a recent systematic analysis showed that in 2011, 314 million children younger than 5 years were mildly, moderately or severely stunted and 258 million were mildly, moderately or severely underweight in the developing countries. in iran a study among 752 high school girls in sistan and baluchestan showed prevalence of 16.2%, 8.6% and 1.5%, for underweight, overweight and obesity, respectively. the prevalence of malnutrition among elementary school aged children in tehran varied from 6% to 16%. anthropometric study of elementary school students in shiraz revealed that 16% of them suffer from malnutrition and low body weight. snack should have 300 - 400 kcal energy and could provide 5 - 10 g of protein / day. nowadays, school nutrition programs are running as the national programs, world - wide. national school lunch program in the united states there are also some reports regarding school feeding programs in developing countries. in vietnam, school base program showed an improvement in nutrient intakes. in iran a national free food program (nffp) is implemented in elementary schools of deprived areas to cover all poor students. however, this program is not conducted in slums and poor areas of the big cities so many malnourished children with low socio - economic situation are not covered by nffp. although the rate of poverty in areas known as deprived is higher than other areas, many students in deprived areas are not actually poor and can afford food. hence, nutritional value of the nffp is lower than the scientific recommended snacks for this age group. furthermore, lack of variety of food packages has decreased the tendency of children toward nffp. on the other hand, the most important one is ministry of education (moe) of iran, which is responsible for selecting and providing the packages for targeted schools. the ministry of health (moh) is supervising the health situation of students and their health needs. welfare organizations, along with charities, have the indirect effect on nutritional status of students by financial support of their family. provincial governors have also the role of coordinating and supervising all activities of these organizations. parent - teacher association is a community - based institution that participates in school's policy such as nffp. in addition to these organizations, nutritional literacy of students, their parents and teachers, is a very important issue, which could affect nutritional status of school age children. therefore, the present study was conducted with the aim of improving the nffp, so that by its resources all poor children will be covered even in big cities. moreover, all food packages were replaced by nutritious and diverse packages that were accessible for non - poor children. according to the aim of this study and multiple factors that could affect the problem, public health advocacy has been chosen as the best strategy to deal with this issue. therefore, the present study determines the effects of nutrition intervention in an advocacy process model on the prevalence of underweight in school aged children in the poor area of shiraz, iran. this interventional study has been carried out between 2009 and 2010 in shiraz, iran. this survey was approved by the research committee of shiraz university of medical sciences. in coordination with education organization of fars province two elementary schools and one middle school in the third region of the urban area of shiraz were selected randomly. in those schools all students (2897, 7 - 13 years old) were screened based on their body mass index (bmi) by nutritionists. according to convenience method all students divided to two groups based on their economic situation; family revenue and head of household's job and nutrition situation; the first group were poor and malnourished students and the other group were well nourished or well - off students. for this report, the children's height and weight were entered into center for disease control and prevention (cdc) to calculate bmi and bmi - for - age z - scores based on cdc for diseases control and prevention and growth standards. the significance of the difference between proportions was calculated using two - tailed z - tests for independent proportions. for implementing the interventions, the advocacy process model weight was to the nearest 0.1 kg on a balance scale (model # seca scale). standing height was measured to the nearest 0.1 cm with a wall - mounted stadiometer. advocacy group formation: this step was started with stakeholder analysis and identifying the stakeholders. the team was formed with representatives of all stakeholders include; education organization, welfare organization, deputy for health of shiraz university, food and cosmetic product supervisory office and several non - governmental organizations and charities. situation analysis: this was carried out by use of existing data such as formal report of organizations, literature review and focus group with experts. the prevalence of malnutrition and its related factors among students was determined and weaknesses and strengths of the nffp were analyzed. accordingly, three sub - groups were established: research and evaluation, education and justification and executive group. designing the strategies: three strategies were identified; education and justification campaign, nutritional intervention (providing nutritious, safe and diverse snacks) and networking. performing the interventions: interventions that were implementing in selected schools were providing a diverse and nutritious snack package along with nutrition education for both groups while the first group (poor and malnourished students) was utilized the package free of charge. education and justification intervention: regarding the literature review and expert opinion, an educational group affiliated with the advocacy team has prepared educational booklets about nutritional information for each level (degree). accordingly, education of these booklets has been integrated into regular education of students and they educated and justified for better nutrition life - style. it leads the educational group to hold several meeting with the student's parents to justify them about the project and its benefit for their children. after these meetings, parental desire for participation in the project illustrated the effectiveness of the justification meeting with them. for educate fifteen talk show programs in tv and radio, 12 published papers in the local newspaper, have implemented to mobilize the community and gain their support. healthy diet, the importance of breakfast and snack in adolescence, wrong food habits among school age children, role of the family to improve food habit of children were the main topics, in which media campaign has focused on. nutritional intervention: the snack basket of the students was replaced with traditional, nutritious and diverse foods. in general, the new snack package in average has provided 380 kcal energy, 15 g protein along with sufficient calcium and iron. low economic and malnourished children were supported by executive group affiliated with advocacy team and the rest of them prepare their snack by themselves. research and evaluation: in this step, the literacy and anthropometric indices (bmi) of students were assessed before and after the interventions. the reference for anthropometric measures was the world health organization / national center for health statistics (who / nchs) standards and the cut - offs were - two standard deviations (sd) from the mean. each student that was malnourished and poor has been taken into account for free food and nutritious snacks. demographic information, height, weight and knowledge of the students were measured by use of a validated and reliable (cronbach 's alpha was 0.61) questionnaire. this project is granted by shiraz university of medical sciences, charities and welfare organization and education organization of fars province. statistical analyses were performed using the statistical package for the social sciences (spss) software, version 17.0 (spss inc ., the are expressed as mean sd and proportions as appropriated . in order to determine the effective variables on the malnutrition status paired t test was used to compare the end values with baseline ones in each group . in this project, the who z - score cut - offs used were as follow : using bmi - for - age z - scores ; overweight : > + 1 sd, i.e., z - score > 1 ( equivalent to bmi 25 kg / m), obesity: > + 2 sd (equivalent to bmi 30 kg / m), thinness: < 2 sd and severe thinness: < 3 sd. this interventional study has been carried out between 2009 and 2010 in shiraz, iran. this survey was approved by the research committee of shiraz university of medical sciences. in coordination with education organization of fars province two elementary schools and one middle school in the third region of the urban area of shiraz were selected randomly. in those schools all students (2897, 7 - 13 years old) were screened based on their body mass index (bmi) by nutritionists. according to convenience method all students divided to two groups based on their economic situation; family revenue and head of household's job and nutrition situation; the first group were poor and malnourished students and the other group were well nourished or well - off students. for this report, the children's height and weight were entered into center for disease control and prevention (cdc) to calculate bmi and bmi - for - age z - scores based on cdc for diseases control and prevention and growth standards. the significance of the difference between proportions was calculated using two - tailed z - tests for independent proportions. for implementing the interventions, weight was to the nearest 0.1 kg on a balance scale (model # seca scale). standing height was measured to the nearest 0.1 cm with a wall - mounted stadiometer. advocacy group formation: this step was started with stakeholder analysis and identifying the stakeholders. the team was formed with representatives of all stakeholders include; education organization, welfare organization, deputy for health of shiraz university, food and cosmetic product supervisory office and several non - governmental organizations and charities. situation analysis: this was carried out by use of existing data such as formal report of organizations, literature review and focus group with experts. the prevalence of malnutrition and its related factors among students was determined and weaknesses and strengths of the nffp were analyzed. accordingly, three sub - groups were established: research and evaluation, education and justification and executive group. designing the strategies: three strategies were identified; education and justification campaign, nutritional intervention (providing nutritious, safe and diverse snacks) and networking. performing the interventions: interventions that were implementing in selected schools were providing a diverse and nutritious snack package along with nutrition education for both groups while the first group (poor and malnourished students) was utilized the package free of charge. duration of intervention was 6 months. education and justification intervention: regarding the literature review and expert opinion, an educational group affiliated with the advocacy team has prepared educational booklets about nutritional information for each level (degree). accordingly, education of these booklets has been integrated into regular education of students and they educated and justified for better nutrition life - style. obviously, student's families had remarkable effect on children's food habit. it leads the educational group to hold several meeting with the student's parents to justify them about the project and its benefit for their children. after these meetings, parental desire for participation in the project illustrated the effectiveness of the justification meeting with them. educate fifteen talk show programs in tv and radio, 12 published papers in the local newspaper, have implemented to mobilize the community and gain their support. healthy diet, the importance of breakfast and snack in adolescence, wrong food habits among school age children, role of the family to improve food habit of children were the main topics, in which media campaign has focused on. nutritional intervention: the snack basket of the students was replaced with traditional, nutritious and diverse foods. in general, the new snack package in average has provided 380 kcal energy, 15 g protein along with sufficient calcium and iron. low economic and malnourished children were supported by executive group affiliated with advocacy team and the rest of them prepare their snack by themselves. research and evaluation: in this step, the literacy and anthropometric indices (bmi) of students were assessed before and after the interventions. the reference for anthropometric measures was the world health organization / national center for health statistics (who / nchs) standards and the cut - offs were - two standard deviations (sd) from the mean. each student that was malnourished and poor has been taken into account for free food and nutritious snacks. demographic information, height, weight and knowledge of the students were measured by use of a validated and reliable (cronbach 's alpha was 0.61) questionnaire. this project is granted by shiraz university of medical sciences, charities and welfare organization and education organization of fars province. advocacy group formation: this step was started with stakeholder analysis and identifying the stakeholders. the team was formed with representatives of all stakeholders include; education organization, welfare organization, deputy for health of shiraz university, food and cosmetic product supervisory office and several non - governmental organizations and charities. situation analysis: this was carried out by use of existing data such as formal report of organizations, literature review and focus group with experts. the prevalence of malnutrition and its related factors among students was determined and weaknesses and strengths of the nffp were analyzed. accordingly, three sub - groups were established: research and evaluation, education and justification and executive group. designing the strategies: three strategies were identified; education and justification campaign, nutritional intervention (providing nutritious, safe and diverse snacks) and networking. performing the interventions: interventions that were implementing in selected schools were providing a diverse and nutritious snack package along with nutrition education for both groups while the first group (poor and malnourished students) was utilized the package free of charge. education and justification intervention: regarding the literature review and expert opinion, an educational group affiliated with the advocacy team has prepared educational booklets about nutritional information for each level (degree). accordingly, education of these booklets has been integrated into regular education of students and they educated and justified for better nutrition life - style. obviously, student's families had remarkable effect on children's food habit. it leads the educational group to hold several meeting with the student's parents to justify them about the project and its benefit for their children. after these meetings, parental desire for participation in the project illustrated the effectiveness of the justification meeting with them. educate fifteen talk show programs in tv and radio, 12 published papers in the local newspaper, have implemented to mobilize the community and gain their support. healthy diet, the importance of breakfast and snack in adolescence, wrong food habits among school age children, role of the family to improve food habit of children were the main topics, in which media campaign has focused on. nutritional intervention: the snack basket of the students was replaced with traditional, nutritious and diverse foods. in general, the new snack package in average has provided 380 kcal energy, 15 g protein along with sufficient calcium and iron. low economic and malnourished children were supported by executive group affiliated with advocacy team and the rest of them prepare their snack by themselves. research and evaluation: in this step, the literacy and anthropometric indices (bmi) of students were assessed before and after the interventions. the reference for anthropometric measures was the world health organization / national center for health statistics (who / nchs) standards and the cut - offs were - two standard deviations (sd) from the mean. each student that was malnourished and poor has been taken into account for free food and nutritious snacks. demographic information, height, weight and knowledge of the students were measured by use of a validated and reliable (cronbach 's alpha was 0.61) questionnaire. this project is granted by shiraz university of medical sciences, charities and welfare organization and education organization of fars province. statistical analyses were performed using the statistical package for the social sciences (spss) software, version 17.0 (spss inc ., chicago, il, usa). the are expressed as mean sd and proportions as appropriated. in order to determine the effective variables on the malnutrition status paired t test was used to compare the end values with baseline ones in each group. two - sided p < 0.05 was considered to be statistically significant. in this project, the who z - score cut - offs used were as follow: using bmi - for - age z - scores; overweight: > + 1 sd, i.e., z - score > 1 (equivalent to bmi 25 kg / m), obesity: > + 2 sd (equivalent to bmi 30 kg / m), thinness: < 2 sd and severe thinness: < 3 sd. study population contains 2897 children; 70.8% were primary school students and 29.2% were secondary school students. 2336 (80.5%) out of total students were well - off and 561 children (19.5%) were indigent. 19.5% of subjects were in case group (n = 561) and 80.5% were in the control group (n = 2336). the mean of age in welfare group was 10.0 2.3 and 10.5 2.5 in non - welfare group. demographic characteristics of school aged children in shiraz, iran table 2 shows the frequency of subjects in different categories of bmi for age in non - welfare and welfare groups of school aged children separately among boys and girls before and after a nutrition intervention based on advocacy process model in shiraz, iran. the frequency of subjects with bmi lower than < 2 sd decreased significantly after intervention among non - welfare girls (p < 0.01). however, there were no significant decreases in the frequency of subjects with bmi lower than < 2 sd boys. when we assess the effect of intervention in total population without separating by sex groups, we found no significant change in this population. bmi for age for iranian students aged 7 - 14 years based on gender according to who growth standards 2007 bmi for age for iranian students aged 7 - 14 years according to who growth standards 2007 in non - welfare and welfare groups of total population table 4 has shown the prevalence of normal bmi, mild, moderate and severe malnutrition in non - welfare and welfare groups of school aged children separately among boys and girls before and after a nutrition intervention based on advocacy process model. according to this table there were no significant differences in the prevalence of mild, moderate and severe malnutrition among girls and boys. table 4 also shows the mean of all anthropometric indices changed significantly after intervention both among girls and boys. the pre- and post - test education assessment in both groups showed that the student's average knowledge score has been significantly increased from 12.5 3.2 to 16.8 4.3 (p < 0.0001). bmi, height and weight in non - welfare and welfare groups of school aged children separately in males and females before and after a nutrition intervention based on advocacy process model in shiraz, iran according to study's finding the odds ratio (or) of sever thinness and thinness in non - welfare compared with welfare is 3.5 (or = 3.5, confidence interval = 2.5 - 3.9, p < 0.001). furthermore, the finding showed or of overweight and obesity in welfare compared to non - welfare is 19.3 (or = 19.3, ci = 2.5 - 3.9, p = 0.04). the of this community intervention study revealed that nutrition intervention based on advocacy program had been successful to reduce the prevalence of underweight among poor girls. this study shows determinant factor of nutritional status of school age children was their socio - economic level. according to our knowledge, this is the first study, which determines the effect of a community intervention based on advocacy process on the malnutrition indices in a big city (shiraz) in iran. the other program in iran (nffp) is specified to deprived area and is not conducted in big cities. allocating millions of dollars to nffp by government, selecting the malnourished students through an active screening system at primary and middle schools, paying attention of policy makers to student's nutrition have provided the opportunity to combat the problem. however, negligence of under - poverty line, providing poor snacks in terms of nutritional value and lack of variety are the main defects of this program. advocacy by definition is a blending of science, ethics and politics for comprehensive approaching health issues. by using advocacy program in california among the high school students for improving their nutrition and physical activity angeles unified school district participants emphasized on nutrition classes for families as well as students in addition to other interventions. in the present study another study revealed that evaluability assessment gave stakeholders the opportunity to reflect on the project and its implementation issues. it seems that in iran, free food program among the students not only is needed in deprived areas, but also it should be performed in big cities such as shiraz. at baseline, no significant difference was founded among wealthy students between the pre- and post - nutritional status intervention. in contrast, the numbers of students who have malnutrition decreased from 44% to 39.4%, which was identified as a significant among impecunious girls students. there was also a significant increase in the proportion of children with bmi that was normal for age (2 to + 1 sd) most of the published community interventions showed better among females compared with males. this difference in the impact of nutritional interventions between male and female might be related to the different age of puberty in the female population compared to the male population. in the age range of the present study female although, there is no nffp in big cities of iran, there are some programs for improving the nutritional status such as providing free milk in schools. a recent publication has shown that school feeding programs focus on milk supplementation had beneficial effects on the physical function and school performances specifically among girls in iran. the of the mentioned study showed an improvement in the weight of children, psychological test's scores and the grade - point average following this school feeding program. the intervention in the present study had focused on the snack intake in the school time. there are some reports regarding the nutrition transition in iran, which shows the importance of nutrition intervention to provide more healthy eating dietary habits among welfare groups of adolescents. hence, nutrition intervention especially in the form of nutrition education is needed in big cities and among welfare children and adolescents. although a study among iranian adolescents showed that dietary behavior of adolescents does not accord to their knowledge, which emphasize on the necessity of community intervention programs. a recent study regarding the major dietary pattern among iranian children showed the presence of four major dietary patterns, in which fast food pattern and sweet pattern as two major dietary patterns can be mentioned among iranian children. in advocacy program audience's analysis accordingly, one of the prominent strategies in this study was working with media and was meeting with parent - teacher association that both of them were secondary target audiences. we also took into account policy makers in different levels, from national to local as primary audiences. advocacy team had several meetings with management and planning organization at national level and education organization of the fars province as well as principal of the targeted schools. providing nutritious snacks need contribution of private sector such as food industries or factories, but their benefits should be warranted. another choice was community involvement; which can be achieved by female health volunteers who are working with the health system. advocacy team by using the support of charities and female health volunteers could establish a local factory that produced student's snacks based on the new definition. however, there are some challenges on the way of expanding this program. mass production of the proposed snacks according to different desires and cultures and getting involvement of food industries with respect to marketing issues is one of those challenges. moreover, providing a supportive environment in order to change the food habits of the students and their parents among the wide range of the population require a sustainable and continuous inter - sector collaboration. although in a limited number of schools, in our study, interventions and advocacy program was successful, expanding this model to another areas around the country depends on convincing the policy makers at national level. in this regard, advocacy team should prepare evidenced based profile and transitional planning to convince the policy makers for improving the rule and regulation of nffp. the same as this study in other studies have also emphasized that there must be efforts to strengthen the capacity within the schools to deal with the nutritional problems either overweight, obesity or malnutrition by using of educational and nutritional intervention. assessing the dietary adherence is very important in nutrition intervention among population. as this population was children and adolescents we had a limitation in the blood sample collection to assess the subject's dietary adherence. furthermore, this intervention was only focused on the intake of snack in school time and we did not have comprehensive information on the dietary intake of children and adolescents after school all over the day. the investigators propose further investigation in different areas of the country based on socio - cultural differences in order to make necessary modification and adapt this model to other areas. regarding the nutritional needs of the school age children, provision of a good platform for implementing and expanding this efficient model to the whole country based upon the socio - economic situation of each region is advisable to the moh and the moe. community nutrition intervention based on the advocacy process model is effective on reducing the prevalence of underweight specifically among female school aged children.

Abstract: : the present study was carried out to assess the effects of community nutrition intervention based on advocacy approach on malnutrition status among school - aged children in shiraz, iran.materials and methods: this case - control nutritional intervention has been done between 2008 and 2009 on 2897 primary and secondary school boys and girls (7 - 13 years old) based on advocacy approach in shiraz, iran. the project provided nutritious snacks in public schools over a 2-year period along with advocacy oriented actions in order to implement and promote nutritional intervention. for evaluation of effectiveness of the intervention growth monitoring indices of pre- and post - intervention were statistically compared.:the frequency of subjects with body mass index lower than 5% decreased significantly after intervention among girls (p = 0.02). however, there were no significant changes among boys or total population. the mean of all anthropometric indices changed significantly after intervention both among girls and boys as well as in total population. the pre- and post - test education assessment in both groups showed that the student's average knowledge score has been significantly increased from 12.5 3.2 to 16.8 4.3 (p < 0.0001).: this study demonstrates the potential success and scalability of school feeding programs in iran. community nutrition intervention based on the advocacy process model is effective on reducing the prevalence of underweight specifically among female school aged children.


it occurs in more than 50% of patients and may reach 90% in certain types of cancers, especially in patients undergoing chemotherapy and/or radiation therapy.1 anemia is defined as an inadequate circulating level of hemoglobin (hb) (hb < 12 g / dl) and may arise as a of the underlying disease, bleeding, poor nutrition, chemotherapy, or radiation therapy. preliminary studies suggest that survival and loco - regional control after radiation therapy, especially in head and neck cancers, may be compromised by anemia.24 anemia often worsens symptoms such as fatigue, weakness, and dyspnea, and thus may have a negative effect on quality of life (qol) and performance status in patients with cancer. thus, to improve physical functioning, qol, and prognosis in patients with cancer, it would be reasonable to take a proactive approach in identifying populations who need treatment for cancer - associated anemia (caa) and provide timely management. blood transfusion is an effective way to replace depleted hb within a short period, but the effect is, unfortunately, temporary and can cause serious adverse risks and increased mortality. in randomized clinical trials in patients with caa , erythropoiesis - stimulating agents (esas) produced significant increases in hb level, decreased transfusion requirements, and improved qol.57 however, 30%50% of patients do not respond to such agents. in addition, the use of esas often causes concern about severe adverse reactions.6,8 in several studies, esas were found to shorten overall survival time, or time to tumor progression in patients whose hb level reached more than 12 g / dl. these studies included patients with different primary cancers, such as breast, lung, head and neck, cervix, and lymphomas.911 the lack of response to erythropoietin stimulation in patients with cancer is partly attributed to the functional iron deficiency state, in which the high rate of erythropoiesis exceeds the delivery of usable iron, despite adequate iron stores.12 absolute iron deficiency, in contrast, occurs when iron delivery is impaired because iron stores are depleted (serum ferritin, < 100 ng / ml ; transferring saturation, < 20%).13 hepcidin, a peptide hormone produced by the liver, is up - regulated in chronic inflammatory states including cancer. hepcidin inhibits iron transport across cell membranes, thus decreasing the accessibility of stored iron and gastrointestinal absorption of dietary iron, leading to an increased frequency of iron - restricted erythropoiesis.1416 many randomized trials examined the role of intravenous (iv) iron in addition to esas in the treatment of anemia in patients with cancer. many of these studies showed improvement in esa response, time to maximal response, reduction in esa dose, and improvement in qol parameters (when measured) in favor of the combination over esas alone. the observed benefit was independent of baseline iron parameters.1721 one study found a 36% reduction in the number of patients transfused.21 this pilot study assessed the efficacy and feasibility of iv iron monotherapy in patients with cancer who have anemia and who are undergoing treatment with chemotherapy and/or radiation therapy without the use of esas. patients received the study treatment for 12 weeks followed by a 4-week follow - up period. eligible patients were at least 18 years old, about to start a cycle of chemotherapy and/or radiation therapy within 1 week of inclusion, and had a nonmyeloid malignancy, hb levels of 11.0 g / dl or less, a life expectancy of more than 24 weeks, and an eastern cooperative oncology group performance status of 02. patients were also required to have a serum ferritin level of 100 ng / ml or higher or transferrin saturation (tsat) levels of 15% or higher and to have received no esas or iv iron therapy within 30 days and no oral iron therapy (27 mg / day or more) within 7 days before enrollment. patients were excluded for leukoerythroblastic features on blood film, hemolysis, gastrointestinal bleeding, folate or vitamin b12 deficiency, elevated serum ferritin (900 ng / ml) or transferrin saturation (tsat) (35%) levels, pregnancy or lactation, liver dysfunction (grade 2 or higher based on national cancer institute common toxicity criteria), renal dysfunction (serum creatinine levels 2.0 mg / dl), active infection requiring systemic antibiotics, personal or family history of hemochromatosis, comorbidities precluding study participation, hypersensitivity to iv iron, red blood cell transfusion within the last 2 weeks, or any investigational agent within 30 days before enrollment. patients were not allowed to take any vitamin, mineral, or herbal supplements containing 27 mg or more of iron per day or 100 mg vitamin c per day during the study or follow - up period. blood transfusions were permitted at the primary physician s discretion if hb levels decreased to 8 g / dl or less, and such patients were considered treatment failures. written informed consent was provided by all patients before study participation, and the protocol and supporting documents were approved by the institutional review board of king hussein cancer center. the study was conducted in accordance with the declaration of helsinki and good clinical practice as contained in the us code of federal regulations that governs the protection of human subjects and the obligations of clinical investigators. patients received 200 mg ferric hydroxide sucrose diluted in 100 ml normal saline and infused over the course of 1 hour weekly for a total of 12 weeks. the first dose was given during the first clinic visit (4 days from the initiation of chemotherapy or radiation therapy). tsat was monitored, as protocol mandated withholding iron therapy when tsat levels were higher than 50%. at the first clinic visit (week 1 ; baseline), a blood sample was obtained for laboratory assessments before the study treatment was started. patients attended weekly clinic visits for treatment and assessment; and returned for follow - up visits at week 14 which included a complete physical examination. complete blood count and tsat were done every 3 weeks, and again 2 weeks after last treatment (week 14). complete laboratory assessment (hb, serum ferritin, reticulocyte count, transferrin, tsat, serum iron, total iron binding capacity, red cell indices, white blood cell count with differential, platelet count, and serum chemistries) were done at week 1 and at week 14 (end of study). adverse events were assessed at each clinic visit until study completion or withdrawal, and during the 30 days after the last study treatment. hb test were presented as mean, median, and range through all 12 weeks. comparison between means of hb level were made between the baseline hb and hb levels in the following weeks, using t - test. a significance criterion of p < 0.05 was used in the analysis. all analyses were performed using sas version 9.1 (sas institute inc, cary, nc, usa). patients received the study treatment for 12 weeks followed by a 4-week follow - up period. eligible patients were at least 18 years old, about to start a cycle of chemotherapy and/or radiation therapy within 1 week of inclusion, and had a nonmyeloid malignancy, hb levels of 11.0 g / dl or less, a life expectancy of more than 24 weeks, and an eastern cooperative oncology group performance status of 02. patients were also required to have a serum ferritin level of 100 ng / ml or higher or transferrin saturation (tsat) levels of 15% or higher and to have received no esas or iv iron therapy within 30 days and no oral iron therapy (27 mg / day or more) within 7 days before enrollment. patients were excluded for leukoerythroblastic features on blood film, hemolysis, gastrointestinal bleeding, folate or vitamin b12 deficiency, elevated serum ferritin (900 ng / ml) or transferrin saturation (tsat) (35%) levels, pregnancy or lactation, liver dysfunction (grade 2 or higher based on national cancer institute common toxicity criteria), renal dysfunction (serum creatinine levels 2.0 mg / dl), active infection requiring systemic antibiotics, personal or family history of hemochromatosis, comorbidities precluding study participation, hypersensitivity to iv iron, red blood cell transfusion within the last 2 weeks, or any investigational agent within 30 days before enrollment. patients were not allowed to take any vitamin, mineral, or herbal supplements containing 27 mg or more of iron per day or 100 mg vitamin c per day during the study or follow - up period. blood transfusions were permitted at the primary physician s discretion if hb levels decreased to 8 g / dl or less, and such patients were considered treatment failures. written informed consent was provided by all patients before study participation, and the protocol and supporting documents were approved by the institutional review board of king hussein cancer center. the study was conducted in accordance with the declaration of helsinki and good clinical practice as contained in the us code of federal regulations that governs the protection of human subjects and the obligations of clinical investigators. patients received 200 mg ferric hydroxide sucrose diluted in 100 ml normal saline and infused over the course of 1 hour weekly for a total of 12 weeks. the first dose was given during the first clinic visit (4 days from the initiation of chemotherapy or radiation therapy). tsat was monitored, as protocol mandated withholding iron therapy when tsat levels were higher than 50%. at the first clinic visit (week 1 ; baseline), a blood sample was obtained for laboratory assessments before the study treatment was started. patients attended weekly clinic visits for treatment and assessment; and returned for follow - up visits at week 14 which included a complete physical examination. complete blood count and tsat were done every 3 weeks, and again 2 weeks after last treatment (week 14). complete laboratory assessment (hb, serum ferritin, reticulocyte count, transferrin, tsat, serum iron, total iron binding capacity, red cell indices, white blood cell count with differential, platelet count, and serum chemistries) were done at week 1 and at week 14 (end of study). adverse events were assessed at each clinic visit until study completion or withdrawal, and during the 30 days after the last study treatment. hb test were presented as mean, median, and range through all 12 weeks. comparison between means of hb level were made between the baseline hb and hb levels in the following weeks, using t - test. a significance criterion of p < 0.05 was used in the analysis. all analyses were performed using sas version 9.1 (sas institute inc, cary, nc, usa). twenty - five patients (17 women and 8 men) were eligible, consented, and included in the study; their mean age (standard deviation,) was 56 years (13.0 years). chemotherapy varied according to the primary cancer and included anthracycline, platinum, taxanes, cyclophosphamide, high - dose ifosfamide, vincristine, vinblastine, bleomycin, and others. many of the included patients had their chemotherapy treatment as second- or third - line therapy. patients characteristics, including age, primary tumor, and active anticancer treatment are summarized in table 1. one patient died during the study from his tumor (after week 2), and five patients withdrew from the study because of inconvenience (three after week 3, and two after week 4). nineteen (76.0%) patients completed a minimum of three treatments, 15 (60.0%) completed nine treatments, and 14 (56.0%) completed all twelve planned weekly treatments. as seen in table 2, the mean hb level of the 25 patients at baseline was 9.6 g / dl (median, 9.9 g / dl ; range, 6.9 g / dl10.9 g / dl). for the 15 patients who completed at least nine treatments, the mean change in their hb level was 1.7 g / dl (median, 1.1 g / dl ; range, 1.9 g / dl to 3.2 g / dl). for the 14 patients who completed the whole treatment period (12 weeks), the mean hb level change was 2.1 g / dl (median, 1.3 g / dl ; range, 0.2 g / dl to 4.6 g / dl ; p = 0.0007). eight (42.1%) of the 19 patients who completed at least three iron infusions had a more than 1 g / dl increase in their hb level. hemoglobin level changes for the 14 patients who completed twelve iron infusions are shown in figure 1. no iv iron - related adverse events were reported among patients during the study or the follow - up period. tsat was monitored during the study period, and no patients had tsat levels increase to more than 50%. the highest ferritin level among patients who completed at least nine iv iron treatments was 1,170 ng / ml; the mean level at the end of study period for the whole group was 379 ng / ml. five (20.0%) patients received blood transfusions and were considered treatment failures (three after week 3, transfused at hb levels of 6.9 g / dl, 7.8 g / dl, and 5.4 g / dl ; one after week 4, transfused at an hb level of 8.2 g / dl ; and one after week 9, transfused at an hb level of 7.2 g / dl). low hb levels are associated with diminished qol and possibly decreased overall survival.2 successful treatment of anemia has undeniable benefits for patients, often yielding dramatic symptomatic improvement. although the role of esas is well - established in treating caa, big concerns were recently raised about the negative effect of esas on survival in some patients with cancer.911 concerns about the risk for thromboembolism in patients with cancer with higher hb levels who are receiving esa were also addressed in many trials.22,23 in addition, the possible immunosuppressive effects of blood product transfusions that may have relevance to neoplasia progression were addressed before.24, 25 in our pilot study, we tested the feasibility of using iron supplementation alone to treat anemia in patients with cancer who are undergoing chemotherapy without the use of esas or blood transfusion, which could be a valid alternative, especially for patients with curable cancers. oral iron is easier to administer and relatively inexpensive, but low patient adherence, poor enteral absorption, and poor tolerance because of a wide range of troublesome gastrointestinal adverse effects limit its overall effectiveness.26 anemia of chronic disease may occur in patients with cancer and is associated with an increase in hepcidin levels, which decreases oral iron absorption and bone marrow iron use, negating any possible effect of regular doses of oral iron.15 iv iron therapy significantly improves response to epoetin alfa when compared with oral iron or no iron in anemic patients with cancer who are receiving chemotherapy.1721 oral iron supplements with esas showed no significant benefit over esas alone in treating caa.21 sodium ferric gluconate and iron sucrose appear to have more favorable safety profiles over iron dextran. a large prospective safety comparison trial failed to show serious anaphylactoid reactions,27 which is confirmed in our study, in which no patients developed reactions and no patients withdrew from the study because of adverse effects. given that the mean hb increase using esas with iv iron in one large controlled trial was 2.4 g / dl,21 the obtained in our study are clinically significant. these findings should be further confirmed and better assessed in larger studies, in which questions such as the optimal timing of iv iron therapy with respect to chemotherapy and the optimal total dose of iv iron should be determined. the use of iv iron monotherapy was recently reviewed by a group in germany that studied the use of ferric carboxymaltose to replace esa and blood transfusions as a treatment for caa. iron - deficient patients treated with ferric carboxymaltose alone (n = 233) had a median of 1.4 g / dl increase in hemoglobin levels compared with those receiving additional treatment with esas (n = 46 ; median, 1.6 g / dl). our study, however, is peculiar in using iron therapy in a non - iron - deficiency state.28 iron overload after iv iron therapy, with potential concerns about the risk of developing secondary cancers and infection, might be raised. the highest serum ferritin level in the present study in patients who completed at least 9 weeks of iv iron therapy was 1,170 ng / ml. most of the literature addressing cancer and infections in iron - overloaded patients comes from patients with hemochromatosis or patients who are undergoing hemodialysis. published reviews report an increase in hepatocellular carcinoma only in patients with hemochromatosis after they develop cirrhosis.29 similarly data supporting the association between iv iron therapy and higher infection rate are weak and not well - supported.30 in fact, anemia itself is a risk factor for infections in patients receiving hemodialysis.31 a multivariate analysis of associations between iron and mortality in more than 58,000 patients receiving hemodialysis reported no increased death rate from serum ferritin levels as high as 1,200 ng / ml.30 the increasing cost of therapy in patients with cancer is of grave concern, which could be an additional benefit of iv iron over the use of esas in such patients. to further address many of the questions raised, our team is planning a bigger trial for iv iron in patients with cancer who have anemia to confirm the discussed in this pilot trial. in addition, we will be looking into predictors of response to iv iron, such as serum hepcidin level. iv iron therapy alone is safe and may be effective in improving hb levels in patients with cancer who are undergoing active anticancer therapy. further randomized trials are needed to address many of the questions raised in our pilot study.

Abstract: anemia in patients with cancer who are undergoing active therapy is commonly encountered and may worsen quality of life in these patients. the effect of blood transfusion is often temporary and may be associated with serious adverse events. erythropoiesis - stimulating agents are not effective in 30%50% of patients and may have a negative effect on overall survival.aimsto assess the efficacy and feasibility of intravenous iron therapy in patients with cancer who have non - iron - deficiency anemia and who are undergoing treatment with chemotherapy without the use of erythropoiesis - stimulating agents.methodsadult patients with solid cancers and non - iron - deficiency anemia were included. ferric sucrose at a dose of 200 mg was given in short intravenous infusions weekly for a total of 12 weeks. hemoglobin level was measured at baseline, every 3 weeks, and 2 weeks after the last iron infusion (week 14). adverse events related to intravenous iron were prospectively reported.of 25 patients included, 19 (76.0%) completed at least three iron infusions and 14 (56.0%) finished the planned 12 weeks of therapy. the mean hemoglobin level of the 25 patients at baseline was 9.6 g / dl (median, 9.9 g / dl ; range, 6.9 g / dl 10.9 g / dl). the mean change in hemoglobin level for the 15 patients who completed at least 9 treatments was 1.7 g / dl (median, 1.1 g / dl ; range, 1.9 g / dl to 3.2 g / dl); it reached 2.1 g / dl (median, 1.3 g / dl ; range, 0.2 g / dl to 4.6 g / dl ; p = 0.0007) for the 14 patients who completed all 12 weekly treatments. five (20.0%) patients were transfused and considered as treatment failures. no treatment - related adverse events were reported.intravenous iron treatment alone is safe and may reduce blood transfusion requirements and improve hemoglobin level in patients with cancer who are undergoing anticancer therapy. further randomized studies are needed to confirm these findings.


tardive dystonia (td), a rarer side effect after longer exposure to antipsychotics, is characterized by local or general, sustained, involuntary contraction of a muscle or muscle group, with twisting movements, generally slow, which may affect the limbs, trunk, neck, or face. td has been shown to develop in about 3% of patients who have had long - term exposure to antipsychotics.. the low risk of td for atypical antipsychotics is thought to from their weak affinity for dopamine receptors. compared with typical, atypical antipsychotic agents have a greater affinity for serotonin 5-ht2a than dopamine d2 receptors, with a low propensity to induce td. among this olanzapine is thought to have preferential action at mesolimbic over nigrostriatal dopaminergic pathways and is, therefore, associated with a very low incidence of extrapyramidal symptom (eps). furthermore, a retrospective analysis of controlled multicentric trials suggested that olanzapine also improves preexisting symptoms of tardive movements. we report a case of 20-year - old male, belonging to lower socioeconomic class, educated up to 2 standard, presented with severe unilateral dystonic left sided neck movements. careful history exploration revealed he was taking risperidone 2 mg irregularly for 2 months and then olanzapine 5 mg for another 4 months. picture of neck dystonia of patient at 19 years, the patient presented with occasional anger outbursts, getting provoked on small matters and beating family members, running away from home, screaming episodes occasionally, fearfulness, sleep disturbance for 2 days; which was precipitated after fever. according to the mother , one friend might have threatened / made fun of him actually and after that patient stopped going out of house, and displayed above mentioned symptoms. this was interpreted as psychosis with persecutory ideas, and he was treated with risperidone 2 mg / day for 2 months and then with olanzapine 5 mg / day for 4 months. in last two follow - ups patient did not present himself, and mother reported unusual neck movements, which were taken as a part of his overall psychopathology and not taken seriously, slight intermittent neck movements reported were missed as part of adolescent behavior problems mimicking some hero in movies. as neck dystonia increased, the patient had a severe disability as patient had to keep his hands behind his head for the support. the movement would decrease when the patient was lying down and was absent during sleep. he even stopped taking food due to severe neck movements making chewing and swallowing difficult. his birth and early developmental milestones were normal. during 210 years of age patient was inattentive and mildly hyperactive. other siblings were educated with master's degree, and patient was also sent to school, but due to inattention and restlessness, he did not pass 2 standard after three attempts. he left the schooling. with average executive functioning and life skills, he worked as an unskilled laborer in the neighborhood shops as a helping hand. , he was found to be getting over familiar, cheerful, moody, and short tempered. sometimes, the patient had inappropriate social judgment; for which his friends made fun of him, and teased him. on mental status assessment, routine investigations, thyroid function tests, electroencephalogram, fundus examination, cervical x - ray, magnetic resonance imaging brain were normal. after consulting neurophysician, wilson's disease and other secondary causes of dystonia were ruled out. the patient was treated with clonazepam 1 mg total dissolved solid (tds), tetrabenazine 25 mg tds, trihexiphenidyl 2 mg bipolar disorder (bd). after 2 months, there was some improvement of around 30%. baclofen 10 mg was added; increased up to 20 mg, trihexyphenidyl reduced to 2 mg. with little improvement after 4 months of treatment for dystonia, levodopa + carbidopa (100 + 25) was added by neurophysician and increased up to tablet tds and baclofen omitted. after 12 months of treatment, patient has improved around 90% with tetrabenazine 75 mg, levodopa + carbidopa (100 + 25) - tablet bd, and clonazepam 1 mg bd. earlier case reports reported td developing with high - dose atypical antipsychotics such as olanzapine 20 mg or aripiprazole 15 mg with longer duration of exposure of around 1215 months in established psychiatric illness like schizophrenia or any other psychotic illness. eps in general and tardive dyskinesia, in particular, have been extensively studied in schizophrenia. even though a number of studies suggest that bipolar patients experience higher rates of eps (parkinsonism, dystonia, akathisia) and td compared to patients with a diagnosis of schizophrenia, research within the bd population has been limited. the risk is found to be 3 to 5 times higher in elderly patients compared to young patients. in addition to age, the risk is directly proportional to: female gender, daily and total dose of the antipsychotic drug, presence of mood disorder, the use of anticholinergics with neuroleptics, previous physical therapies (electroconvulsive therapy), the presence of other physical illness such as diabetes or an organic disorder, younger age of exposure, and the presence of extrapyramidal symptoms early in treatment. this patient's severe dystonic neck movements developed within short period of 6 months of exposure to atypical antipsychotics risperidone 2 mg and then olanzapine 5 mg only, which can cause minimal extrapyramidal side effects. in this case, risk factors for developing serious disabling td were neuroleptic exposure, borderline intellectual functioning, externalizing behavior, probable misdiagnosis, and overlooking early indicators of side effects. this case highlights dangers of casually prescribing low dose second generation antipsychotics in patient with hyperthymic temperament and borderline intellectual functioning with vague short lasting presenting complaints; probably misdiagnosed as psychosis; leading to such severe adverse effects because patients with organic brain damage are more prone to develop adverse effects like td. thus, judicious use of antipsychotics, with detailed and frequent assessments is important, and emergent stereotyped behavior or unexplained movements must be examined carefully and taken seriously. the authors certify that they have obtained all appropriate patient consent forms. in the form the patient(s) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal. the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity can not be guaranteed. the authors certify that they have obtained all appropriate patient consent forms. in the form the patient(s) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal. the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity can not be guaranteed.

Abstract: tardive dystonia (td) is a serious side effect of antipsychotic medications, more with typical antipsychotics, that is potentially irreversible in affected patients. studies show that newer atypical antipsychotics have a lower risk of td. as a , many clinicians may have developed a false sense of security when prescribing these medications. we report a case of 20-year - old male with hyperthymic temperament and borderline intellectual functioning, who developed severe td after low dose short duration exposure to atypical antipsychotic risperidone and then olanzapine. the goal of this paper is to alert the reader to be judicious and cautious before using casual low dose second generation antipsychotics in patient with no core psychotic features, hyperthymic temperament, or borderline intellectual functioning suggestive of organic brain damage, who are more prone to develop adverse effects such as td and monitor the onset of td in patients taking atypical antipsychotics.


syncope is caused by transient diffuse cerebral hypoperfusion and is characterized by transient loss of consciousness with a rapid onset followed by spontaneous and complete recovery. clinical features of syncope may include myoclonic jerks which are often multifocal and asynchronous, convulsions, and urinary incontinence, making it difficult to differentiate from epileptic seizure by clinical features alone. significant fluctuations in cerebral perfusion pressure are prevented by autoregulation of cerebral circulation, but there may be conditions where such mechanism may not compensate adequately. cough syncope, a rare form of syncope, may be a of transient failure of the cerebral autoregulatory mechanism to cope with sudden decrease in cerebral blood flow. we present an unusual case of recurrent cough syncope, which was initially diagnosed and treated as seizures, in the context of a left - sided glomus jugulare tumor, a benign paraganglioma. a 43-year - old right - handed woman with history of glomus jugulare tumor in the left jugular fossa with intracranial extension into the posterior cranial fossa was transferred from another hospital for recurrent seizure - like spells. she had a 90% surgical resection of the tumor done in 2011 followed by radiation therapy in september 2012. her episodes occurred multiple times a day (7 per day on average) during wakeful state. they were triggered by coughing (usually a bout of cough) and were characterized by staring and unresponsiveness as well as stiffening of the body with mild shaking of both upper extremities. she was diagnosed with epileptic seizures but continued to have episodes during treatment with the antiepileptic drugs (aeds) phenytoin, levetiracetam, and lamotrigine. escalation of aed therapy made her increasingly drowsy, and she was on all three aforementioned aeds at the time of presentation. her physical examination was remarkable for excessive drowsiness, mild dysarthria, right sixth cranial nerve palsy, mild hypertonia with hyperreflexia in the lower extremities (left more than right), and bilateral (left more than right) ankle clonus. she had a lumbar puncture done at the outside hospital, and the opening cerebrospinal fluid (csf) pressure was reported to be 25 cm. blood work was also unremarkable except for mild anemia (hemoglobin : 9.4 g / dl), mild hyponatremia (132 meq / l), and mild hypokalemia (3.1 meq / l). antiepileptic drug levels were within therapeutic range (free phenytoin : 1.3 g / ml, levetiracetam : 5.9 g / ml, and lamotrigine : 2.3 g / ml). all started with a bout of cough when the patient was lying in bed (in supine or in lateral position) which was followed by brief (less than a minute) distal upper extremity tremor and subtle proximal upper extremity myoclonic jerks and prolonged unresponsiveness for up to 10 min. all of these episodes were associated with hypotension (7278/3147 mm of hg as revealed by continuous arterial pressure monitoring) and bradycardia (5459 bpm). the eeg during the spells was characterized by generalized synchronous and asynchronous high amplitude 1- to 2-hz delta activity which progressed to generalized attenuation and then transitioned to generalized delta activity again with recovery (fig . 1). a head ct showed recurrence of the glomus jugulare tumor and communicating hydrocephalus. an external ventricular drain (evd) after placement of the evd, her drowsiness gradually started to improve, and episodes decreased in frequency to one per day. 3 showed an enhancing t2 hyperintense left skull base mass in the region of the left jugular foramen with extension into the posterior cranial fossa and below the base of the skull. brain imaging showed evidence of hydrocephalus that had increased compared with her previous brain imaging done 2 months back. her mental status continued to improve, and she had only one mild episode triggered by cough during the next two days before her discharge. repeat surgical resection of the tumor was recommended by the otolaryngology team, which the patient declined. based on the clinical features and eeg findings, the episodes observed in our patient are most consistent with cough syncope. the mechanism underlying cough syncope is not definitively established, but it is postulated that coughing increases intrathoracic and intraabdominal pressures leading to a transient increase in icp. increased icp, in turn, causes a decrease in cerebral perfusion pressure which, if it drops below a critical level, may in global cerebral hypoperfusion leading to syncope. transient cerebral circulatory arrest has been demonstrated by transcranial doppler measurements during cough syncope. our patient also had a drop in blood pressure and heart rate but probably not sufficient to cause syncope by itself. cough syncope has been associated with posterior fossa mass lesions or tonsillar herniation and with hydrocephalus. it may be speculated that bouts of cough caused transient herniation of cerebellar tonsils obstructing csf flow that further contributed to the increase in icp during coughing. decrease in frequency of events following placement of evd to relieve icp lends support to this notion. paragangliomas are rare tumors of extraadrenal chromaffin cell origin that most commonly occur in the head and neck region. catecholamine - hypersecreting paraganglionomas are uncommon in the head and neck region, and most patients (95%) with hypersecreting paraganglionomas have hypertension. hypotension accompanying syncope observed in our patient was not orthostasis - related (the patient was always supine during spells) and was most likely related to cough. identified a subset of patients with cough syncope who lacked a blood pressure overshoot (expected response) after the relief of straining during valsalva maneuver. the authors postulate that cough syncope in these patients might be the of delayed recovery from hypotension that follows a paroxysm of cough, and this was likely contributing to global cerebral hypoperfusion in our patient. this case highlights the fact that cough syncope, a rare form of syncope, may be associated with intracranial mass lesions that indirectly exaggerate the increase in icp in response to cough. glomus caroticum tumor presenting as recurrent unexplained syncope and posterior fossa meningioma presenting as recurrent cough syncope have been described. recurrent cough syncope should trigger search for factors, including brain tumors, with the potential to cause transient elevation in icp. this case also illustrates an important role for ceeg monitoring with video in distinguishing syncope from seizures in cough syncope cases.

Abstract: we present an unusual case of recurrent cough syncope in a 43-year - old woman, which was initially thought to be seizures. syncopal episodes were triggered by paroxysms of cough and were characterized by unresponsiveness and myoclonic jerks in her extremities. she had a left - sided glomus jugulare tumor that extended into the posterior cranial fossa with evidence of worsening communicating hydrocephalus on brain imaging. we postulate that bouts of cough produced increased intracranial pressure both by raising intrathoracic and intraabdominal pressures as well as by transient obstruction to cerebrospinal fluid flow secondary to intermittent tonsillar herniation during cough. this ed in diffuse decrease in cerebral blood flow causing syncope. the patient's syncopal episodes decreased in frequency once an external ventricular drain was placed followed by a ventriculoperitoneal shunt. search for factors that can increase intracranial pressure seems warranted in patients with recurrent cough syncope.


world - wide, infertility affects 1015% of couples who are trying to conceive, and about 15% of these cases are caused by male factors, which affect 1 out of 20 men in the general population. most cases of male infertility are idiopathic, apart from several etiologies, such as obstruction of deferent duct, varicocele, sexual dysfunction, and cryptorchidism. although assisted reproductive technology (art) has helped many sterile couples to conceive, non - obstructive azoospermia (noa), which accounts for a considerable proportion of male infertility, has a dramatically lower rate of sperm retrieval and clinical pregnancy. the etiological mechanism of noa is unknown, but factors such as oxidative stress were considered to have effects on spermatogenesis, and some antioxidants have been effective in protecting spermatogenesis. therefore, it is helpful to explore the underlying pathogenesis of noa in these patients. micrornas are a class of small rnas that do not code amino acid sequences, but they play fundamental roles in regulating gene expression after transcription. lian et al. found 154 down - regulated mirnas and 19 up - regulated mirnas in testes of noa patients compared to fertile males, by using microarray technologies. furthermore, some of the mirnas have been shown to affect the proliferation, apoptosis, and dna damage in germ cells. mir-210 is one of the 19 up - regulated mirnas in testes of noa patients, located within the genomic loci of transcript ak123483. it can be induced by hypoxia, and plays an essential role in cell adaptation to hypoxia. mir-210 also affects regulation of diverse physiological processes, such as angiogenesis, cell survival, proliferation, cell cycle arrest, protein modification, and dna damage repair. although mir-210 has been shown to be involved in regulation of physiological processes in various diseases and to be an up - regulated mirna in testes of noa patients, it remains unknown how mir-210 affects spermatogenesis. hence, the aim of this study was to investigate the underlying mechanisms by which mir-210 is involved in the pathogenesis of spermatogenesis. we enrolled 25 patients (aged 1841 years) with azoospermia (proven by 3 semen analyses from testicular biopsies from the first affiliated hospital of anhui medical university). pathological examinations were performed on each testicular specimen. combined with clinical features, 4 patients were diagnosed as having sertoli - cell - only syndrome (scos), 7 patients were diagnosed as having maturation arrest (ma), 8 patients were diagnosed as having hypospermatogenesis, and the other 6 patients were diagnosed as having obstructive azoospermia (oa). all patients provided informed consent before their participation in this study. our local medical ethics committee approved this study before it began. to examine the location of insulin - like growth factor ii (igf2) in human testicular tissues, we performed immunohistochemistry staining to detect the igf2 expression. tissues were cut into sections for immunoperoxidase staining after being treated with 4% pfa and paraffin wax. after the specific treatment with standard - procedure immunohistochemistry staining as described as lian et al., sections were incubated with igf2 antibody (abcam) overnight at 4c and biotinylated secondary antibody (abcam) for 2 h at room temperature. to detect expression of mir-210, rnas were extracted from nt-2 cells or tissues and subjected to real - time pcr as described as lian et al.. briefly, rna extraction was performed following a standard trizol protocol, real - time pcr was carried out with the abi step one system (applied biosystems), and the sybr premix ex taq ii kit (takara bio, inc .) was used. primers for q - rt pcr were as follows: forward primer: 5-caataactgtgcgtgtgacagc-3 reverse primer: 5-tatggttttgacgactgtgtgat-3 forward primer: 5-cagcacatatactaaaattggaacg-3 reverse primer: 5-acgaatttgcgtgtcatcc-3 western blot analysis was carried out to detect protein expression of igf2 in the human testicular tissues in the 3 groups and in nt2 cells. anti - igf2 (abcam) was used for western blot analysis, and we used -actin as a loading control to detect expression of igf2. we supplemented the medium with 10% fetal bovine serum (life technology inc .), 1% antibiotics (100 units / ml penicillin, and 100 ug / ml streptomycin, life technology inc .). cells were incubated at 37c in a humidified incubator with 5% co2. to transfect oligonucleotides and plasmids into nt-2 cells, lipofectamine rnaimax (invitrogen) and fugene hd (roche) all processes were performed in accordance with the protocols supplied by manufacturers. in this study, all the experiments were performed independently at least 3 times. we enrolled 25 patients (aged 1841 years) with azoospermia (proven by 3 semen analyses from testicular biopsies from the first affiliated hospital of anhui medical university). pathological examinations were performed on each testicular specimen. combined with clinical features, 4 patients were diagnosed as having sertoli - cell - only syndrome (scos), 7 patients were diagnosed as having maturation arrest (ma), 8 patients were diagnosed as having hypospermatogenesis, and the other 6 patients were diagnosed as having obstructive azoospermia (oa). all patients provided informed consent before their participation in this study. to examine the location of insulin - like growth factor ii (igf2) in human testicular tissues, we performed immunohistochemistry staining to detect the igf2 expression. tissues were cut into sections for immunoperoxidase staining after being treated with 4% pfa and paraffin wax. after the specific treatment with standard - procedure immunohistochemistry staining as described as lian et al. , sections were incubated with igf2 antibody (abcam) overnight at 4c and biotinylated secondary antibody (abcam) for 2 h at room temperature. rnas were extracted from nt-2 cells or tissues and subjected to real - time pcr as described as lian et al.. briefly, rna extraction was performed following a standard trizol protocol, real - time pcr was carried out with the abi step one system (applied biosystems), and the sybr premix ex taq ii kit (takara bio, inc .) was used. primers for q - rt pcr were as follows: forward primer: 5-caataactgtgcgtgtgacagc-3 reverse primer: 5-tatggttttgacgactgtgtgat-3 forward primer: 5-cagcacatatactaaaattggaacg-3 reverse primer: 5-acgaatttgcgtgtcatcc-3 western blot analysis was carried out to detect protein expression of igf2 in the human testicular tissues in the 3 groups and in nt2 cells. anti - igf2 (abcam) was used for western blot analysis, and we used -actin as a loading control to detect expression of igf2. we supplemented the medium with 10% fetal bovine serum (life technology inc .), 1% antibiotics (100 units / ml penicillin, and 100 ug / ml streptomycin, life technology inc .). cells were incubated at 37c in a humidified incubator with 5% co2. to transfect oligonucleotides and plasmids into nt-2 cells, lipofectamine rnaimax (invitrogen) and fugene hd (roche) the igf2 gene is part of a cluster of imprinted genes expressing the single polypeptide as igf2, which is only produced from the paternal allele. the maternal allele is transcriptionally silent. to clarify the location of igf2 in human testicular tissues, we found igf2 located in spermatocytes in the testes of patients with oa (figure 1). because igf2 is located in spermatocytes of the testis, we detected the expression of igf2 in cases with ma, hypospermatogenesis, and oa, but not in the scos patients. we found that igf2 was down - regulated in patients with ma and hypospermatogenesis compared to oa patients, which was considered as the control group with normal spermatogenesis, although without a significant difference (figures 2, 3), possibly because there were fewer samples and longer preservation times of some samples. quantitative real - time pcr was performed to examined mir-210 expression in the testis of patients with ma, hypospermatogenesis, and oa. we found that mir-210 was significantly up - regulated in the testis of ma and hypospermatogenesis patients compared to oa patients (figure 4). however, due to errors in the rna extraction in the preliminary experiment, 3 testis samples (1 each) from ma, hypospermatogenesis, and oa patients were damaged and were not tested. in the targetscan database, because the 3utr of the igf2-mrna has a putative mir-210-binding site, igf2 was predicted to be a potential target of mir-210. to identify whether the igf2 gene was targeted by mir-210 directly, renilla luciferase reporters, which include the wild - type full - length 3utr forms of mir-210 seeding sites, figure 5 shows that there was a 60% decrease in luciferase activity after cotransfection of the mir-210 mimic and the renilla luciferase reporters into nt2 cells, and inhibiting mir-210 expression increased activity of the reporter renilla luciferase. expression of igf2 protein was also significantly lower in the nt2 cells transfected with mir-210 mimics than in control cells, and knockdown of mir-210 with mir-210 inhibitor increased protein expression of igf2 (figures 6). the igf2 gene is part of a cluster of imprinted genes expressing the single polypeptide as igf2, which is only produced from the paternal allele. the maternal allele is transcriptionally silent. to clarify the location of igf2 in human testicular tissues, we found igf2 located in spermatocytes in the testes of patients with oa (figure 1). because igf2 is located in spermatocytes of the testis, we detected the expression of igf2 in cases with ma, hypospermatogenesis, and oa, but not in the scos patients. we found that igf2 was down - regulated in patients with ma and hypospermatogenesis compared to oa patients, which was considered as the control group with normal spermatogenesis, although without a significant difference (figures 2, 3), possibly because there were fewer samples and longer preservation times of some samples. quantitative real - time pcr was performed to examined mir-210 expression in the testis of patients with ma, hypospermatogenesis, and oa. we found that mir-210 was significantly up - regulated in the testis of ma and hypospermatogenesis patients compared to oa patients (figure 4). however, due to errors in the rna extraction in the preliminary experiment, 3 testis samples (1 each) from ma, hypospermatogenesis, and oa patients were damaged and were not tested. in the targetscan database, because the 3utr of the igf2-mrna has a putative mir-210-binding site, igf2 was predicted to be a potential target of mir-210. to identify whether the igf2 gene was targeted by mir-210 directly, renilla luciferase reporters, which include the wild - type full - length 3utr forms of mir-210 seeding sites, were used. figure 5 shows that there was a 60% decrease in luciferase activity after cotransfection of the mir-210 mimic and the renilla luciferase reporters into nt2 cells, and inhibiting mir-210 expression increased activity of the reporter renilla luciferase. expression of igf2 protein was also significantly lower in the nt2 cells transfected with mir-210 mimics than in control cells, and knockdown of mir-210 with mir-210 inhibitor increased protein expression of igf2 (figures 6). during recent decades several studies have focused on the effects of mirnas on spermatogenesis in male infertility. however, it was not understood how mir-210, which is one of the up - regulated mirnas in testes of patients with noa, was involved in spermatogenesis in male infertility. the transformation of diploid spermatogonia into mature haploid cells in spermatogenesis is a complex biological process in the testes of males. the insulin / igf system takes part in the processes of cell proliferation, cell growth, differentiation, and survival, which affects nearly every organ in the body. also, insulin / igf plays an important role in the proper function of the testis in males. igf2 binds to igf1r and insr - a with a high affinity and binds to insr - a / igf1r, insr - b / igf1r, but with lower affinity. found that in inactivated insr and igf1r, there was a 79% reduction in daily sperm production in adult mouse testes by a conditional ko approach. taken together, the aforementioned data suggest that igf2 might be involved in the process of spermatogenesis. to examine the specific mechanism by which mir-210 is associated with the process of spermatogenesis, quantitative real - time pcr was performed to detect mir-210 expression. we found that mir-210 was significantly up - regulated in the testes of subjects with ma and hypospermatogenesis patients compared to oa. these agree with findings of lian et al. using microarray technologies performed in noa and normal controls. several studies have suggested that this mirna could be mediated by hypoxia and participate in various types of regulation of angiogenesis, cell survival, proliferation, cell cycle arrest, and protein modification. furthermore, some researchers even found that mir-210 might be considered as one of the indicated markers in some diseases, such as clear cell renal cell carcinoma and acute myeloid leukemia. in the present study we found that igf2 was targeted by mir-210 directly in the in vitro experiment in nt2 cells, and mir-210 might be associated with spermatogenesis by targeting igf2 in male infertility. firstly, as some errors occurred in the rna extraction in the preliminary experiment, mir-210 of 3 testes samples were damaged and not detected in the subsequent quantitative real - time pcr experiment, which might have affected our . secondly, we did not investigate the functions of mir-210 and igf2 in vitro or in vivo, and we plan to do this in future research. we demonstrated that mir-210 might be associated with spermatogenesis by targeting igf2 in male infertility. future mechanistic studies on the role of mir-210/igf2 in the process of spermatogenesis in male infertility will provide new insights into the diagnosis and management of male infertility.

Abstract: micrornas (mirnas) play pivotal roles in spermatogenesis. microrna-210 (mir-210) expression was up - regulated in the testes of sterile men with non - obstructive azoospermia (noa). however, the underlying mechanisms of mir-210 involved in the spermatogenesis in patients with noa are unknown.material/methodsexpression of mir-210 and insulin - like growth factor ii (igf2) in the testes of noa cases (only including maturation arrest and hypospermatogenesis) were detected in this study. we carried out in vitro experiments to determine if igf2 was directly targeted by mir-210 in nt2 cells.compared with obstructive azoospermia (oa) as normal control, our suggest that mir-210 was significantly up - regulated in testis of patients with noa (p<0.05), and igf2 was down - regulated, but without a significant difference. the also indicated that igf2 was directly targeted by mir-210 in nt2 cells.the showed that mir-210 was involved in spermatogenesis by targeting igf2 in male infertility.


midwife - led primary delivery care for low - risk pregnant women during labor has been reported to have various advantages, such as increased odds of high maternal satisfaction and a decrease of unnecessary medical interventions. although the maternity care system for low - risk pregnant women peculiar to one country can not easily be compared with those in other countries, consumer demands for the humanization of obstetric care have arisen in various countries. to date, we have found no evidence that midwife - led primary obstetric care is unsafe for low - risk pregnant women in comparison with obstetric care with the favorable cooperation of obstetricians and midwives in japan. in addition, about 85% of low - risk pregnant women request that they give birth while receiving midwife - led primary delivery care. therefore, safe midwife - led delivery care with the backup of obstetricians may also be required for low - risk pregnant women in japan. if complications occur or threaten to occur during the primary midwife - led delivery care, the midwives have to refer the woman to obstetricians at the same or a neighboring hospital or private obstetric clinic as soon as possible. this is because, in deliveries managed by independent midwives in japan, many intervention measures, such as oxytocin infusion, epidural anesthesia, episiotomy, suture, and instrumental delivery, are not available based on japanese legal restrictions. in our institute, one of the main tokyo city perinatal centers, there are 3 japanese systems of midwife - led delivery care, as follows: those intending to give birth at home managed by midwives who do not belong to our hospital, those planning to give birth on futons (i.e., japanese - style bedding) in japanese tatami mat delivery rooms in our hospital managed by the same midwives who do not belong to our hospital, and those planning to give birth in japanese tatami mat delivery rooms managed by midwives who belong to our hospital. the objective of this study was to describe trends in transfers and perinatal outcomes among labors using these 3 japanese systems of midwife - led primary delivery care. the protocol for this analysis was approved by the ethics committee of the japanese red cross katsushika maternity hospital. in addition, informed consent for analysis from a retrospective database was obtained from each subject during their hospital visit. in our hospital, pregnant women who are initially considered low - risk at 3436 weeks of gestation can choose freely between the 3 systems of midwife - led care and obstetric shared care. in the midwife - led care units, midwives can practice autonomously and are fully accountable for their own practice, unsupervised by obstetricians. factors used to exclude women from the low - risk group comprise the following: medical history: pregnancy - induced hypertension, chronic hypertension, diabetes mellitus, renal disease, idiopathic thrombocytopenia, and other systemic illnesses; gynecological history: history of infertility therapies of in vitro fertilization, congenital uterine anomalies, uterine myomatosis, and adnexal anomaly; obstetric history: narrowing of the pelvic outlet, cephalopelvic disproportion, previous cesarean section, previous anal sphincter injury, previous postpartum hemorrhage 1,000 ml with blood transfusion, previous manual removal of placenta, previous gestational diabetes, and history of severe preeclampsia; complications during the present pregnancy: multiple pregnancy, nonvertex presentation, obesity (maternal body mass index before pregnancy 25 and/or during the third trimester 28), anemia (hemoglobin < 9.0 g / dl), epilepsy with treatment, polyhydramnios, oligohydramnios, low - set placenta, placenta previa, fetal growth restriction, heavy for date fetus, gestational diabetes, and pregnancy - induced hypertension; when risk factors are present, those women are managed by obstetricians and midwives; complications during labor: intrauterine infection, thick meconium staining, prolongation of labor such as active - phase dilation < 1 cm / hour and duration of second stage of labor 2 hours, prolonged rupture of membranes (24 hours), uterine inertia, arrest of labor, and fetal heart rate abnormality such as a nonreassuring fetal status. when these factors are present, the women are transferred to be managed mainly by obstetricians (obstetric shared care) in a standard western - style delivery room or surgery room in our hospital. a retrospective study was performed to examine trends in transfers and perinatal outcomes among labors that started using the 3 systems of midwife - led primary delivery care. in this study, student's t - test was used for continuous variables and the test for categorical variables. odds ratios (ors) and 95% confidence intervals (cis) were also calculated. differences with p between 2009 and 2012, a total of 678 low - risk women were placed in the 3 forms of midwife - led primary delivery care at the onset of labor pains and/or rupture of membranes at 3741 weeks of gestation. of these, 123 (18%) intended to give birth at home, 88 (13%) planned to give birth in the japanese tatami mat rooms in our hospital managed by midwives who do not belong to our hospital, and 467 (59%) planned to give birth managed by the midwives belonging to our hospital. table 1 shows the clinical descriptions of the 678 pregnant women initially considered as low - risk for receiving our midwife - led primary delivery care systems. there were no significant differences in the maternal age or parity among the 3 groups. table 2 shows the rate of transfers in the 3 groups of the midwife - led primary delivery care systems. the total rate of transfers in the system run by the midwives belonging to our hospital (56%) was higher than in the other 2 systems run by the independent midwives (31% in planned home birth : or 1.87, 95% ci 1.23.0, p < 0.01 ; 38% in planned hospital birth : or 2.51, 95% ci 1.73.8, p < 0.01). in addition, the timing of transfers in the system run by the midwives belonging to our hospital (before the second stage of labor : 52%) was earlier than those in the other 2 systems (21% in the planned home birth : or 4.12, 95% ci 2.66.6, p < 0.01 ; 20% in planned hospital birth : or 4.29, 95% ci 2.57.4, p < 0.01). however, if classified into nulliparous and parous women, there were no significant differences in the rate of transfers among the 3 groups, as shown in table 1. in addition, among the 3 groups there were no significant differences in the rate of the main 2 indications for transfer: fetal heart rate abnormality and failure to progress. the main indications for transfer after delivery were maternal postpartum hemorrhage and neonatal respiratory distress associated with asphyxia. table 3 shows the obstetric and neonatal outcomes in the pregnant women initially considered as low - risk for receiving our midwife - led primary delivery care systems. there were no significant differences in these outcomes among the 3 groups our obstetric care system involves the division of women in labor into low- and high - risk groups. the women who are initially considered low - risk can choose freely between midwife - led care and obstetric shared care. if complications occur or risk factors arise during labor in the primary midwife - led care, they are transferred to obstetric shared care. this may be the first report concerning the differences in the timing of transfers from midwife - led care to obstetric shared care among the 3 systems of midwife - led primary delivery care in japan. in this study , there was no evidence that the primary midwife - led care is unsafe for low - risk pregnant women in any of these 3 midwife - led delivery care systems. however, there were no significant differences in the timing of referrals from midwife - led care to obstetric shared care between the system led by midwives who belong to our hospital (hospital midwifery system) and the systems led by the midwives who do not belong to our hospital. in the hospital midwifery system , the timing of transfers seemed to be the earliest due to the ease of transfer within the same hospital and administrator setting. on the other hand, the rate of transfers after delivery with the other 2 systems was higher than that in the hospital midwifery care. during the period, the main indications for transfers were maternal postpartum hemorrhage and/or neonatal respiratory distress associated with asphyxia. fortunately, the difference was not associated with adverse obstetric or neonatal outcomes; however, unfortunately, they led to early mother - to - child separation, especially in cases of planned home birth because healthy puerperal women or newborns can not be transferred from home to hospital according to japanese law. although home birth might be very comfortable, those involved must be prepared for mother - to - child separation in cases of referrals after delivery. the major limitations of this study were the small sample size and lack of long - term follow - up of mothers and children to consider the potential of the findings based on our own context. there were no cases of fetal / neonatal death under the midwife - led delivery care. the most evaluated outcome under midwife - led delivery was the satisfaction of pregnant women with the development of mother - child relationships after delivery. in addition, there might be some bias related to the s in the selection of the systems because this was not a randomized trial study. therefore, a further large prospective study with long - term follow - up may be needed. there were no significant differences in perinatal outcomes among the 3 systems; however, there were some differences in the status of the transfers to the obstetric shared care.

Abstract: objective. the objective of this study was to describe the recent clinical characteristics of labor using 3 systems of japanese midwife - led primary delivery care, as follows: those intending to give birth at home managed by midwives who do not belong to our hospital, those planning to give birth in our hospital managed by the same midwives, and those planning to give birth managed by midwives who belong to our hospital. methods. a retrospective cohort study was performed. . there were no significant differences in the obstetric or neonatal outcomes among the 3 groups. the rate of transfers during labor with the system involving midwives belonging to our hospital was higher than those with the other 2 systems. in addition, the timing of transfers in the system with the midwives belonging to our hospital was earlier than with the other 2 systems. among the 3 groups, there were no significant differences in the rate of the main 2 indications for transfers: fetal heart rate abnormality and failure to progress. . there were no significant differences in perinatal outcomes among the 3 systems; however, there were some differences in the status of transfers to obstetric shared care.