The Healing Effect of Bone Marrow-Derived Stem Cells in Knee Osteoarthritis: A Case Report.

Osteoarthritis (OA) is a prevalent chronic disease impacting on quality of life and has societal and economical burden increasing with age. Yet, no confirmed pharmacological, biological or surgical therapy could prevent the progressive destruction of OA joint. Mesenchymal stem cells (MSCs) with immunosuppressive activities emerged a potential therapy. We describe a magnetic resonance images (MRI) approved 47 years old nomad female suffering from a severe right knee OA. After intra-articular injection of 36×10(6) passage 2 of bone marrow-derived stem cells (BMSCs), the patient's functional status of the knee, the number of stairs she could climb, the pain on visual analog scale (VAS) and walking distance improved after two months post-transplantation. MRI revealed an extension of the repaired tissue over subchondral bone. So as MSC transplantation is a simple technique, resulted into pain relief, minimized donor-site morbidity, provided a better quality of life, significantly improved cartilage quality with no need to hospitalization or surgery, cell transplantation can be considered as a reliable alternative treatment for chronic knee OA. Therefore these findings can be added to the literature on using BMSCs for treatment of OA.

The Effects of Nutrition, Exercise, and a Praying Program on Reducing Iron Overload in Patients With Beta-Thalassemia Major: A Randomized Clinical Trial.

BACKGROUND: Excessive iron accumulation in the visceral organs creates problems for patients with beta-thalassemia major. Despite chelation therapy, mortality rate from the complications of this disease is still quite high. OBJECTIVES: This study aimed to investigate the effectiveness of nutrition, exercise, and a praying program at reducing iron overload in patients with beta-thalassemia major. PATIENTS AND METHODS: This randomized clinical trial assessed the effect of the designed care program on iron overload. The study was conducted in 38 patients with beta-thalassemia major who ranged in age from 15 - 35 years and had been referred to the largest center for thalassemic patients in Shiraz. The patients were randomly assigned to an intervention (n = 18) and a control (n = 20) group. Blood samples were collected from the participants before and two months after the intervention. Then, the data were statistically analyzed using chi-square, Fisher's exact test, Mann-Whitney U-test, Wilcoxon, independent samples t-test, and paired samples t-test. RESULTS: The results showed that the mean level of serum ferritin significantly decreased in the intervention group two months after beginning the intervention. Also, the mean level of serum iron decreased in the intervention group, but the difference was not statistically significant. CONCLUSIONS: The planned educational program could be used to reduce iron overload and ultimately improve the patients' health status.

Comparison of Blood Transfusion Plus Chelation Therapy and Bone Marrow Transplantation in Patients with ß-Thalassemia: Application of SF-36, EQ-5D, and Visual Analogue Scale Measures.

BACKGROUND: ß-Thalassemia is a prevalent genetic disease in Mediterranean countries. The most common treatments for this disease are blood transfusion plus iron chelation (BTIC) therapy and bone marrow transplantation (BMT). Patients using these procedures experience different health-related quality of life (HRQoL). The purpose of the present study was to measure HRQoL in these patients using 2 different multiattribute quality of life (QoL) scales. METHODS: In this cross-sectional study, data were gathered using 3 instruments: a socio-demographic questionnaire, EQ-5D, and SF-36. A total of 196 patients with ß-thalassemia were randomly selected from 2 hospitals in Shiraz (Southern Iran). Data were analyzed using logistic regression and multiple regression models to identify factors that affect the patients' HRQoL. RESULTS: The average EQ-5D index and EQ visual analog scale (VAS) scores were 0.86 (95% CI: 0.83-0.89) and 71.85 (95% CI: 69.13-74.58), respectively. Patients with BMT reported significantly higher EQ VAS scores (83.27 vs 68.55, respectively). The results showed that patients who lived in rural area and patients with BMT reported higher EQ VAS scores (rural; ß= 10.25, P = .006 and BMT; ß= 11.88, P = .000). As well, SF-36 between 2 groups of patients were statistically significant in physical component scale (PCS). CONCLUSION: Patients in the BMT group experienced higher HRQoL in both physical and mental aspects compared to those in the BTIC group. More studies are needed to assess the relative cost-effectiveness of these methods in developing countries.

Epidemiology of hemoglobinopathies and thalassemias in individuals referred to the haematology research centre, Shiraz University of Medical Sciences, Shiraz, Iran from 2006 to 2011.

Hemoglobinopathies and thalassemias are the most frequent genetic hereditary disorders with an increasing global health burden, especially in low- and middle-income countries. We aimed to determine the epidemiologic pattern of hemoglobinopathies and thalassemias in individuals referred to the Haematology Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran, which is the most important referral center in Southern Iran during 2006 to 2011. The most frequent abnormality was ß-thalassemia (ß-thal) minor (24.0%), followed by α-thalassemia (α-thal) trait (10.0%), hemoglobin (Hb) S trait (4.0%) and Hb D-Punjab trait (4.0%). Because this center is a referral center, we detected a higher prevalence compared to the normal population; however, these data could help policymakers and health service providers to better programming for prevention of births affected with Hb disorders.

Relation between costimulatory molecule polymorphism and hepatitis B infections in hematopoietic stem cell transplant recipients.

OBJECTIVES: Costimulatory gene polymorphisms have been proposed to affect the hepatitis B virus pathogenesis by affecting regulation of immune responses. The association between costimulatory molecule gene polymorphisms including CTLA4, PD.1, ICOS, and CD28 with hepatitis B virus infection has been evaluated in hematopoietic stem cell transplant patients. MATERIALS AND METHODS: In a cross-sectional study, single-nucleotide polymorphisms in the loci of the costimulatory molecules were analyzed in 3 study groups. Hepatitis B virus infection was evaluated in plasma samples of each allogeneic and autologous hematopoietic stem cell transplant patients by a third generation HBsAg enzyme-linked immunosorbent assay kit according to the manufacturer 's instructions. RESULTS: Hepatitis B virus infection was found in 19 of 72 allogeneic (26.3%) and 26 of 59 autologous patients (44.1%). The T allele of CTLA4-318 and CC genotype of CD28+17 polymorphisms are significantly more frequent in hepatitis B virus-infected allogeneic hematopoietic stem cell transplant patients. The CC genotype of CD28 +17 was seen more frequently in hepatitis B virus-infected allogeneic hematopoietic transplant patients. The C allele of the PD.1.9 was seen more frequently in hepatitis B virus-infected allogeneic hematopoietic patients experiencing graft-versus-host disease. Also, the frequency of CT genotype and T allele of the PD.1.9 was significantly increased in hepatitis B virus-infected allogeneic hematopoietic stem cell transplant patients experiencing low-grade graft-versus-host disease. CONCLUSIONS: Associations of CTLA4 -318 and CD28 +17 with hepatitis B virus infection in allogeneic hematopoietic stem cell transplant patients was reported, also it was determined that PD.1.9 genotypes and hepatitis B virus infection in allogeneic hematopoietic stem cell transplant patients experiencing low-grade graft-versus-host disease was associated. However, better evaluations of the relations between costimulatory gene polymorphisms with hepatitis B virus infection in hematopoietic stem cell transplant patients requires further investigations.

Association of the costimulatory molecule gene polymorphisms and active cytomegalovirus infection in hematopoietic stem cell transplant patients.

Determinative associations may exist between costimulatory molecule gene polymorphisms with a variety of post hematopoietic stem cell transplantation (HSCT) viral related clinical outcomes especially acute graft versus host disease (aGVHD). Therefore in this study the associations between costimulatory molecule gene polymorphisms including: cytotoxic T-lymphocyte antigen-4 (CTLA4), programmed cell death-1 (PD-1), inducible T cell costimulator (ICOS), and cluster differentiation 28 (CD28) with active cytomegalovirus (CMV) infection were evaluated in HSCT patients. The 72 allogeneic HSCT patients with and without aGVHD were enrolled in this cross sectional study between years: 2004-2011. The single nucleotide polymorphisms in loci of the costimulatory molecules including: CTLA4 gene (-318 C/T, 1722 T/C, 1661 A/G, +49 A/G), PD-1 gene (PD-1.3 A/G, PD-1.9 C/T), ICOS gene (1720 C/T), and CD28 gene (+17 C/T) were analyzed in studied HSCT patients by PCR-RFLP methods. The active CMV infection was evaluated in fresh EDTA-treated blood samples of each allogeneic HSCT patients by CMV antigenemia kit according to manufacturer's instruction. Active CMV infection was found in 11 of 72 (15.27 %) of allogeneic HSCT patients. The T allele and TT genotype of the CD28 +17 C/T were significantly higher frequency in active CMV infected allogeneic HSCT patients experienced aGVHD. The G allele and GG genotype of the CTLA4 -1661 A/G were significantly higher frequent in active CMV infected allogeneic HSCT patients experienced low grade of aGVHD. Finally, finding of significant associations between CD28 +17 C/T and CTLA4 -1661 A/G genotypes with CMV active infection in allogeneic HSCT patients experienced aGVHD emphasize on the importance of the genetic pattern of costimulatory genes in outcomes of active CMV infection in HSCT patients needs completed studies.

Autologous noncryopreserved hematopoietic stem cell transplant with CEAM as a modified conditioning regimen in patients with Hodgkin lymphoma: a single-center experience with a new protocol.

OBJECTIVES: A BEAM regimen including carmustine (BiCNU: bis-chloroethyl nitrosourea), etoposide, cytarabine (cytosine arabinoside), and melphalan is a widely used conditioning regimen for autologous stem cell transplant in patients with Hodgkin lymphoma. We report the results of noncryopreserved autologous stem cell transplant of 45 patients with Hodgkin lymphoma given an alternative regimen, modified BEAM-like regimen (CEAM regimen: lomustine, etoposide, cytarabine, and melphalan), in which carmustine (BiCNU IV) was substituted by oral lomustine (CCNU: 2 chloroethyl cyclohexyl nitrosourea). PATIENTS AND METHODS: Forty-five eligible patients with relapsed/refractory Hodgkin lymphoma were consecutively enrolled and underwent conditioning regimen with BEAM-like regimen protocol as follows: Lomustine 200 mg/m(2) on day -3; etoposide 1000 mg/m(2) on day -3 and -2; cytarabine 1000 mg/m(2) on days -3, -2; and Melphalan 140 mg/m(2) on day -1. RESULTS: All 45 patients showed engraftment of infused stem cell, and there was no graft failure in the study group. The median mononuclear cell dose was 3.4 × 10(8). The median time to absolute neutrophil count > 0.5 × 10(9)/L was 11 days, and the median time to platelet count > 20 × 10(9) was 14 days. Grade 2 and grade 3 mucositis was seen in 64.5% our patients. Transplant-related mortality at 100 days occurred in 1 patient (2.2%). With a median follow-up of 27 months, median disease-free survival was 20 months, mean overall survival was 27 months, and median overall survival has not yet been reached. CONCLUSIONS: These data demonstrate the safety and feasibility of BEAM-like regimen as a new and modified regimen; longer follow-up is required to evaluate fully efficacy and long-term safety of our method.

Non-cryopreserved hematopoietic stem cell transplantation in multiple myeloma, a single center experience.

Several clinical trials have shown the superiority of high-dose therapy (HDT) and autologous stem cell transplantation (ASCT) over conventional dose therapy for patients with multiple myeloma. There is limited experience with non-cryopreserved autologous hematopoietic stem cell transplantation. Between January 2004 and February 2010, we treated 38 patients with myeloma (mean age = 50.6) with a preparative regimen of Melphalan 140-200 mg/m(2) and non-cryopreserved ASCT. All the apheresis products were kept in a conventional blood bank refrigerator at 4°C for 2 d before infusion. The median time to platelet count of >20 × 10(9) /L was 13 d (range 10-31). Also, the median time to absolute neutrophil count >0.5 × 10(9) /L was 11 d (range 9-21). All the 38 patients were engrafted and there was not graft failure in this study group. Twenty-nine of 38 (76.3%) patients are alive and without disease activity after a median follow-up of 31 months (range 6-77). Responses (complete and partial response) were seen in all the 38 patients. The median progression-free survival was 27 months with 95% confidence interval 23.52-30.48, whereas the median overall survival was 30 months. One hundred days transplant-related mortality was 0%. HDT and autologous transplantation without cryopreservation is an effective and safe method which simplifies the procedure and is feasible and cost saving in our patients.

Results of hematopoietic stem cell transplant in Shiraz: 15 years experience in southern Iran.

OBJECTIVES: Over the past 2 decades, hematopoietic stem cell transplant has evolved from an experimental procedure to the standard of care, and it is integrated into the management of many diseases. Hematopoietic stem cell transplant was established at Shiraz University of Medical Sciences in 1993. Here, we describe 15 years experience with stem cell transplant at our center in southern Iran. We provide information on indication, donor type, conditioning chemotherapy regimen, outcome, survival, and long-term follow-up in our stem cell activity. PATIENTS AND METHODS: From May 1993 to October 2008, 423 patients underwent allogeneic (n=311) and autologous (n=112) stem cell transplants at our center. For allogeneic stem cell transplant, the conditioning chemotherapy regimen comprised busulfan, cyclophosphamide, and antithymocyte globulin for thalassemic patients; busulfan and cyclophosphamide for leukemia patients; and cyclophosphamide and antithymocyte globulin for patients with aplastic anemia. RESULTS: During this period, 155 B-thalassemia major patients (mean age, 9.5 years; range, 2-20 years) underwent allogeneic marrow transplant. Of 155 patients with a diagnosis of thalassemia major, 112 are alive (72%) with full engraftment after a median follow-up of about 8.1 years (range, 12-184 months). During this time, 127 leukemia patients including acute myelogenous leukemia (n=68), acute lymphoblastic leukemia (n=30) and chronic myelogenous leukemia (n=29), received allogeneic stem cell transplant. In this group, long-term, disease-free survival (cure rate) was 67%, 60%, and 62%. CONCLUSIONS: These data reflect the important role of hematopoietic stem cell transplant in improving survival for a variety of hematopoietic system disorders at our center in Southern Iran. In patients with B-thalassemia major hematopoietic stem cell transplant seems to be the treatment of choice, because it leads to a cure in all classes (Lucarelli risk group, I-III). Based on high success rates in patients with class II and III thalassemia with the addition of the antithymocyte globulin to conditioning regimen of stem cell transplant, we also recommend using this new method of conditioning in transplant of thalassemia patients.

Combined therapy of silymarin and desferrioxamine in patients with beta-thalassemia major: a randomized double-blind clinical trial.

Silymarin, a flavonolignan complex isolated from Silybum marianum, has a strong antioxidant, hepatoprotective, and iron chelating activities. The present study was designed to investigate the therapeutic activity of orally administered silymarin in patients with thalassemia major under conventional iron chelation therapy. A 3-month randomized, double-blind, clinical trial was conducted in 59 beta-thalassemia major patients in two well-matched groups. Patients were randomized to receive a silymarin tablet (140 mg) three times a day plus conventional desferrioxamine therapy. The second group received the same therapy but a placebo tablet instead of silymarin. Clinical laboratory tests were assessed at the beginning and the end of the trial, except for serum ferritin level that was assessed at the middle of the trial as well. Results of this study revealed that the combined therapy was well tolerated and more effective than desferrioxamine in reducing serum ferritin level. Significant improvement in liver alkaline phosphatase and glutathione levels of red blood cells was also observed in silymarin-treated beta-thalassemia patients. However, no significant difference in serum ferritin levels was detected between silymarin and placebo groups after 1.5 and 3 months treatment, probably because of insufficient sample size to detect subtle changes in ferritin levels between groups. This is the first report showing the beneficial effects of silymarin in thalassemia patients and suggests that silymarin in combination with desferrioxamine can be safely and effectively used in the treatment of iron-loaded patients.

Breast myeloma: a report of 3 cases with fine needle aspiration cytologic findings.

BACKGROUND: Multiple myeloma of the breast is very rare, and the fine needle aspiration (FNA) findings have not been reported before. CASES: Two cases of multiple myeloma presented with bilateral breast nodules during treatment with chemotherapy. One case of multiple myeloma presented initially with a left breast mass. FNA smears of all 3 cases revealed numerous plasma cells, plasmablasts and multinucleated giant plasma cells. The smears were diagnosed as plasma cell tumors. Serum immunoelectrophoresis revealed IgG myeloma in 2 cases and IgA myeloma in 1. Marrow aspirates revealed > 30% plasma cells. Two patients died, and 1 was alive at this writing. CONCLUSION: The aspiration cytology findings of myeloma can be confuse, with primary and secondary tumors of the breast. The previous clinical history and ancillary studies, such as bone marrow study and serum immunoelectrophoresis, are essential to the correct diagnosis.

Molecular analysis of Iranian families with sickle cell disease.

Sickle hemoglobin is a mutant hemoglobin in which valine has been substituted for the glutamic acid normally at the sixth amino acid of the beta-globin chain. Detection of the single base pair mutation at codon 6 of the beta-globin gene is important for the prenatal diagnosis of sickle cell anemia and sickle cell disease. Application of the polymerase chain reaction technology to detect sickle cell patients and heterozygous carriers in a group of patients suspected for sickle cell disease was carried out. The sample was composed of 52 normal individuals and 52 unrelated outpatients who were attending the Hematology Research Center. All patients were interviewed. Results of their medical histories, physical examination, and the hematological analysis were recorded. The blood samples were collected in EDTA and genomic DNA was extracted from leukocytes. An amplified 110 base pair fragment of the beta-globin gene containing codon 6, was digested with the restriction enzyme MS II, and electerophoresed in 3 per cent agarose. We have established the technical condition for detection of sickle cell disease using a PCR assay. Fifteen patients having haemoglobin (Hb SS) and 37 patients in the heterozygous state (Hb AS) were identified. We confirm that the normal controls have the Hb AA genotype. The standardization of a highly sensitive and specific diagnostic test for sickle cell disease permitted us to identify the normal controls, the homozygotes and heterozygotes. This amplification method is rapid, sensitive and simple, and also has application research that is important for the prenatal diagnosis of sickle cell disease.

Significant association between expression of the CD11b surface molecule and favorable outcome for patients with acute myeloblastic leukemia.

The expression of several myeloid and non-lineage associated surface antigens in 70 patients with acute myeloblastic leukemia was investigated in relation to patient and disease characteristics, response to therapy, and prognosis. A leukocyte integrin, CD11b, was the only antigen that showed a significant association with complete remission (CR) duration and survival (P < .025). The mean survival for CD11b+ patients was longer than for CD11b- patients (578 +/- 76 versus 397 +/- 7 days, respectively). CR duration was 897 +/- 84 for CD11b+ patients and 366 +/- 71 for CD11b- patients. Multivariate analysis confirmed the predictive value of CD11b expression for longer survival (relative risk, 3.2; P = .02) and CR duration (relative risk, 3.2; P = .03). CR rate was also significantly higher in CD11b+ patients (77.3%) than in CD11b- patients (46.1%) (P = .01). Survival and remission duration were not influenced by expression of other surface markers including CD13, CD14, CD33, CD34, CD71, CD38, and HLA-DR or by other variables including French-American-British subtype, age, and leukocyte count. Extramedullary disease (EXD) was associated with the presence of both CD13 and CD14 expression (P < .04) but occurred less frequently in CD13+ cases. CD13 expression occurred more frequently in female patients (P = .03). CD38 expression was associated with lower platelet count and an increase in the number of blasts (P < .02).