nodular sclerosis type (5/18;
27.7%) as shown in table (2).
A
E
B
F
C
G
D
H
Figure (3): A, B, C, & D show positive LMP-1 staining seen in the cytoplasm and cell membranes of
Hodgkin's/Reed-Sternberg cells. H & E stain of different subtypes of Hodgkin's lymphoma, E (MCHL),
F (NSHL), G (Classical R-S cell), H (LDHL).
97
Vol. 35 No. 2, 2009
Table (2): Epstein-Barr virus association with various types of Hodgkin's lymphoma.
Histological Types
LMP-1 Positive
LMP-1 Negative
No.
No.
Total
Total No.
% of Positivity
Lymphocytic depletion
1
1
2
50
Mixed cellularity
9
11
20
45
Nodular sclerosis
5
13
18
27.7
Total
15
25
40
37.5
The frequency of EBV expression in relation
to the age is shown in table (3). The highest
rate of EBV expression was seen in the
pediatric age group (< 15 years; 66.6%) and
the lowest rate was among the young adults
(15-40 years; 26.9%). The older adult (> 40
years) have a rate of EBV expression (50%) in
between the 2 groups (higher than the young
adult patients, but less than the pediatric age
group).
Epstein-Barr virus positive cases were mostly
in males (11/15; 73.3%) compared (4/15;
26.7%) females.
Discussion
Most studies on Hodgkin's lymphoma have
shown epidemiological differences between
developed and developing countries. Correa
and O'Conor introduced the concept of at least
three epidemiological patterns of Hodgkin's
lymphoma based upon country of residence. A
type I pattern is characterized by relatively high
incidence rates in male children, low incidence
in the third decade, and a second peak of high
incidence in older age groups. The histological
subtypes are often those with a less favorable
prognosis, usually either mixed cellularity or
lymphocytic depletion. This pattern prevails in
developing countries. Type III is the converse
of the type I pattern, being characterized by
low rates in children and a pronounced initial
peak in young adults. The more favorable
subtype of nodular sclerosis is common and
this pattern is typical of developed countries.
Type II is an intermediate pattern, and reflects
a transition between type I and type III. Correa
and O'Conor interpreted these data as the
result of the interplay of environmental and
host factors influencing the natural history of a
single disease (1, 35).
In this study, young adult group (15-40 years)
was the largest age group, and the third
decade represented the peak incidence. There
is predominance of nodular sclerosis subtype,
which accounts for 58.5% of Hodgkin's
lymphoma. There is relatively equal ratio
between male and female (1.06:1). Al-Dewachi
and Al-Irhayim (36) in a study done in Mosul in
1995 have observed the bimodal age
distribution of the disease, with a peak age
incidence coming one decade earlier than
those reported in the Western countries and
found the predominance of male sex in three
histological types of mixed cellularity, lymphocytic depletion and lymphocytic predominance,
while nodular sclerosis showed an almost
equal gender distribution. In a more recent
study done in Mosul in 2007, Abbas (37) found
an increasing incidence of nodular sclerosis
cases with the peak age incidence in the
second decade, followed by the third decade.
Comparing our findings with these previous
studies shows the gradual changing trends of
Hodgkin's lymphoma to that of developed
countries as described previously by
Table (3): Distribution of Epstein-Barr virus in Hodgkin's lymphoma according to main age groups.
Age group (years)
<15
15 - 40
>40
Total
LMP-1 Positive
No.
4
7
4
15
LMP-1 Negative
No.
2
19
4
25
Total No.
6
26
8
40
Total
% of Positivity
66.6
26.9
50
37.5
98
Vol. 35 No. 2, 2009
Correa and O'Conor (1,35). Similar findings have
been documented from Kuwait, KSA & United
Arab Emirates(38-40).
Moreover EBV association studies have
revealed differences between developed and
developing countries with higher EBV related
Hodgkin's lymphoma cases in developing
countries. In an attempt to summarize the
literature data (Table 4), we found that most
North American and European countries have
20-40% EBV association, as opposed to much
higher rates that may reach more than 90% in
some of Far East and South American reports.
Results from this study confirmed the
presence of EBV in the neoplastic cells of the
Hodgkin's lymphoma cases. The proportion of
HD cases associated with EBV was 37.5%.
Such figures appear to be lower than those
reported in Far East, South America and some
of Middle East Countries while similar to those
reported in Jordan, Saudi Arabia, South Israel,
North America and European Countries.
Takeuchi et al(58) have recorded a
decreasing trend of EBV positive nodular
sclerosis Hodgkin's disease during the last 4
decades, whereas Clarke et al(34) have
observed that EBV positive Hodgkin's
lymphoma patients are less likely to have
nodular sclerosis histology. Flavell et al(59)
have suggested that Hodgkin's lymphoma of
childhood and elderly is commonly EBV
associated, whereas the adult Hodgkin's
disease is not significantly associated with
EBV infection. All these explain the low
percentage of EBV in our locality.
Table (4): Summary of literature on Epstein-Barr virus association with Hodgkin's lymphoma stained
by Immunoperoxidase for LMP-1.
Study
Alkuraya et al41
42
Yilmaz et al
43
Almasri et al
44
Makar et al
45
Benharroch et al
46
Chang et al
47
Country
% of EBV
% of + in MC
% of + in NS
KSA
28.6
52.4
26.1
Turkey
61.5
91.3
NP
Jordan
39.1
52.9
25
Kuwait
56
45.5
37.3
South Israel
30
45
21
USA
24
NP
NP
Austria
26
NP
NP
48
USA
26
69
14
49
Sweden
27
38
23
U.K
33
60
23.8
France
34
58.2
10
Hungary
43
50
35
Mexico
61
75
56
Malaysia
61
87
33.3
China
72
NP
NP
Belkaid et al
Algeria
72
77
NP
Karnik et al55
South India
82
NP
NP
Dinand et al56
India
90.3
NP
NP
Araujo et al57
Brazil
About 100
NP
NP
Krugmann et al
Pinkus et al
Enblad et al
7
Jarrett et al
50
Delsol et al
Keresztes et al
51
52
Dirnhofer et al
53
Peh et al
54
Zhou et al
11
EBV- Epstein-Barr virus. MC- Mixed cellularity. NS- Nodular sclerosis. NP- Not provided
99
Vol. 35 No. 2, 2009
Epstein-Barr virus positivity was related to the
histologic subtypes of Hodgkin's lymphoma.
The lymphocytic depletion and the mixed
cellularity types were the most common
subtypes associated with EBV. Only one fourth
of the nodular sclerosis subtype had evidence
of EBV association. These observations are in
agreement with most data reported in the
literature (Table 4).
Higher percentage of EBV positivity was
observed in children below 15 years of age,
followed by older adult group (> 40 years).
Whereas the least association was seen in
young adult age group. This is in agreement
with many of the other studies (7, 11, 15, 19, 24 , 43,
44, 46, 53, 54 , 59,60)
.
EBV associated with Hodgkin's lymphoma
was seen in males more than in females, this
is in concordance with many other similar
studies (7, 19, 44, 47, 60-62) .
In conclusion, the data from this study and in
comparison with earlier studies, show
changing pattern of Hodgkin's lymphoma in
our locality with a gradual trends to those of
developed countries, including greatest age
group, peak age incidence and subtypes.
Moreover, Epstein-Barr virus is seen in slightly
greater than one third of cases and mostly
seen in childhood, mixed cellularity and
lymphocytic depletion subtypes with a male
predominance.
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Antiemetic activity of ginger in children
receiving cancer chemotherapy
Mazin M. Fawzi
Department of Pediatrics, College of Medicine, University of Mosul.
Received: 21st Dec 2008; Accepted: 9th Sept 2009.
ABSTRACT
Objective: To evaluate the antiemetic effect of ginger versus metoclopramide in children receiving
cancer chemotherapy.
Methods: A sample of 50 patients aged 6 – 14 years attending the Haematooncology unit in Ibn Al –
Atheer Children's Teaching Hospital in Mosul city and receiving chemotherapy for their malignancies
were included. They were randomly subdivided into 2 groups and received different types of treatment
including ginger and metoclopramide.
Results: The study showed that cancer was more common in female than in male with male to
female ratio 0.85/1. Acute lymphoblastic leukemia was the most common type of cancer and
constituted 60% of the cases and it revealed that response rate was higher in those treated by ginger
compared to metoclopramide (72% and 32% respectively); response was found to be higher in males
than in females (86.6% and 50% respectively).
Conclusions: Nausea and vomiting are common problems in children receiving chemotherapy.
Ginger (Zingiber officinale) appears to be promising in controlling these problems.
‫ ﺗﻬﺪف اﻟﺪراﺳﺔ إﻟﻰ اﻟﺒﺤﺚ ﻓﻲ اﻟﺘﺄﺛﻴﺮ اﻟﻤﻀﺎد ﻟﻠﻐﺜﻴﺎن واﻟﻘﺊ ﻟﻤﺎدة اﻟﺰﻧﺠﺒﻴﻞ ﻣﻘﺎرﻧﺔ ﺑﻌﻘﺎر اﻟﻤﻴﺘﻮآﻠﻮﺑﺮاﻣﺎﻳﺪ ﻋﻨﺪ‬:‫اﻟﻬﺪف‬
.‫اﻷﻃﻔﺎل اﻟﺬﻳﻦ ﻳﺨﻀﻌﻮن ﻟﻠﻌﻼج اﻟﻜﻴﻤﻴﺎوي‬
.‫ ﺳﻨﺔ‬١٤-٦ ‫ ﻃﻔﻞ ﺑﻌﻤﺮ‬٥٠ ‫ ﺷﻤﻠﺖ اﻟﺪراﺳﺔ‬:‫اﻟﻤﺸﺎرآﻮن ﻓﻲ اﻟﺪراﺳﺔ‬
.‫ وﺣﺪة أﻣﺮاض اﻟﺪم واﻟﺴﺮﻃﺎن ﻓﻲ ﻣﺴﺘﺸﻔﻰ اﺑﻦ اﻷﺛﻴﺮ اﻟﺘﻌﻠﻴﻤﻲ ﻓﻲ ﻣﺪﻳﻨﺔ اﻟﻤﻮﺻﻞ‬:‫ﻣﻜﺎن اﻟﺪراﺳﺔ‬
.‫ ﺗﻢ ﺗﺤﻠﻴﻞ اﻟﻨﺘﺎﺋﺞ ﺑﺎﺳﺘﺨﺪام ﻣﺮﺑﻊ آﺎي وﻧﺴﺒﺔ اﻟﺨﻄﻮرة ﺑﺎﺳﺘﺨﺪام اﻟﺤﺎﺳﺒﺔ اﻻﻟﻜﺘﺮوﻧﻴﺔ‬:‫ﻗﻴﺎس اﻟﻤﺤﺼﻠﺔ اﻟﻨﻬﺎﺋﻴﺔ‬
‫ و‬%٧٢) ‫ أﻇﻬﺮت اﻟﺪراﺳﺔ أن ﻧﺴﺒﺔ اﻻﺳﺘﺠﺎﺑﺔ ﻟﻠﻌﻼج ﺑﻤﺎدة اﻟﺰﻧﺠﺒﻴﻞ هﻲ أﻋﻠﻰ ﻣﻘﺎرﻧﺔ ﺑﻌﻘﺎر اﻟﻤﻴﺘﻮآﻠﻮﺑﺮاﻣﺎﻳﺪ‬:‫اﻟﻨﺘﺎﺋﺞ‬
‫ وآﺎﻧﺖ ﺣﺎﻻت‬،‫( ﺑﺎﻟﺘﻌﺎﻗﺐ‬%٥٠ ‫ و‬%٨٦,٦) ‫ وان هﺬﻩ اﻻﺳﺘﺠﺎﺑﺔ آﺎﻧﺖ أﻋﻠﻰ ﻋﻨﺪ اﻟﺬآﻮر ﻣﻘﺎرﻧﺔ ﺑﺎﻹﻧﺎث‬،‫( ﺑﺎﻟﺘﻌﺎﻗﺐ‬%٣٢
‫ وﺷﻜﻞ ﺳﺮﻃﺎن اﻟﺪم اﻟﻠﻤﻔﺎوي اﻟﺤﺎد أﻋﻠﻰ ﻧﺴﺒﺔ ﺑﻴﻦ ﺣﺎﻻت اﻟﺴﺮﻃﺎن‬،‫اﻟﺴﺮﻃﺎن أﻋﻠﻰ ﻧﺴﺒﺔ ﻟﺪى اﻹﻧﺎث ﻣﻘﺎرﻧﺔ ﺑﺎﻟﺬآﻮر‬
.(%٦٠) ‫اﻻﺧﺮى‬
‫ ﻓﻲ ﺿﻮء اﻟﻨﺘﺎﺋﺞ اﻟﻤﺴﺘﺨﻠﺼﺔ ﻣﻦ اﻟﺪراﺳﺔ ﻳﻤﻜﻦ اﻻﺳﺘﻨﺘﺎج ﺑﺄن اﻟﻐﺜﻴﺎن واﻟﻘﺊ ﻳﺸﻜﻼن ﻣﺸﻜﻠﺔ ﻟﺪى اﻷﻃﻔﺎل‬:‫اﻻﺳﺘﻨﺘﺎج‬
.‫ وﻣﺎدة اﻟﺰﻧﺠﺒﻴﻞ ﺗﺒﺪو ﻣﺸﺠﻌﺔ ﻓﻲ اﻟﺴﻴﻄﺮة ﻋﻠﻰ هﺬﻩ اﻟﻤﺸﺎآﻞ‬،‫اﻟﺨﺎﺿﻌﻴﻦ ﻟﻠﻌﻼج اﻟﻜﻴﻤﻴﺎوي‬
N
ausea and vomiting have consistently
ranked high on the list of factors most
feared by patients receiving chemotherapy (1,2),
and it is an important and common problem of
cancer treatment. The central nervous system
plays a critical role in the physiology of nausea
and vomiting, serving as the primary site that
receives and processes a variety of emetic
one
of
them
is
cancer
stimuli(3),
chemotherapeutic agents which act on
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Vol. 35 No. 2, 2009
chemoreceptor trigger zone by dopamine or 5hydroxy tryptamine receptor activation.
Because antineoplastic agents are cell cycle
dependent, their adverse effects are generally
related to the proliferation kinetics of individual
cell population, most susceptible are those
with high rates of cell turn over (4). Therefore
chemotherapy can act peripherally causing
damage in gastro intestinal mucosa and
releasing serotonin from enterochromaffin cells
of the small intestinal mucosa which carry
sensory signals to the medulla, leading to
emesis (5). Abdominal vagal afferents appear to
have the greatest relevance for chemotherapy
– induced nausea and vomiting (6). Only few
studies addressing the prevention of
chemotherapy induced emesis have been
carried out in children. Results obtained in
adults can not be applied directly to children,
since metabolism and side effects of drugs
may be different. When tested in children,
metoclopramide, which is a valuable drug for
treatment of nausea and vomiting, had only
moderate efficacy and significant side effects,
most notably sedation and extrapyramidal
reactions (5,7).
Over the last 2 decades, more effective and
better – tolerated agents have been developed
to prevent chemotherapy – induced nausea
Complementary
and
and
vomiting(3).
alternative medicine is increasing in use in the
pediatric oncology
population (8). Ginger
(Zingiber officinale) is considered a safe herbal
medicine with only few and insignificant side
effects (9). The focus of this article was to
compare the antiemetic effect of ginger versus
metoclopramide
in
children
receiving
chemotherapy.
Methods
In this clinical study, the sample consisted of
50 patients, 23 males and 27 females who
were receiving chemotherapy, and suffering
from different types of cancer (30 acute
lymphoblastic leukemia, 5 acute nonlymphoblastic leukemia, 10 non-Hodgkin
lymphoma, 3 neuroblastomas and 2
rhabdomyosarcomas).
They were attending pediatric hemato–
oncology unit in Ibn Al – Atheer Teaching
Hospital in Mosul city during the period from
may to October 2008. The selection of patients
depended on the following entry criteria:
- Histologically confirmed diagnosis of
cancer.
- Currently
receiving
chemotherapy
containing any chemotherapeutic agent at
any dose experiencing nausea and/or
vomiting.
- Chemotherapy regimens given orally, IV, or
by continuous infusion.
- Must have received at least one prior
chemotherapy course containing any
chemotherapy meets the following criteria.
1. Agent is the same that is scheduled
for the next round of chemotherapy.
2. Experienced nausea and/or vomiting
of any severity.
- Must be planning to receive antiemetic.
- No symptomatic brain metastases.
- No concurrent therapeutic doses of
warfarin, aspirin, or heparin.
- Their age range from 6-14 years.
- No history of bleeding disorder.
- No thrombocytopenia.
- No gastric ulcer.
- Able to swallow capsule.
- No clinical evidence of current or impending
bowel obstruction.
Agreements from the health authority and
parents of the children were obtained.
The sample was randomly subdivided into 2
groups, each group consisted of 25 patients.
Ginger and metoclopramide that were used for
treatment were enclosed into empty hard
gelatin capsule in order to have the same
form, so that all patients received their
treatment blindly. The capsules were prepared
by a clinical pharmacist. The ginger was
purchased from the local market (Indian
ginger).
First group of patients were treated by ginger
capsules orally. Dosage was calculated by
adjusting the recommended adult dose to
account for the child's weight. Most herbal
dosages for adults are calculated on the basis
of a (70 kg) adult, therefore if the child weight
(20 – 25 kg), the appropriate dose of ginger for
this child would be 1/3 of the adult dosage
(10,11)
, so each capsule was prepared to
contain 500 mg of fresh ginger and to be taken
105
Vol. 35 No. 2, 2009
one capsule twice daily for 3 days. The second
group was treated by capsules containing 10
mg of metoclopramide 3 times daily for 3 days.
Nausea was recorded by the patient and
vomiting was measured by counting the
number of vomiting episodes after treatment.
Studies have documented that occurrence of
complete response (no nausea and vomiting
episodes) is a highly accurate and reliable
measure (12,13). This outcome has also been
demonstrated to correlate with the patient's
perception of nausea which can be judged
only by the patient and this is according to a
rating scale for nausea and vomiting utilizing
verbal descriptors which was used in series of
assessment studies in children with cancer
aged 5 – 18 years (14,15). The improvement
after treatment was signed by stopped and
reduced nausea and vomiting.
Statistical analysis of data was done by using
X2 test to compare effects of these treatment
modalities.
Results
Fifty patients were included in this study; they
were 23 males and 27 females. Their ages
ranged 6-14 years. All patients received
chemotherapy for treatment of cancer.
Table (1) shows the age and sex distribution
of the study population; it is clear that cancer
was more common in females than in males
with male to female ratio of 0.85/1. Moreover
the highest number of patients was in the age
group 10-12 years.
Table (2) shows the distribution of cases
according to the diagnosis. It is clear that ALL
constituted 60% of cases of pediatric
malignancies, followed by NHL: 20% of cases.
It was evident from table (3) that the
response rate (stopped and reduced nausea
and vomiting) was higher among the group of
patients who received ginger compared to
those who received metoclopramide (72%
and 32% respectively), and the relative risk
was 2.37 with 95% confidence interval (CI)
1.3-3.43. The differences in response between
the 2 groups was statistically highly significant
(p<0.001).
Table (4) shows the response rate to the type
of medications used in the present study in
male population; the table signifies a higher
response rate to ginger than metoclopramide
86.6% and 40% respectively. Moreover the
relative risk observed to be 3.1 with 95%
confidence (CI) 1.35-7.16 and the difference
between the 2 groups was statistically very
highly significant (P < 0.001). On the other
hand, table (5) shows the response rate in
female population. It is evident that the
response rate to ginger in female population
was higher than to metoclopramide (50% and
27% respectively), nevertheless this difference
was statistically not significant (p > 0.05)
relative risk found to be 1.78 with 95%
confidence interval (CI) 0.67-4.61.
Table (1): Distribution of patients with cancer according to age and sex.
Age groups
Male No. (%)
Female No. (%)
Total No. (%)
6–8
years
4 (8)
5 (10)
9 (18)
8 – 10
years
5 (10)
5 (10)
10 (20)
10 – 12 years
8 (16)
9 (18)
17 (34)
12 – 14 years
6 (12)
8 (16)
14 (28)
Total
23 (46)
27 (54)
50 (100)
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Vol. 35 No. 2, 2009
Table (2): Distribution of cases of cancer according to diagnosis.
Male
No. (%)
Female
No. (%)
Total
No. (%)
ALL
16 (32)
14 (28)
30 (60)
NHL
4 (8)
6 (12)
10 (20)
AML
2 (4)
3 (6)
5 (10)
Neuroblastoma
1 (2)
2 (4)
3 (6)
Rhabdomyosarcoma
0 (0)
2 (4)
2 (4)
23 (46)
27 (54)
50 (100)
Diagnosis
Total
ALL =acute lymphoblastic leukemia, NHL = non Hodgkin lymphoma, AML = acute myeloid leukemia.
Table (3): Distribution of cases according to mode of treatment and response rate.
Mode of treatment
Ginger
metoclopromide
Respond
No
%
Not respond
No
%
18
72
7
28
8
32
17
68
Relative risk
p. value
95% confidence interval
of relative risk
2.37
<0.001
1.3 – 3.43
Table (4): Distribution of male patients according to mode of treatment and response rate.
Respond
No
%
Not respond
No
%
Ginger
13
86.6
2
13.4
metoclopromide
4
40
6
60
Mode of treatment
Relative risk
p. value
of relative risk
3.1
<0.001
1.35 – 7.16
Table (5): Distribution of female patients according to mode of treatment and response rate.
Mode of treatment
Ginger
metoclopromide
Respond
No
%
5
4
50
27
Not respond
No
%
5
11
50
73
Discussion
A diagnosis of cancer evokes immediate fear
for patients and their families, in part because
cancer is a potentially fatal disease but also
because cancer and its treatment are
commonly associated with pain, nausea and
other
distressing
symptoms.
Pediatric
oncologists have a primary role in symptoms
management and should reassure patients
and their families that relief of distressing
symptoms is feasible in most situations (14),
Relative risk
p. value
of relative risk
1.73
<0.05
0.67 – 4.61
despite that nausea and vomiting continue to
be significant side effect of cancer therapy (7).
Inadequately controlled emesis significantly
impairs quality of life and increases the risk of
patient
non–compliance
with
therapy.
Substantial progress has been made over the
last decade in developing more effective and
better
tolerated
means
to
prevent
(16)
chemotherapy induced emesis .
Acute lymphoblastic leukemia (ALL) is the
most common childhood cancer(17). The
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Vol. 35 No. 2, 2009
incidence of ALL is higher among boys than
girls, and this difference is greatest among
pubertal children (18) and this is in agreement
with the results of this study which showed that
ALL constitutes 60% of cases of pediatric
malignancies with higher incidence among
boys (32%) than girls (28%).
Antiemetics generally are classified according
to the predominant receptor on which they are
proposed to act. For treatment and prevention
of nausea and vomiting associated with cancer
therapy, several new antiemetic agents may
be combined; particularly the selective
antagonists of type 3 serotonin (5-hydroxy
tryptamine [5HT3]) receptor which are
approved for use(19,20).
This study describes the use of ginger which
has anti nausea properties(21) for management
of chemotherapy-induced emesis in children
and to compare it with metoclopramide.
Ginger is one of the most commonly used
herbal supplements that may be used in
children over 2 years of age to treat such
problem(11), it is a member of family of plants
that include cardamom and turmeric which has
been used to ameliorate symptoms of nausea
and vomiting. The exact mechanism of action
is unclear, although it appears to inhibit
serotonin (5-HT3) receptors and exert
antiemetic effects at the level of CNS and
GIT(21) which are the site of action of
chemotherapeutic agents.
Metoclopramide is a valuable drug, useful for
management
of
chemotherapy-induced
emesis . It acts both peripherally (stimulate the
release of Ach) and centrally (block D2
receptors in the chemoreceptor trigger zone).
Additionally it can inhibit 5-HT3 receptors. (20)
This clinical trial shows that ginger can
significantly reduce nausea and vomiting
induced by chemotherapy in children
compared to metoclopramide ,and this result
was in agreement with other studies(21,23-27)
which conclude that ginger can reduce nausea
and vomiting of the chemotherapy and
reduced use of anti emetic medications, on the
other hand it is in disagreement with others (2831)
.
Another factor that is associated with
increased nausea and vomiting after
chemotherapy is female gender (27,32) which
was associated with more frequent nausea
and vomiting and weaker response to
treatment as was seen in results of this study
which shows higher response rate to treatment
with ginger in male than female (86.6%, 50%
respectively) and this was in agreement with
other studies (33-35). Studies suggest that
anticipatory nausea can occur in pediatric
cancer patients and show features of a
conditioned response with greater severity of
anticipatory nausea for female patients than
The
higher
for
male
patients(36).
responsiveness of female compared with
male, both for conditioning of (anticipatory)
nausea and for its latent inhibition may be
explained by 2 mechanisms: a higher
susceptibility to nausea and to the
development of nausea and vomiting in
female, and/or a higher competence of female
for learning compared with male. Significant
gender effects have been seen for post
treatment nausea, and usually females
respond
more
strongly
with
nausea.
Preliminary evidence has been gathered that
females are more prone to Pavlovian
conditioning theory(37).
Conclusion
Ginger (Zingeber officinale) appears to be
promising in controlling chemotherapy induced
nausea and vomiting in children since it is less
expensive and well tolerated by the patients
with little side effects.
Recommendations
1- Further studies are still needed to confirm
the observation with a larger sample size
and longer follow-up duration in children
with chemotherapy-induced nausea and
vomiting.
2- Further clinical trials are needed to
evaluate the possible side effects of ginger
in children.
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P53 expression in colonic carcinoma –
immunohistochemical study
Dena A. Jerjees, Bedoor A. AL- Irhayim
Department of Pathology, College of Medicine, University of Mosul.
th
th
Received: 20 Oct 2009; Accepted: 24 Mar 2010.
ABSTRACT
Objectives: To evaluate p53 protein expression in colorectal tumors in Mosul city and correlates it
with various clinicopathological parameters and to compare the results with other studies.
Patients and methods: This is a pro and retrospective study of 53 samples of adenocarcinoma of
colon with age range from 5 to 80 years. There were 38 males, with age range (5 to 80) years and 15
females with age range (18 to 70) years. The samples were collected from Al-Jumhuri Teaching
Hospital, Nineveh Private Hospital and private labs during the period from September 2007 through
May 2008. P53 protein was detected immunohistochemically by using the primary antibody
(monoclonal antibody clone (DO-7¹) and ™ G|2 visualizing system/AP, Rabbit/Mouse (permanent
red). Positive and negative controls were included in each run. The interpretation was done by a semi
quantitative method.
Results and conclusions: P53 protein expression was found in 49% (26 cases) of colorectal cancer.
There was no correlation of p53 expression with age, sex, site, and size, but was significantly
correlated with grade and stage (p value =0.001,0.044, respectively). By stepwise backward multiple
logistic regression the grade was the only independent factor (p value =0.033).
Keywords: P53, colonic adenocarcinoma.
‫ ﻓﻲ أورام اﻟﻘﻮﻟﻮن ﻓﻲ ﻣﺪﻳﻨﺔ اﻟﻤﻮﺻﻞ واﻟﺮﺑﻂ ﺑﻴﻨﻬﺎ وﺑﻴﻦ ﻣﺨﺘﻠﻒ اﻟﺼﻔﺎت اﻟﻤﺮﺿﻴﺔ‬p53 ‫ ﻟﺘﻘﻴﻴﻢ إﻇﻬﺎر ﺑﺮوﺗﻴﻦ‬:‫اﻷهﺪاف‬
.‫اﻟﺴﺮﻳﺮﻳﺔ ﻟﻠﻮرم وﻣﻘﺎرﻧﺔ هﺬﻩ اﻟﻨﺘﺎﺋﺞ ﻣﻊ ﻧﺘﺎﺋﺞ دراﺳﺎت أﺧﺮى‬
‫ ﻟﻘﺪ آﺎن‬.‫ ﺳﻨﺔ‬٨٠-٥ ‫ ﺣﺎﻟﺔ ﻟﺴﺮﻃﺎن اﻟﻘﻮﻟﻮن ﺑﺄﻋﻤﺎر ﺗﺘﺮاوح ﻣﻦ‬٥٣ ‫ هﺬﻩ اﻟﺪراﺳﺔ ﻣﺴﺘﻘﺒﻠﻴﺔ و رﺟﻌﻴﺔ ﻓﻴﻬﺎ‬:‫اﻟﺤﺎﻻت واﻟﻄﺮق‬
‫ ﻟﻘﺪ‬.‫( ﺳﻨﺔ‬٧٠-١٨) ‫ وﺑﺄﻋﻤﺎر ﺗﺘﺮاوح‬١٥ ‫ ﺳﻨﺔ( وآﺎن ﻋﺪد ﺣﺎﻻت اﻹﻧﺎث‬٨٠-٥) ‫ وﺑﺄﻋﻤﺎر ﺗﺘﺮاوح‬٣٨ ‫ﻋﺪد ﺣﺎﻻت اﻟﺬآﻮر‬
‫ ﻣﺴﺘﺸﻔﻰ ﻧﻴﻨﻮى اﻷهﻠﻲ واﻟﻤﺨﺘﺒﺮات اﻟﺨﺎﺻﺔ ﺧﻼل ﻓﺘﺮة اﻣﺘﺪت ﺑﻴﻦ‬،‫ﺗﻢ ﺟﻤﻊ اﻟﻨﻤﺎذج ﻣﻦ ﻣﺴﺘﺸﻔﻰ اﻟﺠﻤﻬﻮري اﻟﺘﻌﻠﻴﻤﻲ‬
‫آﻴﻤﻴﺎﺋﻴﺔ ﺑﺎﺳﺘﺨﺪام اﻟﻤﻀﺎد‬-‫ﻧﺴﻴﺠﻴﺔ‬-‫ ﺑﻄﺮﻳﻘﺔ ﻣﻨﺎﻋﻴﺔ‬p53 ‫ ﻟﻘﺪ ﺗﻢ اﻟﺘﺤﺮي ﻋﻦ ﺑﺮوﺗﻴﻦ‬.٢٠٠٨ ‫ ﺧﻼل أﻳﺎر‬٢٠٠٧ ‫ﺷﻬﺮي أﻳﻠﻮل‬
‫ ﻟﻘﺪ‬.(‫ أرﻧﺐ ﻓﺄر )أﺣﻤﺮ داﺋﻢ‬،‫أي ﭙي‬٢\‫( وﻧﻈﺎم إﻇﻬﺎر ﻧﻮع اﻟﻤﻌﻠﻢ ﺗﻲ ام ﺟﻲ‬١^٧ ‫اﻷوﻟﻲ )اﻟﻤﻀﺎد أﺣﺎدي اﻟﻨﺴﻞ ﻧﻮع دي أو‬
.‫ﺗﻢ اﺳﺘﺨﺪام اﻟﻀﻮاﺑﻂ اﻟﻤﻮﺟﺒﺔ واﻟﺴﺎﻟﺒﺔ ﻣﻊ آﻞ وﺟﺒﺔ وﻗﺪ ﺗﻢ ﺗﺤﻠﻴﻞ اﻟﻨﺘﺎﺋﺞ ﺑﻄﺮﻳﻘﺔ ﺷﺒﻪ آﻤﻴﺔ‬
‫ ﻟﻢ ﻳﻜﻦ هﻨﺎك أي ﻋﻼﻗﺔ‬.‫ ﺣﺎﻟﺔ( ﻣﻦ ﺣﺎﻻت ﺳﺮﻃﺎن اﻟﻘﻮﻟﻮن‬٢٦) %٤٩ ‫ ﻓﻲ‬p53 ‫ ﻟﻘﺪ وﺟﺪ ﺑﺮوﺗﻴﻦ‬:‫اﻟﻨﺘﺎﺋﺞ واﻻﺳﺘﻨﺘﺎﺟﺎت‬
‫ وﻟﻜﻦ آﺎﻧﺖ هﻨﺎك ﻋﻼﻗﺔ ﻣﻌﻨﻮﻳﺔ ﻣﻊ ﻣﺮﺗﺒﺔ اﻟﻮرم و‬.‫ ﻣﻮﻗﻊ وﺣﺠﻢ اﻟﻮرم‬،‫ اﻟﺠﻨﺲ‬،‫ ﻣﻊ اﻟﻌﻤﺮ‬p53 ‫رﺑﻂ ﻹﻇﻬﺎر ﺑﺮوﺗﻴﻦ‬
‫ ﺑﺎﻟﻌﻼﻗﺔ اﻟﺮﺟﻌﻴﺔ ﻣﺘﻌﺪدة اﻟﻤﻨﻄﻖ ﻣﺘﺪرﺟﺔ اﻟﺮﺟﻮع آﺎﻧﺖ ﻣﺮﺗﺒﺔ اﻟﻤﺮض هﻲ‬. (Р=٠٫٠٤٤ ،Р= ٠ ٫٠٠١) ‫ﻣﺴﺘﻮى ﺗﻘﺪﻣﻪ‬
.(Р= ٠٫٠٣٣) ‫اﻟﻌﺎﻣﻞ اﻟﻮﺣﻴﺪ اﻟﻤﺴﺘﻘﻞ‬
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"
uardian of the genome"(1),"Death star" (2),
" Good and bad cop" (3), are just a few of
the names that have been attributed to the p53
gene (4), the mammalian p53 family has 3
members: p53, p63, and p73(5). Studies in the
late 1970s revealed that a cellular
phosphoprotein with a relative molecular mass
of about 53000 formed a tight complex with
SV40T antigen, and hence the p53 protein
was so named (5).
There are two types of p53 protein: normal
or wild type and mutant type. The wild type is
located in the nucleus, and it functions
primarily by controlling the transcription of
several other genes. It has a short half life of
only 20 minutes (6).
Wild type p53 is believed to play a role in the
regulation of cell proliferation and acts as a
tumor suppressor by the following mechanism:
when DNA is damaged by irradiation, U.V.
light or mutagenic chemicals, wild p53 protein
levels increase in the cell (7). The accumulated
wild p53 binds to DNA, stimulates transcription
of several genes, and mediates two major
effects on the cell (7). One effect is cell cycle
arrest in G1 phase which allows damaged
DNA to repair. If the DNA repair has occurred
successfully, the level of wild p53 decreases
with the help of MDM2 gene product. Then
cells which are formed later will be normal (7).
The other effect is that: If DNA damage cannot
be successfully repaired, p53 guides cells to
die by apoptosis by the help of death genes
(e.g. BAX) (7). If DNA damage is not
successfully repaired and cell did not die,
mutations become fixed in the dividing cells
and malignant transformation occurs (7).
G
Patients and methods
This is a pro and retrospective study of 53
samples of adeno-carcinoma of the colon. The
samples were collected from Al-Jumhuri
Teaching Hospital, Nineveh Private Hospital
and private laboratories during the period from
September 2007 through May 2008.There was
no follow up of the patients. The patient's age
and sex were retrieved from the biopsies
request forms. Hematoxylin and eosin stained
sections were reviewed for the cases to
assess their types and grades.
The size of the tumor was taken as the
maximum diameter of the tumor in
centimeters. The cases were staged according
to Dukes' staging system (8). The p53
expression was assessed immunohistochemically on formalin fixed paraffin embedded
tissues of the tumor, using mouse monoclonal
antibody isotype clone DO-7¹ (Dako) and the
Envision ™ G|2 system / AP, Rabbit / Mouse
(permanent red).
Immunohistochemical staining
interpretation
The interpretation was done by a semiquantitative method, 1000 tumor cells were
counted in a high power field to assess the
percentage of tumor cells expressing the
mutant p53 protein. If >10% of tumor cells
express the mutant p53 protein they were
considered positive; if <10% of tumor cells
express the protein they were considered
negative (9), irrespective of the intensity.
Statistical analysis
The relation between p53 expression and the
clinicopathological variables was analysed by
the Chi-square test, Observed/Expected Chisquare test, Fisher Freeman Halton test (8) and
Stepwise backward multiple logistic regression
(10)
. The results were considered statistically
significant if the p value was < 0.05.
Results
There were 38 males and 15 females, the
male to female ratio was 2.5:1 and the
patients’ age ranged from 5 to 80 years.
P53 expression was found in 49% of the
cases of adenocarcinoma of the colon with no
significant correlation to age (p value 0.16);
sex (p value 0.150); site whether in colon or
rectum (p value 0.900); or size (p value 0.631).
Concerning the grade, the relation of p53
expression was significant in using Fisher
Freeman Halton test, p value was 0.001 and
the peak of p53 expression was in grade 2, i.e.
(moderately differentiated).
In relation to stage, the p53 expression
showed a significant correlation by using
Fisher Freeman Halton test and the p value
was 0.044. The distribution of p53 expression
according to Dukes stage is shown in figure
(1), most of the cases were of Dukes’ B and C.
112
Vol. 35 No. 2, 2009
10
ve+
9
ve-
8
Number
7
6
5
4
3
2
1
0
Duke A
Duke B
Duke C
Duke D
Stage
Figure (1): P53+/- in colorectal carcinoma
(colectomy) cases versus stage.
Figure (2): Adenocarcinoma of colon IHC
(immunohistichemical) staining negative for
p53(original magnification×100).
Table (1): Stepwise backward multiple logistic
regression.
Independent
parameter
B
OR
p-value
Grade
-1.579
0.033
0.033
Constant
2.906
-
-
By stepwise backward multiple logistic
regression the only independent parameter
which has a significant correlation to p53
expression was the grade, (table 1).
Figures (2-9) are photomicrographs of p53
expression in colonic carcinomas.
Practical application of p53 expression
The value of p53 expression was practically
demonstrated in two of our cases, figures (59):
Case (1): male, 75 years old, with invasive
moderately differentiated adenocarcinoma of
the colon, Dukes' stage C.
Case (2): male, 63 years old, with invasive
moderately differentiated adenocarcinoma of
the rectum, Dukes’ stage B.
These two cases had colonoscopic biopsies
prior to colectomy. Each biopsy was
composed of small fragments of colonic
mucosa, with dysplasia. However p53 was
overexpressed in both, figures (5,8).
The colectomy specimens of the two cases
revealed invasive carcinoma of the colon,
figures (6,7,9).
Figure (3): Adenocarcinoma, IHC
positive for p53, high intensity
magnification×100).
staining
(original
Figure (4): Mucinous carcinoma, IHC staining
negative for p53 (original magnification × 400).
113
Vol. 35 No. 2, 2009
Figure (5): Case study (No.1) /biopsy, with
fragment of malignancy, which show positive
IHC staining for p53 (original magnification ×
100).
Figure (8): Case study (No.2) /biopsy,
carcinoma of the colon, IHC staining positive
for p53 (original magnification×100, the small
box×400).
Figure (9): Case study (No.2) /colectomycarcinoma, IHC staining positive for p53
(original magnification×100).
Discussion
Figures (6,7): Case study (No.1) /colectomy –
carcinoma, upper: H&E (original magnification
× 100), lower: IHC positive for p53 (original
magnification×400).
The etiology of colorectal cancer is complex
involving an interplay of environmental and
genetic factors (11). Colorectal carcinoma
develops through a multistep process as
characterized by histopathologic precursor
lesions and molecular genetic alterations (11).
The natural history of colorectal cancers is not
necessarily similar, and tumor molecular
profile is likely to play an important role in
determining the prognosis for individual
patients (12,13).
It seems that adjuvant therapy relies on a
normal p53 function to trigger apoptosis so
that those cells damaged by chemo or
radiotherapy can be destroyed for therapeutic
purposes. Several studies have shown that
tumor cells with impaired p53 function have
114
Vol. 35 No. 2, 2009
poor response to adjuvant or neoadjuvant
therapy (14).
P53 expression
In our study p53 was expressed in 49 % of the
cases. Other similar studies had shown
variable ratios (42%-82%).
The age factor was not significant. This is
consistent with the results of other studies
(11,15)
.
No significant correlation was found with sex.
Our result is consistent with other studies (11,16)
and is different from a single study that
showed a significant correlation with
male
gender (15).
The correlation with site in this study was not
significant contrary to others who reported
significant correlation (13,17). The site variation
for p53 expression has been attributed to
several factors including right versus left colon,
effects of sex hormones, diet, as well as
genetic causes. It is likely that there are
differences in sensitivity and exposure to
carcinogens for the proximal and distal
sections of colon (18).
The p53 expression in relation to size is not
significant and this result is similar to that of
Asaad et al (17) and differs from that of
Demirbas et al (19).
The p53 expression in relation to grade is
significant and this is consistent with three
studies (19-21) and different from other studies
which had reported no significant correlation
(13,15)
, while an inverse relationship was
reported by one study (22).
The expression of p53 protein in relation to
stage was significant. A single study (20) also
reported a significant correlation of p53
expression with stage while other studies (11,
13,17)
reported no significant correlation.
Assessment of p53 expression in colonic
biopsies is advisable because it may be of
help in predicting malignancy especially when
there is a degree of dysplasia.
Conclusion
- p53 expression was found in 49% of cases,
this result is within the range observed by
others.
- p53 expression was significantly correlated
with tumor grade and stage (positive,
negative). The grade of the tumor was the
only independent parameter by the stepwise
backward multiple logistic regression. All of
the 6 cases of mucinous adenocarcinoma
were negative for p53.
- Age, sex, size and site had no significant
correlation with p53 expression.
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15. Liang JT, Huang KC, Cheng YM, Hsu HC,
et al. p53 ove rexpression predicts poor
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and Improved Survival. Journal of Clinical
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12(4):283-92.
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116
Vol. 35 No. 2, 2009
Bcl-2 oncoprotein expression in breast cancer, its relation to
estrogen and progesterone receptors and other prognostic factors
Banan B. Mohammed, Kassim S. Ibrahim Department of Pathology, College of Medicine, University of Mosul.
Received: 29th Jun 2009; Accepted: 2nd Dec 2009.
ABSTRACT
Aims of the study: To evaluate the expression of the Bcl-2 oncoprotein in patients with primary
breast cancer, to correlate it with estrogen and progesterone receptors and various prognostic
parameters.
Patients and methods: Fifty two cases of primary breast cancer in which the estrogen and
progesterone receptors statuses were previously tested by immuno-histochemical staining, were
included in this retrospective study. The cases were collected from Al- Jamhori Teaching Hospital,
Nineveh Private Hospital and Private laboratories. The expression of Bcl-2 oncoprotein was evaluated
immunohistochemically; the findings were correlated with the estrogen and progesterone receptors,
the age of the patients, size, type and grade of the tumor, lymph node status and vascular invasion.
Results: Bcl-2 oncoprotein was detected in 24 cases of primary breast cancer (46.2%). In this study
the majority of estrogen and progesterone receptors positive cases, (87.5%) and (83.3%)
respectively, showed positive Bcl-2 oncoprotein expression, (P<0.001) and (P=0.0002) respectively. A
significant association was found between Bcl-2 and tumor type (P=0.017). Bcl-2 oncoprotein was
directly correlated with the age of the patients (P=0.0047), and inversely with the grade of the tumor
and vascular invasion (P value = 0.0092, <0.001) respectively. No significant correlation with tumor
size nor with lymph node status could be found, (P=0.078) and (P=0.19) respectively.
Conclusions: Bcl-2 oncoprotein was positive in 46.2% of primary breast cancer. This study revealed
a significantly direct correlation between the Bcl-2 and the estrogen and progesterone receptors. A
significant association was found between Bcl-2 oncoprotein and tumor type. Bcl-2 was directly
related to the age of the patients, and inversely related to the grade of the tumor and vascular
invasion.
Keywords: Bcl-2 oncoprotein, breast cancer, estrogen receptor, progesterone receptor.
‫ وإﻳﺠﺎد‬،‫ ﻟﻤﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻻﺑﺘﺪاﺋﻲ‬Bcl-2 ‫ ﺗﻬﺪف هﺬﻩ اﻟﺪراﺳﺔ اﻟﻰ ﺗﻘ ّﻴﻢ ﺗﻌﺒﻴﺮ اﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬:‫أهﺪاف اﻟﺪراﺳﺔ‬
.‫ﻋﻼﻗﺘﻬﺎ ﺑﻤُﺴﺘﻘﺒِﻼت اﻻﺳﺘﺮوﺟﻴﻦ واﻟﺒﺮوﺟﺴﺘﻴﺮون واﻟﻤﺜﺒﺘﺎت اﻻﻧﺬارﻳﺔ اﻟﻤﺨﺘﻠﻔﺔ‬
‫ﻲ اﻟﺘﻲ ﻓﻴﻬﺎ ﺣﺎﻟﺔ ﻣُﺴﺘﻘﺒِﻼت اﻻﺳﺘﺮوﺟﻴﻦ‬
ِ ‫ اﺛﻨﺎن وﺧﻤﺴﻮن ﺣﺎﻟﺔ ﻣﻦ ﺣﺎﻻت ﺳﺮﻃﺎن اﻟﺜﺪي اﻷﺑﺘﺪاﺋ‬:‫اﻟﻤﺮﺿﻰ وﻃﺮق اﻟﻌﻤﻞ‬
‫ وﻗﺪ‬،‫ ﺗﻢ اﺧﺘﺒﺎرهﺎ ﻓﻲ هﺬﻩ اﻟﺪراﺳ ِﺔ ذات اﻷﺛﺮ اﻟﺮﺟﻌﻲ‬،ً‫وﻣﺴﺘﻘﺒﻼت اﻟﺒﺮوﺟﺴﺘﻴﺮون ﻗﺪ أﺧﺘﺒﺮت َﺑﻜﻴﻤﻴﺎء اﻟﻨﺴﻴﺞ اﻟﻤﻨﺎﻋﻲ ﺳﺎﺑﻘﺎ‬
‫ ُﻗﻴّﻢ ﺗﻌﺒﻴﺮ اﻟﺒﺮوﺗﻴﻦ‬.‫ﺖ اﻟﺤﺎﻻت ﻣﻦ ﻣﺴﺘﺸﻔﻰ اﻟﺠﻤﻬﻮري اﻟﺘﻌﻠﻴﻤﻲ وﻣﺴﺘﺸﻔﻰ ﻧﻴﻨﻮى اﻟﺨﺎص واﻟﻤﺨﺘﺒﺮات اﻟﺨﺎﺻّﺔ‬
ْ ‫ﺟﻤِﻌ‬
ُ
‫ درﺟﺘﻪ و ﺣﺎﻟﺔ‬، ‫ ﻧﻮﻋﻪ‬،‫ ﺑﻜﻴﻤﻴﺎء اﻟﻨﺴﻴﺞ اﻟﻤﻨﺎﻋﻲ وﺗﻢ ﺗﺤﻠﻴﻞ اﻟﻨَﺘﺎﺋِﺞ وﻓﻘﺂ ﻟﻌُﻤﺮ اﻟﻤﺮﺿﻰ و ﺣﺠ ِﻢ اﻟﺴﺮﻃﺎن‬Bcl-2 ‫اﻟﺴﺮﻃﺎﻧﻲ‬
.‫ن‬
ِ ‫ اﻟﻐﺰو اﻟﻮﻋﺎﺋﻲ ووﺟﻮد ﻣﺴﺘﻘﺒﻼت اﻻﺳﺘﺮوﺟﻴﻦ واﻟﺒﺮوﺟﺴﺘﻴﺮو‬،‫اﻟﻌُﻘﺪ اﻟﻠﻤﻔﺎوﻳﺔ‬
‫( و ان أﻏﻠﺒﻴﺔ اﻟﺤﺎﻻت اﻟﺘﻲ ﻓﻴﻬﺎ‬%٤٦,٢) ‫ ﺣﺎﻟﺔ ﻣﻦ ﺣﺎﻻت ﺳﺮﻃﺎن اﻟﺜﺪي‬٢٤ ‫ ﻓﻲ‬Bcl-2 ‫ وﺟﺪ اﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬:‫اﻟﻨﺘﺎﺋﺞ‬
‫( وأﻳﻀًﺎ أﻏﻠﺒﻴﺔ‬P <٠,٠٠١) Bcl-2 ‫( أﻇﻬﺮت ﻧﺘﻴﺠﺔ اﻳﺠﺎﺑﻴﺔ ﻟﻠﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬%٨٧,٥) ‫ﻣُﺴﺘﻘﺒِﻼت اﻻﺳﺘﺮوﺟﻴﻦ إﻳﺠﺎﺑﻴﺔ‬
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Vol. 35 No. 2, 2009
‫ وﻗﺪ‬.(P=٠,٠٠٠٢) Bcl-2 ‫( آﺎﻧﺖ اﻳﺠﺎﺑﻴﺔ ﻟﺘﻌﺒﻴﺮ‬% ٣,٨٣) ‫ن إﻳﺠﺎﺑﻴ ِﺔ‬
ِ ‫اﻟﺤﺎﻻت اﻟﺘﻲ آﺎﻧﺖ ﻓﻴﻬﺎ ﻣُﺴﺘﻘﺒِﻼت اﻟﺒﺮوﺟﺴﺘﻴﺮو‬
‫ آﺎﻧﺖ ﻟﻪ ﻋﻼﻗﺔ ﻣﺒﺎﺷﺮة ﺑﻌُﻤﺮ‬Bcl-2 ‫( واﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬P= ٠,٠١٧) ‫ وﻧﻮع اﻟﺴﺮﻃﺎن‬Bcl-2 ‫وﺟﺪت ﻋﻼﻗﺔ هﺎﻣﺔ ﺑﻴﻦ‬
‫ ﻟﻢ ﻳﺘﻢ‬.(‫ ﻋﻠﻰ اﻟﺘﻮاﻟﻲ‬P< ٠,٠٠١ ،P = ٠,٠٠٩٢) ‫( وﻋﻼﻗﺔ ﻋﻜﺴﻴﺔ ﺑﺪرﺟﺔ اﻟﻮرم واﻟﻐﺰو اﻟﻮﻋﺎﺋﻲ‬P=٠,٠٠٤٧) ‫اﻟﻤﺮﺿﻰ‬
‫ ﻋﻼﻗ َﺔ هﺎ ّﻣ َﺔ‬Bcl-2 ‫ أﻳﻀًﺎ ﻟﻢ ﻳﻈﻬﺮ اﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬.(P= ٠,٠٧٨) ‫ وﺣﺠﻢ اﻟﻮرم‬Bcl-2 ‫اﻟﺤﺼﻮل ﻋﻠﻰ ﻋﻼﻗ َﺔ هﺎ ّﻣ َﺔ ﺑﻴﻦ‬
.(P=٠,١٩) ‫ﻣﻊ ﺣﺎﻟﺔ اﻟﻌُﻘﺪ اﻟﻠﻤﻔﺎوﻳ َﺔ‬
‫ وﻗﺪ أﻇﻬﺮت هﺬﻩ‬.‫ ﻣﻦ ﺣﺎﻻت ﺳﺮﻃﺎن اﻟﺜﺪي اﻷﺑﺘﺪاﺋﻲ‬%٤٦,٢ ‫ آَﺎن إﻳﺠﺎﺑﻲ ﻓﻲ‬Bcl-2 ‫ اﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬:‫اﻻﺳﺘﻨﺘﺎﺟﺎت‬
‫ وﻣﺴﺘﻘﺒﻼت اﻻﺳﺘﺮوﺟﻴﻦ واﻟﺒﺮوﺟﺴﺘﻴﺮون آﻤﺎ وﺟﺪت ﻋﻼﻗﺔ هﺎﻣﺔ ﺑﻴﻦ ﻧﻮع‬Bcl-2 ‫اﻟﺪراﺳﺔ ﻋﻼﻗﺔ ﻣﺒﺎﺷﺮة وهﺎﻣﺔ ﺑﻴﻦ‬
‫ آﺎﻧﺖ ﻟﻪ ﻋﻼﻗﺔ ﻣﺒﺎﺷﺮة ﺑﻌُﻤﺮ اﻟﻤﺮﺿﻰ وﻋﻼﻗﺔ ﻋﻜﺴﻴﺔ‬Bcl-2 ‫ اﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬.Bcl-2 ‫اﻟﺴﺮﻃﺎن واﻟﺒﺮوﺗﻴﻦ اﻟﺴﺮﻃﺎﻧﻲ‬
.‫ﺑﺪرﺟﺔ اﻟﻮرم وﻏﺰو اﻷوﻋﻴﺔ‬
B
cl-2 is an intracellular membraneassociated protein of 24-kilodalton (1, 2). It
has been localized in the nuclear envelope,
endoplasmic
reticulum,
and
outer
mitochondrial membranes of hematopoietic
and lymphoid cells, neurons, many epithelial
cells, and endocrine-influenced glandular
epithelium such as the thyroid, prostate,
endometrium, and breast (1).
Bcl-2 inhibits apoptosis (antiapoptosis) but,
paradoxically, it has antiproliferative effect (3,4).
Cells overexpressing the Bcl-2 gene product,
not only showed a delayed onset of apoptosis
but also a rapid arrest in the G1 phase of the
cell cycle (5). The over-expression of Bcl-2 in
breast cancer has been found to be
associated with several favorable prognostic
factors such as smaller size, ER and PR
positivity, low cell proliferation rate, and low
nuclear grade (1,6,7,8). The Bcl-2 oncoprotein
has been shown to be expressed in 40%-80%
of breast cancers (9,10,11), and in ER positive
cases it is expressed in 80%-90% (11). It was
found that, similar to PR, the Bcl-2 gene itself
is ER regulated. Thus, high Bcl-2 may be
indicative of an intact ER pathway that is
driving tumor growth and should be sensitive
to endocrine therapy(12). It was observed that
there is a greater benefit of tamoxifen in
ER+/Bcl-2+ patients as opposed to ER+/Bcl2– one (13).
Fifty-two cases of primary breast cancer
whose ER and PR statuses had been tested
by immuno-histochemical technique were
included in this retrospective study. The cases
were collected from Al-Jamhori Teaching
Hospital, Nineveh Private Hospital and other
Private Laboratories. Sections from paraffin
embedded tissues were taken on clean slides
and stained with hematoxylin and eosin, then
examined under the light microscope.
Histological typing was determined according
to WHO classification. Histological grading for
invasive ductal carcinoma was performed
following Nottingham Modification of the
Bloom-Richardson system. Other information
regarding the age of the patient, size of tumor,
vascular invasion, axillary lymph node
involvement, and ER and PR statuses were
obtained from the medical records.
The Bcl-2 protein was assessed by
immunohistochemical
technique.
The
procedure followed the instruction provided by
the manufacturer. The materials for the
procedure were obtained from Dakocytomation
(Monoclonal
Mouse
Anti-Human
bcl-2
Oncoprotein Clone: 124 Isotype: IgG1, kappa
(code N1587), and the Detection system
EnVision G|2 System/AP, Rabbit/Mouse
(Permanent Red) (code K5355)).
The Bcl-2 positivity was expressed by reddish
staining that was always localized to the
cytoplasm of malignant epithelial cells. Positive
and negative controls were included in each
run. Sections from normal tonsillar tissue
specimens were used as positive controls and
the same tissue was used as negative control
but with use of universal negative control
instead of primary antibody. Normal ductal
epithelial cells of the breast and infiltrating
lymphocytes, which always expressed Bcl-2,
were used as the internal positive control. Both
118
Vol. 35 No. 2, 2009
the intensity of staining and the percentage of
the stained cells were scored. Intensity score
range from (0-3) depend on the comparison of
the intensity of positive cells to the intensity of
positive control, while the proportional score
estimate the percentage of tumor cells and it
range from (0-4), then multiply both the
intensity score with the proportional score to
get the total score.
Intensity score
(IS)
Statistical analysis: Association between Bcl2 expression and variable categories were
assessed using Chi-square test or Fisher
Freeman Halton test when indicated, and P
value of <0.05 was regarded as statistically
significant.
Results
The various clinical and pathological
parameters of the patients are shown in the
following table.
Intensity score
observation
No.
%
0
None
21-30
5
9.6%
1
Weak
2
Intermediate
31-40
41-50
51-60
9
14
9
17.3%
26.9%
17.3%
3
Strong
61-70
12
23.1%
≥71
3
5.8%
<2cm (T1)
3
5.8%
2-5 cm (T2)
38
73%
Proportion
Score (PS)
Proportional score
observation
Age
Size
0
0%
>5 cm (T3)
11
21.2%
1
< 10%
DCIS
1
1.9%
2
10-50%
ILC
4
7.7%
3
51-80%
43
82.7%
4
> 80%
IDC
(NOS)
Medullary
2
3.85%
Mucinous
2
3.85%
I
3
6.4%
II
22
46.8%
III
22
46.8%
Positive
39
75%
Negative
13
25%
Vascular
invasion
Positive
27
51.9%
Negative
25
48.1%
Estrogen
receptor
Positive
28
53.8%
Negative
24
46.2%
Progestero
ne receptor
Positive
29
55.8%
Negative
23
44.2%
Total score= PS×IS (range = 0-12), 0-4 -----›
Negative, 6-12-----› Positive.
Types
IDC
Grading of
IDC
Lymph
node
metastasis
119
Vol. 35 No. 2, 2009
100
90
Percentage
50
Bcl-2 +
40
Bcl-2 -
Bcl -2 -
30
Bcl -2 +
20
10
0
Positive
Negative
Progesterone receptor
Figure (2): Bcl-2 and progesterone receptor.
80
70
Percentage
60
50
Bcl-2 +
40
Bcl-2 -
30
20
10
0
<2
2-5
Tumor Size (cm)
>5
Figure (3): Bcl-2 and tumor size.
100
90
80
70
60
Bcl-2 +
50
Bcl-2 -
40
30
20
10
0
IDC
Medu.
Muci.
ILC
Types of tumor
DCIS
Figure (4): Bcl-2 and the tumor type.
60
Bcl-2 -
Bcl-2 +
Bcl-2 Bcl-2 -
Percentage
50
40
40
Bcl-2 +
30
Bcl-2 -
20
Bcl-2 +
10
0
60
70
60
50
20
Bcl -2 -
70
70
30
Bcl -2 +
80
Bcl-2 +
80
Percentage
90
Percentage
Immunohistochemical demonstration of Bcl-2
was positive in 24 cases (46.2%). Positive
expression of Bcl-2 was significantly
associated with positive ER and PR. The
majority of ER positive cases (87.5%) showed
Bcl-2 positive (P<0.001) and also the majority
of PR positive cases (83.3%) showed positive
Bcl-2 (P=0.0002), figures (1 & 2). There was a
significant direct correlation between the Bcl-2
and age (P=0.0047), with the largest
percentage of Bcl-2 positivity seen in patients
with the age group 41-50 years. No statistically
significant relation was found between Bcl-2
and the tumor size (P=0.078), figure (3).
Regarding the tumor types, a significant
correlation was found (P=0.017). There were 2
cases of Mucinous carcinoma, both of them
were positive for Bcl-2, half of the cases of
both ILC and medullary carcinoma and 41.9%
of IDC (NOS) were positive for Bcl-2. There
was one case of DCIS, it was positive too,
figure (4).
An inverse significant relation was found
between Bcl-2 and the grade of the tumor, the
Bcl-2 positive cases decreased from 63.7% in
grade II to 22.7% in grade III, while Bcl-2
negative cases increase with the increasing of
the grade (P=0.0092), figure (5). The
expression of Bcl-2 was inversely correlated
with the vascular invasion, among the vascular
invasion positive patients, 75% of them were
Bcl-2 negative and among those with vascular
invasion negative, 75% were Bcl-2 positive
(P<0.001), figure (6). No significant correlation
could be obtained between Bcl-2 and lymph
node metastasis (P=0.19).
10
0
Positive
Negative
Estrogen receptor
Figure (1): Bcl-2 and estrogen receptor.
I
II
Grade of tumor
III
Figure (5): Bcl-2 and the grade of tumor.
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Vol. 35 No. 2, 2009
80
Bcl-2 -
Bcl-2 +
70
Percentage
60
50
Bcl-2 +
40
30
Bcl-2 Bcl-2 +
Bcl-2 -
20
10
0
Positive
Negative
Vascular invasion
Figure (6): Bcl-2 and vascular invasion.
Discussion
Bcl-2 expression in breast cancer is
associated with favorable prognostic factors,
and it predicts a good outcome in early breast
cancer and even in metastatic disease (14).
Therefore evaluation of Bcl-2 expression in
breast cancer may identify a subset of patients
with favorable prognosis, who may not benefit
from chemotherapy but may benefit from Bcl-2
targeting agents in addition to antihormonal
therapy (15).
A strong positive relation between Bcl-2
immunoreactivity and ER and PR statuses was
found in this study. This is in agreement with
other studies (16-22). This observation confirms
the hypothesis that this protein, like PR, is
under oestrogen regulation via ER (1,23).
Binding of estrogen to ER causes its
phosphorylation and dimerization followed by
transcription of a variety of genes, including
secreted growth and angiogenic factors, as
well as PR and Bcl-2 (12). Linke et al in a study
of 324 cases of breast cancer found that the
disease-specific survival and overall survival of
ER-positive patients who were PR negative
and who had low Bcl-2 scores were not
statistically different from ER-negative patients
(12)
. However, if either PR was present or the
Bcl-2 score was high, the ER-positive patients
had significantly better outcome (12). ERpositive patients who were both PR positive
and Bcl-2 high experienced even better
outcome (12). The strong association between
Bcl-2, ER, and PR may suggest that cotargeting these molecules in hormone
receptor-positive breast cancer might provide
greater benefit than chemotherapy, or might
play a role as beneficial strategy for sensitizing
these tumors to chemotherapy (15).
There is a slight increase of Bcl-2 expression
with the increase of the age of the patients, a
significant direct correlation was found
(p=0.0047). This result is in agreement to that
found by Andalib et al (17) and Daidone et al
(21)
. This may be due to the fact that tumors of
elderly patients have a more favorable pathobiological phenotype as to be of well
differentiated, low proliferative rate and higher
ER content, compared to those of younger age
group (21). This observation is helpful in
choosing the method of therapy.
High Bcl-2 expression is associated with
small size tumor (6,13). This can be explained by
the inhibitory effect of Bcl-2 on cell
proliferation. The acquisition of Bcl-2
expression creates a restrictive environment
for the expansion of genetically unstable and
potentially malignant cells, causing a delay in
tumor progression (6,24). Although the Bcl-2
positivity in the present study is high in the
small tumor size and decreases with the
increasing
size of tumors, the relation
between Bcl-2 and the size failed to reach the
significant level (p=0.078). This may be due to
the small size of the sample which contains
few small size tumor; in fact the percentage of
small size tumor in this study was 5.8% <2cm.
This is in agreement with Tustusi et al (5), Li
Zhang et al (16) and Kumravel et al (25).
In the present study, a significant relationship
between Bcl-2 and breast cancer types
(p=0.0171) was found. This is comparable to
those found by Joensuu et al (26). On the other
hand Coppola et al (27) in their study found no
significant relation between Bcl-2 and
histological types of breast cancer. This
difference may be again due to the small
number of cases included in their study (26
cases).
A significant inverse relationship between
expression of Bcl-2 protein and grading of
tumor was reported. Similar association was
noticed by Tsutsui et al (5), Callagy et al (7), and
others (6,13,20,28); this may be due to role of Bcl2 during the early stage of the tumor as it
rescues cells with otherwise lethal mutations
121
Vol. 35 No. 2, 2009
(29)
. But after additional oncogene activation,
some cells would acquire additional ways to
protect themselves against apoptosis (29). At
this point, loss of Bcl-2 might confer a growth
advantage. In fact, Bcl-2 is known to restrain
cell proliferation. Thus, expression of Bcl-2
would change from high levels in early or lowgrade tumors, characterized by low apoptotic
indices, to low levels in advanced or highgrade tumors, characterized by high apoptotic
indices (29).
A significant inverse relation was obtained
between Bcl-2 and LVI. A high Bcl-2 positivity
was observed in the tumors without LVI
compared to those with LVI. This finding is
similar to that of Neri et al (22).
No significant relation could be obtained
between Bcl-2 and axillary lymph node status
in this study, this result is similar to what had
been found by Tsutsui et al (5), Callagy et al (7),
Kumravel et al (25), Joensuu et al (26) and Zhang
et al (28). However, Chen et al (20) in a study
done on 74 cases of breast cancer found, Bcl2 immunoactivity to be significantly correlated
with negative axillary lymph node and in cases
with less nodal involvement.
A number of studies found that the Bcl-2 is an
independent prognostic factor in breast cancer
(7,14,30)
. Morever other studies found that an
independent favorable prognostic impact of
Bcl-2 is particularly significant among LN+
patients, and the prognostic value of Bcl-2
staining among all patients is solely based on
prognostic applicability among LN+ patients
because the association among LN- patients is
clearly not significant (31). Accordingly further
studies may be needed on larger sample of
cases.
Conclusions
Bcl-2 is frequently expressed in breast cancer.
A significant direct association has been
observed between Bcl-2 oncoprotein and
hormonal receptors (ER & PR).
The expression of Bcl-2 is directly correlated
with the age of patients, inversely correlated
with the grade of tumor and vascular invasion.
A significant association was found between
Bcl-2 and tumor type. The Bcl-2 has no
relation with the tumor size and axillary lymph
node metastasis.
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21. Daidone M.G., Coradini D., Martelli G. et
al. Primary breast cancer in elderly
women: biological profile and relation with
clinical out come. Critical Review in
Oncol./Hemat. 2003; 45: 313-325.
22. Neri A., Marrelli D., Roviello F., et al. Bcl-2
expression correlates with lymphovascular
invasion and long-term prognosis in breast
cancer. Breast Ca. Res. Treat. 2006;
99(1): 77-83. (Abstract).
23. Gee J.M., Robertson J.F.R. and Ellis I.O.
Immunocytochemical localization of Bcl-2
protein in human breast cancers and its
relationship to a series of prognostic
markers and response to endocrine
therapy. Intern. J. Ca. 2006; 5: 619-628.
24. Koman I.E., Gurova K.V., Kwek S.S., et al.
Apoptosis inhibitor as a suppressor of
tumor progression: expression of Bcl-2
eliminates selective advantages for p53deficient cells in the tumor. Ca. Biol Ther.
2002; 1(1): 39-44. (Abstract).
25. Kumravel B., Kneko M., Arihiro K. et al.
Expression of bcl-2 Protein in Breast
Carcinoma with Correlation to Expression
of p53 Protein & Clinicopathological
Factors. Breast Ca. 1996; 3(3): 173-179.
26. Joensuu H., Pylkanen L., Toikkanen S.
Bcl-2 protein expression and long-term
survival in breast cancer. Amer. J. Pathol.
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27. Coppola D., Catalano E., Nicosia S.V.
Significance of P53and Bcl-2 protein
expression in human breast carcinoma.
Ca. Cont.1999; 6(2): 181-187.
28. Zhang G.J., Tsuda H., Adachi I., et al.
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p53 and c-erb-2 proteins. Jpn J Clin Oncol
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123
Vol. 35 No. 2, 2009
Molecular characterization of beta-thalassemia
mutations in Ninawa governorate
Waleed Abdelaziz Omer
Hematology, Bone Marrow Transplant Center, Medical city, Baghdad.
Received: 17th May 2009; Accepted: 1st Nov 2009.
ABSTRACT
Objectives: There are currently more than 200 known mutations affecting the beta globin gene; about
20 mutations account for 90 % of beta globin gene mutations in the world, and each ethnic population
has its own unique and frequency of beta globin mutations. Prenatal diagnosis requires identification
of the mutation spectrum in each population, and then it is possible to do direct identification for these
mutations in the majority of the population. The aim of this study is to characterize the spectrum of
beta globin gene mutations in Ninawa governorate patients with beta- thalassemia major.
Patients and methods: Twenty four thalassemic patients were included; they were transfusion
dependent and they were diagnosed and registered in thalassemia center of Ninawa governorate.
After DNA extraction from venous blood and PCR based DNA amplification, the allele's
characterization was achieved by reverse hybridization to specific oligonucleotide probe designed to
detect 22 beta-thalassemic mutations.
Results: Out of the forty eight alleles studied, 42 (87.5%) alleles were characterized, while 6 (12.5%)
alleles were undetermined.
Eight alleles causing beta-thalassemia in Ninawa governorate were identified in these patients, and
these alleles with their frequencies were:
IVS 1.110 (G>A)(27.08%), IVS 1.6 (T>C)(14.5%), cod 8 (-AA)(12.5%), cod 39 (C>T)(12.5%), IVS 2.1
(G>A)(12.5%), cod 44 (-C)(4.16%), IVS 1.5(GÆC)(2.08%) and Cod 5(-CT)(2.08%).
More than 1/3 of the families have more than one affected sibling.
Eleven (45.83%) patients had homozygous alleles, and 12 (50%) patients with compound
heterozygous alleles; In 1 (4.16%) patient the genotype was unknown.
Keywords: Thalassemia,
hybridization.
beta
globin
genes
mutations,
Ninawa,
oligonucleotide,
reverse
‫ ﻧﻮع ﻣﻦ اﻟﻄﻔﺮات اﻟﻮراﺛﻴﺔ اﻟﺘﻲ ﺗﺤﺼﻞ ﻓﻲ ﺟﻴﻦ ﺑﻴﺘﺎآﻠﻮﺑﻴﻦ واﻟﺘﻲ ﺗﺆﺛﺮ ﻋﻠﻰ‬٢٠٠ ‫ ﺣﺎﻟﻴﺎ ﺗﻢ اآﺘﺸﺎف ﻣﺎ ﻳﺰﻳﺪ ﻋﻦ‬:‫ﻣﻘﺪﻣﺔ‬
‫ ان‬.‫ﺗﺼﻨﻴﻊ ﺳﻠﺴﻠﺔ ﺑﻴﺘﺎ آﻠﻮﺑﻴﻦ ﻓﻲ ﻋﺪة ﻣﺮاﺣﻞ ﻣﻦ اﻟﺘﺼﻨﻴﻊ وﺑﺎﻟﺘﺎﻟﻲ ﺗﺆدي اﻟﻰ أﻧﻤﺎط ﺳﺮﻳﺮﻳﺔ ﻣﺘﻌﺪدة ﻟﻤﺮض اﻟﺜﻼﺳﻴﻤﻴﺎ‬
‫ﻋﻤﻠﻴﺔ ﺗﺤﺪﻳﺪ ﻧﻮع اﻟﻄﻔﺮات اﻟﺘﻲ ﺗﺆدي اﻟﻰ ﻓﻘﺮ دم اﻟﺒﺤﺮ اﻟﻤﺘﻮﺳﻂ ﻓﻲ ﻣﺠﺘﻤﻊ ﻣﺎ هﻲ اﻟﻤﺮﺣﻠﺔ اﻟﻼزﻣﺔ اﻷوﻟﻰ ﻹﻧﺸﺎء ﺑﺮﻧﺎﻣﺞ‬
.‫اﻟﺴﻴﻄﺮة ﻋﻠﻰ اﻟﻤﺮض‬
‫ ﺗﺤﺪﻳﺪ أﻧﻮاع اﻟﻄﻔﺮات اﻟﻮراﺛﻴﺔ اﻟﻤﺴﺒﺒﺔ ﻟﻤﺮض اﻟﺜﻼﺳﻴﻤﻴﺎ اﻟﻜﺒﺮى ﻧﻮع ﺑﻴﺘﺎ ﻓﻲ ﻣﺮﺿﻰ ﻣﺤﺎﻓﻈﺔ‬:‫اﻟﻬﺪف ﻣﻦ اﻟﺪراﺳـﺔ‬
.‫ﻧﻴﻨﻮى‬
‫ وآﻞ ﻣﺮﻳﺾ ﻣﺴﺠﻞ ﻓﻲ ﻣﺮآﺰ اﻟﺜﻼﺳﻴﻤﻴﺎ ﻓﻲ ﻣﺤﺎﻓﻈﺔ ﻧﻴﻨﻮى ﻋﻠﻰ‬،‫ ﻣﺮﻳﻀﺎ‬٢٤ ‫ ﺷﻤﻠﺖ هﺬﻩ اﻟﺪراﺳﺔ‬:‫اﻟﻤﺮﺿﻰ وﻃﺮق اﻟﻌﻤﻞ‬
.‫اﻧﻪ ﻣﺼﺎب ﺑﺎﻟﺜﻼﺳﻴﻤﻴﺎ اﻟﻜﺒﺮى ﻧﻮع ﺑﻴﺘﺎ وﻳﺘﻢ ﻟﻪ إﺟﺮاء ﻧﻘﻞ اﻟﺪم ﺑﺸﻜﻞ ﻣﺘﻜﺮر‬
124
Vol. 35 No. 2, 2009
‫ ﺗﻢ إﺟﺮاء ﺗﻔﺎﻋﻞ اﻟﺒﻠﻤﺮﻩ اﻟﻤﺘﺴﻠﺴﻞ ﻟﻠﺤﺎﻣﺾ اﻟﻨﻮوي‬،‫ﺑﻌﺪ اﺳﺘﺨﻼص اﻟﺤﺎﻣﺾ اﻟﻨﻮوي )اﻟﺪﻧﺎ( ﻣﻦ اﻟﺪم اﻟﻮرﻳﺪي ﻟﻠﻤﺮﻳﺾ‬
‫ وﺑﻌﺪ ذﻟﻚ ﺗﻢ ﺗﺤﺪﻳﺪ ﻧﻮع اﻟﻄﻔﺮة ﻓﻲ اﻟﺤﺎﻣﺾ اﻟﻨﻮوي ﺑﻄﺮﻳﻘﺔ اﻟﺘﻬﺠﻴﻦ اﻟﻌﻜﺴﻲ ﻣﻊ ﻣﺴﺒﺎرات ﺧﺎﺻﺔ ﻣﻜﻮﻧﺔ ﻣﻦ ﻋﺪد‬،(‫)اﻟﺪﻧﺎ‬
.‫ ﻃﻔﺮة ﻣﺴﺒﺒﺔ ﻟﻠﺜﻼﺳﻴﻤﻴﺎ ﻧﻮع ﺑﻴﺘﺎ‬٢٢ ‫ﻣﻦ اﻟﻘﻮاﻋﺪ اﻟﻨﺘﺮوﺟﻴﻨﻴﺔ ﻣﺨﺼﺼﺔ ﻟﻠﻜﺸﻒ ﻋﻦ‬
.‫( ﻟﻢ ﻳﺘﻢ ﺗﺤﺪﻳﺪهﺎ‬%١٢,٥) ‫ اﻟّﻴﻞ‬٦ ‫( وﺑﻘﻲ‬%٨٧,٥) ‫ اﻟﻠﻴﻞ‬٤٢ ‫ ﺗﻢ ﺗﺤﺪﻳﺪ‬، ‫ اﻟﻴﻞ ﻣﺴﺒﺐ ﻟﻠﺜﻼﺳﻴﻤﻴﺎ‬٤٨ ‫ ﻣﻦ ﻣﺠﻤﻮع‬:‫اﻟﻨﺘﺎﺋﺞ‬
: ‫ وهﻲ ﻣﻊ ﻧﺴﺒﺔ ﺗﻮاﺟﺪهﺎ آﻤﺎ ﻳﻠﻲ‬،‫ أﻧﻮاع ﻣﻦ اﻟﻄﻔﺮات ﻓﻲ ﻣﺮﺿﻰ ﻣﺤﺎﻓﻈﺔ ﻧﻴﻨﻮى‬٨ ‫ﺗﻢ ﺗﺤﺪﻳﺪ‬
IVS 1.110 (G>A)(27.08%), IVS 1.6 (T>C)(14.5%), cod 8 (-AA)(12.5%), cod 39
(C>T)(12.5%), IVS 2.1 (G>A)(12.5%), cod 44 (-C)(4.16%), IVS 1.5(GÆC)(2.08%) and Cod
5 (-CT)(2.08%).
.(%٣٧,٥) ‫( ﺑﻴﻨﻤﺎ اﻟﻌﻮاﺋﻞ اﻟﺘﻲ أﻧﺠﺒﺖ أآﺜﺮ ﻣﻦ ﻣﺮﻳﺾ ﺷﻜﻠﺖ‬%٦٢,٥) ‫اﻟﻌﻮاﺋﻞ اﻟﺘﻲ أﻧﺠﺒﺖ ﻣﺮﻳﻀﺎ واﺣﺪا ﺷﻜﻠﺖ‬
‫( ﻣﺮﻳﻀﺎ آﺎﻧﻮا ﻳﺤﻤﻠﻮن اﻟﻴﻼت ﻏﻴﺮ‬%٥٠) ‫( ﻣﺮﻳﻀﺎ آﺎﻧﻮا ﻳﺤﻤﻠﻮن اﻟﻴﻼت ﻣﺘﺠﺎﻧﺴﺔ واﺛﻨﺎ ﻋﺸﺮ‬%٤٥,٨٣) ‫أﺣﺪ ﻋﺸﺮ‬
.‫( ﻟﻢ ﻳﺘﻢ اﻟﺘﻌﺮف ﻋﻠﻰ ﺗﺮآﻴﺒﺘﻪ اﻟﺠﻴﻨﻴﺔ‬%٤,١٦) ‫ﻣﺘﺠﺎﻧﺴﺔ ﺑﻴﻨﻤﺎ ﻓﻲ ﻣﺮﻳﺾ واﺣﺪ‬
. ‫ ﻧﻴﻨﻮى‬،‫ ﻃﻔﺮات ﺟﻴﻦ ﺑﻴﺘﺎ آﻠﻮﺑﻴﻦ‬،‫ ﻓﻘﺮ دم اﻟﺒﺤﺮ اﻟﻤﺘﻮﺳﻂ‬،‫ ﺛﻼﺳﻴﻤﻴﺎ‬:‫ﻣﻔﺎﺗﻴﺢ اﻟﻜﻠﻤﺎت‬
T
halassemias are a heterogeneous group
of genetic disorders of hemoglobin
synthesis, all of which result from a reduced
rate of production of one or more of the globin
chains of hemoglobin (1). It is the world's most
common monogenic disorder (2,3).
Most individuals who are homozygous or
compound heterozygous for beta thalassemia
have thalassemia major, a severe, life
threatening anemia that requires regular blood
transfusion for survival. Some patients,
however, are less severely affected with a
milder non-transfusion dependent disorder
referred to as thalassemia intermedia (3, 4).
Since the treatment of thalassemia major is
still unsatisfactory and costly and the disease
is ultimately fatal, prenatal diagnosis has
become an important option for couples at risk
of producing an affected fetus.
Genetic counseling, population screening,
prenatal diagnosis and the option of
termination of affected pregnancies remain the
mainstay strategy in the control of beta
thalassemia major. Many studies have
confirmed and shown the benefits of a
thalassemia prevention program (3,5,6).
There are currently more than 200 known
mutations in the beta globin gene; about 20
mutations account for 90 % of beta globin
gene mutations in the world and each ethnic
population has its own unique and frequency
of beta globin mutations. Prenatal diagnosis
requires identification of the mutation spectrum
in each population, then it is possible to do
direct identification for these mutations in the
majority of the population using monoplex and
multiplex amplification refractory mutation
system (ARMS) or dot blotting (7- 9).
Characterization
of
beta
thalassemia
mutations have been carried out in countries
around Iraq ; in Saudi Arabia (10), in Syria(11), in
Jordan(12), in Kuwait(13), in Turkey(14), and in
Iran(15) .
In Iraq a limited study has been carried out in
Dohuk governorate region (16).
The aim of this study is to characterize the
spectrum of beta globin gene mutations in
Ninawa governorate patients with betathalassemia major who are registered in
thalassemia center, using PCR - based DNA
diagnostic techniques.
This study was conducted during the period:
from Faberuary 2007 to December 2007.
Patients
Twenty four thalassemic patients were
included in this study, and they were randomly
selected and according to the following criteria:
The patients were diagnosed and registered
as thalassemia major in Thalassemia Center in
Ibn Al-Atheer Hospital in Ninawa Governorate.
The diagnosis in the Thalassemia Center
depends on clinical presentation, blood
counting parameters (Hb, PCV and MCH),
findings in blood film stained by Leishman
stain and Hb electrophoresis.
125
Vol. 35 No. 2, 2009
The patient has history of one blood
transfusion or more per month for at least two
months. A case sheet for each patient,
including: name, sex, date of birth, age of
presentation ….. etc had been prepared.
Methods
For each patient two ml of venous blood was
withdrawn from a vein in the antecubital fossa
and was put in a 2.5 ml EDTA tube (AFMADispo-Jordan) and subjected to the following
investigations:
1. DNA extraction: carried out in the
Laboratory of Bone Marrow Transplant
center in Children Welfare Teaching
Hospital, of Medical City, Baghdad-Iraq,
using Wizard Genomic Purification Kit
(Promega Corporation-USA), according to
the method described by the manufacturer
(17)
.
2. DNA
amplification
and
mutation
identification: carried out in Italy by Dott.
Marcello Morgutti (Servizio di Genetica,
IRCCS "Burlo Garofolo", via dell 'Istria 65/1,
34100 TRIESTE, Tel.:0403785424, Fax:
0403785540,
e-mail:
morgutti@
burlo.trieste.it) using β-Globin StripAssayTM
kit (ViennaLab Labordiagnostika GmbHAustria- e-mail: [email protected]) which
intended for the identification of β-globin
gene mutations based on polymerase chain
reaction (PCR) followed by reverse
hybridization to specific wild and mutant
oligoprobes designed to detect 22 β–
thalassemia
mutations
(ViennaLab
Labordiagnostika GmbH) .
The assay cover 22 beta globin mutations as
following: -87(CÆG), -30(TÆA), Codon 5(CT), hemoglobin C (HbC), Hemoglobin S
(HbS), Codon 5(-A), Codon 8(-AA), Codon
8/9(+G), Codon 22(7bp del), Codon 30(GÆC),
IVS 1.1(GÆA), IVS 1.2(TÆA), IVS 1.5(GÆC),
IVS1.6 (TÆC), IVS 1.110(GÆA), IVS
1.116(TÆG), IVS 1-25(25bp del), Codon
36/37(-T), Codon 39(CÆT), Codon 44(-C), IVS
2.1(GÆA), IVS 2.745(CÆG)
(ViennaLab Labordiagnostika GmbH)
Data analysis had been made by the use of
statistical package (Epi-info version 6). The
data was presented by frequency distribution,
and means and standard deviation (SD) were
made for selected variables.
Results
Twenty four patients with 48 alleles from 24
unrelated families resident in Ninawa
governorate were studied (table 1). Twenty
three patients were of Arabic origin for father
and mother, while one patient (no.18) was of
Kurd origin for father and mother.
The following criteria were considered in
addition to the characterization of the alleles:
1. Sex: 8/24(33.3 %) patients were males and
16/24(66.6%) were females.
2. Age: the mean of age was 9.58 years
(SD+/- 4.79) with range of 1-19 years.
3. Other affected siblings: 15/24 (62.5%)
families have only one affected individual
while 9/24(37.5%) families have more than
one affected individual.
4. Location: 12/24( 50% ) patients were from
Mosul (center of Ninawa) and 12/24( 50% )
patients were from the towns outside the
center (Mosul) and as following: 4 patients
from Tal-afar , 2 patients from Badosh and 1
patient from each of the towns : Bartalah,
Baashika, Rabeaa, Kaiarah, Al-Hamdaniah
and Alkosh (table 1).
5. Genotype: 11/24 (45.83%) of patients have
homozygous alleles and 12/24 (50%)
patients with compound heterozygous
alleles (c.heterozygous) In 1/24 (4.16%) the
genotype was unknown.
6. Characterization of the alleles: 42/48
(87.5%) of the alleles were characterized,
while 6/48 (12.5%) of alleles were not
determined.
7. Types of mutations: 8 types of mutations
were determined, and these are: IVS 1.110
(G>A), IVS 1.6 (T>C), cod 8 (-AA), cod 39
(C>T), IVS 2.1 (G>A), cod 44 (-C), IVS
1.5(GÆC) and Cod 5(-CT).
8. Frequency of the mutations (table 2):
126
Vol. 35 No. 2, 2009
- IVS 1.110 (G>A) constitutes 27.08% (13/48)
of alleles, and 76.92% (10/13) of these alleles
present in homozygous state, that is in 5
patients, while 23.07% (3/13) of the alleles
present in c. heterozygous state, that is in 3
patients.
- IVS 1.6 (T>C) constitutes 14.5% (7/48) of
alleles, and 28.57% (2/7) of these alleles
present in homozygous state, that is in one
patient, while 71.42% (5/7) of these alleles
patients.
-cod 8 (-AA) constitutes 12.5%(6/48) of alleles,
and 33.33% (2/6) of these alleles present in
homozygous state, that is in one patient, while
66.66% (4/6) of these alleles present in c.
heterozygous state, that is in 4 patients.
- cod 39 (C>T) constitutes. 12.5% (6/48) of
patients.
- IVS 2.1 (G>A) constitutes 12.5% (6/48) of
patients.
- cod 44 (-C) constitutes 4.16% (2/48) of
alleles, and 100% present in c. heterozygous
state, that is in two patients.
- IVS 1.5 (GÆC) constitutes 2.08% (1/48) of
alleles, and it presents in one patient as c.
heterozygous state.
- Cod 5 (-CT) constitutes 2.08% (1/48) of
alleles, and it presents in one patient as c.
heterozygous state.
- undetermined alleles constitute 12.5 %(6/48)
of alleles, 2 alleles in one patient and four
alleles distribute in 4 patients, each with a
determined allele.
Table (1): Results of thalassemia patients from Ninawa.
Code
no.
Allele no. 1
Allele no. 2
Sex
Age
year
Other
Affe.
Locus
1
IVS 1.110 (G>A)
IVS 1.110 (G>A)
M
15
-
2
IVS 1.110 (G>A)
IVS 1.110 (G>A)
F
5
-
3
IVS 1.110 (G>A)
IVS 1.110 (G>A)
M
17
-
4
IVS 1.110 (G>A)
IVS 1.110 (G>A)
F
15
1
IVS 1.110 (G>A)
F
12
-
Mosul
Rabeaa
Mosul
Mosul
Mosul
Mosul
Tal-afar
Mosul
Tal-afar
Al-Hamdaniah
Mosul
Alkosh
Kaiarah
Badosh
Mosul
Tal-afar
Tal-afar
Baashika
Mosul
Mosul
Mosul
Mosul
Bartalah
Badosh
5
IVS 1.110 (G>A)
6
cod 8 (-AA)
cod 8 (-AA)
F
6
-
7
IVS 1.6 (T>C)
IVS 1.6 (T>C)
F
8
1
8
cod 39 (C>T)
cod 39 (C>T)
F
13
-
9
cod 39 (C>T)
cod 39 (C>T)
F
1
-
10
IVS 2.1 (G>A)
IVS 2.1 (G>A)
M
6
-
11
IVS 2.1 (G>A)
IVS 2.1 (G>A)
M
7
-
12
cod 8 (-AA)
IVS 1.6 (T>C)
F
5
1
13
cod 8 (-AA)
IVS 1.6 (T>C)
M
8
3
14
cod 5 (-CT)
IVS 1.6 (T>C)
F
9
-
15
cod 8 (-AA)
IVS 1.110 (G>A)
M
11
2
16
IVS 1.110 (G>A)
IVS 2.1 (G>A)
F
2
-
17
IVS 1.6 (T>C)
cod 44 (-C)
F
13
-
18*
IVS 1.5 (G>C)
IVS 2.1 (G>A)
M
6
-
19
cod 8 (-AA)
cod 39 (C>T)
M
13
1
20
cod 44 (-C)
not determined
M
15
3
19
1
21
IVS 1.6 (T>C)
not determined
M
22
IVS 1.110 (G>A)
not determined
F
6
-
23
cod 39 (C>T)
not determined
F
12
1
24
not determined
not determined
F
6
-
*patient of Kurd origin, M: Male, F: Female, other affe.: other affected individual in the family
127
Vol. 35 No. 2, 2009
Table (2): Types of mutations, number of
alleles and their frequency.
Number of
alleles
Mutation %
IVS 1.110 (G>A)
13
27.08
IVS 1.6 (T>C)
7
14.5
cod 8 (-AA)
6
12.5
cod 39 (C>T)
6
12.5
IVS 2.1 (G>A)
6
12.5
cod 44 (-C)
2
4.16
IVS 1.5 (GÆC)
1
2.08
Cod 5 (-CT)
1
2.08
Not determined
6
12.5
48
99.90
Mutation
Discussion
In this study eight β-thalassemic mutations
have been characterized in patients from
Ninawa governorate. The patients included,
were from different towns in the governorate.
figure (1). This is the first study that delineates
the β-thalassemic mutations in Ninawa
governorate.
The eight mutations which have been
characterized in the studied group determined
that the main β-thalassemia mutations in
Ninawa are of Mediterranean origin; with few
mutations were of Kurdish and Asian Indian
origins; The mutations, IVS 1.110 (G>A), IVS
1.6 (T>C), cod 8 (-AA), cod 39 (C>T), IVS 2.1
(G>A), and cod 5 (-CT) are included in the
Spectrum of β-thalassemia mutations in
Mediterranean peoples (18-21) and these
mutations constitutes 81.2% of all types of
mutations in the studied group.
The mutation cod 44 (-C), a Kurdish mutation
(18)
constitutes only 4.16% while the Asian
Indian mutation IVS 1.5 (G>C) (18) constitutes
2.08% of all mutations (table 2).
The undetermined alleles constitute 12.5%,
so we would expect that other mutations to βthalassemia exist in this region. Beside that,
this percentage of undetermined alleles was,
also expected, as, such percentage was
obtained in the surrounding areas; the
undetermined alleles in Duhok was 11.5%, in
Syria 12.8%, in Turkey 9.5% and in Iran 19.1%
(16)
. Direct DNA sequencing is one of the
methods which can be used for determining
such rare mutations (3).
Ninawa is one of the largest governorates in
Iraq and although the Arabs form the main
ethnic group, many other ethnic groups are
present as Kurds, Turks and Ashour. The
intermarriages and interrelations between
these groups explains the relatively large
number of mutation types determined in the
studied group, as well as explaining the 12.5%
of alleles which are still undetermined.
On the other hand, we tried to make the
studied group representative for the state of
beta-thalassemia alleles in Ninawa, with the
patients included being from many towns
around the center (Mosul), (figure 1 and table
1).
All the mutations characterized in this study
have been previously described in other
populations: The mutation IVS 1.110 (G>A)
(create new splice site) is the most common
cause of beta-thalassemia in Mediterranean
countries, especially eastern Mediterranean
region, but reaches lower frequencies in
countries around the Arabian Gulf (22,23).
The IVS 1.6 (T>C) (consensus change
mutation) was originally found in a Portuguese
patient and subsequently in Greek Cypriots. It
presents with relatively high frequency in most
Mediterranean Arab Countries. Typically the
clinical course of patients with this mutation is
mild in nature (22,23).
The mutation cod 8 (-AA) (frameshift
mutation) was originally detected in a Turkish
patient (22) and it is the commonest mutation in
Azerbaijan (24), but it is of low frequency in
countries around Iraq and in Arab countries
except Saudi Arabia, where it reaches 10%
(23)
.
The mutation cod 39 (C>T) (nonsense
mutation) has been found in Sardinia, Greece
and Turkey and it was found in all Arab
Countries, but with highest frequencies in
Western Arab Countries such as Tunisia,
Algeria and Morocco (22,23,25,26).
The mutation IVS 2.1 (G>A) (splice junction
mutation) has been found in Mediterranean
peoples (Greece, Italian and Tunisian) and
recorded in most of the Arab countries with
high frequency in north Jordan (20%) and it is
128
Vol. 35 No. 2, 2009
the most common mutation in Kuwait and Iran
(18,23)
.
The cod 44 (-C) (frameshift mutation) is a
mutation of Kurdish origin, but it was detected
in the countries of Arab peninsula (23).
The cod 5 (-CT) (frameshift mutation) is a
Mediterranean mutation, and it was found in all
Arab Mediterranean Countries except Algeria
(23)
.
The IVS 1.5 (G>C) (consensus change
mutation) is interesting because it was
previously found in Chinese and Asian Indian
populations, with its occurrence also in the
Mediterranean region (23).
In this study, the results showed that the
mutation IVS 110 (G>A) is the most common
mutation in thalassemic patients in Ninawa
governorate, a finding similar to that obtained
in the surrounding countries (Turkey, Syria,
Jordan and Saudi Arabia) in which, this
mutation constitutes the most common
mutation; beside that the three most common
mutations are similar in Ninawa and Turkey
(table 3).
Such finding can be explained by the
following:
First: The overwhelming dominance of
Ottoman Empire on Iraq in the past and for
nearly four centuries had led to intermarriages
and admixtures between Arabs and Turks
especially in Ninawa (Nineveh), resulting in
mutations in this governorate showing a high
degree of similarity with the mutations in
Turkey.
Second: The patients included in this study
were of Arab origin (except one patient who
was of Kurdish origin); while the majority of
people in Syria, Jordan, and Saudi Arabia, are,
also of Arab origin and some people in these
countries are related to the same tribes or they
have association through intermarriages or
migration of residence.
Figure (1): Shows the cities of Ninawa governorate, from which the patients were included in the
study in addition to the center (Mosul).
129
Vol. 35 No. 2, 2009
Table (3): Shows the frequency of the mutations in Ninawa and surrounding countries ordered
according to their frequency.
Ninawa
Turkey
Syria
Jordan
Saudi Arabia
IVS 1.110
(27%)
IVS 1.110
(41.4%)
IVS 1.110
(24%)
IVS 1.110
(25%)
IVS 1.110
(22%)
IVS 1.6
(14.5%)
IVS 1.6
(10.6%)
IVS1.1
(17%)
IVS 2.1
(15%)
cod 39
(20%)
cod 8
(12.5%)
cod 8
(5.7%)
cod 5
(8.5%)
IVS 2.745
(14.2%)
IVS 2.1
(15%)
cod 39
(12.5%)
IVS 1.1
(5.3%)
cod 39
(6.4%)
IVS 1.1
(10.0%)
IVS 1-25
(14%)
IVS 2.1
(12.5%)
IVS 2.1
(4.9%)
IVS 2.1
(4%)
IVS 1.5
(5.5%)
cod 8
(10%)
On the other hand, the results showed
difference between the most common mutation
in Ninawa and the eastern surrounding area
that is Duhok and Iran in which the most
common mutation is IVS 2.1 (G>A) (16); in
Duhok this mutation followed by the Kurdish
mutation cod 44 which was relatively
uncommon in Ninawa (table 4).
Such difference can be explained by the
difference in the origin of the people, where
the people in Duhok and north Iran are of Kurd
origin.
The main difference between the results of
this study and what was obtained in the
surrounding areas is the absence of the
mutation IVS 1.1 which was detected in all
areas around Ninawa {in Syria 17%, Jordan
10%, Saudi Arabia 7%, Kuwait 7.3%, Iran
2.9% and in Turkey 5.3% (12,23,16)}, and this
difference can be explained, partly, by the
small size of the sample.
This study demonostrated that 45.83% of
patients have homozygous alleles and as the
consanguineous marriages within certain
ethnic communities having a high incidence of
beta-thalassemia have led to an increase in
homozygous patients within that particular
so
we
expect
that
community(22),
consanguineous marriage is responsible for
such figure of homozygosity.
This study demonstrated another problem,
which is the continuous birth of affected
children in the same family; the results of this
study showed that 37.5% of families in the
studied group have more than one affected
child, so initiation of a preventive program for
beta-thalassemia is a cornerstone in the
management of this disease.
Many experiences confirm that the best way
for the management of thalassemias is
through the introduction of a preventive
program which includes population screening,
genetic counseling, prenatal diagnosis and
options of termination of affected pregnancies.
This was demonstrated in Cyprus, Greece and
many
countries
worldwide.
The
characterization of the common betathalassemia mutation in specific community is
perquisite for such program (3, 18, 22, 27-29).
So characterization of the common mutations
carried out in this study will provide a sound
foundation on which to base a preventive
program
for
thalassemia
in
Ninawa
governorate, and, also, these findings will
facilitate the improvement of medical services
such as carrier screening, genetic counseling
and prenatal diagnosis.
The relatively high frequency (45% of
patients) of homozygous alleles obtained in
this study can be explained by the
consanguineous
marriages
in
our
communities.
130
Vol. 35 No. 2, 2009
Table (4): Shows the frequency of the
mutations in Ninawa and Duhok and Iran
ordered according to their frequency.
Duhok
Iran
Ninawa
IVS 2.1
(18.3%)
IVS 2.1
(33.9%)
IVS 1.110
(27%)
cod 44
(12.5%)
IVS 1.5
(7.6%)
IVS 1.6
(14.5%)
cod 5
(10.6%)
cod 8/9
(4.8%)
cod 8
(12.5%)
cod 39
(8.7%)
IVS 1.110
(4.8%)
cod 39
(12.5%)
IVS 1.1
(8.7%)
cod 8
(4.5%)
IVS 2.1
(12.5%)
Conclusions
1. Eight β-globin alleles causing β-thalassemia
syndrome in Ninawa governorate were
characterized; most of these mutations are
of Mediterranean type.
2. The frequency of these mutations was as
follow:
IVS 1.110 (G>A) (27.08%), IVS 1.6 (T>C)
(14.5%), cod 8 (-AA) (12.5%), cod 39 (C>T)
(12.5%), IVS 2.1 (G>A) (12.5%), cod 44 (-C)
(4.16%), IVS 1.5(GÆC)(2.08%) and Cod 5(CT) (2.08%).
3. More than 1/3 of the families have more
than one affected sibling.
Acknowledgment
- I very much appreciate with gratitude the help
of the Children Welfare Teaching HospitalBaghdad and to the Italian institution (Servizio
di Genetica-IRCCS-TRISTE) and especially to
the researcher DOTT. (Dr.) Marcello Morgutti,
for their great efforts to aid me to complete a
vital stage of this multistage thesis.
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Appendix
‫اﺳﺘﻤﺎرة اﻟﻤﻌﻠﻮﻣﺎت اﻟﺨﺎﺻﺔ ﺑﺘﺤﺪﻳﺪ‬
‫اﻟﻄﻔﺮات اﻟﻮراﺛﻴﺔ ﻓﻰ ﻣﺮﺿﻰ اﻟﺜﻼﺳﻴﻤﻴﺎ‬
‫رﻗﻢ اﻟﻤﻠﻒ‬
‫اﻟﺘﻮﻟﺪ‬
‫اﻟﺠﻨﺲ‬
‫اﻻب‬:‫اﻟﺪﻳﺎﻧﺔ‬
‫اﻻم‬
‫اﻻب‬:‫اﻟﻘﻮﻣﻴﺔ‬
‫اﻻم‬
‫اﻟﺴﻜﻦ اﻻﺻﻠﻰ‬
‫اﺧﻮات ﻣﺼﺎﺑﺎت‬
Presentation:
Age of presentation
Clinical features:
Investigations:
Blood group
Hb
g/dl
Blood film:
:‫اﻟﻤﻮﻗﻊ‬
‫اﻻﺳﻢ اﻟﺜﻼﺛﻰ واﻟﻠﻘﺐ‬
‫اﻻب‬:‫اﻟﻌﺸﻴﺮة‬
‫اﻻم‬
‫ﺻﻠﺔ اﻻب ﺑﺎﻻم‬
‫اﻟﺴﻜﻦ اﻟﺤﺎﻟﻰ‬
‫اﺧﻮة ﻣﺼﺎﺑﻴﻦ‬
date of presentation
PCV
%
Electrophoresis:
Hb-A2
Hb-F
History of transfusion
Date of 1st transfusion:
Frequency of transfusion:
Hb-A
WBC count
/cmm
Hb-S
Date of last transfusion:
Leucocytes filter:
Present state:
Clinical features:
Spleen
cm bcm
endocrine: high
weight
Heart: Hypertrophy, Cardiomyopathy, Heart failure.
Blood film:
puberty
Liver
Serum ferritine
The Mutation:
‫اﻟﺘﺎرﻳﺦ‬
133
Vol. 35 No. 2, 2009
Prevalence of surgical inguino-genital conditions among male
kindergartens and primary school children in Mosul city
Abdul Salaam Al-Masri*, Bassam A. Al-Ne`ema**, Khalaf Rasheed*
*Department of Surgery, **Department of Community Medicine, College of Medicine, University of Mosul.
Received: 12th Aug 2008; Accepted: 10th Feb 2010.
ABSTRACT
Context: Inguino-genital surgical disorders are common problems seen in daily surgical practice. The
aim of this study is to determine the main surgical inguino-genital disorders among kindergartens and
primary school boys less than 10 years of age in Mosul city.
Methods: A random sample of kindergartens and primary school boys from both sides of Mosul city
underwent a cross-sectional study between 1st of Oct. 2004 and 31st of Jan 2005. All boys were
examined by specialized surgeons for the presence of surgical disorders in their inguino-genital
region. The pathological findings were recorded and diagnosed disorders were further assessed by
suitable investigative tools. The parents were informed about their children's disorders and
accordingly, a suitable management for each single disorder was discussed with them.
Results: During the study period, 950 children were examined and (125) children were having
various inguino-genital disorders. The prevalence of these conditions was (13.2%). The present study
showed (7.7%) of the screened children were uncircumcised, (3.2%) were having undescended
testes and (1.2%) has inguinal hernia. The surgical conditions were (54.4%) among the age of 6-7
years, (20.0%) among the age of (5-6) years and (1.6%) among the age of (9-10) years. The study
revealed that 60% of the undescended testes were on the right side, and (36.7%) on the left side.
Moreover (63.67%) of the hernias were right sided and (27.3%) were left sided.
Conclusion and recommendations: Studying male children in schools for any surgical
abnormalities, at the inguino-genital areas provides the opportunity for detection of the early
conditions, further management of the main surgical cases that need correction and the prevention of
any risk of complications.
Keywords: Inguinal, screening, undescended, hernias, uncircumcised.
‫ﺗﻬﺪف اﻟﺪراﺳﺔ اﻟﺤﺎﻟﻴﺔ إﻟﻰ دراﺳﺔ اﻧﺘﺸﺎر اﻟﺤﺎﻻت اﻟﺠﺮاﺣﻴﺔ اﻟﺮﺋﻴﺴﺔ ﻓﻲ اﻟﻤﻨﻄﻘﺔ اﻟﻤﻐﺒﻨﻴﺔ واﻷﻋﻀﺎء اﻟﺘﻨﺎﺳﻠﻴﺔ ﺑﻴﻦ اﻷﻃﻔﺎل‬
.‫ ﺳﻨﻮات ﻓﻲ رﻳﺎض اﻷﻃﻔﺎل واﻟﻤﺪارس اﻻﺑﺘﺪاﺋﻴﺔ ﻓﻲ ﻣﺪﻳﻨﺔ اﻟﻤﻮﺻﻞ‬١٠ ‫اﻟﺬآﻮر اﻟﺬﻳﻦ ﺗﺒﻠﻎ أﻋﻤﺎرهﻢ أﻗﻞ ﻣﻦ‬
‫ ﻟﻘﺪ ﺗﻢ اﺧﺘﻴﺎر ﻃﺮﻳﻘﺔ‬.٢٠٠٥ ‫ إﻟﻰ اﻷول ﻣﻦ آﺎﻧﻮن اﻟﺜﺎﻧﻲ‬٢٠٠٤ ‫أﺟﺮﻳﺖ اﻟﺪراﺳﺔ ﻓﻲ اﻟﻔﺘﺮة ﻣﺎﺑﻴﻦ اﻷول ﻣﻦ ﺗﺸﺮﻳﻦ أول‬
‫ وأﺧﺬت ﻋﻴﻨﺔ ﻋﺸﻮاﺋﻴﺔ ﻣﻦ رﻳﺎض اﻷﻃﻔﺎل وﻃﻼب اﻟﻤﺪارس اﻻﺑﺘﺪاﺋﻴﺔ ﻣﻦ‬،‫اﻟﺪراﺳﺔ اﻟﻤﻘﻄﻌﻴﺔ ﻓﻲ هﺬا اﻟﺒﺤﺚ اﻻﺳﺘﻜﺸﺎﻓﻲ‬
‫ وﺗﻢ ﻓﺤﺺ ﺟﻤﻴﻊ اﻷﻃﻔﺎل ﻓﻲ ﻋﻴﻨﺔ اﻟﺪراﺳﺔ ﻣﻦ ﻗﺒﻞ ﺟﺮاﺣﻴﻦ أﺧﺼﺎﺋﻴﻴﻦ‬.‫ﺟﺎﻧﺒﻲ ﻣﺪﻳﻨﺔ اﻟﻤﻮﺻﻞ ﻋﻠﻰ ﺿﻔﺘﻲ ﻧﻬﺮ دﺟﻠﺔ‬
‫ اﻷﻃﻔﺎل اﻟﺬﻳﻦ‬.‫وﺳﺠﻠﺖ اﻟﻨﺘﺎﺋﺞ ﺣﺴﺐ ﻣﺎ ﺗﻢ اآﺘﺸﺎﻓﻬﺎ ﺑﻌﺪ اﺳﺘﺨﺪام اﻟﻔﺤﻮﺻﺎت اﻟﺴﺮﻳﺮﻳﺔ اﻟﺪﻗﻴﻘﺔ اﻟﻌﺎﻣﺔ واﻟﻤﻮﺿﻌﻴﺔ ﻟﻜﻞ ﻃﻔﻞ‬
‫ وﺗﻢ إﺧﺒﺎر ذوﻳﻬﻢ وﻣﻨﺎﻗﺸﺔ اﻟﺤﺎﻟﺔ ﻣﻌﻬﻢ‬،‫ﺗﻢ اآﺘﺸﺎف اﻟﺤﺎﻻت ﻟﺪﻳﻬﻢ اﺟﺮي ﻟﻬﻢ ﻓﺤﻮص ﺗﺸﺨﻴﺼﻴﺔ ﻣﻨﺎﺳﺒﺔ ﻟﻠﺘﺄآﺪ ﻣﻦ اﻟﺘﺸﺨﻴﺺ‬
‫ ﻃﻔﻼ ﻣﻨﻬﻢ‬١٢٥ ‫ وﻇﻬﺮ أن‬،‫ ﻃﻔﻼ‬٩٥٠ ‫ ﺧﻼل ﻓﺘﺮة اﻟﺪراﺳﺔ ﺗﻢ ﻓﺤﺺ‬.‫ﻟﻐﺮض إﺟﺮاء اﻟﺘﺪاﺑﻴﺮ اﻟﻤﻨﺎﺳﺒﺔ ﻟﻸﻃﻔﺎل اﻟﻤﺼﺎﺑﻴﻦ‬
‫ ﻣﻦ اﻷﻃﻔﺎل ﻓﻲ‬%٧,٧ ‫ وأﻇﻬﺮت اﻟﺪراﺳﺔ أن‬.(%١٣,٢) ‫آﺎﻧﻮا ﻣﺼﺎﺑﻴﻦ ﺑﺤﺎﻻت ﺟﺮاﺣﻴﺔ ﻣﺨﺘﻠﻔﺔ وﻣﻌﺪل اﻻﻧﺘﺸﺎر اﻟﻜﻠﻲ‬
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Vol. 35 No. 2, 2009
‫ وآﺎﻧﺖ ﻧﺴﺐ اﻟﺤﺎﻻت ﺿﻤﻦ‬.‫ ﻟﺪﻳﻬﻢ ﻓﺘﻖ ﻣﻐﺒﻨﻲ‬%١,٢ ‫ ﻟﺪﻳﻬﻢ ﺧﺼﻴﺔ هﺎﺟﺮة و‬%٣,٢ ‫ﻋﻴﻨﺔ اﻟﺪراﺳﺔ آﺎﻧﻮا ﻏﻴﺮ ﻣﺨﺘﻮﻧﻴﻦ و‬
،‫( ﻓﺘﻖ ﻣﻐﺒﻨﻲ‬%٨,٨) ،‫( ﺧﺼﻴﺔ هﺎﺟﺮة‬%٢٤,٠) ،‫( ﻏﻴﺮ ﻣﺨﺘﻮن‬%٥٨,٤) :‫اﻟﻌﺪد اﻟﻜﻠﻲ ﻟﻠﺤﺎﻻت اﻟﺠﺮاﺣﻴﺔ آﺎﻵﺗﻲ‬
.‫( ﻣﺒﺎل ﺗﺤﺘﺎﻧﻲ‬%١,٦)‫( ﻗﻴﻠﺔ ﻣﺎﺋﻴﺔ و‬%٢,٤) ،‫( ﺧﺼﻴﺔ راﺟﻌﺔ‬%٤,٨)
%١,٦ ‫ ﺳﻨﻮات و‬٦-٥ ‫ ﺑﻴﻦ ﻣﻦ هﻢ‬%٢٠ ‫ ﺳﻨﻮات و‬٧-٦ ‫ ﻣﻦ اﻟﺤﺎﻻت هﻲ ﺑﻴﻦ اﻷﻃﻔﺎل‬%٥٤,٤ ‫وﻇﻬﺮ ﻣﻦ اﻟﺪراﺳﺔ أن‬
%٣٦,٧ ‫ ﻣﻦ اﻟﺨﺼﻴﺔ ﻏﻴﺮ اﻟﻨﺎزﻟﺔ آﺎﻧﺖ ﻓﻲ اﻟﺠﻬﺔ اﻟﻴﻤﻨﻰ و‬%٦٠ ‫ وﻣﻦ ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ ﻇﻬﺮ أن‬.‫ ﺳﻨﻮات‬١٠-٩ ‫ﺑﻴﻦ اﻷﻃﻔﺎل‬
.‫ ﻣﻨﻬﺎ آﺎﻧﺖ ﻓﻲ اﻟﺠﻬﺔ اﻟﻴﺴﺮى‬%٢٧ ‫ ﻣﻦ ﺣﺎﻻت اﻟﻔﺘﻖ آﺎﻧﺖ ﻓﻲ اﻟﺠﻬﺔ اﻟﻴﻤﻨﻰ و‬%٦٣ ‫ وآﺬﻟﻚ آﺎن‬.‫آﺎﻧﺖ ﻓﻲ اﻟﺠﻬﺔ اﻟﻴﺴﺮى‬
‫ إن ﻓﺤﺺ أﻃﻔﺎل اﻟﻤﺪارس ورﻳﺎض اﻷﻃﻔﺎل ﻳﻮﻓﺮ ﻓﺮﺻﺔ ﻟﺘﺸﺨﻴﺺ اﻟﺤﺎﻻت وﻣﻦ ﺛﻢ اﻹﺻﻼح‬:‫اﻻﺳﺘﻨﺘﺎج واﻟﺘﻮﺻﻴﺎت‬
.‫اﻟﻤﺒﻜﺮ ﻟﺒﻌﺾ ﺗﻠﻚ اﻟﺤﺎﻻت وﻣﻨﻊ اﻟﻤﻀﺎﻋﻔﺎت اﻟﻤﺤﺘﻤﻠﺔ وﻳﻮﻓﺮ اﻟﻌﻼج ﻟﻠﺤﺎﻻت اﻟﺘﻲ ﺗﺤﺘﺎج ﺗﺪاﺧﻼ ﺟﺮاﺣﻴﺎ ﻣﻨﺎﺳﺒﺎ‬
I
nguino-genital surgical disorders are
problems commonly encountered in daily
surgical practice(1,2). Examples include inguinal
hernias, hydroceles, undescended testes..etc.
Hernias occur in (1- 4%) of all infants; the
incidence may reach (30%) in premature
infants (depending on the child’s gestational
age at birth). One third of all children with
hernias presents before six months of age,
and (13.44%) of the male school children aged
(6-12) years had inguinal hernias(3). Most
hernias occur in males, with a male to female
ratio of (6:1). Female and premature infants of
both sexes face a higher risk of incarceration
than others, leading to tissue death (4). Direct
inguinal hernia and femoral hernia in children
are extremely rare and represent a small
percentage in most studies. About (3- 5%) of
healthy, full-term babies may be born with an
inguinal hernia and one third of hernias of
infancy and childhood appear within the first
six months of life. In just over (10%) of cases,
other members of the family might have also a
hernia at birth or in infancy (5). Infants or
children with inguinal hernias need to have
surgery as soon as possible due to the
increased risk of tissue trapping and damaging
of their blood supply. In (9-20%) of affected
infants, the intestinal or abdominal tissues may
become trapped within the hernial sac and
may lead to incarceration or obstruction as
their deep inguinal ring is narrow. Most of the
time these events occur before the infant is
one year old. (3) Surgery is the only way of
treatment and correction for inguinal hernias.
Inguinal hernial repair is one of the most
common abdominal hernial surgeries. (4) The
percentage of circumcised male infants varies
by geographic location, religious affiliation, and
socioeconomic
to
some
extent,
by
classification. Circumcision is uncommon in
Asia, South America, and Central America,
South Africa and in most of Europe (6). A
hydrocele is a collection of fluid in the tunica
vaginalis. The typical hydrocele observed at or
shortly after birth as a unilateral or bilateral
swelling of the scrotum, which may vary in
size(6- 9).
The incidence of undescended testes in
neonates until one year of age in England and
Wales is (0.8%) (5). Early diagnosis and
management of the undescended testicles are
needed to improve clinically early detection of
testicular malignancy as well as correction the
association of (90%) of patent processus
vaginalis, (25%) of hernia and probably
preservation
of
fertility.
Operation
is
recommended at or below one year of age as
delays in treatment will permanently affect the
intra testicular tissue, lower the rate of surgical
success and probably impair spermatogenesis
in future (6-9). Cryptorchidism is associated with
testicular cancer. The stated risk is about (3.67.4) times higher than in the general
population(8,9). It has been well documented
that men with a history of undescended testicle
have a higher than expected incidence of
testicular germ cell cancers. While the
likelihood of developing testicular cancer
probably overestimated in the past, the
incidence among men with an undescended
testicle is approximately 1:1000 – 1: 2500
(10,11)
. Although significantly higher than the
risk among the general population (1:100,000),
this level of risk does not warrant radical
therapy, such as removal of all intra-abdominal
testes (12, 13, 14).
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Vol. 35 No. 2, 2009
Hypospadius is a congenital abnormality by
which the external urinary meatus is located
anywhere along the ventral aspect of the
phallus with or without chordee (bowing of the
phallus ventrally); its incidence is about (1: 700
newborn males) (1,4,10). Screening of these
condition especially inguinal hernias and
undescended testes is needed for early
management.
The aim of the present study is to measure
the prevalence of inguinal surgical conditions
among male kindergarten and primary school
children aged less than 10 years in Mosul city.
Materials and methods
Official permission was obtained form Nineveh
Directorate of Education for conducting of this
study, where a list of all schools in both sides
of Mosul city was provided from such
directorate
(n=1230
schools
and
kindergartens). A sample of 13 primary
schools and kindergartens, which forms 1.1%
of the total was chosen from the list using
systematic sampling randomization. The
administrations of the chosen schools were
visited and the aim of the study and methods
were discussed with them. The agreement of
the parents for examination of their children
was taken through the kindergartens and the
primary school administrations. A special
private, warm room was prepared for
performing examination of pupils. All children
of the chosen classes were assessed.
The adopted study population includes male
children of kindergartens and primary schools
who were present during the study up to the
age of 10 years during the period from 1st
October 2004 to 31st January 2005.
Examination was carried by specialized
surgeons. The groin and genitalia were
examined for any evidence of inguinal hernia,
undescended
testis,
hydrocele
and
hypospadius. Those who have any inguinogenital abnormality, their disorders were
recorded according to their age and site.
The scrotal examination was performed by a
bimanual technique. One hand at the anterior
superior iliac spine that gently sweeps along
the inguinal canal, the undescended or ectopic
inguinal testicle felt to "pop" under the
examiner's fingers. The ectopic testicle
immediately spring out of the scrotum when it
released. The retractile testicle on the other
hand (that reaches the bottom of the scrotum)
will remain momentarily in the scrotum until
further stimulation causes a cremasteric reflex.
For the examination of hernias, the child
examined in erect and supine position.
Inspection of groin in standing position reveals
whether the lumps extending down to the
scrotum, by palpation, getting above the mass
as well as transillumination are important signs
to differentiate between hydrocele and inguinal
hernia, cough impulse is positive in hernia.
A thorough and precise general and local
clinical examination were done for those with
conditions. Furthermore, they were sent for
further investigations to confirm the diagnosis
made by the surgeon as ultrasonic
examination. The parents were informed about
the children's disorders and suitable ways for
management were discussed with them.
Results
Table (1) depicts the point prevalence of
surgical inguinal conditions among study
sample. Out of 950 children examined 125
showed the conditions making an overall point
prevalence of (13.2%). Uncircumcised children
form (7.7%), those with undescended testes
(3.2%), inguinal hernia (1.2%) and the rest
formed a minority of (1.1%).
Table (2) reveals the inguino-genital
disorders distributed according to age, where
the disorders were present in (54.4%) among
the age of (6-7years), (20.0%) were at age (56 years) and (1.6%) at age (9-10 years).
It is also seen that 60.3% of uncircumcised
boys, 46.6% of undescended testes and
(54.5%) of inguinal hernias were at age (6-7
years). One fourth of the boys with
undescended testes and one third of those
with inguinal hernias were in the age of (<5
years). This table also shows that the point
prevalence among the children under five
years of age examined is 23.1 %, while lower
figures were reported among the older age
groups.
Table (3) shows distribution of study sample
according to site of the condition: right, left or
bilateral; (excluding uncircumcision and
hypospadius n=75).
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Vol. 35 No. 2, 2009
It is shown that (60.0%) of the undescended
testes were on the right side, and (36.7%) on
the left. Moreover (63.6%) of the hernias were
right sided and (27.3%) were on the left. The
table also shows that (83.3%) of the retractile
testes were on the right side and (16.7%) were
on left.
Table (1): Point prevalence of surgical inguinal conditions among study sample (n=950).
Point prevalence (%)
The condition
1.
2.
3.
4.
5.
6.
percentage among
children having
inguinal disorders
n=125
Percentage among
studied children
n=950
58.4
7.7 %
24.0
3.2 %
8.8
1.2 %
4.8
0.6 %
2.4
0.3 %
1.6
0.2 %
100.0
13.2 %
Uncircumcised
n=73
Undescended testes
n=30
Inguinal hernia
n= 11
Retractile testes
n=6
Hydrocele
n= 3
Hypospadius
n=2
Total
Table (2): Distribution of the inguino- genital disorders according to age.
Age in ( years )
The disorder
Total
<5
5-6
6-7
7-8
8-9
9-10
1-Uncircumcised
6
8.2
15
20.5
44
60.3
5
6.8
3
4.1
0
73
58.4
2-Undescended testes
7
23.3
7
23.3
14
46.6
0
0
2
6.7
30
24.0
3-Inguinal hernia
4
36.5
0
6
54.5
1
9.1
0
0
11
8.8
0
3
50.0
0
2
33.3
1
16.7
0
6
4.8
1
33.3
0
2
66.6
0
0
0
3
2.4
0
0
2
100
0
0
0
2
1.2
Total cases
18
14.4
25
20.0
68
54.4
8
6.4
4
3.2
2
1.6
125
100
Total examined
Point prevalence %
78
23.1
195
12.8
473
14.4
64
12.5
39
10.3
101
2.0
950
100
4-Retractile testes
5-Hydrocele
6-Hypospadius
137
Vol. 35 No. 2, 2009
Table (3): Distribution of site of the inguino- genital disorders among studied sample according to site.
The site
The disorder
Right
Left
Bilateral
No.
%
No.
%
No.
%
Total
1.
Undescended testes
18
60.0
11
36.7
1
3.3
30
2.
Inguinal hernia
7
63.6
3
27.3
1
9.1
11
3.
Retractile testes
5
83.3
1
16.7
0
0.0
6
4.
Hydrocele
0
0.0
2
66.7
1
33.3
3
Total
30
24.0
17
13.6
3
2.4
50*
* The rest of total 100% is due to non-circumcised and hypospadius.
Discussion
Examining the inguinal region is valuable in
detecting common surgical inguino-genital
disorders. Some of them may lead to
complications if left untreated as in inguinal
hernias; others may lead to psychological
trauma if uncorrected as in hypospadius.
Others carry the risk of malignant changes
such as undescended testicle (8). In Jordan in
2000, a study of (1748) boys, between the
ages of (6-12) years, performed to investigate
their genital abnormalities, it demonstrated the
presence of such abnormalities in (18.31%) of
examined children. Of these (235) patients
had inguinal hernias, (37) undescended
testes, (22) retractile testes, (13) hypospadius,
eight left varicocele and four hydrocele. (4)
The prevalence of indirect inguinal hernia in
general population of children is approximately
(1- 5%) (9), in the present study the discovered
inguino-genital abnormality was (58.4%) of all
the surgical conditions, whereas the
prevalence of inguinal hernia is (1.2%) among
kindergarten and primary school children less
than 10 years of age. Uncircumcised children
were (7.7%) of the examined children. In the
present study the prevalence of undescended
testes was (3.2%) and (24.0%) of total inguinogenital disorders. Two thirds of them were on
the right side, this fact was also seen in other
similar studies. (11-13)
The trend to perform orchidopexy at younger
ages may reduce the risks associated with
undescended testes as torsion or trauma.
Such operation will make the testis easily
accessible for early detection of any malignant
degeneration later on, and it may help the
chance of being fertile. (14, 16).
Bartone & Schmidt (1985) study revealed half
of undescended testes were between 6-7
years of age (17). Even when bilateral
undescended testes are treated early the
patient generally has a poor chance of being
fertile (18). Operation for undescended testes is
not recommended beyond one year of age
due to the irreversible changes within the
testicular tissues and probably impair
spermatogenesis later on (18).
Retractile testes are not considered a
pathological condition and it was found to be
0.6% in the present study. The retractile
testicle is the most important differential
diagnosis of undescended testes to distinguish
on physical examination as far as no hormone
or surgical therapy is required (17). In the
present study, hydrocele was seen in 0.3% of
children and mainly at age less than 5 year
and between the ages of 6-7years, left side is
more than right. In a study done by Skoog SJ,
Conlin MJ., they found that the incidence of
isolated hydrocele in children older than one
year of age is probably less than 1% (2). The
present study concludes that there is no
obvious variation among the study sample, in
comparison with other studies and the
scientific facts in the text, relation to the
prevalence, site, age and types of the surgical
abnormalities in the inguino- genital areas.
Nevertheless, the implementations of further
cross sectional studies among the school
children are important. In order to promote the
school health education more efforts and
programs should be directed to conduct early
138
Vol. 35 No. 2, 2009
screening of such surgical disorders among
children of different ages to avoid the delay in
their clinical diagnosis, surgical management
and possibly help reduce the risks of their
complications.
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hydrocele. The urologist's perspective.
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study
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boys
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Cryptorchidism and testicular neoplasia.
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London 2000;1-87 cryptorchidism.
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G, Adami HO, Persson I. Occurrence of
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for cryptorchidism and inguinal hernia. J
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15. Circumcision Policy Statement. American
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139
Vol. 35 No. 2, 2009
Pulmonary embolism, seasonal variations in admission to
hospital, and the association of calf deep vein thrombosis
with pulmonary embolism
Dhaher JS. Al-Habbo*, Talal M. Al-Saegh**, Mohammed K. Hammo*, Rami M. Al-Hayali*
*Department of Medicine, College of Medicine, University of Mosul; ** Ibn Sena Teaching Hospital, Mosul.
th
th
Received: 18 Feb 2009; Accepted: 4 Oct 2009.
ABSTRACT
Objective: To look for the presence or absence of seasonal variation of pulmonary embolism (PE).
To analyze the effect of age, sex and the presence or absence of deep vein thrombosis(DVT) and its
risk factors on the occurrence of PE. To analyze the ECG changes and the presence or absence of
sinus tachycardia in patients with acute PE.
Method: One hundred three patients with PE were studied retrospectively, during the years 20022007 at the intensive and respiratory care unit and general medical units in Ibn-Sena Teaching
Hospital.
Results: One hundred three patients with PE were studied. The age of the patients correlates
significantly with the presence of PE being highest between 21-50 year of age, with p-value of <0.001.
There were no seasonal variations in the distribution of PE with P-value of 0.06. Females significantly
outnumbered male patients with P-value of 0.002. There was no statistically significant association
between the clinically evident DVT or its absence and the diagnosis of PE with p-value 0.278. The
association between the presence of PE and positive doppler ultrasound for DVT were significant with
p-value of 0.023. There was a significant association between the presence of PE and sinus
tachycardia with p-value of <0.001, and negative correlation with the classical ECG changes.
Conclusion: There was no seasonal variation in the distribution of PE. There was significant
association between the presence of PE and positive doppler ultrasound for DVT. Sinus tachycardias
were commonly present with acute PE. We need to have more sophisticated facilities for proper
diagnosis of PE.
Keywords: Pulmonary embolism, seasonal variations, deep vein thrombosis.
‫ اﻟﺠﻨﺲ ووﺟﻮد‬،‫ آﺬﻟﻚ ﻟﺘَﺤﻠﻴﻞ ﺗﺄﺛﻴﺮ اﻟﻌُﻤﺮ‬.‫ ﻟﻠﺒﺤﺚ ﻋﻦ وﺟﻮد أَو ﻏﻴﺎب اﻟﺘﻐﻴﺮ اﻟﻤﻮﺳﻤﻲ ﻓﻲ ﺣﺪوث اﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ‬:‫اﻷهﺪاف‬
‫ وﻟﺘَﺤﻠﻴﻞ اﻟﺘﻐﻴﻴﺮات ﻓﻲ ﺗﺨﻄﻴﻂ اﻟﻘﻠﺐ ووﺟﻮد أَو‬،‫أَو ﻏﻴﺎب ﺗﺨﺜّﺮ اﻷوردة اﻟﻌﻤﻴﻘﺔ ﻓﻲ اﻟﺴﺎق ﻋﻠﻰ ﺣﺪوث اﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ‬
.‫ﻏﻴﺎب ﺟﻴﺐ ﺗﺴﺎرع ﺿﺮﺑﺎت اﻟﻘﻠﺐ ﻓﻲ اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﻴﻦ ﺑﺎﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ اﻟﺤﺎدّة‬
‫ ﻣﺎﺋﺔ وﺛﻼﺛﺔ ﻣﺮﺿﻰ ﻣﺼﺎﺑﻴﻦ ﺑﺎﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ اﻟﺤﺎدّة اﻟﻠﺬﻳﻦ ادﺧﻠﻮا اﻟﻌﻨﺎﻳﺔ اﻟﻤﺮآﺰة واﻟﻌﻨﺎﻳﺔ اﻟﺘﻨﻔﺴﻴﺔ ﻓﻲ ﻣﺴﺘﺸﻔﻰ‬:‫اﻟﻄﺮﻳﻘﺔ‬
.٢٠٠٧-٢٠٠٢ ‫ أﺛﻨﺎء اﻟﺴﻨﻮات‬،‫ دُرﺳﻮا ﺑﺸﻜﻞ رﺟﻌﻲ‬،‫اﺑﻦ ﺳﻴﻨﺎ اﻟﺘﻌﻠﻴﻤﻲ ﺑﺎﻟﻤﻮﺻﻞ‬
‫ ﻋُﻤﺮ اﻟﻤﺮﺿﻰ ﻳﺆﺛﺮ ﺑﺸﻜﻞ ﻣﻠﺤﻮظ ﻋﻠﻰ اﻻﺻﺎﺑﺔ ﺑﺎﻟﺠﻠﻄﺔ‬،‫ ﻟﻢ ﻳﻜﻦ هﻨﺎك ﺗﺄﺛﻴﺮ ﻣﻮﺳﻤﻲ ﻓﻲ ﺣﺪوث اﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ‬:‫اﻟﻨﺘﺎﺋـﺞ‬
‫ ﻳُﻤﻜﻦ أَن ﻳﻜﻮن ﺑﺴﺒﺐ إﺣﺎﻟﺔ اﻟﻤﺮﺿﻰ ﻣﻦ ﻣﺴﺘﺸﻔﻴﺎت‬،‫ﺖ اﻻﺻﺎﺑﺔ ﻋﻨﺪ اﻹﻧﺎث ﻋﺪدًا ﻋﻠﻰ اﻟﺬآﻮر ﺑﺸﻜﻞ ﻣﻠﺤﻮظ‬
ْ ‫ ﻓﺎﻗ‬.‫اﻟﺮﺋﻮﻳﺔ‬
‫ آﺎن هﻨﺎك ﻋﻼﻗﺔ ﺳﻠﺒﻴﺔ ﺑﻴﻦ ﺧﺜﺮة اﻷوردة اﻟﻌﻤﻴﻘﺔ ﻟﻠﺴﺎق اﻟﻮاﺿﺤﺔ ﺳﺮﻳﺮﻳًﺎ أَو ﻣﻦ ﻋﺪﻣﻪ وﺗﺸﺨﻴﺺ اﻻﺻﺎﺑﺔ‬.‫اﻟﻨﺴﺎﺋﻴﺔ واﻟﺘﻮﻟﻴﺪ‬
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.‫ اﻹرﺗﺒﺎط ﺑﻴﻦ اﻻﺻﺎﺑﺔ ﺑﺎﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ وأﺷﻌﺔ اﻟﺪوﺑﻠﺮ ﺣﻮل وﺟﻮد ﺧﺜﺮة اﻷوردة اﻟﻌﻤﻴﻘﺔ ﻟﻠﺴﺎق اﻳﺠﺎﺑﻲ‬.‫ﺑﺎﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ‬
.‫آﺎن هﻨﺎك ﻋﻼﻗﺔ إﻳﺠﺎﺑﻴﺔ ﺑﻴﻦ اﻻﺻﺎﺑﺔ ﺑﺎﻟﺠﻠﻄﺔ اﻟﺮﺋﻮﻳﺔ وﺗﺴﺎرع ﺿﺮﺑﺎت اﻟﻘﻠﺐ‬
T
he diagnosis of pulmonary embolism (PE)
is missed more often than it is made,
because PE often causes only vague and
nonspecific symptoms. Pulmonary embolism is
an extremely common and highly lethal
condition and that is why it is a leading cause
of death in all age groups. Risk factors for
venous thromboembolic disease include
increasing age, prolonged immobility, surgery,
trauma, malignancy, pregnancy, congestive
heart failure, and diseases that alter blood
viscosity(1).
Pregnancy by itself is a cause of
hypercoagulability state by production of
plasminogen inhibitors 1 and 2, and increasing
platelet aggregation. There is increase in
factors I, VII, VIII and X. Compression of the
inferior vena cava by the pregnant uterus
contributed to venous stasis (2,3).
Marked increase in the number of cases of
acute myocardial infarction had been reported
during winter (4). The increased serum lipids
levels, plasma viscosity, fibrinogen values,
factor VII:c levels, and platelet counts have
been reported to increase during cold seasons
which may also contribute to PE (5,6).
For the above reasons many pulmonologists
tried to study the seasonal variation of the
occurrence of PE and deep vein thrombosis
(DVT). Seasonal variation for DVT is not
established in many studies (7). Pulmonary
embolism on the other hand, had been
reported to have seasonal variation and
specifically for fatal PE as documented by
postmortem diagnosis (8).
The aim of this retrospective study is to look
for the presence or absence of seasonal
variation of PE among patients admitted to the
respiratory and intensive care units or general
medical units in Ibn-Sena Teaching Hospital in
Mosul. Furthermore, to analyze the effect of
age, sex and the presence or absence of DVT
on the occurrence of PE. Also to analyze the
ECG changes and the presence or absence of
sinus tachycardia in patient with acute PE.
Patients and Methods
One hundred three patients with PE were
studied retrospectively. Their age ranged 1789 year with a mean of 36.85. Thirty six males
and sixty seven females. Most of the them
were admitted to the respiratory and intensive
care unit or in the general medical units where
they were followed by physicians working in
the respiratory and intensive care unit, during
the years 2002-2007. The inclusion criteria
were for patients diagnosed and treated as PE
with or without clinically evident DVT. The
diagnosis of PE was usually done by history,
clinical examination, chest x-ray, pulse
oxymetry and electrocardiography with or
without
echocardiography.
Furthermore,
clinical signs and symptoms of deep venous
thrombosis, heart rate higher than 100
beats/min, immobilization (bed rest, except to
access the bathroom, for ≥ 3 consecutive
days) or surgery in the previous 4 weeks,
previous objectively diagnosed deep venous
or
pulmonary
embolism,
thrombosis
malignancy and pulmonary embolism as likely
as or more likely than an alternative diagnosis,
all the above mentioned signs or symptoms
were used to predict or diagnose PE.
D-dimer test was not available for most of the
times neither pulmonary angiography or
ventilation
perfusion
lung
scan.
The
occurrences of PE were recorded during each
month of the year to look for any seasonal
variation in the admission of these patients.
Statistical analysis was done by utilizing the
Chi-square test and observed / expected Chisquare for the distribution of PE among
patients according to age, month of admission,
sex, the presence or absence of clinically
evident DVT and pulse and ECG changes.
Also we identify the predisposing factors for
PE.
141
Vol. 35 No. 2, 2009
Results
found in 40 patients and negative in 48, (it was
not done in 15 patients, 7 female and 8 males)
and not all clinically suspected DVT were
positive; the association between the presence
of PE and positive doppler ultrasound was
significant with p-value of 0.023 as in table (5).
There was no statistically significant
association between PE and positive classical
ECG changes (i.e. S1Q3T3), with significant
difference between negative and positive ECG
changes with p-value of <0.001 in favor of
negative ECG changes as in table (6).
We found statistically significant association
between the presence of PE and sinus
tachycardia. Sinus tachycardia was present in
77. 7% of the patients, the p-value was <0.001
as in table (7).
The male patients with pulmonary embolism
mostly had orthopedic or pelvic surgery as
predisposing factors as shown in table (8).
Deep vein thrombosis was present alone or in
association with other diseases.
The female patients with pulmonary
embolism, on the other hand, mostly had
cesarean section, pregnancy and pelvic
surgery for gynecological and obstetric
diseases as predisposing factors as shown in
table (9). Deep vein thrombosis was present
alone or in association with other disease.
The one hundred three patients with PE were
studied. They were divided into seven age
groups as their age ranged from 17-89 year.
The analysis of the frequency of occurrence of
PE according to age groups indicates that the
age of the patients showed significant
association with the presence of PE, being
highest between 21-50 year of age (50 female
and 26 male), with p-value of <0.001 as in
table (1) below.
To analyze the distribution of PE according to
the seasons, the months of the years were
divided into six groups because of the small
number of patients per month i.e 1-2, 3-4 and
so on. There were no seasonal variation in the
distribution of PE with P-value of 0.06 as in
table (2).
The distribution of PE according to the
gender of the patients indicates that there
were 36 male and 67 females, with statistically
significant difference, females significantly
outnumbered males with P-value of (0.002) as
in table (3).
There was no significant difference in the
number of patients with clinically evident DVT
from those without. There was no statistically
significant association between the clinically
evident DVT or not and the diagnosis of PE
with p-value of 0.278 as in table (4).
Doppler ultrasound of leg veins was done in
88 patients. Positive results for DVT were
Table (1): Distribution of pulmonary embolism in patients according to age groups.
Female
Male
Number of patients
with PE
Percentage %
17-20
9
0
9
8.7
21-30
21
13
34
33.0
31-40
22
7
29
28.2
41-50
7
6
13
12.6
51-60
4
6
10
9.7
61-70
2
3
5
4.9
71-80
0
3
3
2.9
Age (year)
Total
103
p-value
<0.001
100
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Vol. 35 No. 2, 2009
Table (2): Distribution of pulmonary embolism
according to the groups of months.
Months
1-2
3-4
5-6
7-8
9-10
11-12
Total
Number of
patients with
of PE
Percentage
%
9
23
16
25
13
17
103
8.7
22.3
15.5
24.3
12.6
16.5
100
p-value
0.06 (NS)
Number of
patients with
PE
Percentage
%
Male
36
35.0
Female
67
65.0
Total
103
100
p-value
0.002
in patients with a positive DVT.
55.3
Total
103
100
p-value
0.278
in patients with positive Doppler.
54.5
Total
88
100
80
77.7
Negative Sinus
tachycardia
23
22.3
Total
103
100
<0.001
Table (8): Distribution of diseases Causing
Pulmonary Embolism in Male Patients.
Number
of
patients
8
17
9
11
5
36
Table (9): Distribution of diseases Causing
Pulmonary Embolism in female Patients.
Total
48
Positive Sinus
tachycardia
p-value
Pelvic
Surgery
Negative
Doppler
0.023
Percentage
%
Pregnancy
45.5
p-value
Number of
patients
with PE
Sinus
tachycardia
Cesarean
section
40
100
Deep Vein
Thrombosis
Positive
Doppler
103
Medical
Causes*
Percentage
%
Total
<0.001
Causes
Number of
patients
with PE
Doppler
Ultrasound
70.9
Total
57
73
Pelvic
Surgery
Negative
DVT
Negative
ECG
Orthopedic
surgery
44.7
29.1
Trauma
46
30
Deep Vein
Thrombosis
Positive
DVT
Positive
ECG
p-value
Medical
Causes*
Percentage
%
Percentage
%
Causes
Number of
patients
with PE
DVT
Number of
patients
with PE
ECG
CHANGES
and sinus tachycardia.
according to the sex of patients.
Sex of
patients
in patients with positive ECG changes.
Number
of
patients
9
23
16
15
13
67
*Medical causes e.g. chronic obstructive
airway diseases with or without respiratory
failure, diabetes mellitus, chronic renal failure,
and chronic cardiovascular diseases.
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Vol. 35 No. 2, 2009
Discussion
The inclusion criteria of patients with PE in this
study were based on clinical findings and the
recognition of predisposing factors which
increase the probability of PE. The female
patients mostly had pregnancy, cesarean
section or pelvic surgery which were mostly
gynecology and obstetrics surgery. The male
patients on the other hand mostly had
orthopedic or pelvic surgery. Furthermore, we
do not have the proper diagnostic investigative
facilities
i.e.
pulmonary
angiography,
ventilation perfusion lung scan, high resolution
lung scan and even doppler echo or d-dimer
test. The high resolution lung scan in our
hospital were deficient of injector until 2008,
the doppler ultrasound also were not available
freely till the early 2008. Clinical examination
of patients with PE and recognition of the
predisposing factors remains the cornerstone
of the diagnostic strategies for PE (9, 10).
The seasonal variation in the distribution of
PE was not clear in our patients as indicated
by the results in table (2).These results may be
explained by the fact that in our study ,female
patients outnumber the male patients ,and
pregnancy and its complications had no
relation to particular season. Our finding is
different from other studies; these studies
support the seasonal variation of PE (11). The
explanation of their findings were supported by
the fact that, vasoconstriction induced by cold
and reduced physical activity produce a well
documented reduction in blood flow in the
lower limbs. Hypercoagulability state might be
induced by cold weather and enhanced by
respiratory tract infections during that period
(6)
. While others claim that the seasonal
variation reported by some authors may be
due to the retrospective nature of the studies
in which there is no real indication of the "main
diagnosis” on discharge of these reported
patients. Since some investigators question
the whole issue and claim that, "patients as
well as doctors take vacations in summer,
resulting in a significant decrease in nonurgent surgical activities, admissions, and,
likely, surgery-related complications; similarly,
summer months have been shown to result in
a 20% decrease in admissions for pneumonia
and other emergency respiratory diseases" (12).
The distribution of PE according to the
gender of the patients in this study indicates
that there were more female than male
patients, with statistically significant difference
between them, with P-value of (0.002) as in
table (3). This result is different from other
studies where they report that males are more
commonly affected than females (13,14). The
only explanation of our finding may be due to
the fact that a large number of our patients
came from gynecological and obstetric
hospitals because they do not have proper
intensive care units.
The frequency of PE according to age groups
indicates that the highest incidence of PE were
between 21-50 year of age. In hospitalized
elderly patients, PE is commonly missed and
often is the cause of death. This speculation
may explain the small number of patients with
PE in the age group of 61-80 year of age. The
analysis of our results however, shows that the
age of the patients correlates significantly with
the presence of PE with p-value of <0.001 as
in table (1). Our finding is more or less
(although not clearly defined) is similar to other
studies where they found that for each 10-year
increase in age, the incidence of PE is
doubled(13,14).
In this study deep vein thrombosis was
clinically positive in 44.7% and negative in
55.3% of the patients with PE, with no
statistically significant association between
clinically present or clinically absent DVT with
p-value of 0.278. The presence or absence of
clinical DVT does not represent the real
incidence of DVT as venous thrombosis may
occur anywhere in the body. Deep vein
thrombosis in the calf, when considered alone,
has low predictive value (15%) for PE (15).
Furthermore it was found that few patients
with PE will have evident DVT so they even do
not recommend doppler ultrasound for DVT if it
is clinically absent during the investigation of
suspected PE (16).
The number of patients with positive doppler
ultrasound for DVT was found in 45.5% of the
patients and negative in 54.5%, though it was
not done in 15 patients (7 female and 8 males)
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Vol. 35 No. 2, 2009
and not all clinically suspected DVT had
positive doppler ultrasound. The association
between the presence of PE and positive
doppler ultrasound was statistically significant
with p-value of 0.023. The accuracy of doppler
ultrasound depends on the operator and
cannot distinguish between new clot or old
one. Furthermore, it is not sensitive in
detecting DVT in small vessel of the calf or in
detecting DVT in the presence of obesity or
significant edema as in patients with trauma.
In a study of 41 patients with positive
abnormalities on pulmonary angiography, the
results of leg venography were normal in 12
patients (17). There are many studies to
estimate the prevalence of DVT with PE which
indicates wide discrepancies ranging from 10
to 70% in pulmonary angiography based
studies and 25 to 93% in V/Q based studies,
and in meta-analysis study of the prevalence
of DVT in patients suspected PE was 18% and
in proven PE 36-45%(16, 18,19,20).
There was no statistically significant
association between PE and the finding of a
positive classical ECG changes. The number
of patients with negative classical ECG
changes outnumbered those with a positive
classical ECG changes. The number of
patients with PE and negative classical ECG
changes was statistically significant with pvalue of <0.001 in favor of negative ECG
changes. The abnormal classical ECG
changes in patients with PE is rather
nonspecific and its absence does not rule out
the diagnosis of PE (21).
Clinical examination of most of the patients in
this study revealed sinus tachycardia with a
positive correlation between the presence of
PE and sinus tachycardia. This finding is
consistent with other studies where they found
that in PE the most frequent clinical signs were
tachypnea and tachycardia (22,23).
Rodger M et al, from Canada found in 212
consecutive patients referred for V/Q or
Pulmonary angiogram for suspected PE only 2
abnormalities (tachycardia and incomplete
RBBB) significantly more prevalent in PE
positive than PE negative patients (24). In
another study of patients with positive or
negative PE, they found sinus tachycardia
present in (39% vs 24%) atrial tachy
arhythmias (15% vs 4%), Q3 (40% vs 26%)
and Q3T3 (8% vs1%) (25).
Furthermore, other investigators in an
observational study have compared 49
patients with pulmonary embolism with similar
number of people without PE. They found
sinus tachycardia in (18.8% vs 11.8%),
incomplete RBBB (4.2% vs 0%), S1Q3T3
(2.1% vs 0%) and S1Q3 (0 vs 0) (26).
All the previously mentioned studies support
our findings and add more insight to the
usefulness of the ECG recording and the
monitoring of pulse rate in patients with
suspected PE.
Conclusion
There were no seasonal variations in the
distribution of PE. PE being highest between
21-50 year of age with female patients
significantly outnumbered males. There was
strong association between the presence of
PE and positive doppler ultrasound for DVT.
Sinus tachycardias were commonly present
with acute PE. We need to have more
sophisticated facilities for proper diagnosis of
PE.
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electrocardiographic findings in patients
with acute pulmonary embolism and no
pre-existing cardiac or pulmonary disease.
Chest 1991;100:598-603.
Stein PD, Saltzman HA, Weg JG. Clinical
characteristics of patients with acute
pulmonary embolism. Am. J. Cardiol.
1991; 68: 1723-1724.
Stein PD, Terrin ML, Hales CA, et al.
Clinical laboratory, roentgenographic, and
electrocardiographic findings in patients
with acute pulmonary embolism and no
pre-existing cardiac or pulmonary disease.
Chest 1991;100:598-603.
Rodger M, Makropolous D, Turek M, et al.
Diagnostic value of the Electrocardiogram
in Suspected Pulmonary Embolism.
American Journal of Cardiology 2000; 86:
807-809.
Sinha N, Yalamanchili K, Sukhija R, et al.
Role of the 12-lead electrocardiogram in
diagnosing pulmonary embolism. Cardiol
in review 2005;13:46-9.
Richman PB, Louti H, Lester SJ, et al.
Electrocardiographic
findings
in
Emergency Department patients with
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27:121-6.
146
Vol. 35 No. 2, 2009
Non-compliance to treatment among type 2
diabetic men in Mosul: A case-control study
Waleed G.A. Al-Taee
Department of Community Medicine, College of Medicine, University of Mosul.
Received: 24th May 2009; Accepted: 10th Feb 2010.
ABSTRACT
Context: Non-compliance to treatment among diabetic patients is a world-wide problem and its
underlying risk factors can be the subject of many studies in different localities.
Objective: To identify risk factors for non-compliance to treatment plan among type 2 diabetic men
attending Al-Wafaa Center for diabetes in Mosul City.
Methods: A case-control study design has been adopted. A special questionnaire form has been
prepared and filled in by the investigator for each patient (case and control) through direct interview
with patients.
Results: Study results revealed a significant association between non-compliance and socioeconomic strata, duration of disease >10 years, number of tablets >2 daily, frequency of taking
medication >2, poor patient satisfaction about health personnel, body mass index >30 and sedentary
life style activities.
On the other hand, an inverse association was found between non-compliance and urban place of
residence, marriage, 10 and 20 school level of education, taking medical treatment without herbals and
type A personality.
Conclusion: The study concluded that health care professionals are in need to identify risky patients
for non-compliance and recommends to use the counseling approach of communication before
applying any individual patient management plan characteristics.
Keywords: Type 2 diabetes, compliance, treatment.
‫ ﻳﻌﺘﺒﺮ ﻋﺪم اﻟﺘﺰام ﻣﺮﺿﻰ اﻟﺴﻜﺮي ﺑﺎﻟﻌﻼج ﻣﻦ اﻟﻤﻌﻀﻼت اﻟﻌﺎﻟﻤﻴﺔ وإن دراﺳﺔ ﻋﻮاﻣﻞ اﻟﺨﻄﻮرة‬:‫ﺧﻠﻔﻴﺔ إﺟﺮاء اﻟﺪراﺳﺔ‬
. ‫ﻟﻌﺪم اﻹﻟﺘﺰام ﻣﻦ اﻷﻣﻮر اﻟﺘﻲ ﻳﻤﻜﻦ أن ﺗﺤﺪ ﻣﻦ ﻣﻀﺎﻋﻔﺎت اﻟﻤﺮض وﺗﺄﺛﻴﺮاﺗﻪ اﻟﺴﻠﺒﻴﺔ ﻋﻠﻰ ﺻﺤﺔ ﻣﺮﺿﻰ اﻟﺴﻜﺮي‬
‫ اﻟﻨﻮع اﻟﺜﺎﻧﻲ‬-‫ اﻟﺘﻌﺮف ﻋﻠﻰ ﻋﻮاﻣﻞ اﻟﺨﻄﻮرة ﻟﻌﺪم اﻹﻟﺘﺰام ﺑﺨﻄﺔ اﻟﻌﻼج ﻟﺪى اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﻴﻦ ﺑﺪاء اﻟﺴﻜﺮ‬:‫هﺪف اﻟﺪراﺳﺔ‬
. ‫واﻟﻤﺮاﺟﻌﻴﻦ ﻟﻤﺮآﺰ اﻟﻮﻓﺎء ﻟﺪاء اﻟﺴﻜﺮي ﻓﻲ ﻣﺪﻳﻨﺔ اﻟﻤﻮﺻﻞ‬
‫ ﺗﻢ اﺧﺘﻴﺎر ﺗﺼﻤﻴﻢ دراﺳﺔ اﻟﻌﻴﻨﺔ واﻟﺸﺎهﺪ ﺣﻴﺚ أﻋﺪ اﻟﺒﺎﺣﺚ ﻧﻤﻮذج ﺧﺎص ﻟﺠﻤﻊ اﻟﺒﻴﺎﻧﺎت ﺗﻢ ﻣﻸﻩ ﻣﻦ‬:‫ﻃﺮﻳﻘﺔ إﺟﺮاء اﻟﺪراﺳﺔ‬
.‫ﻗﺒﻞ اﻟﺒﺎﺣﺚ ﻟﻜﻞ ﻣﺮﻳﺾ )ﻋﻴﻨﺔ آﺎن أم ﺷﺎهﺪ( وﺑﺄﺳﻠﻮب اﻟﻤﻘﺎﺑﻠﺔ اﻟﻤﺒﺎﺷﺮة ﻣﻊ اﻟﻤﺮﻳﺾ‬
‫ أﻇﻬﺮت ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ وﺟﻮد ﻋﻼﻗﺔ إﺣﺼﺎﺋﻴﺔ ﻣﻌﻨﻮﻳﺔ ﺑﻴﻦ ﻋﺪم اﻻﻟﺘﺰام ﺑﺎﻟﻌﻼج وﺗﺪﻧﻲ اﻟﻤﺴﺘﻮى اﻹﻗﺘﺼﺎدي‬:‫ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ‬
،‫ وأﺧﺬ أﻗﺮاص ﻋﻼج أآﺜﺮ ﻣﻦ إﺛﻨﻴﻦ وﻷآﺜﺮ ﻣﻦ ﻣﺮﺗﻴﻦ ﺑﺎﻟﻴﻮم‬،‫ وﻣﺪة اﻹﺻﺎﺑﺔ ﺑﺎﻟﻤﺮض ﻷآﺜﺮ ﻣﻦ ﻋﺸﺮ ﺳﻨﻮات‬،‫ﻟﻠﻔﺮد‬
‫ وﺷﺤﺔ إﺟﺮاء اﻟﻨﺸﺎﻃﺎت اﻟﺒﺪﻧﻴﺔ ﻓﻲ ﻧﻤﻂ‬٣٠ ‫ وﻣﻌﻴﺎر اﻟﺒﺪاﻧﺔ أآﺜﺮ ﻣﻦ‬،‫ووﺟﻮد ﻋﺪم ﻗﻨﺎﻋﺔ ﻟﺪى اﻟﻤﺮﻳﺾ ﺑﺎﻟﻜﻮادر اﻟﺼﺤﻴﺔ‬
،‫ واﻟﺰواج‬،‫ وﻣﻦ ﻧﺎﺣﻴﺔ أﺧﺮى ﻓﻘﺪ ﻟﻮﺣﻆ وﺟﻮد ﻋﻼﻗﺔ إﺣﺼﺎﺋﻴﺔ ﻋﻜﺴﻴﺔ ﺑﻴﻦ ﻋﺪم اﻻﻟﺘﺰام ﺑﺎﻟﻌﻼج واﻟﺴﻜﻦ ﻓﻲ اﻟﻤﺪﻳﻨﺔ‬.‫اﻟﻤﻌﻴﺸﺔ‬
. ‫ وأﺧﺬ اﻟﻌﻼج اﻟﻄﺒﻲ ﺑﺪون أﻋﺸﺎب وﻧﻤﻂ اﻟﺸﺨﺼﻴﺔ‬،‫وﻣﺴﺘﻮى اﻟﺘﻌﻠﻴﻢ اﻻﺑﺘﺪاﺋﻲ واﻟﺜﺎﻧﻮي‬
147
Vol. 35 No. 2, 2009
‫ هﻨﺎك ﺣﺎﺟﺔ ﻣﻠﺤﺔ ﻟﻤﻘﺪﻣﻲ اﻟﺮﻋﺎﻳﺔ اﻟﺼﺤﻴﺔ ﻓﻲ اﻟﺘﺤﺪﻳﺪ اﻟﻤﺴﺒﻖ ﻟﻠﻤﺮﺿﻰ اﻟﻤﻌﺮﺿﻴﻦ ﻟﺤﺎﻟﺔ ﻋﺪم اﻻﻟﺘﺰام‬:‫اﺳﺘﻨﺘﺎﺟﺎت اﻟﺪراﺳﺔ‬
. ‫ﺑﺎﻟﻌﻼج وﺗﻮﺻﻲ ﺑﺎﻟﻠﺠﻮء إﻟﻰ اﺳﺘﺨﺪام أﺳﻠﻮب اﻟﻤﺸﺎورة اﻟﻄﺒﻴﺔ ﻣﻌﻬﻢ ﻗﺒﻞ اﻟﺒﺖ ﺑﺨﺼﺎﺋﺺ ﺧﻄﺔ اﻟﻌﻼج ﻷي ﻣﻨﻬﻢ‬
T
ype 2 diabetes is a complex metabolic
disorder of heterogeneous etiology with
social, behavioral, and environmental risk
factors unmasking the effects of susceptibility.
(1,2)
It is the most common clinical form of
diabetes worldwide; it accounts for about 9095% of all cases of diabetes globally (3). The
disease is typically treated with diet regimen,
life style changes and oral medication (1,2).
There is strong evidence that vigorous
treatment can decrease morbidity and
mortality
by
decreasing
its
chronic
complications (4).
Patient's non-compliance to treatment plan
influences glycemic control (5). A wide variety
of studies demonstrate that patients who fail to
adhere to the prescribed clinical regimens
have very poor outcomes (6,7) . The likelihood
of recurrent diabetic crises is related in part to
patient non- compliance (6,8,9) .
In diabetes care, non-compliance may
represent an important component of
unnecessary health care cost, especially
hospital costs. Thus the development of
effective and efficient methods to assess the
possible contributors to non -compliance in the
out-patient setting appears very desirable
(10,11)
.
Non compliant type 2 diabetics refer to those
patients who intentionally don't follow what
they are told about their illness and they don't
follow the recommendations including self
management behaviors, changes in lifestyle
and adherence to medication (12-15). In other
words, non-compliant diabetics disobey the
advice of their health care provider (16).
The concept of non-compliance not only
assumes a negative attitude toward patients,
but also places patients in a passive unequal
role in relationship to their care provider. Noncompliance is attributed to personal qualities of
patients, such as forgetfulness, lack of will
power or discipline, or low level of
education(17). The quality of provider-patient
relationship also influences compliance. (18-20)
Lower regimen adherence can be expected
when a health condition is chronic, when the
course of symptoms varies or when symptoms
are not apparent, when a regimen is more
complex, and when a treatment regimen
requires lifestyle changes (21,22) .
Study aim is to identify risk factors for noncompliance to treatment plan among type 2
diabetic men in Mosul.
Subjects and Methods
To start with, and in regard to ethical issue, a
seminar about the research protocol was
conducted at the Department of Community
Medicine. Also official permissions were
obtained from Al-Wafaa Center for diabetes
and Nineveh Health Directorate. Al-Wafaa
Center for diabetes is the only specialized
center in Mosul that deals with the
management of diabetic patients. It offers
services to all diabetics in Mosul city. It has
been established in 1999. A written consent
form has been prepared to be signed in by
each patient agreed to be involved in the
study. To achieve the aim of the present study
a case control study design has been adopted.
Study subjects are 310 male patients with
type 2 diabetes (150 cases and 160 controls)
within the age ≥18 years. All were taken
randomly from Al-Wafaa center attendants.
Cases were considered as non compliant
patient whose age was ≥18 years with type 2
diabetes for more than one year, and has at
least three of the following inclusion criteria:
1. Doesn't follow a proper dietary regimen .
2. Doesn't take medicine regularly.
3. Doesn't adopt measures to control his
bodyweight.
4. Doesn't conduct regular physical activity.
While controls included compliant patients
whose age was ≥18 years, with type 2
diabetes for more than one year, and has at
least three of the following inclusion criteria
including criterion number two:
148
Vol. 35 No. 2, 2009
1. Follows proper dietary regimen.
2. Takes medication regularly.
3. Follows proper weight control measures.
4. Adopts regular physical activity.
All the above mentioned inclusion criteria for
cases and control have been put by the
investigator and through a seminar which was
conducted
at
Community
Medicine
Department .
Data collection tool was a special
questionnaire
form
prepared
by
the
investigator through utilizing the available
related literatures and taking in consideration
the idea of the specialized physicians at the
Department of Community Medicine and AlWafaa Center for diabetes. All the
questionnaire items were reviewed by
community medicine teaching staff to consider
its validity and reliability which were 85%.
Economic status has been determined high,
middle or low according to the type of
occupation, presence or absence of private
house ownership and car ownership.
Statistical analysis was done after tabulation
of collected data; P value and odds ratio were
calculated, looking for any statistical
association between non compliance and
other factors.
Results
Study results revealed that 42% of study
population are within the age group 41-50
years, more than 80% of them are from urban
regions, married and with 10 and 20 school
education level. No significant difference was
obtained between compliants and noncompliants in regard to age, marital status and
level of education. However, a weak significant
difference between compliants and noncompliants has been found for place of
residence (p=0.048) while socio-economic
strata was significantly differs (p=0.000).
Table 2 shows a significant association
between non-compliance and
duration of
disease more than 10 years. A diabetic who
has the disease since more than 10 years is
almost twenty times not adherent to the
treatment plan as shown from the significant
values of p, odd ratio and 95% C.I. (p=0.000,
OR=18.4, 95%C.I. =10.28 – 33.04) .
In
regard
to
management
plan
characteristics, the results of the study reveals
a highly significant, association between noncompliance and number of tablets >2 and daily
frequency of drugs administration >2 with P
value of 0.000 and OR of 21.5 and 31.2
respectively (Table 3).
Table (1): Socio-demographic characteristics of study population.
Socio-demographic parameter
Age group
(in years)
<30
3040≥50
Mean±SD
Place of residence
Marital status
Level of education
Socio-economic
strata
Urban
Rural
Single
Married
Others
Illiterate
10 and 20 school
University
High
Middle
Low
non-compliants
n=150
No.
%
29
19.3
41
27.3
63
42.0
17
11.3
39.53±9.31
127
84.7
23
15.3
13
8.7
130
86.7
7
4.7
6
4.0
120
80.0
24
16.0
7
4.7
70
46.7
73
48.7
compliants
n=160
No.
%
31
19.4
46
28.8
67
41.9
16
10.0
39.25±9.15
147
91.9
13
8.1
7
4.4
150
93.8
3
1.9
3
1.9
133
83.1
24
15.0
37
23.1
80
50.0
43
26.9
P-Value
0.790*
0.048**
0.105**
0.510**
0.000**
* t-test was used
** chi square was used
149
Vol. 35 No. 2, 2009
Table (2): Association of non- compliance and duration of the disease
non-compliants
n=150
Duration of disease
(in years)
No.
129
21
>10
≤10
%
86.0
14.0
Compliants
n=160
%
25.0
75.0
No.
40
120
Odds ratio
%
95 % C.I
P-value
18.4
10.28 - 33.04
0.000
Table (3): Association between management plan parameters and non-compliance.
Management plan characteristics
Method
of
hyperglycemic
control
Number of tablets
Daily frequency in
taking medication
Way of taking
therapy
Medical
without
herbals
Medical with
herbals
>2
≤2
>2
1-2
Proper
Improper
noncompliants
n=150
No.
%
No.
%
21
157
98.0
14.0
compliants
n=160
129
86.0
3
1.9
124
26
127
23
40
110
82.7
17.3
84.7
15.3
26.7
73.3
29
131
24
136
147
13
18.1
81.9
15.0
85.0
91.9
8.1
Regarding
personal
characteristics
of
patients, table 4 shows a significant
association between non-compliance and poor
patient's satisfaction about health personnel,
Odds
ratio
95 % C.I
P-Value
0.0
0.001 – 0.011
0.000
21.5
12.020 - 38.615
0.000
31.2
16.816 – 58.221
0.000
0.0
0.016 – 0.063
0.000
body mass index>30 and sedentary life style
activity (p=0.000 and OR of 5.3, 20.2, and 10.6
respectively) .
Table (4): Association between health status variables and non-compliance.
noncompliants
n=150
No.
%
No.
%
Dissatisfied
83
55.3
30
18.8
Satisfied
67
44.7
130
81.2
117
78.0
40
25.0
33
22.0
120
75.0
7
4.7
31
19.4
25-29.9
17
11.3
96
60.0
≥30
126
84.0
33
20.6
A
29
19.3
156
97.5
B
121
80.7
4
2.5
0.0
Personal characteristic
Patient's
satisfaction about
health personnel
Personal state of
activity
Sedentary
lifestyle
Physically
active person
<25
Body mass index
Type of
personality
compliants
n=160
Odds
ratio
95 % C.I
P-Value
5.3
3.220 – 8.949
0.000
10.6
6.282 – 18.009
0.000
0.2
0.087 – 0.479
0.000
0.0
0.047 – 0.155
0.000
20.2
11.305 – 36.111
0.000
0.002 – 0.018
0.000
150
Vol. 35 No. 2, 2009
Discussion
A case-control study design was adopted. The
advantages of such design are better
availability of cases, it needs less time and
economically less expensive(23). On the other
hand, bias could occur in selection of cases
and/or controls. In addition no actual causation
can be proved; only associations between
disease and risk factors of interest can be
detected(24). Regarding limitations of the
present study, as it was conducted upon
patients attending Al-Wafaa Center for
diabetes, the study subjects might not
represent all diabetic patients in Mosul.
About 81% of cases and controls were from
the age groups above 30 years. Such result
could be explained through the fact that type 2
diabetes is typically an adult onset disease. No
significant difference was obtained between
cases and controls in regard to age, marital
status and level of education. Such result can
reflect the proper selection of cases and
controls.
More than 80% of cases and controls were
from urban places. Data from developing
countries show that diabetes is more prevalent
among urban population. Urbanization and
high socio economic status are associated
with the development of diabetes in
susceptible people as they adopt western life
style behavior which includes consumption of
unhealthy diet (25).
Around 80% of study population were within
the educational level of 1o and 20 school. Such
result can express the level of education
among such group in Mosul population(25).
From other point of view, (> 10 years)
duration of disease was found to carry higher
levels of non-compliance. Similar to the
findings of a study conducted in Canada: 62%
of people with diabetes for ≥ 15 years were
non-compliant(26).
In
regard
to
management
plan
characteristics, highly significant association
was found with (> 2 number of tablets) and
frequency
of
administration.
Perhaps
forgetfulness in taking drug is the problem. As
the number of pills increases and number of
times pills must be taken each day rises,
compliance fails(27). Patients who took the drug
once a day did a much better job at sticking
with their plan. They took correct number of
doses on more days, and they miss doses
often, less than those taking the drug twice aday. Drugs taken once a-day may have
important advantages over drugs taken twice
a-day in treatment of type 2 diabetes(25,28) .
A significant result was found between noncompliance and poor patient satisfaction about
health personnel. Making patient satisfied with
health personnel is one of the key elements to
success in achieving good glycemic control
(12,22,29)
. Negative view of patients toward their
doctor and poor provider communication have
lower compliance rates to oral medications
and self monitoring of blood glucose(33) .
The present study revealed that 84% of
cases have BMI >30 against 20.6% of
controls. Such high rate of obesity among non
compliant patients goes with the finding of ALChetachi(31) study which demonstrated that
88.3% of diabetic patients were over weight
and obese. Similar finding was documented by
Fadhil et al (32) in 2003.
Study results revealed that 78% of cases had
sedentary life style activities against only
18.8% of controls. Such result goes with the
findings of several studies(25,32,33). Exercise is
an important component in the management of
diabetes. The amount of regular physical
activity plays an important role in maintaining a
healthy body weight, and lowering the risk of
diabetes(34,35,36).
Conclusion
Identification of risk factors to non-compliance
to treatment is essential, prior to applying any
treatment method for diabetic patients in order
to overcome the problem of non-compliance.
Recommendations
Risky diabetic patients for non-compliance
need to be identified initially before applying
any method of management.
In dealing with diabetic patients, physicians
have to choose, when possible, the simplest
plan characteristics in regard to number of
tablets and daily frequency of administration.
For better patient satisfaction, health care
professionals are in need to use the
counseling approach of communication with
151
Vol. 35 No. 2, 2009
diabetic patients rather than the traditionally
used consultation approach.
Utilizing the mass media for diabetes related
health educational programs can improve
patient's knowledge and attitude towards
higher compliance rates.
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153
Vol. 35 No. 2, 2009
Assessing the effects of low dose aspirin on uric
acid and renal function in healthy adults
Jonaya Sarsam*, Yaser Adeep**
*Department of Pharmacolgy, College of Medicine; ** Department of Pharmacology, College of Pharmacy,
University of Mosul.
(Ann. Coll. Med. Mosul 2009; 35(2): 154 -159).
Received: 28th Sep 2009; Accepted: 24th Mar 2010.
ABSTRACT
Objective: To evaluate the effects of low daily aspirin doses on uric acid (UA) level and renal
functions in healthy adults.
Methods: Healthy adults were randomized to receive 100 mg (n= 33), or 300 mg (n = 31) aspirin daily
for one month. Laboratory tests included measurement of blood urea nitrogen (BUN), serum
creatinine, and uric acid (UA) levels. Urine creatinine, urea and uric acid excretion were measured in
a 24 h collection of urine, 24 hours urine uric acid, creatinine clearance (Ccr), were measured at
baseline and then after 4 weeks of therapy.
Results: After 4 weeks of therapy, 100 and 300 mg/d dosage, aspirin caused a 7% and 12%
decrease in the rate of UA excretion respectively (P< 0.05). Patients at the dosage 300 mg/d but not
the 100mg/day had an increase in serum levels of uric acid (UA), creatinine and urea with a
significant decrease in 24 hour creatinine clearance and urinary urea excretion (P<0.05) when
compared with the baseline.
Conclusion: Because of the effects of 300 mg dose aspirin, in the lowering of kidney function and the
potential of aspirin to cause dose-dependent impairment of renal function, patients taking low-dose
aspirin therapy should be monitored for the development of impaired renal function.
Keywords: Low dose aspirin, renal function, healthy adult.
‫ﻦ اﻟﻤﺘﺪﻧﻴﺔ اﻟﻴﻮﻣ ِﻴﺔ ﻋﻠﻰ ﻣﺴﺘﻮى اﻟﺤﺎﻣﺾ اﻟﺒﻮﻟﻲ ووﻇﺎﺋﻒ اﻟﻜﻠﻰ ﻓﻲ اﻟﺒﺎﻟﻐﻴﻦ‬
ِ ‫ ﺗَﻘﻴﻴﻢ ﺗﺄﺛﻴﺮات ﺟﺮﻋﺎت اﻷﺳﺒﻴﺮﻳ‬:‫اﻟﻬــﺪف‬
.‫اﻻﺻﺤّﺎء‬
(‫ ﻣﻠﻐﻢ‬٣٠٠ ‫ واﺣﺪ وﺛﻼﺛﻮن ﺷﺨﺼﺎ أﻋﻄﻮا‬،‫ ﻣﻠﻐﻢ‬١٠٠ ‫ أﻋﻄﻲ اﻷﺳﺒﻴﺮﻳﻦ ﻋﺸﻮاﺋﻴﺎ )ﺛﻼث وﺛﻼﺛﻮن ﺷﺨﺼﺎ أﻋﻄﻮا‬:‫اﻟﻄﺮﻳﻘﺔ‬
‫ آﺮﻳﺎﺗﻴﻨﻴﻦ ﻓﻲ‬،‫ ﻳﻮرﻳﺎ ﻧﺘﺮوﺟﻴﻦ‬،‫ ﺷﻤﻞ اﻟﻔﺤﺺ اﻟﻤﺨﺘﺒﺮي آﻤﻴﺔ اﻟﺤﺎﻣﺾ اﻟﺒﻮﻟﻲ‬.‫ أﺳﺎﺑﻴﻊ‬٤ ‫اﻟﻰ اﻟﺒﺎﻟﻐﻴﻦ اﻷﺻﺤﺎء ﻳﻮﻣﻴﺎ ﻟﻤﺪة‬
‫ أﺳﺎﺑﻴ ِﻊ ﻣﻦ إﻋﻄﺎء‬٤ ‫ل ﻗﺒﻞ وﺑﻌﺪ‬
ِ ‫ ﺳﺎﻋﺔ ﺑﻮ‬٢٤ ‫ اﻟﺤﺎﻣﺾ اﻟﺒﻮﻟﻲ واﻟﻴﻮرﻳﺎ ﻧﺘﺮوﺟﻴﻦ ﻓﻲ اﻟـ‬،‫ ﻃﺮح اﻟﻜﺮﻳﺎﺗﻴﻨﻴﻦ‬،‫ﻣﺼﻞ اﻟﺪم‬
.‫اﻻﺳﺒﻴﺮﻳﻦ‬
‫ ﻧﻘﺼﺎن ﻓﻲ ﻧﺴﺒﺔ ﻃﺮح اﻟﺤﺎﻣﺾ‬%١٢‫ و‬%٧ ‫ ﻣﻠﻐﻢ أﺳﺒﻴﺮﻳﻦ ﻳﻮﻣﻴﺎ ﺗﺴﺒّﺒﺖ ﺑـ‬٣٠٠ ‫ ﻣﻠﻐﻢ و اﻟـ‬١٠٠ ‫ ان ﺟﺮﻋﺔ اﻟـ‬:‫اﻟﻨﺘﺎﺋـﺞ‬
‫ ﻣﻠﻐﻢ آَﺎن ﻋﻨﺪهﻢ زﻳﺎدة ﻓﻲ ﻣﺴﺘﻮﻳﺎت‬١٠٠ ‫ ﻣﻠﻐﻢ وﻟﻴﺲ‬٣٠٠ ‫ ﻣﺮﺿﻰ اﻟﻌﻴﻨﺔ‬،‫ ﻋﻠﻰ أﻳﺔ ﺣﺎل‬.‫ أﺳﺎﺑﻴﻊ‬٤ ‫اﻟﺒﻮﻟﻲ ﻋﻠﻰ اﻟﺘﻮاﻟﻲ ﺑﻌﺪ‬
‫ﻦ واﻟﻴﻮرﻳﺎ ﻣﻘَﺎرﻧﺔ ﻣﻊ ﻣﺎ ﻗﺒﻞ‬
ِ ‫ اﻟﻜﺮﻳﺎﺗﻨﻴﻦ واﻟﻴﻮرﻳﺎ ﻓﻲ ﻣﺼﻞ اﻟﺪم ﻣﻊ ﻧﻘﺺ ﻣﻌﻨﻮي ﻓﻲ ﻃﺮح اﻟﻜﺮﻳﺎﺗﻨﻴ‬،‫ﺾ اﻟﺒﻮﻟﻲ‬
ِ ‫اﻟﺤﺎﻣ‬
.‫اﻟﻌﻼج‬
‫ ﻣﻠﻐﻢ اﺳﺒﻴﺮﻳﻦ ﻳﻮﻣﻴﺎ ﻓﻲ ﺿﻌﻒ اﻟﻮﻇﻴﻔﺔ اﻟﻜﻠﻮﻳﺔ وإﻣﻜﺎﻧﻴﺔ اﻷﺳﺒﻴﺮﻳﻦ ﻓﻲ ﺗﺴ ّﺒﺐ‬٣٠٠ ‫ ﺑﺴﺒﺐ ﺗﺄﺛﻴﺮ ﺟﺮﻋﺔ اﻟـ‬:‫اﻻﺳﺘﻨﺘﺎج‬
‫ اﻟﻤﺮﺿﻰ اﻟﻠﺬﻳﻦ ﻳﺄْﺧﺬون ﺟﺮع ﻣﻨﺨﻔﻀﺔ ﻣﻦ ﻋﻼج أﺳﺒﻴﺮﻳﻦ ﻳﺠِﺐ ﻣﺘﺎﺑﻌﺔ ﺣﺎﻟﺘﻬﻢ‬.‫ﺿﻌﻒ وﻇﻴﻔﺔ اﻟﻜﻠﻴﺔ اﻟﻤﻌﺘﻤﺪ ﻋﻠﻰ اﻟﺠﺮﻋ َﺔ‬
.‫ﻷي ﺗﻄﻮر ﻳﻀﻌﻒ اﻟﻮﻇﻴﻔﺔ اﻟﻜﻠﻮﻳﺔ‬
154
Vol. 35 No. 2, 2009
T
reatment
with
low-dose
aspirin
(acetylsalicylic acid) offers beneficial
effects
on patients with atherothrombotic
vascular disease (1). The therapeutic efficacy
of low-dose aspirin is due to irreversibly
acetylating cyclooxygenase-1 (COX-1), and
thereby reduces thromboxane A2 produced by
platelets. TA2 is a potent inducer of platelet
aggregation and vasoconstriction (2).
Although aspirin is generally a very welltolerated drug, like most medications it carries
a risk of significant adverse effects, many of
which are dose-related (3). Aspirin has a
biphasic effect on urate excretion (that is,
antiuricosuria at low doses and uricosuria at
high doses) (4). Minimal doses of salicylate
(75, 150, and 325 mg daily) were shown to
increase serum uric acid levels (5). On the
other hand, in high doses (as may be used to
treat rheumatoid arthritis), aspirin blocks
reabsorption of uric acid by the kidneys,
resulting in a lowering of the blood level of uric
acid (6,7). The changing of uric acid levels
above or below normal levels could possibly
lead to unwanted side effects (8).
Hyperuricemia has long been associated with
renal disease. Approximately 20 to 60% of
patients with gout have mild or moderate renal
dysfunction; indicating a possible link between
an elevated uric acid level and renal disease(9).
Also, an elevated uric acid has been reported
to predict the development of renal
insufficiency in individuals with normal renal
function (10).
Several studies have identified the value, in
populations, of serum uric acid concentration
in predicting the risk of cardiovascular
events(11-13).
In an experimental hyperuricaemic rat model
study, Kang et al(14) provided evidence that
uric acid may be a true mediator of renal
disease and progression.
A possible mechanism by which uric acid
may worsen the progression of kidney disease
is by the activation of the renin angiotensin
system (RAS). The RAS has been identified as
a contributor to the progression of renal
disease by increasing both systemic and
glomerular pressure and by directly causing
the fibrosis of renal and vascular cells(14,15).
Low dose aspirin has been reported to be a
risk factor of hyperuricemia (5). Therefore the
present study was designed to assess the
effects of the daily use of low dose aspirin on
uric acid and renal functions in healthy adult.
Subjects and methods
Subjects
The study group consisted of 64 healthy adult
volunteers. There were 31 men and 33women
aged 30 to 50 years, mean 39±6.9 (SD).
Healthy volunteers were asked to complete a
questionnaire to detect the history of urinary
tract infection (UTI), renal stone, hematuria,
and renal stones in the family. Any one with
one of these abnormalities was excluded from
the study. They were randomly assigned to 1
of 2 groups: one group received 100 mg/day
(n=33,16 females and 17 males) and the other
300 mg/day (n=31,16 females and 15 males).
Aspirin ( was given as Aspin® (SDI) enteric –
coated tablet) for 4 weeks. The doses selected
for investigation in this trial (100 and 300 mg)
reflect the current, most frequently used for
cardioprotection.
All study participants had 24-h urinary and
fasting blood samples collected prior to dosing
and 4 weeks following aspirin treatment, for
measurement of serum creatinine, uric acid
and urea concentrations and 24-hour urinary
excretion of creatinine, uric acid, and urea.
Laboratory assessment of creatinine, uric
acid, and urea
Creatinine was determined by standard
laboratory procedures(16) utilizing a commercial
kit (Syrbio). Uric acid and urea levels were
measured enzymatically with commercially
available kits (Biolabo for uric acid
measurement by the Tietz method (17);
BioMerieux for urea measurement by the
Fawcett and Scott method (18)).
Clearances of creatinine, uric acid and urea
were calculated as the products of urine
concentrations and 24-hour urine collection
divided by the serum concentrations and
expressed as ml/min using the following
formulas for calculations:
1. Creatinine clearance= urinary creatinine
(mg/dl) × 24-hour urine collection (ml)/
155
Vol. 35 No. 2, 2009
serum creatinine (mg/dl ×1440 (min in
24hr)).
2. Uric acid clearance= urinary uric acid
(mg/dl) × 24-hour urine collection (ml) /
serum uric acid (mg/dl) multiplied by 1440.
3. Urea clearance= urinary urea (mg/dl) ×24hour urine collection (ml)/ serum urea
(mg/dl) multiplied by 1440.
Comparison of kidney function parameters
before and after aspirin therapy was done by
paired t-test and the unpaired t-test to
compare the differences between the 2
groups. Pearson correlation was applied to
evaluate the correlations of serum parameters
with urine parameters. Gender differences
were evaluated to see if the effect of acetyl
salicylic acid varied according to sex.
Results
100 mg/d of aspirin did not significantly affect
serum uric acid, creatinine and urea levels,
whereas it significantly decreased by 21% and
6.74% 24h urinary uric acid fraction and uric
acid clearance rate respectively (Table1).
While 300 mg/d aspirin, caused a significant
elevation in serum uric acid, creatinine and
urea levels, with a significant reduction in the
24h-urinary fractional excretion, and the 24
urine uric acid, creatinine clearance (Table1).
The percent increase in serum uric acid in
300mg/d of-aspirin users was 3-fold compared
with 100 mg/d –aspirin users (300mg/d -aspirin
users versus 100 mg/d -aspirin users,
6.12±4.29% versus 2.14±4.24%, P < 0.05).
A significant correlation between the changes
from baseline to week 4 in both creatinine and
uric acid clearance was documented (r =
0.278, P < 0.042) (Figure 1).
After 4 weeks of 300 and 100 mg/d aspirin
administration (Figure 2), women exhibited a
higher percent change of serum creatinine
compared with the men (9.34 ± 7.48% versus
2.86 ± 3.91%, P < 0.05 and 2.66±1.79%
versus 1.0±1.58%, P<0.05 respectively). The
percent of decline in 24h creatinine clearance
with 300 mg/d aspirin administration was
in women compared with men
greater
(women, -9.8 ± 5.12%; men,- 4.78 ± 6.1 %; P <
0.05).
Table (1): Treatment with low doses of aspirin and alteration in uric acid and renal function
parameters in serum and 24h urine.
Serum Uric Acid
(mg/dl)
Fractional
Excretion of Uric
Acid(mg/dl
Uric Acid
Clearance
(ml/min)
Serum
Creatinine
(mg/dl)
Urine Creatinne
(mg/dl)
CrCl (ml/min)
Serum Urea
(mg/dl)
Urine Urea
(mg/dl)
Aspirin 100 mg/day (no.33)
After 4
Baseline
% change
weeks
Aspirin 300 mg/day (no.31)
Baseline
After 4
% change
weeks
5.01±1.09
5.04±1.04
2.14±4.24
5.09±1.06
5.31±1.01*
6.12±4.29
46.69±15.03
31.82±10.4*
-21.26±20.4
40.73±12.16
22.11±9.13*
-38.3±13.42§
8.32±1.34
7.45±1.37*
-6.74±6.1
8.47±1.45
7.08±1.42*
-12.41±7.24
1.04±0.23
1.06±0.21
1.16±5.01
0.96±0.19
1.04±0.17*
4.43±4.15
131±28
128±25
-2.94±9.07
109±15
98±13*
-11.66±7.95§
108±16
106±14
-1.13±4.89
106±13
97±11*
-8.61±6.54§
29.79±6.37
30.13±6.69
1.05±3.1
29.74±4. 79
31.46±3.92*
3.76±2.86§
1865±312
1836±318
-1.63±5.6
1816±391
1693±271*
-8.18±6.15§
§
§
§
Data are mean±(SD) * P<0.05 versus baseline;
§ Values are number (percentage) P<0.05 versus 100 mg/day aspirin.
156
Vol. 35 No. 2, 2009
Fig. (1): Correlation of 24h-creatinine
clearance with 24h-uric acid clearance before
and after 4 week aspirin treatment.
e
*P<0.05
Fig. (2): Sex difference A- in percentage
change serum creatinine level B- percentage
change 24h creatinine clearance after 4 week
300 mg/d aspirin treatment.
Discussion
In this study, low-dose aspirin has been shown
to produce a dose-dependent depression of
renal function in healthy adults. After 4 weeks
of treatment there was a significant increase
(from baseline to end of study) in serum uric
acid, creatinine and urea levels in aspirin 300
mg/d users, but not with 100 mg per day
aspirin users, with a marked reduction in
creatinine clearance rate and urine urea.
However at both doses of aspirin, a significant
reduction in the fractional excretion of uric acid
and uric acid clearance were observed.
Comparing our results with those of previous
studies, Louthrenoo et al(19) found that both
300 mg/d and 60 mg/d doses of aspirin
decreased the fractional excretion of uric acid
after 2 weeks of therapy. A relatively
significant decreased uric acid clearance and
creatinine clearance was found in those who
were on 300 mg/day aspirin therapy only.
While serum creatinine and uric acid
concentration, remained stable during both
drug administration periods. The important
differences between these studies included
aspirin dosages and duration of therapy.
A related result on the effects of the current
low dose aspirin regimens (75–325 mg/day)
for cardiovascular disease prevention were
previously studied in two groups of elderly
patients(20,21). They found that these doses of
aspirin were capable of inducing a significant
decrease in both creatinine and uric acid
excretion within 1–2 weeks. One week after
the drug was withdrawn, uric acid excretion
returned to normal while creatinine clearance
remained low. In another trial Segal et al(22)
reported that Mini-dose aspirin, even at a
dosage of 75 mg/day, caused significant
changes in renal function and UA handling
within 1 week in a group of elderly inpatients,
mainly
in
those
with
preexisting
hypoalbuminemia.
In contrast, when Low
doses (100 mg/ day) of aspirin were
administered in gouty arthritis patients treated
with allopurinol or benzbromarone for 4 weeks
did not influence serum uric acid level or
urinary uric acid excretion(23).
Small doses of aspirin can increase the level
of uric acid in the blood (24), via effects on the
urate/anion transport mechanism in the renal
proximal tubule(25); conditions that cause a
reduction in the glomerular filtration rate, a
decrease in the excretion of uric acid, or an
increase in overall tubular absorption(12,26).
This seems to be the case for the association
of hyperuricemia with impaired GFR (27,28).
Low-doses of aspirin are associated with an
increase in serum uric acid levels(5) , and it is
suggested that raising uric acid levels can
stimulate the renin- angiotensin- system
accelerating the development of renal
microvascular disease, which could be
mediated by its effect to upregulate
angiotensin-1 receptors on vascular smooth
muscle cells(29) and thereby predispose the
patient to renal disease progression(30,31).
157
Vol. 35 No. 2, 2009
The relation of serum uric acid to
development of renal impairment in healthy
individuals has been reported in clinical
studies. Iseki et al(10) followed 6403 adults and
found that a uric acid of 8.0 mg/dl conferred a
2.9-fold risk in men and a 10.4-fold risk in
women for developing elevated creatinine after
controlling for multiple risk factors.
A recent epidemiologic study(32), determined
the risks of elevated levels of uric acid, on the
progress of new-onset kidney disease in
healthy
individuals.
During
follow-up
examinations, the researchers assessed
glomerular filtration rates. They reported that
individuals in the slightly elevated uric acid
group were 1.26 times as likely to develop
kidney disease as those in the low uric acid
group. The odds of developing kidney disease
among volunteers in the elevated uric acid
group were 1.63 times greater than that of
individuals in the low uric acid group.
In this study, creatinine clearance and serum
creatinine were found to be higher among
women as compared to that in men indicating
that women are at higher adverse effect on
renal function. This may be because of the sex
differences
in
acetylsalicylic
acid
pharmacokinetics and pharmacodynamics that
may affect aspirin dosing and efficacy. Women
are reported to have slower clearance of
acetylsalicylic acid and, therefore, higher
circulating levels(33). There is also a study
suggesting that the clinical efficacy of aspirin
may be sex-dependent(34). Uric acid plays a
this
role in platelet
adhesiveness(35);
relationship between serum uric acid and risk
in aspirin-treated patients has prompted
speculation that treatment-mediated elevation
of serum uric acid might attenuate some of
their potential benefits on platelet and
endothelial function to increase the risk of
vascular related events.
In conclusion our results agree with those of
previous research in that aspirin causes a
dose-dependent impairment of renal function.
A dosage of 300 mg/day aspirin was found to
induce a significantly higher changes in renal
function and secretion of uric than 100
mg/day. The dosage of 100 mg/day aspirin
can be used with more safety during the
treatment. The observation, however, did not
suggest to neglect a careful laboratory
examination when low dose aspirin is added
to therapy in order to ensure their safety.
References
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R, Baigent C. Low-dose aspirin for the
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2. Weisman SM, Graham DY. Evaluation of
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Vol. 35 No. 2, 2009
The effect of nandrolone decanoate on liver of rabbits
using histological and ultrasound methods
Rand A. Hasso*, Mohammed Taib Tahir*, Sameer Abdullateef**
*Department of Anatomy, ** Department of Radiology, College of Medicine, University of Mosul.
Received: 17th Jun 2009; Accepted: 24th Mar 2010.
ABSTRACT
Objective: To compare the effects of nandrolone decanoate on the liver structure in male and female
rabbits using histological and ultrasound examinations.
Materials and methods: Forty-eight adult rabbits were divided into two groups, male and female
groups, each included 24 adult healthy rabbits. The male group was subdivided into 4 subgroups,
group A was the control group which received only normal saline, group B was given nandrolone
decanoate 2mg/kg body weight, group C was given 4 mg/kg body weight of nandrolone decanoate,
while group D was given 6 mg/kg body weight of the drug. The female group was also subdivided into
4 subgroups, group A1 was the control group, group B1 was given 2 mg/kg body weight, group C1
was given 4 mg/kg body weight, group D1 was given 6 mg/kg body weight of nandrolone decanoate.
Results: All treated groups of both sexes showed a significant increase in body and liver weights in
addition to dose related pathological changes ranging from mild to severe form, including vacuolar
degeneration and fatty degenerative changes of hepatocytes. In addition, there was a dilatation and
congestion of sinusoids, central venules and portal veins with mononuclear inflammatory cells
infiltration. Focal areas of necrosis with chronic inflammatory cells infiltration were also noticed in
different hepatic lobules. In spite of these histological changes in the liver no abnormal ultrasound
findings of the liver were noticed.
Conclusion: These changes indicate that the histological effects of the anabolic androgenic steroid
nandrolone decanoate on the liver of adult male and female rabbits is the same in both sexes, but the
treated female rabbit groups of medium and high doses (C1 and D1) showed more increase in body
weight than male rabbit groups. There is no correlation between histological and ultrasound findings.
Keywords: Nandrolone decanoate, liver histology, rabbits.
‫ ﻟﻤﻘﺎرﻧﺔ اﻟﺘﺄﺛﻴﺮ اﻟﺪواﺋﻲ ﻟﻠﻨﺎﻧﺪروﻟﻮن دﻳﻜﺎﻧﻮﻳﺖ ﻋﻠﻰ اﻟﻜﺒﺪ ﺑﻴﻦ ذآﻮر وإﻧﺎث اﻷراﻧﺐ ﺑﺎﺳﺘﻌﻤﺎل اﻟﻮﺳﺎﺋﻞ‬:‫أهﺪاف اﻟﺪراﺳﺔ‬
.‫اﻟﻨﺴﻴﺠﻴﺔ واﻷﻣﻮاج ﻓﻮق اﻟﺼﻮﺗﻴﺔ‬
‫ ﻣﺠﻤﻮﻋﺔ‬.‫ أرﻧﺐ ﺑﺎﻟﻎ ﻣﻌﺎﻓﻰ‬٢٤ ‫ أرﻧﺐ ﺑﺎﻟﻎ ﺗﻢ ﺗﻘﺴﻴﻤﻬﻢ إﻟﻰ ﻣﺠﻤﻮﻋﺘﻴﻦ ذآﻮر وإﻧﺎث آﻞ ﻣﺠﻤﻮﻋﺔ ﺗﺤﻮي ﻋﻠﻰ‬٤٨ :‫اﻟﻄﺮﻳﻘﺔ‬
(‫ ﻣﺠﻤﻮﻋﺔ )ب‬،‫ ﻣﺠﻤﻮﻋﺔ )أ( هﻲ ﻣﺠﻤﻮﻋﺔ اﻟﺴﻴﻄﺮة وﻗﺪ ﺣﻘﻨﺖ ﺑﻤﺤﻠﻮل اﻟﻤﻠﺢ اﻟﻘﻴﺎﺳﻲ ﻓﻘﻂ‬،‫ ﻣﺠﺎﻣﻴﻊ‬٤ ‫اﻟﺬآﻮر ﻗﺴﻤﺖ إﻟﻰ‬
‫ ﻣﺠﻤﻮﻋﺔ )د( ﺣﻘﻨﺖ ﺑـ‬،‫أﺳﺒﻮع‬/‫آﻐﻢ‬/‫ﻣﻎ‬٤ ‫ ﻣﺠﻤﻮﻋﺔ )ج( ﺣﻘﻨﺖ ﺑـ‬،‫أﺳﺒﻮع‬/‫آﻐﻢ‬/‫ﻣﻎ‬٢ ‫ﺣﻘﻨﺖ ﺑﺎﻟﻨﺎﻧﺪروﻟﻮن دﻳﻜﺎﻧﻮﻳﺖ‬
‫( هﻲ ﻣﺠﻤﻮﻋﺔ اﻟﺴﻴﻄﺮة وﻗﺪ ﺣﻘﻨﺖ ﺑﻤﺤﻠﻮل‬١‫ ﻣﺠﻤﻮﻋﺔ ) أ‬،‫ ﻣﺠﺎﻣﻴﻊ‬٤ ‫ ﻣﺠﻤﻮﻋﺔ اﻹﻧﺎث أﻳﻀﺎ ﻗﺴﻤﺖ إﻟﻰ‬.‫أﺳﺒﻮع‬/‫آﻐﻢ‬/‫ﻣﻎ‬٦
‫( ﺣﻘﻨﺖ ﺑـ‬١‫ ﻣﺠﻤﻮﻋﺔ )ج‬،‫أﺳﺒﻮع‬/‫آﻐﻢ‬/‫ﻣﻎ‬٢ ‫( ﺣﻘﻨﺖ ﺑﺎﻟﻨﺎﻧﺪروﻟﻮن دﻳﻜﺎﻧﻮﻳﺖ‬١‫ ﻣﺠﻤﻮﻋﺔ )ب‬،‫اﻟﻤﻠﺢ اﻟﻘﻴﺎﺳﻲ ﻓﻘﻂ‬
.‫أﺳﺒﻮع‬/‫آﻐﻢ‬/‫ﻣﻎ‬٦ ‫( ﺣﻘﻨﺖ ﺑـ‬١‫ ﻣﺠﻤﻮﻋﺔ ) د‬،‫أﺳﺒﻮع‬/‫آﻐﻢ‬/‫ﻣﻎ‬٤
160
Vol. 35 No. 2, 2009
‫ ﺟﻤﻴﻊ اﻟﻤﺠﺎﻣﻴﻊ اﻟﻤﻌﺎﻟﺠﺔ ﻟﻜﻼ اﻟﺠﻨﺴﻴﻴﻦ أﻇﻬﺮت زﻳﺎدة ﻣﻠﺤﻮﻇﺔ ﻓﻲ أوزان اﻟﺠﺴﻢ واﻟﻜﺒﺪ ﺑﺎﻹﺿﺎﻓﺔ إﻟﻰ ﺗﻐﻴﻴﺮات‬:‫اﻟﻨﺘﺎﺋـــﺞ‬
.‫ﻣﺮﺿﻴﺔ ﻣﺘﻌﻠﻘﺔ ﺑﺎﻟﺠﺮﻋﺔ ﺗﺘﺮاوح ﺑﻴﻦ ﻣﻌﺘﺪل إﻟﻰ ﺷﺪﻳﺪ اﻟﺸﻜﻞ ﺗﺘﻀﻤﻦ ﺗﻨﻜﺲ ﻓﺠﻮي و ﺗﻨﻜﺲ دهﻨﻲ ﻓﻲ اﻟﺨﻼﻳﺎ اﻟﻜﺒﺪﻳﺔ‬
‫ اﻷوردة اﻟﻤﺮآﺰﻳﺔ واﻷوردة اﻟﺒﺎﺑﻴﺔ ﻣﻊ وﺟﻮد ﻣﻨﺎﻃﻖ ﺑﺆرﻳﺔ ﻧﺨﺮﻳﺔ ﺗﺤﻮي‬،‫ﺑﺎﻹﺿﺎﻓﺔ إﻟﻰ ﺗﻮﺳﻊ واﺣﺘﻘﺎن ﻓﻲ اﻷوردة اﻟﺠﻴﺒﻴﺔ‬
‫ وﻻ ﻳﻮﺟﺪ ﺗﺸﺎﺑﻪ ﺑﻴﻦ اﻟﺘﻐﻴﺮات اﻟﻨﺴﻴﺠﻴﺔ اﻟﺤﺎﺻﻠﺔ وﻓﺤﻮﺻﺎت اﻟﻤﻮﺟﺎت‬،‫ﺧﻼﻳﺎ اﻟﺘﻬﺎﺑﻴﺔ ﻣﺰﻣﻨﺔ ﻓﻲ ﻓﺼﻴﺼﺎت آﺒﺪﻳﺔ ﻣﺨﺘﻠﻔﺔ‬
.‫ﻓﻮق اﻟﺼﻮﺗﻴﺔ‬
‫ اﻟﺘﺄﺛﻴﺮ اﻟﻨﺴﻴﺠﻲ واﻟﻤﺮﺿﻲ ﻟﻠﻨﺎﻧﺪروﻟﻮن دﻳﻜﺎﻧﻮﻳﺖ ﻋﻠﻰ آﺒﺪ ذآﻮر وإﻧﺎث اﻷراﻧﺐ اﻟﺒﺎﻟﻐﺔ هﻮ ﻣﻤﺎﺛﻞ ﻓﻲ آﻼ‬:‫اﻟﺨﻼﺻﺔ‬
‫( أﻇﻬﺮت زﻳﺎدة أآﺜﺮ ﻓﻲ وزن‬١‫ د‬,١‫ إن ﻣﺠﻤﻮﻋﺎت اﻷراﻧﺐ اﻹﻧﺎث اﻟﻤﻌﺎﻟﺠﺔ ﺑﺎﻟﺠﺮﻋﺔ اﻟﻤﺘﻮﺳّﻄﺔ واﻟﻌﺎﻟﻴﺔ )ج‬.‫اﻟﺠﻨﺴﻴﻴﻦ‬
‫ وﻋﻠﻰ اﻟﺮﻏﻢ ﻣﻦ ﺣﺪوث هﺬﻩ اﻟﺘﻐﻴﺮات اﻟﻨﺴﻴﺠﻴﺔ آﺎﻧﺖ ﻓﺤﻮﺻﺎت اﻷﻣﻮاج ﻓﻮق‬.‫اﻟﺠﺴﻢ ﻣﻦ ﻣﺠﻤﻮﻋﺎت اﻷراﻧﺐ اﻟﺬآﻮر‬
‫اﻟﺼﻮﺗﻴﺔ ﻃﺒﻴﻌﻴﺔ ﻟﻠﻜﺒﺪ واﻟﺪورة اﻟﻜﺒﺪﻳﺔ وﻋﺪم وﺟﻮد ﻋﻼﻗﺔ ﺑﻴﻦ اﻟﺘﻐﻴﺮات اﻟﻨﺴﻴﺠﻴﺔ ﻟﻠﻜﺒﺪ واﻟﻔﺤﺺ ﺑﺎﻷﻣﻮاج ﻓﻮق اﻟﺼﻮﺗﻴﺔ‬
.‫ﻟﻠﻜﺒﺪ ﺣﻴﺚ آﺎﻧﺖ اﻟﻨﺘﺎﺋﺞ ﻃﺒﻴﻌﻴﺔ‬
.‫ اﻷراﻧﺐ‬،‫ أﻧﺴﺠﺔ اﻟﻜﺒﺪ‬،‫ ﻧﺎﻧﺪروﻟﻮن دﻳﻜﺎﻧﻮﻳﺖ‬:‫ﻣﻔﺘﺎح اﻟﻜﻠﻤﺎت‬
A
nabolic-androgenic steroids can exert
strong effects on the human body and are
commonly used at high doses by body builders
and athletes to improve performance levels(1).
The primary clinical application of the
androgens is in the management of androgen
deficiency in males. The principal adverse
effects are virilization and hepatotoxicity (2).
Most laboratory studies did not investigate the
actual doses of anabolic androgenic steroids
currently abused in the field(3).
According to surveys and media reports, the
legal and illegal use of these drugs is gaining
popularity. The androgen hormones are
produced by the testes, ovaries, and adrenal
cortex. The major endogenous androgen is
testosterone. Androgens are noted most for
their ability to promote expression of male sex
characteristics. However, androgens also
influence sexuality in females. In addition,
androgens have significant physiologic effects
and pharmacologic effects unrelated to sex (4).
Androgens increase the synthesis of clotting
factors, hepatic triglyceride lipase, sialic acid,
α1 antitrypsin, and haptoglobin. Conversely,
androgens decrease the production of sex
hormone –binding globulin, other hormonebinding proteins, transferrin, and fibrinogen.
But, hepatic dysfunction is a known side effect
of treatment with anabolic androgenic
steroid(5).
Testosterone has stimulatory effects on
bones, muscles, erythropoietin, libido, mood
and cognition centers in the brain and penile
erection. It is reduced in metabolic syndrome
and diabetes. The best measure is bioavailable testosterone which is the fraction of
testosterone not bound to sex hormone
binding globulin (6).
The aims of the study are to study and
compare the toxic effect of nandrolone
decanoate on the liver tissue between male
and female groups of rabbits with the aids of
histological and ultrasound methods, and to
establish its effect on the body and liver
weights in both sexes.
Materials and methods
Forty-eight adult mature rabbits aged (10-14
months); their weights (1600-2000g), were
divided into male and female groups, each
included 24 rabbits. The male group
subdivided into 4 subgroups, group A was the
normal control group which received only
normal saline, group B was given nandrolone
decanoate
(DecaVinone,
Hikma
pharmaceuticals, Amman- Jordan) 2mg/kg
body weight, group C was given 4 mg/kg body
weight of nandrolone decanoate, and group D
was given 6 mg/kg body weight of the drug.
The female group was also subdivided into 4
subgroups, group A1 was the normal control
group, group B1 was given 2mg/kg body
weight, group C1 was given 4mg/kg body
weight, group D1 was given 6mg/kg body
weight.
Antihelmintic drug (Ivermectin) 2mg/kg body
weight was given subcutaneously to act
against internal and external parasitic
infections (7).
161
Vol. 35 No. 2, 2009
After a week of acclimatization, the animals
were given anabolic androgenic steroids or the
control vehicle once a week for 3 months by
deep intramuscular injections.
Animals were weighed before and after each
injection. Each two rabbits were housed in
individual cage and given access to food and
tap water. Animals were examined daily for
clinical manifestations of jaundice and
behavioral abnormality.
After one week from the date of the last dose
of nandrolone decanoate, the rabbits were
sacrificed after ether inhalation; for tissue
sampling; dissection of the abdomen was
done, the liver was extracted and the weight of
the liver was recorded.
The specimens of liver were washed with
normal saline, and then each liver was cut into
small slices of 4-5 mm thickness. Samples
were fixed for more than 24 hour in 10%
neutral buffered formalin. The tissues were
dehydrated in ascending grades of ethanol,
using 70% ethanol for 1 hour, two changes of
90% ethanol with a period of 1 hour for each,
then followed by two changes of absolute
ethanol; the second one was over night. The
slices cleared by two changes of xylene with a
period of one hour for each. Embedding of the
slices in three changes of paraffin with 57-59
Cº melting point, 1 hour each. Two blocks from
each specimen were used, and cross sections
with an average thickness of 5 micrometer
using Reichert Rotary Microtome were cut
serially. The sections mounted on the glass
slides, and kept for 30 minutes in the vacuumdrying oven at 60 Cº. Deparaffinization of the
sections in two changes of xylene for 5
minutes. Rehydration by transferring sections
into graded ethanol, absolute, 95%, and 70%
ethanol, two minutes each. Sections
transferred into distilled water for two minutes
to be ready for staining. Paraffin sections were
stained with Mayar’s hematoxylin and eosin,
and microscopical examination was done
using light microscope (8).
Statistical analysis was done using unpaired
T- test at P-value ≤0.05(9). At the end of the
study and after completion of treatment an
ultrasonic investigation of the liver was done
for all treated animals. Kretz ultrasound unit
with high frequency linear probe (7.5 M. Hz)
was used.
Observations and results
The body weights were recorded for all
animals of both male and female groups every
week (Table 1, 2). All animals gained weight
during the 12 weeks of treatment and they
showed a very good appetite and physical
activity. No signs of fatigue or abnormal
weakness were observed on the animals and
they had normal hair coat and no signs of
jaundice were seen among the treated groups.
Aggressive behavior was very evident among
subgroups C and C1, in addition to D and D1.
Animals of these subgroups quarreled with
each other and abnormal homosexual
behavior was noticed among the subgroups C
and D and even bleeding from wounds were
noticed especially around the anal region. This
is evident only among the male treated groups
C and D, but not with the female group which
showed only little signs of aggression.
There was a significant difference between
group A in which their mean body weight was
(1821.25+ 128.33) and group A1 (1660.00+
83.47) and the P-value was (0.014). Also there
was a significant difference between groups B
(1830.00+ 108.10) and B1(1700.00+ 86.60)
and their P-value was (0.025), a little
difference was noticed between group C
(1907.50 + 180.53) and C1 (1756.86 + 78.20)
in which their P-value was( 0.062) and group D
(1927.50 + 104.84) and D1 (1867.14 + 78.25)
and their P- value was( 0.234)(for details see
Table 1).
There was an evident increase in the mean
weight of the livers in both male and female
treated subgroups D and D1 when compared
to other subgroups; in all no statistical
difference was noticed in the mean liver weight
between both male and female subgroups (for
details see Table 2).
Histological findings
In spite of the fact that nandrolone decanoate
is an androgenic hormone, almost similar
findings were found in both sexes. Sections of
liver taken from group B and B1 showed the
same changes. They had normal architecture
of liver. Sinusoids, central venules and portal
162
Vol. 35 No. 2, 2009
veins were dilated and congested and
infiltrated with mononuclear inflammatory cells.
Focal areas of necrosis infiltrated by chronic
inflammatory cells were also seen. Mild
vacuolar degeneration affecting hepatocytes
around the central venule were noticed too
(Fig.1 & 2).
Groups C and C1 also showed the same
histological changes. The architecture of liver
was preserved. Sinusoids, central venules and
portal veins were dilated and congested and
infiltrated with mononuclear inflammatory cells.
Moderate vacuolar degeneration was also
seen affecting mainly the hepatocytes around
the central venule. Focal areas of necrosis
infiltrated by chronic inflammatory cells were
also seen in different lobules (Fig.3 & 4).
In groups D and D1 the vacuolar
degeneration was markedly seen and it was
severe in the way that it affected the majority
of the hepatocytes in all liver lobules and fatty
degenerative changes were also seen, except
for a very small area around the portal tract in
which the hepatocytes were preserved or
mildly affected. Sinusoids, central venules and
portal veins were dilated and congested, with
mononuclear inflammatory cells infiltration.
Focal areas of necrosis with chronic
inflammatory cells infiltration were also noticed
in different hepatic lobules. Binucleation of
some hepatocytes was common and evident in
these two groups (Fig.5).
Ultrasound Examination
At the end of the three months all the treated
animals were examined by ultrasound device
before they were killed, the liver showed
normal homogenous echoes without space
occupying lesion or enlargement in liver size.
No dilatation of gall bladder. Intra-hepatic and
extra hepatic billiary passages were normal
(Fig. 6).
Table (1): Showing the mean body weights of
both male and female groups.
Groups
A , A1
B , B1
C , C1
D , D1
Mean + SD
Male (n=8)
Female(n=7)
Mean body
Mean body
weight + SD
weight + SD
1821.25+ 128.33
1830.00+ 108.10
1907.50+ 180.53
1927.50+ 104.84
1660.00+ 83.47
1700.00+86.60
1756.86+78.20
1867.14+78.25
PValue
0.014
0.025
0.062
0.234
Unpaired T- test was used
Table (2): Showing the mean liver weights of
both male and female groups.
Groups
A , A1
B , B1
C , C1
D , D1
Mean + SD
Male (n=8)
Mean liver
Mean liver
weight + SD
weight + SD
69.15+2.61
70.13+12.60
72.34+14.70
81.93+13.75
65.45+ 2.01
68.79+1.87
72.64+1.71
78.50+3.02
P- Value
0.458
0.786
0.958
0.5310
Unpaired T- test was used
Fig. (1): Photomicrograph of liver of group B
showing the congested central venule (C) and
sinusoids(S). (H & E X 400).
163
Vol. 35 No. 2, 2009
Fig. (2): Photomicrograph of liver of group B1
showing the portal area with mild vacuolar
degeneration affecting the hepatocytes (white
arrow) with mononuclear inflammatory cells
infiltration (black arrow). (H & E X 400).
Fig. (5): Photomicrograph of liver group D
showing the severe ballooning degeneration
affecting the majority of hepatocytes around
the central venule (C). (H & E X 400).
Fig. (3): Photomicrograph of liver group C
showing the portal area with moderate
ballooning degeneration (white arrow) and
mononuclear inflammatory cells infiltration
around the bile duct (black arrow). (H & E X
400).
Fig. (4): Photomicrograph of liver group C1
showing the focal area of necrosis with
mononuclear inflammatory cells infiltration. (H
& E X 400).
Fig. (6): Abdominal ultrasound of group D
showing normal hepatic echoes, no abnormal
masses.
Discussion
Almost any subject abusing androgenicanabolic steroids will experience some
adverse effects. Among these adverse effects
is liver toxicity (10).
Because of the secrecy surrounding the use
of high doses of androgens, few data are
available on the relation of adverse effects to
the doses or compounds used. In addition
whereas some effects are due to androgenic
or estrogenic actions, others may be due to
the toxic (non hormonal) effects of the
androgen or its metabolites, especially when
the dose is very large (11).
The liver is morphologically and functionally
modulated by sex hormones. Long-term use of
oral contraceptives and anabolic-androgenic
steroids can both induce (hemangioma,
164
Vol. 35 No. 2, 2009
adenoma, focal nodular hyperplasia and
hepatocellular carcinoma). Hepatic adenomas
are rare, benign neoplasms usually occur in
young women. The human liver expresses
estrogen and androgen receptors and
experimentally both androgens and estrogens
have
been
implicated
in
stimulating
hepatocytes proliferation and may act as liver
tumor inducers or promoters (12).
In the current study, we noticed that there
was a significant difference in the mean body
weight of group A which was the male control
group and group A1 which was the female
control group and this occurred because the
male rabbits had more muscular body and
larger body build than the female group.
Groups B and B1 which received the lowest
dose (2mg/kg/week) of the drug also showed
significant difference in their mean body
weight, but animals of groups C and C1 which
received 4mg/kg/week showed no significant
difference between male and female rabbits,
and the same for rabbits that received the
highest dose of nandrolone decanoate which
was 6mg/kg/week. They revealed no
significant difference between male and
female rabbits of these two groups. This
means that the groups received the lowest
dose were the same as the control group of
both sexes and at this low dose the body
weight did not increase significantly in the
female group. While groups (C and C1) which
received 4mg/kg/week showed no significant
difference, because the mean body weights of
the female group at this dose start to increase
and make no significant difference with the
male group which received the same dose.
This is also evident for the high dose treated
groups of both sexes (D and D1) in which the
body weight of the female group was
increased and make no difference with the
male group that received the same dose, and
this is because this drug is an appetizer and
has anabolic effect through the stimulation of
protein synthesis (13).
Concerning the microscopical changes, both
groups B and B1 showed the same
microscopical picture; only few hepatocytes
showed vacuolar degeneration, while in
groups C and C1 the vacuolar degeneration
affected more hepatocytes especially those
around the central venules as these cells were
more exposed to hypoxia than those around
the portal area (14). In groups D and D1 which
received
higher
dose
of
the
drug
(6mg/kg/week) the vacuolar degeneration
affected nearly all the hepatocytes and areas
of focal necrosis were infiltrated with
mononuclear
inflammatory
cells
were
commonly seen. This is in agreement with
Boada's (15) findings, who observed the
presence of centrilobular degeneration and
lipidic vacuolization in male rats treated with
high doses of anabolic androgenic steroids.
Vieira et al. (16) found that subchronic treatment
with
nandrolone
decanoate,
mainly
administered at higher doses, are potentially
deleterious to the liver and cause fibrosis.
Patill et al. (1) reported a case of spontaneous
hepatic
rupture
with
life-threatening
hemorrhage associated with a past history of
anabolic steroid intake.
Ultrasound examination performed shortly
after the end of the treatment, showed no
evidence of hepatomegaly or hyperechogenic
masses. Boada et al.(17) reported a case of a
young man who had been using anabolicandrogenic steroids for six months and the
hepatic
ultrasound
showed
mild
hepatomegaly, with hyperechogenic nodules
close together.
In spite of the fact that nandrolone is
androgenic hormone, the histological findings
of the liver in both sexes were more or less the
same. This suggests that there is no variation
in the toxic effect of nandrolone decanoate on
both sexes. No correlation between the
severity of histological findings and ultrasonic
examinations of liver, gall bladder, and billiary
ducts was found.
References
1. Patil JJ, O'Donohoe B, Loyden CF,
Shanahan D. Near-fatal spontaneous
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2. McCullough MC, Namias N, Schulman C,
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L, Ward GC. Incidence of hepatic
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CO., USA, P3-158.
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made easy. Martin Dunitz company 2004;
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Osorio M, Rojo A, Benitez B, Torre A,
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Bagatell CJ, Bremner WJ. Androgens in
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Cervello M, D'Alessandro N, Montalto G.
Sex hormones and risk of liver tumor. Ann.
N. Y. Acad. Sci. 2006; 1089: 228-236.
13. Demling R, Oxandrolone, an anabolic
steroid, enhances the healing of a
cutaneous wound in the rat. Wound
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14. Strugill G, Lambert H. Xenobiotic-induced
hepatotoxicity: mechanisms of liver injury
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34: 1512-1526.
15. Boada LD, Zumbado M, Torres S, Lopez
A, Diaz-chico BN,
Cabrera JJ, Luzardo
OP. Evauation of acute and chronic
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16. Vieira PR, Franca RF, DamacenoRodrigues NR, Dolhnikoff M, Caldini EG,
Carvalho CR, Ribeiro W. Dose- dependent
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166
‫‪Annals of the College of Medicine‬‬
‫‪Vol. 35 No. 2, 2009‬‬
‫‪ ‬‬
‫@ @‬
‫@ @‬
‫’‪@ @‹í‡Ômë@‹Ø‬‬
‫@ @‬
‫ﺗﺸﻜﺮ ﻫﻴﺌﺔ ﲢﺮﻳﺮ ﳎﻠﺔ ﻃﺐ ﺍﳌﻮﺻﻞ ﻛﻞ ﻣﻦ ﺍﻟﺬﻭﺍﺕ ﺍﻟﺘﺎﻟﻴﺔ ﺃﲰﺎﺋﻬﻢ ﳉﻬﻮﺩﻫﻢ ﺍﳌﺒﺬﻭﻟﺔ ﻭﳋﱪ‪‬ﻢ ﺍﻟﻌﻠﻤﻴﺔ ﺍﻟﻌﺎﻟﻴﺔ ﰲ‬
‫ﳎﺎﻝ ﲣﺼﺼﻬﻢ ﲟﺴﺎﻋﺪﺓ ﻫﻴﺌﺔ ﺍﻟﺘﺤﺮﻳﺮ ﰲ ﺗﻘﻴﻴﻢ ﺍﻟﺒﺤﻮﺙ ﻟﻠﻌﺪﺩﻳﻦ ‪ ١‬ﻭ‪ - ٢‬ﺍ‪‬ﻠﺪ ‪ ٣٥‬ﻟﺴﻨﺔ ‪ ٢٠٠٩‬ﻟﺘﻘﺮﻳﺮ‬
‫ﺻﻼﺣﻴﺘﻬﺎ ﻟﻠﻨﺸﺮ‪:‬‬
‫ﺩ‪ .‬ﺍﲪﺪ ﺟﺎﺳﻢ ﺍﳊﺴﻴﲏ‬
‫‪ ‬‬
‫ﺩ‪ .‬ﺍﲪﺪ ﺣﺴﲔ‬
‫ﺃ‪.‬ﺩ‪ .‬ﺃﲰﺎﺀ ﺃﲪﺪ ﺍﳉﻮﺍﺩﻱ‬
‫ﺩ‪ .‬ﺍﻟﻴﺎﺱ ﺍﺳﺤﻖ ﺷﻌﻴﺎ‬
‫ﺃ‪.‬ﺩ‪ .‬ﺑﺎﺳﻞ ﳏﻤﺪ ﳛﲕ‬
‫ﺩ‪ .‬ﺑﺴﺎﻡ ﻋﺒﺪ ﺍﳌﺒﺪﻱ ﳏﻤﺪ‬
‫ﺩ‪ .‬ﺑﺸﺎﺭ ﺷﺎﻛﺮ‬
‫ﺩ‪ .‬ﺣﺬﻳﻔﺔ ﺳﻌﻴﺪ ﺍﻟﺪﻳﻮﺟﻲ‬
‫ﺩ‪ .‬ﺧﺎﻟﺪ ﻏﺎﱎ ﺍﻟﻌﺒﺎﺟﻲ‬
‫ﺩ‪ .‬ﺧﺎﻟﺪ ﻧﺎﻓﻊ ﺍﳋﲑﻭ‬
‫ﺩ‪ .‬ﲰﲑ ﳛﲕ ﻋﺜﻤﺎﻥ‬
‫ﺩ‪ .‬ﺷﻌﻴﺐ ﻫﺎﺷﻢ ﺳﻠﻴﻢ‬
‫ﺃ‪.‬ﺩ‪ .‬ﻃﺎﺭﻕ ﻳﻮﻧﺲ‬
‫ﺍﻟﺴﻴﺪ ﻋﺒﺪ ﺍﻹﻟﻪ ﺧﻠﻴﻞ ﺣﺴﲔ‬
‫ﺩ‪ .‬ﻋﺒﺪ ﺍﳉﺒﺎﺭ ﻳﺎﺳﲔ ﺍﳊﺒﻴﻄﻲ‬
‫ﺩ‪ .‬ﻋﻠﻲ ﻋﺒﺪ ﺍﳌﻄﻠﺐ ﳏﻤﺪ‬
‫ﺃ‪.‬ﺩ‪ .‬ﻓﺎﺭﺱ ﺑﻜﺮ ﺍﻟﺼﻮﺍﻑ‬
‫ﺩ‪ .‬ﻓﺎﺭﺱ ﻋﺒﺪ ﺍﳌﻮﺟﻮﺩ‬
‫ﺩ‪ .‬ﻓﺎﺭﺱ ﻳﻮﻧﺲ ﺑﺸﲑ‬
‫ﺩ‪ .‬ﻓﺮﺍﺱ ﳏﻤﻮﺩ ﺍﳉﻠﱯ‬
‫ﺃ‪.‬ﺩ‪ .‬ﻓﺮﺝ ﳏﻤﺪ ﻋﺒﺪ ﺍﷲ‬
‫ﺩ‪ .‬ﻗﺎﺳﻢ ﺳﻌﻴﺪ ﺍﺑﺮﺍﻫﻴﻢ‬
‫ﺩ‪ .‬ﻗﺤﻄﺎﻥ ﻋﺒﺪ ﺍﷲ ﺭﺿﻮﺍﻥ‬
‫ﺩ‪ .‬ﳏﻤﺪ ﳏﻤﻮﺩ ﺍﻟﺸﻴﺦ ﻋﻴﺴﻰ‬
‫ﺩ‪ .‬ﻣﺰﺍﺣﻢ ﻓﺘﺎﺡ ﺍﳉﻴﺘﺠﻲ‬
‫ﺩ‪ .‬ﻣﲎ ﻋﺒﺪ ﺍﻟﺒﺎﺳﻂ ﻛﺸﻤﻮﻟﺔ‬
‫ﺩ‪ .‬ﻧﺎﻓﻊ ﳏﻤﻮﺩ ﺷﻬﺎﺏ‬
‫ﺩ‪ .‬ﻧﺒﻴﻞ ﳒﻴﺐ ﻓﺎﺿﻞ‬
‫ﺩ‪ .‬ﻧﺰﺍﺭ ﳎﻴﺪ ﻗﺒﻊ‬
‫ﺩ‪ .‬ﻧﻮﺋﻴﻞ ﺳﻠﻴﻤﺎﻥ ﺍﻟﺼﻘﺎﻝ‬
‫ﺃ‪.‬ﺩ‪ .‬ﻳﺴﺎﺭ ﳛﲕ ﺍﻟﺘﻤﺮ‬
‫ﺩ‪ .‬ﻳﺴﺮﻯ ﻃﺎﻫﺮ ﺟﺮﺟﻴﺲ‬
‫‪Annals of the College of Medicine‬‬
‫‪Vol. 35 No. 2, 2009‬‬
‫‪ ‬‬
‫@ @‬
‫@ @‬
‫@@@@@‪@ @òíŠb“nüa@ò÷îa‬‬
‫@ @‬
‫ﺍﻷﺳﺘﺎﺫﺓ ﺍﻟﺪﻛﺘﻮﺭﺓ ﺃﲰﺎﺀ ﺃﲪﺪ ﺍﳉﻮﺍﺩﻱ‬
‫ﻃﺐ ﺍ‪‬ﺘﻤﻊ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﺃﻛﺮﻡ ﺟﺮﺟﻴﺲ ﺃﲪﺪ‬
‫ﺍﻟﻜﻴﻤﻴﺎﺀ ﺍﳊﻴﺎﺗﻴﺔ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﺑﺎﺳﻞ ﳏﻤﺪ ﳛﲕ‬
‫ﻛﻠﻴﺔ ﺍﻟﺼﻴﺪﻟﺔ – ﺟﺎﻣﻌﺔ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫﺓ ﺍﻟﺪﻛﺘﻮﺭﺓ ‪‬ﺎﱐ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ ﺍﻟﺼﻨﺪﻭﻕ‬
‫ﻛﻠﻴﺔ ﻃﺐ ﺍﻷﺳﻨﺎﻥ – ﺟﺎﻣﻌﺔ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﺯﻳﻦ ﺍﻟﻌﺎﺑﺪﻳﻦ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬
‫ﺍﻷﺣﻴﺎﺀ ﺍ‪‬ﻬﺮﻳﺔ – ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﺻﻤﻴﻢ ﺃﲪﺪ ﺍﻟﺪﺑﺎﻍ‬
‫ﻃﺐ ﺍ‪‬ﺘﻤﻊ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺩﻫﻮﻙ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻃﺎﺭﻕ ﻳﻮﻧﺲ‬
‫ﺍﻟﻜﻴﻤﻴﺎﺀ ﺍﳊﻴﺎﺗﻴﺔ ‪ -‬ﻛﻠﻴﺔ ﺍﻟﻌﻠﻮﻡ‪ /‬ﺟﺎﻣﻌﺔ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻋﺒﺪ ﺍﻹﻟﻪ ﺃﲪﺪ ﺍﳉﻮﺍﺩﻱ‬
‫ﺍﻟﻄﺐ ﺍﻟﺒﺎﻃﲏ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‪ /‬ﻣﺘﻘﺎﻋﺪ‬
‫ﺍﻟﺪﻛﺘﻮﺭ ﻋﺒﺪ ﺍﳋﺎﻟﻖ ﺭﺷﻴﺪ ﺍﳌﻼﺡ‬
‫ﺍﻟﻔﺴﻠﺠﺔ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‪ /‬ﻣﺘﻘﺎﻋﺪ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻋﺒﺪ ﺍﻟﺮﲪﻦ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ ﺳﻠﻴﻤﺎﻥ‬
‫ﺍﳉﺮﺍﺣﺔ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻓﺎﺭﺱ ﺑﻜﺮ ﺍﻟﺼﻮﺍﻑ‬
‫ﻃﺐ ﺍﻷﻃﻔﺎﻝ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﻧﻴﻨﻮﻯ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻓﺮﺝ ﳏﻤﺪ ﻋﺒﺪ ﺍﷲ‬
‫ﺍﻷﺩﻭﻳﺔ ‪ -‬ﺍﻟﺸﺮﻛﺔ ﺍﻟﻌﺎﻣﺔ ﻟﺼﻨﺎﻋﺔ ﺍﻷﺩﻭﻳﺔ‬
‫ﻭﺍﳌﺴﺘﻠﺰﻣﺎﺕ ﺍﻟﻄﺒﻴﺔ‪ /‬ﻧﻴﻨﻮﻯ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻓﺆﺍﺩ ﻗﺎﺳﻢ‬
‫ﺍﻷﺩﻭﻳﺔ ‪ -‬ﻛﻠﻴﺔ ﺍﻟﻄﺐ ﺍﻟﺒﻴﻄﺮﻱ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻣﺰﺍﺣﻢ ﻗﺎﺳﻢ ﺍﳋﻴﺎﻁ‬
‫ﺍﳉﺮﺍﺣﺔ ﺍﻟﻨﺎﻇﻮﺭﻳﺔ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‬
‫ﺍﻟﺪﻛﺘﻮﺭ ﻧﺰﺍﺭ ﳎﻴﺪ ﻗﺒﻊ‬
‫ﺍﻟﻄﺐ ﺍﻟﺒﺎﻃﲏ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﻧﻴﻨﻮﻯ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻳﺴﺎﺭ ﳛﲕ ﺍﻟﺘﻤﺮ‬
‫ﺍﻟﻜﻴﻤﻴﺎﺀ ﺍﳊﻴﺎﺗﻴﺔ ‪ -‬ﻛﻠﻴﺔ ﻃﺐ ﻧﻴﻨﻮﻯ‬
‫‪@ @Ý–ì¾a@k @òÜª‬‬
‫ﺍ‪‬ﻠﺪ ‪٣٥‬‬
‫@@@@@@@‬
‫@@‬
‫ﺍﻟﻌﺪﺩ ‪٢‬‬
‫ﻛﺎﻧﻮﻥ ﺍﻷﻭﻝ ‪٢٠٠٩‬‬
‫@@@@@@@@@@@@@@‪@ @‹í‹znÛa@ò÷îç‬‬
‫ﺭﺋﻴﺲ ﻫﻴﺌﺔ ﺍﻟﺘﺤﺮﻳﺮ‬
‫ﺃﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻫﺸﺎﻡ ﺃﲪﺪ ﺍﻷﻃﺮﻗﺠﻲ‬
‫ﺃﻋﻀﺎﺀ ﻫﻴﺌﺔ ﺍﻟﺘﺤﺮﻳﺮ‬
‫ﺃﻷﺳﺘﺎﺫﺓ ﺍﻟﺪﻛﺘﻮﺭﺓ ﺇﳍﺎﻡ ﺧﻄﺎﺏ ﺍﳉﻤﺎﺱ‬
‫ﺃﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﺭﻋـﺪ ﳛﲕ ﺍﳊﻤﺪﺍﱐ‬
‫ﺃﻟﺪﻛﺘﻮﺭﺓ ﺑﺪﻭﺭ ﻋﺒﺪ ﺍﻟﻘﺎﺩﺭ ﺍﻻﺭﺣﻴــﻢ‬
‫ﺃﻟﺪﻛﺘﻮﺭ ﻗﺤﻄـﺎﻥ ﺑﺸﲑ ﺇﺑﺮﺍﻫﻴــﻢ‬
‫ﺃﻟﺪﻛﺘﻮﺭ ﺭﺍﻣﻲ ﳏﻤﺪ ﻋﺎﺩﻝ ﺍﳊﻴﺎﻟـــﻲ‬
‫ﺃﻟﺪﻛﺘﻮﺭ ﻣﺎﺯﻥ ﳏﻤﻮﺩ ﻓﻮﺯﻱ ﺍﻟﺼﺮ‪‬ﺍﻑ‬
‫)ﻣﺪﻳــﺮ ﺍﻟﺘﺤﺮﻳــﺮ(‬
‫ﺍﶈﺮﺭ ﺍﳋﺎﺭﺟﻲ‬
‫ﺃﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ﻃﺎﻫﺮ ﻗﺎﺳﻢ ﺍﻟﺪﺑﺎﻍ‬
‫ﺍﻟﺸﺆﻭﻥ ﺍﻹﺩﺍﺭﻳﺔ‪ :‬ﺍﻵﻧﺴﺔ ﻓﺎﺋﺰﺓ ﻋﺒﻴﺪ ﺁﻏﺎ‬
‫@@@@@@‪ Ý–ì¾a@k @òÜª‬ﳎﻠﺔ ﺩﻭﺭﻳﺔ ﻃﺒﻴﺔ ﻋﻠﻤﻴﺔ ﺗﺼﺪﺭﻫﺎ ﻛﻠﻴﺔ ﺍﻟﻄﺐ ﰲ ﺟﺎﻣﻌﺔ ﺍﳌﻮﺻﻞ ﻣﻨﺬ ﻋﺎﻡ ‪ ،١٩٦٦‬ﻭﻫﻲ‬
‫ﻣﺪﺭﺟﺔ ﰲ ﺍﻟﻔﻬﺮﺱ ﺍﻟﻄﱯ ﳌﻨﻈﻤﺔ ﺍﻟﺼﺤﺔ ﺍﻟﻌﺎﳌﻴﺔ ﳌﻨﻄﻘﺔ ﺷﺮﻕ ﺍﳌﺘﻮﺳﻂ ﻭﺃﻧﻈﻤﺔ ﺍﻹﻳﺪﺍﻉ ﺍﻟﻌﺎﳌﻴﺔ ﰲ ﻓﺮﻧﺴﺎ‪ ،‬ﺭﻗﻢ ﺍﻹﻳﺪﺍﻉ‬
‫‪ ١٢‬ﻟﺴﻨﺔ ‪.١٩٩٠‬‬
‫ﲢﺘﻔﻆ ﺍ‪‬ﻠﺔ ﲝﻘﻮﻕ ﺍﻟﻄﺒﻊ ﻭﺍﻟﻨﺸﺮ‪ ،‬ﻭﺍﳌﻌﻠﻮﻣﺎﺕ ﺍﳌﻨﺸﻮﺭﺓ ﻓﻴﻬﺎ ﺗﻌﱪ ﻋﻦ ﺭﺃﻱ ﺃﺻﺤﺎ‪‬ﺎ ﻭﻫﻲ ﻻ ﲤﺜﻞ ﻭﺟﻬـﺔ ﻧﻈـﺮ‬
‫ﻫﻴﺌﺔ ﺍﻟﺘﺤﺮﻳﺮ‪ .‬ﺗﺮﺳﻞ ﲨﻴﻊ ﺍﳌﺮﺍﺳﻼﺕ ﻭﻃﻠﺒﺎﺕ ﺍﻻﺷﺘﺮﺍﻙ ﺇﱃ‪ :‬ﻣﻜﺘﺐ ﺳﻜﺮﺗﺎﺭﻳﺔ ﳎﻠﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‪ ،‬ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‪،‬‬
‫ﳏﺎﻓﻈﺔ ﻧﻴﻨﻮﻯ‪ -‬ﲨﻬﻮﺭﻳﺔ ﺍﻟﻌﺮﺍﻕ ‪.E-mail: [email protected]‬‬
‫ﲤﺖ ﻃﺒﺎﻋﺔ ﻫﺬﺍ ﺍﻟﻌﺪﺩ ﰲ ﺗﺸﺮﻳﻦ ﺍﻷﻭﻝ‪ ٢٠١٠ /‬ﰲ ﻛﻠﻴﺔ ﻃﺐ ﺍﳌﻮﺻﻞ‪.‬‬

Epstein-Barr virus in Hodgkin`s lymphoma

Transcription

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