Outcome of Peripheral Blood Allogeneic Hematopoietic Stem Cell Transplantation as a Treatment Option in Patients With Severe Aplastic Anemia Between 40 and 50 Years.

The frontline treatment for patients younger than 40 years with severe aplastic anemia (AA) is allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen-identical sibling donor. However, in patients with severe AA who are older than 40 years, allogeneic HSCT has been found to be associated with increased treatment-related mortality and toxicity, even when matched sibling donors are used. We report our institutional experience with allogeneic HSCT in patients with severe AA between 40 and 50 years. A total of 19 patients with severe AA were included in the study. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. The mean age of patients at the time of transplant was 43.79 years, and 57.9% were male. The mortality rate was 36.8%, attributed to infection (10.5%), relapse (15.8%), and renal failure (5.3%) in all cases. Acute graft-versus-host disease (GVHD) occurred in five patients (26.3%), and chronic GVHD occurred in two patients (10.5%). The 5-year OS was 62% and the 5-year DFS was 52%. We found that the patient's age, platelet level prior to transplantation, and the number of CD3 cells infused for each transplant were independent prognostic factors for OS, and the age and sex of the patient, graft rejection, and platelet level prior to transplantation were significant prognostic factors associated with DFS. We recommend that immunosuppressive therapy be considered as a first-line treatment in patients with severe AA who are older than 40 years. Allogeneic HSCT can be considered a valid alternative option in patients whose suppression therapy fails.

The effect of bone marrow-derived mesenchymal stem cell co-transplantation with hematopoietic stem cells on liver fibrosis alleviation and survival in patients with class III ß-thalassemia major.

BACKGROUND: Hepatic fibrosis is a common complication in transfusion-dependent thalassemia patients. Data on the co-transplantation of mesenchymal stem cells (MSCs) with hematopoietic stem cells (HSCs) in beta-thalassemia major patients are scarce. Therefore, we aimed to evaluate the effect of co-transplantation of bone marrow-derived MSC with HSCs on the liver fibrosis alleviation and transplant outcomes in class III beta-thalassemia major. METHODS: Between April 1998 and January 2017, a total of 224 consecutive patients with class III beta-thalassemia major underwent allogeneic HSCT in the Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran. To assess liver fibrotic changes after transplantation, 47 patients participated in the MSC plus HSC group and 30 patients in the HSC only group at the end of the follow-up period. All patients underwent laboratory tests, especially serum ferritin and liver function testing, hepatic T2* MRI, liver biopsy, and FibroScan before and 2 years after transplantation. Kaplan-Meier curves were derived to determine survival and were compared using the log-rank test. Repeated-measure, mixed-effect linear regression models were used to examine the changes in liver fibrosis over time. RESULTS: The 10-year OS rate was 71.84% in the mesenchymal group and 61.89% in the non-mesenchymal group (P value = 0.294), while the 10-year TFS rate was 63.64% in the mesenchymal group and 52.78% in the non-mesenchymal group (P value = 0.285). No significant difference was observed in the 10-year NRM, rejection rate, ANC engraftment, platelet engraftment, acute GvHD, and chronic GvHD between the two groups. In addition, the results of repeated-measure, mixed-effect linear regression models showed that none of the variables determining hepatic fibrosis had a significant difference between patients receiving MSCs and patients who did not receive MSCs. CONCLUSIONS: Based on the results of this study, a single infusion of MSCs at the time of HSCT to patients with class III beta-thalassemia major could not significantly improve the liver fibrosis alleviation and transplantation outcomes, including OS, TFS, TRM, rejection rate, ANC engraftment, platelet engraftment, acute GvHD, and chronic GvHD.

Effectiveness of booster dose of tetanus and diphtheria toxoids (Td) vaccine in management of recurrent aphthous stomatitis: a prospective, randomized, triple-blind and placebo-controlled clinical trial.

BACKGROUND: Recurrent aphthous stomatitis (RAS) is the most common oral disease. The activation of the immune system by vaccines might reduce the interactions between oral mucosa and microorganisms. AIM: To evaluate the effect of the tetanus-diphtheria toxoids (Td) vaccine in management of RAS. DESIGN AND SETTING: This prospective, randomized, triple-blind and placebo-controlled clinical trial study was conducted on 70 eligible patients with minor RAS at the dermatology outpatient clinic. METHOD: Finally, a total of 66 participants (48 male, 18 female; mean age: 38.56 ± 10.98 years) completed the study in two groups, one in which colchicine and a single dose of vitamin B6 (placebo group) was treated and one in which colchicine and a single dose of Td vaccine (intervention group) was treated. RESULTS: After six months of follow-up, the patients were evaluated, which revealed significant effects of the Td vaccine on pain intensity, ulcer size, recovery time, and the interval between episodes. At the end of the six month follow-up, 27 patients (81.8%) in the intervention group and 13 patients (39.4%) in the placebo group showed partial or complete recovery, and there was statistically significant difference between the groups (p < .001). Recovery was not significantly associated with sex, education level, marital status and duration of RAS. However, occupation and positive family history of RAS had significant relations with recovery. CONCLUSIONS: A booster dose of Td vaccine had relatively favorable effects on pain intensity and recurrence of RAS, but further research is needed to confirm its efficacy.

Co-transplantation of bone marrow-derived mesenchymal stem cells with hematopoietic stem cells does not improve transplantation outcome in class III beta-thalassemia major: A prospective cohort study with long-term follow-up.

Bone marrow transplantation is the only curative treatment for beta-thalassemia major. Data on the co-transplantation of MSCs with HSCs in beta-thalassemia major patients are scarce. We aimed to investigate the outcomes of thalassemia major patients who underwent bone marrow-derived MSC co-transplantation with HSCs compared with those who only received HSCs. This prospective randomized study included patients with class III thalassemia major undergoing HSCT divided randomly into two groups: Thirty-three patients underwent co-transplantation of bone marrow-derived MSCs with HSCs, and 26 patients only received HSCs. Five-year OS, TFS, TRM, graft rejection rate, and GVHD were estimated. The 5-year OS was 66.54% (95% CI, 47.8% to 79.9%) in patients who underwent co-transplantation of MSCs with HSCs vs 76.92% (95% CI, 55.7% to 88.9%) in patients who only received HSCs (P = .54). No significant difference was observed in the 5-year TFS between the two groups (59.1% vs 69.2%; P = .49). The 5-year cumulative incidence of TRM was not statistically significant among patients who underwent co-transplantation of MSCs with HSCs (27.27%) vs those who only received HSCs (19.23%; P = .61). There was no statistically significant difference in graft rejection, acute GvHD, and chronic GvHD between the two groups. Based on our findings, the co-transplantation of MSCs and HSCs to class III thalassemia major patients does not alter their transplantation outcomes including OS, TFS, rejection rate, transplant-related mortality, and GvHD.

Management of central nervous system involvement in multiple myeloma after autologous hematopoietic stem cell transplantation.

Multiple myeloma (MM) is characterized by uncontrolled clonal proliferation of plasma cells, mainly in bone marrow, and its extramedullary involvement is rare. Central nervous system involvement in MM is a highly aggressive disease with a survival of less than 6 months. The best treatment regimen for MM with CNS involvement is still unknown and in most patients, the prognosis is unfavorable. To date, there is no report of CNS involvement without evidence of systemic involvement in a known case with MM. Here, we report a 58-year-old male with MM who recurred CNS involvement without evidence of systemic involvement following autologous stem cell transplant.

Indicators of male fertility potential in adult patients with beta-thalassemia major: a comparative study between patients undergone allogeneic stem cell transplantation and transfusion-dependent patients.

BACKGROUND: Allogeneic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment for thalassemia major (TM). Infertility and its indicators have been assessed in transfusion dependent TM men, but in this study, we sought to compare the fertility indicators of TM patients after HSCT with those in patients treated conventionally. The possible influential factors on reproductive capacity in TM patients undergone allogeneic HSCT were also evaluated. PATIENTS AND METHODS: In this cross-sectional study, we compared the gonadal hormones level, testicular volume, Tanner stage and sperm analysis in transfusion-dependent thalassemia major (TDTM) patients who survived matched sibling HSCT (n = 43) with patients conventionally treated by transfusion and iron chelation (n = 52). RESULTS: The patients' age range was between 16 to 41 years. Tanner stage 4-5 was seen in 39 patients (41%). The prevalence of hypogonadism in our patients was 32.63% but its frequency was not significantly different between the two groups (p = 0.35). Azospermia, oligospermia, astenospermia, teratospermia and even having dry and low volume ejaculate were all significantly more frequent in the post-transplant patients compared to TDTM group. In the post-HSCT group, neither patients' age at transplantation nor the conditioning regimen used in their transplant process did significantly affect their hormonal status and sperm parameters. Chronic graft versus host disease (GVHD) occurred in 14 (40%) patients. No significant difference was observed between the grade of chronic GVHD and hypogonadism (P = 0.853). CONCLUSIONS: Thalassemia patients undergone allogeneic HSCT have lower fertility potential, mainly in sperm parameters compared with patients treated with blood transfusion and chelation. This information is important for thalassemic patients considering HSCT.

Association between Ki-67 expression and clinicopathological features in prognosis of breast cancer: A retrospective cohort study.

BACKGROUND: Breast cancer is the most common diagnosed female cancer. Breast cancer is also the leading cause of cancer death in females accounting for 13.7% of female cancer-related mortality globally. Variable known prognostic factors such as histological tumor type, tumor size, nodal status, grade, age, and estrogen receptor (ER) status and the proliferation marker - Ki-67 influence the type of treatment decision. The purpose of this present study is to investigate the association between Ki-67 expression with several clinicopathological variables and patients' outcome. MATERIALS AND METHODS: This is a retrospective cohort study from September 2008 to March 2017; 165 newly diagnosed breast cancer patients were enrolled in the study. Ki67 levels were measured using immunohistochemistry and compared with clinicopathological variables. The relation of Ki67 expression with disease-free survival (DFS) and overall survival (OS) was also analyzed. RESULTS: The result of this study revealed that age, tumor size, menopausal status, and human epidermal growth factor receptor 2 (HER2) status had no effect on the patients' outcome. Patients with ER-positive, progesterone receptor (PR)-positive, and HER2-negative tumors expressed a higher rate of Ki-67 (>10%) than patients with ER-negative, PR-negative, and HER2-positive tumors, respectively. However, we found that Ki-67 levels were not significantly increased statistically with ER, PR, and HER2 statuses. There was a statistically significant correlation between Ki-67 expression and with higher stages of the disease. Multivariate analysis showed that Ki-67 expression could not to be an independent prognostic factor for 5-year OS and DFS. Furthermore, p53 status was only prognostic factor for 5-year OS whereas higher stages of disease and p53 status were prognostic factors for 5-year DFS. CONCLUSION: Ki67 could not be an independent variable for prediction of breast cancer outcome.

Acute Physiology and Chronic Health Evaluation II score for the assessment of mortality prediction in the intensive care unit: a single-centre study from Iran.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II is still commonly used as an index of illness severity in patients admitted to intensive care unit (ICU) and has been validated for many research and clinical audit purposes. AIMS AND OBJECTIVES: To investigate the diagnostic value of the APACHE II score for predicting mortality rate of critically ill patients. DESIGN: This was a single-centre, retrospective study of 200 Iranian patients admitted in the medical-surgical adult ICU from June 2012 to May 2013. METHODS: Demographic data, pre-existing comorbidities and variables required for calculating the APACHE II score were recorded. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated to assess the predictive value of the APACHE II score. RESULTS: Of the 200 patients with a mean age of 55·27 ± 21·59 years enrolled in the study, 112 (54%) were admitted in the medical ICU and 88 (46%) in the surgical ICU. Finally, 116 patients (58%) died, and 84 patients (42%) survived. The overall actual and predicted ICU mortality were 58% and 25·16%, respectively. The mean APACHE II score was 16·31 in total patients, 17·78 in medical ICU and 14·45 in surgical ICU patients (P = 0·003). Overall, the APACHE II score had the highest prognostic value for predicting the mortality rate of critically ill patients with an area under the cure of 0·88, and with a cut-off value of 15, the APACHE II score predicted mortality of patients with a sensitivity of 85·3%, a specificity of 77·4%, a positive predictive value of 83·9% and a negative predictive value of 73·9%. CONCLUSION: This study shows that an APACHE II score of 15 provides the best diagnostic accuracy to predict mortality of critically ill patients. Our observed mortality rate was greater than the predicted death rate, in comparison to the other prestigious centres in the world. Therefore, it appears that we must improve our intensive care to reduce mortality. RELEVANCE TO CLINICAL PRACTICE: There is a need to create a suitable scoring system to predict the mortality rate of critically ill patients in accordance with the advanced technological equipment and experienced physicians and nurses in that ICU.

The Incidence Rate, Risk Factors and Clinical Outcome of Acute Kidney Injury in Critical Patients.

BACKGROUND: Acute kidney injury (AKI) is the most common cause of organ dysfunction in intensive care unit (ICU) patients. There is no consensus definition of AKI in ICU patients. Therefore, we aimed to evaluate the incidence rate, risk factors and clinical outcome of AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification in ICU patients. METHODS: We performed a retrospective cohort study, on 900 patients admitted to the ICU during a one year period at Imam Khomeini Hospital in Ardebil, Iran from 2014 to 2015. AKI was defined by the consensus RIFLE criteria. RESULTS: The overall incidence rate of AKI was 37%. The patients with AKI were also classified according to RIFLE as follows: Risk (8.2%), Injury (13.4%), Failure (13.2%), Loss of kidney function (1.3%), and End-stage kidney disease (0.8%). The mortality rate was 58.3% for AKI patients, and 13.4% for non-AKI patients (P<0.001). Patients in RIFLE-R (Risk) had a mortality rate of 37.8% compared with 48.8% for those in RIFLE-I (Injury) and 76.5% for RIFLE-F (Failure) patients (P<0.0001). Significant risk factors to the development of AKI were included: age more than 60 yr, increased length of hospital stay, systolic blood pressure less than 100 mm Hg, requirement of mechanical ventilation, relevant comorbidities, anemia, thrombocytopenia, increased serum bilirubin and liver enzymes, and serum sodium abnormalities. CONCLUSION: The RIFLE classification is a useful and suitable clinical tool to evaluate the incidence and mortality rate of AKI. In ICU patients, AKI is associated with increased mortality rate.

The prevalence of chronic obstructive pulmonary disease in hookah smokers.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Hookah smoking is growing worldwide and particularly in Iran. The aim of this study was to determine the prevalence of obstructive pulmonary dysfunction in hookah smokers. We conducted a population-based study in Bushehr Province, Iran. A total of 245 subjects aged 35 years or older who were taking hookah for at least 15 years and 245 healthy controls were enrolled in the study and spirometry was done. Statistical analyses were performed using SPSS for windows software version 19. The prevalence of COPD among the exposed group of hookah smoke was 10.2%, with the rate being significantly higher in the patients with older age ( p < 0.001), duration of hookah smoking ( p < 0.001), men ( p = 0.026), ≥3 hookahs/day ( p = 0.006), history of cough for ≥2 years ( p = 0.002), in patients with a history of sputum for ≥2 years ( p = 0.031), and in patients with a history of dyspnea for ≥2 years ( p = 0.001). The results of the logistic regression analysis demonstrated that older age, male gender, smoking, and occupational exposure were independent predictive factors for COPD. The results of our study suggest that hookah smoking significantly increases the risk of COPD. Given the importance of COPD in the global burden of diseases, it is necessary to carry out further studies on the relationship between hookah use and COPD.

Evaluation of the serum zinc level in adult patients with melasma: Is there a relationship with serum zinc deficiency and melasma?

BACKGROUND: Melasma is a common acquired hypermelanosis of sun-exposed skin, particularly on the face, which presents as symmetric, light- to gray-brown-colored macules and patches. There are several studies of serum zinc levels in cutaneous disorders. So far, no studies have been carried out to assess the serum zinc level in patients with melasma. The aim of this study is to determine the serum zinc level in patients with melasma compared to healthy subjects. MATERIALS AND METHODS: A total of 118 patients with melasma and 118 healthy controls were enrolled in this prospective cross-sectional study. The two groups were matched for age and sex. Atomic absorption spectrophotometry was used to measure serum zinc levels. The statistical analysis was performed using SPSS software. RESULTS: The mean serum level of zinc in melasma patients and controls was 77.4±23.2 µg/dL and 82.2±23.9 µg/dL, respectively (P-value=.0001). Serum zinc deficiency was found in 45.8% and 23.7% of melasma patients and control subjects, respectively. A positive family history of melasma in first-degree relatives was present in 46 (39%) of the cases, and a history of taking oral contraceptive pill was found in 95 (81%) of women with melasma. The aggravating factors for melasma were stated as: sun exposure (11.1%), pregnancy (15.3%), nutrition (2.5%), oral contraceptive pills (18.6%), and emotional stress (5.9%). The malar and centrofacial patterns were seen in 3.4% and 72% of cases, respectively, whereas 24.6% of the patients had both centrofacial distribution and malar distribution, and there was no patient with mandibular pattern. Among patients with melasma, 20.3% had thyroid dysfunction, while in the control subjects, 8.4% had thyroid dysfunction (P=.001). CONCLUSION: There is a significant relationship between low levels of zinc and melasma. Zinc deficiency may be involved in the pathogenesis of melasma. Also, treatment with oral zinc supplements can be tried in these patients to see the outcome. However, to make recommendations on screening for zinc deficiency in patients with melasma, future research of good methodological quality is needed.

Multiple Myeloma in a Patient With Familial Mediterranean Fever.

Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurrent episodes of painful inflammation in the abdomen, chest, or joints. The coexistence of multiple myeloma (MM) and FMF is an extremely rare event. Here, we report a case of FMF with concurrent MM. A 63-year-old woman was diagnosed with FMF since 15 years earlier. She was admitted with a complaint of low back pain. Regarding the presence of back pain, anemia, hypercalcemia, and kidney failure, a diagnosis of MM was suspected. A skeletal survey showed punched-out lesions in the skull. Serum protein electrophoresis demonstrated an immunoglobulin G kappa monoclonal gammopathy, and bone marrow aspiration revealed 30% involvement by abnormally appearing plasma cells, suggestive of MM. Although the association between FMF and MM may be a mere coincidence, further studies are necessary to understand their concurrent development.

The first report of two cases of fatal liver injury due to anti-tuberculosis drugs in the presence of alpha-1 antitrypsin deficiency.

Tuberculosis (TB) is a major global health problem. Awareness of liver injury due to anti-TB therapy is vital because fulminant hepatic failure is a devastating and often fatal condition without liver transplantation. Here, we report for the first time, two patients of fatal liver injury due to anti-TB drugs in the presence of alpha-1 antitrypsin deficiency. Based on the triad of rapid loss in hepatocyte function, the onset of hepatic encephalopathy, and absence of a prior history of liver disease, the diagnosis of acute liver failure was established. Both patients had low levels of serum alpha-1 antitrypsin, consistent with alpha-1 antitrypsin deficiency. Despite aggressive medical therapy and supportive care, patients developed multi-organ failure and died. It seems measuring the serum levels of alpha 1-antitrypsin before beginning anti-TB therapies is necessary, especially when there is emphysema or bronchiectasis.

Evaluation of the serum zinc level in patients with vitiligo.

INTRODUCTION: Vitiligo is an acquired, idiopathic disorder characterized by circumscribed depigmented macules and patches, which affects approximately 0.1-2% of the general population worldwide. Zinc is an essential trace element that is necessary for growth and development at all stages of life. Some studies have reported an association between serum zinc levels and vitiligo. AIM: To measure the serum zinc level in patients with vitiligo compared to healthy subjects. MATERIAL AND METHODS: One hundred patients with vitiligo and 100 healthy controls were referred to our clinic. The two groups were matched for age and sex. Atomic absorption spectrophotometry was used to measure serum zinc levels. The statistical analysis was performed using SPSS software. RESULTS: The mean serum level of zinc in vitiligo patients and controls was 80.11 ±17.10 µg/dl and 96.10 ±16.16 µg/dl, respectively. The serum zinc level in patients with vitiligo was significantly lower than in healthy controls (p = 0.0001). CONCLUSIONS: The results of our study revealed a significant association between vitiligo and serum zinc levels. A relative decrease in the serum zinc level in vitiligo patients can highlight the role of zinc in the pathogenesis of vitiligo, and large-scale studies need to be conducted to confirm these findings and assess the effect of oral zinc supplements in patients with low zinc levels.

Overexpression of Drosha, DiGeorge syndrome critical region gene 8 (DGCR8), and Dicer mRNAs in the pathogenesis of psoriasis.

INTRODUCTION: Psoriasis is a complex autoimmune inflammatory disease that occurs in genetically susceptible individuals and presents with the development of inflammatory plaques on the skin. Recent studies have indicated that microRNAs (miRNAs) play important roles in psoriasis. OBJECTIVE: To investigate whether expression of Drosha, DGCR8, and Dicer mRNAs is involved in the pathogenesis of psoriasis. METHODS: Biopsies were obtained from involved psoriatic skin (PP), noninvolved psoriatic skin (PN), and healthy skin (NN). Expression of Drosha, Dicer, and DGCR8 was assessed with real-time quantitative real-time PCR in 25 patients with psoriasis and 25 healthy volunteers. RESULTS: We observed that expression levels of Drosha, Dicer, and DGCR8 were upregulated in patients with psoriasis compared to the control group. However, the Drosha and Dicer expression levels were higher in PP tissues and PN tissues compared to NN tissues, but they were more upregulated in PP tissues compared to PN tissues (P<.001). Although the DGCR8 expression was higher in PP tissues and PN tissues compared to NN tissues, it was more upregulated in PN tissues compared to PP tissues (P<.001). CONCLUSION: Our data demonstrate that upregulated expression of Drosha, DGCR8, and Dicer mRNAs may be involved in the pathogenesis of psoriasis.

Left Main Coronary Artery Aneurysm.

Aneurysms of the left main coronary artery are exceedingly rare clinical entities, encountered incidentally in approximately 0.1% of patients who undergo routine angiography. The most common cause of coronary artery aneurysms is atherosclerosis. Angiography is the gold standard for diagnosis and treatment. Depending on the severity of the coexisting coronary stenosis, patients with left main coronary artery aneurysms can be effectively managed either surgically or pharmacologically. We herein report a case of left main coronary artery aneurysm in a 72-year-old man with a prior history of hypertension presenting to our hospital because of unstable angina. The electrocardiogram showed ST-segment depression and T-wave inversion in the precordial leads. All the data of blood chemistry were normal. Echocardiography showed akinetic anterior wall, septum, and apex, mild mitral regurgitation and ejection fraction of 45%. Coronary angiography revealed a saccular aneurysm of the left main coronary artery with significant stenosis in the left anterior descending, left circumflex, and right coronary artery. The patient immediately underwent coronary artery bypass grafting and ligation of the aneurysm. At six months' follow-up, he remained asymptomatic.

Association of serum prostate-specific antigen levels with the results of the prostate needle biopsy.

AIM: To investigate the relationship of serum prostate-specific antigen (PSA) levels with outcomes of prostate needle biopsy in men 50 or more years old. METHODS: We measured serum PSA levels in 1472 healthy men 50 or more years old. Men who had serum PSA values 4.0ng/mL or higher underwent digital rectal examination. If there were either an elevated PSA level (≥4ng/mL) or abnormal digital rectal examination, a transrectal ultrasound-guided prostate biopsy was performed. RESULTS: The mean serum total PSA level was 13.73±11.44ng/mL, and the mean serum free PSA level was 4.99±0.97ng/mL. Of the 260 men who had serum total PSA levels of≥4ng/mL, 139 underwent biopsy. Of these 139 men, 45 (32.4%) had prostate cancer. Benign prostatic hyperplasia with or without prostatitis was diagnosed in 94 patients (67.6%). There was no significant correlation between age and histologic results of prostate needle biopsy (P-value=0.469). The serum free PSA showed no significant correlation with histologic results of prostate needle biopsy, whereas the serum total PSA level had a significant correlation in patients with adenocarcinoma compared with other diagnosis. CONCLUSIONS: The overall frequency of detection of prostate adenocarcinoma was 32.4%. This study revealed that no level of PSA was associated with a 100% positive predictive value and negative biopsy can occur virtually at any PSA level. There is a need to create awareness among the general population and health professionals for an early diagnosis of this common form of cancer.