Efficacy of Herbal Medicine in Hand Osteoarthritis: A Narrative Review.

OBJECTIVE: Osteoarthritis (OA) is one of the most prevalent joint disorders in the world that has placed an enormous economic and social burden on governments and healthcare sectors in many countries. Hand OA (HOA) is the most common peripheral arthritis, which is less investigated than knee and hip OA. Due to limited approved drug choices and adverse effects of long-term use of current regimens, we aimed to review the existing evidence that were used as oral herbal medicine to treat HOA. METHODS: The PubMed database was searched for both observational and interventional studies that have investigated herbal medicine safety and efficacy in HOA, written in English and published between 2010 and 2022. RESULTS: A total of 5 original articles fulfilled the inclusion criteria, and each article assessed a different herbal regimen. Overall, it seems desirable to add specific herbal treatments to the regimen of HOA patients, specifically in case of early stages of HOA. CONCLUSION: Currently, the need for a low-risk alternative treatment in HOA patients is felt more than ever. There are reliable references relating to the safety of Korean red ginseng, GCSB-5, XLGB, and GS-GCu in these patients, although their efficacy was limited. Additionally, herbs like curcumin and Boswellia serrata have positively affected patients with knee osteoarthritis. However, there is a lack of strong evidence supporting their effectiveness in hand osteoarthritis (HOA). This emphasizes the potential benefits that these herbs may have for HOA patients.

Influence of Air Pollutants on the Disease Activity and Quality of Life in Rheumatoid Arthritis, an Iranian Observational Longitudinal Study.

Background: Environmental exposures and genetic predisposition interactions may result in autoimmune rheumatic diseases. This study aimed to determine the effect of outdoor air pollutants on the activity of rheumatoid arthritis (RA) in a longitudinal follow-up. Methods: We longitudinally studied 50 patients with RA bimonthly over 6 months in Mashhad, one of the most polluted cities in Iran. Disease activity and health-related quality of life (HRQoL) were examined according to the disease activity score (DAS28ESR), health assessment questionnaires (HAQ), physical health component summary (PCS), and visual analogue scale (VAS) criteria. The outdoor air pollutant was measured by monitoring the average concentration of nitrogen oxide (NO), carbon monoxide (CO), O2 level, Sulfur dioxide (SO2), and some particles less than 10 and 2.5 micrometers in diameter (PM <10 µm, PM <2.5 µm). The temperature and humidity levels were also measured. The univariate and multivariate statistical analyses were used for data analysis and the role of confounding factors was determined using the generalized estimation equation method. Results: Statistical analysis indicated a significant increase of the DAS28ESR (B = 0.04 [0.08]; P = 0.01) and VAS (B = 4.48 [1.73]; P = 0.01) by CO concentration. Moreover, a number of polluted days increased the VAS in patients. In addition, other air pollutants, temperature, and humidity were not affected significantly by the DAS28ESR and quality of life indexes by considering confounders such as medications, age, and job. Conclusion: Based on our findings, CO concentration was the only effective outdoor air pollutant that could increase RA disease activity. In addition, CO concentration and the number of polluted days make patients feel more ill. As the role of indoor air pollutants is highly important, further research on this critical topic is required to establish the role of air pollution on RA disease activity.

Expression pattern of glucocorticoid receptor α gene and associations with clinicolaboratory features in patients with systemic lupus erythematosus.

Background: Glucocorticoid receptor α (GRα) gene is a transcription factor with clinically significant immune-modulating properties in various autoimmune diseases. However, the expression pattern of the GRα gene and associations with clinical features in patients with systemic lupus erythematosus (SLE) is controversial. This study aimed to assess the correlation between the GRα expression and different clinical and laboratory-related parameters in SLE patients. Methods: A total of 45 women with newly diagnosed SLE and 31 gender and age-matched healthy controls were enrolled in this cross-sectional study. The real-time quantitative PCR (qRT-PCT) method evaluated the differences in GRα expression in peripheral blood mononuclear cells from cases and controls. The correlation between the GRα gene expression levels, clinicolaboratory features, and potential prognostic application was also analyzed. Results: Compared to the healthy individuals, the GRα gene expression in newly diagnosed SLE patients who did not receive any treatment was numerically reduced, but this reduction did not achieve statistical significance (P=0.87). No significant correlation was also found with the activity and severity of SLE according to SLEDAI2K (P=0.41). The GRα gene expression showed a negative correlation with CRP (P=0.034) and a positive correlation with lupus anticoagulant (P=0.039) levels in SLE. The receiver operating characteristic (ROC) curve analysis indicated that the GRα expression level might be a predictor biomarker for low CRP and positive lupus anticoagulant in SLE, respectively. Conclusion: This study proposed that expression of the GRα in newly diagnosed lupus patients has no statistically significant difference with healthy age and sex-matched controls. Besides, its expression does not correlate with lupus disease activity according to SLEDAI2k. However, further studies in this area are required.

Comparison of the efficacy and safety of methotrexate alone or in combination with leflunomide in the treatment of juvenile idiopathic arthritis: a double-blind, placebo-controlled, randomized trial.

Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disorder in children. Although methotrexate (MTX) is the first line disease-modifying antirheumatic drug for JIA, many patients do not respond well or cannot tolerate MTX. The aim of this study was to compare the effect of combination therapy of MTX and leflunomide (LFN) with MTX in patients who do not respond to MTX. Material and methods: Eighteen patients (2-20 years old) with polyarticular, oligoarticular or extended oligoarticular subtypes of JIA who did not respond to conventional JIA therapy participated in this double-blind, placebo-controlled, randomized trial. The intervention group received LFN and MTX for 3 months while the control group received oral placebo and MTX at a similar dose to the intervention group. Response to treatment was assessed every 4 weeks using the American College of Rheumatology Pediatric criteria (ACRPed) scale. Results: Clinical criteria, including number of active joints and restricted joints, physician and patient global assessment, Childhood Health Assessment Questionnaire (CHAQ38) score, and serum erythrocyte sedimentation ratelevel, did not differ significantly between groups at baseline and at the end of the 4th and 8th weeks of treatment. Only the CHAQ38 score was significantly higher in the intervention group at the end of the 12th week of treatment. Analysis of the effect of treatment on study parameters revealed that only the global patient assessment score differed significantly between groups (p = 0.003). Conclusions: The results of this study showed that combining LFN with MTX does not improve clinical outcomes of JIA and may increase side effects in patients who do not respond to MTX.

Efficacy of Raloxifene as Add-on Therapy on Disease Activity of Postmenopausal Women with Rheumatoid Arthritis: A Double-blind, Randomized, Placebo-controlled Clinical Trial.

OBJECTIVE: The current study aimed to evaluate the effect of raloxifene on the disease activity of postmenopausal patients with rheumatoid arthritis (RA) and the prevention of glucocorticoid- induced osteoporosis. METHODS: This double-blind, randomized clinical trial was conducted at the Rheumatic Diseases Research Center affiliated with Mashhad University of Medical Sciences from 2015 to 2016. Postmenopausal women with RA were randomly treated with raloxifene or placebo after discontinuation of alendronate. Disease activity was evaluated using DAS28ESR, HAQ, and VAS before and every two months after the intervention. In addition, bone mineral densitometry was performed for patients before and 14 months after the intervention. The disease activity and densitometric criteria were compared between the two groups at a significant level of p <0.05. RESULTS: A total of 17 patients were allocated to each group. The two groups were similar at baseline in underlying disease, age, duration of RA, duration of alendronate use, laboratory findings, and rheumatoid arthritis drugs. Moreover, the mean scores of DAS28ESR, HAQ, and VAS during visits were not significantly different between the intervention and control groups (p >0.05). CONCLUSION: The current study results could not prove any clinical benefits of adding raloxifene to standard therapies for patients with rheumatoid arthritis in improving their disease activity compared to placebo. CLINICAL TRIAL REGISTRATION NUMBER: Trial registration number is NCT02982083.

Frequency and Predictors of Opioid Use in Rheumatoid Arthritis and Seronegative Spondyloarthropathy Patients.

Background: Pain is one of the most challenging symptoms in patients with rheumatoid arthritis (RA) and spondyloarthropathies (SpAs), and pain relief is one of the top priorities for improving health-related quality of life. When medication therapy does not significantly reduce pain, chronic opioid consumption becomes more prominent in such patients. This study aimed to evaluate the state of opioid use in RA and SpA patients. Methods: This cross-sectional study was performed on 316 patients with RA and spondyloarthropathies (SpAs) from January to March 2014. The convenience sampling method was used to select the participants, and by obtaining verbal consent, everyone was given 15 minutes to complete a checklist independently. Demographic and opioid use data were evaluated in terms of opioid use and its predictors. In this regard, univariate and multivariate logistic regressions were used to evaluate the predictors of opioid consumption in patients. All analyses were conducted using SPSS 21 and the significance level was set at P<0.05. Findings: About 9.5% of all participants, including 8.8% of RA and 22.6% of SpA cases, were opioid abusers. In the first step of the analysis, it was observed that opioid abuse was significantly higher in men, married participants, urban residents, patients with no biological therapy, and patients with a negative family history of addiction. The most prevalent ways of drug abuse were smoking and ingestion. The results of univariate logistic regression analysis revealed SpA and other factors significantly increase the chance of opioid abuse. Furthermore, multivariate logistic regression analysis showed male gender (OR=10.4) and negative family history of addiction (OR=3.19) significantly affected addiction in RA and SpA patients with a 95% confidence interval. Conclusion: Lack of suitable responsiveness to medication therapy to relieve pain, inconsistent pain evaluation, and shame of asking direct questions about addiction in RA and SpA patients may lead to opioid consumption in some cases. Seronegative SpA may make patients more prone to addiction. However, in this study, male gender and no family history of addiction were related to opioid abuse.

Skin reaction to capsaicin in patients with systemic lupus erythematosus compared to healthy controls.

BACKGROUND: The interaction between nervous and immune systems has been under investigation. Transient receptor potential vanilloid type 1(TRPV1) is a ligand gated calcium channel expressed by sensory neurons which mediates neurogenic inflammatory response. Substance p which can be released following exposure to capsaicin is a TRPV1 inducer, shown to have altered concentration and function in mice with systemic lupus erythematosus (SLE). We evaluated skin reaction to capsaicin in newly diagnosed and established SLE patients compared to healthy controls. METHODS: Twenty-nine SLE patients (12 newly diagnosed cases under treatment, and 17 established ones, not receiving medications) who referred to rheumatologic disease research center, and 33 healthy subjects of the control group were recruited in this study. A topical solution of capsaicin (0.075%) was applied on the volar forearm during skin test, and time to the tingling sensation, area of induration and area of redness (centimeters2) were recorded after 5, 10, and 20 minutes. RESULTS: The area of redness and area of induration within 15 minutes, time to the tingling sensation (P=0.02), and the overall frequency of tingling sensation (P=0.01) after capsaicin skin test was considerably higher in SLE patients than the healthy controls. Redness, induration and tingling sensation were more frequent but not statistically significant among the established SLE group compared to the newly diagnosed patients. CONCLUSION: Since skin reaction to capsaicin is more prominent in SLE patients than the healthy individuals, neurogenic inflammation and the role of P substance should be investigated more in ongoing lupus. Capsaicin test can not predict lupus activity.

Serum interleukin-18 and its relationship with subclinical atherosclerosis in systemic lupus erythematosus.

BACKGROUND: Interleukin-18 (IL-18) is a pro-inflammatory and pro-atherogenic factor, and its blood level has shown a direct correlation with atherosclerosis. We aimed to evaluate the serum IL-18 level in patients with systemic lupus erythematosus (SLE) and its relationship with the intima-media thickness (IMT) of the carotid artery in these patients, as an indicator of atherosclerosis. METHODS: In this cross-sectional study, 60 patients as the patient group and 30 healthy volunteers as the control group [matched sex, age, and body mass index (BMI)] were selected, and their disease status and general data were gathered using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) form. A blood sample was also obtained from all participants to determine the serum level of IL-18 and other metrics, including high-sensitivity C-reactive protein (hs-CRP), cholesterol, triglyceride (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), anti-double stranded deoxyribonucleic acid (anti-dsDNA), complement 3 (C3), and C4. The IMT of the carotid artery was calculated in both groups. We also evaluated the clinical cardiovascular manifestations. RESULTS: The serum IL-18 levels in patients were significantly higher than in the control group (P ˂ 0.005). It had no significant correlation with disease activity (P = 0.10). The patients with SLE with high IL-18 serum levels (> 280 pg/ml) had higher SLEDAI-2K (P = 0.02) than the patients with a low level (< 280), where 280 was the median of the IL-18 levels. The serum IL-18 level had no significant correlation with the carotid artery IMT. CONCLUSION: A high level of IL-18 reflects the disease activity, but it was not significantly correlated with subclinical atherosclerosis, denoted by the carotid artery IMT.

Investigation of the Association Between Carotid Artery Intima-Media Thickness (IMT) and Cardiac Risk Factors in Patients with Systemic Lupus Erythematosus.

BACKGROUND: The relationship between SLE and traditional risk factors for cardiovascular events was evaluated. METHODS: The data regarding sixty patients with SLE and 30 healthy controls (age and sex matched) were gathered using SLEDAI forms. Venous blood (10mL) from all the participants was examined for hs-CRP, homocysteine, VCAM1, CBC, anti-DNA antibody, C3, C4, low-density lipoprotein (LDL), cholesterol, FBS and triglyceride. The IMT of carotid arteries was determined bilaterally by ultrasound. Other measurements included insulin levels via Elisa (Linco/Millipore Corp) and the HOMA-IR index for insulin resistance. RESULTS: The mean age (in years) in the test and control groups was 28.8±10.3 (18-52) and 33.8±9.13 (18-48), respectively. The average IMT in the test group was directly related to serum levels of VCAM1 (p<0.001), homocysteine (p<0.001), cholesterol (p<0.009), LDL (p<0.001), TG (p<0.001), and FPG (p=0.004). The association between other risk factors, insulin resistance, carotid IMT and SLEDAI, was nonexistent. Mean insulin and insulin resistance levels in all the participants were 0.43±2.06 µU/mL and 0.09±0.44, respectively. There was no significant difference between the test and control groups regarding serum insulin and insulin resistance levels (p=0.42 and p=0.9, respectively). None of the risk factors, such as hsCRP, VCAM1, or homocysteine, were shown to be related to insulin resistance (p=0.6, p=0.6, p=0.09, respectively). CONCLUSION: Our findings did not show an increase in the prevalence of atherosclerosis in patients with SLE. There was no association between IMT and insulin resistance. However, the former was associated with FPG, total cholesterol, LDL, TG, homocystein and VCAM1.

Curcumin effects on myeloperoxidase, interleukin-18 and matrix metalloproteinase-9 inflammatory biomarkers in patients with unstable angina: A randomized clinical trial.

OBJECTIVE: Inflammation along with oxidative stress plays an important role in the development, progression, instability and rupture of coronary atherosclerotic plaques. Several studies introduced curcumin (diferuloylmethane) as a wonderful chemical in Curcuma longa (turmeric) with appropriate anti-inflammatory and antioxidant effects. The effect of curcumin on inflammatory biomarkers was assessed in several clinical trials. This study was designed to evaluate the effect of curcumin on three pro-inflammatory biomarkers in patients with unstable angina. MATERIALS AND METHODS: Forty patients with unstable angina who met the inclusion criteria, participated in this double-blind randomized clinical trial. Patients were randomly divided into two groups. The patients in the treatment group received nanocurcumin 80 mg per day for 5 days and the control group received placebo 80 mg per day for five days. Blood samples were obtained before the administration, and also 1, 2 and 4 days after taking the treatment. Serum concentrations of Myeloperoxidase (MPO), matrix metalloproteinase-9 (MMP-9) and interleukin 18 (IL-18) biomarkers were measured by ELISA. RESULTS: There was no significant difference in concentration of these biomarkers before the administration and 1, 2 and 4 days after the start of the trial, between the two groups; however, the concentration of IL-18 on the first day significantly varied between the groups. CONCLUSION: Based on the findings of this study, administration of nanocurcumin capsules at the dose of 80 mg per day for 5 days, did not significantly decrease inflammatory biomarkers in patients with unstable angina.

The effects of curcumin on the prevention of atrial and ventricular arrhythmias and heart failure in patients with unstable angina: A randomized clinical trial.

OBJECTIVE: Inflammation along with oxidative stress has an important role in the pathophysiology of unstable angina which leads to acute myocardial infarction, arrhythmias and eventually heart failure. Curcumin has anti-inflammatory and anti-oxidant effects and thereby, it may reduce cardiovascular complications. This randomized controlled trial aimed to investigate the effects of curcumin on the prevention of atrial and ventricular arrhythmias and heart failure in patients with unstable angina. MATERIALS AND METHODS: Forty patients with unstable angina who met the trial inclusion and exclusion criteria, participated in this double-blind randomized clinical trial. The patients were randomized into two groups: curcumin (80 mg/day for 5days) and placebo (80 mg/day for 5days). Cardiac function was evaluated by two-dimensional echocardiography devices at baseline (immediately after hospitalization) and 5 days after the onset of the trial. Atrial and ventricular arrhythmias were recorded by Holter monitors in cardiology ward, Ghaem academic hospital, Mashhad, Iran. Progression to heart failure, myocardial infarction, and pulmonary and cardiopulmonary resuscitation events as well as mortality were recorded daily throughout the study. RESULTS: There were no significant differences between the two groups in atrial and ventricular arrhythmias (p=0.2), and other echocardiographic parameters (Ejection fraction, E, A, E/A ratio, Em, and pulmonary artery pressure) at baseline and five days after the start of the trial. CONCLUSION: Nanocurcumin administered at the dose of 80 mg/day for five days had no effect in the incidence of cardiovascular complications in patients with unstable angina.

Skin inflammatory reactions to capsaicin in rheumatoid arthritis patients compared to healthy controls.

OBJECTIVE: Previous studies have examined the role of sensory nerves and neural mediators in symmetrical joint inflammation and autoimmunity in rheumatoid arthritis (RA). In this study, we sought to examine the association between capsaicin skin test and disease activity in RA patients. MATERIALS AND METHODS: Eighty RA patients (case group) and 20 healthy volunteers were enrolled in this experiment. The subjects in case group were calcified to newly diagnosed patients and those previously diagnosed with RA. A topical solution of capsaicin (0.075%) was applied on the volar forearm during the skin test, and evaluations were done after 5, 10, and 20 min. The parameters recorded in capsaicin skin test were time to tingling, area of induration (cm2), and area of redness (cm2). RESULTS: A faster capsaicin skin reaction was observed in healthy controls compared to the case group (p=0.02). Newly diagnosed and previously diagnosed RA patients were not significantly different in terms of reaction latency (p=0.06). The redness area after 15 (p=0.04) and 20 (p=0.001) min was significantly larger in previously diagnosed RA patients than in newly diagnosed ones. The ​​area of redness and time to tingling did not show any difference between active and inactive RA patients, but after 15 and 20 min, the area of redness was significantly greater in inactive RA patients compared to active RA patients (p=0.01 and p=0.03, respectively). CONCLUSION: This study suggested that capsaicin skin test is not an efficient tool for the examination of synovial inflammation and disease activity in RA.

Musculoskeletal Manifestations of Sarcoidosis: A Review Article.

BACKGROUND: Sarcoidosis is a multisystem inflammatory disease with an etiology that is not clearly understood. Amongst the different organs that may be affected, the lungs are the most common. Musculoskeletal manifestations of the disease are uncommon. OBJECTIVES: They include arthropathy, bone lesions, or myopathy, all of which may occur as initial symptoms or develop during the course of the disease. METHODS: Articular involvement my present as arthralgia or arthritis. Skeletal complications usually develop in the chronic state of the disease. Muscular disease is rare and usually asymptomatic. Appropriate imaging modalities including X-ray, MRI, FDG-PET/CT assist in the diagnosis of rheumatic sarcoidosis. However, biopsy is necessary for definite diagnosis. RESULT AND CONCLUSION: In most cases of musculoskeletal involvement, NSAIDs and corticosteroids are sufficient for symptomatic management. For more resistant cases immunosuppressive drugs (i.e., methotrexate) and TNF- inhibitors are used. Our aim is to review various types of musculoskeletal involvement in sarcoidosis and their existing treatment options.

Comparing the Effect of Psyllium Seed on Gastroesophageal Reflux Disease With Oral Omeprazole in Patients With Functional Constipation.

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases. Several studies have been carried out on the treatment of symptoms associated with GERD. The present study aimed to compare the effect of Psyllium seed and oral omeprazole on GERD in patients with functional constipation. In this trial, 132 patients were divided into 2 groups. The impact of omeprazole and Psyllium seed on the treatment and recurrence of GERD was studied. Among the patients, the rate of response to treatment was 89.2% (n = 58) in the Psyllium seed group, while in omeprazole group, it was 94% (n = 63; P = .31). The recurrence rates of Psyllium seed and omeprazole groups were 24.1% (n =14) and 69.8% (n = 44), respectively ( P < .001). The results showed that treatment of functional constipation by Psyllium seed in patients with GERD leads to improvement of GERD and its recurrences in comparison with omeprazole.

HTLV-1 seroprevalance in sarcoidosis. A clinical and laboratory study in northeast of Iran.

AIM: Sarcoidosis is an autoimmune multiorgan granulomatosis disease with unknown origin. Some environmental factors such as viruses may induce the disease in genetically susceptible individuals. Human T cell lymphotropic virus type 1 (HTLV-1) can dysregulate the human immune system and the role of this virus in the pathogenesis of autoimmune diseases has been investigated and documented, such as in uveitis. In this study, we have focused on the seroprevalence of HTLV-1 in sarcoidosis in comparison to the normal population in the northeast of Iran, an endemic area for HTLV-1. METHODS: This cross-sectional study enrolled 125 patients with established sarcoidosis to evaluate the frequency of HTLV-1 and compare it with the normal population of Mashhad, Iran. Participants' blood samples were analyzed for HTLV-1 antibody by an enzyme-linked immunosorbent assay kit. Positive results were confirmed by polymerase chain reaction method. Finally, data were analyzed using SPSS 11. RESULTS: Among sarcoidosis patients 106 (84.8%) patients had a history of acute course and 19 (15.2%) had chronic sarcoidosis. Four percent of the patients versus 2.12% of the Mashhad population were HTLV-1 positive with no statistical difference (P = 0.201). In age- and sex-matched selected controls, 3.6% were HTLV-1 positive again with no statistical difference by sarcoidosis group (P = 0.52). There was no statistical difference between arthritis, erythema nodusom, uveitis, constitutional symptoms, abnormal chest radiography (parahilar lymphadenopathy) and computed tomography scan findings, respiratory symptoms, sex, the course of the sarcoidosis in HTLV-1 positive and negative sarcoidosis patients. CONCLUSION: The frequency of HTLV-1 in 125 sarcoidosis patients was 4%. In comparison with prevalence of HTLV-1 in Mashhad, HTLV-1 seroprevalence did not show any significant difference.

Gastrointestinal symptoms associated with gastroesophageal reflux disease, and their relapses after treatment with proton pump inhibitors: A systematic review.

Gastroesophageal reflux disease (GERD) is a common functional gastrointestinal disorder with significant effects on the quality of life. The burden of GERD is soaring in Asia. Preventing symptom relapse is a therapeutic goal in GERD patients. Since proton pump inhibitors (PPI) are the first-line treatment of GERD, drug failure has become a major problem in the treatment procedure. We reviewed the literature in order to find articles related to comorbidities and symptoms affecting GERD from 1980 to 2015 via PubMed and Google Scholar using keywords such as 'Gastroesophageal reflux disease', 'Gastrointestinal symptoms' and Boolean operators (such as AND, OR, NOT). Due to the cost of PPI therapy and the high rate of GERD relapse after PPI therapy, demand for continuing this type of treatment is decreasing. Thus, we need to discover new approaches to treat the disease and also investigate the relationship between the treatment of GERD and its comorbidities and symptoms such as functional constipation.

The Effect of Oral Levamisole Co-administration on the Level of Immune Response to Hepatitis B Vaccine in Healthy Individuals: A Randomized Clinical Trial.

Despite its proven efficacy, the hepatitis B vaccine requires improvements in immune enhancement and durability, especially in the elderly. Levamisole, an immune modulator, has been tested as an adjuvant to hepatitis B vaccine in several studies in immune-compromised populations. However, we aimed to evaluate the effect of levamisole on the immune response to hepatitis B vaccine in healthy subjects. In this randomized clinical trial, healthy family members of chronic hepatitis B patients were given twenty-microgram intramuscular injections of hepatitis B vaccine at 0, 1, and 6 months and 50 miligrams of oral  levamisole twice a day for two weeks with every vaccination dose. Serum hepatitis B surface antibody (HBsAb) levels of ultimately 98 individuals were measured one month after the final vaccination dose and compared to those of 119 subjects that received placebo and vaccine with an identical regimen. HBsAb levels >10 mIU/mL were considered protective. The Student's t-test, Mann-Whitney test, Kruskal-Wallis analysis (quantitative comparison in age groups), Chi-square test, and the Pearson correlation were used to analyze data. p<0.05 was considered significant. Serum HBsAb levels were significantly higher in the test group (p<0.001). All test subjects had levels above 50 mIU/mL (86.7% exceeding 100 mIU/mL). The quantitative response according to age groups was remarkable (p=0.01 and p<0.001 for placebo and levamisole, respectively), while that of gender was insignificant (p=0.9). Unlike HBsAb titers amongst controls, levels in the levamisole group were affected by smoking (p=0.79 and p=0.006, respectively). We conclude that oral levamisole as an adjuvant to the hepatitis B vaccine enhances the anti-HBs antibody in healthy vaccinees.

Complementary and Alternative Medicines: Usage and Its Determinant Factors Among Outpatients in Southeast of Iran.

Prevalence of complementary and alternative medicines is increasing specially in patients with chronic diseases. Therefore, based on the high prevalence of chronic disorders, the present study aimed to determine complementary and alternative medicine usage frequency and its determinant factors. This was a cross-sectional study. Five hundred clients participated in the study by using convenience sampling. A 2-part questionnaire (including demographic form and researcher-created questionnaire) was used for studying the prevalence of using complementary and alternative medicine methods, and users' satisfaction. Findings showed that 75.4% of people used at least one complementary and alternative medicine method. Most of users consumed medicinal plants (69.4%). The most common reason of using a complementary and alternative medicine method was common cold (32.9%). The highest satisfaction belonged to massage (2.94 ± 0.74). The usage of complementary and alternative medicine was 3.22 times higher in people with academic educations when compared with illiterate people. Concerning the high usage of complementary and alternative medicine, it is necessary to train specialists in this field in order to offer such treatments in a safe manner. Also, outcomes of application of complementary and alternative medicine methods should be studied.

Efficacy of egg yolk and nitroglycerin ointment as treatments for acute anal fissures: A randomized clinical trial study.

BACKGROUND: Acute anal fissure as a common disease in society has several etiologies and manifestations such as severe anal pain and bleeding. Nitroglycerin ointment 0.2% is the most common topical treatment used. The most common side effect of nitroglycerin is headache, which is annoying for patients and often leads to discontinuation of the drug. OBJECTIVE: Comparison of egg yolk as a natural substance with analgesic and anti-inflammatory properties and minimal side effects with nitroglycerin ointment in the treatment of acute anal fissure. METHODS: This randomized clinical trial was carried out during a 10-day period in the Gastroenterology clinic of Ghaem Hospital, Mashhad, Iran (year 2015). 126 patients who filled the inclusion criteria were enrolled. The patients were randomly divided into two groups. Nitroglycerin ointment (0.2%) was applied by patients in the first group, twice daily for 10 days. For the second group, one egg yolk once a day was administered rectally up to 10 days. The pain and bleeding severity were recorded every two days up to 10 days after finishing the treatment course, based on visual scale. RESULTS: The results showed that egg yolk caused a significant reduction in pain and bleeding compared with nitroglycerin (p<0.05). At the beginning of the study, the difference in pain intensity between the two groups was not statistically significant (p-value = 0.25). However, it became significant in the following days. Changes in the frequency of rectorrhagia were also significant in both groups, showing a major decrease in the number of rectorrhagia cases (p<0.001). CONCLUSION: Egg yolk is more efficient than nitroglycerin in the treatment of acute anal fissure. In addition, lack of any side effects results in the completion of the treatment course by the patients. TRIAL REGISTRATION: The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2015050718915N3. FUNDING: This work was supported by a grant from the Vice Chancellor of Research of Mashhad University of Medical Sciences.

Prophylactic Effect of Rectal Indomethacin Administration, with and without Intravenous Hydration, on Development of Endoscopic Retrograde Cholangiopancreatography Pancreatitis Episodes: A Randomized Clinical Trial.

BACKGROUND: Acute Post ERCP Pancreatitis (PEP) is the most common major complication of Endoscopic retrograde cholangiopancreatography (ERCP). The aim of the current study was to assess the utility of single dose rectal indomethacin with and without  intravenous perfusion of normal saline to prevent acute pancreatitis. METHODS: In this randomized clinical trial, 406 patients with choledocolithiasis underwent ERCP. Based on computer-generated  numbers, the patients were allocated into 4 groups, each group receiving a different intervention prior to the ERCP procedure. The interventions included rectal indomethacin (100mg) in the first group, intravenous (IV) saline perfusion in the second, both rectal indomethacin and IV saline in the third, and the fourth (control) group receiving rectal glycerin. Serum amylase levels were measured and clinical pancreatitis episodes were quantified and classified according to APACHE II prognostic criteria. Statistical inference was performed using the chi-square or Fisher's exact test for qualitative variables, while Student's zxA-test was used for quantitative variables. RESULTS: A diagnosis of mild pancreatitis was present in 38 (9.4%) cases. The numbers of events in the four study groups were 11, 10, 0, and 17, respectively, corresponding to an absolute risk reduction of 5.2% , 6.2%, 16.2% (number needed to prevent one episode of PEP) and a relative risk reduction of 32%, 38% and 100% in the three study groups, respectively. The frequency of PEP was only significant in the third group (P ˂ 0.001). CONCLUSIONS: The combination of rectal indomethacin and intravenous normal saline before ERCP significantly prevents post-ERCP pancreatitis.