Virology & Mycology Infectious Diseases
 
   Publications A-Z
A
»Accounting & Marketing
» Addiction Research & Therapy
» Advanced Chemical Engineering
»Advances in Automobile Engineering
»Advances in Crop Science and Technology
»Advances in Dairy Research
»Advancements in Genetic Engineering
»Advances in Pharmacoepidemiology & Drug Safety
»Advances in Robotics & Automation
»Advanced Techniques in Biology & Medicine
»Advance Research in Meteorological Sciences
»Aeronautics & Aerospace Engineering
»Aging Science
»Agrotechnology
»AIDS & Clinical Research
»Alcoholism and Drug Dependence
»Allergy & Therapy
»Alternative & Integrative Medicine
»Air & Water borne Diseases
»Alzheimers Disease & Parkinsonism
»Analytical & Bioanalytical Techniques
»Anaplastology
»Anatomy & Physiology
»Ancient Diseases & Preventive Remedies
»Andrology-Open Access
»Anesthesia & Clinical Research
»Angiology: Open Access
»Antivirals & Antiretrovirals
»Anthropology
»Applied & Computational Mathematics
»Applied Mechanical Engineering
»Aquaculture Research & Development
» Arabian Journal Business and Management Review
»Architectural Engineering Technology
»Arthritis
»Arts and Social Sciences Journal
» Astrobiology & Outreach
»Astrophysics & Aerospace technology
»Autacoids
»Automatic Control of Physiological State and Function
»Autism-Open Access
  
B
»Bacteriology & Parasitology
»Bioanalysis & Biomedicine
»Bioceramics Development and Applications
»Biochemistry and Analytical Biochemistry
»Biochemistry & Pharmacology: Open Access
»Biochips & Tissue Chips
»Biodiversity & Endangered Species
»Bioenergetics: Open Access
»Bioengineering & Biomedical Science
»Bioequivalence & Bioavailability
»Biosafety & Health Education
»Biofertilizers & Biopesticides
»Biometrics & Biostatistics
»Biomimetics Biomaterials and Tissue Engineering
»Biomolecular Research & Therapeutics
» Biomusical Engineering
»Biochemistry & Physiology: Open Access
»Biological Systems- Open Access
»Biology and Medicine
»Bioprocessing & Biotechniques
»Bioremediation & Biodegradation
»Biosafety
»Biosensors & Bioelectronics
» Biosensors Journal
»Biotechnology & Biomaterials
»Bioterrorism & Biodefense
»Blood Disorders & Transfusion
»Blood & Lymph
»Bone Marrow Research
»Brain Disorders & Therapy
»Business and Economics Journal
»Business and Financial Affairs
  
C
»Cancer Science & Therapy
»Climatology & Weather forecasting
»Carcinogenesis & Mutagenesis
»Cardiovascular Diseases & Diagnosis
»Cardiovascular Pharmacology: Open Access
»Cell & Developmental Biology
»Cell Science & Therapy
»Chemical Engineering & Process Technology
»Chemical Sciences Journal
»Chemotherapy: Open Access
»Child and Adolescent Behavior
»Chromatography & Separation Techniques
»Civil & Environmental Engineering
»Civil & Legal Sciences
»Clinical & Cellular Immunology
»Clinical Case Reports
»Clinical & Experimental Cardiology
»Clinical & Experimental Dermatology Research
»Clinical & Experimental Ophthalmology
»Clinical & Experimental Pathology
»Clinical & Experimental Pharmacology
»Clinical Microbiology: Open Access
»Clinical Pharmacology & Biopharmaceutics
»Clinical Research & Bioethics
»Clinical Research on Foot & Ankle
»Clinical Toxicology
»Clinical Trials
»Clinics in Mother and Child Health
»Cloning & Transgenesis
»Community Medicine & Health Education
»Communication Disorders, Deaf Studies & Hearing Aids
»Computer Science & Systems Biology
» Current Synthetic & Systems Biology
»Cytology & Histology
D
»Data Mining in Genomics & Proteomics
»Defense Management
»Dentistry
»Depression and Anxiety
»Developing Drugs
»Diabetes & Metabolism
»Drug Designing
»Drug Metabolism & Toxicology
  
E
»Earth Science & Climatic Change
»Ecosystem & Ecography
»Endocrinology & Metabolic Syndrome
»Entomology, Ornithology & Herpetology
»Environmental & Analytical Toxicology
»Epidemiology: Open Access
»Emergency Medicine
»Ergonomics
»Electrical & Electronics
»Enzyme Engineering
»Entrepreneurship & Organization Management
  
F
»Family Medicine & Medical Science Research
»Fermentation Technology
»Fertilization: In Vitro - IVF-Worldwide
»Fisheries and Aquaculture Journal
»Fisheries & Livestock Production
»Food Processing & Technology
»Forensic Biomechanics
»Forensic Research
»Forest Research: Open Access
»Fundamentals of Renewable Energy and Applications
»Fungal Genomics & Biology
  
G
»Gastrointestinal & Digestive System
»Genetic Syndromes & Gene Therapy
»Gene Technology
»Generalized Lie Theory and Applications
»Glycobiology
»Glycomics & Lipidomics
»Gynecology& Obstetrics
»General Medicine
»General Practice
»Geography & Natural Disasters
»Geology & Geosciences
»Geophysics & Remote Sensing
»Gerontology & Geriatric Research
»Global Economics
»Global Journal of Technology and Optimization
  
H
»Hair : Therapy & Transplantation
»Hematology & Thromboembolic Diseases
»Health Care : Current Reviews
»Health & Medical Informatics
»Hereditary Genetics
»Homeopathy & Ayurvedic Medicine
»Horticulture
»Hotel & Business Management
»Human Genetics & Embryology
»Hydrology: Current Research
»Hypertension- Open Access
  
I
»Industrial Engineering & Management
»Irrigation and Drainage Systems Engineering
»Infectious Diseases and Therapy
»Information Technology & Software Engineering
»Intellectual Property Rights: Open Access
»Integrative Oncology
»Internal Medicine
»International Journal of Accounting Research
»International Journal of Advanced Innovations, Thoughts & Ideas
»International Journal of Biomedical Data Mining
»International Journal of Economics and Management Science
»International Journal of Sensor Networks and Data Communications
»International Journal of Swarm Intelligence and Evolutionary Computation
»International Journal of waste resources
»International Journal of Genomic Medicine
»International Journal of Physical Medicine & Rehabilitation
»Innovative Energy Policies
»Immunome Research
  
J
»JBR Journal of Interdisciplinary Medicine and Dental Science
»JBR Journal of Clinical Diagnosis and Research
»JBR Journal of Young Scientist
  
L
»Liver
» Leukemia
» Lovotics
  
M
»Marine Science: Research & Development
»Malaria Chemotherapy, Control & Elimination
»Mass Communication & Journalism
»Material Sciences & Engineering
»Medicinal Chemistry
»Medicinal & Aromatic Plants
»Medical Diagnostic Methods
»Medical Microbiology & Diagnosis
»Medical & Surgical Urology
»Membrane Science & Technology
»Metabolic Syndrome
»Metabolomics:Open Access
»Microbial & Biochemical Technology
»Modern Chemistry & Applications
»Molecular Biology
»Molecular Biomarkers & Diagnosis
»Molecular and Genetic Medicine
»Molecular Imaging & Dynamics
»Molecular Pharmaceutics & Organic Process Research
»Mycobacterial Diseases
N
»Natural Products Chemistry & Research
»Nanomedicine & Biotherapeutic Discovery
»Nanomedicine & Nanotechnology
»Neonatal Biology
»Nephrology & Therapeutics
»Neurology & Neurophysiology
»Neuroinfectious Diseases
»Neurological Disorders
»Novel Physiotherapies
»Nuclear Medicine & Radiation Therapy
»Nutrition & Food Sciences
»Nutritional Disorders & Therapy
»Nursing & Care
  
O
»Obesity & Weight Loss Therapy
»Oceanography-Open Access
»Occupational Medicine & Health Affairs
»OMICS Journal of Radiology
»Osteoporosis and Physical Activity
»Oral Health and Dental Management
»Oral Hygiene & Health
»Organic Chemistry: Current Research
»Orthopedic & Muscular System: Current Research
»Otolaryngology
  
P
»Pain & Relief
»Palliative Care & Medicine
»Pancreatic Disorders & Therapy
»Pediatrics & Therapeutics
»Petroleum & Environmental Biotechnology
»Pharmaceutica Analytica Acta
»Pharmaceutical Regulatory Affairs: Open Access
»Pharmacogenomics & Pharmacoproteomics
»Pharmacovigilance
»Physical Chemistry & Biophysics
»Physical Mathematics
»Plant Pathology & Microbiology
»Plant Biochemistry & Physiology
»Pollution Effects & Control
»political Sciences & public affairs
»Poultry, Fisheries & Wildlife Sciences
»Powder Metallurgy & Mining
»Primatology
»Primary Health Care: Open Access
»Probiotics & Health
» Phylogenetics & Evolutionary Biology
»Proteomics & Bioinformatics
»Phylogenetics & Evolutionary Biology
»Psychology & Psychotherapy
»Psychological Abnormalities in Children
»Pulmonary & Respiratory Medicine
  
R
»Reproductive System & Sexual Disorders
»Research and Development
»Review of Public Adminstration and Management
»Rheumatology: Current Research
»Rice Research: Open Access
  
S
» Single Cell Biology
»Sleep Disorders & Therapy
»Socialomics
»Sociology and Criminology-Open Access
»Sports Medicine & Doping Studies
»Spine
»Stem Cell Research & Therapy
»Steroids & Hormonal Science
»Stock & Forex Trading
»Surgery: Current Research
  
T
»Telecommunications System & Management
»Textile Science & Engineering
»Theoretical and Computational Chemistry:Open Access
»Thermodynamics & Catalysis
»Thyroid Disorders & Therapy
»Tissue Science & Engineering
»Translational Medicine
»Transplantation Technologies & Research
»Transcriptomics: Open Access
»Trauma & Treatment
»Tropical Diseases
»Tropical Medicine and Surgery
»Tourism & Hospitality
  
V
»Vaccines & Vaccination
»Vascular Medicine & surgery
»Veterinary Science & Technology
»Virology & Mycology
»Vitamins & Minerals
»Vortex Science and Technology
  
W
»Women's Health Care
  
Y
»Yoga & Physical Therapy
 
   Browse by Subjects
Clinical
» AIDS & Clinical Research
» Anesthesia & Clinical Research
» Angiology
» Cancer Science & Therapy
» Carcinogenesis & Mutagenesis
» Cell Science & Therapy
» Chemotherapy
» Child & Adolescent Behavior
» Clinical & Cellular Immunology
» Clinical Case Reports
» Clinical & Experimental Cardiology
» Clinical & Experimental Dermatology Research
» Clinical & Experimental Ophthalmology
» Clinical & Experimental Pharmacology
» Clinical & Experimental Pathology
» Clinical Microbiology: Open Access
» Clinical Research & Bioethics
» Clinical Research on Foot & Ankle
» Clinical Toxicology
» Clinical Trials
»Clinics in Mother and Child Health
» Communication Disorders, Deaf Studies & Hearing Aids
» Cytology & Histology
» Forensic Research
»Forensic Biomechanics
» Integrative Oncology
»Immunome Research
»JBR Journal of Clinical Diagnosis and Research
» Neurology & Neurophysiology
» Pulmonary & Respiratory Medicine
» Stem Cell Research & Therapy
» Transplantation Technologies & Research
   
Pharmaceutical Sciences
» Advances in Pharmacoepidemiology & Drug Safety
» Alcoholism and Drug Dependence
» Bioanalysis & Biomedicine
» Biochemical Pharmacology
» Bioequivalence & Bioavailability
» Cardiovascular Pharmacology: Open Access
» Clinical Pharmacology & Biopharmaceutics
» Developing Drugs
» Drug Designing
» Drug Metabolism & Toxicology
» Medicinal & Aromatic Plants
» Molecular Pharmaceutics & Organic Process Research
» Pharmaceutica Analytica Acta
» Pharmaceutical Regulatory Affairs
» Pharmacovigilance
» Vaccines & Vaccination
   
Chemistry
» Advanced Chemical Engineering
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» Chemical Sciences Journal
» Chromatography & Separation Techniques
» Medicinal Chemistry
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» Natural Products Chemistry & Research
» Organic Chemistry
» Physical Chemistry & Biophysics
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» Thermodynamics & Catalysis
» Theoretical and Computational Chemistry:Open Access
   
Environmental
» Anthropology
» Aquaculture Research & Development
» Astrobiology & Outreach
» Biodiversity & Endangered Species
» Earth Science & Climatic Change
» Ecosystem & Ecography
» Environmental & Analytical Toxicology
» Fisheries & Livestock Production
»Fundamentals of Renewable Energy and Applications
» Geography & Natural Disasters
» Hydrology: Current Research
»Innovative Energy Policies
»International Journal of waste resources
» Oceanography-Open Access
» Petroleum & Environmental Biotechnology
» Pollution Effects & Control
» Poultry, Fisheries & Wildlife Sciences
   
Omics
» Data Mining in Genomics & Proteomics
»Ergonomics
» Glycomics & Lipidomics
» Health & Medical Informatics
»JBR Journal of Young Scientist
» Metabolomics:Open Access
» OMICS Journal of Radiology
» Pharmacogenomics & Pharmacoproteomics
» Phylogenetics & Evolutionary Biology
» Proteomics & Bioinformatics
» Transcriptomics
   
Life Sciences
» Advanced Techniques in Biology & Medicine
»Advancements in Genetic Engineering
»Advances in Crop Science and Technology
»Advances in Dairy Research
» Aging Science
» Agrotechnology
» Air & Water Borne Diseases
» Antivirals & Antiretrovirals
» Autism-Open Access
» Bacteriology & Parasitology
» Biochemistry & Physiology
» Biochemistry and Analytical Biochemistry
» Bioenergetics
» Bioengineering & Biomedical Science
» Biofertilizers & Biopesticides
» Biological Systems
» Biometrics & Biostatistics
»Biomimetics Biomaterials and Tissue Engineering
» Biomolecular Research & Therapeutics
» Bioremediation & Biodegradation
» Biosafety
» Biosafety & Health Education
» Biosensors & Bioelectronics
» Biosensors Journal
» Biotechnology & Biomaterials
» Bioterrorism & Biodefense
» Cell & Developmental Biology
» Current Synthetic & Systems Biology
» Entomology, Ornithology & Herpetology
» Enzyme Engineering
» Fermentation Technology
» Fertilization: In Vitro - IVF-Worldwide
» Fisheries and Aquaculture Journal
» Forest Research
» Fungal Genomics & Biology
» Gene Technology
» Glycobiology
» Horticulture
» Homeopathy & Ayurvedic Medicine
»International Journal of Swarm Intelligence and Evolutionary Computation
» Marine Science: Research & Development
» Membrane Science & Technology
» Microbial & Biochemical Technology
» Molecular Biology
» Molecular Imaging & Dynamics
» Nanomedicine & Biotherapeutic Discovery
» Nanomedicine & Nanotechnology
» Nutrition & Food Sciences
» Plant Pathology & Microbiology
» Primatology
» Probiotics & Health
» Rice Research: Open Access
» Single Cell Biology
» Sociology and Criminology-Open Access
» Tissue Science & Engineering
» Tropical Diseases
» Veterinary Science & Technology
» Vitamins & Minerals
»Virology & Mycology
   
Engineering
» Advances in Automobile Engineering
» Advances in Robotics & Automation
» Aeronautics & Aerospace Engineering
» Applied & Computational Mathematics
» Applied Mechanical Engineering
» Architectural Engineering Technology
» Astrophysics & Aerospace technology
» Biochips & Tissue Chips
» Bioprocessing & Biotechniques
» Chemical Engineering & Process Technology
» Civil & Environmental Engineering
» Computer Science & Systems Biology
» Electrical & Electronics
» Food Processing & Technology
» Geology and Geosciences
» Geophysics & Remote sensing
»Global Journal of Technology and Optimization
» Industrial Engineering & Management
» Information Technology & Software Engineering
» International Journal of Advance Innovations, Thoughts & Ideas
»International Journal of Sensor Networks and Data Communications
» Irrigation and Drainage Systems Engineering
»Generalized Lie Theory and Applications
» Lovotics
» Material Sciences & Engineering
»Physical Mathematics
» Powder Metallurgy & Mining
» Telecommunications System & Management
» Textile Science & Engineering
»Vortex Science and Technology
   
Medical Sciences
» Addiction Research & Therapy
» Allergy & Therapy
» Alternative & Integrative Medicine
» Alzheimers Disease & Parkinsonism
» Anaplastology
» Anatomy & Physiology
» Ancient Diseases & Preventive Remedies
» Andrology
» Arthritis
» Autacoids
»Automatic Control of Physiological State and Function
» Bioceramics Development and Applications
» Biology and Medicine
» Biomusical Engineering
» Blood & Lymph
» Blood Disorders & Transfusion
» Bone Marrow Research
» Brain Disorders & Therapy
» Cardiovascular Diseases & Diagnosis
» Cloning & Transgenesis
» Community Medicine & Health Education
» Dentistry
» Depression and Anxiety
» Diabetes & Metabolism
» Emergency Medicine
» Endocrinology & Metabolic Syndrome
» Epidemiology: Open Access
» Family Medicine & Medical Science Research
» Gastrointestinal & Digestive System
» General Medicine
» General Practice
» Genetic Syndromes & Gene Therapy
» Gynecology& Obstetrics
» Gerontology & Geriatrics Research
» Hematology & Thromboembolic Diseases
» Hair: Therapy & Transplantation
» Health Care : Current Reviews
» Hereditary Genetics
» Human Genetics & Embryology
» Hypertension-Open Access
» Infectious Diseases & Therapy
» International Journal of Genomic Medicine
» Internal Medicine
»International Journal of Biomedical Data Mining
» International Journal of Physical Medicine & Rehabilitation
»JBR Journal of Interdisciplinary Medicine and Dental Science
» Leukemia
» Liver
»Malaria Chemotherapy, Control & Elimination
» Medical & Surgical Urology
» Medical Diagnostic Methods
» Medical Microbiology & Diagnosis
» Metabolic Syndrome
» Molecular Biomarkers & Diagnosis
» Molecular and Genetic Medicine
» Mycobacterial Diseases
» Neonatal Biology
» Nephrology & Therapeutics
»Neuroinfectious Diseases
» Neurological Disorders
» Novel Physiotherapies
» Nuclear Medicine & Radiation Therapy
» Nursing & Care
» Nutritional Disorders & Therapy
» Obesity & Weight Loss Therapy
» Occupational Medicine & Health Affairs
» Oral Health and Dental Management
» Oral Hygiene & Health
» Orthopedic & Muscular System
» Osteoporosis & Physical Activity
» Otolaryngology
» Pain & Relief
» Palliative Care & Medicine
» Pancreatic Disorders & Therapy
» Pediatrics & Therapeutics
» Primary Health Care
» Psychological Abnormalities in Children
» Psychology & Psychotherapy
» Reproductive System & Sexual Disorders
»Research and Development
» Rheumatology: Current Research
» Sleep Disorders & Therapy
» Spine
» Sports Medicine & Doping Studies
» Steroids & Hormonal Science
» Surgery: Current Research
» Thyroid Disorders & Therapy
» Translational Medicine
» Trauma & Treatment
» Tropical Medicine and Surgery
» Vascular Medicine & surgery
» Women's Health Care
» Yoga & Physical Therapy
 
Management
» Accounting & Marketing
» Arabian Journal Business and Management Review
» Arts and Social Sciences Journal
» Business and Economics Journal
» Business and Financial Affairs
» Civil & Legal Sciences
» Defense Management
» Entrepreneurship & Organization Management
» Global Economics
» Hotel & Business Management
» Intellectual Property Rights: Open Access
»International Journal of Accounting Research
» International Journal of Economics & Management Sciences
» Mass Communication & Journalism
» political Sciences & public affairs
»Review of Public Adminstration and Management
» Socialomics
» Stock & Forex Trading
» Tourism & Hospitality
 
   Conferences
Upcoming Conferences
»3rd International Conference and Exhibition on Cosmetology & Trichology July 21-23, 2014 Las Vegas, USA
»3rd International Conference and Exhibition on Food Processing & Technology July 21-23, 2014 Las Vegas, USA
»2nd International Conference on Oceanography July 21-23 , 2014 Las Vegas USA
»Health Informatics & Technology Conference July 28-29, 2014 Baltimore, USA
»3rd International Conference on Gastroenterology & Urology July 28-30, 2014 San Francisco, USA
»3rd International Conference on Earth Science & Climate Change July 28-30, 2014 San Francisco, USA
»3rd International Conference and Exhibition on Orthopedics & Rheumatology July 28-30, 2014 San Francisco, USA
»International Conference on Business Economics of Broadcasting Media & Film Industry July 28-30, 2014, Baltimore, USA
»4th International Conference on Proteomics & Bioinformatics August 04-06, 2014 Chicago, USA
»3rd International Conference and Exhibition on Addiction Research & Therapy August 04-06, 2014 Chicago, USA
»2nd International Conference on Integrative Biology Summit August 04-05, 2014 Chicago, USA
»3rd International Conference and Exhibition on Biosensors & Bioelectronics August 11-13, 2014 San Antonio, USA
»2nd World Associations Congress August 11-13, 2014 San Antonio, USA
»International Meeting on Space- Open Debate August 12-13, 2014 San Antonio, USA
»5th International Conference and Exhibition on Analytical & Bioanalytical Techniques August 18-20, 2014 Beijing, China
»2nd International Conference on Epidemiology and Evolutionary Genetics August 18-19, 2014 Beijing, China
»2nd International Conference and Exhibition on Pharmacognosy, Phytochemistry & Natural Products August 25-27, 2014 Beijing, China
»2nd International Conference and Exhibition on Traditional & Alternative Medicine August 25-26, 2014 Beijing, China
»2nd International Conference and Exhibition on Mechanical & Aerospace Engineering September 08-10, 2014 Philadelphia, USA
»2nd International Conference and Exhibition on Lasers, Optics & Photonics September 08-10, 2014 Philadelphia, USA
»3rd International Conference and Exhibition on Neurology & Therapeutics September 08-10, 2014 Philadelphia, USA
»4th International Conference on Pharmaceutical Regulatory Affairs September 08-10, 2014 Raleigh, USA
»2nd International Conference on Radiology and Imaging September 08-09, 2014 Raleigh, USA
»2nd International Conference on Genomics & PharmacogenomicsSeptember 08-09, 2014 Raleigh, USA
»2nd International Conference on Alzheimer's Disease and Dementia September 23-25, 2014 Valencia Convention Centre, Valencia, Spain
»3rd International Conference and Exhibition on Nutrition & Food Sciences September 23-25, 2014 Valencia, Spain
»3rd International Conference on Clinical Microbiology & Microbial Genomics September 24-26, 2014 Valencia, Spain
»3rd International Conference on Tissue Science & Regenerative Medicine September 24-26, 2014 Valencia, Spain
»4th International Conference on Vaccines & Vaccination September 24-26, 2014 Valencia, Spain
»3rd International Summit on GMP, GCP & Quality Control September 25-26, 2014 Valencia, Spain
»5th World Congress on Bioequivalence and Bioavailability: Pharmaceutical R&D Summit September 29-October 01, 2014 Baltimore, USA
»2nd International Conference on Hematology & Blood Disorders September 29-October 01, 2014 Baltimore, USA
»3rd International Conference and Exhibition on Clinical & Cellular Immunology September 29-October 01, 2014 Baltimore, USA
»3rd International Conference and Exhibition on Materials Science & Engineering October 06-08, 2014 San Antonio, USA
»3rd International Conference on Forensic Research and Technology October 06-08, 2014 San Antonio, USA
»4th World Congress on Virology October 06-08, 2014 San Antonio, USA
»2nd International Conference on Endocrinology October 20-22, 2014 Chicago, USA
»3rd 3rd International Summit on Toxicology & Applied Pharmacology October 20-22, 2014 Chicago, USA
»3rd 4th World Congress on Cancer Science and Therapy October 20-22, 2014 Chicago, USA
»3rd 3rd International Conference and Exhibition on Cell & Gene Therapy October 27-29, 2014 Las Vegas, USA
»2nd International Conference on HIV/AIDS, STDs & STIs October 27-29, 2014 Chicago, USA
»2nd World Congress on Petrochemistry and Chemical Engineering October 27-29, 2014 Las Vegas, USA
»3rd International Conference and Exhibition on Pharmacovigilance & Clinical Trials October 27-29, 2014 Hyderabad, India
»3rd International Conference and Exhibition on Biowaivers and Biosimilars October 27-29, 2014 Hyderabad, India
»3rd International Conference on Translational Medicine November 03-05, 2014 Las Vegas, USA
»2nd International Conference on Predictive, Preventive and Personalized Medicine & Molecular Diagnostics November 03-05, 2014 Las Vegas, USA
»5th International Conference on Diabetes & Metabolism November 03-05, 2014 Las Vegas, USA
»2nd International Congress on Bacteriology and Infectious Diseases November 17-19, 2014 Chicago, USA
»2nd International Conference on Nursing & Healthcare November 17-19, 2014 Chicago, USA
»3rd International Conference on Surgery and Anesthesia November 17-19, 2014 Chicago, USA
»4th International Conference on Nanotek & Expo December 01-03, 2014 San Francisco, USA
»3rd International Conference and Exhibition on Obesity & Weight Management December 01-03, 2014 San Francisco, USA
»2nd International Summit on Clinical PharmacyDecember 02-03, 2014 San Francisco, USA
»3rd International Conference on Medicinal Chemistry & Computer Aided Drug Designing December 08-10, 2014 San Francisco, USA
»3rd International Conference and Exhibition on Probiotics & Functional Foods December 08-10, 2014 San Francisco, USA
Previous Conferences Organized/Co-organized
»4th International Conference on Clinical & Experimental Ophthalmology July 14-16, 2014 Baltimore, USA
»3rd International Conference & Exhibition on Biometrics & Biostatistics July 14-16, 2014 Baltimore, USA
»2nd International Conference and Exhibition on Physical Medicine & Rehabilitation July 14-16, 2014 Baltimore, USA
»International Conference on Geriatrics & Gerentology July 08-10, 2014 Chicago , USA
»International Conference on Women's Health, Gynecology & Obstetrics July 08-10, 2014 Chicago, USA
»International Conference on Computer Graphics and Media Design July 08-10, 2014 Chicago, USA
»4th International Conference on Clinical & Experimental Cardiology April 14-16, 2014 San Antonio, USA
»4th International Conference on Clinical & Experimental Dermatology April 14-16, 2014 San Antonio, USA
»3rd International Conference and Exhibition on Pathology April 14-16, 2014 San Antonio, USA
»5th International Conference on Biomarkers and Clinical Research April 15-17, 2014 University of Oxford, UK
»2nd International Conference on Business Economics and Management April 21-23, 2014 Dubai, UAE
»2nd International Conference on Dental and Oral Health April 21-23, 2014 Dubai, UAE
»4th World Congress on Cell Science & Stem Cell Research June 24-26, 2014 Valencia, Spain
»3rd International Conference on Biodiversity & Sustainable Energy Development June 24-26, 2014 Valencia, Spain
»3rd International Conference and Exhibition on Occupational Health & Safety June 24-25, 2014 Valencia, Spain
»5th World congress on Biotechnology June 25-27, 2014 Valencia, Spain
»3rd International Conference on Nephrology & Therapeutics June 26-27, 2014 Valencia, Spain
»2nd International Conference on Bioprocess and Engineering June 26-27, 2014 Valencia, Spain
»2nd International Conference on Dental and Oral Health April 21-23, 2014 Dubai, UAE
»5th International Conference on Biomarkers and Clinical Research April 15-17, 2014 University of Oxford, UK
»3rd International Conference and Exhibition on Pathology April 14-16, 2014 San Antonio, USA
»4th International Conference on Clinical & Experimental Dermatology April 14-16, 2014 San Antonio, USA
»4th International Conference on Clinical & Experimental Cardiology April 14-16, 2014 San Antonio, USA
»4th International Conference and Exhibition on Pharmaceutics & Novel Drug Delivery Systems March 24-26, 2014 San Antonio, USA
»3rd International Conference and Exhibition on Metabolomics & Systems Biology March 24-26, 2014 San Antonio, USA
»2nd International Conference on Agricultural & Horticultural Sciences, February 03-05, 2014 Hyderabad, India
»International Conference and Exhibition on Traditional & Alternative Medicine, December 09-11, 2013 Hyderabad, India
»2nd International Conference and Exhibition on Obesity & Weight Management, December 02-04, 2013 Las Vegas, USA
»International Conference on Nursing & Emergency Medicine, December 02-04, 2013 Las Vegas, USA
»3rd International Conference on Nanotek & Expo, December 02-04, 2013 Las Vegas, USA
»3rd World Congress on Virology, November, 20-22, 2013 Baltimore, USA
»International Congress on Bacteriology and Infectious diseases, November 20-22, 2013 Baltimore, USA
»3rd World Congress on Cell Science & Stem Cell Research, November 20-22, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Pharmacovigilance & Clinical Trials, November 18-19, 2013 San Antonio, USA
»International Summit on Clinical Pharmacy & Dispensing, November 18-20, 2013 San Antonio, USA
»World Congress on Petrochemistry and Chemical Engineering, November 18-20, 2013 San Antonio, USA
»International Conference on Functional and Comparative Genomics & Pharmacogenomics, November 12-14, 2013 Chicago, USA
»2nd International Conference and Exhibition on Cosmetology & Trichology, November 12-14, 2013 Chicago, USA
»2nd International Summit on GMP, QA & QC, November 12-14, 2013 Chicago, USA
»2nd International Summit on GLP, GCP & Clinical Pharmacology, November 12-14, 2013 Chicago, USA
» International Conference on Fermentation Technology, Bioprocess and Cell Culture, October 28-30, 2013 Kansas City, USA
»2nd International Conference and Exhibition on Food Processing & Technology, October 28-30, 2013 Kansas City, USA
»International Conference on HIV/AIDS, STDs, & STIs, October 24-25, 2013 Orlando-FL, USA
»2nd International Conference and Exhibition on Cell & Gene Therapy, October 23-25, 2013 Orlando, USA
»2nd International Conference and Exhibition on Probiotics & Functional Foods, October 23-25, 2013 Orlando, USA
»International Conference and Exhibition on Pharmacognosy, Phytochemistry and Natural Products, October 21-23, 2013 Hyderabad, India
» 3rd World Congress on Cancer Science & Therapy, October 21-23, 2013 California, USA
»3rd International Conference on Pharmaceutical Regulatory Affairs, October 21-23, 2013 California, USA
»2nd International Conference on Clinical & Cellular Immunology, October 15-17, 2013 Las Vegas, USA
»2nd International Conference on Medicinal Chemistry & Computer Aided Drug Designing, October 15-17, 2013 Las Vegas, USA
»4th International Conference and Exhibition on Analytical & Bioanalytical Techniques, October 15-17, 2013 Las Vegas, USA
»2nd International Summit on Toxicology, October 07-09, 2013 Las Vegas, USA
»International Conference and Exhibition on Lasers, Optics & Photonics, October 7-9, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Materials Science & Engineering, October 07-09, 2013 Las Vegas, USA
»2nd International Conference on Forensic Research & Technology, October 07-09, 2013 Las Vegas, USA
»International Conference and Exhibition on Biochemical & Molecular Engineering, October 07-08, 2013 San Antonio, USA
»International Conference on Psychology, Autism and Alzheimer's Disease, September 30-October 01, 2013 San Antonio, USA
»International Conference and Exhibition on Mechanical & Aerospace Engineering, September 30-October 02, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Biowaivers & Biosimilars, September 23-25, 2013 Raleigh, USA
»4th World Congress on Biotechnology, September 23-25, 2013 Raliegh, USA
»International Conference on Hematology & Blood Disorders, September 23-25, 2013 Raliegh, USA
»2nd International Conference on Surgery and Anesthesia, September 16-18, 2013 Las Vegas, USA
»2nd International Conference on Clinical Microbiology & Microbial Genomics, September 16-18, 2013 Las Vegas, USA
» International Conference on Omics Studies, September 04-06, 2013 Orlando-FL, USA
»International Symposia on Entomology, September 04-06, 2013 Miami, USA
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Research Article Open Access
Aspirin and Warfarin are Associated with Improved Overall Survival in Medically Inoperable Endometrial Cancer Patients Treated with Radiation Therapy
1Department of Obstetrics/Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
2Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
3Gynecologic Oncology University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
4Radiation Oncology University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
*Corresponding author: Geraldine M Jacobson
Department of Radiation Oncology
University of Iowa Hospitals and Clinics
200 Hawkins Drive, Iowa City
IA, 52242, USA
Tel: 319-353-7019
Fax: 319-356-1530
E-mail: geraldine-jacobson@uiowa.edu
 
Received November 02, 2011; Accepted January 19, 2012; Published January 25, 2012
 
Citation: Fornalik H, Goodheart MJ, Buekers TE, Geest KD, Jacobson GM (2012) Aspirin and Warfarin are Associated with Improved Overall Survival in Medically Inoperable Endometrial Cancer Patients Treated with Radiation Therapy. Gynecol Obstetric S4:002. doi:10.4172/2161-0932.S4-002
 
Copyright: 2012 Fornalik H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 
Abstract
 
Objective: To assess factors associated with improved survival of medically inoperable endometrial carcinoma.
 
Methods: Patients with endometrial cancer who were not surgical candidates, underwent primary radiation therapy. Data were collected from medical records Survival estimates were calculated and compared.
 
Results: Twenty-nine of 39 patients who underwent primary radiation therapy were considered medically inoperable. Median follow up was 19 months (range 3-66). Overall survival (OS) was 38% (11 out of 29). Progressionfree survival (PFS) was 34% (10 out of 29). The cancer-specific mortality was 14% (4 out 29). Fourteen of 18 deceased patients (78%) had no evidence of recurrent disease. A history of pulmonary embolism was associated with improved survival (Rate ratio of death 0.2; 95%CI, 0.01-0.98; p=0.046). Grade 3 tumors were associated with shorter survival, compared to combined grades 1 and 2 (Rate ratio of death 3.21; 95%CI, 1-8.76; p=0.05). The median OS in patients on aspirin or warfarin was 20 months (range 7-66), and 11 months (range 3-43) in patients who did not take aspirin or warfarin (Rate ratio of death: 0.35, 95%CI, 0.13-0.89; p=0.028).
 
Conclusion: Radiation therapy provides acceptable tumor control in patients with medically inoperable endometrial cancer. Aspirin or warfarin therapy may result in longer overall survival.
 
Keywords
 
Aspirin; Warfarin; Endometrial cancer; Radiation therapy
 
Introduction
 
Endometrial cancer is the most common gynecological cancer with an estimated 42,160 new cases and 7,780 deaths occurring in 2009 [1]. Primary treatment consists of surgery and surgical staging. However, secondary to age, obesity and comorbidities approximately 3-9% of patients are at high risk for surgical complications and are considered medically inoperable [2]. These patients have been successfully treated with primary radiation therapy administered as brachytherapy alone or in combination with external beam radiation. Current clinical evidence supporting such therapy is based on case series collected by single institutions over a period of many years [2-6]. Studies did not report comorbidities in a uniform fashion and included patients who were treated with radiation therapy primarily because of advanced age, morbid obesity, or refusal of surgery. The purpose of this study is to present a single institution experience with primary radiation therapy in patients with endometrial carcinoma considered inoperable for medical reasons only. The unexpected finding of improved survival associated with usage of anticoagulants and anti-inflammatory medication is analyzed with respect to recent discoveries in the role of angiogenesis in cancer growth and metastasis. Clinical data supporting this approach in selected groups are reviewed.
 
Materials and Methods
 
Following approval by the Institutional Review Board, the medical records of all patients with endometrial cancer treated at the University of Iowa Hospitals and Clinics between February 2003 and April 2008 were reviewed. Only patients who received primary radiation therapy, and who were considered medically inoperable by their Gynecologic Oncologist were included in the analysis. Patients who received radiation therapy because of extreme obesity, refusal of surgery, advanced age, and patients with incomplete records were excluded. Data regarding medical history, current medication use, performance status, clinical stage and tumor histology were collected. When the performance status was not stated in the records, it was assigned based on available information. The Satariano co-morbidity index was calculated [7]. One point was given for each of the following: myocardial infarction, other types of heart disease, diabetes, other types of cancer, respiratory, gallbladder, and liver conditions. OS, PFS, and disease-specific survival were obtained on all patients.
 
Information on radiation therapy was collected. Treatment consisted of pelvic external beam radiation therapy, with subsequent high dose rate tandem and ovoid (T&O) brachytherapy or external beam boost. The external beam boost was delivered with either conformal fields or Intensity Modulated Radiation Therapy (IMRT).
 
Actuarial survival estimates were calculated using the Kaplan Meier method. Associations between prognostic variables and survival were compared using the log-rank test and rate ratios, with a p – value < 0.05 considered significant. Rates of death were calculated as the number of deaths divided by the time at risk. A rate ratio is the rate of death in the group with the variable of interest, divided by rate of death in the group without it. Values >1 indicates a higher number of deaths in a group with the given risk factor. Forests’ plots with comparison of rate ratios were created using a published template [8]. The low number of subjects did not allow for meaningful multivariate analysis.
 
Results
 
Thirty-nine patients were identified who received primary radiation therapy for endometrial cancer. Six patients received radiation therapy primarily because of morbid obesity, advanced age, or refusal of surgery, and were excluded. Information was incomplete in 4 patients, leaving 29 patients eligible for analysis. The patient characteristics are presented in Table 1. Median age at diagnosis was 74 (range 36-95). Median body mass index (BMI) was 42 (range 17-66). The mean GOG performance score was 2.38 ± 1.47. Twenty seven patients were clinical stage I, one was stage II and one stage III. Median follow up was 19 months (range 3-66). OS was 38% (11 out of 29), PFS was 34% (10 out of 29). The cancer-specific mortality was 14% (4 out 29). Out of eighteen deceased patients, fourteen (78%) had no evidence of recurrence. Fourteen fatalities were related to medical conditions; only four resulted from cancer. Details of the radiation therapy are presented in Table 2. Four patients had recurrent disease, of these two had local recurrence, and two had distant metastasis. One patient with stage III had persistent disease. All but one patient (97%) were able to complete the prescribed treatment. This patient suffered an acute myocardial infarction during cardiac catheterization performed before brachytherapy. One patient had a rectal perforation 16 days after completion of her second T&O. She required colostomy and died of a stroke 23 months after the cancer diagnosis, with metastatic disease.
 
Table 1: Patient Characteristics.
 
Table 2: Radiation dose and modality.
 
Patients’ comorbidities and risk factors are listed in Figure 1. All listed conditions were present at the time of diagnosis of endometrial cancer. A trend in improved OS was observed in patients with deep vein thrombosis (DVT) and pulmonary embolism (PE), and in patients with medical conditions possibly associated with thrombosis (cerebrovascular accident, myocardial infarction (MI), congestive heart failure and arrhythmia). Those results were statistically significant for a history of PE (Rate ratio of death 0.2 95%CI, 0.01-0.98; p=0.046) and the combined category of patients with a history of pulmonary embolism or deep venous thrombosis (Rate ratio of death 0.2 95%CI, 0.01-0.98; p=0.046). History of DVT when analyzed separately also showed a much lower risk of death (Rate ratio 0.23), but results were not statistically significant (95%CI, 0.01-1.13, p=0.076), suggesting insufficient power to detect this relationship in such a small study. Patients with coronary artery disease listed here, were the ones without concomitant arrhythmia, history of congestive heart failure or history of myocardial infarction. Analysis of medications taken by patients at the time of cancer diagnosis revealed significantly improved overall survival in a group taking any one of the two antithrombotic drugs – warfarin or aspirin (Figure 2) (Rate ratio of death: 0.35, 95%CI, 0.13- 0.89). Survival curves comparison showed early separation and steady to increasing distance between the slopes (Figure 3). Overall survival was 56% (9 out of 16 aspirin or warfarin users) and 15% (2 out 13 non users). Aspirin was given at a dose of 81 mg for 44% of patients, and at a dose of 325 mg in the remaining 56%. The warfarin cumulative weekly dose ranged from 7 to 42 mg with a mean of 23 mg ± 15.7. INR data was not available for majority of patients. No patients took heparin products.
 
Figure 1: Patient co-morbidities and rate ratio of death.
 
Figure 2: Patient medications and rate ratio of death.
 
Figure 3: Survival and Aspirin/Warfarin usage.
 
The mean Satariano comorbidity index was 2.38 ± 1.47. There was no statistical difference in the mean score between the living and deceased (2.36 vs. 2.39 p=0.95) groups, or between patients on aspirin/ warfarin and a group not on those medications (2.19 vs. 2.61 p=0.45). Survival among patients with 0-1 score was longer than in a group with a higher index, but not statistically significant (mean: 25 vs. 19 months p=0.26).
 
Grade III tumors were associated with shorter survival as compared to combined grades 1 and 2 (Rate ratio of death 3.21 95%CI, 1-8.76). This result could partially be affected by our sole stage III patient, and below median survival of 10 months (persistent disease). The remaining five grade III patients died without evidence of disease with a median survival of 12 months for the entire group (range 3-28 months). There were three recurrences among eleven grade II patients (27%) and one among twelve grade I patients (8%). Of the 4 recurrences and cancerassociated deaths, 2 were on aspirin/warfarin and 2 were not.
 
Discussion
 
This study describes a group of patients with medically inoperable endometrial cancer. The criteria to diagnose “medical inoperability” has not been defined. This determination is usually established by Gynecologic Oncologists with, or without contribution from other specialties. This group of patients is very heterogenous with a variable number and complexity of comorbidities. Overall survival (OS) data reported in the literature reflects this variation, while disease-specific survival is very similar. Results range from 28% OS at 2 years for patients older than 75 from the Pittsburgh group [5], to 55% at 5 years in the same age group from St. Louis, to 78% at 5 years for patients younger than 75 from the same institution [3]. Although our results of 38% OS at 19 months appears to be similar, it is difficult to draw conclusions on how comparable the populations are. At UIHC the medically inoperable patients with endometrial cancer are older on average by 13 years than a comparable group undergoing surgery. In elderly populations the assessment of functional status by Karnofsky or the Eastern Cooperative Oncology Group (ECOG), scale does not seem to be as effective as in the adult group because comorbidities in the elderly may interfere with the performance status [9]. We selected Satariano index for two reasons: it is a well-established tool and it can be applied retrospectively. In a large study of breast cancer patients, individuals with a score of 3 or more had a 20-fold higher rate of mortality from causes other than breast cancer [7]. The Breast cancer population is similar to ours secondary with a relatively early stage at diagnosis, low recurrence rate and similar tumor interaction with steroidal hormones. Early studies on the Satariano index were subsequently validated in other populations and the index was adopted as a part of Comprehensive Geriatric Assessment (CGA) [9].
 
The strength of our data lies in the observation of improved survival with a history of any condition with thrombotic pathophysiology. Statistical significance was reached for history of PE and with the combined group with a history of either PE or DVT. This relationship is very strong since the ratio of death rate is only 0.2, and it was possible to observe it in such a small study.
 
The concept of anticoagulation in patients with cancer and no history of thrombosis have been evaluated in lung cancers, breast cancers and heterogenous groups of patients with solid tumors. Metaanalysis of eleven randomized clinical trials showed significantly decreased 1-year overall mortality with use of anticoagulation (RR 0.905, 95%CI, 0.847-0.967, p=0.003). [10]. Considered separately, only one study of 302 patients with locally advanced or metastatic solid tumors (7 gynecological cases, 19 controls) was statistically significant, showing improved median survival following a 6 week course of subcutaneous nadroparin when compared to placebo (HR 0.75 95%CI, 0.59-0.96, p=0.021) [11]. In similar situations where patients with localized prostate cancer were treated with definitive radiation, anticoagulants (warfarin, clopidogrel or aspirin) were associated with improved biochemical control (PSA level) and decreased rate of distant metastasis at 4 years of follow up (1 vs. 5% p=0.0248). In this recently published retrospective study, overall survival at 4 years was no different (92.2% anticoagulation group vs. 90.3% control, p=0.884) [12].
 
Anticoagulation carries considerable risk of complications. In previously mentioned meta-analysis, warfarin was associated more with major bleeding than unfractionated heparin or low molecular weight heparin (RR 2.979 p<0.0001 vs. 1.007 p=0.996 vs. 1.679 p=0.128 respectively) [10]. Low intensity treatment with warfarin (INR 1.4 to 2.8) had a comparable safety profile to aspirin in stroke secondary prevention trials in the general population [13]. There is mounting evidence that aspirin may play a role in cancer treatment. Literature has shown that aspirin can decrease the incidence of metastatic disease in adenocarcinoma via COX-2 inhibition [14] while improving cardiovascular outcomes via COX-1 [15]. COX-2 is related to tumor angiogenesis, growth, apoptosis, metastasis and local immunosupression [14]. Survivin, which is a COX-2 dependent protein, is critical for apoptosis resistance in non-small cell lung cancer [16]. Clinical evidence supports a dual effect of Aspirin on cancer patients. A recent study in endometrial cancer showed that expression of survivin, c-erbB2 and COX-2 correlates with tumor stage, grade, myometrial invasion and survival [17]. A retrospective cohort study of breast cancer patients enrolled in Nurses’ Health Study revealed decreased breast cancer mortality if aspirin was taken 2-5 times per week (RR 0.29 95%CI, 0.16-0.52), or 6-7 d per week (RR 0.36 95%CI 0.24-0.54). Overall mortality was also reduced, but to a lesser extent (RR 0.53 95%CI, 0.37-0.76 and RR 0.54 95%CI, 0.41-07, respectively; test for trend, p=0.004). This led investigators to conclude that therapeutic effect was driven by aspirin affecting breast cancer mortality [18]. A retrospective study on 1353 patients with non-small cell lung cancers after surgical resection showed more than 5 % (p=0.05) increased overall survival associated with taking aspirin [19].
 
Our data is similar to the literature in reporting significantly improved overall survival in studied populations without detecting clinical thrombosis. In a previously cited meta-analysis of RCT of prophylactic anticoagulants in cancer, only 5 studies report incidence of thromboembolism which ranged from 2 to 7% in the placebo group [11,20-22]. Contribution of thrombosis to death is suggested by frequent observation of pulmonary embolism in post mortem studies: 18.6% in 4077 autopsies carried out between 1979-1989 [23]. In our group, only 2 patients had documented thrombotic events after initiation of radiation treatment. Out of primary radiation treatment series, only one case series of HDR brachytherapy reports thrombotic complications.
 
Anticoagulants may not improve survival in all patients with cancer, but there appear to be certain cancer types that may benefit more from such treatment. It is possible that the overall survival difference in our study patients may be due to the impact of aspirin/ warfarin on co-morbid conditions and not necessarily its effect on the cancer. We propose that the use of aspirin/warfarin in this population should be further investigated.
 
A major limitation in a study of this type is the subjective determination of medical inoperability. We propose using the Satariano index to compare our data to other institutions.
 
In this group of medically inoperable patients with endometrial cancer, primary radiation provided acceptable tumor control. An unexpected finding was the association between aspirin or warfarin and longer overall survival.
 
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