[ prevalence of drug resistance in patients with HIV/AIDS attending to Imam Khomeini Hospital in Tehran, Iran during 2008-2009: letter to editor]

The combinations of antiretroviral [ARV] drugs have proven effective in controlling the progression of AIDS, but these benefits can be compromised by drug resistance. Thus, drug-resistance testing has become an important tool in the management of HIV-infected individuals.1 Drug resistance develops when mutations in the HIV virus proteins occur due to amino acid substitutions.2 Drug resistance testing is done in two ways: phenotypic test and genotypic test.3 In the first method, virus proliferation is measured in the presence of different concentrations of the drugs. In the second, the genetic structure of viral genome sequences are investigated.4 Although, the first case of HIV infection in Iran was identified 23 years ago [1988], there is still no study published on its drug resistance. The main purpose of this study was to determine the prevalence of drug resistance mutations in patients with HIV/AIDS attending Imam Khomeini Hospital in Tehran. The secondary objectives of the study were to determine the frequency of drug resistance to specific drugs such as nucleoside reverse transcriptase inhibitors [NRTIs], non-nucleoside reverse transcriptase inhibitors [NNRTIs] and protease inhibitors [PI]. We collected plasma samples from 25 patients with HIV/AIDS and immunological failure. After the extraction of the viral RNA from plasma, genomic sequencing was performed. Finally, the data for determining drug resistance were analyzed by the Stanford HIV Drug Resistance Database [http:/hivdb.stanford.edu] software. Out of the 25 patients under study, 20 were male [80%] and five were female [20%]. Routes of HIV transmission were: 56% by needle sharing among injecting drug users [IDUs], 20% through sexual contact, 12% through blood transfusions and 12% by unknown routes. High-level drug resistance for ARV drugs included: 24% to NRTIs, 28% to NNRTIs and zero percent to PI drugs. In addition, 15 patients had been infected with genotype A and 10 patients with genotype B of the virus subtypes. More than half of the patients [56%] had HCV co-infection and 44% had prison histories. Overall, the prevalence of drug resistance was 28% which is lower to those of other countries which range from 30% to 90%. Among NRTI drugs, 24% had high-level drug resistance to Lamivudin while no resistance was witnessed against Tenofovir. Among NRTI drugs, 8% had high-level and 68% had low-level resistance to Stavudine. Among NNRTI drugs, 24% and 28% of the patients showed high-level resistance to Efavirenze and Nevirapine, respectively, although the resistance rate in the present study was much lower in comparison to similar studies in China, Venezuela and Chile with respective resistance rates of 61%, 38% and 84%. In this study, no resistance was seen against PI drugs, while the resistance rates in other countries, such as Venezuela, Chile, Brazil and the U.S. have been respectively reported to be 47%, 45%, 45% and 41%.5 With higher genetic barriers than NNRTI drugs, and lack of resistance to them, PI drugs can be used effectively in health care systems in triple drug regimens. With a compliance rate of 32% in our study, 2NRTI+PI combination seems to be preferable to 2NRTI+NNRTI combination for the treatment of HIV/AIDS patients

Prognostic value of B-type natriuretic peptide for assessment of left ventricular function in patients with chronic kidney disease

Since the level of B-type natriuretic peptide [BNP] increases in heart failure, elevated plasma BNP concentration is used as a predictor in the diagnosis and management of heart failure. Due to the diminished renal clearance of BNP, its level is above normal in kidney failure. This study evaluated the BNP prognostic value for assessing ventricular function in patients with chronic kidney disease. All the participants were diagnosed with chronic kidney disease. Echocardiography was employed to assess ejection fraction. Body mass index, serum creatinine, and BNP were measured for all the patients. Prognostic value of BNP was assessed for ventricular function measured by ejection fraction. Forty-four patients, including 34 men and 10 women, participated in the study. Level of BNP had a significant correlation with body mass index, ejection fraction, age, and gender. The sensitivity and specificity of BNP levels of 150 pg/mL and 705 pg/mL were 93.3% and 28.6% and 50.0% and 85.7%, respectively, for the diagnosis of ventricular dysfunction in the patients with chronic kidney disease. These findings suggest that a level of BNP of 705 pg/mL is a rather acceptable predictive factor for heart failure in patients with chronic kidney disease. The participants' height and weight, which were associated with BNP as body mass index, contributed to this level

Comparison of oral folic acid and folinic acid on blood homocysteine level of patients on hemodialysis

Hyperhomocysteinemia is common in patients with chronic kidney disease. There is a direct relationship between cardiovascular mortality and increase of blood homocysteine. Folic acid is used as common treatment in such patients. Folinic acid, a shortened form of folic acid, is not affected by inhibitors of dihydrofolate reductase enzyme such as methoterxate. This study was performed to evaluate the effect of oral folinic acid on the blood homocysteine level of hemodialysis patients, in comparison with folic acid. This clinical trial was performed on 60 hemodialysis patients. The participants were divided into 2 groups to receive either 15 mg of oral folic acid or 15 mg of oral folinic acid, daily. Blood homocysteine levels were measured before dialysis and after the study period. Folic acid and folinic acid decreased the blood homocysteine levels by 33.0% and 28.7%, respectively [P < .001]. However, only 3 patients [6.5%] enjoyed a normalized homocysteine level. Our study showed that both folic and folinic acid decreased the blood homocysteine level and no meaningful difference was observed between them; therefore, we suggest they can be used interchangeably

Use of letrozole versus clomiphene citrate combined with gonadotropins in patients with clomiphene resistant polycystic ovarian syndrome: a comparative study

To compare the clinical outcomes between letrozole and clomiphene citrate [cc] combined with gonadotropins in Clomiphene - resistant polycystic ovary syndrome [PCOS] patients. One hundred and twenty PCOS women after clomiphene response failure were randomly divided into two equal groups to receive clomiphene [100 mg/day] or letrozole [5mg/ day] on days 3-7 of menstrual cycle, combined with human menopausal gonadotropin at a dose 150 IU on days 5-8. The number of dominant follicles, consumed gonadotropin ampoules, endometrial thickness, and clinical pregnancy rates were compared. No significant difference was found regarding the number of dominant follicles, endometrial thickness and consumed gonadotropin ampoules between letrozole and CC groups. Although, the pregnancy rate in letrozole group was higher than that of the CC, the difference was not significant [36.7% vs. 33.3%, p=0.702]. In clomiphene - resistant PCOS patients, similar to Clomiphene, letrozole in combined regimens with gonadotropin can be effective for the induction of ovulation