Archives of Iranian Medicine
Volume:10 Issue: 2, Apr 2007

Polycystic ovary syndrome is not uncommon in women of reproductive age. We conducted this study to determine the clinical, hormonal, and biochemical effects of metformin therapy on girls with polycystic ovary syndrome. In a self-controlled clinical trial conducted at the Gynecology Center of Yahyanejad Hospital, affiliated to Babol University of Medical Sciences, Babol, North of Iran, 36 girls with polycystic ovary syndrome were studied. The patients were treated with 500 mg of metformin three times a day for six months. Clinical symptoms, menstrual pattern, and hirsutism, as well as serum concentration of sex steroid (follicular stimulating hormone, luteinizing hormone, dihydroepiandrosterone, testosterone, 17-OH progesterone, estradiol), and lipids (triglyceride, cholesterol, high-density lipoprotein, low-density lipoprotein) were assessed pre- and posttreatment. Sixteen girls (53% of those with menstrual disturbances) experienced more regular cycles during the treatment. A significant decrease in weight (P = 0.004) and body mass index (P = 0.006) was noticed after six months of treatment. The number of patients with hirsutism was also decreased. The mean levels of triglyceride (P = 0.03) and low-density lipoprotein (P = 0.0.01) were decreased while high density lipoprotein (P = 0.003) was increased significantly. We also found a significant decrease in luteinizing hormone (P = 0.006), estradiol (P = 0.005), and dihydroepi-androsterone (P = 0.026) after treatment. Changes in the follicular stimulating hormone and 17-OH progesterone levels were not significant. Metformin therapy has many useful effects in these patients

Adenocarcinoma arising from adenomyosis uteri is rare. Herein, we reported a patient with papillary serous carcinoma arising from adenomyosis. The patient was a 61-year-old woman who received tamoxifen for treatment of her breast cancer over the past five years. In hysterectomy specimen taken for investigating her uncontrolled bleeding with suspicion of uterine myoma, multiple adenomyotic foci were found in the uterine wall. In one of these foci, papillary serous carcinoma was found. No evidence of tumor was seen in endometrial surface, peritoneum, and both adnexa.

Depression is an important mental health problem, which is quite unknown among adolescents in our community. We conducted this study to determine the prevalence of depression among high school and preuniversity students of Rasht, northern Iran. We studied 4,020 randomly-selected individuals out of 41,815 high school and preuniversity students. Beck’s self-administered standard questionnaire and a predetermined form containing some demographic variables were applied to measure variables. Two hundred ninety-nine subjects (due to incomplete responses) and 40 subjects (evening-school students) were excluded from our study. One thousand two hundred fifty (34%: CI95% 32.4 – 35.4%) out of 3,681 subjects suffered from depression. There were significant differences between the prevalence of depression and type of school (P < 0.001), educational field (P < 0.0005), socioeconomic class (P = 0.0002), and gender (P < 0.001). There was no significant difference between the prevalence of depression and city district, school grade, and age of participants. Our study indicates that depressive symptoms are common in our subjects and they have significant association with low socioeconomic status. We, therefore, recommend the use of psychiatric interview and analytical methods for determination of the prevalence of depressive disorders and its relationship with studied variables.

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood-onset psychiatric disorders. Although the onset of ADHD is frequently prior to the age of seven years, there is a paucity of data on the prevalence of the disorder in preschool-age children. This study was performed to determine the prevalence rate of ADHD in preschool-age children in kindergartens of Mashhad, North-East of Iran. One thousand eighty-three (553 males and 530 females) children aged between five and six years, were selected at random from 155 kindergartens in ten districts of Mashhad. The ten-item Conner’s Index questionnaire was completed for each child by teachers and parents. Parents of children whose scores were positive for ADHD (>15) were interviewed by a psychiatrist and the ADHD was diagnosed based on DSM-IV diagnostic criteria and the Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime Version. One hundred thirty-three (12.3%; CI95%: 10.3 –14.2%) children were diagnosed to have ADHD. The prevalence of ADHD in preschool-age children in North-East of Iran is consistent with previous studies in other countries. This study recommends the need for diagnosis and treatment of ADHD in preschool-age children.

Although multiple sclerosis is considered as an inflammatory demyelinating disease of young adults, nearly 3% of patients manifest it under the age of 16 years. The aim of this study was to highlight the clinical and demographic features of early-onset multiple sclerosis in Isfahan, Iran. This prospective study concerned multiple sclerosis patients in whom the disease started before the age of 16 years and who were referred to the only clinic of multiple sclerosis in Isfahan from October 1997 through February 2003. All early-onset multiple sclerosis patients underwent magnetic resonance imaging. Magnetic resonance imaging findings were analyzed according to the Barkhof''s criteria. All early-onset multiple sclerosis patients were followed for a mean period of 4.7 years. Among 1,238 multiple sclerosis patients, 82 early-onset multiple sclerosis patients were identified. The female to male ratio was 4.5:1. The mean age of onset was 14.1 (range: 5 to 16) years. In 53 (65%) patients, the onset was monosymptomatic; in the remaining 29 (35%), it was polysymptomatic. Sixty-four (78%) patients presented a relapsing-remitting course, 14 (17%) had a secondary-progressive and 4 (5%) had a primary-progressive course. At the last evaluation, the expanded disability status scale score was ≥6 in only 8 (10%) patients. According to Barkhof’s criteria, the characteristic magnetic resonance imaging findings were observed in 80 (98%) of early-onset multiple sclerosis patients. In our study, a high rate of childhood multiple sclerosis was observed that may be because of geographical or ethnic differences. Our study also showed that Barkhof’s criteria, which is mostly used in adult patients, could be also applied to early-onset multiple sclerosis cases.

One of the important issues in the diagnosis and treatment of patients with trauma to the cervical spine is the stability of injured segment of vertebral column. This study was performed to compare the success rate and capacities of nonsurgical (halo cast) versus surgical management of lower cervical spine injuries. Forty patients admitted to hospitals affiliated to Shiraz University of Medical Sciences, Shiraz, Iran with such injuries were divided into two equal groups (halo cast versus surgery). In each group, cases were divided into three categories, based on the type of lesion. The percentage of sagittal subluxation and the degree of sagittal angulation were chosen as the criteria for assessing the treatment outcome; each of these indices was measured on radiographical images, which were recorded at the time of admission and six months later. Members of both groups showed significant improvements in the measured indices. The amount of correction in subluxation was not significantly different between the two groups; however, surgical approach resulted in a significantly better correction of angulation. Nonsurgical approach can be an acceptable alternative to surgical correction in selected patients with various lower cervical spine injuries.

Furazolidone has been effective against Helicobacter pylori in Iran, with no resistance, but with intolerable side effects in the second week. One-week regimens have not been useful here. We compared the efficacy and side effect profiles of three anti-H.pylori regimens. Patients with peptic ulcer disease and positive H.pylori infection were randomly allocated into three groups. The patients in group A received omeprazole 20 mg + amoxicillin 1g + metronidazole 500 mg, and bismuth subcitrate 240 mg twice daily each, for two weeks; the patients in group B received the same regimen but metronidazole was replaced by furazolidone 200 mg twice daily; and the patients in group C received regimen B for the first week and regimen A for the second week. H.pylori eradication was verified with 13C- urea breath test at the tenth week. Three hundred and fourteen patients were enrolled; 107, 104, and 103 patients in groups A-C, respectively but 278 patients completed the study. Seven, three, and six patients discontinued their medication in groups A-C, respectively. Fever, dizziness, and weakness were more common in group B than group C (P < 0.05). Vomiting, pruritus, and rash were more common in group C than group A (P < 0.05). Per-protocol eradication rates were 83.1%, 95.2%, and 95.3% in groups A-C, respectively (P = 0.005, groups A and C). Intention to treat eradication rates were 74.5%, 87.0%, and 86.6% in groups A-C, respectively (P = 0.02, groups A and C). One-week furazolidone followed by one-week metronidazole regimen is as efficient as two-week furazolidone regimen but with fewer side effects. Furazolidone

Thyroid dysfunction is associated with changes in the appetite. Ghrelin can regulate feeding behavior. The aim of this study was to evaluate whether ghrelin plays a role in the appetite changes in different states of thyroid dysfunction. The serum ghrelin levels were measured in 45 newly diagnosed hyperthyroid and 45 newly diagnosed hypothyroid patients before and after medical treatment. Forty-five healthy subjects were also studied as control group. The ghrelin levels did not change significantly in patients with hyperthyroidism or hypothyroidism before and after the treatment. The ghrelin levels were not different from those of the control group. Ghrelin is not likely to be the primary determinant of appetite changes in thyroid dysfunction

Transforming growth factor-beta is a regulatory protein that plays a key role in inflammatory, fibrotic, and immunological events in the intestinal mucosa. Recently, attention has been focused on the role of transforming growth factor-beta in the etiopathogenesis of inflammatory bowel disease. Enhanced expression of transforming growth factor-beta mRNA in the lamina propria and a disordered expression pat­tern of transforming growth factor-beta1 receptors I and II in epithelial cells have been documented in the colonic mucosa of patients with ulcerative colitis and Crohn''s dis­ease. Based on these associations, we report in this study, the restriction fragment length polymorphism-polymerase chain reaction and allele frequen­cies of the transforming growth factor-beta gene polymorphisms in a population of Iranian patients with ulcerative colitis and healthy controls. We analyzed whether these two polymorphisms are related with the disease characteristics. One hundred fifty-seven (75 males and 82 females) unrelated patients with ulcerative colitis attending the Departments of Gastroenterolo­gy, Nemazi and Faghihi Hospitals, affiliated to Shiraz University of Medical Sciences, Shiraz, Iran were enrolled into this study. Ninety-four age- and sex-matched healthy volunteers with no history of chronic bloody diarrhea and abdominal pain (41 males and 53 females) served as the control group. The change at position –509 (C/T) of the transforming growth factor-beta1 gene was studied using restriction fragment length polymorphism-polymerase chain reaction in this study. The mean age of patients was 36.4 (range: 23 – 51) years. The genotype at position −509 (C/T) in 58 (37%) patients with ulcerative colitis, and 39 (41.5%) normal subjects, were homozygous as CC. In addition, 65 (41.5%) patients and 44 (47%) normal individuals were heterozygous as CT. Thirty-four (21.5%) of 157 patients, and 11 (11.5%) of 94 normal individuals, were homozygous as TT. There was no statistically significant difference between patients and normal female individuals in respect to genotype distribution and allele frequency at the said position (P = 0.138). No association could be found between transforming growth factor-beta1 −509 (C/T) promoter gene polymorphism and patients with ulcerative colitis.

The journal impact factor is increasingly employed to evaluate the quality of scientific research. This is in contrary to its critical limitations, e.g., its marked variation across scientific disciplines. This study was conducted to describe, in both quantitative and qualitative terms, the contribution of Iranian universities and research institutes to biomedical publications in 2004 and to examine the possible effect of impact factor normalization by subject on their rankings. The Iranian biomedical articles were recruited from Thomson Science Citation Index Expanded and PubMed databases according to Thomson Scientific subject categorization of journals. Three subject-normalized impact factors were employed: rank-normalized impact factor, journal to field impact score, and standardized impact factor. Tehran and Shiraz Universities of Medical Sciences and University of Tehran were the top three institutes regarding the sum of impact factor in 2004. On the basis of the mean crude impact factor, Sharif University of Technology, University of Shiraz, and Baqiyatollah University were ranked as the first to third. However, the subject normalization of impact factor made some considerable changes in impact factor-based rankings of research institutes. The Iranian scientific community and science development policy makers are recommended to employ subject-normalized impact factor, rather than crude impact factor, in quality assessment of biomedical research held in various academic and research institutes

Despite the recent advances in medicine, still many people suffer from long-standing tuberculosis. Delay in the diagnosis may result in further mortality and morbidity. Because of the importance of delay in the diagnosis, we decided to study and evaluate the patient delay and physician delay. A descriptive analytical study was done on 97 patients referred to the National Research Institute of Tuberculosis and Lung Disease in Tehran from September 2002 through March 2003. Those individuals who fulfilled the inclusion criteria underwent a face to face interview. The questionnaires were filled out. The interval between the first appearance of the clinical manifestation and the first visit to the physician was calculated (patient delay). Also, the period between the patient’s first visit to the physician and the final diagnosis was worked out. The mean patient delay time was 15 ± 13 days with a median of 13 days. The mean physician delay time was 93 ± 72 days with a median of 75 days. The mean total delay time was 108 ± 71 days with a median of 96 days. The patient delay in our country is at an acceptable level compared with other countries, but our physician delay time has not been shortened during the last eight years. Improving and upgrading the mycobacteriological courses for general physicians and specialists during their academic years should be accompanied by short-term teaching courses after the graduation.

Cerebral lymphoma is a rare non-Hodgkin’s lymphoma, which involves the brain primarily or after systemic involvement. Because of its infiltrating nature and its sensitivity to radio- and chemotherapy, surgical removal has a limited role in its treatment and only a stereotactic biopsy is necessary for confirming the diagnosis. The data from all cases in whom the cerebral lymphomas were pathologically confirmed and were admitted to the Neurosurgery Department of Shohada Hospital for stereotactic biopsy during a 15-year period were analyzed retrospectively. The male to female ratio was 1.3:1 and the mean age was 51.7 years. Sixty-seven percent of the patients had multiple lesions and the remainder had solitary lesions. The most common site of involvement in patients with multiple lesions was diencephalon and in patients with solitary lesions was frontal lobe. The mean duration from symptom presentation to stereotactic biopsy was three months. Systemic lymphoma was detected in nine patients and three patients had a history of immunosuppressive drug consumption. The most common presenting symptom was headache in 42% and the most common sign was paresis in 59% of the patients. In 53 patients, follow-up was performed by phone call. Of these, seven cases had died without treatment in an average of 40 days after diagnosis, 28 patients died despite adjuvant treatment in an average of 8.5 months, and 18 cases were alive by the time of last follow-up with average of 17 months. Overall survival of the treated group was 12 months. There was no mortality related to stereotactic biopsies in these patients.

There are controversial reports about the role of Demodex mites in pathogenesis of acne rosacea. The aim of this study was to examine the relationship between the presence and number of Demodex mites and the pathogenesis of rosacea. In this case-control study, the prevalence of Demodex mites was studied in facial biopsy of 75 patients with acne rosacea as case group, and in 75 patients with discoid lupus erythematosus and 75 patients with actinic lichen planus as control groups. The prevalence of Demodex mites in patients with acne rosacea (38.6%) was significantly higher than the patients with discoid lupus erythematosus (21.3%) and actinic lichen planus patients (10.6%) (P < 0.001). This study suggests that Demodex mites may play a role in pathogenesis of rosacea but it is not clear whether rosacea merely provides a suitable environment for multiplication of mites, or the mites play a role in the pathological changes.

Crimean-Congo hemorrhagic fever is a tick-borne viral disease reported from more than 30 countries in Africa, Asia, South-East Europe, and the Middle East. The majority of human cases are workers in livestock industry, agriculture, slaughterhouses, and veterinary practice. Nosocomial transmission is also well described. Clinical manifestations are nonspecific and symptoms typically include high fever, headache, malaise, arthralgia, myalgia, nausea, abdominal pain, and nonbloody diarrhea. Patients may show signs of progressive hemorrhagic diathesis. Laboratory abnormalities may include anemia, leukopenia, thrombocytopenia, increased AST/ALT levels, and prolonged prothrombin, bleeding, and activated partial thromboplastin times. Diagnostic methods include antibody detection by enzyme-linked immunosorbent assay, virus isolation, antigen detection, and polymerase chain reaction. The mainstay of treatment of Crimean-Congo hemorrhagic fever is supportive, with careful maintenance of fluid and electrolyte balance, circulatory volume, and blood pressure. The Crimean-Congo hemorrhagic fever virus is susceptible to ribavirin in vitro. There is no controlled study evaluating oral versus intravenous ribavirin in treating Crimean-Congo hemorrhagic fever patients, but few studies have evaluated oral ribavirin. This article reviews the epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment, prevention, and prognosis of Crimean-Congo hemorrhagic fever with a special focus on oral ribavirin as a choice of medical treatment.

The number of patients who suffer from snoring and sleep apnea in Iran has been increasing in proportionate to the rest of the world as the prevalence of obesity has soared within the last two decades. This pandemic obesity is blamed on consumption of more energy-dense, nutrient-poor foods with high levels of sugar and saturated fats. Obesity is one of the major contributing factors of obstructive sleep apnea. The number of people snoring in Iran is not well established, but since many years ago this bizarre behaviour was looked upon as an annoying sound that some people have and it was thought that they have to live with it. It was not until early twentieth century that scientists began to relate an association between snoring, obesity, and sleep-related disorders. At present time, it is well documented and universally agreed that snoring as well as sleep apnea are far more prevalent in societies and can lead to other serious illnesses including heart attack, stroke, and even nocturnal death. Obstructive sleep apnea is a term used to describe cession of breathing while sleep for a period of 10 seconds or more and repeated over five times per hour of sleep. In this article, we review various methods of surgical treatments and the long-term relapse potential for each.

Cancer is the eventual outcome of the interaction between genetic factors and environmental exposures. Nutrition and diet, as environmental factors and determinants of growth and body composition can contribute to the risk of some human cancers such as oral cancer. This article explains the ways of carcinogenesis and the effect of diet on this process, especially focusing on head, neck, and oral cancers.To reduce the risk of oral and pharyngeal cancer, especially squamous cell carcinoma, the most common oral cancer, diet must be optimized, primarily to reduce calorie intake, mono­unsaturated fat, and red or processed meat. Consumption of fruits, vegetables, and cereals, which are the major source of vitamins and fiber, should be adequate in the daily diet.Optimal levels of daily allowance of micronutrients like vitamin C, E, antioxidants, zinc, β-carotene, and folate are effective in prevention of oral cancer.Consumption of fried or broiled foods and employment of microwave cooking, because of formation of hetero­cyclic amines, must be avoided because of increasing risks of oral cancer including the salivary gland tumors.

Auditory neuropathy is defined as a sensorineural hearing loss characterized by normal cochlear hair cell function and absent or abnormal auditory brainstem evoked potentials. These people can hear the sound but can not understand it. They have neural hearing loss and the auditory rehabilitation approach for these people may be different from those who have sensorineural hearing loss. Therefore, screening of auditory neuropathy among hearing impaired students is essential. The prevalence of auditory neuropathy among the students with hearing impairment in specific schools for them was the objective of the current research.From 2002 through 2003, 841 hearing impaired students, aged 2 – 20 years, underwent a complete history taking, clinical examination, and audiometry. We found 13 students with auditory neuropathy who comprised 1.55% (CI95%: 0.71 – 2.38%) of the students with hearing impairment. We suggest that a complete panel of audiological tests for detection of auditory neuropathy be performed before admission of students with hearing impairment to schools.

Several studies have shown that patients with acromegaly are at increased risk of developing colorectal polyps and cancer. The prevalence of polyp in colon of patients with acromegaly was variously reported between 23% and 53%. This study was conducted to determine the prevalence of polyp and cancer of colon in patients with acromegaly. Twenty-three patients with acromegaly were evaluated with colonoscopy for the presence of colonic polyps and cancer. Three patients were found to have colonic polyps. This translates to a prevalence rate of 13%. We recommend that screening colonoscopy be carried out once every three years in all acromegalic patients over the age of 40 years.

Experience with horseshoe kidney transplantation is limited. Horseshoe kidney may be underutilized for transplantation because of the greater incidence of vascular and other associated urological anomalies. Nowadays, owing to a greater number of patients waiting for a kidney donation and to a shortage of organs donated, more suitable organ acceptance criteria have been formulated. The aim of this paper is to present the first Iranian experience with horseshoe kidney transplantation.

Liver penetration is a rare but serious complication of peptic ulcer disease. We report a 60-year-old man, without any serious risk factor for peptic ulcer, presented with mild abdominal discomfort, food-related vomiting and weight loss, and a mass in the left hepatic lobe, which was the result of a silent duodenal ulcer penetration. The diagnosis was based on histological examination of the endoscopicl biopsies

Olmsted syndrome is a rare congenital entity characterized by combination of symmetrical, sharply-defined palmoplantar keratoderma with flexion deformities of the digits, periorificial keratosis, perianal involvement, onychodystrophy, and variable leukokeratosis. Herein, we report two new related male patients—the third familial cases of Olmsted syndrome—one with the full-blown spectrum of the syndrome, and the other with early signs and symptoms of the disorder.

Distant metastases are unusual at presentation and during the course of ovarian carcinoma. Skin metastases may be the first presenting sign of metastatic carcinoma of the ovary. Ovarian epithelial adenocarcinoma rarely metastasizes to the skin, and can be seen in less than 4% of patients. It usually presents as subcutaneous nodules and, less commonly, as inflammatory metastases, which mimic viral or bacterial skin infections. The histology in most of the tumors is serous papillary adenocarcinoma (grade 1 or 2). The prognosis in most patients is poor, thus palliative treatment is usually indicated. We report a patient with widespread skin metastases and review the literature on this rare presentation.

Primary intimal angiosarcoma of the aorta (i.e., mostly intraluminal sarcomas with evidence of endothelial differentiation) is extraordinarily rare. We report a case in which the diagnosis was accurately made using immunohistochemistry in an embolectomy specimen. The patient was a 78-year-old man with a two-month history of bilateral claudication. Doppler ultrasound proved an embolus in both popliteal arteries, which was removed. The highly atypical cells comprising these emboli were positive immunohistochemically for CD68, vimentin, and CD31. Magnetic resonance imaging also showed an irregular tumor (invasion to the left main bronchus). This case emphasizes the need for a wide panel of immunohistochemical studies in tumor emboli of unknown origin

Pigmented Bowen''s disease is an uncommon in situ squamous cell carcinoma of the skin, which has been rarely reported on the finger. Herein, we report an unusual case of pigmented Bowen''s disease of the pulp of the fourth finger in a 20-year-old white woman, which was clinically presented as a superficial, spreading malignant melanoma. Physical examination revealed a solitary hyperpigmented patch, measuring 1 cm in its greatest diameter. The lesion had an irregular, but well-defined margin, and was homogeneously brown with a smooth surface. There was no nodularity or induration in the lesion or in its surrounding skin. A skin biopsy was obtained with the clinical suspicion of malignant melanoma. Histological examination was compatible with the diagnosis of pigmented Bowen’s disease. Surgical treatment was then considered and the patient underwent complete excision of the lesion. In spite of its rarity, Bowen’s disease should be considered in the differential diagnosis of pigmented lesions, particularly malignant melanoma.

Epidermodysplasia verruciformis is an inherited disorder, characterized by multiple plane warts, pityriasis versicolor-like lesions, defects of cell-mediated immunity, and tendency to develop skin malignancies, primarily on sun-exposed areas. In this article, we present a case of epidermodysplasia verruciformis with multiple plane warts, pityriasis versicolor-like lesions, and squamous cell carcinomas on non-sun-exposed areas of skin. After acitretin prescription, significant improvement was found in plane warts, but not in pityriasis versicolor-like lesions.

Neurilemmoma rarely develops in the biliary tree. Here, we report a 39-year-old Iranian woman with neurilemmoma in the extrahepatic bile duct presenting with progressively deepening jaundice. On the basis of clinical and radiological features, this tumor was initially suspected as Klatskin tumor. Histologically, the tumor was a typical neurilemmoma. Immunostaining showed that tumor cells were strongly and diffusely positive for S-100 protein, which supported the diagnosis of neurilemmoma. Neurilemmoma should be considered in the differential diagnosis of obstructive jaundice.

Shiraz Faculty of Medicine was officially inaugurated in 1952. In 1958, an eminent Austrian anatomist Professor Joseph Tomasch joined Shiraz Medical School. Professor Tomasch was a great teacher and an active researcher. He published about 40 original papers mainly on neuroanatomy in some reputable international journals. Presented here is a brief account of his fruitful academic efforts in Iran